Effect of extracorporeal shock wave therapy on gait pattern in hemiplegic cerebral palsy: a randomized controlled trial

Effectiveness of Extracorporeal Shock Wave Therapy after Botulinum Toxin Injection for Post-Stroke Upper Extremity Spasticity: A Randomized Controlled Study

Post-stroke spasticity is a common complication that limits the functional performance of patients. Botulinum toxin (BTx) is an effective treatment for spasticity. Numerous researchers have applied extracorporeal shock wave therapy (ESWT) to address post-stroke spasticity, yielding positive clinical outcomes. We aimed to clarify the add-on effects of ESWT on BTx therapy for spasticity in patients with post-stroke. Sixteen eligible patients with upper extremity spasticity after stroke were recruited for this study. They were randomized to either a BTx with focused ESWT treatment group or a BTx alone group. Spasticity, measured using the modified Ashworth score (MAS) and modified Tardieu scale (MTS), showed statistically significant improvements in the elbow and wrist flexor muscles in both BTx + ESWT group and BTx alone groups. However, no significant differences were observed between the two groups with time flow. The BTx + ESWT group showed significantly decreased MAS of the finger flexors at follow-up and increased R1 (MTS) of the finger flexors at 3 weeks after treatment, which was not observed in the BTx alone group. This is the first study to identify the add-on effect of ESWT on BTx injections to improve post-stroke upper limb spasticity.

Effectiveness of Extracorporeal Shock Wave Therapy in Treatment of Spasticity of Different Aetiologies: A Systematic Review and Meta-Analysis

Background: Spasticity is a motor disorder characterised by exaggerated movements of the tendons and accompanied by hyperreflexia and hypertonia. Extracorporeal shock wave therapy (ESWT) is used as a treatment for spasticity, although more evidence is needed on the effectiveness of this therapy in the treatment of spasticity. Therefore, the aim of this study was to assess the effectiveness ESWT in the treatment of upper and lower limbs spasticity in both children and adults through different aetiologies. Methods: A systematic search was performed in different databases from inception to December 2023. Random-effects meta-analysis was used to estimate the efficacy of ESWT on spasticity using the Modified Ashworth Scale. Results: Sixteen studies were included in the systematic review and meta-analysis. The effect of ESWT on spasticity measured with the Modified Ashworth Scale shows a significant decrease in spasticity in the upper limbs and in the lower limbs in adults with chronic stroke and in children with cerebral palsy, is more effective immediately after application, and maintains its effect up to 12 weeks post treatment. Conclusions: These findings are important for clinical practice since they show evidence that ESWT is effective in reducing spasticity in both children and adults.

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 .

Clinical efficacy of ultrasound-guided stellate ganglion block combined with extracorporeal shock wave therapy on limb spasticity in patients with ischemic stroke

INTRODUCTION

To observe the clinical efficacy of ultrasound-guided stellate ganglion block (SGB) + extracorporeal shock wave therapy (ESWT) for limb spasticity in patients with ischemic stroke.

METHODS

A total of 60 patients with post-stroke limb spasticity in our hospital were selected and randomly divided into four groups (n = 15). In the control group, patients received routine rehabilitation training. Based on routine rehabilitation training, SGB group patients underwent ultrasound-guided SGB, ESWT group patients received ESWT, and SGB + ESWT group patients received ultrasound-guided SGB combined with ESWT. The total treatment course was one month. The Modified Barthel Index (MBI) score, Fugl-Meyer Assessment and upper limb rehabilitation training system were applied to evaluate the activities of daily living, upper limb motor function and upper limb performance before and after treatment. Finally, the improvement after treatment was compared among different groups.

RESULTS

After treatment, compared with the control group, the MBI score and the upper limb score based on Fugl-Meyer Assessment in the SGB, ESWT, and SGB + ESWT groups were significantly increased (P < 0.05). Furthermore, compared with the SGB and ESWT groups, SGB + ESWT exhibited a higher upper limb function score (P < 0.05), while the MBI score was not significantly different (P > 0.05). In terms of upper limb performance ability, patients in the SGB, ESWT and SGB + ESWT groups had better fitting degree, participation and exertion of exercise than those in the control group, and the SGB + ESWT group patients had the same movement trajectory as robots.

CONCLUSION

Ultrasound-guided SGB and ESWT can reduce the muscle tension of patients, alleviate spasticity, promote the motor function of the upper limb, and improve the working performance of patients. However, the effect of SGB combined with ESWT is better.

Conventional physical therapy combined with extracorporeal shock wave leads to positive effects on spasticity in stroke survivors: a prospective observational study

The study aimed to evaluate the effectiveness of radial extracorporeal shock wave therapy (rESWT) and conventional physical therapy (CPT) protocol on the gait pattern in stroke survivors through a new gait analysis technology. Fifteen (n=15) stroke survivors took part in this prospective, observational study and were assessed clinically and through an instrumented treadmill before and after rESWT and CPT. Spasticity grade 95% CI 0.93 (0.79 +/- 1.08), pain intensity 95% CI 1.60 (1.19 +/- 2.01), and clonus score decreased significantly 95% CI 1.13 (0.72 +/- 1.54). The sensorimotor function 95% CI -2.53 (-3.42 +/- 1.65), balance 95% CI -5.67 (-6.64 +/- - 4.69), and gait parameters were enhanced at the end of the program. Step length 95% CI -3.47 (-6.48 +/- 0.46) and step cycle were improved 95% CI -0.09 (-0.17 +/- -0.01), and hip 95% CI -3.90 (-6.92 +/- -0.88), knee 95% CI -2.08 (-3.84 +/- -0.32) and ankle flexion-extension 95% CI -2.08 (-6.64 +/- -4.69) were augmented. Adding the quantitative analysis to the clinical assessment, we gained easy access to track progress and obtained an individualized therapeutic approach for stroke survivors.

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.

Effects of Extracorporeal Shockwave Therapy on Functional Recovery and Circulating miR-375 and miR-382-5p after Subacute and Chronic Spinal Cord Contusion Injury in Rats

Extracorporeal shockwave therapy (ESWT) can stimulate processes to promote regeneration, including cell proliferation and modulation of inflammation. Specific miRNA expression panels have been established to define correlations with regulatory targets within these pathways. This study aims to investigate the influence of low-energy ESWT—applied within the subacute and chronic phase of SCI (spinal cord injury) on recovery in a rat spinal cord contusion model. Outcomes were evaluated by gait analysis, µCT and histological analysis of spinal cords. A panel of serum-derived miRNAs after SCI and after ESWT was investigated to identify injury-, regeneration- and treatment-associated expression patterns. Rats receiving ESWT showed significant improvement in motor function in both a subacute and a chronic experimental setting. This effect was not reflected in changes in morphology, µCT-parameters or histological markers after ESWT. Expression analysis of various miRNAs, however, revealed changes after SCI and ESWT, with increased miR-375, indicating a neuroprotective effect, and decreased miR-382-5p potentially improving neuroplasticity via its regulatory involvement with BDNF. We were able to demonstrate a functional improvement of ESWT-treated animals after SCI in a subacute and chronic setting. Furthermore, the identification of miR-375 and miR-382-5p could potentially provide new targets for therapeutic intervention in future studies.

Extracorporeal Shock Wave Therapy on Spasticity After Upper Motor Neuron Injury: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study was to evaluate the effectiveness and safety of extracorporeal shock wave therapy on spasticity after upper motor neuron injury.

DESIGN

Eight electronic databases were searched systematically from their inception to August 3, 2021, to provide robust evidence for the efficacy of extracorporeal shock wave therapy for spasticity and range of motion after upper motor neuron injury. Study screening, data extraction, risk of bias assessment, and evaluation of the certainty of evidence were performed independently by two independent reviewers. Data analysis was conducted using RevMan 5.3.5 and R 3.6.1 software.

RESULTS

Forty-two studies with 1973 patients who met the eligibility criteria were selected from articles published from 2010 to 2021, of which 34 were included in the meta-analysis. A comparison intervention revealed that extracorporeal shock wave therapy significantly decreased the Modified Ashworth Scale score and increased the passive range of motion of a joint. Regarding the safety of extracorporeal shock wave therapy, slightly adverse effects, such as skin injury, bone distortion, muscle numbness, pain, petechiae, and weakness, were reported in five studies.

CONCLUSIONS

Extracorporeal shock wave therapy may be an effective and safe treatment for spasticity after upper motor neuron injury. However, because of poor methodological qualities of the included studies and high heterogeneity, this conclusion warrants further investigation.

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CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) Determine the impact of extracorporeal shock wave therapy on spasticity after upper motor neuron injury; (2) Describe the factors that affect the efficacy of extracorporeal shock wave therapy on spasticity; and (3) Discuss the mechanism of action of extracorporeal shock wave therapy on spasticity.

LEVEL

Advanced.

ACCREDITATION

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Comparative Effectiveness of Botulinum Toxin Injections and Extracorporeal Shockwave Therapy for Post-Stroke Spasticity: A Systematic Review and Network Meta-Analysis

BACKGROUND

The anti-spasticity efficacy of botulinum toxin (BoNT) injection has been well established for patients with chronic stroke; however, extracorporeal shock wave therapy (ESWT), i.e. focused shockwave (FSW) and radial shockwave (RSW), has recently been applied. We aimed to investigate the comparative effectiveness of BoNT vs. ESWT in the reduction of spasticity among stroke survivors.

METHODS

PubMed, EMBASE, MEDLINE and Cochrane CENTRAL were searched from the earliest record to September 2021 for randomized controlled trials. Weighted mean differences (WMDs) on the reduction of the Modified Ashworth Scale before or at the 6th post-treatment week (short-term) and between the 7th and 12th weeks (mid-term) after the intervention were calculated. Ranking probabilities of the WMD were simulated to determine which treatment had the potential to possess the best effectiveness. inplasy.com registration: INPLASY202170018.

FINDINGS

A total of 33 studies comprising 1,930 patients were enrolled. The network meta-analysis revealed that BoNT injections, FSW and RSW were better in spasticity reduction than the control treatment(s) at the short term, with WMDs of -0.69 (95% CI, -0.87 to -0.50), -0.36 (95% CI, -0.69 to -0.03) and -0.62 (95% CI, -0.84 to -0.40), respectively. Likewise, mid-term effects of BoNT injections, FSW and RSW also revealed superiority, with WMDs of -0.44 (95% CI, -0.62 to -0.26), -0.74 (95% CI, -1.26 to -0.23) and -0.79 (95% CI, -1.07 to -0.51), respectively. Ranking probability analysis revealed that RSW had the highest probability of being the best treatment for spasticity reduction at the short-term (62.2%) and mid-term (72.3%) periods during the follow up.

INTERPRETATION

BoNT injections and ESWT are effective in alleviating post-stroke spasticity at the mid-term. The effectiveness of ESWT was comparable to BoNT injections, and RSW had the potential to be the best treatment for spasticity reduction among the three treatment options. More prospective trials incorporating head-to-head comparisons of BoNT injections vs. ESWT are needed to validate the role of ESWT in reducing post-stroke spasticity.

FUNDING

The current research project was supported by (1) National Taiwan University Hospital, Bei-Hu Branch; (2) Ministry of Science and Technology (MOST 106-2314-B-002-180-MY3 and 109-2314-B-002-114-MY3); 3) Taiwan Society of Ultrasound in Medicine.

Effect of functional electrical stimulation versus TheraTogs on gait and balance in children with hemiplegic cerebral palsy: a randomized controlled trial

Background

Children with cerebral palsy exhibit postural restrictions and gait problems as a result of both primary and secondary brain damage impairments. One of the main goals of cerebral palsy rehabilitation is to improve gait and balance. As a result, the purpose of this study was to compare the effects of FES and TheraTogs on gait and balance in children with hemiplegic CP. A randomized controlled study was conducted on 30 children with hemiplegic CP (18 boys and 12 girls) between the ages of 8 and 12 years. The children were divided into two equal groups. In addition to the traditional physical treatment program, the FES group received functional electrical stimulation (pulse width 300 μs, frequency 33 Hz, 2 h/day, 3 days/week, 3 months). The TheraTogs group, on the other hand, received the TheraTogs strapping system as well as the same traditional program for the same time period. The 3-D motion analysis and the Biodex balance system were used to analyze gait parameters and postural stability at baseline and 3 months after the intervention.

Results

When comparing the mean values of the gait parameters and postural stability indices of children in both groups before and after treatment, a significant improvement was reported. Furthermore, the FES group showed a greater improvement in all of the measured outcomes (P < 0.001).

Conclusion

Functional electrical stimulation improves gait pattern and postural stability in children with hemiplegic cerebral palsy significantly more than TheraTogs strapping systems.

Clinical trial registration

This study was registered in the ClinicalTrial.gov PRS (NCT05020834).

Effectiveness of Extracorporeal Shock Wave Therapy on Postural Control and Balance in Children With Unilateral Cerebral Palsy: A Randomized Controlled Trial

The aim of this study was to investigate the effects of Extracorporeal Shock Wave Therapy (ESWT) applied to paraspinal muscles on balance and postural control in children with unilateral Cerebral Palsy (CP). A total of 32 children with unilateral CP were included in the study. The children participated in a one-session control to evaluate their reactions to ESWT before randomly assigning them into experimental and control groups. We evaluated children twice: before and after the treatment. We used the Trunk Control Measurement Scale, Trunk Impairment Scale, Pediatric Balance Scale (PBS), and Timed Up and Go (TUG) test in these assessments. Following the pre-test session, we applied Neuro-Developmental Treatment (NDT) programs to both groups at the rate of twice per week for eight weeks; additionally, we applied ESWT only to the experimental group at the rate of twice a week for eight weeks. While there were trends toward increased trunk control skills, PBS scores and TUG test performances from pre- to post-testing in both groups, these improvements were only statistically significant in the experimental group (p < 0.05). We conclude that for children with unilateral CP, ESWT applied to paraspinal muscles has significant additive value when combined with NDT to improve postural control and balance.

Efficacy of axial TheraTogs on gait pattern in children with dyskinetic cerebral palsy: a randomized controlled trial

Background

TheraTogs promotes proprioceptive sense of a child with cerebral palsy and improves abnormal muscle tone, posture alignment, balance, and gait. Therefore, the aim of this study was to investigate the efficacy of TheraTogs orthotic undergarment on gait pattern in children with dyskinetic cerebral palsy. Thirty children with dyskinetic cerebral palsy were selected for this randomized controlled study. They were randomly assigned to (1) an experimental group that received TheraTogs orthotic undergarment (12 h/day, 3 days/week) plus traditional physical therapy for 3 successive months and (2) a control group that received only traditional physical therapy program for the same time period. Gait parameters were measured at baseline and after 3 months of intervention using Pro-Reflex motion analysis.

Results

Children in both groups showed significant improvements in the gait parameters (P < 0.05), with significantly greater improvements in the experimental group than in the control group.

Conclusions

The use of TheraTogs may have a positive effect to improve gait pattern in children with dyskinetic cerebral palsy.

Trial registration

This trial was registered in the ClinicalTrial.gov PRS (NCT03037697).

Does extracorporeal shock wave therapy decrease spasticity of ankle plantar flexor muscles in patients with stroke: A randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of radial extracorporeal shock wave therapy on ankle flexor spasticity in stroke survivors and to reveal changes in the fibroelastic components of muscle.

DESIGN

Randomized controlled trial.

SETTING

Inpatient neuro-rehabilitation clinic of a university hospital.

PARTICIPANTS

Stroke patients with ankle flexor spasticity.

INTERVENTIONS

Patients were randomized to three groups; radial extracorporeal shock wave therapy, sham, or control. Active and sham therapy were administered two sessions/week for two weeks. All patients received conventional rehabilitation.

MAIN MEASURES

The primary outcome was Modified Ashworth Scale. Secondary outcomes were the Tardieu Scale and elastic properties of plantar flexor muscles assessed by elastography (strain index). All assessments were performed before, immediately after the treatment, and four weeks later at follow-up.

RESULTS

Fifty-one participants were enrolled (active therapy n = 17, sham n = 17, control n = 17). Modified Ashworth scores showed a significant decrease in the active therapy group (from 2.47 ± 0.72 to 1.41 ± 0.62) compared to sham (from 2.19 ± 1.05 to 2.06 ± 1.12) and control (from 2.06 ± 0.85 to 2.00 ± 0.73) groups immediately after the treatment (P < 0.001). Tardieu results were also in concordance (P < 0.001), however this effect was not preserved at follow-up. Elastic properties of the ankle flexors were improved in all groups at both assessments after the therapy showing significant decreases in strain index (P < 0.001). However, there was no difference among the groups in terms of improvement in elastography.

CONCLUSION

Radial extracorporeal shock wave therapy has short-term anti-spastic effects on ankle flexor muscles when used as an adjunct to conventional rehabilitation.

Intrathecal baclofen, selective dorsal rhizotomy, and extracorporeal shockwave therapy for the treatment of spasticity in cerebral palsy: a systematic review

Cerebral palsy (CP) is a chronic congenital disorder as the result of abnormal brain development. Children suffering from CP often battle debilitating chronic spasticity, which has been the focus of recent academic literature. In this systematic review, the authors aim to update the current neuromodulation procedures for the treatment of spasticity associated with CP in all age groups. A systematic review following was conducted using PubMed from inception to 2020. After initial title and abstract screening, 489 articles were identified, and 48 studies met the inclusion criteria for this review. In total, a majority of the published articles of treatments for CP were reporting the use of selective dorsal rhizotomy (SDR) (54%), and the remainder were of intrathecal baclofen (ITB) pumps (29%) and extracorporeal shockwave therapy (ESWT) (17%). Each method was found to have improvement of spasticity at a rate that achieved statistical significance. ITB pump therapy is an all-encompassing method of treating spasticity in children from CP, as it allows for a less invasive treatment that can be titrated to individual patient needs; however, its disadvantages include its long-term maintenance requirements. SDR appears to be an effective method for permanent spasticity relief in young patients. ESWT is a more recent and innovative technique for offering relief of spasticity while being minimally invasiveness. Further studies are needed to establish optimal frequencies and sites of application for ESWT.

Effect of shockwave therapy on kinematic gait parameters in children with spastic diplegic cerebral palsy

Background/aims

Extracorporeal shockwave therapy might be a considerable substitute to present treatment alternatives to reduce spasticity and improve range of motion in patients with cerebral palsy, which could improve their quality of life and gait pattern. The aim of this study was to investigate the effect of extracorporeal shockwave therapy on gait parameters in children with spastic diplegic cerebral palsy.

Methods

A total of 34 children with spastic diplegia (19 boys and 15 girls) participated in the study. Their ages ranged from 5–7 years (mean 5.8 ± standard deviation 1.2 years). They were randomly assigned into two equal groups, the study and the control group. Both groups received the traditional physiotherapy programme, three sessions a week consecutively for 3 months. Children in the study group also received extracorporeal shockwave therapy one session a week for 3 months.

Results

There was a significant improvement of spasticity, step length and stride width in the control group (P=0.017, 0.015, 0.033 respectively). Walking speed did not show a significant change in the control group (P=0.1). In the study group, there was a significant improvement in spasticity, stride length, stride width, and walking speed (P=0.0001, 0.005, 0.029, 0.014 respectively). Comparing the gained improvement in the study and the control group, the results showed that the improvement in the study group significantly exceeded that of the control group in spasticity, stride length, stride width and walking speed (P=0.0003, 0.011, 0.043, 0.002 respectively).

Conclusions

Extracorporeal shockwave therapy is effective in reducing spasticity and improving gait patterns in children with spastic diplegia cerebral palsy.

Management of Muscle Spasticity in Children with Cerebral Palsy by Means of Extracorporeal Shockwave Therapy: A Systematic Review of the Literature

The purpose of this systematic review was to investigate the effectiveness of extracorporeal shockwave therapy for the management of muscle spasticity in children with cerebral palsy. An electronic database search was performed to identify studies relevant to the research question. Assessment of the quality of evidence in all relevant studies was performed with the help of the Oxford Center for Evidence-based Medicine guide. Four studies met our inclusion criteria for review: one was a low-quality randomized controlled clinical trial, two were individual case-control studies and one was a case series study. Reduction in muscle stiffness and improvement in joint range of motion were the outcomes in all of the selected studies that used extracorporeal shockwave therapy. However, considering the limited evidence provided by these studies, further research is needed to support the use of extracorporeal shockwave therapy in the management of muscle spasticity in children with cerebral palsy.

Effectiveness of Shock Wave Therapy as a Treatment for Spasticity: A Systematic Review

BACKGROUND

The purpose of this study was to collect and analyse the available scientific evidence on the effectiveness of shock wave therapy as a treatment for spasticity.

METHODS

the search was performed in the following databases: PubMed, PEDro, Cochrane, Embase, and the Virtual Health Library. All publications from November 2009 to November 2019 were selected that included a sample of patients with spasticity and prior suspension of botulinum toxin, to whom shock wave therapy was applied. The methodological quality of the articles was evaluated using the Jadad scale and the pyramid of quality of scientific evidence.

RESULTS

25 studies involving 866 participants with spasticity were selected. The results obtained suggest that shock wave therapy appears to be effective in reducing spasticity levels irrespective of the age of the participants, the type of injury, and the tool used to measure the effect.

CONCLUSIONS

shock wave therapy reports evidence of improvement in motor function, motor impairment, pain, and functional independence, applied independently of botulinum toxin. However, due to the heterogeneity of the protocols, there is no optimum protocol for its application, and it would be appropriate to gain more high-quality scientific evidence through primary studies.

Effects of acupuncture treatment on motor function in patients with subacute hemorrhagic stroke: A randomized controlled study

OBJECTIVE

The aim of this study was to evaluate the additional effects of acupuncture treatment on motor function in patients with subacute hemorrhagic stroke.

DESIGN

One hundred and thirty-four patients with subacute hemorrhagic stroke were randomized to receive acupuncture treatment plus conventional treatment (treatment group) or conventional treatment only (control group). Acupuncture treatments were given in 24 sessions over 4 weeks, with 3-month follow-up period. Blinded evaluation was based on Fugl-Meyer Assessment, Barthel Index with an intention-to-treat analysis. For those patients who were able to walk, a three-dimensional gait analysis system was employed to objectively record spatiotemporal and kinematic parameters.

RESULTS

Compared with control group, the treatment group showed a significantly greater over-time improvement in total Fugl-Meyer, lower-limb Fugl-Meyer, but not in upper-limb Fugl-Meyer and Barthel Index. The spatiotemporal parameters of velocity, step length, cadence, step width all showed significant difference between the 2 groups. The velocity in treatment group decreased unexpectedly at day 14, then increased sharply and overcame control group at day 28. The treatment group also showed a significantly greater increase in peak circumduction, peak hip hiking, hip range of motion, knee range of motion and a tendency for the ankle range of motion.

CONCLUSIONS

Acupuncture may promote the motor function recovery of hemorrhagic stroke patients in subacute phase mainly by enhancing the lower limb ability. It probably diminishes the compensation strategies earlier to correct the abnormal gait pattern. Although this adjustment may result in a compromise in the improvement of gait velocity temporarily, patients would benefit from it in a long run.

Shock Waves as a Treatment Modality for Spasticity Reduction and Recovery Improvement in Post-Stroke Adults - Current Evidence and Qualitative Systematic Review

Purpose

This systematic review examines intervention studies using extracorporeal shock wave therapy (ESWT) application in post-stroke muscle spasticity with particular emphasis on the comparison of two different types of radial (rESWT) and focused shock waves (fESWT).

Methods

PubMed, PEDro, Scopus, and EBSCOhost databases were systematically searched. Studies published between the years 2000 and 2019 in the impact factor journals and available in the English full-text version were eligible for inclusion. All qualified articles were classified in terms of their scientific reliability and methodological quality using the PEDro criteria. The PRISMA guidelines were followed and the registration on the PROSPERO database was done.

Results

A total of 17 articles were reviewed of a total sample of 303 patients (age: 57.87±10.45 years and duration of stroke: 40.49±25.63 months) who were treated with ESWT. Recent data confirm both a subjective (spasticity, pain, and functioning) and objective (range of motion, postural control, muscular endurance, muscle tone, and muscle elasticity) improvements for post-stroke spasticity. The mean difference showing clinical improvement was: ∆=34.45% of grade for fESWT and ∆=34.97% for rESWT that gives a slightly better effect of rESWT (∆=0.52%) for spasticity (p<0.05), and ∆=38.83% of angular degrees for fESWT and ∆=32.26% for rESWT that determines the more beneficial effect of fESWT (∆=6.57%) for range of motion (p<0.05), and ∆=18.32% for fESWT and ∆=22.27% for rESWT that gives a slightly better effect of rESWT (∆=3.95%) for alpha motor neuron excitability (p<0.05). The mean PEDro score was 4.70±2.5 points for fESWT and 5.71±2.21 points for rESWT, thus an overall quality of evidence grade of moderate (“fair” for fESWT and “good” for rESWT). Three studies in fESWT and four in rESWT obtained Sackett’s grading system’s highest Level 1 of evidence.

Conclusion

The studies affirm the effectiveness of ESWT in reducing muscle spasticity and improving motor recovery after stroke.

Effect of extracorporeal shockwave therapy on muscle spasticity in patients with cerebral palsy: meta-analysis and systematic review

INTRODUCTION

Recently, clinical trials have been performed to evaluate the efficacy of extracorporeal shockwave therapy (ESWT) in patients with cerebral palsy (CP). However, various studies adopted different clinical scales, making it insufficient to draw a definite conclusion about the efficacy of ESWT in reducing spasticity after cerebral palsy. The purpose of this meta-analysis was to assess the effects of ESWT on reducing spasticity after applying ESWT in patients with CP.

EVIDENCE ACQUISITION

In accordance with the PRISMA statement, authors searched MEDLINE, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials and Scopus from their inception dates through December 11th 2018. We included randomised controlled trials in any language that using ESWT for the purpose of ameliorating spasticity in patients with CP. We assessed spasticity measured by modified Ashworth Scale (MAS), range of motion (ROM) and baropodometric values as outcomes.

EVIDENCE SYNTHESIS

Two authors independently extracted and verified data. Meta-analysis was completed where possible, otherwise data were synthesised narratively. From a total of 206 articles, 16 manuscripts were selected and 5 of them were ultimately included in this meta-analysis. MAS grade as primary outcome was significantly improved after ESWT compared to that in the control group (mean difference [MD]: -0.62; 95% CI: -1.52 to -0.18). ROM after ESWT was also significantly improved compared to that in the control groups (MD: 18.01; 95% CI: 6.11 to 29.91). Baropodometric measures showed significantly increases in foot contact area during gait (SMD: 29.00; 95% CI: 11.08 to 46.92), but not significantly in peak pressure under the heel (MD: 15.12; 95% CI: -1.85 to 32.10) immediately after ESWT.

CONCLUSIONS

No serious side effects were observed in any patient after ESWT. ESWT may be a valid alternative to existing treatment options targeting spasticity diminishment and ROM improvement in CP patients to maintain healthy lifestyles and normalize spastic gait pattern. Further standardization of treatment protocols including treatment intervals and intensities needs to be established and long-term follow-up studies are needed to verify our results.

Effect of physical therapy interventions on spatiotemporal gait parameters in children with cerebral palsy: a systematic review

AIM

To investigate the effect of physical therapy interventions on spatiotemporal gait parameters in children with cerebral palsy.

METHODS

Six databases were searched: PubMed, Embase, Web of Science, Science Direct, Lilacs, and Scopus. Two independent reviewers worked on primary study selection based on titles, abstracts, and full text reading. We included randomized controlled trials investigating the role of therapeutic interventions on gait kinematics in children with cerebral palsy. The independent reviewers extracted information about study population, intervention type, main outcomes, and methodological quality according to PEDro Scale. The body of evidence was synthesized through GRADE.

RESULTS

Twenty-six studies were found addressing the following treatment categories: functional electrical stimulation, transcranial stimulation, gait training, muscular strengthening, vibratory platform training, and serial casting. A moderate level of evidence was identified for vibratory platform training, gait training, transcranial stimulation (positive effect), and isolated muscle strengthening (negative effect) in relation to gait velocity. Electrical stimulation showed a moderate level of evidence regarding stride length. The evidence for other outcomes was of low or very low quality.

CONCLUSION

Vibratory platform, gait training, electrical stimulation, and transcranial stimulation were effective to improve spatiotemporal gait parameters, especially velocity in children with cerebral palsy.Implication for rehabilitationImprovement and maintenance of gait of children with cerebral palsy is a great challenge to rehabilitation professionalsVibratory platform, gait training, electrical stimulation, and transcranial stimulation improve gait parameters.Isolated strength training was not effective to improve gait parameters in Cerebral Palsy.Long-term effect of most techniques on gait parameters until unclear.

Effects of Radial Shockwave Therapy and Orthotics Applied with Physical Training on Motor Function of Children with Spastic Diplegia: A Randomized Trial

Aims: To explore the effects of radial shockwave therapy (rSWT) combined with standard orthotic management (SOM) on spasticity, functional balance, and gait in children with spastic diplegia. Methods: Sixty children with diplegia were allocated to group I (rSWT, n = 20), group II (SOM, n = 20), or group III (rSWT + SOM, n = 20). All groups received a physical training program 3 times/week for 3 months. Assessments were completed before and immediately after the intervention and included the Hoffman reflex/Myogenic response ratio of the soleus muscle (H/M ratio), balance, and gait. Results: At a significance criterion adjusted to p ˂ .006, there were no between-group differences in balance or gait (p > .006). The rSWT + SOM group had a greater improvement of H/M ratio compared to rSWT alone (p = .001) but not to SOM alone (p = .04). Within-group analysis demonstrated significant improvement of all variables for rSWT + SOM (p ˂ .006). The H/M ratio and knee midstance angle exhibited clinically meaningful improvement for rSWT alone (p ˂ .006). No significant changes were observed in any variable for SOM alone (p > .006). Conclusions: Radial shockwave and orthotics together, or either of them along with physical training did not differ in improving balance or gait. Their combination was more effective than rSWT alone in reducing spasticity.

Extracorporeal Shock Waves Versus Botulinum Toxin Type A in the Treatment of Poststroke Upper Limb Spasticity: A Randomized Noninferiority Trial

OBJECTIVE

To investigate whether extracorporeal shock wave therapy (ESWT) is noninferior to botulinum toxin type A (BoNT-A) for the treatment of poststroke upper limb spasticity.

DESIGN

Randomized noninferiority trial.

SETTING

Referral medical center.

PARTICIPANTS

Patients (N=42) with chronic stroke (28 men; mean age, 61.0±10.6y).

INTERVENTIONS

Patients received either ESWT or BoNT-A. During the study period, all patients continued their regular rehabilitation.

MAIN OUTCOME MEASURES

Assessments were performed at baseline and at 1, 4, and 8 weeks after the intervention. The primary outcome was the change from baseline of the modified Ashworth scale (MAS) score of the wrist flexors at week 4. Secondary outcomes included the change of the MAS scores, Tardieu angles of the wrist and elbow flexors, wrist and elbow passive range of motion (PROM), and upper extremity Fugl-Meyer Assessment (UE-FMA) score during the study period, as well as the treatment response rate.

RESULTS

The primary outcome result in the ESWT group (-0.80±0.41) was similar to that in the BoNT-A group (-0.90±0.44), with a higher confidence limit (0.4) for the difference between groups within the prespecified margin of 0.5, indicating the noninferiority of ESWT to BoNT-A. The response rate was not significantly different between the 2 groups. Both groups showed significant improvement in secondary outcomes relative to baseline; however, the ESWT group yielded greater improvement in wrist and elbow PROM and UE-FMA score.

CONCLUSION

Our results suggest that ESWT is a noninferior treatment alternative to BoNT-A for poststroke upper limb spasticity. ESWT and BoNT-A caused similar reduction in spasticity of the wrist and elbow flexors; however, ESWT yielded greater improvement in wrist and elbow PROM and UE-FMA score.

Immediate effect of scalp acupuncture on the gait of patients with subacute intracerebral haemorrhage analysed by three-dimensional motion: secondary analysis of a randomised controlled trial

OBJECTIVE

To investigate the immediate effect of scalp acupuncture on walking pattern, using three-dimensional gait analysis (3D-GA), among patients in the subacute stage of intracerebral haemorrhage (ICH).

METHODS

A subset of 30 patients with subacute ICH participating in a recently published randomised controlled trial who were able to walk independently were assessed by 3D-GA before and immediately after scalp acupuncture treatment (treatment group) or no intervention (control group) and the results presented here as a secondary analysis. The acupuncture manipulation was repeated three times with an interval of 5 min. Spatiotemporal and kinematic parameters during walking were collected and analysed using a 3D motion analysis system.

RESULTS

After treatment, there were significant differences between the treatment and control groups in the spatiotemporal parameters of step length, velocity and cadence (p<0.05) and double-limb support. No significant difference was found in step width. When kinematic parameters were evaluated, the treatment group showed a significantly decreased peak pelvic anterior tilt angle and an increased hip extension angle after scalp acupuncture treatment, whereas the control group demonstrated no temporal changes. There were no significant changes in any other kinematic parameters in either group.

CONCLUSIONS

As the first exploratory study to investigate the effect of the scalp acupuncture on gait performance in patients with subacute ICH, this secondary analysis of a recent randomised trial suggested an immediate effect of treatment on spatiotemporal parameters. Improvement in gait pattern may be associated with a decreased anterior tilt of the pelvis and augmented hip joint motion during walking.

TRIAL REGISTRATION NUMBER

ChiCTR-TRC-08000225; Post-results.

Effects of Antigravity Treadmill Training on Gait, Balance, and Fall Risk in Children With Diplegic Cerebral Palsy

OBJECTIVE

The aim of this study was to investigate the effects of antigravity treadmill training on gait, balance, and fall risk in children with diplegic cerebral palsy.

DESIGN

Thirty children with diplegic cerebral palsy were selected for this randomized controlled study. They were randomly assigned to (1) an experimental group that received antigravity treadmill training (20 mins/d, 3 d/wk) together with traditional physical therapy for 3 successive mos and (2) a control group that received only traditional physical therapy program for the same period. Outcomes included selected gait parameters, postural stability, and fall risk. Outcomes were measured at baseline and after 3 mos of intervention.

RESULTS

Children in both groups showed significant improvements in the mean values of all measured variables (P < 0.05), with significantly greater improvements in the experimental group than the control group. The posttreatment gait parameters (i.e., velocity, stride length, cadence, and percent of time spent in double-limb support) were 0.74 m/sec, 119 steps/min, 0.75 m/sec, 0.65 sec, and 55.9% as well as 0.5 m, 125 steps/min, 0.6 m/sec, 0.49 sec, and 50.4% for the experimental and control group, respectively.

CONCLUSIONS

Antigravity treadmill training may be a useful tool for improving gait parameters, balance, and fall risk in children with diplegic cerebral palsy.

Sonographic and clinical effects of botulinum toxin Type A combined with extracorporeal shock wave therapy on spastic muscles of children with cerebral palsy

OBJECTIVE

The aim of this study was to compare the combined sonographic and clinical effects of botulinum toxin type A (BoNT-A) and extracorporeal shock wave therapy (ESWT) versus BoNT-A alone in children with cerebral palsy.

METHODS

Ten children with spastic cerebral palsy were randomly assigned to one of two groups. Group 1 received BoNT-A injection into the spastic muscles of the affected limbs plus three ESWT sessions. Group 2 received BoNT-A alone. Assessment was performed before and 1 month after injection. Sonographic outcomes were injected muscles echo intensity and their hardness percentage, and clinical outcomes the modified Ashworth scale and the Tardieu scale.

RESULTS

At 1-month evaluation, significant differences in the injected muscles percentage of hardness (P = 0.021) and the modified Ashworth scale (P = 0.001) were found between groups.

CONCLUSIONS

Our results support the hypothesis that the combined effects of BoNT-A and ESWT derive from their respective action on neurological and non-neural rheological components in spastic muscles.

The Effect of Radial Extracorporeal Shock Wave Stimulation on Upper Limb Spasticity in Chronic Stroke Patients: A Single-Blind, Randomized, Placebo-Controlled Study

The main purpose of this study was to determine the clinical, electrophysiological and thermal effects of radial extracorporeal shock wave (rESW) stimulation on upper limb muscles affected by spasticity in patients with chronic stroke. Patients included in the study were randomly assigned into the following two groups: 30 patients stimulated with active rESW (A); and 30 patients stimulated with placebo rESW (B). All patients were analyzed using the Modified Ashworth Scale (MAS) to test the spasticity levels of the elbow (E), radio carpal (RC) and fingers (FF) joints; surface electromyography (sEMG) was performed for the resting bioelectrical activity registration of the flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU) muscles; and infrared thermal imaging (IRT) was used to assess the temperature distributions of the carpal flexor muscles (CFM). All assessments were performed at baseline (t0), immediately after rESW (t1) as well as 1 and 24 h following its finalization (t2 and t3). Patients treated with active rESW showed a statistically significant reduction in the MAS score for the RC joint at t1 and for the FF joints at t1, t2 and t3 (p < 0.05). A significant decrease in sEMG activity was observed in the FCR and FCU muscles at t1, t2 and t3 (p < 0.05); significant increases in the mean and maximum values of the IRT detection was observed using inter-group comparisons in t2 and t3 (p < 0.05). No significant alterations were observed in patients after placebo rESW stimulation (p > 0.05). Applications of rESW demonstrating positive effects at reducing the level of spastic hypertonia of the upper limb muscles in patients with chronic stroke. ESW treatments should be considered as a potential anti-spastic effect to regulate vasculature.

Extracorporeal Shock Wave Stimulation as Alternative Treatment Modality for Wrist and Fingers Spasticity in Poststroke Patients: A Prospective, Open-Label, Preliminary Clinical Trial

Objective. To evaluate the effectiveness of radial shock waves (rESW) for wrist and fingers flexors spasticity in stroke patients. Methods. Twenty patients with upper limb muscle spasticity were enrolled in the study and treated with a single session of rESW. The spasticity level of the radio carpal (RC) and finger (FF) joints was assessed using Modified Ashworth Scale (MAS). The resting bioelectrical activity of the flexor carpi radialis (FCR) and flexor carpi ulnaris (FCU) was examined using surface electromyography (sEMG). Trophic conditions were measured using infrared thermal (IRT) imaging. All measurements were conducted at baseline (t₀), immediately after rESW (t₁), and 1 (t₂) and 24 (t₃) hours following rESW. Results. Significant reduction in MAS was observed for the RC joint in t₁, as well as for the FF joints in t₁, t₂, and t₃. A significant decrease in sEMG was shown for the FCR muscle in t₁ and t₂, as well as for the FCU muscle in t₁ and t₃. Also, a significant increase in IRT value was observed in t₃ only. Conclusions. A single session of rESW could be an effective alternative treatment for reduction of limb spasticity and could lead to improvement of trophic conditions of the spastic muscles.

Effect of Radial Shock Wave Therapy on Spasticity of the Upper Limb in Patients With Chronic Stroke: A Prospective, Randomized, Single Blind, Controlled Trial

Recently, studies have reported that extracorporeal shock wave therapy (ESWT) is a safe, noninvasive, alternative treatment for spasticity. However, the effect of ESWT on spasticity cannot be determined, because most studies to date have enrolled small patient numbers and have lacked placebo-controlled groups and/or long-term follow-up. In addition, whether varying the number of ESWT sessions would affect the duration of the therapeutic effect has not been investigated in a single study. Hence, we performed a prospective, randomized, single blind, placebo-controlled study to investigate the long-term effect of radial ESWT (rESWT) in patients with poststroke spasticity and surveyed the outcome of functional activity.Sixty patients were randomized into 3 groups. Group A patients received 1 session of rESWT per week for 3 consecutive weeks; group B patients received a single session of rESWT; group C patients received one session of sham rESWT per week for 3 consecutive weeks. The primary outcome was Modified Ashworth Scale of hand and wrist, whereas the secondary outcomes were Fugl-Meyer Assessment of hand function and wrist control. Evaluations were performed before the first rESWT treatment and immediately 1, 4, 8, 12, and 16 weeks after the last session of rESWT.Compared to the control group, the significant reduction in spasticity of hand and wrist lasted at least 16 and 8 weeks in group A and B, respectively. Three sessions of rESWT had a longer-lasting effect than one session. Furthermore, the reduction in spasticity after 3 sessions of rESWT may be beneficial for hand function and wrist control and the effect was maintained for 16 and 12 weeks, respectively.rESWT may be valuable in decreasing spasticity of the hand and wrist with accompanying enhancement of wrist control and hand function in chronic stroke patients.

A Prospective Case-Control Study of Radial Extracorporeal Shock Wave Therapy for Spastic Plantar Flexor Muscles in Very Young Children With Cerebral Palsy

To assess the effects of radial extracorporeal shock wave therapy (rESWT) on plantar flexor muscle spasticity and gross motor function in very young patients with cerebral palsy (CP).The design was case-control study (level of evidence 3).The setting was the Department of Pediatric Neurology and Neurorehabilitation, First Hospital of Jilin University, Changchun, China.Those with a diagnosis of CP and spastic plantar flexor muscles were recruited between April 2014 and April 2015.According to the parents' decision, patients received 1 ESWT session per week for 3 months, with 1500 radial shock waves per ESWT session and leg with positive energy flux density of 0.03 mJ/mm, combined with traditional conservative therapy (rESWT group) or traditional conservative therapy alone (control group).The Modified Ashworth Scale (MAS) (primary outcome measure) and passive range of motion (pROM) measurements were collected at baseline (BL), 1 month (M1), and 3 months (M3) after BL. The Gross Motor Function Measure (GMFM)-88 was collected at BL and M3.Sixty-six patients completed the final review at 3 months and were included in the study. Subjects ranged in age from 12 to 60 months (mean age 27.0 ± 13.6 months; median age 22.0 months; 33.3% female). For the rESWT group (n = 34), mean MAS grades at BL, M1, and M3 were 2.6, 1.9, and 1.5 on the left side and 1.9, 1.7, and 1.2 on the right side. For the control group (n = 32), mean MAS grades at BL, M1, and M3 were 2.5, 2.4, and 2.1 on the left side and 1.8, 1.8, and 1.5 on the right side. The within-subject effects time × side and time × treatment were statistically significant (P < 0.01). Similar results were found for the improvement of mean pROM. GMFM-88 improved from BL to M3, but showed no statistically significant difference between the groups. There were no significant complications.This study demonstrates that the combination of rESWT and traditional conservative therapy is more effective than traditional conservative therapy alone in the treatment of spasticity in very young patients with CP.

Efficacy and safety of extracorporeal shock wave therapy for orthopedic conditions: a systematic review on studies listed in the PEDro database

BACKGROUND

Extracorporeal shock wave therapy (ESWT) is an effective and safe non-invasive treatment option for tendon and other pathologies of the musculoskeletal system.

SOURCES OF DATA

This systematic review used data derived from the Physiotherapy Evidence Database (PEDro; www.pedro.org.au, 23 October 2015, date last accessed).

AREAS OF AGREEMENT

ESWT is effective and safe. An optimum treatment protocol for ESWT appears to be three treatment sessions at 1-week intervals, with 2000 impulses per session and the highest energy flux density the patient can tolerate.

AREAS OF CONTROVERSY

The distinction between radial ESWT as 'low-energy ESWT' and focused ESWT as 'high-energy ESWT' is not correct and should be abandoned.

GROWING POINTS

There is no scientific evidence in favour of either radial ESWT or focused ESWT with respect to treatment outcome.

AREAS TIMELY FOR DEVELOPING RESEARCH

Future randomized controlled trials should primarily address systematic tests of the aforementioned optimum treatment protocol and direct comparisons between radial and focused ESWT.