Recent Advances in the Treatment of Spasticity: Extracorporeal Shock Wave Therapy

Unlocking new Frontiers: The cellular and molecular impact of extracorporeal shock wave therapy (ESWT) on central nervous system (CNS) disorders and peripheral nerve injuries (PNI)

Neurological disorders encompassing both central nervous system (CNS) diseases and peripheral nerve injuries (PNI), represent significant challenges in modern clinical practice. Conditions such as stroke, spinal cord injuries, and carpal tunnel syndrome can cause debilitating impairments, leading to reduced quality of life and placing a heavy burden on healthcare systems. Current treatment strategies, including pharmacological interventions and surgical procedures, often yield limited results, and many patients experience suboptimal outcomes or treatment-associated risks. In light of these limitations, there is a growing interest in exploring non-invasive therapeutic alternatives. Among these, extracorporeal shock wave therapy (ESWT) has eme rged as a promising modality, demonstrating efficacy in musculoskeletal conditions and gaining attention for its potential role in neurological disorders. This manuscript aims to provide a comprehensive overview of the cellular and molecular mechanisms underlying ESWT, focusing on its therapeutic applications in CNS diseases and PNI, thereby shedding light on its potential to revolutionize the treatment landscape for neurological conditions.

Investigation of The Effectiveness of Extracorporeal Shock Wave Therapy in Patients Diagnosed with Plantar Fasciitis: Comparison of Radial and Focus Applications

The aim of the study was to investigate the effectiveness of radial and focus (extracorporeal shock wave therapy) ESWT treatment on pain, function and size of the calcaneal spur in patients with clinical and radiological diagnosis of plantar fasciitis. A total of 112 patients aged between 18 and 95 years, were divided into 2 groups; group 1, rESWT (2.4 bar 12 hz 2000 beats), group 2 received fESWT (0.14 bar 14 hz 1000 beats) 3 times a week for 3 weeks. All patients were evaluated using the Visual Analog Scale (VAS)-pain and Foot Function Index before and after the treatment, at 4 week and 12 weeks. Calcaneal spur size was measured radiographically in the patients before and after the treatment at the 12th week follow-up. According to our records, VAS scores were found to be similar between the groups before treatment and at follow-ups (all p > .05). In both groups, a significant decrease in VAS scores was found in the follow-ups compared to before treatment (p < .001). FFI total, pain, activity and disability scores were found to be similar between the groups before treatment and at follow-up (all p > .05). In both groups, a significant decrease in Foot Function Index scores was found in the follow-ups compared to before treatment (p < .001). Both of rESWT and fESWT were effective in plantar fasciitis treatment there were no significant difference between 2 modalities in long term.

Effect of extracorporeal shock wave therapy on nerve conduction: a systematic review and meta-analysis

Background

Extracorporeal shock wave therapy (ESWT), as a non-invasive physical agent modality, was effective in relieving spasticity, reducing pain, and improving dysfunction. This systematic review and meta-analysis aimed to investigate the effect of ESWT on nerve conduction, and to find out whether the ESWT group is superior to the control or other comparison groups, thus providing support for guiding the rehabilitation of peripheral nerve injury in clinical work.

Methods

PubMed, Web of Science, the Cochrane Library, and Embase were searched from inception to August 20, 2024. This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered in the PROSPERO database (registration number CRD42024500891). It aimed to compare (1) the ESWT group (ESWT) and baseline, and (2) subgroup analyses: ESWT and the control group (Control), ESWT and the local corticosteroid injection group (LCI), ESWT combined with physical therapy (ESWT + PT) and PT alone, and ESWT and PT. Outcome indicators extracted were nerve conduction study results: sensory nerve action potential (SNAP) amplitude, SNAP distal latency, sensory nerve conduction velocity (SNCV), compound muscle action potential (CMAP) amplitude, motor nerve distal latency (MNDL), motor nerve conduction velocity (MNCV), H/M ratio and H-reflex latency.

Results

A total of 879 papers were identified through the database searches. Twenty-four trials were included in the systematic review, and 22 trials were included in the meta-analysis. The results showed that: (1) compared to the baseline, ESWT reduced SNAP distal latency mid-term (MD, -0.39; 95% CI: -0.52, -0.26; I 2 = 85%), and improved SNCV both short-term (MD, 4.36; 95% CI: 1.23, 7.49; I 2 = 91%) and mid-term (MD, 2.65; 95% CI: 1.79, 3.51; I 2 = 61%). At the same time, it reduced MNDL short-term (MD, -0.61; 95% CI: -0.91, -0.30; I 2 = 92%), but had no significant effect on MNCV. (2) Subgroup analyses showed that ESWT was superior to Control but not significantly better than LCI, especially in SNCV. The excitatory effect of ESWT + PT on the sensory and motor nerves was significantly better than that of PT alone.

Conclusion

ESWT had some excitatory effect on peripheral nerves, especially on sensory nerve studies. Although the efficacy of this treatment was superior to that of the control group, and the combined treatment with PT was more effective than PT alone, its efficacy might not exceed that of LCI.

Systematic review registration

Unique identifier: PROSPERO (CRD42024500891).

EFFECTIVENESS OF RADIAL EXTRACORPOREAL SHOCKWAVE THERAPY IN THE LOCAL MANAGEMENT OF HYPERTONIA (SPASTICITY AND DYSTONIA) IN PATIENTS WITH CEREBRAL PALSY

Objective

To assess the effect of radial extracorporeal shockwave therapy on the reduction of local hypertonia in patients with cerebral palsy.

Design

Explorative pre-post intervention study.

Subjects/Patients

Forty-five patients with cerebral palsy.

Methods

All patients received 3 sessions of radial extracorporeal shockwave therapy with a time interval of 1 week for each session. The outcomes were V1 and V3 of the Tardieu scale, the Timed Up and Go test, and the 10-metre walk test. The measurements were collected at baseline, immediately after the last session of shockwaves, at 12 and 24 weeks after baseline.

Results

The statistical analysis used was a mixed linear model of repeated measures. The degrees on the Tardieu scale increased significantly in all the treated muscles. The results of the Timed Up and Go test and the 10 m walk test confirmed a significant functional effect after the shockwave therapy (p < 0.001).

Conclusion

Functional improvement in patients treated with extracorporeal shockwave therapy has been observed to last up to 24 weeks.

The effectiveness of early interventions for post-stroke spasticity: a systematic review

PURPOSE

To synthesize evidence on the effect of early post-stroke spasticity interventions.

METHODS

Systematic literature search (PubMed, Embase, and Web of Science) encompassing studies on spasticity reducing interventions within 3 months post stroke on outcome defined within the International Classification of Functioning (ICF).

RESULTS

In total, 27 studies were identified with n = 1.658 cases. Botulinum toxin (2-12 weeks; 10 studies, n = 794) showed consistent and significant reduced spasticity by Modified Ashworth Scale (MAS) or electromyography (EMG). Electrical muscle stimulation (1-8 weeks; 6 studies, n = 335) showed lower MAS/Composite Spasticity Scale scores in 4 studies. Transcranial stimulation (3 studies; n = 131), oral spasmolytics (1 study; n = 38), shockwave (1 study; n = 40), orthotics (3 studies; n = 197 and robot-assisted therapy (3 studies; n = 123) showed inconclusive results. Effects on ICF activity domain could not be established due to limited data and large outcome measures heterogeneity. One out of two studies showed significant benefit for early compared to late BoNT intervention (< 90 vs> 90 days).

CONCLUSION

This study provides evidence for early applied (<3 months) BoNT to effectively reduce spasticity and probable effectiveness of electrical stimulation. Establishing effects of interventions in the acute/hospitalization phase (<7 days) needs further work, specifically on the ICF activity domain. Standardization of outcome measures is required.

Radial extracorporeal shock wave therapy for the management of spasticity in cerebral palsy: study protocol for a randomized controlled trial

Background

Spasticity is the most common motor disorder in cerebral palsy (CP), and its management is complex, posing a significant challenge for the rehabilitation team. Radial extracorporeal shock wave therapy (rESWT) has emerged in recent years as an effective, non-invasive, and low-risk alternative for the management of spasticity in CP patients, with only minor side effects such as small bruises or discomfort during application. There is great variability in rESWT administration protocols, ranging from a single session up to the 12 sessions. The most extensively studied protocol involves 3 rESWT sessions with a one-week interval between session. According to current literature, the effect of rESWT has not been investigated by extending the time interval between sessions beyond 1 week to determine if therapeutic effects on spasticity can be prolonged over time.

Methods

Following a power calculation using the minimal clinical important difference of our primary outcome (R2 of Modified Tardieu Scale), 72 patients will be included in the study. Enrolment is based upon inclusion/exclusion criteria outlined in the Methods section. Participants will be randomized in 3 groups. Each patient will receive 2000 impulses in the Triceps Sural muscle (distributed by all the plantar flexor muscles: soleus and gastrocnemius), at a 2.2 Bars pressure and a frequency of 8 Hz. The Control Group will receive 3 rESWT sessions with a time interval of 1 week between each session. The Experimental Group A will receive 3 rESTW sessions with a time interval of 2 weeks between each session and the Experimental Group B will receive 3 rESTW sessions with a time interval of 4 weeks between each session.

Discussion

This study will provide further information regarding the effect of rESWT on spasticity in patients with CP. If an increase in the time interval between rESWT sessions allows for the prolongation of therapeutic benefits on spasticity, it will be clinically relevant fact. With the same treatment dosage, patients will be able to benefit from its effects for a longer period of time.

Clinical trial registration

ClinicalTrials.gov, identifier NCT05702606.

Safety and effectiveness of thermal radiofrequency applied to the musculocutaneous nerve for patients with spasticity

Objective

Evaluate safety and effectiveness of thermal radiofrequency in the musculocutaneous nerve in patients with focal elbow flexor spasticity.

Design

Ambispective observational follow-up study. Patients with focal spasticity secondary to central nervous system injury with elbow flexor pattern who received thermal radiofrequency treatment in the musculocutaneous nerve between 2021 and 2023 were included.

Subjects

12 patients.

Methods

Ultrasound-guided thermal radiofrequency was applied to the musculocutaneous nerve at 80°C for 90 s. Effectiveness was assessed prior to thermal radiofrequency and at 6 months using scales to measure pain (VAS), spasticity (MAS), disability (DAS), quality of life (SQol-6D), patient-perceived and physician-perceived satisfaction (PIG-C, PGA), and goal attainment (GAS). Elbow joint range of motion was evaluated via goniometry. Safety was evaluated by assessing side effects.

Results

Patients had statistically significant improvements in spasticity (p = 0.003), severe elbow flexion (p = 0.02), pain (p = 0.046), functioning (p < 0.05), and spasticity-related quality of life (p < 0.05 in three sections). Furthermore, treatment goals were attained. Patient- and physician-perceived clinical improvement was achieved. Regarding side effects, two patients had dysesthesia that was self-limiting, with maximum duration of 1 month.

Conclusion

Thermal radiofrequency in the musculocutaneous nerve can be a safe, effective treatment for patients with severe spasticity with an elbow flexor pattern.

Extracorporeal Shockwave Treatment as Additional Therapy in Patients with Post-Stroke Spasticity of Upper Limb-A Narrative Review

Stroke is a severe injury of the central nervous system (CNS) and one of the leading causes of long-term disability and mortality. One of the main symptoms of neurological diseases is spasticity. This is defined as a motor condition characterized by a velocity-dependent increase in tonic stretch reflexes with exaggerated tendon jerks and resulting in the hyperexcitability of the stretch reflex. Rehabilitation after a stroke is focused on relearning lost skills and regaining independence. Many new methods in neurorehabilitation have been introduced. This review concentrates on the current evidence for extracorporeal shockwave therapy (ESWT) as a noninvasive alternative to treat spasticity. We present the effect of EWST and radial EWST interventions to post-stroke patients with spasticity in the upper limb. Our collected data suggest that different parameters of shockwaves can be used to achieve functional improvementsin the upper limb after a stroke. Our accumulated data imply that ESWT is safe and can be used for pain relief, reduced muscle tension, and an increased range of motion. According to many studies, complications after shockwave treatment are infrequent. Transient complications after shockwave therapy (ESWT) include redness, tingling, pain, and bruising. We reviewed clinical trials that present the possible benefits in upper-limb function after shockwave therapy for post-stroke patients. In this article, we used many database search engines, including PEDro. In the stroke rehabilitation literature, a key methodological problem is the design of double-blind studies, which very often are not feasible.

Research progress in spasmodic torticollis rehabilitation treatment

Spasmodic torticollis (ST) is a focal dystonia that affects adults, causing limited muscle control and impacting daily activities and quality of life. The etiology and curative methods for ST remain unclear. Botulinum toxin is widely used as a first-line treatment, but long-term usage can result in reduced tolerance and adverse effects. Rehabilitation therapy, with its minimal side effects and low potential for harm, holds significant clinical value. This article explores the effectiveness of adjunctive therapies, including exercise therapy, transcranial magnetic stimulation, shockwave therapy, neuromuscular electrical stimulation, vibration therapy, electromyographic biofeedback, and acupuncture, in the treatment of ST. The aim is to provide clinicians with additional treatment options and to discuss the efficacy of rehabilitation therapy for ST.

Acupuncture for post-stroke spasticity: An overview of systematic reviews

BACKGROUND

Post-stroke spasticity (PSS) is the most common complication of stroke. Acupuncture is widely used in clinical practice for the treatment of PSS, and is therefore considered a common complementary treatment. Several systematic reviews (SRs) and meta-analyses (MAs) have demonstrated the efficacy and safety of acupuncture in the treatment of PSS; however, the quality of evidence of these studies has not been adequately assessed.

OBJECTIVE

To evaluate and summarize the SRs/MAs and inform future research and clinical practice on the efficacy and safety of acupuncture for PSS.

DATA SOURCES AND EXTRACION

The following databases were searched from their dates of inception to March 26, 2023: PubMed, Embase, The Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Wanfang Database, SinoMed, and Chinese Science and Technology Periodical Database (VIP), and grey literature were manually searched. Two reviewers independently completed literature retrieval, screening, and data extraction.

REVIEW APPRAISAL

Systematic evaluation tools to Assess Systematic Reviews (AMSTAR) 2, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020 Checklist), and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system were used to systematically evaluate the methodological, reporting, and evidence quality of the SRs/MAs.

RESULTS

Overall, 226 papers were examined, and after careful consideration, 10 SRs/MAs were deemed eligible for inclusion. The AMSTAR 2 assessment revealed that one SR/MA had medium, one study had low, and the remaining eight studies had critically low methodological qualities. Additionally, four SRs/MAs completed more than 60 % of the PRISMA 2020 checklist. The GRADE system indicated that six outcomes were medium, 26 outcomes were low, and 24 outcomes were critically low.

CONCLUSION

Based on the evidence, acupuncture may be a promising complementary treatment to improve post-stroke spasticity and quality of life. Further high-quality RCTs are needed in future studies to support the broader application of acupuncture for the treatment of PSS.

Conventional physical therapy combined with extracorporeal shock wave leads to positive effects on spasticity in stroke survivors: a prospective observational study

The study aimed to evaluate the effectiveness of radial extracorporeal shock wave therapy (rESWT) and conventional physical therapy (CPT) protocol on the gait pattern in stroke survivors through a new gait analysis technology. Fifteen (n=15) stroke survivors took part in this prospective, observational study and were assessed clinically and through an instrumented treadmill before and after rESWT and CPT. Spasticity grade 95% CI 0.93 (0.79 +/- 1.08), pain intensity 95% CI 1.60 (1.19 +/- 2.01), and clonus score decreased significantly 95% CI 1.13 (0.72 +/- 1.54). The sensorimotor function 95% CI -2.53 (-3.42 +/- 1.65), balance 95% CI -5.67 (-6.64 +/- - 4.69), and gait parameters were enhanced at the end of the program. Step length 95% CI -3.47 (-6.48 +/- 0.46) and step cycle were improved 95% CI -0.09 (-0.17 +/- -0.01), and hip 95% CI -3.90 (-6.92 +/- -0.88), knee 95% CI -2.08 (-3.84 +/- -0.32) and ankle flexion-extension 95% CI -2.08 (-6.64 +/- -4.69) were augmented. Adding the quantitative analysis to the clinical assessment, we gained easy access to track progress and obtained an individualized therapeutic approach for stroke survivors.

A Comprehensive Review of the Effects of Extracorporeal Shock Wave Therapy on Stroke Patients: Balance, Pain, Spasticity

Stroke remains a leading cause of disability worldwide, with survivors often experiencing impairments in balance, pain, spasticity, and control that limit their ability to perform daily living activities. Extracorporeal shock wave therapy (ESWT) has emerged as a potential treatment modality to improve these outcomes in stroke patients. This review aims to provide a comprehensive examination of the effects of ESWT on stroke patients, focusing on the theoretical background, balance, pain reduction, muscle spasticity and control, and upper and lower extremities. This study reviewed the use of ESWT in treating balance, pain, and spasticity in stroke patients, focusing on articles published in PubMed between January 2003 and January 2023. Systematic reviews related to stroke were used to provide an overview of stroke, and a total of 33 articles related to balance, pain, and spasticity were selected. ESWT has several shock wave generation methods and application methods, and it has been shown to have positive therapeutic effects on various aspects of rehabilitation for stroke patients, such as improving balance, reducing pain, decreasing muscle spasticity and increasing control, and enhancing functional activities of the upper and lower extremities. The efficacy of ESWT may vary depending on the patient's condition, application method, and treatment area. Therefore, it is important to apply ESWT according to the individual characteristics of each patient in clinical practice to maximize its potential benefits.

The Effects of Shock Wave Therapy on Spasticity and Walking Ability in People with Stroke: A Comparative Study of Different Application Sites

BACKGROUND

This study was conducted to investigate the effects of extracorporeal shock wave therapy on the improvement of walking ability through a reduction in spasticity in stroke patients.

METHODS

Thirty-three patients diagnosed with ischemic stroke by a rehabilitation medicine specialist were randomly assigned to three groups. The patients were divided into experimental group 1 in which shock waves were applied to the muscle-tendon junction, experimental group 2 in which shock waves were applied to the middle of the muscle, and experimental group 3 in which shock waves were applied to both the muscle-tendon junction and the middle of the muscle. The MAS was used to evaluate spasticity in the subjects, and the Dartfish software was used to measure knee and ankle angles during heel-off when walking.

RESULTS

Based on the results of the study, a significant decrease in spasticity and increased joint angles were found in experimental groups 1 and 3 compared to experimental group 2, and the change in joint angle was significantly greater in experimental group 3 than in experimental groups 1 and 2.

CONCLUSIONS

These results indicate that treatment effect may vary depending on the application site of the shock wave, and to obtain the best treatment effect, the shock wave should be applied to both the muscle-tendon junction and the middle part of the muscle.

Research progress in extracorporeal shock wave therapy for upper limb spasticity after stroke

Spasticity is one of the most common complications after stroke. With the gradual intensification of spasticity, stroke patients will have a series of problems such as joint ankylosis and movement restriction, which affect the daily activities and increase the burden on patients' families, medical staff and society. There are many ways to treat post-stroke spasticity before, including physical therapy and exercise therapy, drug therapy, surgery and so on, but not satisfied because of a few shortcomings. In recent years, many researchers have applied extracorporeal shock wave therapy (ESWT) for the treatment of post-stroke spasm and achieved good clinical effect, because it is non-invasive, safe, easy to operate, low cost and other advantages compared with other treatment methods. This article reviews the research progress and existing problems of ESWT in the treatment of post-stroke spasticity.

An online method to monitor hand muscle tone during robot-assisted rehabilitation

Introduction: Robot-assisted neurorehabilitation is becoming an established method to complement conventional therapy after stroke and provide intensive therapy regimes in unsupervised settings (e.g., home rehabilitation). Intensive therapies may temporarily contribute to increasing muscle tone and spasticity, especially in stroke patients presenting tone alterations. If sustained without supervision, such an increase in muscle tone could have negative effects (e.g., functional disability, pain). We propose an online perturbation-based method that monitors finger muscle tone during unsupervised robot-assisted hand therapy exercises. Methods: We used the ReHandyBot, a novel 2 degrees of freedom (DOF) haptic device to perform robot-assisted therapy exercises training hand grasping (i.e., flexion-extension of the fingers) and forearm pronosupination. The tone estimation method consisted of fast (150 ms) and slow (250 ms) 20 mm ramp-and-hold perturbations on the grasping DOF, which were applied during the exercises to stretch the finger flexors. The perturbation-induced peak force at the finger pads was used to compute tone. In this work, we evaluated the method performance in a stiffness identification experiment with springs (0.97 and 1.57 N/mm), which simulated the stiffness of a human hand, and in a pilot study with subjects with increased muscle tone after stroke and unimpaired, which performed one active sensorimotor exercise embedding the tone monitoring method. Results: The method accurately estimates forces with root mean square percentage errors of 3.8% and 11.3% for the soft and stiff spring, respectively. In the pilot study, six chronic ischemic stroke patients [141.8 (56.7) months after stroke, 64.3 (9.5) years old, expressed as mean (std)] and ten unimpaired subjects [59.9 (6.1) years old] were tested without adverse events. The average reaction force at the level of the fingertip during slow and fast perturbations in the exercise were respectively 10.7 (5.6) N and 13.7 (5.6) N for the patients and 5.8 (4.2) N and 6.8 (5.1) N for the unimpaired subjects. Discussion: The proposed method estimates reaction forces of physical springs accurately, and captures online increased reaction forces in persons with stroke compared to unimpaired subjects within unsupervised human-robot interactions. In the future, the identified range of muscle tone increase after stroke could be used to customize therapy for each subject and maintain safety during intensive robot-assisted rehabilitation.

Shock waves modulate corticospinal excitability: A proof of concept for further rehabilitation purposes?

Background

Focal extracorporeal shock wave therapy (fESWT) is a physical therapy vastly studied and used for various musculoskeletal disorders. However, the effect of fESWT on central nervous system is still to be determined.

Objective

To elucidate spinal and supra-spinal mechanisms of fESWT in healthy subjects, in order to widen the spectrum of its clinical applications.

Methods

In this quasi-experimental, unblinded, proof-of-concept clinical study, 10 voluntary healthy subjects underwent fESWT and were assessed immediately before (T0), immediately after (T1) and seven days after (T2) the intervention. As neurophysiological outcomes, motor evoked potentials (resting motor threshold, maximal motor evoked potential and maximal compound muscle action potential ratio, cortical silent period, total conduction motor time, direct and indirect central motor conduction time), F-waves (minimal and mean latency, persistence and temporal dispersion) and H-reflex (threshold, amplitude, maximal H reflex and maximal compound muscle action potential ratio, latency) were considered.

Results

Resting motor threshold and F-waves temporal dispersion significantly decreased, respectively, from T1 and T2 and from T0 and T2 (for both, p <  0.05). H-reflex threshold increase between T0 and T1. Analysis disclosed a strong negative correlation between Δ3 cortical silent period (i.e., T2 -T1 recordings) and Δ1 Hr threshold (i.e., T1 -T0 recordings) (r = -0.66, p <  0.05), and a positive strong relationship between Δ3 cortical silent period and Δ3 Hr threshold (r = 0.63, p <  0.05).

Conclusions

fESWT modulates corticospinal tract excitability in healthy volunteers, possibly inducing an early inhibition followed by a later facilitation after one week.

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.

Isokinetic Resistance Training for Ankle Plantarflexor Spasticity and Muscle Weakness in People With Multiple Sclerosis: A Proof-of-Concept Case Series

OBJECTIVE

To the best of the authors' knowledge, no data are available about the use of isokinetic resistance training for managing ankle plantarflexor spastic hypertonia in people with multiple sclerosis (MS). The aim of this proof-of-concept study was to explore the feasibility and effects of concentric contractions on spasticity-related resistance to passive motion, strength, and mobility in people with MS and ankle plantarflexor spasticity.

METHODS

In this pretest/posttest case series, 5 people with MS (mean age = 53.6 [SD = 8.8] years; median Expanded Disability Status Scale score = 5; Modified Ashworth Scale range = 1-4) received 6 weeks of isokinetic resistance training of the spastic plantarflexors. Before and after the intervention, the following outcomes were assessed: average peak torque during passive robotic mobilization, isometric strength, surface electromyography (sEMG) from the spastic muscles, time to complete the 10-m Walk Test, and the Timed "Up & Go" Test. The standardized effect size was used to test pretest and posttest effects at the individual level. Group-level analyses were also performed.

RESULTS

Following the training, the average peak torque recorded from the plantarflexors during passive motion at a velocity of 150 degrees per second was found to be decreased by at least 1 SD in all participants but 1, with a significant reduction at the group level of 23.8%. Conversely, no changes in sEMG activity were detected. Group-level analyses revealed that the maximal strength of the trained plantarflexors increased significantly (31.4%). Fast walking speed increased and time to complete the Timed "Up & Go" Test decreased in 4 participants, although not significantly at the group level.

CONCLUSION

Isokinetic resistance training proved safe and feasible in people who had MS and ankle plantarflexor spasticity. The observed reductions in resistance to passive motion from the spastic plantarflexors in the absence of sEMG changes might suggest a mechanical rather than a neural effect of the training.

IMPACT

Based on these preliminary findings, isokinetic resistance training does not exacerbate hypertonia in people with MS and ankle plantarflexor spasticity and could be safely used to manage muscle weakness in this population.

Quantitative Analysis of the Multicomponent and Spectrum-Effect Correlation of the Antispasmodic Activity of Shaoyao-Gancao Decoction

Shaoyao-Gancao Decoction (SGD) is a well-known classic traditional Chinese medicine (TCM) with antispasmodic, anti-inflammatory, and analgesic effects. This preparation has been widely used to treat spasticity diseases in the clinic. To date, the material basis of SGD remains unclear, and the spectrum-effect correlation of its antispasmodic activity has not been reported yet. In this study, high-performance liquid chromatography (HPLC) was used to establish the fingerprint and determine the multiple components of SGD. The common peaks of fingerprints were evaluated by the similarity with the chromatographic fingerprints of the TCM. Meanwhile, the multiple components were quantified and analysed using the heatmap and box size analysis. Furthermore, data on the antispasmodic effect were extracted through in vitro smooth muscle contraction assay. Grey relational analysis combined with partial least square regression was used to study the spectrum-effect correlation of SGD. Finally, the potential antispasmolytic components were validated using an isolated tissue experiment. The HPLC fingerprint was established, and 20 common peaks were identified. The similarities of 15 batches of SGD were all above 0.965. The HPLC method for simultaneous determination of the multiple components was accurate and reliable. The contents of albiflorin, paeoniflorin, liquiritin, and glycyrrhizic acid were higher than the other components in SGD. The heatmap and box size also showed that X3 (albiflorin), X4 (paeoniflorin), X5 (liquiritin), X11 (liquirtigenin), and X16 (glycyrrhizic acid) could be used as quality indicators in the further establishment of quality standards. The spectrum-effect correlation results indicated that X4, X11, and X16 were highly correlated with antispasmolytic activity. Verification tests showed that paeoniflorin (11.7-29.25 μg/mL) and liquirtigenin (17.19-28.65 μg/mL) could significantly reduce the maximum contractile (P < 0.01). These compounds exerted concentration-dependent spasmolytic effects with the inhibitory response for acetylcholine (Ach)-evoked contraction. Thus, SGD had a significant antispasmodic effect, which resulted from the synergistic activity of its multiple components. These findings can be used for the pharmacodynamics study of SGD and are of great significance for the determination of quality markers and quality control.

The effect of extracorporeal shock wave therapy on large neurogenic heterotopic ossification in a patient with pontine hemorrhage: A case report and literature review

RATIONALE

Heterotopic ossification (HO), an ectopic bone formation in soft tissue around the joint, is a complication observed in stroke patients. HO around the hip joint causes a reduction in the functional ability of patients by generating pain and limiting range of motion (ROM). In addition, it results in impaired mobility, ultimately affecting quality of life and increasing the mortality of patients. Extracorporeal shock wave therapy (ESWT) has demonstrated efficacy in treating soft tissue inflammation and has been used to reduce patients' pain in HO. However, almost none of the studies reported degradation in the size of HO on images obtained before and after ESWT application.

PATIENT CONCERNS AND DIAGNOSIS

We report a case of a 36-year-old man who developed HO around both hip joints 3 months after bilateral pontine hemorrhage.

INTERVENTIONS

Seven months after HO development, ESWT was administered to the area of HO every other day for a total of 10 sessions.

OUTCOMES

Immediately following treatment, the ROM of both hip joints increased. Thus the patient was able to maintain a sitting posture without having to be bound to the wheelchair. In addition, the tolerable sitting time before groaning increased from less than ten minutes to almost 60 minutes by the end of all ESWT sessions. Unlike other previous reports, a diminished HO size was confirmed by comparing plain X-rays and bone scans obtained before and after treatment sessions.

LESSONS

In this case, we report an objective size reduction in HO in radiologic findings after applying ESWT to both hips. ESWT is a safe, easy-to-apply, and noninvasive modality. We would like to emphasize the use of ESWT as a treatment option for HO to decrease the extent of HO, as well as to improve pain, spasticity and function in patients with stroke.

Use of the Shock Wave Therapy in Basic Research and Clinical Applications-From Bench to Bedsite

Shock Waves (SW) are acoustic disturbances that propagate through a medium carrying the energy. These specific sonic pulses are composed of two phases—high positive pressure, a rise time < 10 ns, and a tensile wave. Originally Shock Waves were introduced to clinical practice as a part of the lithotripsy therapy focused on disrupting calcific deposits in the body. Since that time, shock wave therapy (SWT) has gone far beyond the original application related to the destruction of kidney stones. In this narrative Review, we present basic clinical applications of the SWT along with the potential therapeutic application in clinical practice.

Effect of Botulinum Toxin Injection and Extracorporeal Shock Wave Therapy on Nerve Regeneration in Rats with Experimentally Induced Sciatic Nerve Injury

This study was designed to compare the roles of botulinum neurotoxin A (BoNT/A) and extracorporeal shock wave therapy (ESWT) in promoting the functional recovery and regeneration of injured peripheral nerves. A total of 45 six-week-old rats with sciatic nerve injury were randomly divided into two experimental groups and one control group. The experimental groups received a single session of intranerve BoNT/A or ESWT immediately after a nerve-crushing injury. The control group was not exposed to any treatment. Differentiation of Schwann cells and axonal sprouting were observed through immunofluorescence staining, ELISA, real-time PCR, and Western blot at 3, 6, and 10 weeks post-nerve injury. For clinical assessment, serial sciatic functional index analysis and electrophysiological studies were performed. A higher expression of GFAP and S100β was detected in injured nerves treated with BoNT/A or ESWT. The levels of GAP43, ATF3, and NF200 associated with axonal regeneration in the experimental groups were also significantly higher than in the control group. The motor functional improvement occurred after 7 weeks of clinical observation following BoNT/A and ESWT. Compared with the control group, the amplitude of the compound muscle action potential in the experimental groups was significantly higher from 6 to 10 weeks. Collectively, these findings indicate that BoNT/A and ESWT similarly induced the activation of Schwann cells with the axonal regeneration of and functional improvement in the injured nerve.