Author Names

Parikh RJ, Sutaria JM, Ahsan M, Nuhmani S, Alghadir AH, Khan M

Reviewer Name

Megan Hayden, SPT

Reviewer Affiliation(s)

Duke University Doctor of Physical Therapy

 

Paper Abstract

Background: Impaired motor function and upper extremity spasticity are common concerns in patients after stroke. It is essential to plan therapeutic techniques to recover from the stroke. The objective of this study was to investigate the effects of myofascial release with the tennis ball on spasticity and motor functions of the upper extremity in patients with chronic stroke.  Methods: Twenty-two chronic stroke patients (male-16, female-6) were selected to conduct this study. Two groups were formed: the control group (n=11) which included conventional physiotherapy only and the experimental group (n=11) which included conventional physiotherapy along with tennis ball myofascial release – in both groups interventions were performed for 6 sessions (35 minutes/session) per week for a total of 4 weeks. The conventional physiotherapy program consisted of active and passive ROM exercises, positional stretch exercises, resistance strength training, postural control exercises, and exercises to improve lower limb functions. All patients were evaluated with a modified Ashworth scale for spasticity of upper limb muscles (biceps brachii, pronator teres, and the long finger flexors) and a Fugl-Meyer assessment scale for upper limb motor functions before and after 4 weeks. Nonparametric (Mann–Whitney U test and Wilcoxon signed-rank test) tests were used to analyze data statistically. This study has been registered on clinicaltrial.gov (ID: NCT05242679).  Results: A significant improvement (P < .05) was observed in the spasticity of all 3 muscles in both groups. For upper limb motor functions, significant improvement (P < .05) was observed in the experimental group only. When both groups were compared, greater improvement (P < .05) was observed in the experimental group in comparison to the control group for both spasticity of muscles and upper limb motor functions.  Conclusion: Myofascial release performed with a tennis ball in conjunction with conventional physiotherapy has more beneficial effects on spasticity and motor functions of the upper extremity in patients with chronic stroke compared to conventional therapy alone.  Keywords: chronic stroke, Fugl–Meyer assessment scale, modified Ashworth scale, motor functions, myofascial release, spasticity

 

NIH Risk of Bias Tool

Quality Assessment of Controlled Intervention Studies

  1. Was the study described as randomized, a randomized trial, a randomized clinical trial, or an RCT
  • Yes
  1. Was the method of randomization adequate (i.e., use of randomly generated assignment)?
  • Yes
  1. Was the treatment allocation concealed (so that assignments could not be predicted)?
  • Yes
  1. Were study participants and providers blinded to treatment group assignment?
  • No
  1. Were the people assessing the outcomes blinded to the participants’ group assignments?
  • Yes
  1. Were the groups similar at baseline on important characteristics that could affect outcomes (e.g., demographics, risk factors, co-morbid conditions)?
  • Yes
  1. Was the overall drop-out rate from the study at endpoint 20% or lower of the number allocated to treatment?
  • Yes
  1. Was the differential drop-out rate (between treatment groups) at endpoint 15 percentage points or lower?
  • Yes
  1. Was there high adherence to the intervention protocols for each treatment group?
  • Yes
  1. Were other interventions avoided or similar in the groups (e.g., similar background treatments)?
  • Yes
  1. Were outcomes assessed using valid and reliable measures, implemented consistently across all study participants?
  • Yes
  1. Did the authors report that the sample size was sufficiently large to be able to detect a difference in the main outcome between groups with at least 80% power?
  • No
  1. Were outcomes reported or subgroups analyzed prespecified (i.e., identified before analyses were conducted)?
  • Yes
  1. Were all randomized participants analyzed in the group to which they were originally assigned, i.e., did they use an intention-to-treat analysis?
  • Yes

 

Key Finding #1

Spasticity and increased tone secondary to stroke can be major contributors to chronic pain and reduced functional capacity, but myofascial release may be an easy supplement to therapeutic exercise to address these deficits.

Key Finding #2

Myofascial release may take a role in altering afferent signals by inhibiting motor neuron excitability as well as having a musculoskeletal effect of breaking down the fibrous adhesive tissues in the muscle.

Key Finding #3

The study sample was very small so further research would be needed before applying these findings to a larger stroke population.

 

Please provide your summary of the paper

The study was a double-blinded randomized control trial that observed the effects of using a myofascial release to address spasticity where the control group consisted of active and passive ROM exercises, positional stretch exercises, resistance strength training, and postural control exercises, and the experimental group performed these same therapeutic exercises as well as incorporated myofascial release with a tennis ball in the UE. The Modified Ashworth Scale was used to examine spasticity and a Fugl-Meyer Assessment Scale was used to examine upper limb motor function. Patients in the experimental group were taught to perform myofascial release with a tennis ball to the biceps brachii, pronator teres, and long finger flexors. Research has been conducted on myofascial release in the lower extremity as well that found that myofascial release reduces spasticity by inhibiting motor neuron excitability through prolonged stretch and compression on muscle spindles, Golgi tendon organ, joint and cutaneous receptors. other research also suggests a neuro-reflexive component when manual forces are applied to skeletal tissue. The results of this study were that both groups showed statistically significant changes in spasticity as well as upper limb motor function; however, the experimental group displayed an even greater change in the outcome measures.

Please provide your clinical interpretation of this paper.  Include how this study may impact clinical practice and how the results can be implemented.

While further research needs to be conducted on larger sample sizes, this paper is very supportive of the use of myofascial release for a reduction in spasticity. It can be a great supplement to already prescribed exercises given to a patient to perform at home. The technique can be easily taught to the patient and/or their caregiver and is not time-consuming; the study prescribed only 2 minutes for each muscle (a total of 6 minutes) every day and resources already found in the home like a tennis or lacrosse ball can be used. Because of its potential to reduce spasticity in the UE, it may be useful to perform first, before other prescribed exercises that may be limited due to higher levels of spasticity.