Effectiveness of physical therapy interventions on post-stroke spasticity: An umbrella review

Abstract

BACKGROUND:

Post-stroke spasticity is often one of the primary impairments addressed in rehabilitation. However, limited guidance exists on the effectiveness of physical therapy (PT) interventions for post-stroke spasticity.

OBJECTIVE:

To evaluate the quality of evidence of PT interventions for post-stroke spasticity.

METHODS:

Ovid (Medline), Cochrane Library, CINAHL, Scopus, PEDro, and PROSPERO were searched to identify reviews based on the following criteria: 1) published between 2012 and 2021, 2) participants older than 18 years old, 3) post-stroke spasticity, 4) PT interventions, 5) clinical or neurophysiological measures of spasticity as primary outcomes. Assessment of Multiple Systematic Reviews 2 and the Grades of Recommendations Assessment, Development, and Evaluation assessed methodological quality.

RESULTS:

Eight articles were included in the analysis. No high-quality evidence was found. Moderate quality evidence exists for transcutaneous electrical nerve stimulation, neuromuscular electrical stimulation, resistance training, and lower extremity ergometer training with or without functional electrical stimulation. Low quality evidence exists for dynamic stretching, botulinum toxin with constraint-induced movement therapy, and static stretching using positional orthoses.

CONCLUSION:

Findings suggest that PT should prioritize a combination of active strategies over passive interventions, but further studies are needed prioritizing analyses of the movement system in managing post-stroke spasticity in conjunction with medical therapies.

Keywords

Muscle spasticity stroke physical therapy physical therapy modalities electric stimulation exercise

1 Introduction

Stroke, or cerebral vascular accident (CVA), is one of the most prevalent and costly health conditions worldwide, affecting an average of 7.8 million people from 1990–2017. The financial costs of CVA are also profound. In 2017, the total aggregate cost incurred in the United States was $103.5 billion and the 2020 annual cost of CVA per patient in the United States was $59,900 (Collaborators et al., 2021; Girotra et al., 2020; Strilciuc et al., 2021). After a CVA, spasticity is a common neurologic impairment following the damage to the upper motor neuron (UMN). The 2005 SPASM Consortium defined spasticity as “disordered sensorimotor control, resulting from an UMN lesion, presenting as intermittent or sustained involuntary activation of muscles” (Wissel et al., 2015). Spasticity development reportedly increases in patients at six weeks post-stroke from 4 –27% to approximately 42.6% of patients at six months post-stroke (Thibaut et al., 2013; Wissel et al., 2015).

The pathophysiology of spasticity is not completely understood; however, it is evident that following a CVA, an imbalance of excitatory and inhibitory output to the alpha motor neuron of the muscle occurs. Over time this leads to a chronic decrease in cortical inhibition and neuronal reorganization that contributes to the increase in both primitive reflexes and active tonic stretch reflex and when combined with cortical disinhibition, leads to spasticity (Thibaut et al., 2013). Spasticity can present in a number of ways in an individual with CVA and may lead to specific patterns of motor dysfunction or abnormal posturing in the upper and lower extremities (Schinwelski et al., 2019; Thibaut et al., 2013). The abnormal motor control caused by spasticity after a CVA may hinder the individual’s overall functioning and quality of life, but may also assist the individual’s function. For example, extensor spasticity in the lower extremities may have a positive effect on function by overriding residual post-stroke muscle weakness and lead to the ability to perform gait and standing activities; however, activities requiring lower extremity flexion or volitional control may be impaired (Bakheit, 2012; Schinwelski et al., 2019). On the other hand, it is well documented that spasticity may lead to decreased quality of life secondary to pain, development of contracture, loss of skin integrity, positional and postural deficits, muscle weakness, fatigue, and impaired sleep (Bakheit, 2012; Khan et al., 2019; Milinis et al., 2016).

Spasticity is best managed through a multidisciplinary approach that may often include pharmacologic interventions, neurolytic injections, surgical methods, or non-invasive therapies, such as physical therapy (Bakheit, 2012; Dromerick, 2002; Lazorthes et al., 2002; McIntyre et al., 2012). Systematic reviews have been published that describe physical therapy interventions often used to manage spasticity post-stroke: stretching, static and dynamic splinting, transcutaneous electrical nerve stimulation (TENS), neuromuscular electrical stimulation (NMES), aerobic exercise, and resistance exercise (Bovend’Eerdt et al., 2008; Demetrios et al., 2013; Fernandez-Tenorio et al., 2019; Gomez-Cuaresma et al., 2021; Kinnear et al., 2014; Stein et al., 2015). Implementation of interventions in clinical management of patients with CVA may include many of these interventions that lack high quality evidence for effectiveness or demonstrate conflicting outcomes due to differing methodology, parameters, frequency of use, and lack of consistent utilization. Current literature suggests that both NMES and TENS may be beneficial as an adjunct therapy in treating spasticity; however, heterogeneity throughout studies has led to a lack of high quality evidence and high variability across clinical practice (Stein et al., 2015). Stretching and splinting are some of the most historic interventions utilized to treat spasticity, yet current literature shows either inconclusive outcomes or limited benefit when implementing stretching alone, with only some studies in favor of stretching with botulinum toxin and other neurolytic injections (Francisco et al., 2021; Gomez-Cuaresma et al., 2021; Katalinic et al., 2011; Katalinic et al., 2010; Lin et al., 2018). Both resistance and aerobic training are used to target a variety of cardiovascular and neuromuscular deficits following CVA, and recent literature suggests both may be used as adjunct therapies to pharmacologic interventions like neurolytic toxin injections to improve spasticity (Khan et al., 2019; Veldema & Jansen, 2020b).

Due to the abundance of variability in published physical therapy interventions on treating post-stroke spasticity and the growing number of systematic reviews on these topics, an umbrella review is warranted in order to grade the current evidence for each intervention, provide evidence-based conclusions that can be practically implemented in the clinical setting, and provide recommendations to improve the current body of knowledge of post-stroke spasticity management. To date, there is no review of systematic reviews published documenting the effectiveness of physical therapy interventions for spasticity in people post-stroke. Providing practitioners with a consolidated high-quality resource can provide clarity in choice of rehabilitation interventions for spasticity management of individuals post-stroke. Thus, the aim of this study was to conduct a comprehensive umbrella review of systematic reviews evaluating current physical therapy interventions on spasticity outcomes in adults post-stroke.

2 Methods

This study, as a systematic review of systematic reviews (umbrella review), is exempt from Institutional Review Board approval.

2.1 Data sources and search strategy

A comprehensive search of Ovid (Medline), Cochrane Library, CINAHL, Scopus, PEDro (Physiotherapy Evidence Database), and PROSPERO was completed on August 13, 2021. The search was conducted by a university liaison with expertise in search operation methods. Results of the search were then presented to authors of this review. The search strategy included combinations of multiple search terms with 3 primary themes: spasticity, physical therapy techniques (rehabilitation), and stroke. The themes and related key words used in the search are located in Table 1 and the search strategies used for each database are provided in the Appendix.

Table 1
Search terms and themes utilized in search strategy

Theme 1 Spasticity Spasticity, muscle spasticity, pain, range of motion (ROM), balance, gait speed, walking speed, mobility

Theme 2 Physical Therapy Interventions (Rehabilitation) Physiotherapy, physical therapy, rehabilitation, dry needling, resistance training, resistance strengthening, Botox, Botulinum toxins, muscle stretching, low load stretching, casting, splinting, vibration (localized muscle vibration, focal muscle vibration), electrical stimulation (transcutaneous electrical nerve stimulation, neuromuscular electrical stimulation), extracorporeal shock wave therapy/shock wave, aquatic therapy/hydrotherapy, transcranial magnetic stimulation (TMS), ultrasonic therapy

Theme 3 Stroke Chronic stroke, stroke, cerebrovascular accident

Theme 1	Spasticity	Spasticity, muscle spasticity, pain, range of motion (ROM), balance, gait speed, walking speed, mobility
Theme 3	Stroke	Chronic stroke, stroke, cerebrovascular accident

2.2 Study selection

The authors of the study independently screened titles and abstracts that were obtained using the search strategy and based on the eligibility criteria. Systematic reviews were selected with the intention of assessing the use of current physical therapy interventions for the management of post-stroke spasticity. The authors aimed to assess interventions that are specific to physical therapy practice for the highest relevance to the field.

2.3 Population

Systematic reviews that included participants older than 18 years of age were selected for analysis. The systematic reviews selected for analysis included those papers in which spasticity resulting from CVA was a primary variable of interest. Spasticity resulting from other neurological origins were excluded. The participants’ sex was irrelevant and CVA of all chronicity, acute to chronic, were included.

2.4 Intervention and control

The interventions included were those within the scope of a physical therapist either alone or in combination with pharmacological intervention. Treatments that included only non-physical therapy approaches, such as only pharmacological or surgical interventions, were excluded. Control groups included conventional physical therapy alone, no intervention, or various protocols with the given treatment.

2.5 Outcomes

Measures used to assess the results included clinical and neurophysiological tools for spasticity. While clinical assessment tools, such as the Modified Ashworth Scale, are helpful, there is a level of subjectivity to consider between assessors. While neurophysiological tools are less applicable to clinic settings, they have improved objectivity. Studies that did not assess spasticity directly were excluded.

2.6 Inclusion criteria

The authors included studies with participants 18 years of age or older who had experienced a CVA. There was not a distinction made for inclusion or exclusion based on chronicity of CVA due to the limited number of studies focusing only on chronic or acute CVA. The authors also included studies that focused on physical therapy interventions rather than pharmacological interventions. Further, studies were included if they measured spasticity as an outcome.

2.7 Exclusion criteria

Exclusion criteria for systematic reviews included participants under the age of 18, studies including non-physical therapy interventions including pharmacological and surgical management, spasticity resulting from other various neurological origins, such as multiple sclerosis, cerebral palsy, and traumatic brain injury. Reviews published prior to 2012 and reviews in languages other than English were excluded.

2.8 Data extraction and synthesis

Once the yielded studies were received, four reviewers removed duplicates and screened titles, abstracts, and key words of the remaining non-duplicates to identify the studies relevant for full-text review. The main points of inclusion were post-stroke spasticity and physical therapy management. Any uncertainty was resolved through group discussion and full-text review. Full texts of the remaining reviews were assessed by four reviewers using stricter adherence to inclusion and exclusion criteria. Attentiveness to publication date, participants’ age, spasticity etiology, and spasticity as an outcome measure was imperative. Additionally, each full text was assessed for appropriateness of sample characteristics, objectives, and included studies in the systematic review. Any disputes for final inclusion were settled by group discussion and with consultation of content experts included in this manuscript.

2.9 Methodological quality assessment

Four reviewers independently assessed the methodological quality of the obtained full text reviews using the Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) tool. The AMSTAR is a valid and reliable assessment of methodological quality of systematic reviews and meta-analyses. The AMSTAR 2 consists of 16 items but is not intended to generate an overall score. Therefore, findings of each item for each review should be carefully considered when appraising results (Shea et al., 2017). After AMSTAR 2 assessments were completed for each study, results were compiled and all discrepancies among reviewers were resolved by re-assessing the reviews’ characteristics and AMSTAR criteria to reach consensus. Inter-rater reliability was determined using Fleiss’ κ (.81–1.00 almost perfect agreement, .61–.80 substantial agreement, .40–.60 moderate agreement, .21–.40 fair agreement, .00–.20 slight agreement) (Landis & Koch, 1977).

Further, two authors independently assessed the methodological quality of the reviews using the guidelines established by the Grades of Recommendations Assessment, Development and Evaluation (GRADE) criteria. The GRADE is a tool used for assessing quality of evidence for a given outcome in a review based on risk of bias, indirectness, inconsistency, imprecision, and publication bias. In this review, spasticity was the outcome being assessed. Each systematic review was upgraded or downgraded according to the GRADE guidelines and rated high, moderate, low, or very low quality, reflecting the confidence that can be placed in results and effect size (Ryan & Hill, 2016). After each study’s methodological quality was assessed by the two reviewers, results were compiled and incongruencies were settled through a third reviewer and consultation with content experts. The purpose of the AMSTAR 2 and GRADE is to critically appraise the methodological quality of the included reviews and consider its effect on the overarching results and findings.

3 Results

3.1 Search results

Using the search strategy, 512 articles were retrieved. 240 duplicates were removed with manual crosschecking. The titles, abstracts and key words of the remaining 272 reviews were assessed by four reviewers to identify the studies pertinent to established inclusion and exclusion criteria. This resulted in 168 excluded articles based on: published prior to 2010, non-English language, pharmacological or surgical intervention, pediatric populations, diagnoses other than CVA, and lack of spasticity outcome measure(s). 12 articles were removed due to lack of retrieval access; however, they were not pertinent to this review based on title and abstract review. 92 articles remained for thorough full text assessment by the reviewers against eligibility criteria set forth. The final sample of studies included 8 reviews appropriate for inclusion in the present review. A PRISMA review of the study selection process is provided in Fig. 1 (Page et al., 2021).

Fig. 1

PRISMA flow diagram of study selection. Inclusion criteria were reviews with participants over 18 years old, post-stroke spasticity of any chronicity, 3) physical therapy interventions, spasticity as primary outcome using clinical and neurophysiological measures.

3.2 Quality of findings

The agreement amongst the four evaluators was almost perfect according to Fleiss’ κ, κ = 0.852, 95% CI [0.800, 0.905], p < 0.001. The results of the AMSTAR 2 tool used for quality assessment are detailed for each study in Table 2. The AMSTAR 2 tool does not generate a summed score, but rather, each independent item should be considered when reporting results. Table 3 details the results of the GRADE for each review. One study was rated very low quality, two were rated low quality, four were rated moderate quality. None of the included studies had a GRADE of high-quality evidence. The results of the AMSTAR 2 and GRADE suggest low to moderate methodological quality. This should be considered when weighing the reported findings of each study and this umbrella review.

Table 2
Quality assessment of included systematic reviews (AMSTAR 2)

Author, year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Nasb et al. (2021) Y PS N PS Y Y Y PS Y N N N N Y N Y

Kerr et al. (2020) Y N N PS N N Y PS PS N N/A N/A Y N N/A N

Marcolino et al. (2020) Y PS N YS Y Y Y PS Y N N N Y N N Y

Veldema and Jansen (2020b) Y N N PS Y Y N PS PS N N N N Y N N

Veldema and Jansen (2020a) Y N N PS Y N N PS Y N Y N Y Y N Y

Hong et al. (2018) Y N N PS N Y Y PS Y N N N Y Y Y N

Mahmood et al. (2019) Y PS N PS Y Y Y PS Y N Y Y N Y N N

Salazar et al. (2019) Y Y N PS Y Y Y PS PS N Y Y Y Y Y Y

Author, year	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16
Nasb et al. (2021)	Y	PS	N	PS	Y	Y	Y	PS	Y	N	N	N	N	Y	N	Y
Kerr et al. (2020)	Y	N	N	PS	N	N	Y	PS	PS	N	N/A	N/A	Y	N	N/A	N
Marcolino et al. (2020)	Y	PS	N	YS	Y	Y	Y	PS	Y	N	N	N	Y	N	N	Y
Veldema and Jansen (2020b)	Y	N	N	PS	Y	Y	N	PS	PS	N	N	N	N	Y	N	N
Veldema and Jansen (2020a)	Y	N	N	PS	Y	N	N	PS	Y	N	Y	N	Y	Y	N	Y
Hong et al. (2018)	Y	N	N	PS	N	Y	Y	PS	Y	N	N	N	Y	Y	Y	N
Mahmood et al. (2019)	Y	PS	N	PS	Y	Y	Y	PS	Y	N	Y	Y	N	Y	N	N
Salazar et al. (2019)	Y	Y	N	PS	Y	Y	Y	PS	PS	N	Y	Y	Y	Y	Y	Y

Y, yes; N, no; PS, Partial Yes; N/A, not applicable.

Table 3

Quality of evidence using GRADE criteria

Author, year	1	2	3	4	5	6	7	Quality of Evidence
Nasb et al. (2021)	High	–1	No	No	–1	No	None	Moderate
Kerr et al. (2020)	High	–1	–1	–1	–1	No	None	Low
Marcolino et al. (2020)	High	–1	–1	No	No	No	None	Moderate
Veldema and Jansen (2020b)	High	–1	–1	No	No	No	None	Moderate
Veldema and Jansen (2020a)	High	No	–2	No	No	No	None	Moderate
(Hong et al. 2018)	High	–2	No	No	No	No	None	Moderate
Mahmood et al. (2019)	Low	–2	No	–1	No	No	None	Very low
Salazar et al. (2019)	High	–1	–1	–1	No	No	None	Low

Quality interpretation (Balshem et al., 2011): Very low: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect. Low: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect. Moderate: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. High: We are very confident that the true effect lies close to that of the estimate of the effect.

3.3 Evidence synthesis of intervention

A wide array of physical therapy interventions was included in this umbrella review. Of the eight reviews included, most compared a form of exercise therapy alone or in conjunction with another intervention to investigate the most efficacious approach for treatment of post-stroke spasticity. Three reviews evaluated the use of electrical stimulation (two TENS, one NMES), two reviews evaluated stretching techniques, one review evaluated constraint induced movement therapy, two reviews evaluated various exercise approaches (i.e., resistance training, ergometry exercise). Marcolino et al. (2020) and Nasb et al. (2021) included an assessment of botulinum toxin injection within their reviews. Although botulinum toxin injection is not a treatment provided directly by a physical therapist, it is often adopted as a management strategy in patient care. Therefore, its effects in conjunction with a physical therapy intervention were considered in this review. The evidence of all reviews is summarized in Table 4. The findings indicate that there are a variety of interventions that may be incorporated in the plan of care for someone post-stroke to reduce adverse effects of spasticity. However, given the methodological findings of the AMSTAR 2 and GRADE tools, a limit to the quality and clarity of the presented findings must be considered. The overall findings of this review suggest the following:

Table 4
Overview and summary of results of included systematic reviews

Author, year Aim No. of included studies, design Population, no. of participants Intervention Control Outcome measure Main findings Quality of evidence (GRADE)

Nasb et al. (2021) To evaluate the safety and efficacy of Constraint-Induced Movement Therapy combined with botulinum toxin in stroke patients with upper limb spasticity 2 RCT 93 participants Adolescents and adults with chronic poststroke spasticity Upper extremities assessed Botulinum toxin A injection with modified CIMT Botulinum toxin A injection with conventional therapy Modified Ashworth Scale The effectiveness of the BTX-CIMT combination over conventional therapy for improving post-stroke spasticity still needs to be explored. Despite numerical reduction of spasticity within studies, no statistically significant reductions were found in intervention (BTX-CIMT) versus control groups. Low

Kerr et al. (2020) To examine the evidence for the effectiveness of stretching interventions, including splinting, on reducing upper extremity spasticity, increasing hand function, and improving functional tasks for adults with poststroke spasticity. 3 RCT, 2 observational studies 86 participants Adults with subacute to chronic stroke Upper extremities assessed Dynamic and static splints+physiotherapy, occupational therapy or home exercise program Stretching device with stretching session No control or home exercise program only Modified Ashworth Scale For spasticity reduction, there is low strength of evidence for the use of static and dynamic splinting and strong strength of evidence for the use of stretching devices. Dynamic splints may have a more beneficial effect than static splints in reducing spasticity. Stretching and splinting cannot be provided as stand-alone interventions and should be used in conjunction with other hands-on interventions from therapists. Home exercise programs did not provide significant results compared to hands-on therapies. Low

Marcolino et al. (2020) To evaluate the effect and use of TENS alone or as additional therapy in chronic post-stroke spasticity 10 RCT 360 participants Adults with chronic stroke and related spasticity Upper and lower extremities included TENS alone (3 studies)TENS+conventional therapy, task-related training, Bobath inhibitory techniques or botulinum toxin A and stretching Placebo TENS alonePlacebo TENS+conventional therapy, task-related training, Bobath inhibitory techniques or botulinum toxin A and stretchingPhysical therapy alone Therapeutic ultrasound and botulinum toxin A aloneBotulinum toxin A with taping or stretching MAS, Composite spasticity scale, Modified composite spasticity scale TENS as an additional treatment to physical interventions can lead to an additional reduction in chronic spasticity of stroke patients. There was numerical, but non-significant difference between high and low frequency TENS Moderate

Veldema and Jansen (2020b) Resistance training To investigate the effects of resistance training in supporting the recovery in stroke patients. 4 RCT 102 participants Adults with chronic stroke Upper and lower extremities assessed Resistance training protocols. All protocols varied in muscle groups used and concentric vs eccentric movements. No intervention (Akbari and Karim, Fernandez-Gonzalo et al.) or functional task training (Patten et al.) or passive mobilizations (Coroian et al.) Modified Ashworth Scale There is limited data about the influence of resistance training exercises on spasticity and muscle tone after stroke. The results suggest resistance training may reduce spasticity, although only one study was able to provide a statistically significant difference. Moderate

Veldema and Jansen (2020a) Ergometer training To investigate the effects of ergometer training in supporting the recovery in stroke patients. 4 RCT 220 participants Adults with chronic stroke Lower extremities assessed Ergometer training, various durations and intensities based on individual study No intervention (Yang et al), stretching and walking (Jin et al), ergometer training with FES to affected limb (Yeh et al, Bauer et al) Modified Ashworth Scale Ergometer training can provide more beneficial effects to stroke recovery than no intervention. However, no significant differences were found between ergometer training and stretching when looking at spasticity reduction. Moderate

Hong et al. (2018) To investigate the effectiveness of NMES with or without other interventions in improving lower limb activity after chronic stroke. 7 RCT 358 participantsAdults with subacute and chronic stroke Lower extremities assessed Electrical stimulation alone or with combined with forms of therapyNMES+conventional therapyTENS+task-related trainingTENS aloneTENS+therapeutic exerciseFES+conventional therapy Forms of therapy alone or combined with placebo electrical stimulation conventional therapyPlacebo+task-related training conventional therapy therapeutic exercise Modified Ashworth Scale Application of NMES, especially with treatment durations of 6–12 weeks, in conjunction with other interventions resulted in reduction of lower extremity spasticity in patients with chronic stroke. Moderate

Mahmood et al. (2019) To determine the effect of TENS on poststroke spasticity, the effect of different TENS parameters on spasticity reduction, and to determine the influence of time since stroke on effectiveness of TENS on spasticity. 10 RCT5 non-RCT/ Quasi-RCT 516 participants Adults with acute, subacute or chronic stroke Upper and lower extremities assessed TENS alone TENS+other (exercise therapy, inhibition and facilitation techniques, electrotherapy modalities, pharmaceutical drugs, or surgical interventions) Use of no intervention, placebo-controlled interventions, or active controls such as surgical interventions, pharmacological interventions, of physical therapy interventions (electrotherapy modalities, exercise training) Neurophysiological tools: H/M reflex, H-reflex amplitude, and latency, stretch reflex latency, duration, and magnitude, F wave, stretch reflex threshold, and tonic stretch reflex threshold Clinical tools: Ashworth Scale, Modified Ashworth Scale, Composite Spasticity Scale, Modified Composite Spasticity Scale, Tardieu) Scale) TENS is effective in reducing lower limb spasticity when administered along with other forms of physical therapy in chronic stroke survivors. TENS applied > 30 minutes, high frequencies (90–100 Hz), and electrode placement along the nerve or muscle belly was most effective. Reduction in spasticity via TENS is most obvious in chronic survivors. No studies reported negative or adverse effects of TENS on spasticity. Very low

Salazar et al. (2019) To investigate the effects of static stretching with positioning orthoses or simple positioning combined or not with other therapies on upper-limb spasticity and mobility in adults after stroke. 6 RCT 184 participants Adults with acute to chronic stroke Upper extremities assessed Static stretching with conventional physiotherapy (De Jong et al, 2006)Static positioning+ NMES+ conventional physiotherapy (De Jong et al, 2013) Static stretching device (Jang et al, Jung et al, Kim et al) Static stretching device+ routine therapy (Lannin et al) Conventional therapy without static stretching Conventional physiotherapy+sham positioning+sham TENSNo training program Conventional physiotherapy without static stretching Ashworth Scale, Tardieu Scale, Modified Ashworth Scale, Further studies needed to support or refute the use of static stretching for improving upper-limb spasticity.There is very low-quality evidence that static stretching with positioning orthoses is effective to diminish wrist flexor spasticity as compared with no therapy.There is low quality evidence that static stretching by simple positioning is not better than conventional physiotherapy for preventing loss of mobility in the shoulder and wrist. Low

Author, year	Aim	No. of included studies, design	Population, no. of participants	Intervention	Control	Outcome measure	Main findings	Quality of evidence (GRADE)
Nasb et al. (2021)	To evaluate the safety and efficacy of Constraint-Induced Movement Therapy combined with botulinum toxin in stroke patients with upper limb spasticity	2 RCT	93 participants Adolescents and adults with chronic poststroke spasticity Upper extremities assessed	Botulinum toxin A injection with modified CIMT	Botulinum toxin A injection with conventional therapy	Modified Ashworth Scale	The effectiveness of the BTX-CIMT combination over conventional therapy for improving post-stroke spasticity still needs to be explored. Despite numerical reduction of spasticity within studies, no statistically significant reductions were found in intervention (BTX-CIMT) versus control groups.	Low
Kerr et al. (2020)	To examine the evidence for the effectiveness of stretching interventions, including splinting, on reducing upper extremity spasticity, increasing hand function, and improving functional tasks for adults with poststroke spasticity.	3 RCT, 2 observational studies	86 participants Adults with subacute to chronic stroke Upper extremities assessed	Dynamic and static splints+physiotherapy, occupational therapy or home exercise program Stretching device with stretching session	No control or home exercise program only	Modified Ashworth Scale	For spasticity reduction, there is low strength of evidence for the use of static and dynamic splinting and strong strength of evidence for the use of stretching devices. Dynamic splints may have a more beneficial effect than static splints in reducing spasticity. Stretching and splinting cannot be provided as stand-alone interventions and should be used in conjunction with other hands-on interventions from therapists. Home exercise programs did not provide significant results compared to hands-on therapies.	Low
Marcolino et al. (2020)	To evaluate the effect and use of TENS alone or as additional therapy in chronic post-stroke spasticity	10 RCT	360 participants Adults with chronic stroke and related spasticity Upper and lower extremities included	TENS alone (3 studies)TENS+conventional therapy, task-related training, Bobath inhibitory techniques or botulinum toxin A and stretching	Placebo TENS alonePlacebo TENS+conventional therapy, task-related training, Bobath inhibitory techniques or botulinum toxin A and stretchingPhysical therapy alone Therapeutic ultrasound and botulinum toxin A aloneBotulinum toxin A with taping or stretching	MAS, Composite spasticity scale, Modified composite spasticity scale	TENS as an additional treatment to physical interventions can lead to an additional reduction in chronic spasticity of stroke patients. There was numerical, but non-significant difference between high and low frequency TENS	Moderate
Veldema and Jansen (2020b) Resistance training	To investigate the effects of resistance training in supporting the recovery in stroke patients.	4 RCT	102 participants Adults with chronic stroke Upper and lower extremities assessed	Resistance training protocols. All protocols varied in muscle groups used and concentric vs eccentric movements.	No intervention (Akbari and Karim, Fernandez-Gonzalo et al.) or functional task training (Patten et al.) or passive mobilizations (Coroian et al.)	Modified Ashworth Scale	There is limited data about the influence of resistance training exercises on spasticity and muscle tone after stroke. The results suggest resistance training may reduce spasticity, although only one study was able to provide a statistically significant difference.	Moderate
Veldema and Jansen (2020a) Ergometer training	To investigate the effects of ergometer training in supporting the recovery in stroke patients.	4 RCT	220 participants Adults with chronic stroke Lower extremities assessed	Ergometer training, various durations and intensities based on individual study	No intervention (Yang et al), stretching and walking (Jin et al), ergometer training with FES to affected limb (Yeh et al, Bauer et al)	Modified Ashworth Scale	Ergometer training can provide more beneficial effects to stroke recovery than no intervention. However, no significant differences were found between ergometer training and stretching when looking at spasticity reduction.	Moderate
Hong et al. (2018)	To investigate the effectiveness of NMES with or without other interventions in improving lower limb activity after chronic stroke.	7 RCT	358 participantsAdults with subacute and chronic stroke Lower extremities assessed	Electrical stimulation alone or with combined with forms of therapyNMES+conventional therapyTENS+task-related trainingTENS aloneTENS+therapeutic exerciseFES+conventional therapy	Forms of therapy alone or combined with placebo electrical stimulation conventional therapyPlacebo+task-related training conventional therapy therapeutic exercise	Modified Ashworth Scale	Application of NMES, especially with treatment durations of 6–12 weeks, in conjunction with other interventions resulted in reduction of lower extremity spasticity in patients with chronic stroke.	Moderate
Mahmood et al. (2019)	To determine the effect of TENS on poststroke spasticity, the effect of different TENS parameters on spasticity reduction, and to determine the influence of time since stroke on effectiveness of TENS on spasticity.	10 RCT5 non-RCT/ Quasi-RCT	516 participants Adults with acute, subacute or chronic stroke Upper and lower extremities assessed	TENS alone TENS+other (exercise therapy, inhibition and facilitation techniques, electrotherapy modalities, pharmaceutical drugs, or surgical interventions)	Use of no intervention, placebo-controlled interventions, or active controls such as surgical interventions, pharmacological interventions, of physical therapy interventions (electrotherapy modalities, exercise training)	Neurophysiological tools: H/M reflex, H-reflex amplitude, and latency, stretch reflex latency, duration, and magnitude, F wave, stretch reflex threshold, and tonic stretch reflex threshold Clinical tools: Ashworth Scale, Modified Ashworth Scale, Composite Spasticity Scale, Modified Composite Spasticity Scale, Tardieu) Scale)	TENS is effective in reducing lower limb spasticity when administered along with other forms of physical therapy in chronic stroke survivors. TENS applied > 30 minutes, high frequencies (90–100 Hz), and electrode placement along the nerve or muscle belly was most effective. Reduction in spasticity via TENS is most obvious in chronic survivors. No studies reported negative or adverse effects of TENS on spasticity.	Very low
Salazar et al. (2019)	To investigate the effects of static stretching with positioning orthoses or simple positioning combined or not with other therapies on upper-limb spasticity and mobility in adults after stroke.	6 RCT	184 participants Adults with acute to chronic stroke Upper extremities assessed	Static stretching with conventional physiotherapy (De Jong et al, 2006)Static positioning+ NMES+ conventional physiotherapy (De Jong et al, 2013) Static stretching device (Jang et al, Jung et al, Kim et al) Static stretching device+ routine therapy (Lannin et al)	Conventional therapy without static stretching Conventional physiotherapy+sham positioning+sham TENSNo training program Conventional physiotherapy without static stretching	Ashworth Scale, Tardieu Scale, Modified Ashworth Scale,	Further studies needed to support or refute the use of static stretching for improving upper-limb spasticity.There is very low-quality evidence that static stretching with positioning orthoses is effective to diminish wrist flexor spasticity as compared with no therapy.There is low quality evidence that static stretching by simple positioning is not better than conventional physiotherapy for preventing loss of mobility in the shoulder and wrist.	Low

RCT, randomized control trial; TENS, transcutaneous electrical nerve stimulation; FES, functional electrical stimulation; (m)CIMT, (modified) constraint-induced movement therapy.

3.4 Overall quality recommendations

High quality evidence:

None.

Moderate quality evidence:

TENS used as an adjunct to physical interventions can aid in reduction of chronic post-stroke spasticity. High and low frequency TENS demonstrated similar results, with a small but non-significant superiority of low frequency TENS.

NMES in conjunction with physical interventions can aid in reduction of lower extremity spasticity in chronic CVA.

Resistance training may reduce spasticity, although only one study was able to provide a statistically significant difference.

Lower extremity ergometer training can provide more beneficial effects to stroke recovery than no intervention. Clinicians could consider use of functional electrical stimulation (FES)-assisted ergometer training.

Low quality evidence

Stretching devices appeared to be more beneficial compared to static and dynamic splinting for spasticity reduction. Dynamic splints may be more beneficial than static splints. The effectiveness of botulinum toxin type A combined with constraint-induced movement therapy (BTX-CIMT) over conventional therapy for improving post-stroke spasticity still needs to be explored. No statistically significant reductions in spasticity were found in the BTX-CIMT group versus the control group.

Static stretching with positioning orthoses is effective to diminish wrist flexor spasticity as compared with no therapy; static stretching by simple positioning is not better than conventional physiotherapy for preventing loss of mobility in the shoulder and wrist.

Very low-quality evidence:

TENS of durations greater than 30 minutes, using higher frequencies, electrode placement along the nerve or muscle belly, and used as an adjunct to physical interventions can aid in reduction of chronic, lower limb spasticity.

4 Discussion

Current evidence supports a multidisciplinary, long-term approach to help direct treatment strategies in the management of post-stroke spasticity. This review outlined current evidence from published systematic reviews regarding the effectiveness of physical therapy interventions for post-stroke spasticity. Despite a variety of clinical intervention strategies for post-stroke spasticity, there remains a lack of high-quality evidence and consensus supporting these interventions in rehabilitation practice.

This review included both passive and active treatment strategies that can be implemented in treating patients with stroke experiencing spasticity that is interfering with functional tasks. The overall findings of this review suggest moderate quality of evidence for [1] using TENS or NMES in conjunction with therapeutic interventions to help reduce chronic post-stroke spasticity; [2] resistance training exercises providing potential positive effect on reducing spasticity; and [3] lower extremity ergometer training with or without FES-assistance to provide enhanced stroke recovery compared to no intervention. There is low quality evidence for [1] dynamic stretching being superior to static splints in reducing spasticity; [2] effectiveness of botulinum toxin with constraint-induced movement therapy in improving post-stroke spasticity; and [3] static stretching with positional orthosis is effective to reduce wrist flexor spasticity and is superior to conventional therapy. For other rehabilitation interventions, the quality of evidence was very low and warrants further investigation.

According to the American Heart Association and American Stroke Association guidelines for adult CVA rehabilitation and recovery, there continues to be gaps in the literature in this practice area due to a lack of large-scale clinical trials (Williams et al., 2022; Winstein et al., 2016). As of today, current guidelines for management of post-stroke spasticity support the use of pharmacological management in the form of botulinum toxin. There is an abundant amount of high-quality evidence from multiple randomized controlled trials and meta-analyses that exclusively favor targeted injection of botulinum toxin leading to reduction of spasticity, improving both active and passive range of motion, limb position, gait function, and quality of life (Francisco et al., 2021; Santamato et al., 2019; Sun et al., 2019; Winstein et al., 2016). However, there continues to be a need for more high-quality evidence addressing the efficacy of botulinum toxin in conjunction with physical therapy interventions to determine its significance for reduction of spasticity in the long term (Francisco et al., 2021; Picelli et al., 2019). The results of this review demonstrate a need for publication of high-quality, evidence-informed therapeutic guidelines for rehabilitation practitioners to use post-toxin injection. One potential reason for the broad scope of the body of literature on interventions for post-stroke spasticity may be that there is debate about when to manage spasticity. Determining the outcome that is being affected by spasticity is critical, including but not limited to pain, decreased range of motion, and impaired motor planning due to synergistic activity which may lead to deficits in activity, participation, and quality of life (Francisco & McGuire, 2012; Milinis et al., 2016; Thompson et al., 2005). This review suggests that interventions may be best used to supplement medical management to target impairment level deficits for carryover into functional tasks such as gait.

This review determined that there is moderate quality evidence to support physical therapy interventions that include TENS and NMES in treating post-stroke spasticity. For example, clinically a person with significant lower extremity extensor spasticity interfering with swing phase of gait on the hemiparetic limb may benefit from TENS or NMES to the quadriceps (agonist) to decrease extensor spasticity in order to allow the passive knee flexion required for a successful swing phase. Utilizing electrical stimulation over stretching or splinting may be beneficial due to its mechanism of action. Electrical stimulation directly targets the nerves innervating the spastic muscle, leading to afferent input into the spinal cord with resulting efferent output, whether it be subthreshold to a muscle contraction or resulting in muscle contraction. Because spasticity results from damage to the central nervous system, specifically the brain and spinal cord, electrical stimulation may target the root cause of spasticity and induce favorable neuroplastic changes (Carson & Buick, 2021; Knutson et al., 2015). One study confirmed an active approach, supporting the use of NMES in conjunction with other PT interventions for overall improvements of spasticity and ROM in those post stroke while suggesting passive treatment styles have generally very low quality of evidence to support management of spasticity throughout all neurologic conditions (Khan et al., 2019). There is more research needed to investigate optimal parameters for NMES and TENS as well as the benefits of providing electrical stimulation directly to the spastic muscle, to fatigue the spasticity, or to the antagonist, to essentially “overpower” the spastic muscle (Maffiuletti et al., 2018).

According to this umbrella review, resistance training and aerobic interventions have a moderate quality of evidence that suggests a resulting decreased spasticity in individuals post-stroke. These interventions may also be utilized for increasing strength, endurance, cardiovascular fitness, respiratory capacity, gastrointestinal benefits, and improvements in activities of daily living (Hong et al., 2018; Veldema & Jansen, 2020b). Prioritizing these active interventions over passive interventions may target the forementioned body structures and functions, and also lead to a decrease in spasticity which could improve activity, participation and quality of life (Hong et al., 2018; Veldema & Jansen, 2020b). Our findings do indicate that stretching and splinting have low quality evidence to support their use in decreasing post-stroke spasticity. The findings did not support that these interventions had a negative effect on outcomes, but rather the evidence suggests that other interventions, such as electrical stimulation and aerobic and resistance exercise, may be more effective if the goal of the intervention is to decrease spasticity. Resistance exercise training may have weaker evidence to improve walking speed or distance in individuals post-stroke (Hornby et al., 2020); however, our umbrella review found moderate level evidence of resistance training improving spasticity symptoms, suggesting other interventions may be needed for walking speed and distance.

Spasticity is a complex disorder that presents in multiple central nervous system conditions such as multiple sclerosis, cerebral palsy, traumatic brain injury, spinal cord injury in addition to post-stroke. A systematic review and meta-analysis regarding the effects of physical therapy interventions on spasticity in people with multiple sclerosis found exercise therapy in the forms of robot gait training and outpatient exercises (active and passive stretch, strength, stability, balance, coordination, aquatic, endurance, walking, and mobilization exercise) to have significant beneficial effects on self-perceived spasticity and muscle tone respectively (Etoom et al., 2018). As for individuals with spinal cord injury or traumatic brain injury and their management of spasticity, the literature remains to be inconclusive due to lack of high quality evidence, much like many studies regarding post-stroke (Barbosa et al., 2021; Synnot et al., 2017). In general, the overarching theme of low-quality evidence remains with newer emerging publication suggesting spasticity throughout the spectrum of CNS presentations should be treated with an active approach, which supports the findings in this review of post-stroke spasticity.

The researchers recommend future studies to compare existing interventions in larger-scale studies, using best current evidence prior to the intervention. More studies are also needed to assess physical therapy interventions in conjunction with medical, pharmacological, and surgical interventions. The researchers also recommend additional randomized controlled trials aimed at finding the optimal parameters for electrical stimulation and comparing NMES and TENS to further inform clinicians for practical tools to implement in the clinical treatment of post-stroke spasticity.

4.1 Study limitations and strengths

This study presents a number of limitations. First, many of the included studies presented low to moderate methodological quality with a moderate risk of bias. Thus, the results of this review should be interpreted with caution. Second, the inclusion and exclusion criteria of this review was relatively stringent and excluded many systematic reviews that may have included non-pharmacological interventions not commonly accessible to physical therapist practice. The criteria may have also excluded studies that included spasticity as an outcome but may not have specified the measurement tool to assess spasticity. Third, there is a paucity of studies included to firmly conduct a quantitative analysis based on the heterogeneity of the interventions included in the studies, as well as the outcomes and endpoints used for assessment. Future studies should consider the efficacy of specific physical therapy interventions with greater methodological rigor, as well as studying their effects in conjunction with medical and pharmacological interventions.

Although our review presents some limitations, our umbrella review has a number of strengths. We conducted a comprehensive search, including only the highest-quality reviews based on our strict inclusion criteria. We were able to condense this information in one place to improve accessibility for physical therapists and clinicians engaged in stroke rehabilitation and research. Our assessment of the methodological quality of the included studies followed recommended guidelines, assessing not only the systematic review through the AMSTAR 2 but also the interventional outcomes through the GRADE.

5 Conclusions

The results of this present umbrella review showed there is moderate quality evidence for using TENS, NMES, FES, aerobic exercise, and resistance training to improve and manage post-stroke spasticity. Low quality evidence currently exists for interventions such as stretching and splinting to improve spasticity and the study of botulinum toxin in conjunction with physical therapy interventions continues to grow. Our findings suggest that physical therapy interventions should prioritize the combination of active therapies over passive interventions.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest

The authors report no competing interests.

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