Table 1 Studies of Passive Movement-based Approaches for Reducing Spasticity

Author Year

Country
Research Design

Score
Total Sample Size

Methods Outcome

Fang et al. 2015

Taiwan

RCT Crossover

PEDro=5

N=10

Population: Mean age: 30.1 yr; Gender: males=8, females=2; Injury etiology: SCI=10; Level of injury: C2-C6=2, T3-T7=6, L2-L11=2; Mean time since injury: 5.7 yr.

Intervention: Patients wore robot-assisted passive exercise devices on their ankle joints. Patients were randomly assigned in a crossover design to one of three interventions: high speed cyclic passive exercise (50 cycles/min), low speed cyclic passive exercise (20 cycles/min), or electrical stimulation-induced contractions (ES) for 8 min, 1x/wk for 3 wk. They were allocated to the other treatments 2 wk later. Outcomes were assessed before each intervention and at 10, 20 min after each intervention.

Outcome Measures: H reflex, M waves, Total resistance during cyclic stretching, Isometric torque.

1.     The amplitude of the H reflex was significantly reduced at 10 and 20 min post high-speed cyclic passive exercises (p<0.05), and 20 min post low-speed cyclic passive exercises (p<0.05).

2.     There were no significant changes in M waves after any of the interventions (p>0.05).

3.     For patients whom received ES, and then the high speed cyclic passive exercise, the total resistance during cyclic stretching increased significantly (p<0.05).

4.     Isometric torque decreased significantly after 8 min of ES and the reduction persisted up to 20 min (p<0.05).

Chang et al. 2013

Taiwan

RCT

PEDro=6

N=14

Population: Control (N=7): Mean age: 31.1 yr; Mean time since injury: 20.4 mo. Experimental (N=7): Mean age: 35.3 yr; Mean time since injury: 29.1 mo; Chronicity: chronic.

Intervention: Subjects received continuous passive motion training for 60 min/day, 5 days/wk for 4 wk. PAD recordings were measured from pairs of soleus H-reflexes elicited at 0.1 Hz, 1 Hz, 5 Hz and 10 Hz.

Outcome Measures: Modified Ashworth Scale (MAS), Postactivation depression (PAD).

1.    Before treatment, the H-reflex was not significantly depressed at 1 Hz or 5 Hz, but was significantly depressed in both groups at 10 Hz (p<0.05).

2.    PAD increased significantly (p=0.038) after CPM treatment compared with pretest conditions.

3.    MAS scores decreased significantly (p=0.013) after CPM treatment compared with pretest conditions.

4.    The control group did not exhibit significant changes in either PAD or MAS after 4 wk.

5.    One subject who completed 12 wk of training displayed further increases in PAD at 1 Hz and 5 Hz stimulation frequencies, but no further increases in PAD were seen at the 10 Hz stimulation frequency.

Rayegani et al. 2011

Iran

RCT

PEDro=3

NInitial=74,

NFinal=64

Population: Mean age: 43.0 yr; Gender: males=60, females=4; Level of injury: cervical=11, upper thoracic=22, lower thoracic=29, lumbar=2; Level of severity: AIS A=63, AIS B=1.

Intervention: Patients were randomly allocated to either the passive cycling group (n=37) or the controlled physical therapy group (n=37). The passive cycling intervention consisted of patients sitting in their wheelchair while a motor passively moved their legs for up to 20 min/set, 3 sets/day for 2 mo (weekly regiment unspecified). The physical therapy included stretching, range of motion (ROM) and strengthening exercises (no further details provided).

Outcome Measures: Level of SCI, Kondal scale (for muscle strength), Modified Ashworth Scale (MAS), goniometer measurements (for passive range of motion (ROM) in the hip, knee and ankle) and electrodiagnostic parameters (H-reflex, H (max)/M (max), and F-wave parameters).

 

1.     MAS scores significantly decreased in the passive cycling group post intervention (p=0.003).

2.     Range of motion of the hip, ankle dorsiflexion and plantar flexion increased significantly post intervention in the passive cycling group (hip: p=0.005; ankle dorsi: mean difference=10°, p=0.000; ankle plantar: mean difference=9.4643, p=0.000) no significant change was observed in the knee flexion ROM in the passive cycling group (p=0.111).

3.     The F/M ratio (p<0.027) and the H max/M max (p=0.000) decreased significantly in the passive cycling group post intervention.

4.     H-reflex amplitude was not significantly different post intervention in either group.

5.     No significant differences were observed in the physical therapy group in regards to MAS scores and ROM of the hip, knee flexion, ankle dorsiflexion or plantar flexion.

Effect Sizes: Forest plot of standardized mean differences (SMD±95%C.I.) as calculated from pre- to post-intervention and pre-intervention to retention. Effect Sizes

Harvey et al. 2009

Australia

RCT

PEDro=6

N=20

Population: Injury etiology: SCI=20; Level of injury: C2-C7.

Intervention: Passive movement of the experimental ankle, 5 days/wk for 6 mo.

Outcome Measures: Passive dorsiflexion of ankles; Modified Ashworth Scale (MAS) of the hamstring and plantar-flexor muscles; Global Impression of Change scale.

1.     Passive dorsiflexion increased for the experimental ankle (88±9 versus 91±10) and decreased for the control (89±8 versus 87±9) (p=0.002), overall difference of 4.0o.

2.     There was no significant difference in the MAS scores between ankles

3.     Subjects reported a median of 2-4 points on the 15-pt Global Impression of Change scale for the experimental ankle, and 0 for control.

Effect Sizes: Forest plot of standardized mean differences (SMD±95%C.I.) as calculated from pre- and post-intervention data. Effect Sizes
 

Li et al. 2007

China

RCT

PEDro=6

N=28

 

Population: SCI: Mean age: 56.0 yr; Gender: males=17, females=11; Level of injury: paraplegic, thoracic; Level of severity: complete=16, incomplete=12; Mean time since injury: 38 days; Chronicity: acute.

Intervention: Control Group: Routine Therapy (undefined). Intervention group: Routine Therapy+oral baclofen (initial dose 5 mg, increase by 5mg every 5 days to maximum of 60mg) + neural facilitation (Rood, Brunnstrom and Bobath techniques) for 1-2 40 min sessions 6 days/wk for 6 wk.

Outcome Measures: Modified Ashworth Scale (MAS), BI tested pre-post 6 wk intervention.

1.     More subjects had reduced spasticity (reduced MAS scores) with neural facilitation and baclofen Grade I (n=2 to 12 from pre-to post), Grade II (n=7 to 2) and Grade III (n=5 to 0) in the intervention group, as compared to the control group, Grade I (n=1 to 6), Grade II (n=7 to 4) and Grade III (n=6 to 4) (p<0.05).

2.     Significantly higher BI scores were found for the treatment versus control group in complete SCI (45.35±12.01 versus 30.86±11.20) and incomplete SCI (57.98±11.54 versis 42.14±12.75) (p<0.05).

Effect Sizes: Forest plot of standardized mean differences (SMD±95%C.I.) as calculated from pre- and post-intervention data. Effect Sizes
 

 

Lechner et al. 2007

Switzerland

RCT Crossover

PEDro=4

NInitial=12,

NFinal=11

 

 

Population: SCI: Mean age: 44.0 yr; Gender: males=12, females=0; Level of injury: paraplegia=8, tetraplegia=4; Level of severity: AIS A-B; Mean time since injury: 13.1yr; Chronicity: chronic.

Intervention: 1) Control–no intervention; 2) Intervention H–hippotherapy treatment; 3) Intervention S–sitting on a rocker board driven by motor adjusted to mimic a horse’s rhythm and amplitude; 4) Intervention R–sitting astride a bobath roll. Twice-weekly sessions for 4wk.

Outcome Measures: Ashworth Scale (AS), Visual Analog Scale (VAS)-self rating of spasticity, Mental well-being Bf-S.

 

1.     Overall, significant reductions in spasticity were observed as indicated by AS sum score changes caused by Hippotherapy versus none for the control condition or other interventions (p<0.05).

2.     Significant differences were found when comparing pre versus post-session AS scores, in all 3 intervention groups [H (p=0.004), R (p=0.003), S (p=0.005)] but not for the control condition (p=0.083).

3.     Overall, significant spasticity reductions (VAS-self rated spasticity) were found for hippotherapy versus intervention R (p<0.05) and S (p<0.05) but not for the control condition.

4.     Significant spasticity reductions were found in the VAS scores before and after treatment sessions for interventions H (p=0.004), R (p=0.014) and the control condition (p=0.021) but not S (p=0.181).

5.     Improved mental well-being (i.e., reduced Bf-S scores) was seen with hippotherapy (p=0.048) but not with R (p=0.933) or S (p=0.497).

6.     There were no long-term effects (i.e., 4 days post-intervention) for any intervention.

Kakebeeke et al. 2005

Switzerland

Pre-Post

N=10

Population: Age range: 23-60 yr; Gender: males=9, females=1; Level of injury: C6-T12; Level of severity: AIS A-B; Time since injury range: 1-25 yr.

Intervention: Passive cycling with motorized cycle for 30 min at 40 RPM (1 session) versus no cycling.

Outcome Measures: Torque resistance to movement on isokinetic dynamometer, Subjective subject assessment collected just prior and following cycling (or control).

1.     Six out of ten subjects estimated that their spasticity was less after cycling and 3/10 estimated it was less after no cycling.

2.     No effect on objective assessment of spasticity was noted as indicated by no differences with torque before and after cycling or before and after the control (no cycling) condition.

Lechner et al. 2003

Switzerland

Pre-Post

N=32

Population: Mean age: 37.0 yr; Gender: males=28, females=4; Level of injury: C4-T12; Level of: AIS: A-D; Time since injury range: 1 mo-6 yr.

Intervention: Hippotherapy-K® (HTK; Kuenzle 2000): An average of 11 sessions (5-24) each lasting 25-30 min. Sheepskin (no saddle) on Icelander horse.

Outcome Measures: Ashworth Scale (AS) of 8 limb movements bilaterally for a summed score of 16-80. Measures were taken pre-and post each session and the proportion of scores with a +ve or -ve change was recorded.

1.     93% of treatment sessions led to lower AS scores immediately after sessions.

2.     Significant decrease in muscle tone as indicated by reduced AS scores in the lower limbs (p<0.001).

3.     There was no carry-over effect from session to session as there was no longitudinal trend or trend of the before and after session differences.

4.     No significant difference between para/tetraplegic subjects (p=0.4).

Sköld, 2000

Sweden

Pre-Post

N=45 (Passive stretches performed on n=12)

Population: Age range: 17-47 yr; Gender: males=39, females=6; Level of injury: cervical, thoracic; Level of severity: AIS A-D; Time since injury range: 3-26 yr, (Passive stretches performed on n=12, thoracic AIS C, D).

Intervention: Repetitive passive movements of standardized range of motion in three different positions administered with motorized table, 10 min per position, 20-30 movements/min, 2 sessions/wk for 6 wk.

Outcome Measures: Self-reported Visual Analog Scale (VAS): “no spasticity” to “most imaginable spasticity”, Modified Ashworth Scale (MAS), collected just prior and after each treatment session.

1.     Spasticity decreased after each intervention session as indicated by VAS (p<0.001) and MAS (p<0.001).

2.     Spasticity reductions were maintained in VAS values (albeit to a lesser degree) after treatment was discontinued for four days (p<0.018).

 

Odeen & Knutsson, 1981

Sweden

Pre-Post

N=9

Population: Age range: 21-67 yr; Gender males=8, females=1; Time since injury: >3 yr.

Intervention: Standing in forced dorsiflexion or plantarflexion (i.e., load applied) versus stretch applied to plantar flexors while supine. 30 min sessions.

Outcome Measures: Torque resistance and angular displacement to sinusoidal ankle movement as measured by strain gauge transducer and potentiometer respectively. EMG recorded for some subjects as well. All collected just prior and following treatment.

1.     Average reduction in resistance to passive movement at 1 cycle/s was 32%, 26% and 17 % for standing in dorsiflexion, standing in plantarflexion and supine dorsiflexion respectively.

2.     Greater reductions were seen at one cycle/sec than at 0.25 cycle/sec, although significant reductions were still seen for both conditions of dorsiflexion stretch (i.e., standing and supine) at the slower test speed.

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