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      Effect of Ankle Plantar Flexor Spasticity Level on Balance in Patients With Stroke: Protocol for a Cross-Sectional Study


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          The lower limb spasticity after stroke can affect the balance and gait of patients with stroke.


          The aim of this study is to assess the effects of ankle plantar flexor spasticity level on balance in patients with stroke.


          Patients with stroke were recruited from neurology and physiotherapy clinics in Tehran, Iran. Based on the level of ankle plantar flexor spasticity according to the Modified Modified Ashworth Scale (MMAS), the eligible patients with stroke were divided into 2 groups: high spasticity (MMAS score≥2) and low spasticity (MMAS score<2). The primary outcome measures were the MMAS scores, Activities-Specific Balance Confidence questionnaire scores, eyes-open and eyes-closed posturography measures, and Timed Up and Go test results. The secondary outcome measures were the ankle passive range of motion and ankle joint proprioception. The t test, mixed model univariate analysis of variance, and Spearman rank correlation were used for statistical analysis.


          Data collection and statistical analysis are complete. The interpretation of results is underway. We expect the results to be published in winter 2020.


          We believe that patients with high ankle plantar flexor spasticity after stroke will demonstrate greater balance dysfunction, which will worsen with impaired proprioception, passive range of motion, and eyes closed.

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          Most cited references28

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          The control of muscle tone, reflexes, and movement: Robert Wartenbeg Lecture

          J LANCE (1980)
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            Relationship between step length asymmetry and walking performance in subjects with chronic hemiparesis.

            To understand the relationship between step length asymmetry and hemiparetic walking performance. Descriptive. Gait analysis laboratory. Convenience sample of 49 subjects with chronic hemiparesis. Not applicable. Subjects walked at their self-selected walking speed over both an instrumented mat and forceplates to collect spatiotemporal parameters and ground reaction forces, respectively. Step length asymmetry was quantified by using a step length ratio (SLR) defined as paretic step length divided by nonparetic step length. Paretic leg propulsion, self-selected walking speed, hemiparetic severity (assessed by Brunnstrom stages of motor recovery), and some spatiotemporal walking parameters quantified the hemiparetic walking performance. Paretic leg propulsion was quantified by the paretic propulsion (P(P)) ratio, calculated as the percentage contribution of paretic leg to the total propulsive impulse. Significant negative correlation (r=-.78) was revealed between SLR and P(P), indicating that subjects generating less propulsive force with the paretic leg walked asymmetrically with longer paretic steps than nonparetic steps. SLR and self-selected walking speed revealed a weaker correlation (r=-.35), whereas hemiparetic severity correlated strongly with SLR (rho=-.53). Step length asymmetry is related to propulsive force generation during hemiparetic walking. Subjects generating least paretic propulsion walk with relatively longer paretic steps. This suggests that one of the mechanisms for the longer paretic step may be the relatively greater compensatory nonparetic leg propulsion. Further, those with more severe hemiparesis (those dependent on abnormal flexor and extensor synergies) walk with the longest paretic steps relative to nonparetic. Finally, our results indicated that asymmetrical step lengths may not necessarily limit the self-selected walking speed, likely due to other compensatory mechanisms.
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              The relation between ankle impairments and gait velocity and symmetry in people with stroke.

              To identify the most important factor among the ankle impairments on gait velocity and symmetry in stroke patients. Cross-sectional, descriptive analysis of convenience sample. Patients from outpatient rehabilitation and neurovascular neurology departments in medical centers and municipal hospitals in Taiwan. Sixty-eight subjects with hemiparesis poststroke with the ability to walk independently. Not applicable. Maximal isometric strength of plantarflexors and dorsiflexors were examined by a handheld dynamometer. Spasticity index, slope magnitudes between electromyographic activities, and muscle lengthening velocity of gastrocnemius during lengthening period of stance phases were measured to represent the dynamic spasticity. Passive stiffness of pantarflexors was indicated by degrees of dorsiflexion range that were less than normative values. Position error was measured by the degree of proprioceptive deficits of ankle joint by evaluating the joint position sense. Gait velocity, symmetry, and other gait parameters were measured by the GAITRite system. Regression analyses revealed that the dorsiflexors strength was the most important factor for gait velocity and temporal symmetry (R(2)=.30 for gait velocity, P<.001; R(2)=.36 for temporal asymmetry, P<.001). Dynamic spasticity was the most important determinant for gait spatial symmetry (R(2)=.53, P<.001). Gait velocity and temporal asymmetry are mainly affected by the dorsiflexors strength, whereas dynamic spasticity of plantarflexors influenced the degree of spatial gait asymmetry in our patients who were able to walk outdoors. Treatment aiming to improve different aspects of gait performance should emphasize on different ankle impairments.

                Author and article information

                JMIR Res Protoc
                JMIR Res Protoc
                JMIR Research Protocols
                JMIR Publications (Toronto, Canada )
                August 2020
                21 August 2020
                : 9
                : 8
                : e16045
                [1 ] Department of Physiotherapy School of Rehabilitation Tehran University of Medical Sciences Tehran Iran
                [2 ] Neuroscience Institute Sports Medicine Research Center Tehran University of Medical Sciences Tehran Iran
                [3 ] Prosthetics and Orthotics Department Musculoskeletal Research Center Isfahan University of Medical Sciences Isfahan Iran
                [4 ] Department of Human Movement Science University of Zululand Kwazulu-Natal South Africa
                Author notes
                Corresponding Author: Noureddin Nakhostin Ansari nakhostin@ 123456sina.tums.ac.ir
                Author information
                ©Ashraf Mahmoudzadeh, Noureddin Nakhostin Ansari, Soofia Naghdi, Ebrahim Sadeghi-Demneh, Omid Motamedzadeh, Brandon S Shaw, Ardalan Shariat, Ina Shaw. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 21.08.2020.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on http://www.researchprotocols.org, as well as this copyright and license information must be included.

                : 28 August 2019
                : 25 September 2019
                : 10 October 2019
                : 20 October 2019

                stroke,muscle spasticity,balance,rehabilitation,lower extremity,posturography


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