Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Sep 4;33(3):11607.
doi: 10.4081/ejtm.2023.11607.

Conventional physical therapy combined with extracorporeal shock wave leads to positive effects on spasticity in stroke survivors: a prospective observational study

Emanuela Elena Mihai  1 , Jannis Papathanasiou  2 , Kiril Panayotov  3 , Yana Kashilska  4 , Eugenia Rosulescu  5 , Calogero Foti  6 , Mihai Berteanu  7
Affiliations

Conventional physical therapy combined with extracorporeal shock wave leads to positive effects on spasticity in stroke survivors: a prospective observational study

Emanuela Elena Mihai et al. Eur J Transl Myol. .

Abstract

The study aimed to evaluate the effectiveness of radial extracorporeal shock wave therapy (rESWT) and conventional physical therapy (CPT) protocol on the gait pattern in stroke survivors through a new gait analysis technology. Fifteen (n=15) stroke survivors took part in this prospective, observational study and were assessed clinically and through an instrumented treadmill before and after rESWT and CPT. Spasticity grade 95% CI 0.93 (0.79 +/- 1.08), pain intensity 95% CI 1.60 (1.19 +/- 2.01), and clonus score decreased significantly 95% CI 1.13 (0.72 +/- 1.54). The sensorimotor function 95% CI -2.53 (-3.42 +/- 1.65), balance 95% CI -5.67 (-6.64 +/- - 4.69), and gait parameters were enhanced at the end of the program. Step length 95% CI -3.47 (-6.48 +/- 0.46) and step cycle were improved 95% CI -0.09 (-0.17 +/- -0.01), and hip 95% CI -3.90 (-6.92 +/- -0.88), knee 95% CI -2.08 (-3.84 +/- -0.32) and ankle flexion-extension 95% CI -2.08 (-6.64 +/- -4.69) were augmented. Adding the quantitative analysis to the clinical assessment, we gained easy access to track progress and obtained an individualized therapeutic approach for stroke survivors.

PubMed Disclaimer

Conflict of interest statement

We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.

Stroke is one of the leading causes of long-term disability in adults worldwide with an increasing number of persons affected by this condition. Stroke related impairments such as spasticity, muscle weakness, pain, sensorimotor deficits, and poor balance can often lead to a decreased tolerance to daily life activities, autonomy restriction, and sedentary lifestyle., Gait is a complex task and parameters such as spatiotemporal, kinematic, and kinetic variables are often modified in patients with walking disorders. Currently, new technological gait analysis systems offer the possibility of creating a database, reproducible results, and easy access for tracking progress and efficacy of neurorehabilitation programs through telerehabilitation (TR) implementation in the clinical practice, especially since the COVID-19 pandemic context., Quantitative gait analysis systems include instrumented treadmills as a new alternative to previous overground gait analysis systems, and also promote the assessments and effective therapeutic delivery of care to neurological patients after discharge.,, Objective, quantitative parameters are needed to ensure good quality in clinical practice since the most commonly used methods for gait analysis were based either on visual observation or questionnaires, which are considered poorly reliable and insufficient methods. Currently, the gold standard for measuring and evaluating spatiotemporal and kinematic gait parameters is represented by various 3D motion capture systems., Poor balance control and gait impairments interfere with standing and walking ability in stroke survivors. Gait dynamics changes its pattern especially in stroke survivors due to increased muscle tone and balance impairment. Early detection and assessment of gait anomalies through gait analysis systems evaluate stride length and duration, lower limb range of motion (ROM), limb symmetry or asymmetry, providing objective parameters and ensuring evaluation of progress and recovery during the rehabilitation program.

Usually, the rehabilitation of post-stroke patients is a long-term process involving multiple assessments. However, during the pandemic of COVID-19, the access to healthcare delivery throughout the world has been significantly impacted creating collateral damages for both, rehabilitation facilities and stroke survivors.

One of the key changes implemented by the health care systems in order to promote rehabilitation continuity, was the rapid expansion of several TR programs and tele-assessments strategies., Systems such as newly instrumented treadmills for spatiotemporal, kinematic, and kinetic parameters assessment with good levels of agreement, seem a new alternative to previous overground gait analysis systems. Integrating clinical assessment and virtual evaluation can easily offer objective data by tracking progress and also give the possibility to a tailored treatment for patients based on their performance at different moments.

Among the emerging therapies, extracorporeal shock wave therapy (ESWT) is a non-invasive therapeutic intervention used for musculoskeletal disorders, several inflammatory tendon diseases, or spasticity. The findings suggest that ESWT may be useful in decreasing plantar flexor muscle tone for adults and children affected by lower limb spasticity., There are some trials which had also showed that radial extracorporeal shockwave therapy (rESWT) was more effective on augmenting the ankle passive range of motion (PROM) compared to focal extracorporeal shockwave therapy (fESWT)., In addition, ESWT proved to be effective not only as treatment for lower limb spasticity, but also for gait pattern since combined with a conventional physical therapy (CPT) program decreased spasticity and improved gait pattern in children with hemiplegic cerebral palsy (CP). The findings on ESWT effectiveness for gait pattern improvement could open a new paradigm applicable for the research of this promising, non-invasive therapy already effective for spasticity management.

Added to clinical evaluation, the instrumented treadmills serve both as a tool for gait training and also for recording and measuring spatiotemporal and kinematic parameters, offering objective data for gait analysis, especially after treatment delivery., Gait analysis through systems such as instrumented treadmills play an important role in clinical practice and clinical trials by assessing gait patterns related to various disorders. This type of analysis through instrumented treadmills is based on measurements which offer the possibility for repeatability. Through the inertial measurement units (IMUs) usage it is granted good validity and reliability for mean spatiotemporal parameters during gait phases. Although there are trials validating different types of 3D cameras for gait analysis on the treadmills and overground, only few of them assessed the instrumented treadmills. However, there are gait analysis systems which showed good levels of agreement, and added to the clinical assessment provide the assessor with objective, real-time data.,,

Therefore, the aim of this study is to objectively evaluate the effectiveness of rESWT and CPT protocol on the gait pattern in stroke survivors through a new gait analysis technology. This type of technology encompasses spatiotemporal and kinematic parameters, and the findings are correlated with the clinical evaluation, offering a global assessment of gait parameters.

Figures

Fig 1.
Fig 1.
Application of rESWT in a stroke survivor. The original picture was taken by the author E.E. Mihai in the Department of Physical and Rehabilitation Medicine, Elias University Emergency Hospital, Bucharest, using a digital camera.
Fig 2.
Fig 2.
Schematic of the CPT protocol and rESWT delivery
Fig 3.
Fig 3.
Schematic of the instrumented treadmill Walker View and one participant with IMUs sensors applied on the feet (red dots). Original figure taken by the author E.E. Mihai at the Physical and Rehabilitation Medicine Department of Elias University Emergency Hospital, Bucharest using a digital camera.. Abbreviations: IMUs – inertial measurement units.
Fig 4.
Fig 4.
STROBE flow chart of the study. Abbreviations: STROBE: STrengthening the Reporting of OBservational studies in Epidemiology.
See this image and copyright information in PMC

References

    1. Donkor ES. Stroke in the 21st Century: A Snapshot of the Burden, Epidemiology, and Quality of Life. Stroke Res Treat. 2018. Nov 27;2018:3238165. doi: 10.1155/2018/3238165. PMID: 30598741; PMCID: PMC6288566. - PMC - PubMed
    1. Zhang M, You H, Zhang H, Zhao W, Han T, Liu J, Jiang S, Feng X. Effects of visual feedback balance training with the Pro-kin system on walking and self-care abilities in stroke patients. Medicine (Baltimore). 2020. Sep 25;99(39):e22425. doi: 10.1097/MD.0000000000022425. PMID: 32991477; PMCID: PMC7523840. - PMC - PubMed
    1. Bravi M, Massaroni C, Santacaterina F, Di Tocco J, Schena E, Sterzi S, Bressi F, Miccinilli S. Validity Analysis of WalkerViewTM Instrumented Treadmill for Measuring Spatiotemporal and Kinematic Gait Parameters. Sensors (Basel). 2021. Jul 14;21(14):4795. doi: 10.3390/s21144795. PMID: 34300534; PMCID: PMC8309770. - PMC - PubMed
    1. Mohan DM, Khandoker AH, Wasti SA, Ismail Ibrahim Ismail Alali S, Jelinek HF, Khalaf K. Assessment Methods of Post-stroke Gait: A Scoping Review of Technology-Driven Approaches to Gait Characterization and Analysis. Front Neurol. 2021. Jun 8;12:650024. doi: 10.3389/fneur.2021.650024. PMID: 34168608; PMCID: PMC8217618. - PMC - PubMed
    1. Papathanasiou J, Kashilska Y, Bozov H, Petrov I, Masiero S. The outbreak of the SARS-CoV-2 Omicron variant make imperative the adoption of telerehabilitation in the Bulgarian health care system. Eur J Transl Myol. 2022. Feb 2;32(1):10355. doi: 10.4081/ejtm.2022.10355. PMID: 35107088; PMCID: PMC8992671. - PMC - PubMed