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Li S, Winston P, Mas MF. Spasticity Treatment Beyond Botulinum Toxins. Phys Med Rehabil Clin N Am 2024; 35:399-418. [PMID: 38514226 DOI: 10.1016/j.pmr.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Botulinum toxin (BonT) is the mainstream treatment option for post-stroke spasticity. BoNT therapy may not be adequate in those with severe spasticity. There are a number of emerging treatment options for spasticity management. In this paper, we focus on innovative and revived treatment options that can be alternative or complementary to BoNT therapy, including phenol neurolysis, cryoneurolysis, and extracorporeal shock wave therapy.
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Affiliation(s)
- Sheng Li
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center - Houston, Houston, TX, USA; TIRR Memorial Herman.
| | - Paul Winston
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Victoria, British Columbia, Canada; Canadian Advances in Neuro-Orthopedics for Spasticity Consortium, Victoria, British Columbia, Canada
| | - Manuel F Mas
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Puerto Rico, San Juan, Puerto Rico
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Suputtitada A, Chatromyen S, Chen CPC, Simpson DM. Best Practice Guidelines for the Management of Patients with Post-Stroke Spasticity: A Modified Scoping Review. Toxins (Basel) 2024; 16:98. [PMID: 38393176 PMCID: PMC10892074 DOI: 10.3390/toxins16020098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 01/19/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
This article aims to provide a concise overview of the best available evidence for managing post-stroke spasticity. A modified scoping review, conducted following the PRISMA guidelines and the PRISMA Extension for Scoping Reviews (PRISMA-ScR), involved an intensive search on Medline and PubMed from 1 January 2000 to 31 August 2023. The focus was placed on high-quality (GRADE A) medical, rehabilitation, and surgical interventions. In total, 32 treatments for post-stroke spasticity were identified. Two independent reviewers rigorously assessed studies, extracting data, and evaluating bias using GRADE criteria. Only interventions with GRADE A evidence were considered. The data included the study type, number of trials, participant characteristics, interventions, parameters, controls, outcomes, and limitations. The results revealed eleven treatments supported by GRADE A evidence, comprising 14 studies. Thirteen were systematic reviews and meta-analyses, and one was randomized control trial. The GRADE A treatments included stretching exercises, static stretching with positional orthosis, transcutaneous electrical nerve stimulation, extracorporeal shock wave therapy, peripheral magnetic stimulation, non-invasive brain stimulation, botulinum toxin A injection, dry needling, intrathecal baclofen, whole body vibration, and localized muscle vibration. In conclusion, this modified scoping review highlights the multimodal treatments supported by GRADE A evidence as being effective for improving functional recovery and quality of life in post-stroke spasticity. Further research and exploration of new therapeutic options are encouraged.
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Affiliation(s)
- Areerat Suputtitada
- Department of Rehabilitation Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Rama 4 Road, Patumwan, Bangkok 10330, Thailand
- Principles and Practice of Clinical Research (PPCR) Program, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Supattana Chatromyen
- Neurological Institute of Thailand, Department of Medical Services, Ministry of Public Health, Bangkok 10400, Thailand;
| | - Carl P. C. Chen
- Department of Physical Medicine & Rehabilitation, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, Guishan District, Taoyuan City 33343, Taiwan;
| | - David M. Simpson
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, NY 10029, USA;
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Su TY, Huang YC, Ko JY, Hsin YJ, Yu MY, Hung PL. Therapeutic effects of extracorporeal shock wave therapy on patients with spastic cerebral palsy and Rett syndrome: clinical and ultrasonographic findings. Orphanet J Rare Dis 2024; 19:6. [PMID: 38172891 PMCID: PMC10763338 DOI: 10.1186/s13023-023-03010-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Extracorporeal shock wave therapy (ESWT) is reportedly effective for improving spasticity and motor function in children with cerebral palsy (CP). Because late-stage Rett syndrome has a similar presentation, this study aimed to investigate the effects of ESWT on these two diseases. MATERIAL AND METHODS Patients diagnosed with spastic CP and Rett syndrome received 1500 impulses of ESWT at 4 Hz and 0.1 mJ/mm2, on their spastic legsonce weekly for a total of 12 weeks. Outcomes were assessed before and 4 and 12 weeks after ESWT. Clinical assessments included the Modified Ashworth Scale (MAS), passive range of motion (PROM), and Gross Motor Function Measure 88 (GMFM-88). Ultrasonographic assessments included muscle thickness, acoustic radiation force impulse (ARFI), and strain elastography. RESULTS Fifteen patients with CP and six with Rett syndrome were enrolled in this study. After ESWT, patients with CP showed significant clinical improvement in the MAS (P = 0.011), ankle PROM (P = 0.002), walking/running/jumping function (P = 0.003), and total function (P < 0.001) of the GMFM-88. The patients with Rett syndrome showed improved MAS scores (P = 0.061) and significantly improved total gross motor function (P = 0.030). Under ARFI, patients with CP demonstrated decreased shear wave speed in the gastrocnemius medial head (P = 0.038). Conversely, patients with Rett syndrome show increased shear-wave speeds after ESWT. CONCLUSION Our study provides evidence that a weekly course of low-dose ESWT for 12 weeks is beneficial for children with both CP and Rett syndrome, with the clinical effects of reducing spasticity and improving the gross motor function of the lower limbs. The ARFI sonoelastography reveals improvement of muscle stiffness in patients with CP after ESWT, but deteriorated in patients with Rett syndrome. The diverse therapeutic response to ESWT may be caused by the MECP2 mutation in Rett syndrome, having a continuous impact and driving the pathophysiology differently as compared to CP, which is secondary to a static insult. Trial registration IRB 201700462A3. Registered 22March 2017, https://cghhrpms.cgmh.org.tw/HRPMS/Default.aspx .
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Affiliation(s)
- Ting-Yu Su
- Department of Pediatric Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Dist., Kaohsiung City, 833, Taiwan
| | - Yu-Chi Huang
- Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Jih-Yang Ko
- Department of Orthopedic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Yi-Jung Hsin
- Department of Physical Medicine and Rehabilitation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Min-Yuan Yu
- Department of Rehabilitation, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan
| | - Pi-Lien Hung
- Department of Pediatric Neurology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong Dist., Kaohsiung City, 833, Taiwan.
- Center for Shockwave Medicine and Tissue Engineering, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung City, Taiwan.
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Suputtitada A. Emerging theory of sensitization in post-stroke muscle spasticity. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1169087. [PMID: 37791371 PMCID: PMC10542400 DOI: 10.3389/fresc.2023.1169087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 08/28/2023] [Indexed: 10/05/2023]
Abstract
Spasticity, characterized by a velocity-dependent increase in muscle tone and exaggerated reflexes, is a common complication in individuals with upper motor neuron syndrome, such as stroke survivors. Sensitization, the heightened responsiveness of the nervous system to sensory stimuli, has emerged as a potential cause of spasticity. This perspective article explores three emerging treatments targeting sensitization. Recent studies have investigated novel treatment modalities for spasticity, including Extracorporeal Shockwave Therapy (ESWT), repetitive peripheral magnetic stimulation (rPMS), and needling. ESWT has shown promising results in reducing spasticity in both the upper and lower extremities, potentially through mechanisms such as nitric oxide production, rheological property changes, and neuromuscular transmission dysfunction. rPMS offers a non-invasive approach that may reduce spasticity by increasing sensory input, enhancing cortical activation, and exerting tissue-softening effects. Needling has also demonstrated positive effects on spasticity reduction. The high heterogeneity observed indicates the need for more rigorous research to confirm these findings. Recently, mechanical needling and sterile water injection invented by the author is also promising for reducing spasticity through removing sensitization. In conclusion, the emerging treatment options discussed in this perspective article provide promising avenues for addressing sensitization in spasticity and improving motor function. However, further research is needed to validate their findings, optimize treatment protocols, and investigate their long-term effects on motor recovery and overall quality of life in individuals with spasticity.
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Affiliation(s)
- Areerat Suputtitada
- Department of Rehabilitation Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Bangkok, Thailand
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Duan H, Lian Y, Jing Y, Xing J, Li Z. Research progress in extracorporeal shock wave therapy for upper limb spasticity after stroke. Front Neurol 2023; 14:1121026. [PMID: 36846123 PMCID: PMC9947654 DOI: 10.3389/fneur.2023.1121026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 01/20/2023] [Indexed: 02/11/2023] Open
Abstract
Spasticity is one of the most common complications after stroke. With the gradual intensification of spasticity, stroke patients will have a series of problems such as joint ankylosis and movement restriction, which affect the daily activities and increase the burden on patients' families, medical staff and society. There are many ways to treat post-stroke spasticity before, including physical therapy and exercise therapy, drug therapy, surgery and so on, but not satisfied because of a few shortcomings. In recent years, many researchers have applied extracorporeal shock wave therapy (ESWT) for the treatment of post-stroke spasm and achieved good clinical effect, because it is non-invasive, safe, easy to operate, low cost and other advantages compared with other treatment methods. This article reviews the research progress and existing problems of ESWT in the treatment of post-stroke spasticity.
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Affiliation(s)
- Haoyang Duan
- Department of Rehabilitation Medicine, First Hospital of Jilin University, Changchun, China
| | - Yawen Lian
- Department of Rehabilitation Medicine, First Hospital of Jilin University, Changchun, China
| | - Yuling Jing
- Department of Rehabilitation Medicine, First Hospital of Jilin University, Changchun, China
| | - Jingsong Xing
- Department of Rehabilitation Medicine, First Hospital of Jilin University, Changchun, China
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Fernández-Cuadros ME, Martín-Martín LM, Pérez-Moro OS, Albaladejo-Florín MJ. [Can we associate botulinum toxin with radial electroshock wave therapy in the treatment of spasticity?]. Rehabilitacion (Madr) 2022:S0048-7120(22)00087-1. [PMID: 36344303 DOI: 10.1016/j.rh.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/15/2022] [Accepted: 09/17/2022] [Indexed: 06/16/2023]
Affiliation(s)
- M E Fernández-Cuadros
- Servicio de Rehabilitación y Medicina Física, Hospital Universitario Santa Cristina, Madrid, España.
| | - L M Martín-Martín
- Servicio de Neurofisiología Clínica, Hospital Universitario Santa Cristina, Madrid, España
| | - O S Pérez-Moro
- Servicio de Rehabilitación y Medicina Física, Hospital Universitario Santa Cristina, Madrid, España
| | - M J Albaladejo-Florín
- Servicio de Rehabilitación y Medicina Física, Hospital Universitario Santa Cristina, Madrid, España
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