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To evaluate and compare the effects of stretching and combined therapy (stretching and massage) on postural balance in people aged 50 to 65 years.
Twenty-three subjects participated in this nonrandomized clinical trial study. Each participant randomly received plantar flexor muscle stretching (3 cycles of 45 seconds with a 30-second recovery period between cycles) alone and in combination with deep stroking massage (an interval of at least 30 minutes separated the two interventions). The data were recorded with a force platform immediately after each condition with eyes open and closed. The center of pressure displacement and velocity along the mediolateral and anteroposterior axes were calculated under each condition. The data were analyzed with multiple-pair t-tests.
The center of pressure displacement and velocity along the mediolateral axis increased after both stretching and the combined intervention. There were significant differences in both values between participants in the stretching and combined interventions (p<0.05).
Plantar flexor muscle stretching (for 45 seconds) combined with deep stroking massage may have more detrimental effects on postural balance than stretching alone because each intervention can intensify the effects of the other.
Citations
Sciatic nerve injury after stretching exercise is uncommon. We report a case of an 18-year-old female trained dancer who developed sciatic neuropathy primarily involving the tibial division after routine stretching exercise. The patient presented with dysesthesia and weakness of the right foot during dorsiflexion and plantarflexion. The mechanism of sciatic nerve injury could be thought as hyperstretching alone, not caused by both hyperstretching and compression. Electrodiagnostic tests and magnetic resonance imaging revealed evidence of the right sciatic neuropathy from the gluteal fold to the distal tibial area, and partial tear of the left hamstring origin and fluid collection between the left hamstring and ischium without left sciatic nerve injury. Recovery of motor weakness was obtained by continuous rehabilitation therapy and some evidence of axonal regeneration was obtained by follow-up electrodiagnostic testing performed at 3, 5, and 12 months after injury.
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To describe a hand-stretching device that was developed for the management of hand spasticity in chronic hemiparetic stroke patients, and the effects of this device on hand spasticity.
Fifteen chronic hemiparetic stroke patients with finger flexor spasticity were recruited and randomly assigned to an intervention group (8 patients) or a control group (7 patients). The stretching device consists of a resting hand splint, a finger and thumb stretcher, and a frame. In use, the stretched state was maintained for 10 minutes per exercise session, and the exercise was performed twice daily for 4 weeks. Spasticity of finger flexor muscles in the two groups was assessed 3 times, 4 weeks apart, using the Modified Ashworth Scale (MAS). Patients in the intervention group were assessed twice (pre-1 and pre-2) before and once (post-1) after starting the stretching program.
Mean MAS (mMAS) scores at initial evaluations were not significantly different at pre-1 in the intervention group and at 1st assessment in the control group (p>0.05). In addition, no significant differences were observed between mMAS scores at pre-1 and pre-2 in the intervention group (p>0.05). However, mMAS scores at post-1 were significantly lower than that at pre-2 in the intervention group (p<0.05). Within the control group, no significant changes in mMAS scores were observed between 1st, 2nd, and 3rd assessments (p>0.05). In addition, mMAS scores at post-1 in the intervention group were significantly decreased compared with those at the 3rd assessment in the control group (p<0.05).
The devised stretching device was found to relieve hand spasticity effectively in chronic hemiparetic stroke patients.
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To evaluate normal healthy persons without spasticity to observe normal findings of the elbow stretch reflex using a newly developed, portable, hand-driven spasticity-measuring system.
Thirty normal persons without any disease involving the central or peripheral nervous system were enrolled in this study. The portable hand-driven isokinetic system is able to measure the joint angle, angular velocity, electromyographic (EMG) signals, and torque during elbow passive extension-flexion. One set of 10 passive elbow extension and flexion movements was performed for data acquisition at each angular velocity, including 60, 90, 120, 150 and 180 degrees per second (°/sec). Electromyographic data were collected from the biceps brachii and the triceps brachii. Torque data were collected from sensors around the wrist.
We were able to detect EMG activity and torque in all subjects by using the new portable hand-driven isokinetic system. EMG activity and torque increased with incremental increase of angular velocities. The joint angle of maximal EMG activity according to different angular velocities did not show any significant difference (116°-127° in elbow extension and 37°-66° in elbow flexion). The joint angles of maximal torque according to different angular velocities were not significantly different either.
Using the portable hand-driven isokinetic system on the elbows of normal subjects, we were able to obtain expected results. By considering our normal findings of the elbow stretch reflex using this system, we propose that the various aspects of spasticity-related data can be measured successfully.
Citations
Method: Spinal cords of 25 rabbits were contused by 20 g⁓20 cm weight drop in the 11th thoracic spine. After 2 weeks, muscle stretch reflex was measured. Triceps surae was dissected and stretched for 5 mm at the rate of 2 mm/sec and the length-tension curve were obtained. The slope in the length-tension curve was defined as stiffness index (SI). After baseline measurement, group I (n=6) received 50 mg/kg GBP IM injection and group II (n=8) received 100 mg/kg GBP IM injection, but control group (n=5) did not. Muscle stretch reflex was measured again after 30 minutes and 60 minutes, and then after sciatic nerve section. Active tension was calculated by subtracting passive tension from total tension. Proportion of SI was calculated by dividing follow-up SI with baseline SI.
Results: The proportion of SI of active tension reduced significantly at 30 minutes and 60 minutes compared to baseline (p＜0.001, p＜0.001). The proportion of SI of active tension in both group I and group II reduced significantly than control group (p=0.041, p＜0.001). The proportion of SI of active tension in group II reduced than group I, but it was not statistically significant (p=0.166).
Conclusion: The GBP reduced significantly muscle stretch reflex in spinal cord injured rabbits and showed dose-response tendency.
Method: Twelve spinal cord injured patients who had neurogeic bladder manifested with urinary incontinence resistant to oral and intravesical anticholinergic instillation treatment were selected. Oxybutynin solution was instillated via foley catheter and the catheter was clamped until incontinence occur. This was performed twice a day for 7 days. The urodynamic studies were compared before and after therapy. Total volume of daily incontinence and total volume of daily fluid intake were also monitored.
Results: After stretching therapy, median maximal bladder capacity increased from 190.08 to 457.17 ml (p＜0.01), mean bladder compliance increased from 8.46 to 18.85 ml/cmH2O (p＜0.01), mean reflex volume increased from 148.75 to 252.17 ml (p＜0.05), mean maximal detrusor pressure decreased from 52.17 to 28.29 cmH2O (p＜0.01), mean clinical maximal capacity increased from 277.50 to 537.50 ml (p＜0.01), and mean daily incontinent volume decreased from 508.33 ml to 20.83 ml (p＜0.01). No significant correlation was found between the duration since onset of injury and the urodynamic finding.
Conclusion: This study proved that stretching therapy of bladder was an effective method in spinal cord injured patients who had neurogenic bladder with uncontrolled incontinence with conventional therapy. (J Korean Acad Rehab Med 2003; 27: 344-348)
Objective: The purpose of this study is to develop an experimental spinal cord injury spasticity model using rabbits and to evaluate a quantitative spasticity measure.
Method: After an general anesthesia, 19 rabbits out of total 24 rabbits were laminectomized posteriorly and the spinal cords contused with 15 g⁓20 cm weight drop around 11th and 12th thoracic cord. After two weeks, behavioral analysis and clinical measurements of hindlimb spasticity were assessed. After that, rabbits' triceps surae was dissected and the length-tension plot was obtained by stretching it 5 mm, 2 mm/sec. And then the stiffenss of stretch reflex was determined from the length-tension plot. The stiffness of stretch reflex of the five normal control group was measured.
Results: 1) The measure was possible among 15 out of 19 spinal cord injured rabbits. One out of 19 rabbits was died
from urinary infection. Two rabbits was died from intraop-
erative bleeding at 2 weeks. Another one was excluded from the measurement due to joint contracture. 2) All of 15 rabbits showed clinical spasticity of hindlimb in 2 weeks. The spasticity was increased after the 4th day. 3) On the length-tension plot, the stiffness of stretch reflex of 15 rabbits significantly increased more than that of 5 normal group. 4) The total stiffness is correlated with the deep tendon reflex of knee and muscle tone of ankle. The stiffness of stretch reflex is weakly correlated with the deep tendon reflex of knee, digital hyperreflexia and ankle clonus.
Conclusion: The experimental spinal cord injury model and the quantitative spasticity measure method would contribute to measure the effect of the new therapy of spasticity more accurately, and to establish a principle of the new therapy. In addition, the study is expected to contribute to establish pathophysiology of spasticity. (J Korean Acad Rehab Med 2002; 26: 37-45)
Objective: This study was designed to evaluate the effect of stretching on decreasing spasticity of ankle plantar flexor muscles by biomechanical assessments.
Method: Twenty two ankle joints of nineteen patients with upper motor neuron lesion were included. The spasticity was assessed both clinically and biomechanically before and after stretching of ankle plantar flexor muscles by tilt table. For clinical assessment modified Ashworth scale (MAS) was used. For biomechanical assessment, ankle plantar flexor muscles were stretched isokinetically while EMG signals were recorded simultaneously and peak eccentric torque, stiffness index and stretch reflex threthold speed (SRTS) were measured.
Results: Two cases showed improvement in MAS after stretching but the others did not. SRTS of ankle plantar flexor was increased significantly while peak eccentric torque and stiffness index were unchanged.
Conclusion: Passive stretching of ankle plantar flexor muscles decreased the stretch threshold, that is a neural component of spasticity but it did not decrease the mechanical component of spasticity.
Objective: To investigate the effect of peripheral nerve stretching on motor evoked potentials (MEP) as a method of facilitation.
Methods: Twenty three normal healthy volunteers were enrolled. Transcranial magnetic stimulation (TMS) was applied to the contralateral scalp at 7 cm lateral to Cz using 90 cm round coil. Intensity of stimulation was adjusted to 90% of maximal stimulation intensity. Recording was done on the abductor pollicis brevis muscle in three different conditions; firstly resting state, secondly voluntary contraction of abductor pollicis brevis muscle, and lastly with stretching of median nerve. The onset latency and amplitude were obtained and compared between three conditions.
Result: The amplitude of MEP was significantly increased in the condition with muscle contraction and peripheal nerve stretching compared with resting state. The latency was shortened in the condition with muscle contraction with statistical significance and with peripheral nerve stretching without significance.
Conclusion: We concluded that stretching of peripheral nerve can be used as a method of facilitation of MEP. This method is considered to be useful especially for the patients with motor paralysis or poor cooperarion for voluntary contraction.
Objective: The purpose of this study was to investigate the influence of hyperactive stretch reflexes and contralateral adductor spread on the prognosis of gait in cerebral palsy with spastic diplegia and to investigate the reflex characteristics of spastic patients according to motor development.
Method: Thirty three children with spastic diplegia were examined. Compound muscle action potentials elicited by electrical hammer were used for quantification of stretch reflexes. Clinical spasticity was evaluated with the modified Ashworth scale and re-evaluation was done at least for 18 months. The patients were classified as 3 groups according to the stage of motor development: Group I consisted of children who were unable to sit; Group II children were able to pull to stand but unable to walk independently; Group III children could walk independently more than ten steps. Reflex irradiation, amplitudes of compound muscle action potentials, amplitude ratios, and Ashworth scores were analyzed and compared between the groups. Twenty four normal infants and 18 children were examined as control.
Results: Contralateral adductor responses were elicited with patellar tendon tap stimulation in all spastic diplegic children. The amplitudes of contralateral adductor were 2.41 mV in group I, 1.75 mV in group II, and 1.21 mV in group III. The amplitude ratio of contralateral adductor to rectus femoris were 0.53 in group I, 0.40 in group II, and 0.26 in group III, respectively, and correlated with the degree of spasticity.
Conclusion: The stretch reflex responses in children with cerebral palsy with spastic diplegia were highly exaggerated, and correlated with motor development. Spread of reflexes to contralateral adductor muscle would be in clinical and electrophysiological value.
Objective: This study was designed to evaluate the usefulness of stretch reflex threshold speed (SRTS) in biomechanical assesment of spasticity of hemiplegic patients.
Method: Thirty-eight hemiplegic patients and twenty-seven control subjects were studied. The spasticity of ankle plantar flexor muscles were assessed both clinically and biomechanically. Modified Ashworth scale (MAS) and Brunnstrom stage were used in clinical assessment. For biomechanical assessment, ankle plantar flexor muscles were stretched isokinetically while EMG signals were recorded simultaneously. SRTS was defined as a minimum angular velocity in which EMG signals evoked by stretch reflex were recorded.
Results: SRTSs of ankle plantar flexors were 128.1⁑47.1o/sec in control group, 163.7⁑79.7o/sec in intact legs, and 83.4⁑69.1o/sec in involved legs of hemiplegic group. STRS was significantly lower in involved legs of hemiplegic group than in intact legs of hemiplegic group and control group. Significant reverse correlation was observed between SRTS and MAS. There was significant difference in SRTS between MAS 0 group and other groups. The patients with Brunnstrom stage 3 and 4 groups showed decreased SRTS compared to the patients with other groups.
Conclusion: SRTS is thought to reflect increased excitability of stretch reflex and seems to be one of useful parameters in quantitative assessment of spasticity.
Objective: The purpose of this study was to titrate the nerve block effect of phenol with different concentrations of phenol solution by electrophysiological and mechanical measurements.
Method: Right tibial nerves of twenty three adult rabbits were blocked by phenol solution with different concentrations (3%, 5%). Nerve conduction study for compound muscle action potential (CMAP), tension by electrical stimulation, and stiffness (slope) of stretch reflex of the triceps surae were performed after nerve block (4 weeks, 8 weeks, 16 weeks). The ratios of each values of right limb to those of left limb were used to evaluate the nerve block effect.
Results: The ratios of CMAP amplitude, tension, and slope of 3% group were 0.36, 0.55, and 0.56 at 4 weeks and those of 5% group were 0.21, 0.25, and 0.58. There were statistically significant differences of the CMAP amplitude and tension ratios, however there was no statistically significant difference of the slope ratio between two groups at 4 weeks. The ratios of CMAP amplitude, tension, and slope of 5% phenol group were increased with time.
Conclusion: Nerve block effects by 5% phenol solution were greater than 3%. These data suggest that nerve block effect can be titrated with concentration of phenol solution.
We present a 50-year-old woman who sustained spastic left hemiplegia secondary to the right thalamic hemorrhage 6 years ago. She complained of persistent severe left calf pain after serial casting for the treatment of shortened plantar flexors of the left ankle. Two months later, magnetic resonance T1-weighted images showed diffuse high signal intensity involving the whole muscle bulk of the soleus and normal signal intensity of thin atrophied gastrocnemius. Needle electromyography of the soleus revealed myopathic patterns. Histologic findings of the soleus showed necrotic muscle fibers with phagocytosis, endomyseal collagen and fat deposition. We concluded that prolonged passive stretch of spastic plantar flexors of the ankle under serial casting induced soleus myopathy with segmental myonecrosis, and which developed left calf pain. Selective induction of soleus myopathy could be explained by the higher stretch tension produced by ankle dorsiflexion in the soleus compared to the gastrocnemius because of different proximal ends.
Objective: To determine whether ankle plantar flexors stretching exercise affects functional reach in elderly men.
Method: Twenty elderly men with an average age of 78.2 years were selected for this study. A active range of motion of ankle dorsiflexion and a functional reach (FR) distance were measured before and after ankle stretching exercise. The ankle dorsiflexion was measured by goniometer in knee extended position. The FR distance was measured in standing position. Ankle plantar flexors stretching exercises were carried out by physical therapist 4 times per week for 4 weeks. At 4 weeks after the stretching exercise, we retested the active range of motion of ankle dorsiflexion and the FR distance using the same method.
Results: At 4 weeks after the stretching exercise, the active range of motion of right ankle dorsiflexion was increased from 2.81⁑3.26o to 5.98⁑4.34o, and the left ankle dorsiflexion was increased from 3.15⁑3.77o to 6.35⁑2.45o. The FR distance was increased form 12.22⁑7.54 cm to 19.69⁑8.59 cm after the stretching exercise.
Conclusion: The FR distance was significantly increased after the ankle plantar flexors stretching exercise (p＜0.01). This results suggest that the ankle plantar flexors stretching excercise may be capable of increasing the FR distance in elderly.
Objective: The aim of this study was to develop objective evaluation method which reflect the velocity dependent increase of stretch reflex in spasticity using the pendulum test and dynamic electromyography.
Method: Kinematic analysis for knee angle and angular velocity measurement, and dynamic electromyography were performed simultaneously during pendulum movement of spastic lower extremity in supine position for nineteen spastic hemiplegia patients and ten normal control subjects. Angular relaxation index (ARI), Maximum angular velocity (MAV), Angular threshold (AT) and Angular velocity threshold (AVT) were used for the evaluation of spsticity.
Results: 1) ARI was 1.64⁑0.04 in normal, 1.28⁑0.14 in modified Ashworth scale (MAS) I, 1.18⁑0.16 in MAS II, 1.02⁑0.13 in MAS III, 2) MAV was 325.0⁑29.4 in normal, 301.7⁑37.8 in MAS I, 269.2⁑29.7 in MAS II, 232.4⁑28.2 in MAS III, 3) In normal subjects EMG activity did not occur, whereas in spastic hemiplegic patient a stretch reflex appears in thigh muscle. AT and AVT were 57.39⁑4.45, 256.24⁑14.07 in MAS I, 38.59⁑4.26, 184.45⁑12.7 in MAS II, 19.13⁑7.13, 136.06⁑12.88 in MAS III, respectively, 4) Correlation coefficients of the ARI (r=0.786), AT (r=0.960), AVT (r=0.949) showed significantly negative correlations with the MAS.
Conclusion: 1) AT and AVT are more sensitive parameters than ARI for documenting spasticity in hemiplegic patients. 2) An evaluation of spasticity using pendulum test and dynamic electromyography would provide consistent results with little error and would not be influenced by the change of examiner or environment. Thus we can get very reliable results using this method.
Objective: We designed this study to evaluate muscle tone by using a biomechanical method and to provide data for the future studies about muscle tone.
Method: We evaluated 29 subjects without known neuromuscalar diseases using the biomechanical method. Both plantar flexors of each subject were passively stretched by isokinetic dynamometer from 30oplantar flexion position to 10odorsiflexion position. Peak eccentric torque (PET) and torque threshold angle (TTA) were calculated at angular velocity of 10o/sec, 90o/sec and 300o/sec. Regression lines from torque/position curve at 10o/sec and 300o/sec were considered an intrinsic stiffness index (ISI) and total stiffness index (TSI). Stretch reflex threshold speed (SRTS) was defined as the minimum speed of plantar flexion movement in which EMG reflex activity in plantar flexor muscles is induced.
Results: The mean of TTA was higher in 10o/sec than in 300o/sec. The means of ISI and TSI were 0.11⁑0.08, and 0.18⁑0.04. The mean of SRTS was 125.2⁑48.3o. No statistical difference in each parameter was found according to the side or gender.
Conclusion: ISI, TSI, PET, TTA and SRTS using a biomechanical method are thought to be useful parameters for the quantitative assessment of muscle tone change of ankle plantar flexors.
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