O Acidente Vascular Cerebral (AVC) é um quadro de alta incidência e uma das principais causas de incapacidade no mundo. Uma de suas complicações frequentes e de grande impacto na funcionalidade é a Síndrome do Ombro Doloroso Hemiplégico (SODH). O presente trabalho consiste em revisar a literatura a respeito da eficácia do tratamento da SODH com toxina botulínica tipo A (TXB-A). Foram pesquisados os bancos de dados eletrônicos PubMed e ISI web of Science, no período de 1996 a 2014. Incluímos os estudos tipo ensaio clínico duplo-cego, randomizado e aleatorizado que utilizaram a TXB-A como tratamento da SODH. Os artigos deveriam obter pontuação 3 ou superior pelos critérios de Jadad. Seis estudos foram encontrados e dois foram considerados de baixa qualidade. Os quatro artigos restantes possuíam 114 participantes no total. Três autores avaliaram os artigos de forma independente quanto aos critérios de inclusão. A extração de dados incluiu as características dos pacientes, dose e marca comercial da TXB-A utilizada, músculos e efeitos na avaliação da dor. Houve grande variação de dose, técnicas de aplicação e músculos tratados, bem como das intervenções após a aplicação. Três estudos demonstraram efeitos positivos do tratamento da dor e função do membro superior. A meta-análise não pode ser realizada, pois a informação quantitativa necessária foi indisponível. Os resultados da literatura são discordantes e apesar dos indícios serem favoráveis, não há resultados estatisticamente significantes para corroborar tal prática. Maior investigação e pesquisa são necessários para definir a indicação da TXB-A como tratamento da SODH. Mesmo assim, esta abordagem pode ser considerada particularmente quando a espasticidade é relevante. A intervenção pode ser realizada como uma alternativa ou ser utilizada em combinação com outros tratamentos. Para melhores resultados, mais de um músculo deve ser alvo, preferencialmente os músculos peitoral maior e subescapular. / The Stroke presents a high incidence and is a major cause of disability the in the world. One of it`s frequent complications and a cause of great loss of quality of life is the post-stroke shoulder pain (PSSP). The purpose of this study is to explore the effectiveness of botulinum neurotoxin type A (BoNT-A) in the treatment of PSSP. The electronic databases PubMed and ISI web of Science were searched from 1996 to 2014. We included double-blind randomized controlled trials that used BoNT-A for the treatment of PSSP in spastic hemiplegic patients. Articles should be scored 3 or more with the Jadad criteria. Six studies fulfilled the first search and two were considered low quality. The four remaining studies comprised 114 participants. Three authors independently evaluated articles eligible for inclusions. Data extracted included patient characteristics, doses and types of commercialized BoNT-A used, muscles injected, and effects on pain evaluation. There was a large variation in doses, injection techniques and treated muscles, as well as post-injection interventions. Three studies demonstrated positive effects of BoNT-A in the treatment of pain or upper limb functioning. Meta-analysis was not performed because of unavailable quantitative data. Literature results are discordant and despite evidence be favorable, there are no statistically significant results to support this practice. Further investigation and research is needed to define the indication of BoNT-A on PSSP. Nevertheless, this approach can be seen particularly when the spasticity is relevant. The intervention may be performed as an alternative or used in combination with other treatments. For best results, more than one muscle should be targeted, preferably the pectoralis major and subscapularis muscles.

This Master's thesis focuses on Occupational therapy for patients after application of botulinum toxin to upper limb. The aim of the thesis was to evaluate and compare a progress of functional independence in patients after acquired brain injury. There were twenty patients involved in the research, who were further divided into two groups and separated by ten people in each group. Both groups underwent the application of botulinum toxin whereas the experimental group A went through the occupational therapy. The control group had ordinary rehabilitation at home and without any occupational intervention for the duration of twelve week under guided self-rehabilitation contract of spastic paresis, so-called GSC. A programme of the group A included over the counter rehabilitation outpatient occupational therapy. The patients attended the course twice a week for the duration of four weeks. Afterwards, they received a home programme for the duration of eight weeks, during which they had two examinations at occupational therapy. All the participants were evaluated by Global Subjective Self-Assessment which is focused on spasticity. There were further evaluated according to Functional Independece Measure and modified Frenchay Arm Test. The experimental group with outpatient occupational therapy was...

The submitted diploma thesis shows overview of the problem using upper extremity orthoses for adult with spasticity after the stroke. The aim of the thesis is to explore possibilities of using orthoses at different stages of the spasticity development. The theoretical part includes main information about the important point from central motoneuron disorder, it means spasticity. There is information about materials, production, availability and usability in various types of orthoses. Main part of the theoretical section shows research studies and available literature, which interprets using kinds of orthoses in various time when the spasticity was developed. The theoretical part follows the practical part. In the practical part are demonstrated available possibilities of using orthoses for interference spasticity in the upper extremity. For the practical part were chosen three groups of patients and each group of patients represents one case study. In the thesis are represented patients in acute, subacute and chronic stadium after the stroke. In each stadium were used different kind of orthoses: neoprene brace for acute, static-progressive for subacute and static thermoplastic for the chronic stadium. The measurement neuromuscular parameters were conducted according to Five steps clinical...

Title: Evaluation of the spasticity level in wheelchair bound individuals, observing movement in a virtual reality environment Objective: Investigate whether people watching movement in virtual reality, experience changes in the level of spasticity due to intervention of the therapeutic programme. Methods: A pilot study was orchestrated with probands diagnosed with spastic paraplegia due to an incomplete spinal cord lesion. Seven probands have partaken in the study (5 men and 2 women) aged 49 ± 8 years. All probands were clients of Centrum Paraple, where they have been undergoing a regular rehabilitation programme. In addition to their regular programme they have undergone a virtual reality therapeutic programme, where each intervention consisted of 10 minutes spent in a therapeutic virtual environment. 3 probands resigned after the first intervention. Interventions were organized into 5 consecutive days. The levels of spasticity were evaluated by a modified Tardieu scale on plantar flexors of both ankles and knee joints of both lower limbs. Furthermore, a modified, subjective spasticity scale was created in order to observe individual, subjective inputs of each proband. Using this scale, probands evaluated their feelings towards individual spasticity changes on a scale 1-10 (0 = no spasticity, 10...

Title: Evaluation of the spasticity level in wheelchair bound individuals, observing movement in a virtual reality environment Objective: Investigate whether people watching movement in virtual reality, experience changes in the level of spasticity due to intervention of the therapeutic programme. Methods: Two case studies were orchestrated, both of probands diagnosed with spastic paraplegia due to an incomplete spinal cord lesion. Both probands did undergo a therapeutic programme in virtual reality, where each intervention consisted of 30 minutes in said programme. Interventions were organised in 10 consecutive days in the case of the first proband and 5 consecutive days in the case of the second. The levels of spasticity before and after each intervention were taken into account and evaluated by a modified Tardieu scale on plantar flexors of both ankle and knee joints of both lower limbs. Furthermore, a modified, subjective spasticity scale was created in order to observe individual, subjective inputs of each proband. Using this scale, probands evaluated their feelings towards individual spasticity changes on a scale 1-10 (0 = no spasticity, 10 = unbearable spasticity sensations). This evaluation took place before and after each individual intervention. Results: Seven hypotheses were defined in...

Background: Spasticity is a common symptom post-stroke which causes vast complications regarding important daily functions among patients. This manifests as a resistance in the muscle during a velocity-dependent passive motion and is commonly evaluated by using the Modified Ashworth Scale (MAS). Extra corporeal shock wave therapy (ESWT) is a relatively novel way to treat spasticity, with promising results. Purpose: The aim of the current study was to investigate the scientific evidence of ESWT as treatment regarding spasticity and function among patients with prolonged stroke. Methods: The purpose was tackled by conducting a literature review of randomized controlled trials with MAS as outcome measurement. PubMed was searched for relevant studies followed by a quality assessment through the PEDro Scale. The reliability of the evidence was assessed with the use of GRADEstud.  Results: The quality of the included articles was mainly deemed as good with eight of nine articles receiving a PEDro Score of 6 or higher. This review found generally positive effects from ESWT regarding spasticity with MAS as the outcome measurement. The results regarding function were equivocal. The reliability of the results was graded as very low due to the methodological heterogeneity of the included studies. Conclusion: ESWT showed positive results regarding spasticity and function, although the reliability of the evidence was considered very low. More research is inquired to further explore the potential effects of ESWT on spasticity and function among post-stroke patients. This could potentially increase the reliability of the evidence regarding ESWT as a treatment option. / Bakgrund: Spasticitet är ett vanligt förekommande funktionsnedsättande centralt symptom bland patienter med stroke och har tendens att öka med tiden efter insjuknandet. Spasticitet manifesteras i form av ett ökat muskelmotstånd vid hastighetsberoende passivt rörelseuttag och bedöms oftast med Modified Ashworth Scale (MAS). Stötvågsterapi (ESWT) är en relativt ny behandlingsmetod och visats ha en lovande effekt mot spasticitet.   Syfte: Syftet med arbetet har varit att undersöka det vetenskapliga underlaget för ESWT som behandling för spasticitet och funktion hos individer med långvarig stroke. Metod: Arbetets syfte har angripits genom en systematisk narrativ litteraturstudie. Sökning av relevanta studier gjordes i databasen PubMed och skulle uteslutande vara randomiserade kontrollerade studier med MAS som utfallsmått. Studierna utvärderades gällande risk för snedvridning genom PEDro Scale. Tillförlitligheten i evidensen av effekterna av ESWT har bedömts med GRADEstud.  Resultat: Arbetets urval bedömdes ha låg risk för snedvridning då åtta av nio artiklar fick ≥ 6 poäng på PEDro Scale. ESWT sågs övergripligt ha positiva effekter på spasticitet mätt med MAS, både som isolerad och kombinerad behandling. Gällande funktion var resultaten mer tvetydiga. Dock bedömdes tillförlitligheten gällande evidensen för effekterna som mycket låg pga. genomlöpande heterogenitet bland studierna gällande design och urval.   Slutsatser: Övergripligt visade ESWT-behandling ha en positiv effekt på spasticitet och funktion. Tillförlitligheten i evidensen bedömdes dock som mycket låg. Mer forskning efterfrågas i att belysa effekterna av ESWT på patienter med stroke för att uppnå högre tillförlitlighet.

1 Abstract Electrical stimulation by coupled impulses according to Hufschmidt was created with the primary goal of reducing spasticity. However, there are currently few studies that confirm or refute the effect of this type of electrical stimulation in reducing spasticity. The aim of this diploma thesis was to determine the effect of electrostimulation according to Hufschmidt on the reduction of biceps brachii spasticity in patients after stroke. In addition, the effect of electrical stimulation on increasing the active range of movement of the antagonist of the examined muscle and on the active function of the spastic limb was investigated. For these purposes, a non-randomized controlled pilot study was created, which involved a total of 16 probands, 8 - in the therapeutic group, 8 - in the control group. Five-step clinical assessment in spastic paresis according to Gracies were used for the examination. In the therapeutic group, electrostimulation took place 3 times a week, a total of 8 times. The intragroup difference was evaluated using the Friedman and Wilcoxon paired tests, the intergroup difference was subsequently evaluated using the Mann-Whitney U test. The significance level p = 0.05 applies to all tests. The measured values show that Hufschmidt's electrical stimulation has a positive effect on...

Aim: According to Swedish and Danish law interventions must be based on evidence, and evidence related to rest orthoses in contracture management is limited and inconclusive, making justification of using rest orthoses difficult. The aim is to understand the clinicians’ perceptions of the benefit of rest orthoses when managing wrist and hand contractures, to shape a basis for clinical evidence.Method: A qualitative interview study was made and a total of 13 participants with 2 to 40 years of experience was included. Interviews were transcribed and translated into English. A thematic analysis was undertaken by two researchers. Three themes and seven subthemes were identified and discussed. Results: There was congruence among the participants that rest orthoses can maintain RoM when used but they need to be used at least 6 to 8 hours every day. Combination of botox and rest orthoses has a good effect in many patients with spasticity for maintaining RoM and some function. Many patients gain a benefit in maintaining hygiene, a reduction in pain and easier for patients getting dressed. Conclusion: The interviewed clinicians perceived that rest orthoses can impact pain and prevent contracture formation however evidence was inconclusive, but it merits further research. / Syfte: Enligt svensk och dansk lag måste insatser baseras på evidens, och evidensen relaterad till viloortoser i kontrakturhantering är begränsad och motsägelsefull, vilket gör det svårt att motivera användningen av viloortoser. Syftet är att förstå klinikernas uppfattningar om fördelarna med viloortoser vid hantering av hand- och handledskontrakturer, för att skapa en grund för klinisk evidens. Metod: En kvalitativ intervjustudie genomfördes och totalt 13 deltagare med 2 till 40 års erfarenhet inkluderades. Intervjuerna transkriberades och översattes till engelska varpå en tematisk analys utfördes av två forskare. Tre teman och sju underteman identifierades och diskuterades. Resultat: Det fanns samstämmighet bland deltagarna att viloortoser kan bibehålla rörelseomfång när de används, men de måste användas minst 6 till 8 timmar varje dag. Kombinationen av botox och viloortoser har god effekt hos många patienter med spasticitet för att bibehålla rörelseomfång och viss funktion. Många patienter får fördelar i form av bibehållen hygien, minskad smärta och det blir lättare för patienter att klä på sig.Slutsats: De intervjuade klinikerna ansåg att viloortoser kan påverka smärta och förhindra kontrakturbildning, men evidensen är ofullständiga och kräver ytterligare forskning.

Aneurysmal subarachnoid hemorrhage (SAH) is a devastating disease with mean age of 59 years. SAH accounts for 5% of all stroke and more than one quarter of potential life years lost through stroke. With the advanced neurosurgical methods of today two thirds of the patients survive. We know, however, that various cognitive, psychiatric and physical impairments are common that affect quality of life, social life, and the ability to work in the aftermath of SAH. The overall aim constituting this PhD dissertation is to better understand some of the challenges often faced by those surviving SAH. Two SAH patient cohorts have been studied. The first followed 96 consecutively included patients during the first year after ictus. Spasticity and cognitive impairment was assessed after 6 months and the Swedish stroke register follow-up form was used to investigate family support and the use of medical and social services. Return to work was assessed at 12 months. The second cohort assessed attention deficits using the test of variables of attention (T.O.V.A.) at 7 months after ictus in 19 patients with moderate to good recovery. Spasticity was just as common in our SAH patients as after other stroke, though it was rarely treated pharmacologically. By assessing cognitive impairment at 6 months after ictus using the Montreal cognitive assessment, 68% of the patients could be correctly predicted as having returned/not returned to work at 12 months. Seventeen percent of the patients had not had a follow-up appointment 6 months after ictus. These patients were older, more often living alone, had a lower quality of life, more depressive symptoms and more cognitive impairment compared to those having had a follow-up appointment. Twenty percent had had a follow-up in primary care. Seventy-eight percent of those with moderate to severe disability were living in their own accommodations. Fifty-eight percent of the patients had attention deficits. Challenges after SAH were common and often dealt with in the home environment of the patients. The results of this thesis highlight the importance of assisting the patients and their relatives in their struggle back to life after SAH.

La sclérose amyotrophique latérale (SLA) est une maladie neurodégénérative due à la dégénérescence des motoneurones supérieurs dans le cortex moteur et des motoneurones inférieurs situés dans la moelle épinière et le tronc cérébral. La perte des neurones moteurs provoque l’atrophie et la paralysie progressive des muscles. Notre laboratoire a démontré en 2013 que la dégénérescence associée à la SLA n’était pas limitée aux motoneurones mais aussi aux neurones sérotoninergiques chez les patients et les modèles animaux de SLA. L’objectif de ma thèse a été de caractériser le rôle des neurones sérotoninergiques dans la SLA. On a observé une augmentation de l’expression du gène codant pour le récepteur 2B de la sérotonine (5-HT2B) chez les modèles murins de SLA. L’analyse du rôle du récepteur 5-HT2B dans le cas de SLA a montré que ce dernier est un modulateur de la maladie. La perte du récepteur 5-HT2B accélère la progression de la maladie et modifie la régulation de la réponse inflammatoire. En plus, nos travaux ont révélé que la perte des neurones sérotoninergiques est à l’origine du développement de la spasticité, un symptôme douloureux chez les patients SLA. Ces résultats ouvrent la voie à des approches thérapeutiques qui ciblent cette population neuronale affectée lors de la maladie pour traiter la spasticité et la neuroinflammation au cours de la maladie. / Amyotrophic lateral sclerosis (SLA) is a neurodegenerative disease characterize by the loss of upper motor neurons in the motor cortex and lower motor neurons in the brainstem and spinal cord. The loss of motor neurons leads to muscle atrophy and progressive paralysis. In 2013 our laboratory identified a new neuronal population affected in ALS. They observed the degeneration of serotoninergic neurons in ALS patients and animal models. For this, the aim of my PhD is to identify the role of serotoninergic neurons in case of ALS. We observed an upregulation of serotonin receptor 5-HT2B in ALS mice models. The investigation of the role of 5-HT2B receptor in case of ALS showed its role as a disease modulator. The loss of 5-HT2B receptor accelerated disease progression and modulated neuroinflammatory response. Moreover, our results showed that the loss of serotoninergic neurons is responsible of the development of spasticity, a painful symptom observed in ALS patients. All these opened the way for therapeutic strategies targeting spasticity and neuroinflammation in case of ALS.