La efectividad de diferentes duraciones de pulso de NMES en pacientes con espasticidad relacionada con el tracto piramidal medida mediante herramientas neurofisiológicas (PD-NMES-SPAS)

Participants will receive 15 minutes Conventional physiotherapy training program (same as control group) and 30 minutes High Pulse Duration Neuromuscular Electrical Stimulation (HPD-NMES)

30 minutes High Pulse Duration Neuromuscular Electrical Stimulation (HPD-NMES)

• NMES Application Parameters:

  • Waveform: rectangular, biphasic. Symmetrical
  • Pulse Duration:450μsec
  • Frequency: 100Hz
  • Intensity: Optical muscle contraction and patients' tolerability
  • Ramp up: 2sec
  • Ramp down:2sec
  • ON/OFFtime: 10sec/30sec (1:3)

• Treatment Duration: 30 minutes per session, 3 times per week for 6 weeks total.

• HPD-NMES

Conventional physiotherapy training program

• Seated upper extremity program, single limb exercises, strength training, stretching training (with or without) external resistance, Neurofacilitatory techniques (ie. Propriocetive Neuromuscular Facilitation (PNF), NeuroDevelopmental Treatment- Bobath (NDT-Bobath) etc)
• Treatment Duration: 15minutes per session, 3 times per week for 6 weeks total.

• Grupo de control

Participants will receive 15 minutes Conventional physiotherapy training program (same as control group) and 30 minutes Low Pulse Duration Neuromuscular Electrical Stimulation (LPD-NMES)

Conventional physiotherapy training program

• Seated upper extremity program, single limb exercises, strength training, stretching training (with or without) external resistance, Neurofacilitatory techniques (ie. Propriocetive Neuromuscular Facilitation (PNF), NeuroDevelopmental Treatment- Bobath (NDT-Bobath) etc)
• Treatment Duration: 15minutes per session, 3 times per week for 6 weeks total.

• Grupo de control

30 minutes Low Pulse Duration Neuromuscular Electrical Stimulation (LPD-NMES)

• NMES Application Parameters:

  • Waveform: rectangular, biphasic. Symmetrical
  • Pulse Duration:100μsec
  • Frequency: 100Hz
  • Intensity: Optical muscle contraction and patients' tolerability
  • Ramp up: 2sec
  • Ramp down:2sec
  • ON/OFFtime: 10sec/30sec (1:3)

• Treatment Duration: 30 minutes per session, 3 times per week for 6 weeks total.

• LPD-NMES

Patients will receive 15 minute conventional physiotherapy training program that includes seated upper extremity program, single limb exercises, strength training, stretching training (with or without) external resistance, Neurofacilitatory techniques (ie. Propriocepive Neuromuscular Facilitation (PNF), NeuroDevelopmental Treatment -Bobath (NDT-Bobath) etc)

Conventional physiotherapy training program

• Seated upper extremity program, single limb exercises, strength training, stretching training (with or without) external resistance, Neurofacilitatory techniques (ie. Propriocetive Neuromuscular Facilitation (PNF), NeuroDevelopmental Treatment- Bobath (NDT-Bobath) etc)
• Treatment Duration: 15minutes per session, 3 times per week for 6 weeks total.

• Grupo de control

1. Changes in surface electromyography (EMG) parameters (Hoffmann reflex(H-reflex) of the flexor carpi radialis, M wave, F response of the median nerve, Hmax/Mmax ratio (or M/H amplitude ratio), motor unit number estimation (MUNE) and F response of the spastic upper limb).

1. Changes in Modified Ashworth Scale (MAS) scores. A 5-item evaluation scale that assessed muscle hypertonia. The minimum score is 0 (normal muscle tone) and the maximum is 4 (limb rigid). Higher scores indicate increase in spasticity.

Changes in Range of Motion (ROM) scores: The assessment will be conducted using an electronic goniometer to precisely determine the range of motion of the elbow joint affected by spasticity. Patients will be positioned in the supine position on the examination table with the affected side oriented toward the examiner. Then, the examiner will align the goniometer with anatomical landmarks the base of the goniometer over the lateral epicondyle of the humerus, the stable axis along the humerus and the movable axis along the radius. The angle of the elbow-flexion will be recorded, and the measured value will be substracted from 145o (the range of motion of a full elbow flexion) in order to calculate elbow extension. Decreases in elbow extension scores indicate reduction in spasticity levels.

Changes in Modified Barthel Index (MBI) scores. Modified Barthel Index is an evaluation scale that assesses patient's performance in activities of daily living. It consists of 10 domains with activities of daily living and mobility. Greater scores are correlated with decreased level of dependence

Changes in 12 version World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) scores: WHODAS 2.0 is an evaluation scale that assesses perceived disability associated with the health condition in the 30 days preceding its application. Is divided into six domains: i) cognition, ii) mobility, iii) self-care, iv) interpersonal relationships, v) activities of daily living and vi) participation. Each item is rated from 1 (no difficulty) to 5 (extreme difficulty or unable to do). Larger scores refer to larger disability.

Biceps brachii diameter will be objectively assessed by standardized multi-mode ultrasound at baseline and in 6 weeks in all three study groups (HPD-NMES, LPD-NMES, and Control). The diameter's assessment will be measured on 90o elbow flexion and on 0ο extension.This non-invasive, safe and reproduciple measure requires minimal time and is conducted within scheduled study visits, without altering trial design, primary outcomes, or participant burden.