Circumferential pressure treatment reduces post-stroke spasticity: a pilot randomized controlled trial
More details
Hide details
Escuela de Fisioterapia, Universidad Industrial de Santander, Bucaramanga, Colombia
Submission date: 2020-06-05
Acceptance date: 2020-07-28
Publication date: 2022-03-29
Physiother Quart. 2022;30(1):39-45
Circumferential pressure is used to promote the inhibition of the spastic muscle. The purpose of this study was to evaluate the immediate effect of circumferential pressure applied by Johnstone pressure splint on the tonus level, reflex excitability, and electromyographic activity of plantar flexor and dorsiflexor muscles in post-stroke patients.

An experimental single-blinded study with random allocation of patients to a control group (conventional inhibition techniques) or experimental group (conventional inhibition techniques along with circumferential pressure) was performed. All patients received one 25-minute therapeutic session. The muscle tonus according to the Modified Ashworth Scale, soleus H-reflex, and electromyographic signals during the sit-to-stand movement of plantar flexor-dorsiflexor muscles were evaluated before and after treatment.

Overall, 30 stroke survivors (20 men, 10 women; age: 60.3 ± 5.7 years; evolution time: 27.8 ± 14.7 months) were studied. The muscle tone decreased in both groups, but the experimental group exhibited a greater reduction. The experimental group presented a significant increase in the H-wave duration and maximal H/maximal M wave ratio of the H-reflex as compared with the control group. No significant difference was observed in muscular electrical activity.

One session of combined therapy contributes to a reduction in the tone of plantar flexor muscles and the reflex activity, without altering the muscle activity.

Urban PP, Wolf T, Uebele M, Marx JJ, Vogt T, Stoeter P, et al. Occurence and clinical predictors of spasticity after ischemic stroke. Stroke. 2010;41(9):2016–2020; doi: 10.1161/STROKEAHA.110.581991.
Welmer A-K, Holmqvist LW, Sommerfeld DK. Location and severity of spasticity in the first 1–2 weeks and at 3 and 18 months after stroke. Eur J Neurol. 2010;17(5):720–725; doi: 10.1111/j.1468-1331.2009.02915.x.
Benamer HTS, Grosset D. Stroke in Arab countries: a systematic literature review. J Neurol Sci. 2009;284(1–2):18–23; doi: 10.1016/j.jns.2009.04.029.
Hirtz D, Thurman DJ, Gwinn-Hardy K, Mohamed M, Chaudhuri AR, Zalutsky R. How common are the “common” neurologic disorders? Neurology. 2007;68(5):326–337; doi: 10.1212/01.wnl.0000252807.38124.a3.
Wissel J, Schelosky LD, Scott J, Christe W, Faiss JH, Mueller J. Early development of spasticity following stroke: a prospective, observational trial. J Neurol. 2010;257(7):1067–1072; doi: 10.1007/s00415-010-5463-1.
Sunnerhagen KS. Predictors of spasticity after stroke. Curr Phys Med Rehabil Rep. 2016;4:182–185; doi: 10.1007/s40141-016-0128-3.
Burridge JH, Wood DE, Hermens HJ, Voerman GE, Johnson GR, van Wijck F, et al. Theoretical and methodological considerations in the measurement of spasticity. Disabil Rehabil. 2005;27(1–2):69–80; doi: 10.1080/09638280400014592.
Li S, Francisco GE. New insights into the pathophysiology of post-stroke spasticity. Front Hum Neurosci. 2015;9:192; doi: 10.3389/fnhum.2015.00192.
Kohan AH, Abootalebi S, Khoshnevisan A, Rahgozar M. Comparison of modified Ashworth scale and Hoffmann reflex in study of spasticity. Acta Med Iran. 2010;48(3):154–157.
Levin MF, Hui-Chan C. Are H and stretch reflexes in hemiparesis reproducible and correlated with spasticity? J Neurol. 1993;240(2):63–71; doi: 10.1007/BF00858718.
Voerman GE, Gregoric M, Hermens HJ. Neurophysiological methods for the assessment of spasticity: the Hoffmann reflex, the tendon reflex, and the stretch reflex. Disabil Rehabil. 2005;27(1–2):33–68; doi: 10.1080/09638280400014600.
Prudente C, Rodrigues-de-Paula F, Faria CDCM. Lower limb muscle activation during the sit-to-stand task in subjects who have had a stroke. Am J Phys Med Rehabil. 2013;92(8):666–675; doi: 10.1097/PHM.0b013e318282c87a.
Khemlani MM, Carr JH, Crosbie WJ. Muscle synergies and joint linkages in sit-to-stand under two initial foot positions. Clin Biomech. 1999;14(4):236–246; doi: 10.1016/s0268-0033(98)00072-2.
Silva A, Sousa ASP, Pinheiro R, Ferraz J, Tavares JMRS, Santos R, et al. Activation timing of soleus and tibialis anterior muscles during sit-to-stand and stand-to-sit in post-stroke vs. healthy subjects. Somatosens Mot Res. 2013;30(1):48–55; doi: 10.3109/08990220.2012.754755.
Katalinic OM, Harvey LA, Herbert RD. Effectiveness of stretch for the treatment and prevention of contractures in people with neurological conditions: a systematic review. Phys Ther. 2011;91(1):11–24; doi: 10.2522/ptj.20100265.
Pollock A, Baer G, Campbell P, Choo PL, Forster A, Morris J, et al. Physical rehabilitation approaches for the recovery of function and mobility following stroke. Cochrane Database Syst Rev. 2014;2014(4):CD001920; doi: 10.1002/14651858.CD001920.
Vaughan-Graham J, Cott C, Wright FV. The Bobath (NDT) concept in adult neurological rehabilitation: what is the state of the knowledge? A scoping review. Part II: intervention studies perspectives. Disabil Rehabil. 2015;37(21):1909–1928; doi: 10.3109/09638288.2014.987880.
Pollock A, Baer G, Langhorne P, Pomeroy V. Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke: a systematic review. Clin Rehabil. 2007;21(5):395–410; doi: 10.1177/0269215507073438.
Kollen BJ, Lennon S, Lyons B, Wheatley-Smith L, Sche­per M, Buurke JH, et al. The effectiveness of the Bobath concept in stroke rehabilitation: what is the evidence? Stroke. 2009;40(4):e89–e97; doi: 10.1161/STROKEAHA.108.533828.
Kerem M, Livanelioglu A, Topcu M. Effects of Johnstone pressure splints combined with neurodevelopmental therapy on spasticity and cutaneous sensory inputs in spastic cerebral palsy. Dev Med Child Neurol. 2001;43(5):307–313; doi: 10.1017/s0012162201000585.
Kukulka CG, Fellows WA, Oehlertz JE, VanderWilt SG. Effect of tendon pressure on alpha motoneuron excitability. Phys Ther. 1985;65(5):595–600; doi: 10.1093/ptj/65.5.595.
Leone JA, Kukulka CG. Effects of tendon pressure on alpha motoneuron excitability in patients with stroke. Phys Ther. 1988;68(4):475–480; doi: 10.1093/ptj/68.4.475.
Robinson KL, McComas AJ, Belanger AY. Control of soleus motoneuron excitability during muscle stretch in man. J Neurol Neurosurg Psychiatry. 1982;45(8):699–704; doi: 10.1136/jnnp.45.8.699.
Johnstone M. Current advances in the use of pressure splints in the management of adult hemiplegia. Physiotherapy. 1989;75(7):381–384; doi: 10.1016/S0031-9406(10)62589-8.
Cox Steck G. PANat: theoretical framework, clinical management and application of the Urias® Johnstone air splints. PRO-Active approach to Neurorehabilitation integrating air splints and other therapy tools; 2019. Available from: www.panat.info.
Poole JL, Whitney SL, Hangeland N, Baker C. The effectiveness of inflatable pressure splints on motor function in stroke patients. Occup Ther J Res. 1990;10(6):360–366; doi: 10.1177/153944929001000605.
Robichaud JA, Agostinucci J, Vander Linden DW. Effect of air-splint application on soleus muscle motoneuron reflex excitability in nondisabled subjects and subjects with cerebrovascular accidents. Phys Ther. 1992;72(3):176–183; doi: 10.1093/ptj/72.3.176.
Hazneci B, Tan AK, Guncikan MN, Dincer K, Kalyon TA. Comparison of the efficacies of botulinum toxin A and Johnstone pressure splints against hip adductor spasticity among patients with cerebral palsy: a randomized trial. Mil Med. 2006;171(7):653–656; doi: 10.7205/milmed.171.7.653.
Kitiş A, Kayıhan H. Comparison of EMG biofeedback and Johnstone pressure splints in children with hemiplegic cerebral palsy [in Turkish]. Turk Fiz Tip Rehab Derg. 2010;56(3):116–123; doi: 10.4274/tftr.56.116.
Ansari NN, Naghdi S, Arab TK, Jalaie S. The interrater and intrarater reliability of the Modified Ashworth Scale in the assessment of muscle spasticity: limb and muscle group effect. NeuroRehabilitation. 2008;23(3):231–237; doi: 10.3233/NRE-2008-23304.
Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther. 1987;67(2):206–207; doi: 10.1093/ptj/67.2.206.
Burke D. Clinical uses of H reflexes of upper and lower limb muscles. Clin Neurophysiol Pract. 2016;1:9–17; doi: 10.1016/j.cnp.2016.02.003.
Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G. Development of recommendations for SEMG sensors and sensor placement procedures. J Electromyogr Kinesiol. 2000;10(5):361–374; doi: 10.1016/s1050-6411(00)00027-4.
Annaswamy T, Mallempati S, Allison SC, Abraham LD. Measurement of plantarflexor spasticity in traumatic brain injury: correlational study of resistance torque compared with the modified Ashworth scale. Am J Phys Med Rehabil. 2007;86(5):404–411; doi: 10.1097/PHM.0b013e31804a7d85.
Clopton N, Dutton J, Featherston T, Grigsby A, Mobley J, Melvin J. Interrater and intrarater reliability of the Modified Ashworth Scale in children with hypertonia. Pediatr Phys Ther. 2005;17(4):268–274; doi: 10.1097/01.pep.0000186509.41238.1a.
Chen Y-S, Zhou S, Cartwright C, Crowley Z, Baglin R, Wang F. Test-retest reliability of the soleus H-reflex is affected by joint positions and muscle force levels. J Electromyogr Kinesiol. 2010;20(5):980–987; doi: 10.1016/j.jelekin.2009.11.003.
Edin BB. Quantitative analyses of dynamic strain sensitivity in human skin mechanoreceptors. J Neurophysiol. 2004;92(6):3233–3243; doi: 10.1152/jn.00628.2004.
Tsai K-H, Yeh C-Y, Chang H-Y, Chen J-J. Effects of a single session of prolonged muscle stretch on spastic muscle of stroke patients. Proc Natl Sci Counc Repub China B. 2001;25(2):76–81.
Lowrey CR, Strzalkowski NDJ, Bent LR. Skin sensory information from the dorsum of the foot and ankle is necessary for kinesthesia at the ankle joint. Neurosci Lett. 2010;485(1):6–10; doi: 10.1016/j.neulet.2010.08.033.
Agostinucci J. Effect of air-splint pressure on the soleus stretch reflex during a voluntary ramp plantar flexion. Neurophysiology. 2010;42(1):31–38; doi: 10.1007/s11062-010-9128-6.
Bressel E, McNair PJ. The effect of prolonged static and cyclic stretching on ankle joint stiffness, torque relaxation, and gait in people with stroke. Phys Ther. 2002;82(9):880–887; doi: 10.1093/ptj/82.9.880.
Frigon A, Carroll TJ, Jones KE, Zehr EP, Collins DF. Ankle position and voluntary contraction alter maximal M waves in soleus and tibialis anterior. Muscle Nerve. 2007;35(6):756–766; doi: 10.1002/mus.20747.
Selles RW, Li X, Lin F, Chung SG, Roth EJ, Zhang L-Q. Feedback-controlled and programmed stretching of the ankle plantarflexors and dorsiflexors in stroke: effects of a 4-week intervention program. Arch Phys Med Rehabil. 2005;86(12):2330–2336; doi: 10.1016/j.apmr.2005.07.305.
Journals System - logo
Scroll to top