Effectiveness of static stretching positioning on post-stroke upper-limb spasticity and mobility: Systematic review with meta-analysis

The effects of exercise interventions on depressive symptoms in stroke patients: a systematic review and meta-analysis

Purpose

This systematic review and meta-analysis aimed to evaluate the effects of exercise interventions on depressive symptoms in stroke patients.

Methods

Following PRISMA guidelines, We conducted searches in PubMed, Embase, CENTRAL, and Web of Science. The topic was the effect of exercise on depression levels in stroke patients. Patient's performance on depression scales after exercise was assessed using standardized mean difference (SMD) and 95% confidence intervals (95% CI). A random effects model (RE) was used to conduct a meta-analysis and compare the results between subgroups conducted based on adherence to ACSM guidelines and the length of exercise interventions.

Results

The analysis included 24 randomized controlled trials (RCTs) involving 1,757 participants. The meta-analysis revealed that exercise interventions had a significant positive effect on reducing depressive symptoms in stroke patients, with a standardized mean difference (SMD) of -0.43 (95% CI: 0.65, -0.21). Subgroup analysis indicated that high compliance with ACSM guidelines resulted in a more substantial reduction in depressive symptoms (SMD = -0.79, 95% CI: 1.10, -0.49), compared with low or uncertain compliance (SMD = -0.03, 95% CI: 0.16, 0.10). Longer exercise intervention was associated with greater mitigation of depressive symptoms. The differences between intervention groups of different lengths were statistically significant (p < 0.05).

Conclusion

These findings support the integration of tailored exercise programs into post-stroke care to optimize mental health outcomes. Compliance to ACSM-recommended exercise dosages significantly ameliorate depression levels in stroke patients. Further research is warranted to explore standardized exercise regimens in larger, multicenter trials.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/#recordDetails, identifier PROSPERO(CRD42024579095).

Pathophysiology and Management Strategies for Post-Stroke Spasticity: An Update Review

Post-stroke spasticity (PSS), characterized by a velocity-dependent increase in muscle tone and exaggerated reflexes, affects a significant portion of stroke patients and presents a substantial obstacle to post-stroke rehabilitation. Effective management and treatment for PSS remains a significant clinical challenge in the interdisciplinary aspect depending on the understanding of its etiologies and pathophysiology. We systematically review the relevant literature and provide the main pathogenic hypotheses: alterations in the balance of excitatory and inhibitory inputs to the descending pathway or the spinal circuit, which are secondary to cortical and subcortical ischemic or hemorrhagic injury, lead to disinhibition of the stretch reflex and increased muscle tone. Prolongation of motoneuron responses to synaptic excitation by persistent inward currents and secondary changes in muscle contribute to hypertonia. The guidelines for PSS treatment advocate for a variety of therapeutic approaches, yet they are hindered by constraints such as dose-dependent adverse effects, high cost, and limited therapeutic efficacy. Taken together, we highlight key processes of PSS pathophysiology and summarize many interventions, including neuroprotective agents, gene therapy, targeted therapy, physiotherapy, NexTGen therapy and complementary and alternative medicine. We aim to confer additional clinical benefits to patients and lay the foundation for the development of new potential therapies against PSS.

Effect of Dry Needling Plus Static Stretching on Plantar Flexors Spasticity in Chronic Stroke Patients

Importance

Stroke is a leading cause of disability worldwide and is often accompanied by complications such as spasticity. Static stretching (SS) is a common physiotherapy intervention for reducing spasticity, whereas dry needling (DN) is a novel approach. However, the combined effects of DN and SS on spasticity have not been thoroughly investigated. Given the pivotal effect of spasticity on daily activities, mitigating spasticity can significantly contribute to restoring patient independence.

Objective

This study will explore the impact of DN plus SS on spasticity, alpha motor neuron excitability, overall function, and quality of life in patients with chronic stroke.

Design, Setting, and Population

A double-blind, randomized, sham-controlled trial will be conducted in patients with post-stroke spasticity in the plantar flexor muscles. Twentyeight participants will be randomly assigned to either an intervention or control group. The intervention group will receive DN (60s × 3 days/week; 1 week) plus SS (20 min × 5 days/ week; 1 week). The control group will undergo sham DN (60s × 3 days/week; 1 week) and SS (20 min × 5 days/week; 1 week).

Exposures

DN plus SS or sham DN plus SS.

Main Outcomes and Measures

Both groups will be assessed at baseline, immediately post-treatment, and after 1 week of follow-up. Outcome measures will include the Modified Modified Ashworth Scale, H-reflex latency, Hmax/Mmax ratio, active and passive ankle dorsiflexion range of motion, timed up and go test, and the EuroQol questionnaire.

Results

Results from this randomized, sham-controlled study will provide evidence for the effectiveness of DN in combination with SS for spasticity.

Conclusions and Relevance

The additional impact of DN in conjunction with SS, a widely used method for reducing muscle tone, remains unclear and warrants investigation. This study, with a high level of evidence, aims to address this knowledge gap.

AAPM&R consensus guidance on spasticity assessment and management

BACKGROUND

The American Academy of Physical Medicine and Rehabilitation (AAPM&R) conducted a comprehensive review in 2021 to identify opportunities for enhancing the care of adult and pediatric patients with spasticity. A technical expert panel (TEP) was convened to develop consensus-based practice recommendations aimed at addressing gaps in spasticity care.

OBJECTIVE

To develop consensus-based practice recommendations to identify and address gaps in spasticity care.

METHODS

The Spasticity TEP engaged in a 16-month virtual meeting process, focusing on formulating search terms, refining research questions, and conducting a structured evidence review. Evidence quality was assessed by the AAPM&R Evidence, Quality and Performance Committee (EQPC), and a modified Delphi process was employed to achieve consensus on recommendation statements and evidence grading. The Strength of Recommendation Taxonomy (SORT) guided the rating of individual studies and the strength of recommendations.

RESULTS

The TEP approved five recommendations for spasticity management and five best practices for assessment and management, with one recommendation unable to be graded due to evidence limitations. Best practices were defined as widely accepted components of care, while recommendations required structured evidence reviews and grading. The consensus guidance statement represents current best practices and evidence-based treatment options, intended for use by PM&R physicians caring for patients with spasticity.

CONCLUSION

This consensus guidance provides clinicians with practical recommendations for spasticity assessment and management based on the best available evidence and expert opinion. Clinical judgment should be exercised, and recommendations tailored to individual patient needs, preferences, and risk profiles. The accompanying table summarizes the best practice recommendations for spasticity assessment and management, reflecting principles with little controversy in care delivery.

Stretching exercises in managing spasticity: effectiveness, risks, and adjunct therapies

Spasticity is a component of upper motor neuron disorders and can be seen in neurological conditions like stroke and multiple sclerosis. Although the incidence rate of spasticity is unknown, it can put pressure on the health condition of those with spasticity, and there is no absolute effective way to control it. In the past, stretching exercises were an accessible tool for physical therapists to manage and control spasticity, but opinions on the optimal dose, aftereffects, and mechanism of effects were controversial. Therefore, this article tries to provide an overview of the effectiveness and risks of stretching exercises. Furthermore, there are several adjunct therapies, such as brain stimulation and botulinum injection, that can increase the effectiveness of a simple stretch by increasing cortical excitability and reducing muscle tone and their role is evaluated in this regard. The results of this study propose that several prospective and case studies have demonstrated the benefits of stretching to control spasticity, but it seems that other methods such as casting can be more effective than a simple stretch. Therefore, it is better to use stretching in combination with other therapeutic regimes to increase its effectivity of it.

Effectiveness of specific scapular therapeutic exercises in patients with shoulder pain: a systematic review with meta-analysis

Background

Therapeutic exercise has been considered a useful tool to rehabilitate shoulder pain, namely through its influence on scapular dynamics. Accordingly, the effectiveness of scapular therapeutic exercise needs to be explored. The present study aims to evaluate the effectiveness of scapular therapeutic exercises in shoulder pain and to identify the most effective exercise type (focal or multijoint) and ways of delivering them (as dose and progression).

Methods

Search was conducted at EMBASE, Cochrane Library, MEDLINE via PubMed, Web of Science, PEDro (Physiotherapy Evidence Database), and trial registration databases. The meta-analysis considered randomized controlled/crossover trials that compared the effect of scapular exercises against other types of intervention in the shoulder pain, shoulder function, scapular motion, and/or muscular activity. The risk of bias was assessed through the PEDro scale.

Results

From the 8318 records identified, 8 (high to low risk of bias- scoring from 4 to 8 on the PEDro scale) were included. The overall data, before sensitivity analysis, indicated that the scapular therapeutic exercises are: a) more effective than comparators in improving shoulder function (standardized mean difference [SMD] = 0.52 [95% Cl: 0.05, 0.99], P = .03, I2 = 76%); and b) as effective as comparators in reducing shoulder pain (SMD = 0.32 [95% Cl: -0.09, 0.73], P = .13, I2 = 70%). Subgroup analysis revealed that scapular exercises are more effective in improving shoulder function when the program duration is equal to or higher than 6 weeks (SMD = 0.43 [95% Cl: 0.09, 0.76] P = .01, I2 = 21%) and/or when the maximum number of exercise repetitions per session is lower than 30 (SMD = 0.79 [95% Cl: 0.15, 1.42], P = .01, I2 = 77%). Only 1 study considered scapular motion as an outcome measure, revealing therapeutic exercise effectiveness to improve scapular range of motion.

Conclusions

Intervention programs involving scapular therapeutic exercises are effective in improving shoulder function, presenting benefits when performed for 6 or more weeks and/or when used up to a maximum of 30 repetitions per exercise, per session.

Best Practice Guidelines for the Management of Patients with Post-Stroke Spasticity: A Modified Scoping Review

This article aims to provide a concise overview of the best available evidence for managing post-stroke spasticity. A modified scoping review, conducted following the PRISMA guidelines and the PRISMA Extension for Scoping Reviews (PRISMA-ScR), involved an intensive search on Medline and PubMed from 1 January 2000 to 31 August 2023. The focus was placed on high-quality (GRADE A) medical, rehabilitation, and surgical interventions. In total, 32 treatments for post-stroke spasticity were identified. Two independent reviewers rigorously assessed studies, extracting data, and evaluating bias using GRADE criteria. Only interventions with GRADE A evidence were considered. The data included the study type, number of trials, participant characteristics, interventions, parameters, controls, outcomes, and limitations. The results revealed eleven treatments supported by GRADE A evidence, comprising 14 studies. Thirteen were systematic reviews and meta-analyses, and one was randomized control trial. The GRADE A treatments included stretching exercises, static stretching with positional orthosis, transcutaneous electrical nerve stimulation, extracorporeal shock wave therapy, peripheral magnetic stimulation, non-invasive brain stimulation, botulinum toxin A injection, dry needling, intrathecal baclofen, whole body vibration, and localized muscle vibration. In conclusion, this modified scoping review highlights the multimodal treatments supported by GRADE A evidence as being effective for improving functional recovery and quality of life in post-stroke spasticity. Further research and exploration of new therapeutic options are encouraged.

Latent transition analysis to explore patterns of physical functional decline among older adults in China: A national 6-year longitudinal study

BACKGROUND AND AIMS

Multiple limitations often co-occur and accumulate, leading to subsequent function decline. However, there is a scarcity of longitudinal studies examining the progression of physical function among the general population of older adults in China. This study aimed to define typical physical function status and its change, which were characterized by the coexistence and accumulation of diverse limitations targeting a Chinese sample of older adults.

METHODS

This study used the three recent public data waves of the Chinese Longitudinal Healthy Longevity Survey during a 6-year follow-up period. 9765 individuals who were over 65 and participated in the 2011 survey were included. Latent transition analysis was used to identify the latent physical function status and explore the transition of older adults among different latent statuses.

RESULTS

Seven latent statuses of physical function were identified, with visual impairment and related limitations being particularly prevalent among older adults. Upper limb mobility appeared to be a differentiated indicator of physical functional status. Physical function decline mainly started with the limitations in squatting, carrying weights and walking, then to the status with intact upper limb mobility and hearing function only, or converted directly into the latter, then to complete dysfunction.

CONCLUSIONS

Our findings suggest some indicative limitations and critical steps in the process of functional decline among older adults. These results may provide insight for researchers and policymakers to develop tailored preventive and rehabilitation care and provide support for physically limited elderly according to their latent status and course of functional decline.

Upper Limb Spasticity: The Quality of Online Patient Resources

OBJECTIVE

The aim of the study is to assess the quality, readability, content, accessibility, and structure of online resources for patients with upper limb spasticity.

DESIGN

This was a cross sectional study examined Internet searches across three search engines related to patient resources for upper limb spasticity. Search phrases for either hand or upper limb spasticity were used. The top 20 Websites from each search were evaluated using the four readability metrics and the DISCERN scale for quality assessment. YouTube videos with exact search phrases were evaluated using DISCERN. Descriptive statistical analyses were performed using SPSS software.

RESULTS

Thirty-six Websites and 33 videos met the inclusion criteria for this study. The average Flesh-Kincaid Grade Level of the Websites was 11.7 ± 3.1, showing low Website readability. According to this index, only two Websites were written at the suggested sixth-grade level (5.4%). With a maximum score of 75, the mean DISCERN score for both Websites and videos scored in the "good" range (53.5 ± 8 and 50.5 ± 6.6), respectively.

CONCLUSIONS

Current online resources for upper limb spasticity are good in quality but are written above the health literacy level of American citizens. Organizations should consider reviewing their present materials and developing high-quality patient education materials that are easier to understand.

Wet cupping with rehabilitation training for upper-limb poststroke spasticity: A systematic review and meta-analysis of randomized controlled trials

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.

Prevalence and clinical predictors of spasticity after intracerebral hemorrhage

BACKGROUND

Spasticity is a common complication of intracerebral hemorrhage (ICH). However, no consensus exists on the relation between spasticity and initial clinical findings after ICH.

METHODS

This retrospective study enrolled adult patients with a history of ICH between January 2012 and October 2020. The modified Ashworth scale was used to assess spasticity. A trained image analyst traced all ICH lesions. Multivariable logistic regression was used to examine the association between ICH lesion sites and spasticity.

RESULTS

We finally analyzed 304 patients (mean age 54.86 ± 12.93 years; 72.04% men). The incidence of spasticity in patients with ICH was 30.92%. Higher National Institutes of Health stroke scale (NIHSS) scores were associated with an increased predicted probability for spasticity (odds ratio, OR = 1.153 [95% confidence interval, CI 1.093-1.216], p < .001). Logistic regression analysis revealed that lower age, higher NIHSS scores, and drinking were associated with an increased risk of moderate-to-severe spasticity (OR = 0.965 [95% CI 0.939-0.992], p = .013; OR = 1.068 [95% CI 1.008-1.130], p = .025; OR = 4.809 [95% CI 1.671-13.840], p = .004, respectively). However, smoking and ICH in the thalamus were associated with a reduced risk of moderate-to-severe spasticity (OR = 0.200 [95% CI 0.071-0.563], p = .002; OR = 0.405 [95% CI 0.140-1.174], p = .046, respectively) compared with ICH in the basal ganglia.

CONCLUSIONS

Our results suggest that ICH lesion locations are at least partly associated with post-stroke spasticity rather than the latter simply being a physiological reaction to ICH itself. The predictors for spasticity after ICH were age, NIHSS scores, past medical history, and ICH lesion sites.

A Novel Neurorehabilitation Approach for Neural Plasticity Overstimulation and Reorganization in Patients with Neurological Disorders

Neurological disorders are those that are associated with impairments in the nervous system. These impairments affect the patient’s activities of daily living. Recently, many advanced modalities have been used in the rehabilitation field to treat various neurological impairments. However, many of these modalities are available only in clinics, and some are expensive. Most patients with neurological disorders have difficulty reaching clinics. This review was designed to establish a new neurorehabilitation approach based on the scientific way to improve patients’ functional recovery following neurological disorders in clinics or at home. The human brain is a network, an intricate, integrated system that coordinates operations among billions of units. In fact, grey matter contains most of the neuronal cell bodies. It includes the brain and the spinal cord areas involved in muscle control, sensory perception, memory, emotions, decision-making, and self-control. Consequently, patients’ functional ability results from complex interactions among various brain and spinal cord areas and neuromuscular systems. While white matter fibers connect numerous brain areas, stimulating or improving non-motor symptoms, such as motivation, cognitive, and sensory symptoms besides motor symptoms may enhance functional recovery in patients with neurological disorders. The basic principles of the current treatment approach are established based on brain connectivity. Using motor, sensory, motivation, and cognitive (MSMC) interventions during rehabilitation may promote neural plasticity and maximize functional recovery in patients with neurological disorders. Experimental studies are strongly needed to verify our theories and hypothesis.

Effectiveness of physical therapy interventions on post-stroke spasticity: An umbrella review

BACKGROUND

Post-stroke spasticity is often one of the primary impairments addressed in rehabilitation. However, limited guidance exists on the effectiveness of physical therapy (PT) interventions for post-stroke spasticity.

OBJECTIVE

To evaluate the quality of evidence of PT interventions for post-stroke spasticity.

METHODS

Ovid (Medline), Cochrane Library, CINAHL, Scopus, PEDro, and PROSPERO were searched to identify reviews based on the following criteria: 1) published between 2012 and 2021, 2) participants older than 18 years old, 3) post-stroke spasticity, 4) PT interventions, 5) clinical or neurophysiological measures of spasticity as primary outcomes. Assessment of Multiple Systematic Reviews 2 and the Grades of Recommendations Assessment, Development, and Evaluation assessed methodological quality.

RESULTS

Eight articles were included in the analysis. No high-quality evidence was found. Moderate quality evidence exists for transcutaneous electrical nerve stimulation, neuromuscular electrical stimulation, resistance training, and lower extremity ergometer training with or without functional electrical stimulation. Low quality evidence exists for dynamic stretching, botulinum toxin with constraint-induced movement therapy, and static stretching using positional orthoses.

CONCLUSION

Findings suggest that PT should prioritize a combination of active strategies over passive interventions, but further studies are needed prioritizing analyses of the movement system in managing post-stroke spasticity in conjunction with medical therapies.

Treatment of spasticity

Spasticity is characterized by an enhanced size and reduced threshold for activation of stretch reflexes and is associated with "positive signs" such as clonus and spasms, as well as "negative features" such as paresis and a loss of automatic postural responses. Spasticity develops over time after a lesion and can be associated with reduced speed of movement, cocontraction, abnormal synergies, and pain. Spasticity is caused by a combination of damage to descending tracts, reductions in inhibitory activity within spinal cord circuits, and adaptive changes within motoneurons. Increased tone, hypertonia, can also be caused by changes in passive stiffness due to, for example, increase in connective tissue and reduction in muscle fascicle length. Understanding the cause of hypertonia is important for determining the management strategy as nonneural, passive causes of stiffness will be more amenable to physical rather than pharmacological interventions. The management of spasticity is determined by the views and goals of the patient, family, and carers, which should be integral to the multidisciplinary assessment. An assessment, and treatment, of trigger factors such as infection and skin breakdown should be made especially in people with a recent change in tone. The choice of management strategies for an individual will vary depending on the severity of spasticity, the distribution of spasticity (i.e., whether it affects multiple muscle groups or is more prominent in one or two groups), the type of lesion, and the potential for recovery. Management options include physical therapy, oral agents; focal therapies such as botulinum injections; and peripheral nerve blocks. Intrathecal baclofen can lead to a reduction in required oral antispasticity medications. When spasticity is severe intrathecal phenol may be an option. Surgical interventions, largely used in the pediatric population, include muscle transfers and lengthening and selective dorsal root rhizotomy.

A systematic review on extracorporeal shock wave therapy and botulinum toxin for spasticity treatment: a comparison on efficacy

INTRODUCTION

The complexity of spasticity requires a continuous effort in terms of more adapted treatments for patients, and accurate management. Through this systematic review, we aimed to evaluate and compare the effectiveness of extracorporeal shock wave therapy (ESWT) with botulinum toxin type A (BoNT-A) on reducing spasticity both in children and adults.

EVIDENCE ACQUISITION

An electronic search of PubMed/Medline, Scopus, Ovid Medline(R), and search engine of Google Scholar was performed. Publications ranging from January 2010 to January 2021, published in the English language and available as full-texts were eligible for inclusion and they were searched without any country restriction. The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines.

EVIDENCE SYNTHESIS

A total of five studies were included in the present systematic review. Screening of the references, data extraction, and risk of bias assessment were performed by two independent authors. The methodological quality and risk of bias were conducted using the Physiotherapy Evidence Database (PEDro) Scale. The primary outcome was spasticity grade assessed by the Modified Ashworth Scale (MAS) and/or Modified Tardieu Scale (MTS). Additional outcomes were active range of motion (AROM), passive range of motion (PROM), upper extremity Fugl-Meyer Assessment (UE-FMA), pain intensity assessed through Visual Analogue Scale (VAS), spasm frequency scale (SFS), sonographic parameters, between-group comparison, and treatment response rate.

CONCLUSIONS

A beneficial effect on spasticity was found for both treatments: evidence showed that ESWT and BoNT-A can ameliorate spasticity considering parameters such as MAS, MTS, AROM, PROM, UE-FMA, VAS and SFS in post-stroke, multiple sclerosis, and cerebral palsy patients. Further research is required to strengthen the evidence, and more suitable study protocols are highly needed.

Effects of Functional Acupuncture on Upper Limb Spasticity After Ischemic Stroke: A Protocol for a Randomized Controlled Parallel Clinical Trial

Background

Upper limb spasticity (ULS) is a common complication after stroke, which seriously affects the quality of life and rehabilitation of patients. There are different treatment methods for post-stroke spasticity (PSS). Our group found that functional acupuncture (FA) can effectively improve forearm spasticity and hand dysfunction after stroke, but the efficacy of ULS needs to be further verified. Therefore, this subject has mainly used clinical randomized controlled trials to evaluate the clinical efficacy of FA in the treatment of ULS after ischemic stroke.

Method

This is a parallel design and randomized controlled trial. We selected 108 patients who met the predefined criteria and randomized them into two groups, the experimental group and the control group. The experimental group receives FA and routine rehabilitation treatment. The control group received traditional acupuncture (TA) and routine rehabilitation treatment. All patients received 20 courses of treatment for 4 weeks, and the modified Ashworth score (MAS), clinical neurological deficit score (CSS), Fugl-Meyer upper extremity function assessment (FMA-UE), and the Modified Barthel Index (MBI) scores were evaluated before and after treatment.

Discussion

This trial is mainly to study the clinical efficacy of FA in the treatment of ULS after ischemic stroke. It will not only provide a new idea for the clinical treatment of upper limb post-stroke spasticity (ULPSS) but also will provide effective experimental support and a theoretical basis for the clinic.

Trial registration

China Clinical Trials Registry No. ChiCTR2100050440. Registered on 27 August 27 2021.

Calligraphy-based rehabilitation exercise for improving the upper limb function of stroke patients: protocol for an evaluator-blinded randomised controlled trial

INTRODUCTION

A common complication of stroke is upper limb dysfunction. Chinese calligraphy handwriting (CCH) is an aesthetical exercise developed from the traditional way of writing in China and holds potential to become a rehabilitation method to improve upper limb functions in patients with stroke. This study aims to design a randomised controlled trial to assess the effect of a customised CCH-based exercise for poststroke rehabilitation of upper limb dysfunction.

METHODS AND ANALYSIS

A single-blinded randomised controlled trial will be conducted on 60 stroke patients. The patients will be randomly allocated into three groups: (1) conventional occupational therapy (COT) group, (2) COT+CCH group, (3) COT+Graded Repetitive Arm Supplementary Program (GRASP) group. For the COT group, patients will receive COT treatment of 1 hour/day. For the COT+CCH group, patients will receive 30 mins COT treatment and 30 mins CCH training. For the COT+GRASP group, patients will receive 30 mins COT treatment and 30 mins GRASP training. All the interventions will be performed 5 days per week for a total of 3 weeks. The upper limb functions will be assessed before and after the interventions using a series of rating scales.

ETHICS AND DISSEMINATION

This study has been approved by the Research Ethics Committees of the Second Rehabilitation Hospital of Shanghai (study ID: 2020-32-01) and the Shanghai University of Sport (study ID: 102772021RT043). Results will be directly disseminated to the patients at the end of the study and to the public via publications in peer-reviewed journals and presentations in conferences.

TRIAL REGISTRATION NUMBER

ChiCTR 2100043036; Chinese Clinical Trials Registry.

Do Muscle Changes Contribute to the Neurological Disorder in Spastic Paresis?

Background

At the onset of stroke-induced hemiparesis, muscle tissue is normal and motoneurones are not overactive. Muscle contracture and motoneuronal overactivity then develop. Motor command impairments are classically attributed to the neurological lesion, but the role played by muscle changes has not been investigated.

Methods

Interaction between muscle and command disorders was explored using quantified clinical methodology-the Five Step Assessment. Six key muscles of each of the lower and upper limbs in adults with chronic poststroke hemiparesis were examined by a single investigator, measuring the angle of arrest with slow muscle stretch (XV1) and the maximal active range of motion against the resistance of the tested muscle (XA). The coefficient of shortening CSH = (XN-XV1)/XN (XN, normally expected amplitude) and of weakness CW = (XV1-XA)/XV1) were calculated to estimate the muscle and command disorders, respectively. Composite CSH (CCSH) and CW (CCW) were then derived for each limb by averaging the six corresponding coefficients. For the shortened muscles of each limb (mean CSH > 0.10), linear regressions explored the relationships between coefficients of shortening and weakness below and above their median coefficient of shortening.

Results

A total of 80 persons with chronic hemiparesis with complete lower limb assessments [27 women, mean age 47 (SD 17), time since lesion 8.8 (7.2) years], and 32 with upper limb assessments [18 women, age 32 (15), time since lesion 6.4 (9.3) years] were identified. The composite coefficient of shortening was greater in the lower than in the upper limb (0.12 ± 0.04 vs. 0.08 ± 0.04; p = 0.0002, while the composite coefficient of weakness was greater in the upper limb (0.28 ± 0.12 vs. 0.15 ± 0.06, lower limb; p < 0.0001). In the lower limb shortened muscles, the coefficient of weakness correlated with the composite coefficient of shortening above the 0.15 median CSH (R = 0.43, p = 0.004) but not below (R = 0.14, p = 0.40).

Conclusion

In chronic hemiparesis, muscle shortening affects the lower limb particularly, and, beyond a threshold of severity, may alter descending commands. The latter might occur through chronically increased intramuscular tension, and thereby increased muscle afferent firing and activity-dependent synaptic sensitization at the spinal level.

Home-Based Therapy After Stroke Using the Hand Spring Operated Movement Enhancer (HandSOME II)

We have developed a passive and lightweight wearable hand exoskeleton (HandSOME II) that improves range of motion and functional task practice in laboratory testing. For this longitudinal study, we recruited 15 individuals with chronic stroke and asked them to use the device at home for 1.5 h per weekday for 8 weeks. Subjects visited the clinic once per week to report progress and troubleshoot problems. Subjects were then given the HandSOME II for the next 3 months, and asked to continue to use it, but without any scheduled contact with the project team. Clinical evaluations and biomechanical testing was performed before and after the 8 week intervention and at the 3 month followup. EEG measures were taken before and after the 8 weeks of training to examine any recovery associated brain reorganization. Ten subjects completed the study. After 8 weeks of training, functional ability (Action Research Arm Test), flexor tone (Modified Ashworth Test), and real world use of the impaired limb (Motor Activity Log) improved significantly (p < 0.05). Gains in real world use were retained at the 3-month followup (p = 0.005). At both post-training and followup time points, biomechanical testing found significant gains in finger ROM and hand displacement in a reaching task (p < 0.05). Baseline functional connectivity correlated with gains in motor function, while changes in EEG functional connectivity paralleled changes in motor recovery. HandSOME II is a low-cost, home-based intervention that elicits brain plasticity and can improve functional motor outcomes in the chronic stroke population.

Efficacy of rehabilitative techniques in reducing hemiplegic shoulder pain in stroke: Systematic review and meta-analysis

BACKGROUND

Hemiplegic shoulder pain (HSP) is a disabling complication affecting stroke survivors. In this context, rehabilitation might play a key role in its clinical management. Recent systematic reviews of the impact of rehabilitative approaches on pain reduction in patients with HSP are lacking.

OBJECTIVE

This systematic review of randomized controlled trials (RCTs) with meta-analysis aimed to investigate the efficacy of rehabilitative techniques in reducing HSP in stroke survivors.

METHODS

PubMed, Scopus, and Web of Science were searched from inception to March 8, 2021 to identify RCTs of stroke survivors with HSP undergoing specific rehabilitative techniques combined with conventional therapy to reduce pain intensity. A network meta-analysis and meta-analysis of the Bayesian network of random effects were performed. The risk of bias of studies was assessed with Version 2 of the Cochrane Risk of Bias tool for randomized trials.

RESULTS

Of 1139 articles identified, 12 were included in the final synthesis. We analyzed data for 723 stroke survivors, reporting a significant overall decrease in pain intensity after a rehabilitative approach by the Bayesian meta-analysis (standardized mean difference 2.78, 95% confidence interval 0.89;-4.59; p = 0.003). We report a significant reduction in HSP with botulinum toxin type A injection (p = 0.001), suprascapular nerve pulsed radiofrequency (p = 0.030), suprascapular nerve block (p = 0.020), and trigger-point dry needling (p = 0.005) as compared with conventional rehabilitation. Concerning the effect size, we identified a Bayesian factor₁₀ of 97.2, with very strong evidence of superiority of rehabilitative techniques.

CONCLUSIONS

The present systematic review and meta-analysis showed that adding other rehabilitative techniques to conventional rehabilitation was significantly more effective than conventional rehabilitation alone in the complex management of patients affected by HSP.

Effectiveness of Stretching in Post-Stroke Spasticity and Range of Motion: Systematic Review and Meta-Analysis

Spasticity is one of the most frequent and disabling clinical manifestations of patients with stroke. In clinical practice, stretching is the most widely used physiotherapeutic intervention for this population. However, there is no solid evidence for its effectiveness. The aim of this study was to evaluate the effectiveness of different types of stretching in reducing post-stroke spasticity. Research was carried out until March 2021 in the following scientific databases: PubMed, CINAHL, Scopus, Cochrane Library, Web of Science, and PEDro. The PEDro scale and the Cochrane collaboration tool were used to assess the methodological quality and risk of bias of the studies. Eight articles were selected for qualitative analysis; six of them contributed information to the meta-analysis. No conclusive evidence was obtained on the effectiveness of stretching in terms of treating spasticity and range of motion in patients with stroke. Further research is necessary in order to determine the effectiveness of the use of stretching in this population, considering the different types of stretching (static and dynamic), the time of application, the measurement of the different components of spasticity, and the extrapolation of functional results.

Pilot Test of Dosage Effects in HEXORR II for Robotic Hand Movement Therapy in Individuals With Chronic Stroke

Impaired use of the hand in functional tasks remains difficult to overcome in many individuals after a stroke. This often leads to compensation strategies using the less-affected limb, which allows for independence in some aspects of daily activities. However, recovery of hand function remains an important therapeutic goal of many individuals, and is often resistant to conventional therapies. In prior work, we developed HEXORR I, a robotic device that allows practice of finger and thumb movements with robotic assistance. In this study, we describe modifications to the device, now called HEXORR II, and a clinical trial in individuals with chronic stroke. Fifteen individuals with a diagnosis of chronic stroke were randomized to 12 or 24 sessions of robotic therapy. The sessions involved playing several video games using thumb and finger movement. The robot applied assistance to extension movement that was adapted based on task performance. Clinical and motion capture evaluations were performed before and after training and again at a 6-month followup. Fourteen individuals completed the protocol. Fugl-Meyer scores improved significantly at the 6 month time point compared to baseline, indicating reductions in upper extremity impairment. Flexor hypertonia (Modified Ashworth Scale) also decreased significantly due to the intervention. Motion capture found increased finger range of motion and extension ability after the intervention that continued to improve during the followup period. However, there was no change in a functional measure (Action Research Arm Test). At the followup, the high dose group had significant gains in hand displacement during a forward reach task. There were no other significant differences between groups. Future work with HEXORR II should focus on integrating it with functional task practice and incorporating grip and squeezing tasks.

Trial Registration:ClinicalTrials.gov, NCT04536987. Registered 3 September 2020 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/record/NCT04536987.

Effectiveness of a New 3D-Printed Dynamic Hand-Wrist Splint on Hand Motor Function and Spasticity in Chronic Stroke Patients

Spasticity, a common stroke complication, can result in impairments and limitations in the performance of activities and participation. In this study, we investigated the effectiveness of a new dynamic splint on wrist and finger flexor muscle spasticity in chronic stroke survivors, using a randomized controlled trial. Thirty chronic stroke survivors were recruited and randomly allocated to either an experimental or control group; 25 completed the 6-week intervention program. The participants in the experimental group were asked to wear the dynamic splint at least 6 h/day at home, for the entire intervention. The participants in the control group did not wear any splint. All the participants were evaluated 1 week before, immediately, and after 3 and 6 weeks of splint use, with the modified Ashworth scale and the Fugl−Meyer assessment for upper extremity. User experience was evaluated by a self-reported questionnaire after the 6-week intervention. The timed within-group assessments showed a significant reduction in spasticity and improvements in functional movements in the experimental group. We found differences, in favor of the experimental group, between the groups after the intervention. The splint users indicated a very good satisfaction rating for muscle tone reduction, comfort, and ease of use. Therefore, this new splint can be used for at-home rehabilitation in chronic stroke patients with hemiparesis.

Effects of Radial Extracorporeal Shock Wave Therapy on Flexor Spasticity of the Upper Limb in Post-stroke Patients: Study Protocol for a Randomized Controlled Trial

Background: Flexor spasticity of the upper limb is common in poststroke patients and seriously affects the recovery of upper limb function. However, there are no standard management protocols for this condition. Radial extracorporeal shock wave therapy (rESWT) is widely used for various diseases, some studies reported the effects of ESWT on reducing spasticity, but the mechanism of ESWT to reduce spasticity by affecting the excitability of stretch reflex or non-neural rheological components in spastic muscles or both is not yet clear. A large randomized controlled trial with comprehensive evaluation indicators is still needed. The study is to observe the effect of rESWT on flexor spasticity of the upper limb after stroke and explore its mechanism.

Methods: A prospective, randomized, double-blind controlled trial is to be performed. One hundred participants will be recruited from the Inpatient Department of Zhujiang Hospital. Eligible patients will be randomly allocated to either receive three sessions of active rESWT (group A) or sham-placebo rESWT (group B) with 3-day intervals between each session. Assessment will be performed at baseline and at 24 h after each rESWT (t1, t2, and t3). The primary assessment outcome will be the Modified Ashworth Scale, and other assessments include surface electromyography, MyotonPRO digital muscle function evaluation, and infrared thermal imaging. All data will be analyzed using intention-to-treat principles. Multiple imputation by chained equations will be used to address missing data caused by loss to follow-up and nonresponses. Per protocol, analyses will also be performed on the participants who complete other assessments. Statistical analysis will be performed using SPSS software (version 20.0) and the significance level set at p < 0.05.

Discussion: This trial aims to analyze the application of rESWT for the management of spasticity after stroke via appropriate assessments. We hypothesized that after receiving active rESWT, patients would show greater improvement of upper limb muscles compared with patients within the sham-placebo group. The rESWT would be an alternative to traditional methods, and the results of this study may provide support for the further study of potential mechanisms.

Clinical Trial Registration:www.chictr.org.cn, identifier: ChiCTR1800016144.

Implementing technology enhanced real-time action observation therapy in persons with chronic stroke: A pilot study

This pilot study examined a novel technology-enhanced real-time action observation therapy (TERTAOT) of symmetrical bilateral movements in survivors of chronic stroke regardless of their ability to move their paretic limb(s). The TERTAOT used a Kinect XBox One to project mirror images of non-paretic limbs as participants performed symmetrical bilateral motor tasks involving whole-body movements in sitting or standing. The participants received eight weeks of treatment consisting of 30-minutes of conventional physical therapy (balance training, gait training, neuromuscular reeducation, and generalized strength training) and 30-minutes of the TERTAOT protocol per session (three sessions per week for a total of 24 sessions). Ten Meter Walk Test (10MWT), Five Times Sit-to-Stand (5TSTS), Timed Up and Go (TUG), Motor Activity Log - Quality of Movement (QOM) and Amount of Use (AOU) were administered at baseline (pretest), 4 weeks (posttest 1) and 8 weeks (posttest 2) post-TERTAOT, and 3 months after TERTAOT ended (retention). A General Linear Model Repeated Measures (parametric test) or the Friedman Test (non-parametric test) was used to compare outcomes across time points, depending on the normality of data distribution. Bonferroni post-hoc corrections were applied. Seventeen participants completed >80% of TERTAOT sessions without adverse events. The effect of time was significant for 10MWT (p = .001), 5TSTS (p = .001), TUG (p = .005), QOM (p = .001), and AOU (p = .017). TERTAOT may be feasible to be implemented in an outpatient setting. Improvements in functional outcomes including gait, balance, and use of upper limbs were observed after eight weeks of conventional therapy and TERTAOT protocol in survivors of chronic stroke.

In-Bed Sensorimotor Rehabilitation in Early and Late Subacute Stroke Using a Wearable Elbow Robot: A Pilot Study

Objects: To evaluate the feasibility and effectiveness of in-bed wearable elbow robot training for motor recovery in patients with early and late subacute stroke. Methods: Eleven in-patient stroke survivors (male/female: 7/4, age: 50.7 ± 10.6 years, post-stroke duration: 2.6 ± 1.9 months) received 15 sessions of training over about 4 weeks of hospital stay. During each hourly training, participants received passive stretching and active movement training with motivating games using a wearable elbow rehabilitation robot. Isometric maximum muscle strength (MVC) of elbow flexors and extensors was evaluated using the robot at the beginning and end of each training session. Clinical measures including Fugl-Meyer Assessment of upper extremity (FMA-UE), Motricity Index (MI) for upper extremities, Modified Ashworth Scale (MAS) were measured at baseline, after the 4-week training program, and at a 1-month follow-up. The muscle strength recovery curve over the training period was characterized as a logarithmic learning curve with three parameters (i.e., initial muscle strength, rate of improvement, and number of the training session). Results: At the baseline, participants had moderate to severe upper limb motor impairment {FMA-UE [median (interquartile range)]: 28 (18-45)} and mild spasticity in elbow flexors {MAS [median (interquartile range)]: 0 (0-1)}. After about 4 weeks of training, significant improvements were observed in FMA-UE (p = 0.003) and MI (p = 0.005), and the improvements were sustained at the follow-up. The elbow flexors MVC significantly increased by 1.93 Nm (95% CI: 0.93 to 2.93 Nm, p = 0.017) and the elbow extensor MVC increased by 0.68 Nm (95% CI: 0.05 to 1.98 Nm, p = 0.036). Muscle strength recovery curve showed that patients with severe upper limb motor impairment had a greater improvement rate in elbow flexor strength than those with moderate motor impairment. Conclusion: In-bed wearable elbow robotic rehabilitation is feasible and effective in improving biomechanical and clinical outcomes for early and late subacute stroke in-patients. Results from the pilot study suggested that patients with severe upper limb motor impairment may benefit more from the robot training compared to those with moderate impairment.

Long-Term Efficacy of Extracorporeal Shock Wave Therapy on Lower Limb Post-Stroke Spasticity: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The purpose of this systematic review and meta-analysis is to evaluate the long-term efficacy of Extracorporeal Shock Wave Therapy (ESWT) on reducing lower limb post-stroke spasticity in adults. A systematic electronic search of PubMed/ MEDLINE, Physiotherapy Evidence Database (PEDro), Scopus, Ovid MEDLINE(R), and search engine of Google Scholar was performed. Publications that ranged from January 2010 to August 2020, published in English, French, Spanish, Portuguese, and Italian language and available as full texts were eligible for inclusion and they were searched without any restrictions of country. The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and followed the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions. Two authors screened the references, extracted data, and assessed the risk of bias. The primary outcome was spasticity grade mainly assessed by the Modified Ashworth Scale (MAS). Secondary outcomes were passive range of motion (PROM), pain intensity, electrophysiological parameters, gait assessment, and adverse events. A total of seven recent randomized controlled trials (RCTs) were included in the systematic review and meta-analysis, and a beneficial effect on spasticity was found. The high level of evidence presented in this paper showed that ESWT ameliorates spasticity considering the parameters: MAS: standardized mean difference (SMD) = 0.53; 95% confidence interval (95% CI): (0.07-0.99); Modified Tardieu Scale (MTS): SMD = 0.56; 95% CI: (0.01-1.12); Visual Analogue Scale (VAS): SMD = 0.35; 95% CI: (-0.21-0.91); PROM: SMD = 0.69; 95% CI: (0.20-1.19). ESWT presented long-term efficacy on lower limb post-stroke spasticity, reduced pain intensity, and increased range of motion. The effect of this novel and non-invasive therapy was significant and the intervention did not present adverse events, proving a satisfactory safety profile.

Self-rehabilitation combined with botulinum toxin to improve arm function in people with chronic stroke. A randomized controlled trial

BACKGROUND

Botulinum toxin injection (BTI) reduces muscle hyperactivity, but its effect on active upper-limb function is limited. Intensive rehabilitation could optimize the effects; however, outpatient post-stroke rehabilitation is usually not intensive. One solution could be self-rehabilitation.

OBJECTIVES

The aim of this randomized controlled trial was to determine the effect of a self-rehabilitation program combined with BTI on upper-limb function in individuals with chronic hemiparesis.

METHODS

In total, 33 outpatients were randomly allocated to receive BTI+self-rehabilitation (R group: n=17) or BTI alone (C group: n=16). Outcomes evaluated just before the BTI and 4 weeks later included the Wolf Motor Function Test (WMFT time: primary outcome), Action Research Arm Test, fatigue and quality of life.

RESULTS

Change in WMFT did not differ between groups at 4 weeks (WMFT time: -14% for R group, -4% for C group. WFMT score: +12% for R group, 0% in C group). WFMT time and score improved significantly in the R group only (-14%, P=0.01, and +12%, P=0.02). In addition, the proportion of patients with improved WMFT time and score was higher in the R than C group (R group: 71% improved score, 77% improved time; C group: 43% improved score, 50% improved time). Also, passive range of shoulder flexion (P=0.03) and wrist extension (P=0.01) improved only in the R group. No other variables changed significantly. Compliance was excellent; average daily training time was greater than that prescribed.

CONCLUSIONS

The addition of a self-rehabilitation program to BTI did not significantly improve functional outcomes more than BTI alone; however, movement quality and speed improved only in the self-rehabilitation group. Participants in the self-rehabilitation group trained more than they were asked to, which suggests that they found the program worthwhile. These clinically relevant findings justify larger-scale studies of the effects of self-rehabilitation to enhance the effects of BTI.

CLINICAL TRIAL

NCT02699762.

Dry needling for the management of spasticity, pain, and range of movement in adults after stroke: A systematic review

OBJECTIVE

To summarise the available evidence about the effectiveness of deep dry needling (DN) on spasticity, pain-related outcomes, and range-of-movement (ROM) in adults after stroke.

DESIGN

A computer search of Web of Science, Scopus, Medline, Cochrane Library, Cinahl, and Physiotherapy Evidence Database (PEDro) was conducted. A hand search of the reference lists of the selected studies and other relevant publications was also undertaken. Studies were assessed by two independent reviewers and included if they complied with the following criteria: (1) participants were adults after a stroke, (2) use of DN alone or within a multimodal approach, compared to no intervention or other treatments; (3) assessment of spasticity, pain, or joint ROM as a primary or secondary outcome. We included randomised controlled trials (RCTs), case series, and case reports. Data were extracted using a standardised protocol. The methodological quality of the studies was assessed with the Checklist for Measuring quality.

RESULTS

A total of sixteen studies, 7 of which were RCTs, were selected. All studies generally reported an improvement of spasticity level, pain intensity, and ROM after the use of DN, alone or combined with other interventions, in stroke survivors.

CONCLUSION

The management of adults after stroke with DN may impact positively on spasticity, pain, and ROM. However, there was significant heterogeneity across trials in terms of sample size, control groups, treated muscles, and outcome measures, and a meta-analysis was not feasible. Further research should include proper blinding, sham placebo DN as control intervention, and investigate long-term effects.

Effectiveness of interventions to improve hand motor function in individuals with moderate to severe stroke: a systematic review protocol

INTRODUCTION

The human hand is extremely involved in our daily lives. However, the rehabilitation of hand function after stroke can be rather difficult due to the complexity of hand structure and function, as well as neural basis that supports hand function. Specifically, in individuals with moderate to severe impairment following a stroke, previous evidence for effective treatments that recover hand function in this population is limited, and thus has never been reviewed. With the progress of rehabilitation science and tool development, results from more and more clinical trials are now available, thereby justifying conducting a systematic review.

METHODS AND ANALYSIS

This systematic review protocol is consistent with the methodology recommended by the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and the Cochrane handbook for systematic reviews of interventions. Electronic searches will be carried out in the PubMed, CINAHL, Physiotherapy Evidence Database and Cochrane Library databases, along with manual searches in the reference lists from included studies and published systematic reviews. The date range parameters used in searching all databases is between January 1999 and January 2019. Randomised controlled trials (RCTs) published in English, with the primary outcome focusing on hand motor function, will be included. Two reviewers will screen all retrieved titles, abstracts and full texts, perform the evaluation of the risk bias and extract all data independently. The risk of bias of the included RCTs will be evaluated by the Cochrane Collaboration's tool. A qualitative synthesis will be provided in text and table, to summarise the main results of the selected publications. A meta-analysis will be considered if there is sufficient homogeneity across outcomes. The quality of the included publications will be evaluated by the Grading of Recommendations Assessment, Development and Evaluation system from the Cochrane Handbook for Systematic Reviews of Interventions.

ETHICS AND DISSEMINATION

No ethical approval is needed, and the results of this review will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

CRD42019128285.

Effectiveness of neuromuscular electrical stimulation combined with rehabilitation training for treatment of post-stroke limb spasticity

BACKGROUND

This study aims to systematically explore the effectiveness of neuromuscular electrical stimulation (NMES) combined with rehabilitation training (RT) for the treatment of post-stroke limb spasticity (PSLS).

METHODS

We will search Cochrane Library, MEDILINE, EMBASE, CINAHL, AMED, PsycINFO, WOS, Scopus, OpenGrey, and 4 Chinese databases from inception to the present without language restrictions. We will only consider randomized controlled trial on assessing the effectiveness and safety of NMES combined with RT for the treatment of PSLS. All included randomized controlled trials will be assessed using Cochrane risk of bias tool. Two researchers will independently perform study selection, risk of bias assessment, and data extraction, respectively. Any disagreements will be solved by a third researcher through discussion.

RESULTS

Primary outcome is limb spasticity status. Secondary outcomes comprise of limb function, quality of life, and adverse events.

CONCLUSION

This study will summarize the latest evidence of NMES combined with RT for the treatment of patients with PSLS.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019138900.