Comparing the validity of the Modified Modified Ashworth Scale (MMAS) and the Modified Tardieu Scale (MTS) in the assessment of wrist flexor spasticity in patients with stroke: protocol for a neurophysiological study

High-dose high-intensity Queen Square upper-limb rehabilitation for people with chronic stroke (INTENSIVE): protocol for a single-centre, randomised controlled trial

INTRODUCTION

There is currently insufficient high-quality evidence to make general recommendations about high-dose high-intensity upper-limb rehabilitation programmes. Here we describe a randomised controlled trial that will determine the efficacy of two forms of high-dose, high-intensity upper-limb rehabilitation provided in a rehabilitation unit setting.

METHODS AND ANALYSIS

Patients with moderate upper-limb impairment (n=105, at least 6 months after stroke) will be randomised to either (1) high-dose high-intensity conventional upper-limb rehabilitation, (2) high-dose high-intensity virtual reality-based upper-limb rehabilitation and (3) usual care (a waiting list control group). Groups 1 and 2 will receive a minimum of 45 hours of active time on task over 3 weeks. Outcome measures will be collected at (T1) baseline; (T2) immediately post intervention and (T3) 3 months after the intervention has finished. The primary outcome measure will be the Fugl-Meyer Upper Extremity Assessment at 3 months after the intervention. Secondary outcome measures will be clinical, kinematic and neurophysiological using transcranial magnetic stimulation and electroencephalography. Explanatory measures will include MRI-based markers for integrity of the corticospinal tract, dorsal column-medial lemniscal pathway, grey and white matter and lesion load. The aim is to detect a difference of 7.25 points on the Fugl-Meyer Upper Extremity Assessment between each treatment group and the waitlist control group, with a power of 0.9 and significance of 0.025 (to account for two primary analyses). Analysis of change in the primary and secondary outcome measures will be performed using mulitple regression analysis.

ETHICS AND DISSEMINATION

The study protocol (V.1) has been approved by the Wales Research Ethics Committee 2 Cardiff (Rec reference: 22/WA/0065) on 15 March 2022. All recruited participants will provide informed consent. Trial results will be disseminated through peer-reviewed publications, presentations at major stroke/neurorehabilitation conferences and outreach to relevant stakeholder communities.

TRIAL REGISTRATION NUMBER

NCT05527262.

SpasticSim: a synthetic data generation method for upper limb spasticity modelling in neurorehabilitation

In neurorehabilitation, assessment of functional problems is essential to define optimal rehabilitation treatments. Usually, this assessment process requires distinguishing between impaired and non-impaired behavior of limbs. One of the common muscle motor disorders affecting limbs is spasticity, which is complicated to quantify objectively due to the complex nature of motor control. Thus, the lack of heterogeneous samples of patients constituting an acceptable amount of data is an obstacle which is relevant to understanding the behavior of spasticity and, consequently, quantifying it. In this article, we use the 3D creation suite Blender combined with the MBLab add-on to generate synthetic samples of human body models, aiming to be as sufficiently representative as possible to real human samples. Exporting these samples to OpenSim and performing four specific upper limb movements, we analyze the muscle behavior by simulating the six degrees of spasticity contemplated by the Modified Ashworth Scale (MAS). The complete dataset of patients and movements is open-source and available for future research. This approach advocates the potential to generate synthetic data for testing and validating musculoskeletal models.

Alberta Stroke Program Early CT Score can Predict Severity of Spasticity and Functional Outcome in Ischemic Stroke Survivors

Background

Post-stroke spasticity is common and an early predictor of the severity of spasticity can help track recovery trajectory helping to modify rehabilitation plans.

Objectives

We explored the utility of the Alberta Stroke Program Early CT Score (ASPECTS) to predict functional motor capacity in patients after acute ischemic stroke.

Methods

One hundred and one patients (mean age of 58.6 ± 7.6 years; M:F = 72: 29) with the first documented acute ischemic stroke were followed up for three to twelve months after the stroke. Cerebral lesions within the territory of the middle cerebral artery were evaluated using the ASPECTS. Spasticity was assessed using the Modified Ashworth Score (MAS) and walking with Timed Up and Go test (TUG). The associations between severity of spasticity and size/extent of infarct as derived from ASPECTS and between spasticity and functional walking in post-stroke survivors were analyzed.

Results

Among the patients studied, 61.3% (n = 62) had infarct in the region of supply of the left middle cerebral artery (MCA) and 38.7% (n = 39) had infarct in the region supplied by the right MCA. Three percent (n = 3) had a low ASPECTS, 53.6% (n = 54) had an intermediate score and 44.4% (n = 44) had a high score. The majority of patients with no to mild spasticity had high ASPECTS. Worse spasticity was significantly associated with low ASPECTS (P = 0.001). High scores in Timed Up and Go test (TUG) were associated with low ASPECTS (P < 0.001). Patients with high ASPECTS had the propensity to have subcortical infarcts (P < 0.001) when compared to those with moderate ASPECTS, who had a mix of cortical and subcortical infarcts.

Conclusion

ASPECTS at admission in patients with acute ischemic stroke is a good predictor of post-stroke spasticity and functional walking. Low ASPECTS is associated with higher spasticity and lower functional walking status on follow-up after stroke.

Effect and Optimal Timing of Extracorporeal Shock-Wave Intervention to Patients With Spasticity After Stroke: A Systematic Review and Meta-analysis

OBJECTIVE

This study investigated the efficacy of extracorporeal shock wave therapy as well as the optimal intervention timing for extracorporeal shock wave therapy for patients with spasticity after stroke.

DESIGN

A search of randomized controlled trials was conducted in different electronic databases. We performed a meta-analysis to measure the effect of extracorporeal shock wave therapy versus sham interventions on spasticity and limb functionality. The meta-regression analysis was performed to determine the adequate intervention timing of extracorporeal shock wave therapy. The follow-up period of the outcomes was divided into the short (<2 wks), mid (>2 wks and ≤4 wks), and long (>4 wks and ≤3 mos) terms.

RESULTS

Thirteen studies with 677 participants were evaluated. Spasticity significantly improved throughout the follow-up duration. Limb functionality significantly improved in the short-term follow-up period. The meta-regression analysis showed that patients with stroke duration less than 45 mos may be benefited from extracorporeal shock wave therapy in improving limb function in all follow-up periods.

CONCLUSIONS

Extracorporeal shock wave therapy is an effective method for reducing spasticity in patients with stroke, and the effect could be maintained for up to 3 mos. Its effects on limb functionality could persist for at least 2 wks. Patients who had stroke for less than 45 mos may have significant benefit from extracorporeal shock wave therapy in all follow-up periods.

Reliability of the Modified Ashworth and Modified Tardieu Scales with Standardized Movement Speeds in Children with Spastic Cerebral Palsy

The Modified Ashworth Scale (MAS) and Modified Tardieu Scale (MTS) are widely used to quantify spasticity. However, the reliability of their use for ankle plantar flexors has been questioned. In this study, we aimed to examine whether their reliabilities could be increased to acceptable levels for ankle plantar flexors using standardized movement speed in children with spastic cerebral palsy. The MAS and MTS scores for 92 limbs were assessed by two raters on two occasions, 1 week apart. A metronome was used to maintain the stretching velocity at 120 beats per minute. The intraclass correlation coefficients (ICCs) of the intra-rater reliabilities of the MAS and MTS and inter-rater reliability of the MAS were over 0.7. However, the ICCs for the inter-rater reliability of the MTS were <0.7 and >0.75 for the gastrocnemius and soleus muscles, respectively. The ICCs for the inter- and intra-rater reliabilities of the R1 angles ranged from 0.68 to 0.84, while those of the R2 angles ranged from 0.74 to 0.93. The reliabilities of the R2-R1 angles were not satisfactory. In conclusion, with a standardized movement speed, the reliability of the MAS for the ankle plantar flexors and the MTS for the soleus were satisfactory; however, that of the MTS for the gastrocnemius was not.

Assessment, goal setting, and botulinum neurotoxin a therapy in the management of post-stroke spastic movement disorder: updated perspectives on best practice

INTRODUCTION

Post-stroke spastic movement disorder (PS-SMD) appears up to 20% in the first week following stroke and 40% in the chronic phase. It may create major hurdles to overcome in early stroke rehabilitation and as one relevant factor that reduces quality of life to a major degree in the chronic phase.

AREAS COVERED

In this review, we discuss predictors,early identification, clinical assessments, goal setting, and management in multiprofessional team, including Botulinum neurotoxin A (BoNT-A) injection for early and chronic management of PS-SMD.

EXPERT OPINION

The earlier PS-SMD is recognized and managed, the better the outcome will be. The comprehensive management in the subacute or chronic phase of PS-SMD with BoNT-A injections requires detailed assessment, patient-centered goal setting, technical-guided injection, effective dosing of BoNT-A per site, muscle, and session and timed adjunctive treatment, delivered in a multi-professional team approach in conjunction with physical treatment. Evidence-based data showed BoNT-A injections are safe and effective in managing focal, multifocal, segmental PS-SMD and its complications. If indicated, BoNT-A therapy should be accompanied with adjunctive treatment in adequate time slots. BoNT-A could be added to oral, intrathecal, and surgical treatment in severe multisegmental or generalized PS-SMD to reach patient/caregiver's goals, especially in chronic PS-SMD.

Evaluating Viscoelastic Properties of the Wrist Joint During External Perturbations: Influence of Velocity, Grip, and Handedness

In this study, we designed a robot-based method to compute a mechanical impedance model that could extract the viscoelastic properties of the wrist joint. Thirteen subjects participated in the experiment, testing both dominant and nondominant hands. Specifically, the robotic device delivered position-controlled disturbances in the flexion-extension degree of freedom of the wrist. The external perturbations were characterized by small amplitudes and fast velocities, causing rotation at the wrist joint. The viscoelastic characteristics of the mechanical impedance of the joint were evaluated from the wrist kinematics and corresponding torques. Since the protocol used position inputs to determine changes in mean wrist torque, a detailed analysis of wrist joint dynamics could be made. The scientific question was whether and how these mechanical features changed with various grip demands and perturbation velocities. Nine experimental conditions were tested for each hand, given by the combination of three velocity perturbations (fast, medium, and slow) and three hand grip conditions [self-selected grip, medium and high grip force, as percentage of the maximum voluntary contraction (MVC)]. Throughout the experiments, electromyographic signals of the extensor carpi radialis (ECR) and the flexor carpi radialis (FCR) were recorded. The novelty of this work included a custom-made soft grip sensor, wrapped around the robotic handle, to accurately quantify the grip force exerted by the subjects during experimentation. Damping parameters were in the range of measurements from prior studies and consistent among the different experimental conditions. Stiffness was independent of both direction and velocity of perturbations and increased with increasing grip demand. Both damping and stiffness were not different between the dominant and nondominant hands. These results are crucial to improving our knowledge of the mechanical characteristics of the wrist, and how grip demands influence these properties. This study is the foundation for future work on how mechanical characteristics of the wrist are affected in pathological conditions.

Translation and cross-cultural adaptation to Brazilian Portuguese of the Modified Tardieu Scale for muscle tone assessment among patients with spinal cord injury

BACKGROUND

Assessment of muscle tone is of great importance for evaluating people with spinal injuries.

OBJECTIVE

To translate and adapt the Modified Tardieu Scale (MTS) to Brazilian Portuguese and validate its use for evaluating patients with spinal cord injury.

METHODS

The translation and adaptation of the "Escala de Tardieu Modificada" went through the steps of translation, translation synthesis, back-translation and expert committee meeting. Two evaluators rated the tone of the elbow flexors/extensors, wrist extensors, knee flexors/extensors and ankle plantar flexors of 51 patients with spinal cord injury. These patients were reevaluated after one week. Validation included intra and inter-rater reliability (ICC) and internal and external consistency. The Modified Ashworth Scale (MAS) was used in the evaluations, to investigate the correlations.

RESULTS

The Brazilian Portuguese version of the MTS is presented in this study. ICCs ranged from 0.60 to 0.99 (intra and inter-examiner) and there was a moderate to strong correlation with MAS.

CONCLUSIONS

The MTS proved to be adequate for assessing the muscle tone of people with spinal cord injury in Brazil.

Real-World Adherence to OnabotulinumtoxinA Treatment for Spasticity: Insights From the ASPIRE Study

OBJECTIVE

To identify baseline characteristics and treatment-related variables that affect adherence to onabotulinumtoxinA treatment from the Adult Spasticity International Registry (ASPIRE) study.

DESIGN

Prospective, observational registry (NCT01930786).

SETTING

International clinical sites.

PARTICIPANTS

Adults with spasticity (N=730).

INTERVENTIONS

OnabotulinumtoxinA at clinician's discretion.

MAIN OUTCOME MEASURES

Clinically meaningful thresholds used for treatment adherent (≥3 treatment sessions during 2-year study) and nonadherent (≤2 sessions). Data analyzed using logistic regression and presented as odds ratios (ORs) with 95% confidence intervals (CIs). Treatment-related variables assessed at sessions 1 and 2 only.

RESULTS

Of the total population, 523 patients (71.6%) were treatment adherent with 5.3±1.6 sessions and 207 (28.4%) were nonadherent with 1.5±0.5 sessions. In the final model (n=626/730), 522 patients (83.4%) were treatment adherent and 104 (16.6%) were nonadherent. Baseline characteristics associated with adherence: treated in Europe (OR=1.84; CI, 1.06-3.21; P=.030) and use of orthotics (OR=1.88; CI, 1.15-3.08; P=.012). Baseline characteristics associated with nonadherence: history of diplopia (OR=0.28; CI, 0.09-0.89; P=.031) and use of assistive devices (OR=0.51; CI, 0.29-0.90; P=.021). Treatment-related variables associated with nonadherence: treatment interval ≥15 weeks (OR=0.43; CI, 0.26-0.72; P=.001) and clinician dissatisfaction with onabotulinumtoxinA to manage pain (OR=0.18; CI, 0.05-0.69; P=.012). Of the population with stroke (n=411), 288 patients (70.1%) were treatment adherent with 5.3±1.6 sessions and 123 (29.9%) were nonadherent with 1.5±0.5 session. In the final stroke model (n=346/411), 288 patients (83.2%) were treatment adherent and 58 (16.8%) were nonadherent. Baseline characteristics associated with adherence: treated in Europe (OR=2.99; CI, 1.39-6.44; P=.005) and use of orthotics (OR=3.18; CI, 1.57-6.45; P=.001). Treatment-related variables associated with nonadherence: treatment interval ≥15 weeks (OR=0.42; CI, 0.21-0.83; P=.013) and moderate/severe disability on upper limb Disability Assessment Scale pain subscale (OR=0.40; CI, 0.19-0.83; P=.015).

CONCLUSIONS

These ASPIRE analyses demonstrate real-world patient and clinical variables that affect adherence to onabotulinumtoxinA and provide insights to help optimize management strategies to improve patient care.

Contribution of Single-Fiber Evaluation on Monitoring Outcomes Following Injection of Botulinum Toxin-A: A Narrative Review of the Literature

Botulinum toxin-A (BoNT-A) blocks acetylcholine release at the neuromuscular junction (NMJ) and is widely used for neuromuscular disorders (involuntary spasms, dystonic disorders and spasticity). However, its therapeutic effects are usually measured by clinical scales of questionable validity. Single-fiber electromyography (SFEMG) is a sensitive, validated diagnostic technique for NMJ impairment such as myasthenia. The jitter parameter (µs) represents the variability of interpotential intervals of two muscle fibers from the same motor unit. This narrative review reports SFEMG use in BoNT-A treatment. Twenty-four articles were selected from 175 eligible articles searched in Medline/Pubmed and Cochrane Library from their creation until May 2020. The results showed that jitter is sensitive to early NMJ modifications following BoNT-A injection, with an increase in the early days’ post-injection and a peak between Day 15 and 30, when symptoms diminish or disappear. The reappearance of symptoms accompanies a tendency for a decrease in jitter, but always precedes its normalization, either delayed or nonexistent. Increased jitter is observed in distant muscles from the injection site. No dose effect relationship was demonstrated. SFEMG could help physicians in their therapeutic evaluation according to the pathology considered. More data are needed to consider jitter as a predictor of BoNT-A clinical efficacy.

Monitoring Involuntary Muscle Activity in Acute Patients with Upper Motor Neuron Lesion by Wearable Sensors: A Feasibility Study

Sustained involuntary muscle activity (IMA) is a highly disabling and not completely understood phenomenon that occurs after a central nervous system lesion. We tested the feasibility of in-field IMA measuring at an acute rehabilitation ward. We used wearable probes for single differential surface EMG (sEMG), inclusive of a 3D accelerometer, onboard memory and remote control. We collected 429 h of data from the biceps brachii of 10 patients with arm plegia. Data quality was first verified in the time and frequency domains. Next, IMA was automatically identified based on the steady presence of motor unit action potential (MUAP) trains at rest. Feasibility was excellent in terms of prep time and burden to the clinical staff. A total of 350.5 h of data (81.7%) were reliable. IMA was found in 85.9 h (25%). This was often present in the form of exceedingly long-lasting trains of one or a few MUAPs, with differences among patients and variability, both within and between days in terms of IMA duration, root mean square (RMS) and peak-to-peak amplitude. Our results proved the feasibility of using wearable probes for single differential sEMG to identify and quantify IMA in plegic muscles of bedridden acute neurological patients. Our results also suggest the need for long-lasting acquisitions to properly characterize IMA. The possibility of easily assessing IMA in acute inpatients can have a huge impact on the management of their postures, physiotherapy and treatments.

Quantitative Ultrasound to Assess Skeletal Muscles in Post Stroke Spasticity

Quantitative ultrasound (QUS) techniques such as pixel intensity, ultrasound strain, and shear wave elastography have made it possible to identify the echogenicity (brightness) and mechanical properties (stiffness) of normal and pathological tissues. These techniques can be utilized as an alternative diagnosis tool to assess post stroke spasticity. Current clinical assessment methods include the Modified Ashworth Scale (MAS) and the Modified Tardieu Scale (MTS), which can result in inconsistencies due to their subjective nature. QUS provides robust approaches to assessing muscle stiffness associated with post stroke spasticity. Computer-aided pixel count quantifies tissue echogenicity in grayscale image. A strain ratio in ultrasound strain imaging compares the stiffness and movement (lengthening or shortening) of a spastic muscle with nonspecific muscle. In addition, shear wave elastography provides the shear wave velocity of an affected muscle that directly associated with the muscle stiffness before and after treatment for spasticity. This article reviews the theory behind these aforementioned concepts and discuss the relations between QUS and skeletal muscles in post stroke spasticity.

Long-Term Observational Results from the ASPIRE Study: OnabotulinumtoxinA Treatment for Adult Lower Limb Spasticity

INTRODUCTION

OnabotulinumtoxinA treatment for spasticity varies according to numerous factors and is individualized to meet treatment goals.

OBJECTIVE

To explore real-world onabotulinumtoxinA utilization and effectiveness in patients with lower limb spasticity from the Adult Spasticity International Registry (ASPIRE) study.

DESIGN

Two-year, multicenter, prospective, observational registry (NCT01930786).

SETTING

Fifty-four international clinical sites.

PATIENTS

Adults (naïve or non-naïve to botulinum toxin[s] treatment for spasticity, across multiple etiologies) with lower limb spasticity related to upper motor neuron syndrome.

INTERVENTIONS

OnabotulinumtoxinA administered at the clinician's discretion.

MAIN OUTCOME MEASURES

OnabotulinumtoxinA treatment utilization, clinician- and patient-reported satisfaction.

RESULTS

In ASPIRE, 530 patients received ≥1 onabotulinumtoxinA treatment for lower limb spasticity (mean age, 52 years; stroke, 49.4%; multiple sclerosis, 20.4%). Equinovarus foot was treated most often (80.9% of patients), followed by flexed knee (26.0%), stiff extended knee (22.5%), and flexed toes (22.3%). OnabotulinumtoxinA doses ranged between 10 and 1100 U across all presentations. Electromyography (EMG) was most commonly used for injection localization (≥41.1% of treatment sessions). Despite low patient response on the satisfaction questionnaire, clinicians (94.6% of treatment sessions) and patients (84.5%) reported satisfaction/extreme satisfaction that treatment helped manage spasticity, and clinicians (98.3%) and patients (91.6%) would probably/definitely continue onabotulinumtoxinA treatment. These data should be interpreted with care. Twenty-one adverse events (AEs) in 18 patients (3.4%) were considered treatment-related. Sixty-seven patients (12.6%) reported 138 serious AEs; 3 serious AEs in two patients (0.4%) were considered treatment-related. No new safety signals were identified.

CONCLUSIONS

ASPIRE provides long-term observational data on the treatment of lower limb spasticity with onabotulinumtoxinA. Real-world data from this primary analysis can help to guide the clinical use of onabotulinumtoxinA to improve spasticity management.

Effect of Ankle Plantar Flexor Spasticity Level on Balance in Patients With Stroke: Protocol for a Cross-Sectional Study

BACKGROUND

The lower limb spasticity after stroke can affect the balance and gait of patients with stroke.

OBJECTIVE

The aim of this study is to assess the effects of ankle plantar flexor spasticity level on balance in patients with stroke.

METHODS

Patients with stroke were recruited from neurology and physiotherapy clinics in Tehran, Iran. Based on the level of ankle plantar flexor spasticity according to the Modified Modified Ashworth Scale (MMAS), the eligible patients with stroke were divided into 2 groups: high spasticity (MMAS score≥2) and low spasticity (MMAS score<2). The primary outcome measures were the MMAS scores, Activities-Specific Balance Confidence questionnaire scores, eyes-open and eyes-closed posturography measures, and Timed Up and Go test results. The secondary outcome measures were the ankle passive range of motion and ankle joint proprioception. The t test, mixed model univariate analysis of variance, and Spearman rank correlation were used for statistical analysis.

RESULTS

Data collection and statistical analysis are complete. The interpretation of results is underway. We expect the results to be published in winter 2020.

CONCLUSIONS

We believe that patients with high ankle plantar flexor spasticity after stroke will demonstrate greater balance dysfunction, which will worsen with impaired proprioception, passive range of motion, and eyes closed.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/16045.

Individualized OnabotulinumtoxinA Treatment for Upper Limb Spasticity Resulted in High Clinician- and Patient-Reported Satisfaction: Long-Term Observational Results from the ASPIRE Study

Introduction

OnabotulinumtoxinA treatment for spasticity is dependent on numerous factors and varies according to selected treatment goals.

Objective

To examine real‐world onabotulinumtoxinA treatment utilization and effectiveness in patients with upper limb spasticity over 2 years from the Adult Spasticity International Registry (ASPIRE) study.

Design

Multicenter, prospective, observational registry (NCT01930786).

Setting

Fifty‐four international clinical sites in North America, Europe, and Asia.

Patients

Adults (naïve or non‐naïve to botulinum toxins for spasticity) with upper limb focal spasticity related to upper motor neuron syndrome across multiple etiologies.

Interventions

OnabotulinumtoxinA administered at clinician's discretion.

Main Outcome Measures

OnabotulinumtoxinA utilization, clinician and patient satisfaction.

Results

Four hundred eighty‐four patients received ≥1 treatment of onabotulinumtoxinA for upper limb spasticity. Patients were on average 55.1 years old, 50.8% male, predominantly Caucasian (72.3%), and 38.6% were naïve to botulinum toxins. Stroke was the most frequently reported underlying etiology (74.0%). Most patients (81.2%) had moderate to severe spasticity at baseline. The most commonly treated upper limb clinical presentation was clenched fist (79.1% of patients). Across all presentations, onabotulinumtoxinA doses ranged between 5‐600U. Electromyography (EMG) was most often utilized to localize muscles (≥57.0% of treatment sessions). Clinicians (92.9% of treatment sessions) and patients (85.7%) reported being extremely satisfied/satisfied that treatment helped manage spasticity, and clinicians (98.6%) and patients (92.2%) would definitely/probably continue onabotulinumtoxinA treatment. One hundred seventy‐nine patients (37.0%) reported 563 adverse events (AEs); 15 AEs in 14 patients (2.9%) were considered treatment related. Sixty‐nine patients (14.3%) reported 137 serious AEs; 3 serious AEs in 2 patients (0.4%) were considered treatment related. No new safety signals were identified.

Conclusions

ASPIRE captured the real‐world individualized nature of onabotulinumtoxinA utilization for upper limb spasticity over 2 years, with consistently high clinician‐ and patient‐reported satisfaction. Data in this primary analysis will guide clinical use of onabotulinumtoxinA, as well as provide insights to improve educational programs on spasticity management.

Clinimetrics of the Upright Motor Control Test in chronic stroke

INTRODUCTION

Insufficient literature exists regarding the clinimetric properties of the Upright Motor Control Test Knee Extension and Flexion subtests (UMCT-KE and UMCT-KF, respectively). This study examined the interrater and test-retest reliability of these subtests, and determined the relationship between the UMCT-KE and a clinical measure of muscle function in a sample of adults with chronic stroke.

METHODS

Three raters independently administered the UMCT-KE and UMCT-KF on adults with chronic stroke with spasticity/abnormal movement patterns. Testing of each participant occurred on two occasions (T1 and T2) separated by a two-week interval. A fourth rater independently administered the Five Times Sit to Stand Test (FTSST), a measure of lower extremity muscle function (power), on T2.

RESULTS

Twenty-nine adults aged 55 ± 8 years, comprising 21 men (72%), and who were 9 ± 5 years poststroke, completed the study. Most of the participants (66%, 19/29) did not require an assistive device during walking. The UMCT-KE and UMCT-KF demonstrated substantial interrater reliability (W = 0.63-0.67 and 0.72-0.75, respectively) and substantial to almost perfect test-retest reliability across the raters (W = 0.75-0.82 and 0.85-0.87, respectively). The UMCT-KE showed positive inverse correlation with the FTSST (ρ = -0.52, p = .003).

CONCLUSIONS

Scores on both subtests are reproducible within raters and across different raters. The relationship of UMCT-KE scores with FTSST scores implies that the UMCT-KE can provide information that relates with the construct of muscle function in a weight-bearing position.

Effective Site for the Application of Extracorporeal Shock-Wave Therapy on Spasticity in Chronic Stroke: Muscle Belly or Myotendinous Junction

OBJECTIVE

To compare the effect of extracorporeal shock-wave therapy (ESWT) applied at the muscle belly and myotendinous junction on spasticity in the upper and lower limbs of chronic stroke patients.

METHODS

Of the 151 patients, a total of 80 patients with stroke-induced spasticity on the elbow flexor and 44 patients on the knee flexor were enrolled for a prospective, randomized clinical trial. The patients were divided into control, muscle belly, and myotendinous junction groups, and a total of three ESWT sessions (0.068-0.093 mJ/mm², 1,500 shots) were conducted at one per week. A Modified Ashworth Scale (MAS) and Modified Tardieu Scale (MTS) were collected at the baseline and at 1 week after each session.

RESULTS

After interventions, the MAS and MTS of both the belly and the junction groups showed positive effects from the ESWT on spasticity in the elbow and knee flexors, but the control group did not. The results also tended to improve after each session until the entire intervention was completed. However, there was no significant difference between the belly and junction groups.

CONCLUSION

ESWT could be effective for treating chronic spasticity after stroke when applied to muscle belly or myotendinous junction.

Knee orthosis with variable stiffness and damping that simulates hemiparetic gait

Individuals with unilateral stroke have neuromuscular weakness or paralysis on one side of the body caused by some muscles disengaging and others overexciting. Hyperextension of the knee joint and complete lack of plantar flexion of the ankle joint are common symptoms of stroke. This paper focuses on the creation and implementation of a small, lightweight, and adjustable orthotic device to be positioned around the knee of an able-bodied person to simulate hemiparetic gait. Force and range of motion data from able-bodied subjects fitted with the orthosis, inducing hemiparetic gait, was collected using the Computer Assisted Rehabilitation ENvironment (CAREN) system. The four parameters that the design focused on are damping, catch, hysteresis, and stiffness. The main goal of the project was to discern whether this device could be utilized as a viable research instrument to simulate hemiparetic gait. It was hypothesized that the device has the potential to be utilized in the future as a rehabilitation device for people with stroke since it has been designed to induce larger knee flexion as an after effect. A comparison between how the dominant leg was affected by the orthosis and how the non-dominant leg was affected was investigated as well. The results show that the device affected the velocities, knee angles, and force profiles of the subject's gait.

A single group, pretest-posttest clinical trial for the effects of dry needling on wrist flexors spasticity after stroke

BACKGROUND

Spasticity is a common complication after stroke. Dry needling (DN) is suggested as a novel method for treatment of muscle spasticity.

OBJECTIVE

To explore the effects of DN on wrist flexors spasticity poststroke.

METHODS

A single group, pretest-posttest clinical trial was used. Twenty nine patients with stroke (16 male; mean age 54.3 years) were tested at baseline (T0), immediately after DN (T1), and one hour after DN (T2). DN was applied for flexor carpi radialis (FCR) and flexor carpi ulnaris on the affected arm for single session, one minute per muscle. The Modified Modified Ashworth Scale (MMAS), passive resistance force, wrist active and passive range of motion, Box and Block Test, and FCR H-reflex were outcome measures.

RESULTS

Significant reductions in MMAS scores were seen both immediately after DN and at 1-hour follow-up (median 2 at T0 to 1 at T1 and T2). There were significant improvements in other measures between the baseline values at T0 and those recorded immediately after the DN at T1 or one hour later at T2.

CONCLUSIONS

This study suggests that DN reduced wrist flexors spasticity and alpha motor neuron excitability in patients with stroke, and improvements persisted for one hour after DN.

Selecting relevant and feasible measurement instruments for the revised Dutch clinical practice guideline for physical therapy in patients after stroke

PURPOSE

To select relevant and feasible instruments for the revision of the Dutch clinical practice guideline for physical therapy in patients with stroke.

METHODS

In this implementation study a comprehensive proposal for ICF categories and matching instruments was developed, based on reliability and validity. Relevant instruments were then selected in a consensus round by 11 knowledge brokers who were responsible for the implementation of the selected instruments. The feasibility of the selected instruments was tested by 36 physical therapists at different work settings within stroke services. Finally, instruments that were deemed relevant and feasible were included in the revised guideline.

RESULTS

A total of 28 instruments were recommended for inclusion in the revised guideline. Nineteen instruments were retained from the previous guideline. Ten new instruments were tested in clinical practice, seven of which were found feasible. Two more instruments were added after critical appraisal of the set of the measurement instruments.

CONCLUSIONS

The revised guideline contains 28 relevant and feasible instrument selected and tested in clinical practice by physical therapists. Further education and implementation is needed to integrate instruments in clinical practice. Further research is proposed for developing and implementing a core set of measurement instruments to be used at fixed time points to establish data registries that allow for continuous improvement of rehabilitation for stroke patients. Implications for Rehabilitation The revised Dutch Stroke Physical Therapy Guideline recommends a total of 28 instruments, that are relevant and feasible for clinical practice of physical therapist in the different settings of stroke rehabilitation. The selection of instrument in daily practice should be part of the clinical reasoning process of PTs and be tailored to individual patients' needs and the degree of priority of the affected ICF category. Suggested education strategies for further integration of instruments in of the daily practice of PTs in Stroke Rehabilitation are: 'Training on the job' and 'peer assessment in clinical situations'.

Normative NeuroFlexor data for detection of spasticity after stroke: a cross-sectional study

Background and Objective

The NeuroFlexor is a novel instrument for quantification of neural, viscous and elastic components of passive movement resistance. The aim of this study was to provide normative data and cut-off values from healthy subjects and to use these to explore signs of spasticity at the wrist and fingers in patients recovering from stroke.

Methods

107 healthy subjects (age range 28–68 years; 51 % females) and 39 stroke patients (age range 33–69 years; 33 % females), 2–4 weeks after stroke, were assessed with the NeuroFlexor. Cut-off values based on mean + 3SD of the reference data were calculated. In patients, the modified Ashworth scale (MAS) was also applied.

Results

In healthy subjects, neural component was 0.8 ± 0.9 N (mean ± SD), elastic component was 2.7 ± 1.1 N, viscous component was 0.3 ± 0.3 N and resting tension was 5.9 ± 1 N. Age only correlated with elastic component (r = −0.3, p = 0.01). Elasticity and resting tension were higher in males compared to females (p = 0.001) and both correlated positively with height (p = 0.01). Values above healthy population cut-off were observed in 16 patients (41 %) for neural component, in 2 (5 %) for elastic component and in 23 (59 %) for viscous component. Neural component above cut-off did not correspond well to MAS ratings. Ten patients with MAS = 0 had neural component values above cut-off and five patients with MAS ≥ 1 had neural component within normal range.

Conclusion

This study provides NeuroFlexor cut-off values that are useful for detection of spasticity in the early phase after stroke.

[Effect of botulinum toxin A injection in the treatment of gastrocnemius spasticity in children aged 9-36 months with cerebral palsy: a prospective study]

OBJECTIVE

To investigate the long-term clinical efficacy and adverse effects of botulinum toxin-A (BTX-A) injection in the treatment of gastrocnemius spasticity in children aged 9-36 months with cerebral palsy.

METHODS

Eighty children aged 9-36 months with cerebral palsy and gastrocnemius spasticity were selected and randomly divided into a BTX-A injection group and a conventional treatment group (n=40 each). The children in the BTX-A injection group received injections of BTX-A guided by color Doppler ultrasound and 4 courses of rehabilitation training after injection. Those in the conventional treatment group received 4 courses of the same rehabilitation training alone. Before treatment and at 1, 2, 3, and 6 months after treatment, the modified Tardieu scale (MTS) was applied to assess the degree of gastrocnemius spasticity, the values in the passive state measured by surface electromyography (sEMG) were applied to evaluate muscle tension, and the Gross Motor Function Measure (GMFM) was used to evaluate gross motor function.

RESULTS

Compared with the conventional treatment group, the BTX-A injection group had significantly greater reductions in MTS score and the values in the passive state measured by sEMG (P<0.05), as well as significantly greater increases in joint angles R1 and R2 in MTS and gross motor score in GMFM (P<0.05). No serious adverse reactions related to BTX-A injection were found.

CONCLUSIONS

BTX-A injection is effective and safe in the treatment of gastrocnemius spasticity in children aged 9-36 months with cerebral palsy.

[Effect of botulinum toxin A injection in the treatment of gastrocnemius spasticity in children aged 9-36 months with cerebral palsy: a prospective study]

OBJECTIVE

To investigate the long-term clinical efficacy and adverse effects of botulinum toxin-A (BTX-A) injection in the treatment of gastrocnemius spasticity in children aged 9-36 months with cerebral palsy.

METHODS

Eighty children aged 9-36 months with cerebral palsy and gastrocnemius spasticity were selected and randomly divided into a BTX-A injection group and a conventional treatment group (n=40 each). The children in the BTX-A injection group received injections of BTX-A guided by color Doppler ultrasound and 4 courses of rehabilitation training after injection. Those in the conventional treatment group received 4 courses of the same rehabilitation training alone. Before treatment and at 1, 2, 3, and 6 months after treatment, the modified Tardieu scale (MTS) was applied to assess the degree of gastrocnemius spasticity, the values in the passive state measured by surface electromyography (sEMG) were applied to evaluate muscle tension, and the Gross Motor Function Measure (GMFM) was used to evaluate gross motor function.

RESULTS

Compared with the conventional treatment group, the BTX-A injection group had significantly greater reductions in MTS score and the values in the passive state measured by sEMG (P<0.05), as well as significantly greater increases in joint angles R1 and R2 in MTS and gross motor score in GMFM (P<0.05). No serious adverse reactions related to BTX-A injection were found.

CONCLUSIONS

BTX-A injection is effective and safe in the treatment of gastrocnemius spasticity in children aged 9-36 months with cerebral palsy.