Study on spasticity in patient 3 months after stroke in Viet Nam

T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 157 STUDY ON SPASTICITY IN PATIENT 3 MONTHS AFTER STROKE IN VIETNAM Nguyen Duc Thuan1, Dang Thanh Chung2 SUMMARY Objectives: To identify the percentage of patients who develop spasticity 3 months after stroke and the predictive factors of spasticity after acute stroke. Subjects and methods: In a prospective cohort study, 77 consecutive patients with clinical signs of central paresis due to a stroke were examined in the acute stage and 59 patients completed the re-examination 3 months later. At both point-times, the degree and pattern of paresis and muscle tone, the Barthel Index, modified Rankin Scale were evaluated. Spasticity was assessed on the Modified Ashworth Scale and defined as Modified Ashworth Scale ≥ 1 in any of the examined joints. Results: Fifty-nine patients (76.6%) were reassessed after 3 months. Of them, 30.5% developed spasticity. Spasticity was seen in upper limb (100%), in lower limb (50%) and in both limbs (50%). Slight and mild spasticity was mostly observed in upper as well as lower limb. Severe spasticity defined as Modified Ashworth Scale ≥ 3 was not detected in the study. Patients with spasticity had more severe paresis in the proximal and distal limb a lower Barthel Index and higher modified Rankin score compared with the group without spasticity (p < 0.01). Conclusions: Spasticity was present in 30.5% of patients with initial central paresis. Slight and mild spasticity was predominant. Predictors for the development of spasticity were a severe degree of paresis and lower Barthel Index and higher modified Rankin score. * Keywords: Stroke; Spasticity; Paresis. INTRODUCTION Stroke is considered as a major challenge in health care due to its high rate of prevalence, morbidity and disability. After stroke, a lot of early and late complications may appear including physical and mental disorders as well as paralysis, spasticity, aphasia, cognitive reduction, depression [1, 2]. Among those, spasticity is one of the most observed impairments with the prevalence ranging from 3 to 46% [4]. Spasticity is often associated with exaggerated reflexes and clonus. Spasticity is classified as a sign of upper motor neurone (UMN) syndrome, which is a clinical phenomena observed after lesions of cortical motor areas or the corticofugal descending tracts [5]. 1Department of Neurology, Military Hospital 103, Vietnam Military Medical University 2Department of Pathophysiology, Vietnam Military Medical University Corresponding author: Nguyen Duc Thuan (thuanneuro82@gmail.com) Date received: 18/9/2020 Date accepted: 19/9/2020 T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 158 If not exactly diagnosed and treated, it may cause pain, movement disorder; reduce motor recovery process, cause bad effect on activity of daily life as well as poor quality of life of stroke patient [6]. Recently, it has been paid much attention worldwide but in Vietnam, little is known about its prevalence and correlation with other factors after stroke. For these reasons, this study was conducted: To estimate the prevalence of spasticity, and to identify risk factors in the acute phase for spasticity 3 months after stroke. SUBJECTS AND METHODS 1. Subjects A total of 77 patients diagnosed as stroke and admitted to Stroke Unit, Military Hospital 103 were eligible for the study. The recruitment period was from October 2016 to April 2018. At 3 months after stroke, 59 patients with all data could follow the study. *Inclusion criteria: Patient with stroke diagnosed according to World Health Organization 1970 experienced limb paralysis at the examination time and agreed to participate in the study. *Exclusion criteria: Patient had other nervous system diseases, previously suffering from stroke with spasticity, consciousness disorder, other severe internal diseases inluding end-state heart failure, liver, kidney failure, severe pneumonia or patient refused to participate in the study. 2. Methods * Study design: Prospective cohort study. * Procedure: In a prospective cohort study, the procedure was conducted as below: - At the first examination (T0): within 7 days after hospitalization, patients data were collected including: Demographics, Neurological status according to National Institutes of Health Stroke Scale (NIHSS), Muscle power according to British Medical Research Council Scale (BMRC) [7], Muscle tone according to modified Ashworth Scale (MAS). The modified Ashworth Scale is a 5-point ordinary scale with documented reliability. Its score ranks from 0 to 4, with score 0 indicating absence of spasticity meanwhile score 4, severe spasticity. Spasticity is defined as MAS score equal or greater 1 in any of the joints tested [8], activity of daily life according to Barthel Index (BI), disability status according to modified Rankin Scale (mRS). - At 3 months after stroke (T1): The stroke patients were similarly reassessed at the hospital or at home depending on their health condition. The data was collected by the same investigator at both times. * Statistical analysis: Statistical analysis was carried out using SPSS version 20. All statistical tests were carried out at a 5% level of significance. T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 159 RESULTS AND DISCUSSION 1. Demographics and clinical manifestation of the study population Table 1: Demographics of the study population at acute phase. Characteristics Number of patients Percentage (%) Age, X̅ ± SD 65.3 ± 12.5 Male 51 66.2 Gender Female 26 33.8 Hypertension 53 68.8 Previous stroke 23 29.9 Diabetes 18 234 Smoking 11 14.3 Cardiac diseases 11 14.3 Risk factors of stroke Hyperlipidemia 6 7.8 In our study, the mean age of the population study was 65.3. Of those, age group 50 - 69 was dominant. The stroke patients with the age over 70 accounted for 90.9% (70/77). The result was similar to outcomes of the previous publication which concluded that stroke mainly occurred in elderly people [1, 2, 9]. Among 77 patients, male to female ratio was 2/1. N.V.Chuong, V.A.Nhi, Rathore gave the different rate, but they had a similar conclusion that man showed the higher rate of stroke than women [2, 3, 9]. In term of risk factors of stroke (table 1), hypertension and previous stroke ranked the highest with the prevalence of 68.8% and 29.9%, respectively. Our results were consistent with most studies on stroke, showing the prevalence of hypertension between 59.35 and 76% [1, 2, 3]. Other risk factors were seen with a high rate in a lot of previous publication about stroke in the last decades [2, 9]. Only patients without existing spasticity which had no influence on the development of spasticity, could be included in the study. Table 2: Clinical characteristics of the study population. Signs Number of patients Percentage (%) Motor disorder 77 100.0 Cranial nerve disorder 51 66.2 Sensory disorder 27 35.1 Reflex disorder 16 20.8 Conscious disorder 12 15.6 Vestibular/cerebellar syndrome 5 6.5 Bowel/blader disorder 4 5.2 Meningeal syndrome 3 3.9 T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 160 Stroke that causes a lot of neurological disorders is divided into two groups: focal and general neurological sign. In the study, both groups were observed in which motor disorder was at the first rank with 100%, followed by cranial nerves, sensory, reflex and conscious disorder with 66.2%, 35.1%, 20.8% and 15.6%, respectively. The above- mentioned disorders were also seen with high proportion in other previous studies. N.V.Chuong studied 150 stroke patients and found that paralysis after stroke accounted for 90.67%, central facial nerve palsy and conscious disorder were observed in 87.33% and 24.0% patients, respectively [2]. The similar results were reported in publication of N.V.Dang [1]. Table 3: Disability and activity of daily life of the study population at acute phase. Number of patients Percentage (%) 1 24 31.2 2 8 10.4 3 13 16.9 4 18 23.3 Modified Rankin Scale 5 14 18.2 < 25 8 10.4 25 - 64 35 45.4 65 - 94 19 24.7 Barthel Index > 94 15 19.5 In the study, the patients with slight disability defined as mRS ≤ 2 accounted for 41.6% and mean mRS score was 2.82 which meant a moderate disability. Regarding activity of daily life, 34 patients (44.2%) had slight or no difficulty in finishing their functional task of activity of daily life (BI ≥ 65) and mean BI score was 57.6 which meant a moderate dependence. Because of different inclusion criteria and sample size, we found no study on stroke for comparison with our outcomes. Despite this condition, we could recognize that after stroke almost patients had to receive support from care givers which meant that stroke caused a huge burden for not only the patients themselves but also their family and society [9]. World Health Organization also determined that stroke is the leading cause of disability in adult people worldwide. T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 161 2. Prevalence of spasticity and its relationship with other factors * Prevalence of spasticity: At 3 months after stroke, 18/59 patients (30.5%) developed spasticity in any joint. Table 4: Distribution of spasticity. Patients with spasticity (n = 18) Percentage (%) Upper limb 18 100.0 Lower limb 9 50.0 Distribution of spasticity Both limbs 9 50.0 0 0 0.0 1 8 44.5 1+ 9 50.0 2 1 5.5 Upper limb (MAS grade) 3 or 4 0 0.0 MAS (mean) 1.31 ± 0.29 0 9 50.0 1 1 5.5 1+ 7 38.5 2 1 5.5 Lower limb (MAS grade) 3 or 4 0 0.0 MAS (mean) 0.75 ± 0.77 From the table 4, eighteen (100%) had spasticity in the upper limb, 9 (50%) in the lower limb and 9 (50%) in both the upper and the lower limb. Most patients had mild spasticity, presented as MAS grade 1 or 1+. Prevalence of spasticity in the present study was higher than most studies on stroke. Sommerfeld et al. (2003) found 18/95 (18.9%) patients developed spasticity at 3 months after stroke [10]. In the Lundstrom’s study (2009), at 12 months after stroke, spasticity was detected in 17% of patients. In a study of 95 patients with stroke, prevalence of spasticity was 19% for the entire group of patients [11]. 64 out of the 95 patients had initial hemiparesis, and 18 (28%) developed spasticity 3 months later. In the recent study on 87 patients with subarachnoid hemorrhage, the 6-month poststroke prevalence of spasticity was reported to be 22% for all the patients. However, some studies reported higher prevalence, from 42.6% up to 46%. The reason for this difference may be due to differences in inclusion criteria or in the method of assessing spasticity. For example, Sommerfeld [10], Wallmark [12] included the stroke patients regardless of T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 162 initial paresis. The time for re-examination in some studies was different. Urban investigated spasticity at 6 months after stroke while Opheim et al. [4] reassessed the patients within 12 months poststroke. Another explanation for this was the different sample size of each study. In term of distribution of spasticity, our observation was similar to other previous studies that spasticity was detected in different joint of upper and lower limb. Slight, mild severity of spasticity was predominant in the present and previous researches [10, 12, 13]. 3. Relation between spasticity and other variables Table 5: Clinical characteristics of patients with and without spasticity. Spasticity (n, %) Non-spasticity (n, %) p-value < 50, n (%) 2 (40) 3 (60) Age ≥ 50, n (%) 16 (29.6) 38 (70.4) 0.63 Age (mean) 69.11 ± 13.57 63.27 ± 11.44 0.094 Male, n (%) 9 (23.7) 29 (76.3) Sex Female, n (%) 9 (42.9) 12 (57.1) 0.126 Proximal (mean) 1.33 ± 1.74 3.02 ± 1.79 0.001 Upper limb muscle strength (BMRC) Distal (mean) 1.39 ± 1.72 2.88 ± 1.61 0.002 Proximal (mean) 1.72 ± 1.64 3.05 ± 1.76 0.009 Lower limb muscle strength (BMRC) Distal (mean) 1.72 ± 1.64 3.05 ± 1.67 0.007 Barthel Index (mean) 65.12 ± 29.46 42.50 ± 21.97 0.002 mRS (mean) 2.49 ± 1.64 3.50 ± 1.15 0.009 Similar to the findings reported by Lundstrom et al. [11], Wissel et al. [6] and Urban et al. [13], we did not identify an influence of sex and age on the occurrence of spasticity. We further analyzed the association between spasticity and risk factors, type as well as location of stroke and were able to demonstrate that there was no statistically significant difference in occurrence of spasticity in these groups. In addition, we found there was no relationship between clinical signs at acute phase and spasticity which reported in the study by Opheim et al. However, Urban et al. noticed that patients with hemihypesthesia were more often affected by spasticity of the upper and lower limb than patients without sensory deficits. The reason for the findings could be different in the method of sensation examination, number of population study or duration of patient observation. In the present study, we noticed that patients in spasticity group had higher BMRC score than patients without spasticity for both proximal and distal upper and T¹p chÝ y - d−îc häc qu©n sù sè 8-2020 163 lower limb, which was confirmed in previous observations. These findings strongly suggest the need for thorough follow-up and increased awareness of the development of spasticity in patients with severe paresis. We were further able to demonstrate that the presence of spasticity had an impact on disability after stroke, as reflected in the mRS score, as well as on activities of daily living, as shown by the BI. The same findings were reported in studies by Wissel et al., Urban et al. and Opheim et al. CONCLUSION Study on 59 patients 3 months after stroke, we found that spasticity developed in 30.5% of all stroke patients. Spasticity in upper limb, lower limb and both limbs was 100%, 50% and 50%, respectively. Slight and mild spasticity was mostly observed in the patients. Severe spasticity was relatively rare. Risk factors for the development of spasticity 3 months after stroke was severe paresis, a lower Barthel Index, and a higher modified Rankin score at acute phase. REFERENCES 1. Nguyễn Văn Đăng. Tai biến mạch máu não. Nhà xuất bản Y học 2006:9-21. 2. Nguyễn Văn Chương. Đặc điểm lâm sàng đột quỵ não, những số liệu qua 150 bệnh nhân. Tạp chí Y học Thực hành 2003; 10:75-77. 3. Vũ Anh Nhị. 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