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Willaert J, Desloovere K, Van Campenhout A, Ting LH, De Groote F. Identification of Neural and Non-Neural Origins of Joint Hyper-Resistance Based on a Novel Neuromechanical Model. IEEE Trans Neural Syst Rehabil Eng 2024; 32:1435-1444. [PMID: 38526884 PMCID: PMC11032725 DOI: 10.1109/tnsre.2024.3381739] [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] [Indexed: 03/27/2024]
Abstract
Joint hyper-resistance is a common symptom in neurological disorders. It has both neural and non-neural origins, but it has been challenging to distinguish different origins based on clinical tests alone. Combining instrumented tests with parameter identification based on a neuromechanical model may allow us to dissociate the different origins of joint hyper-resistance in individual patients. However, this requires that the model captures the underlying mechanisms. Here, we propose a neuromechanical model that, in contrast to previously proposed models, accounts for muscle short-range stiffness (SRS) and its interaction with muscle tone and reflex activity. We collected knee angle trajectories during the pendulum test in 15 children with cerebral palsy (CP) and 5 typically developing children. We did the test in two conditions - hold and pre-movement - that have been shown to alter knee movement. We modeled the lower leg as an inverted pendulum actuated by two antagonistic Hill-type muscles extended with SRS. Reflex activity was modeled as delayed, linear feedback from muscle force. We estimated neural and non-neural parameters by optimizing the fit between simulated and measured knee angle trajectories during the hold condition. The model could fit a wide range of knee angle trajectories in the hold condition. The model with personalized parameters predicted the effect of pre-movement demonstrating that the model captured the underlying mechanism and subject-specific deficits. Our model may help with the identification of neural and non-neural origins of joint hyper-resistance and thereby opens perspectives for improved diagnosis and treatment selection in children with spastic CP, but such applications require further studies to establish the method's reliability.
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Panahi F, Ebrahimi S, Rojhani-Shirazi Z, Shakibafard A, Hemmati L. Effects of neurorehabilitation with and without dry needling technique on muscle thickness, reflex torque, spasticity and functional performance in chronic ischemic stroke patients with spastic upper extremity muscles: a blinded randomized sham-controlled clinical trial. Disabil Rehabil 2024; 46:1092-1102. [PMID: 36970837 DOI: 10.1080/09638288.2023.2190168] [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: 10/05/2022] [Accepted: 03/08/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE Evaluation the effects of dry needling on sonographic, biomechanical and functional parameters of spastic upper extremity muscles. METHODS Twenty-four patients (35-65 years) with spastic hand were randomly allocated into two equal groups: intervention and sham-controlled groups. The treatment protocol was 12-sessions neurorehabilitation for both groups and 4-sessions dry needling or sham-needling for the intervention group and sham-controlled group respectively on wrist and fingers flexor muscles. The outcomes were muscle thickness, spasticity, upper extremity motor function, hand dexterity and reflex torque which were assessed before, after the 12th session, and after one-month follow-up by a blinded assessor. RESULTS The analysis showed that there was a significant reduction in muscle thickness, spasticity and reflex torque and a significant increment in motor function and dexterity in both groups after treatment (p < 0.01). However, these changes were significantly higher in the intervention group (p < 0.01) except for spasticity. Moreover, a significant improvement was seen in all outcomes measured one-month after the end of the treatment in the intervention group (p < 0.01). CONCLUSIONS Dry needling plus neurorehabilitation could decrease muscle thickness, spasticity and reflex torque and improve upper-extremity motor performance and dexterity in chronic stroke patients. These changes were lasted one-month after treatment.Trial Registration Number: IRCT20200904048609N1IMPLICATION FOR REHABILITATIONUpper extremity spasticity is one of the stroke consequences which interfere with motor function and dexterity of patient hand in activity of daily livingApplying the dry needling accompanied with neurorehabilitation program in post-stroke patients with muscle spasticity can reduce the muscle thickness, spasticity and reflex torque and improve upper extremity functions.
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Affiliation(s)
- Fatemeh Panahi
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Samaneh Ebrahimi
- Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
- Rehabilitation Sciences Research Centre, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Rojhani-Shirazi
- Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
- Rehabilitation Sciences Research Centre, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Ladan Hemmati
- Department of Physical Therapy, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
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Hahn A, Moeller S, Schlausch A, Ekmann M, de Chelle G, Westerlund M, Braatz F, Mayr W. Effects of a full-body electrostimulation garment application in a cohort of subjects with cerebral palsy, multiple sclerosis, and stroke on upper motor neuron syndrome symptoms. BIOMED ENG-BIOMED TE 2024; 69:49-59. [PMID: 38354212 DOI: 10.1515/bmt-2023-0271] [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: 03/23/2023] [Accepted: 07/31/2023] [Indexed: 02/16/2024]
Abstract
OBJECTIVES Dysfunction of the central nervous system may inflict spastic movement disorder (SMD). Electrical stimuli were identified as promising therapeutic option. Electrical stimulation provided by a 58-electrode full body garment was investigated based on data from regular trial fittings. METHODS Data from 72 testees were investigated. Age averages 36.6 (19.8) ys with 44 females. The cohort spans infantile cerebral paresis (CP) (n=29), multiple sclerosis (MS) (n=23) and stroke (n=20). Data were stratified by etiology and an entry BBS Score<45. RESULTS Effect sizes (Cohen`s d) related BBS, TUG, FGA, 10mWT, WMFT, EQ5D5L and Pain. Significance levels are indicated by *: p<0.05, **: p<0.01, ***: p<0.001, (t): p<0.1: CP: 1.64***, 0.29*, 1.59***, 0.76(t), 1.00***, 0.5*, 1.28***; MS: 1.83***, 0.83***, 1.28**, 1.07***, 0.93*, 1,11**, 0.78*; Stroke: 1.28**, 0.78**, 0.89, 0.92**, 0.71, 1.26*, 0.78*. CONCLUSIONS Multi-site transcutaneous electrical stimulation may increase ambulation related skills in subjects with SMD stemming from CP, MS and stroke. The results indicate effects on static and dynamic balance, fall risk, mobility, upper extremity improvement and an overall increase in health utility and a reduction in spasticity related pain. Effects are immediate as well as sustained. These results may inspire individual trial fittings and inform further controlled trials.
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Affiliation(s)
- Andreas Hahn
- Ottobock Healthcare Products GmbH, Vienna, Austria
| | - Susan Moeller
- Academy, Otto Bock HealthCare Deutschland GmbH, Duderstadt, Germany
| | - Arne Schlausch
- Clinical Research & Services Otto Bock HealthCare Deutschland GmbH, Duderstadt, Germany
| | - Matilda Ekmann
- Clinical Research, Exoneural Network AB, Danderyd, Sweden
| | | | | | - Frank Braatz
- Private Hochschule Göttingen, Göttingen, Germany
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Mahmoud W, Hultborn H, Zuluaga J, Zrenner C, Zrenner B, Ziemann U, Ramos-Murguialday A. Testing spasticity mechanisms in chronic stroke before and after intervention with contralesional motor cortex 1 Hz rTMS and physiotherapy. J Neuroeng Rehabil 2023; 20:150. [PMID: 37941036 PMCID: PMC10631065 DOI: 10.1186/s12984-023-01275-9] [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: 06/18/2023] [Accepted: 11/01/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Previous studies showed that repetitive transcranial magnetic stimulation (rTMS) reduces spasticity after stroke. However, clinical assessments like the modified Ashworth scale, cannot discriminate stretch reflex-mediated stiffness (spasticity) from passive stiffness components of resistance to muscle stretch. The mechanisms through which rTMS might influence spasticity are also not understood. METHODS We measured the effects of contralesional motor cortex 1 Hz rTMS (1200 pulses + 50 min physiotherapy: 3×/week, for 4-6 weeks) on spasticity of the wrist flexor muscles in 54 chronic stroke patients using a hand-held dynamometer for objective quantification of the stretch reflex response. In addition, we measured the excitability of three spinal mechanisms thought to be related to post-stroke spasticity: post-activation depression, presynaptic inhibition and reciprocal inhibition before and after the intervention. Effects on motor impairment and function were also assessed using standardized stroke-specific clinical scales. RESULTS The stretch reflex-mediated torque in the wrist flexors was significantly reduced after the intervention, while no change was detected in the passive stiffness. Additionally, there was a significant improvement in the clinical tests of motor impairment and function. There were no significant changes in the excitability of any of the measured spinal mechanisms. CONCLUSIONS We demonstrated that contralesional motor cortex 1 Hz rTMS and physiotherapy can reduce the stretch reflex-mediated component of resistance to muscle stretch without affecting passive stiffness in chronic stroke. The specific physiological mechanisms driving this spasticity reduction remain unresolved, as no changes were observed in the excitability of the investigated spinal mechanisms.
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Affiliation(s)
- Wala Mahmoud
- Institute for Clinical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Eberhard Karls University Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
| | - Hans Hultborn
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark
| | - Jagoba Zuluaga
- Institute for Clinical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
| | - Christoph Zrenner
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Eberhard Karls University Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
| | - Brigitte Zrenner
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Eberhard Karls University Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany.
- Hertie Institute for Clinical Brain Research, University of Tübingen, Eberhard Karls University Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany.
| | - Ander Ramos-Murguialday
- Institute for Clinical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Tecnalia, Basque Research and Technology Alliance, San Sebastián, Spain
- Athenea Neuroclinics, San Sebastián, Spain
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Piscitelli D, Pellicciari L, Vidmar T, Kregar NG, Puh U. Is It Time to Go Beyond the Modified Ashworth Scale? Letter to the Editor on "Reliability of the Modified Ashworth Scale After Stroke for 13 Muscle Groups". Arch Phys Med Rehabil 2023; 104:1735-1736. [PMID: 37479163 DOI: 10.1016/j.apmr.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 06/03/2023] [Indexed: 07/23/2023]
Affiliation(s)
| | | | - Tjaša Vidmar
- Department of Rehabilitation of Patients After Stroke, University Rehabilitation Institute, Republic of Slovenia, Ljubljana, Slovenia.
| | - Nika Goljar Kregar
- Department of Rehabilitation of Patients After Stroke, University Rehabilitation Institute, Republic of Slovenia, Ljubljana, Slovenia
| | - Urška Puh
- Research and Development Unit, University Rehabilitation Institute, Republic of Slovenia, Ljubljana, Slovenia
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Asci F, Falletti M, Zampogna A, Patera M, Hallett M, Rothwell J, Suppa A. Rigidity in Parkinson's disease: evidence from biomechanical and neurophysiological measures. Brain 2023; 146:3705-3718. [PMID: 37018058 PMCID: PMC10681667 DOI: 10.1093/brain/awad114] [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: 10/14/2022] [Revised: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 04/06/2023] Open
Abstract
Although rigidity is a cardinal motor sign in patients with Parkinson's disease (PD), the instrumental measurement of this clinical phenomenon is largely lacking, and its pathophysiological underpinning remains still unclear. Further advances in the field would require innovative methodological approaches able to measure parkinsonian rigidity objectively, discriminate the different biomechanical sources of muscle tone (neural or visco-elastic components), and finally clarify the contribution to 'objective rigidity' exerted by neurophysiological responses, which have previously been associated with this clinical sign (i.e. the long-latency stretch-induced reflex). Twenty patients with PD (67.3 ± 6.9 years) and 25 age- and sex-matched controls (66.9 ± 7.4 years) were recruited. Rigidity was measured clinically and through a robotic device. Participants underwent robot-assisted wrist extensions at seven different angular velocities randomly applied, when ON therapy. For each value of angular velocity, several biomechanical (i.e. elastic, viscous and neural components) and neurophysiological measures (i.e. short and long-latency reflex and shortening reaction) were synchronously assessed and correlated with the clinical score of rigidity (i.e. Unified Parkinson's Disease Rating Scale-part III, subitems for the upper limb). The biomechanical investigation allowed us to measure 'objective rigidity' in PD and estimate the neuronal source of this phenomenon. In patients, 'objective rigidity' progressively increased along with the rise of angular velocities during robot-assisted wrist extensions. The neurophysiological examination disclosed increased long-latency reflexes, but not short-latency reflexes nor shortening reaction, in PD compared with control subjects. Long-latency reflexes progressively increased according to angular velocities only in patients with PD. Lastly, specific biomechanical and neurophysiological abnormalities correlated with the clinical score of rigidity. 'Objective rigidity' in PD correlates with velocity-dependent abnormal neuronal activity. The observations overall (i.e. the velocity-dependent feature of biomechanical and neurophysiological measures of objective rigidity) would point to a putative subcortical network responsible for 'objective rigidity' in PD, which requires further investigation.
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Affiliation(s)
- Francesco Asci
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
- IRCCS Neuromed Institute, 86077 Pozzilli (IS), Italy
| | - Marco Falletti
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Alessandro Zampogna
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Martina Patera
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20814, USA
| | - John Rothwell
- UCL Queen Square Institute of Neurology, London WC1N 3BG, UK
| | - Antonio Suppa
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
- IRCCS Neuromed Institute, 86077 Pozzilli (IS), Italy
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Selves C, Lejeune T, Detrembleur C, Haustrate MA, Stoquart G. Validity and reliability of the assessment of hand flexors stiffness using a new electromechanical oscillatory device in people with stroke. Int J Rehabil Res 2023; 46:170-177. [PMID: 36916037 DOI: 10.1097/mrr.0000000000000574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Hyper-resistance after a central nervous system injury has been largely referred to as spasticity, which is but one of its neural components. Assessment largely relies on clinical scales (Modified Ashworth scale - MAS and Modified Tardieu scale, MTS) which are unable to distinguish between the non-neural (tissue-related) and the neural (central nervous system-related) components. This study assessed criterion validity and reliability (reproducibility) of muscle stiffness measures, namely, maximum elastic stiffness (ELmax), viscous stiffness (VI), and path length (L-path) in the hand flexor muscles among people with stroke. Measurements were obtained with a wrist-electromechanical oscillatory device (w-EOD). Twenty-four people with arm impairment after stroke were evaluated with the w-EOD and clinical assessment (MAS and MTS), twice on the same day (short-term reliability) and once 10 days later (long-term reliability). For criterion validity, a Spearman coefficient ( r ) was calculated between stiffness values and the clinical scales. For reliability, intraclass correlation coefficients (ICCs), SEM, and MDC95 were calculated. Moderate correlations were observed between EL max and MAS ( r = 0.49) and MTS (V2, r = 0.43; V3, r = 0.49) of the wrist flexors, and finger flexors (MAS, r = 0.60; MTS V2, r = 0.56; MTS V3, r = 0.55). There was a poor correlation between the clinical scales and VI and L-path. Reliability was excellent for all stiffness measurements at short term (EL max : 0.95, VI: 0.94, L-path: 0.92) and good at long term (EL max : 0.87, VI: 0.76, L-path: 0.82). In conclusion, stiffness measurements are valid and reliable to evaluate hyper-resistance in people with stroke.
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Affiliation(s)
- Clara Selves
- Department of Physical Medicine and Rehabilitation, Cliniques universitaires Saint-Luc, Avenue Hippocrate
- Institut de Recherche Expérimentale et Clinique (IREC), Neuro Musculo Skeletal Lab (NMSK), Université catholique de Louvain, Avenue Mounier, Brussels
| | - Thierry Lejeune
- Department of Physical Medicine and Rehabilitation, Cliniques universitaires Saint-Luc, Avenue Hippocrate
- Institut de Recherche Expérimentale et Clinique (IREC), Neuro Musculo Skeletal Lab (NMSK), Université catholique de Louvain, Avenue Mounier, Brussels
| | - Christine Detrembleur
- Institut de Recherche Expérimentale et Clinique (IREC), Neuro Musculo Skeletal Lab (NMSK), Université catholique de Louvain, Avenue Mounier, Brussels
| | - Marie-Adeline Haustrate
- Department of Physical Medicine and Rehabilitation, Cliniques Saint Pierre, Avenue Reine Fabiola, Ottignies, Belgium
| | - Gaëtant Stoquart
- Department of Physical Medicine and Rehabilitation, Cliniques universitaires Saint-Luc, Avenue Hippocrate
- Institut de Recherche Expérimentale et Clinique (IREC), Neuro Musculo Skeletal Lab (NMSK), Université catholique de Louvain, Avenue Mounier, Brussels
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Mahmoud W, Haugland M, Ramos-Murguialday A, Hultborn H, Ziemann U. Measuring resistance to externally induced movement of the wrist joint in chronic stroke patients using an objective hand-held dynamometer. Clin Neurophysiol Pract 2023; 8:97-110. [PMID: 37273789 PMCID: PMC10238875 DOI: 10.1016/j.cnp.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 04/20/2023] [Accepted: 05/07/2023] [Indexed: 06/06/2023] Open
Abstract
Objective We evaluated the resistance to externally induced wrist extension in chronic stroke patients. We aimed to objectively measure and distinguish passive (muscle and soft tissue stiffness) and active (spasticity and spastic dystonia) components of the resistance. Methods We used a hand-held dynamometer, which measures torque, joint movement and electromyography (EMG) simultaneously, to assess the resistance to externally induced wrist extension. Slow and fast stretches were applied to the affected and unaffected wrists in 57 chronic stroke patients (57 ± 11 years). We extracted from the data parameters that represent passive and muscle activity components and assessed the validity, test-retest reliability and the clinical utility of the measurement. Results The analysis showed (1) a significant difference in the passive and muscle activity components between the affected and unaffected sides; (2) a significant correlation between passive and muscle activity components and the modified Ashworth scale (MAS); (3) a significant difference between the subgroups of patients stratified by the MAS; (4) an excellent intra-rater reliability on each of the passive and muscle activity components with intra-class coefficients between 0.92 and 0.99; (5) and small measurement error. Conclusions Using a hand-held dynamometer, we were able to objectively measure the resistance to muscle stretch in the wrist joint in chronic stroke patients and discriminate muscle overactivity components from muscle and soft tissue stiffness. We demonstrated validity, test-retest reliability and the clinical utility of the measurement. Significance Quantification of the different components of resistance to externally induced movement enables the objective evaluation of neurorehabilitation effects in chronic stroke patients.
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Affiliation(s)
- Wala' Mahmoud
- Institute for Clinical Psychology and Behavioral Neurobiology, University of Tübingen, Germany
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | | | - Ander Ramos-Murguialday
- Institute for Clinical Psychology and Behavioral Neurobiology, University of Tübingen, Germany
- Tecnalia, Basque Research and Technology Alliance, San Sebastián, Spain
- Athenea Neuroclinics, San Sebastián, Spain
| | - Hans Hultborn
- Department of Neuroscience, University of Copenhagen, Denmark
| | - Ulf Ziemann
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
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Gong Z, Lo WLA, Wang R, Li L. Electrical impedance myography combined with quantitative assessment techniques in paretic muscle of stroke survivors: Insights and challenges. Front Aging Neurosci 2023; 15:1130230. [PMID: 37020859 PMCID: PMC10069712 DOI: 10.3389/fnagi.2023.1130230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 02/27/2023] [Indexed: 03/18/2023] Open
Abstract
Aging is a non-modifiable risk factor for stroke and the global burden of stroke is continuing to increase due to the aging society. Muscle dysfunction, common sequela of stroke, has long been of research interests. Therefore, how to accurately assess muscle function is particularly important. Electrical impedance myography (EIM) has proven to be feasible to assess muscle impairment in patients with stroke in terms of micro structures, such as muscle membrane integrity, extracellular and intracellular fluids. However, EIM alone is not sufficient to assess muscle function comprehensively given the complex contributors to paretic muscle after an insult. This article discusses the potential to combine EIM and other common quantitative methods as ways to improve the assessment of muscle function in stroke survivors. Clinically, these combined assessments provide not only a distinct advantage for greater accuracy of muscle assessment through cross-validation, but also the physiological explanation on muscle dysfunction at the micro level. Different combinations of assessments are discussed with insights for different purposes. The assessments of morphological, mechanical and contractile properties combined with EIM are focused since changes in muscle structures, tone and strength directly reflect the muscle function of stroke survivors. With advances in computational technology, finite element model and machine learning model that incorporate multi-modal evaluation parameters to enable the establishment of predictive or diagnostic model will be the next step forward to assess muscle function for individual with stroke.
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Affiliation(s)
- Ze Gong
- Research & Development Institute of Northwestern Polytechnical University in Shenzhen, Shenzhen, China
- Institute of Medical Research, Northwestern Polytechnical University, Xi’an, China
| | - Wai Leung Ambrose Lo
- Department of Rehabilitation Medicine, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ruoli Wang
- KTH MoveAbility Lab, Department of Engineering Mechanics, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Le Li
- Research & Development Institute of Northwestern Polytechnical University in Shenzhen, Shenzhen, China
- Institute of Medical Research, Northwestern Polytechnical University, Xi’an, China
- *Correspondence: Le Li,
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van’t Veld RC, Flux E, van Oorschot W, Schouten AC, van der Krogt MM, van der Kooij H, Vos-van der Hulst M, Keijsers NLW, van Asseldonk EHF. Examining the role of intrinsic and reflexive contributions to ankle joint hyper-resistance treated with botulinum toxin-A. J Neuroeng Rehabil 2023; 20:19. [PMID: 36750869 PMCID: PMC9906865 DOI: 10.1186/s12984-023-01141-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 01/18/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Spasticity, i.e. stretch hyperreflexia, increases joint resistance similar to symptoms like hypertonia and contractures. Botulinum neurotoxin-A (BoNT-A) injections are a widely used intervention to reduce spasticity. BoNT-A effects on spasticity are poorly understood, because clinical measures, e.g. modified Ashworth scale (MAS), cannot differentiate between the symptoms affecting joint resistance. This paper distinguishes the contributions of the reflexive and intrinsic pathways to ankle joint hyper-resistance for participants treated with BoNT-A injections. We hypothesized that the overall joint resistance and reflexive contribution decrease 6 weeks after injection, while returning close to baseline after 12 weeks. METHODS Nine participants with spasticity after spinal cord injury or after stroke were evaluated across three sessions: 0, 6 and 12 weeks after BoNT-A injection in the calf muscles. Evaluation included clinical measures (MAS, Tardieu Scale) and motorized instrumented assessment using the instrumented spasticity test (SPAT) and parallel-cascade (PC) system identification. Assessments included measures for: (1) overall resistance from MAS and fast velocity SPAT; (2) reflexive resistance contribution from Tardieu Scale, difference between fast and slow velocity SPAT and PC reflexive gain; and (3) intrinsic resistance contribution from slow velocity SPAT and PC intrinsic stiffness/damping. RESULTS Individually, the hypothesized BoNT-A effect, the combination of a reduced resistance (week 6) and return towards baseline (week 12), was observed in the MAS (5 participants), fast velocity SPAT (2 participants), Tardieu Scale (2 participants), SPAT (1 participant) and reflexive gain (4 participants). On group-level, the hypothesis was only confirmed for the MAS, which showed a significant resistance reduction at week 6. All instrumented measures were strongly correlated when quantifying the same resistance contribution. CONCLUSION At group-level, the expected joint resistance reduction due to BoNT-A injections was only observed in the MAS (overall resistance). This observed reduction could not be attributed to an unambiguous group-level reduction of the reflexive resistance contribution, as no instrumented measure confirmed the hypothesis. Validity of the instrumented measures was supported through a strong association between different assessment methods. Therefore, further quantification of the individual contributions to joint resistance changes using instrumented measures across a large sample size are essential to understand the heterogeneous response to BoNT-A injections.
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Affiliation(s)
- Ronald C. van’t Veld
- grid.6214.10000 0004 0399 8953Department of Biomechanical Engineering, University of Twente, Enschede, The Netherlands
| | - Eline Flux
- grid.12380.380000 0004 1754 9227Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Wieneke van Oorschot
- grid.452818.20000 0004 0444 9307Department of Research, Sint Maartenskliniek, Nijmegen, The Netherlands ,grid.452818.20000 0004 0444 9307Department of Rehabilitation, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Alfred C. Schouten
- grid.6214.10000 0004 0399 8953Department of Biomechanical Engineering, University of Twente, Enschede, The Netherlands ,grid.5292.c0000 0001 2097 4740Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Marjolein M. van der Krogt
- grid.12380.380000 0004 1754 9227Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Herman van der Kooij
- grid.6214.10000 0004 0399 8953Department of Biomechanical Engineering, University of Twente, Enschede, The Netherlands ,grid.5292.c0000 0001 2097 4740Department of Biomechanical Engineering, Delft University of Technology, Delft, The Netherlands
| | - Marije Vos-van der Hulst
- grid.452818.20000 0004 0444 9307Department of Rehabilitation, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Noël L. W. Keijsers
- grid.452818.20000 0004 0444 9307Department of Research, Sint Maartenskliniek, Nijmegen, The Netherlands ,grid.10417.330000 0004 0444 9382Department of Rehabilitation, Cognition and Behavior, Donders Institute for Brain, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Edwin H. F. van Asseldonk
- grid.6214.10000 0004 0399 8953Department of Biomechanical Engineering, University of Twente, Enschede, The Netherlands
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Muscle Tonus Evaluation in Patients with Neurological Disorders: A Scoping Review. J Med Biol Eng 2023. [DOI: 10.1007/s40846-023-00773-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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12
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Guo X, Wallace R, Tan Y, Oetomo D, Klaic M, Crocher V. Technology-assisted assessment of spasticity: a systematic review. J Neuroeng Rehabil 2022; 19:138. [PMID: 36494721 PMCID: PMC9733065 DOI: 10.1186/s12984-022-01115-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Spasticity is defined as "a motor disorder characterised by a velocity dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks". It is a highly prevalent condition following stroke and other neurological conditions. Clinical assessment of spasticity relies predominantly on manual, non-instrumented, clinical scales. Technology based solutions have been developed in the last decades to offer more specific, sensitive and accurate alternatives but no consensus exists on these different approaches. METHOD A systematic review of literature of technology-based methods aiming at the assessment of spasticity was performed. The approaches taken in the studies were classified based on the method used as well as their outcome measures. The psychometric properties and usability of the methods and outcome measures reported were evaluated. RESULTS 124 studies were included in the analysis. 78 different outcome measures were identified, among which seven were used in more than 10 different studies each. The different methods rely on a wide range of different equipment (from robotic systems to simple goniometers) affecting their cost and usability. Studies equivalently applied to the lower and upper limbs (48% and 52%, respectively). A majority of studies applied to a stroke population (N = 79). More than half the papers did not report thoroughly the psychometric properties of the measures. Analysis identified that only 54 studies used measures specific to spasticity. Repeatability and discriminant validity were found to be of good quality in respectively 25 and 42 studies but were most often not evaluated (N = 95 and N = 78). Clinical validity was commonly assessed only against clinical scales (N = 33). Sensitivity of the measure was assessed in only three studies. CONCLUSION The development of a large diversity of assessment approaches appears to be done at the expense of their careful evaluation. Still, among the well validated approaches, the ones based on manual stretching and measuring a muscle activity reaction and the ones leveraging controlled stretches while isolating the stretch-reflex torque component appear as the two promising practical alternatives to clinical scales. These methods should be further evaluated, including on their sensitivity, to fully inform on their potential.
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Affiliation(s)
- Xinliang Guo
- grid.1008.90000 0001 2179 088XUoM and Fourier Intelligence Joint Robotics Laboratory, Mechanical Engineering Department, The University of Melbourne, Melbourne, Australia
| | - Rebecca Wallace
- grid.416153.40000 0004 0624 1200Allied Health Department, The Royal Melbourne Hospital, Melbourne, Australia
| | - Ying Tan
- grid.1008.90000 0001 2179 088XUoM and Fourier Intelligence Joint Robotics Laboratory, Mechanical Engineering Department, The University of Melbourne, Melbourne, Australia
| | - Denny Oetomo
- grid.1008.90000 0001 2179 088XUoM and Fourier Intelligence Joint Robotics Laboratory, Mechanical Engineering Department, The University of Melbourne, Melbourne, Australia
| | - Marlena Klaic
- grid.1008.90000 0001 2179 088XSchool of Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Vincent Crocher
- grid.1008.90000 0001 2179 088XUoM and Fourier Intelligence Joint Robotics Laboratory, Mechanical Engineering Department, The University of Melbourne, Melbourne, Australia
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13
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Quantitative measurement of resistance force and subsequent attenuation during passive isokinetic extension of the wrist in patients with mild to moderate spasticity after stroke. J Neuroeng Rehabil 2022; 19:110. [PMID: 36224659 PMCID: PMC9559851 DOI: 10.1186/s12984-022-01087-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Accepted: 09/27/2022] [Indexed: 11/13/2022] Open
Abstract
Background Spasticity is evaluated by measuring the increased resistance to passive movement, primarily by manual methods. Few options are available to measure spasticity in the wrist more objectively. Furthermore, no studies have investigated the force attenuation following increased resistance. The aim of this study was to conduct a safe quantitative evaluation of wrist passive extension stiffness in stroke survivors with mild to moderate spastic paresis using a custom motor-controlled device. Furthermore, we wanted to clarify whether the changes in the measured values could quantitatively reflect the spastic state of the flexor muscles involved in the wrist stiffness of the patients. Materials and methods Resistance forces were measured in 17 patients during repetitive passive extension of the wrist at velocities of 30, 60, and 90 deg/s. The Modified Ashworth Scale (MAS) in the wrist and finger flexors was also assessed by two skilled therapists and their scores were averaged (i.e., average MAS) for analysis. Of the fluctuation of resistance, we focused on the damping just after the peak forces and used these for our analysis. A repeated measures analysis of variance was conducted to assess velocity-dependence. Correlations between MAS and damping parameters were analyzed using Spearman’s rank correlation. Results The damping force and normalized value calculated from damping part showed significant velocity-dependent increases. There were significant correlations (ρ = 0.53–0.56) between average MAS for wrist and the normalized value of the damping part at 90 deg/s. The correlations became stronger at 60 deg/s and 90 deg/s when the MAS for finger flexors was added to that for wrist flexors (ρ = 0.65–0.68). Conclusions This custom-made isokinetic device could quantitatively evaluate spastic changes in the wrist and finger flexors simultaneously by focusing on the damping part, which may reflect the decrease in resistance we perceive when manually assessing wrist spasticity using MAS. Trial registration UMIN Clinical Trial Registry, as UMIN000030672, on July 4, 2018
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Tanikawa H, Mukaino M, Itoh S, Kondoh H, Fujimura K, Teranishi T, Ohtsuka K, Hirano S, Kagaya H, Saitoh E, Otaka Y. Development of a simple mechanical measurement method to measure spasticity based on an analysis of a clinical maneuver and its concurrent validity with the modified Ashworth scale. Front Bioeng Biotechnol 2022; 10:911249. [PMID: 36046668 PMCID: PMC9420860 DOI: 10.3389/fbioe.2022.911249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 07/18/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Despite recent developments in the methodology for measuring spasticity, the discriminative capacity of clinically diagnosed spasticity has not been well established. This study aimed to develop a simple device for measuring velocity-dependent spasticity with improved discriminative capacity based on an analysis of clinical maneuver and to examine its reliability and validity. Methods: This study consisted of three experiments. First, to determine the appropriate motion of a mechanical device for the measurement of velocity-dependent spasticity, the movement pattern and the angular velocity used by clinicians to evaluate velocity-dependent spasticity were investigated. Analysis of the procedures performed by six physical therapists to evaluate spasticity were conducted using an electrogoniometer. Second, a device for measuring the resistance force against ankle dorsiflexion was developed based on the results of the first experiment. Additionally, preliminary testing of validity, as compared to that of the Modified Ashworth Scale (MAS), was conducted on 17 healthy participants and 10 patients who had stroke with spasticity. Third, the reliability of the measurement and the concurrent validity of mechanical measurement in the best ankle velocity setting were further tested in a larger sample comprising 24 healthy participants and 32 patients with stroke. Results: The average angular velocity used by physical therapists to assess spasticity was 268 ± 77°/s. A device that enabled the measurement of resistance force at velocities of 300°/s, 150°/s, 100°/s, and 5°/s was developed. In the measurement, an angular velocity of 300°/s was found to best distinguish patients with spasticity (MAS of 1+ and 2) from healthy individuals. A measurement of 300°/s in the larger sample differentiated the control group from the MAS 1, 1+, and 2 subgroups (p < 0.01), as well as the MAS 1 and 2 subgroups (p < 0.05). No fixed or proportional bias was observed in repeated measurements. Conclusion: A simple mechanical measurement methodology was developed based on the analysis of the clinical maneuver for measuring spasticity and was shown to be valid in differentiating the existence and extent of spasticity. This study suggest possible requirements to improve the quality of the mechanical measurement of spasticity.
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Affiliation(s)
- Hiroki Tanikawa
- Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, Toyoake, Japan
| | - Masahiko Mukaino
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
- *Correspondence: Masahiko Mukaino,
| | - Shota Itoh
- Department of Rehabilitation, Fujita Health University Hospital, Toyoake, Japan
| | - Hikaru Kondoh
- Department of Rehabilitation, Fujita Health University Hospital, Toyoake, Japan
| | - Kenta Fujimura
- Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, Toyoake, Japan
| | - Toshio Teranishi
- Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, Toyoake, Japan
| | - Kei Ohtsuka
- Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, Toyoake, Japan
| | - Satoshi Hirano
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Hitoshi Kagaya
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Eiichi Saitoh
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Yohei Otaka
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
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15
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Leng Y, Lo WLA, Mao YR, Bian R, Zhao JL, Xu Z, Li L, Huang DF. The Impact of Cognitive Function on Virtual Reality Intervention for Upper Extremity Rehabilitation of Patients With Subacute Stroke: Prospective Randomized Controlled Trial With 6-Month Follow-up. JMIR Serious Games 2022; 10:e33755. [PMID: 35802415 PMCID: PMC9308068 DOI: 10.2196/33755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 03/28/2022] [Accepted: 04/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background Stroke is among the leading causes of long-term disability worldwide. Motor impairments after stroke not only impact the individuals quality of life but also lay substantial burdens on the society. Motor planning is a key component of cognitive function that impacts motor control. Hand movements such as grasping or reaching to grasp require the application of correct force and the coordination of multiple limb segments. Successful completion of hand motor task requires a certain degree of cognitive function to anticipate the requirement of the task. Cognitive function may thus be a confounding factor to rehabilitation outcomes. Objective This study aims to explore the impact of cognitive function on functional outcomes in people with subacute stroke after VR intervention. Methods Patients with stroke were first stratified into cognitively normal (CN) and cognitively impaired (CI), followed by allocation to the VR or control group (CG). Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Barthel Index (BI), and Instrumental Activities of Daily Living (IADL) were recorded at baseline, 3 weeks after the intervention, and 3 and 6 months after the intervention. The between-group and within-group differences were assessed by repeated-measures analysis of variance (ANOVA). Results The between-group comparison indicated that FMA-UE, BI, and IADL (time effect P<.001 for all) scores improved significantly in both groups after the intervention. Repeated-measures ANOVA indicated that FMA-UE, BI, and IADL (time effect P<.001 for all) were significantly different in each subgroup after the intervention. For BI score, the ANOVA results showed obvious interaction effects (treatment × time × cognitive effect, P=.04). Conclusions VR intervention was as effective as traditional conventional therapy in improving upper limb function regardless of the cognitive functional level. Patients with stroke with impaired cognitive function may gain more improvement in upper limb function and independency in performing activities of daily living after a VR-based intervention. Trial Registration Chinese Clinical Trial Registry ChiCTR-IOC-15006064; https://tinyurl.com/4c9vkrrn
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Affiliation(s)
- Yan Leng
- Department of Rehabilitation Medicine, First Affiliated Hospital Sun Yat-sen University, Guangzhou, China
| | - Wai Leung Ambrose Lo
- Department of Rehabilitation Medicine, First Affiliated Hospital Sun Yat-sen University, Guangzhou, China.,Guangdong Engineering and Technology Research Center for Rehabilitation Medicine and Translation, Sun Yat-sen University, Guangzhou, China
| | - Yu Rong Mao
- Guangdong Engineering and Technology Research Center for Rehabilitation Medicine and Translation, Sun Yat-sen University, Guangzhou, China.,Department of Rehabilitation Medicine, Seventh Affiliated Hospital Sun Yat-sen University, Shenzhen, China
| | - Ruihao Bian
- Department of Rehabilitation Medicine, First Affiliated Hospital Sun Yat-sen University, Guangzhou, China
| | - Jiang Li Zhao
- Department of Rehabilitation Medicine, First Affiliated Hospital Sun Yat-sen University, Guangzhou, China
| | - Zhiqin Xu
- Department of Rehabilitation Medicine, First Affiliated Hospital Sun Yat-sen University, Guangzhou, China
| | - Le Li
- Institute of Medical Research, Northwestern Polytechnical University, Xi'an, China
| | - Dong Feng Huang
- Guangdong Engineering and Technology Research Center for Rehabilitation Medicine and Translation, Sun Yat-sen University, Guangzhou, China.,Department of Rehabilitation Medicine, Seventh Affiliated Hospital Sun Yat-sen University, Shenzhen, China
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16
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Fujimura K, Mukaino M, Itoh S, Miwa H, Itoh R, Narukawa D, Tanikawa H, Kanada Y, Saitoh E, Otaka Y. Requirements for Eliciting a Spastic Response With Passive Joint Movements and the Influence of Velocity on Response Patterns: An Experimental Study of Velocity-Response Relationships in Mild Spasticity With Repeated-Measures Analysis. Front Neurol 2022; 13:854125. [PMID: 35432169 PMCID: PMC9007406 DOI: 10.3389/fneur.2022.854125] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/07/2022] [Indexed: 11/24/2022] Open
Abstract
Background Spasticity is defined as a velocity-dependent increase in tonic stretch reflexes and is manually assessed in clinical practice. However, the best method for the clinical assessment of spasticity has not been objectively described. This study analyzed the clinical procedure to assess spasticity of the elbow joint using an electrogoniometer and investigated the appropriate velocity required to elicit a spastic response and the influence of velocity on the kinematic response pattern. Methods This study included eight healthy individuals and 15 patients with spasticity who scored 1 or 1+ on the modified Ashworth Scale (MAS). Examiners were instructed to manually assess spasticity twice at two different velocities (slow and fast velocity conditions). During the assessment, velocity, deceleration value, and angle [described as the % range of motion (%ROM)] at the moment of resistance were measured using an electrogoniometer. Differences between the slow and fast conditions were evaluated. In addition, variations among the fast condition such as the responses against passive elbow extension at <200, 200–300, 300–400, 400°/s velocities were compared between the MAS 1+, MAS 1, and control groups. Results Significant differences were observed in the angular deceleration value and %ROM in the fast velocity condition (417 ± 80°/s) between patients and healthy individuals, but there was no difference in the slow velocity condition (103 ± 29°/s). In addition, the deceleration values were significantly different between the MAS 1 and MAS 1+ groups in velocity conditions faster than 300°/s. In contrast, the value of %ROM plateaued when the velocity was faster than 200°/s. Conclusion The velocity of the passive motion had a significant effect on the response pattern of the elbow joint. The velocity-response pattern differed between deceleration and the angle at which the catch occurred; the value of deceleration value for passive motion was highly dependent on the velocity, while the %ROM was relatively stable above a certain velocity threshold. These results provide clues for accurate assessment of spasticity in clinical practice.
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Affiliation(s)
- Kenta Fujimura
- Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, Toyoake, Japan
| | - Masahiko Mukaino
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
- *Correspondence: Masahiko Mukaino
| | - Shota Itoh
- Department of Rehabilitation, Fujita Health University Hospital, Toyoake, Japan
| | - Haruna Miwa
- Department of Rehabilitation, Fujita Health University Hospital, Toyoake, Japan
| | - Ryoka Itoh
- Department of Rehabilitation, Fujita Health University Hospital, Toyoake, Japan
| | - Daisuke Narukawa
- Department of Rehabilitation, Fujita Health University Hospital, Toyoake, Japan
| | - Hiroki Tanikawa
- Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, Toyoake, Japan
| | - Yoshikiyo Kanada
- Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, Toyoake, Japan
| | - Eiichi Saitoh
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Yohei Otaka
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Japan
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Andringa A, Meskers C, van de Port I, Zandvliet S, Scholte L, de Groot J, Kwakkel G, van Wegen E. Quantifying neural and non-neural components of wrist hyper-resistance after stroke: Comparing two instrumented assessment methods. Med Eng Phys 2021; 98:57-64. [PMID: 34848039 DOI: 10.1016/j.medengphy.2021.10.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/28/2021] [Accepted: 10/21/2021] [Indexed: 11/18/2022]
Abstract
Patients with poor upper limb motor recovery after stroke are likely to develop increased resistance to passive wrist extension, i.e., wrist hyper-resistance. Quantification of the underlying neural and non-neural elastic components is of clinical interest. This cross-sectional study compared two methods: a commercially available device (NeuroFlexor®) with an experimental EMG-based device (Wristalyzer) in 43 patients with chronic stroke. Spearman's rank correlation coefficients (r) between components, modified Ashworth scale (MAS) and range of passive wrist extension (PRoM) were calculated with 95% confidence intervals. Neural as well as elastic components assessed by both devices were associated (r = 0.61, 95%CI: 0.38-0.77 and r = 0.53, 95%CI: 0.28-0.72, respectively). The neural component assessed by the NeuroFlexor® associated significantly with the elastic components of NeuroFlexor® (r = 0.46, 95%CI: 0.18-0.67) and Wristalyzer (r = 0.36, 95%CI: 0.06-0.59). The neural component assessed by the Wristalyzer was not associated with the elastic components of both devices. Neural and elastic components of both devices associated similarly with the MAS (r = 0.58, 95%CI: 0.34-0.75 vs. 0.49, 95%CI: 0.22-0.69 and r = 0.51, 95%CI: 0.25-0.70 vs. 0.30, 95%CI: 0.00-0.55); elastic components associated with PRoM (r = -0.44, 95%CI: -0.65- -0.16 vs. -0.74, 95%CI: -0.85- -0.57 for NeuroFlexor® and Wristalyzer respectively). Results demonstrate that both methods perform similarly regarding the quantification of neural and elastic wrist hyper-resistance components and have an added value when compared to clinical assessment with the MAS alone. The added value of EMG in the discrimination between neural and non-neural components requires further investigation.
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Affiliation(s)
- Aukje Andringa
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Carel Meskers
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands; Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA; Department of Neurorehabilitation, Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, the Netherlands.
| | | | - Sarah Zandvliet
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Larissa Scholte
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands; Department of Biomechanical Engineering, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Delft, the Netherlands
| | - Jurriaan de Groot
- Department of Rehabilitation Medicine, Leiden University Medical Centre, Leiden, the Netherlands
| | - Gert Kwakkel
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands; Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA; Department of Neurorehabilitation, Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, the Netherlands
| | - Erwin van Wegen
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, the Netherlands
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Pennati GV, Bergling H, Carment L, Borg J, Lindberg PG, Palmcrantz S. Effects of 60 Min Electrostimulation With the EXOPULSE Mollii Suit on Objective Signs of Spasticity. Front Neurol 2021; 12:706610. [PMID: 34721255 PMCID: PMC8554021 DOI: 10.3389/fneur.2021.706610] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 09/06/2021] [Indexed: 11/20/2022] Open
Abstract
Background: The EXOPULSE Mollii method is an innovative full-body suit approach for non-invasive electrical stimulation, primarily designed to reduce disabling spasticity and improve motor function through the mechanism of reciprocal inhibition. This study aimed to evaluate the effectiveness of one session of stimulation with the EXOPULSE Mollii suit at different stimulation frequencies on objective signs of spasticity and clinical measures, and the subjective perceptions of the intervention. Methods: Twenty patients in the chronic phase after stroke were enrolled in a cross-over, double-blind controlled study. Electrical stimulation delivered through EXOPULSE Mollii was applied for 60 min at two active frequencies (20 and 30 Hz) and in OFF-settings (placebo) in a randomized order, every second day. Spasticity was assessed with controlled-velocity passive muscle stretches using the NeuroFlexor hand and foot modules. Surface electromyography (EMG) for characterizing flexor carpi radialis, medial gastrocnemius, and soleus muscles activation, Modified Ashworth Scale and range of motion were used as complementary tests. Finally, a questionnaire was used to assess the participants' perceptions of using the EXOPULSE Mollii suit. Results: At group level, analyses showed no significant effect of stimulation at any frequency on NeuroFlexor neural component (NC) and EMG amplitude in the upper or lower extremities (p > 0.35). Nevertheless, the effect was highly variable at the individual level, with eight patients exhibiting reduced NC (>1 N) in the upper extremity after stimulation at 30 Hz, 5 at 20 Hz and 3 in OFF settings. All these patients presented severe spasticity at baseline, i.e., NC > 8 N. Modified Ashworth ratings of spasticity and range of motion did not change significantly after stimulation at any frequency. Finally, 75% of participants reported an overall feeling of well-being during stimulation, with 25% patients describing a muscle-relaxing effect on the affected hand and/or foot at both 20 and 30 Hz. Conclusions: The 60 min of electrical stimulation with EXOPULSE Mollii suit did not reduce spasticity consistently in the upper and lower extremities in the chronic phase after stroke. Findings suggest a need for further studies in patients with severe spasticity after stroke including repeated stimulation sessions. Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT04076878, identifier: NCT04076878.
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Affiliation(s)
- Gaia Valentina Pennati
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Stockholm, Sweden
| | - Hanna Bergling
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Stockholm, Sweden
| | - Loïc Carment
- Institut de Psychiatrie et Neurosciences de Paris, Inserm U1266, Université de Paris, Paris, France
| | - Jörgen Borg
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Stockholm, Sweden
| | - Påvel G Lindberg
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Stockholm, Sweden.,Institut de Psychiatrie et Neurosciences de Paris, Inserm U1266, Université de Paris, Paris, France
| | - Susanne Palmcrantz
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Stockholm, Sweden
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20
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Mehraein M, Rojhani-Shirazi Z, Zeinali Ghotrom A, Salehi Dehno N. Effect of inhibitory kinesiotaping on spasticity in patients with chronic stroke: a randomized controlled pilot trial. Top Stroke Rehabil 2021; 29:568-578. [PMID: 34427177 DOI: 10.1080/10749357.2021.1967658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is no consensus regarding the positive effect of kinesiotaping (KT) on spasticity. All previous studies have measured spasticity by Modified Ashworth Scale (MAS) scale which is a subjective clinical assessment. OBJECTIVE To investigate the effect of inhibitory KT on the spasticity of plantar flexor muscles using both Hoffmann-reflex (H-reflex) and MAS scale. H-reflex is a neurophysiological technique that objectively evaluates spasticity by reflecting the excitability of motor neurons. METHODS Thirty patients were randomly assigned into inhibitory KT (n = 15) and control (n = 15) groups. The inhibitory KT group received KT from insertion to the origin of gastrocsoleus muscle . Spasticity was assessed at baseline and 30 min and 48 h after taping by H-reflex and MAS scale. The control group received no taping and spasticity was assessed at baseline and 30 min and 48 h after the baseline. RESULT There was a significant time × group effect for the maximal peak-to-peak amplitude of the Hmax/Mmax ratio (p = .007), indicating that Hmax/Mmax ratio decreased significantly after 48 h in the inhibitory KT in comparison with the baseline (P = .001) and 30 min after-intervention (p = .002); meanwhile, it did not change significantly in the control group (P > .05). However, none of the groups showed a statistically significant change in MAS score (P > .05). CONCLUSIONS Application of inhibitory KT was found to be able to reduce the Hmax/Mmax ratio in patients with stroke. As a result, inhibitory KT could have beneficial effects on spasticity.
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Affiliation(s)
- Mahdad Mehraein
- Physical Therapy Department, School Of Rehabilitation Sciences, Shiraz University Of Medical Sciences, Shiraz, Iran.,Physical Therapy Department, Student Research Committee, School Of Rehabilitation Sciences, Shiraz University Of Medical Sciences, Shiraz, Iran
| | - Zahra Rojhani-Shirazi
- Physical Therapy Department, School Of Rehabilitation Sciences, Shiraz University Of Medical Sciences, Shiraz, Iran.,Physical Therapy Department, Rehabilitation Sciences Research Center, Shiraz University Of Medical Sciences, Shiraz, Iran
| | - Ahmad Zeinali Ghotrom
- Department Of Physical Medicine And Rehabilitation, Shahid Sadoughi University Of Medical Sciences, Yazd, Iran
| | - Nasrin Salehi Dehno
- Physical Therapy Department, School Of Rehabilitation Sciences, Shiraz University Of Medical Sciences, Shiraz, Iran
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21
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Plantin J, Verneau M, Godbolt AK, Pennati GV, Laurencikas E, Johansson B, Krumlinde-Sundholm L, Baron JC, Borg J, Lindberg PG. Recovery and Prediction of Bimanual Hand Use After Stroke. Neurology 2021; 97:e706-e719. [PMID: 34400568 PMCID: PMC8377875 DOI: 10.1212/wnl.0000000000012366] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 05/20/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine similarities and differences in key predictors of recovery of bimanual hand use and unimanual motor impairment after stroke. METHOD In this prospective longitudinal study, 89 patients with first-ever stroke with arm paresis were assessed at 3 weeks and 3 and 6 months after stroke onset. Bimanual activity performance was assessed with the Adult Assisting Hand Assessment Stroke (Ad-AHA), and unimanual motor impairment was assessed with the Fugl-Meyer Assessment (FMA). Candidate predictors included shoulder abduction and finger extension measured by the corresponding FMA items (FMA-SAFE; range 0-4) and sensory and cognitive impairment. MRI was used to measure weighted corticospinal tract lesion load (wCST-LL) and resting-state interhemispheric functional connectivity (FC). RESULTS Initial Ad-AHA performance was poor but improved over time in all (mild-severe) impairment subgroups. Ad-AHA correlated with FMA at each time point (r > 0.88, p < 0.001), and recovery trajectories were similar. In patients with moderate to severe initial FMA, FMA-SAFE score was the strongest predictor of Ad-AHA outcome (R 2 = 0.81) and degree of recovery (R 2 = 0.64). Two-point discrimination explained additional variance in Ad-AHA outcome (R 2 = 0.05). Repeated analyses without FMA-SAFE score identified wCST-LL and cognitive impairment as additional predictors. A wCST-LL >5.5 cm3 strongly predicted low to minimal FMA/Ad-AHA recovery (≤10 and 20 points respectively, specificity = 0.91). FC explained some additional variance to FMA-SAFE score only in unimanual recovery. CONCLUSION Although recovery of bimanual activity depends on the extent of corticospinal tract injury and initial sensory and cognitive impairments, FMA-SAFE score captures most of the variance explained by these mechanisms. FMA-SAFE score, a straightforward clinical measure, strongly predicts bimanual recovery. CLINICALTRIALSGOV IDENTIFIER NCT02878304. CLASSIFICATION OF EVIDENCE This study provides Class I evidence that the FMA-SAFE score predicts bimanual recovery after stroke.
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Affiliation(s)
- Jeanette Plantin
- From the Department of Clinical Sciences (J.P., A.K.G., G.V.P., E.L., J.B., P.G.L.), Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden; Institut de Psychiatrie et Neurosciences de Paris (M.V., J.-C.B., P.G.L.), Inserm U1266, Paris, France; Division of Rehabilitation Medicine (B.J.), Danderyd University Stockholm; Department of Women's and Children's Health (L.K.S.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurology (J.-C.B.), Hôpital Sainte-Anne, Université de Paris, France.
| | - Marion Verneau
- From the Department of Clinical Sciences (J.P., A.K.G., G.V.P., E.L., J.B., P.G.L.), Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden; Institut de Psychiatrie et Neurosciences de Paris (M.V., J.-C.B., P.G.L.), Inserm U1266, Paris, France; Division of Rehabilitation Medicine (B.J.), Danderyd University Stockholm; Department of Women's and Children's Health (L.K.S.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurology (J.-C.B.), Hôpital Sainte-Anne, Université de Paris, France
| | - Alison K Godbolt
- From the Department of Clinical Sciences (J.P., A.K.G., G.V.P., E.L., J.B., P.G.L.), Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden; Institut de Psychiatrie et Neurosciences de Paris (M.V., J.-C.B., P.G.L.), Inserm U1266, Paris, France; Division of Rehabilitation Medicine (B.J.), Danderyd University Stockholm; Department of Women's and Children's Health (L.K.S.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurology (J.-C.B.), Hôpital Sainte-Anne, Université de Paris, France
| | - Gaia Valentina Pennati
- From the Department of Clinical Sciences (J.P., A.K.G., G.V.P., E.L., J.B., P.G.L.), Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden; Institut de Psychiatrie et Neurosciences de Paris (M.V., J.-C.B., P.G.L.), Inserm U1266, Paris, France; Division of Rehabilitation Medicine (B.J.), Danderyd University Stockholm; Department of Women's and Children's Health (L.K.S.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurology (J.-C.B.), Hôpital Sainte-Anne, Université de Paris, France
| | - Evaldas Laurencikas
- From the Department of Clinical Sciences (J.P., A.K.G., G.V.P., E.L., J.B., P.G.L.), Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden; Institut de Psychiatrie et Neurosciences de Paris (M.V., J.-C.B., P.G.L.), Inserm U1266, Paris, France; Division of Rehabilitation Medicine (B.J.), Danderyd University Stockholm; Department of Women's and Children's Health (L.K.S.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurology (J.-C.B.), Hôpital Sainte-Anne, Université de Paris, France
| | - Birgitta Johansson
- From the Department of Clinical Sciences (J.P., A.K.G., G.V.P., E.L., J.B., P.G.L.), Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden; Institut de Psychiatrie et Neurosciences de Paris (M.V., J.-C.B., P.G.L.), Inserm U1266, Paris, France; Division of Rehabilitation Medicine (B.J.), Danderyd University Stockholm; Department of Women's and Children's Health (L.K.S.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurology (J.-C.B.), Hôpital Sainte-Anne, Université de Paris, France
| | - Lena Krumlinde-Sundholm
- From the Department of Clinical Sciences (J.P., A.K.G., G.V.P., E.L., J.B., P.G.L.), Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden; Institut de Psychiatrie et Neurosciences de Paris (M.V., J.-C.B., P.G.L.), Inserm U1266, Paris, France; Division of Rehabilitation Medicine (B.J.), Danderyd University Stockholm; Department of Women's and Children's Health (L.K.S.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurology (J.-C.B.), Hôpital Sainte-Anne, Université de Paris, France
| | - Jean-Claude Baron
- From the Department of Clinical Sciences (J.P., A.K.G., G.V.P., E.L., J.B., P.G.L.), Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden; Institut de Psychiatrie et Neurosciences de Paris (M.V., J.-C.B., P.G.L.), Inserm U1266, Paris, France; Division of Rehabilitation Medicine (B.J.), Danderyd University Stockholm; Department of Women's and Children's Health (L.K.S.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurology (J.-C.B.), Hôpital Sainte-Anne, Université de Paris, France
| | - Jörgen Borg
- From the Department of Clinical Sciences (J.P., A.K.G., G.V.P., E.L., J.B., P.G.L.), Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden; Institut de Psychiatrie et Neurosciences de Paris (M.V., J.-C.B., P.G.L.), Inserm U1266, Paris, France; Division of Rehabilitation Medicine (B.J.), Danderyd University Stockholm; Department of Women's and Children's Health (L.K.S.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurology (J.-C.B.), Hôpital Sainte-Anne, Université de Paris, France
| | - Påvel G Lindberg
- From the Department of Clinical Sciences (J.P., A.K.G., G.V.P., E.L., J.B., P.G.L.), Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden; Institut de Psychiatrie et Neurosciences de Paris (M.V., J.-C.B., P.G.L.), Inserm U1266, Paris, France; Division of Rehabilitation Medicine (B.J.), Danderyd University Stockholm; Department of Women's and Children's Health (L.K.S.), Karolinska Institutet, Stockholm, Sweden; and Department of Neurology (J.-C.B.), Hôpital Sainte-Anne, Université de Paris, France
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22
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Fernandez-Lobera M, Morales M, Valls-Solé J. Repetitive peripheral magnetic stimulation for the assessment of wrist spasticity: reliability, validation and correlation with clinical measures. Disabil Rehabil 2021; 44:5257-5267. [PMID: 34027756 DOI: 10.1080/09638288.2021.1925979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE To determine feasibility and reliability of using repetitive peripheral magnetic stimulation (rPMS) to induce wrist extension movement for the assessment of spasticity in wrist flexors, instead of the passive stretch used in the modified Tardieu scale. METHODS Spasticity was assessed with the index of movement restriction (iMR), calculated as the difference between the range of maximum wrist passive movement and the rPMS-induced movement, in 12 healthy subjects (HS), 12 acute stroke patients without spasticity (AS) and 12 chronic stroke patients with spasticity (CS). Test-retest reliability and clinical correlation were assessed in CS patients before Botulinum neurotoxin type A (BoNT-A) treatment. RESULTS In comparison to HS and AS patients, CS patients showed statistically significant reduction of rPMS-induced movement amplitude, velocity, and acceleration. The mean iMR was 2.8 (SD = 2.6) in HS, 13.0 (SD = 11.2) in AS and 59.2 (SD = 23.4) in CS. This score significantly reduced to 41.1 (SD = 19.7) in CS after BoNT-A (p < 0.01). Test-retest reliability was very good, with an intraclass correlation coefficient ranging between 0.85 and 0.99 for the variables analysed. CONCLUSIONS We have shown good reliability and feasibility of a new method providing quantifiable data for the assessment of spasticity and its response to BoNT-A treatment.IMPLICATIONS FOR REHABILITATIONThe muscle contraction induced by repetitive peripheral magnetic stimulation (rPMS) in paretic muscles of post-stroke patients was used to assess spasticity.The index of movement restriction (iMR), calculated as the difference between the maximum passive range of movement and the rPMS induced movement, improved after botulinum toxin treatment.Measuring spastic reactions to rPMS provides quantifiable and reliable data for follow-up and assessment of therapeutic benefits.
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Affiliation(s)
- Marta Fernandez-Lobera
- Escoles Universitaries de Fisioterapia i infermeria Gimbernat, Universitat Autònoma de Barcelona, Sant Cugat del Vallès, Spain
| | | | - Josep Valls-Solé
- IDIBAPS (Institut d, Investigació August Pi i Sunyer), Barcelona, Spain
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23
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Moron H, Gagnard-Landra C, Guiraud D, Dupeyron A. Contribution of Single-Fiber Evaluation on Monitoring Outcomes Following Injection of Botulinum Toxin-A: A Narrative Review of the Literature. Toxins (Basel) 2021; 13:toxins13050356. [PMID: 34067540 PMCID: PMC8156529 DOI: 10.3390/toxins13050356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Hélène Moron
- Department of Functional Exploration of the Nervous System and Acupuncture, CHU Nîmes, Univ Montpellier, 30029 Nîmes, France;
- EuroMov DHM, IMT Ales, Univ Montpellier, 34090 Montpellier, France;
- CAMIN, INRIA, Univ Montpellier, 34090 Montpellier, France;
- Correspondence:
| | - Corine Gagnard-Landra
- Department of Functional Exploration of the Nervous System and Acupuncture, CHU Nîmes, Univ Montpellier, 30029 Nîmes, France;
| | - David Guiraud
- CAMIN, INRIA, Univ Montpellier, 34090 Montpellier, France;
| | - Arnaud Dupeyron
- EuroMov DHM, IMT Ales, Univ Montpellier, 34090 Montpellier, France;
- Department of Physical and Rehabilitation Medicine, CHU Nîmes, Univ Montpellier, 30029 Nîmes, France
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24
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Andringa A, van Wegen E, van de Port I, Guit L, Polomski W, Kwakkel G, Meskers C. The effect of botulinum toxin-A on neural and non-neural components of wrist hyper-resistance in adults with stroke or cerebral palsy. PM R 2021; 14:486-495. [PMID: 33811454 PMCID: PMC9290733 DOI: 10.1002/pmrj.12602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 03/01/2021] [Accepted: 03/16/2021] [Indexed: 12/05/2022]
Abstract
Background Botulinum toxin‐A (BoNT) is widely used to manage focal upper limb spasticity and is effective in reducing resistance to passive movement, as measured with the modified Ashworth scale. Discrimination and quantification of the underlying neural and non‐neural components of hyper‐resistance may further improve understanding of the effect of BoNT. Objective To explore the effects of BoNT on neural (NC), non‐neural elastic (EC), and viscous (VC) components of resistance to passive wrist extension in adults with stroke or cerebral palsy and the association between the effects on wrist hyper‐resistance components and clinical spasticity, pain and motor function scales. Design Pre‐experimental study with pre‐ and post‐intervention measurements at 6 and 12 weeks. Setting An outpatient clinic of a hospital. Participants Adults with chronic stroke or cerebral palsy indicated for BoNT treatment for hyper‐resistance in the wrist (N = 18). Interventions BoNT injections in the wrist and/or finger flexor muscles. Main Outcome Measures Wrist hyper‐resistance components, using the NeuroFlexor, and clinical scales (modified Ashworth scale, Tardieu scale, passive wrist extension, pain, Fugl‐Meyer motor assessment of the upper extremity, and action research arm test). Results NC was significantly reduced 6 and 12 weeks post‐intervention (median −11.96 Newton, P < .001 and median −9.34 Newton, P = .001, respectively); non‐neural EC and VC showed no change. NC reduction 6 weeks post‐intervention correlated significantly with BoNT dose (Pearson correlation coefficient rp = −0.56). No significant correlations were found between change scores in wrist hyper‐resistance components and clinical scales. Conclusions BoNT affected the neural component of resistance to passive wrist extension, while leaving the non‐neural elastic and viscous components unaffected. This instrumented approach to quantify the effects of BoNT in the wrist and finger flexor muscles on the components of wrist hyper‐resistance may have an added value for BoNT treatment evaluation in clinical practice.
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Affiliation(s)
- Aukje Andringa
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Erwin van Wegen
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Lisette Guit
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Gert Kwakkel
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois, USA.,Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, The Netherlands
| | - Carel Meskers
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois, USA
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25
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Chen Y, Yu S, Cai Q, Huang S, Ma K, Zheng H, Xie L. A spasticity assessment method for voluntary movement using data fusion and machine learning. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2020.102353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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26
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Leng Y, Lo WLA, Hu C, Bian R, Xu Z, Shan X, Huang D, Li L. The Effects of Extracorporeal Shock Wave Therapy on Spastic Muscle of the Wrist Joint in Stroke Survivors: Evidence From Neuromechanical Analysis. Front Neurosci 2021; 14:580762. [PMID: 33551718 PMCID: PMC7859269 DOI: 10.3389/fnins.2020.580762] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/21/2020] [Indexed: 12/13/2022] Open
Abstract
Background: This study combined neuromechanical modeling analysis, muscle tone measurement from mechanical indentation and electrical impedance myography to assess the neural and peripheral contribution to spasticity post stroke at wrist joint. It also investigated the training effects and explored the underlying mechanism of radial extracorporeal shock wave (rESW) on spasticity. Methods: People with first occurrence of stroke were randomly allocated to rESW intervention or control group. The intervention group received one session of rESW therapy, followed by routine therapy which was the same frequency and intensity as the control group. Outcome measures were: (1) NeuroFlexor method measured neural component (NC), elastic component (EC) and viscosity component (VC), and (2) myotonometer measured muscle tone (F) and stiffness (S), (3) electrical impedance myography measured resistance (R), reactance (X) and phase angle (θ); (4) modified Asworth scale; (5) Fugl Meyer Upper limb scale. All outcome measures were recorded at baseline, immediately post rESW and at 1-week follow-up. The differences between the paretic and non-paretic side were assessed by t-test. The effectiveness of rESW treatment were analyzed by repeated-measures one-way analysis of variance (ANOVA) at different time points. Results: Twenty-seven participants completed the study. NC, EC, and VC of the Neuroflexor method, F and S from myotonometer were all significantly higher on the paretic side than those from the non-paretic side. R, X, and θ from electrical impedance were significantly lower on the paretic side than the non-paretic side. Immediately after rESW intervention, VC, F, and S were significantly reduced, and X was significantly increased. The clinical scores showed improvements immediate post rESW and at 1-week follow-up. Conclusions: The observed changes in upper limb muscle properties adds further support to the theory that both the neural and peripheral components play a role in muscle spasticity. ESW intervention may be more effective in addressing the peripheral component of spasticity in terms of muscle mechanical properties changes. The clinical management of post stroke spasticity should take into consideration of both the neural and non-neural factors in order to identify optimal intervention regime.
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Affiliation(s)
- Yan Leng
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wai Leung Ambrose Lo
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chengpeng Hu
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ruihao Bian
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhiqin Xu
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiyao Shan
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dongfeng Huang
- Department of Rehabilitation Medicine, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Le Li
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Institute of Medical Research, Northwestern Polytechnical University, Xi'an, China
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27
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Zeng H, Chen J, Guo Y, Tan S. Prevalence and Risk Factors for Spasticity After Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2021; 11:616097. [PMID: 33551975 PMCID: PMC7855612 DOI: 10.3389/fneur.2020.616097] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 12/16/2020] [Indexed: 12/11/2022] Open
Abstract
Background: Spasticity is a common sequela of stroke. The incidence of poststroke spasticity (PSS) has not been systematically reviewed in recent years, and some risk factors remain debated. This systematic review and meta-analysis was conducted to determine the prevalence and risk factors for PSS. Methods: We searched electronic databases (PubMed, Embase, Cochrane Library, CNKI, WANFANG and CBM) inception to May 12, 2020. Observational studies summarizing the incidence or risk factors for PSS were included. Only cohort studies were enrolled in meta-analysis. For risk factors examined in at least three different studies, we combined effects into odds ratios (OR) and 95% confidence intervals (CI). Results: One thousand four hundred sixty-seven studies were retrieved and 23 were involved in meta-analysis. The pooled prevalence of spasticity after stroke was 25.3% and that after the first-ever stroke was 26.7%. The incidence of spasticity after the first-ever stroke with paresis was 39.5%. The prevalence of disabling or severe spasticity (MAS ≥ 3) in stroke patients with paresis was 9.4% (95% CI 0.056-0.133), and severe spasticity was 10.3% (95% CI 0.058-0.149). Moderate to severe paresis (OR = 6.573, 95% CI 2.579-16.755, I 2 = 0.0%), hemorrhagic stroke (OR = 1.879, 95% CI 1.418-2.490, I 2 = 27.3%) and sensory disorder were risk factors for PSS. Conclusions: The incidence of PSS was significantly higher in stroke patients with paresis. Patients with moderate to severe paresis and sensory disorder should be closely followed up. The role of hemorrhagic stroke in predicting PSS remains to be further explored.
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Affiliation(s)
- Huangling Zeng
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Jian Chen
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Yang Guo
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Sheng Tan
- Department of Neurology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
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28
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Panny M, Mayr A, Nagiller M, Kim Y. A domestic robotic rehabilitation device for assessment of wrist function for outpatients. J Rehabil Assist Technol Eng 2020; 7:2055668320961233. [PMID: 33329903 DOI: 10.1177/2055668320961233] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/27/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction Available robot-assisted stroke rehabilitation systems are often limited in their utilization in the home environment, due to several barriers such as high cost, absence of therapists, tedious training tasks, or encumbering interfaces. This paper presents a low-cost robotic rehabilitation and assessment device for restoring wrist function, offering wrist exercises incorporating pronation-supination and flexion-extension movements. Furthermore, the device is designed for the assessment of joint stiffness of the wrist, and range of motion in two degrees of freedom. Methods: Mechanical/electrical design of the device as well as the control system is described. A preliminary evaluation focused on the measurement of the torsional stiffness of the limb is presented. It is evaluated by reconstructing the known stiffness values of torsional springs by measuring the motor current required to displace them. Results The device demonstrates the ability to determine the stiffness of an object with low-cost hardware. Use case scenarios of the device for training and assessment of the wrist are presented, allowing for a range of motion of ± 75 ° and ± 65 ° , for pronation-supination and flexion-extension respectively. Conclusion The device shows potential to help objectively quantify the stiffness of the wrist movement, which consecutively could be used to represent and quantify the degree of impairment of patients after stroke in a more objective manner. Further clinical study is necessary to examine this.
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Affiliation(s)
- Matthias Panny
- Department of Mechatronics, MCI, University of Applied Sciences, Innsbruck, Austria
| | - Andreas Mayr
- Department of Neurology, Hospital Hochzirl-Natters, Zirl, Austria
| | - Marco Nagiller
- Department of Mechatronics, MCI, University of Applied Sciences, Innsbruck, Austria
| | - Yeongmi Kim
- Department of Mechatronics, MCI, University of Applied Sciences, Innsbruck, Austria
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29
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Xie T, Leng Y, Zhi Y, Jiang C, Tian N, Luo Z, Yu H, Song R. Increased Muscle Activity Accompanying With Decreased Complexity as Spasticity Appears: High-Density EMG-Based Case Studies on Stroke Patients. Front Bioeng Biotechnol 2020; 8:589321. [PMID: 33313042 PMCID: PMC7703112 DOI: 10.3389/fbioe.2020.589321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/28/2020] [Indexed: 12/20/2022] Open
Abstract
Spasticity is a major contributor to pain, disabilities and many secondary complications after stroke. Investigating the effect of spasticity on neuromuscular function in stroke patients may facilitate the development of its clinical treatment, while the underlying mechanism of spasticity still remains unclear. The aim of this study is to explore the difference in the neuromuscular response to passive stretch between healthy subjects and stroke patients with spasticity. Five healthy subjects and three stroke patients with spastic elbow flexor were recruited to complete the passive stretch at four angular velocities (10°/s, 60°/s, 120°/s, and 180°/s) performed by an isokinetic dynamometer. Meanwhile, the 64-channel electromyography (EMG) signals from biceps brachii muscle were recorded. The root mean square (RMS) and fuzzy entropy (FuzzyEn) of EMG recordings of each channel were calculated, and the relationship between the average value of RMS and FuzzyEn over 64-channel was examined. The two groups showed similar performance from results that RMS increased and FuzzyEn decreased with the increment of stretch velocity, and the RMS was negatively correlated with FuzzyEn. The difference is that stroke patients showed higher RMS and lower FuzzyEn during quick stretch than the healthy group. Furthermore, compared with the healthy group, distinct variations of spatial distribution within the spastic muscle were found in the EMG activity of stroke patients. These results suggested that a large number of motor units were recruited synchronously in the presence of spasticity, and this recruitment pattern was non-uniform in the whole muscle. Using a combination of RMS and FuzzyEn calculated from high-density EMG (HD-EMG) recordings can provide an innovative insight into the physiological mechanism underlying spasticity, and FuzzyEn could potentially be used as a new indicator for spasticity, which would be beneficial to clinical intervention and further research on spasticity.
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Affiliation(s)
- Tian Xie
- Key Laboratory of Sensing Technology and Biomedical Instrument of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, China
| | - Yan Leng
- Department of Rehabilitation Medicine, Guangdong Engineering Technology Research Center for Rehabilitation Medicine and Clinical Translation, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yihua Zhi
- Key Laboratory of Sensing Technology and Biomedical Instrument of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, China
| | - Chao Jiang
- Key Laboratory of Sensing Technology and Biomedical Instrument of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, China
| | - Na Tian
- Key Laboratory of Sensing Technology and Biomedical Instrument of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, China
| | - Zichong Luo
- Department of Electromechanical Engineering, Faculty of Science and Technology, University of Macau, Macau, China
| | - Hairong Yu
- Key Laboratory of Sensing Technology and Biomedical Instrument of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, China
| | - Rong Song
- Key Laboratory of Sensing Technology and Biomedical Instrument of Guangdong Province, School of Biomedical Engineering, Sun Yat-sen University, Guangzhou, China
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Cha Y, Arami A. Quantitative Modeling of Spasticity for Clinical Assessment, Treatment and Rehabilitation. SENSORS (BASEL, SWITZERLAND) 2020; 20:E5046. [PMID: 32899490 PMCID: PMC7571189 DOI: 10.3390/s20185046] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 11/23/2022]
Abstract
Spasticity, a common symptom in patients with upper motor neuron lesions, reduces the ability of a person to freely move their limbs by generating unwanted reflexes. Spasticity can interfere with rehabilitation programs and cause pain, muscle atrophy and musculoskeletal deformities. Despite its prevalence, it is not commonly understood. Widely used clinical scores are neither accurate nor reliable for spasticity assessment and follow up of treatments. Advancement of wearable sensors, signal processing and robotic platforms have enabled new developments and modeling approaches to better quantify spasticity. In this paper, we review quantitative modeling techniques that have been used for evaluating spasticity. These models generate objective measures to assess spasticity and use different approaches, such as purely mechanical modeling, musculoskeletal and neurological modeling, and threshold control-based modeling. We compare their advantages and limitations and discuss the recommendations for future studies. Finally, we discuss the focus on treatment and rehabilitation and the need for further investigation in those directions.
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Affiliation(s)
- Yesung Cha
- Neuromechanics and Assistive Robotics Laboratory, University of Waterloo, 200 University Ave W, Waterloo, ON N2L 3G1, Canada;
| | - Arash Arami
- Neuromechanics and Assistive Robotics Laboratory, University of Waterloo, 200 University Ave W, Waterloo, ON N2L 3G1, Canada;
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON M5G 2A2, Canada
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Salehi Dehno N, Kamali Sarvestani F, Shariat A, Jaberzadeh S. Test-retest reliability and responsiveness of isokinetic dynamometry to assess wrist flexor muscle spasticity in subacute post-stroke hemiparesis. J Bodyw Mov Ther 2020; 24:38-43. [PMID: 32826006 DOI: 10.1016/j.jbmt.2020.02.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 12/11/2019] [Accepted: 02/17/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION To overcome the limitations of clinical scales, objective measurement methods are becoming prominent in spasticity assessment. The aim of this study was to assess the test-retest reliability and responsiveness of isokinetic dynamometry to evaluate wrist flexor spasticity in patients with subacute stroke. METHODS Twenty six patients with hemiparetic stroke (13 men, 13 women, mean age 51.38 ± 12.64 years) volunteered to take part in this study. Resistive torque in the wrist flexor muscles was measured twice, 1 day apart, with an isokinetic dynamometer. Wrist extension was tested at four speeds (5, 60, 120 and 180°/s). Torque response at the lowest speed (5°/s) was attributed to the non-neural component of the wrist flexor muscles, and was subtracted from the torque response at the higher speeds to calculate reflex torque (spasticity). The reliability of reflex torque measurements at 60, 120 and 180°/s was evaluated with the intraclass correlation coefficient (ICC2,1) and standard error of measurement (SEM and SEM%), which reflect reproducibility and measurement error, respectively. Responsiveness was calculated as the smallest real difference (SRD and SRD%). RESULTS Reproducibility was excellent at different movement speeds (ICC2, 1 0.76-0.85). SEM% ranged from 11% to 21%, and SRD% ranged from 30% to 58%. ICC values increased, and SEM% and SRD% decreased, as test speed increased. CONCLUSION Our results support the reliability and responsiveness of isokinetic dynamometry to quantify spasticity in wrist flexor muscles in patients with subacute stroke. Reliability and responsiveness increased as the speed of wrist movement increased.
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Affiliation(s)
- Nasrin Salehi Dehno
- Physical Therapy Department, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran; Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fahimeh Kamali Sarvestani
- Physical Therapy Department, School of Rehabilitation Sciences, Shiraz University of Medical Sciences, Shiraz, Iran; Rehabilitation Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Abdolhamid Shariat
- Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shapour Jaberzadeh
- Department of Physiotherapy, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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Palmcrantz S, Pennati GV, Bergling H, Borg J. Feasibility and potential effects of using the electro-dress Mollii on spasticity and functioning in chronic stroke. J Neuroeng Rehabil 2020; 17:109. [PMID: 32778118 PMCID: PMC7419224 DOI: 10.1186/s12984-020-00740-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/29/2020] [Indexed: 12/21/2022] Open
Abstract
Background Spasticity after lesions of central motor pathways may be disabling and there is a need for new, cost-effective treatment methods. One novel approach is offered by the electro-dress Mollii®, primarily designed to enhance reciprocal inhibition of spastic muscles by multifocal, transcutaneous antagonist stimulation. Methods The Mollii® suit was set individually for 20 participants living with spasticity and hemiplegia after stroke and used in the home setting for 6 weeks. Usability and perceived effects were monitored by weekly telephone interviews. Outcome was assessed by use of the NeuroFlexor™ method for quantification of the neural component (NC) of resistance to passive stretch (spasticity), and the modified Ashworth scale (MAS) for total resistance, Fugl-Meyer Assessment of motor recovery for sensorimotor function in upper (FM-UE) and lower extremities (FM-LE), activity performance with the Action Research Arm Test (ARAT), Berg balance scale, 10 m and 6 min walk tests, and perceived functioning with the Stroke Impact Scale. Results Compliance was high (mean 19.25 of 21 sessions). Perceived positive effects were reported by 60% and most commonly related to decreased muscle tone (n = 9), improved gait pattern function (n = 7) and voluntary movement in the upper extremity (n = 6). On a group level, the NC decreased significantly in the wrist flexors of the affected hand (p = 0.023) and significant improvements according to FM-UE (p = 0.000) and FM-LE (p = 0.003) were seen after the intervention. No significant difference was detected with MAS or assessed activity performance, except for the ARAT (p = 0.000). FM-UE score change correlated significantly and fairly with the perceived effect in the upper extremity (r 0.498 p = 0.025) and in the corresponding analysis for the FM-LE and perceived effect in the lower extremity (r = 0.469 p = 0.037). Conclusion This study indicates that the Mollii® method is feasible when used in the home setting to decrease spasticity and improve sensorimotor function. The results may guide a larger controlled study combined with rehabilitation interventions to enhance effects on activity and participation domains. Trial registration NCT04076878. Registered 2 September 2019 - Retrospectively registered
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Affiliation(s)
- Susanne Palmcrantz
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Entrévagen 8, SE-182 88, Stockholm, Sweden.
| | - Gaia Valentina Pennati
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Entrévagen 8, SE-182 88, Stockholm, Sweden
| | - Hanna Bergling
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Entrévagen 8, SE-182 88, Stockholm, Sweden
| | - Jörgen Borg
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Entrévagen 8, SE-182 88, Stockholm, Sweden
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33
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Andringa A, Meskers C, van de Port I, van Wegen E, Kwakkel G. Time Course of Wrist Hyper-Resistance in Relation to Upper Limb Motor Recovery Early Post Stroke. Neurorehabil Neural Repair 2020; 34:690-701. [PMID: 32508291 PMCID: PMC7502985 DOI: 10.1177/1545968320932135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background. Patients with an upper limb motor impairment are likely to develop wrist hyper-resistance during the first months post stroke. The time course of wrist hyper-resistance in terms of neural and biomechanical components, and their interaction with motor recovery, is poorly understood. Objective. To investigate the time course of neural and biomechanical components of wrist hyper-resistance in relation to upper limb motor recovery in the first 6 months post stroke. Methods. Neural (NC), biomechanical elastic (EC), and viscous (VC) components of wrist hyper-resistance (NeuroFlexor device), and upper limb motor recovery (Fugl-Meyer upper extremity scale [FM-UE]), were assessed in 17 patients within 3 weeks and at 5, 12, and 26 weeks post stroke. Patients were stratified according to the presence of voluntary finger extension (VFE) at baseline. Time course of wrist hyper-resistance components and assumed interaction effects were analyzed using linear mixed models. Results. On average, patients without VFE at baseline (n = 8) showed a significant increase in NC, EC, and VC, and an increase in FM-UE from 13 to 26 points within the first 6 months post stroke. A significant increase in NC within 5 weeks preceded a significant increase in EC between weeks 12 and 26. Patients with VFE at baseline (n = 9) showed, on average, no significant increase in components from baseline to 6 months whereas FM-UE scores improved from 38 to 60 points. Conclusion. Our findings suggest that the development of neural and biomechanical wrist hyper-resistance components in patients with severe baseline motor deficits is determined by lack of spontaneous neurobiological recovery early post stroke.
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Affiliation(s)
- Aukje Andringa
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Carel Meskers
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA
| | | | - Erwin van Wegen
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Gert Kwakkel
- Department of Rehabilitation Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, USA.,Department of Neurorehabilitation, Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, The Netherlands
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Sung J, Choi S, Kim J, Kim J. A Simplified Estimation of Abnormal Reflex Torque due to Elbow Spasticity Using Neuro-musculoskeletal Model. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:5076-5079. [PMID: 31947000 DOI: 10.1109/embc.2019.8856613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This paper is to develop a simplified estimation method of internal torque for clinical use, such as spasticity assessment. Compared with many parameters to be tuned, the proposed estimation method only has a single tuning parameter by simplifying the neuro-musculoskeletal model. Moreover, based on forward dynamics, the proposed method uses EMG signals as the input, and uses muscle activation dynamics and musculotendon dynamics to calculate internal torque. A biomechanical method based on dynamometer was applied to determine the tuning parameter and to validate the estimation result of the proposed model. Through a pilot study with healthy subjects and stroke patients, we found that the proposed estimation method would be helpful for spasticity assessment.
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35
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Luo Z, Lo WLA, Bian R, Wong S, Li L. Advanced quantitative estimation methods for spasticity: a literature review. J Int Med Res 2019; 48:300060519888425. [PMID: 31801402 PMCID: PMC7607521 DOI: 10.1177/0300060519888425] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Post-stroke spasticity seriously affects patients’ quality of life. Spasticity is
considered to involve both neural and non-neural factors. Current clinical
scales, such as the Modified Ashworth Scale and the Modified Tardieu Scale, lack
reliability and reproducibility. These scales are also unable to identify the
neural and non-neural contributions to spasticity. Surface electromyography and
biomechanical and myotonometry measurement methods for post-stroke spasticity
are discussed in this report. Surface electromyography can provide neural
information, while myotonometry can estimate muscular properties. Both the
neural and non-neural contributions can be estimated by biomechanical
measurement. These laboratory methods can quantitatively assess spasticity. They
can provide more valuable information for further study on treatment and
rehabilitation than clinical scales.
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Affiliation(s)
- Zichong Luo
- Department of Electromechanical Engineering, Faculty of Science
and Technology, University of Macau, Macau, China
| | - Wai Leung Ambrose Lo
- Department of Rehabilitation Medicine, The First Affiliated
Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ruihao Bian
- Department of Rehabilitation Medicine, The First Affiliated
Hospital, Sun Yat-sen University, Guangzhou, China
| | - Sengfat Wong
- Department of Electromechanical Engineering, Faculty of Science
and Technology, University of Macau, Macau, China
| | - Le Li
- Department of Rehabilitation Medicine, The First Affiliated
Hospital, Sun Yat-sen University, Guangzhou, China
- Le Li, Department of Rehabilitation
Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou,
China.
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36
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Measuring muscle tone with isokinetic dynamometer technique in stroke patients. BIOMEDICAL HUMAN KINETICS 2019. [DOI: 10.2478/bhk-2019-0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Summary
Study aim: Increased muscle tone, a common consequence of stroke, has neural and non-neural components. Spasticity is related to the neural component. Non-neural resistance arises from passive stiffness. This study was designed to assess the feasibility of using isokinetic dynamometry to evaluate wrist flexor muscle spasticity in stroke patients.
Materials and methods: Twenty-six patients with hemiplegia in the subacute phase of stroke participated in this study. An isokinetic dynamometer was used to stretch wrist flexor muscles at four velocities of 5, 60, 120 and 180°/s on both the paretic and non-paretic sides. Peak torque at the lowest speed (5°/s) and reflex torque at the three higher speeds were quantified. Peak torque at the lowest speed was attributed to the non-neural component of muscle tone, and was subtracted from the torque response at higher velocities to estimate reflex torque (spasticity). Data from the two sides were compared.
Results: There was no significant difference in peak torque between the paretic (2.47 ± 0.22 N·m) and non-paretic side (2.41 ± 0.28 N·m) at the lowest velocity of 5°/s (p=0.408). However, compared to the non-paretic side, the paretic side showed higher reflex torque (p<0001), and reflex torque increased rapidly with increasing velocity (p < 0.05).
Conclusion: The isokinetic dynamometer distinguished spasticity from the non-neural component and showed higher reflex torque on the paretic side compared to the non-paretic side. This instrument is potentially useful to assess the efficacy of therapeutic interventions aimed at modifying spasticity.
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Effectiveness of Botulinum Toxin Treatment for Upper Limb Spasticity Poststroke Over Different ICF Domains: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil 2019; 100:1703-1725. [DOI: 10.1016/j.apmr.2019.01.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 12/17/2018] [Accepted: 01/21/2019] [Indexed: 11/20/2022]
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Zschorlich VR, Hillebrecht M, Tanjour T, Qi F, Behrendt F, Kirschstein T, Köhling R. Repetitive Peripheral Magnetic Nerve Stimulation (rPMS) as Adjuvant Therapy Reduces Skeletal Muscle Reflex Activity. Front Neurol 2019; 10:930. [PMID: 31507528 PMCID: PMC6718706 DOI: 10.3389/fneur.2019.00930] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 08/09/2019] [Indexed: 12/02/2022] Open
Abstract
Background: The reduction of muscle hypertonia and spasticity, as well as an increase in mobility, is an essential prerequisite for the amelioration of physiotherapeutical treatments. Repetitive peripheral magnetic nerve stimulation (rPMS) is a putative adjuvant therapy that improves the mobility of patients, but the underlying mechanism is not entirely clear. Methods: Thirty-eight participants underwent either an rPMS treatment (N = 19) with a 5 Hz stimulation protocol in the posterior tibial nerve or sham stimulation (N = 19). The stimulation took place over 5 min. The study was conducted in a pre-test post-test design with matched groups. Outcome measures were taken at the baseline and after following intervention. Results: The primary outcome was a significant reduction of the reflex activity of the soleus muscle, triggered by a computer-aided tendon-reflex impact. The pre-post differences of the tendon reflex response activity were −23.7% (P < 0.001) for the treatment group. No significant effects showed in the sham stimulation group. Conclusion: Low-frequency magnetic stimulation (5 Hz rPMS) shows a substantial reduction of the tendon reflex amplitude. It seems to be an effective procedure to reduce muscular stiffness, increase mobility, and thus, makes the therapeutic effect of neuro-rehabilitation more effective. For this reason, the 5 Hz rPMS treatment might have the potential to be used as an adjuvant therapy in the rehabilitation of gait and posture control in patients suffering from limited mobility due to spasticity. The effect observed in this study should be investigated conjoined with the presented method in patients with impaired mobility due to spasticity.
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Affiliation(s)
- Volker R Zschorlich
- Faculty of Philosophy, Institute of Sports Science, University of Rostock, Rostock, Germany.,Department of Ageing of Individuals and Society, Faculty of Interdisciplinary Research, University of Rostock, Rostock, Germany
| | - Martin Hillebrecht
- Department of Sport Science, University of Oldenburg, Oldenburg, Germany
| | - Tammam Tanjour
- Faculty of Philosophy, Institute of Sports Science, University of Rostock, Rostock, Germany
| | - Fengxue Qi
- Faculty of Philosophy, Institute of Sports Science, University of Rostock, Rostock, Germany.,Department of Psychology and Neurosciences, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Dortmund, Germany.,Department of Sport Training, Sport Coaching College, Beijing Sport University, Bejing, China
| | - Frank Behrendt
- Reha Rheinfelden, Research Department, Rheinfelden, Switzerland
| | - Timo Kirschstein
- Oscar-Langendorff-Institute of Physiology, University Medicine Rostock, Rostock, Germany
| | - Rüdiger Köhling
- Department of Ageing of Individuals and Society, Faculty of Interdisciplinary Research, University of Rostock, Rostock, Germany.,Oscar-Langendorff-Institute of Physiology, University Medicine Rostock, Rostock, Germany
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Plantin J, Pennati GV, Roca P, Baron JC, Laurencikas E, Weber K, Godbolt AK, Borg J, Lindberg PG. Quantitative Assessment of Hand Spasticity After Stroke: Imaging Correlates and Impact on Motor Recovery. Front Neurol 2019; 10:836. [PMID: 31456734 PMCID: PMC6699580 DOI: 10.3389/fneur.2019.00836] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 07/19/2019] [Indexed: 12/19/2022] Open
Abstract
Objective: This longitudinal observational study investigated how neural stretch-resistance in wrist and finger flexors develops after stroke and relates to motor recovery, secondary complications, and lesion location. Methods: Sixty-one patients were assessed at 3 weeks (T1), three (T2), and 6 months (T3) after stroke using the NeuroFlexor method and clinical tests. Magnetic Resonance Imaging was used to calculate weighted corticospinal tract lesion load (wCST-LL) and to perform voxel-based lesion symptom mapping. Results: NeuroFlexor assessment demonstrated spasticity (neural component [NC] >3.4N normative cut-off) in 33% of patients at T1 and in 51% at T3. Four subgroups were identified: early Severe spasticity (n = 10), early Moderate spasticity (n = 10), Late developing spasticity (n = 17) and No spasticity (n = 24). All except the Severe spasticity group improved significantly in Fugl-Meyer Assessment (FMA-HAND) to T3. The Severe and Late spasticity groups did not improve in Box and Blocks Test. The Severe spasticity group showed a 25° reduction in passive range of movement and more frequent arm pain at T3. wCST-LL correlated positively with NC at T1 and T3, even after controlling for FMA-HAND and lesion volume. Voxel-based lesion symptom mapping showed that lesioned white matter below cortical hand knob correlated positively with NC. Conclusion: Severe hand spasticity early after stroke is negatively associated with hand motor recovery and positively associated with the development of secondary complications. Corticospinal tract damage predicts development of spasticity. Early quantitative hand spasticity measurement may have potential to predict motor recovery and could guide targeted rehabilitation interventions after stroke.
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Affiliation(s)
- Jeanette Plantin
- Division of Rehabilitation Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Gaia V Pennati
- Division of Rehabilitation Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Pauline Roca
- Institut de Psychiatrie et Neurosciences de Paris, Inserm U1266, Paris, France.,Department of Neuroimaging, Sainte-Anne Hospital Center, Université Paris Descartes Sorbonne Paris Cité, Paris, France
| | - Jean-Claude Baron
- Department of Neurology, Hôpital Sainte-Anne, Université de Paris, Paris, France
| | - Evaldas Laurencikas
- Division of Rehabilitation Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden.,Division of Radiology, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Karin Weber
- Division of Rehabilitation Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Alison K Godbolt
- Division of Rehabilitation Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Jörgen Borg
- Division of Rehabilitation Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden
| | - Påvel G Lindberg
- Division of Rehabilitation Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd University Hospital, Stockholm, Sweden.,Institut de Psychiatrie et Neurosciences de Paris, Inserm U1266, Paris, France
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40
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Leng Y, Wang Z, Bian R, Lo WLA, Xie X, Wang R, Huang D, Li L. Alterations of Elastic Property of Spastic Muscle With Its Joint Resistance Evaluated From Shear Wave Elastography and Biomechanical Model. Front Neurol 2019; 10:736. [PMID: 31354610 PMCID: PMC6635717 DOI: 10.3389/fneur.2019.00736] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Accepted: 06/24/2019] [Indexed: 01/10/2023] Open
Abstract
This study aims to quantify passive muscle stiffness of spastic wrist flexors in stroke survivors using shear wave elastography (SWE) and to correlate with neural and non-neural contributors estimated from a biomechanical model to hyper-resistance measured during passive wrist extension. Fifteen hemiplegic individuals after stroke with Modified Ashworth Scale (MAS) score larger than one were recruited. SWE were used to measure Young's modulus of flexor carpi radialis muscle with joint from 0° (at rest) to 50° flexion (passive stretch condition), with 10° interval. The neural (NC) and non-neural components i.e., elasticity component (EC) and viscosity component (VC) of the wrist joint were analyzed from a motorized mechanical device NeuroFlexor® (NF). Combining with a validated biomechanical model, the neural reflex and muscle stiffness contribution to the increased resistance can be estimated. MAS and Fugl-Meyer upper limb score were also measured to evaluate the spasticity and motor function of paretic upper limb. Young's modulus was significantly higher in the paretic side of flexor carpi radialis than that of the non-paretic side (p < 0.001) and it increased significantly from 0° to 50° of the paretic side (p < 0.001). NC, EC, and VC on the paretic side were higher than the non-paretic side (p < 0.05). There was moderate significant positive correlation between the Young's Modulus and EC (r = 0.565, p = 0.028) and VC (r = 0.645, p = 0.009) of the paretic forearm flexor muscle. Fugl-Meyer of the paretic forearm flexor has a moderate significant negative correlation with NC (r = -0.578, p = 0.024). No significant correlation between MAS and shear elastic modulus or NF components was observed. This study demonstrated the feasibility of combining SWE and NF as a non-invasive approach to assess spasticity of paretic muscle and joint in stroke clinics. The neural and non-neural components analysis as well as correlation findings of muscle stiffness of SWE might provide understanding of mechanism behind the neuromuscular alterations in stroke survivors and facilitate the design of suitable intervention for them.
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Affiliation(s)
- Yan Leng
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhu Wang
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ruihao Bian
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wai Leung Ambrose Lo
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaoyan Xie
- Department of Medical Ultrasonics, Institute of Diagnostic and Interventional Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ruoli Wang
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Mechanics, Royal Institute of Technology, Stockholm, Sweden.,KTH BioMEx Center, Royal Institute of Technology, Stockholm, Sweden
| | - Dongfeng Huang
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Department of Rehabilitation Medicine, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, China
| | - Le Li
- Department of Rehabilitation Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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41
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Wang H, Huang P, Li X, Samuel OW, Xiang Y, Li G. Spasticity Assessment Based on the Maximum Isometrics Voluntary Contraction of Upper Limb Muscles in Post-stroke Hemiplegia. Front Neurol 2019; 10:465. [PMID: 31133969 PMCID: PMC6514055 DOI: 10.3389/fneur.2019.00465] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 04/17/2019] [Indexed: 11/23/2022] Open
Abstract
Background: The assessment of muscle properties is an essential prerequisite in the treatment of post-stroke patients with limb spasticity. Most existing spasticity assessment approaches do not consider the muscle activation with voluntary contraction. Including voluntary movements of spastic muscles may provide a new way for the reliable assessment of muscle spasticity. Objective: In this study, we investigated the effectiveness and reliability of maximum isometrics voluntary contraction (MIVC) based method for spasticity assessment in post-stroke hemiplegia. Methods: Fourteen post-stroke hemiplegic patients with arm spasticity were asked to perform two tasks: MIVC and passive isokinetic movements. Three biomechanical signals, torque, position, and time, were recorded from the impaired and non-impaired arms of the patients. Three features, peak torque, keep time of the peak torque, and rise time, were computed from the recorded MIVC signals and used to evaluate the muscle voluntary activation characteristics, respectively. For passive movements, two features, the maximum resistance torque and muscle stiffness, were also obtained to characterize the properties of spastic stretch reflexes. Subsequently, the effectiveness and reliability of the MIVC-based spasticity assessment method were evaluated with spearman correlation analysis and intra class correlation coefficients (ICCs) metrics. Results: The results indicated that the keep time of peak torque and rise time in the impaired arm were higher in comparison to those in the contralateral arm, whereas the peak torque in the impaired side was significantly lower than their contralateral arm. Our results also showed a significant positive correlation (r = 0.503, p = 0.047) between the keep time (tk) and the passive resistant torque. Furthermore, a significantly positive correlation was observed between the keep time (tk) and the muscle stiffness (r = 0.653, p = 0.011). Meanwhile, the ICCs for intra-time measurements of MIVC ranged between 0.815 and 0.988 with one outlier. Conclusion: The findings from this study suggested that the proposed MIVC-based approach would be promising for the reliable and accurate assessment of spasticity in post-stroke patients.
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Affiliation(s)
- Hui Wang
- CAS Key Laboratory of Human-Machine Intelligence-Synergy Systems, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China.,Shenzhen College of Advanced Technology, University of Chinese Academy of Sciences, Shenzhen, China
| | - Pingao Huang
- CAS Key Laboratory of Human-Machine Intelligence-Synergy Systems, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China.,Shenzhen College of Advanced Technology, University of Chinese Academy of Sciences, Shenzhen, China
| | - Xiangxin Li
- CAS Key Laboratory of Human-Machine Intelligence-Synergy Systems, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Oluwarotimi Williams Samuel
- CAS Key Laboratory of Human-Machine Intelligence-Synergy Systems, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Yun Xiang
- CAS Key Laboratory of Human-Machine Intelligence-Synergy Systems, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China.,The Rehabilitation Department, Shenzhen Sixth People's Hospital (Nanshan hospital), Shenzhen, China
| | - Guanglin Li
- CAS Key Laboratory of Human-Machine Intelligence-Synergy Systems, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
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Zhang X, Tang X, Zhu X, Gao X, Chen X, Chen X. A Regression-Based Framework for Quantitative Assessment of Muscle Spasticity Using Combined EMG and Inertial Data From Wearable Sensors. Front Neurosci 2019; 13:398. [PMID: 31130834 PMCID: PMC6509177 DOI: 10.3389/fnins.2019.00398] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 04/08/2019] [Indexed: 01/27/2023] Open
Abstract
There have always been practical demands for objective and accurate assessment of muscle spasticity beyond its clinical routine. A novel regression-based framework for quantitative assessment of muscle spasticity is proposed in this paper using wearable surface electromyogram (EMG) and inertial sensors combined with a simple examination procedure. Sixteen subjects with elbow flexor or extensor (i.e., biceps brachii muscle or triceps brachii muscle) spasticity and eight healthy subjects were recruited for the study. The EMG and inertial data were recorded from each subject when a series of passive elbow stretches with different stretch velocities were conducted. In the proposed framework, both lambda model and kinematic model were constructed from the recorded data, and biomarkers were extracted respectively from the two models to describe the neurogenic component and biomechanical component of the muscle spasticity, respectively. Subsequently, three evaluation methods using supervised machine learning algorithms including single-/multi-variable linear regression and support vector regression (SVR) were applied to calibrate biomarkers from each single model or combination of two models into evaluation scores. Each of these evaluation scores can be regarded as a prediction of the modified Ashworth scale (MAS) grade for spasticity assessment with the same meaning and clinical interpretation. In order to validate performance of three proposed methods within the framework, a 24-fold leave-one-out cross validation was conducted for all subjects. Both methods with each individual model achieved satisfactory performance, with low mean square error (MSE, 0.14 and 0.47) between the resultant evaluation score and the MAS. By contrast, the method using SVR to fuse biomarkers from both models outperformed other two methods with the lowest MSE at 0.059. The experimental results demonstrated the usability and feasibility of the proposed framework, and it provides an objective, quantitative and convenient solution to spasticity assessment, suitable for clinical, community, and home-based rehabilitation.
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Affiliation(s)
- Xu Zhang
- Department of Electronic Science and Technology, University of Science and Technology of China, Hefei, China
| | - Xiao Tang
- Department of Electronic Science and Technology, University of Science and Technology of China, Hefei, China
| | - Xiaofei Zhu
- Department of Electronic Science and Technology, University of Science and Technology of China, Hefei, China
| | - Xiaoping Gao
- Department of Rehabilitation Medicine, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiang Chen
- Department of Electronic Science and Technology, University of Science and Technology of China, Hefei, China
| | - Xun Chen
- Department of Electronic Science and Technology, University of Science and Technology of China, Hefei, China
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43
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Andringa A, van Wegen E, van de Port I, Kwakkel G, Meskers C. Measurement Properties of the NeuroFlexor Device for Quantifying Neural and Non-neural Components of Wrist Hyper-Resistance in Chronic Stroke. Front Neurol 2019; 10:730. [PMID: 31379705 PMCID: PMC6618514 DOI: 10.3389/fneur.2019.00730] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 06/19/2019] [Indexed: 01/17/2023] Open
Abstract
Introduction: Differentiating between the components of wrist hyper-resistance post stroke, i.e., pathological neuromuscular activation ("spasticity") and non-neural biomechanical changes, is important for treatment decisions. This study aimed to assess the reliability and construct validity of an innovative measurement device that quantifies these neural and non-neural components by biomechanical modeling. Methods: Forty-six patients with chronic stroke and 30 healthy age-matched subjects were assessed with the NeuroFlexor, a motor-driven device that imposes isokinetic wrist extensions at two controlled velocities (5 and 236°/s). Test-retest reliability was evaluated using intraclass correlation coefficients (ICC) and smallest detectable changes (SDC), and construct validity by testing the difference between patients and healthy subjects and between subgroups of patients stratified by modified Ashworth scale (MAS), and the association with clinical scales. Results: Test-retest reliability was excellent for the neural (NC) and non-neural elastic (EC) components (ICC 0.93 and 0.95, respectively), and good for the viscous component (VC) (ICC 0.84), with SDCs of 10.3, 3.1, and 0.5 N, respectively. NC and EC were significantly higher in patients compared to healthy subjects (p < 0.001). Components gradually increased with MAS category. NC and EC were positively associated with the MAS (r s 0.60 and 0.52, respectively; p < 0.01), and NC with the Tardieu scale (r s 0.36, p < 0.05). NC and EC were negatively associated with the Fugl-Meyer Assessment of the upper extremity and action research arm test (r s ≤ -0.38, p < 0.05). Conclusions: The NeuroFlexor reliably quantifies neural and non-neural components of wrist hyper-resistance in chronic stroke, but is less suitable for clinical evaluation at individual level due to high SDC values. Although construct validity has been demonstrated, further investigation at component level is needed.
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Affiliation(s)
- Aukje Andringa
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Erwin van Wegen
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | | | - Gert Kwakkel
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, United States
- Department of Neurorehabilitation, Amsterdam Rehabilitation Research Centre, Reade, Amsterdam, Netherlands
| | - Carel Meskers
- Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, IL, United States
- *Correspondence: Carel Meskers
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44
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McPherson JG, Stienen AHA, Schmit BD, Dewald JPA. Biomechanical parameters of the elbow stretch reflex in chronic hemiparetic stroke. Exp Brain Res 2018; 237:121-135. [PMID: 30353212 DOI: 10.1007/s00221-018-5389-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 10/01/2018] [Indexed: 11/30/2022]
Abstract
We sought to determine the relative velocity sensitivity of stretch reflex threshold angle and reflex stiffness during stretches of the paretic elbow joint in individuals with chronic hemiparetic stroke, and to provide guidelines to streamline spasticity assessments. We applied ramp-and-hold elbow extension perturbations ranging from 15 to 150°/s over the full range of motion in 13 individuals with hemiparesis. After accounting for the effects of passive mechanical resistance, we modeled velocity-dependent reflex threshold angle and torque-angle slope to determine their correlation with overall resistance to movement. Reflex stiffness exhibited substantially greater velocity sensitivity than threshold angle, accounting for ~ 74% (vs. ~ 15%) of the overall velocity-dependent increases in movement resistance. Reflex stiffness is a sensitive descriptor of the overall velocity-dependence of movement resistance in spasticity. Clinical spasticity assessments can be streamlined using torque-angle slope, a measure of reflex stiffness, as their primary outcome measure, particularly at stretch velocities greater than 100°/s.
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Affiliation(s)
- Jacob G McPherson
- Department of Biomedical Engineering, Florida International University, 10555 W. Flagler St., EC #3171, Miami, FL, 33176, USA
| | - Arno H A Stienen
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, 645 N Michigan Ave, Suite 1100, Chicago, IL, 60611, USA
| | - Brian D Schmit
- Department of Biomedical Engineering, Marquette University, P.O. Box 1881, Milwaukee, WI, 53201, USA
| | - Julius P A Dewald
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, 645 N Michigan Ave, Suite 1100, Chicago, IL, 60611, USA.
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45
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Yamaguchi T, Hvass Petersen T, Kirk H, Forman C, Svane C, Kofoed-Hansen M, Boesen F, Lorentzen J. Spasticity in adults with cerebral palsy and multiple sclerosis measured by objective clinically applicable technique. Clin Neurophysiol 2018; 129:2010-2021. [PMID: 30053672 DOI: 10.1016/j.clinph.2018.07.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 06/19/2018] [Accepted: 07/01/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The present study evaluated ankle stiffness in adults with and without neurological disorders and investigated the accuracy and reproducibility of a clinically applicable method using a dynamometer. METHODS Measurements were obtained from 8 healthy subjects (age 39.3), 9 subjects with spastic cerebral palsy (CP) (age 39.8) and 8 subjects with multiple sclerosis (MS) (age 49.9). Slow and fast dorsiflexion stretches of the ankle joint were performed to evaluate passive muscle-tendon-joint stiffness, reflex mediated stiffness and range of movement (ROM), respectively. Intra/inter-rater reliability for passive and reflex mediated ankle muscle stiffness was assessed for all groups. RESULTS Subjects with CP and MS showed significantly larger values of passive stiffness in the triceps surae muscle tendon complex and smaller ROM compared to healthy individuals, while no significant difference in reflex mediated stiffness. Measurements of passive muscle-tendon-joint stiffness and reflex mediated stiffness showed good to excellent inter- and intra-rater reliability (ICC: 0.62-0.91) in all groups. CONCLUSION Increased stiffness was found in subjects with CP and MS with a clinically applicable method that provides valid and reproducible measurement of passive ankle muscle-tendon-joint stiffness and reflex mediated stiffness. SIGNIFICANCE The present technique may provide important supplementary information for the clinician.
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Affiliation(s)
- Tomofumi Yamaguchi
- Institute of Neuroscience, University of Copenhagen, Blegdamsvej 3, DK-2200 Copenhagen N, Denmark.
| | - Tue Hvass Petersen
- Research Unit on Brain Injury Neurorehabilitation, Rigshospitalet, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark
| | - Henrik Kirk
- Department of Nutrition, Exercise and Sports and Elsass Institute, University of Copenhagen, Blegdamsvej 3, DK-2200 Copenhagen N, Denmark
| | - Christian Forman
- Department of Nutrition, Exercise and Sports and Elsass Institute, University of Copenhagen, Blegdamsvej 3, DK-2200 Copenhagen N, Denmark.
| | - Christian Svane
- Department of Nutrition, Exercise and Sports and Elsass Institute, University of Copenhagen, Blegdamsvej 3, DK-2200 Copenhagen N, Denmark.
| | | | - Finn Boesen
- The Danish MS Hospitals, Ringstedvej 106, DK-4650 Haslev, Denmark.
| | - Jakob Lorentzen
- Institute of Neuroscience, University of Copenhagen, Blegdamsvej 3, DK-2200 Copenhagen N, Denmark; Department of Nutrition, Exercise and Sports and Elsass Institute, University of Copenhagen, Blegdamsvej 3, DK-2200 Copenhagen N, Denmark.
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46
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de Gooijer-van de Groep KL, de Groot JH, van der Krogt H, de Vlugt E, Arendzen JH, Meskers CGM. Early Shortening of Wrist Flexor Muscles Coincides With Poor Recovery After Stroke. Neurorehabil Neural Repair 2018; 32:645-654. [PMID: 29938584 PMCID: PMC6066858 DOI: 10.1177/1545968318779731] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background. The mechanism and time course of increased wrist
joint stiffness poststroke and clinically observed wrist flexion deformity is
still not well understood. The components contributing to increased joint
stiffness are of neural reflexive and peripheral tissue origin and quantified by
reflexive torque and muscle slack length and stiffness coefficient parameters.
Objective. To investigate the time course of the components
contributing to wrist joint stiffness during the first 26 weeks poststroke in a
group of patients, stratified by prognosis and functional recovery of the upper
extremity. Methods. A total of 36 stroke patients were measured
on 8 occasions within the first 26 weeks poststroke using ramp-and-hold
rotations applied to the wrist joint by a robot manipulator. Neural reflexive
and peripheral tissue components were estimated using an electromyography-driven
antagonistic wrist model. Outcome was compared between groups cross-sectionally
at 26 weeks poststroke and development over time was analyzed longitudinally.
Results. At 26 weeks poststroke, patients with poor
recovery (Action Research Arm Test [ARAT] ≤9 points) showed a higher predicted
reflexive torque of the flexors (P < .001) and reduced
predicted slack length (P < .001) indicating shortened
muscles contributing to higher peripheral tissue stiffness (P
< .001), compared with patients with good recovery (ARAT ≥10 points).
Significant differences in peripheral tissue stiffness between groups could be
identified around weeks 4 and 5; for neural reflexive stiffness, this was the
case around week 12. Conclusions. We found onset of peripheral
tissue stiffness to precede neural reflexive stiffness. Temporal identification
of components contributing to joint stiffness after stroke may prompt
longitudinal interventional studies to further evaluate and eventually prevent
these phenomena.
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Affiliation(s)
| | | | | | | | | | - Carel G M Meskers
- 3 VU Medical Center, Amsterdam, Netherlands.,4 Amsterdam Movement Sciences, Amsterdam, The Netherlands
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47
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Wang R, Gäverth J, Herman PA. Changes in the Neural and Non-neural Related Properties of the Spastic Wrist Flexors After Treatment With Botulinum Toxin A in Post-stroke Subjects: An Optimization Study. Front Bioeng Biotechnol 2018; 6:73. [PMID: 29963551 PMCID: PMC6013585 DOI: 10.3389/fbioe.2018.00073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 05/22/2018] [Indexed: 11/13/2022] Open
Abstract
Quantifying neural and non-neural contributions to the joint resistance in spasticity is essential for a better evaluation of different intervention strategies such as botulinum toxin A (BoTN-A). However, direct measurement of muscle mechanical properties and spasticity-related parameters in humans is extremely challenging. The aim of this study was to use a previously developed musculoskeletal model and optimization scheme to evaluate the changes of neural and non-neural related properties of the spastic wrist flexors during passive wrist extension after BoTN-A injection. Data of joint angle and resistant torque were collected from 21 chronic stroke patients before, and 4 and 12 weeks post BoTN-A injection using NeuroFlexor, which is a motorized force measurement device to passively stretch wrist flexors. The model was optimized by tuning the passive and stretch-related parameters to fit the measured torque in each participant. It was found that stroke survivors exhibited decreased neural components at 4 weeks post BoNT-A injection, which returned to baseline levels after 12 weeks. The decreased neural component was mainly due to the increased motoneuron pool threshold, which is interpreted as a net excitatory and inhibitory inputs to the motoneuron pool. Though the linear stiffness and viscosity properties of wrist flexors were similar before and after treatment, increased exponential stiffness was observed over time which may indicate a decreased range of motion of the wrist joint. Using a combination of modeling and experimental measurement, valuable insights into the treatment responses, i.e., transmission of motoneurons, are provided by investigating potential parameter changes along the stretch reflex pathway in persons with chronic stroke.
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Affiliation(s)
- Ruoli Wang
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Department of Mechanics, Royal Institute of Technology, Stockholm, Sweden.,KTH Biomex Center, Royal Institute of Technology, Stockholm, Sweden
| | - Johan Gäverth
- Functional Area Occupational Therapy & Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | - Pawel A Herman
- Department of Computational Science and Technology, Royal Institute of Technology, Stockholm, Sweden
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48
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Wang R, Herman P, Ekeberg Ö, Gäverth J, Fagergren A, Forssberg H. Neural and non-neural related properties in the spastic wrist flexors: An optimization study. Med Eng Phys 2017; 47:198-209. [PMID: 28694106 DOI: 10.1016/j.medengphy.2017.06.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 06/14/2017] [Accepted: 06/14/2017] [Indexed: 10/19/2022]
Abstract
Quantifying neural and non-neural contributions to increased joint resistance in spasticity is essential for a better understanding of its pathophysiological mechanisms and evaluating different intervention strategies. However, direct measurement of spasticity-related manifestations, e.g., motoneuron and biophysical properties in humans, is extremely challenging. In this vein, we developed a forward neuromusculoskeletal model that accounts for dynamics of muscle spindles, motoneuron pools, muscle activation and musculotendon of wrist flexors and relies on the joint angle and resistant torque as the only input measurement variables. By modeling the stretch reflex pathway, neural and non-neural related properties of the spastic wrist flexors were estimated during the wrist extension test. Joint angle and resistant torque were collected from 17 persons with chronic stroke and healthy controls using NeuroFlexor, a motorized force measurement device during the passive wrist extension test. The model was optimized by tuning the passive and stretch reflex-related parameters to fit the measured torque in each participant. We found that persons with moderate and severe spasticity had significantly higher stiffness than controls. Among subgroups of stroke survivors, the increased neural component was mainly due to a lower muscle spindle rate at 50% of the motoneuron recruitment. The motoneuron pool threshold was highly correlated to the motoneuron pool gain in all subgroups. The model can describe the overall resistant behavior of the wrist joint during the test. Compared to controls, increased resistance was predominantly due to higher elasticity and neural components. We concluded that in combination with the NeuroFlexor measurement, the proposed neuromusculoskeletal model and optimization scheme served as suitable tools for investigating potential parameter changes along the stretch-reflex pathway in persons with spasticity.
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Affiliation(s)
- R Wang
- Department of Mechanics, Royal Institute of Technology, Stockholm, Sweden; KTH Biomex Center, Royal Institute of Technology, Stockholm, Sweden; Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
| | - P Herman
- Dept. of Computational Science and Technology, Royal Institute of Technology, Stockholm, Sweden.
| | - Ö Ekeberg
- Dept. of Computational Science and Technology, Royal Institute of Technology, Stockholm, Sweden.
| | - J Gäverth
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
| | | | - H Forssberg
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.
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KAPS (kinematic assessment of passive stretch): a tool to assess elbow flexor and extensor spasticity after stroke using a robotic exoskeleton. J Neuroeng Rehabil 2017. [PMID: 28629415 PMCID: PMC5477344 DOI: 10.1186/s12984-017-0272-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Spasticity is a common sequela of stroke. Traditional assessment methods include relatively coarse scales that may not capture all characteristics of elevated muscle tone. Thus, the aim of this study was to develop a tool to quantitatively assess post-stroke spasticity in the upper extremity. Methods Ninety-six healthy individuals and 46 individuals with stroke participated in this study. The kinematic assessment of passive stretch (KAPS) protocol consisted of passive elbow stretch in flexion and extension across an 80° range in 5 movement durations. Seven parameters were identified and assessed to characterize spasticity (peak velocity, final angle, creep (or release), between-arm peak velocity difference, between-arm final angle, between-arm creep, and between-arm catch angle). Results The fastest movement duration (600 ms) was most effective at identifying impairment in each parameter associated with spasticity. A decrease in peak velocity during passive stretch between the affected and unaffected limb was most effective at identifying individuals as impaired. Spasticity was also associated with a decreased passive range (final angle) and a classic ‘catch and release’ as seen through between-arm catch and creep metrics. Conclusions The KAPS protocol and robotic technology can provide a sensitive and quantitative assessment of post-stroke elbow spasticity not currently attainable through traditional measures.
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50
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Stubbs PW, Pedersen AR, Nielsen JF. Day-to-day features of soleus stretch reflexes in sub-acute stroke patients. Somatosens Mot Res 2017; 34:123-128. [PMID: 28535701 DOI: 10.1080/08990220.2017.1328405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The aim of the study was to assess the reliability and variability of stretch reflex magnitude (SRmag) in sub-acute stroke patients. For testing, rapid dorsiflexion stretches were induced 24 h apart in 22 patients and 34 controls. SRmag between sessions in patients and controls was not different and the SRmag on the more-affected side was significantly larger than the less-affected, dominant, and non-dominant sides. The SRmag was consistent between sessions. Therefore, patients were not as variable between sessions as we had hypothesized.
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Affiliation(s)
- Peter William Stubbs
- a Hammel Neurorehabilitation and Research Center , Aarhus University , Hammel , Denmark
| | - Asger Roer Pedersen
- a Hammel Neurorehabilitation and Research Center , Aarhus University , Hammel , Denmark
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