The Immediate Effect of Radial Extracorporeal Shockwave Therapy

for Spasticity and Motor Function in Chronic Post-stroke Patients

Andre Tanuwijaya, Jeane Claudia Profita, Ardi Soeharta Chandra, Vitriana Biben, Ellyana Sungkar

Department of Physical Medicine and Rehabilitation, Dr. Hasan Sadikin General Hospital,

University of Padjadjaran, Bandung, Indonesia.

drandrefkunpad@gmail.com

Keywords: Chronic Stroke, Motor Function, Spasticity, Radial ESWT, Rehabilitation.

Abstract: This study aimed to report the immediate effect on spasticity and motor function of radial extracorporeal

shockwave therapy (rESWT) as part of a comprehensive treatment program for chronic stroke patients

with spasticity and functional problem in upper extremities. Chronic poststroke patients with spasticity on

upper extremity were enrolled and got rESWT that applied at muscle belly of the biceps muscle, flexor

carpi ulnaris muscle, and flexor carpi radialis muscle. Patients were evaluated for elbow flexor and wrist

flexor spasticity using Modified Ashworth Scale (MAS), and for motor function using Fugl-Meyer

Assessment for Upper Extremity (FMA-UE) at baseline and immediately after rESWT therapy session. 6

male and 1 female patients participated, age 59.7+5.5 years old, with mean onset time of stroke were 40.4

+ 25.2 months. The MAS score was 5.4  1.5 at baseline and 4.2  1.2 after the treatment (p<0.05). The

score of motor function FMA-UE scale was 26.4  9.0 at baseline and 28.6  9.9 after the treatment

(p<0.05). Radial ESWT immediately improved spasticity and motor function in some chronic poststroke

patients. More studies are necessary to establish if rESWT for spasticity and motor function in chronic

poststroke is clinically effective.

1 INTRODUCTION

Spasticity, commonly defined as “a motor disorder

characterized by a velocity-dependent increase in

tonic stretch reflexes with exaggerated tendon jerks,

resulting from hyperexcitability of the stretch reflex”

is a common complication in poststroke associated

with other signs and symptoms of the upper motor

neuron syndrome (Francisco, 2012). The prevalence

of poststroke spasticity has been reported

approximately 39% in patients with a first attack

stroke after 12 months (Watkins, 2002), and

approximately 17-25% after 3 months post stroke,

21-25% since 1-3 weeks after the attack.

(Sommerfeld, 2012; Katoozian, 2018).

Poststroke patients, presented with spasticity and

other upper motor neuron syndromes such as

agonist/antagonist co-contraction, weakness, and

lack of coordination, may have worse impairments

and functional problems that can predispose other

costly complications and detain rehabilitation

process (Francisco, 2012; Duncan, 2005). The

pathomechanism of spasticity is caused by

hyperexcitability of motor neurons by augmented of

excitatory synapse input and excitability of muscle

spindle, reduction of inhibiting synapse input,

change of nerve electrical characteristics or

mechanical alteration in intrinsic muscle

components (Hasuk, 2010). The main factor of the

spasticity in chronic poststroke is the mechanical

change of intrinsic muscle characteristics, such as

structural shortening of muscles (Lundy, 2013) and

muscle fibrosis (Mirbagheri, 2008). The current

general treatment for spasticity consists of passive

stretching, splints, oral medications, phenol

injection and botulinum toxin (BTX). However,

until recently spasticity therapy in poststroke

patients often inadequate (Francisco, 2012).

Radial ESWT (rESWT) is a type of shock wave

that is pneumatically generated, producing low to

medium energy, superficial, larger therapeutic area,

and more economical compared to traditional

focused ESWT (fESWT) (Chang, 2012). Recent

studies have reported that ESWT is a safe, non-

invasive, and is an alternative spasticity therapy that

does not cause muscle weakness or unwanted

Tanuwijaya, A., Proﬁta, J., Chandra, A., Biben, V. and Sungkar, E.

The Immediate Effect of Radial Extracorporeal Shockwave Therapy for Spasticity and Motor Function in Chronic Post-stroke Patients.

DOI: 10.5220/0009088202090214

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 209-214

ISBN: 978-989-758-409-1

209

effects in patients with strokes (Santamato, 2013).

The mechanism underlying the beneficial effects of

ESWT on spasticity still needs to be explored.

Previous studies have proposed the theory that

ESWT affects the production of nitric oxides (NO)

(Mariotto, 2005), decreases muscle fibrosis,

modifies spinal cord excitability (Manganotti,

2005), or impacts on Golgi tendon organs or

mechanical vibrations (Hasuk, 2010).

Hypothetically, mechanical vibration from ESWT

will cause an immediate decrease of muscle fibrosis

that will modify muscle spindle excitability causing

decreases the spasticity (Manganotti, 2005).

Some studies have shown that ESWT

administration can reduce hand and wrist spasticity

accompanied by improved wrist and hand control

function in chronic poststroke patients (Li, 2016)

(Guo, 2017). Even though rESWT immediate effect

on spasticity poststroke using Modified Ashworth

Scale (MAS) had been done in many studies (Hasuk,

2010; Li, 2016), there is no other study evaluate

rESWT immediate effect on motor function using

Fugl-Meyer Assessment for Upper Extremity (FMA-

UE). The Fugl-Meyer Assesment is a well-designed,

feasible and efficient clinical examination method

that has been tested widely in the stroke population.

The Fugl-Meyer motor scale is recommended highly

as a clinical and research tool for evaluating changes

in motor impairment following stroke (Gladstone,

2002).

Therefore, the aim of this study is to report the

immediate effect on spasticity and motor function of

radial extracorporeal shockwave therapy (rESWT)

as part of a comprehensive rehabilitation program

for chronic post-stroke patients with spasticity and

functional problem in upper extremities.

2 METHODS

This is an experimental study, done at the outpatient

Physical and Medical Rehabilitation Clinic of Dr.

Hasan Sadikin General Hospital, Bandung,

Indonesia. This study included chronic post-stroke

patients with spasticity on upper extremity (MAS



1+) that persist more than 3 months after stroke.

Patients with joint contracture, recently got phenol

or botox injection, had malignancy, coagulopathy,

infection, using pacemaker were excluded.

Each subject got rESWT (Swiss Dolorclast

Smart20) that applied at muscle belly of the biceps

muscle, flexor carpi ulnaris muscle, and flexor carpi

radialis muscle. Each site had 2000 shot of rESWT

with pressure 3 bar, frequency 8 Hz, applicator 36

Patients were evaluated for elbow flexor and

wrist flexor spasticity using Modified Ashworth

Scale (MAS). The maximum MAS score in this

study was 5, and 1+ was converted to 2. The average

MAS score was calculated as the mean MAS score

of the elbow flexor and wrist flexor spasticity (Chia-

Ling, 2019). Evaluation motor function was using

total motor function score Fugl-Meyer Assessment

for Upper Extremity (FMA-UE) with minimum

score is 0 and maximum score is 66. The evaluation

was done at baseline and immediately after rESWT

session. Each participant signed the informed

consent form. This study had been approved by the

local hospital ethical review board (No:

LB.02.01/X.6.5/101/2019).

All analyses were performed using Statistical

Package for Social Sciences (SPSS) software ver.

17.0 (SPSS Inc., Chicago, IL, USA). A paired t-test

was conducted to determine statistical differences in

the variables between the pre and post treatment.

Values are presented as mean±standard deviation for

data with normal distribution, and p<0.05 was

considered statistically significant.

3 RESULTS

Six male and 1 female patients were included, mean

age 59.7+5.5 years. Mean time were 40.4+25.2

months after the onset of stroke. The scores of MAS

improved immediately after radial rESWT in 71.4 %

of patients. The MAS score was 5.4



1.5 at baseline

and 4.3



1.1 after the treatment (p=0.007). The score

of motor function FMA-UE scale was improved

immediately after rESWT in 71.4 % patients. The

score of motor function FMA-UE scale was

26.4



9.0 at baseline and 28.6



9.9 after the treatment

(p=0.015)(Table 1, Figure 1).

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

210

Figure 1: Immediate Improvements after rESWT.

Table 1: Results.

M: Male, F: Female, MAS-B: Modified Ashworth Scale Baseline, MAS-I: Modified Ashworth Scale Immediate, MF-

B: Motor Function from Fugl-Meyer Assesment for Upper Extremity Baseline, MF-I: Motor Function from Fugl-

Meyer Assesment for Upper Extremity Immediate. *The result is significant at p < 0.05

4 DISCUSSIONS

The present study evaluated the effects of rESWT in

chronic post-stroke patients with spasticity on the

upper extremity in terms of spasticity improvement,

and motor function features. We found statistically

significant improvement in spasticity after the

treatment in this study. The score change of

spasticity (1.1429±0.667) in this study exceeds the

minimal clinically important difference of average

Modified Ashworth Scale of the effect size 0.8

standard deviations for extremity muscles which are

0.76 (Chia-Ling, 2019). This result is similar to

previous study that there was immediate effect of

rESWT on chronic poststroke patient's spasticity

(Hasuk, 2010).

The effect of ESWT for chronic poststroke

spasticity in the short-term and long-term had been

studied in many studies (Suputtitada, 2018). Li et al.

found that the effect of a single application of

rESWT on post stroke spasticity persists at least 8 to

12 weeks, while 3 sessions of rESWT effect persist

at least 16 weeks (Li, 2016). However, Hasuk et al.

study had a different result. They conclude that

spasticity after chronic poststroke improved

immediately after rESWT, but was not changed

Subject

No.

Gender

(M/F)

Age

(years)

Time since stroke

(months)

x

MAS-B

x

MAS-I

∑

MF-B

∑

MF-I

meanSD

59.7+5.5

40.4+25.2

5.4+1.5

4.2+1.2

26.4+9.0

28.6+9.9

t-test

p =0.007*

p =0.015*

The Immediate Effect of Radial Extracorporeal Shockwave Therapy for Spasticity and Motor Function in Chronic Post-stroke Patients

211

significantly at 1 week and 4 weeks after rESWT

(Hasuk, 2010). We conduct this preliminary report

as a part of an ongoing, larger and long-term study

about the effect of rESWT on poststroke spasticity.

We intended to give additional prespective to those

contradictory results about the short-term and long-

term effects of rESWT on spasticity poststroke.

The spasticity can be categorized into the part by

stretch reflex, as the neural component of hypertonia,

and stiffness of muscle intrinsic, as the nonneural

component of hypertonia. Spasticity triggered by

stretch reflex progressively increases for 1-3 months

after stroke and after that, it decreases, so the muscle

intrinsic stiffness takes part in the main trigger of the

spasticity. Over the course of time, prolonged

muscle activation due to spasticity will cause muscle

fiber shortening which results in increased passive

stiffness that caused by increased amounts of

collagen in the extracellular matrix of muscle fiber

bundles (Lynn, 2015). Mirbagheri et al also found

that there is neural reflex of skeletal muscle factor

and intrinsic mechanical factor contribute to

spasticity that is different according to the status of

disease, patients' age, and duration of disease

(Mirbagheri, 2008). In this study, we found that

there was an immediate improvement of spasticity

after treatment in most patients, but there is no

immediate improvement in 2 patients with shorter

duration of disease. The muscle intrinsic factor

would be the main factor in the spasticity is highly

probable in patient with longer duration of diseases

and there could be marked immediate effect of

spasticity reduction effect by mechanical high-

frequency vibration of ESWT in those patients

(Manganotti, 2005; Hasuk, 2010). The reduced

extensibility, due to soft tissue changes, causes

pullings to be transmitted more readily to the muscle

spindles. In this condition, an exaggerated spindle

discharge in response to muscle stretch might lead to

an increased stretch reflex. The reduction of non-

reflex hypertonia could modify muscle spindles

excitability, leading to a secondary reduction of

spasticity (Gracies, 2005; Marinelli 2015).

The improvement of motor function from Fugl-

Meyer Assesment for Upper Extremity is found in 5

of 7 patients in this study. The improvement was

statistically significant when compared with the

baseline. The increased score indicates improvement

of the motor function of poststroke patients and in

this study, the increment exceeded the minimal

clinically important difference for Fugl-Meyer

Assesment for Upper Extremity which is more than

4.25 in 3 patients (Page, 2012).

The upper limb function of poststroke patients is

affected by many factors, such as muscle strength,

muscle tone, joint disturbances, proprioception, pain,

and motor control. However, spasticity and

weakness are the primary reason for rehabilitative

intervention in the chronic stages (Bang 2009;

Gandolfi, 2019). Upper limb weakness after stroke is

prevalent and determinant of upper limb function in

ADLs. Literature supports upper limb strengthening

training effectiveness for all levels of impairment

and in all stages of recovery (Harris, 2010). Those

findings were underlining the importance the

neurorehabilitation treatment such as strengthening

exercises for the antagonist muscles, endurance

exercises, balance and coordination training for

enhancement the movement ability and the

functional outcome of the patients (Suputtitada,

2018).

Improvement of the spasticity from the rESWT

therapy session not directly make the improvement

of the upper limb function in our study. Poststroke

patients with mild-moderate impairment of muscle

strength with reduce spasticity seems will have

greater improvement of upper limb function

compare patients to one with severe impairment of

muscle strength. Unfortunately, we didn’t collect

data on muscle strength of each patient to conduct

such analysis.

In addition, we conducted data collection for

pain during and after shockwave therapy using

Numeric Rating Scale (NRS) and asked if they

would recommend ESWT for other patients with

same condition as them because recent studies have

found that ESWT application is considered painfull

(Roerdink, 2017; Haake, 2002) and would make

some rejection of the patients. From those data, we

found that all patients reported shockwave to be

painful during treatment (NRS ≥ 6 out of 10), but

there is no post treatment pain. Furthermore, 5 of 7

patients still would recommend ESWT for other

patients with same condition as them.

Our study has several limitations. First, this

study had a small sample size. Second, we evaluated

only the immediate outcomes. Third, there is no

control group. We suggest to do a further

investigation with larger sample size, with

evaluation short-term and long-term effect of

rESWT on poststroke spasticity with comparison to

conventional therapy. The study also needed to

evaluate characteristics of poststroke patient have

good response to rESWT and specific regimen with

regard to dose, frequency, and location of therapy

that more effective to decrease the spasticity.

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

212

5 CONCLUSIONS

Radial ESWT immediately improved spasticity and

motor function in some chronic poststroke patients.

More studies are necessary to establish the

effectiveness of rESWT in spasticity and motor

function in chronic poststroke.

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