To investigate whether extracorporeal shock wave therapy (ESWT) is noninferior to botulinum toxin type A (BoNT-A) for the treatment of poststroke upper limb spasticity.
(1) To determine the effect of transcutaneous electrical nerve stimulation (TENS) on poststroke spasticity. (2) To determine the effect of different parameters (intensity, frequency, duration) of TENS on spasticity reduction in adults with stroke. (3) To determine the influence of time since stroke on the effectiveness of TENS on spasticity.
PubMed, PEDro, CINAHL, Web of Science, CENTRAL, and EMBASE databases were searched from inception to March 2017.
Randomized controlled trial (RCT), quasi-RCT, and non-RCT were included if (1) they evaluated the effects of TENS for the management of spasticity in participants with acute or subacute or chronic stroke using clinical and neurophysiological tools; and (2) TENS was delivered either alone or as an adjunct to other treatments.
Two authors independently screened and extracted data from 15 of the 829 studies retrieved through the search using a pilot tested pro forma. Disagreements were resolved through discussion with other authors. Quality of studies was assessed using Cochrane risk of bias criteria.
Meta-analysis was performed using a random-effects model that showed (1) TENS along with other physical therapy treatments was more effective in reducing spasticity in the lower limbs compared to placebo TENS (SMD −0.64; 95% confidence interval [95% CI], −0.98 to −0.31; P=.0001; I2=17%); and (2) TENS, when administered along with other physical therapy treatments, was effective in reducing spasticity when compared to other physical therapy interventions alone (SMD −0.83; 95% CI, −1.51 to −0.15; P=.02; I2=27%). There were limited studies to evaluate the effectiveness of TENS for upper limb spasticity.
There is strong evidence that TENS as an adjunct is effective in reducing lower limb spasticity when applied for more than 30 minutes over nerve or muscle belly in chronic stroke survivors (review protocol registered at PROSPERO: CRD42015020151)
To systematically review the effects of static stretching with positioning orthoses or simple positioning combined or not with other therapies on upper-limb spasticity and mobility in adults after stroke.
This meta-analysis was conducted according to PRISMA guidelines and registered at PROSPERO. MEDLINE (Pubmed), Embase, Cochrane CENTRAL, Scopus and PEDro databases were searched from inception to January 2018 for articles. Two independent researchers extracted data, assessed the methodological quality and rated the quality of evidence of studies.
Three studies (57 participants) were included in the spasticity meta-analysis and 7 (210 participants) in the mobility meta-analysis. Static stretching with positioning orthoses reduced wrist-flexor spasticity as compared with no therapy (mean difference [MD]=-1.89, 95% confidence interval [CI] -2.44 to -1.34; I2 79%, P<0.001). No data were available concerning the spasticity of other muscles. Static stretching with simple positioning, combined or not with other therapies, was not better than conventional physiotherapy in preventing loss of mobility of shoulder external rotation (MD=3.50, 95% CI -3.45 to 10.45; I2 54.7%, P=0.32), shoulder flexion (MD=-1.20, 95% CI -8.95 to 6.55; I2 0%, P=0.76) or wrist extension (MD=-0.32, 95% CI -6.98 to 5.75; I238.5%, P=0.92). No data were available concerning the mobility of other joints.
This meta-analysis revealed very low-quality evidence that static stretching with positioning orthoses reduces wrist flexion spasticity after stroke as compared with no therapy. Furthermore, we found low-quality evidence that static stretching by simple positioning is not better than conventional physiotherapy for preventing loss of mobility in the shoulder and wrist. Considering the limited number of studies devoted to this issue in post-stroke survivors, further randomized clinical trials are still needed.
To investigate whether extracorporeal shock wave therapy (ESWT) is noninferior to botulinum toxin type A (BoNT-A) for the treatment of poststroke upper limb spasticity.
Randomized noninferiority trial.
Referral medical center.
Patients (N=42) with chronic stroke (28 men; mean age, 61.0±10.6y).
Patients received either ESWT or BoNT-A. During the study period, all patients continued their regular rehabilitation.
Assessments were performed at baseline and at 1, 4, and 8 weeks after the intervention. The primary outcome was the change from baseline of the modified Ashworth scale (MAS) score of the wrist flexors at week 4. Secondary outcomes included the change of the MAS scores, Tardieu angles of the wrist and elbow flexors, wrist and elbow passive range of motion (PROM), and upper extremity Fugl-Meyer Assessment (UE-FMA) score during the study period, as well as the treatment response rate.
The primary outcome result in the ESWT group (−0.80±0.41) was similar to that in the BoNT-A group (−0.90±0.44), with a higher confidence limit (0.4) for the difference between groups within the prespecified margin of 0.5, indicating the noninferiority of ESWT to BoNT-A. The response rate was not significantly different between the 2 groups. Both groups showed significant improvement in secondary outcomes relative to baseline; however, the ESWT group yielded greater improvement in wrist and elbow PROM and UE-FMA score.
Our results suggest that ESWT is a noninferior treatment alternative to BoNT-A for poststroke upper limb spasticity. ESWT and BoNT-A caused similar reduction in spasticity of the wrist and elbow flexors; however, ESWT yielded greater improvement in wrist and elbow PROM and UE-FMA score.
Aims: Does the addition of botulinum toxin type A increase the effect of casting for improving wrist extension after stroke in people with upper limb spasticity?
Methods: Randomized trial with concealed allocation, assessor blinding and intention-to-treat analysis which was part of a larger trial included 18 adults with upper limb spasticity two years after stroke (89%) or stroke-like conditions (11%). The experimental group (n=7) received botulinum toxin type A injections to upper limb muscles for spasticity management followed by two weeks of wrist casting into maximum extension. The control group (n=11) received two weeks of casting only. Range of motion (goniometry) measured at baseline and after two weeks of casting.
Results: Passive wrist extension for the experimental group improved over two weeks from 22 degrees (SD 16) to 54 degrees (SD 16), while the control group improved from 21 degrees (SD 29) to 43 degrees (SD 26). The experimental group increased passive wrist extension 13 degrees (95% CI 4 to 31) more than the control group which was not statistically significant.
Conclusion: Joint range of motion improved over a two-week period for both groups. Botulinum toxin type A injection followed-by casting produced a mean, clinically greater range of motion than casting alone, therefore, a fully-powered trial is warranted.
Botulinum toxin-A is provided for adults with post-stroke spasticity. Following injection, there is a variation in the rehabilitation therapy type and amount provided. The purpose of this study was to determine if it is feasible to add intensive therapy to botulinum toxin-A injections for adults with spasticity and whether it is likely to be beneficial.
Randomized trial with concealed allocation, assessor blinding, and intention to treat analysis. Thirty-seven adults (n = 3 incomplete or lost follow-up) with spasticity in the upper or lower limb were allocated to one of three groups: experimental group received a single dose of botulinum toxin-A plus an intensive therapy for 8 weeks, control group 1 received a single dose of botulinum toxin-A only, and control group 2 received intensive therapy only for 8 weeks. Feasibility was measured by examining recruitment, intervention (adherence, acceptability, safety), and measurement. Benefit was measured as goal achievement (Goal Attainment Scale), upper limb activity (Box and Block Test), walking (6-min walk test) and spasticity (Tardieu scale), at baseline (week 0), immediately after (week 8), and at three months (week 12).
Overall recruitment fraction for the trial was 37% (eligibility fraction 39%, enrolment fraction 95%). The 26 participants allocated to receive intensive rehabilitation attended 97% of clinic-based sessions (mean 11 ± 2 h) and an averaged 58% (mean 52 ± 32 h) of prescribed 90 h of independent practice. There were no study-related adverse events reported. Although participants in all groups increased their goal attainment, there were no between-group differences for this or other outcomes at week 8 or 12.
Providing intensive therapy following botulinum toxin-A is feasible for adults with neurological spasticity. The study methods are appropriate for a future trial. A future trial would require 134 participants to detect a between-group difference of 7 points on Goal Attainment Scale t-scores with an alpha of 0.05 and power of 80%.
Spasticity affects approximately 20% of stroke survivors [1–4] and is thought to significantly contribute to falls after stroke [5, 6] as well as decreased activity participation [3, 4]. Unsurprisingly, higher costs are thus incurred by patients with spasticity during the first year of survival . Health professionals identify that addressing spasticity is a high priority during rehabilitation , and there is international consensus that localized spasticity (i.e., in the upper or lower limbs) is best managed with a combination of botulinum toxin and physical therapy [9, 10]. While these consensus papers appear to agree, clinical management remains diverse [11, 12] and provides an ongoing challenge for both therapists and health services alike.
In Australia, stroke rehabilitation is guided by the Stroke Foundation clinical practice guidelines . These guidelines recommend that management of moderate to severe spasticity include the use of botulinum toxin type A in additionto physical therapy interventions . Unfortunately, clinical survey data suggests that occupational therapists and physiotherapists report providing therapy post-botulinum toxin type A injections less than a quarter of the time (an estimated 16%) . This low rate of therapy provision suggests ongoing uncertainty among clinicians as to how to treat patients with spasticity. Such uncertainty is likely to stem from the lack of research studies that describe the type, frequency, intensity, and duration of therapy that is effective for people who have received botulinum toxin injections. While there are previous studies which have tested the efficacy of botulinum toxin type A for spasticity management after stroke [14–16], what remains unknown is whether or not therapy should be provided to this group of patients.
To inform best practice in the treatment and rehabilitation of spasticity in people with neurological conditions, understanding whether the suggested combined effects of using both therapy and botulinum toxin type A together is more beneficial than botulinum toxin-A alone or physiotherapy interventions alone is key. Given the lack of research in this area, a large, powered randomized controlled trial is required. In preparation for this trial, it is key to understand both the feasibility and likely effects of the interventions; therefore, the research questions posed in this pilot study were:
BACKGROUND: Spasticity is a muscle disorder associated with upper motor neuron syndrome occurring in neurological disorders, such as stroke, multiple sclerosis, spinal cord injury and others. It influences the patient’s rehabilitation, interfering with function, limiting independence, causing pain and producing secondary impairments, such as contractures or other complications. Due to the heterogeneity of clinical signs of spasticity, there is no agreement on the most appropriate assessment and measurement modality for the evaluation of treatment outcomes.
AIM: The aim of this article is to propose the use of new robotic devices for upper-limb spasticity assessment and describe the most relevant measures of spasticity which could be automatically assessed by using a technologically advanced device.
DESIGN: Observational pilot study.
SETTING: The treatment was provided in a Rehabilitation Centre where the device was located and the subjects were treated in an outpatients setting.
POPULATION: Five post-stroke patients, age range 19-79 years (mean age 61, standard deviation [SD]±25) in their chronic phase.
METHODS: A new robotic device able to automatically assess upper-limb spasticity during passive and active mobilization has been developed. The elbow spasticity of five post stroke patients has been assessed by using the new device and by means of the Modified Ashworth Scale (MAS). After the first assessment, subjects were treated with botulin toxin injections, and then underwent 10 sessions of robotic treatments. After the treatment, subjects spasticity was assessed by using the robotic device and the MAS Score.
RESULTS: In four out of five patients, the botulin toxin injection and robotic treatment resulted in the improvement of the MAS Score; in three patients the robotic measures were able to detect the MAS changes. In one subject botulin toxin was not effective and the robotic device was able to detect the lack of effectiveness.
CONCLUSIONS: By using the robotic device some spasticity parameters can be continuously recorded during the rehabilitation treatment in order to objectively measure the effectiveness of the interventions provided.
CLINICAL REHABILITATION IMPACT: The standardized evaluation parameters recorded using robotic devices may provide several advantages: 1) the measures for spasticity assessment can be monitored during every rehabilitation session (even during each movement); 2) these measurements are able to highlight even small changes; 3) the recovery plateau can be detected early thus avoiding further rehabilitation sessions; and 4) these measurements can reduce the assessment bias in multicenter studies.
Spastic paresis is a common feature of an upper motor neuron impairment caused by stroke, brain injury, multiple sclerosis and other central nervous system (CNS) disorders. Existing national and international guidelines for the treatment of adult spastic paresis tend to focus on the treatment of muscle overactivity rather than the comprehensive approach to care, which may require life-long management. Person-centered care is increasingly adopted by healthcare systems in a shift of focus from “disease-oriented” towards “person-centered” medicine. The challenge is to apply this principle to the complex management of spastic paresis and to include an educative process that engages care providers and patients and encourages them to participate actively in the long-term management of their own disease. To address this issue, a group of 13 international clinicians and researchers used a pragmatic top-down methodology to evaluate the evidence and to formulate and grade the strength of recommendations for applying the principles of person-centered care to the management of spastic paresis. There is a distinct lack of clinical trial evidence regarding the application of person-centered medicine to the rehabilitation setting. However, the current evidence base supports the need to ensure that treatment interventions for spastic paresis should be centered on as far as reasonable on the patient’s own priorities for treatment. Goal setting, negotiation and formal recording of agreed SMART goals should be an integral part of all spasticity management programs, and goal attainment scaling should be recorded alongside other standardized measures in the evaluation of outcome. When planning interventions for spastic paresis, the team should consider the patient and their family’s capacity for self-rehabilitation, as well as ways to enhance this approach. Finally, the proposed intervention and treatment goals should consider the impact of any neuropsychological, cognitive and behavioral deficits on rehabilitation. These recommendations support a person-centric focus in the management of spastic paresis.
via A comprehensive person-centered approach to adult spastic paresis: a consensus-based framework – European Journal of Physical and Rehabilitation Medicine 2018 August;54(4):605-17 – Minerva Medica – Journals
Spasticity is a common condition in stroke survivors, and may be associated with pain and joint contracture, leading to poor quality of life and increased caregiver burden. Although the underlying mechanisms are not well-understood, it may be due to disruption of the balance of supra-spinal inhibitory and excitatory sensory inputs directed to the spinal cord, leading to a state of disinhibition of the stretch reflex. The treatment options include physical therapy, modality and pharmacological treatments, neurolysis with phenol and botulinum toxin, and surgical treatment. A successful treatment of spasticity depends on a clear comprehension of the underlying pathophysiology, natural history, and impact on patient’s performances. This review focuses on the epidemiology, presumed mechanism, clinical manifestation, and recent evidences of management.
Stroke is one of the leading causes of mortality and morbidity in adults in most countries.1; 2 ; 3 Spasticity is a common, but not an inevitable condition, in patients with stroke. Spasticity following stroke is often associated with pain, soft tissue stiffness, and joint contracture, and may lead to abnormal limb posture, decreased quality of life, increased treatment cost, and increased caregiver burden.4 Early detection and management of post-stroke spasticity may not only reduce these complications, but may also improve function and increase independency in patients with spasticity.
Spasticity was first described by Lance5 in 1980 as a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone), with exaggerated tendon jerks, resulting from hyper-excitability of the neurons involved in stretch reflex, as a component of the upper motor neuron syndrome. This definition is useful in clinical practice, because the guideline “velocity-dependent increase in tonic stretch reflexes,” can distinguish spasticity from other similar movement disorders such as hypertonia, rigidity, and hyperreflexia. However, this definition ignores the important aspect of sensory input in the experience of spasticity. Some studies have found that abnormal processing of sensory inputs from muscle spindles leads to excessive reflex activation of alpha-motoneurons, and increases spasticity. The new definition from the Support Program for Assembly of a Database for Spasticity Measurement (SPASM) project defines spasticity as “disordered sensory-motor control, resulting from an upper motor neuron lesion, presenting as intermittent or sustained involuntary activation of muscles”.6This definition takes into account the contribution of viscoelastic properties of soft tissue to joint stiffness, and the roles of proprioceptive and cutaneous sensory pathways.[…]
INTRODUCTION: Spasticity is associated with various diseases of the nervous system. Current treatments such as drug therapy, botulinum toxin injections, kinesitherapy, and physiotherapy are not sufficiently effective in a large number of patients. Transcranial magnetic stimulation (TMS) can be considered as an alternative method of treatment. The purpose of this article was to conduct a systematic review and meta-analysis of all available publications assessing the efficacy of repetitive TMS in treatment of spasticity.
EVIDENCE ACQUISITION: Search for articles was conducted in databases PubMed, Willey, and Google. Keywords included “TMS”, “spasticity”, “TMS and spasticity”, “non-invasive brain stimulation”, and “non-invasive spinal cord stimulation”. The difference in scores according to the Modified Ashworth Scale (MAS) for one joint before and after treatment was taken as the effect size.
EVIDENCE SYNTHESIS: We found 26 articles that examined the TMS efficacy in treatment of spasticity. Meta-analysis included 6 trials comprising 149 patients who underwent real stimulation or simulation. No statistically significant difference in the effect of real and simulated stimulation was found in stroke patients. In patients with spinal cord injury and spasticity, the mean effect size value and the 95% confidence interval were -0.80 and (-1.12, -0.49), respectively, in a group of real stimulation; in the case of simulated stimulation, these parameters were 0.15 and (-0.30, -0.00), respectively. Statistically significant differences between groups of real stimulation and simulation were demonstrated for using high-frequency repetitive TMS or iTBS mode for the M1 area of the spastic leg (P=0.0002).
CONCLUSIONS: According to the meta-analysis, the statistically significant effect of TMS in the form of reduced spasticity was demonstrated only for the developed due to lesions at the brain stem and spinal cord level. To clarify the amount of the antispasmodic effect of repetitive TMS at other lesion levels, in particular in patients with hemispheric stroke, further research is required.
via Transcranial and spinal cord magnetic stimulation in treatment of spasticity: a literature review and meta-analysis – European Journal of Physical and Rehabilitation Medicine 2018 February;54(1):75-84 – Minerva Medica – Journals