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Prevalence of Spasticity and Postural Patterns in the Upper Extremity Post

Stroke

Article  in  Journal of Stroke and Cerebrovascular Diseases · November 2020

DOI: 10.1016/j.jstrokecerebrovasdis.2020.105253

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 Prevalence of Spasticity and Postural Patterns in the Upper
Extremity Post Stroke

lveda,§ G. Carvallo,{
A. Doussoulin,* C. Rivas,† J. Bacco,‡ P. Sepu
C. Gajardo,# A. Soto,k ** and R. Rivas,**,††
,

Introduction: A high number of patients with stroke develop upper extremity spas-
ticity, causing abnormal postures and patterns. These alterations limit the use of
arm in functional activities and affect social participation. Aim: To determine the
prevalence of spasticity and postural patterns of the upper extremity post stroke.
Materials and methods: A cross-sectional descriptive design was used with a prospec-
tive follow-up. The sample included 136 patients. The study included 3 measuring
times; at 10 days (T1), applying a record with sociodemographic-clinical data, the
evaluation of muscle tone in the elbow and wrist and the postural patterns of the
UE, and at 3 months (T2) and 12 months (T3) post stroke, re-evaluating tone and
patterns. Prevalence was calculated through the one-sample chi-squared (x2) test
followed by inspection of the standardized residuals (z) in each cell. The Kappa
coefficient evaluated the degree of agreement in elbow and wrist tone. Results: The
prevalence of spasticity in the elbow was 37.5% at T1, 57.4% at T2, and 57.4% at T3.
At each time there was a high degree of agreement between elbow and wrist tone.
Patients developed increased elbow tone between T1 and T2, with maintained tone
between T2 and T3. Postural pattern III was the most prevalent according to
Hefter’s classification. Conclusion: The prevalence of spasticity in the elbow and
wrist increases between 10 days and 3 months post stroke, and is maintained
between 3 and 12 months. The onset of spasticity occurs in almost half of patients
during the first 10 days post stroke. Postural pattern III according to Hefter’s classi-
fication presented the greatest prevalence in the spastic UE.
Key Words: Muscle spasticity—Postural patterns—Prevalence—Stroke—Upper
extremity
© 2020 Elsevier Inc. All rights reserved.

From the *Physiotherapist, Associate Professor, Departamento de
Pediatría y Cirugía Infantil - Universidad de La Frontera Temuco,
Hochstetter 405, Temuco, Chile; †Physiotherapist MV Clinical
Temuco, Chile; ‡Rehabilitation Physician, Instituto Telet

on − Valpar-
aíso; §Physiotherapist, Departamento Ciencias Preclínicas − Universi-
dad de La Frontera, Temuco; {Physiotherapist, Hospital Dr. Hern
an
Henríquez Aravena, Temuco, Chile; #Physiotherapist, Centro Habili-
dades Clínicas, Universidad de La Frontera, Temuco, Chile;
kNeurologist, Hospital Dr. Hern
an Henríquez Aravena, Temuco,
Chile; **Departamento de Especialidades M
edicas, Universidad de La
Frontera, Temuco, Chile; and ††Neurologist, Clínica Alemana de
Temuco, Chile.
Received July 31, 2020; accepted August 15, 2020.
Corresponding author. E-mail: arlette.doussoulin@ufrontera.cl.
1052-3057/$ - see front matter
© 2020 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.105253
Introduction
Spasticity is one of the clinical manifestations of upper
motor neuron syndrome (UMNS), resulting from deterio-
rated function and inducing alterations in rheological
muscle properties such as fibrosis, rigidity, and atrophy.1
Its onset is highly variable and can occur during the
first weeks or even a year after a stroke.2 Its prevalence is
considered to range from 4% to 43%, with an incidence of
disability of 2% to 13%.3
Clinically, spasticity varies in degree: from focal
involvement of some muscle groups to a global manifesta-
tion. Thus, the spastic case is typically expressed in the
upper and lower extremities through characteristic pat-
terns, affecting mainly the elbow (79%), wrist (66%) and
ankle (66%).4
Scientific evidence suggests that spasticity in the upper
extremity (UE) is associated with reduced function and

Journal of Stroke and Cerebrovascular Diseases, Vol. 29, No. 00 (), 2020: 105253 1
2 A. DOUSSOULIN ET AL.
lower levels of independence.5 This situation is also iden-
tified in the clinical practice, affecting the rehabilitation
process.6
Although the classic position of the UE is described with
shoulder adducted with internal rotation, flexed elbow,
flexed wrist and closed fist.7 This is not the only pattern of
spasticity that can manifest in the upper extremity.
Starting from a differentiated analysis of the position
and movement of the arms, a method to identify homoge-
nous sub-groups of patients with stroke could be the basis
for a common terminology, facilitating the exchange of
information between clinicians and allowing for a poten-
tial increase in the effectiveness of interventions.8
The aim of this study was to determine the prevalence
of spasticity and postural patterns of the UE after a stroke.
Materials and methods
Design
A cross-sectional descriptive study was conducted with
a prospective follow-up.
Sample
Non-probability sampling was used, initially recruiting
186 patients, of whom 45 were excluded for not meeting
the inclusion criteria, leaving 141 to participate in the first
assessment period (T1). The final sample, i.e., those with
all three evaluations, was composed of 136 patients due
to the loss of 5 subjects between T1 and T2 (Fig. 1).
Fig. 1. Flow chart of the study.
Inclusion criteria
 Aged between 18 and 90 years
 No prior history of motor disability
 Diagnosis of first ischemic or hemorrhagic stroke con-
firmed by computed tomography (CT) and/or mag-
netic resonance imaging (MRI).
 Voluntary agreement to participate in the study by
signing the informed consent, personally or through a
relative.
Exclusion criteria
 Musculoskeletal pathology in the affected UE.
 Medical contraindication (e.g. decompensated: heart
failure, diabetes mellitus, severe chronic pulmonary
disease and end-stage renal disease).
 History of prior stroke.
Procedure
Identification and recruitment and of the sample was
performed during the first 10 days of hospitalization (T1).
Potential participants were initially assessed by a neurolo-
gist belonging to one of the participating health centers,
who verified the inclusion criteria, confirmed demo-
graphic data and clinical aspects referring to comorbid-
ities such as hypertension, cardiopathies and diabetes and
verified the type, extent and severity of the stroke. The
severity of the neurological deficit was evaluated using
SPASTICITY AND POSTURAL PATTERNS AFTER STROKE
the NIHSS (National Institute of Health Stroke Scale), which
contains of 42 points, with an increase in score indicating
greater neurological involvement. The final score was cat-
egorized as: no deficit (0), mild deficit 1-4, moderate defi-
cit 5-15 and severe deficit > 15 points.9
The extent and severity of the damage was evaluated
through ASPECTS (the Alberta Stroke Program Early CT
Score), which is a quantitative topographic scale (0 to 10
points) that assesses acute ischemic changes in the terri-
tory of the middle cerebral artery (MCA) at the level of
the basal ganglia and above the basal ganglia through cra-
nial CT in patients with a recent stroke.10 For the present
study, the scores derived from the CT were added accord-
ing to four categories of damage in the MCA: severe (0-4),
moderate,5−7 mild,8−9 and no damage.10,11
The damaged area of the brain was identified using the
four subtypes from the classification of the Oxfordshire
Community Stroke Project (OCSP): lacunar infarct
(LACI), total anterior circulation infarct (TACI), partial
anterior circulation infarct (PACI), and posterior circula-
tion infarct (POCI). This classification provides fast, sim-
ple and prognostically valuable information.12 In
addition, it can predict the size and location of the lesion
in 75% of patients.13
During this period (T1), and 3 months (T2) and 12
months (T3) after the onset of the stroke,14 a previously
trained physiotherapist from each health center assessed
muscle tone in the elbow and wrist, motor damage and
postural patterns.
Muscle tone was categorized as flaccid, normal or spas-
tic. To determine the degree of spasticity the Modified
Ashworth Scale (MAS) was used,15,16 given its utility
Fig. 2. Postural patterns of spastic UE, Hefter’s classification of patterns.8
3
when applied to the UE17 and its high interobserver reli-
ability.18 For this study the 6 original values of the MAS
were regrouped into 4: normal (value 0), mild spasticity
(values 1 and +1), moderate spasticity (values 2 and 3),
and severe spasticity (value 4). This classification has been
used in other studies about spasticity.19
Motor damage in the UE was assessed by asking the
patient to execute the movement, “place your affected
hand above your head”, categorized as normal if the com-
plete movement was achieved, as hemiparesis if the
movement was begun but not concluded, and as hemiple-
gia if the movement was not performed.
The postural patterns of the UE were assessed through
clinical observation using the classification of patterns
proposed by Hefter.8 The description of these patterns
appears in Fig. 2.
This study was conducted in 2018 and 2019, with prior
approval from the Ethics Committee of the Servicio de
Salud Araucanía Sur (SSAS). It was also registered at Clin-
icalTrials.gov (NCT0358883).
Analysis
The prevalence of spasticity was estimated as the per-
centage of patients with at least mild muscle tone accord-
ing to the MAS, thus excluding normal tone and
flaccidity. Cohen’s kappa coefficient (1960) was used to
evaluate the degree of agreement in muscle tone between
the elbow and wrist at each time period.33 The prevalence
of UE patterns was calculated using the one-sample x2
test followed by inspection of the standardized residuals
(z) in each cell.20 The positive and negative residuals with
4 A. DOUSSOULIN ET AL.

Table 1. Sociodemographic and clinical characteristics. Table 2. Patient distributions according to the patterns evalu-
ated and x2 test results and the analyses of the standardized
Characteristics %
residuals (z).
Sex Female 51 37.5
Male 85 62.5 Pattern taxonomies x2 % n z
Age ranges 25 to 44 years 15 11.0 UE Hefter (N = 136) 152.81***
45 to 64 years 54 39.7 Pattern I 3.4 5 3.98***
65 and over 67 49.3 Pattern II 9.4 14 2.17*
Residence Urban 104 76.5 Pattern III 52.3 73 10.67***
Rural 32 23.5 Pattern IV 19.5 24 0.84
Type of stroke Ischemic 105 77.2 Pattern V 3.4 5 3.98***
Hemorrhagic 31 22.8 Other 12.1 15 1.37
NIHSS Score 0: Normal 12 8.8
*p < 0.05. **p < 0.01. ***p < 0.001.
Score 1 to 4: Slight 75 55.1
Score 5 to 15: Moderate 40 29.4
Score 16 to 20: Severe 9 6.6 In relation to the type of stroke, post hoc spasticity tests
HBP Yes 103 75.7 at T1 indicated that 36.2% of subjects with ischemic stroke
No 33 24.3 presented normal tone and 58.1% of the subjects with
ASPECTS Moderate damage 35 25.7 hemorrhagic stroke presented mild spasticity. At T2, only
MCA (5−7 points) the difference in the normal category was significant
Slight damage 44 32.4 (45.7% in ischemic stroke vs. 19.4% in hemorrhagic
MCA (8−9 points)
stroke). These results indicate that, in relative terms, the
No damage MCA (10 point) 25 18.4
patients with ischemic stroke tend to have normal tone
Not applicable 32 23.5
OCSP TACI 17 12.5 and the subjects with hemorrhagic stroke mild spasticity.
PACI 77 56.6 No statistically significant differences were observed
LACI 11 8.1 between to spasticity and stroke severity (NIHSS) and age.
POCI 31 22.8 The analyses of prevalence suggest that spasticity in the
Motor damage Hemiplegia UE 47 34.6 elbow was 37.5% at T1 and 57.4% at T2 and T3. Similar
Hemiparesis UE 67 49.3 percentages were observed in the wrist: 36.8% at T1 and
No change 22 16.2 57.4% at both T2 and T3. These results indicate that the
Note: NIHSS: National Institute Health Stroke Scale; HBP: High prevalence of spasticity in both joints increased from T1 to
blood pressure; ASPECTS: Alberta Stroke Program Early CT Score; T2 but remained the same from T2 to T3. Among the 114
OCSP: Oxfordshire Community Stroke Project classification; TACI: patients with motor damage, for 44.7% spasticity in the
total anterior circulation infarct; PACI: partial anterior circulation elbow set in during T1 (i.e., the first 10 days), for 23.7%
infarct; LACI: lacunar infarct; POCI: posterior circulation infarct;
between T1 and T2 and for 0.9% between T2 and T3. A
UE: upper extremity; f: frequency; %: percentage.
total of 30.7% of these patients lacked spasticity in the
p < 0.05 were interpreted, respectively, as high prevalence elbow at all three times. The results were very similar for
(predominant occurrence or above random) and low spasticity in the wrist.
prevalence (unusual occurrence or below random). The Table 2 provides the distribution of patients according
SPSS 25 program was used for the statistical analysis. to the taxonomies of spastic patterns and the results of the
corresponding one-sample x2 tests and the analyses of
the standardized residues. All the distributions were sig-
Results
nificantly different from the expected random distribu-
In relation to the sample, Table 1 describes the main tion. With respect to Hefter’s patterns, a high prevalence
results referring to the sociodemographic and clinical of Pattern III was observed and low prevalence of Patterns
characteristics: 62.5% were men, 49.3% were aged 65 years I, II, and V.
or more, and 76.5% of the subjects lived in an urban area.
Ischemic stroke is worthy of note with 77.2% in the clin-
Discussion
ical characterization. Hypertension stands out as the most
relevant comorbidity with 75.7%. The assessment of neu- In this study a high prevalence of spasticity in the UE
rological deficit using the NIHSS presented categorization was detected at the three measurement times. A predomi-
in the mild range of 55.1%, moderate 29.4% and severe nant postural pattern in the study population was also
6.6%. A total of 58.1% of the subjects presented moderate clearly identified.
to mild damage to the MCA (according to the ASPECTS) The onset of spasticity for almost half of the patients
and 56.6% presented PACI according to the OCSP. With with motor damage began in the first 10 days after the
respect to motor damage, 83.9% presented hemiparesis or stroke. This finding agrees the results reported in the stud-
hemiplegia in the UE. ies by Wissel (2015) and Sommerfeld (2004),5,21 but differs
SPASTICITY AND POSTURAL PATTERNS AFTER STROKE
from that reported by Urban (2010), who found 43% of
spasticity at 6 months after the stroke. These results indi-
cate that the onset of spasticity continues to be highly var-
iable, information that prevents determination of a
universal prevalence.22 Some approaches try to explain
this wide variability by associating it with the diverse ter-
minology and complex phenomenology of spasticity.23
The term has been subject to a huge number of historical
and conceptual zigzags,24 a situation that is limiting when
clinicians and researchers are evaluating and defining
subjects with spasticity.
The prevalence of spasticity in the elbow and wrist pre-
sented similar percentages during the first 3 months after
the stroke. That to say, in both joints spasticity increased
between the first 10 days and 3 months post stroke, and
remained constant between this period and 12 months;
similar results were obtained in recent studies.25,26 Sup-
porting these results, a study with electromyography con-
cluded that the increase in muscle tone reaches its
maximum between the first and third month post stroke.27
With respect to postural patterns, pattern III presented
the greatest prevalence according to Hefter’s classifica-
tion, while two patterns were relatively rare (patterns I
and V). This information differs from the typical pattern
of spasticity of the UE exhibited in neurology texts (pat-
tern IV; Wernicke-Mann posture).28 However, the pattern
identified is correlated with the results obtained in
Hefter’s study, 2012.8 The greatest prevalence of pattern
III, unlike the Wernicke-Mann posture, can be explained
by the extensor muscles tending to be more affected by
weakness than the flexors in the UE.29 Contributing to
this information, Schaefer (2007) identified that the distal
muscles of the UE are more affected after UMNS, with
greater weakness in the wrist and fingers.30
With respect to type of stroke, although the percentage
of ischemic strokes was greater, a correlation was noted
between hemorrhagic strokes and the presence of spastic-
ity. Similar data were reported by other studies.25,31 This
information is relevant considering that this type of stroke
is associated with greater severity and, probably, greater
spasticity than the ischemic stroke.32
Although spasticity can be beneficial for certain func-
tional movements (for example, locomotion and the sup-
port of body weight),33 it continues to be an important
neurological alteration that frequently limits the motor
functions of many stroke survivors34, leading to abnormal
muscle activation patterns and disabling body and joint
positions in the extremities.35
The impact that spasticity may have on recovery can be
variable and is not identified initially; however, in sub-
acute and chronic stages, spasticity is associated with
hypertonia, where the resistance to passive movement
and abnormal positions that affect the UE can limit the
rehabilitation process.36,37
The strengths of the study include it being the first
study conducted in Latin America that assesses the
5
prevalence, onset time, and postural patterns of spasticity
post stroke. Moreover, the percentage of loss to follow-up
was also very low, and all the patients were evaluated
clinically and through neuroimaging, using scales widely
validated in vascular neurology.11
The limitations of the study include the recruitment of
the sample, since two health centers (one public and one
private) in the city were included, which do not necessarily
represent the reality of other centers; nevertheless, it is
important to emphasize that these centers attend 80% of
the stroke admissions in the geographic sector of reference.
Another aspect to consider is the low percentage of patients
with severe stroke, which could lead to underestimation of
the prevalence of spasticity; however, this was a character-
istic of the subjects who comprised the study sample.
Conclusion
The prevalence of spasticity in the elbow and wrist
increases between 10 days and 3 months post stroke, and
remains constant between 3 and 12 months. The onset of
spasticity occurs in almost half of patients during the first
10 days post stroke. Postural pattern III according to
Hefter’s classification presented the greatest prevalence.
This information is an important input for the func-
tional prognosis of patients and for the generation of
future studies that seek to advise on therapeutic strategies
that promote the rehabilitation and recovery of the UE.
Declarations of Computing Interest
The authors declare that they have no known compet-
ing financial interests or personal relationships that could
have appeared to influence the work reported in this
paper.
Grant support
Project DIUFRO DI18-0034, Universidad de La Frontera,
Chile.
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