Post-stroke distal lower limb spasticity impairs mobility, limiting activities of daily living, requiring additional caregiver time.
Post-stroke distal lower limb spasticity impairs mobility, limiting activities of daily living, requiring additional caregiver time.
To evaluate the efficacy, safety, and sustained benefit of onabotulinumtoxinA in adults with post-stroke lower limb spasticity (PSLLS).
A multicenter, randomized, double-blind, phase 3, placebo-controlled trial.
60 study centers across North America, Europe, Russia the United Kingdom, and South Korea.
Adult patients (18 to 65 years of age) with PSLLS (Modified Ashworth Scale [MAS] ≥3) of the ankle plantar flexors and the most recent stroke ≥3 months prior to study enrollment. .
During the open-label phase, patients received ≤3 onabotulinumtoxinA treatments (≤400 U) or placebo at approximately 12-week intervals. Treatments were into the ankle plantar flexors (onabotulinumtoxinA 300 U into ankle plantar flexors; ≤100 U, optional lower limb muscles).
The double-blind primary endpoint was MAS change from baseline (average score at weeks 4 and 6). Secondary measures included physician-assessed Clinical Global Impression of Change (CGI), MAS change from baseline in optional muscles, Goal Attainment Scale (GAS), and pain scale.
Of 468 patients enrolled, 450 (96%) completed the double-blind phase and 413 (88%) completed the study. Small improvements in MAS observed with onabotulinumtoxinA during the double-blind phase (onabotulinumtoxinA, –0.8; placebo, –0.6, P=0.01) were further enhanced with additional treatments through week 6 of the third open-label treatment cycle (onabotulinumtoxinA/onabotulinumtoxinA, –1.2; placebo/onabotulinumtoxinA, –1.4). Small improvements in CGI observed during the double-blind phase (onabotulinumtoxinA, 0.9; placebo, 0.7, P=0.01) were also further enhanced through week 6 of the third open-label treatment cycle (onabotulinumtoxinA/onabotulinumtoxinA, 1.6; placebo/onabotulinumtoxinA, 1.6). Physician- and patient-assessed GAS scores improved with each subsequent treatment. No new safety signals emerged.
OnabotulinumtoxinA significantly improved ankle MAS, CGI, and GAS scores compared with placebo; improvements were consistent and increased with repeated treatments of onabotulinumtoxinA over 1 year in patients with PSLLS.
Clinical Trial Registration URL: https://clinicaltrials.gov/ct2/show/NCT01575054?term=NCT01575054&rank=1
Recovery of voluntary movement is a main rehabilitation goal. Efforts to identify effective upper limb (UL) interventions after stroke have been unsatisfactory. This study includes personalized impairment-based UL reaching training in virtual reality (VR) combined with non-invasive brain stimulation to enhance motor learning. The approach is guided by limiting reaching training to the angular zone in which active control is preserved (“active control zone”) after identification of a “spasticity zone”. Anodal transcranial direct current stimulation (a-tDCS) is used to facilitate activation of the affected hemisphere and enhance inter-hemispheric balance. The purpose of the study is to investigate the effectiveness of personalized reaching training, with and without a-tDCS, to increase the range of active elbow control and improve UL function.
This single-blind randomized controlled trial will take place at four academic rehabilitation centers in Canada, India and Israel. The intervention involves 10 days of personalized VR reaching training with both groups receiving the same intensity of treatment. Participants with sub-acute stroke aged 25 to 80 years with elbow spasticity will be randomized to one of three groups: personalized training (reaching within individually determined active control zones) with a-tDCS (group 1) or sham-tDCS (group 2), or non-personalized training (reaching regardless of active control zones) with a-tDCS (group 3). A baseline assessment will be performed at randomization and two follow-up assessments will occur at the end of the intervention and at 1 month post intervention. Main outcomes are elbow-flexor spatial threshold and ratio of spasticity zone to full elbow-extension range. Secondary outcomes include the Modified Ashworth Scale, Fugl-Meyer Assessment, Streamlined Wolf Motor Function Test and UL kinematics during a standardized reach-to-grasp task.
This study will provide evidence on the effectiveness of personalized treatment on spasticity and UL motor ability and feasibility of using low-cost interventions in low-to-middle-income countries.
Stroke is a leading cause of long-term disability. Up to 85% of patients with sub-acute stroke present chronic upper limb (UL) sensorimotor deficits . While post-stroke UL recovery has been a major focus of attention, efforts to identify effective rehabilitation interventions have been unsatisfactory. This study focuses on the delivery of personalized impairment-based UL training combined with low-cost state-of-the-art technology (non-invasive brain stimulation and commercially available virtual reality, VR) to enhance motor learning, which is becoming more readily available worldwide.
A major impairment following stroke is spasticity, leading to difficulty in daily activities and reduced quality of life . Studies have identified that spasticity relates to disordered motor control due to deficits in the ability of the central nervous system to regulate motoneuronal thresholds through segmental and descending systems [3, 4]. In the healthy nervous system, the motoneuronal threshold is expressed as the “spatial threshold” (ST) or the specific muscle length/joint angle at which the stretch reflex and other proprioceptive reflexes begin to act [5, 6, 7]. The range of ST regulation in the intact system is defined by the task-specific ability to activate muscles anywhere within the biomechanical joint range of motion (ROM). However, to relax the muscle completely, ST has to be shifted outside of the biomechanical range .
We also consider that inter-hemispheric balance is disrupted after stroke, interfering with recovery. UL motor function depends on the modulation of inter-hemispheric inhibition between cortical areas via transcallosal projections [9, 10] and descending projections to fingers, hand and arm . Unilateral hemispheric damage reduces activity in the affected hemisphere while activity in the unaffected hemisphere increases , becoming more dominant. UL recovery may relate to rebalancing of inter-hemispheric inhibition  using, for example, anodal transcranial direct current stimulation (a-tDCS) over the affected hemisphere [14, 15]. a-tDCS is considered a safe technique with transient adverse effects, such as slight scalp itching or tingling and/or mild headaches, that are not expected to impede the patient’s ability to participate in the training protocol .
The underlying idea of this proposal is that recovery of voluntary movement is tightly linked to the recovery of threshold control. We propose an intervention that combines current knowledge about motor learning and disorders in ST control. The intervention involves personalized UL reach training designed according to the spatial structure of motor deficits of an individual, with excitatory a-tDCS over the sensorimotor areas of the affected hemisphere. […]
Improved walking is one of the highest priorities in people living with stroke. Post-stroke lower limb spasticity (PSLLS) impedes walking and quality of life (QOL). The understanding of the evidence of improved walking and QOL following botulinum toxin (BoNTA) injection is not clear. We performed a systematic review of the randomized control trials (RCT) to evaluate the effectiveness of BoNTA injection on walking and QOL in PSLLS.
We searched PubMed, Web of Science, Embase, CINAHL, ProQuest Thesis and Dissertation checks, Google Scholar, WHO International Clinical Trial Registry Platform, ClinicalTrials.gov, Cochrane, and ANZ and EU Clinical Trials Register for RCTs looking at improvement in walking and QOL following injection of BoNTA in PSLLS. The original search was carried out prior to 16 September 2015. We conducted an additional verifying search on CINHAL, EMBASE, and MEDLINE (via PubMed) from 16 September 2015 to 6 June 2017 using the same clauses as the previous search. Methodological quality of the individual studies was critically appraised using Joanna Briggs Institute’s instrument. Only placebo-controlled RCTs looking at improvement in walking and QOL were included in the review.
Of 2026 records, we found 107 full-text records. Amongst them, we found five RCTs qualifying our criteria. No new trials were found from the verifying search. Two independent reviewers assessed methodological validity prior to inclusion in the review using Joanna Briggs Institute’s appraisal instrument. Two studies reported significant improvement in gait velocity (p = 0.020) and < 0.05, respectively. One study showed significant improvement in 2-min-walking distance (p < 0.05). QOL was recorded in one study without any significant improvement. Meta-analysis of reviewed studies could not be performed because of different methods of assessing walking ability, small sample size with large confidence interval and issues such as lack of power calculations in some studies. Findings from our systematic and detailed study identify the need for a well-designed RCT to adequately investigate the issues highlighted.
This review could not conclude there was sufficient evidence to support or refute improvement on walking or QOL following BoNTA injection. Reasons for this are discussed, and methods for future RCTs are developed.
Stroke is a common cause of adult disability worldwide . More than two thirds of the stroke survivors develop post-stroke sequelae including impaired motor functions and spasticity . The prevalence of post-stroke spasticity ranges from 19.0 to 42.6% . There have been many recent developments in diagnosis, management, and prevention of stroke, while advances in rehabilitation have been modest . There has, however, been progress with the use of botulinum toxin (BoNTA) as a treatment to improve spasticity in the upper limb [5, 6, 7]. Three systematic reviews [8, 9, 10] have addressed research progress on both the upper and lower limbs, with the conclusion from two of these that the effect on the upper and lower limbs spasticity favored BoNTA [8, 9]; however, these reviews did not fulfill the criteria for inclusion in this study.
As far as the lower limb is concerned, improvement in spasticity while important is only a first stage in post-stroke improvement, and the aim of RCTs should be to address the more important questions of functional activity including walking. How well this outcome has been addressed is the aim of this study. This is also an important question for many countries to resolve, because to date, botulinum toxin A is not approved for use in the post-stroke lower limb spasticity (PSLLS) by the pharmaceutical authorities except in the USA .
Lower limb spasticity most commonly involves the foot and the ankle leading to equinovarus (plantarflexion and inversion) deformity. Post-stroke patients with equinovarus deformity fail to achieve optimal contact with the ground leading to a poor stance, loss of heel to toe rhythm while walking and post-stroke patients walk predominantly with plantarflexion/inversion of the foot. Transfers and walking are essentially bipedal activity involving phases like balancing on one leg and swinging the other leg forward. The awkward position of the foot in addition to spasticity impairs balance, transfer, stride, gait, and mobility, besides causing spasm and pain. In many cases, complications like falls, fractures, deep vein thrombosis, and pressure ulcers may also result . Inability to walk is associated with loss of independence and premature residential aged care placement [13, 14] and in the older population contributes substantially to adverse health outcomes including activities of daily living and mortality . Improving and maintaining walking ability and activities of daily living are therefore vital for post-stroke survivors  and a major contributor to functional improvements. The overall human and economic cost of spasticity is, therefore, considerable, and interventions potentially can deliver significant benefits .
Given the evidence for efficacy of BoNTA in reducing spasticity, the objective of this review was to assess the available evidence of BoNTA injection: (1) to improve mobility (using gait velocity and walking distance as measuring parameters) and quality of life (QOL) and (2) to make appropriate recommendations for further research regarding these questions. […]
Rationale: Spasticity is a major complication after stroke, and botulinumtoxin A (BoNT-A) injection is commonly used to manage focal spasticity. However, it is uncertain whether BoNT-A can improve voluntary motor control or activities of daily living function of paretic upper limbs. This study investigated whether BoNT-A injection combined with robot-assisted upper limb therapy improves voluntary motor control or functions of upper limbs after stroke.
Patient concerns: Two subacute stroke patients were transferred to the Department of Rehabilitation.
Diagnoses: Patients demonstrated spasticity in the upper extremity on the affected side.
Interventions: BoNT-A was injected into the paretic muscles of the shoulder, arm, and forearm of the 2 patients at the subacute stage. Conventional rehabilitation therapy and robot-assisted upper limb training were performed during the rehabilitation period.
Outcomes: Manual dexterity, grip strength, muscle tone, and activities of daily living function were improved after multidisciplinary rehabilitation treatment.
Lessons: BoNT-A injection in combination with multidisciplinary rehabilitation treatment, including robot-assisted arm training, should be recommended for subacute spastic stroke patients to enhance appropriate motor recovery.
Upper limb spasticity is a common complication following stroke, occurring in 20% to 40% of stroke survivors. As upper limb spasticity, joint contractures, and pain limit the voluntary motor control of the arm and hand, the functions of which are essential for the activity of daily living (ADL), ADL dependencies, including hygiene, dressing, and positioning, can be exacerbated.
Injection of botulinumtoxin A (BoNT-A), which is commonly used in the management of focal spasticity in the chronic phase of stroke, reduces muscle tone and passive range of motion. However, it is unclear whether BoNT-A can improve voluntary motor control or ADL functions of upper limbs.
Recently, task-specific high-intensity training with a multidisciplinary team approach has become an important concept in stroke rehabilitation therapy, and robot-assisted arm training (RAT) has been shown to allow well tolerated and intensive task-specific repetitive training of the paretic arm. However, multidisciplinary rehabilitation therapies using RAT in combination with BoNT-A injection have rarely been applied to subacute poststroke spasticity. Thus, we report on 2 cases showing the beneficial effects of RAT in combination with BoNT-A injection on upper limb spasticity in the subacute phase of stroke. […]
A Doody’s Core Title 2012
Spasticity: Diagnosis and Management is the first book solely dedicated to the diagnosis and treatment of spasticity. This pioneering work defines spasticity in the broad context of Upper Motor Neuron Syndrome and focuses not on a single component, but on the entire constellation of conditions that make up the UMNS and often lead to disability.
Spasticity: Diagnosis and Management clearly defines the process for the diagnosis of spasticity, the basic science behind its pathophysiology, the measurement tools used for evaluation, and reviews the available treatment options. Divided into five sections, this comprehensive clinical resource provides a roadmap for assessing the complicated picture of spasticity and choosing the appropriate interventions. Therapies including oral medications, intrathecal baclofen, botulinum toxin and phenol, and surgical options are thoroughly discussed, as are non-medical therapies and the role of the emerging technologies. The full spectrum of diseases involving spasticity in adults and children and the unique diagnostic and management challenges they present is addressed by experienced clinicians. This text is a one-stop source for physicians, therapists and other members of the spasticity management team tasked with the goal of improving patient care and outcomes.
Special Features of Spasticity: Diagnosis and Management include
Life after a stroke can be challenging. Many patients wonder if they will ever fully recover their muscle coordination, or how long or difficult the process of recovery may be. Fortunately, the field of occupational and physical therapy has come a long way in developing approaches that help patients regain controlled muscle movements after a stroke.
There are seven recognized stages of stroke recovery through which most patients progress. Also known as the Brunnstrom Approach, the seven stages framework views spastic and involuntary muscle movement as part of the process and uses them to aid in rehabilitation.
The Brunnstrom Approach was developed in the 1960’s by Signe Brunnstrom, an occupational and physical therapist from Sweden. With seven stages, the Brunnstrom Approach breaks down how motor control can be restored throughout the body after suffering a stroke.
Normally, muscle movements are the result of different muscle groups working together. Researchers have termed this collaboration between muscles as “synergies”. The brain has the delicate task of coordinating these movements, many of which become severely affected after a stroke.
After the stroke has occurred, your muscles become weak due to the lack of coordination between the brain and body. This causes the muscle synergies to move in abnormal patterns. Most treatments offered to stroke patients will focus on trying to inhibit atypical muscle synergies and movements. The Brunnstrom Approach, on the other hand, teaches patients how to use the abnormal synergy patterns to their advantage.
This approach has become a popular choice among both occupational and physical therapists as well as patients since its inception. It can be effective in clinical settings and can dramatically improve voluntary muscle movements after suffering a stroke.
Stage 1: Flaccidity
The first stage in Brunnstrom’s Approach is the initial period of shock immediately after stroke where flaccid paralysis sets in. Flaccid paralysis (flaccidity) is the medical term for a complete lack of voluntary movement. This paralysis is caused by nerve damage that prevents the muscles from receiving appropriate signals from the brain, whether or not the brain is still capable of moving those muscles.
In the early state of flaccid paralysis, the stroke survivor cannot initiate any muscle movements on the affected side of their body. If this continues for long enough without intervention or physical therapy, the unused muscles become much weaker, and begin to atrophy. Simply put, muscles need to be used in order to retain their tone and definition, and flaccid paralysis prevents muscles from doing this important work.
The medical term for this loss of muscle tone is hyptonia. Hyptonia causes weakness and sometimes numbness that seriously interferes with a patient’s quality of life. In addition to therapy exercises and treatments that reduce the severity of hypotonia, this Stage 1 condition also requires lifestyle modifications to protect the affected limbs from injury.
Though stroke does serious neurological damage, other healthy brain cells and muscles can help make up for some of this damage. In fact, the patient’s own body is full of tools that reduce complications and increase their likelihood of entering new stages of recovery. It’s never too early to start retraining the body and brain after stroke, even if patients are still experiencing flaccid paralysis and hypotonia.
The second stage in stroke recovery marks the redevelopment of some basic limb synergies as certain muscles are stimulated or activated and other muscles in the same system begin to respond. Muscles begin to make small, spastic, and abnormal movements during this stage. While these movements are mostly involuntary, they can be a promising sign during your recovery. Minimal voluntary movements might or might not be present in stage two.
Muscle synergies result from muscles coordinating movements to perform different tasks. These synergies allow common patterns of movement that involve either cooperative or reciprocal activation of muscle. Because the muscles are linked, one activated muscle may lead to partial or complete responses in other muscles. These synergies may limit patient’s muscles to certain movements, preventing them from completing the voluntary movements they want to make. However, as neurological development and cell regrowth occurs after a stroke, some new connections may be formed to impaired muscle tissue.
Two limb synergies determine a patient’s reactions to cell regrowth during Stage 2 of recovery. The first, the flexor synergy, includes the external rotation of the shoulder, flexion of the elbow, and supination of the forearm. The second, the extensor synergy, includes internal rotation of the shoulder with elbow extension and pronation of the forearm. These synergies may produce one or both of the following postures, which indicate varying levels of brain trauma after stroke.
Coupled with the presence of muscle synergies, between 30 and 40 percent of stroke survivors also experience spasticity. This is a velocity-dependent increase in your normal stretch reflexes, and during Stage 2, it presents as aresistance to passive movement. Stage 2 spasticity contributes to the jerky upper body movements characteristic of the flexor and extensor synergies.
Unused limbs still need stimulation to maintain or form connections to neurons. Though the nerves and connections that originally controlled your affected limbs may be damaged too much to create voluntary movements, it could still be possible to regain movement in later stages of recovery. In order to leave this possibility open and prevent the body’s tendency toward learned non-use, it’s important to continue using and moving your affected limbs and muscles as much as possible.
Spasticity in muscles increase during stage three of stroke recovery, reaching its peak. Spasticity is a feeling of unusually stiff, tight, or pulled muscles. It is caused by damage from a stroke to nerve pathways within the brain or spinal cord that control muscle movement. The lack of ability to restrict the brain’s motor neurons causes muscles to contract too often. Spasticity causes an abnormal increase in muscle stiffness and tone that can interfere with movement, speech, or cause discomfort and pain.
During stage 3, synergy patterns also start to emerge and minimal voluntary movements should be expected. The increase in voluntary movement is due to being able to initiate movement in the muscle, but not control it (yet). The appearance of synergy patterns and coordination between muscles facilitate the voluntary movements which become stronger with occupational and physical therapy.
Muscles with severe spasticity, like the ones in stage 3 of stroke recovery, are likely to be more limited in their ability to exercise and may require help to do this. Patients and family/caregivers should be educated about the importance of maintaining range of motion and doing daily exercises. It is important to minimize highly stressful activities this early in training.
Passive exercises, also known as passive range-of-motion (PROM) exercises, should be continued during this stage to improve your range of motion. Treatment includes how far the therapist can move your joints in different directions, like raising your hand over your head or bending your knee toward your chest.
During stage four of stroke recovery, spastic muscle movement begins to decline. Patients will regain control mostly in the extremities, and they will have a limited ability to move normally. The movements may still be out of sync with muscle synergies, but this will improve quickly over the length of this stage.
The focus during this stage is to strengthen and improve muscle control. Now that you are regaining motor control and can start to make normal, controlled movements on a limited basis, you can start to build strength back in your limbs and continue work on your range of motion. Continuing to stretch out your muscles is still important in this stage.
Therapists use active-assisted range of motion (AAROM) exercises when a stroke patient has some ability to move but still needs help to practice the exercises or complete the movement. A therapist may help guide the movement with their own body (hold the limb, for example) or use bands and other exercise equipment to support the patient. Gravity-assisted devices such as the SaeboMAS, are beneficial in helping the patient perform the movements.
You can begin active range-of-motion (AROM) exercises once you have regained some muscle control and can perform some exercises without assistance. They often involve moving a limb along its full range of motion, like bending an elbow or rotating a wrist. AROM exercises increase flexibility, muscle strength, and endurance. Range-of-motion exercises should be practiced equally on both the affected and unaffected sides of the body.
Of course, when it comes to building a stage 4 stroke recovery exercise program, you should always consult with a professional physical or occupational therapist. They can help you with exercise specifics, finding the right tools and equipment, and, of course, to provide assistance, especially in the beginning.
In stage 5, spasticity continues to decline and synergy patterns within the muscles also become more coordinated, allowing voluntary movements to become more complex. Abnormal movements also start to decline dramatically during stage 5, but some may still be present.
The patient will be able to make more controlled and deliberate movements in the limbs that have been affected by the stroke. Isolated joint movements might also be possible.
All voluntary movements involve the brain, which sends out the motor impulses that control movement. These motor signals are initiated by thought and must also involve a response to sensory stimuli. The sensory stimuli that trigger voluntary responses are dealt with in many parts of the brain.
Voluntary movements are purposeful and goal directed. They are learned movements that improve with repetition or practice and require less attention. Some examples include combing hair, swinging a bat, driving a car, swimming, and using eating utensils.
At stage six, spasticity in muscle movement disappears completely. You are able to move individual joints, and synergy patterns become much more coordinated. Motor control is almost fully restored, and you can coordinate complex reaching movements in the affected extremities. Abnormal or spastic movements have ceased, and a full recovery may be on the horizon.
Stage 7: Normal Function Returns
The last stage in Brunnstrom’s Approach is when you regain full function in the areas affected by the stroke. You are now able to move your arms, legs, hands, and feet in a controlled and voluntary manner.
Since you have full control over your muscle movements, synergy patterns have also returned to normal. Reaching stage seven is the ultimate goal for therapists and patients alike.
With the seven stages of recovery, Brunnstrom effectively changed the way stroke recovery is approached by occupational and physical therapists. She theorized that spastic and primitive muscle movements were a natural part of the recovery process after a stroke. Moreover, she developed an approach that allows patients to use these involuntary movements to their advantage instead of trying to inhibit them.
During each phase, an increasing amount of synergies are available to use. Using the Brunnstrom Approach, occupational and physical therapists will teach you how to use the synergies that are currently available to you. These techniques are used to improve movement and regain motor control.
There is no one approach to stroke recovery, and the stages laid out in these guides may not apply to everyone. Since the Brunnstrom Approach can be effective, however, therapists still use this method to help patients recover after suffering a stroke. Thanks to new medical technology, therapists can use the Brunnstrom Approach in conjunction with tools like the SaeboGlove, SaeboReach, and SaeboMAS to help patients reach new levels of independence.
Introduction: Spasticity acts as a limiting factor in motor and functional recovery after Stroke, impairing the performance of daily living activities.
Objective: To analyze the influence of spasticity on main muscle groups and to associate it with motor impairment and functional level of chronic hemiparetic patients after stroke.
Methods: Twenty-seven chronic hemiparetic patients of both sexes were selected at the Physical Therapy and Occupational Therapy Service of the Unicamp Clinics Hospital. Assessments were carried out in two sessions, in the first one the motor impairment (Fugl-Meyer Assessment – FM) and functional impairment (Barthel Index – BI) were evaluated, and in the second, the degree of spasticity of the main muscle groups (Modified Ashworth Scale – MAS).
Results: A negative correlation was detected between upper limb spasticity and motor and functional impairment. No muscle group evaluated in the lower limbs showed correlation between muscle tone and the level of impairment of the lower extremity on FM and the functional level measured by BI.
Conclusion: Spasticity has been shown to be a negative influence factor in the level of motor and functional impairment of the upper limbs of chronic hemiparetic patients after stroke.
Even though robotic rehabilitation is very useful to improve motor function, there is no conclusive evidence on its role in reducing post-stroke spasticity. Focal muscle vibration (MV) is instead very useful to reduce segmental spasticity, with a consequent positive effect on motor function. Therefore, it could be possible to strengthen the effects of robotic rehabilitation by coupling MV. To this end, we designed a pilot randomized controlled trial (Clinical Trial NCT03110718) that included twenty patients suffering from unilateral post-stroke upper limb spasticity. Patients underwent 40 daily sessions of Armeo-Power training (1 hour/session, 5 sessions/week, for 8 weeks) with or without spastic antagonist MV. They were randomized into two groups of 10 individuals, which received (group-A) or not (group-B) MV. The intensity of MV, represented by the peak acceleration (a-peak), was calculated by the formula (2πf)2A, where f is the frequency of MV and A is the amplitude. Modified Ashworth Scale (MAS), short intracortical inhibition (SICI), and Hmax/Mmax ratio (HMR) were the primary outcomes measured before and after (immediately and 4 weeks later) the end of the treatment. In all patients of group-A, we observed a greater reduction of MAS (p = 0.007, d = 0.6) and HMR (p<0.001, d = 0.7), and a more evident increase of SICI (p<0.001, d = 0.7) up to 4 weeks after the end of the treatment, as compared to group-B. Likewise, group-A showed a greater function outcome of upper limb (Functional Independence Measure p = 0.1, d = 0.7; Fugl-Meyer Assessment of the Upper Extremity p = 0.007, d = 0.4) up to 4 weeks after the end of the treatment. A significant correlation was found between the degree of MAS reduction and SICI increase in the agonist spastic muscles (p = 0.004). Our data show that this combined rehabilitative approach could be a promising option in improving upper limb spasticity and motor function. We could hypothesize that the greater rehabilitative outcome improvement may depend on a reshape of corticospinal plasticity induced by a sort of associative plasticity between Armeo-Power and MV.
Spasticity is defined as a velocity-dependent increase in muscle tone due to the hyper-excitability of muscle stretch reflex . Spasticity of the upper limb is a common condition following stroke and traumatic brain injury and needs to be assessed carefully because of the significant adverse effects on patient’s motor functions, autonomy, and quality of life .
Different pharmacological and non-pharmacological approaches are currently available for upper limb spasticity management, as physiotherapy (including magnetic stimulation, electromagnetic therapy, sensory-motor techniques, and functional electrical stimulation treatment) and robot-assisted therapy [3–4]. In this regard, several studies suggest robotic devices, including the Armeo® (a robotic exoskeleton for the rehabilitation of upper limbs), may help reducing spasticity by modifying spasticity-related synaptic processes at either the brain or spinal level [5–13], resulting in spasticity reduction in antagonist muscles through, e.g., a strengthening of spinal reciprocal inhibition mechanisms .
Growing research is proposing segmental muscle vibration (MV) as being a powerful tool for the treatment of focal spasticity in post-stroke patients [14–15]. Mechanical devices deliver low-amplitude/high-frequency vibratory stimuli to specific muscles [16–17], thus offering strong proprioceptive inputs by activating the neural pathway from muscle spindle annulospiral endings to Ia-fiber, dorsal column–medial lemniscal pathway, the ventral posterolateral nucleus of the thalamus (and other nuclei of the basal ganglia), up to the primary somatosensory area (postcentral gyrus and posterior paracentral lobule of the parietal lobe), and the primary motor cortex [18–19]. At the cortical network level, proprioceptive inputs can alter the excitability of the corticospinal pathway by modulating intracortical inhibitory and facilitatory networks within primary sensory and motor cortex, and affecting the strength of sensory inputs to motor circuits [20–22]. In particular, periods of focal MV delivered alone can modify sensorimotor organization within the primary motor cortex (i.e., can increase or decrease motor evoked potential—MEP—and short intracortical inhibition (SICI) magnitude in the vibrated muscles, while opposite changes occur in the neighboring muscles), thus reducing segmental hyper-excitability and spasticity [20–22].
While focal MV is commonly used to reduce upper limb post-stroke spasticity, there is no conclusive evidence on the role of robotic rehabilitation in such a condition [14–17,23–27]. A strengthening of the effects of neurorobotics and MV on spasticity could be achieved by combining MV and neurorobotics. The rationale for combining Armeo-Power and MV to reduce spasticity could lie in the summation and amplification of their single modulatory effects on corticospinal excitability . Specifically, it is hypothesizable that MV may strengthen the learning-dependent plasticity processes within sensory-motor areas that are in turn triggered by the intensive, repetitive, and task-oriented movement training offered by Armeo-Power [29–30]. Such an amplification may depend on a sort of associative plasticity (i.e., the one generated by timely coupling two different synaptic inputs) between MV and Armeo-Power [31–33].
To the best of our knowledge, this is the first attempt to investigate such approach. Indeed, a previous study combining MV with conventional physiotherapy used Armeo only as evaluating tool .
The aim of our study was to assess whether a combined protocol employing MV and Armeo-Power training, as compared to Armeo-Power alone, may improve upper limb spasticity and motor function in patients suffering from a hemispheric stroke in the chronic phase. To this end, we compared the clinical and electrophysiological after-effects of Armeo-Power with or without MV on upper limb spasticity. We also assessed the effects on upper limb motor function and muscle activation, disability burden, and mood, given that spasticity may have significant negative consequences on these outcomes. Further, it is important to evaluate mood, as it may negatively affect functional recovery [34–36], increase mortality , and weaken the compliance of the patient to the rehabilitative training [38–39].[…]
Spasticity Awareness Week is April 17 – 21, 2017. Please join us in raising awareness about this condition that affects over 12 million people worldwide.
The National Stroke Association has partnered with a growing number of leading organizations to form the Spasticity Alliance. To commemorate Spasticity Awareness Week in 2017, the Spasticity Alliance has launched a Spanish version of its website. Both English and Spanish websites contain resources for individuals living with spasticity, family members, and caregivers who want to learn more about spasticity. The English website can be found at spasticityalliance.org; the Spanish website can be found at spanish.spasticityalliance.org.
The resources below contain information about the symptoms of spasticity, management techniques and treatments that help to ease the symptoms of spasticity. While there is no cure for this condition, there are many tactics that can help individuals living with spasticity resume their normal daily activities.
WHAT IS SPASTICITY?
After a stroke, damage to the brain can block messages between muscles and the brain causing arm and leg muscles to cramp or spasm (spasticity), kind of like a bad charley horse. This will limit your coordination and muscle movement. This post-stroke condition makes daily activities such as bathing, eating and dressing more difficult.
Spasticity can cause long periods of strong contractions in major muscle groups, causing painful muscle spasms. These spasms can produce:
CAN SPASTICITY BE TREATED?
There are many strategies and treatments for spasticity to help you recover, return to work and regain function. In order to achieve the best results possible, a mixture of therapies and medications are often used to treat spasticity. Ask a healthcare professional about the best treatment plan for you. Some of the options include:
TIPS TO LIVE WITH SPASTICITY
Managing spasticity with assistive devices, aids and home adaptations can help ensure your safety and reduce the risk of spasticity-related falls. Physical and occupational therapists will recommend the appropriate aid(s) as well as safety procedures, maintenance and proper fit. Some modifications in your home to improve safety include:
Always follow rehabilitation therapists’ recommendations regarding limitations and safety needs.
Source: Spasticity | Stroke.org