Journal of Novel Physiotherapies
Open Access

Spasticity; Shockwave therapy; Botulinum toxin

Introduction

Spasticity is a common consequence of neurological illnesses and a significant clinical problem [1]. It also has significant financial and care burdens [2]. Since the 19th century, the idea has been recognized as a resistance to passive movement [3]. It has also been described as a motor condition with excessive tendon jerks caused by hyperexcitability of the stretch reflex, which is one of the symptoms of upper motor neurone syndrome (MNS) [4]. Chronic neuropathic pain, sensory issues, bone deformities with demineralization, severe muscle spasms, muscle fibre fibrosis, and muscular atrophy with rheological alterations are some of the most typical spasticity-related consequences [5-7]. Along with the emotional effects (on character, mood, and self-esteem), it also affects everyday functioning by affecting physical capacities (limited range of joint movement, loss of dexterity, decreased balance, and walking) [8,9], which can result in social isolation [10]. Approximately 10 out of every 1000 people in Spain have this complex clinical disease [2]. It is thought to afflict 20-40% of stroke survivors after 12 months [11,12], 60-90% of those with multiple sclerosis, and 80% of those with cerebral palsy (CP). Its incidence is linked to concomitant disease. Spasticity is prevalent in between 60 and 78 percent [2] of spinal cord injury victims and between 13 and 20 percent [2] of victims of head trauma. Different therapeutic approaches are employed to modify muscle tone, which makes the choice of a therapy strategy challenging [8]. Physiotherapy, antispasmodic drugs and orthopaedic surgery [10] are a few of the treatment methods. Inter-disciplinary rehabilitation employs a combination of pharmacology (dantrolene, benzodiazepine, gabapentin, nabiximols, intrathecal baclofen, tizanidine, clonidine, phenol injections, ethanol, and botulinum toxin (BTA)) and surgery (tenotomies, tendon transfers, neurectomies, and rhizotomies). The use of physical agents and various methods and techniques, including muscular stretching, cryotherapy, taping, splints and orthoses, ultrasounds, vibration therapy, electrical stimulation, transcutaneous electrical nerve stimulation, and dry needling for hypertonia and spasticity (DNHS), is crucial in the clinical management of spasticity [12]. New non-invasive treatment options are, however, required for spasticity, such as shock wave therapy, a relatively new technique that is reversible and non-invasive.

The term "shock wave therapy" refers to a series of single sonic pulses with high peaks, a rapid increase in pressure, and short duration. These pulses act directly on the rheological characteristics of the muscle tissue; it appears that the vibration breaks the functional connection between the actin and the myosin, reducing the rigidity of the connective tissue. Focused or radial shock waves can be utilized to categories the different treatment modalities. A minimum of 1 session and a maximum of more than 20 sessions make up the total number of sessions. It is possible to provide 500-4000 injections, with energies that vary from 0.03 mJ/mm2-1.5 bar to 3.5 bar and frequencies that range from 4 Hz to 10 Hz. Shock waves have been studied on spasticity recently and have been found to be both safe and effective in reducing it, with just a few transient negative effects.

Discussion

866 individuals in total, most of whom had CP or stroke-related spasticity were included. The subjects also had motor impairment, a history of BTA suspension, and varying degrees of requirement for walking assistance. Shock wave treatment may be able to lessen spasticity regardless of the age of the participants or the nature of the injury, according to the results obtained via the factors analyzed, such as motor function, motor impairment, pain, functional independence, and electrodiagnostic procedures.

A direct manipulation of the rheological characteristics of the spastic muscle may be the mechanism of action of shock wave treatment. The functional connection between actin and myosin can be broken by the mechanical shock (vibration) of the shock wave, lowering the stiffness of the connective tissue of the spastic muscle. Additionally, it was proposed that the waves may widen blood arteries by producing nitric oxide both enzymatically and non-enzymatically (NO). NO has a role in the development of neuromuscular junctions in the peripheral nervous system as well as in physiological processes in the central nervous system such synaptic plasticity, memory, and neurotransmission. The following induction of neovascularization by NO production increases blood flow to the tissue, controls interleukin release, controls inflammation, and activates the growth factor in the spastic muscle.

Although they all use a minimum of 500 pulses per research region to cause a cellular stimulation effect and the identical intervention times between groups, different investigations employ shock waves according to various methods. Only one study out of the eleven included in the review lists focused waves as the kind of wave utilized. This is consistent with the data that radial waves cover a greater treatment area, need a less exact focus, don't require local anaesthesia, and are less expensive. A clinical difficulty that calls for the completion of specialized investigations is the definition of the best application procedure for this treatment for spasticity. According to the data, there is no correlation between the quantity of injections given and the treatment outcome for spasticity reduction. Additionally, the studies included applied therapy on a variety of muscles, including the subscapularis, biceps brachii, intrinsics, and finger flexors, soleus and gastrocnemius flexor carpi radialis, and flexor carpi ulnaris, which led to positive results regardless of the area treated.

Even though it was only examined in two of the 25 research, pain is one of the most prevalent complaints among patients with spasticity. The evidence shows how the shock waves' effects could decrease localised ischemia in areas of shortening muscles, which would then decrease the secretion of various pain-inducing substances and inhibit the induction of pain due to stimulation of the nociceptors of the affected muscle, increasing joint range of motion and, consequently, quality of life. Studies using protocols with several sessions have found that they produce greater benefits in terms of motor function. Particularly, one session each week for three to six weeks resulted in a total of 1500 pulses being given to the muscle's belly in the center.

Limitations

Because 22 of the 25 studies included in the evaluation demonstrated statistically significant improvements for at least one outcome variable linked to spasticity, independent of the research design, it is possible that the study design had only a very little impact on the outcomes. Shock wave treatment was shown to be non-inferior to the control in two of the RCTs included in the review, whereas only one RCT did not demonstrate statistically significant improvements. Despite this variation, the majority of studies showed substantial improvements, which confirms the effectiveness of shock waves in treating spasticity independent of the procedure and method of assessment. Additionally, this study shows that shock waves are an effective treatment that may be used in addition to other therapies.

The methods used to treat people with spasticity nowadays differ considerably. One of the methods employed is BTA, which has demonstrated its effectiveness in reducing muscular spasticity, since it acts on the cytosol of nerve terminals to diminish excitability and inhibits the release of acetylcholine at neuromuscular junctions. Evidence demonstrates that complementary therapy can enhance outcomes following BTA injection. However, several of these treatments come with a high risk of long-term adverse effects. For example, antispasmodic drugs used orally can cause healthy muscles to become weak, chemical neurolysis might result in dysaesthesia, and frequent BTA injections can promote the production of antibodies. Since shock wave therapy is a non-pharmacological and non-invasive method for reducing spasticity, its effectiveness with a minimal risk of side effects is one of its benefits. It may be used alone or in conjunction with medicine and/or other physiotherapy methods to reduce spasticity.

Conclusion

Even after a single session, shock wave therapy exhibits promising outcomes when used independently of BTA to treat spasticity, enhance motor function and motor impairment, lessen discomfort, and promote functional independence. To find the circumstances in which the optimum outcomes may be attained, more research is necessary due to the variability of the shock wave protocols used (in terms of the number of sessions, duration, shots, energy, and frequency).

Acknowledgement

Not applicable.

Conflicts of Interest

Author declares no conflict of interest.

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