Feasibility of Robot-Assistance Hand Physiotherapy in Post-Stroke Patients.

Background: Patients with experienced stroke have suffered from long-term disability, especially in their distal upper extremities. Physiotherapy programs are considered a proper treatment to overcome the complications caused by stroke. The use of robots in physiotherapy is also considered a newfound procedure as an alternative to conventional methods. Objective: This study aimed to describe a feasibility test on a physiotherapy robot and evaluate the efficacy of the proposed device. Material and Methods: In this experimental study, a 4-degrees-of-freedom robot was designed and fabricated for hand physiotherapy, which was tested on 17 and 4 post-strokes in the passive and active modes for the best efficiency. Additionally, the patient's hand spasticity was measured according to the Modified Ashworth Scale pre- and post-usage of the device. Results: A total of 12 of 17 individuals could do the exercises and follow the instructions without any problem, and 8 of 12 individuals had a decrease in their spasticity. All 4 patients in active-assisted mode could fulfill the activity. Conclusion: Physiotherapy based on a robot-assisted is considered a promising method with effective treatments for post-stroke patients, which can be a good alternative to routine methods of physiotherapy. However, more tests are needed to determine the rate of functions' restoration.

Comparative effect of oral drugs in improving spasticity of different etiology: a network meta-analysis.

INTRODUCTION: Spasticity, a prevalent manifestation of various neurological conditions, significantly impacts the quality of life of patients. Research on the effects of oral drugs on spasticity has produced controversial results. Thus, the aim of this network meta-analysis was to compare the efficacy of oral drugs for improving spasticity in patients with different etiologies. METHODS: We searched four different databases from their inception to 30 November 2023. A network meta-analysis using a frequentist perspective was conducted to assess the effects of different oral drugs on spasticity, evaluated by the modified Ashworth scale. RESULTS: Our findings showed that, in a frequentist network meta-analysis, eperisone, diazepam, and baclofen had significantly greater spasticity, as measured by the modified Ashworth scale, than did the placebo (MD: -0.80; 95% CIs: -1.42, -0.18; MD: -0.68; 95% CIs: -1.28, -0.09; MD: -0.58; 95% CIs: -1.11, -0.06, respectively). CONCLUSION: In summary, our study confirmed that eperisone, diazepam, and baclofen could be effective approaches for reducing spasticity of different etiologies and could be useful approaches for improving patient quality of life. Key messages What is already known on this topic: The impact of oral drugs, such as baclofen, gabapentin, tizanidine, and dantrolene, in the treatment of spasticity has been documented. What this study adds: This study determines which of the oral drugs aimed at treating spasticity is the most effective across different etiologies. How this study might affect research, practice, or policy: This study suggests tailored treatment strategies for spasticity based on its etiology.

Mechanomyography-Based Metric Scale for Spasticity: A Pilot Descriptive Observational Study.

(1) Background: The Modified Ashworth Scale (MAS) is commonly used clinically to evaluate spasticity, but its qualitative nature introduces subjectivity. We propose a novel metric scale to quantitatively measure spasticity using mechanomyography (MMG) to mitigate these subjective effects. (2) Methods: The flexor and extensor muscles of knee and elbow joints were assessed with the Modified Ashworth Scale (MAS) during the acquisition of mechanomyography (MMG) data. The median absolute amplitude of the MMG signals was utilized as a key descriptor. An algorithm was developed to normalize the MMG signals to a universal gravitational (G) acceleration scale, aligning them with the limits and range of MAS. (3) Results: We evaluated 34 lower and upper limbs from 22 volunteers (average age 39.91 ± 13.77 years) of both genders. Polynomial regression provided the best fit (R2 = 0.987), with negligible differences (mean of 0.001 G) between the MAS and MMG. We established three numerical sets for the median, minimum, and maximum MMG(G) values corresponding to each MAS range, ensuring consistent alignment of the Modified Ashworth levels with our proposed scale. (4) Conclusions: Muscle spasticity can now be quantitatively and semi-automatically evaluated using our algorithm and instrumentation, enhancing the objectivity and reliability of spasticity assessments.

Immediate Effect of Ultrasound-Guided Dry Needling on Soleus Muscle Spasticity in Stroke Survivors.

BACKGROUND: Dry needling (DN) is commonly used to treat various neuromuscular syndromes. It is effective in reducing spasticity in stroke and other neurological conditions. The current study explores the immediate effect of ultrasound-guided dry needling on soleus muscle spasticity and thickness in individuals with stroke. METHODS: Approval was obtained from the Institutional Sub-ethics Committee of Dr. D. Y. Patil College of Physiotherapy, Pune. The trial was registered with the Clinical Trials Registry of India. Thirty stroke survivors having soleus muscle spasticity ranging from grade 1 to 4 on the Modified Modified Ashworth Scale (MMAS) were selected. Spasticity was also assessed using the Modified Tardeau Scale (MTS) and H-reflex. Soleus muscle architecture was assessed by using ultrasonography (USG). Participants received a single session of DN for the spastic soleus muscle. Pre and immediate post-DN outcome measures were assessed. RESULTS: Based on USG findings, the thickness of the soleus muscle significantly increased by 2.67 mm (p<0.001) after dry needling treatment. The MMAS showed decreased spasticity by 1.47 (p<0.001) for ankle plantar flexors. A significant reduction of H-reflex values by 1.4 mV (p<0.001) was noted. The MTS also showed a significant increase in the range of ankle motion by 2.7 (p<0.001). All these indicate an immediate reduction of spasticity following DN. CONCLUSION: Based on the findings of the current study, we can conclude that a single session of USG-guided DN has an immediate beneficial effect on reducing soleus muscle spasticity and increased muscle thickness in individuals with stroke.

A portable system to measure knee extensor spasticity after spinal cord injury.

BACKGROUND: The pendulum test is a quantitative method used to assess knee extensor spasticity in humans with spinal cord injury (SCI). Yet, the clinical implementation of this method remains limited. The goal of our study was to develop an objective and portable system to assess knee extensor spasticity during the pendulum test using inertial measurement units (IMU). METHODS: Spasticity was quantified by measuring the first swing angle (FSA) using a 3-dimensional optical tracking system (with external markers over the iliotibial band, lateral knee epicondyle, and lateral malleolus) and two wireless IMUs (positioned over the iliotibial band and mid-part of the lower leg) as well as a clinical exam (Modified Ashworth Scale, MAS). RESULTS: Measurements were taken on separate days to assess test-retest reliability and device agreement in humans with and without SCI. We found no differences between FSA values obtained with the optical tracking system and the IMU-based system in control subjects and individuals with SCI. FSA values from the IMU-based system showed excellent agreement with the optical tracking system in individuals with SCI (ICC > 0.98) and good agreement in controls (ICC > 0.82), excellent test-retest reliability across days in SCI (ICC = 0.93) and good in controls (ICC = 0.87). Notably, FSA values measured by both systems showed a strong association with MAS scores ( ρ  ~ -0.8) being decreased in individuals with SCI with higher MAS scores, reflecting the presence of spasticity. CONCLUSIONS: These findings suggest that our new portable IMU-based system provides a robust and flexible alternative to a camera-based optical tracking system to quantify knee extensor spasticity following SCI.

Harnessing Neuroplasticity: A Case Report on Physiotherapy Rehabilitation for Millard-Gubler Syndrome.

This case report glances at the physiotherapy management and motor recovery outcomes of a 47-year-old female who had a pontine infarction complicated by Millard-Gubler syndrome. Pontine infarction is a stroke that occurs in the pons region of the brainstem, resulting in impaired blood flow and subsequent tissue damage. Millard-Gubler syndrome, a rare form of pontine infarction, is distinguished by ipsilateral abducens (sixth cranial nerve) and facial (seventh cranial nerve) nerve palsy, which cause horizontal gaze palsy and facial weakness, respectively. Other common symptoms include contralateral hemiparesis or hemiplegia, dysarthria, and hypertonia. In this case, the patient had nystagmus, dysarthria, hypertonia, decreased consciousness, and limited mobility. Physiotherapy interventions were used in a multidisciplinary approach to address these deficits, with a focus on improving gaze stability, reducing hypertonia, facilitating bed mobility, and improving respiratory function. The outcomes were evaluated using standardised measures such as the Brunnstrom staging for motor recovery, the Modified Ashworth Scale for hypertonia, and the Functional Independence Measure for functional status. This case demonstrates the critical role of physiotherapy in improving motor recovery and functional outcomes.

Intrathecal baclofen efficacy for managing motor function and spasticity severity in patients with cerebral palsy: a systematic review and meta-analysis.

BACKGROUND: Spasticity can significantly affect a patient's quality of life, caregiver satisfaction, and the financial burden on the healthcare system. Baclofen is one of only a few options for treating spasticity. The purpose of this study is to investigate the impact of intrathecal baclofen (ITB) therapy on severe40.23 spasticity and motor function in patients with cerebral palsy. METHODS: We conducted a systematic review in PubMed, Scopus, Ovid, and the Cochrane Library in accordance with the PRISMA guidelines. We included studies based on eligibility criteria that included desired participants (cerebral palsy patients with spasticity), interventions (intrathecal baclofen), and outcomes (the Ashworth scales and the Gross Motor Function Measure [GMFM]). The within-group Cohen's d standardized mean differences (SMD) were analyzed using the random effect model. RESULTS: We screened 768 papers and included 19 in the severity of spasticity section and 6 in the motor function section. The pre-intervention average spasticity score (SD) was 3.2 (0.78), and the post-intervention average score (SD) was 1.9 (0.72), showing a 40.25% reduction. The SMD for spasticity reduction was - 1.7000 (95% CI [-2.1546; -1.2454], p-value < 0.0001), involving 343 patients with a weighted average age of 15.78 years and a weighted average baclofen dose of 289 µg/day. The SMD for the MAS and Ashworth Scale subgroups were - 1.7845 (95% CI [-2.8704; -0.6986]) and - 1.4837 (95% CI [-1.8585; -1.1088]), respectively. We found no relationship between the participants' mean age, baclofen dose, measurement time, and the results. The pre-intervention average GMFM (SD) was 40.03 (26.01), and the post-intervention average score (SD) was 43.88 (26.18), showing a 9.62% increase. The SMD for motor function using GMFM was 0.1503 (95% CI [0.0784; 0.2223], p-value = 0.0030), involving 117 patients with a weighted average age of 13.63 and a weighted average baclofen dose of 203 µg/day. In 501 ITB implantations, 203 medical complications were reported, including six new-onset seizures (2.96% of medical complications), seven increased seizure frequency (3.45%), 33 infections (16.26%), eight meningitis (3.94%), and 16 cerebrospinal fluid leaks (7.88%). Delivery system complications, including 75 catheter and pump complications, were also reported. CONCLUSION: Despite the risk of complications, ITB has a significant impact on the reduction of spasticity. A small but statistically significant improvement in motor function was also noted in a group of patients.

The Complex Role of Botulinum Toxin in Enhancing Goal Achievement for Post-Stroke Patients.

INTRODUCTION: The rehabilitation medical team is responsible for the therapeutic management of post-stroke patients and, therefore, for the complex therapeutic approach of spasticity. Considering the generous arsenal at our disposal in terms of both pharmacological treatment, through the possibility of administering botulinum toxin to combat spasticity, and in terms of accurate assessment through developed functional scales such as the GAS (Goal Attainment Scale), one of our purposes is to monitor the parameters that influence the achievement of functional goals set by patients together with the medical team in order to render the patients as close as possible to achieving their proposed functional goals, thus enhancing their quality of life. By assessing and establishing statistical and clinical correlations between the GAS and quantifiable parameters related to the affected post-stroke upper limb, namely degree of spasticity, motor control, pain level and evolution of pain under treatment with BoNT-A (abobotulinum toxin A), and patients' overall response to BoNT-A treatment, we aim to quantify the improvement of the therapeutic management of post-stroke patients with spasticity and develop a more personalized and effective approach to their disability and impairment. RESULTS AND DISCUSSIONS: The analysis concluded that there were two independent predictors of the Achieved GAS-T score (the study's endpoint parameter) motor control at any level of the upper limb and number of prior BoNT-A injections. The number of prior BoNT-A injections was an independent predictor of Achieved GAS-T score improvement but had no significant influence over Baseline GAS-T score. Enhancement in proximal and intermediate motor control showed a GAS score improvement of 3.3 points and a 0.93-point GAS score improvement for wrist motor control progress. From a separate viewpoint, patients with motor deficit on the left side have shown significantly greater improvement in Changed GAS-T scores by 2.5 points compared to patients with deficits on the right side; however, we note as a study limitation the fact that there was no statistical analysis over the dominant cerebral hemisphere of each patient. CONCLUSIONS: Improvement in the Achieved GAS-T score means better achievement of patients' goals. Thus, after the BoNT- A intervention, at follow-up evaluation, GAS was found to be directly correlated with improvement in motor control of the affected upper limb. Mobility of the corresponding limb was enhanced by pain decrease during p-ROM (passive range of motion) and by amelioration of spasticity. MATERIALS AND METHODS: We conducted an observational, non-randomized clinical study on 52 stroke patients, a representative sample of patients with post-stroke spasticity and disability from our neurological rehabilitation clinic, who have been treated and undergone a specific rehabilitation program in our tertiary diagnostic and treatment medical center, including BoNT-A focal treatment for spasticity in the affected upper limb. The primary objective of the study was to assess the influence of abobotulinum toxin A treatment on the Goal Attainment Scale. Secondary objectives of the study included the assessment of BoNT-A treatment efficacy on spasticity with the MAS (Modified Ashworth Scale), pain with the NRS (Numerical Rating Scale), and joint passive range of motion (p-ROM), identifying demographic, clinical, and pharmacological factors that influence the response to BoNT-A treatment, as well as to conduct a descriptive and exploratory analysis of the studied variables.

Effectiveness of simple and basic home-based exercise programs including pediatric massage executed by caregivers at their homes in the management of children with spastic cerebral palsy: A randomized controlled trial.

PURPOSE: This study aimed to assess the effectiveness of simple and basic home-based exercise programs (HEPs), including pediatric massage (PM), executed by caregivers at their homes in the management of children with spastic cerebral palsy (CP). METHODS: Sixty-eight children with spastic CP (diplegia) aged 4-12 years were randomly assigned to PM and HEP groups for a randomized controlled trial continuing from November 01, 2021 to June 2022. Parents provided home-based exercises to both groups, five times a week for 12 weeks. However, the PM group was additionally provided with PM. Modified Ashworth Scale (MAS), Gross Motor Function Measure (GMFM-88) and Gross Motor Function Classification System (GMFCS) were used for evaluation of spasticity and gross motor activity at baseline as well as after six and 12 weeks of intervention. Comparative analysis of data was carried out with SPSS-20. RESULTS: Mean age in HEP and PM groups was 6.65±2.12 and 7.09±2.22 years respectively. Data revealed homogeneity of both groups at the beginning of study. The PM group showed a statistically significant decrease in MAS scores after six and 12 weeks of intervention (p < 0.05) when compared with the HEP group, but similar changes did not happen in GMFM scores and GMFCS levels. However, comparative analysis revealed statistically significant change in GMFM scores and GMFCS levels (p < 0.05) when compared from baseline to 12 weeks of intervention in both groups. CONCLUSION: PM along with HEPs can be used effectively to reduce spasticity and to improve gross motor ability if performed for a period of at least six and 12 weeks respectively. In conjunction with HEPs, PM has better outcomes in the management of tone and movement disorders of spastic CP than HEPs alone.

Therapeutic effects of extracorporeal shock wave therapy on patients with spastic cerebral palsy and Rett syndrome: clinical and ultrasonographic findings.

BACKGROUND: Extracorporeal shock wave therapy (ESWT) is reportedly effective for improving spasticity and motor function in children with cerebral palsy (CP). Because late-stage Rett syndrome has a similar presentation, this study aimed to investigate the effects of ESWT on these two diseases. MATERIAL AND METHODS: Patients diagnosed with spastic CP and Rett syndrome received 1500 impulses of ESWT at 4 Hz and 0.1 mJ/mm2, on their spastic legsonce weekly for a total of 12 weeks. Outcomes were assessed before and 4 and 12 weeks after ESWT. Clinical assessments included the Modified Ashworth Scale (MAS), passive range of motion (PROM), and Gross Motor Function Measure 88 (GMFM-88). Ultrasonographic assessments included muscle thickness, acoustic radiation force impulse (ARFI), and strain elastography. RESULTS: Fifteen patients with CP and six with Rett syndrome were enrolled in this study. After ESWT, patients with CP showed significant clinical improvement in the MAS (P = 0.011), ankle PROM (P = 0.002), walking/running/jumping function (P = 0.003), and total function (P < 0.001) of the GMFM-88. The patients with Rett syndrome showed improved MAS scores (P = 0.061) and significantly improved total gross motor function (P = 0.030). Under ARFI, patients with CP demonstrated decreased shear wave speed in the gastrocnemius medial head (P = 0.038). Conversely, patients with Rett syndrome show increased shear-wave speeds after ESWT. CONCLUSION: Our study provides evidence that a weekly course of low-dose ESWT for 12 weeks is beneficial for children with both CP and Rett syndrome, with the clinical effects of reducing spasticity and improving the gross motor function of the lower limbs. The ARFI sonoelastography reveals improvement of muscle stiffness in patients with CP after ESWT, but deteriorated in patients with Rett syndrome. The diverse therapeutic response to ESWT may be caused by the MECP2 mutation in Rett syndrome, having a continuous impact and driving the pathophysiology differently as compared to CP, which is secondary to a static insult. Trial registration IRB 201700462A3. Registered 22March 2017, https://cghhrpms.cgmh.org.tw/HRPMS/Default.aspx .

Predicting the Progression of Spasticity in the Early Phase of Spinal Cord Injury: A Prospective Cohort Study.

Spasticity-defined as involuntary movements caused by insult to upper motor neurons after spinal cord injury (SCI)-interferes with patients' activities of daily living. Spasticity is generally identified and managed in the chronic phase of SCI, but few reports have examined the onset of spasticity after injury. The purpose of this study is to elucidate serial changes in spasticity after SCI and clarify the timing of severe spasticity. We prospectively examined individuals with acute traumatic SCI admitted within two weeks after injury. Severity of spasticity was evaluated using the Modified Ashworth Scale (MAS) at 2, 4, 6, and 8 weeks, followed by 3, 4, 5, and 6 months after injury. After completing evaluation of the cohort, the patients were divided into two groups: a spasticity group with MAS scores ≥3 (marked increase in muscle tone through most of the range of motion (ROM)) in at least one joint movement within 6 months of injury and a control group with MAS scores ≤2 in all joint movements throughout the 6 months after injury. Neurological findings such as the American Spinal Injury Association (ASIA) Impairment Scale grades and ASIA motor scores were also assessed at all time points, and the correlations between the onset of spasticity, severity of spasticity, and neurological findings were analyzed. There were 175 patients with traumatic SCI who were assessed consecutively for 6 months after injury. The MAS scores of the group significantly increased over time until 4 months after injury. The spasticity group had significantly higher MAS scores compared with the control group as early as 2 weeks post-injury. We found that the patients with earlier onset of spasticity had higher final MAS scores. No correlation was found between the ASIA Impairment Scale grade and the onset of spasticity. Our results reveal that the development of severe spasticity may be predictable from as early as 2 weeks after SCI, suggesting that early therapeutic intervention to mitigate problematic spasticity may enhance the benefits of post-injury rehabilitation.

Treatment effects of low-frequency repetitive transcranial magnetic stimulation combined with motor relearning procedure on spasticity and limb motor function in stroke patients.

Objective: Limb paralysis, which is a sequela of stroke, limits patients' activities of daily living and lowers their quality of life. The purpose of this study was to investigate the effects of repetitive transcranial magnetic stimulation (rTMS) combined with a motor relearning procedure (MRP) on motor function and limb spasticity in stroke patients. Methods: Stroke patients were randomly divided into a combined treatment group (rTMS + MRP) and a control group (MRP) (n = 30 per group). The control group was given MRP in addition to conventional rehabilitation, and the combined treatment group was given 1 Hz rTMS combined with MRP. The treatment efficacy was assessed by the modified Ashworth scale (MAS), Fugl-Meyer motor function scale, and motor evoked potential (MEP) testing. Results: After 4 weeks of treatment, the Brunnstrom score, Fugl-Meyer lower extremity motor function, and Fugl-Meyer balance function were significantly higher in the combination treatment group compared to the control group, while the MAS score was lower in the combination treatment group compared to the control group. The MEP extraction rate was higher in the combined treatment group compared to the control group, while the threshold and central motor conduction time (CMCT) were lower in the combined treatment group compared to the control group. Conclusion: Low-frequency rTMS combined with MRP had better efficacy on spasticity and motor function in stroke patients with hemiparesis than MRP alone.

Reliability of the Modified Ashworth Scale After Stroke for 13 Muscle Groups.

OBJECTIVE: To evaluate the reliability of the protocol for administration of the Modified Ashworth Scale (MAS) for all commonly affected muscle groups after stroke. DESIGN: A repeated-measures design was used in administration of MAS for 13 muscle groups on 2 assessment days. Intrarater reliability and interrater reliability (between 3 raters) was assessed. SETTING: Inpatient rehabilitation. PARTICIPANTS: 30 patients, 1-19 months after stroke (age 55.1±13.5 years; N=30). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Intra- and interrater reliability of the muscle tone assessment protocol with MAS for 7 upper and 6 lower limb muscle groups compiled from previous studies; 1 modified and 4 originally described. The weighted kappa was calculated. RESULTS: The most and the least frequently assigned MAS grades were 0 and 4, respectively. Agreement was the highest for grade 0 (49% within raters, 32% between raters). Intrarater reliability was good to excellent for upper limb (κ=0.71-0.94) and moderate to excellent for lower limb (κ=0.55-0.97) muscles. Interrater reliability was poor to good for upper limb (κ=0.25-0.66) and moderate for lower limb (κ=0.41-0.54) muscles. CONCLUSIONS: The intrarater reliability of MAS was moderate for the hip flexors. The reliability results for the other 4 muscles studied anew after stroke were similar to the predetermined ones. The better intrarater reliability results confirmed previous findings. Because of the low interrater reliability, caution is needed in interpreting the results when reassessment is not possible by the same examiner. A well-described protocol for administering the MAS may lead to its standardization.

Quantitative assessment of biceps brachii muscle stiffness by using Young's modulus-Angle curve during passive stretching in stroke patients.

Purpose: This study aims to use shear wave elastography (SWE) to dynamically describe the characteristics of biceps brachii muscle stiffness during passive stretching in healthy participants, investigate changes in the Young's modulus-angle curve under various states of muscle tone in stroke patients, and develop a new method for measuring muscle tone quantitatively. Methods: In total, 30 healthy volunteers and 54 stroke patients were evaluated for elbow flexor muscle tone on both sides using passive motion examination and were divided into groups based on their muscle tone status. The real-time SWE video of the biceps brachii and the Young's modulus data were recorded during the passive straightening of the elbow. The Young's modulus-elbow angle curves were created and fitted using an exponential model. The parameters yielded from the model were subjected to further intergroup analysis. Results: The repeatability of the Young's modulus measurement was generally good. During passive elbow extension, the Young's modulus of the biceps brachii steadily increased as muscle tone increased, and it increased faster when the modified Ashworth scale (MAS) score got higher. The exponential model's fitness was generally good. The curvature coefficient was significantly different between the MAS 0 group and the hypertonia groups (MAS 1, 1+, and 2 groups). Conclusion: The passive elastic characteristics of the biceps brachii are consistent with the exponential model. The Young's modulus-elbow angle curve of the biceps brachii changes in distinct ways depending on the muscle tone status. SWE can be used to quantify muscular stiffness during passive stretching as a new way of muscle tone evaluation, allowing for quantitative muscle tone evaluation and mathematical assessment of muscle mechanical properties in stroke patients.

Clinical Spasticity Assessment Assisted by Machine Learning Methods and Rule-Based Decision.

The Modified Ashworth Scale (MAS) is commonly used to assess spasticity in clinics. The qualitative description of MAS has resulted in ambiguity during spasticity assessment. This work supports spasticity assessment by providing measurement data acquired from wireless wearable sensors, i.e., goniometers, myometers, and surface electromyography sensors. Based on in-depth discussions with consultant rehabilitation physicians, eight (8) kinematic, six (6) kinetic, and four (4) physiological features were extracted from the collected clinical data from fifty (50) subjects. These features were used to train and evaluate the conventional machine learning classifiers, including but not limited to Support Vector Machine (SVM) and Random Forest (RF). Subsequently, a spasticity classification approach combining the decision-making logic of the consultant rehabilitation physicians, SVM, and RF was developed. The empirical results on the unknown test set show that the proposed Logical-SVM-RF classifier outperforms each individual classifier, reporting an accuracy of 91% compared to 56-81% achieved by SVM and RF. A data-driven diagnosis decision contributing to interrater reliability is enabled via the availability of quantitative clinical data and a MAS prediction.

Effectiveness of Extracorporeal Shockwave Therapy on Controlling Spasticity in Cerebral Palsy Patients: A Meta-Analysis of Timing of Outcome Measurement.

Extracorporeal shockwave therapy (ESWT) has been suggested as an alternative treatment for reducing spasticity in patients with cerebral palsy (CP). However, the duration of its effect was rarely known. A meta-analysis was performed to investigate the effectiveness of ESWT at controlling spasticity in patients with CP according to the follow-up period. We included studies in which ESWT was used to manage spasticity in patients with CP, and the effect was compared with that in a control group. Finally, three studies were included. In the meta-analysis, spasticity, measured using the modified Ashworth scale (MAS), was significantly reduced after ESWT compared with that in the control group; however, it was sustained for only 1 month. After ESWT, significant increases in passive ankle range of motion (ROM) and plantar surface area in the standing position were observed compared with those in the control group and sustained for up to 3 months. Although spasticity measured using MAS was significantly reduced for only 1 month, improvement in spasticity-associated symptoms, such as ankle ROM and plantar surface area contacting the ground, persisted for over 3 months. ESWT appears to be a useful and effective therapeutic option for managing spasticity in patients with CP.

Spasticity Management Teams, Evaluations, and Tools: A Canadian Cross-Sectional Survey.

OBJECTIVE: The objective of this study is to determine the physical evaluations and assessment tools used by a group of Canadian healthcare professionals treating adults with spasticity. METHODS: A cross-sectional web-based 19-question survey was developed to determine the types of physical evaluations, tone-related impairment measurements, and assessment tools used in the management of adults with spasticity. The survey was distributed to healthcare professionals from the Canadian Advances in Neuro-Orthopedics for Spasticity Congress database. RESULTS: Eighty study participants (61 physiatrists and 19 other healthcare professionals) completed the survey and were included. Nearly half (46.3%, 37/80) of the participants reported having an inter- or trans-disciplinary team managing individuals with spasticity. Visual observation of movement, available range of motion determination, tone during velocity-dependent passive range of motion looking for a spastic catch, spasticity, and clonus, and evaluation of gait were the most frequently used physical evaluations. The most frequently used spasticity tools were the Modified Ashworth Scale, goniometer, and Goal Attainment Scale. Results were similar in brain- and spinal cord-predominant etiologies. To evaluate goals, qualitative description was used most (37.5%). CONCLUSION: Our findings provide a better understanding of the spasticity management landscape in Canada with respect to staffing, physical evaluations, and outcome measurements used in clinical practice. For all etiologies of spasticity, visual observation of patient movement, Modified Ashworth Scale, and qualitative goal outcomes descriptions were most commonly used to guide treatment and optimize outcomes. Understanding the current practice of spasticity assessment will help provide guidance for clinical evaluation and management of spasticity.

The impact of intrathecal baclofen on the ability to walk: A systematic review.

OBJECTIVE: Intrathecal baclofen (ITB) is an effective treatment for lower limb spasticity. In ambulatory patients with spasticity, there is a justifiable concern that ITB treatment may compromise ambulatory function by reducing the heightened muscle tone, thereby unmasking underlying muscle weakness. ITB is hence offered with reservation in ambulant patients. In this article, we review the literature surrounding the effect of ITB therapy on ambulatory function in patients with concurrent spasticity and discuss the key findings. DATA SOURCES: A literature search of ProQuest Medline and EBSCO CINAHL databases was performed. REVIEW METHOD: Inclusion criteria included (a) studies reporting the effect of ITB in adult ambulatory patients; (b) studies with an intervention of screening test trial via either bolus injections or continuous infusion tests; and (c) studies with an intervention of ITB pump implantation. Seventeen eligible studies were identified and two authors independently assessed the study quality using the risk of bias in nonrandomised studies of interventions tool (ROBINS-I). RESULTS: Seventeen studies were included, with a total of 534 participants. Most of the patients remain ambulatory after ITB treatment, accompanied by improvements in gait speed and reduction in spasticity. CONCLUSION: ITB therapy when administered in carefully selected ambulatory patients with spasticity is not associated with loss of ambulatory function.

A Pilot Study of A2NTX, a Novel Low-Molecular-Weight Neurotoxin Derived from Subtype A2 for Post-Stroke Lower Limb Spasticity: Comparison with OnabotulinumtoxinA.

All the currently used type A botulinum neurotoxins for clinical uses are of subtype A1. We compared the efficacy and safety for the first time head-to-head between a novel botulinum toxin A2NTX prepared from subtype A2 and onabotulinumtoxinA (BOTOX) derived from A1 for post-stroke spasticity. We assessed the modified Ashworth scale (MAS) of the ankle joint, the mobility scores of Functional Independence Measure (FIM), and the grip power of the unaffected hand before and after injecting 300 units of BOTOX or A2NTX into calf muscles. The procedure was done in a blinded manner for the patient, the injecting physician, and the examiner. Stroke patients with chronic spastic hemiparesis (15 for A2NTX and 16 for BOTOX) were enrolled, and 11 for A2NTX and 13 for BOTOX (MAS of ankle; > or = 2) were entered for the MAS study. Area-under-curves of changes in MAS (primary outcome) were greater for A2NTX by day 30 (p = 0.044), and were similar by day 60. FIM was significantly improved in the A2NTX group (p = 0.005), but not in the BOTOX group by day 60. The hand grip of the unaffected limb was significantly decreased in the BOTOX-injected group (p = 0.002), but was unaffected in the A2NTX-injected group by day 60, suggesting there was less spread of A2NTX to the upper limb than there was with BOTOX. Being a small-sized pilot investigation with an imbalance in the gender of the subjects, the present study suggested superior efficacy and safety of A2NTX, and warrants a larger scale clinical trial of A2NTX to confirm these preliminary results.

Design of a Multi-Sensor System for Exploring the Relation between Finger Spasticity and Voluntary Movement in Patients with Stroke.

A novel wearable multi-sensor data glove system is developed to explore the relation between finger spasticity and voluntary movement in patients with stroke. Many stroke patients suffer from finger spasticity, which is detrimental to their manual dexterity. Diagnosing and assessing the degrees of spasticity require neurological testing performed by trained professionals to estimate finger spasticity scores via the modified Ashworth scale (MAS). The proposed system offers an objective, quantitative solution to assess the finger spasticity of patients with stroke and complements the manual neurological test. In this work, the hardware and software components of this system are described. By requiring patients to perform five designated tasks, biomechanical measurements including linear and angular speed, acceleration, and pressure at every finger joint and upper limb are recorded, making up more than 1000 features for each task. We conducted a preliminary clinical test with 14 subjects using this system. Statistical analysis is performed on the acquired measurements to identify a small subset of features that are most likely to discriminate a healthy patient from patients suffering from finger spasticity. This encouraging result validates the feasibility of this proposed system to quantitatively and objectively assess finger spasticity.