To evaluate the effects and safety of electro-acupuncture (EA) for stroke patients with spasticity.
Objective: To present interdisciplinary practical guidance for the assessment and treatment of spastic equinovarus foot after stroke.
Results: Clinical examination and diagnostic nerve block with anaesthetics determine the relative role of the factors leading to spastic equinovarus foot after stroke: calf spasticity, triceps surae – Achilles tendon complex shortening and dorsiflexor muscles weakness and/or imbalance. Diagnostic nerve block is a mandatory step in determining the cause(s) of, and the most appropriate treatment(s) for, spastic equinovarus foot. Based on interdisciplinary discussion, and according to a patient-oriented goal approach, a medical and/or surgical treatment plan is proposed in association with a rehabilitation programme. Spasticity is treated with botulinum toxin or phenol–alcohol chemodenervation and neurotomy, shortening is treated by stretching and muscle-tendon lengthening, and weakness is treated by ankle-foot orthosis, functional electrical stimulation and tendon transfer. These treatments are frequently combined.
Conclusion: Based on 20 years of interdisciplinary expertise of management of the spastic foot, guidance was established to clarify a complex problem in order to help clinicians treat spastic equinovarus foot. This work should be the first step in a more global international consensus.
Stroke is the third most common cause of death and the primary cause of severe disability in industrialized countries. Following stroke, approximately 80% of patients regain walking function with decreased gait velocity and asymmetrical gait pattern (1). Spastic equinovarus foot (SEVF) is one of the most common disabling deformities observed among hemiplegic patients. SEVF is frequently associated with other kinematic gait abnormalities, such as stiff knee gait, genu recurvatum, and painful claw toes. SEVF deformity forces the patient to increase their hip and knee flexion in the swing phase. If they are unable to do this (e.g. if they have associated stiff knee gait), the patient will present a hip circumbduction in the swing phase. Correction of such equinus may therefore improve distal as well as proximal gait disturbances.
SEVF deformity has 4 main causes (2, 3). The first is spasticity of the calf muscles (soleus, gastrocnemius, tibialis posterior, flexor digitorum and flexor hallucis longus muscles), responsible for SEVF in the stance phase of gait and for painful toe curling with callosities on the pulp and dorsum of the toes. The peroneus longus and brevis muscles may also be spastic (often with clonus), but such spasticity is useful to limit the varus and stabilize the ankle. Secondly, the spastic muscles have a tendency to remain in a shortened position for prolonged periods, which, in turn, results in soft-tissue changes and contractures, leading to a fixed deformity (4). Thirdly, weakness of the ankle dorsiflexor muscles (tibialis anterior, extensor digitorum and hallucis muscles) as well as the peroneus longus and brevis muscles is responsible for drop-foot in the swing phase of gait. Such weakness is often emphasized by triceps spastic co-contraction and/or contracture. The weakness also affects the triceps surae muscles, leading to a lack of propulsion at the end of the stance phase of gait. Lastly, an imbalance between the tibialis anterior and the peroneus muscles leads to varus of the hind-foot in the swing phase, as peroneus activation must compensate for physiological varus positioning related to contraction of the tibialis anterior. In such a case, the foot will be placed in an unstable varus position during the swing phase and at the beginning of the stance phase.
The respective role of the main causes of SEVF (spasticity, shortening, weakness, and imbalance) varies from patient to patient, and therapeutic decisions are therefore challenging. Indeed, as emphasized by Fuller, the causes of SEVF are varied and complex, due to a variety of deforming forces, and thus a single procedure does not exist to correct all deformities (3). Hence there is a need for guidance and guidelines.
Treatments for SEVF described in the literature are multimodal and include rehabilitation, orthosis, botulinum toxin (BoNT-A) injections, alcohol and phenol nerve blocks, functional neurosurgery (selective neurotomy and intrathecal baclofen therapy) and orthopaedic surgery (tendon transfer, tendon lengthening and bone surgery) (5). SEVF rehabilitation programmes include strengthening of the tibialis anterior and peroneus muscles, electrical stimulation, stretching of the triceps surae to reduce spasticity and prevent contracture, and gait and balance training. Modern therapeutic approaches, such as task-oriented strategy and treadmill with bodyweight support, are promoted. Several publications support the effectiveness of these treatments in SEVF (6–8). However, only 3 studies have compared different treatment options (9–11). A systematic review of surgical correction in adult patients with stroke emphasized the need to compare treatments in order to generate evidence on which to base algorithms (8). In fact, no practical guidelines are available for use in daily practice. Evidence regarding choice of treatment is poor, thus therapeutic decision-making is based on professional personal preferences and beliefs rather than on scientific evidence. An interdisciplinary approach with a physical medicine and rehabilitation (PMR) specialist and rehabilitation team, neurosurgeon, and orthopaedic surgeon is therefore mandatory in order to optimize treatments.
The aim of this paper is to present and discuss the Mont-Godinne interdisciplinary guidance (Fig. 1), based on the existing literature and on 20 years of experience of an interdisciplinary medical and surgical approach to SEVF.
Objective: To examine the relationship between patient-rated physician empathy and outcome of botulinum toxin treatment for post-stroke upper limb spasticity.
Design: Cohort study.
Subjects: Twenty chronic stroke patients with upper limb spasticity.
Methods: All patients received incobotulinumtoxinA injection in at least one muscle for each of the following patterns: flexed elbow, flexed wrist and clenched fist. Each treatment was performed by 1 of 5 physiatrists with equivalent clinical experience. Patient-rated physician empathy was quantified with the Consultation and Relational Empathy Measure immediately after botulinum toxin treatment. Patients were evaluated before and at 4 weeks after botulinum toxin treatment by means of the following outcome measures: Modified Ashworth Scale; Wolf Motor Function Test; Disability Assessment Scale; Goal Attainment Scaling.
Results: Ordinal regression analysis showed a significant influence of patient-rated physician empathy (independent variable) on the outcome (dependent variables) of botulinum toxin treatment at 4 weeks after injection, as measured by Goal Attainment Scaling (p < 0.001).
Conclusion: These findings support the hypothesis that patient-rated physician empathy may influence the outcome of botulinum toxin treatment in chronic stroke patients with upper limb spasticity as measured by Goal Attainment Scaling.
Stroke is a leading cause of adult disability (1, 2). Damage to the descending tracts and sensory-motor networks results in the positive and negative signs of the upper motor neurone syndrome (UMNS) (1–3). The upper limb is commonly involved after stroke, with up to 69% of patients having arm weakness on admission to hospital (4). Recovery of upper limb function has been found to correlate with the degree of initial paresis and its topical distribution according to the cortico-motoneuronal representation of arm movements (5–9).
Spasticity is a main feature of UMNS. It is defined as a state of increased muscle tone with exaggerated reflexes characterized by a velocity-dependent increase in resistance to passive movement (10). Upper limb spasticity has been found to be associated with reduced arm function, low levels of independence and high burden of direct care costs during the first year post-stroke (11). It affects nearly half of patients with initial impaired arm function, with a prevalence varying from 17% to 38% of all patients at one year post-stroke (11). Up to 13% of patients with stroke need some form of spasticity treatment (drug therapy, physical therapy or other rehabilitation approaches) within 6–12 months post-onset (11, 12). Botulinum toxin type A (BoNT-A) has been proven safe and effective for reducing upper limb spasticity and improving arm passive function in adult patients (13, 14). While current literature reports highly patient-specific potential gains in function after BoNT-A treatment, there is inadequate evidence to determine the efficacy of BoNT-A in improving active function associated with adult upper limb spasticity (13).
Empathy refers to the ability to understand and share the feelings, thoughts or attitudes of another person (15). It is an essential component of the physician-patient relationship and a key dimension of patient-centred care (15, 16). This is even more important in rehabilitation medicine, where persons with disabilities often report encountering attitudinal and environmental barriers when trying to obtain rehabilitative care and express the need for better communication with their healthcare providers (17).
To the best of our knowledge, no previous research has investigated the influence of physician empathy on patient outcome after spasticity treatment. The aim of this study was to examine the relationship between patient-rated physician empathy and clinical outcome of BoNT-A treatment for upper limb spasticity due to chronic stroke. […]
Continue —> Journal of Rehabilitation Medicine – Influence of physician empathy on the outcome of botulinum toxin treatment for upper limb spasticity in patients with chronic stroke: A cohort study – HTML
Spasticity is common following stroke; however, high subject variability and unreliable measurement techniques limit research and treatment advances. Our objective was to investigate the use of shear wave elastography (SWE) to characterize the spastic reflex in the biceps brachii during passive elbow extension in an individual with spasticity. The patient was a 42-year-old right-hand-dominant male with history of right middle cerebral artery-distribution ischemic infarction causing spastic left hemiparesis. We compared Fugl-Meyer scores (numerical evaluation of motor function, sensation, motion, and pain), Modified Ashworth scores (most commonly used clinical assessment of spasticity), and SWE measures of bilateral biceps brachii during passive elbow extension. We detected a catch that featured markedly increased stiffness of the brachialis muscle during several trials of the contralateral limb, especially at higher extension velocities. SWE was able to detect velocity-related increases in stiffness with extension of the contralateral limb, likely indicative of the spastic reflex. This study offers optimism that SWE can provide a rapid, real-time, quantitative technique that is readily accessible to clinicians for evaluating spasticity.
An estimated 795,000 Americans experience stroke every year , and stroke incidence is expected to increase as the population ages . It is estimated that the prevalence of spasticity after stroke ranges from 18% to 39% ,  and , and spasticity-associated functional limitations create significant burdens on survivors and caregivers . Health care costs for individuals with stroke who develop spasticity are estimated to be fourfold higher than those without spasticity . However, high subject variability and indeterminate measurement techniques limit research investigation and treatment advances  and .
Though classically considered to have increased stiffness resulting solely from the over-active velocity-dependent stretch reflex, chronically spastic muscles associated with stroke appear to also have increased nonreflex stiffness when compared to the side of the body ipsilateral to the lesioned hemisphere, as well as healthy controls  and . Clinically, spasticity is diagnosed and monitored using the 5-point Modified Ashworth Scale (MAS): a simple technique that requires no equipment, though is subjective, qualitative, and varies widely with muscle groups  and . Though the precise mechanism behind spasticity is not known, we now recognize a variety of biomechanical changes within skeletal muscle connective tissue that likely limit the effectiveness of a simplistic tool, such as the MAS, for evaluating spasticity in chronic stroke  and . Electromyography or biomechanical measures may offer more reliable, quantitative information, though are impractical for routine clinical use ,  and . Furthermore, elevated muscle tone in persons with spasticity may not be related to activation of the muscle groups in question  and .
A variety of imaging-based elastography techniques have emerged with great promise for skeletal muscle evaluation, including ultrasound elastography and magnetic resonance elastography , , ,  and . Strain elastography, a qualitative measure of relative stiffness, is also available but offers little advantage over the MAS, as neither offers a quantitative, objective measure ,  and . The two quantitative imaging modalities, magnetic resonance elastography and ultrasound shear wave elastography (SWE), show good agreement in both phantoms and tissues, though SWE is especially promising for its flexibility, accessibility, and real-time results ,  and . For this reason, SWE may be uniquely suited for evaluating pathologic alterations in stiffness of individual muscles, especially for quantifying spasticity , , ,  and .
This study evaluated the feasibility of using SWE to characterize the spastic reflex during passive elbow extension in an individual with spasticity caused by stroke. We hypothesized that SWE would capture heightened skeletal muscle stiffness, representing the spastic reflex, during passive elbow range of motion.
Primary objectives: The main aim of this study was to determine whether the presence of distal lower-limb spasticity had a greater impact on mobility for those who had greater levels of muscle paresis following traumatic brain injury (TBI).
Research design: This was a cross-sectional cohort study of convenience. Seventy-five people attending physiotherapy for mobility limitations following TBI participated in this study. All participants had sustained a moderate–severe TBI and were grouped according to the presence or absence of ankle plantarflexor spasticity for comparison.
Main outcomes and results: The primary outcome measure for mobility was self-selected walking speed and the primary outcome measure for muscle strength was hand-held dynamometry. Secondary outcome measures for mobility and muscle strength were the High-level Mobility Assessment Tool (HiMAT) and ankle power generation (APG) at push-off. Spasticity was quantified with the Modified Tardieu scale. Participants with ankle plantarflexor spasticity (Group 2) had slower self-selected walking speeds. There was no statistically significant effect for Group and plantarflexor strength (p = 0.81).
Conclusion: Although participants with ankle plantarflexor spasticity walked significantly slower than those without, the presence of ankle plantarflexor spasticity did not lead to greater mobility limitations for those who were weak.
Objective: We aimed to develop a goal classification of individualised goals for spasticity treatment incorporating botulinum toxin intervention for upper limb spasticity to under-pin a more structured approach to future goal setting.
Design: Individualised goals for spasticity treatment incorporating botulinum toxin intervention for upper limb spasticity (n=696) were analysed initially from four studies published in 2008-2012, spanning a total of 18 centres (12 in the UK and 6 in Australia). Goals were categorised and mapped onto the closest matching domains of the WHO International Classification of Functioning. Confirmatory analysis included a further 927 goals from a large international cohort study spanning 22 countries published in 2013.
Results: Goal categories could be assigned into two domains, each subdivided into three key goal areas: Domain 1: symptoms/impairment n=322 (46%): a. pain/discomfort n=78 (11%), b. involuntary movements n=75 (11%), c. range of movement/contracture prevention n=162 (23%). Domain 2: Activities/function n=374 (54%): a. passive function (ease of caring for the affected limb) n=242 (35%), b active function (using the affected limb in active tasks) n=84 (12%), c. mobility n=11 (2%).
Over 99% of the goals from the large international cohort fell into the same six areas, confirming the international applicability of the classification.
Conclusions: Goals for management of upper limb spasticity, in worldwide clinical practice, fall into six main goal areas.
Background: Many previous studies have demonstrated that botulinum toxin A (BTX-A) injections satisfactorily reduce spasticity. Nevertheless, BTX-A, with or without an adjuvant therapy, effectively improves the direct functional movement in few patients with spastic upper extremity paralysis. Therefore the present study aimed to determine the effectiveness of task-orientated therapy on spasticity and functional movement by using electromyography-triggered functional electrical stimulation (EMG-FES) after BTX-A injections. Design: Open-label, prospective clinical trial Method: The subjects were 15 patients with spastic paresis (12 male, 3 female; age range, 17-74 years; 14 due to stroke, 1 due to spinal cord injury) who received BTX-A injections. Before the study was started, all subjects had undergone task-orientated therapy sessions with EMG-FES for 4 months. Despite all patients showing a various extent of improved upper extremity function, upper extremity function reached a plateau because of upper extremity spasticity. After BTX-A injection, all patients underwent task-orientated therapy sessions with EMG-FES for 4 months. The outcomes were assessed with the modified Ashworth scale, the simple test for evaluating hand function, box and block test, grip and release test, finger individual movement test, and grip strength. Assessments were performed at baseline and 10 days and 4 months after BTX-A injection. Results: The median modified Ashworth scale score decreased from 2 at baseline to 1 at 10 days and 4 months after BTX-A injection. The finger individual movement test score increased slightly at 10 days (p=0.29) and further increased at 4 months (p<0.05). The simple test for evaluating hand function, grip and release test, box and block test, and grip strength decreased after 10 days (p<0.05, p=0.26, p<0.01, andp<0.01, respectively) but increased after 4 months (p<0.01, p<0.05, p<0.01, and p=0.18, respectively). Conclusion: Task-orientated therapy with EMG-FES after BTX-A injection effectively reduced spasticity and improved upper limb motor function. Our results also suggest that spasticity occurs as a compensation for the force of the affected muscles and leads to misuse movements and ostensible dexterity in many patients. In addition, we hypothesize that BTX-A injection initializes the abnormal adapted movement pattern and that more active hand movements with facilitation of the paretic muscles when using EMG-FES induce an efficient muscle reeducation of the inherent physiological movement pattern that ultimately could prove useful in the activities of daily living.
Objective: To evaluate the evidence regarding transcranial direct current stimulation (tDCS) and to assess its impact on spasticity after stroke.
Data sources: The following databases were searched up to 6 January 2016: Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, latest issue), MEDLINE (from 1948), EMBASE (from 1980), CINAHL (from 1982), AMED (from 1985), Science Citation Index (from 1900).
Study selection: One author screened titles and abstracts and eliminated obviously irrelevant studies. Two authors retrieved the full text of the remaining studies and checked them for inclusion.
Data extraction: Two authors independently extracted data from the studies using predefined data extraction sheets. In case an author of being involved in an included trial, another author extracted data.
Data synthesis: Five trials were included, with a total of 315 participants. There was moderate-to-low quality of evidence for no effect of tDCS on improving spasticity at the end of the intervention period. There were no studies examining the effect of tDCS on improving spasticity at long-term follow-up.
Conclusion: There is moderate-to-low quality evidence for no effect of tDCS on improving spasticity in people with stroke.
Objective: To determine the quality of evidence from randomized controlled trials on the efficacy of adjunct therapies following botulinum toxin injections for limb spasticity.
Data sources: MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials electronic databases were searched for English language human studies from 1980 to 21 May 2015.
Study selection: Randomized controlled trials assessing adjunct therapies postbotulinum toxin injection for treatment of spasticity were included. Of the 268 studies screened, 17 met selection criteria.
Data extraction: Two reviewers independently assessed risk of bias using the Physiotherapy Evidence Database (PEDro) scale and graded according to Sackett’s levels of evidence.
Data synthesis: Ten adjunct therapies were identified. Evidence suggests that adjunct use of electrical stimulation, modified constraint-induced movement therapy, physiotherapy (all Level 1), casting and dynamic splinting (both Level 2) result in improved Modified Ashworth Scale scores by at least 1 grade. There is Level 1 and 2 evidence that adjunct taping, segmental muscle vibration, cyclic functional electrical stimulation, and motorized arm ergometer may not improve outcomes compared with botulinum toxin injections alone. There is Level 1 evidence that casting is better than taping, taping is better than electrical stimulation and stretching, and extracorporeal shock wave therapy is better than electrical stimulation for outcomes including the Modified Ashworth Scale, range of motion and gait. All results are based on single studies.
Conclusion: There is high level evidence to suggest that adjunct therapies may improve outcomes following botulinum toxin injection. No results have been confirmed by independent replication. All interventions would benefit from further study.
Background: Many previous studies have demonstrated that botulinum toxin A (BTX-A) injections satisfactorily reduce spasticity. Nevertheless, BTX-A, with or without an adjuvant therapy, effectively improves the direct functional movement in few patients with spastic upper extremity paralysis. Therefore the present study aimed to determine the effectiveness of task-orientated therapy on spasticity and functional movement by using electromyography-triggered functional electrical stimulation (EMG-FES) after BTX-A injections.
Design: Open-label, prospective clinical trial
Method: The subjects were 15 patients with spastic paresis (12 male, 3 female; age range, 17-74 years; 14 due to stroke, 1 due to spinal cord injury) who received BTX-A injections. Before the study was started, all subjects had undergone task-orientated therapy sessions with EMG-FES for 4 months. Despite all patients showing a various extent of improved upper extremity function, upper extremity function reached a plateau because of upper extremity spasticity. After BTX-A injection, all patients underwent task-orientated therapy sessions with EMG-FES for 4 months. The outcomes were assessed with the modified Ashworth scale, the simple test for evaluating hand function, box and block test, grip and release test, finger individual movement test, and grip strength. Assessments were performed at baseline and 10 days and 4 months after BTX-A injection.
Results: The median modified Ashworth scale score decreased from 2 at baseline to 1 at 10 days and 4 months after BTX-A injection. The finger individual movement test score increased slightly at 10 days (p=0.29) and further increased at 4 months (p<0.05). The simple test for evaluating hand function, grip and release test, box and block test, and grip strength decreased after 10 days (p<0.05, p=0.26, p<0.01, andp<0.01, respectively) but increased after 4 months (p<0.01, p<0.05, p<0.01, and p=0.18, respectively).
Conclusion: Task-orientated therapy with EMG-FES after BTX-A injection effectively reduced spasticity and improved upper limb motor function. Our results also suggest that spasticity occurs as a compensation for the force of the affected muscles and leads to misuse movements and ostensible dexterity in many patients. In addition, we hypothesize that BTX-A injection initializes the abnormal adapted movement pattern and that more active hand movements with facilitation of the paretic muscles when using EMG-FES induce an efficient muscle reeducation of the inherent physiological movement pattern that ultimately could prove useful in the activities of daily living.