Topics in Stroke Rehabilitation
ISSN: 1074-9357 (Print) 1945-5119 (Online) Journal homepage: http://www.tandfonline.com/loi/ytsr20
Efficacy of Mechano-Acoustic Vibration on Strength, Pain, and Function in Poststroke Rehabilitation: A Pilot Study Cosimo Constantino, Laura Galuppo & Davide Romiti To cite this article: Cosimo Constantino, Laura Galuppo & Davide Romiti (2014) Efficacy of Mechano-Acoustic Vibration on Strength, Pain, and Function in Poststroke Rehabilitation: A Pilot Study, Topics in Stroke Rehabilitation, 21:5, 391-399, DOI: 10.1310/tsr2105-391 To link to this article: http://dx.doi.org/10.1310/tsr2105-391
Published online: 22 Dec 2014.
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Date: 14 April 2016, At: 08:22
Efficacy of Mechano-Acoustic Vibration on Strength, Pain, and Function in Poststroke Rehabilitation: A Pilot Study Cosimo Constantino, MD, PhD, 1 Laura Galuppo, MD, 1 and Davide Romiti, MD1 1
Downloaded by [University of California, San Diego] at 08:22 14 April 2016
Department of Biomedical, Biotechnological and Translational Sciences, University of Parma, Italy
Background: Vibration therapy may be used to help cortical reorganization after stroke as it can cause different adaptive metabolic and mechanical effects. Objective: This study examined whether the application of mechano-acoustic vibration on upper limb muscles could induce changes in range of motion (ROM), function, pain, and grip strength in individuals with chronic stroke. Methods: Out of 52 individuals post stroke with upper limb spasticity who were eligible,16 received mechano-acoustic vibration therapy (ViSS device) 3 times weekly for 12 sessions. The frequency of vibration was set to 300 Hz for 30 minutes. The treated muscles were the extensor carpi radialis longus and brevis and triceps brachii during voluntary contraction. All participants were evaluated in both upper limbs before (T0) and at the end (T1) of treatment with a dynamometer (hand grip strength), Modified Ashworth Scale, QuickDASH, FIM score, Fugl-Meyer scale, Verbal Numerical Rating Scale of pain, and Jebsen-Taylor Hand Function Test. Results: After 4 weeks, hand grip power had improved and pain and spasticity had decreased. Improvements were recorded for all parameters and were considered statistically significant. Conclusions: Application of vibratory stimuli to a muscle can increase the motor-evoked potential recorded from the muscle, suggesting an enhancement of corticospinal excitability. Low amplitude, high-frequency vibration treatment (300 Hz) can significantly decrease tone and pain and improve strength in upper limb of hemiplegic individuals, when applied for 30 minutes, 3 times a week over 4 weeks. Key words: mechano-acoustic vibration, poststroke, strength, upper limb, vibration
pper limb spasticity secondary to a stroke is a common complication that can lead to abnormal limb posture and interfere with both active and passive function, resulting in a reduction of quality of life and increased carer burden.1 Spasticity of the upper limb is a major obstacle to rehabilitation of hemiplegic individuals with stroke and can seriously impair activities of daily living, even if hemiplegia is comparatively mild.2 Vibration therapy has been studied with different purposes, and it has been shown that it can cause different adaptive metabolic and mechanical effects.3,4 The effectiveness of this therapy has been proven in the prevention and treatment of osteoporosis,5 for orthopedic and neurological rehabilitation,6 and in inducing an increase of muscle mass and strength in elderly people.7 In addition, it has been used to evoke the
U
tonic vibration reflex (TVR), to study spinal reflex activity,8,9 and in pain medicine.10 Vibration is a stimulus determined by mechanical oscillation, which is characterized by amplitude, frequency, and acceleration. 11 Two forms of vibration therapy are used in athletic training and medicine: whole-body vibration (WBV) and repeated local vibration (mechano-acoustic) of a single muscle. Both vibration types use mechanical stimulation. In recent years, many studies have investigated the effect of WBV on athletes and patients,12,13 whereas local vibration treatment has received less attention. Local vibration excludes any contribution from changes in gravitational load, and the optimal frequency of stimulation is an important factor. An experimental study has suggested that muscle tension increases linearly with vibration
Corresponding author: Cosimo Costantino, Department of Biomedical, Biotechnological and Translational Sciences, University of Parma, Via Gramsci, 14, 43126, Parma, Italy; phone: +390521703517; fax: +390521702147; e-mail: [email protected]
Top Stroke Rehabil 2014;21(5):391–399 © 2014 Thomas Land Publishers, Inc. www.strokejournal.com doi: 10.1310/tsr2105-391
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frequency,14 and another study has indicated that the primary endings of muscle spindles are stimulated with a one-to-one discharge rate up to 100 Hz.15 The effects of high-frequency vibration on the neuromuscular tissue are not well known. However, it was demonstrated that high-frequency vibration significantly increased muscle force in elderly subjects, without signs of hypertrophy.7,16 Few controlled trials with a small number of participants have demonstrated that repeated muscle vibration could induce a persistent improvement on muscle performance in sedentary young-elderly women17 and hypoactive immobilized persons18 and on muscle trophism in elderly people with sarcopenia.7 Lundeburg et al19 used vibration with a frequency of 100 Hz in treating pain. In the study by Casale et al,10 they reported that vibration conditioning of 300 Hz induced modifications in initial values of conduction velocity (CV) in the recruited motor unit pool and greater alterations in the rate of fatigue only when voluntary contractions demanded more effort. Murillo et al demonstrated a decrease of limb spasticity in patients with spinal cord injury using a prolonged vibration on proximal lower extremity muscles,20 but only few recent studies with a small number of participants have assessed the use of vibration in the poststroke clinical recovery. In a pilot study, Doucet and Griffin21 examined the effects of low- and highfrequency vibration on fine motor control in chronic hemiplegia of the hand, Tavernese et al22 proved its effectiveness in improving upper limb motor performances, and Paoloni et al23 demonstrated its benefit in improving gait performance. Noma et al24 argued that vibratory stimulus is an effective nonpharmacological antispastic treatment immediately after the intervention, whereas Conrad et al25 suggested that it could enhance stability of the proximal arm in hemiparetic patients. Most of these studies used repeated local lowfrequency vibration, even though high-frequency vibration during voluntary contraction seems promising in modifying the centrally driven motor unit recruitment order.10 Starting from these premises, the aim of this pilot study was to examine the short-term effects of repeated muscle low amplitude, high-frequency (300 Hz)
vibration, using ViSS equipment (Vibration Sound System; Vissman, Rome, Italy) on range of motion (ROM), muscle tone, pain, and hand grip strength in upper limb of individuals post stroke. Methods Fifty-two chronic individuals post stroke with upper limb spasticity were recruited from Parma University Hospital Rehabilitation Center and assessed for eligibility. The participants were informed in detail on the scope and procedures of the study and then they were asked to take part in a clinical trial. The Institutional Ethic Review Board of our university hospital approved the study, and individuals provided written informed consent before participating in the study in accordance with the National Health Council Resolution No. 196/96 and with the Helsinki Declaration of 1975, as revised in 2000. Inclusion criteria were patients affected by hemorrhagic or ischemic stroke with stable outcomes, at least 12 months after the stroke event, with no cognitive deficits and upper limb spasticity in shoulder, elbow, or wrist rated from mild to moderate (Modified Ashworth Scale [MAS] scores from 1 to 3) in at least 1 of the 3 joints. The exclusion criteria were severe spasticity (MAS score = 4), inflammatory osteoarticular diseases, neoplastic diseases, anticoagulant and antiepileptic therapies, hearing aids, pacemakers, recent trauma, metallic implants, joint replacements on treated articulation, treatments with botulinum toxin, or other substances interfering with neuromuscular function since the stroke event. Out of 52 individuals assessed at the first evaluation, 29 were excluded: 7 individuals did not meet the inclusion criteria, 8 were excluded because of inflammatory osteoarticular diseases, 2 because of neoplastic diseases, 7 because of anticoagulant and antiepileptic therapies, 1 because of pacemaker, and 4 because of recent trauma. Twenty-three individuals were then included in our clinical trial, and 7 dropped out at the beginning of the study: 4 individuals refused to sign our written consent and 3 had family problems. Therefore our study involved 16 participants (10 males and 6 females), aged
Downloaded by [University of California, San Diego] at 08:22 14 April 2016
Efficacy of Vibration in Poststroke Rehabilitation
between 36 and 77 years (mean age, 61.69 ± 15.43 years) (Figure 1). Stroke diagnosis was based on computed tomography or magnetic resonance imaging, and neurological functions were completely investigated as well. The average time since the stroke was 41.00 ± 28.50 months. Eleven participants were affected by left upper limb spasticity (10 righthanded and 1 left-handed), whereas 5 were affected by right upper limb spasticity (5 righthanded and no left-handed). Eleven patients were diagnosed with ischemic cerebral infarction and 5 with cerebral hemorrhage. All subjects had to be able to actively move the paretic upper limb, with limitations, in order to perform the activities of daily living and the movements needed for the hand grip and functional tests. The conditioning protocol consisted of the application of local high-intensity vibrations on the upper limbs with the ViSS device, which was applied to the skin covering the venter of the extensor carpi radialis longus and brevis and triceps
Figure 1. Flow diagram.
393
brachii muscles (Figure 2). The entire treatment of 12 sessions (3 per week over 4 weeks), for 30 minutes each, was performed with vibrations set to a frequency of 300 Hz and amplitude of 2 mm over the aforementioned muscles. During the treatment, the paretic upper limb was positioned on a rigid surface to allow the patient to contract isometrically the treated muscle and to work against the resistance provided by the rigid surface.7 During the treatment of extensor carpi radialis, subjects were seated with the elbow flexed at 120°, forearm and wrist in pronation, hand with metacarpus positioned on the rigid surface, and fingers extended; whereas for the triceps brachii muscle treatment, the elbow was extended, the forearm was in pronation, and the hand was pushing against the rigid surface. All participants were evaluated by an independent observer who was blinded to the intervention performed in the protocol using the following clinical and instrumental tests before (T0) and 2 to 3 days after the 4-week treatment (T1):
Downloaded by [University of California, San Diego] at 08:22 14 April 2016
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Figure 2. Treatment on venter of the extensor carpi radialis longus muscle.
• Hand Grip Strength Test measures muscle force with a hand-held dynamometer. The patient’s elbow is flexed to form a 90° angle and locked into position by the hand of the physician. The measurements were carried out in both standard position 2 (SP2) and standard position 3 (SP3) in both upper limbs.26 Because we assessed the hand grip strength in both upper limbs, it can be stated that each individual was analyzed as casecontrol. • Jebsen-Taylor Hand Function Test for upper limbs measures the time taken to complete 7 manipulative trials such as writing, turning pages of a newspaper, picking up small objects, etc.27 To complete our clinical assessment, the following scales were used: • Modified Ashworth Scale (MAS) assesses muscle spasticity and uses a 5-point scale to score the average resistance to passive movement for each joint: shoulder, elbow, and wrist. It divides spasticity into 5 degrees (0 to 4), where MAS 0 indicates no increase in muscle tone and MAS 4 indicates affected part rigid in flexion or extension. We can infer the degree of spasticity by mobilizing the affected limb.2,28 • QuickDASH (Disabilities of the Arm, Shoulder and Hand ) assigns a score to activities of daily life using 11 questions.29 • FIM consists of questions on activities of daily life, such as personal care, locomotion, and language. It is considered an international
instrument for measuring disability. The score ranges from 1 (full assistance) to 7 (complete self-sufficiency).30 • Fugl-Meyer assessment scale as modified by Lindmark and Hamrin (Motor Capacity Assessment) is a rating scale for impairment. It is used to obtain goniometric measurements of passive and active shoulder, elbow, wrist, and fingers joint ROM. It is a useful tool to assess the ROM, assigning a score from 0 (
ISSN: 1074-9357 (Print) 1945-5119 (Online) Journal homepage: http://www.tandfonline.com/loi/ytsr20
Efficacy of Mechano-Acoustic Vibration on Strength, Pain, and Function in Poststroke Rehabilitation: A Pilot Study Cosimo Constantino, Laura Galuppo & Davide Romiti To cite this article: Cosimo Constantino, Laura Galuppo & Davide Romiti (2014) Efficacy of Mechano-Acoustic Vibration on Strength, Pain, and Function in Poststroke Rehabilitation: A Pilot Study, Topics in Stroke Rehabilitation, 21:5, 391-399, DOI: 10.1310/tsr2105-391 To link to this article: http://dx.doi.org/10.1310/tsr2105-391
Published online: 22 Dec 2014.
Submit your article to this journal
Article views: 13
View related articles
View Crossmark data
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ytsr20 Download by: [University of California, San Diego]
Date: 14 April 2016, At: 08:22
Efficacy of Mechano-Acoustic Vibration on Strength, Pain, and Function in Poststroke Rehabilitation: A Pilot Study Cosimo Constantino, MD, PhD, 1 Laura Galuppo, MD, 1 and Davide Romiti, MD1 1
Downloaded by [University of California, San Diego] at 08:22 14 April 2016
Department of Biomedical, Biotechnological and Translational Sciences, University of Parma, Italy
Background: Vibration therapy may be used to help cortical reorganization after stroke as it can cause different adaptive metabolic and mechanical effects. Objective: This study examined whether the application of mechano-acoustic vibration on upper limb muscles could induce changes in range of motion (ROM), function, pain, and grip strength in individuals with chronic stroke. Methods: Out of 52 individuals post stroke with upper limb spasticity who were eligible,16 received mechano-acoustic vibration therapy (ViSS device) 3 times weekly for 12 sessions. The frequency of vibration was set to 300 Hz for 30 minutes. The treated muscles were the extensor carpi radialis longus and brevis and triceps brachii during voluntary contraction. All participants were evaluated in both upper limbs before (T0) and at the end (T1) of treatment with a dynamometer (hand grip strength), Modified Ashworth Scale, QuickDASH, FIM score, Fugl-Meyer scale, Verbal Numerical Rating Scale of pain, and Jebsen-Taylor Hand Function Test. Results: After 4 weeks, hand grip power had improved and pain and spasticity had decreased. Improvements were recorded for all parameters and were considered statistically significant. Conclusions: Application of vibratory stimuli to a muscle can increase the motor-evoked potential recorded from the muscle, suggesting an enhancement of corticospinal excitability. Low amplitude, high-frequency vibration treatment (300 Hz) can significantly decrease tone and pain and improve strength in upper limb of hemiplegic individuals, when applied for 30 minutes, 3 times a week over 4 weeks. Key words: mechano-acoustic vibration, poststroke, strength, upper limb, vibration
pper limb spasticity secondary to a stroke is a common complication that can lead to abnormal limb posture and interfere with both active and passive function, resulting in a reduction of quality of life and increased carer burden.1 Spasticity of the upper limb is a major obstacle to rehabilitation of hemiplegic individuals with stroke and can seriously impair activities of daily living, even if hemiplegia is comparatively mild.2 Vibration therapy has been studied with different purposes, and it has been shown that it can cause different adaptive metabolic and mechanical effects.3,4 The effectiveness of this therapy has been proven in the prevention and treatment of osteoporosis,5 for orthopedic and neurological rehabilitation,6 and in inducing an increase of muscle mass and strength in elderly people.7 In addition, it has been used to evoke the
U
tonic vibration reflex (TVR), to study spinal reflex activity,8,9 and in pain medicine.10 Vibration is a stimulus determined by mechanical oscillation, which is characterized by amplitude, frequency, and acceleration. 11 Two forms of vibration therapy are used in athletic training and medicine: whole-body vibration (WBV) and repeated local vibration (mechano-acoustic) of a single muscle. Both vibration types use mechanical stimulation. In recent years, many studies have investigated the effect of WBV on athletes and patients,12,13 whereas local vibration treatment has received less attention. Local vibration excludes any contribution from changes in gravitational load, and the optimal frequency of stimulation is an important factor. An experimental study has suggested that muscle tension increases linearly with vibration
Corresponding author: Cosimo Costantino, Department of Biomedical, Biotechnological and Translational Sciences, University of Parma, Via Gramsci, 14, 43126, Parma, Italy; phone: +390521703517; fax: +390521702147; e-mail: [email protected]
Top Stroke Rehabil 2014;21(5):391–399 © 2014 Thomas Land Publishers, Inc. www.strokejournal.com doi: 10.1310/tsr2105-391
391
Downloaded by [University of California, San Diego] at 08:22 14 April 2016
392
TOPICS IN STROKE REHABILITATION/SEPT-OCT 2014
frequency,14 and another study has indicated that the primary endings of muscle spindles are stimulated with a one-to-one discharge rate up to 100 Hz.15 The effects of high-frequency vibration on the neuromuscular tissue are not well known. However, it was demonstrated that high-frequency vibration significantly increased muscle force in elderly subjects, without signs of hypertrophy.7,16 Few controlled trials with a small number of participants have demonstrated that repeated muscle vibration could induce a persistent improvement on muscle performance in sedentary young-elderly women17 and hypoactive immobilized persons18 and on muscle trophism in elderly people with sarcopenia.7 Lundeburg et al19 used vibration with a frequency of 100 Hz in treating pain. In the study by Casale et al,10 they reported that vibration conditioning of 300 Hz induced modifications in initial values of conduction velocity (CV) in the recruited motor unit pool and greater alterations in the rate of fatigue only when voluntary contractions demanded more effort. Murillo et al demonstrated a decrease of limb spasticity in patients with spinal cord injury using a prolonged vibration on proximal lower extremity muscles,20 but only few recent studies with a small number of participants have assessed the use of vibration in the poststroke clinical recovery. In a pilot study, Doucet and Griffin21 examined the effects of low- and highfrequency vibration on fine motor control in chronic hemiplegia of the hand, Tavernese et al22 proved its effectiveness in improving upper limb motor performances, and Paoloni et al23 demonstrated its benefit in improving gait performance. Noma et al24 argued that vibratory stimulus is an effective nonpharmacological antispastic treatment immediately after the intervention, whereas Conrad et al25 suggested that it could enhance stability of the proximal arm in hemiparetic patients. Most of these studies used repeated local lowfrequency vibration, even though high-frequency vibration during voluntary contraction seems promising in modifying the centrally driven motor unit recruitment order.10 Starting from these premises, the aim of this pilot study was to examine the short-term effects of repeated muscle low amplitude, high-frequency (300 Hz)
vibration, using ViSS equipment (Vibration Sound System; Vissman, Rome, Italy) on range of motion (ROM), muscle tone, pain, and hand grip strength in upper limb of individuals post stroke. Methods Fifty-two chronic individuals post stroke with upper limb spasticity were recruited from Parma University Hospital Rehabilitation Center and assessed for eligibility. The participants were informed in detail on the scope and procedures of the study and then they were asked to take part in a clinical trial. The Institutional Ethic Review Board of our university hospital approved the study, and individuals provided written informed consent before participating in the study in accordance with the National Health Council Resolution No. 196/96 and with the Helsinki Declaration of 1975, as revised in 2000. Inclusion criteria were patients affected by hemorrhagic or ischemic stroke with stable outcomes, at least 12 months after the stroke event, with no cognitive deficits and upper limb spasticity in shoulder, elbow, or wrist rated from mild to moderate (Modified Ashworth Scale [MAS] scores from 1 to 3) in at least 1 of the 3 joints. The exclusion criteria were severe spasticity (MAS score = 4), inflammatory osteoarticular diseases, neoplastic diseases, anticoagulant and antiepileptic therapies, hearing aids, pacemakers, recent trauma, metallic implants, joint replacements on treated articulation, treatments with botulinum toxin, or other substances interfering with neuromuscular function since the stroke event. Out of 52 individuals assessed at the first evaluation, 29 were excluded: 7 individuals did not meet the inclusion criteria, 8 were excluded because of inflammatory osteoarticular diseases, 2 because of neoplastic diseases, 7 because of anticoagulant and antiepileptic therapies, 1 because of pacemaker, and 4 because of recent trauma. Twenty-three individuals were then included in our clinical trial, and 7 dropped out at the beginning of the study: 4 individuals refused to sign our written consent and 3 had family problems. Therefore our study involved 16 participants (10 males and 6 females), aged
Downloaded by [University of California, San Diego] at 08:22 14 April 2016
Efficacy of Vibration in Poststroke Rehabilitation
between 36 and 77 years (mean age, 61.69 ± 15.43 years) (Figure 1). Stroke diagnosis was based on computed tomography or magnetic resonance imaging, and neurological functions were completely investigated as well. The average time since the stroke was 41.00 ± 28.50 months. Eleven participants were affected by left upper limb spasticity (10 righthanded and 1 left-handed), whereas 5 were affected by right upper limb spasticity (5 righthanded and no left-handed). Eleven patients were diagnosed with ischemic cerebral infarction and 5 with cerebral hemorrhage. All subjects had to be able to actively move the paretic upper limb, with limitations, in order to perform the activities of daily living and the movements needed for the hand grip and functional tests. The conditioning protocol consisted of the application of local high-intensity vibrations on the upper limbs with the ViSS device, which was applied to the skin covering the venter of the extensor carpi radialis longus and brevis and triceps
Figure 1. Flow diagram.
393
brachii muscles (Figure 2). The entire treatment of 12 sessions (3 per week over 4 weeks), for 30 minutes each, was performed with vibrations set to a frequency of 300 Hz and amplitude of 2 mm over the aforementioned muscles. During the treatment, the paretic upper limb was positioned on a rigid surface to allow the patient to contract isometrically the treated muscle and to work against the resistance provided by the rigid surface.7 During the treatment of extensor carpi radialis, subjects were seated with the elbow flexed at 120°, forearm and wrist in pronation, hand with metacarpus positioned on the rigid surface, and fingers extended; whereas for the triceps brachii muscle treatment, the elbow was extended, the forearm was in pronation, and the hand was pushing against the rigid surface. All participants were evaluated by an independent observer who was blinded to the intervention performed in the protocol using the following clinical and instrumental tests before (T0) and 2 to 3 days after the 4-week treatment (T1):
Downloaded by [University of California, San Diego] at 08:22 14 April 2016
394
TOPICS IN STROKE REHABILITATION/SEPT-OCT 2014
Figure 2. Treatment on venter of the extensor carpi radialis longus muscle.
• Hand Grip Strength Test measures muscle force with a hand-held dynamometer. The patient’s elbow is flexed to form a 90° angle and locked into position by the hand of the physician. The measurements were carried out in both standard position 2 (SP2) and standard position 3 (SP3) in both upper limbs.26 Because we assessed the hand grip strength in both upper limbs, it can be stated that each individual was analyzed as casecontrol. • Jebsen-Taylor Hand Function Test for upper limbs measures the time taken to complete 7 manipulative trials such as writing, turning pages of a newspaper, picking up small objects, etc.27 To complete our clinical assessment, the following scales were used: • Modified Ashworth Scale (MAS) assesses muscle spasticity and uses a 5-point scale to score the average resistance to passive movement for each joint: shoulder, elbow, and wrist. It divides spasticity into 5 degrees (0 to 4), where MAS 0 indicates no increase in muscle tone and MAS 4 indicates affected part rigid in flexion or extension. We can infer the degree of spasticity by mobilizing the affected limb.2,28 • QuickDASH (Disabilities of the Arm, Shoulder and Hand ) assigns a score to activities of daily life using 11 questions.29 • FIM consists of questions on activities of daily life, such as personal care, locomotion, and language. It is considered an international
instrument for measuring disability. The score ranges from 1 (full assistance) to 7 (complete self-sufficiency).30 • Fugl-Meyer assessment scale as modified by Lindmark and Hamrin (Motor Capacity Assessment) is a rating scale for impairment. It is used to obtain goniometric measurements of passive and active shoulder, elbow, wrist, and fingers joint ROM. It is a useful tool to assess the ROM, assigning a score from 0 (
