Journal Club August 2013 Brought to you by the AOCPMR Student Council Article title: Effect of radial shock wave therapy on muscle spasticity in children with cerebral palsy. Authors: Mariya I. Gonkova, Elena M Ilieva, Giorgio Ferriero, Ivan Chavdarov Journal/Source: International Journal of Rehabilitation Research, 2013;36:284-290 Discussion: Cerebral palsy (CP) is an umbrella term encompassing disorders that cause major limitations in gait, movement, and posture. It is caused by damage to the developing brain, typically occuring during pregnancy, childbirth, or up to age three. It is characterized by spasticity. Spasticity is clinically defined as velocity dependent resistance to stretch. As a result, limbs have tremors and increased deep tendon reflexes. CP patients also demonstrate a scissors gait and toe walking. If spasticity is not well managed, it can result in serious long-term consequences for children with CP. For example, muscle shortening and tendon contractures cause further balance, sitting, and walking problems. This study was an open observational, placebo-controlled double-blinded study in which each child served as their own control. The effectiveness of one radial shock wave therapy (RSWT) treatment was tested for plantar flexor muscles in children with CP. RSWT is a type of extracorpeal shock wave therapy that has been used in medical practice for decades, typically for tendinopathies. Twenty-five children were subjects in the study, and they had diagnoses of spastic hemiplegia or spastic diplegia. Spasticity was assessed with passive range of motion, the Modified Ashworth Scale (MAS), and a baropodometric measurement that used a force plate for foot and gait analysis. After placebo treatments, no changes were observed in spasticity. After one treatment with RSWT, however, spasticity was reduced in the study subjects. Specifically, there was a statistically significant decrease in the MAS and an increase in the passive range of motion. Importantly, the reduction in muscle tone also persisted 4 weeks post-RSWT treatment. The mechanism behind the effect of RSWT on spasticity is not clear, but is thought to be an improvement in the connective tissue stiffness because the chronically hypertonic muscles of CP patients become fibrotic. More studies will need to be done to clarify the mechanism of action and evaluate the stability of these results in more than one rehabilitation setting. 1 www.aocpmr.org Questions: 1. The study stated that forty plantar flexor groups were treated. Which muscle groups, specifically, do you think were treated with RSWT? 2. Explain the difference between spastic hemiplegia and spastic diplegia. 3. What is the Modified Ashworth Scale? In what other PM&R patients could it be used to qualitatively measure spasticity? 4. List the advantages of RSWT over FSWT. 5. If you were going to design the next study to follow up this one, how would you set it up? What would be your primary and secondary outcome measures? Reviewer: Sarah Welch, OMS-III, AOCPMR Student Council Education Committee Co-Chair 2 www.aocpmr.org