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.

Post-Stroke Treatment with Neuromuscular Functional Electrostimulation of Antagonistic Muscles and Kinesiotherapy Evaluated with Electromyography and Clinical Studies in a Two-Month Follow-Up

The aim of this study was to determine the sustained influence of personalized neuromuscular functional electrical stimulation (NMFES) combined with kinesiotherapy (mainly, proprioceptive neuromuscular facilitation (PNF)) on the activity of muscle motor units acting antagonistically at the wrist and the ankle in a large population of post-stroke patients. Clinical evaluations of spasticity (Ashworth scale), manual muscle testing (Lovett scale), and surface electromyography recordings at rest (rEMG) and during attempts of maximal muscle contraction (mcEMG) were performed three times in 120 post-stroke patients (T0: up to 7 days after the incidence; T1: after 21 days of treatment; T2: after 60 days of treatment). Patients (N = 120) were divided into two subgroups—60 patients received personalized NMFES and PNF treatment (NMFES+K), and the other 60 received only PNF (K). The NMFES+K therapy resulted in a decrease in spasticity and an increase in muscle strength of mainly flexor muscles, in comparison with the K group. A positive correlation between the increase of rEMG amplitudes and high Ashworth scale scores and a positive correlation between low amplitudes of mcEMG and low Lovett scale scores were found in the wrist flexors and calf muscles on the paretic side. Negative correlations were found between the rEMG and mcEMG amplitudes in the recordings. The five-grade alternate activity score of the antagonists’ actions improved in the NMFES+K group. These improvements in the results of controlled NMFES treatment combined with PNF in patients having experienced an ischemic stroke, in comparison to the use of kinesiotherapy alone, might justify the application of conjoined rehabilitation procedures based on neurophysiological approaches. Considering the results of clinical and neurophysiological studies, we suppose that NMFES of the antagonistic muscle groups acting at the wrist and the ankle may evoke its positive effects in post-stroke patients by the modulation of the activity more in the spinal motor centers, including the level of Ia inhibitory neurons, than only at the muscular level.

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.

The Effect and Dose-Response of Functional Electrical Stimulation Cycling Training on Spasticity in Individuals With Spinal Cord Injury: A Systematic Review With Meta-Analysis

Background: To investigate the effect and dose-response of functional electrical stimulation cycling (FES-cycling) training on spasticity in the individuals with spinal cord injury (SCI).Method: Five electronic databases [PubMed, Scopus, Medline (Proquest), Embase, and Cochrane Central Register of Controlled Trials (CENTRAL)] were searched before September 2021. The human trials and studies of English language were only included. Two authors independently reviewed and extracted the searched studies. The primary outcome measure was spasticity assessed by Modified Ashworth Scale or Ashworth Scale for lower limbs. The secondary outcome measures were walking abilities, such as 6 Min Walk Test (6MWT), Timed Up and Go (TUG), and lower limbs muscle strength (LEMS). A subgroup analysis was performed to investigate the efficacious threshold number of training sessions. A meta-regression analysis was used to examine the linear relationship between the training sessions and the effect on spasticity.Results: A total of 764 studies were identified. After screening, 12 selected studies were used for the qualitative synthesis, in which eight of them were quantitatively analyzed. Eight studies included ninety-nine subjects in total with SCI (male: female = 83:16). The time since injury was from less than 4 weeks to 17 years. The age ranged from 20 to 67 years. American Spinal Injury Association (ASIA) impairment level of the number of participants was 59 for ASIA A, 11 for ASIA B, 18 for ASIA C, and 11 for ASIA D. There were 43 subjects with tetraplegia and 56 subjects with paraplegia. Spasticity decreased significantly (95% CI = − 1.538 to − 0.182, p = 0.013) in favor of FES-cycling training. The walking ability and LEMS also improved significantly in favor of FES-cycling training. The subgroup analysis showed that spasticity decreased significantly only in more than 20 training sessions (95% CI = − 1.749 to − 0.149, p = 0.020). The meta-regression analysis showed training sessions and spasticity were not significantly associated (coefficient = − 0.0025, SE = 0.0129, p = 0.849, R2 analog = 0.37).Conclusion: Functional electrical stimulation-cycling training can improve spasticity, walking ability, and the strength of the lower limbs in the individuals with SCI. The number of training sessions is not linearly related to the decrease of spasticity. Twenty sessions of FES-cycling training are required to obtain the efficacy to decrease spasticity.

Risk factors for shoulder pain after stroke: A clinical study

Objectives: To investigate the risk factors for shoulder pain after stroke, and prevent its occurrence effectively. Methods: The patients with stroke treated in our hospital between September 2016 and October 2020 were reviewed retrospectively. The medical records of the included patients including age, gender, lesion side, stroke duration, hospital stay, diabetes, hypertension, heart disease, limitation of shoulder joint activity, alcohol abuse, smoking, type of stroke, Ashworth scale, Brunnstrom stage, sensory disorders, and motor arm score of National Institutes of Health Stroke Scale (NIHSS) were collected and analyzed to determine the risk factors for shoulder pain after stroke. Results: A total of 1390 patients were included based on the inclusion and exclusion criteria, consisting of 162 patients with shoulder pain after stroke and the prevalence was 11.6%. The included patients were divided into shoulder pain group and non-shoulder pain group. There were significant differences in age, stroke duration, hospital stay, diabetes, limitation of shoulder joint activity, Ashworth scale, Brunnstrom stage, sensory disorders, and motor arm score of NIHSS between the two groups (P < 0.05). Based on the multivariate regression analysis, the independent risk factors for shoulder pain after stroke included diabetes, limited shoulder joint activity, Brunnstrom grade I-III period, Ashworth 3-4 grade, motor arm score of NIHSS 3-4 points, and sensory disturbance. Conclusion: Great emphasis should be placed on the stroke patients with diabetes, limited shoulder joint activity, Brunnstrom grade I-III period, Ashworth 3-4 grade, motor arm score of NIHSS 3-4 points, or sensory disturbance, as these patients have higher risks for shoulder pain after stroke. doi: https://doi.org/10.12669/pjms.38.1.4594 How to cite this:Hao N, Zhang M, Li Y, Guo Y. Risk factors for shoulder pain after stroke: A clinical study. Pak J Med Sci. 2022;38(1):---------. doi: https://doi.org/10.12669/pjms.38.1.4594 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

EFFECT OF VIBRATION STIMULUS ON SPASTICITY IN POST STROKE HEMIPLEGIC PATIENTS

Physical treatment such as vibration has been proposed as possible non-pharmacological way to control spasticity. The aim of the study was 1) can a selective vibration of the lower limb Dorsiexors of foot and quadriceps, reduce the spasticity of the plantar exors and hamstrings muscle; 2) is vibrations association with physiotherapy better than physiotherapy alone in reducing spasticity. This was a Pre Post study design wherein all the patients were taken from OPD in Govt. Medical College & Hospital, Sector 32 Chandigarh, India. Atotal of Sixty post stroke hemiplegic patients were taken for the study. Method. (VIB + PT) group A received physiotherapy plus vibration by means of a hand held vibrator applied over the belly of the Dorsiexors of leg and belly of Quadriceps muscle of the spastic side (contact surface 2 cm2; frequency 100 Hz; amplitude 2 mm; mean pressure 250 mBar). Control group B received conventional physiotherapy treatment alone. Both groups had 45 minutes of physiotherapy including Bobath therapy, muscle lengthening stretching exercises for 5 days a week for 2 weeks.Main Outcome Measure was Spasticity measurement by Modied Ashworth scale for both the groups before starting treatment and after the end of 2 weeks. Results: Fisher's exact test showed a statistically non signicant improvements in the (VIB + PT) group (p≥0.05) compared to in the (PT) group after 2 weeks of treatment for the Modied Ashworth scale. AlthoughStuart Maxwell Test showed that there was a statistically signicant difference within Group A i.e. Vibration plus Conventional physiotherapy with (p≤0.05) Conclusion. 1) 100 Hz vibration applied to the Dorsiexors of foot and Quadriceps muscle of a spastic lower limb in association with physiotherapy is able to reduce the spasticity of the exor agonist i.e. plantar exors and hamstrings 2) this association is not better than physiotherapy alone in controlling spasticity. Clinical Rehabilitation Impact :100 Hz antagonist muscle vibration, a non-pharmacological treatment, can help physiotherapy to reduce exors spasticity in the rehabilitation of lower limb spasticity.

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.