Taal in het Nederlands Language is English
Become a member | Lost your password?
Banner Leiden Marathon
Physicaltherapyscience.com- Articles - Proof of safety of Mobilization and Stimulation of Neuromuscular Tissue (MaSoNT) on the hemiplegic upper-limb: a case report

Proof of safety of Mobilization and Stimulation of Neuromuscular Tissue (MaSoNT) on the hemiplegic upper-limb: a case report

F&W 2018; 7: 1
D. Athanasiadis MSc

I. Introduction
  Every year, there are approximately 100,000 stroke incidents in the UK, with the majority of those patients leaving the hospital with disability1. The upper-limb is most commonly affected by permanent disability2 with six out of eight stroke patients presenting symptoms at this area3.  Six out of ten stroke survivors could not manage to recover some dexterity of the hemiplegic hand even after a six-month intervention4. Hence, even though many “hands-on” techniques are applied in order to trigger functional recovery to the upper-limb5, a vast majority of them failed to establish a standard of usefulness in that regard6 accompanied by a necessity for more evidence-based practice as well as a better reasoning for their application7.
  Mobilization and Stimulation of Neuromuscular Tissue (MaSoNT) is a newly-invented sensory facilitatory technique for the hemiplegic upper-limb where the therapist offers somatosensory stimuli aiming to trigger functional recovery through cortical reorganization8. The safety of the technique was studied and supported in theory8, and an exploratory study was conducted in a small number of stroke patients9. This case study primarily aims to offer a proof of safety of use for MaSoNT. Secondarily, it aims to report the effects of applying MaSoNT on a subject regarding pain, spasticity and recovery.

II. Case Report
  The patient was a 71 year-old male stroke survivor, classified to have lacunar circulation ischemic stroke syndrome10. The areas of infract were the pons and the basal ganglia. The dominant side was the hemiplegic side and that was the right. He was recruited on the basis of being more suitable for the technique according to evidence8. Other inclusion criteria were that the patient was treated early after the cerebrovascular accident, was aged between 21 and 85 years old and that the hemiplegic hand did not produce any voluntary movement. Exclusion criteria were a Mini Mental Exam Status ≤ 24, 2, significant neglect and presence of spasticity. As this patient was the first one to receive MaSoNT in a monitored and regular manner, the sample had to be of convenience. The patient received MaSoNT one week after his cerebrovascular accident which was his second. The first mild one infracted the left pons and occurred 2 years before the second. Patient presented dysarthria and positive (+) Babinski sign on the hemiplegic side. Moreover, the patient showed history of hyperlipidemia, hypertension, diabetes mellitus type 2, chronic kidney disease and deep vein thrombosis at the superficial femoral vein and the popliteal vein. Pharmaceutical treatment includes: Actrapid, Lantus, Ivor 2500 IU, TBS Salsospir, Omeprazole, Amlopen, Coaprovel, TBS Atorstat 20, TBS Hytrin. This intervention was the first he received after stroke. The patient gave informed consent to participate in the study. Clinical features of the patient are presented in table 1.




III. Study Design
  According to evidence8, the intervention offered was standard upper-limb therapy twice per week for a quarter of an hour, along with MaSoNT. The standard upper-limb therapy included passive/active movement exercises and static/dynamic stretching. No electrically generated stimuli were offered (device-free). MaSoNT was applied four times in a minute, with an interval of 15 seconds, repeated every half an hour for 71/2 hours. In total, this is 15 minutes of MaSoNT intervention. The experiment lasted 3 weeks. Positioning of the hemiplegic upper limb was offered twice a day for 30 minutes according to evidence11. The study’s design abides by the CARE guidelines12 for case reports.

Measurement Tools
  In order to assess pain, VAS was not preferred due to the criticism on its use on stroke survivors13. A pain dichotomous was used instead (pain versus no pain) as inspired by other studies on stroke survivors14. Pain was assessed both at rest and when at movement of the hemiplegic arm. To assess spasticity at the shoulder, elbow and wrist, the Modified Asworth Scale15 (MAS) was used whose psychometrics on stroke patients are supported16-22 but, also, being aware of MAS’s limitations 23-25. Moreover, to assess motor function, the Motricity Index26 (MI) was used which is widely evidence-based 27-31, along with items 6, 7 and 8 of the Motor Assessment Scale32 which is again supported by evidence33-36. Lastly, the Thumb Localization (TL) test was used to assess proprioception37-38 and the Nottingham Sensory Assessment (NSA) to assess the somatosensory effects39-40. The independent assessor was a physiotherapist who was blinded to the intervention. However, there was no blinding for the patient.

MaSoNT Application Procedure
  The patient received MaSoNT either seated or lying supine and no distractive stimuli were apparent nearby. The upper-limb was lifted with specific handling by the therapist and brought towards the patient’s point of view in order to gain his full attention. The position acquired through the therapists handling was: shoulder in flexion, adduction, mid-rotation, elbow in mid-flexion and forearm in prone. The wrist, along with the fingers, was free of handling, and thus placed relaxingly by gravity force in flexion.
  Seconds before applying MaSoNT, the therapist instructed the patient to focus on the hand and the contraction that is going to occur. The therapist targeted the muscle belly and applied a transverse stretch. A brisk contraction was seen as a result of this application. If a contraction was not elicited once applied over a particular spot, an additional application was offered in another spot that would trigger it. If even an additional application could not elicit a contraction, no other effort was attempted due to safety reasons for the biomechanical infrastructure of the neuromusculature.
  The application was offered at four different spots and included several areas of the forearm’s dorsal surface aiming to trigger the extensors muscle group. One application spot also included the brachioradialis muscle belly area aiming to trigger this particular muscle which could elicit contraction with regards to the elbow. Such an application spot could not be detected for the triceps brachii insertion close to the olecranon. Vulnerable application spots of the radial nerve as pictured in the figure41 were avoided.

IV. Results
  The outcomes of the intervention are summarized in table 2. Regarding pain, no increase of pain was noticed in week 3 neither at rest nor at movement. Spasticity was not increased. The MI showed an increase of 47% while the Motor Assessment Scale revealed a 28% improvement compared to baseline. Lastly, the TL test presented 25% increase and the NSA demonstrated a 33% increase in tactile sensation and 25% in kinaesthesia. No harmful effect was present with regards to stereognosis which was unaltered.




V. Observations
  Early during the experiment, while the thumb, index and middle finger presented voluntary movement, no such effect was shown in the ring and the little finger. Consequently, the therapist started aiming more laterally and distant to the elbow in order to trigger the respective neuromusculature. Small movement of the index and middle finger were apparent within week 1.
  Moreover, in the middle of week 2 of the experiment, a taut band appeared medially at the surface of application on the forearm. No tenderness or pain pattern was apparent neither under palpation, ischemic compression nor in calm. It was speculated to be a latent (silent) trigger point42 and it was never used again as an application spot. This clinical sign disappeared by the end of week 3.
  Contractures were not apparent. Evidence supports that the earliest contractures can be apparent is two months after stroke43. Moreover, given that early functional recovery was achieved at week 3, the patient is not likely to present any contractures in the future44.

VI. Discussion
  This is the first clinical study on MaSoNT and the effects of its use on the hemiplegic arm. MaSoNT belongs to a group of sensory facilitatory techniques that can be used in every-day clinical practice in order to assist functional recovery. That group of techniques could be named “zero-to-one” techniques as they aim to improve function of a flaccid hemiplegic hand from no voluntary movement (zero condition) to at least some movement (one condition) upon which another therapeutic approach can build on and improve to an even better condition.
  Previous studies that implemented similar interventions of somatosensory stimulation had been reported. Sensorimotor training improved functional recovery of two chronic stroke survivors in a two-week intervention with neural reorganization being induced45. Moreover, a program of stretching, range of motion exercises and soft tissue mobilization techniques offered to five chronic stroke patients in a three-week intervention managed to provide functional improvement along with cortical reorganization46. Noteworthy, the current study is the first to apply such a sensorimotor intervention on the hemiplegic hand so early after stroke.
  Regarding cortical reorganization measurements, the rational of use of MaSoNT is to offer functional recovery by eliciting cortical reorganization8. As no imaging scanning device was implemented in the study due to financial reasons, no information on the effect of the intervention on cortical reorganization could be granted. It could be speculated that neuroplastic reorganizational alterations did occur in the patient’s brain otherwise no functional recovery would be seen at all47. However, whether these cortical reorganizational changes and the extent of them are to be attributed to the intervention is questionable as some physiological neuroplastic changes would occur naturally48. Unknown mechanisms can trigger motor recovery through cortical reorganization when a sensorimotor technique is applied49. Evidence strongly supports that therapeutic interventions can enhance functional recovery through cortical reorganization in stroke patients45-46,50-52. Notably, passive movement alone is able to trigger changes in cortical representation and excitability of healthy individuals53-56.
  Apart from the effects, the study can support the safety of the technique. Pain levels for both at rest and in movement remained absent both before and after the intervention. Certainly, this does not imply that pain will not be apparent for the patient in the future as this phenomenon is highly prevalent six months after stroke57. Additionally, there was no negative effect regarding the development of spasticity. Again, spasticity may appear as early as two weeks after stroke in a patient’s life58 and its prevalence increases at three59 and six60 weeks after stroke. However, given the low degree of motor and sensory deficit as well as the absence of spasticity at this early stage, the patient probably will not be seriously affected by spasticity58,60-61. Thus, some proof of safety of MaSoNT intervention can be granted by the current study.

Limitations
  More assessment scales on functional recovery could have been included but the study did not primarily aim to it. Even if more such scales were included, in a convenience sample such as the one recruited, no spherical generalized conclusion could be reached. That was the second limitation of the study. Lastly, no blinding of the patient was achieved. This risk of bias diminishes the credibility of the results but, when studying alternative innovative interventions, full blinding becomes almost impossible62.

VII. Conclusions
  This study was the first where MaSoNT is offered early on a stroke patient’s upper-limb. The major conclusion is that MaSoNT possibly cannot cause any harmful effects on the recovery of the hemiplegic hand. Additionally, it might cause motor and sensory improvement. Hence, it could be recommended to apply it in combination with the conventional treatment approach. Future research with larger number of subjects is needed to validate duration and doses and generalize the efficacy of the intervention to the greater stroke population.
 
 
List of abbreviations
MaSoNT -> Mobilization and Stimulation of Neuromuscular Tissue
MI -> Motricity Index
TL -> Thump Localization
MAS -> Modified Asworth Scale
NSA -> Nottingham Sensory Assessment
 
 References
1. G. Broeks, J., Lankhorst, G. J., Rumping, K. & Prevo, A. J. H. (1999). The long-term outcome of arm function after stroke: results of a follow-up study. Disability and rehabilitation. 21(8): 357-364.
2. Lawrence, E. S., Coshall, C., Dundas, R., Stewart, J., Rudd, A. G., Howard, R. & Wolfe, C. D. (2001). Estimates of the prevalence of acute stroke impairments and disability in a multiethnic population. Stroke. 32(6): 1279-1284.
3. Kwakkel, G., Kollen, B. J., van der Grond, J. & Prevo, A. J. (2003). Probability of regaining dexterity in the flaccid upper limb. Stroke. 34(9): 2181-2186.
4. Jackson, J. (2011). Specific treatment techniques. In: Stokes, M. & Stack, E. (eds.) Physical management for neurological conditions. 3rd ed. Edinburgh: Elsevier.
 5. Langhorne, P., Coupar, F. & Pollock, A. (2009). Motor recovery after stroke: a systematic review. The Lancet Neurology. 8(8): 741-754.
6. Langhorne, P., Bernhardt, J. & Kwakkel, G. (2011). Stroke rehabilitation. The Lancet. 377(9778): 1693-1702.
7. Athanasiadis, D. (2015). Physiology underpinning Mobilization and Stimulation of Neuromuscular Tissue (MaSoNT): a review. Master’s Thesis, University of Keele, Keele, United Kingdom.
8. Athanasiadis, D., Dionys-siotis, Y., Papathanasiou, J. & Stefas, E. (2018). Mobilization and Stimulation of Neuromuscular Tissue (MASONT) for stroke survivors. Folia Medica. 60(1): 95-99.
9. Bamford, J., Sandercock, P., Dennis, M., Warlow, C. & Burn, J. (1991). Classification and natural history of clinically identifiable subtypes of cerebral infarction. The Lancet. 337(8756): 1521-1526.
10. Ada, L., Goddard, E., Mccully, J., Stavrinos, T. & Bampton, J. (2005). Thirty minutes of positioning reduces the development of shoulder external rotation contracture after stroke: a randomized controlled trial. Archives of physical medicine and rehabilitation. 86(2): 230-234.
11. Gagnier JJ, Kienle G, Altman DG, Moher D, Sox H, Riley D, CARE Group (2013). Glob Adv Health Med. 2(5):38-43.
12. Price, C. I. M., Curless, R. H. & Rodgers, H. (1999). Can stroke patients use visual analogue scales? Stroke. 30(7): 1357-136.
13. Pandyan, A. D., Cameron, M., Powell, J., Stott, D. J. & Granat, M. H. (2003). Contractures in the post-stroke wrist: a pilot study of its time course of development and its association with upper limb recovery. Clinical Rehabilitation. 17(1): 88-95.
14. Bohannon, R. & Smith, M. (1987). Interrater reliability of a modified Ashworth scale of muscle spasticity. Physical Therapy. 67(2): 206-207.
15. Katz, R. T., Rovai, G. P., Brait, C. & Rymer, W. Z. (1992). Objective quantification of spastic hypertonia: correlation with clinical findings. Archives of Physical Medicine and Rehabilitation. 73(4): 339-47.
16. Allison, S. C., Abraham, L. D. & Petersen, C. L. (1996). Reliability of the Modified Ashworth Scale in the assessment of plantarflexor muscle spasticity in patients with traumatic brain injury. International Journal of Rehabilitation Research. 19(1): 67-78.
17. Fu-Mei, L. & Mohamed, S. (1999). Correlation of spasticity with hyperactive stretch reflexes and motor dysfunction in hemiplegia. Archives of physical medicine and rehabilitation. 80(5): 526-530.
18. Gregson, J. M., Leathley, M. J., Moore, A. P., Smith, T. L., Sharma, A. K. & Watkins, C. L. (2000). Reliability of measurements of muscle tone and muscle power in stroke patients. Age and ageing. 29(3): 223-228.
19. Blackburn, M., van Vliet, P. & Mockett, S. P. (2002). Reliability of measurements obtained with the modified Ashworth scale in the lower extremities of people with stroke. Physical therapy. 82(1): 25-34.
20. Brashear, A., Zafonte, R., Corcoran, M., Galvez-Jimenez, N., Gracies, J. M., Gordon, M. F. Mcafee, A., Ruffing, K., Thompson, B., Williams, M., Lee, C. H. & Turkel C. (2002). Inter-and intrarater reliability of the Ashworth Scale and the Disability Assessment Scale in patients with upper-limb poststroke spasticity. Archives of physical medicine and rehabilitation. 83(10): 1349-1354.
21. Kaya, T., Karatepe, A. G., Gunaydin, R., Koc, A. & Ercan, U. A. (2011). Inter-rater reliability of the Modified Ashworth Scale and modified Modified Ashworth Scale in assessing poststroke elbow flexor spasticity. International Journal of Rehabilitation Research. 34(1): 59-64.
22. Pandyan, A. D., Johnson, G. R., Price, C. I. M., Curless, R. H., Barnes, M. P. & Rodgers, H. (1999). A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity. Clinical rehabilitation. 13(5): 373-383.
23. Kamper, D. G., Schmit, B. D. & Rymer, W. Z. (2001). Effect of muscle biomechanics on the quantification of spasticity. Annals of biomedical engineering. 29(12): 1122-1134.
24. Salter, K., Jutai, J. W., Teasell, R., Foley, N. C. & Bitensky, J. (2005). Issues for selection of outcome measures in stroke rehabilitation: ICF Body Functions. Disability and Rehabilitation. 27(4): 191-207.
25. Collin, C. & Wade, D. T. (1990). Assessing motor impairment after stroke: a pilot reliability study. Journal of Neurology, Neurosurgery & Psychiatry. 53(7): 576-579.
26. Kopp, B., Kunkel, A., Flor, H., Platz, T., Rose, U., Mauritz, K. H., Gresser, K., McCulloch, K. L. & Taub, E. (1997). The Arm Motor Ability Test: reliability, validity, and sensitivity to change of an instrument for assessing disabilities in activities of daily living. Archives of physical medicine and rehabilitation. 78(6): 615-620.
27. Hsieh, C. L., Hsueh, I. P., Chiang, F. M. & LIN, P. H. (1998). Inter-rater reliability and validity of the action research arm test in stroke patients. Age and ageing. 27(2): 107-113.
28. Bohannon, R. W. (2001). Motricity index scores are valid indicators of paretic upper extremity strength following stroke. Journal of Physical Therapy Science. 11(2): 59-61.
29. Safaz, I., Ylmaz, B., Yasar, E. & Alaca, R. (2009). Brunnstrom recovery stage and motricity index for the evaluation of upper extremity in stroke: analysis for correlation and responsiveness. International Journal of Rehabilitation Research. 32(3): 228-231.
30. Kumar P. (2015). Reliability of Motricity Index Strength Assessments for Upper Extremity in Post Stroke Hemiparesis- a Correlation Study. Maharishi Markendeswar University.
31. Carr, J. H., Shepherd, R. B., Nordholm, L. & Lynne, D. (1985). Investigation of a new motor assessment scale for stroke patients. Physical Therapy. 65(2): 175-180.
32. Poole, J. L. & Whitney, S. L. (1988). Motor assessment scale for stroke patients: concurrent validity and interrater reliability. Archives of physical medicine and rehabilitation. 69(3 Pt 1): 195-197.
33. Malouin, F., Pichard, L., Bonneau, C., Durand, A. & Corriveau, D. (1994). Evaluating motor recovery early after stroke: comparison of the Fugl-Meyer Assessment and the Motor Assessment Scale. Archives of physical medicine and rehabilitation. 75(11): 1206-1212.
34. Lannin, N. A. (2004). Reliability, validity and factor structure of the upper limb subscale of the Motor Assessment Scale (UL-MAS) in adults following stroke. Disability and rehabilitation. 26(2): 109-116.
35. English, C. K., Hillier, S. L., Stiller, K., & Warden-Flood, A. (2006). The sensitivity of three commonly used outcome measures to detect change amongst patients receiving inpatient rehabilitation following stroke. Clinical rehabilitation. 20(1): 52-55.
36. Hirayama, K., Fukutake, T. & Kawamura, M. (1999). ‘Thumb localizing test’ for detecting a lesion in the posterior column–medial lemniscal system. Journal of the neurological sciences. 167(1): 45-49.
37. Welmer, A. K., Von Arbin, M., Murray, V., Holmqvist, L. W. & Sommerfeld, D. K. (2007). Determinants of mobility and self-care in older people with stroke: importance of somatosensory and perceptual functions. Physical therapy. 87(12): 1633-1641.
38. Lincoln, N. B., Jackson, J. M. & Adams, S. A. (1998). Reliability and revision of the Nottingham Sensory Assessment for stroke patients. Physiotherapy. 84(8): 358-365.
39. Stolk-Hornsveld, F., Crow, J. L., Hendriks, E. P., Van Der Baan, R. & Harmeling-Van der Wel, B. C. (2006). The Erasmus MC modifications to the (revised) Nottingham Sensory Assessment: a reliable somatosensory assessment measure for patients with intracranial disorders. Clinical rehabilitation. 20(2): 160-172.
40. Butler, D.S (eds.) (1991). Mobilisation of the nervous system. Melbourne; New York : Churchill Livingstone.
41. Dommerholt, J. &  Fernández-de-las-Peñas (eds.) (2013). Oxford : Churchill Livingstone.
42. O'Dwyer, N. J., Ada, L. & Neilson, P. D. (1996). Spasticity and muscle contracture following stroke. Brain. 119(5): 1737-1749.
43. Pandyan, A. D., Cameron, M., Powell, J., Stott, D. J. & Granat, M. H. (2003). Contractures in the post-stroke wrist: a pilot study of its time course of development and its association with upper limb recovery. Clinical Rehabilitation. 17(1): 88-95.
44. Borstad, A.L., Bird, T., Choi, S., Goodman, L., Schmalbrock, P. & Nichols-Larsen, D. S. (2013). Sensorimotor training induced neural reorganization after stroke: a case series. Journal of neurologic physical therapy. 37(1): 27-36.
45. Nelles, G., Jentzen, W., Jueptner, M., Müller, S. & Diener, H. C. (2001). Arm training induced brain plasticity in stroke studied with serial positron emission tomography. Neuroimage. 13(6): 1146-1154.
46. Nudo, R. J. (2011). Neural bases of recovery after brain injury. Journal of communication disorders. 44(5): 515-520.
47. Shumway-Cook, A. & Woollacott, M.H. (eds.) (2012). Motor control: translating research into clinical practice. 4th ed. Philadelphia, PA: Wolters Kluwer Health in association with Lippincott, Williams & Wilkins.
48. Flor, H. & Diers, M. (2009) Sensorimotor training and cortical reorganization. NeuroRehabilitation. 25(1): 19-27.
49. Miles, T. S. (2005). Reorganization of the human motor cortex by sensory signals: a selective review. Clinical and experimental pharmacology and physiology. 32(1‐2): 128-131.
50. Taub, E., Uswatte, G. & Mark, V. W. (2014). The functional significance of cortical reorganization and the parallel development of CI therapy. Frontiers in human neuroscience. 8(396): 1-20.
51. Hara, Y. (2015). Brain Plasticity and Rehabilitation in Stroke Patients. Journal of Nippon Medical School. 82(1): 4-13.
52. Carel, C., Loubinoux, I., Boulanouar, K., Manelfe, C., Rascol, O., Celsis, P. & Chollet, F. (2000). Neural Substrate for the Effects of Passive Training on Sensorimotor Cortical Representation: A Study With Functional Magnetic Resonance Imaging in Healthy Subjects. Journal of Cerebral Blood Flow & Metabolism. 20(3): 478-484.
53. Lewis, G. N., Byblow, W. D. & Carson, R. G. (2001). Phasic modulation of corticomotor excitability during passive movement of the upper limb: effects of movement frequency and muscle specificity. Brain research. 900(2): 282-294.
54. Lewis, G. N. & Byblow, W. D. (2004). The effects of repetitive proprioceptive stimulation on corticomotor representation in intact and hemiplegic individuals.Clinical neurophysiology. 115(4): 765-773.
55. Macé, M. J., Levin, O., Alaerts, K., Rothwell, J. C. & Swinnen, S. P. (2008). Corticospinal facilitation following prolonged proprioceptive stimulation by means of passive wrist movement. Journal of Clinical Neurophysiology. 25(4): 202-209.
56. Hansen, A. P., Marcussen, N. S., Klit, H., Andersen, G., Finnerup, N. B. & Jensen, T. S. (2012). Pain following stroke: a prospective study. European journal of pain. 16(8): 1128-1136.
57. Wissel, J., Schelosky, L. D., Scott, J., Christe, W., Faiss, J. H. & Mueller, J. (2010). Early development of spasticity following stroke: a prospective, observational trial. Journal of neurology. 257(7): 1067-1072.
58. Sommerfeld, D. K., Eek, E. U. B., Svensson, A. K., Holmqvist, L. W. & von Arbin, M. H. (2004). Spasticity after stroke. Stroke. 35(1): 134-139.
59. Urban, P. P., Wolf, T., Uebele, M., Marx, J. J., Vogt, T., Stoeter, P., Bauermann, T., Weibrich, C., Vucurevic, G.,  Schneider, A. & Wissel, J. (2010). Occurence and clinical predictors of spasticity after ischemic stroke. Stroke. 41(9): 2016-2020.
60. Sommerfeld, D. K., Gripenstedt, U. & Welmer, A. K. (2012). Spasticity after stroke: an overview of prevalence, test instruments, and treatments. American Journal of Physical Medicine & Rehabilitation. 91(9): 814-820.
61. Day, S. J. & Altman, D. G. (2000). Blinding in clinical trials and other studies. British Medical Journal. 321(7259): 504.