Peripheral magnetic theta burst stimulation to muscles can effectively reduce spasticity: a randomized controlled trial

Background Spasticity is a common complication of many neurological diseases and despite contributing much disability; the available therapeutic options are limited. Peripheral magnetic stimulation is one promising option. In this study, we investigated whether peripheral intermittent theta burst stimulation (piTBS) will reduce spasticity when applied directly on spastic muscles. Methods In this sham-controlled study, eight successive sessions of piTBS were applied directly to spastic muscles with supra threshold intensity. Assessment was done by modified Ashworth scale (mAS) and estimated Botulinum toxin dose (eBTD) at baseline and after the 8th session in both active and sham groups. Results A total of 120 spastic muscles of 36 patients were included in the analysis. Significant reduction of mAS and eBTD was found in the active compared to sham group (p < 0.001). The difference in mAS was also significant when tested in upper limb and lower limb subgroups. The degree of reduction in mAS was positively correlated with the baseline scores in the active group. Conclusion piTBS could be a promising method to reduce spasticity and eBTD. It consumes less time than standard high frequency protocols without compromising treatment efficacy. Trial registration: Clinical trial registry number: PACTR202009622405087. Retrospectively Registered 14th September, 2020.

Functional intermuscular reduction in spasticity for people with multiple sclerosis

Background Eighty-five percent of people with multiple sclerosis (MS) incur gait impairments debilitating enough to significantly impact their function. Objectives The aim of this study was to determine if a novel combination of intermuscular electrical stimulation, followed by functional electrical stimulation combined with supported bodyweight treadmill training, would improve gait, decrease spasticity and fatigue, and improve muscle strength. Methods Using a pre-post experimental design, we implemented this combination six-week protocol in 16 individuals with MS. We completed summary statistics and longitudinal pre-post results using Wilcoxon sign rank tests with Bonferroni adjustment. Results Participants responded with median increases of 29.4 feet ( p < 0.0001) during the Six Minute Walk Test, median decreases of 0.7 s ( p = 0.0011) in the 25-Foot Walk Test, median increases of 3.8 toe taps to fatigue ( p = 0.0306) and median increases of 5.0 heel raises ( p = 0.0093). Significant changes were noted in the Modified Ashworth Scale, both after intermuscular electrical stimulation (median change = −0.5 p = 0.0039) and after treadmill walking (median change = −0.5, p < 0.0005). Conclusions Results of this novel protocol suggest this intervention combination has the potential to decrease spasticity, and improve gait speed and endurance in individuals with MS. Observed changes in mobility occurred without accompanying increases in fatigue.

Hubungan Antara Rasio H/M pada Stroke Akut dengan Derajad Spastisitas Pascastroke

Pendahuluan: Spastisitas adalah gangguan motorik yang sering dijumpai dan muncul setelah stroke. Spastisitas dapat menyebabkan nyeri dan disabililitas pada bagian tubuh yang mengalaminya. Tujuan: mencari hubungan antara rasio H/M yang diukur dengan elektromiografi dengan derajad spastisitas yang terjadi setelah fase akut stroke. Metode: Penelitian ini adalah studi analisis korelatif observasional, dengan 26 sampel. Pasien diukur rasio H/M pada saat stroke akut dan diukur derajad spastisitasnya dengan menggunakan Modified Ashworth Scale setelah 3 bulan. Hasil yang didapatkan dilakukan analisa statistik dengan menggunakan tes korelatif kategorik dari Spearman. Hasil: Pasien yang mengikuti penelitian ini sebanyak 26 orang. Terdapat perbedaaan antara nilai H/M rasio antara sisi parese dengan sisi sehat dan tidak didapatkan hubungan yang bermakna antara nilai rasio H/M yang diukur saat fase akut stroke dengan derajad spastisitas yang diukur dengan Modified Ashworth Scale (MAS) setelah 3 bulan (p = 0,06 ; r = 0, 37). Kesimpulan: Rasio H/M pada pasien stroke akut meningkat pada sisi parese dibanding pada sisi sehat, namun peningkatan ini tidak memiliki hubungan yang signifikan dengan derajad spastisitas pasca stroke yang diukur dengan MAS, sehingga rasio H/M tidak dapat digunakan sebagai prediktor munculnya spastisitas pasca stroke

Punctual mechanical oscillation in modulation of muscular tonus in children with spasticity

Spasticity is a motor condition present in 75 to 88% of children with Cerebral Palsy (CP). One form of treatment is called punctual mechanical oscillation (PO). The current study aimed to study different protocols for the application of PO and the magnitude of their effects. In total, 7children with medical diagnosis of CP and ICD (International Classification of Diseases) were included. The first intervention protocol (Int1) consisted of the application of PO to the spastic muscle tendon and the second intervention protocol (Int2) to the muscle belly ofthe spastic antagonist muscle. For evaluation, the Modified Ashworth Scale (MAS) was used, while simultaneously capturing the mechanomyography (MMG) signals. Data were collected pre-intervention and 1 (Post1), 15 (Post15), 30 (Post30), 45 (Post45), and60 (Post60) minutes after the interventions. The MAS values (median ± interquartile range) post intervention were statistically lower when compared to the pre values in the 2 protocols studied; in Int1between Pre (2 ± 0) andPost15 (0 ± 1.75), Post30 (0 ± 1), Post45 (1 ± 1),and Post60 (1 ± 1), and in Int2only between Pre (2 ± 1) and Post1 (0 ± 1).The values found in the MMG in both its temporal and spectral domains did not follow a pattern (p>0.05). The comparison between the protocols did not demonstrate statistical differences in any characteristics (MAS, MMGMF, and MMGRMS). However, PO was shown to be a therapeutic resource that modulated spasticity for up to 60 minutes after its application, and PO could contribute as a tool to aid the treatment of spasticity.

A randomized double-blind controlled study on the efficacy and safety of Sangdantongluo granule in the treatment of post-stroke spasticity

BackgroundStroke is the first leading cause of mortality and disability worldwide, and post-stroke spasticity (PSS) is the common complication of stroke. Sangdantongluo Granule, a modern patent Traditional Chinese medicine (TCM), is widely used in clinical practice to treat PSS. Whereas, there is limited evidence of effectiveness for Sangdantongluo Granule to treat PSS. This study will evaluate the clinical efficacy and safety of Sangdantongluo granule in the treatment of PSS. MethodsThis multicenter, randomized, double-blind and placebo-controlled study will recruit 132 participants in China who develops PSS 15 days to 90 days after stroke. Participants will be randomly assigned in an equal ratio to receive either Sangdantongluo granule or placebo for 2 months twice a day orally. The primary measure is the Modified Ashworth Scale (MAS), Secondary outcome measures include Compopsite Spasticity Scale (CSS), Simplified Fugl-Meyer Motor Scale (S-FM), National Institute of Health stroke scale (NIHSS), Modified Rankin Scale (mRS), Modified Barther Index (MBI), and Surface electromyography. Adverse events will be supervised throughout the trial. DiscussionThe results of this study will present whether Sangdantongluo granule is clinical effective and safe for managing PSS.Trial registrationClinicalTrials.gov ChiCTR2100044544. Registered on 23 March 2021.

Development of Simple Measurement Device to Measure Spasticity Based on an Analysis of Clinical Maneuver and Its Concurrent Validity With Modified Ashworth Scale

BackgroundDespite recent developments in the methodology for measuring spasticity, the discriminative capacity of clinically diagnosed spasticity has not been well established. This study aimed to develop a simple device for measuring velocity-dependent spasticity with improved discriminative capacity based on an analysis of clinical maneuver and to examine its reliability and validity.MethodsThis study consisted of three experiments. First, to determine the appropriate motion of a mechanical device for the measurement of velocity-dependent spasticity, the movement pattern and the angular velocity that the clinicians use in evaluating velocity-dependent spasticity were investigated. Analysis of the procedures performed by six physical therapists in evaluating spasticity were conducted using an electrogoniometer. Second, a device for measuring the resistance force against ankle dorsiflexion was developed based on the investigation in the first experiment. Additionally, preliminary testing of validity, as compared to that of the Modified Ashworth Scale (MAS), was conducted on 17 healthy participants and 10 patients who had stroke with spasticity. Third, the reliability of measurement and the concurrent validity of mechanical measurement in the best ankle velocity setting were further tested in a larger sample comprising 24 healthy participants and 32 patients with stroke.ResultsThe average angular velocity used by physical therapists to assess spasticity was 268±77°/s. A device that enabled the measurement of resistance force at velocities of 300°/s, 150°/s, 100°/s, and 5°/s was developed. Based on the analysis of clinical procedures, a stretching motion prior to measurement was added. In the measurement, an angular velocity of 300°/s was found to best distinguish patients with spasticity (MAS of 1+ and 2) from healthy individuals. A measurement of 300°/s in the larger sample differentiated the control group from the MAS 1, 1+, and 2 subgroups (p<0.01), as well as the MAS 1 and 2 subgroups (p<0.05). No fixed or proportional bias was observed in repeated measurements.ConclusionsA simple mechanical measurement device was developed based on the analysis of clinical maneuver for measuring spasticity and was shown to be valid in differentiating the existence and extent of spasticity.Trial registrationUMIN000026305, date of registration: 25 February 2017; jRCTs042180044, date of registration: 21 November 2018; UMIN000040472, date of registration: 21 May 2020.

Ultrasound-Guided BoNT-A (Botulinum Toxin A) Injection Into the Subscapularis for Hemiplegic Shoulder Pain: A Randomized, Double-Blind, Placebo-Controlled Trial

Background and Purpose: This study aimed to assess the efficacy of an ultrasound-guided lateral approach for BoNT-A (botulinum toxin A) injections into the subscapularis in patients with hemiplegic shoulder pain. Methods: This single-center trial used a randomized, double-blind, placebo-controlled design. The key inclusion criteria were a visual analog scale score of ≥4 cm and a modified Ashworth scale score of ≥1+. The patients were randomized to receive either BoNT-A injections or a placebo. The outcomes included the visual analog scale score, modified Ashworth scale score, pain-free passive range of motion of the hemiplegic shoulder, Fugl-Meyer assessment score for the upper extremities, and Stroke-Specific Quality-of-Life score. Results: A total of 49 hemiplegic shoulder pain patients were screened, and 36 were included. The participants receiving the BoNT-A injection reported a significant decrease in pain (visual analog scale, −1.39 [95% CI, −2.41 to −0.36]; P =0.002) and spasticity (modified Ashworth scale score for shoulder internal rotation, −0.72 [95% CI, −1.10 to −0.35]; P =0.001; modified Ashworth scale score for shoulder abduction, −0.44 [95% CI, −0.90 to −0.01]; P =0.026) and improved pain-free passive shoulder internal rotation range of motion (14.56 [95% CI, 6.70–21.41]; P <0.001) and quality of life (Stroke-Specific Quality-of-Life upper extremity subscale, P =0.025) compared with those receiving the placebo at the end point. The shoulder abduction range of motion did not significantly improve after the BoNT-A injection at the end point ( P =0.127). In addition, the patients in the BoNT-A group showed significant improvements in the visual analog scale score and shoulder external rotation range of motion at the 12-week follow-up. No injection-related adverse events were observed during or after the interventions in either group. Conclusions: The ultrasound-guided lateral approach for BoNT-A injections into the subscapularis is a precise and reliable method for reducing pain and spasticity and improving quality of life in stroke survivors with hemiplegic shoulder pain. Registration: URL: https://www.chictr.org.cn ; Unique identifier: ChiCTR1900023513.

Motor and functional outcome of selective dorsal rhizotomy in children with spastic diplegia at 12 and 24 months of follow-up

Background Selective dorsal rhizotomy (SDR) in ambulatory children affected by cerebral palsy (CP) is a surgical treatment option to lower spasticity and thereby improve gait and ambulation. The aim of the current study is to investigate the outcome of children with respect to spasticity, muscle strength, and overall function after SDR. Methods All children who underwent SDR via a single-level laminotomy in the time period from January 2007 to April 2015 at our center were enrolled in this study. Within a standardized evaluation process, the following was assessed routinely pre-operatively and 12 and 24 months following surgery: extent of spasticity at hip adductors and hamstrings as characterized by the Modified Ashworth Scale (MAS), maximal muscle strength as characterized by the Medical Council Research Scale (MRC), overall function regarding ambulation as characterized by the Gross Motors Function Classification System (GFMCS), and overall function as characterized by the Gross Motor Function Measure (GMFM-88). Results Matching sets of pre- and post-operative assessments of the chosen outcome parameters were available for 109 of the 150 children who underwent SDR within the observation period. After 24 months, the MAS scores of hip adductors (n = 59) improved in 71% and 76% of children on the right and left side, respectively. In 20% and 19%, it remained unchanged and worsened in 9% and 5% of children on the right and left side, respectively (p < 0.00625). For hamstrings, the rates for the right and left sides were 81% and 79% improvement, 16% and 16% unchanged, and 4% and 5% worsened, respectively (p < 0.00625). Muscle strength of ankle dorsiflexion and knee extension significantly improved after 24 months. Overall function assessed by GMFM-88 improved significantly by 4% after 12 months (n = 77) and by 7% after 24 months (n = 56, p < 0.0001). Conclusions The presented data underlines the benefit of SDR in a pediatric patient collective with bilateral spastic CP. The procedure resulted in an effective and permanent reduction of spasticity and improved overall function without causing relevant weakness of the lower extremities.

Electrophysiological Evaluation of the Modified Ashworth Scale in Assessment of Post Stroke Ankle Plantar Spasticity

Background: Spasticity is a common impairment following upper motor neuron lesions such as stroke. The appropriate measure of muscle spasticity, using validated tools to evaluate the outcome of therapies is important in clinical and research settings. Objective: To determine the concurrent criterion-related validity of the Modified Ashworth Scale in assessing post stroke Ankle flexor muscle spasticity based on its correlation with Modified Tardieu scale and the H-reflex tests. Methods: A total of 35 adult stroke participants underwent clinical and electrophysiological assessment of the ankle flexor muscle spasticity on the affected side. The primary outcome measures were: MMAS grade, R2−R1 of the MTS; and the H-reflex indices of H-max/M-max ratio. Results: Correlations tests revealed the correlation between the MMAS and MTS but did not reveal significant associations between the MMAS and the H-reflex tests. Conclusions: This study suggests that the MMAS may not be a valid tool to evaluate the ankle flexor muscle spasticity in these stroke participants. Key words: Stroke, spasticity, Modified Ashworth Scale, Tardieu Scale, H-reflex, criterion validity.

A Study to Compare Effect of Hold-Relax v/s Static Stretching on Elbow Flexors Muscle Spasticity in Stroke - A Comparative Study

Background: Stroke is a condition in which Spasticity in the body musculature greatly affect the functional independence of the patients. Hold- Relax and Static Stretching is one of the useful treatment to reduce Spasticity. Aim: To find out the effect of Hold – Relax V/S Static Stretching on Elbow flexors muscle Spasticity in Stroke Patient Materials and Methods: 20 subjects were randomly allocated into two groups (Group A and Group B). For 10 subjects in Group A Control group was given Static Stretching with conventional rehab and Group B Experimental group was given Hold- Relax with conventional rehab. Treatment were given to 3 weeks 3 sets per sessions. The outcome measure used to assess the Spasticity before and after the intervention was Modified Ashworth Scale (MAS). Results and Discussion: The Hold-Relax group showed a significant reduction in Spasticity of Elbow flexors muscle, compared to the control group (p<0.05). Conclusions: Hold- Relax is more effective than Static Stretching. Key words: Stroke, Spasticity, Hold- Relax, Static Stretching, MAS.