Posts Tagged Muscle spasticity

[ARTICLE] Quantifying spasticity in individual muscles using shear wave elastography – Full Text

Abstract

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.

Introduction

An estimated 795,000 Americans experience stroke every year [1], and stroke incidence is expected to increase as the population ages [2]. It is estimated that the prevalence of spasticity after stroke ranges from 18% to 39% [3], [4] and [5], and spasticity-associated functional limitations create significant burdens on survivors and caregivers [6]. Health care costs for individuals with stroke who develop spasticity are estimated to be fourfold higher than those without spasticity [7]. However, high subject variability and indeterminate measurement techniques limit research investigation and treatment advances [8] and [9].

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 [9] and [10]. 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 [11] and [12]. 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 [13] and [14]. Electromyography or biomechanical measures may offer more reliable, quantitative information, though are impractical for routine clinical use [14], [15] and [16]. Furthermore, elevated muscle tone in persons with spasticity may not be related to activation of the muscle groups in question [17] and [18].

A variety of imaging-based elastography techniques have emerged with great promise for skeletal muscle evaluation, including ultrasound elastography and magnetic resonance elastography [18], [19], [20], [21] and [22]. 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 [21], [23] and [24]. 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 [25], [26] and [27]. For this reason, SWE may be uniquely suited for evaluating pathologic alterations in stiffness of individual muscles, especially for quantifying spasticity [18], [28], [29], [30] and [31].

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.

Continue —> Quantifying spasticity in individual muscles using shear wave elastography

Fig. 1. Shear wave speeds, ultrasound images, and elastograms for 60°/s ipsilateral elbow extension trials. (A) Ipsilateral biceps; (B) ipsilateral brachialis; (C) ultrasound images and elastograms from trial 1 with sample regions of interest demonstrated in the first panel.

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[Abstract] Ankle plantarflexor spasticity is not differentially disabling for those who are weak following traumatic brain injury

ABSTRACT

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.

Source: Ankle plantarflexor spasticity is not differentially disabling for those who are weak following traumatic brain injury: Brain Injury: Vol 0, No 0

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[Abstract] Common goal areas in the treatment of upper limb spasticity: a multicentre analysis.

Abstract

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.

 

Source: Common goal areas in the treatment of upper limb spasticity: a multicentre analysis

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[ARTICLE] Effect of Dual Therapy with Botulinum Toxin A Injection and Electromyography-controlled Functional Electrical Stimulation on Active Function in the Spastic Paretic Hand – Full Text PDF

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.

Source: Effect of Dual Therapy with Botulinum Toxin A Injection and Electromyography-controlled Functional Electrical Stimulation on Active Function in the Spastic Paretic Hand

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[Review] TRANSCRANIAL DIRECT CURRENT STIMULATION FOR IMPROVING SPASTICITY AFTER STROKE: A SYSTEMATIC REVIEW WITH META-ANALYSIS – Full Text PDF

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.

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[Review] Systematic review of adjunct therapies to improve outcomes following botulinum toxin injection for treatment of limb spasticity.

Abstract

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.

 

Source: Systematic review of adjunct therapies to improve outcomes following botulinum toxin injection for treatment of limb spasticity

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[Abstract] Effect of Dual Therapy with Botulinum Toxin A Injection and Electromyography-controlled Functional Electrical Stimulation on Active Function in the Spastic Paretic Hand

Abstract

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.

Source: Effect of Dual Therapy with Botulinum Toxin A Injection and Electromyography-controlled Functional Electrical Stimulation on Active Function in the Spastic Paretic Hand

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[Book Chapter] Passive Hand Rehabilitation: Soft-Actuated Finger Mobilizer – Springer

Abstract

Stroke is one of the top five diseases in Malaysia contributing to major morbidity and mortality not only in Malaysia but in the whole world. Severe stroke can lead to death while the stroke survivors will face weakness (flaccid), spasticity and decrease in proprioceptive sensation depending on the affected part of the brain. The cost of rehabilitation session as well as the restriction in mobility demotivates the patient to undergo rehabilitation therapy in occupational therapy. A portable, lightweight and low cost device was proposed for finger mobilizer specifies for these patients. In order to develop the device, we need to consider muscle conditions of the patient which is muscle spasticity and muscle flaccid. After considering the condition of the patient and the efficiency of the device used, the most suitable design which incorporated the concept of soft actuated finger mobilize is chosen. A glovelike device which uses the application of air pressure as the mobility mechanisms was identified as the most suitable concept for this project. The final design was fabricated and tested on five normal subjects with no pathological condition of the hand. Quantitative analysis was conducted to acquire public opinion on the prototype produced. Nearly all of them agreed on this concept although a lot of improvement needs to be done regarding the design of the prototype.

Source: Passive Hand Rehabilitation: Soft-Actuated Finger Mobilizer – Springer

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[Abstract] Passive Hand Rehabilitation: Soft-Actuated Finger Mobilizer

Abstract

Stroke is one of the top five diseases in Malaysia contributing to major morbidity and mortality not only in Malaysia but in the whole world. Severe stroke can lead to death while the stroke survivors will face weakness (flaccid), spasticity and decrease in proprioceptive sensation depending on the affected part of the brain. The cost of rehabilitation session as well as the restriction in mobility demotivates the patient to undergo rehabilitation therapy in occupational therapy. A portable, lightweight and low cost device was proposed for finger mobilizer specifies for these patients. In order to develop the device, we need to consider muscle conditions of the patient which is muscle spasticity and muscle flaccid. After considering the condition of the patient and the efficiency of the device used, the most suitable design which incorporated the concept of soft actuated finger mobilize is chosen. A glovelike device which uses the application of air pressure as the mobility mechanisms was identified as the most suitable concept for this project. The final design was fabricated and tested on five normal subjects with no pathological condition of the hand. Quantitative analysis was conducted to acquire public opinion on the prototype produced. Nearly all of them agreed on this concept although a lot of improvement needs to be done regarding the design of the prototype.

Source: Passive Hand Rehabilitation: Soft-Actuated Finger Mobilizer – Springer

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[ARTICLE] Randomized, placebo-controlled trial of incobotulinumtoxinA for upper-limb post-stroke spasticity

Cover image for Vol. 52 Issue 2Abstract

Introduction: Efficacy and safety of incobotulinumtoxinA in post-stroke upper-limb spasticity were studied.

Methods: Subjects randomized 2:1 to incobotulinumtoxinA (fixed dose 400U) or placebo, with fixed doses for the primary target clinical pattern (PTCP; flexed elbow:200U; flexed wrist:150U; clenched fist:100U). Doses for non-primary patterns were flexible within predefined ranges.

Results: At Week-4, incobotulinumtoxinA led to larger improvements in PTCP Ashworth Scale (AS) scores than placebo [least squares mean change±standard error: −0.9±0.06 (n=171) versus −0.5±0.08 (n=88); P<0.001], and more subjects were PTCP AS responders (≥1-point improvement) with incobotulinumtoxinA (69.6%) than placebo (37.5%; P<0.001). Investigator’s Global Impression of Change confirmed superiority of incobotulinumtoxinA versus placebo (P=0.003). IncobotulinumtoxinA was associated with functional improvements, demonstrated in responder rates for Disability Assessment Scale principal target at Week-4 (P=0.007). Adverse events were mainly mild/moderate, and were reported by 22.4% (incobotulinumtoxinA) and 16.8% (placebo) subjects.

Conclusions: IncobotulinumtoxinA significantly improved upper-limb spasticity and associated disability, and was well-tolerated. This article is protected by copyright. All rights reserved.

via Randomized, placebo-controlled trial of incobotulinumtoxinA for upper-limb post-stroke spasticity – Elovic – Muscle & Nerve – Wiley Online Library.

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