Posts Tagged Spasticity
[Abstract] Evaluation of custom-made VR exergame for at-home Stroke rehabilitation. A longitudinal single-arm study. – Full Text PDF
Posted by Kostas Pantremenos in Paretic Hand, Video Games/Exergames, Virtual reality rehabilitation on April 26, 2024
Abstract
Exercise games (Exergames) based on Virtual Reality (VR) have emerged as a promising option for supporting physical rehabilitation in stroke users. As a com- plementary therapy, they offer valuable benefits such as therapy engagement and enjoyment. In this study, we assessed the effectiveness of an immersive, custom- made VR exergame designed for upper limb rehabilitation in stroke participants aged 50 and above. We conducted 14 sessions of 15 minutes involving ten par- ticipants (6 females, ages 58.1 ± 7.5 years old) who volunteered to participate in an assisted at-home rehabilitation process. The study employed a range of evaluation tests to measure physical rehabilitation and game user experience out- comes. The tests included pre- and post-assessments of range of motion (ROM), the Ashworth spasticity test, and the Borg rating of perceived fatigue question- naire. To evaluate the game participant experience, we used the VR Neuroscience Questionnaire (VRNQ), and the Immersive Tendencies Questionnaire (ITQ). Our results revealed significant improvements in the range of motion for elbow and shoulder flexion, extension, adduction, and abduction. Furthermore, we observed a reduction in Ashworth spasticity, and the fatigue scale showed reduced per- ception comparing the last with the first session, although the difference was insignificant. The VRNQ questionnaire indicated significant enhancements in the domains related to ”Game Experience” and ”Game Mechanics” and an overall reduction of the perceived “Motion Sickness”. In the ITQ questionnaire, partic- ipants reported high levels of ”Attention,” and while there were no significant differences in ”Immersion” and ”Enjoyment,” a considerable improvement was observed in ”Excitement”. In summary, our results indicate that the immersive VR exergame improved the range of motion, spasticity, and overall game user experience among participants with stroke in a longitudinal, single-arm inter- vention. We conclude that using custom-made VR exergames is an effective and motivating tool for upper limb rehabilitation, with positive changes in both clin- ical and perception outcomes, and the positive and measurable effects persist after the first sessions. These findings support using VR exergames as a comple- mentary tool for at-home rehabilitation therapy with good ease of use, improved physical rehabilitation outcomes, and high treatment adherence.
[Abstract] Evaluation of custom-made VR exergame for at-home Stroke rehabilitation. A longitudinal single-arm study. – Full Text PDF
Posted by Kostas Pantremenos in Tele/Home Rehabilitation, Video Games/Exergames, Virtual reality rehabilitation on April 21, 2024
Abstract
Exercise games (Exergames) based on Virtual Reality (VR) have emerged as a promising option for supporting physical rehabilitation in stroke users. As a com- plementary therapy, they offer valuable benefits such as therapy engagement and enjoyment. In this study, we assessed the effectiveness of an immersive, custom- made VR exergame designed for upper limb rehabilitation in stroke participants aged 50 and above. We conducted 14 sessions of 15 minutes involving ten par- ticipants (6 females, ages 58.1 ± 7.5 years old) who volunteered to participate in an assisted at-home rehabilitation process. The study employed a range of evaluation tests to measure physical rehabilitation and game user experience out- comes. The tests included pre- and post-assessments of range of motion (ROM), the Ashworth spasticity test, and the Borg rating of perceived fatigue question- naire. To evaluate the game participant experience, we used the VR Neuroscience Questionnaire (VRNQ), and the Immersive Tendencies Questionnaire (ITQ). Our results revealed significant improvements in the range of motion for elbow and shoulder flexion, extension, adduction, and abduction. Furthermore, we observed a reduction in Ashworth spasticity, and the fatigue scale showed reduced per- ception comparing the last with the first session, although the difference was insignificant. The VRNQ questionnaire indicated significant enhancements in the domains related to ”Game Experience” and ”Game Mechanics” and an overall reduction of the perceived “Motion Sickness”. In the ITQ questionnaire, partic- ipants reported high levels of ”Attention,” and while there were no significant differences in ”Immersion” and ”Enjoyment,” a considerable improvement was observed in ”Excitement”. In summary, our results indicate that the immersive VR exergame improved the range of motion, spasticity, and overall game user experience among participants with stroke in a longitudinal, single-arm inter- vention. We conclude that using custom-made VR exergames is an effective and motivating tool for upper limb rehabilitation, with positive changes in both clin- ical and perception outcomes, and the positive and measurable effects persist after the first sessions. These findings support using VR exergames as a comple- mentary tool for at-home rehabilitation therapy with good ease of use, improved physical rehabilitation outcomes, and high treatment adherence.
[Abstract] Effects of Circuit Class Training Versus Individual, Task Specific Training on Upper Extremity Function in Chronic Stroke Patients
Posted by Kostas Pantremenos in Paretic Hand, Spasticity on February 15, 2024
Abstract
Background: Stroke is a leading contributor to disability globally, emphasizing the need for effective rehabilitation techniques. Circuit class training (CCT) and individual, task-specific training (ITST) have emerged as potential approaches for enhancing upper extremity function in stroke survivors. Comparative analyses of their efficacy, especially among chronic stroke patients, are scant.
Objective: This study aimed to evaluate and compare the impacts of CCT and ITST on upper extremity spasticity, motor function, and quality of life in individuals with chronic stroke.
Methods: In a randomized controlled trial, 36 chronic stroke patients were allocated to either CCT or ITST groups. Participants were aged 45-70 years, had experienced a single stroke episode, and were at least 6 months post-stroke, with specific inclusion criteria regarding spasticity and motor function levels. The interventions were delivered for 1.5 hours daily, five days a week, over eight weeks. Outcomes were measured using the Modified Ashworth Scale (MAS) for spasticity, Functional Independence Measure for Upper Extremity (FMA-UE) for motor function, and Stroke-Specific Quality of Life (SS-QOL) scale for quality of life, analyzed using SPSS version 25.
Results: Post-intervention, both CCT and ITST participants exhibited significant improvements in their outcomes. MAS scores showed a reduction in spasticity, with average improvements not significantly differing between the groups. FMA-UE scores increased by an average of 10 points in both groups, indicating enhanced motor function without a significant difference between the groups (p > 0.05). SS-QOL scores improved by an average of 20 points in each group, reflecting better quality of life, with no significant intergroup difference observed.
Conclusion: The study concludes that CCT and ITST are equally effective in ameliorating upper extremity spasticity, motor function, and quality of life among chronic stroke patients. The selection between CCT and ITST can thus be personalized based on patient preferences, available resources, and logistical considerations, maintaining rehabilitation efficacy.
References
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Bastola P, Singh P, Pinto D. A comparison of the effect of resistance training on upper extremity motor function, motor recovery, and quality of life in sub-acute stroke participants. Medical Journal of Dr DY Patil University. 2021;14(2):219-25.
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da Silva ESM, Ocamoto GN, Santos-Maia GLd, de Fatima Carreira Moreira Padovez R, Trevisan C, de Noronha MA, et al. The effect of priming on outcomes of task-oriented training for the upper extremity in chronic stroke: a systematic review and meta-analysis. Neurorehabilitation and Neural Repair. 2020;34(6):479-504.
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[VIDEO] Understanding and Managing Spasticity in Poststroke Rehabilitation
Posted by Kostas Pantremenos in Spasticity, Video on January 11, 2024
The medical director of the Inpatient Rehabilitation Unit at Ascension Genesis Hospital talked about the management of poststroke spasticity and highlighted the importance of awareness, education, and early intervention. [WATCH TIME: 5 minutes]
WATCH TIME: 5 minutes
https://imasdk.googleapis.com/js/core/bridge3.609.1_en.html#goog_308621131PlayMute
“Spasticity is a word that most people have never heard of, but it means it’s a stiffness in the muscle—a velocity-dependent resistance to movement. With poststroke spasticity, you have to stretch. It is your medicine that you cannot miss and you have to take every day. Educating patients about potential poststroke spasticity and closely monitoring its development are crucial, as spasticity can manifest in diverse ways impacting individuals’ daily lives.”
Poststroke spasticity, a common complication, is associated with other signs and symptoms of the upper motor neuron syndrome, including agonist/antagonist co-contraction, weakness, and lack of coordination. These symptoms combined may result in impairments and functional issues that can predispose to costly complications for patients seeking treatment. According to a review previously published in Stroke, researchers suggest that the goal of managing poststroke spasticity should not only consider the reduction of muscle hypertonia but also the impact of the condition on function and well-being.1
Treatment interventions recommended by clinicians for patients with poststroke spasticity typically focus on peripheral and central strategies, including physical techniques to increase muscle length like stretching and pharmacological modulation. Despite limited comparative studies on the superiority of one method over another for poststroke spasticity, researchers have found that optimal management involves a combined and coordinated compendium of therapies.1 These combined recommendations for care encompass cost-effective pharmacological and surgical interventions as well as rehabilitative efforts for patients.
Harmony Sierens, MD, a physiatrist, recently sat down in an interview with NeurologyLive® to discuss how spasticity manifests poststroke, and why early awareness and education is essential for patients. Sierens, who also serves as the medical director at Ascension Genesis Inpatient Rehab Unit, spoke about the role that stretching plays in the management of poststroke spasticity, and why it is considered a crucial component of treatment. Additionally, she talked about how healthcare professionals effectively monitor and intervene early in cases of spasticity after brain or spinal cord injuries.
REFERENCES
1. Francisco GE, McGuire JR. Poststroke spasticity management. Stroke. 2012;43(11):3132-3136. doi:10.1161/STROKEAHA.111.639831
[ARTICLE] Management of Upper-Limb Spasticity Using Modern Rehabilitation Techniques versus Botulinum Toxin Injections Following Stroke – Full Text
Posted by Kostas Pantremenos in Pharmacological, Spasticity on November 29, 2023
Abstract
Our purpose is to emphasize the role of botulinum toxin in spasticity therapy and functional recovery in patients following strokes. Our retrospective study compared two groups, namely ischemic and hemorrhagic stroke patients. The study group (BT group) comprised 80 patients who received focal botulinum toxin as therapy for an upper limb with spastic muscle three times every three months. The control group (ES group) comprised 80 patients who received only medical rehabilitation consisting of electrostimulation and radial shockwave therapy for the upper limb, which was applied three times every three months. Both groups received the same stretching program for spastic muscles as a home training program. We evaluated the evolution of the patients using muscle strength, Ashworth, Tardieu, Frenchay, and Barthel scales. The analysis indicated a statistically significant difference between the two groups for all scales, with better results for the BT group (p < 0.0001 for all scales). In our study, the age at disease onset was an important prediction factor for better recovery in both groups but not in all scales. Better recovery was obtained for younger patients (in the BT group, MRC scale: rho = −0.609, p-value < 0.0001; Tardieu scale: rho = −0.365, p-value = 0.001; in the ES group, MRC scale: rho = −0.445, p-value < 0.0001; Barthel scale: rho = −0.239, p-value = 0.033). Our results demonstrated the effectiveness of botulinum toxin therapy compared with the rehabilitation method, showing a reduction of the recovery time of the upper limb, as well as an improvement of functionality and a reduction of disability. Although all patients followed a specific kinetic program, important improvements were evident in the botulinum toxin group.
1. Introduction
Stroke is one of the main causes of mortality and disability in surviving patients worldwide. More specifically, stroke is the second highest cause of morbidity and mortality, and motor deficit is the third most common sequela found in stroke patients [1,2].
Thus, stroke remains a health problem worldwide. This assertion is supported by statistical data that are worrying regarding mortality and residual disability after a stroke. In the European Union in 2017, there were 1.12 million cases of stroke, resulting in 0.46 million deaths and 7.06 million patients with disabilities who required additional medical care, personal caretakers, and auxiliary medical devices, such as orthoses and wheelchairs, to improve quality of life. By 2047, it is estimated that there will be a 3% increase in case incidence, a 27% increase in prevalence, a 17% decrease in mortality rate, and a 33% decrease in mortality compared to present figures. The decrease in mortality rate is estimated to be lower for less-developed countries, such as Romania, where the estimated mortality rate decrease is only 0.23%. Romania is one of the top three countries in terms of stroke cases, death, and disability [3,4].
Stroke is the second highest cause of death on a world scale, the same as in Romania, with an increasing trend in incidence and prevalence globally, so it is estimated that by 2030, it will be the main cause of death worldwide. Surviving patients, estimated to be an increasing population, will have a permanent disability, according to the extent of the stroke, for the rest of their lives. This aspect of permanent disability, with great effects on the life quality of the patient and their family, makes this disease a major health problem [5].
In Romania, stroke prevalence is 252,774 cases per year, with a rate of 8333 cases per 100,000 inhabitants, which represents a very high rate and explains the interest in finding new therapeutic solutions to minimize the disability through combined pharmacological and rehabilitation techniques [6].
The WHO reports that stroke is the second highest cause of death in Romania, after heart attack, with a very small difference between the sexes [7]. Stroke is defined as rapidly developing clinical signs of focal or global disturbance of cerebral function lasting more than 24 h or leading to death with no other origin than vascular. In more than 60% of strokes, there are symptoms related to spasticity. The clinical characteristics of spasticity are high tone, hyperreflexia, flexor spasm clasp knife reaction, extensor spasm, and associated reactions [8].
In stroke patients, there are several stages of evolution. In the early stage, patients typically exhibit motor deficits, abolished tendon reflexes, and the appearance of pathological specific reflexes. Swallowing deficit, sphincter control deficit, impaired speech, and cognitive disorders may also be observed. The spastic phase begins after a variable time, usually within a few weeks of the onset of stroke. Spasticity affects specific muscle groups, such as the flexors of the upper limbs and the extensors of the lower limbs. The arm tends to assume a pronated and flexed position, and the leg assumes an adducted and extended position. These positions indicate that some spinal neurons are reflexively more active than others. There is no constant relationship between spasticity and weakness. The pathophysiology of spasticity is further dependent on two descending tracts: the dorsal reticulospinal tract and the medial reticulospinal and vestibulospinal tracts. The dorsal reticulospinal tract has inhibitory effects on stretch reflexes. Medial reticulospinal and vestibulospinal tracts facilitate the extensor tone. This is the moment when reflexes intensify, and it is also the ideal moment to begin rehabilitation. For adequate rehabilitation, spasticity must be kept at an appropriate level to initiate and continue rehabilitation [9].
Spasticity is a disorder of the stretch reflex that is clinically manifested by increased muscle tone [10,11]. Also, spasticity is a common condition in post-stroke patients that can be associated with pain and joint contracture [12,13], which leads to decreased quality of life through vicious limb positions, deformity, involuntary movement, and medical complications (skin maceration and pressure sores) when untreated [14]. Spasticity after stroke occurs in approximately one third of patients and has been shown in many studies to have a negative effect on a patient’s life and influences upper-limb function negatively [15], which can lead to falls, fractures, and a difficult recovery [16].
The motor control of the affected limb being deficient causes abnormal movements, misdirected systematically, which is a primary consequence of brain injury and a secondary non-use consequence [17].
Reducing disability and recovery time is an increasingly important aspect nowadays, given the high costs and socioeconomic implications. Thus, finding new therapeutic methods to reduce the remaining spasticity becomes a major objective. Spasticity management is a complex mechanism that requires a holistic approach which includes pharmacological therapy associated with adequate and personalized rehabilitation programs. The objective of spasticity treatment is to reduce the motor hyperactivity and improve mobility, but without accentuating the motor deficit [18].
The advantages of local therapy over other spasticity treatments are that unlike the systemic anti-spasticity drugs which are commonly associated with generalized weakness and functional loss, botulinum toxin is a targeted therapy and unlike chemical neurolysis with alcohol or phenol injection does not causes skin sensory loss or dysesthesia [8].
The pharmacological treatment for spasticity in stroke patients includes both focal, localized administration of medication in the spastic muscle and also conventional oral therapy. Systemic therapy distributes medication throughout the body, without specifically targeting the spastic muscle, making it less beneficial for patients. On the other hand, focal therapy involves injecting botulinum toxin directly into the spastic muscle, the target zone of treatment, using ultrasound-guided in situ injection with a precise and personalized dosage, for each muscle group, every 3 months or more [14,16].
The objectives of our study were to highlight the differences between botulinum toxin type A (incobotulinum toxin and abobotulinum toxin) and recovery therapy, combined with specific kinetic programs, in the management of spasticity and functionality in stroke patients. We aimed to emphasize that the association of a kinetic program with focal therapy with botulinum toxin leads to better results compared to those of the group that received the same kinetic program but with electromyostimulation and radial shockwaves. This combination proves more effective in enhancing muscle force and functionality and reducing spasticity to a convenient level.[…]
Hand stretching elements. (A). Stretching elements for flexor pollicis longus and brevis, opponens pollicis, adductor pollicis. (B). Stretching elements for flexor digitorum profundus, flexor digitorum superficilis. (C). Stretching elements for flexor carpi radialis.
[ARTICLE] Testing spasticity mechanisms in chronic stroke before and after intervention with contralesional motor cortex 1 Hz rTMS and physiotherapy – Full Text
Posted by Kostas Pantremenos in Spasticity, tDCS/rTMS on November 12, 2023
Abstract
Background
Previous studies showed that repetitive transcranial magnetic stimulation (rTMS) reduces spasticity after stroke. However, clinical assessments like the modified Ashworth scale, cannot discriminate stretch reflex-mediated stiffness (spasticity) from passive stiffness components of resistance to muscle stretch. The mechanisms through which rTMS might influence spasticity are also not understood.
Methods
We measured the effects of contralesional motor cortex 1 Hz rTMS (1200 pulses + 50 min physiotherapy: 3×/week, for 4–6 weeks) on spasticity of the wrist flexor muscles in 54 chronic stroke patients using a hand-held dynamometer for objective quantification of the stretch reflex response. In addition, we measured the excitability of three spinal mechanisms thought to be related to post-stroke spasticity: post-activation depression, presynaptic inhibition and reciprocal inhibition before and after the intervention. Effects on motor impairment and function were also assessed using standardized stroke-specific clinical scales.
Results
The stretch reflex-mediated torque in the wrist flexors was significantly reduced after the intervention, while no change was detected in the passive stiffness. Additionally, there was a significant improvement in the clinical tests of motor impairment and function. There were no significant changes in the excitability of any of the measured spinal mechanisms.
Conclusions
We demonstrated that contralesional motor cortex 1 Hz rTMS and physiotherapy can reduce the stretch reflex-mediated component of resistance to muscle stretch without affecting passive stiffness in chronic stroke. The specific physiological mechanisms driving this spasticity reduction remain unresolved, as no changes were observed in the excitability of the investigated spinal mechanisms.
Background
Besides paresis, post-stroke disability often arises from spasticity and soft tissue contractures which emerge weeks or months after the injury. Spasticity, which impacts 20–40% of survivors [1] can contribute to issues such as restricted range of motion (ROM), abnormal posture, and pain [2]. Lance’s widely cited 1985 definition describes spasticity as a “velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex as part of the upper motor neuron syndrome” [3].
Many non-invasive and non-pharmacologic intervention options are emerging for treatment of spasticity [4, 5]. In particular, there is growing evidence to support the use of the non-invasive brain stimulation method, repetitive transcranial magnetic stimulation (rTMS), for reducing spasticity after stroke [6,7,8,9,10,11,12]. RTMS elicits an electric field within the brain, causing alterations in the excitability of neurons not only in the targeted brain areas at the stimulation site but also in distant brain areas, including the contralateral motor cortex and subcortical structures [13,14,15]. The precise mechanism by which rTMS might cause behavioral effects on spasticity is unclear. It is plausible that rTMS can modulate the activity of the spinal circuitry, implicated in spasticity observed in spastic stroke patients, by modifying the excitability of cortical centers that project to this circuitry [16,17,18].
A recent systematic review of randomized controlled trials concluded that the use of contralesional motor cortex 1 Hz rTMS has a positive effect on reducing spasticity as estimated from the modified Ashworth scale (MAS) [19]. The MAS [20] is performed by passively stretching a joint and simultaneously estimating the perceived resistance on a 6-point ordinal scale. Though widely used, the MAS suffers from poor reliability, sensitivity and objectivity [2, 21,22,23]. Importantly, the examiner perceiving the resistance cannot discriminate the velocity-dependent stretch reflex, i.e., true spasticity, from the passive stiffness that results from changes that occur in the muscle and the surrounding soft tissues after the injury [24,25,26,27,28,29]. Establishing therapeutic effects of rTMS on spasticity requires careful quantification of the reflex-mediated component of the resistance to muscle stretch and discriminating it from the passive stiffness components.
Significant progress has been achieved in recent years regarding the development and testing of devices that enable the objective quantification of spasticity and discrimination of the different components which contribute to the resistance to passive joint stretch [25, 30,31,32,33,34]. Using a hand-held dynamometer, which enables the simultaneous recording of biomechanical and muscle activity data [29, 33,34,35,36,37], we objectively measured the stretch reflex-mediated stiffness in the wrist joint in a cohort of chronic stroke patients [38].
Central to the pathophysiology of spasticity is the excitability of the monosynaptic Ia afferent-motoneurone (MN) pathway underlying the stretch reflex [39]. The excitability of the stretch reflex circuit is regulated by complex spinal circuitries, which themselves are modulated by supraspinal pathways descending from cortical and brainstem structures [40]. After an upper motor neuron injury, there is an imbalance in the cortical and subcortical regulatory input to the spinal cord, which triggers secondary changes in the excitability of the spinal circuitry over weeks and months [41,42,43]. As a result, reflex hyperexcitability emerges as a gradual adaptation in the spinal circuitry distal to the lesion [42, 44,45,46]. Changes in the excitability of certain pathways and their contribution to the clinical picture of spasticity has been the topic of many studies in humans and animal models in the last decades [40, 44, 47,48,49].
Multiple spinal inhibitory mechanisms have been found to be reduced in spastic stroke patients and identified as potentially contributing to stretch reflex hyperexcitability in both upper and lower limbs (for review see [44, 46]). These include (1) post-activation depression, a frequency-dependent reduction in the release of neurotransmitters from previously activated fibers. A mechanism that has consistently been found to be reduced on the affected but not the unaffected side in spastic patients after stroke, both in the lower [50,51,52] and upper limbs [50, 53]. The extent of the reduction in post-activation depression was also found to be related to the degree of spasticity measured clinically in the lower limb [50, 52] as well as in the upper limb [53]; (2) presynaptic inhibition of Ia terminals, a mechanism which modulates the synaptic transmission from Ia afferents before they reach the target neurons. Multiple studies have reported a significant reduction in presynaptic inhibition in the upper limb in the stroke population [54,55,56], but this reduction was found to be not exclusive to the affected side [53]; (3) reciprocal inhibition from muscle spindles of the antagonist muscle group. This disynaptic inhibition is mediated through Ia afferents and Ia inhibitory interneurons, which are normally controlled by excitatory descending pathways including the corticospinal tract [46]. At rest, a decrease in Ia reciprocal inhibition has been observed in spastic patients in the upper limb [55, 56] and even potentially converted into facilitation from flexors to extensors in the lower limb [57,58,59].
An intervention which causes clinical improvements in “spasticity” would be expected to interact with its central pathophysiological mechanisms i.e., the excitability of the stretch reflex and the spinal circuits involved in its modulation. In humans, corticospinal neurons project to a large group of spinal interneurons and modulate their activity [60,61,62,63,64]. It is likely that rTMS can change the excitability of the spinal circuitry by modulating the excitability of cortical centers that project to this circuitry [16,17,18]. In addition, rTMS can modify transmission in neuronal circuitries in deeper lying structures in the brain including the brain stem, which itself plays an important role in controlling the spinal reflex excitability through direct and indirect projections [40].
In this study we aimed to objectively quantify the effects of an rTMS and physiotherapy intervention on spasticity of the wrist flexors in chronic stroke patients. Additionally, we explored possible mechanisms through which the cortical effects of rTMS might interact with spinal mechanisms thought to be related to stretch reflex hyperexcitability. […]
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[ARTICLE] Wet cupping with rehabilitation training for upper-limb poststroke spasticity: A systematic review and meta-analysis of randomized controlled trials – Full Text
Posted by Kostas Pantremenos in Paretic Hand, REHABILITATION, Spasticity on November 2, 2023
Abstract
Background
Upper-limb poststroke spasticity (PSS) negatively impacts on patients’ quality of life. An increasing number of clinical trials have indicated that wet cupping with rehabilitation training is conductive to alleviate spastic muscle tone, thereby to improve upper-limb function. However, related evidence base is insufficient. This study systematically investigates the efficacy and safety of wet cupping with rehabilitation training on stroke patients with upper-limb spasticity.
Methods
Eight separate databases and two clinical trial registries were searched from their inception to December 6, 2022. Two reviewers extracted the data and assessed the quality of the literature, independently. The mean difference (MD) or risk ratio (RR) were used as measure of effect size in meta-analysis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used for the certainty of evidence.
Results
Eight randomized controlled trials (RCTs) were quantified for meta-analysis. The results indicated that in comparison with the control group, wet cupping with rehabilitation training was more effective in reducing modified Ashworth scale score (MD = −0.60, 95% CI: −0.74, −0.46; P < 0.00001) and the integral electromyography value of biceps muscle (MD = −4.71, 95% CI: −6.74, −2.67; P < 0.00001), but improving effective rate (RR = 1.28, 95% CI: 1.15, 1.41; P < 0.00001), Fugl-Myer Assessment score (MD = 4.84, 95% CI: 3.05, 6.64; P < 0.00001) as well as Barthel Index score (MD = 6.38, 95% CI: 2.20, 10.57; P = 0.003). However, no significant difference was found regarding the integral electromyography value of triceps muscle between groups (MD = 1.72, 95% CI: −2.05, 5.48; P = 0.37).
Conclusion
Wet cupping with rehabilitation training should be included in a comprehensive therapeutic regimen for stroke patients with upper-limb spasticity. However, these results need to be further verified by more RCTs with rigorous design and large sample size.
Keywords
1. Introduction
As population aging becomes more conspicuous worldwide, stroke has been a huge public health challenge attributable to the second-leading cause of both death and disability globally [
,
]. More than one-quarter of stroke survivors will develop poststroke spasticity (PSS), particularly with upper-limb involvement, which impairs arm functional activity and patients’ social participation [
,
]. The direct cost of care provision associated with PSS has risen fourfold compared with those without spasticity, bringing a heavy financial burden to the family and society [
].
At present, a wide range of antispastic regimens are available, and are sorted into pharmacological and nonpharmacological interventions [
]. Pharmacological interventions mainly refer to baclofen either taken orally or injected intrathecally. Although it was found that the use of baclofen is favorable to muscle hypertonia reduction, certain adverse events, such as long-term intake of baclofen inducing general muscle weakness, hepatorenal damage and paranesthesia, remain problematic. Nonpharmacological interventions include but are not limited to physiotherapy and surgery as well as complementary and alternative medicine such as acupuncture, traditional Chinese exercise, and cupping therapy. However, the long-term treatment duration and relatively low efficiency of physiotherapy and surgery-related high risks and expensive medical costs decrease patients’ preference and compliance [
,
,
]. Thus, a better therapeutic regimen for upper-limb PSS is highly expected.
Cupping therapy is a commonly used traditional Chinese medicine nursing practice that normally utilizes flaming heating power to induce negative pressure inside the cup and make it easily attachable to the selected area to then produce hyperemia or hemostasis purposefully [
]. With the merits of noninvasive characteristics, relatively shorter treatment duration, fewer acupoint selections and lower treatment costs compared to acupuncture [
], cupping therapy has increased worldwide, especially among athletes with muscle discomfort [
,
]. Cupping is dry or wet, which depends on whether there is a need for the expulsion of blood. Wet cupping, also named blood pricking and cupping, is commonly used for PSS and other motor impairments (e.g., joint immobilization) [
,
]. Wet cupping has shown superior efficacy to dry cupping because it removes stagnant blood and toxins that are deemed the source of disease, whereas dry cupping works merely by diluting and redistributing pathogenic substances [
]. Although the antispastic mechanisms of wet cupping remain obscure, previous studies have indicated that wet cupping helps to suppress the inflammatory response and oxidative stress [
,
], restore blood supply to the skin and muscle [
] and alleviate stiffness in deep muscles [
], which potentially favors relaxation of muscle hypertonia and reconstruction of motor ability.
Rehabilitation is a process that integrates and coordinates the application of medical, social, educational, and vocational methods to alleviate physical, mental, and social impairments in disabled individuals and thereby to improve their quality of life [
]. Currently, rehabilitation strategies for PSS management are gradually developing. Previous research has indicated changes within peripheral muscle properties after stroke, including shortened and stiffer muscle tissues or an increased proportion of type I muscle fibers [
,
]. Notably, these alterations could be soothed by specific rehabilitation training (stretching) to prevent excessive muscle contracture and lessen spasticity as well as related pain [
,
]. In addition, other rehabilitation regimens, such as robot-assisted training, weight-supported treadmill training and task-oriented training, have also shown positive effects on spasticity alleviation [
]. These regimens are therefore widely used as an adjunct therapy for stoke with spasticity. Recently, poststroke rehabilitation has been developed by combining wet cupping and rehabilitation training. Increasing clinical evidence shows that such a combination has better antispastic effects than rehabilitation training alone or other combined therapies based on rehabilitation training [
,
,
,
,
,
,
,
]; however, relevant evidence is still insufficient.
Given the role of wet cupping with rehabilitation training in the management of upper-limb PSS, a critical systematic review and meta-analysis was designed to examine the efficacy and safety of this combination. Comparing wet cupping with rehabilitation training to wet cupping/rehabilitation training alone or other combinations (e.g., rehabilitation with baclofen). If we found a valid evidence base, then it might serve as a meaningful inspiration for practitioners to incorporate such a combination of the two therapies into the clinical management of upper-limb PSS and may provide patients with a safer, more effective, and more economical therapeutic option. […]
[ARTICLE] Rehabotics: A Comprehensive Rehabilitation Platform for Post-Stroke Spasticity, Incorporating a Soft Glove, a Robotic Exoskeleton Hand and Augmented Reality Serious Games – Full Text
Posted by Kostas Pantremenos in Paretic Hand, Rehabilitation robotics, Spasticity, Video Games/Exergames on October 31, 2023
Abstract
Spasticity following a stroke often leads to severe motor impairments, necessitating comprehensive and personalized rehabilitation protocols. This paper presents Rehabotics, an innovative rehabilitation platform incorporating a multi-component design for the rehabilitation of patients with post-stroke spasticity in the upper limbs. This system incorporates a sensor-equipped soft glove, a robotic exoskeleton hand, and an augmented reality (AR) platform with serious games of varying difficulties for adaptive therapy personalization. The soft glove collects data regarding hand movements and force exertion levels when the patient touches an object. In conjunction with a web camera, this enables real-time physical therapy using AR serious games, thus targeting specific motor skills. The exoskeleton hand, facilitated by servomotors, assists patients in hand movements, specifically aiding in overcoming the challenge of hand opening. The proposed system utilizes the data collected and (in combination with the clinical measurements) provides personalized and refined rehabilitation plans and targeted therapy to the affected hand. A pilot study of Rehabotics was conducted with a sample of 14 stroke patients. This novel system promises to enhance patient engagement and outcomes in post-stroke spasticity rehabilitation by providing a personalized, adaptive, and engaging therapy experience.
1. Introduction
Stroke is one of the leading causes of long-term disability globally, frequently resulting in upper limb spasticity. Spasticity is characterized by increased muscle tone, stiffness, exaggerated tendon reflexes, involuntary activation of the muscles and resistance to passive movement [1], which significantly affects patients’ quality of life [2]. Rehabilitation, including physical therapy and occupational therapy, is a key part of recovery after a stroke. However, the amount of time that post-stroke patients typically spend in the hospital working on their upper limb rehabilitation is inadequate for achieving a full recovery of function [3,4].
Traditional physiotherapy, while crucial for recovery, often encounters challenges such as suboptimal patient engagement and lack of personalization. Serious games have demonstrated a significant enhancement in patient motivation [5]. Also, innovative technologies, such as robotic exoskeletons and augmented reality (AR), have shown promising results in rehabilitating patients with motor impairments [6]. This maximizes the results when paired with the presence of a therapist (as in traditional physiotherapy), allowing for immediate adjustment and personalization of therapy based on the patient’s performance and feedback. Nevertheless, in telerehabilitation, while immediate therapist feedback might not be possible, the use of advanced technologies like AR can enable real-time adaptation and personalization of therapy protocols. The concept of serious games in rehabilitation is not new. In 2009, Burke et al. determined the principles of game design suitable for upper limb stroke rehabilitation, and several games were developed and showcased based on these principles [5]. Based on this premise, the challenge of customizing games for rehabilitation purposes, as stated in [7], lies in rehabilitation complexity, as it often demands human involvement. For instance, research on game usability has been conducted where assessment involved interviewing both rehabilitators and their patients [4]. In a proposal by Rabin et al. [8], the impact of serious games on motor control was studied using a serious game that progressively increases in difficulty for upper-limb rehabilitation. The primary issue with this approach is the adjustment of game parameters. Hocine et al. [7] detailed a universal technique for adjusting the difficulty of games intended for upper-limb rehabilitation, focusing on modifying pointing tasks and creating game levels. González-González et al. [9] proposed a recommender system which is able to provide the user with personalized games according to their history and skills. Also, devices such as KINECT have been used to adjust the difficulty levels using a fuzzy system [10].
To enhance motor functions, exoskeleton hand rehabilitation robots have been frequently applied, mimicking human limbs in their design, while being attached to the patient at various locations and having joint axes that align with those of the human joints. Moreover, they can be anchored to a table or be either mobile or fixed relative to the patient’s body [11]. Long-term therapy also includes a significant financial burden of the patients involved, as well as the necessity for patients to physically attend therapy sessions. This contributes to diminished enthusiasm, potentially leading to a decline in quality of life.
Taking the above into account, these challenges highlight the need for innovative systems that can support both therapists and patients during the rehabilitation process. Robotic systems, for instance, can alleviate the physical strain experienced by therapists while facilitating more intensive and extended training periods for patients. This can expedite recovery and enable the more effective execution of repetitive action exercises [6,12]. In this paper, we propose an innovative platform, “Rehabotics”, that addresses these limitations by combining a soft glove for data collection, a robotic exoskeleton hand, and AR serious games, thereby offering a comprehensive, patient-centric, and engaging approach to post-stroke spasticity rehabilitation.
The paper is organized as follows: Section 2 describes the components and methodology involved in the proposed system. In Section 3, we present the results from our pilot study. Finally, Section 4 includes a discussion section, reflecting on the study’s results, highlighting the potential of the Rehabotics system to enhance rehabilitation outcomes while suggesting areas for future research and addressing the limitation of the study. […]
[ARTICLE] Daily Vibrotactile Stimulation Exhibits Equal or Greater Spasticity Relief Than Botulinum Toxin in Stroke – Full Text
Posted by Kostas Pantremenos in Pharmacological, Spasticity on October 6, 2023
Highlights
- •The VTS Glove is a new, wireless, wearable device that provides therapeutic tactile stimulation to the hand.
- •This study evaluated use of the VTS Glove to relieve post-stroke spasticity and hypertonia.
- •Spasticity and hypertonia in the hand was significantly reduced when patients wore the VTS Glove daily, and one month after stopping use.
- •The VTS Glove was associated with greater average improvement in spasticity and hypertonia than Botox injection.
- •Some participants opted to stop taking Baclofen and Botox after using the VTS Glove.
Abstract
Objective
To test the feasibility and efficacy of the VibroTactile Stimulation (VTS) Glove, a wearable device that provides VTS to the impaired limb to reduce spastic hypertonia.
Design
Prospective 2-arm intervention study—including 1 group of patients who use Botulinum toxin (BTX-A) for spasticity and 1 group of patients who do not use BTX-A.
Setting
Participants were recruited through rehabilitation and neurology clinics.
Participants
Patients with chronic stroke (N=20; mean age=54 years, mean time since stroke=6.9 years). Patients who were previously receiving the standard of care (BTX-A injection) were eligible to participate and started the intervention 12 weeks after their last injection.
Intervention
Participants were instructed to use the VTS Glove for 3 hours daily, at home or during everyday activities, for 8 weeks.
Main Outcome Measures
Spasticity was assessed with the Modified Ashworth Scale and the Modified Tardieu Scale at baseline and then at 2-week intervals for 12 weeks. Primary outcomes were the difference from baseline and at week 8 (end of VTS Glove use) and week 12 (4 weeks after stopping VTS Glove use). Patients who were receiving BTX-A were also assessed during the 12 weeks preceding the start of VTS Glove use to monitor the effect of BTX-A on spastic hypertonia. Range of motion and participant feedback were also studied.
Results
A clinically meaningful difference in spastic hypertonia was found during and after daily VTS Glove use. Modified Ashworth and Modified Tardieu scores were reduced by an average of 0.9 (P=.0014) and 0.7 (P=.0003), respectively, at week 8 of daily VTS Glove use, and by 1.1 (P=.00025) and 0.9 (P=.0001), respectively, 1 month after stopping VTS Glove use. For participants who used BTX-A, 6 out of 11 showed greater change in Modified Ashworth ratings during VTS Glove use (mean=-1.8 vs mean=-1.6 with BTX-A) and 8 out of 11 showed their lowest level of symptoms during VTS Glove use (vs BTX-A).
Conclusions
Daily stimulation from the VTS Glove provides relief of spasticity and hypertonia. For more than half of the participants who had regularly used BTX-A, the VTS Glove provided equal or greater symptom relief. […]
[Abstract] Does Spasticity Correlate With Motor Impairment in the Upper and Lower Limbs in Ambulatory Chronic Stroke Survivors?
Posted by Kostas Pantremenos in Gait Rehabilitation - Foot Drop, Paretic Hand, REHABILITATION, Spasticity on September 14, 2023
Abstract
Objective
This study aimed to explore correlations between spasticity and motor impairments in the upper and lower limbs in ambulatory chronic stroke survivors.
Design
We performed clinical assessments in 28 ambulatory chronic stroke survivors with spastic hemiplegia (female: 12; male: 16; mean ages = 57.8 ± 11.8 yrs; 76 ± 45 mos after stroke).
Results
In the upper limb, spasticity index and Fugl-Meyer Motor Assessment showed a significant correlation. Spasticity index for the upper limb showed a significant negative correlation with handgrip strength of the affected side (r = −0.4, P = 0.035) while Fugl-Meyer Motor Assessment for the upper limb had a significant positive correlation (r = 0.77, P < 0.001). In the LL, no correlation was found between SI_LL and FMA_LL. There was a significant and high correlation between timed up and go test and gait speed (r = 0.93, P < 0.001). Gait speed was positively correlated with Spasticity index for the lower limb (r = 0.48, P = 0.01), and negatively correlated with Fugl-Meyer Motor Assessment for the lower limb (r = −0.57, P = 0.002). Age and time since stroke showed no association in analyses for both upper limb and lower limb.
Conclusions
Spasticity has a negative correlation on motor impairment in the upper limb but not in the lower limb. Motor impairment was significantly correlated with grip strength in the upper limb and gait performance in the lower limb of ambulatory stroke survivors.
TBI Rehabilitation 