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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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          Abstract

          Background

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

          Objective

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

          Methods

          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.

          Results

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

          Conclusions

          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.

          International Registered Report Identifier (IRRID)

          RR1-10.2196/16045

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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.

            Chitralakshmi Balasubramanian, Mark Bowden, Richard Neptune … (2007)
            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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              Spasticity, Motor Recovery, and Neural Plasticity after Stroke

              Sheng Li (2017)
              Spasticity and weakness (spastic paresis) are the primary motor impairments after stroke and impose significant challenges for treatment and patient care. Spasticity emerges and disappears in the course of complete motor recovery. Spasticity and motor recovery are both related to neural plasticity after stroke. However, the relation between the two remains poorly understood among clinicians and researchers. Recovery of strength and motor function is mainly attributed to cortical plastic reorganization in the early recovery phase, while reticulospinal (RS) hyperexcitability as a result of maladaptive plasticity, is the most plausible mechanism for poststroke spasticity. It is important to differentiate and understand that motor recovery and spasticity have different underlying mechanisms. Facilitation and modulation of neural plasticity through rehabilitative strategies, such as early interventions with repetitive goal-oriented intensive therapy, appropriate non-invasive brain stimulation, and pharmacological agents, are the keys to promote motor recovery. Individualized rehabilitation protocols could be developed to utilize or avoid the maladaptive plasticity, such as RS hyperexcitability, in the course of motor recovery. Aggressive and appropriate spasticity management with botulinum toxin therapy is an example of how to create a transient plastic state of the neuromotor system that allows motor re-learning and recovery in chronic stages.
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                Author and article information

                Contributors
                Noureddin Nakhostin Ansari:
                ORCID: https://orcid.org/0000-0003-2742-2273
                Department of PhysiotherapySchool of RehabilitationTehran University of Medical SciencesEnghelab Ave, Pich-e-shemiranTehran, 11489Iran98 21 7753393998 21 77727009nakhostin@sina.tums.ac.ir
                Journal
                Journal ID (nlm-ta): JMIR Res Protoc
                Journal ID (iso-abbrev): JMIR Res Protoc
                Journal ID (publisher-id): ResProt
                Title: JMIR Research Protocols
                Publisher: JMIR Publications (Toronto, Canada )
                ISSN (Electronic): 1929-0748
                Publication date Collection: August 2020
                Publication date (Electronic): 21 August 2020
                Volume: 9
                Issue: 8
                Electronic Location Identifier: e16045
                Affiliations
                [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
                https://orcid.org/0000-0002-1416-2102
                https://orcid.org/0000-0003-2742-2273
                https://orcid.org/0000-0002-5062-7747
                https://orcid.org/0000-0003-0590-8512
                https://orcid.org/0000-0002-5149-5651
                https://orcid.org/0000-0002-2285-8361
                https://orcid.org/0000-0002-1877-4747
                https://orcid.org/0000-0001-8400-8234
                Article
                Publisher ID: v9i8e16045
                DOI: 10.2196/16045
                PMC ID: 7474409
                PubMed ID: 32663137
                SO-VID: 2ec567d3-2fef-4ad6-ba34-ab527066f4ad
                Copyright © ©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.
                License:

                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.

                History
                Date received : 28 August 2019
                Date revision requested : 25 September 2019
                Date revision received : 10 October 2019
                Date accepted : 20 October 2019
                Categories
                Subject: Protocol
                Subject: Protocol

                Keywords: stroke,muscle spasticity,balance,rehabilitation,lower extremity,posturography
                Data availability:
                Keywords: stroke, muscle spasticity, balance, rehabilitation, lower extremity, posturography

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