Anti-spastic effects of the direct application of vibratory stimuli to the spastic muscles of hemiplegic limbs in post-stroke patients: A proof-of-principle study

IMPROVE study protocol, investigating post-stroke local muscle vibrations to promote cerebral plasticity and functional recovery: a single-blind randomised controlled trial

INTRODUCTION

Spasticity is a frequent disabling consequence following a stroke. Local muscle vibrations (LMVs) have been proposed as a treatment to address this problem. However, little is known about their clinical and neurophysiological impacts when used repeatedly during the subacute phase post-stroke. This project aims to evaluate the effects of a 6-week LMV protocol on the paretic limb on spasticity development in a post-stroke subacute population.

METHODS AND ANALYSIS

This is an interventional, controlled, randomised, single-blind (patient) trial. 100 participants over 18 years old will be recruited, within 6 weeks following a first stroke with hemiparesis or hemiplegia. All participants will receive a conventional rehabilitation programme, plus 18 sessions of LMV (ie, continuously for 30 min) on relaxed wrist and elbow flexors: either (1) at 80 Hz for the interventional group or (2) at 40 Hz plus a foam band between the skin and the device for the control group.Participants will be evaluated at baseline, at 3 weeks and 6 weeks, and at 6 months after the end of the intervention. Spasticity will be measured by the modified Ashworth scale and with an isokinetic dynamometer. Sensorimotor function will be assessed with the Fugl-Meyer assessment of the upper extremity. Corticospinal and spinal excitabilities will be measured each time.

ETHICS AND DISSEMINATION

This study was recorded in a clinical trial and obtained approval from the institutional review board (Comité de protection des personnes Ile de France IV, 2021-A03219-32). All participants will be required to provide informed consent. The results of this trial will be published in peer-reviewed journals to disseminate information to clinicians and impact their practice for an improved patient's care.

TRIAL REGISTRATION NUMBER

Clinical Trial: NCT05315726 DATASET: EUDRAct.

Comparison of tendon and muscle belly vibratory stimulation in the treatment of post-stroke upper extremity spasticity: a retrospective observational pilot study

Previous studies have reported the effects of vibratory stimulation (VS) therapy in reducing upper extremity spasticity after stroke. However, the effective location of the VS in patients with stroke remains unclear. This study aimed to determine the VS location that is most effective in reducing post-stroke finger and wrist flexor spasticity. We enrolled 27 consecutive patients with stroke and upper extremity spasticity in this retrospective observational study. The participants received stretching, tendon vibration, and muscle belly vibration for 5 min over a period of 3 days. To evaluate spasticity, we assessed the Modified Ashworth Scale score before and immediately after each treatment and immediately after voluntary finger flexion. Participants who received tendon vibration showed greater improvement in flexor tone in the fingers than participants who received stretching and muscle belly vibration (P < 0.05 and < 0.001, respectively). Participants who underwent VS showed no significant improvement in the wrist flexor tone compared to those who underwent stretching. Our results suggest that the tendon may be the most effective location for treating spasticity of the finger flexor muscles and that VS may not significantly improve spasticity of the wrist flexors more than stretching.

Effects of vibration therapy for post-stroke spasticity: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The efficacy of vibration therapy (VT) in people with post-stroke spasticity (PSS) remains uncertain. This study aims to conduct a comprehensive meta-analysis to assess the effectiveness of VT in PSS.

METHODS

PubMed, Embase, Cochrane Library, Physiotherapy Evidence Database, and Web of Science were searched from inception to October 2022 for randomized controlled trials (RCTs) of VT in people with PSS. The primary outcome was spasticity, and secondary outcomes included pain, motor function, gait performance, and adverse events. A meta‑analysis was performed by pooling the standardized mean difference (SMD) with 95% confidence intervals (CI).

RESULTS

A total of 12 studies met the inclusion criteria. Overall, VT had significant effects on reducing spasticity (SMD = - 0.77, 95% CI - 1.17 to - 0.36, P < 0.01) and pain (SMD =  - 1.09, 95% CI - 1.74 to - 0.45, P < 0.01), and improving motor function (SMD = 0.42, 95% CI 0.21 to 0.64, P < 0.01) in people with PSS. However, VT had no significant effect on gait performance (SMD =  - 0.23, 95% CI - 0.56-0.10). In addition, subgroup differences in short-term anti-spasticity effects between different vibration subtypes, vibration frequencies, vibration durations, frequency of sessions, control therapy, spasticity distribution, and population classification were not significant.

CONCLUSION

We found that VT significantly alleviated spasticity and pain in people with PSS and improved motor function, but its effect on gait performance was unclear. However, further studies are needed to validate these findings.

The effect of local vibration applied to the forearm extensor muscles on hand function and muscle activation in stroke patients: a randomized controlled study

OBJECTIVE

This study aims to reveal the effect of low-frequency local vibration applied to the forearm extensor muscles on stroke patients' muscle activation and hand functions.

METHODS

Twenty-four stroke patients were randomized to the vibration group (n = 12) or control group (n = 12). The vibration was applied at a 30 Hz frequency to the forearm extensor muscles with a local vibration device three days a week after the routine, conventional physical therapy sessions for four weeks. Six vibration sets were applied, including one vibration for one minute and a rest for 2 min. Routine, traditional physical therapy was used for the control group in 60-min sessions for 4 weeks. Patients were assessed for muscle activation with surface electromyography (MVC) and The Wolf Motor Function Test (WMFT), Functional Independent Test (FIM) was applied to all patients before and after treatment.

RESULTS

As a result of our study, MVC measurement, WMFT and FIM scores of the vibration group showed more improvement than the control group. Measurement results of vibration group; While MVC measurement increased from 10.21 to 13.79, WMFT-Functional Ability score increased from 42 to 50, WMFT-Performance Time duration increased from 68.78 to 61.83, and FIM score increased from 74.5 to 83. and the measurement results of the control group; MVC measurement increased from 12.28 to 12.22, WMFT-Functional Ability score increased from 48.5 to 51, WMFT-Performance Time duration increased from 70.39 to 70.61, and FIM score increased from 72.5 to 80.5.

CONCLUSION

It was concluded that low-frequency local vibration applied to the forearm extensor muscles improve forearm extensor muscle activation and hand motor function.

CLINICAL TRIAL REGISTRATION

NCT04562220.

Daily Vibrotactile Stimulation Exhibits Equal or Greater Spasticity Relief Than Botulinum Toxin in Stroke

OBJECTIVE

To test the feasibility and efficacy of the VibroTactile Stimulation (VTS) Glove, a wearable device that provides VTS to the impaired limb to reduce spastic hypertonia.

DESIGN

Prospective 2-arm intervention study-including 1 group of patients who use Botulinum toxin (BTX-A) for spasticity and 1 group of patients who do not use BTX-A.

SETTING

Participants were recruited through rehabilitation and neurology clinics.

PARTICIPANTS

Patients with chronic stroke (N=20; mean age=54 years, mean time since stroke=6.9 years). Patients who were previously receiving the standard of care (BTX-A injection) were eligible to participate and started the intervention 12 weeks after their last injection.

INTERVENTION

Participants were instructed to use the VTS Glove for 3 hours daily, at home or during everyday activities, for 8 weeks.

MAIN OUTCOME MEASURES

Spasticity was assessed with the Modified Ashworth Scale and the Modified Tardieu Scale at baseline and then at 2-week intervals for 12 weeks. Primary outcomes were the difference from baseline and at week 8 (end of VTS Glove use) and week 12 (4 weeks after stopping VTS Glove use). Patients who were receiving BTX-A were also assessed during the 12 weeks preceding the start of VTS Glove use to monitor the effect of BTX-A on spastic hypertonia. Range of motion and participant feedback were also studied.

RESULTS

A clinically meaningful difference in spastic hypertonia was found during and after daily VTS Glove use. Modified Ashworth and Modified Tardieu scores were reduced by an average of 0.9 (P=.0014) and 0.7 (P=.0003), respectively, at week 8 of daily VTS Glove use, and by 1.1 (P=.00025) and 0.9 (P=.0001), respectively, 1 month after stopping VTS Glove use. For participants who used BTX-A, 6 out of 11 showed greater change in Modified Ashworth ratings during VTS Glove use (mean=-1.8 vs mean=-1.6 with BTX-A) and 8 out of 11 showed their lowest level of symptoms during VTS Glove use (vs BTX-A).

CONCLUSIONS

Daily stimulation from the VTS Glove provides relief of spasticity and hypertonia. For more than half of the participants who had regularly used BTX-A, the VTS Glove provided equal or greater symptom relief.

Relief of post-stroke spasticity with acute vibrotactile stimulation: controlled crossover study of muscle and skin stimulus methods

Background

Prior work suggests that vibratory stimulation can reduce spasticity and hypertonia. It is unknown which of three predominant approaches (stimulation of the spastic muscle, antagonist muscle, or cutaneous regions) most reduces these symptoms.

Objective

Determine which vibrotactile stimulation approach is most effective at reducing spastic hypertonia among post-stroke patients.

Methods

Sham-controlled crossover study with random assignment of condition order in fourteen patients with post-stroke hand spasticity. All patients were studied in four conditions over four visits: three stimulation conditions and a sham control. The primary outcome measure was the Modified Ashworth Scale, and the secondary outcome measure was the Modified Tardieu Scale measured manually and using 3D motion capture. For each condition, measures of spastic hypertonia were taken at four time points: baseline, during stimulation, after stimulation was removed, and after a gripping exercise.

Results

A clinically meaningful difference in spastic hypertonia was found during and after cutaneous stimulation of the hand. Modified Ashworth and Modified Tardieu scores were reduced by a median of 1.1 (SD = 0.84, p = 0.001) and 0.75 (SD = 0.65, p = 0.003), respectively, during cutaneous stimulation, and by 1.25 (SD = 0.94, p = 0.001) and 0.71 (SD = 0.67, p = 0.003), respectively, at 15 min after cutaneous stimulation. Symptom reductions with spastic muscle stimulation and antagonist muscle stimulation were non-zero but not significant. There was no change with sham stimulation.

Conclusions

Cutaneous vibrotactile stimulation of the hand provides significant reductions in spastic hypertonia, compared to muscle stimulation.

Clinical trial registration

www.ClinicalTrials.gov, identifier: NCT03814889.

Validity of Accelerometer-Based Sensor System for Muscle Tightness Estimation through Vibration on the Upper Limb

Spasticity is a condition that profoundly impacts the ability to perform everyday tasks. However, its diagnosis requires trained physicians and subjective evaluations that may vary depending on the evaluator. Focal vibration of spastic muscles has been proposed as a non-invasive, pain-free alternative for spasticity modulation. We propose a system to estimate muscular tightness based on the propagation of elastic waves in the skin generated by focal vibration of the upper limb. The developed system generates focalized displacements on the biceps muscle at frequencies from 50 to 200 Hz, measures the vibration acceleration on the vibration source (input) and the distant location (output), and extracts features of ratios between input and output. The system was tested on 5 healthy volunteers while lifting 1.25 - 11.25 kg weights to increase muscle tone resembling spastic conditions, where the vibration frequency and weight were selected as explanatory variables. An increase in the ratio of the root mean squares proportional to the weight was found, validating the feasibility of the current approach to estimating muscle tightness.Clinical Relevance- This work presents the feasibility of a vibration-based system as an alternative method to objectively diagnose the degree of spasticity.

Inhibitory Effects of Prolonged Focal Muscle Vibration on Maximal Grip Strength and Muscle Activity of Wrist and Extrinsic Finger Flexor Muscles

Objective

The objective of this study was to identify effective stimulus time by quantifying the inhibitory effects of focal muscle vibration (FMV) on maximal grip strength and muscle activities of the wrist and extrinsic finger flexors.

Methods

A randomized repeated-measures design was used in this study. A total of 22 healthy volunteers (mean age, 20.9 years) participated. An FMV of 86 Hz was applied to the anterior surface of the distal forearm under the following 3 conditions: no FMV (control), 5-minute FMV, and 10-minute FMV. Maximal grip strength was measured before and after FMV. The muscle activities of the flexor digitorum superficialis, flexor digitorum profundus (FDP), and flexor carpi ulnaris were simultaneously recorded using surface electromyography. Discomfort and complications following FMV were also assessed.

Results

Compared with the control group, a significant decrease in muscle activity was observed in both the flexor digitorum superficialis and flexor carpi ulnaris after 5 and 10 minutes of FMV. In contrast, there was no significant decrease in the maximal grip strength or FDP muscle activity after either FMV condition. The discomfort was significantly higher immediately after both FMV conditions than in the control group, but it decreased 15 minutes after FMV, indicating no significant difference among the 3 conditions. Redness and/or swelling were observed in 13.6% and 36.3% of the participants after 5 and 10 minutes of FMV, respectively.

Conclusion

Five-minute FMV to the distal forearm could be a useful therapeutic method with few complications. However, the FMV in this area alone was not sufficient to suppress the muscle activity of the FDP located in the deep layer.

Deep muscle stimulator in the treatment of post-stroke spasticity: A protocol for systematic review and meta-analysis

BACKGROUND

Spasticity is one of the most common complications and sequelae of stroke, with the main clinical manifestations being increased muscle tension, pain, stiffness, and other disorders. It not only increases the length of hospitalization and medical costs but also affects the quality of daily life and the stress of returning to society, increasing the burden on patients and their families. At present, 2 driver types of deep muscle stimulator (DMS) have been used in the clinical treatment of post-stroke spasticity (PSS) with good clinical results, but there is no evidence of clinical efficacy and safety. Therefore, this study aims to integrate direct and indirect comparative clinical evidence through a systematic review and network meta-analysis (NMA). According to the data, different driver types for DMS with the same body of evidence will be collected, analyzed, and sequenced in a quantitative and comprehensive manner and then screened for the optimal driver type of DMS device for PSS treatment. The study also aims to provide reference value and an evidence-based theoretical basis for the clinical optimization of DMS equipment selection.

METHODS

A comprehensive retrieval of China National Knowledge Infrastructure, Chinese scientific journal database, China biological feature database, Wanfang Chinese databases and the Cochrane Library, PubMed, Web of Science, and Embase foreign databases will be conducted. Randomized controlled trials of these 2 driver types of DMS devices combined with conventional rehabilitation training of PSS will be searched and published. The retrieval time is from the establishment of the database to December 20, 2022. The 2 first authors will screen references that meet the inclusion criteria, independently extract data according to predesigned rules, and assess the quality of the included studies and the risk of bias according to the Cochrane 5.1 Handbook criteria. R programming and Aggregate Data Drug Information System software will be used to perform a combined NMA of the data and to evaluate the probability of ranking for all interventions.

RESULTS

The NMA and probability ranking will determine the best driver type of DMS device for PSS.

CONCLUSION

This study will offer a comprehensive evidence-based approach to DMS therapy and assist doctors, PSS patients, and decision-makers in selecting a more efficient, secure, and cost-effective treatment option.

Effects of prolonged local vibration superimposed to muscle contraction on motoneuronal and cortical excitability

Introduction: Acute effects of prolonged local vibration (LV) at the central nervous system level have been well investigated demonstrating an altered motoneuronal excitability with a concomitant increase in cortical excitability. While applying LV during isometric voluntary contraction is thought to optimize the effects of LV, this has never been addressed considering the acute changes in central nervous system excitability. Materials and Methods: In the present study, nineteen healthy participants were engaged in four randomized sessions. LV was applied for 30 min to the relaxed flexor carpi radialis muscle (VIB_RELAXED) or during wrist flexions (i.e. intermittent contractions at 10% of the maximal voluntary contraction: 15 s ON and 15 s OFF; VIB_CONTRACT). A control condition and a condition where participants only performed repeated low-contractions at 10% maximal force (CONTRACT) were also performed. For each condition, motor evoked potentials (MEPs) elicited by transcranial magnetic stimulation and cervicomedullary evoked potentials (CMEPs) elicited by corticospinal tract electrical stimulation were measured before (PRE) and immediately after prolonged LV (POST) to investigate motoneuronal and corticospinal excitability, respectively. We further calculated the MEP/CMEP ratio as a proxy of cortical excitability. Results: No changes were observed in the control nor CONTRACT condition. At POST, CMEP decreased similarly in VIB_RELAXED (-32% ± 42%, p < .001) and VIB_CONTRACT (-41% ± 32%, p < .001). MEP/CMEP increased by 110% ± 140% (p = .01) for VIB_RELAXED and by 120% ± 208% (p = .02) for VIB_CONTRACT without differences between those conditions. Discussion: Our results suggest that LV to the flexor carpi radialis muscle, either relaxed or contracted, acutely decreases motoneuronal excitability and induces some priming of cortical excitability.

Spastic muscle stiffness evaluated using ultrasound elastography and evoked electromyogram in patients following severe traumatic brain injury: an observational study

OBJECTIVE

To determine the relationship between muscle stiffness assessed using ultrasound shear wave elastography, spinal motor neuron excitability assessed using the F wave, and clinical findings of spasticity in patients with spastic muscle overactivity following severe traumatic brain injury.

METHODS

This study enrolled 17 inpatients with severe traumatic brain injury and 20 healthy volunteers. Biceps brachii muscle stiffness was then evaluated using ultrasound shear wave speed. Spinal motor neuron excitability was evaluated using the F/M ratio recorded from abductor pollicis brevis muscle. Clinical parameters, such as the modified Ashworth scale and modified Tardieu scale, were assessed in the patient with traumatic brain injury.

RESULTS

The patients with traumatic brain injury group had a significantly higher shear wave speed and F/M ratio compared with the healthy group. A higher shear wave speed was correlated with higher clinical spastic severity in patients with traumatic brain injury. The F/M ratio was not significantly correlated with clinical spastic severity.

CONCLUSION

Ultrasound shear wave elastography might be helpful for assessing muscle stiffness in patients with spastic muscle overactivity following severe traumatic brain injury. Further studies comprising larger cohorts are warranted.

Focal vibration of the plantarflexor and dorsiflexor muscles improves poststroke spasticity: a randomized single-blind controlled trial

BACKGROUND

Post-stroke spasticity is a cause of gait dysfunction and disability. Focal vibration (FV) of agonist-antagonist upper limb muscle pairs reduces flexor spasticity; however, its effects on ankle plantarflexor spasticity are uncertain.

OBJECTIVE

To assess the effects of focal vibration administered by a trained operator to the ankle plantarflexor and dorsiflexor muscles on post-stroke lower limb spasticity.

METHODS

A randomized, single-blind controlled trial of 64 participants with stroke and plantarflexor spasticity assigned to 3 groups by centralized, computer-generated randomization (1:1:1): 1) physiotherapy alone (CON), 2) physiotherapy+gastrocnemius vibration (FV_GM) and 3) physiotherapy+tibialis anterior vibration (FV_TA). Physiotherapists and assessors were blinded to group assignment. The experimental groups underwent 15, 20-min vibration sessions at 40 Hz. We performed evaluations at baseline and after the final treatment: Modified Ashworth Scale (MAS), Clonus scale, Functional Ambulation Categories (FAC), Fugl-Meyer Assessment - Lower Extremity (FMA_LE), Modified Barthel Index (MBI), and electromyography and ultrasound elastography. Primary outcome was remission rate (number and proportion of participants) of the MAS.

RESULTS

MAS remission rate was higher in FV_GM and FV_TA than CON groups (CON vs. FV_GM: p=0.009, odds ratio 0.15 [95% confidence interval 0.03-0.67]; CON vs. FV_TA: p=0.002, 0.12 [0.03-0.51]). Remission rate was higher in the experimental than CON groups for the Clonus scale (CON vs. FV_GM: p<0.001, OR 0.07 [95% CI 0.01-0.31]; CON vs. FV_TA: p=0.006, 0.14 [95% CI 0.03-0.61]). FAC remission rate was higher in the FV_TA than the CON (p=0.009, 0.18 [0.05-0.68]) and FV_GM (p=0.014, 0.27 [0.07-0.99]) groups. Ultrasound variables of the paretic medial gastrocnemius decreased more in FV_GM than CON and FV_TA groups (shear modulus: p=0.006; shear wave velocity: p=0.008).

CONCLUSIONS

Focal vibration reduced post-stroke spasticity of the plantarflexor muscles. Vibration of the tibialis anterior improved ambulation more than vibration of the gastrocnemius or physiotherapy alone. Gastrocnemius vibration may reduce spasticity by changing muscle stiffness.

User Participatory Design of a Wearable Focal Vibration Device for Home-Based Stroke Rehabilitation

Stroke often leads to the significant impairment of upper limb function and is associated with a decreased quality of life. Despite study results from several interventions for muscle activation and motor coordination, wide-scale adoption remains largely elusive due to under-doses and low user compliance and participation. Recent studies have shown that focal vibration has a greater potential to increase and coordinate muscle recruitment and build muscle strength and endurance. This form of treatment could widely benefit stroke survivors and therapists. Thus, this study aimed to design and develop a novel wearable focal vibration device for upper limb rehabilitation in stroke survivors. A user participatory design approach was used for the design and development. Five stroke survivors, three physical therapists, and two occupational therapists were recruited and participated. This pilot study may help to develop a novel sustainable wearable system providing vibration-based muscle activation for upper limb function rehabilitation. It may allow users to apply the prescribed vibratory stimuli in-home and/or in community settings. It may also allow therapists to monitor treatment usage and user performance and adjust the treatment doses based on progression.

Corticospinal modulation of vibration-induced H-reflex depression

The purpose of this study was to examine corticospinal modulation of spinal reflex excitability, by determining the effect of transcranial magnetic stimulation (TMS) on soleus H-reflexes while they were almost completely suppressed by lower extremity vibration. In 15 healthy adults, a novel method of single-limb vibration (0.6 g, 30 Hz, 0.33 mm displacement) was applied to the non-dominant leg. Soleus muscle responses were examined in six stimulation conditions: (1) H-reflex elicited by tibial nerve stimulation, (2) tibial nerve stimulation during vibration, (3) subthreshold TMS, (4) subthreshold TMS during vibration, (5) tibial nerve stimulation 10 ms after a subthreshold TMS pulse, and (6) tibial nerve stimulation 10 ms after a subthreshold TMS pulse, during vibration. With or without vibration, subthreshold TMS produced no motor evoked potentials and had no effect on soleus electromyography (p > 0.05). In the absence of vibration, H-reflex amplitudes were not affected by subthreshold TMS conditioning (median (md) 35, interquartile range (IQ) 18-56 vs. md 46, IQ 22-59% of the maximal M wave (Mmax), p > 0.05). During vibration, however, unconditioned H-reflexes were nearly abolished, and a TMS conditioning pulse increased the H-reflex more than fourfold (md 0.3, IQ 0.1-0.7 vs. md 2, IQ 0.9-5.0% of Mmax, p < 0.008). Limb vibration alone had no significant effect on corticospinal excitability. In the absence of vibration, a subthreshold TMS pulse did not influence the soleus H-reflex. During limb vibration, however, while the H-reflex was almost completely suppressed, a subthreshold TMS pulse partially restored the H-reflex. This disinhibition of the H-reflex by a corticospinal signal may represent a mechanism involved in the control of voluntary movement. Corticospinal signals that carry the descending motor command may also reduce presynaptic inhibition, temporarily increasing the impact of sensory inputs on motoneuron activation.

Concurrent impact of bilateral multiple joint functional electrical stimulation and treadmill walking on gait and spasticity in post-stroke survivors: a pilot study

Background: Stroke causes multi-joint gait deficits, so a major objective of post-stroke rehabilitation is to regain normal gait function. Design and Setting: A case series completed at a neuroscience institute. Aim: The aim of the study was to determine the concurrent impact of functional electrical stimulation (FES) during treadmill walking on gait speed, knee extensors spasticity and ankle plantar flexors spasticity in post-stroke survivors. Participants: Six post-stroke survivors with altered gait patterns and ankle plantar flexors spasticity (4 = male; age 56.8 ± 4.8 years; Body Mass Index (BMI) 26.2 ± 4.3; since onset of stroke: 30.8 ± 10.4 months; side of hemiplegia [L/R]: 3:3) were recruited. Intervention: Nine treatment sessions using FES bilaterally while walking on a treadmill. Main Outcome Measures: Primary outcome measures included the Modified Modified Ashworth Scale (MMAS), Timed Up and Go test (TUG), 10-m walking test, gait speed, and Functional ambulation category (FAC). Secondary outcome measures included the Step Length Test (SLT), and active range of motion (ROM) of the affected ankle and the knee. Measurements were taken at baseline (T0), at the end of last treatment (T1), and 1 month after the final treatment session (T2). Results: The TUG, 10-m walking test, gait speed, FAC, active ROM, and SLT all significantly improved following treatment (P< .05), while ankle plantar flexors spasticity (P = .135), and knee extensors spasticity (P = .368) did not show any significant decrease. Conclusions: A short duration of bilateral FES in conjugation with treadmill walking contributed to significant improvement in gait speed, functional mobility, functional ambulation, range of motion and step length in post-stroke survivors. In contrast, no significant decreases were identified in the spasticity of the ankle plantar flexors and knee extensors muscles.

Effects of lower limb segmental muscle vibration on primary motor cortex short-latency intracortical inhibition and spinal excitability in healthy humans

We examined the effects of lower limb segmental muscle vibration (SMV) on intracortical and spinal excitability in 13 healthy participants (mean age: 34.9 ± 7.8 years, 12 males, 1 female). SMV at 30 Hz was applied to the hamstrings, gastrocnemius, and soleus muscles for 5 min. Paired-pulse transcranial magnetic stimulation protocols were used to investigate motor-evoked potential (MEP)  amplitude, short-interval intracortical inhibition (SICI) and short-interval intracortical facilitation (SICF) from the abductor hallucis muscle (AbdH). These assessments were compared to the results of a control experiment (i.e., non-vibration) in the same participants. F-waves were evaluated from the AbdH on the right (vibration side) and left (non-vibration side) sides, and we calculated the ratio of the F-wave amplitude to the M-response amplitude (F/M ratio). These assessments were obtained before, immediately after, and 10, 20, and 30 min after SMV. For SICI, there was no change immediately after SMV, but there was a decrease over time (before vs. 30 min after, p = 0.021; immediately after vs. 30 min after, p = 0.015). There were no changes in test MEP amplitude, SICF, or the F/M ratio. SMV causes a gradual decrease in SICI over time perhaps owing to long-term potentiation. The present results may have implications for the treatment of spasticity.

Effects of augmented somatosensory input using vibratory insoles to improve walking in individuals with chronic post-stroke hemiparesis

BACKGROUND

Stroke survivors suffer from hemiparesis and somatosensory impairments, which adversely impact walking performance, placing them at higher risks for trips and falls. Post-stroke, somatosensory deficits are commonly observed as impaired interpretation of afferent input and increased threshold. Diminishing or augmenting somatosensory inputs via various techniques have been demonstrated to be able to modify static and dynamic balance, postural and locomotor control in non-neurologically impaired as well as neurologically impaired individuals.

RESEARCH QUESTION

We sought to investigate whether enhancing somatosensory input using vibratory insoles, can improve post-stroke gait. We hypothesized that with augmentation of somatosensory input at the soles via vibratory insoles would improve post-stroke gait via increased propulsive forces, decreased braking forces and increased ankle angle movements in the paretic legs of individuals with chronic post-stroke hemiparesis.

METHODS

Fifteen individuals with chronic post-stroke hemiparesis and 15 age-similar non-neurologically impaired controls participated in this cross-sectional study. Enhanced somatosensory stimulation was delivered using a pair of tactor-embedded insoles, providing suprathreshold vibratory stimulation to the bottom of the feet. Participants walked over an instrumented treadmill with self-selected speeds, under 5 conditions: no insole in shoe (NT), insoles in shoe with no vibration (BOFF), vibration under both feet (BON), vibration under one foot only (ION, CON). Kinetics and kinematics during walking were recorded and analyzed offline.

RESULTS

Suprathreshold vibratory stimulations did not alter gait kinetics under any stimulation conditions. We observed increased paretic ankle dorsiflexions in the paretic legs, when vibratory stimuli were applied unilaterally.

SIGNIFICANCE

Vibratory stimulations applied at suprathreshold intensity to the bottom of the feet to augment somatosensory feedback can potentially be used as a low-cost solution to address the inadequate toe clearance during walking in people post-stroke, which is an important goal in post-stroke rehabilitation.

Effects of low vs. high frequency local vibration on mild-moderate muscle spasticity: Ultrasonographical and functional evaluation in patients with multiple sclerosis

BACKGROUND

Local vibration (LV) is a physiotherapy application that aims to reduce spasticity. The study aimed to compare the effects of 50 Hz vs. 100 Hz LV on mild-moderate spasticity, functional performance and muscle architecture.

METHODS

Thirty-three patients were randomly divided into three groups: 50 Hz LV group, 100 Hz LV group and the control group. Physical therapy was applied for one hour a day, three days a week, for a total of eight weeks. LV was applied to the right and left medial gastrocnemius muscles for five minutes. Clinical (spasticity, ankle joint position sense, balance, gait) and ultrasonographic (gastrocnemius fascicle length and pennation angle) measurements were performed before and after treatment.

RESULTS

The study was completed with 27 patients. The decrease in spasticity and the increase in fascicle length were found to be statistically significant in the 50 Hz group (both p<0.05). Ankle joint position sense, single-leg stance time, limits of stability/postural sway range in the medio-lateral direction significantly improved in the vibration treatment groups (all p<0.05). The antero-posterior limits of stability and postural sway showed significant improvement in all groups (all p<0.05). While the 50 Hz group showed significant improvement for all walking parameters; velocity, step length and base of support values improved in the 100 Hz group (all p<0.05). The exercise group showed significant improvement only for single support and stance phase percentages of the gait cycle (both p<0.05). According to between group comparisons, significant difference was found only in medio-lateral limits of stabillity (p<0.05). Medio-lateral limits of stabillity scores were better for the 50 Hz group than the 100 Hz and exercise group.

CONCLUSION

Our findings show that LV does not have any substantial effect except for medio-lateral limits of stability.

CLINICAL TRIAL NUMBER

NCT04192786.

Combination therapy with repetitive facilitative exercise program and botulinum toxin type A to improve motor function for the upper-limb spastic paresis in chronic stroke: A randomized controlled trial

STUDY DESIGN

An open-label, randomized, controlled, observer-blinded trial.

INTRODUCTION

Repetitive facilitative exercise (RFE) is a movement therapy to recover from hemiparesis after stroke. However, improvement is inhibited by spasticity. Recently, botulinum toxin type A (BoNT-A) injection has been shown to reduce spasticity.

PURPOSE

To examine the combined effect of an RFE program and BoNT-A treatment on upper-limb spastic paresis in chronic stroke.

METHODS

Forty chronic stroke inpatients with upper-limb spastic paresis (Brunnstrom stage ≥III and Modified Ashworth Scale [MAS] score ≥1) were enrolled. Subjects were randomized into 2 groups of 20 each and received 4 weeks of treatment. The intervention group received RFE and BoNT-A injection; the control group underwent RFE only. Assessments were performed at baseline and at study conclusion. The primary outcome was change in Fugl-Meyer Assessment score for the upper extremity (FMA). The Action Research Arm Test (ARAT), active range of motion, Box and Block Test, and MAS were also evaluated.

RESULTS

All participants completed this study. After 4 weeks, the intervention group evidenced a significantly greater increase in FMA score (median 11.0 [range 4-20]) than the control group (median 3.0 [range 0-9]) (P < .01, r = 0.79); as well as improvements in the other measures such as ARAT (median 12.5 [range 4-22] vs 7 [0-13]) (P < .01, r = 0.6), and MAS in the elbow flexors (median -1.5 [range -2 to 0] vs -1 [-2 to 0]) (P < .01, r = 0.45).

DISCUSSION

A high degree of repetitive volitional movement induced by the facilitative technique with concomitant control of spasticity by BoNT-A injection might increase efficiency of motor learning with continuous movement of the affected upper-limb.

CONCLUSIONS

The combination of RFE and BoNT-A for spastic paresis might be more effective than RFE alone to improve upper-limb motor function and to lessen impairment in chronic stroke.

Wearable vibrotactile stimulation for upper extremity rehabilitation in chronic stroke: clinical feasibility trial using the VTS Glove

OBJECTIVE

Evaluate the feasibility and potential impacts on hand function using a wearable stimulation device (the VTS Glove) which provides mechanical, vibratory input to the affected limb of chronic stroke survivors.

METHODS

A double-blind, randomized, controlled feasibility study including sixteen chronic stroke survivors (mean age: 54; 1-13 years post-stroke) with diminished movement and tactile perception in their affected hand. Participants were given a wearable device to take home and asked to wear it for three hours daily over eight weeks. The device intervention was either (1) the VTS Glove, which provided vibrotactile stimulation to the hand, or (2) an identical glove with vibration disabled. Participants were randomly assigned to each condition. Hand and arm function were measured weekly at home and in local physical therapy clinics.

RESULTS

Participants using the VTS Glove showed significantly improved Semmes-Weinstein monofilament exam results, reduction in Modified Ashworth measures in the fingers, and some increased voluntary finger flexion, elbow and shoulder range of motion.

CONCLUSIONS

Vibrotactile stimulation applied to the disabled limb may impact tactile perception, tone and spasticity, and voluntary range of motion. Wearable devices allow extended application and study of stimulation methods outside of a clinical setting.

Development and Preliminary Validation of a Pneumatic Focal Vibration System to the Mitigation of Post-Stroke Spasticity

Some evidence has demonstrated that focal vibration (FV) plays an important role in the mitigation of spasticity. However, the research on developing the FV system to mitigate the spasticity effectively has been seldom reported. To relieve post-stroke spasticity, a new pneumatic FV system has been proposed in this paper. An image processing approach, in which the edge of vibration actuator was identified by the Canny edge detector, was utilized to quantify this system's parameters: the frequency ranging from 44 Hz to 128 Hz and the corresponding amplitude. Taking one FV protocol with the frequency of 87 Hz and the amplitude 0.28 mm of this system as an example, a clinical experiment was carried out. In the clinical experiment, FV was applied over the muscle belly of the antagonist of spastic muscle for twelve chronic spastic stroke patients. Spasticity was quantified by the muscle compliance and area under the curve for muscle (AUC_muscle). The result has demonstrated that, in the state of flexion of spastic muscle, the AUC_muscle and muscle compliance of the spastic muscle significantly increased immediately after FV compared with before-FV, illustrating the mitigation of the spasticity. This study will not only provide a potential tool to relieve post-stroke spasticity, but also contribute to improving the sensory and motor function of patients with other neurological diseases, e.g. spinal cord injury, multiple sclerosis, Parkinson and dystonia, etc.

Efficacy of foam rolling with additional vibration stimulation on the mobility of the thoracolumbar fascia. An observational study

INTRODUCTION

Observations show that foam rolling improves joint movements. Likewise, it can be stated that a vibration stimulation of the tissue leads to improved joint mobility.

METHOD

This study investigates whether the combination of foam rolling and vibrations (31 Hz) can influence the sliding of the thoracolumbar fascia more effectively than normal foam rolling. 45 subjects participated in the study and were divided into a foam roll with additional vibration group (FRV), a foam roll group (FR) and a control group (CG). The intervention groups rolled out the gluteal muscles, the lateral trunk and the upper and lower back. Mobility measures were taken pre and post the respective intervention. Subsequent cross correlation software analysis quantified the sliding of the fascia and calculated its shear strain mobility (SSM).

RESULTS

The sliding of the thoracolumbar fascia improved significantly within the FRV by 2.83 mm (SD ± 1.08/p < .001), in the FR by 0.96 mm (SD ± 0.43/p < .001) and in the CG decreased the sliding by 0.1401 mm (SD ± 0.28/p = .076). The fascia/fascia SSM increased in the FRV by 22.61% (SD ± 15.64/p < .001), in the FR by 11.41% (SD ± 20.38/p = .056) and in the CG decreased the SSM by 0.9473% (SD ± 11.35/p < .751). The lumbar movement increased in both intervention groups, but showed no significant result.

CONCLUSION

The use of a foam roll with additional vibration and standard intervention have increased thoracolumbar fascia sliding and lumbar movements. The improved shear strain mobility can be attributed to the multi-activity of mechanoreceptors, such as Pacini- and Ruffini-Bodies.

Motor Recovery After Stroke: From a Vespa Scooter Ride Over the Roman Sampietrini to Focal Muscle Vibration (fMV) Treatment. A 99mTc-HMPAO SPECT and Neurophysiological Case Study

Focal repetitive muscle vibration (fMV) is a safe and well-tolerated non-invasive brain and peripheral stimulation (NIBS) technique, easy to perform at the bedside, and able to promote the post-stroke motor recovery through conditioning the stroke-related dysfunctional structures and pathways. Here we describe the concurrent cortical and spinal plasticity induced by fMV in a chronic stroke survivor, as assessed with 99mTc-HMPAO SPECT, peripheral nerve stimulation, and gait analysis. A 72-years-old patient was referred to our stroke clinic for a right leg hemiparesis and spasticity resulting from a previous (4 years before) hemorrhagic stroke. He reported a subjective improvement of his right leg's spasticity and dysesthesia that occurred after a30-min ride on a Vespa scooter as a passenger over the Roman Sampietrini (i.e., cubic-shaped cobblestones). Taking into account both the patient's anecdote and the current guidelines that recommend fMV for the treatment of post-stroke spasticity, we then decided to start fMV treatment. 12 fMV sessions (frequency 100 Hz; amplitude range 0.2–0.5 mm, three 10-min daily sessions per week for 4 consecutive weeks) were applied over the quadriceps femoris, triceps surae, and hamstring muscles through a specific commercial device (Cro®System, NEMOCOsrl). A standardized clinical and instrumental evaluation was performed before (T0) the first fMV session and after (T1) the last one. After fMV treatment, we observed a clinically relevant motor and functional improvement, as assessed by comparing the post-treatment changes in the score of the Fugl-Meyer assessment, the Motricity Index score, the gait analysis, and the Ashworth modified scale, with the respective minimal detectable change at the 95% confidence level (MDC₉₅). Data from SPECT and peripheral nerve stimulation supported the evidence of a concurrent brain and spinal plasticity promoted by fMV treatment trough activity-dependent changes in cortical perfusion and motoneuron excitability, respectively. In conclusion, the substrate of post-stroke motor recovery induced by fMV involves a concurrently acting multisite plasticity (i.e., cortical and spinal plasticity). In our patient, operant conditioning of both cortical perfusion and motoneuron excitability throughout a month of fMV treatment was related to a clinically relevant improvement in his strength, step symmetry (with reduced limping), and spasticity.

Localized muscle vibration in the treatment of motor impairment and spasticity in post-stroke patients: a systematic review

INTRODUCTION

During the last decades, many studies have been carried out to understand the possible positive effects of vibration therapy in post-stroke rehabilitation. In particular, the use of localized muscle vibration (LMV) seems to have promising results. The aim of this systematic review was to describe the use of LMV in post-stroke patients to improve motor recovery, reducing spasticity and disability in both upper and lower limb.

EVIDENCE ACQUISITION

A search was conducted on PubMed, Scopus, Pedro and REHABDATA electronic database. Only randomized controlled trials have been included, excluding no-localized vibratory treatments and other pathological conditions. Fourteen studies met the inclusion criteria and were included in this review.

EVIDENCE SYNTHESIS

Collectively, the studies involved 425 stroke patients. Most studies included chronic stroke patients (ten) and treated only the upper limb (eleven). There is evidence that LMV therapy is effective in reducing spasticity and improving motor recovery, especially when associated with conventional physical therapy.

CONCLUSIONS

LMV may be a feasible and safe tool to be integrated into traditional and conventional neurorehabilitation programs for post-stroke patients to reduce spasticity. Analysis of the available clinical trials do not allow us to indicate vibration therapy as effective in functional motor recovery, despite some studies showed encouraging results. Further studies, with larger size of homogeneous patients and with a shared methodology are needed to produce more reliable data, especially on the lower limb.

Using Cutaneous Receptor Vibration to Uncover the Effect of Transcranial Magnetic Stimulation (TMS) on Motor Cortical Excitability

Background

Little is known about how vibrational stimuli applied to hand digits affect motor cortical excitability. The present transcranial magnetic stimulation (TMS) study investigated motor evoked potentials (MEPs) in the upper extremity muscle following high-frequency vibratory digit stimulation.

Material/Methods

High-frequency vibration was applied to the upper extremity digit II utilizing a miniature electromagnetic solenoid-type stimulator-tactor in 11 healthy study participants. The conditioning stimulation (C) preceded the test magnetic stimulation (T) by inter-stimulus intervals (ISIs) of 5–500 ms in 2 experimental sessions. The TMS was applied over the primary motor cortex for the hand abductor pollicis-brevis (APB) muscle.

Results

Dunnett’s multiple comparisons test indicated significant suppression of MEP amplitudes at ISIs of 200 ms (P=0.001), 300 ms (P=0.023), and 400 ms (P=0.029) compared to control.

Conclusions

MEP amplitude suppression was observed in the APB muscle at ISIs of 200–400 ms, applying afferent signaling that originates in skin receptors following the vibratory stimuli. The study provides novel insight on the time course and MEP modulation following cutaneous receptor vibration of the hand digit. The results of the study may have implications in neurology in the neurorehabilitation of patients with increased amplitude of MEPs.

Reaching exercise for chronic paretic upper extremity after stroke using a novel rehabilitation robot with arm-weight support and concomitant electrical stimulation and vibration: before-and-after feasibility trial

Background

Our group developed a rehabilitation robot to assist with repetitive, active reaching movement of a paretic upper extremity. The robot is equipped with a servo motor-controlled arm-weight support and works in conjunction with neuromuscular electrical stimulation and vibratory stimulation to facilitate agonist-muscle contraction. In this before-and-after pilot study, we assessed the feasibility of applying the robot to improve motor control and function of the hemiparetic upper extremity in patients who suffered chronic stroke.

Methods

We enrolled 6 patients with chronic stroke and hemiparesis who, while sitting and without assistance, could reach 10 cm both sagitally and vertically (from a starting position located 10 cm forward from the patient’s navel level) with the affected upper extremity. The patients were assigned to receive reaching exercise intervention with the robot (Yaskawa Electric Co., Ltd. Fukuoka, Japan) for 2 weeks at 15 min/day in addition to regular occupational therapy for 40 min/day. Outcomes assessed before and after 2 weeks of intervention included the upper extremity component of the Fugl-Meyer Assessment (UE-FMA), the Action Research Arm Test (ARAT), and, during reaching movement, kinematic analysis.

Results

None of the patients experienced adverse events. The mean score of UE-FMA increased from 44.8 [SD 14.4] to 48.0 [SD 14.4] (p = 0.026, r = 0.91), and both the shoulder–elbow and wrist–hand scores increased after 2-week intervention. An increase was also observed in ARAT score, from mean 29.8 [SD 16.3] to 36.2 [SD 18.1] (p = 0.042, r = 0.83). Kinematic analysis during the reaching movement revealed a significant increase in active range of motion (AROM) at the elbow, and movement time tended to decrease. Furthermore, trajectory length for the wrist (“hand path”) and the acromion (“trunk compensatory movement”) showed a decreasing trend.

Conclusions

This robot-assisted modality is feasible and our preliminary findings suggest it improved motor control and motor function of the hemiparetic upper extremity in patients with chronic stroke. Training with this robot might induce greater AROM for the elbow and decrease compensatory trunk movement, thus contributing to movement efficacy and efficiency.

Trial registration UMIN Clinical Trial Registry, as UMIN000018132, on June 30, 2015. https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000020398

Focal Vibration Stretches Muscle Fibers by Producing Muscle Waves

Focal vibration is an effective intervention for the management of spasticity. However, its neuromechanical effects, particularly how tonic vibration reflex is induced explicitly, remain implicit. In this paper, we utilize a high-speed camera and a method of image processing to quantify the muscle vibration rigorously and disclose the neuromechanical mechanism of focal vibration. The vibration of 75 Hz is applied on the muscle belly of the biceps brachii and muscle responses are captured by a high-speed camera in profile. The muscle silhouettes are identified by the Canny edge detector to represent the stretch of muscle fibers, and the consistency between the muscle stretch and profile deformation has been confirmed by the magnetic resonance imaging in advance. Oscillations of muscle points discretized by pixels are identified by the fast Fourier transformation, respectively, and results demonstrate that focal vibration stretches muscle by producing muscle waves. Specifically, each point vibrates harmonically, and, given the linear phase modulation with transverse position, the muscle vibration propagates as traveling waves. The propagation of muscle waves is associated with muscle stretch, whose frequency is the same with the vibrator due to the curved baseline, and thus induces the tonic vibration reflex via spinal circuits.

Short-Term Effects of Focal Muscle Vibration on Motor Recovery After Acute Stroke: A Pilot Randomized Sham-Controlled Study

Repetitive focal muscle vibration (rMV) is known to promote neural plasticity and long-lasting motor recovery in chronic stroke patients. Those structural and functional changes within the motor network underlying motor recovery occur in the very first hours after stroke. Nonetheless, to our knowledge, no rMV-based studies have been carried out in acute stroke patients so far, and the clinical benefit of rMV in this phase of stroke is yet to be determined. The aim of this randomized double-blind sham-controlled study is to investigate the short-term effect of rMV on motor recovery in acute stroke patients. Out of 22 acute stroke patients, 10 were treated with the rMV (vibration group-VG), while 12 underwent the sham treatment (control group-CG). Both treatments were carried out for 3 consecutive days, starting within 72 h of stroke onset; each daily session consisted of three 10-min treatments (for each treated limb), interspersed with a 1-min interval. rMV was delivered using a specific device (Cro®System, NEMOCO srl, Italy). The transducer was applied perpendicular to the target muscle's belly, near its distal tendon insertion, generating a 0.2-0.5 mm peak-to-peak sinusoidal displacement at a frequency of 100 Hz. All participants also underwent a daily standard rehabilitation program. The study protocol underwent local ethics committee approval (ClinicalTrial.gov NCT03697525) and written informed consent was obtained from all of the participants. With regard to the different pre-treatment clinical statuses, VG patients showed significant clinical improvement with respect to CG-treated patients among the NIHSS (p < 0.001), Fugl-Meyer (p = 0.001), and Motricity Index (p < 0.001) scores. In addition, when the upper and lower limb scales scores were compared between the two groups, VG patients were found to have a better clinical improvement at all the clinical end points. This study provides the first evidence that rMV is able to improve the motor outcome in a cohort of acute stroke patients, regardless of the pretreatment clinical status. Being a safe and well-tolerated intervention, which is easy to perform at the bedside, rMV may represent a valid complementary non-pharmacological therapy to promote motor recovery in acute stroke patients.

Effect of segmental muscle vibration on upper extremity functional ability poststroke: A randomized controlled trial

BACKGROUND

Upper extremity functional impairments are common consequences of stroke. Therefore, continuous investigation of effective interventions for upper extremity functions after stroke is a necessity. Segmental muscle vibration (SMV) is one of the interventions that incorporate sensory stimulation to improve motor cortical excitability. The aim of this study was to investigate the influence of 5-minute SMV application along with supervised physical therapy (SPT) on improving activities of daily living and motor recovery on the hemiparetic upper extremity in patients with stroke.

METHODS

A sample of 37 patients poststroke (29 males) was randomly allocated to either SPT control group (n = 18) or SPT and SMV (SPT-SMV) experimental group (n = 19). All patients received 3 sessions per week of SPT for 8 weeks. The SPT-SMV experimental group received SMV at the end of each SPT session. Outcome measures used were Barthel index (BI), modified Ashworth scale, manual muscle testing, and goniometry for range of motion (ROM) assessment.

RESULTS

Thirty-four patients completed the study. Patients in both groups improved significantly after treatment in BI, elbow ROM, and elbow muscles strength. However, muscle tone in elbow joint of the hemiplegic upper extremity improved significantly after SMV only in the experimental group (SPT-SMV).

CONCLUSION

The SPT intervention can improve functional outcomes of upper extremity in people after stroke. However, using SMV may have superior effect on improving muscle tone after stroke.

Plasticity Induced in the Human Spinal Cord by Focal Muscle Vibration

The spinal cord spinal cord has in the past been considered a hardwired system which responds to inputs in a stereotyped way. A growing body of data have instead demonstrated its ability to retain information and modify its effector capabilities, showing activity-dependent plasticity. Whereas, plasticity in the spinal cord is well documented after different forms of physical exercise, whether exogenous stimulation can induce similar changes is still a matter of debate. This issue is both of scientific and clinical relevance, since at least one form of stimulation, i.e., focal muscle vibration (fMV), is currently used as a treatment for spasticity. The aim of the present study was to assess whether fMV can induce plasticity at the SC level when applied to different muscles of the upper limb. Changes in different electrophysiological measures, such as H-reflex testing homonymous and heteronymous pathways, reciprocal inhibition and somatosensory evoked potentials were used as outcomes. We found that fMV was able to induce long-term depression-like plasticity in specific spinal cord circuits depending on the muscle vibrated. These findings helped understand the basic mechanisms underlying the effects of fMV and might help to develop more advanced stimulation protocols.

Sensorimotor integration in chronic stroke: Baseline differences and response to sensory training

BACKGROUND

The integration of somatosensory information from the environment into the motor cortex to inform movement is essential for motor function. As motor deficits commonly persist into the chronic phase of stroke recovery, it is important to understand potential contributing factors to these deficits, as well as their relationship with motor function. To date the impact of chronic stroke on sensorimotor integration has not been thoroughly investigated.

OBJECTIVES

The current study aimed to comprehensively examine the influence of chronic stroke on sensorimotor integration, and determine whether sensorimotor integration can be modified with an intervention. Further, it determined the relationship between neurophysiological measures of sensorimotor integration and motor deficits post-stroke.

METHODS

Fourteen individuals with chronic stroke and twelve older healthy controls participated. Motor impairment and function were quantified in individuals with chronic stroke. Baseline neurophysiology was assessed using nerve-based measures (short- and long-latency afferent inhibition, afferent facilitation) and vibration-based measures of sensorimotor integration, which paired vibration with single and paired-pulse TMS techniques. Neurophysiological assessment was performed before and after a vibration-based sensory training paradigm to assess changes within these circuits.

RESULTS

Vibration-based, but not nerve-based measures of sensorimotor integration were different in individuals with chronic stroke, as compared to older healthy controls, suggesting that stroke differentially impacts integration of specific types of somatosensory information. Sensorimotor integration was behaviourally relevant in that it related to both motor function and impairment post-stroke. Finally, sensory training modulated sensorimotor integration in individuals with chronic stroke and controls.

CONCLUSION

Sensorimotor integration is differentially impacted by chronic stroke based on the type of afferent feedback. However, both nerve-based and vibration-based measures relate to motor impairment and function in individuals with chronic stroke.

The Impact of Whole Body Vibration Therapy on Spasticity and Disability of the Patients with Poststroke Hemiplegia

OBJECTIVE

To determine if whole body vibration therapy (WBV) effectively improves functional outcome in patients with poststroke hemiplegia.

MATERIALS AND METHODS

In this single-blind RCT, WBV group (n = 10) had 40 hz frequency/4 mm amplitude vibration during 5 minutes/session, 3 days a week, for a duration of 4 weeks. The control group (n = 11) had no vibration therapy for the same duration while standing on the same platform. Patients in both of the groups did 15 minutes of stretching and active range of motion exercises before the intervention. Outcome measures were Modified Ashworth Scale (MAS), Functional Independence Measurement (FIM), and Timed 10-Meter Walk Test (10 mWT).

RESULTS

Only 10 mWT improved at the 1st week (p = 0.002), 1st month (p < 0.001), and 3rd month (p < 0.001) in favor of the intervention group. There was positive correlation also between 10 mWT and ankle spasticity (p < 0.001, r = 0.931).

CONCLUSION

This study suggests that WBV therapy may be a complementary therapy in gait rehabilitation and functional outcome of the patients with calf muscle spasticity.

A clinical single blind study to investigate the immediate effects of plantar vibration on balance in patients after stroke

Balance disorder is a very common cause of disability in patients after a stroke. Vibration therapy is one of the physiotherapeutic modalities used to improve balance.

OBJECTIVE

To investigate the immediate effects of plantar vibration on balance in patients with stroke.

METHODS

In this single blind comparative study, 22 patients with stroke (8 females, 14 males; age 55.82 ± 11.87 years old) participated. Patients underwent treatment, first with the placebo vibration and 1 week later with active vibration (frequency 100 HZ, 5 min). Mini-BESTest score, Modified Modified Ashworth Scale for plantar flexor spasticity, and ankle dorsiflexion passive range of motion (PROM) were evaluated before and immediately after the placebo or active vibration.

RESULTS

A significant clinical improvement in balance, ankle plantar flexor spasticity, and the ankle dorsiflexion PROM was observed following either placebo or active vibration. The improvements after active vibration were significantly greater for all outcome measures compared with placebo vibration. There was a large effect size (Cohen's d = 0.85) for balance after active vibration.

CONCLUSION

The vibration applied to the sole of the affected foot of patients after stroke was effective for improving balance, reducing ankle plantar flexor spasticity, and increasing ankle dorsiflexion PROM.

Efficacy of mechano-acoustic vibration on strength, pain, and function in poststroke rehabilitation: a pilot study

BACKGROUND

Vibration therapy may be used to help cortical reorganization after stroke as it can cause different adaptive metabolic and mechanical effects.

OBJECTIVE

This study examined whether the application of mechano-acoustic vibration on upper limb muscles could induce changes in range of motion (ROM), function, pain, and grip strength in individuals with chronic stroke.

METHODS

Out of 52 individuals post stroke with upper limb spasticity who were eligible,16 received mechano-acoustic vibration therapy (ViSS device) 3 times weekly for 12 sessions. The frequency of vibration was set to 300 Hz for 30 minutes. The treated muscles were the extensor carpi radialis longus and brevis and triceps brachii during voluntary contraction. All participants were evaluated in both upper limbs before (T0) and at the end (T1) of treatment with a dynamometer (hand grip strength), Modified Ashworth Scale, QuickDASH, FIM score, Fugl-Meyer scale, Verbal Numerical Rating Scale of pain, and Jebsen-Taylor Hand Function Test.

RESULTS

After 4 weeks, hand grip power had improved and pain and spasticity had decreased. Improvements were recorded for all parameters and were considered statistically significant.

CONCLUSIONS

Application of vibratory stimuli to a muscle can increase the motor-evoked potential recorded from the muscle, suggesting an enhancement of corticospinal excitability. Low amplitude, high-frequency vibration treatment (300 Hz) can significantly decrease tone and pain and improve strength in upper limb of hemiplegic individuals, when applied for 30 minutes, 3 times a week over 4 weeks.

Effect of whole body vibration on spasticity in hemiplegic legs of patients with stroke

BACKGROUND

Several reports have focused on the effects of whole body vibration (WBV) on spasticity with differing results. Most studies used modified Ashworth scale (MAS) for qualitative measurements, but the effect was small.

OBJECTIVE

To investigate the effect of WBV on spasticity in hemiplegic legs of patients with stroke using F-wave parameters.

METHODS

Sixteen patients with stroke (mean age, 54.7 ± 13.5 years: time after stroke, 28.0 ± 26.3 months) were enrolled in a comparative before-and-after intervention trial. WBV was applied at 30 Hz (4-8 mm amplitude) for 5 min on the hamstrings, gastrocnemius, and soleus muscles in a sitting position. Spasticity was assessed according to the F-wave parameters, MAS, and active and passive range of motion (A-ROM and P-ROM, respectively). These assessments were obtained before, immediately after, and 20 min after each intervention.

RESULTS

The F-wave parameters, MAS score, and P-ROM improved significantly after the WBV and remained below the baseline level, even after 20 min; no such change was noted in the unaffected limb via the F-wave parameters. The WBV also improved volitional movement immediately after intervention, as indicated by the A-ROM.

CONCLUSIONS

These results confirmed a significant reduction of motor neuron excitability until 20 min after the WBV, as indicated by F-wave parameters.

Is two better than one? Muscle vibration plus robotic rehabilitation to improve upper limb spasticity and function: A pilot randomized controlled trial

Even though robotic rehabilitation is very useful to improve motor function, there is no conclusive evidence on its role in reducing post-stroke spasticity. Focal muscle vibration (MV) is instead very useful to reduce segmental spasticity, with a consequent positive effect on motor function. Therefore, it could be possible to strengthen the effects of robotic rehabilitation by coupling MV. To this end, we designed a pilot randomized controlled trial (Clinical Trial NCT03110718) that included twenty patients suffering from unilateral post-stroke upper limb spasticity. Patients underwent 40 daily sessions of Armeo-Power training (1 hour/session, 5 sessions/week, for 8 weeks) with or without spastic antagonist MV. They were randomized into two groups of 10 individuals, which received (group-A) or not (group-B) MV. The intensity of MV, represented by the peak acceleration (a-peak), was calculated by the formula (2πf)2A, where f is the frequency of MV and A is the amplitude. Modified Ashworth Scale (MAS), short intracortical inhibition (SICI), and H_max/M_max ratio (HMR) were the primary outcomes measured before and after (immediately and 4 weeks later) the end of the treatment. In all patients of group-A, we observed a greater reduction of MAS (p = 0.007, d = 0.6) and HMR (p<0.001, d = 0.7), and a more evident increase of SICI (p<0.001, d = 0.7) up to 4 weeks after the end of the treatment, as compared to group-B. Likewise, group-A showed a greater function outcome of upper limb (Functional Independence Measure p = 0.1, d = 0.7; Fugl-Meyer Assessment of the Upper Extremity p = 0.007, d = 0.4) up to 4 weeks after the end of the treatment. A significant correlation was found between the degree of MAS reduction and SICI increase in the agonist spastic muscles (p = 0.004). Our data show that this combined rehabilitative approach could be a promising option in improving upper limb spasticity and motor function. We could hypothesize that the greater rehabilitative outcome improvement may depend on a reshape of corticospinal plasticity induced by a sort of associative plasticity between Armeo-Power and MV.

The effects of vibratory stimulation employed to forearm and arm flexor muscles on upper limb function in patients with chronic stroke

[Purpose] The purpose of this study was to investigate not only the effects of stimulatory vibration but also the retained effects 2 weeks after the last session of the intervention. [Subjects and Methods] Ten subjects with post-stroke hemiplegia were recruited in this study. The experimental group (EG) received vibratory stimulation for 30 minutes in each session, three times a week for 2 weeks. Grip strength (GS), box-and-block test (BBT), and Weinstein monofilament were used to assess hand strength, dexterity, and sensory in the affected hand, respectively. [Results] A significant difference was found between the pre- and post-follow-up BBT. Significant differences were found among the pre-posttest, post-follow-up test, and pre-follow-up test results for GS and BBT. [Conclusion] This study was conducted with 10 subjects, without a control group, to verify the pure effect of the intervention. As a result, significant positive effects were observed in the post-test and follow-up test of GS and BBT. Therefore, repeated vibratory stimulation influenced GS and BBT after the 2-week intervention and retained the effect for 2 more weeks.

Effects of repeated vibratory stimulation of wrist and elbow flexors on hand dexterity, strength, and sensory function in patients with chronic stroke: a pilot study

[Purpose] The aim of this study was to investigate the effects of repeated vibratory stimulation to muscles related to hand functions on dexterity, strength, and sensory function in patients with chronic stroke. [Subjects and Methods] A total of 10 stroke patients with hemiplegia participated in this study. They were divided into two groups: a) Experimental and b) Control, with five randomly selected subjects for each group. The experimental group received vibratory stimulation, while the control group received the traditional physical therapy. Both interventions were performed for 30 minutes each session, three times a week for four weeks. [Results] There was a significant within-group improvement in the box and block test results in both groups for dexterity. Grip strength improved in both groups but the improvement was not statistically significant. [Conclusion] The vibratory stimulation activated the biceps brachii and flexor carpi radialis, which increased dexterity to grasp and lift the box and block from the surface. Therefore, repeated vibratory stimulation to muscles related to hand functions improved hand dexterity equality to the traditional physical therapy in patients with chronic stroke.

Acupuncture Reduces Excitability of Spinal Motor Neurons in Patients with Spastic Muscle Overactivity and Chronic Disorder of Consciousness Following Traumatic Brain Injury

BACKGROUND AND OBJECTIVE

Spastic hypertonia usually occurs in patients with chronic disorders of consciousness (DOC) following severe traumatic brain injury (TBI). Spinal motor neuron excitability has been reported to increase in patients with brain damage. The aim of this study was to evaluate the immediate effects of acupuncture on spinal motor neuron excitability in patients with DOC following TBI by using evoked electromyography.

SETTING AND PARTICIPANTS

Eleven male patients (mean age, 33 ± 14 years) with refractory muscle spasticity of the upper extremity accompanying chronic DOC following TBI and admitted to Chubu Medical Center for Prolonged Traumatic Brain Dysfunction were included.

DESIGN

A crossover study design was used. Changes in variables in the acupuncture session were compared with those in the control session in the same patients.

INTERVENTION

Acupuncture treatment was performed at GV 26, Ex-HN 3, bilateral LI 4, and ST 36 for 10 minutes.

OUTCOME MEASURES

F-wave was recorded from the abductor pollicis brevis muscle. The main outcome measure was F/M amplitude ratio (F-wave amplitude/M-wave amplitude), calculated as an index for spinal motor neuron excitability. F-waves were recorded before treatment (baseline), 10 minutes after needle insertion (phase 1), and 10 minutes after needle removal (phase 2). The same procedure was followed in the control session without acupuncture on a separate day.

RESULTS

F/M ratio was significantly reduced from baseline to phase 1 (p < 0.001) and phase 2 (p < 0.001) in the acupuncture session, whereas no significant changes were observed in the control session. Changes in F/M ratio from baseline to phase 1 and phase 2 were greater in the acupuncture session than the control session (p = 0.001 and <0.001, respectively).

CONCLUSION

The excitability of the spinal motor neurons in patients with DOC following TBI was reduced after acupuncture treatment, suggesting that it is beneficial for reducing spastic muscle hypertonia in these patients.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Effects of repetitive facilitative exercise with neuromuscular electrical stimulation, vibratory stimulation and repetitive transcranial magnetic stimulation of the hemiplegic hand in chronic stroke patients

AIM

Repetitive facilitative exercise (RFE) is a developed approach to the rehabilitation of hemiplegia. RFE can be integrated with neuromuscular electrical stimulation (NMES), direct application of vibratory stimulation (DAVS) and repetitive transcranial magnetic stimulation (rTMS). The aims of the present study were to retrospectively compare the effects of RFE and NMES, DAVS with those of RFE and rTMS, and to determine the maximal effect of the combination of RFE with NMES, DAVS, rTMS and pharmacological treatments in stroke patients.

SUBJECTS AND METHODS

Thirty-three stroke patients were enrolled and divided into three groups: 15 who received RFE with rTMS (4 min) (TMS4 alone), 9 who received RFE with NMES, DAVS (NMES, DAVS alone) and 9 who received RFE with NMES, DAVS and rTMS (10 min) (rTMS10 + NMES, DAVS). The subjects performed the Fugl-Meyer Assessment (FMA) and Action Research Arm Test (ARAT) before and after the 2-week session. The 18 patients in the NMES, DAVS alone and rTMS10 + NMES, DAVS group underwent the intervention for 4 weeks.

RESULT

There were no significant differences in the increases in the FMA, ARAT scores in the three groups. The FMA or ARAT scores in the NMES, DAVS alone and the rTMS10 + NMES, DAVS group were increased significantly. The FMA and ARAT scores were significantly improved after 4 weeks in the NMES, DAVS alone group.

DISCUSSION

RFE with NMES, DAVS may be more effective than RFE with rTMS for the recovery of upper-limb function. Patients who received RFE with NMES, DAVS and pharmacological treatments showed significant functional recovery.