Effects of sit-to-stand training combined with transcutaneous electrical stimulation on spasticity, muscle strength and balance ability in patients with stroke: A randomized controlled study. Inter-rater reliability of the Modified Modified Ashworth Scale as a clinical tool in measurements of post-stroke elbow flexor spasticity. A single trial of transcutaneous electrical nerve stimulation (TENS) improves spasticity and balance in patients with chronic stroke. Effectiveness of neuromuscular taping on painful hemiplegic shoulder: a randomised clinical trial Effects of repetitive transcranial magnetic stimulation on lower extremity spasticity and motor function in stroke patients Occurence and Clinical Predictors of Spasticity After Ischemic Stroke Impact of botulinum toxin type A on disability and carer burden due to arm spasticity after stroke: a randomised double blind placebo controlled trial The relation between Ashworth scores and neuromechanical measurements of spasticity following stroke Effects of surface electrical stimulation on the muscle–tendon junction of spastic gastrocnemius in stroke patients A controlled trial of teaching critical appraisal of the clinical literature to medical students. Predicting accidental falls in people with multiple sclerosis — a longitudinal study Critical Appraisal Turkey Shoot: Linking Critical Appraisal to Clinical Decision Making The effect of quadriceps femoris muscle strengthening exercises on spasticity in children with cerebral palsy. Effects of a 6-month self-rehabilitation programme in addition to botulinum toxin injections and conventional physiotherapy on limitations of patients with spastic hemiparesis following stroke (ADJU-TOX): protocol study for a randomised controlled, investigator blinded study Treatment of human spasticity with delta 9-tetrahydrocannabinol. The journal club in postgraduate medical education: a systematic review Rationale and design of a multicentre, double-blind, prospective, randomized, European and Canadian study: evaluating patient outcomes and costs of managing adults with post-stroke focal spasticity. Effect of Transcutaneous Electrical Nerve Stimulation on Plantar Flexor Muscle Spasticity and Walking Speed in Stroke Patients. The Role of Kinesiotaping Combined With Botulinum Toxin to Reduce Plantar Flexors Spasticity After Stroke Goal attainment scaling in the evaluation of treatment of upper limb spasticity with botulinum toxin: a secondary analysis from a double-blind placebo-controlled randomized clinical trial. Botulinum toxin type A and short-term electrical stimulation in the treatment of upper limb flexor spasticity after stroke: a randomized, double-blind, placebo-controlled trial Transcutaneous Electrical Nerve Stimulation Combined With Task-Related Training Improves Lower Limb Functions in Subjects With Chronic Stroke The effects of whole-body vibration therapy on bone turnover, muscle strength, motor function, and spasticity in chronic stroke: a randomized controlled trial.
Sit-to-st and is a fundamental movement of human being for performing mobility and independent activity . However , Stroke people symptoms experience difficulty in conducting the sit-to-st and due to paralysis and especially ankle spasticity . Recently , transcutaneouselectrical- stimulation ( TENS ) is used to reduce pain but also to manage spasticity . The purpose of this study was to determine ( 1 ) whether TENS would lead to ankle spasticity reduction and ( 2 ) whether sit-to-st and training combined with TENS would improve spasticity , muscle strength and balance ability in stroke patients . Forty-stroke patients were recruited and were r and omly divided into two groups : TENS group ( n=20 ) and sham group ( n=20 ) . All participants underwent 30-sessions of sit-to-st and training ( for 15-min , five-times per week for 6-weeks ) . Prior to each training session , 30-min of TENS over the peroneal nerve was given in TENS group , whereas sham group received non-electrically stimulated TENS for the same amount of time . Composite-Spasticity-Score was used to assess spasticity level of ankle plantar-flexors . Isometric strength in the extensor of hip , knee and ankle were measured by h and held dynamometer . Postural-sway distance was measured using a force platform . The spasticity score in the TENS group ( 2.6±0.8 ) improved significantly greater than the sham group ( 0.7±0.8 , p<0.05 ) . The muscle strength of hip extensor in the TENS group ( 2.7±1.1 kg ) was significantly higher than the sham group ( 1.0±0.8 kg , p<0.05 ) . Significant improvement in postural-sway was observed in the TENS group compared to the sham group ( p<0.05 ) . Thus , sit-to-st and training combined with TENS may be used to improve the spasticity , balance function and muscle strength in stroke patients Patients with neurological conditions may be affected by spasticity . The Modified Modified Ashworth Scale ( MMAS ) is a clinical tool used to measure spasticity . The purpose of the present study was to investigate the inter-rater reliability of the MMAS during the assessment of elbow flexor spasticity in adult patients with post-stroke hemiplegia . Twenty-one adult patients with stroke ( 5 women , 16 men ) with a median age of 60 years ( interquartile range , 47 - 68 ) were tested . Elbow flexors on the affected side were examined . Inter-rater reliability for two inexperienced raters was very good . The weighted Kappa value was 0.81 ( St and ard Error = 0.097 , 95 % CI : 0.62 - 1.00 , p = 0.0002 ) . The weighted percentage agreement was 97.4 % . The agreement between raters occurred mostly on score 1 ( 38.1 % ) followed by score 0 ( 23.8 % ) . The MMAS yielded reliable measurements between raters when used on patients post-stroke with elbow flexor spasticity Spasticity management is pivotal for achieving functional recovery of stroke patients . The purpose of this study was to investigate the effects of a single trial of transcutaneous electrical nerve stimulation ( TENS ) on spasticity and balance in chronic stroke patients . Forty-two chronic stroke patients were r and omly allocated into the TENS ( n = 22 ) or the placebo-TENS ( n = 20 ) group . TENS stimulation was applied to the gastrocnemius for 60 min at 100 Hz , 200 µs with 2 to 3 times the sensory threshold ( the minimal threshold in detecting electrical stimulation for subjects ) after received physical therapy for 30 min . In the placebo-TENS group , electrodes were placed but no electrical stimulation was administered . For measuring spasticity , the resistance encountered during passive muscle stretching of ankle joint was assessed using the Modified Ashworth Scale , and the H and held dynamometer was used to assess the resistive force caused by spasticity . Balance ability was measured using a force platform that measures postural sway generated by postural imbalance . The TENS group showed a significantly greater reduction in spasticity of the gastrocnemius , compared to the placebo-TENS group ( p < 0.05 ) . TENS result ed in greater balance ability improvements , especially during the eyes closed condition ( p < 0.05 ) . However , these effects returned to baseline values within one day . This study shows that TENS provides an immediately effective means of reducing spasticity and of improving balance in chronic stroke patients . The present data may be useful to establish the st and ard parameters for TENS application in the clinical setting of stroke Abstract Purpose : The purpose of this trial was to investigate changes in pain , the range of motion ( ROM ) and spasticity in people with painful hemiplegic shoulder ( PHS ) after the application of an upper limb neuromuscular taping ( NMT ) . Methods : We conducted a r and omised clinical trial . The study included 32 people , 31 % female ( mean ± SD age : 66 ± 9 years ) , with PHS after stroke with pain at rest and during functional movements . The experimental group received the application of NMT and a st and ard physical therapy programme ( SPTP ) , whereas the control group received SPTP . The groups received four 45-minute long sessions over four weeks . The VAS , ROM and spasticity were assessed before and after the intervention with follow-up at four weeks . Results : The experimental group had a greater reduction in pain compared to the control group at the end of the intervention , as well as at one month after the intervention ( p < 0.001 ; all the group differences were greater than 4.5 cm , which is greater than the minimal clinical ly important difference of 2.0 cm ) . The experimental group had a significantly higher ( i.e. better ) ROM , by 30.0 ° , than the control group in shoulder flexion ( 95 % CI : 37.3–22.7 ) at 4 weeks and by 24.8 ° ( 95 % CI : 32.1–17.6 ) at 8 weeks as well as in abduction by 30.6 ° ( 95 % CI : 37.5–23.7 ) at 4 weeks and 25.1 ° ( 95 % CI : 33.8–16.3 ) at 8 weeks . Conclusion : Our study demonstrates that NMT decreases pain and increases the ROM in subjects with shoulder pain after a stroke . Implication s for Rehabilitation Painful hemiplegic shoulder is a frequent complication after stroke with negative impacts on functional activities and on quality of life of people , moreover restricts rehabilitation intervention . Neuromuscular taping is a technique introduced by David Blow for the treatment of neuromuscoloskeletal problems . This study shows the reduction of pain and the improvement of range of motion after the application of an upper limb neuromuscular taping . Rehabilitation professionals who are involved in the management of painful hemiplegic shoulder may like to consider the benefits that neuromuscular taping can produce on upper limb Abstract Purpose : To investigate the effect of low-frequency repetitive transcranial magnetic stimulation ( rTMS ) on lower extremity ( LE ) spasticity , motor function and motor neurone excitability in chronic stroke patients . Method : This study was a r and omised sham-controlled cross-over trial with 1-week follow-up . A total of 20 post-stroke patients were r and omised to receive active ( n = 10 ) or sham ( n = 10 ) rTMS . Fourteen of them ( 7 in each group ) crossed over to the sham or active rTMS after a washout period of 1 month . Interventions consist of five consecutive daily sessions of active or sham rTMS to the unaffected lower extremity motor area ( 1000 pulses ; 1 Hz ; 90 % of the tibialis anterior motor threshold ) . Outcome measures were modified modified ashworth scale ( MMAS ) , the H-reflex , lower extremity section of Fugl – Mayer assessment ( LE-FMA ) and timed UP and GO ( TUG ) test . All outcomes were measured at three levels in each intervention period : pre- and post-intervention and 1-week follow-up . Results : Friedman ’s test revealed significant improvement in MMAS score only after active rTMS . This improvement lasted for one week after the active rTMS . Repeated measure analysis of variance ( ANOVA ) showed significant time*intervention interaction for LE-FMA . There are no differences between groups for the MMAS and LE-FMA . No significant change in Hmax/Mmax ratio and TUG test was noted . Conclusion : Low-frequency rTMS over the LE motor area can improve clinical measures of muscle spasticity and motor function . More studies are needed to clarify the changes underlying this improvement in spasticity . Implication s for Rehabilitation Spasticity is a common disorder and one of the causes of long-term disability after stroke . Physical therapy modalities , oral medications , focal intervention and surgical procedures have been used for spasticity reduction . Beneficial effect of the repetitive transcranial magnetic stimulation ( rTMS ) for post-stroke upper extremity spasticity reduction and motor function improvement was demonstrated in previous studies . This study shows amelioration of lower extremity spasticity and motor function improvement after five daily sessions of inhibitory rTMS to the unaffected brain hemisphere which lasted for at least 1 week following the intervention Background and Purpose — There is currently no consensus on ( 1 ) the percentage of patients who develop spasticity after ischemic stroke , ( 2 ) the relation between spasticity and initial clinical findings after acute stroke , and ( 3 ) the impact of spasticity on activities of daily living and health-related quality of life . Methods — In a prospect i ve cohort study , 301 consecutive patients with clinical signs of central paresis due to a first-ever ischemic stroke were examined in the acute stage and 6 months later . At both times , the degree and pattern of paresis and muscle tone , the Barthel Index , and the EQ-5D score , a st and ardized instrument of health-related quality of life , were evaluated . Spasticity was assessed on the Modified Ashworth Scale and defined as Modified Ashworth Scale > 1 in any of the examined joints . Results — Two hundred eleven patients ( 70.1 % ) were reassessed after 6 months . Of these , 42.6 % ( n=90 ) had developed spasticity . A more severe degree of spasticity ( Modified Ashworth Scale ≥3 ) was observed in 15.6 % of all patients . The prevalence of spasticity did not differ between upper and lower limbs , but in the upper limb muscles , higher degrees of spasticity ( Modified Ashworth Scale ≥3 ) were more frequently ( 18.9 % ) observed than in the lower limbs ( 5.5 % ) . Regression analysis used to test the differences between upper and lower limbs showed that patients with more severe paresis in the proximal and distal limb muscles had a higher risk for developing spasticity ( P≤0.001 ) . Spasticity of the upper and lower limb was more frequent in patients with hemihypesthesia than in patients without sensory deficits ( P≤0.001 ) . Patients with spasticity showed a lower Barthel Index and EQ-5D score compared with the group without spasticity . Conclusions — Spasticity was present in 42.6 % of patients with initial central paresis . However , severe spasticity was relatively rare . Predictors for the development of spasticity were a severe degree of paresis and hemihypesthesia at stroke onset 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 r and omised 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 assessment s ( 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 Background Spasticity is a common impairment that follows stroke , and it results typically in functional loss . For this reason , accurate quantification of spasticity has both diagnostic and therapeutic significance . The most widely used clinical assessment of spasticity is the modified Ashworth scale ( MAS ) , an ordinal scale , but its validity , reliability and sensitivity have often been challenged . The present study addresses this deficit by examining whether quantitative measures of neural and muscular components of spasticity are valid , and whether they are strongly correlated with the MAS . Methods We applied abrupt small amplitude joint stretches and Pseudor and om Binary Sequence ( PRBS ) perturbations to both paretic and non-paretic elbow and ankle joints of stroke survivors . Using advanced system identification techniques , we quantified the dynamic stiffness of these joints , and separated its muscular ( intrinsic ) and reflex components . The correlations between these quantitative measures and the MAS were investigated . Results We showed that our system identification technique is valid in characterizing the intrinsic and reflex stiffness and predicting the overall net torque . Conversely , our results reveal that there is no significant correlation between muscular and reflex torque/stiffness and the MAS magnitude . We also demonstrate that the slope and intercept of reflex and intrinsic stiffnesses plotted against the joint angle are not correlated with the MAS . Conclusion Lack of significant correlation between our quantitative measures of stroke effects on spastic joints and the clinical assessment of muscle tone , as reflected in the MAS suggests that the MAS does not provide reliable information about the origins of the torque change associated with spasticity , or about its contributing components Purpose : The purpose of this study was to explore the effects of spasticity suppression by surface electrical stimulation ( ES ) on the muscle – tendon junction of spastic gastrocnemius muscles in stroke . Methods : Twenty-four neurologically stable stroke patients ( aged 41 – 69 years , 12 – 35 months post-stroke ) , with spasticity grade d 2 or 3 on the modified Ashworth scale , were recruited and divided into two groups . In the ES group , each patient received 20 min of surface ES once daily , 6 days per week for 1 month . In the control group , ES was used with stimulation intensity kept at zero . To evaluate the therapeutic effect , the modified Ashworth scale , Fmax/Mmax ratio , H-reflex latency , H-reflex recovery curve , and the 10-m walking time were tested before and after the 1-month treatment . Results : In the ES group , the modified Ashworth Scale showed a trend toward reduced spasticity after 1 month of treatment . The Fmax/Mmax ratio decreased from 8.10 % ± 4.84 % to 4.00 % ± 1.36 % ; the H-reflex latency increased from 28.87 ± 2.45 ms to 29.40 ± 2.57 ms ; the H-reflex recovery curves indicated a downward shift ; and the 10-metre walking time significantly decreased after ES . In the control group , none of the measures showed a statistically significant change . Conclusions : In the study , we demonstrated a way to suppress spasticity at a metameric site and to increase walking speed effectively by applying surface ES on the muscle – tendon junction of spastic gastrocnemius muscles We carried out a controlled trial of teaching the critical appraisal of clinical literature among final-year clinical clerks . Tutors at two of four teaching hospitals were offered a short course in the critical appraisal of clinical articles that describe diagnostic tests and treatments and were assisted in identifying and appraising specialty-specific articles that described those diagnostic tests and treatments that clinical clerks were sure to encounter during their clerkship tutorials . Tutors and clerks at the other two hospitals received no special intervention and served as controls . Experimental and control clinical clerks completed pretests and posttests of their ability to take and defend a st and on whether to apply specific diagnostic tests and treatments in specific clinical situations . Experimental clerks demonstrated both statistically and " clinical ly " significant increases in their critical appraisal skills , improving 37 % on the diagnostic test exercise and 8 % on the treatment exercise ; control students ' scores deteriorated for both Objective : To investigate accidental falls and near fall incidents in people with multiple sclerosis with respect to clinical variables and the predictive values of four tests . Design : A longitudinal , multi-centred cohort study with prospect ively collected falls . Procedures : Self-reported incidents during the three months following a st and ardized test procedure . Subjects : Seventy-six people with multiple sclerosis and an Exp and ed Disability Status Scale score between 3.5 and 6.0 . Main outcome measures : Berg Balance Scale , Timed Up and Go cognitive , Four Square Step Test ( FSST ) and 12-item Multiple Sclerosis Walking Scale . Results : Forty-eight people ( 63 % ) registered 270 falls . Most falls occurred indoors during activities of daily life . We found a correlation of rs=0.57 between near falls and falls , and of rs = 0.82 between registered and retrospectively recalled falls . Fallers and non-fallers differed significantly regarding Exp and ed Disability Status Score ( odds ratio ( OR ) 1.99 , 95 % confidence interval ( CI ) 1.22 ; 3.40 ) , spasticity ( OR 1.14 , CI 1.02 ; 1.31 ) , proprioception ( OR 2.50 , CI 1.36 ; 5.12 ) and use of walking aids ( OR 2.27 , CI 1.23 ; 4.37 ) . Reported use of walking aids both indoors and outdoors increased the odds of falling fivefold while disturbed proprioception increased the odds 2.5—15.6 times depending on severity . The odds of falling were doubled for each degree of increased Exp and ed Disability Status Score and more than doubled for each degree of increased spasticity . The Berg Balance Scale , use of walking aids and Timed Up and Go cognitive best identified fallers ( 73—94 % ) and proprioception , Exp and ed Disability Status Score , 12-item Multiple Sclerosis Walking Scale and Four Square Step Test best identified non-fallers ( 75—93 % ) . Conclusions : In clinical practice , looking at the use of walking aids , investigating proprioception and spasticity , rating Exp and ed Disability Status Score and using Berg Balance Scale or Timed Up and Go cognitive all contribute when identifying fallers Since the publication of Physicians for the Twenty-First Century —‘‘the GPEP Report ’ ’ of 1984 , medical educators have identified the need for physicians to become lifelong learners . Part of the impetus for this conclusion arises from several studies that have demonstrated that knowledge and /or competence of physicians  decline as a function of time since graduation ; the evidence indicates the cause to be failure to acquire new knowledge rather than a tendency to forget previously learned material . Thus , physicians need to be trained to identify the relevant medical literature ( i.e. , information-seeking skills ) and to apply ‘ ‘ critical appraisal ’’ techniques to analyze potentially useful articles culled from the literature search . There is little published evidence that educational interventions around critical appraisal teaching in undergraduate or postgraduate medical curricula impact in a sustained way the knowledge of epidemiologic principles or the critical application of current research information for clinical decision making . In considering the impact on conceptual knowledge , one could argue that there is a lack of vali date d tools available for evaluating critical appraisal skills ; alternatively , the format of instruction , timing in the curriculum , and duration of instruction may be at fault . More important , studies have not addressed the issue of whether the demonstration of mastery of particular critical appraisal skills can be related to clinical decision making . Ultimately , such mastery becomes largely irrelevant if it does not translate into better judgment . The authors of this study were concerned that , despite the inclusion in the first-year undergraduate curriculum of several focused objectives surrounding critical appraisal in the domain of clinical epidemiology , feedback from clinical faculty suggested that students had only rudimentary knowledge of the application of these principles at the end of the first year . In contrast to this feedback , problem-based learning ( PBL ) is believed to hold the potential to equip graduates with the skills to learn after graduation . In fact , several studies have shown significant differences between students of PBL  and students of conventional curricula in the use of recently published medical literature . With this inconsistency in mind , two experimental questions were asked BACKGROUND AND PURPOSE The Bobath neurodevelopmental treatment approach advised against the use of resistive exercise , as proponents felt that increased effort would increase spasticity . The purpose of this study was to test the premise that the performance of exercises with maximum efforts will increase spasticity in people with cerebral palsy ( CP ) . Spasticity , in the present study , was defined as a velocity-dependent hyperexcitability of the muscle stretch reflex . SUBJECTS Twenty-four subjects with the spastic diplegic form of CP ( mean age=11.4 years , SD=3.0 , range=7 - 17 ) and 12 subjects without known neurological impairments ( mean age=11.6 years , SD=3.5 , range=7 - 17 ) were assessed . METHODS Knee muscle spasticity was assessed bilaterally using the pendulum test to elicit a stretch reflex immediately before and after 3 different forms of right quadriceps femoris muscle exercise ( isometric , isotonic , and isokinetic ) during a single bout of exercise training . Pendulum test outcome measures were : ( 1 ) first swing excursion , ( 2 ) number of lower leg oscillations , and ( 3 ) duration of the oscillations . RESULTS There were no changes in spasticity following exercise between the 2 groups of subjects . DISCUSSION AND CONCLUSION These results do not support the premise that exercises with maximum efforts increase spasticity in people with CP Introduction Home-based self-rehabilitation programmes combined with botulinum toxin injections ( BTIs ) appear to be a relevant approach to increase the recommended intensive rehabilitation of patients with spasticity following a stroke . The literature highlights a lack of evidence of beneficial effects of this adjuvant therapy to reduce limitations of patients with stroke . The aim of this study is to assess the effects of a 6-month self-rehabilitation programme in adjunction to BTI , in comparison with BTI alone , to reduce limitations of patients with spasticity following a stroke . Methods and analysis 220 chronic patients will participate to this multicentre , prospect i ve , r and omised , controlled , assessor blinded study . All patients will benefit from two successive BTI ( 3 months apart ) , and patients r and omised in the self-rehabilitation group will perform in adjunction 6 months of self-rehabilitation at home . All patients continue their conventional physiotherapy . The main outcome is the primary treatment goal ( PTG ) , which will be determined jointly by the patient and the medical doctor using Goal Attainment Scaling . Impairments and functions , quality of life , mood and fatigue will be assessed . Botulinum toxin will be injected into the relevant muscles according to the PTG . Patients in the self-rehab group will be taught the self-rehabilitation programme involving respectively 10 min of stretching , 10 min of strengthening and 10 min of task-oriented exercises , corresponding to their PTG . Compliance to the self-rehabilitation programme will be monitored . Ethics and dissemination Patients will sign written informed consent . Ethical approval was obtained from ethics committee . The results will be disseminated in a peer- review ed journal and presented at international congresses . The results will also be disseminated to patients . Trial registration number NCT02944929 Spasticity is a common neurologic condition in patients with multiple sclerosis , stroke , cerebral palsy or an injured spinal cord . Animal studies suggest that THC has an inhibitory effect on polysynaptic reflexes . Some spastic patients cl aim improvement after inhaling cannabis . We tested muscle tone , reflexes , strength and performed EMGs before and after double-blinded oral administration of either 10 or 5 mg THC or placebo . The blinded examiner correctly identified the trials in which the patients received THC in seven of nine cases . For the group , 10 mg THC significantly reduced spasticity by clinical measurement ( P less than 0.01 ) . Quadriceps EMG interference pattern was reduced in those four patients with primarily extensor spasticity . THC was administered to eight other patients with spasticity and other CNS lesions .  Responses varied , but benefit was seen in three of three patients with " tonic spasms . " No benefit was noted in patients with cerebellar disease An investigation was made as to whether studies have found  journal clubs for physicians in training to be effective for improving patient . care , teaching critical appraisal skills , improving reading habits , increasing knowledge of clinical epidemiology and biostatistics , and increasing the use of medical literature in clinical practice . A literature search was undertaken using 10 data bases and retrieval systems and h and search es of journals , conference proceedings and personal files . The rigor of studies meeting the inclusion criteria was analyzed using a protocol based on methods established by the Cochrane Collaboration . One r and omized controlled trial found an improvement in knowledge of clinical epidemiology and biostaristics , reading habits , and the use of medical literature in practice , but no improvement in critical appraisal skills . Six less method ologically rigorous studies found possible improvement in critical appraisal skills . It is concluded that journal clubs may improve knowledge of clinical epidemiology and biostatistics , reading habits , and the use of medical literature in practice . A multi-center , r and omized controlled trial of journal clubs is needed to assess whether journal clubs improve critical appraisal skills OBJECTIVE This report describes the design of a study aim ing to provide evidence for the extended use of botulinum toxin A in focal post-stroke upper and lower limb spasticity and to evaluate the impact of incorporating botulinum toxin treatment into the rehabilitation of patients with spasticity . DESIGN International , prospect i ve , r and omized , double-blind , placebo-controlled study with an open-label extension . METHODS Approximately 300 adults with a stroke occurring ≥ 3 months before screening , presenting with symptoms and signs of an upper motor neuron syndrome and focal spasticity-related functional impairment , were r and omized to botulinum toxin ( BOTOX ® , Allergan Inc. ) + st and ard care or placebo + st and ard care . Study medication was administered at baseline and again at Week 12 if required , with follow-up to 52 weeks . The primary endpoint was the number of patients who achieved their investigator-rated principal active functional goal ( as measured by Goal Attainment Scaling ) , at 10 weeks after the second injection ( Weeks 22 - 34 ) or at the 24-week visit if no second injection was administered . Secondary endpoints included changes from baseline in level of goal achievement , health-related quality of life and re source utilization . CONCLUSION Botulinum toxin A Economic Spasticity Trial ( BEST ) will provide information regarding clinical and cost-effectiveness of botulinum toxin + st and ard care vs st and ard care alone in patients with upper and /or lower limb post-stroke spasticity typically seen in clinical practice . TRIAL REGISTRATION Clinical Trials.gov number NCT-00549783 BACKGROUND AND PURPOSE Spasticity is a major disabling symptom in patients post stroke . Although studies have demonstrated that transcutaneous electrical nerve stimulation ( TENS ) can reduce spasticity , the duration of single session TENS is a subject of debate . The purpose of this study was to determine the sustainability of the effects of TENS applied over common peroneal nerve in the reduction of ankle plantar-flexor spasticity and improving gait speed in patients post stroke . METHODS Thirty patients ( 11 women and 19 men ) ( mean age of 46.46 years ) were r and omly assigned to group 1 ( task oriented exercises ) , group 2 ( TENS for 30 min and task oriented exercises ) and group 3 ( TENS for 60 min and task oriented exercises ) for a period of five sessions per week for 6 weeks . All patients were assessed for ankle plantar-flexor spasticity , passive ankle dorsi-flexion range of motion , clonus and timed up and go test at the time of recruitment to study , at 3 and 6 weeks of therapeutic intervention . RESULTS The overall results of the study suggest that there was a decrease in ankle plantar flexor spasticity , ankle clonus and timed up and go score in all the groups . A greater reduction of spasticity was seen in TENS groups ( groups 2 and 3 ) when compared to control . No significant improvement was found in timed up and go test ( TUG ) scores between groups . CONCLUSION Both 30 min and 60 min of application of TENS are effective in reducing spasticity of ankle plantar flexors , improving walking ability and increase the effectiveness of task related training . Based on the effect size , we would recommend a longer duration application for the reduction of spasticity . Copyright © 2015 John Wiley & Sons , Abstract Purpose : To evaluate the effect of kinesiotaping as an adjuvant therapy to botulinum toxin A ( BTX-A ) injection in lower extremity spasticity . Methods : This is a single-center , r and omized , and double-blind study . Twenty hemiplegic patients with spastic equinus foot were enrolled into the study and r and omized into 2 groups . The first group ( n=10 ) received BTX-A injection and kinesiotaping , and the second group ( n=10 ) received BTX-A injection and sham-taping . Clinical assessment was done before injection and at 2 weeks and 1 , 3 , and 6 months . Outcome measures were modified Ashworth scale ( MAS ) , passive ankle dorsiflexion , gait velocity , and step length . Results : Improvement was recorded in both kinesiotaping and sham groups for all outcome variables . No significant difference was found between groups other than passive range of motion ( ROM ) , which was found to have increased more in the kinesiotaping group at 2 weeks . Conclusion : There is no clear benefit in adjuvant kinesiotaping application with botulinum toxin for correction of spastic equinus in stroke OBJECTIVE To examine goal attainment scaling for evaluation of treatment for upper limb post-stroke spasticity with  botulinum toxin-A. DESIGN Secondary analysis of a multi-centre double-blind , placebo-controlled r and omized clinical trial . SETTING Six outpatient clinics in Australia . PARTICIPANTS Patients ( n=90 ) completing per protocol 2 cycles of treatment/placebo . Mean age 54.5 ( st and ard deviation 13.2 ) years . Mean time since stroke 5.9 ( st and ard deviation 10.5 ) years . INTERVENTIONS Intramuscular botulinum toxin-A ( Dysport 500 - 1000U ) or placebo given at 0 and 12 weeks . Measurement points were baseline , 8 and 20 weeks . MAIN OUTCOME MEASURES Individualized goal attainment and its relationship with spasticity and other person-centred measures - pain , mood , quality of life and global benefit . RESULTS A significant treatment effect was observed with respect to goal attainment ( Mann-Whitney z=-2.33 , p < or = 0.02 ) . Goal -attainment scaling outcome T-scores were highly correlated with reduction in spasticity ( rho=0.36 , p=0.001 ) and global benefit ( rho=0.45 , p<0.001 ) , but not with other outcome measures . Goal -attainment scaling T-scores were lower than expected ( median 32.4 , interquartile range 29.6 - 40.6 ) . Goals related to passive tasks were more often achieved than those reflecting active function . Qualitative analysis of goals nevertheless demonstrated change over a wide area of patient experience . CONCLUSION Goal -attainment scaling provided a responsive measure for evaluating focal intervention for upper limb spasticity , identifying outcomes of importance to the individual/carers , not otherwise identifiable using st and ardized measures Objective : To investigate whether the combined approach of botulinum toxin type A ( BtxA ) and electrical stimulation was more effective than the toxin alone in the treatment of chronic upper limb spasticity after stroke . Design : R and omized , placebo-controlled study with four treatment groups : 1000 units BtxA ( Dysport ® ) + electrical stimulation ( A ) , 1000 units BtxA ( B ) , placebo + electrical stimulation ( C ) and placebo ( D ) . Setting : A neurological rehabilitation clinic . Subjects : Twenty-four stroke patients with chronic upper limb spasticity after stroke , six patients in each treatment group . Interventions : Intramuscular injection of either toxin or placebo into six upper limb flexor muscles . In group A and C additional electrical stimulation of the injected muscles with surface electrodes , three times half an hour each day for three days . Main outcome measures : Muscle tone rated with the modified Ashworth score , limb position at rest and difficulties encountered during three upper limb motor tasks assessed before and 2 , 6 and 12 weeks after injection . Results : Most improvements were observed in patients of group A. Cleaning the palm ( p = 0.004 ) differed across groups . Pairwise comparison for this target variable showed that group A differed from group B and D ( p < 0.01 ) , but not from C. Indicative across-group differences were obtained for elbow spasticity reduction ( p = 0.011 ) , and improvement of putting the arm through a sleeve ( p = 0.020 ) . Conclusions : The placebo-controlled trial favours the conceptthat electrical stimulation enhances the effectiveness of BtxA in the treatment of chronic upper limb flexor spasticity after stroke Background and Purpose — Previous studies have shown that repeated sensory inputs could enhance brain plasticity and cortical motor output . The purpose of this study was to investigate whether combining electrically induced sensory inputs through transcutaneous electrical nerve stimulation ( TENS ) with task-related training ( TRT ) in a home-based program would augment voluntary motor output in chronic stroke survivors better than either treatment alone or no treatment . Methods — Eighty-eight patients with stroke were assigned r and omly to receive a home-based program of ( 1 ) TENS , ( 2 ) TENS+TRT , ( 3 ) placebo TENS+TRT , or ( 4 ) no treatment ( control ) 5 days a week for 4 weeks . Outcome measurements included Composite Spasticity Scale , peak torques generated during maximum isometric voluntary contraction of ankle dorsiflexors and plantarflexors , and gait velocity recorded at baseline , after 2 and 4 weeks of treatment , and 4 weeks after treatment ended . Results — When compared with TENS , the combined TENS+TRT group showed significantly greater improvement in ankle dorsiflexion torque at follow-up and in ankle plantarflexion torque at week 2 and follow-up ( P<0.01 ) . When compared with placebo+TRT , the TENS+TRT group produced earlier and greater reduction of plantarflexor spasticity and improvement in ankle dorsiflexion torque at week 2 ( P<0.01 ) . When compared with all 3 groups , the TENS+TRT group showed significantly greater improvement in gait velocity ( P<0.01 ) . Conclusions — In patients with chronic stroke , 20 sessions of a combined TENS+TRT home-based program decreased plantarflexor spasticity , improved dorsiflexor and plantarflexor strength , and increased gait velocity significantly more than TENS alone , placebo+TRT , or no treatment . Such improvements can even be maintained 4 weeks after treatment ended BACKGROUND Whole-body vibration ( WBV ) has been used in older adults to improve bone health and neuromuscular function , and may have potential applications for stroke patients . AIM To investigate the effects of WBV on bone turnover , leg muscle strength , motor function , and spasticity among chronic stroke patients . DESIGN R and omized controlled trial ( RCT ) . SETTING Community . POPULATION Eighty-two chronic stroke patients . METHODS The experimental group underwent exercise training with WBV stimulation for a maximum of 15 minutes , 3 days per week for 8 weeks . The controls received the same exercises without WBV . Participants were evaluated for isokinetic knee muscle strength , serum levels of bone formation and resorption markers , spasticity and motor function of the paretic leg at baseline , immediately after the 8-week training period , and 1-month follow-up . RESULTS Intention-to-treat analysis revealed no significant changes in levels of bone turnover markers and motor function of the paretic leg over time in both groups . Muscle strength outcomes showed no significant group × time interaction , with similar significant improvements found in both groups . Spasticity of the paretic knee was significantly reduced in the experimental group ( P=0.005 ) , but not in controls ( P=0.465 ) . No serious adverse events were reported . CONCLUSION The WBV protocol used in this study did not induce additional effects on bone turnover , knee muscle strength and paretic leg motor function among chronic stroke patients . WBV may have potential to modulate spasticity , but this requires further investigation . CLINICAL REHABILITATION IMPACT More study on WBV is required before it can be recommended as an adjunct treatment in rehabilitation of chronic stroke patients
None of the review ed measurement tools demonstrated satisfactory results for all psychometric properties evaluated , and the majority lacked evidence concerning validity and absolute reliability .
This systematic review found limited evidence to support the use of most of clinical measures of spasticity for people post-stroke .
This review identified various clinical measures of spasticity that have been investigated in people after stroke .
PURPOSE To identify and appraise the literature on clinical measures of spasticity that has been investigated in people after stroke .