MEDLINE Abstracts: Spasticity and Stroke
What's the latest concerning the management of stroke-related spasticity? Find out in this easy-to-navigate collection of recent MEDLINE abstracts compiled by the editors of Medscape Neurology & Neurosurgery.
Management of Spasticity in Stroke
Br Med Bull 2000;56(2):476-85
Bhakta BB
Spasticity treatment must be considered in relation to other impairments with functional goals defined prior to intervention. The effects of muscle co-contraction and involuntary limb movement associated with exaggerated cutaneous reflexes or effort as well as stretch reflex hyperexcitability need to be considered. Exacerbating factors such as pain must be identified. Physical therapy and conventional orthoses are the mainstays of spasticity management during acute rehabilitation. Botulinum toxin shows promise but needs further evaluation in the context of acute rehabilitation. Phenol chemodenervation can produce good results in spasticity refractory to standard treatments. Muscle strengthening exercises may be appropriate in chronic hemiparesis without adversely affecting tone. Electrical stimulation may be a useful adjunct to other spasticity treatments. Difficulty demonstrating functional benefit from antispasticity treatment may imply that interventions directed at single motor impairments whether weakness or spasticity are not likely to result in functional benefit, but it is their combination that is important.
Electrical Stimulation for Preventing and Treating Post-Stroke Shoulder Pain (Cochrane Review)
Cochrane Database Syst Rev 2000;4:CD001698
Price CI, Pandyan AD
Background: Shoulder pain after stroke is common and disabling. The optimal management is uncertain, but electrical stimulation (ES) is often used to treat and prevent pain.
Objectives: The objective of this review was to determine the efficacy of any form of surface ES in the prevention and / or treatment of pain around the shoulder at any time after stroke.
Search Strategy: We searched the Cochrane Stroke Review Group trials register and undertook further searches of MEDLINE, EMBASE and CINAHL. Contact was established with equipment manufacturers and centres that have published on the topic of ES.
Selection Criteria: We considered all randomised trials that assessed any surface ES technique (functional electrical stimulation (FES), transcutaneous electrical nerve stimulation (TENS) or other), applied at any time since stroke for the purpose of prevention or treatment of shoulder pain.
Data Collection and Analysis: Two reviewers independently selected trials for inclusion, assessed trial quality and extracted the data.
Main Results: Four trials (a total of 170 subjects) fitted the inclusion criteria. Study design and ES technique varied considerably, often precluding the combination of studies. Population numbers were small. There was no significant change in pain incidence (Odds Ratio (OR) 0.64; 95% CI 0.19 to 2.14) or change in pain intensity (Standardised Mean Difference (SMD) 0.13; 95% CI -1.0 to 1.25) after ES treatment compared to control. There was a significant treatment effect in favour of ES for improvement in pain-free range of passive humeral lateral rotation (Weighted Mean Difference (WMD) 9.17; 95% CI 1.43 to 16.91). In these studies ES reduced the severity of glenohumeral subluxation (SMD -1.13; 95% CI -1.66 to -0.60), but there was no significant effect on upper limb motor recovery (SMD 0.24; 95% CI -0.14 to 0.62) or upper limb spasticity (WMD 0.05; 95% CI -0.28 to 0.37). There did not appear to be any negative effects of electrical stimulation at the shoulder.
Reviewer's Conclusions: The evidence from randomised controlled trials so far does not confirm or refute that ES around the shoulder after stroke influences reports of pain, but there do appear to be benefits for passive humeral lateral rotation. A possible mechanism is through the reduction of glenohumeral subluxation. Further studies are required.
Short-Term Effects of Dynamic Lycra Splints on Upper Limb in Hemiplegic Patients
Arch Phys Med Rehabil 2000 Dec;81(12):1547-55
Gracies JM, Marosszeky JE, Renton R, Sandanam J, Gandevia SC, Burke D
Objective: To assess acceptability, effects on swelling, resting posture, spasticity, and active (AROM) and passive range of motion (PROM) of individually tailored upper limb Lycra garments, designed as dynamic splints to exert directional pull on certain limb segments, when worn for 3 hours by hemiplegic patients.
Design: Crossover trial.
Setting: Outpatient and inpatient rehabilitation center.
Patients: Convenience sample of 16 patients with hemiparesis and upper limb spasticity caused by a stroke more than 3 weeks before the study. INTERVENTIONS: Assessments performed at the start and end of a 3-hour period during a standard rehabilitation day when the patients were and were not wearing the garment.
Main Outcome Measures: (1) Comfort assessed by questionnaire; (2) circumference of each limb segment; (3) resting posture at elbow and wrist; (4) spasticity at shoulder, elbow, and wrist using the Tardieu scale; and (5) AROM and PROM at shoulder, elbow, and wrist measured using a goniometer; (6) elbow proprioception using McCloskey's method; (7) visual neglect syndrome using the line bisection test. Differences between changes occurring with and without the garment were compared using Wilcoxon's signed rank test for ordinal variables (spasticity grading) and Student's t test for continuous variables (all other data).
Results: During 3 hours, garments worn on the arm by patients with hemiplegia (1) were comfortable, (2) improved wrist posture and reduced wrist and finger flexor spasticity, (3) reduced swelling in patients with swollen limbs (digit circumference decreased by 4%; p<.01), (4) improved PROM at shoulder (mean increase in range, 4.1 degrees +/- 13.0 degrees per shoulder movement; p<.01); and (5) impaired ability to flex fingers (range of voluntary flexion of digit III reduced from 107.3 degrees +/-79.6 degrees to 91.4 degrees +/-74.1 degrees; p<.05).
Conclusion: Lycra garments, designed to produce continuous stretch of spastic muscles when worn for several hours each day, have rapid splinting and antispastic effects on wrist and fingers in patients with hemiplegia. These garments may help severely affected patients with major spasticity or painful swollen limbs.
A Randomized, Double-Blind, Placebo-Controlled, Dose-Ranging Study to Compare the Efficacy and Safety of three Doses of Botulinum Toxin Type A (Dysport) With Placebo In Upper Limb Spasticity After Stroke
Stroke 2000 Oct;31(10):2402-6
Bakheit AM, Thilmann AF, Ward AB, Poewe W, Wissel J, Muller J, et al.
Background and Purpose-We sought to define an effective and safe dose of botulinum toxin type A (Dysport) for the treatment of upper limb muscle spasticity due to stroke.
Methods:-This was a prospective, randomized, double-blind, placebo-controlled, dose-ranging study. Patients received either a placebo or 1 of 3 doses of Dysport (500, 1000, 1500 U) into 5 muscles of the affected arm. Efficacy was assessed periodically by the Modified Ashworth Scale and a battery of functional outcome measures.
Results:-Eighty-three patients were recruited, and 82 completed the study. The 4 study groups were comparable at baseline with respect to their demographic characteristics and severity of spasticity. All doses of Dysport studied showed a significant reduction from baseline of muscle tone compared with placebo. However, the effect on functional disability was not statistically significant and was best at a dose of 1000 U. There were no statistically significant differences between the groups in the incidence of adverse events.
Conclusions:-The present study suggests that treatment with Dysport reduces muscle tone in patients with poststroke upper limb spasticity. Treatment was effective at doses of Dysport of 500, 1000, and 1500 U. The optimal dose for treatment of patients with residual voluntary movements in the upper limb appears to be 1000 U. Dysport is safe in the doses used in this study.
Functional and Clinical Changes in Upper Limb Spastic Patients Treated With Botulinum Toxin
Funct Neurol 2000 Jul-Sep;15(3):147-55
Panizza M, Castagna M, di Summa A, Saibene L, Grioni G, Nilsson J
Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks. In order to study the usefulness of botulinum toxin type A (BTX) as a therapy for spasticity, we studied 15 patients affected by spasticity secondary to stroke. Tests included: clinical evaluation of tone (Ashworth scale); active angles of extension and flexion at elbow and wrist; Hmax/Mmax ratio from flexor carpi radialis (FCR); Hreflex presynaptic inhibition from FCR during vibration; Task score; and video recording. Patients were injected with BTX into one or more muscles with total doses not exceeding 200 International Units (IU). The tests were performed immediately prior to injection and repeated 2 weeks afterwards. Furthermore, in eight patients, testing was also performed one month after BTX injection. Between two weeks and one month after BTX there were no statistically significant differences. A statistically significant difference in the Task and Ashworth scores before and after treatment emerged (p < 0.0014), but only 6 patients showed a clear improvement in motor performance. Overall, we observed an improvement in the angle of active extension and flexion at the wrist and elbow. There were no significant changes in the Hmax/Mmax ratio and the Hreflex presynaptic inhibition during vibration. All the patients reported a subjective improvement. The results suggest that subjective benefits can be gained from the use of BTX in patients affected by spasticity, and that the degree of motor improvement seems to depend on the motor recovery obtained before treatment.
Impact of Botulinum Toxin Type A on Disability and Carer Burden Due to Arm Spasticity After Stroke: A Randomised Double Blind Placebo Controlled Trial
J Neurol Neurosurg Psychiatry 2000 Aug;69(2):217-21
Bhakta BB, Cozens JA, Chamberlain MA, Bamford JM
Objectives: After stroke, abnormal arm posture due to spasticity in a functionally useless arm may interfere with self care tasks. In these patients botulinum toxin treatment presents an opportunity to reduce disability. The purpose was to investigate whether reduction in spasticity after botulinum toxin treatment translates into reduction in disability and carer burden.
Methods: Forty patients with stroke with spasticity in a functionally useless arm (median duration 3.1 years) were randomised to receive intramuscular botulinum toxin type A (BT-A; Dysport) (n=20) or placebo (n=20) in a total dose of 1000 MU divided between elbow, wrist, and finger flexors. Spasticity (using the modified Ashworth scale), muscle power, joint movement, and pain were assessed. Disability and carer burden were measured using an eight item and a four item scale respectively. Two baseline and three post-treatment assessments (weeks 2, 6, and 12) were made. Concurrent treatments as far as possible remained unchanged and not optimised.
Results: Disability improved at week 6 with BT-A compared with placebo. This effect, present at week 2, wore off by week 12. Reduction in carer burden was seen at week 6 with BT-A and continued for at least 12 weeks. Forearm flexor spasticity was reduced with BT-A up to 12 weeks after treatment. Although significant improvement in elbow flexor spasticity was seen at week 2 with BT-A compared with placebo, this effect was not evident at weeks 6 and 12. Arm pain was not improved after BT-A. Grip strength was reduced with BT-A. No serious BT-A related adverse effects were reported.
Conclusion: BT-A is useful for treating patients with stroke who have self care difficulties due to arm spasticity. The decision to treat should also include relief of carer burden. As muscle weakness may occur, its potential impact on functional activities must be assessed before intervention.
Post-Stroke Spasticity Management With Repeated Botulinum Toxin Injections in the Upper Limb
Am J Phys Med Rehabil 2000 Jul-Aug;79(4):377-84; quiz 391-4
Lagalla G, Danni M, Reiter F, Ceravolo MG, Provinciali L
Objective: Although the botulinum toxin A (BTX-A) treatment has proved effective in spasticity management, no information is available with regard to the effects of repeated injections over time.
Design: To evaluate the effects of BTX-A on moderate or severe upper limb spasticity, an exploratory investigation was performed on 28 stroke patients treated for 2 yr or longer and observed for 3 yr. Every 3 to 5 mo, each patient received BTX-A injections in upper limb muscles. The assessment, performed before and 1 mo after each injection for a median of 28 mo, included technical and functional objectives and the burden of care. The former were evaluated by using the modified Ashworth Scale for spasticity and the goniometric measurement of rest position and range of motion; functional objectives were evaluated by means of the Frenchay Arm Test and a patient/caregiver goals assessment scale.
Results: BTX-A treatment was followed by an improvement in all technical outcome measures. Motor dexterity scores improved in only 8 of 28 patients, vs. daily living activities, which increased in all subjects. Although the average dosage injected per session did not change, intervals between injections became longer. No relationship between either spasticity onset or residual motoricity and response to treatment could be found.
Conclusions: This investigation is relevant clinically because repeated BTX-A injections show unchanging effectiveness in the management of focal spasticity after stroke.
Quantitative Measures of Spasticity in Post-Stroke Patients
Clin Neurophysiol 2000 Jun;111(6):1015-22
Pisano F, Miscio G, Del Conte C, Pianca D, Candeloro E, Colombo R
Objective: Quantitative evaluation of muscle tone in post-stroke patients; correlation of biomechanical indices with conventional clinical scales and neurophysiological measures; characterization of passive and neural components of muscle tone.
Methods: Mechanical stretches of the wrist flexor muscles of 53 post-stroke patients were imposed by means of a torque motor at constant speed. Patients were clinically studied using the Ashworth scale for spasticity and the Medical Research Council score for residual muscle strength. The neurophysiological measures were Hoffmann reflex latency, Hmax/Mmax ratio, stretch reflex threshold speed (SRTS), stretch reflex (SR) latency and area, passive (ISI) and total (TSI) stiffness indices.
Results: Hmax/Mmax ratio, SR area, ISI and TSI values were significantly higher in patients, while SRTS was significantly lower. TSI, SRTS and SR area were highly correlated to the Ashworth score.
Conclusions: This EMG-biomechanical technique allows an objective evaluation of changes in muscle tone in post-stroke patients, providing easily measurable, quantitative indices of muscle stiffness. The linear distribution of these measures is particularly indicated for monitoring changes induced by treatment. The apparatus seems suitable to characterize neural stiffness, while difficulties were found in isolating the passive components, because of the occurrence of tonic EMG activity in most spastic patients.
Low TENS Treatment on Post-Stroke Paretic Arm: A Three-Year Follow-Up
Clin Rehabil 2000 Feb;14(1):14-9
Sonde L, Kalimo H, Fernaeus SE, Viitanen M
Objective: To determine whether stroke patients with initial increases in arm motor recovery following low-frequency transcutaneous electrical nerve stimulation (low TENS) treatment go on to show long-term benefits. Also whether the same therapy results in long-term improvements in motor function, spasticity or activities of daily living (ADL).
Design: A three-year follow-up study. SUBJECTS: Twenty-eight stroke patients, who had participated in a randomized trial of daily treatment with low-frequency (1.7 Hz) transcutaneous electrical nerve stimulation (low TENS) on the paretic arm for three months starting 6-12 months after stroke. OUTCOMES: Fugl-Meyer Motor Performance Scale for evaluation of changes in arm motor function. A 6-point Ashworth Scale to measure spasticity. Barthel Index to evaluate performance in ADL.
Results: Motor function of the paretic arm had deteriorated in both treatment and control groups. Increased spasticity was seen in both groups. ADL score remained at a similar level in the low TENS group, whereas the control group had deteriorated during the same time period.
Conclusions: Low TENS stimulation started 6-12 months after stroke may not have a specific effect on arm motor function years after completion of treatment.
Hybrid Functional Electrical Stimulation Orthosis System for the Upper Limb: Effects on Spasticity in Chronic Stable Hemiplegia
Am J Phys Med Rehabil 1998 Jul-Aug;77(4):276-81
Weingarden HP, Zeilig G, Heruti R, Shemesh Y, Ohry A, Dar A, et al.
A new hybrid functional electrical stimulation orthosis system for the upper limb has been designed to allow for ease of use in the home as a daily treatment modality, as well as offer the opportunity for function enhancement. In a pilot study, the system was used by ten patients with chronic stable hemiparesis secondary to cerebral vascular accident and head injuries. The patients were referred by their treating physicians or therapists after meeting the inclusion criteria of good general health, being greater than one year after head injury, or being ten months post-stroke, with no observed neurologic changes in the prior six weeks. Each of these patients had received prolonged physical therapy, either continuous from the initial inpatient rehabilitation treatment or on an intermittent basis over a period of years. The baseline status for factors related to increased muscle tone, i.e., passive range of motion at the wrist and elbow, posture at rest, posture immediately following activity, and spasticity were quantified before the treatment protocol with the functional electrical stimulation orthosis. Active range of motion and tests of functional use of the involved upper limb were also assessed. The patients were instructed in the protocol, trained in the use of the system, and then used the electrical orthosis at home for up to several hours per day. Follow-up assessments were at six months. A statistically significant improvement was noted in all muscle tone/spasticity parameters measured. A separate report will describe the effects on voluntary motion and functional capabilities