Search Results (26)

Objectives: To investigate current Canadian physicians’ practice patterns of treating upper limb post-stroke spasticity (PSS) and hemiplegic shoulder pain (HSP) acutely after a stroke. In addition, by examining Canadian physicians’ diagnostic capabilities, time till treatment, minimum criteria to begin treatment, mechanisms of treatment, targeting of muscles, and benefits and adverse effects of treatment, we aim to learn about areas of improvement to optimize PSS management for Canadians. Design: The present study was a cross-sectional survey, polling practicing Canadian physicians. Results: A total of 17 physicians completed the survey, all PM&R specialists, save one neurologist. Four provinces were represented in the responses. Participants had, on average, over ten years of experience managing post-stroke spasticity in outpatient and inpatient clinics. All 17 perform botulinum neurotoxin A (BoNT-A) injections for HSP associated with PSS. Most participants reported that they will begin BoNT-A treatments 2–3 weeks post-stroke, most commonly targeting the pectoralis major, subscapularis, and latissimus dorsi. Participants reported the mean median dosage they use as onabotulinum toxin A (169.12 units, SD = 73.70), incobotulinum toxin A (178.13 units, SD = 65.75), and abobotulinum toxin A (470.83 units, SD = 171.17). For injection guidance, participants responded that they use ultrasound for the largest percentage of their caseload, followed by electromyography, then electrical stimulation, then palpation. Very seldom did participants use palpation alone. Conclusions: From the limited sample included in analyses, the Canadian physicians respondents seem to be treating HSP and associated PSS with variable strategies. Further research is required to align dosages, targets, and guidance strategies as they vary considerably. 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

Shoulder spasticity is a common consequence of upper motor neuron lesions and may be associated with soft tissue contractures, limiting functional recovery. While both cryoneurolysis and tendon lengthening procedures are used individually in refractory cases, their combined effect has not been clearly established. It is consequently necessary to assess the efficacy of combining cryoneurolysis and percutaneous pectoral tenotomy in reducing shoulder spasticity and improving passive range of motion in patients with refractory shoulder spasticity and contracture. This retrospective, single-centre cohort study included 15 adults (≥19 years) with chronic shoulder spasticity and clinically confirmed musculotendinous contracture, previously treated with botulinum toxin injections without sufficient functional response, and free of pharmacological effects (last injection >4 months prior). All patients underwent cryoneurolysis targeting motor branches to the pectoral muscles. Outcomes included Modified Ashworth Scale (MAS) and shoulder Passive Range Of Motion (PROM). The combined approach provided significant improvements in spasticity severity for shoulder flexion (p < 0.01) and abduction (p < 0.01), and significant improvements in maximum PROM for shoulder flexion (p < 0.0001) and abduction (p < 0.0001). Combining cryoneurolysis and pectoral tenotomy appears feasible, safe, and clinically beneficial in selected patients with both spasticity and tendon contracture. Cryoneurolysis addresses the neural component, while tenotomy may restore mechanical excursion. This sequential diagnostic and therapeutic approach may enhance personalized management of mixed spastic–contracture shoulder limitations and could be applicable to other joints. 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: Upper-limb spasticity involving the shoulder girdle and elbow flexors often impairs functional hand use, and although Botulinum toxin type A (BoNT-A) is a first-line therapy, severe proximal synergies may persist while higher doses risk distal weakness. Methods: We report a case of a 47-year-old woman with neurodegenerative tetraparesis and marked shoulder and elbow flexor spasticity treated with bilateral percutaneous cryoneurolysis of the lateral pectoral, thoracodorsal, and musculocutaneous nerves, followed by distal BoNT-A injections, and we conducted a scoping review following Arksey and O’Malley, Levac, and PRISMA-ScR methods to contextualize the current evidence. Results: At one-month follow-up, the patient showed a reduction in MAS from 4 to 1–2, complete resolution of pain, improved passive shoulder abduction and elevation, preserved distal dexterity, and high satisfaction with no adverse events. The scoping review identified consistent MAS and range-of-motion improvements across multiple case reports and small series involving similar proximal nerve targets. Conclusions: The combined proximal cryoneurolysis–distal BoNT-A approach appears to be a feasible dual-modulation strategy for complex upper-limb spasticity when the preservation of hand function is essential, and the emerging literature supports its further investigation. Full article

There is limited published guidance available to help less experienced practitioners assess and manage shoulder conditions, including spasticity, after acquired central nervous system (CNS) lesions. To address this gap, 11 spasticity and dystonia experts convened in a 2023 meeting to build on existing guidance, provide consensus on best treatment practice, and develop expert recommendations to guide the diagnosis and treatment of complications of shoulder conditions following CNS lesions. Presentations by each expert on diagnosis and management were followed by discussion; consensus on assessment and treatment practices was identified and recommendations developed. The expert panel recommended an assessment approach structured using the following components: patient history, including interpretation of reported symptoms; observation of postures and pain responses; clinical examination with targeted tests for specific signs; diagnostic tests; and assessment of upper limb impairment, activity limitations, and participation restrictions. This assessment process and the recommended measures recognize the importance of identifying shoulder involvement in upper limb spasticity as part of the diagnostic process in shoulder conditions following CNS lesions. These recommendations provide a practical approach to diagnosis and treatment for clinicians who are less experienced in evaluating and treating such conditions, simplifying otherwise complicated clinical scenarios. Full article

Background/Objectives: Dyskinetic cerebral palsy (DCP) often implies severe motor impairment and risk of health problems. Our aim was to follow up a group of young adults with DCP that we previously examined as children, to describe health, function, and living conditions. Methods: Interviews regarding health issues, treatments, and living conditions, and quality of life (RAND-36) and fatigue questionnaires were completed. Gross and fine motor function, communication, and speech ability were classified, and weight, height, spasticity, and dystonia were assessed and compared to previous data. Joint range of motion (ROM) was compared to older adults with DCP. Results: Dystonia was present in all fifteen participants, and spasticity in all but two. A decrease was found mainly in those who received intrathecal baclofen (ITB). ROM limitations were most pronounced in shoulder flexion, abduction and inward rotation (while outward rotation was hypermobile), hip abduction, hamstrings, and knee extension. The majority had frequent contact with primary and specialist healthcare. Seven participants were underweight, eight had a gastrostomy, and seven had ITB. Upper gastrointestinal and respiratory problems were frequent. Orthopedic surgery for scoliosis was reported in five, and lower extremity in nine, while fractures were reported in six participants. RAND-36 revealed physical functioning, general health, and vitality as the greatest problem areas. Fatigue was significant in 64%. Eight participants lived with their parents. Participants at more functional levels completed tertiary education and lived independently. Conclusions: Most participants had severe impairment and many health issues, despite decreased dystonia and spasticity due to ITB. Sleep problems and pain were uncommon. Full article

Background and Objectives: Hemiplegic shoulder pain (HSP) is a common and disabling complication in stroke patients, yet its pathogenesis remains unclear. This longitudinal study aimed to investigate the clinical and ultrasound characteristics of HSP emerging within the first 72 h (T0) post-stroke, with follow-ups at one month (T1) and three months (T2). Materials and Methods: A total of 28 stroke patients with hemiparesis were assessed for HSP. Evaluations included pain severity during passive shoulder mobilization, passive and active range of motion, muscle strength, spasticity, and functional disability. Ultrasound examinations were conducted to assess tendon disorders, bursitis, effusion, glenohumeral subluxation, and adhesive capsulitis. Results: HSP prevalence increased over time, affecting 11% of patients at T0, 32% at T1, and 57% at T2. Higher baseline scores on the National Institutes of Health Stroke Scale (NIHSS), an established marker of stroke severity, were significantly associated with HSP (p < 0.05). At T2, patients with HSP exhibited greater impairment, including restricted passive and active range of movement, pronounced muscle weakness, and increased spasticity (p < 0.05). Ultrasound findings at T2 revealed that adhesive capsulitis and glenohumeral subluxation were significantly more frequent in HSP patients (p < 0.05). Adhesive capsulitis showed a significant increase from 0% at T0 to 21% at T2 (p = 0.031), while glenohumeral subluxation exhibited a non-significant rise from 4% to 21% (p = 0.063). Patients with these conditions experienced significantly greater pain progression (p < 0.001). Conclusions: These findings suggest that capsular pathology plays a key role in the development of HSP within the first three months after stroke. The results highlight the need for targeted interventions addressing glenohumeral subluxation and adhesive capsulitis to alleviate pain and improve rehabilitation outcomes. Full article

Cervical spine injuries that impact young horses and foals can result in mild to severe neurological signs or even result in sudden death. There are only a few reports on conservative treatment options for this condition in the scientific literature. If the condition is left untreated, it can lead to the development of degenerative joint disease, resulting in chronic neurological symptoms and discomfort. We present the case of a two-day-old Arabian foal that showed signs of ataxia following a neck injury, being the result of cervical spine subluxation. Radiological examination revealed a dislocation between the second and third cervical vertebrae. At admission to the clinic on the seventh day of life, the foal’s clinical examination parameters were within physiological ranges. The head posture at the presentation was consistently low, the foal could not lift its head above the shoulder joint throughout the whole examination, the neck muscles were spastically tensed and clinical signs of ataxia were present. The foal underwent a closed reduction in the subluxation under general anesthesia and a fiberglass semicircular gutter was created to stabilize the neck in the desired position. The ataxia symptoms began to improve around day 12 post manipulation, and the fiberglass stabilizer was removed after 16 days post manipulation, followed by radiographs. The dislocation of C2/C3 was no longer visible on the radiographs, and the foal was able to assume a normal neck posture after the removal of the fixator. Full article

The study aimed to identify expert opinions and obtain recommendations on the management of post-stroke hemiplegic shoulder pain (HSP) and treatment with botulinum toxin A (BoNT-A). A multicenter Delphi study was conducted using an online survey designed by a committee of experts with at least 10 years of experience in post-stroke HSP management with BoNT-A in Spain. Forty-seven panelists (specialists with at least 5 years of experience in post-stroke HSP management with BoNT-A) rated their level of agreement in two rounds based on acceptance by ≥66.7% of them. In round 1, 245 statements on three dimensions were evaluated (diagnosis, treatment, and follow-up of the HSP patients treated with BoNT-A). A total of 159 statements (70.9%) were finally accepted after round 2. Experts recommended BoNT-A as soon as spasticity affects daily activities. They considered ultrasound as the preferred guided technique. Experts recommended regular assessments using validated scales and patient-reported outcomes to evaluate treatment goals and safety. In case of lack of response, experts suggested increasing the dose or number of treated muscles or considering alternative treatments. These consensus-based recommendations offer clinicians an approach to the management of post-stroke HSP with BoNT-A, supporting informed decision making. Full article

Botulinum toxin A (BONT/A) injections play a central role in the treatment of upper limb spasticity in stroke patients. We proposed structured stretching exercises to enhance the effect of post-stroke spasticity relief of the upper limbs following BONT/A injections. A total of 43 patients who had a stroke with grade 2 spasticity or higher on the Modified Ashworth Scale (MAS) in their upper-limb muscles were randomly assigned to the intervention (n = 21) or control group (n = 22). The former received structured stretching exercises after their BONT/A injections for 20 min, 5 days per week, for 6 months at a hospital, while the others conducted self-stretching exercises at home. The outcome measures were assessed before the intervention (T0) and after three (T1) and six months (T2). Significantly greater improvements in the MAS scores of the elbows, wrists, and fingers were found in the intervention group’s patients at T1 and T2. The behavioral outcome measures, including shoulder pain, activities of daily living, and quality of life, and our electrophysiological studies also showed a significantly higher enhancement in this patient group. In conclusion, the structured stretching exercises plus BONT/A injections for six months showed a superior effect in relieving post-stroke upper-limb spasticity compared to self-stretching exercises. Full article

Underarm throwing motions are crucial in various sports, including boccia. Unlike healthy players, people with profound weakness, spasticity, athetosis, or deformity in the upper limbs may struggle or find it difficult to control their hands to hold or release a ball using their fingers at the proper timing. To help them, our study aims to understand underarm throwing motions. We start by defining the throwing intention in terms of the launch angle of a ball, which goes hand-in-hand with the timing for releasing the ball. Then, an appropriate part of the body is determined in order to estimate ball-throwing intention based on the swinging motion. Furthermore, the geometric relationship between the movements of the body part and the release angle is investigated by involving multiple subjects. Based on the confirmed correlation, a calibration-and-estimation model that considers individual differences is proposed. The proposed model consists of calibration and estimation modules. To begin, as the calibration module is performed, individual prediction states for each subject are updated online. Then, in the estimation module, the throwing intention is estimated employing the updated prediction. To verify the effectiveness of the model, extensive experiments were conducted with seven subjects. In detail, two evaluation directions were set: (1) how many balls need to be thrown in advance to achieve sufficient accuracy; and (2) whether the model can reach sufficient accuracy despite individual differences. From the evaluation tests, by throwing 20 balls in advance, the model could account for individual differences in the throwing estimation. Consequently, the effectiveness of the model was confirmed when focusing on the movements of the shoulder in the human body during underarm throwing. In the near future, we expect the model to expand the means of supporting disabled people with ball-throwing disabilities. Full article

Internally rotated and adducted shoulder is a common posture in upper limb spasticity. Selective peripheral neurectomy is a useful and viable surgical technique to ameliorate spasticity, and the lateral pectoral nerve (LPN) could be a potential good target to manage shoulder spasticity presenting with internal rotation. However, there are some limitations related to this procedure, such as potential anatomical variability and the necessity of intraoperative surgical exploration to identify the target nerve requiring wide surgical incisions. This could result in higher post-surgical discomfort for the patient. Therefore, the aim of our study was to describe a modification of the traditional selective peripheral neurectomy procedure of the LPN through the perioperative ultrasound-guided marking of the target nerve with methylene blue. The details of the localization and marking procedure are described, as well as the surgical technique of peripheral selective neurectomy and the potential advantages in terms of nerve localization, surgical precision and patients’ post-surgical discomfort. We suggest that the proposed modified procedure could be a valid technique to address some current limitations and move the surgical treatment of spasticity toward increasingly tailored management due to the ease of nerve identification, the possibility of handling potential anatomical variability and the resulting smaller surgical incisions. Full article

Objective: The primary objective of this paper is to assess whether the use of 200 units of abobotulinum in the pectoralis major and subscapularis muscles modifies the pain complaint assessed using the visual analog scale in subjects with shoulder pain after the onset of spastic hemiplegia due to cerebrovascular disease when compared to the application of a placebo to the same muscles. Design: A prospective, double-blind, randomized, and placebo-controlled clinical trial study in two different rehabilitation centers. Setting: Two distinct outpatient neurological rehabilitation services. Participants: Patients older than 18 years who were included presented upper limb spasticity resulting from ischemic or hemorrhagic stroke and a diagnosis of Painful Hemiplegic Shoulder Syndrome (PHSS) that was independent of motor dominance. Interventions: Patients were divided into two groups, one of them underwent the application of botulinum toxin (TXB-A) in the pectoralis major and subscapularis muscles, at a total dose of 400 U. Main Outcome Measure: Patients were assessed for a change in pain using the Visual Analog Scale (VAS) for at least 13 mm. Results: An improvement in pain and spasticity levels in both groups, more intense in the toxin group, but without statistical significance. The comparison between the groups showed a reduction in pain by VAS (p = 0.52). Conclusions: The use of botulinum toxin in the subscapularis and pectoralis major muscles resulted in a reduction in shoulder pain in spastic hemiplegic patients without statistical significance. Full article

Stroke is a common pathology worldwide, with an age-standardized global rate of new strokes of 150.5 per 100,000 population in 2017. Stroke causes upper motor neuron impairment leading to a spectrum of muscle weakness around the shoulder joint, changes in muscle tone, and subsequent soft tissue changes. Hemiplegic shoulder pain (HSP) is the most common pain condition in stroke patients and one of the four most common medical complications after stroke. The importance of the appropriate positioning and handling of the hemiplegic shoulder for prevention of HSP is therefore of high clinical relevance. Nevertheless, HSP remains a frequent and disabling problem after stroke, with a 1-year prevalence rate up to 39%. Furthermore, the severity of the motor impairment is one of the most important identified risk factors for HSP in literature. Spasticity is one of these motor impairments that is likely to be modifiable. After ruling out or treating other shoulder pathologies, spasticity must be assessed and treated because it could lead to a cascade of unwanted complications, including spastic HSP. In clinical practice, Botulinum toxin A (BTA) is regarded as the first-choice treatment of focal spasticity in the upper limb, as it gives the opportunity to target specifically selected muscles. It thereby provides the possibility of a unique patient tailored focal and reversible treatment for post stroke spasticity. This scoping review aims to summarize the current evidence of BTA treatment for spastic HSP. First, the clinical manifestation and outcome measures of spastic HSP will be addressed, and second the current evidence of BTA treatment of spastic HSP will be reviewed. We also go in-depth into the elements of BTA application that may optimize the therapeutic effect of BTA. Finally, future considerations for the use of BTA for spastic HSP in clinical practice and research settings will be discussed. Full article