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.
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.
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.
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.
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.
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.
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
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