Search Results (135)

Background: Post-stroke neuropathic pain, particularly central post-stroke pain and facial pain syndromes, continues to be challenging to manage with conventional pharmacological approaches. While botulinum toxin A (BoNT-A) is well established for treating spasticity after stroke, its use in the management of central neuropathic pain remains less well established. Methods: This report presents two cases of patients with refractory neuropathic pain following ischemic cerebrovascular accidents who achieved significant pain relief through subcutaneous botulinum toxin administration, after failure of multiple conventional and intramuscular BoNT-A approaches. Results: Case 1 involves a 66-year-old patient with 18 years of post-stroke hemicorporeal pain who responded dramatically to subcutaneous BoNT-A injections after extensive prior treatment failures. Case 2 describes a 54-year-old with trigeminal-region and mandibular pain following ICA dissection who achieved complete pain resolution at facial sites with subcutaneous administration of BoNT-A. Conclusions: These cases demonstrate the potential efficacy of subcutaneous botulinum toxin for managing post-stroke neuropathic pain in selected patients and suggest a mechanism of action related to peripheral pain sensitization rather than motor denervation. Our findings support further investigation of subcutaneous administration techniques for pain management in specialized centers. Full article

Background: Post-stroke upper-limb spasticity can cause pain, hinder passive care, and lead to secondary musculoskeletal complications. Current minimally invasive treatments have important limitations. Cryoneurolysis, which creates a controlled cold lesion of peripheral nerves, may offer a partially reversible focal denervation alternative. Methods: We conducted a feasibility case series in the outpatient department of a rehabilitation centre. Three adults with chronic post-stroke hemiparesis and a non-functional spastic upper limb underwent ultrasound- and nerve stimulation-guided cryoneurolysis of the musculocutaneous, median, and/or ulnar nerves. All had demonstrated a positive response to diagnostic nerve blocks beforehand. Feasibility outcomes included completion of planned nerve targets, tolerability under local anesthesia, absence of serious adverse events, and completion of 6-month follow-up. Secondary outcomes were Modified Ashworth Scale (MAS), qualitatively assessed passive joint mobility (video-documented), pain measured by visual analogue scale, sensory testing, and electroneuromyography (ENMG). Results: All procedures were completed as planned. Treatment was well tolerated under local anesthesia, and no serious adverse events occurred. MAS decreased by at least 2 points in targeted patterns, with immediate improvement in passive mobility; these effects persisted at 6 months. Pain remained unchanged in two participants and improved in one. Sensory testing at 6 weeks was stable. ENMG findings were heterogeneous, including reduced ulnar sensory action potential amplitude and biceps denervation activity in one participant. Conclusions: In this small series, cryoneurolysis for post-stroke upper-limb spasticity was feasible and associated with sustained tone reduction and improved passive mobility. Larger controlled studies are required to better define safety, optimize targeting strategies, and assess patient-centred outcomes. Full article

Background: Botulinum neurotoxin type A is widely used in the management of post-stroke upper-limb spasticity; however, many studies report total injected doses rather than muscle-specific dosing, limiting clinical applicability. This study aimed to evaluate how frequently muscle-level dosing protocols of onabotulinumtoxinA are reported and to assess consistency of dosing patterns across published studies. Methods: A literature search was conducted in PubMed, Wiley/Cochrane Library, and EBSCO/CINAHL using a structured search strategy informed by PRISMA guidelines. Studies published within the last 10 years reporting on onabotulinumtoxinA treatment in post-stroke upper-limb spasticity with muscle-specific dosing data were included. Studies not providing muscle-level dosing or not allowing extraction of post-stroke upper-limb data were excluded. Data were summarized descriptively and compared across studies. Results: Twenty-seven full-text articles were assessed, and five studies met the inclusion criteria. Muscle-specific dosing was consistently reported for commonly treated muscles such as biceps brachii and wrist and finger flexors, whereas other muscles were less frequently targeted. Variability in dosing between studies was observed, particularly in multicenter real-world datasets. Standardized high-dose protocols contrasted with individualized dosing strategies, which generally showed more moderate dose ranges. Expert recommendations often suggest higher doses than those observed in routine clinical practice. Conclusions: Muscle-specific dosing of onabotulinumtoxinA in post-stroke upper-limb spasticity is reported infrequently, and substantial variability exists between studies and clinical practice. Standardized reporting of muscle-level dosing and its relationship to baseline spasticity severity is needed to improve clinical applicability and reproducibility. Full article

Continuous monitoring of pathological motor features is vital for post-stroke rehabilitation but remains challenged by power reliance and low sensitivity of wearable sensors. Here, we develop a high-sensitivity, self-powered breathable nanogenerator (BN-TENG) utilizing fish-scale-derived biological hydroxyapatite/carbon (Bio-HAp/C) fillers within electrospun polyvinylidene fluoride (PVDF) nanofibers. The Bio-HAp/C enhances electron-trapping capability, while a high-resilience ethylene-vinyl acetate (EVA) spacer optimizes contact-separation dynamics. The BN-TENG achieves a superior sensitivity of 16.28 V·N⁻¹ and remarkable stability over 10,000 cycles. By implementing a multi-node sensing strategy, the sensor successfully captures complex hemiplegic patterns, including compensatory shoulder hiking, distal muscle spasticity, and postural asymmetry. By resolving subtle micro-vibrations missed by traditional electronics, this work provides a sustainable, autonomous interface for characterizing pathological motor features and assessing rehabilitation progress in hemiplegic patients. Full article

Post-stroke upper limb pain is prevalent and challenging to manage once established. Early use of botulinum toxin can reduce spasticity and contracture development and has potential to prevent or reduce pain. A secondary analysis of the EUBoSS study was undertaken to report pain prevalence in people post-stroke with severe upper limb impairment and spasticity in a hyper/acute setting, identify if botulinum toxin Type-A (BoNTA) could prevent pain developing and reduce pain if already present and evaluate differences in analgesic use between BoNTA and placebo groups. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. Ninety-three participants (48F:45M) were randomised at a median of 11 days post-stroke (IQR 8–19) and included in the intention-to-treat analysis. Pain prevalence increased from 29.0% (95% CI [20.1–37.9%]) to 63.4% (95% CI [54.0–72.9%]) at six months. BoNTA treatment may prevent the development of pain at six months (OR = 0.42, 95% CI [0.18 to 1.01]) but not at three months (OR = 0.57, 95% CI [0.25 to 1.32]). The odds ratio for being on at least one analgesic at six months in the BoNTA group was 0.35 ([95% 0.14 to 0.87]). This secondary analysis suggests that early treatment of spasticity with BoNTA may potentially help prevent post-stroke upper limb pain and reduce analgesic use but appears less effective once pain is established. Further prospective studies are required to verify the hypotheses generated from this secondary analysis. Full article

Background: Moyamoya disease (MMD) is a rare, progressive cerebrovascular arteriopathy characterized by stenosis and occlusion of the distal internal carotid arteries with the development of compensatory collateral networks. In children, MMD is a major cause of ischemic stroke; however, neurological morbidity frequently extends beyond cerebrovascular events to include epilepsy, headache, cognitive impairment, and psychiatric manifestations. Data regarding the long-term evolution of these complications in Caucasian pediatric patients remains limited. Case Report: We present the longitudinal case of a Caucasian female diagnosed with advanced MMD after an ischemic stroke at the age of 7 years, followed by indirect surgical revascularization (encephalo-duro-arterio-synangiosis) and chronic antiplatelet therapy. Four years later, she developed recurrent focal aware sensory–motor seizures associated with chronic post-ischemic cortical injury. Despite stable vascular imaging and absence of recurrent infarction, the patient experienced persistent neurological sequelae, including residual spastic hemiparesis, episodic tension-type headaches, and evolving neuropsychological complications. Cognitive assessment initially suggested mild neurocognitive impairment, with subsequent improvement during adolescence. In late follow-up, prominent anxiety symptoms emerged, and psychiatric evaluation confirmed panic disorder requiring psychological and pharmacological support. The patient remained neurologically stable into adulthood under continued multidisciplinary care. This case illustrates the broad spectrum of neurological and psychiatric complications that may accompany pediatric MMD, even in the absence of new ischemic events. The accompanying literature review emphasizes that epilepsy, headache, cognitive dysfunction, and psychiatric disorders represent clinically significant components of the long-term disease burden in children with MMD. Conclusions: Pediatric moyamoya disease should be regarded not only as a cause of childhood stroke, but also as a chronic condition with long-term epileptic, cognitive, and psychiatric sequelae that may evolve independently of recurrent ischemic injury. By providing longitudinal follow-up from childhood into adulthood in a Caucasian patient, this report underscores the importance of integrating neuropsychological and psychiatric surveillance into standard care pathways, alongside vascular and surgical management, to better address the full spectrum of morbidity and improve quality of life. Full article

Background: Post-stroke pain (PSP), particularly shoulder pain, is frequent and often underdiagnosed, limiting rehabilitation adherence and functional recovery. Current pharmacological and physical treatments offer only partial relief. Robotic-assisted therapy (RAT), such as the gravity-supporting Armeo^® Spring exoskeleton, delivers intensive, task-specific training with visual 2D feedback that may also alleviate PSP while enhancing motor outcomes. This study investigates whether RAT performed with the Armeo^® Spring reduces upper-limb PSP in chronic stroke patients versus conventional therapy and evaluates its effects on motor function and functional independence. Methods: In this retrospective parallel group study, 32 chronic post-stroke patients (8 females and 24 males with a mean age of 57 ± 11.74) were allocated to two groups: 16 received upper-limb RAT with the Armeo^® Spring, a gravity-supporting exoskeleton, (RAT group) and 16 underwent conventional rehabilitation (CR). The RAT group completed one-hour sessions 6 days/week for 8 weeks, performing 2D/3D gamified tasks targeting shoulder, elbow and forearm movements. The CR group received an equivalent amount of standard therapy, including passive/active-assisted mobilization, Bobath-based neuromuscular facilitation and reaching exercises. Results: Both the Armeo^® Spring and conventional therapy groups showed significant reductions in post-stroke pain (RAT p < 0.001 and conventional rehabilitation p = 0.004) and improvements in upper-limb motor function and functional independence (both p ≤ 0.002). Spasticity in the impaired limb decreased modestly in the RAT group (p = 0.031), with no significant between-group differences in pain or spasticity change (p = 0.437; p > 0.05, respectively). Conclusions: Gravity-support exoskeleton training reduced upper-limb spasticity, and no statistically significant between-group differences were observed compared with conventional physiotherapy for pain, mobility, and functional independence. Although clinical outcomes improved, health-related quality-of-life domains showed heterogeneous trajectories, underscoring the complexity of perceived health changes during chronic stroke rehabilitation. Larger randomized controlled trials incorporating neurophysiological and kinematic endpoints and longer follow-up are warranted to confirm effectiveness, particularly in chronic stroke and durability. Full article

Background/Objectives: Shear wave elastography (SWE) has emerged as a quantitative imaging technique for assessing muscle mechanical properties and has been increasingly applied to post-stroke spasticity. However, the clinical validity of SWE relative to established clinical spasticity scales and the influence of assessment protocols remain incompletely understood. This systematic review and meta-analysis aimed to evaluate the clinical validity of SWE for post-stroke spasticity and to identify clinically relevant methodological moderators. Methods: A systematic literature search was conducted in PubMed, Cochrane Library, CINAHL, and Web of Science to identify studies reporting correlations between SWE measures and clinical spasticity scales in individuals with stroke. Random-effects meta-analyses were performed using robust variance estimation to account for dependent effect sizes within studies. Prespecified subgroup and meta-regression analyses examined potential moderators, including clinical scale, muscle position during assessment, output metric, limb segment, and stroke chronicity. Results: Ten studies involving 303 participants contributed 38 correlation estimates. The pooled correlation between SWE and clinical spasticity scales was moderate (r = 0.42, 95% CI 0.34–0.49). SWE demonstrated significantly stronger correlations with the Modified Tardieu Scale than with the Modified Ashworth Scale. Measurements obtained in stretched muscle positions showed higher validity than those obtained at rest. Other examined moderators were not statistically significant. No evidence of publication bias was detected. Conclusions: SWE shows a moderate association with clinician-rated spasticity scales and appears to reflect the mechanical consequences of post-stroke spasticity. Associations were influenced by scale selection and measurement position. These findings support protocol-informed integration of SWE as a quantitative adjunct for assessing passive muscle stiffness rather than as a replacement for established clinical scales. Full article

Background: Post-stroke spasticity (PSS) is a common complication in stroke survivors, significantly impairing functional recovery and quality of life. Despite its prevalence, Italy lacks national guidelines or structured good clinical practice documents, resulting in heterogeneous clinical management. Methods: An Italian Delphi study was conducted to establish expert-based recommendations for PSS management. A panel of 93 rehabilitation medicine specialists and neurologists, each with over 5 years of experience in PSS management with botulinum toxin A (BoNT-A), participated in two rounds of voting on 47 statements drafted and approved by seven Key Opinion Leaders (KOLs), recognized for their national and international expertise. Consensus was defined as ≥75% of respondents answering ‘strongly agree’ or ‘somewhat agree’. Results: In Round 1, consensus was reached for 90% of statements; five items did not achieve the threshold. After revision and a second round, consensus was achieved for all items, including consideration of lesion site in clinical management and the role of adjuvant post-injection interventions. The panel’s heterogeneity ensured broad representativeness. Conclusion: This Delphi study provides the first structured Italian expert recommendations for PSS management. Full consensus was reached in all 47 statements and in the Symptoms domain, particularly regarding pain, stiffness and heaviness, which highlights the importance of a structured framework to support consistent, individualized care. By standardizing patient assessment, treatment planning, and follow-up strategies, these findings provide a practical reference for clinicians. Full article

Background: Motor imagery (MI) and mirror therapy (MT) are widely used neurorehabilitation strategies to enhance motor recovery after stroke and are commonly applied as adjuncts to conventional rehabilitation therapy (CRT). However, direct comparative evidence between these interventions remains limited. This systematic review compared the effects of MI and MT on motor function, functional performance, spasticity, and gait-related outcomes in adults after stroke. Methods: A systematic comparative review with narrative synthesis was conducted following PRISMA guidelines and registered in PROSPERO (CRD420251274308). PubMed, Cochrane Library, CINAHL, Scopus, Web of Science, and ScienceDirect were searched up to July 2025. Clinical trials directly comparing MI and MT in adults with stroke were included. Methodological quality was assessed using the PEDro scale, and risk of bias was evaluated with the Cochrane RoB 2 tool. Results: Six clinical trials involving 206 participants were included. Both MI and MT were associated with significant pre–post improvements across motor function, functional performance, spasticity, and gait-related outcomes. Between-group comparisons yielded heterogeneous findings, with no consistent evidence supporting the superiority of either intervention. Isolated advantages of MI were reported for specific upper-limb subdomains, but these effects were not consistently replicated. Overall methodological quality ranged from low to moderate, and all included studies were judged to be at high risk of bias according to the RoB 2 tool. Conclusions: MI and MT appear to provide comparable benefits for motor and functional recovery after stroke when used as adjuncts to CRT. Current evidence does not support the preferential use of one intervention, highlighting the need for well-designed trials with improved methodological rigor. Full article

This study evaluated the effect of time of botulinum toxin A (BoNT-A) treatment on clinical outcomes in adults with post-stroke spasticity (PSS). Individual data were pooled from five studies. Eligible patients received ≥1 BoNT-A injection(s) for PSS and had goal attainment scaling (GAS) scores measured at baseline and 12 weeks. Patients were grouped according to time of treatment post-stroke: early (<1 year) or late (≥1 year). The primary endpoint was the total GAS (GAS-T) score change from baseline to 12 weeks. Secondary outcomes included the proportion of patients with a GAS-T score ≥ 50. Overall, 968 patients were included (166 early and 802 late). Median time post-stroke to BoNT-A treatment was 0.5 (early) versus 5.4 (late) years. Mean (standard deviation [SD]) baseline GAS scores were similar between cohorts (early: 36.9 [3.5]; late: 36.9 [3.6]). The mean (SD) change in the GAS-T score from baseline to 12 weeks was greater in the early versus late cohort (15.7 [8.9] vs. 13.1 [8.9]; p < 0.001). More patients in the early versus late cohort had a GAS-T score ≥ 50 (63.9% vs. 47.4%; p < 0.001) at 12 weeks. No new safety concerns were reported. Early treatment of PSS with BoNT-A has a positive impact on patients’ ability to achieve treatment goals. Plain Language Summary: After a stroke, people can experience muscle stiffness in their limbs, called post-stroke spasticity (PSS), which can lead to pain and make movement difficult. Treatment can include botulinum toxin A (BoNT-A) injections given directly into affected muscles. The aim of our study was to assess whether giving BoNT-A within a year after experiencing a stroke was more effective in treating PSS than delaying treatment. We combined data from 968 patients across five different studies. Most people (802 patients) received BoNT-A treatment 1 year or more after their stroke (late treatment group), while 166 people received treatment within a year of their stroke (early treatment group). In the studies, patients set treatment goals with their physician, for example being able to hold an object or walk a certain distance. After treatment, the extent to which each goal was achieved was assessed and scored based on whether the result was less than expected, as expected, or better than expected by the patient and physician. The scores from the two treatment groups were compared. People in the early treatment group did better in achieving their treatment goals compared with those in the late treatment group. We also looked at any side effects patients experienced. No unexpected side effects were reported. BoNT-A treatment of PSS can help patients achieve their treatment goals, and patients treated early (within 1 year after stroke) may do better than those treated later. This information may help in rehabilitation planning for stroke patients. Full article

Limited data are available on gender differences in patients with post-stroke spasticity (PSS) treated with onabotulinumtoxinA (onabotA). This subgroup analysis of data from the BOTOX^® Economic Spasticity Trial (BEST) focused on onabotA-treated patients stratified by gender. BEST was a double-blind, placebo-controlled, randomized study with an open-label extension that allowed for up to five treatments. It evaluated the effectiveness of onabotA + Standard of Care (SC) vs. placebo + SC for the treatment of PSS. At baseline, out of 139 patients treated with onabotA, females (n = 54) had a slightly higher body mass index (BMI) compared to males (n = 85) (28.3 vs. 26.9 kg/m²), and a greater percentage of females (40.7%) took analgesic medications compared to males (31.8%). Scores from baseline assessments for pain, spasticity severity, and stroke recovery were comparable between groups. Despite these similarities at baseline, females received an average lower dose (range, 337–365 U) of onabotA compared to males (range, 343–421 U) across treatment sessions. Females also had lower changes from baseline compared to males on pain, spasticity severity, stroke recovery, and functional goal achievement assessments across most onabotA treatment sessions. There is a need for further investigation into treatment approaches to optimize outcomes for both males and females with PSS. Full article

Background: Chronic post-stroke spasticity often limits gait despite best-practice botulinum-toxin intramuscular injections (BTIs), whose benefit is constrained by short duration, dose ceilings, and tachyphylaxis. Cryoneurolysis (CNL) induces a reversible axonotmesis with preserved endoneurium, potentially providing longer tone reduction with fewer adverse effects, but its impact on whole-gait quality and its compatibility with implanted functional electrical stimulation (FES) remain poorly documented. Case presentation: A 43-year-old man, 12 years after right middle cerebral artery stroke, walked independently with an implanted common peroneal FES system but complained of effortful gait with left-knee “locking” and drop foot without FES. Multiple BTI series to triceps surae and quadriceps yielded only transient benefit. Two ultrasound-guided CNL sessions targeted tibial (soleus, medial gastrocnemius) and femoral (rectus femoris, vastus intermedius) motor branches. Quantitative gait analysis and fine-wire electromyography (EMG) were performed at baseline, 6 weeks after each CNL, and at 6 months, with and without FES. CNL produced immediate and sustained reductions in triceps surae and quadriceps overactivity, resolution of genu recurvatum, normalization of stiff-knee gait, improved ankle dorsiflexion, and increased swing phase knee flexion (>50°). Gait Deviation Index rose from 69 to 80 and Gillette Gait Index decreased by more than 50%, with preserved strength and without adverse events. Conclusions: Targeted, sequential CNL of tibial and femoral motor branches can safely deliver durable, clinically meaningful gait improvements when BTI has reached its ceiling and can act synergistically with implanted FES. Quantitative gait analysis and EMG sharpen clinical decision-making in spasticity management. Full article

Objective: This study investigated the efficacy and neural mechanisms of robot-assisted mirror therapy (RMT) for post-stroke upper limb rehabilitation. RMT integrates the multimodal feedback of mirror therapy with robotic precision and repetition to enhance cortical activation and neuroplasticity. Methods: Seventy-eight stroke patients were randomly assigned to control, mirror therapy (MT), or RMT groups. All received conventional rehabilitation; the MT group additionally underwent mirror therapy, and the RMT group received robot-assisted mirror therapy combined with functional electrical stimulation. The primary outcome was the Fugl–Meyer Assessment for Upper Extremity (FMA-UE), with secondary measures including spasticity, dexterity, daily living, and quality of life. Functional near-infrared spectroscopy (fNIRS) was applied to assess cortical activation and connectivity at baseline, post-intervention, and one-month follow-up. Results: All groups showed significant time effects, though between-group differences were limited. Subgroup analysis revealed that patients at Brunnstrom stages I–II in the MT group achieved greater improvements in upper limb function, dexterity, and daily living ability. fNIRS findings showed enhanced activation in the right sensory association cortex and increased prefrontal–sensory connectivity. Conclusions: While all interventions improved motor outcomes, MT yielded slightly superior recovery associated with neuroplastic changes. RMT demonstrated high safety, compliance, and potential benefit for patients with severe motor deficits. Full article