Effects of dry needling on spasticity, cortical excitability, and range of motion in a patient with multiple sclerosis: a case report.

BACKGROUND: Dry needling is an intervention used by physiotherapists to manage muscle spasticity. We report the effects of three sessions of dry needling on ankle plantar flexor muscle spasticity and cortical excitability in a patient with multiple sclerosis. CASE PRESENTATION: The patient was a 40-year-old Iranian woman with an 11-year history of multiple sclerosis. The study outcomes were measured by the modified modified Ashworth scale, transcranial magnetic stimulation parameters, and active and passive ankle range of motion. They were assessed before (T0), after three sessions of dry needling (T1), and at 2-week follow-up (T2). Our result showed: the modified modified Ashworth scale was improved at T2 from, 2 to 1. The resting motor threshold decreased from 63 to 61 and 57 at T1 and T2, respectively. The single test motor evokes potential increased from 76.2 to 78.3. The short intracortical inhibition increased from 23.6 to 35.4 at T2. The intracortical facilitation increased from 52 to 76 at T2. The ankle active and passive dorsiflexion ROM increased ~ 10° and ~ 6° at T2, respectively. CONCLUSION: This case study presented a patient with multiple sclerosis who underwent dry needling of ankle plantar flexors with severe spasticity, and highlighted the successful use of dry needling in the management of spasticity, ankle dorsiflexion, and cortical excitability. Further rigorous investigations are warranted, employing randomized controlled trials with a sufficient sample of patients with multiple sclerosis. Trial registration IRCT20230206057343N1, registered 9 February 2023, https://en.irct.ir/trial/68454.

Dry needling combined with exercise therapy: Effects on wrist flexors spasticity in post-stroke patients - A randomized controlled trial.

BACKGROUND: The positive contribution of dry needling (DN) in conjunction with exercise therapy for patients with stroke and spasticity remains uncertain. OBJECTIVE: To examine the effects of DN combined with exercise therapy on wrist flexor spasticity and motor function in patients with stroke. METHODS: Twenty-four participants with stroke were randomly assigned to either the DN and exercise therapy group or the DN alone group. Assessments were conducted at baseline, after the 4th treatment session, and 3 weeks post-treatment. RESULTS: A significant Group×Time interaction was observed for wrist active range of motion (ROM) (P = 0.046), favoring the DN with exercise therapy group (∼10° at baseline, ∼15° immediately after the 4th session, and 15.4° at follow-up). The improvements in spasticity, passive ROM, and H-reflex latency were sustained during follow-up. However, there were no significant between-group differences in any outcome at any measurement time point. CONCLUSION: The combined DN and exercise therapy did not exhibit superiority over DN alone concerning spasticity severity and motor function. However, it demonstrated additional advantages, particularly in improving motor neuron excitability and wrist passive extension.

Upper extremity physical performance tests in female overhead athletes: a test-retest reliability study.

OBJECTIVE: Despite the studies that have investigated the reliability of Upper Extremity Functional Tests(UEFTs), the reliability of Closed Kinetic Chain Upper Extremity Stability(CKCUES), Seated Medicine Ball Throw(SMBT), push-up(PU) and Unilateral Seated Shot Put(USSP) tests in overhead athletes has yet to be assessed. The objective of this study was to determine both the relative and absolute test-retest reliability of the four UEFTs in female overhead athletes. METHODS: Twenty-nine female overhead athletes (age: 26.6 ± 5.29 years) underwent the four UEFTs twice within a three- day interval. The upper limb stability was assessed through PU and CKCUES tests, while the power was assessed though SMBT and USSP tests. The Intraclass Correlation of Coefficient (ICC) was applied to assess the relative reliability. Absolute reliability was determined by calculating the Standard Error of Measurement (SEM) and the Minimal Detectable Change (MDC). Furthermore, Bland-Altman plots were used to detect the agreements between the two measurements. RESULTS: The relative reliability of PU, CKCUES, SMBT, and non-dominant arm USSP tests was excellent (ICC = 0.83, 0.80, 0.91, and 0.83, respectively). SEM was within a range of 1.69 to 1.72 for stability tests and a range of 13.61 to 52.12 for power (based on a 95% confidence interval). The MDC was 4.68 for PU and 4.75 for CKCUES test. At least four repetitions are needed to be considered a real improvement on PU and CKCUES tests. This value was 144.04, in SMBT and 59.03, 37.62 cm (dominant and non-dominant arm, respectively) in USSP tests, which represents the minimum change that must occur to be considered an athlete's progression. CONCLUSION: This study revealed that both the upper limb stability and power tests have acceptable relative and absolute intra-rater reliability in female overhead athletes. These can be considered as reliable tools in research and clinical settings.

Knee joint repositioning error in different trunk positions among females with chronic nonspecific low back pain: A cross-sectional study.

PURPOSE: Proprioception is a self-perceived sense of position and movement of one's body and its deficits can lead to motor control problems such as delayed muscle reflexes. Previous studies have confirmed lumbar proprioception impairments among individuals with Low Back Pain (LBP), which can afflict the normal central sensory-motor control and hence increases the risk of abnormal loading on the lumbar spine. Although the local investigation of proprioception is important, its influence on other joints in a kinetic chain particularly between extremities and spine should not be ignored. Therefore, the aim of this study was to compare the proprioception of knee joint in different trunk positions among females with chronic nonspecific low back pain (CNSLBP) and healthy females. DESIGN: The study included 24 healthy subjects and 25 patients with CNSLBP participated in this study. Repositioning error of knee joint in four different lumbar positions including flexion, neutral position, 50% ROM of left rotation and 50% ROM right rotation was evaluated using an inclinometer. Absolute error and constant error were obtained and analyzed. RESULTS: Absolute error in flexion and neutral positions in the individuals with CNSLBP were significantly higher than in healthy individuals; whereas, there was no significant difference in absolute and constant error between the two groups in 50% rotation to either side. CONCLUSION: This study showed that knee joint repositioning accuracy was reduced in patients with CNSLBP compared to healthy ones.

Computerized Simulation Education on Physiotherapy Students' Skills and Knowledge: A Systematic Review.

Introduction: Applying computerized simulation education tool for learning in medical domains is widely used in many countries. This review is aimed at systematically investigating the computerized simulation tools developed to educate physiotherapy students and determine the effectiveness of these interventions. Methods: A comprehensive search was conducted in Medline (through PubMed) and Scopus databases from inception to Sept. 10, 2022. The studies that examined the effectiveness of computerized simulation-based interventions were included. Results: Sixteen studies were included in this systematic review. All included examinations were ranked "good" or "low risk of bias" based on the criteria utilized in the Joanna Briggs Institute (JBI) scale and the Effective Public Health Practice Project (EPHPP) tool. Most of the articles (43%) were conducted in the USA and 25% in Australia. In 43% of the total studies, the study population was only physiotherapy students, and in 12.5% of them, the scope of education was related to practical skills training. Three of the 16 reviewed articles presented positive qualitative results; thirteen quantitative investigations also declared statistically positive effects. Positive effects have been seen in areas such as improving professional and behavioral abilities, improving knowledge and self-confidence, and reducing stress. The sample size of the studies ranged from eight to 162 participants. The limited sample sizes in groups, lack of interaction, and short follow-up duration were the most consistent limitations evident within the included studies. Conclusion: Computerized simulation education approaches can help to improve physiotherapy students' skills and knowledge. They also have great potential to reduce learning costs and increase the quality of education.

Effects of dry needling and exercise therapy on post-stroke spasticity and motor function- protocol of randomized clinical trial.

Background: Spasticity is one of the most common problems after the first stroke. Dry needling (DN) has been presented as a new therapeutic approach used by physiotherapists for the management of post-stroke spasticity. This study aimed to determine whether the addition of exercise therapy to the DN results in better outcomes in wrist flexors spasticity, motor neuron excitability, motor function and range of motion (ROM) in patients with chronic stroke. Methods: We will use a single-blind randomized controlled trial (RCT) in accordance with the CONSORT guidelines. A total of 24 patients with stroke will be included from the University Rehabilitation Clinics. The outcome measures will include Modified Modified Ashworth Scale, Hmax/Mmax ratio, H-reflex latency, Action Research Arm Test, Fugl-Meyer Assessment, and wrist extension active and passive range of motion. Patients in the DN and exercise therapy group will undergo 4 sessions of deep DN in flexor carpi radialis and flexor carpi ulnaris muscles on the affected upper limb and exercise therapy. Participants in the DN group will only receive DN for target muscles. Clinical and neurophysiological tests will be performed at baseline, after four therapy sessions, and at three weeks' follow-up. Discussion: This study will provide evidence for additional effects of exercise therapy to DN in comparison to DN alone on wrist flexors spasticity, motor neuron excitability, upper-limb motor function, and ROM in patients with chronic stroke.

Effects of dry needling plus exercise therapy on post-stroke spasticity and motor function: A case report.

BACKGROUND AND PURPOSE: The use of dry needling (DN) with other treatments may be more beneficial in managing post-stroke spasticity. We report the effects of DN plus exercise therapy (ET) on wrist flexor spasticity. PATIENT PRESENTATION: The patient was a 45-year-old man with an 8-year history of stroke. The outcome measures included the Modified Modified Ashworth Scale (MMAS), Hmax/Mmax ratio, H-reflex latency, Action Research Arm Test (ARAT), Fugl-Meyer Assessment (FMA), and range of motion (ROM) which were assessed before (T1), after (T2), and after 3-week follow-up (T3). CONCLUSION: The MMAS was improved at T2 from "3" to "2". The Hmax/Mmax decreased from 0.77 to 0.53 at T3. The H-reflex latency increased from 15.4 ms to 18.5 ms at T3. The wrist active and passive ROM increased ∼30° and ∼20° at T2, respectively. A 4-session DN plus ET may improve spasticity and ROM. No meaningful improvement was observed in function.

Reliability of ultrasound measurement of the lateral abdominal and lumbar multifidus muscles in individuals with chronic low back pain: A cross-sectional test-retest study.

OBJECTIVES: Ultrasound (US) imaging has been suggested to evaluate the morphology and function of trunk muscles; however, little is known about the reliability of the US measures in patients with chronic low back pain (CLBP). This study aimed to evaluate intrarater reliability of US imaging of the lateral abdominal and lumbar multifidus muscles in individuals with nonspecific CLBP. METHODS: In this cross-sectional study, intrarater within-day and between-day reliability of US measurements of the transversus abdominis, internal oblique, external oblique and lumbar multifidus (at the L3-L4, L4-L5, and L5-S1 levels) muscles were obtained on both sides. The resting and contracted thickness and contraction ratio of each muscle were measured in 21 individuals with nonspecific CLBP. RESULTS: All US measurements of the lateral abdominal and lumbar multifidus muscles demonstrated good to excellent within-day (Intraclass correlation coefficients (ICCs: 0.80-0.98) and between-day (ICCs: 0.80-0.97) reliability. The standard error of the measurement (SEMs) and minimal detectable change (MDCs) of the lateral abdominal muscles on both sides ranged 0.5-1.6 mm and 0.4-4.4 mm, respectively. The SEMs and MDCs of the LM muscles on both sides ranged 1.1-2.7 mm and 2.86-7.49 mm, respectively. CONCLUSION: The findings indicate that US imaging has good to high intrarater within- and between-day reliability for assessing absolute thickness and contraction ratio of the trunk muscles on both right and left sides in patients with nonspecific CLBP. The vertical alignment of the US transducer is a reliable method for assessing the lateral abdominal muscles.

Learning promotion of physiotherapy in neurological diseases: Design and application of a virtual reality-based game.

INTRODUCTION: The virtual reality-based (VR) game can be considered as a new approach to education and to enhance the skills of health-care students. AIMS: The purposes of this research were to design a VR game and to apply it to teach physiotherapy in neurological diseases. METHODOLOGY: In this study, at first, a VR game was designed for upper limb rehabilitation in brain-injured patients based on the literature and the opinions of physiotherapy experts and game designers. Then, the designed game was used for teaching physiotherapy in neurological diseases. Thereafter, the opinions of 31 undergraduate students about the teaching session were evaluated by two anonymous questionnaires. Data analysis was performed using descriptive statistics through SPSS (version 19). RESULTS: The VR game developed under expert supervision. The evaluation showed that the median score for students' perception of learning was 3.11. The median scores of questions related to the "facilitating level of virtual reality" and "student satisfaction" were 8.66 and 9, respectively. The analysis of students' responses to open-ended questions highlighted the therapeutic aspect of the game compared to its educational aspect. CONCLUSIONS: Application of VR games in education can enhance the students' perception of learning. Furthermore, it can provide a better understanding of physiotherapy in patients with neurological diseases as well as the satisfaction of students. However, the survey indicated that the good results of this teaching method are due to the use of VR for guiding the patient's movements.

Short-term effect of kinesiology taping on pain, functional disability and lumbar proprioception in individuals with nonspecific chronic low back pain: a double-blinded, randomized trial.

BACKGROUND: This study aimed to evaluate the effect of kinesiology taping (KT) on lumbar proprioception, pain, and functional disability in individuals with nonspecific chronic low back pain (CLBP). METHODS: Thirty individuals with nonspecific CLBP participated in this double-blinded, randomized clinical trial from July 2017 to September 2018. The participants were randomized into two groups: KT (n = 15) and placebo group (n = 15). KT was applied with 15-25% tension for 72 h, and placebo taping was used without tension. Lumbar repositioning error was measured by a bubble inclinometer at three different angles (45° and 60° flexion, and 15° extension) in upright standing. Pain and disability were assessed by the Short-Form McGill Pain Questionnaire and Oswestry Disability Index, respectively. All measurements were recorded at baseline and 3 days after taping. RESULTS: Pain and disability scores reduced 3 days after taping in the KT group with large effect sizes (p < 0.05). Only the total score of pain was significantly different between the groups 3 days after taping and improved more in the KT group with a large effect size (p < 0.05). However, lumbar repositioning errors were similar between the groups after 3 days (p > 0.05). Also, only constant error of 15° extension showed a moderate correlation with disability (r = 0.39, p = 0.02). CONCLUSION: KT can decrease pain and disability scores after 3 days of application. Although placebo taping can reduce pain, the effect of KT is higher than placebo taping. The findings do not support the therapeutic effect of KT and placebo taping as a tool to enhance lumbar proprioception in patients with nonspecific CLBP. TRIAL REGISTRATION: The study prospectively registered on 21.05.2018 at the Iranian Registry of Clinical Trials: IRCT20090301001722N20 .

Investigating post-stroke fatigue: An individual participant data meta-analysis.

OBJECTIVE: The prevalence of post-stroke fatigue differs widely across studies, and reasons for such divergence are unclear. We aimed to collate individual data on post-stroke fatigue from multiple studies to facilitate high-powered meta-analysis, thus increasing our understanding of this complex phenomenon. METHODS: We conducted an Individual Participant Data (IPD) meta-analysis on post-stroke fatigue and its associated factors. The starting point was our 2016 systematic review and meta-analysis of post-stroke fatigue prevalence, which included 24 studies that used the Fatigue Severity Scale (FSS). Study authors were asked to provide anonymised raw data on the following pre-identified variables: (i) FSS score, (ii) age, (iii) sex, (iv) time post-stroke, (v) depressive symptoms, (vi) stroke severity, (vii) disability, and (viii) stroke type. Linear regression analyses with FSS total score as the dependent variable, clustered by study, were conducted. RESULTS: We obtained data from 14 of the 24 studies, and 12 datasets were suitable for IPD meta-analysis (total n = 2102). Higher levels of fatigue were independently associated with female sex (coeff. = 2.13, 95% CI 0.44-3.82, p = 0.023), depressive symptoms (coeff. = 7.90, 95% CI 1.76-14.04, p = 0.021), longer time since stroke (coeff. = 10.38, 95% CI 4.35-16.41, p = 0.007) and greater disability (coeff. = 4.16, 95% CI 1.52-6.81, p = 0.010). While there was no linear association between fatigue and age, a cubic relationship was identified (p < 0.001), with fatigue peaks in mid-life and the oldest old. CONCLUSION: Use of IPD meta-analysis gave us the power to identify novel factors associated with fatigue, such as longer time since stroke, as well as a non-linear relationship with age.

The effects of cryotherapy versus cryostretching on clinical and functional outcomes in athletes with acute hamstring strain.

PURPOSE: Hamstring strain is a common sport injury that results in pain and functional limitation. Despite its high frequency in active populations, there is no agreement regarding the best method used for early intervention of hamstring strain. The aim of the present study was to compare the effects of cryotherapy and cryostretching on clinical and functional outcomes in athletes with acute hamstring strain. MATERIALS AND METHODS: Thirty seven elite athletes with an acute grade I or II hamstring strain were randomly assigned to either cryotherapy (n = 19) or cryostretching (n = 18) group, receiving 5 sessions of supervised treatment plus home-based intervention monitored by the therapist. Pre-treatment to post-treatment changes in pain, active and passive knee extension range of motion and functional status were compared between the two groups. RESULTS: Compared to cryotherapy, cryostretching resulted in larger improvement of function and passive knee extension range of motion. Changes in active knee extension range of motion and pain severity were not significantly different between the two groups. CONCLUSION: A rehabilitation protocol involving gentle stretching following cryotherapy is more effective than cryotherapy alone in the improvement of function and passive knee range of motion in patients with grade I and II hamstring strain.

Immediate effects of transcutaneous electrical nerve stimulation on six-minute walking test, Borg scale questionnaire and hemodynamic responses in patients with chronic heart failure.

[Purpose] This study examined the immediate effects of transcutaneous electrical nerve stimulation on a six-minute walking test, Borg scale questionnaire and hemodynamic responses in patients with chronic heart failure. [Subjects and Methods] Thirty patients with stable systolic chronic heart failure came to the pathophysiology laboratory three times. The tests were randomly performed in three sessions. In one session, current was applied to the quadriceps muscles of both extremities for 30 minutes and a six-minute walking test was performed immediately afterward. In another session, the same procedure was followed except that the current intensity was set to zero. In the third session, the patients walked for six minutes without application of a current. The distance covered in each session was measured. At the end of each session, the subjects completed a Borg scale questionnaire. [Results] The mean distance traveled in the six-minute walking test and the mean score of the Borg scale questionnaire were significantly different across sessions. The mean systolic and diastolic pressures showed no significant differences across sessions. [Conclusion] The increase in distance traveled during the six-minute walking test and decrease in fatigue after the use of current may be due to a decrease in sympathetic overactivity and an increase in peripheral and muscular microcirculation in these patients.

Electrophysiological evaluation of the Modified Tardieu Scale (MTS) in assessing poststroke wrist flexor spasticity.

BACKGROUND: Spasticity is a common impairment following upper motor neuron lesions such as stroke. The appropriate measurement of muscle spasticity using validated tools to evaluate the outcome of therapies is important in clinical and research settings. OBJECTIVE: To determine the concurrent criterion-related validity of the Modified Tardieu Scale (MTS) in assessing poststroke wrist flexor muscle spasticity based on its correlation with H-reflex tests. METHODS: A total of 20 adult patients poststroke underwent clinical and electrophysiological assessment of wrist flexor muscle spasticity on the affected side. The primary outcome measures were: R2-R1 of the MTS; and the H-reflex indices of Hmax/Mmax ratio and Hslp/Mslp ratio. The Hslp and the latency of H-reflex were also measured. RESULTS: Correlations tests did not reveal significant associations between the clinical and H-reflex tests. CONCLUSIONS: This study suggests that the MTS may not be a valid tool to evaluate muscle spasticity in this sample of patients after stroke.

Reaction time and anticipatory skill of athletes in open and closed skill-dominated sport.

In sports, reaction time and anticipatory skill are critical aspects of perceptual abilities. To date, no study has compared reaction time and anticipatory skill of athletes from open and closed skill-dominated sport. Accordingly, the present study investigated whether a difference exists in sensory-cognitive skills between these two different sport domains. Eleven volleyball players and 11 sprinters participated in this experiment. Reaction time and anticipatory skill of both groups were recorded by a custom-made software called SART (speed anticipation and reaction time test). This software consists of six sensory-cognitive tests that evaluate visual choice reaction time, visual complex choice reaction time, auditory choice reaction time, auditory complex choice reaction time, and anticipatory skill of the high speed and low speed of the ball. For each variable, an independent t-test was performed. Results suggested that sprinters were better in both auditory reaction times (P<0.001 for both tests) and volleyball players were better in both anticipatory skill tests (P = 0.007 and P = 0.04 for anticipatory skill of the high speed and low speed of the ball, respectively). However, no significant differences were found in both visual choice reaction time tests (P > 0.05 for both visual reaction time tests). It is concluded that athletes have greater sensory-cognitive skills related to their specific sport domain either open or closed.

Comparing the validity of the Modified Modified Ashworth Scale (MMAS) and the Modified Tardieu Scale (MTS) in the assessment of wrist flexor spasticity in patients with stroke: protocol for a neurophysiological study.

INTRODUCTION: Reliable and valid tools must be used to assess spasticity in clinical practise and research settings. There is a paucity of literature regarding the validity of the Modified Modified Ashworth Scale (MMAS) and the Modified Tardieu Scale (MTS). No study, to date, has been performed to compare the validity of the MMAS and the MTS. This neurophysiological study protocol will compare the validity of the MMAS and the MTS in the assessment of poststroke wrist flexor spasticity. METHODS AND ANALYSIS: Thirty-two patients with stroke from the University Rehabilitation clinics will be recruited to participate in this cross-sectional, non-interventional study. All measurements will be taken in the Physical Medicine and Rehabilitation Department of Shafa University Hospital in Tehran, Iran. First, wrist flexor spasticity will be assessed clinically using the MMAS and MTS. The tests will be applied randomly. For the MTS, the components of R1, R2, R2-R1 and quality of muscle reaction will be measured. Second, neurophysiological measures of H-reflex latency, H(max)/M(max) ratio, H(slp) and H(slp)/M(slp) ratio will be collected from the affected side. The results will be analysed using Spearman's ρ test or Pearson's correlation test to determine the validity of the MMAS and the MTS as well as to compare the validity between the MMAS and the MTS. ETHICS AND DISSEMINATION: The Research Council, School of Rehabilitation and the Ethics Committee of Tehran University of Medical Sciences (TUMS) approved the study protocol.  The study results will be disseminated in peer-reviewed publications and presented at international congresses.

Measurement of lower-limb muscle spasticity: intrarater reliability of Modified Modified Ashworth Scale.

The Modified Modified Ashworth Scale (MMAS) is a clinical instrument for measuring spasticity. Few studies have been performed on the reliability of the MMAS. The aim of the present study was to investigate the intrarater reliability of the MMAS for the assessment of spasticity in the lower limb. We conducted a test-retest study on spasticity in the hip adductors, knee extensors, and ankle plantar flexors. Each patient was measured by a hospital-based clinical physiotherapist. Twenty-three patients with stroke or multiple sclerosis (fourteen women, nine men) and a mean +/- standard deviation age of 37.3 +/- 14.1 years participated. The weighted kappa was moderate for the hip adductors (weighted kappa = 0.45, standard error [SE] = 0.16, p = 0.007), good for the knee extensors (weighted kappa = 0.62, SE = 0.12, p < 0.001), and very good for the ankle plantar flexors (weighted kappa = 0.85, SE = 0.05, p < 0.001). The kappa value for overall agreement was very good (weighted kappa = 0.87, SE = 0.03, p < 0.001). The reliability for the ankle plantar flexors was significantly higher than that for the hip adductors. The intrarater reliability of the MMAS in patients with lower-limb muscle spasticity was very good, and it can be used as a measure of spasticity over time.

Inter-rater reliability of the Modified Modified Ashworth Scale in assessing lower limb muscle spasticity.

PRIMARY OBJECTIVE: To assess the inter-rater reliability of the Modified Modified Ashworth Scale (MMAS) in lower limb muscle spasticity. RESEARCH DESIGN: Cross-sectional observational study. INTERVENTIONS: Not applicable. METHODS AND PROCEDURES: Twenty-two adults with neurological conditions (17 women, five men, age range 21-82 years; mean +/- SD, 44 +/- 18 years) participated. Hip adductor, knee extensor and ankle plantarflexor were assessed in a random order. MAIN OUTCOMES AND RESULTS: Inter-rater agreement for two raters was very good for the hip adductor and the knee extensor (weighted kappa = 0.82, p < 0.0001) and good for the ankle plantarflexor (weighted kappa = 0.74, p < 0.0001). CONCLUSIONS: The Modified Modified Ashworth Scale produced reliable measurements between raters in the assessment of lower limb muscle spasticity.