Effectiveness of stretch for the treatment and prevention of contractures in people with neurological conditions: a systematic review

AAPM&R consensus guidance on spasticity assessment and management

BACKGROUND

The American Academy of Physical Medicine and Rehabilitation (AAPM&R) conducted a comprehensive review in 2021 to identify opportunities for enhancing the care of adult and pediatric patients with spasticity. A technical expert panel (TEP) was convened to develop consensus-based practice recommendations aimed at addressing gaps in spasticity care.

OBJECTIVE

To develop consensus-based practice recommendations to identify and address gaps in spasticity care.

METHODS

The Spasticity TEP engaged in a 16-month virtual meeting process, focusing on formulating search terms, refining research questions, and conducting a structured evidence review. Evidence quality was assessed by the AAPM&R Evidence, Quality and Performance Committee (EQPC), and a modified Delphi process was employed to achieve consensus on recommendation statements and evidence grading. The Strength of Recommendation Taxonomy (SORT) guided the rating of individual studies and the strength of recommendations.

RESULTS

The TEP approved five recommendations for spasticity management and five best practices for assessment and management, with one recommendation unable to be graded due to evidence limitations. Best practices were defined as widely accepted components of care, while recommendations required structured evidence reviews and grading. The consensus guidance statement represents current best practices and evidence-based treatment options, intended for use by PM&R physicians caring for patients with spasticity.

CONCLUSION

This consensus guidance provides clinicians with practical recommendations for spasticity assessment and management based on the best available evidence and expert opinion. Clinical judgment should be exercised, and recommendations tailored to individual patient needs, preferences, and risk profiles. The accompanying table summarizes the best practice recommendations for spasticity assessment and management, reflecting principles with little controversy in care delivery.

Immediate effects of TECAR therapy on lower limb to decrease hypertonia in chronic stroke survivors: a randomized controlled trial

PURPOSE

To analyze immediate effects of TECAR therapy (TT) to reduce lower limb hypertonia and improve functionality in chronic post-stroke.

MATERIALS AND METHODS

It is a single-blind randomized controlled clinical trial. A total of 36 chronic stroke survivors were divided into two groups. The experimental group received a single 30-minute session of TT with functional massage (FM) on lower limb. The control group received a single 30-minute session sham treatment of TT plus FM. The primary outcome measure was hypertonia (Modified Ashworth Scale, MAS). Secondary outcomes were gait speed (4-Meter Walk-Test), standing knee-flexion (Fugl-Meyer Assessment Scale IV-item), change in weight bearing ankle dorsiflexion (Ankle Lunge Test, ALT), and functional lower limb strength (5-Times Sit-to-Stand Test). All measurements were performed at baseline, immediately and 30-minutes after treatment.

RESULTS

There was a group-time interaction in MAS-knee (p = 0.044), MAS-ankle (p = 0.018) and ALT (p = 0.016) between T1 and T0 (p<.0001) and T2 and T0 (p<.0001) for the experimental group. There was a significant increase in ALT between T1 and T0 (p = 0.003) in the control group.

CONCLUSIONS

A single session of TT performed at the same time as FM immediately reduces plantar-flexors and knee-extensor muscle hypertonia and increases change in weight bearing ankle dorsiflexion in chronic stroke survivors.

Impact of contractures on daily functioning in adolescents with spinal muscular atrophy: a qualitative study

PURPOSE

Exploring the impact of contractures in adolescents and young adults (AYA) with spinal muscular atrophy (SMA) on daily functioning and participation and the impact of received contracture management.

METHODS

We included 14, non-ambulant AYA with SMA types 2/3 (10 females and 4 males), aged 16-30 years. Interviews focused on two topics: perceived impact of contractures on daily functioning and of previous contracture management. We used inductive thematic analysis for interview analysis.

RESULTS

In general, participants experienced muscle weakness to be more of a hindrance than contractures; they had adapted to their contractures over time. Participants considered contracture treatment useful when goals were meaningful and realistic. Participants mentioned that their perspective on contracture management would change in light of a promise of improved motor function due to disease-modifying treatment.

CONCLUSION

Despite the relatively low impact of contractures in comparison to the loss of muscle strength, non-ambulant AYA with SMA should be informed on the potential impact of contractures and benefits and potential adverse effects of their management. This information can support the shared decision-making process. While respecting individual choices, allows for incorporating interventions into daily life and the promotion of daily functioning and participation when children with SMA are growing up.

Transient Worsening of Dysphagia and Dysarthria after Treatment with Botulinum Toxin in Patients with Acquired Brain Injury

Although botulinum toxin is widely considered an effective and safe treatment for a variety of neurological conditions (such as disabling spasticity), local or systemic adverse effects have often been reported. This study describes three cases of patients with severe acquired brain injury who were receiving speech therapy for recovering dysphagia and dysarthria but showed worsening of these symptoms after receiving BoNT treatment for motor spasticity. To increase clinicians' knowledge of these adverse effects, we present our cases and explore their significance to avoid major complications such as aspiration pneumonia.

Eight weeks of proprioceptive neuromuscular facilitation stretching and static stretching do not affect muscle-tendon properties, muscle strength, and joint function in children with spastic cerebral palsy

BACKGROUND

While the effect of static stretching for individuals with cerebral palsy is questionable, recent results suggest that the combination with activation seems promising to improve muscle-tendon properties and function. Therefore, this study analyzed the effects of 8-week proprioceptive neuromuscular facilitation stretching on the gastrocnemius medialis muscle-tendon properties, muscle strength, and the ankle joint in children with spastic cerebral palsy in comparison to static stretching.

METHODS

Initially, 24 children with spastic cerebral palsy were randomly assigned to a static stretching (10.7 ± 1.8 years) or proprioceptive neuromuscular facilitation stretching group (10.9 ± 2.6 years). Plantar flexors were manually stretched at home for 300 s and ∼ 250-270 s per day four times a week for eight weeks, respectively. Assessments of ankle joint function (e.g., range of motion), muscle-tendon properties, and isometric muscle strength were conducted using 3D motion capture, 2D ultrasound, dynamometry, and electromyography. A mixed analysis of variance was used for the statistical analysis.

FINDINGS

Stretching adherence was high in the proprioceptive neuromuscular facilitation stretching (93.1%) and static stretching group (94.4%). No significant changes (p > 0.05) were observed in ankle joint function, muscle-tendon properties, and isometric muscle strength after both interventions. Moreover, no differences (p > 0.05) were found between the stretching techniques.

INTERPRETATION

The findings support the idea that manual stretching (neither proprioceptive neuromuscular facilitation stretching nor static stretching) performed in isolation for eight weeks may not be appropriate to evoke significant changes in muscle-tendon properties, voluntary muscle strength, or joint function in children with spastic cerebral palsy.

CLINICAL TRIAL REGISTRATION NUMBER

NCT04570358.

Effectiveness of physical therapy interventions on post-stroke spasticity: An umbrella review

BACKGROUND

Post-stroke spasticity is often one of the primary impairments addressed in rehabilitation. However, limited guidance exists on the effectiveness of physical therapy (PT) interventions for post-stroke spasticity.

OBJECTIVE

To evaluate the quality of evidence of PT interventions for post-stroke spasticity.

METHODS

Ovid (Medline), Cochrane Library, CINAHL, Scopus, PEDro, and PROSPERO were searched to identify reviews based on the following criteria: 1) published between 2012 and 2021, 2) participants older than 18 years old, 3) post-stroke spasticity, 4) PT interventions, 5) clinical or neurophysiological measures of spasticity as primary outcomes. Assessment of Multiple Systematic Reviews 2 and the Grades of Recommendations Assessment, Development, and Evaluation assessed methodological quality.

RESULTS

Eight articles were included in the analysis. No high-quality evidence was found. Moderate quality evidence exists for transcutaneous electrical nerve stimulation, neuromuscular electrical stimulation, resistance training, and lower extremity ergometer training with or without functional electrical stimulation. Low quality evidence exists for dynamic stretching, botulinum toxin with constraint-induced movement therapy, and static stretching using positional orthoses.

CONCLUSION

Findings suggest that PT should prioritize a combination of active strategies over passive interventions, but further studies are needed prioritizing analyses of the movement system in managing post-stroke spasticity in conjunction with medical therapies.

New insights into acupuncture techniques for poststroke spasticity

With the trend of aging population getting more obvious, stroke has already been a major public health problem worldwide. As a main disabling motor impairment after stroke, spasticity has unexpected negative impacts on the quality of life and social participation in patients. Moreover, it brings heavy economic burden to the family and society. Previous researches indicated that abnormality of neural modulation and muscle property corelates with the pathogenesis of poststroke spasticity (PSS). So far, there still lacks golden standardized treatment regimen for PSS; furthermore, certain potential adverse-events of the mainstream therapy, for example, drug-induced generalized muscle weakness or high risk related surgery somehow decrease patient preference and compliance, which brings challenges to disease treatment and follow-up care. As an essential non-pharmacological therapy, acupuncture has long been used for PSS in China and shows favorable effects on improvements of spastic hypertonia and motor function. Notably, previous studies focused mainly on the research of antispastic acupoints. In comparison, few studies lay special stress on the other significant factor impacting on acupuncture efficacy, that is acupuncture technique. Based on current evidences from the clinic and laboratory, we will discuss certain new insights into acupuncture technique, in particular the antispastic needling technique, for PSS management in light of its potential effects on central modulations as well as peripheral adjustments, and attempt to provide some suggestions for future studies with respect to the intervention timing and course, application of acupuncture techniques, acupoint selection, predictive and aggravating factors of PSS, aiming at optimization of antispastic acupuncture regimen and improvement of quality of life in stroke patients. More innovations including rigorous study design, valid objective assessments for spasticity, and related experimental studies are worthy to be expected in the years ahead.

Treatment of spasticity

Spasticity is characterized by an enhanced size and reduced threshold for activation of stretch reflexes and is associated with "positive signs" such as clonus and spasms, as well as "negative features" such as paresis and a loss of automatic postural responses. Spasticity develops over time after a lesion and can be associated with reduced speed of movement, cocontraction, abnormal synergies, and pain. Spasticity is caused by a combination of damage to descending tracts, reductions in inhibitory activity within spinal cord circuits, and adaptive changes within motoneurons. Increased tone, hypertonia, can also be caused by changes in passive stiffness due to, for example, increase in connective tissue and reduction in muscle fascicle length. Understanding the cause of hypertonia is important for determining the management strategy as nonneural, passive causes of stiffness will be more amenable to physical rather than pharmacological interventions. The management of spasticity is determined by the views and goals of the patient, family, and carers, which should be integral to the multidisciplinary assessment. An assessment, and treatment, of trigger factors such as infection and skin breakdown should be made especially in people with a recent change in tone. The choice of management strategies for an individual will vary depending on the severity of spasticity, the distribution of spasticity (i.e., whether it affects multiple muscle groups or is more prominent in one or two groups), the type of lesion, and the potential for recovery. Management options include physical therapy, oral agents; focal therapies such as botulinum injections; and peripheral nerve blocks. Intrathecal baclofen can lead to a reduction in required oral antispasticity medications. When spasticity is severe intrathecal phenol may be an option. Surgical interventions, largely used in the pediatric population, include muscle transfers and lengthening and selective dorsal root rhizotomy.

A Novel and Clinically Feasible Instrument for Quantifying Upper Limb Muscle Tone and Motor Function via Indirect Measure Methods

Objective: Quantifying muscle tone is often based on a tester’s subjective judgment in clinical settings. There is, however, a lack of suitable tools that can be used to objectively assess muscle tone. This study thus introduces a reliable, clinically-feasible device, called the Arm Circumference Motor Evaluation System (ACMES), for quantifying the muscle tone of upper limbs without using mechanical torque transducers. Methods: While the ACMES conducts continuously passive arm circumduction motions, the voltage and current of the driving motor is transduced into torque values via a least square approximation. A torque sensor and springs with different spring constants were used for the validity and reliability test in the first part of this study. Fifteen healthy adults and two patients who had experienced a stroke participated in the second part, which was a clinical experiment used to examine the in-vivo test-retest reliability and to explore the inspection differences between healthy and patient participants. Results: The results showed that the ACMES has high validity (R²: ~0.99) and reliability (R²: 0.96~0.99). The reliability of the ACMES used on human subjects was acceptable (R²: 0.83~0.85). The various muscle tone patterns could be found among healthy and stroke subjects via the ACMES. Conclusion: Clinically, abnormal muscle tone, which seriously affects motion performance, will be found in many diagnoses, such as stroke or cerebral palsy. However, objectively and feasibly measuring abnormal tone in modern clinical settings is still a challenging task. Thus, the ACMES was developed and tested to verify its feasibility as a measurement system for detecting the mechanical torque associated with muscle tone.

Stimuli for Adaptations in Muscle Length and the Length Range of Active Force Exertion-A Narrative Review

Treatment strategies and training regimens, which induce longitudinal muscle growth and increase the muscles’ length range of active force exertion, are important to improve muscle function and to reduce muscle strain injuries in clinical populations and in athletes with limited muscle extensibility. Animal studies have shown several specific loading strategies resulting in longitudinal muscle fiber growth by addition of sarcomeres in series. Currently, such strategies are also applied to humans in order to induce similar adaptations. However, there is no clear scientific evidence that specific strategies result in longitudinal growth of human muscles. Therefore, the question remains what triggers longitudinal muscle growth in humans. The aim of this review was to identify strategies that induce longitudinal human muscle growth. For this purpose, literature was reviewed and summarized with regard to the following topics: (1) Key determinants of typical muscle length and the length range of active force exertion; (2) Information on typical muscle growth and the effects of mechanical loading on growth and adaptation of muscle and tendinous tissues in healthy animals and humans; (3) The current knowledge and research gaps on the regulation of longitudinal muscle growth; and (4) Potential strategies to induce longitudinal muscle growth. The following potential strategies and important aspects that may positively affect longitudinal muscle growth were deduced: (1) Muscle length at which the loading is performed seems to be decisive, i.e., greater elongations after active or passive mechanical loading at long muscle length are expected; (2) Concentric, isometric and eccentric exercises may induce longitudinal muscle growth by stimulating different muscular adaptations (i.e., increases in fiber cross-sectional area and/or fiber length). Mechanical loading intensity also plays an important role. All three training strategies may increase tendon stiffness, but whether and how these changes may influence muscle growth remains to be elucidated. (3) The approach to combine stretching with activation seems promising (e.g., static stretching and electrical stimulation, loaded inter-set stretching) and warrants further research. Finally, our work shows the need for detailed investigation of the mechanisms of growth of pennate muscles, as those may longitudinally grow by both trophy and addition of sarcomeres in series.

Effectiveness of Stretching in Post-Stroke Spasticity and Range of Motion: Systematic Review and Meta-Analysis

Spasticity is one of the most frequent and disabling clinical manifestations of patients with stroke. In clinical practice, stretching is the most widely used physiotherapeutic intervention for this population. However, there is no solid evidence for its effectiveness. The aim of this study was to evaluate the effectiveness of different types of stretching in reducing post-stroke spasticity. Research was carried out until March 2021 in the following scientific databases: PubMed, CINAHL, Scopus, Cochrane Library, Web of Science, and PEDro. The PEDro scale and the Cochrane collaboration tool were used to assess the methodological quality and risk of bias of the studies. Eight articles were selected for qualitative analysis; six of them contributed information to the meta-analysis. No conclusive evidence was obtained on the effectiveness of stretching in terms of treating spasticity and range of motion in patients with stroke. Further research is necessary in order to determine the effectiveness of the use of stretching in this population, considering the different types of stretching (static and dynamic), the time of application, the measurement of the different components of spasticity, and the extrapolation of functional results.

Effect of metformin treatment and its time of administration on joint capsular fibrosis induced by mouse knee immobilization

Joint contracture leads to major patient discomfort. Metformin, one of the most extensively used oral drugs against type 2 diabetes has recently been found to suppress tissue fibrosis as well. However, its role in suppressing tissue fibrosis in joint contractures remains unknown. In this study, we examined the role of metformin treatment in suppressing joint capsular fibrosis and the most effective time of its administration. Joint capsular fibrosis was induced by immobilizing the knee joints of mice using splints and tapes. Metformin was administered intraperitoneally every alternate day after immobilization. Histological and immunohistochemical changes and expression of fibrosis-related genes were evaluated. Metformin treatment significantly suppressed fibrosis in joint capsules based on histological and immunohistochemical evaluation. Joint capsular tissue from metformin-treated mice also showed decreased expression of fibrosis-related genes. Early, but not late, metformin administration showed the same effect on fibrosis suppression in joint capsule as the whole treatment period. The expression of fibrosis-related genes was most suppressed in mice administered with metformin early. These studies demonstrated that metformin treatment can suppress joint capsular fibrosis and the most effective time to administer it is early after joint immobilization; a delay of more than 2 weeks of administration is less effective.

Factors Associated with Development of New Joint Contractures in Long-Term Care Residents

OBJECTIVE

Limb contractures are associated with poor outcomes and quality of life in long-term care (LTC) residents. This study examined the rate of developing new joint contracture in the LTC residents and associated risk factors to formulate effective interventions in this critical but understudied area.

DESIGN

This is an observational study with data obtained from the Hong Kong Longitudinal Study on LTC Residents between 2005 and 2016.

SETTING AND PARTICIPANTS

Trained assessors (nurses, social workers, and therapists) used the Minimum Data Set Resident Assessment Instrument (MDS-RAI 2.0) to collect the data of the residents from 9 residential LTC facilities.

MEASURES

Limb contractures were defined as a functional limitation in the range of motion involving the upper or lower limbs. Primary outcomes included annual prevalence of joint contractures and factors that were associated with the development of new joint contractures.

RESULTS

We analyzed the data for 1914 older residents (674 males, mean age 83.4 years). During the first 5 years since admission, the annual prevalence of upper limb contractures increased from 29.8% to 36.5%, and lower limb contractures increased from 41.5% to 57.4%. Overall, the increment of the prevalence rate of joint contractures per year ranged from 0.7% to 3.2% for the upper limbs and 0.3% to 6.0% per year for the lower limbs. Impaired mobility, presence of neurologic diseases, and older age were the leading independent risk factors for the development of new joint contractures.

CONCLUSIONS AND IMPLICATIONS

Joint contractures are highly prevalent among residents admitted to the LTC facilities, and many residents develop new contractures during the first 5 years of their admission. Immobility appears to be the main modifiable risk factor. Further studies are needed to identify potential strategies to prevent new contractures in this vulnerable group.

Estimation of maximal muscle electromyographic activity from the relationship between muscle activity and voluntary activation

Maximal muscle activity recorded with surface electromyography (EMG) is an important neurophysiological measure. It is frequently used to normalize EMG activity recorded during passive or active movement. However, the true maximal muscle activity cannot be determined in people with impaired capacity to voluntarily activate their muscles. Here, we determined whether maximal muscle activity can be estimated from muscle activity produced during submaximal voluntary activation. Twenty-five able-bodied adults (18 males, mean age 29 yr, range 19-64 yr) participated in the study. Participants were seated with the knee flexed 90° and the ankle in 5° of dorsiflexion from neutral. Participants performed isometric voluntary ankle plantarflexion contractions at target torques, in random order: 1, 5, 10, 15, 25, 50, 75, 90, 95, and 100% of maximal voluntary torque. Ankle torque, muscle activity in soleus, medial and lateral gastrocnemius muscles, and voluntary muscle activation determined using twitch interpolation were recorded. There was a strong log_e-linear relationship between measures of muscle activation and muscle activity in all three muscles tested. Linear mixed models were fitted to muscle activation and log_e-transformed EMG data. Each 1% increase in muscle activation increased muscle activity by a mean of 0.027 ln(mV) [95% confidence interval (CI) 0.025 to 0.029 ln(mV)] in soleus, 0.025 ln(mV) [0.022 to 0.028 ln(mV)] in medial gastrocnemius, and 0.028 ln(mV) [0.026 to 0.030 ln(mV)] in lateral gastrocnemius. The relationship between voluntary muscle activation and muscle activity can be described with simple mathematical functions. In future, it should be possible to normalize recorded muscle activity using these types of functions.NEW & NOTEWORTHY Muscle activity is often normalized to maximal muscle activity; however, it is difficult to obtain accurate measures of maximal muscle activity in people with impaired voluntary neural drive. We determined the relationship between voluntary muscle activation and plantarflexor muscle activity across a broad range of muscle activation values in able-bodied people. The relationship between voluntary muscle activation and muscle activity can be described with simple mathematical functions capable of estimating maximal muscle activity.

Filling the gaps in knowledge translation: Physical therapy recommendations for individuals with spinal muscular atrophy compared to standard of care guidelines

This study describes the current landscape of physical therapy practice recommendations in the United States for children with spinal muscular atrophy (SMA) and their relationship to current SMA standard of care (SMA-SOC) guidelines. Pediatric physical therapists were surveyed to determine their knowledge of SMA-SOC guidelines, and the type, duration and frequency of intervention they recommend for children with SMA, as well as perceived barriers and facilitators to progress in physical therapy. Physical therapists recommend five key intervention areas for individuals with SMA; however discrepancies exist between the SOC recommended intervention parameters and respondents' reported frequency and duration of recommendations. After individuals with SMA initiated disease modifying pharmacotherapies, a majority of physical therapist respondents recommended increases in both frequency and duration of interventions. Nearly all respondents reported that familiarity with SOC guidelines was beneficial to their practice. The primary facilitator to progress was parent/caregiver support, while the primary barrier was limited access to resources. Variation in practice exists regarding care for those with SMA, particularly in the areas of frequency and duration of specific interventions. These findings can guide educational initiatives, identify future research needs and further inform SMA-SOC and best-practice rehabilitation management.

Transcutaneous application of carbon dioxide improves contractures after immobilization of rat knee joint

OBJECTIVE

Joint contractures are a major complication following joint immobilization. However, no fully effective treatment has yet been found. Recently, carbon dioxide (CO₂) therapy was developed and verified this therapeutic application in various disorders. We aimed to verify the efficacy of transcutaneous CO₂ therapy for immobilization-induced joint contracture.

METHOD

Twenty-two Wistar rats were randomly assigned to three groups: caged control, those untreated after joint immobilization, and those treated after joint immobilization. The rats were treated with CO₂ for 20 min once a daily either during immobilization, (prevention) or during remobilization after immobilization (treatment). Knee extension motion was measured with a goniometer, and the muscular and articular factors responsible for contractures were calculated. We evaluated muscle fibrosis, fibrosis-related genes (collagen Type 1α1 and TGF-β1) in muscles, synovial intima's length, and fibrosis-related proteins (Type I collagen and TGF-β1) in the joint capsules.

RESULTS

CO₂ therapy for prevention and treatment improved the knee extension motion. Muscular and articular factors decreased in rats of the treatment group. The muscular fibrosis of treated rats decreased in the treatment group. Although CO₂ therapy did not repress the increased expression of collagen Type 1α1, the therapy decreased the expression of TGF-β1 in the treatment group. CO₂ therapy for treatment improved the shortening of the synovial membrane after immobilization and decreased the immunolabeling of TGF-β1 in the joint capsules.

CONCLUSIONS

CO₂ therapy may prevent and treat contractures after joint immobilization, and appears to be more effective as a treatment strategy for the deterioration of contractures during remobilization.

Intramuscular fat in children with unilateral cerebral palsy

BACKGROUND

Many children with cerebral palsy develop muscle contractures. The mechanisms of contracture are not well understood. We investigated the possibility that, because fat is stiffer than passive muscle, elevated intramuscular fat contributes to contracture. In this cross-sectional study, we compared the quantity and distribution of intramuscular fat in muscles from typically developing children and children with cerebral palsy who have contractures.

METHODS

mDixon magnetic resonance images were obtained from the legs of 20 ambulant children with unilateral spastic cerebral palsy who had ankle contractures (mean age 11 SD 3 years, 13 male, mean moderate level contracture) and 20 typically developing children (mean age 11 SD 4 years, 13 male). The images were analyzed to quantify the intramuscular fat fraction of the medial gastrocnemius muscles. The amount and distribution of intramuscular fat were compared between muscles of children with cerebral palsy and typically developing children.

FINDINGS

In typically developing children, the medial gastrocnemius muscles had a mean intramuscular fat fraction of 4.7% (SD 1.6%). In children with cerebral palsy, the mean intramuscular fat fractions in the more- and less-affected medial gastrocnemius muscle were 11.4% (8.1%) and 6.9% (3.4%) respectively. There were small but statistically significant regional differences in the distribution of intramuscular fat. There was no evidence of a relationship between intramuscular fat fraction and severity of contracture.

INTERPRETATION

Children with cerebral palsy have higher proportions of intramuscular fat than typically developing children. There is no clear relationship between intramuscular fat fraction and dorsiflexion range of motion in children with cerebral palsy.

No pain, no gain? Children with cerebral palsy and their experience with physiotherapy

OBJECTIVES

Recent studies have shown that physiotherapy can induce pain in children and young adults with cerebral palsy (CP). There is a lack of knowledge of children's pain experiences during therapy sessions and the specific causes of pain. The main objective of this study was to better understand the experience of children and young adults with CP during physiotherapy sessions and to analyse the coping strategies used by children and therapists.

METHODS

Qualitative study with focus groups. Eighteen children/young adults with CP who experienced pain during physiotherapy were interviewed, using focus groups as a source of data collection in a phenomenological perspective. Data collection and analysis were consecutive to ensure that the data saturation point was reached. The transcripts were coded manually using thematic analysis. First, interesting features of the verbatim were coded, then codes were collated into potential themes and then the themes were checked to ensure they worked in relation to the coded extracts. Multiple coding was performed by 3 different researchers, and results were merged at each step.

RESULTS

This study confirmed that among the 18 children interviewed (mean [SD] age 13.17 [4.02] years, 10 girls), physiotherapy, particularly stretching, induced pain. Participants reported that the experience of pain led to a dislike of physiotherapy, although some believed that the pain was necessary to show that the treatment was effective. The use of distraction techniques and the relationship with the physiotherapist were key elements associated with the perception and experience of pain.

CONCLUSIONS

This study confirmed that patients with CP experience pain during physiotherapy. Stretching seems to be the main source of pain. Beliefs and practices regarding the concept of pain show that physiotherapists need training in this field.

Neurotrophic, anti-neuroinflammatory, and redox balance mechanisms of chalcones

The passage of time that evoke aging; the tilted redox balance that contribute oxidative entropy; the polarization of microglia cells that produce inflammatory phenotype; all represent the intricacies of CNS-dependent disease progression. Neurological diseases that result from CNS injury raise social concerns and the available therapeutic strategies are frustrated by low efficacy, high toxicity, and multiple side effects. However, emergent studies have shown the neuroprotective role of natural compounds - including chalcones - with high efficacy in the protection of CNS structures. These compounds reportedly demonstrate neurotrophic mechanism through the upregulation of neurotrophic factors, anti-apoptotic Bcl-2, and downregulation of Bax protein; anti-neuroinflammatory mechanism via the inhibition of neuroinflammatory pathways, attenuated secretion of pro-inflammatory cytokines, prevention of blood brain barrier (BBB) disruption, and protection against nerve senescence; antioxidant mechanism through the upregulation of Nrf2 activities, inhibition of Keap1, synthesis of antioxidant enzymes, and maintenance of high antioxidant/oxidant ratio. All these mechanisms represent chalcones' neuroprotective mechanisms. In this review, we highlight different pathways involved in CNS-related diseases and elucidate various mechanisms by which chalcones can perturb these shunts as a potential therapeutic modality.

MS Spasticity: Take Control (STC) for ambulatory adults: protocol for a randomized controlled trial

Background

Spasticity affects 60–80% of people with multiple sclerosis (MS), impacting activity, participation and quality of life. We developed the group delivered spasticity self-management program, “MS Spasticity: Take Control” (STC), with DVDs for education and lower extremity stretching. STC is based on an international guideline and recommendations from systematic reviews and emphasizes the importance of stretching with specific stretching exercises. Our pilot trial (n = 38) compared STC followed by one month of home stretching practice to unguided use of the National MS Society (NMSS) brochure titled “Stretching for People with MS: An Illustrated Manual,” also followed by one month of home stretching practice. In this pilot trial, STC showed promising effects on the impact of spasticity (MS Spasticity Scale-88) and other self-report and physical performance measures. We will now carry out a fully-powered trial to evaluate the effect of STC compared to a comparably delivered control program on the impact and severity of spasticity in people with MS and self-reported lower extremity spasticity.

Methods

Two hundred-twenty ambulatory adults with MS self-reported spasticity interfering with daily activities will be randomized 1:1 to STC or control, using the same NMSS brochure used in the pilot study, with both programs delivered in groups with trained facilitators. Outcomes are the impact of spasticity with the MS Spasticity Scale-88, the severity of spasticity with the Numeric Rating Scale for Spasticity, other self-report questionnaires, and physical performance walking measures at baseline and one and 6 months after the interventions.

Discussion

Stretching is the cornerstone of spasticity management. Stretching takes time and energy every day. Unfortunately, beyond the logical expectation that regular stretching should help prevent muscle shortening and contractures in the presence of spasticity, there is very little data on the effects of stretching on spasticity in people with MS or any other condition. Our pilot trial of STC suggested that education and stretching help reduce the impact of spasticity. To definitively determine if this education and instructional program with daily stretching practice is effective, a fully powered trial with a comparable control intervention and facilitators who did not create STC is needed. Here we report the protocol for this trial.

Trial registration

NCT03166930 May 25, 2017.

Stretching and Splinting Interventions for Poststroke Spasticity, Hand Function, and Functional Tasks: A Systematic Review

Importance: Spasticity is one of the most common and disabling motor impairments after stroke.

Objective: To examine the evidence for the effectiveness of stretching interventions, including splinting, on reducing upper extremity spasticity, increasing hand function, and improving functional tasks for adults with poststroke spasticity.

Data Sources: Databases searched were MEDLINE, CINAHL, OTseeker, AgeLine, and the Cochrane Library; results were limited to studies published from 2004 to January 2017.

Study Selection and Data Collection: Following PRISMA guidelines, we included articles describing Level I–III studies with participants who were adults with upper extremity spasticity and received a stretching intervention.

Findings: Eleven articles describing 6 Level I and 5 Level III studies met inclusion criteria.

Conclusion and Relevance: For reducing upper extremity spasticity, low strength of evidence was found to support the use of static splinting, strong strength of evidence was found for the use of stretching devices, and low strength of evidence was found to support the use of dynamic splinting; no evidence was found for manual stretching to address spasticity. For increasing hand function, moderate strength of evidence was found to support the use of static splinting, dynamic splinting, and manual stretching, and low strength of evidence was found for the use of stretching devices. For improving functional tasks, moderate strength of evidence was found to support the use of static splinting, dynamic splinting, and manual stretching, and low strength of evidence was found for the use of stretching devices.

What This Article Adds: This updated synthesis summarizes the current literature regarding the effectiveness of stretching interventions to improve poststroke spasticity, hand function, and functional tasks.

Stretching Interventions in Children With Cerebral Palsy: Why Are They Ineffective in Improving Muscle Function and How Can We Better Their Outcome?

Hyper-resistance at the joint is one of the most common symptoms in children with cerebral palsy (CP). Alterations to the structure and mechanical properties of the musculoskeletal system, such as a decreased muscle length and an increased joint stiffness are typically managed conservatively, by means of physiotherapy involving stretching exercises. However, the effectiveness of stretching-based interventions for improving function is poor. This may be due to the behavior of a spastic muscle during stretch, which is poorly understood. The main aim of this paper is to provide a mechanistic explanation as to why the effectiveness of stretching is limited in children with CP and consider clinically relevant means by which this shortcoming can be tackled. To do this, we review the current literature regarding muscle and tendon plasticity in response to stretching in children with CP. First, we discuss how muscle and tendon interact based on their morphology and mechanical properties to provide a certain range of motion at the joint. We then consider the effect of traditional stretching exercises on these muscle and tendon properties. Finally, we examine possible strategies to increase the effectiveness of stretching therapies and we highlight areas of further research that have the potential to improve the outcome of non-invasive interventions in children with cerebral palsy.

Longitudinal Change in Common Impairments in Children With Cerebral Palsy From Age 1.5 to 11 Years

PURPOSE

This project aimed to determine whether change occurs over time for impairments of balance, range of motion, endurance, and strength of children with cerebral palsy, by Gross Motor Function Classification System (GMFCS) levels.

METHODS

Measurements were completed in 77 children at 2 sessions (T1, T2) on average 5.8 years apart. Mean ages were 2.9 years (SD = 0.9) and 8.7 years (SD = 1.1) at T1 and T2, respectively.

RESULTS

There were significant differences from T1 to T2 for some children (GMFCS levels I, II, and III/IV: balance increased; GMFCS levels I and II: strength increased; and GMFCS levels III/IV and V: range of motion decreased). Endurance scores were not different and did not change.

CONCLUSIONS

Longitudinal changes in most impairments occurred in children with cerebral palsy. Monitoring and targeted interventions should support each child's development.

Transcutaneous Carbon Dioxide Improves Contractures After Spinal Cord Injury in Rats

BACKGROUND

Joint contractures are a major complication in patients with spinal cord injuries. Positioning, stretching, and physical therapy are advocated to prevent and treat contractures; however, many patients still develop them. Joint motion (exercise) is crucial to correct contractures. Transcutaneous carbon dioxide (CO2) therapy was developed recently, and its effect is similar to that of exercise. This therapy may be an alternative or complementary approach to exercise.

QUESTION/PURPOSES

Using an established model of spinal cord injury in rats with knee flexion contractures, we sought to clarify whether transcutaneous CO2 altered (1) contracture, as measured by ROM; (2) muscular and articular factors contributing to the loss of ROM; (3) fibrosis and fibrosis-related gene expression in muscle; and (4) the morphology of and fibrosis-related protein expression in the joint capsule.

METHODS

Thirty-six Wistar rats were divided into three equal groups: caged control, those untreated after spinal cord injury, and those treated with CO2 after spinal cord injury. The rats were treated with CO2 from either the first day (prevention) or 15th day (treatment) after spinal cord injury for 2 or 4 weeks. The hindlimbs of rats in the treated group were exposed to CO2 gas for 20 minutes once daily. Knee extension ROM was measured with a goniometer and was measured again after myotomy. We calculated the muscular and articular factors responsible for contractures by subtracting the post-myotomy ROM from that before myotomy. We also quantified histologic muscle fibrosis and evaluated fibrosis-related genes (collagen Type 1, α1 and transforming growth factor beta) in the biceps femoris muscle with real-time polymerase chain reaction. The synovial intima's length was measured, and the distribution of fibrosis-related proteins (Type I collagen and transforming growth factor beta) in the joint capsule was observed with immunohistochemistry. Knee flexion contractures developed in rats after spinal cord injuries at all timepoints.

RESULTS

CO2 therapy improved limited-extension ROM in the prevention group at 2 weeks (22° ± 2°) and 4 weeks (29° ± 1°) and in the treatment group at 2 weeks (31° ± 1°) compared with untreated rats after spinal cord injuries (35° ± 2°, mean difference, 13°; 39° ± 1°, mean difference, 9°; and 38° ± 1°, mean difference, 7°, respectively) (95% CI, 10.50-14.86, 8.10-10.19, and 4.73-9.01, respectively; all p < 0.001). Muscular factors decreased in treated rats in the prevention group at 2 weeks (8° ± 2°) and 4 weeks (14°± 1°) and in the treatment group at 2 weeks (14 ± 1°) compared with untreated rats (15° ± 1°, 4.85-9.42; 16° ± 1°, 1.24-3.86; and 17° ± 2°, 1.16-5.34, respectively; all p < 0.05). The therapy improved articular factors in the prevention group at 2 weeks (4° ± 1°) and 4 weeks (6° ± 1°) and in the treatment group at 2 weeks (8° ± 1°) compared with untreated rats (10° ± 1°, 4.05-7.05; 12° ± 1°, 5.18-8.02; and 11° ± 2°, 1.73-5.50, respectively; all p < 0.05). CO2 therapy decreased muscle fibrosis in the prevention group at 2 weeks (p < 0.001). The expression of collagen Type 1, α1 mRNA in the biceps femoris decreased in treated rats in the prevention group at 2 and 4 weeks compared with untreated rat (p = 0.002 and p = 0.008, respectively), although there was little difference in the expression of transforming growth factor beta (p > 0.05). CO2 therapy did not improve shortening of the synovial intima at all timepoints (all p > 0.05). CO2 therapy decreased transforming growth factor beta immunolabeling in joint capsules in the rats in the prevention group at 2 weeks. The staining intensity and Type I collagen pattern showed no differences among all groups at all timepoints.

CONCLUSION

CO2 therapy may be useful for preventing and treating contractures after spinal cord injuries. CO2 therapy particularly appears to be more effective as a prevention and treatment strategy in early-stage contractures before irreversible degeneration occurs, as shown in a rat model.

CLINICAL RELEVANCE

Our findings support the idea that CO2 therapy may be able to improve the loss of ROM after spinal cord injury.

A clinical study to assess the influence of acupuncture at "Wang's Jiaji" acupoints on limb spasticity in patients in convalescent stage of ischemic stroke: study protocol for a randomized controlled trial

BACKGROUND

Stroke is characterized by high morbidity, high mortality, and high disability. Spasticity, one of the most common complications after stroke, may reduce the potential success of rehabilitation and has a detrimental effect on stroke patients' daily function and quality of life. Moreover, the long-term management of spasticity is a financial burden to patients and increases societal costs. The current treatments, mainly including physical therapy, oral drugs, drug injection therapy, and surgical interventions, have been used to reduce spasticity. However, every conventional approach has its limitations. Acupuncture at the "Wang's Jiaji" acupoints, based on the experience of the famous old doctor of traditional Chinese medicine (TCM) Le Ting Wang in treating post-stroke limb spasm, has been widely practiced in our department. This intervention has effectively avoided the controversy around acupuncture at local acupoints on the limbs, and is easy to apply without side effects. Our previous studies had found that acupuncture at the "Wang's Jiaji-points" can reduce the occurrence and severity of spasticity occurring after stroke in the early stage (the first 21 days). In this study, we chose patients in the convalescent stage, 1-6 months after stroke, so as to study the efficacy and the specific intervention time of "Wang's jiaji" in the convalescent stage after stroke.

METHODS

This is a randomized, controlled, and single-blind study. Patients in the convalescent stage within 1-6 months of ischemic stroke will be selected as subjects. A total of 100 subjects will be randomly assigned to two groups. The acupuncture group will be given acupuncture treatment five times a week; the medicine group will be given 10mg baclofen three times a day. These two groups will continue to receive current usual care for the prevention and treatment of cerebrovascular diseases, but drugs that affect muscle tone will not be allowed. The treatment will last for 2 weeks. The primary outcome measurement is the simplified Fugl-Meyer Assessment. The secondary outcome measurements are the Modified Ashworth Scale, Modified Barthel Scale, and the H-reflex, F response, and H/M ratios of electromyography. All outcome measurements are assessed at baseline, 2 weeks, 4 weeks, and 12 weeks after first treatment except the electromyography, which is assessed at baseline and 2 weeks after first acupuncture.

DISCUSSION

This trial aims to evaluate the effects and the specific intervention time of "Wang's Jiaji" acupoints on spasticity after stroke.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN31511176 . Registered on 29 August 2017. Version number of protocol 2016-2-1161 Version date of protocol: 2016-1.

Small amounts of involuntary muscle activity reduce passive joint range of motion

When assessing passive joint range of motion in neurological conditions, concomitant involuntary muscle activity is generally regarded small enough to ignore. This assumption is untested. If false, many clinical and laboratory studies that rely on these assessments may be in error. We determined to what extent small amounts of involuntary muscle activity limit passive range of motion in 30 able-bodied adults. Subjects were seated with the knee flexed 90° and the ankle in neutral, and predicted maximal plantarflexion torque was determined using twitch interpolation. Next, with the knee flexed 90° or fully extended, the soleus muscle was continuously electrically stimulated to generate 1, 2.5, 5, 7.5, and 10% of predicted maximal torque, in random order, while the ankle was passively dorsiflexed to a torque of 9 N·m by a blinded investigator. A trial without stimulation was also performed. Ankle dorsiflexion torque-angle curves were obtained at each percent of predicted maximal torque. On average (mean, 95% confidence interval), each 1% increase in plantarflexion torque decreases ankle range of motion by 2.4° (2.0 to 2.7°; knee flexed 90°) and 2.3° (2.0 to 2.5°; knee fully extended). Thus 5% of involuntary plantarflexion torque, the amount usually considered small enough to ignore, decreases dorsiflexion range of motion by ~12°. Our results indicate that even small amounts of involuntary muscle activity will bias measures of passive range and hinder the differential diagnosis and treatment of neural and nonneural mechanisms of contracture.

NEW & NOTEWORTHY The soleus muscle in able-bodied adults was tetanically stimulated while the ankle was passively dorsiflexed. Each 1% increase in involuntary plantarflexion torque at the ankle decreases the range of passive movement into dorsiflexion by >2°. Thus the range of ankle dorsiflexion decreases by ~12° when involuntary plantarflexion torque is 5% of maximum, a torque that is usually ignored. Thus very small amounts of involuntary muscle activity substantially limit passive joint range of motion.

Additional early active repetitive motor training did not prevent contracture in adults receiving task-specific upper limb training after stroke: a randomised trial

QUESTION

In adults undergoing rehabilitation after stroke, does 1 hour of additional active repetitive reaching per day prevent or reduce upper limb contracture?

DESIGN

Multi-centre, randomised controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

Fifty adults undergoing rehabilitation after stroke who were unable to actively extend the affected wrist past neutral or were unable to flex the affected shoulder to 90 deg.

SETTING

Three inpatient rehabilitation units in Australia.

INTERVENTION

Both groups received usual upper limb therapy 5 days a week for 5 weeks. In addition, the experimental group received up to 1 hour a day of active, intensive, repetitive upper limb training using the SMART Arm device 5 days a week for 5 weeks.

OUTCOME MEASURES

Measures were collected at baseline (Week 0), after intervention (Week 5) and at follow-up (Week 7). The primary outcomes were passive range of wrist extension, elbow extension, and shoulder flexion at Week 5. The secondary outcomes were: the three primary outcomes measured at Week 7; passive range of shoulder external rotation; arm function; and pain at rest, on movement and during sleep measured at Weeks 5 and 7.

RESULTS

Following an average of 2310 reaching repetitions, the mean effect at Week 5 on passive range of wrist extension was 1 deg (95% CI -6 to 8), elbow extension -6 deg (95% CI -12 to -1), and shoulder flexion 5 deg (95% CI -8 to 17). There were no statistically significant or clinically important effects of the intervention on any secondary outcomes.

CONCLUSION

In adults who are already receiving task-specific motor training for upper limb rehabilitation following stroke, 5 weeks of up to 1 hour of additional daily active repetitive motor training using the SMART Arm device did not prevent or reduce contracture in upper limb muscles.

TRIAL REGISTRATION

ACTRN12614001162606.

Involuntary hamstring muscle activity reduces passive hip range of motion during the straight leg raise test: a stimulation study in healthy people

Background

Involuntary hamstring muscle activity is present in some people during the straight leg raise test, but it is not known to what extent involuntary muscle activity limits passive joint range of motion. This study aimed to determine whether small amounts of involuntary hamstring activity limit passive hip range of motion during the straight leg raise test in healthy people.

Methods

Thirty healthy subjects were recruited from The University of Sydney. As the hamstring muscles were continuously stimulated to generate 0, 2.5, 5, 7.5 and 10% of knee flexion maximal voluntary contraction force, an investigator blinded to the amount of stimulation performed a straight leg raise test by passively raising the tested leg while keeping the knee extended. The test was stopped when the knee started to flex, at which point hip range of motion was recorded.

Results

On average, passive hip range of motion decreased by 0.6° for every 1% increase in knee flexion force caused by muscle activation (95% CI 0.3 to 0.9°, p = 0.0012). Subjects were instructed to fully relax when the straight leg raise test was performed, but a small amount of involuntary muscle activity (median 2.4% of maximal activation) was present during the trial without stimulation.

Conclusions

Small amounts of involuntary hamstring muscles activity reduce passive hip range of motion during the straight leg raise test in healthy people.

Trial registration

The protocol for this study was registered with the Open Science Framework, reference: https://osf.io/fejpf/. Registered 9 March 2017.

Nociceptor-dependent locomotor dysfunction after clinically-modeled hindlimb muscle stretching in adult rats with spinal cord injury

In the course of investigating how common clinical treatments and adaptive technologies affect recovery after spinal cord injury (SCI), we discovered that a clinically-modeled hindlimb stretching protocol dramatically, but transiently, reduces locomotor function. Nociceptive sensory input is capable of altering motor output at the spinal level, and nociceptive neurons are sensitized after SCI. Here we tested the hypotheses that stretch-induced locomotor deficits are dependent on nociceptive afferents by depleting TRPV1+ sensory afferents using capsaicin injections in neonatal rats. Following maturation, animals received 25g-cm contusive SCI at T10. After plateau of locomotor recovery at 6 weeks, daily stretching was performed for 3 weeks, followed by 2 weeks without stretch, and again for two additional weeks. Animals were sacrificed 2 h after the last stretching session for histological assessments. Consistent with previous findings, stretch-induced drops in locomotor function were observed in nociceptor-intact animals but were nearly absent in nociceptor-depleted animals. These functional changes were accompanied by corresponding increases in the number of c-Fos+ nuclei throughout the lumbar enlargement. As expected, nociceptor-depleted animals had very little CGRP+ axonal innervation of the dorsal horn. Nociceptor-intact stretched animals had significantly higher levels of CGRP+ as compared to non-stretched SCI rats, suggesting that stretching promoted intraspinal CGRP+ sprouting. These results indicate that stretch-induced locomotor dysfunction in animals with incomplete SCI involves C-fibers, adding a negative post-SCI role to their adaptive roles (e.g., bladder control), and suggesting that the clinical use of muscle stretching to combat contractures and spasticity may be unintentionally detrimental to locomotor function.

Effectiveness of a programme comprising serial casting, botulinum toxin, splinting and motor training for contracture management: a randomized controlled trial

OBJECTIVE

To determine the effectiveness of a programme comprising serial casting, botulinum toxin, splinting and motor training in contracture management.

DESIGN

A randomized trial with concealed allocation and assessor blinding, a deferred treatment cross-over design within the control group, was conducted.

SETTING

Inpatient Brain Injury Unit of a rehabilitation centre.

SUBJECTS

A total of 10 patients with severe acquired brain injury (13 ankles).

INTERVENTIONS

The intervention group received botulinum toxin and then serial casting. The control group was placed on a wait list for six weeks (control phase) and then received the same interventions as the intervention group (intervention phase). Both groups received splinting and motor training following serial casting.

MAIN MEASURES

The primary outcome was passive ankle dorsiflexion range. Secondary outcomes included spasticity, ankle dorsiflexor strength, Functional Independence Measure score for the walking item and walking speed.

RESULTS

The mean between-group difference for passive ankle dorsiflexion range at completion of casting was 26° (95% confidence interval (CI): 17-35); at Week 2, after casting was 24° (95% CI: 14-33). The mean within-group differences for passive ankle dorsiflexion at completion of casting, Week 2 after casting and Week 8 after casting were 26° (95% CI: 20-31), 26° (95% CI: 18-33) and 24° (95% CI: 19-30), respectively. These improvements were sustained at Week 2 and Week 8 after casting.

CONCLUSIONS

A programme for contracture management comprising serial casting, botulinum toxin, motor training and splinting can be useful in improving joint range.

The evidence for prolonged muscle stretching in ankle joint management in upper motor neuron lesions: considerations for rehabilitation - a systematic review

BACKGROUND

As clinicians, muscles stretching approaches are one of the most commonly used interventions in rehabilitation. However, there is a need for an in-depth evaluation of research on prolonged stretching in terms of the features of the stretching approaches, such as duration and frequency, as well as the compatible measures of a successful stretching approach.

OBJECTIVE

This review is an effort to synthesize findings from studies on "prolonged" stretching approaches in patients with UMNs including stroke, spinal cord injuries, and traumatic brain injuries. We investigated the compatible features of successful stretching regimens in terms of reducing spasticity, improving the Active Range of Motion (AROM), Passive Range of Motion (PROM), and gait training of spastic patient with upper motor neuron lesions.

METHODS

Studies evaluating the effectiveness of "prolonged" stretching on spastic ankle planterflexor muscles and its complications were critically reviewed, and the level of evidence was analyzed.

RESULTS

There is a sufficient level of evidence to support the use of stretching as and effective techniques in rehabilitation. However, more research is yet to be done to objectively examine the ideal parameters of a successful stretching approach using functional assessments, such as walking, speed, walking capacity, and balance.

CONCLUSION

The review adds stronger understanding with regard to stretching considerations in rehabilitation following UMNs. The ideal approach, as well as the functional implications on motor performance are yet to be further studied.

Non-Muscular Structures Can Limit the Maximal Joint Range of Motion during Stretching

Stretching is widely used in sport training and clinical practice with the aim of increasing muscle-tendon extensibility and joint range of motion. The underlying assumption is that extensibility increases as a result of increased passive tension applied to muscle-tendon units. In some stretching protocols, this condition is not always met sufficiently to trigger adaptation within the muscle-tendon unit. For example, there is experimental evidence that both acute and chronic stretching interventions may increase the maximal range of motion in the absence of changes in the passive torque-angle curve. We contend that these results are partly explained by the influence of non-muscular structures that contribute only marginally to the passive torque. The potential candidates are the nervous system and fasciae, which would play an important role in the perception of the stretch and in the limitation of the range of motion of the maximal joints. At least in part, this may explain the lack of a significant effect of some chronic stretching interventions to change passive muscle tension.

Motor Impairment-Related Alterations in Biceps and Triceps Brachii Fascicle Lengths in Chronic Hemiparetic Stroke

Poststroke deficits in upper extremity function occur during activities of daily living due to motor impairments of the paretic arm, including weakness and abnormal synergies, both of which result in altered use of the paretic arm. Over time, chronic disuse and a resultant flexed elbow posture may result in secondary changes in the musculoskeletal system that may limit use of the arm and impact functional mobility. This study utilized extended field-of-view ultrasound to measure fascicle lengths of the biceps (long head) and triceps (distal portion of the lateral head) brachii in order to investigate secondary alterations in muscles of the paretic elbow. Data were collected from both arms in 11 individuals with chronic hemiparetic stroke, with moderate to severe impairment as classified by the Fugl-Meyer assessment score. Across all participants, significantly shorter fascicles were observed in both biceps and triceps brachii ( P < .0005) in the paretic limb under passive conditions. The shortening in paretic fascicle length relative to the nonparetic arm measured under passive conditions remained observable during active muscle contraction for the biceps but not for the triceps brachii. Finally, average fascicle length differences between arms were significantly correlated to impairment level, with more severely impaired participants showing greater shortening of paretic biceps fascicle length relative to changes seen in the triceps across all elbow positions ( r = -0.82, P = .002). Characterization of this secondary adaptation is necessary to facilitate development of interventions designed to reduce or prevent the shortening from occurring in the acute stages of recovery poststroke.

Botulinum toxin type A or selective neurotomy for treating focal spastic muscle overactivity?

OBJECTIVE

To discuss the effectiveness, indications, limitations and side effects of botulinum toxin type A and selective neurotomy for treating focal spastic muscle overactivity to help clinicians choose the most appropriate treatment.

METHODS

Expert opinion based on scientific evidence and personal experience.

RESULTS

Botulinum toxin type A can decrease muscle tone in different types of spastic muscle overactivity, which allows for treating a large variety of spastic patterns with several etiologies. The toxin effect is sometimes insufficient to improve functional outcome and is transient, thereby requiring repeated injections. Selective neurotomy is a permanent surgical treatment of the reflex component of the spastic muscle overactivity (spasticity) that is effective for spastic equinovarus foot. The neurotomy provides a greater and more constant reduction in spasticity. However, the long-lasting effect on the non-reflex muscle overactivity, especially dystonia, is doubted. The effectiveness, clinical indications, advantages, side effects and limitations of both techniques are discussed.

CONCLUSION

Botulinum toxin type A has the highest level of evidence and the largest range of indications. However, the botulinum toxin effect is reversible and seems less effective, which supports a permanent surgical treatment such as selective neurotomy, especially for the spastic foot. Further research is needed to compare the effect of botulinum toxin type A and selective neurotomy for the different types of spastic muscle overactivity and clinical patterns.

Evaluation of a toolkit for standardizing clinical measures of muscle tone

OBJECTIVE

To evaluate a new portable toolkit for quantifying upper and lower extremity muscle tone in patients with upper motor neuron syndrome (UMNS).

APPROACH

Cross-sectional, multi-site, observational trial to test and validate a new technology.

SETTING

Neurorehabilitation clinics at tertiary care hospitals.

PARTICIPANTS

Four cohorts UMNS patient, >6 mo post acquired brain injury, spinal cord injury, multiple sclerosis and cerebral palsy, and a sample of healthy age-matched adult controls.

MEASURES

Strength: grip, elbow flexor and extensor, and knee extensor; range of motion (ROM): passive ROM (contracture) and passive-active ROM (paresis); objective spasticity: stretch-reflex test for elbow, and pendulum test for knee; subjective spasticity: modified Ashworth scale scores for elbow and knee flexors and extensors.

RESULTS

Measures were acquired for 103 patients from three rehabilitation clinics. Results for patient cohorts were consistent with the literature. Grip strength correlated significantly with elbow muscle strength and all patient populations were significantly weaker in upper- and lower-extremity compared to controls. Strength and paresis were correlated for elbow and knee but neither correlated with contracture. Elbow spasticity correlated with strength and paresis but not contracture. Knee spasticity correlated with strength, and subjective spasticity correlated with contracture.

SIGNIFICANCE

The BioTone^™ toolkit provided comprehensive objective measures for assessing muscle tone in patients with UMNS. The toolkit could be useful for standardizing outcomes measures in clinical trials and for routine practice.

Spasticity in adults with cerebral palsy and multiple sclerosis measured by objective clinically applicable technique

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.

Awareness, potential factors, and post-amputation care of stump flexion contractures among transtibial amputees

Objectives

This study aims to assess the level of awareness of transtibial amputee patients on stump contractures and their compliance with efforts implemented to prevent the condition.

Patients and methods

This study included 50 unilateral transtibial amputees (26 males, 24 females; mean age 55.4±14.7 years; range, 18 to 78 years) who met the respondent criteria of the study. The respondents were randomly selected and were issued with a questionnaire.

Results

The majority of the transtibial amputees were aware of stump contracture complications. It was found that they also preferred methods of prevention which required less effort, was cost-effective, and were also practical.

Conclusion

More focus should be placed on contracture prevention methods which were most complied with by the patients. This is because the effectiveness of a prevention method is highly influenced by patients' compliance with the method. Patients with a higher risk of developing stump contractures should be also given more attention in post-amputation care.

Paratonia in Flemish Nursing Homes: Current State of Practice

BACKGROUND

Paratonia is a major underlying motor problem impeding functionality and locomotion in dementia. Despite its undeniable impact on patient's quality of life and daily care, there is a lack of evidence-based therapy on patients with this condition.

METHODS

We surveyed physiotherapists working in nursing homes in Flanders (Belgium) concerning the use and perceived effect of therapeutic strategies and positioning methods/aids.

RESULTS

Positioning and soft passive mobilization were the most applied and positively appraised therapeutic interventions. Highest ratings for positioning were found for C-shaped positioning cushions and multi-position wheelchair. According to the respondents, key points for paratonia approach were relaxation, positioning, active movement stimulation, and-to some extent-passive mobilization. Indispensable for any success however is multidisciplinary cooperation.

CONCLUSION

These findings might provide an inspirational path for research to verify possible (evidence based) beneficial treatments that could be applied to improve current and future treatment of patients with paratonia.

Daily muscle stretching enhances blood flow, endothelial function, capillarity, vascular volume and connectivity in aged skeletal muscle

KEY POINTS

In aged rats, daily muscle stretching increases blood flow to skeletal muscle during exercise. Daily muscle stretching enhanced endothelium-dependent vasodilatation of skeletal muscle resistance arterioles of aged rats. Angiogenic markers and capillarity increased in response to daily stretching in muscles of aged rats. Muscle stretching performed with a splint could provide a feasible means of improving muscle blood flow and function in elderly patients who cannot perform regular aerobic exercise.

ABSTRACT

Mechanical stretch stimuli alter the morphology and function of cultured endothelial cells; however, little is known about the effects of daily muscle stretching on adaptations of endothelial function and muscle blood flow. The present study aimed to determine the effects of daily muscle stretching on endothelium-dependent vasodilatation and muscle blood flow in aged rats. The lower hindlimb muscles of aged Fischer rats were passively stretched by placing an ankle dorsiflexion splint for 30 min day^-1 , 5 days week^-1 , for 4 weeks. Blood flow to the stretched limb and the non-stretched contralateral limb was determined at rest and during treadmill exercise. Endothelium-dependent/independent vasodilatation was evaluated in soleus muscle arterioles. Levels of hypoxia-induced factor-1α, vascular endothelial growth factor A and neuronal nitric oxide synthase were determined in soleus muscle fibres. Levels of endothelial nitric oxide synthase and superoxide dismutase were determined in soleus muscle arterioles, and microvascular volume and capillarity were evaluated by microcomputed tomography and lectin staining, respectively. During exercise, blood flow to plantar flexor muscles was significantly higher in the stretched limb. Endothelium-dependent vasodilatation was enhanced in arterioles from the soleus muscle from the stretched limb. Microvascular volume, number of capillaries per muscle fibre, and levels of hypoxia-induced factor-1α, vascular endothelial growth factor and endothelial nitric oxide synthase were significantly higher in the stretched limb. These results indicate that daily passive stretching of muscle enhances endothelium-dependent vasodilatation and induces angiogenesis. These microvascular adaptations may contribute to increased muscle blood flow during exercise in muscles that have undergone daily passive stretch.

Mirror therapy and treadmill training for a patient with chronic stroke: A case report

INTRODUCTION

A large proportion of patients with chronic stroke have permanent lower limb functional disability leading to reduced levels of independent mobility. Individually, both mirror therapy and treadmill training have been shown to improve aspects of lower limb functioning in patients with stroke. This case report examined whether a new combination of both interventions would lead to improvements in lower limb functional disability for a patient with chronic stroke.

CASE DESCRIPTION

The participant was a 50-year-old female who had a left middle cerebral artery infarction (47 months' post stroke). Due to hemiparesis, she had lower limb motor impairment and gait deficits.

INTERVENTION

The participant engaged in a combination of mirror therapy and treadmill training for 30 minutes per day, 3 days per week, for 4 weeks.

OUTCOMES

Modified Ashworth Scale, Fugl-Meyer Assessment-Lower Extremity and the 10 m Walk Test demonstrated clinically meaningful change. The 6 Minute Walk Test did not demonstrate meaningful change.

DISCUSSION

The positive outcomes from this new combination therapy for this participant are encouraging given the relatively small dose of training and indicate the potential benefit of mirror therapy as an adjunct to treadmill training for enhancing lower limb muscle tone, motor function and walking velocity in patients with chronic stroke.

Accumulation of advanced-glycation end products (AGEs) accelerates arthrogenic joint contracture in immobilized rat knee

Joint mobility decreases in the elderly and in diabetics, this process is thought to be caused by accumulation of advanced-glycation end products (AGEs). Here, we aimed to elucidate the role of AGEs in joint contracture formation in rat knees. Rats were injected with ribose or saline into the knees twice weekly for 8 weeks. Pentosidine (AGE) levels were measured in the knee-joint tissues. After serial injections, rats were subjected to unilateral knee-joint immobilization in a flexion position for various periods. At day 21, the passive knee ranges of motions (ROMs) were measured. Knee joint histopathology were assessed, and the expression of fibrotic genes in the posterior joint capsules was examined using real-time PCR. Ribose injection induced a 7.0-fold increase in pentosidine levels relative to saline injection. Joint immobilization resulted in equal myogenic ROM restriction in both groups. Arthrogenic ROM restriction was greater with ribose injection in the immobilized joints (p < 0.05), but was not affected in nonimmobilized joints. Type-I (COL1A1) and type-III (COL3A1) collagen gene expression increased significantly in immobilized joints relative to nonimmobilized joints in the ribose group, but was not affected in the saline group. Ribose injection increased COL1A1 expression slightly and COL3A1 expression significantly in immobilized joints. Histologically, inflammatory changes appeared at day 3 of immobilization and peaked at day 7. These responses trended to be more severe and prolonged in the ribose group than in the saline group. Our data provide evidence for a causal relationship between AGEs and joint contracture formation following immobilization. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:854-863, 2018.

Non-pharmacological interventions for spasticity in adults: An overview of systematic reviews

OBJECTIVES

Spasticity causes significant long-term disability-burden, requiring comprehensive management. This review evaluates evidence from published systematic reviews of clinical trials for effectiveness of non-pharmacological interventions for improved spasticity outcomes.

METHODS

Data sources: a literature search was conducted using medical and health science electronic (MEDLINE, EMBASE, CINAHL, PubMed, and the Cochrane Library) databases for published systematic reviews up to 15th June 2017.

DATA EXTRACTION AND SYNTHESIS

two reviewers applied inclusion criteria to select potential systematic reviews, independently extracted data for methodological quality using Assessment of Multiple Systematic Reviews (AMSTAR). Quality of evidence was critically appraised with Grades of Recommendation, Assessment, Development and Evaluation (GRADE).

RESULTS

Overall 18 systematic reviews were evaluated for evidence for a range of non-pharmacological interventions currently used in managing spasticity in various neurological conditions. There is "moderate" evidence for electro-neuromuscular stimulation and acupuncture as an adjunct therapy to conventional routine care (pharmacological and rehabilitation) in persons following stroke. "Low" quality evidence for rehabilitation programs targeting spasticity (such as induced movement therapy, stretching, dynamic elbow-splinting, occupational therapy) in stroke and other neurological conditions; extracorporeal shock-wave therapy in brain injury; transcranial direct current stimulation in stroke; transcranial magnetic stimulation and transcutaneous electrical nerve stimulation for other neurological conditions; physical activity programs and repetitive magnetic stimulation in persons with MS, vibration therapy for SCI and stretching for other neurological condition. For other interventions, evidence was inconclusive.

CONCLUSIONS

Despite the available range of non-pharmacological interventions for spasticity, there is lack of high-quality evidence for many modalities. Further research is needed to judge the effect with appropriate study designs, timing and intensity of modalities, and associate costs of these interventions.

To Evaluate the Effectiveness of TBTS - A Novel Device to do Self-Stretching of Gastroc-Soleus Muscle in Patients with Equinus Deformity

INTRODUCTION

Various methods have been used for management of equinus deformity. However, stretching gastroc-soleus muscle and achilles tendon is a difficult task. It is labour intensive, which makes the provision of treatment difficult for many patients.

AIM

To study the effectiveness of Tension Bar Tendon Stretch (TBTS) compared to conventional stretching in patients with equinus deformity in terms of improvement in equinus angle and spasticity.

MATERIALS AND METHODS

A prospective randomised case control study was done on 16 patients of both the sexes in the age group four years to 56 years. Patients were stratified based on presence or absence of spasticity. Patients were further randomly allotted to the study or control group. Study group received stretching with TBTS in addition to the conventional rehabilitation programme. Patients were assessed in terms of improvement in equinus deformity and spasticity (modified Ashworth scale). These indices were measured at 0 month (pre-treatment), 1 month (post-treatment), and 6 months (follow up).

RESULTS

Equinus deformity in patients with spastic equinus changed from 22.4° to 12° in study group while in control group change was from 21° to 17°. The difference was statistically significant with p-value of 0.001. Non-spastic (post accidental) changed from 30° to 15° in study group while in control group change was from 31° to 23° with p-value of 0.001. Modified Ashworth Score (MAS) was assessed only in spastic equinus, while in study group MAS changed from 2.8 to 1.5 and MAS change was 2.6 to 2 in control group; this difference after six months of therapy was statistically significant with a p-value of 0.001.

CONCLUSION

TBTS can be an effective tool in rehabilitation of patients having equinus deformity; it provides an effective and patient controlled stretching and no need for a physical therapist. TBTS is a novel but simple instrument that can be made locally by the patient or the family.

Coupling Timing of Interventions With Dose to Optimize Plasticity and Participation in Pediatric Neurologic Populations

PURPOSE

The purpose of this article is to propose that coupling of timing of interventions with dosing of interventions optimizes plasticity and participation in pediatric neurologic conditions, specifically cerebral palsy. Dosing includes frequency, intensity, time per session, and type of intervention. Interventions focus on body structures and function and activity and participation, and both are explored. Known parameters for promoting bone, muscle, and brain plasticity and evidence supporting critical periods of growth during development are reviewed. Although parameters for dosing participation are not yet established, emerging evidence suggests that participation at high intensities has the potential for change. Participation interventions may provide an additional avenue to promote change through the life span. Recommendations for research and clinical practice are presented to stimulate discussions and innovations in research and practice.

School-Based Work Capacity Evaluation in Young People With Intellectual Disabilities: 2 Case Reports

PURPOSE

These case reports examine the application of a work capacity/work-hardening model to increase work capacity in young people with disabilities.

KEY POINTS

Examination, evaluation, interventions, and outcomes are described for 2 teenagers with intellectual disability. This approach is novel in that it uses functional capacity evaluation concepts used in ergonomic/occupational health contexts and applies them to youth with disabilities in educational settings.

CONCLUSION

These concepts expand the scope of practice for physical therapists in school settings and potentially increase work opportunities for youth with disabilities.