Vibrotherapy combined with botulinum toxin treats spasticity in people with multiple sclerosis

The use of segmental local vibrotherapy in combination with botulinum toxin injections reduced spasticity of the knee and ankle joint in people with multiple sclerosis. The positive effects of both therapies: vibrotherapy and botulinum toxin used together or separately were observed three months after treatment.

Spasticity in patients with multiple sclerosis should be carefully analysed and treated, as it is a symptom that negatively affects mobility and overall mobility and balance. Intramuscular injection of botulinum toxin has been effective in treating spasticity in patients with multiple sclerosis, especially in conjunction with early mobilisation and physiotherapy. Segmental muscle vibration is a new therapeutic modality for the treatment of spasticity in post-stroke patients. The aim of this study was to evaluate the effect of episodic muscle vibration, either alone or in combination with botulinum toxin, on reducing spasticity in patients with multiple sclerosis.

• In all study groups (the group receiving segmental muscle vibration, the group using botulinum toxin and segmental muscle vibration, and the group using botulinum toxin), there was a decrease in spasticity at the knee and ankle both at the end of therapy and 3 months after therapy.
• The decrease in spasticity at the ankle and knee persisted up to 3 months after therapy in the group using vibration therapy and in the group using vibration therapy combined with botulinum toxin injections.
• The greatest improvement in physical performance was seen in the group using topical vibrotherapy in combination with botulinum toxin.

Compiled from:

Study population

The study design included female and male multiple sclerosis patients aged 18-65 years with lower limb spasticity and following anti-spasticity/anti-epileptic treatment lasting at least three months prior to the study. Previous treatment with botulinum toxin and use of vibrotherapy were exclusion factors from the study.

Study procedure

Participants who met the inclusion criteria were allocated to three groups: group A receiving episodic muscle vibration, group B using botulinum toxin type A and episodic muscle vibration and group C using botulinum toxin. The subjects were clinically assessed before the start of treatment, four weeks after the treatment period and three months after the end of treatment. For four weeks, all participants were subjected to a 60-minute general physiotherapy session three times a week. Exercises included maintaining muscle length through passive or active exercises and stretching exercises at the site of vibration therapy or injections. Fifteen days before the start of general physiotherapy, subjects in groups B and C received botulinum toxin injections. Subjects in groups A and B received 30 minutes of segmental muscle vibrotherapy, which was conducted at the end of each general physiotherapy session. In group C, only general physiotherapy sessions were conducted. Botulinum toxin was injected into the rectus femoris muscle, the gastrocnemius muscle (lateral and medial head) and the patellar muscle. Each patient was assessed using the Modified Ashworth Scale including assessment of lower limb spasticity, assessment of fatigue using the Fatigue Severity Scale and the Barthel scale assessing independence in performing daily activities.

Results

In all study groups (group A receiving segmental muscle vibration, group B using botulinum toxin and segmental muscle vibration and group C using botulinum toxin), there was a decrease in spasticity at the knee and ankle both at the end of therapy and 3 months after therapy. The decrease in ankle spasticity persisted 3 months after therapy in the group using vibration therapy and in the group using vibration therapy combined with botulinum toxin injections (Modified Ashworth Scale: group A before therapy 4, after 4 weeks 2, after 3 months of therapy 3: group B before therapy 4, after 4 weeks 3, after 3 months 3; group C before therapy 4, after 4 weeks 3, after 3 months 4). Knee spasticity decreased after vibration therapy and vibration therapy in combination with botulinum toxin (Modified Ashworth Scale: group A before therapy 3, after 4 weeks 2, after 3 months of therapy 3: group B before therapy 4, after 4 weeks 2, after 3 months 3; group C before therapy 4, after 4 weeks 3, after 3 months 3). Fatigue Severity Scale scores changed significantly in all groups, with the group using local vibrotherapy together with botulinum toxin having the best scores (before therapy 43.4, after 4 weeks 37.3, after 3 months of therapy 39.7). The highest Barthel scale scores between baseline and subsequent measurement points indicating an improvement in mobility were observed in the group using vibrotherapy combined with botulinum toxin injections (before therapy 76.4, after 4 weeks 78.1, after 3 months after therapy 77.8).

Summary

Episodic muscle vibration and botulinum toxin used alone or in combination reduce muscle tension and fatigue symptoms both one month and three months after therapy in multiple sclerosis patients. Episodic muscle vibration can be applied to individual muscles are useful in the treatment of focal spasticity. Vibration platforms can also be used in the treatment of spasticity, but this results in the vibratory stimulus being transmitted throughout the body. Vibratory stimuli applied directly to muscles induce presynaptic inhibition of Ia afferent fibres and presumably reduce the release of transmitter from Ia afferent fibres, thereby reducing the excitability of the monosynaptic reflex. The application of 91 Hz vibratory stimuli to spastic upper limb muscles in post-stroke patients leads to a significant and sustained (up to 30 minutes) reduction in muscle tone, which is also accompanied by a reduction in F-wave amplitude and F/M ratio, indicating a reduction in motor-neural excitability. In addition, vibration also reduces the H-reflex, probably through post-stimulus stasis mechanisms and dendritic depolarisation. Episodic muscle vibrotherapy also has effects at the central nervous system level, as demonstrated by transcranial magnetic stimulation studies. Repeated interventions of muscle vibration, applied during voluntary contractions of the target muscles (i.e. the radial wrist flexor muscle) induce long-term intracortical inhibition of the radial wrist flexor and the opposite pattern in the antagonist muscle. These findings advance the hypothesis that muscle vibration may, by inducing motor-cortical reorganisation, influence functional recovery during neurological disorders. According to this hypothesis, the application of episodic muscle vibration to the injured lower limb leads to improved movement parameters among stroke patients, which was seen not only on the side with paresis, but also on the opposite, healthy side of the body. Neither segmental muscle vibration nor botulinum toxin had a negative effect on fatigue. In the third month after therapy, fatigue values were significantly lower than those at baseline in all study groups. One causal mechanism that plays an important role in the onset of fatigue associated with multiple sclerosis is the distortion of functional connections within the brain-muscle circuit. The improvement seen in fatigue symptoms can be attributed to functional changes that are induced by segmental muscle vibration or botulinum toxin injection and expresses modulations of afferent Ia fibres, which are more ‘open and responsive’ to therapeutic treatment. Positive effects of both therapies: vibrotherapy and botulinum toxin used together or separately were observed three months after treatment.

More in: