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DOI:10.3233/NRE-192863
IOS Press
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3
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4 with stroke: A systematic review
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5 Anas R. Alashrama,b,∗ , Elvira Paduac , Cristian Romagnolid and Giuseppe Anninob
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a Department of Experimental Medicine and Surgery, University of Rome “Tor Vergata”Rome, Italy
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b Department of Medicine Systems, University of Rome “Tor Vergata”Rome, Italy
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c Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma
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9 Open University, Rome, Italy
10 d Science and Culture of Well-being and Lifestyle, Alma Mater University, Bologna, Italy
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11 Abstract.
12 BACKGROUND: The upper extremity spasticity following stroke limited individuals’ activities of daily livings. Focal
13 muscle vibration (FMV) is a device producing vibration signals affecting the central nervous system.
14 OBJECTIVE: This systematic review was conducted to investigate the effects of FMV on individuals with stroke, and to
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15 identify the effective training protocol in reducing upper extremities spasticity post-stroke.
16 METHODS: We searched in SCOPUS, PEDro, PUBMED, REHABDATA, and web of science for randomized clinical trials
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17 (RCTs) and pseudo-RCTs published in English. The outcome measure was included is the Modified Ashworth Scale (MAS)
18 scale. The methodological quality of the included trials was evaluated using the Cochrane Collaboration’s instrument. Effect
19 sizes were calculated.
20 RESULTS: Eight articles published from 2012 to 2019 were included in this systematic review. A total of 268 post-stroke,
21 28.73% of which were females were included in all studies. The methodological quality for included studies ranged from
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22 moderate to high. FMV showed some evidence in reducing hemiplegic upper extremity spasticity in patients with stroke.
23 CONCLUSIONS: The FMV may an efficient intervention in reducing upper extremity spasticity in the stroke population.
24 The efficient treatment protocol and dosage remain unclear. Additional randomized controlled trials are strongly needed to
25 study the effects of FMV on spasticity in individuals with stroke.
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28 Stroke is a leading cause of morbidity and mortal- stroke worldwide ranged from 76 to 119 per 100,000 31
ity worldwide and is frequently linked with upper (Thrift et al., 2016). About 80% of stroke patients 32
lier street, 00133, Rome, Italy. E-mail: anasalashram@gmail.com. More than 40% of stroke survivors experiencing 37
ORCID ID: 0000-0002-3066-3943. this deficit chronically and more than 80% acutely 38
ISSN 1053-8135/19/$35.00 © 2019 – IOS Press and the authors. All rights reserved
2 A.R. Alashram et al. / Focal muscle vibration after stroke
39 (Cramer et al., 1997). Stroke individuals with mild of FMV on spasticity of the upper extremity in indi- 91
40 to moderate upper extremity paresis have a good viduals with stroke, and if possible, to identify the 92
41 prognosis for functional recovery in the acute stage; effective treatment protocol. 93
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47 (Kwakkel et al., 2003, van Kuijk et al., 2008).
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48 Stroke is characterized by positive features include A systematic literature search of multiple 96
49 spasticity (O’Dwyer et al., 1996). About 39 % of databases; SCOPUS, PEDro, PUBMED, National 97
50 patients with first-ever stroke are spastic after 12 Rehabilitation information REHABDATA database, 98
51 months (Watkins et al., 2002). Spasticity defined as a and web of science, was conducted for articles ran- 99
52 velocity-dependent motor disorder characterized by domized clinical trials (RCTs) and pseudo-RCTs 100
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53 an increase in tonic stretch reflexes (Lance, 1980). published in English. The keywords used for the 101
54 The available treatment options in manage of spas- electronic search were (focal muscle vibration OR 102
55 ticity post stroke include numerous physical methods local muscle vibration OR segmental muscle vibra- 103
56 such as electrostimulation, splinting and muscle tion OR localized muscle vibration OR vibration OR 104
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57 lengthening, use of spasmolytic drugs, surgeries such muscle vibration) AND (stroke OR cerebrovascu- 105
58 as muscle-tendon lengthening, neurectomy, and teno- lar accident OR cerebral hemorrhage OR cerebral 106
59 tomy. As well as various invasive procedures for ischemia) AND (upper limb OR upper extrem- 107
60 neuromuscular blockade (Caldwell et al., 1969, Cald- ity OR arm) AND (Spasticity OR hypertonia OR 108
61 well et al., 1974, Katz,1980, Glenn & Elovic,1997, tone OR spastic). MeSH terms were used in rel- 109
63 have shown that in order for rehabilitation interven- OR cerebrovascular∗ OR cerebral∗ ) AND (Vibration 111
64 tion to be effective, treatment needs to be highly [MeSH]) AND (Upper Extremity [MeSH] OR upper 112
65 repetitive, raise afferent input and be functional, as limb OR arm) AND (Muscle Spasticity [MeSH]). No 113
66 well as engage the individual and encourage frequent restriction in time was applied to the search strategy 114
practice (Pollock et al., 2014). that was conducted in February 2019. A summary of
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67 115
68 Focal muscle vibration (FMV) defined as a tech- the literature search strategy is presented in Fig. 1. 116
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73 1989), leading to alteration of corticospinal pathways were: published paper in English language, used 119
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74 (Styvers et al., 2003). Many studies reported increase focal muscle vibration in as a treatment intervention, 120
75 excitability in the primary motor cortex following low classified as Randomized Clinical Trials (RCTs) or 121
76 amplitude FMV when applied to the intrinsic hand Pseudo-RCTs, assessed tone in the upper extremity, 122
77 muscles and flexor carpi radialis muscle in healthy investigated individuals with the confirmed diagnosis 123
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78 subjects (Rosenkranz et al., 2003). Concerning indi- for stroke. We excluded any articles assessed individ- 124
79 viduals with stroke, several studies were published uals with other vibration modalities (i.e. whole body 125
80 recently. One of these studies demonstrated a reduc- vibration) (Fig. 1). 126
82 (Annino et al., 2019). While another study by Celletti 2.3. Methodological quality 127
85 that investigated the influences of FMV on spasticity pendently for the methodological quality using the 129
86 among people with stroke in the past decade. Besides, Cochrane Collaboration’s tool for evaluating the risk 130
87 no systematic review has yet been published provide of bias (Higgins et al., 2011). The Cochrane tool has 131
88 clear assent about the effects of focal muscle vibra- become the standard method to assess the risk of 132
89 tion on upper extremity post-stroke. Thus, the aims of bias in randomized clinical trials (Jørgensen et al., 133
90 this systematic review were to investigate the effects 2016). The items include random sequence gener- 134
A.R. Alashram et al. / Focal muscle vibration after stroke 3
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135 ation, allocation concealment, blinding, incomplete erogeneity treatment protocols and parameters and 151
136 outcome data, selective reporting, other bias (Hig- the inability to contact the authors of some studies, 152
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137 gins et al., 2008). Any disagreement resolved through data were not pooled for meta-analysis. The effect 153
138 discussion with the third author. Table 1 displays the size was estimated by dividing the variations between 154
139 methodological quality assessment. the mean of groups by the pooled of standard devi- 155
141 One reviewer has extracted the data then checked 2.5. Outcome measure 158
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144 the selected studies were: participant characteris- measure muscle tone and evaluate the level of spas- 160
145 tics (number, gender, mean age, type of stroke, ticity. The MAS contains 6 items ranging from 0 to 161
146 hemiplegic side, time since stroke), Parameters 4, where 0 indicates have no increase in muscle tone. 162
147 (Apparatus, frequency, amplitude, force, rest inter- Item 1 indicates a slight increase in muscle tone at the 163
148 val, target muscle, the status of muscle), experimental end of the range of motion. Item 1+ indicates a slight 164
149 and control interventions (Table 2). The outcome increase in muscle tone throughout less than half of 165
150 measures were displayed in Table 3. Owing to the het- the range of motion. Item 2 indicates an increase in 166
4 A.R. Alashram et al. / Focal muscle vibration after stroke
Table 1
Methodological quality assessment
Random Allocation Blinding Incomplete Selective Other bias
sequence concealment (performance outcome data reporting
generation (selection and detection (attrition (reporting
(selection bias) bias) bias) bias) bias)
Caliandro et al., 201230 + + ? + + +
Celletti et al., 201723 + + + + ? +
Costantino et al., 201734 + + ? + + +
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Tavernese et al., 201331 + ? + – + +
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Paoloni et al., 201432 + ? + – + +
Casale et al., 201435 + ? ? – + +
Noma et al., 201233 + + – – + +
Annino et al., 201922 + – – + + +
Note: + = low risk; ? = unclear risk; – = high risk.
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167 muscle tone through most of the range of motion. were females were included in all studies, the mean 199
168 Item 3 indicates the difficult passive movement of age for all patients was 60 years old. Six studies 200
169 the extremity. Item 4 indicates the extremity is rigid were included chronic stroke patients (>12 months) 201
170 in flexion or extension (Bohannon & Smith, 1987). (Annino et al., 2019, Caliandro et al., 2012, Taver- 202
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171 Owing the aim of the present review was to examine nese et al., 2013, Paoloni et al., 2014, Noma et al., 203
172 the influence of FMV on upper extremity spasticity, 2012, Costantino et al., 2016), and one included acute 204
173 varied other measurements in included studies were stroke patients (Celletti et al., 2017), while one did 205
174
not considered when interpreting findings. not provide sufficient information about the stage of 206
177 The process of study selection for this review Three studies investigated FMV versus conven-
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178 displayed in Fig. 1. A computerized search of tional physiotherapy (CPT) (Annino et al., 2019, 211
PubMed (producing 141 articles), SCOPUS (51),
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179
Tavernese et al., 2013, Casale et al., 2014), two exam- 212
180 PEDro (12), REHABDATA (11), and Web of Science ined FMV versus Placebo (Caliandro et al., 2012, 213
181 (175) produced a total of 390 citations. After remov- Costantino et al., 2016), one investigated FMV versus 214
182 ing duplicates, 170 citations were reviewed. Out of CPT (Celletti et al., 2017), one examined FMV ver- 215
183 those, 136 publications were excluded because their sus (placebo + CPT) (Paoloni et al., 2014), and one 216
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184 abstracts showed that they did not match the inclusion studied FMV versus stretching (control 1) and rest 217
185 criteria. (control 2) (Noma et al., 2012). 218
186 Thirty-four publications were subjected to more The experimental interventions were FMV (Cel- 219
187 detailed analysis because their abstracts did not reveal letti et al., 2017, Caliandro et al., 2012, Noma 220
that they satisfied the inclusion criteria. Twenty-six
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188
et al., 2012, Costantino et al., 2016) or (FMV + CPT) 221
189 studies were excluded for the subsequent reasons: 1) (Annino et al., 2019, Tavernese et al., 2013, Paoloni 222
190 used other forms of vibration, 2) did not assess upper et al., 2014, Casale et al., 2014). In terms of the treat- 223
191 extremity. A total of 8 studies were recognized for ment frequency, the frequency of treatment reneged 224
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192 inclusion criteria in the present review. from two (Celletti et al., 2017), to three (Annino et al., 225
193 3.2. Patient characteristics or five (Tavernese et al., 2013, Paoloni et al., 2014, 227
194 The PICOS (Patients, Intervention, Control, Out- ment protocol duration, the duration of the treatment 229
195 comes, and Subjects) approach was followed protocol was one week (Caliandro et al., 2012), two 230
196 (Liberati,2009). A total 268 post-stroke (Hem- weeks (Tavernese et al., 2013, Paoloni et al., 2014, 231
197 orrhagic = 36, Ischemic = 232), Hemiplegic side Casale et al., 2014), four weeks (Costantino et al., 232
198 (Left = 144, Right = 118). About 28.73% of which 2016), six weeks (Celletti et al., 2017), or eight weeks 233
A.R. Alashram et al. / Focal muscle vibration after stroke 5
Table 2
Participant characteristics and study design
Study Participants characteristics Parameters Intervention
Caliandro et al., 201230 Participants, n: 49 Apparatus: CroSystem, Rome, Exp: FMV 30 min (10 min/muscle)
Gender M/F: 34/15 Italy × 3/wk × 1 wk
Mean age: 59.3 Frequency (Hz): 100 Con: Placebo
Stroke type, H/I, n: 33/17 Amplitude (mm): 0.2–0.5
Hemiplegic side Rt/Lt, n : 26/23 Force (N): 7–9
Time since stroke: >12 months Rest interval: 1 min
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Target muscle: Pectoralis minor,
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Biceps brachii,
Flexor carpi muscle
Status of muscle: Contract
Celletti et al., 201723 Participants, n: 18 Apparatus: CroSystem, Rome, Exp: FMV 30 min (10 min/muscle)
Gender M/F: 12/6 Italy × 2/wk × 6 wk
Mean age: 49.5 Frequency (Hz): 100 Con: CPT 30 min × 2/wk × 6 wk
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Stroke type, H/I, n: 9/9 Amplitude (mm): 0.2–0.5
Hemiplegic side Rt/Lt, n : 9/9 Force (N): 7–9
Time since stroke: <6 months Rest interval: 1 min
Target muscle: Pectoralis minor,
Biceps brachii,
Flexor carpi muscle
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Status of muscle: Contract
Costantino et al., 201734 Participants, n: 32 Apparatus: VISSMAN, Rome, Exp: FMV 30 min (10 min/muscle)
Gender M/F: 21/11 Italy × 3/wk × 4 wk
Mean age: 61.6 Frequency (Hz): 300 Con: Placebo
Stroke type, H/I, n: 21/13 Amplitude (mm): 2
Hemiplegic side Rt/Lt, n: 23/9 Force (N): –
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Time since stroke: >12 months Rest interval: –
Target muscle: Triceps brachii,
Extensor carpi radialis longus
& brevis
Status of muscle: Contract
Tavernese et al., 201331 Participants, n: 44 Apparatus: Horus, Akropolis, Exp: FMV 30 min+CPT
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Paoloni et al., 201432 Participants, n: 22 Apparatus: Horus, Akropolis, Exp: FMV 30 min + CPT
Gender M/F: 13/9 Rome, Italy 60 min × 5/wk × 2 wk
Mean age: 60.5 Frequency (Hz): 120 Con: Placebo + CPT 60 min
Stroke type, H/I, n: 22/0 Amplitude (mm): 10 × 5/wk × 2 wk
Hemiplegic side Rt/Lt, n: 14/8 Force (N): -
Time since stroke:>12 months
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Table 2
(Continued)
Study Participants characteristics Parameters Intervention
Noma et al., 201233 Participants, n: 36 Apparatus: Thrive Co., Ltd, Exp: FMV 5 min
Gender M/F: 25/11 Osaka, Japan Con1: stretching
Mean age: 60 Frequency (Hz): 91 Con2: rest
Stroke type, H/I, n: 36/0 Amplitude (mm): 1
Hemiplegic side Rt/Lt, n: 20/16 Force (N): –
Time since stroke:>12 months Rest interval: –
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Target muscle: Biceps brachii,
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Wrist flexors
Status of muscle: Stretched
Annino et al., 201922 Participants, n: 37 Apparatus: – Exp: FMV 5 min + CPT
Gender M/F: 29/8 Frequency (Hz): 30 30 min × 3/wk × 8 wk
Mean age: 68.6 Amplitude (mm): 2 Con: CPT 30 min × 3/wk × 8 wk
Stroke type, H/I, n: 37/0 Force (N): –
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Hemiplegic side Rt/Lt, n: 18/19 Rest interval: 1 min
Time since stroke: >12 months Target muscle: Triceps brachii
Status of muscle: Stretched
FMV: focal muscle vibration, CPT: conventional physiotherapy, I/H: ischemic/hemorrhagic, Lt/Rt: Left/Right, Exp: experimental, Con:
control, wk: week, min: minute, n: number, M/F: male/female, sec: second.
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234 (Annino et al., 2019). One study involved only one rest interval, it was 10 seconds (Tavernese et al., 2013, 266
235 session (Noma et al., 2012). In terms of session dura- Paoloni et al., 2014), or one minute (Annino et al., 267
236 tion, the session duration was 5 minutes (Noma et al., 2019, Celletti et al., 2017, Caliandro et al., 2012). 268
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237 2012), 30–35 minutes (Annino et al., 2019, Celletti Treated muscles was pectoralis minor (Celletti 269
238 et al., 2017, Tavernese et al., 2013, Costantino et al., et al., 2017, Caliandro et al., 2012), biceps brachii 270
239 2016) or 90 minutes (Tavernese et al., 2013, Paoloni (Celletti et al., 2017, Caliandro et al., 2012, Taver- 271
240 et al., 2014, Casale et al., 2014). nese et al., 2013, Paoloni et al., 2014, Noma et al., 272
241 FMV apparatus was varied between studies, 2012), triceps brachii (Annino et al., 2019, Costantino 273
CroSystem, Rome, Italy (Caliandro et al., 2012, et al., 2016, Casale et al., 2014), extensor carpi radi-
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242 274
243 Celletti et al., 2017), Horus, Akropolis, Rome, alis longus and brevis (Costantino et al., 2016), flexor 275
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244 Italy (Tavernese et al., 2013, Paoloni et al., 2014), carpi ulnaris (Tavernese et al., 2013, Paoloni et al., 276
245 VISSMAN, Rome, Italy (Costantino et al., 2016), 2014), and wrist flexors (Noma et al., 2012). Regard- 277
246 VIS-BRA,Circle (Casale et al., 2014), and Thriye ing the status of muscles, it was contracted (Celletti 278
247 CO., Ltd, Osaka, Japan (Noma et al., 2012). Concern- et al., 2017, Caliandro et al., 2012, Costantino et al., 279
248 ing FMV total treatment duration, the FMV duration 2016) or stretched (Annino et al., 2019, Noma et al., 280
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249 was 5 minutes (Annino et al., 2019, Noma et al., 2012) 2012). The summary of the study design and method- 281
250 or 30 minutes (Celletti et al., 2017, Caliandro et al., ology for each study was reported in Table 2. 282
255 et al., 2019), 91–100 Hz (Celletti et al., 2017, Calian- quality. All of the included studies have a low risk of 285
256 dro et al., 2012, Noma et al., 2012, Casale et al., bias in Random sequence generation and other bias 286
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257 2014), 120 Hz (Tavernese et al., 2013, Paoloni et al., items. With the exception of Celletti et al., (2017), the 287
258 2014), and 300 Hz (Costantino et al., 2016). Regard- studies have a low risk of bias in selective reporting 288
259 ing the amplitude, the FMV amplitude was set at (Table 1). 289
264 Concerning the force, the force was set at 7–9 N (Cel- ferent due to different study designs. One study 292
265 letti et al., 2017, Caliandro et al., 2012). In terms the used (ANOVA) for repeated measures to verify the 293
Table 3
Outcome measure
Author Outcome Evaluated muscle/area Assessment time Experimental group Control Group Reported Effect
measure Median Median effect size
Caliandro et al., 201230 MAS Shoulder abduction and Baseline, one week after Pre-Shoulder 1 Pre-Shoulder 1
aduction, flexion and treatment, and one Post-Shoulder 0 Post-Shoulder 1 = –
Pre-Elbow 2 Pre-Elbow 1
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extension of elbow and month after treatment
wrist Post-Elbow 1 Post-Elbow 1.5 = –
Pre-Wrist 1 Pre-Wrist 2
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MAS Flexion and extension of
elbow
Baseline and
post-treatment
Pre-Group (1) 2
Post-Group (1) 1.1
Pre-Group (2) 2.35
Post-Group (2) 1.6 = –
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∗ Costantino et al., 201734 MAS Shoulder, elbow, and Baseline, post-treatment, Pre-Shoulder 1.59 ± 1.33 Pre-Shoulder 1.73 ± 1.28 0.11
wrist and after 4 weeks of Post-Shoulder 1.12 ± 1.05 Post-Shoulder 1.73 ± 1.28 + 0.52
study protocol Pre-Elbow 2.00 ± 1.22 Pre-Elbow 1.93 ± 1.22 0.10
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Post-Elbow 1.47 ± 1.12 Post-Elbow 1.87 ± 1.19 + 0.34
Pre-Wrist 1.76 ± 1.39 Pre-Wrist 1.67 ± 1.35 0.10
Post-Wrist 1.18 ± 1.24 Post-Wrist 1.60 ± 1.30 + 0.33
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Tavernese et al., 201331 MAS Shoulder, elbow, and Baseline and Pre-Shoulder 1.0 Pre-Shoulder 2.0 – –
wrist post-treatment Pre-Elbow 1.5 Pre-Elbow 2.0 – –
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Pre-Wrist 0.5 Pre-Wrist 1.0 – –
Paoloni et al., 201432 MAS Shoulder, elbow, and Baseline and Pre-Shoulder 1.0 Pre-Shoulder 1.0 + –
wrist post-treatment Pre-Elbow 1.0 Pre-Elbow 1.0 + –
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Pre-Wrist 1.0 Pre-Wrist 1.0 + –
Casale et al., 201435 MAS Biceps brachii Baseline, day number 8, – – + –
and post-treatment
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Noma et al., 201233 MAS Biceps brachii Baseline, 30 minutes after Pre-Elbow group (1) 1.0 Pre-Elbow group (2) 1.0
Flexors of wrist and each intervention, and Pre-Wrist group (1) 2.0 Pre-Wrist group (2) 2.0 + –
fingers post-treatment Pre-Elbow group (3) 1.0
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Pre-Wrist group (3) 2.0 + –
∗ Annino et al., 201922 MAS Triceps Baseline and Pre-Elbow 1.7 ± 0.7 Pre-Elbow 1.5 ± 0.9 + 0.25
post-treatment Post-Elbow 1.1 ± 0.8 Post-Elbow 1.2 ± 0.8 + 0.12
MAS: Modified Ashworth Scale. ∗ : Presented as Mean ± SD change, effect size was calculated. +, significant improvement in experimental group only. =, no significant differences between
experimental and control group.
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8 A.R. Alashram et al. / Focal muscle vibration after stroke
294 differences of variables over time in both groups produce a reduction in hemiplegic upper extrem- 339
295 (Caliandro et al., 2012). Mann-Whitney U test used ity spasticity in patients with stroke. In agreement 340
296 to compare the central tendency measures (medi- with our findings, Rosenkranz & Rothwell, (2006) 341
297 ans) of the MAS in both groups (Annino et al., demonstrated to increase the primary motor cortex 342
298 2019, Caliandro et al., 2012, Tavernese et al., 2013, excitability following vibrated intrinsic hand muscles 343
299 Paoloni et al., 2014, Noma et al., 2012). Wilcoxon focally. FMV generates the Ia inputs as a consequence 344
300 test used to evaluate the change of MAS over time of the activation primary ending of muscle spindle 345
301 (Annino et al., 2019, Celletti et al., 2017, Taver- (Roll et al., 1989). Alteration of the excitability of 346
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302 nese et al., 2013, Paoloni et al., 2014, Noma et al., the corticospinal pathway result of activation of Ia 347
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303 2012). Moreover, one-way (ANOVA) used to com- inputs by FMV (Steyvers et al., 2003) by facilitating 348
304 pare baseline demographic information and clinical inputs and modulating of intracortical inhibiting to 349
305 characteristics of subjects between groups in addition the primary motor cortex in the brain (Rosenkranz 350
306 to 2-way repeated measures (ANOVA) (Costantino et al., 2003, Rosenkranz et al., 2006). The vibra- 351
307 et al., 2016). Shapiro-Wilk statistics test used to tion of a specific muscle can increase the motor 352
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308 assess the normality of the distribution of all variables evoked potential (MEP) recorded from the muscle 353
309 (Casale et al., 2014). Paired t-test use to compare the at rest (Mileva et al., 2009), suggesting the progress 354
310 variables between assessment intervals (Casale et al., of corticospinal excitability changes during vibration 355
311 2014). (Rosenkranz et al., 2006, Smith & Brouwer, 2005). 356
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Increased duration of cortical silent period (CSP) in 357
312 3.6. Outcome measures flexor muscles of the forearm during vibration of 358
313 All of the included studies were assessed the spas- (Binder et al., 2009) and evidence strongly proposes 360
314 ticity of the upper extremity in individuals with stroke that a period of pure sensory stimulation can affect 361
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315 using the Modified Ashworth Scale (MAS). Outcome motor cortical excitability (Ford et al., 1995). 362
316 measure details reported effect, and the effect size Selected studies were superior in the research 363
317 was presented in Table 3. pyramid being randomized control trials or pseudo- 364
318 3.7. Effect of FMV on upper extremity spasticity results in the blinding of participants and therapists 366
367
319 In the studies by Caliandro et al., (2012) and Cel- et al., 2013, Paoloni et al., 2014, Noma et al., 2012, 368
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320 letti et al., (2017), the patients in both experimental Costantino et al., 2016, Casale et al., 2014) leading to 369
321 and control groups demonstrated a reduction in the potential bias. While it is difficult to blind participants 370
322 MAS scores (reduction in spasticity) of the upper or therapists to vibration intervention, it is possible 371
323 extremity, however, with no significant difference to blind the examiner to the vibration intervention. 372
324 between groups. The remaining studies demonstrated This is important to reduce the bias correlated with 373
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325 a significant reduction in MAS scores of the shoul- measurement based on outcomes (Higgins & Green, 374
326 der (Tavernese et al., 2013, Paoloni et al., 2014, 2008). Five studies have poor results in incomplete 375
327 Costantino et al., 2016), elbow (Annino et al., 2019, outcome data (Annino et al., 2019, Tavernese et al., 376
328 Tavernese et al., 2013, Paoloni et al., 2014, Noma 2013, Paoloni et al., 2014, Noma et al., 2012, Casale 377
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329 et al., 2012, Costantino et al., 2016, Casale et al., et al., 2014), and four studies have poor results in 378
330 2014), and wrist (Tavernese et al., 2013, Paoloni et al., allocation concealment (Annino et al., 2019, Taver- 379
331 2014, Noma et al., 2012, Costantino et al., 2016) in the nese et al., 2013, Paoloni et al., 2014, Casale et al., 380
334 To our knowledge, this is the first systematic review Noma et al., 2012, Costantino et al., 2016, Casale 386
335 aimed to examine the impacts of FMV in the treat- et al., 2014). Three of these studies demonstrated 387
336 ment of upper extremities spasticity post stroke and a reduction in the spasticity of the upper extrem- 388
337 to detect the effective training protocol. The initial ity in the experimental group (30 min FMV + 60 min 389
338 findings showed that the FMV interventions may CPT × 5/wk × 2 wk) compared to the control group 390
A.R. Alashram et al. / Focal muscle vibration after stroke 9
391 (Tavernese et al., 2013, Paoloni et al., 2014, Casale Besides, the effective treatment protocol and dosage 443
392 et al., 2014). These studies were of moderate method- remain unclear. Furthermore, the selected studies did 444
393 ological quality and the sample sizes were large so not report details about the vibration apparatuses, 445
394 the clinical conclusion can be confirmed. Moreover, which it is difficult to homogenize the outcomes. 446
395 Costantino et al., (2017) demonstrated a reduc- Reporting characteristics of the vibration device in 447
396 tion in the spasticity of the upper extremity in the future studies would allow specifying the outcomes. 448
397 experimental group (30 min FMV × 3/wk × 6 wk) Further high-quality studies with large sample sizes 449
398 compared to the control group. This study was of are definitely warranted. 450
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399 high methodological quality and the sample size
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400 was large, the effect sizes were small to moder-
401 ate for wrist and elbow (0.10–0.34), and small to 5. Conclusion 451
402 medium for shoulder joint (0.11–0.52), so the clini-
403 cal significance of reported effects can be established. In conclusion, the FMV may reduce the spasticity 452
404 Furthermore, in a study by Annino et al., (2019), of the upper extremity in individuals with stroke if it is
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405 the participants demonstrated a reduction in upper applied to the antagonist muscle. In fact, it seems that 454
406 extremity spasticity following (5 min FMV + 30 min vibrated antagonist muscle may reduce the spasticity 455
407 CPT × 3/wk × 8 wk) compared to the control group. of the agonist muscle. We propose that adding the 456
408 This study was of moderate methodological quality FMV into conventional physiotherapy intervention 457
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409 and the sample size was large, the effect sizes were may produce superior effects than FMV intervention 458
410 small to moderate (0.12–0.25) so the clinical mean- alone. No confirmed conclusion can be established 459
411 ing of reported effects can be confirmed. As well, a regarding efficient treatment protocols and dosages 460
412 study by Noma et al., (2012), he reported improve- due to the heterogeneity of the treatment interven- 461
413 ment after a single session of FMV, despite it was tions. Considering there was a reduction in spasticity 462
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414 of high quality and involved large sample size, how- with various frequency rangy, it seems that the vibra- 463
415 ever, one study using a single session is not enough tion frequency is not a discriminative factor in FMV 464
416 to generalize their results. intervention. We suppose that the treatment protocol 465
417 On the other hand, two studies reported a reduction and dosage could depend on the affected muscles and 466
418 in upper extremity spasticity in both experimental and degree of spasticity more than other factors consid- 467
control groups (Celletti et al., 2017, Caliandro et al.,
d
419
ered in the analysed studies. In this context, further 468
420 2012). Although one of these studies was of high high methodological quality trials with large sam- 469
cte
421 methodological quality, however, it involved small ple size are strongly warranted to understand effects 470
422 sample size, besides, the time since stroke <6 months of FMV on upper extremity spasticity in strokes 471
423 (months) (Celletti et al., 2017), so we propose that the patients. 472
424 reduction in upper extremity spasticity of both groups
425 was due to spontaneous recovery, as well as small
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434 studies that fail to report significant results (Egger None to report. 476
435 & Smith, 1998). Effect size not reported for some
436 outcome measures because of insufficient data (Tav-
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