Xiao Ding, Zhen-Yao Wang, Hu Zhang, Xin-Wei Wang, Wei-Hao Fang, Da-Wei Zhang

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Kinematic improvement after the external-application herbs combine rehabilitation in upper-limb spasticity due to stroke

Xiao Ding1, *, Zhen-Yao Wang1, Hu Zhang1, Xin-Wei Wang1, Wei-Hao Fang1, Da-Wei Zhang1

1Beijing Shunyi Hospital of Traditional Chinese Medicine, Beijing, 101314, China.

: Spasm is one of the most serious physical impairment after stroke. The external-application of herbs has showed the curative effects on the spasm to some degree. This study was conducted to evaluate the effects of external-application of traditional Chinese medicine (TCM) based on both conventional medicine therapy and rehabilitation therapy in upper limb spasticity after stroke.: A total of 100 patients with upper limb spasm after stroke (stroke occurred less than 1 month), have been recruited in Shunyi Hospital of Beijing Traditional Chinese Medicine Hospital. Patients were randomly allotted to two groups respectively (n = 50, respectively): the control group (conventional medicine therapy and rehabilitation therapy), and the treatment group (external-application of traditional Chinese medicine (TCM) based on conventional medicine therapy and rehabilitation therapy). The two groups were administered once a month for three months. The primary outcome were Modified Ashworth score and Fugl-Meyer assessment for upper limb.: Muscle tension and motor function were evaluated before and 4 weeks after treatments. There was a significant improvement in muscle tension and motor function in patients with stroke after the therapy of external-application herbs combined with conventional medicine therapy and rehabilitation therapy (< 0.05).: Patients’ kinematic function can be improved after the external-application of herbs and modern rehabilitation therapy in upper limb.

External application of Chinese herbs, Anti-spastic position, Upper limb.

TCM compress combined with modern rehabilitation is obviously superior to single rehabilitation training, which serves as a safe, simple, fast and effective therapeutic method for motor function rehabilitation of stroke patients.

For stroke patients, combined with non-drug therapy can significant improve the therapeutic effects of conventional medicine treatment. However, the standard of the treatment should be noteworthiness.

TCM, Traditional Chinese medicine; FMA, Fugl-Meyer assessment; ROM, Range of motion; MAS, Modified Ashworth score.

The authors declare that there is no conflict of interests regarding the publication of this paper.

Chang Liu

Introduction

Stroke is a common disease with a high disability and mortality rateand many are left with disabling spasticity, especially the hand spasticity [1]. Nowadays, physiotherapy is recommended for patients with spasticity, but its effect is uncertain. The treatment of spasticity with botulinum toxin in combination with physiotherapy is suggested to improve functioning in patients with severe spasticity, but the side effects are enormous. There are many ways in traditional Chinese medicine (TCM) dealing with spasm such as acupuncture, moxibustion, massage and oral decoction, but the curative effects of TCM on spasm caused by cerebrovascular disease is still unclear. With positive curative effect, the TCM hot compress is popular among patients with upper-limb spasticity. Hot compress with herbs is widely used in natural medicine as it has different effects with different kinds of herbs [2]. It can relieve pain and activate blood circulation, which may help improve the spasm after stoke [3]. Here, a randomized controlled trial with the external-application herbs and physical therapy to treat upper limb spasm was conducted to evaluate the comparative effectiveness of in upper limb spasticity after stroke.

Methods

Study setting

100 cases of stroke patients were admitted to this program from July 2018 to February 2019. They were hospitalized in the Department of Rehabilitation in Shunyi Hospital of Beijing Traditional Chinese Medicine Hospital.

Ethical consideration

This study followed the ethical standards of the responsible committee in Beijing TCM Hospital. All the datasets were de-identified and encrypted before released by the Research Ethics Committee and hospital approved this study. Signed written informed consents were obtained from all participants before the study.

Participants

Inclusion criteria (1) 35-80 years old patients were diagnosed as stroke, cerebrovascular infarction or cerebral hemorrhage according to Cerebrovascular Disease Classification formulated at the 4th Chinese Conference of Cerebrovascular Disease in 1995 with complete computed tomography or magnetic resonance imaging information [4]. (2) Diagnosed less than 1 months. (3) Suffer from upper limb spasms, manifested by significant increase of upper limb muscle tension, and resistance increased in most areas of passive flexion and extension through Range of motion (ROM). The muscle tension was greater than grade II according to Modified Ashworth score (MAS) [5]. Their upper limbs motor function was moderately or severely impaired according to Fugl-Meyer assessment (FMA) [6]. (4) The vital index were stable and the disease did not progress more than 48 hours. (5) They were conscious and could cooperate with examination and treatment.

Exclusion criteria (1) Patients with moderate to severe cognitive and intellectual impairment, aphasia, and unable to carry out rehabilitation assessment and treatment. (2) Complicated with severe heart, lung, liver and kidney and other important organ dysfunction. (3) Non-stroke impairment such as cerebral trauma, brain tumors, encephalitis and neuromuscular diseases caused by upper limb spasm. (4) Muscle, tendon and other soft tissue degeneration, muscle fibers or joint dysfunction caused by various other diseases.

Randomization and data sources

100 patients were randomly divided into two groups, control group and treatment group by random number table.

Intervention

Control group Patients with cerebral hemorrhage were given hemostasis, blood pressure control and intracranial pressure reduction according to their condition [8]. Patients with cerebral infarction were given thrombolysis, anti-platelet aggregation and other medical treatments according to the situation [9]. Rehabilitation therapy mainly includes limb position on bed, passive joint movement, transfer training, walking training[10]. Hand function and job training were conducted to treat upper limb spasm later. Passive traction was used to maximize the ROM of the joint, lasted for a few seconds at the end to combat spasm. Rehabilitation therapy should be implemented step by step according to the situation of stroke patients. The treatment takes 30 minutes a day, 4 weeks as a course of treatment.

Treatment group Patients in this group have the same treatment as in the control group, along with a hot compress of TCM. Chinese herbal preparations:10g,10g,10g10g10g10g10g10g10g10g10g10g10gThey have been decocted 500 mL liquid and added into 3000 mL warm water and then poured into a hand bathtub.

The water temperature is kept at 40 ℃ and hot compress is carried out in an anti-spastic position. Method: Place the hand bathtub on a table about 80 cm high. The patient stands on the side of the hand bathtub. The patient's hand is placed in the anti-spastic position. The liquid level is 5-10 cm above the wrist joint. When immersed, keep the interphalangeal joint stretching, wrist joint stretching about 90 ℃ and the elbow joint stretching. The elbow joint can be straightened with the help of the other healthy hand and tilted part of the body weight to keep the impair hand in an anti-spasm position for 30 minutes. This treatment lasts 4 weeks. Herbal hot compress can be done in the treatment room, requiring the help and protection of family members (see Figure 1).

Figure 1 Anti-spastic position

Outcome measures

The patients were given MAS grading and FMA upper limb motor function assessment before treatment and 4 weeks after treatment, and the results were recorded in detail. MAS was used to evaluate upper limb muscle tension [11]. Grade 0: no increase in muscle tension; Grade I: slightly elevated muscle tension, when the affected part of passive flexion and extension appears at the end of ROM in the minimum resistance; Grade II: slightly increased muscle tension, the resistances increased at the last 50 % of ROM when passive flexion and extension are exerted with the minimum resistance; Grade III: muscle tension is significantly increased; resistance increases in most areas through ROM during flexion and extension, but the affected part is still easy to move; Grade IV: severe increase in muscle tension, so it is difficult to flex and extend in passive movement; Grade Ⅴ: stiffness, the affected part cannot flex and stretch. If the muscle tension of patients returned to normal, it means the patients have recovered. If the muscle tension did not return to normal, but the MAS has decreased by two levels, it means significant improved. And if muscle tension dropped by one level, it means it has improved. If the muscle tension remains unchanged after treatment, it means the treatment was invalid [7].

The simplified FMA upper limb kinematics score is divided into 10 major items and 33 minor items: the separation and coordination ability of shoulder, elbow, wrist and finger were evaluated in detail [12]. The higher the score, the more sufficient the separation movement of upper limb is.

Statistical processing

SPSS 17.0 software (Chicago, IL, USA) was used for statistical analysis. Data were analyzed by-test. Experimental data are expressed with mean ± standard deviation (SD). Countable data were tested by Chi-square.< 0.05 was considered to indicate a statistically significant difference.

Results

One patient in the treatment group was withdrew from TCM hot compress due to mild pruritus of skin. The other patients completed medical treatment and rehabilitation training with no adverse reactions. Their liver and kidney function, blood and urine routine tests were normal. Basic data between the groups had no obvious difference through statistical processing (> 0.05 for all). There was no significant difference between the two groups before treatment (> 0.05) (Table 1).

After treatment

50 cases in the control group had a FMA score of 12.33 ± 5.64 before treatment, and a score of 16.76 ± 6.25 after treatment. The FMA score of 49 patients in the treatment group was 12.83 ± 6.16 before treatment and 26.62 ± 8.37 after treatment. There was no significant difference in FMA score between the two groups (> 0.05) before treatment, so the data is comparable; the scores of both groups are higher than that of 4 weeks before treatment, indicating that both groups could improve upper limb motor function; there was a significant difference between the treatment group and the control group after treatment (< 0.05), and the outcome of treatment group was significantly better than the control group in curative effects (Table 2).

Comparison of muscle tension between the two groups: 7 cases in the control group were cured, 13 cases improved significantly, 17 cases improved, 13 cases ineffective, the total effective rate was 74.0 %; 11 cases in the treatment group were cured, 24 cases improved significantly, 10 cases improved, 4 case ineffective, the total effective rate was 91.8 %. There was significant difference between the two groups (< 0.05) (Table 3).

Table 1 Comparison of general data

Table 2 Comparison of FMA

Note: Compared with the control group, *< 0.05. FMA: Fugl-Meyer assessment.

Table 3 Comparison of muscle tension

Note: Compared with the control group, *< 0.05

Discussion

Upper limb spasm seriously affects the life quality of stroke patients. Due to loss of selective movement control, the patients’ daily activities such as eating, dressing and trimming cannot be completed. Although medication is benefit for the stroke treatment, but the effects on spasm are not great, and rehabilitation therapy is necessary for the following treatment of spasm [13-15]. With positive curative effect, the TCM hot compress is popular among patients with upper-limb spasticity. It can relieve pain and activate blood circulation, which may help improve the spasm after stoke [3]. Here, a randomized controlled trial with the external-application herbs and physical therapy to treat upper limb spasm was conducted to evaluate the comparative effectiveness of in upper limb spasticity after stroke. The results suggest that the combination of external-application herbs and rehabilitation therapy can effectively alleviate spasm and promote the recovery of motor dysfunction caused by spasm.

Chinese medicine extract pellets can better improve the blood supply of limb endings, expand micro-vessels, improve the function of blood vessels and nerves to fight spasm, and improve patients' daily living ability and life quality [16]. Chinese medicine extract pellets combined with modern rehabilitation is obviously superior to single rehabilitation training, which serves as a safe, simple, fast and effective new method for motor function rehabilitation of stroke patients [17].

In the TCM theory, it believes that limb spasm after stroke belongs to the category of spasm, which mostly due to Qi [a vital force forming part of living entity in traditional Chinese culture. https://en.wikipedia.org /wiki/Qi) stagnation, blood stasis and blockage of collaterals. The movement of Qi and blood is not smooth, and further results in the loss of skin tendons in immersion [18].andin the prescription can dispel wind and dampness;andChuanxiong can activate blood circulation and remove blood stasis;andhave the functions of relaxing tendons and activating collaterals;andcan nourish blood and activate blood circulation;andwarm meridians and channel [19-30]. The Chinese medicine extract pellets with those herbs play the roles of activating blood circulation and removing blood stasis, relaxing tendons and activating collaterals, by which can improved the limb spasm.

In conclusion

The results suggest that patients’ kinematic function can be improved after the external-application of herbs and modern rehabilitation therapy in upper limb. Maintained in a specified position in herbs can effectively alleviate spasm and promote the recovery of motor dysfunction caused by spasm. Compressed in an anti-spasm position with TCM can better improve the blood supply of limb endings, expand micro-vessels, improve the function of blood vessels and nerves to fight spasm.

TCM compress combined with modern rehabilitation therapy is obviously superior to single rehabilitation training, which adds a safe, simple, fast and effective new method for motor function rehabilitation of stroke patients.

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10.12032/TMRND201902010

Ding X, Wang ZY, Zhang H. Kinematic improvement after the external-application herbs in upper-limb spasticity due to stroke. TMR Non-Drug Therapy 2019, 2(2): 48-54.

8 April 2019,

Submitted: 8 March 2019,

Online:13 May 2019.

*Corresponding to:Xiao Ding, Beijing Shunyi Hospital of Traditional Chinese Medicine, No.3 Guangming South Street, Shunyi District, Beijing, 101314, China. E-mail: bjucmdx@126.com