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

Cross-Education Effects of Isokinetic Eccentric Plantarflexor Training on Flexibility, Strength, and Muscle-Tendon Mechanics

INTRODUCTION

Large increases in joint range of motion (ROM) have been reported after eccentric resistance training; however, limited data exist describing the associated mechanisms or potential cross-education effects in the contralateral limb. Therefore, the effects of a 6-wk isokinetic eccentric plantarflexor training program were examined in 26 participants.

METHODS

Before and after the training program, dorsiflexion ROM, plantarflexor strength, and muscle-tendon unit (MTU) morphology and mechanics were measured in control ( n = 13) and experimental ( n = 13) young adult groups. Training consisted of 5 sets of 12 maximal isokinetic eccentric plantarflexor contractions twice weekly on the right limb.

RESULTS

Significant ( P < 0.05) increases in dorsiflexion ROM (4.0-9.5°), stretch tolerance (40.3-95.9%), passive elastic energy storage (47.5-161.3%), and isometric (38.1-40.6%) and eccentric (46.7-67.0%) peak plantarflexor torques were detected in both trained and contralateral limbs in the experimental group. Significant increases in gastrocnemius medialis and soleus thickness (5.4-6.1%), gastrocnemius medialis fascicle length (7.6 ± 8.5%), passive plantarflexor MTU stiffness (30.1 ± 35.5%), and Achilles tendon stiffness (5.3 ± 4.9%) were observed in the trained limb only. Significant correlations were detected between the changes in trained and contralateral limbs for dorsiflexion ROM ( r = 0.59) and both isometric ( r = 0.79) and eccentric ( r = 0.73) peak torques. No significant changes in any metric were detected in the control group.

CONCLUSIONS

Large ROM increases in the trained limb were associated with neurological, mechanical, and structural adaptations, with evidence of a cross-education effect in the contralateral limb being primarily driven by neurological adaptation (stretch tolerance). The large improvements in ROM, muscle size, and strength confirm that isokinetic eccentric training is a highly effective training tool, with potential for use in athletic and clinical populations where MTU function is impaired and current therapies are ineffective.

Stretching exercises in managing spasticity: effectiveness, risks, and adjunct therapies

Spasticity is a component of upper motor neuron disorders and can be seen in neurological conditions like stroke and multiple sclerosis. Although the incidence rate of spasticity is unknown, it can put pressure on the health condition of those with spasticity, and there is no absolute effective way to control it. In the past, stretching exercises were an accessible tool for physical therapists to manage and control spasticity, but opinions on the optimal dose, aftereffects, and mechanism of effects were controversial. Therefore, this article tries to provide an overview of the effectiveness and risks of stretching exercises. Furthermore, there are several adjunct therapies, such as brain stimulation and botulinum injection, that can increase the effectiveness of a simple stretch by increasing cortical excitability and reducing muscle tone and their role is evaluated in this regard. The results of this study propose that several prospective and case studies have demonstrated the benefits of stretching to control spasticity, but it seems that other methods such as casting can be more effective than a simple stretch. Therefore, it is better to use stretching in combination with other therapeutic regimes to increase its effectivity of it.

Long-Term Enhancement of Botulinum Toxin Injections for Post-Stroke Spasticity by Use of Stretching Exercises-A Randomized Controlled Trial

Botulinum toxin A (BONT/A) injections play a central role in the treatment of upper limb spasticity in stroke patients. We proposed structured stretching exercises to enhance the effect of post-stroke spasticity relief of the upper limbs following BONT/A injections. A total of 43 patients who had a stroke with grade 2 spasticity or higher on the Modified Ashworth Scale (MAS) in their upper-limb muscles were randomly assigned to the intervention (n = 21) or control group (n = 22). The former received structured stretching exercises after their BONT/A injections for 20 min, 5 days per week, for 6 months at a hospital, while the others conducted self-stretching exercises at home. The outcome measures were assessed before the intervention (T0) and after three (T1) and six months (T2). Significantly greater improvements in the MAS scores of the elbows, wrists, and fingers were found in the intervention group's patients at T1 and T2. The behavioral outcome measures, including shoulder pain, activities of daily living, and quality of life, and our electrophysiological studies also showed a significantly higher enhancement in this patient group. In conclusion, the structured stretching exercises plus BONT/A injections for six months showed a superior effect in relieving post-stroke upper-limb spasticity compared to self-stretching exercises.

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.

Best Practice Guidelines for the Management of Patients with Post-Stroke Spasticity: A Modified Scoping Review

This article aims to provide a concise overview of the best available evidence for managing post-stroke spasticity. A modified scoping review, conducted following the PRISMA guidelines and the PRISMA Extension for Scoping Reviews (PRISMA-ScR), involved an intensive search on Medline and PubMed from 1 January 2000 to 31 August 2023. The focus was placed on high-quality (GRADE A) medical, rehabilitation, and surgical interventions. In total, 32 treatments for post-stroke spasticity were identified. Two independent reviewers rigorously assessed studies, extracting data, and evaluating bias using GRADE criteria. Only interventions with GRADE A evidence were considered. The data included the study type, number of trials, participant characteristics, interventions, parameters, controls, outcomes, and limitations. The results revealed eleven treatments supported by GRADE A evidence, comprising 14 studies. Thirteen were systematic reviews and meta-analyses, and one was randomized control trial. The GRADE A treatments included stretching exercises, static stretching with positional orthosis, transcutaneous electrical nerve stimulation, extracorporeal shock wave therapy, peripheral magnetic stimulation, non-invasive brain stimulation, botulinum toxin A injection, dry needling, intrathecal baclofen, whole body vibration, and localized muscle vibration. In conclusion, this modified scoping review highlights the multimodal treatments supported by GRADE A evidence as being effective for improving functional recovery and quality of life in post-stroke spasticity. Further research and exploration of new therapeutic options are encouraged.

Spiral strapping for improving upper extremity motor functions in individuals with stroke: A randomized controlled trial

BACKGROUND

The rehabilitation process for the upper extremities of individuals with stroke requires therapists to use splints for supportive and corrective purposes. The aim of this study was to assess the effectiveness of spiral strapping in inhibiting spasticity and improving the upper extremity motor functions of individuals with chronic stroke.

METHODS

Forty Saudi individuals aged 50-60 years with chronic stroke participated in this study. Their degrees of spasticity according to the Modified Ashworth Scale ranged across grades 1, 1+, and 2. Participants were randomly assigned to experimental and control groups. Participants in both groups received 1 h of conventional physical therapy for 3 d/wk to improve the motor functions of their upper extremities. In addition, participants in the experimental group wore an upper-limb spiral strapping with a hand splint 10 h/d for 6 d/wk. The treatment program for both groups was delivered for 4 weeks. Changes in the scores of Action Research Arm Test for elbow joint spasticity, active range of motion of the shoulder, elbow, and forearm joints, and hand grip strength were evaluated before and after treatment in both groups.

RESULTS

Significant improvements in all measured variables after treatment were reported in both groups, except for elbow joint spasticity in the control group. The experimental group showed significant post-treatment improvement in the scores for all measured variables compared with the control group.

CONCLUSIONS

Spiral strapping was beneficial in inhibiting mild degrees of spasticity and improving the motor functions of the upper extremities of stroke patients.

Stretching is not essential for managing MS spasticity: A randomized controlled trial

BACKGROUND

Clinical practice, expert opinion, and evidence-based guidelines recommend daily stretching as first-line treatment for multiple sclerosis (MS) spasticity, but this has not been evaluated by fully powered clinical trials.

OBJECTIVE

To determine whether MS Spasticity: Take Control (STC), a guideline-based program of spasticity education and stretching exercises has different effects on the impact of spasticity than a control program of different spasticity education and range of motion (ROM) exercises.

METHODS

Ambulatory people with self-reported MS spasticity were randomly assigned to STC or ROM, delivered in same duration, facilitator-led, group classes, face-to-face (F2F) initially and later virtually, due to coronavirus disease 2019 (COVID-19). Multiple Sclerosis Spasticity Scale (MSSS) scores were compared between groups at 1 (primary outcome) and 6 months after interventions.

RESULTS

A total of 231 people enrolled. There was no significant difference in MSSS scores between STC and ROM at 1 month (mean difference = 0.28, 95% (confidence interval (CI)) = [-9.45 to 10.01], p = 0.955). There were significant group mean improvements in MSSS scores and most other outcomes at 1 and 6 months.

CONCLUSION

Education with stretching exercises, the first-line recommended treatment for MS spasticity, and education with ROM exercises may both improve MS spasticity to a similar degree. This study debunks the belief that stretching is essential to managing MS spasticity.

Neuro-orthopaedic assessment and management in patients with prolonged disorders of consciousness: A review

BACKGROUND

Following a severe acquired brain injury, neuro-orthopaedic disorders are commonplace. While these disorders can impact patients' functional recovery and quality of life, little is known regarding the assessment, management and treatment of neuro-orthopaedic disorders in patients with disorders of consciousness (DoC).

OBJECTIVE

To describe neuro-orthopaedic disorders in the context of DoC and provide insights on their management and treatment.

METHODS

A review of the literature was conducted focusing on neuro-orthopaedic disorders in patients with prolonged DoC.

RESULTS

Few studies have investigated the prevalence of spastic paresis in patients with prolonged DoC, which is extremely high, as well as its correlation with pain. Pilot studies exploring the effects of pharmacological treatments and physical therapy show encouraging results yet have limited efficacy. Other neuro-orthopaedic disorders, such as heterotopic ossification, are still poorly investigated.

CONCLUSION

The literature of neuro-orthopaedic disorders in patients with prolonged DoC remains scarce, mainly focusing on spastic paresis. We recommend treating neuro-orthopaedic disorders in their early phases to prevent complications such as pain and improve patients' recovery. Additionally, this approach could enhance patients' ability to behaviourally demonstrate signs of consciousness, especially in the context of covert awareness.

Spastic paraplegia is the main manifestation of a spinocerebellar ataxia type 8 lineage in China: a case report and review of literature

The diagnosis and treatment of cerebellar atrophy remain challenging owing to its nonspecific symptoms and laboratory indicators. Three patients with spinocerebellar ataxia type 8 caused by ATXN8OS were found among the 16 people in the studied family. The clinical manifestations of the patients included progressive spastic paraplegia of the lower extremities, mild ataxia, mild cognitive impairment, and cerebellar atrophy. After administering antispasmodic rehabilitation treatment, using oral drugs, botulinum toxin injection, baclofen pump, and other systems in our hospital, the patients' lower extremity spasticity was significantly relieved. To our knowledge, till date, this is the first domestic report of spinocerebellar ataxia type 8 affecting a family, caused by ATXN8OS with spasticity onset in early childhood. Manifestations of the disease included spastic dyskinesia (in early disease stages) and cerebellar atrophy. Through systematic rehabilitation, the daily life of patients with this movement disorder was improved. This case report adds to the literature on spinocerebellar ataxia type 8 by summarizing its features.

Effects of Therapist Intervention during Upper-Extremity Robotic Rehabilitation in Patients with Stroke

This study aimed to determine whether the treatment effect differs for patients with stroke who perform robot-assisted upper-extremity rehabilitation by themselves compared to those whose rehabilitation is actively assisted by a therapist. Stroke patients with hemiplegia were randomly divided into two groups and received robot-assisted upper-limb rehabilitation for four weeks. In the experimental group, a therapist actively intervened in the treatment, while in the control group, the therapist only observed. After four weeks of rehabilitation, the manual muscle strength, Brunnstrom stage, Fugl-Meyer assessment of the upper-extremity (FMA-UE), box and block test, and functional independence measure (FIM) showed significant improvement in both groups compared to that before treatment; however, no interval change in spasticity was noted. The post-treatment values showed that the FMA-UE and box and block tests were significantly improved in the experimental group compared to those in the control group. Comparing the changes in the pre- and post-treatment values, the FMA-UE, box and block test, and FIM of the experimental group were significantly improved compared to those in the control group. Our results suggest that active intervention by therapists during robot-assisted upper-limb rehabilitation positively impacts upper-extremity function outcomes in patients with stroke.

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.

Focal vibration of the plantarflexor and dorsiflexor muscles improves poststroke spasticity: a randomized single-blind controlled trial

BACKGROUND

Post-stroke spasticity is a cause of gait dysfunction and disability. Focal vibration (FV) of agonist-antagonist upper limb muscle pairs reduces flexor spasticity; however, its effects on ankle plantarflexor spasticity are uncertain.

OBJECTIVE

To assess the effects of focal vibration administered by a trained operator to the ankle plantarflexor and dorsiflexor muscles on post-stroke lower limb spasticity.

METHODS

A randomized, single-blind controlled trial of 64 participants with stroke and plantarflexor spasticity assigned to 3 groups by centralized, computer-generated randomization (1:1:1): 1) physiotherapy alone (CON), 2) physiotherapy+gastrocnemius vibration (FV_GM) and 3) physiotherapy+tibialis anterior vibration (FV_TA). Physiotherapists and assessors were blinded to group assignment. The experimental groups underwent 15, 20-min vibration sessions at 40 Hz. We performed evaluations at baseline and after the final treatment: Modified Ashworth Scale (MAS), Clonus scale, Functional Ambulation Categories (FAC), Fugl-Meyer Assessment - Lower Extremity (FMA_LE), Modified Barthel Index (MBI), and electromyography and ultrasound elastography. Primary outcome was remission rate (number and proportion of participants) of the MAS.

RESULTS

MAS remission rate was higher in FV_GM and FV_TA than CON groups (CON vs. FV_GM: p=0.009, odds ratio 0.15 [95% confidence interval 0.03-0.67]; CON vs. FV_TA: p=0.002, 0.12 [0.03-0.51]). Remission rate was higher in the experimental than CON groups for the Clonus scale (CON vs. FV_GM: p<0.001, OR 0.07 [95% CI 0.01-0.31]; CON vs. FV_TA: p=0.006, 0.14 [95% CI 0.03-0.61]). FAC remission rate was higher in the FV_TA than the CON (p=0.009, 0.18 [0.05-0.68]) and FV_GM (p=0.014, 0.27 [0.07-0.99]) groups. Ultrasound variables of the paretic medial gastrocnemius decreased more in FV_GM than CON and FV_TA groups (shear modulus: p=0.006; shear wave velocity: p=0.008).

CONCLUSIONS

Focal vibration reduced post-stroke spasticity of the plantarflexor muscles. Vibration of the tibialis anterior improved ambulation more than vibration of the gastrocnemius or physiotherapy alone. Gastrocnemius vibration may reduce spasticity by changing muscle stiffness.

Effects of repetitive peripheral magnetic stimulation on spasticity evaluated with modified Ashworth scale/Ashworth scale in patients with spastic paralysis: A systematic review and meta-analysis

BACKGROUND

Spasticity is a common motor disorder resulting from upper motor neuron lesions. It has a serious influence on an individual's motor function and daily activity. Repetitive peripheral magnetic stimulation (rPMS) is a non-invasive and painless approach developed for therapeutic intervention in clinical rehabilitation. However, the effectiveness of this intervention on spasticity in patients with spastic paralysis remains uncertain.

OBJECTIVE

This study aimed to investigate the effectiveness of rPMS on spasticity, motor function, and activities of daily living in individuals with spastic paralysis.

METHODS

PubMed, PEDro, Embase, Cochrane Library, and Web of Science were searched for eligible papers with date up to March 31, 2022. Two independent researchers conducted study screening, data extraction, and methodological quality assessment. RCTs that explored the effects of rPMS on spasticity, motor function, and activities of daily living in patients with spastic paralysis were included for review. The Cochrane collaboration tool was used to assess methodological quality. The cumulative effects of available data were processed for a meta-analysis using Reedman software.

RESULTS

Eight studies with 297 participants were included. Most of the studies presented low to moderate risk of bias. Compared with the control group, the results showed that rPMS had a significant effect on spasticity (all spasticity outcomes: standardized mean difference [SMD] = -0.55, 95% confidence interval [CI]: -0.94 to -0.16, I 2 = 40%, and P = 0.006, Modified Ashworth Scale: mean difference [MD] = -0.48, 95% CI: -0.82 to -0.14, I 2 = 0%, and P = 0.006), motor function (Fugl-Meyer Assessment: MD = 4.17, 95% CI: 0.89 to 7.46, I 2 = 28%, and P = 0.01), and activities of daily living (Barthel Index: MD = 5.12, 95% CI: 2.58 to 7.67, I 2 = 0%, and P < 0.0001). No side effect was reported.

CONCLUSION

The meta-analysis demonstrated that the evidence supported rPMS in improving spasticity especially for passive muscle properties evaluated with Modified Ashworth Scale/Ashworth Scale, as well as motor function and daily activity of living in individuals with spastic paralysis.

STUDY REGISTRATION

The reviewed protocol of this study is registered in the international prospective register of systematic reviews (PROSPERO) (CRD42022322395).

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier CRD42022322395.

Microvascular Adaptations to Muscle Stretch: Findings From Animals and the Elderly

Microcirculation in skeletal muscle is disturbed with advancing aging, causing limited capillary blood flow and exercise incapacity. Muscle stretch has been widely performed in physical therapy, sports medicine, and health promotion. However, the effect of stretch on microvascular reactivity and muscle blood flow remains unknown. This review focuses on stretch-induced microvascular adaptations based on evidence from cultured cells, small animals, and human studies. Vascular endothelium senses and responds to mechanical stimuli including stretch. This endothelial mechanotransduction potentially plays a vital role in the stretch-induced microvascular adaptation alongside hypoxia. Aging impairs microvascular endothelial function, but muscle stretch has the potential to restore it. Muscle stretch may be an alternative to improve vascular function and enhance exercising blood flow, especially for those who have difficulties in participating in exercise due to medical, functional, or psychological reasons.

Personalized Approaches to Stroke: One Step Forward for Functional Recovery of Stroke Patients

Recent advances in diagnoses, management, and rehabilitation have had a significant impact to reduce mortality and functional recovery in stroke patients. In spite of these medical advances, many stroke survivors still suffer from significant disabilities. Stroke is a complex disease caused by a combination of multiple risk factors. Therefore, personalized medicine is more important than any other field to overcome the limitations of current stroke management and rehabilitation. It is necessary to apply accurate evaluation for functions and a personalized approach in consideration of various characteristics of each stroke patient to improve function. The objective of this Special Issue is to inform the recent scientific knowledge, current limitations, and challenges for an individually tailored strategy in the areas of diagnosis, treatment, and rehabilitation of stroke. A multidisciplinary approach and research will be strongly encouraged for personalized medicine in the field of stroke treatment and rehabilitation.

Virtual Reality and Physiotherapy in Post-Stroke Functional Re-Education of the Lower Extremity: A Controlled Clinical Trial on a New Approach

Numerous Virtual Reality (VR) systems address post-stroke functional recovery of the lower extremity (LE), most of them with low early applicability due to the gait autonomy they require. The aim of the present study was to evaluate the feasibility of a specific VR treatment and its clinical effect on LE functionality, gait, balance, and trunk control post-stroke. A controlled, prospective, clinical trial was carried out with 20 stroke patients, who were divided into two groups: the first group (VR + CP; n = 10) received combined therapy of 1 h VR and 1 h of conventional physiotherapy (CP) and the second group (CP; n = 10) received 2 h of CP (5 days/week, for 3 weeks). The following pre-post-intervention measuring scales were used: Functional Ambulatory Scale (FAC), Functional Independence Measure (FIM), Fugl-Meyer Assessment (FM), Berg Balance Scale (BBS), and Trunk Control Test (TCT). Only VR + CP showed a significant improvement in FAC. In FIM, CP presented a tendency to significance, whereas VR + CP showed significance. Both groups improved significantly in FM (especially in amplitude/pain in VR + CP and in sensitivity in CP) and in BBS. In TCT, there was a non-significant improvement in both groups. The results indicate that the intervention with VR is a feasible treatment in the post-stroke functional re-education of the LE, with the potential to be an optimal complement of CP.