Complementary Therapies in Clinical Practice 46 (2022) 101520

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Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctcp

Effects of dry needling plus exercise therapy on post-stroke spasticity and

motor function: A case report
Seyedeh Saeideh Babazadeh-Zavieh a, Noureddin Nakhostin Ansari a, b, Nastaran Ghotbi a, *,
Soofia Naghdi a, Korosh Mansouri c, Mohammadreza Khanmohammadi a,
Seyed Mohammad Jafar Haeri d
a
Physical Therapy Department, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
b
Research Center for War-affected People, Tehran University of Medical Sciences, Tehran, Iran
c
Neuromusculoskeletal Research Center, Iran University of Medical Sciences, Tehran, Iran
d
Department of Anatomical Sciences, Medical School, Arak University of Medical Sciences, Arak, Iran

A R T I C L E I N F O A B S T R A C T

Keywords: Background and purpose: The use of dry needling (DN) with other treatments may be more beneficial in managing
Dry needling post-stroke spasticity. We report the effects of DN plus exercise therapy (ET) on wrist flexor spasticity.
Exercise therapy Patient presentation: The patient was a 45-year-old man with an 8-year history of stroke. The outcome measures
Motor function
included the Modified Modified Ashworth Scale (MMAS), Hmax/Mmax ratio, H-reflex latency, Action Research
Motor neuron excitability
Spasticity
Arm Test (ARAT), Fugl-Meyer Assessment (FMA), and range of motion (ROM) which were assessed before (T1),
Stroke after (T2), and after 3-week follow-up (T3).
Conclusion: The MMAS was improved at T2 from “3” to “2”. The Hmax/Mmax decreased from 0.77 to 0.53 at T3.
The H-reflex latency increased from 15.4 ms to 18.5 ms at T3. The wrist active and passive ROM increased ~30◦
and ~20◦ at T2, respectively.
A 4-session DN plus ET may improve spasticity and ROM. No meaningful improvement was observed in function.

1. Introduction
Spasticity is one of the major problems in patients with chronic
stroke. The spasticity is characterized by velocity-dependent increase in
muscle tone resulting from stretch reflex hyper-excitability [1]. Devel­
opment of spasticity 6 months after the first stroke is estimated to be
about 42.6% [2]. Spasticity affects motor performance of the upper limb
and interferes with rehabilitation [3]. Therefore, the management of
spasticity in stroke is imperative.
Several rehabilitation approaches have been used to manage spas­
ticity after stroke [3–5]. Recently, dry needling (DN) has been presented
as a new therapeutic approach for the treatment of post-stroke spasticity
[3,5–7]. However, most of the studies in patients post-stroke have used
DN alone and investigated its immediate effects [3,6,7].
The combination of therapeutic approaches may be more effective
than using one technique alone in managing spasticity and rehabilita­
tion of the post-stroke patients [3,4,8]. There was only one study that
examined the effects of DN combined with rehabilitation programs on
upper limb spasticity in the patients after stroke [5]. No previous study
investigated the short-term effects of DN plus exercise therapy (ET) on
motor function in patients with stroke.
The ET is the standard, effective approach for the motor rehabilita­
tion of the patients with stroke [3,9,10]. Previous studies that used the
DN alone demonstrated the immediate effects of DN in reduction of
spasticity and improving the range of motion (ROM) [6,7]. We hy­
pothesize that the combination of DN and ET may improve spasticity
level and motor function post-stroke [7]. In this case study, we report the
effects of DN plus ET on wrist flexor spasticity, motor neuron excit­
ability, and motor function in a patient with chronic stroke.
2. Case presentation
The patient was a 45-year-old man with an 8-year history of ischemic
stroke resulted in right hemiplegia. He had no comorbidities. He was
alert and could follow the instructions.
The Modified Modified Ashwoth Scale (MMAS), a valid and reliable

* Corresponding author. Physical Therapy Department, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, P. O. Box: 113635 – 1683, Iran.
E-mail address: nghotbi@sina.tums.ac.ir (N. Ghotbi).

https://doi.org/10.1016/j.ctcp.2021.101520
Received 4 November 2020; Received in revised form 14 November 2021; Accepted 27 November 2021
Available online 2 December 2021
1744-3881/© 2021 Published by Elsevier Ltd.
S.S. Babazadeh-Zavieh et al. Complementary Therapies in Clinical Practice 46 (2022) 101520

scale to measure the muscle spasticity, was used to evaluate the wrist Table 1
flexor spasticity one time at each session to avoid varying spasticity Patient scores, pre and post treatment.
[11]. The Persian version of MMAS was used [12]. Outcomes Pre-treatment Post-treatment After 3-week follow
The maximal H wave/maximal M wave ratio (Hmax/Mmax) and the (T1) (T2) up (T3)
latency of H-reflex (Hoffmann’s reflex) were calculated to measure the MMAS grade 3 2 3
alpha motor neuron excitability [13]. The MytoII EMG (Electromyog­ AROM (wrist 13.3 43.3 41.7
raphy) machine (Italy) with sensitivity at 200–500 V/div, band-pass extension)
filter at 5 Hz to 3 kHz, and sweep speed at 5 msec/div was used. To (Degree)
PROM (wrist 61.7 81.7 68.3
measure the H-reflex, the patient was positioned in supine with the extension)
shoulder in abduction and forearm in supination. The surface stimu­ (Degree)
lating electrode was placed on the medial side of the elbow joint, and a ARAT 55.0 57.0 57.0
rectangular pulse of 1 ms duration was applied to stimulate the median FMA 55.0 59.0 60.0
H reflex latency 15.4 18.1 18.5
nerve. The recording electrode was placed over the flexor carpi radialis
(ms)
(FCR) muscle [6]. The H-reflex latency was recorded as the time from the Hmax/Mmax ratio 0.77 0.66 0.53
beginning of the stimulation to the start of the initial deflection of the
MMAS, Modified Modified Ashworth Scale; AROM, Active Range of Motion;
H-reflex, and the Hmax/Mmax ratio was calculated by dividing the Hmax
PROM, Passive Range of Motion; ARAT, Action Research Arm Test, FMA, Fugl-
by Mmax [7].
Meyer Assessment; ms, millisecond; Hmax/Mmax, maximal H wave/maximal M
Motor function was assessed by an Action Research Arm Test (ARAT) wave.
and Fugl-Meyer Assessment (FMA). The ARAT is a 19-item measure
composed of four subscales used to assess the coordination, dexterity,
after the treatment; 0.77 at T1 and 0.53 at T3 follow-up.
and functioning of the upper limb. The ARAT has been demonstrated to
The ARAT did not improve considerably (Table 1). The FMA score
have good validity and reliability in patients with stroke [14]. We used
increased 4 and 5 points at T2 and T3, respectively. The wrist active
the FMA upper extremity subscale which includes 33 items, total score
extension increased ~30◦ and the wrist passive extension increased
of 0–66 points [15]. A standard goniometer was used to measure the
~20◦ at T2 relative to T1.
active and passive ROM of wrist extension. Three times measurements of
At the end of the treatment after the 4th session, the patient scored
wrist extension were recorded, and the average was calculated for data
the improvement level of “4” according to GRCS indicating “much
analyses.
improvement”.
The Global Rating of Change Scale (GRCS) is a self-reported measure
to determine whether the patient improved or worsened after the
4. Discussion
treatment. The GRCS is an 11-point tool from − 5 (very much worse) to
0 (unchanged) to +5 (completely improved) [16]. The GRCS has been
In this case with stroke, the combination of DN with ET reduced the
demonstrated to be a reliable and valid self-reported measure that has
spasticity of the wrist flexors, but the motor function did not improve in
adequate sensitivity to assess the changes after an intervention [16]. The
terms of ARAT and FMA. The decrease in spasticity after DN has been
GRCS was responded by the patient after treatment at T2. All other
shown in the previous studies [3,6,7]. A recent systematic review
measurements were assessed before (T1), after (T2), and after 3-week
concluded that the DN had a positive impact on the management of
follow-up (T3).
spasticity after stroke [19]. The improvement in spasticity in this case
After the baseline assessment, information about the procedure was
with post-stroke spasticity after 4 weeks further confirms the positive
provided to the patient. The treatment consisted of a combination of DN
effects of DN on spasticity. One-point decrease in spasticity grade of
and ET provided by another experienced physiotherapist. Following
MMAS in this case with post-stroke spasticity is greater than the mini­
obtaining the patient’s written informed consent, the DN was applied to
mally clinically important changes (MCIC) of 0.48 and 0.76 reported for
the affected FCR and flexor carpi ulnaris (FCU) muscles, each for 1 min.
upper limb muscles [20]. The meaningful improvement of spasticity
The needle (size 0.20 × 25, Dong Bang, Korea) was inserted deeply into
may be explained by changes occurring in the soft tissue level by needle
the muscle following a fast-in fast-out cone shape technique [7]. The
mechanical manipulation as well as in the neural level [6,7].
patient received a 4-session DN plus ET, one session per week for a
In the current study, the Hmax/Mmax ratio reduced and the H-reflex
4-week period in the physiotherapy clinic. The patient was required to
latency increased at T2 and T3 that indicates decreases in alpha motor
continue the exercises at home once a day for a 4-week period.
neuron excitability. The more reduction in Hmax/Mmax ratio at T3
The points needled in previous studies were selected for DN [6,7].
(~31%) and more increases in H-reflex latency (~20%) indicates that
For the FCU, the midpoint of the proximal third segment of a line from
the positive effects of DN plus ET on alpha motor neuron excitability
the medial epicondyle to the ulnar styloid process was needled. For the
appeared with time. The improvement in Hmax/Mmax ratio is consistent
FCR, a line from 1 cm medial to the midpoint of elbow crease to 4 cm
with previous studies that showed improvements in the values of Hmax/
below was needled [7]. These sites are approximate motor points of the
Mmax ratio after DN in patients with stroke [6,7]. Improvements in the
muscles needled, demonstrated to be effective in reducing spasticity and
H-reflex measures in this patient with post-stroke spasticity may explain
improving motor function post-stroke [6,7,17]. It follows that the sites
the reduction in MMAS grade after the treatment. However, the MMAS
needled for spastic wrist flexor muscles are standardized. After the DN
score at T3 was measured similar to the baseline grade of “3”. A recent
treatment, the patient was asked to perform a 30-min exercise program
study on the effect of DN on wrist flexor spasticity found a significant
designed according to the International Classification of Functioning
relationship between the Hmax/Mmax ratio and the MMAS scores (rho =
(ICF) of structure, function, and activity [18]. In the structural and
0.42, p = 0.03) [7]. This inconsistency in the outcomes of the H-reflex
functional level, there were nine exercises that were done in the pro­
(progressive improvements of Hmax/Mmax ratio and latency) and MMAS
nation, supination, and neutral position of the forearm respectively. In
scores (increased to the baseline) observed at T3 may be explained by
activity level, six functional exercises were done. Each exercise was
the fact that the Hmax/Mmax ratio, though improved progressively, did
performed 5 times and there was a 1-min rest between each section.
not improve to the normal level after the treatment reflecting the higher
amount of excitatory of alpha motor neurons.
3. Results
Both active and passive wrist extension ROM in the affected hand
increased after the treatment that is in agreement with previous reports
The results are shown in Table 1. After the treatment, the spasticity
[5–7]. The improvement in wrist extension active ROM of 30◦ at T2 that
grade was improved from “3” to “2”. The Hmax/Mmax ratio decreased

2
S.S. Babazadeh-Zavieh et al.
remained at follow-up is clinically relevant and meaningful. This effect
size on wrist extension active ROM demonstrates that active exercises
after DN had beneficial effects such that enhanced the amount of wrist
extension active ROM. The improvements of wrist active and passive
ROM may be explained by the improvements of spasticity and alpha
motor neuron excitability. However, we used a combination therapy
method and it is difficult to determine how much each component of the
treatment played a role in the improvement of wrist extension active
ROM. A study to compare the effects of DN alone with DN plus ET is
required to detect the additional benefits on spasticity associated with
ET when combined with the DN.
The improvement of wrist extension active ROM may reflect the
recruitment of central motor neuron areas involved in the active
movements. A recent case report used functional magnetic resonance
imaging to investigate the effects of DN on the brain activity of a stroke
patient with spasticity and found the increased activation of the sensory
and motor areas in the affected hemisphere after DN [17]. It follows that
the improvement in wrist extension active ROM may be explained by the
activation of the affected motor cortex area.
In this case with post-stroke spasticity, negligible changes occurred
in motor function after the treatment measured according to the ARAT
and FMA. To consider changes in upper limb motor function clinically
important, a minimal difference of 5.7 points in ARAT and 12.4 points in
FMA has to be observed [21,22]. In this case with stroke, the wrist
extension active ROM showed a considerable improvement; conse­
quently, we expected an improvement in motor function in terms of
ARAT and FMA. However, although the improvement in wrist extension
active ROM of 30◦ is a great achievement, the active movements in all
muscles of the upper limb are required for performing functions with
coordination and dexterity. We did not evaluate the proximal and other
hand muscle groups in the affected upper limb for spasticity and active
movements. A study is suggested to consider this matter and use the DN
plus ET to elucidate whether the improvements of spasticity and
restored activity in paralyzed muscle groups will improve the upper limb
motor function. The lack of meaningful changes on the ARAT and FMA
might be expected as the exercise program did not specifically target the
activities incorporated in the two tests, ARAT and FMA. The items on
ARAT and FMA cover a range of fine and gross activities that are
applicable to individuals with stroke, but those were not the focus of the
exercise program. Another possible reason for the lack of recovery of
motor function could be the low dose of the treatment program. Despite
the negligible improvement of motor function on ARAT and FMA, the
patient was satisfied with the treatment program and scored the level of
changes as being “much improvement” after the end of treatment.
5. Conclusion
This case report showed that using 4-session DN of spastic wrist
flexor muscles combined with ET led to a meaningful reduction of
spasticity and improvement of both active and passive wrist ROM in a
patient with chronic stroke. DN plus ET had no clinically meaningful and
relevant effects on motor function according to the ARAT and FMA. A
study with a large sample using a rigorous study design is needed to
reveal the combined effects of DN and ET on the motor function of pa­
tients with stroke.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Authors’ contribution
S.S. Babazadeh-Zavieh: Study concept and design, Acquisition of
data, Analysis and interpretation of data, Drafting of the manuscript. N.
Ghotbi: Study concept and design, Critical revision of the manuscript
3
Complementary Therapies in Clinical Practice 46 (2022) 101520
for important intellectual content, Study supervision. N. Nakhostin
Ansari: Study concept and design, Analysis and interpretation of data,
Drafting of the manuscript, Critical revision of the manuscript for
important intellectual content, Study supervision. S. Naghdi: Study
concept and design, Analysis and interpretation of data, Critical revision
of the manuscript for important intellectual content. M. Khanmo­
hammadi: Acquisition of data. S.M.J Haeri: Drafting of the manuscript.
K. Mansouri: Acquisition of data.
Declaration of competing interest
There are no conflicts of interest.
Acknowledgments
We would like to thank the Research Deputy, Tehran University of
Medical Sciences. We are grateful to the patient and the staff from the
Neurophysiologic Clinic, University Shafa Yahyaian Hospital.
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