Fluent Essays

Assignment:  Students will be assigned a body region.  Each student will then be responsible for choosing one article from a peer reviewed journal using the virtual library in relation to applied anatomy and kinesiology for the assigned body region. L.I.R.N. Annotated Bibliography Assignment Assignment: Students will be assigned a body region. Each student will then be responsible for choosing one article from a peer reviewed journal using the virtual library in relation to applied anatomy and kinesiology for the assigned body region. Students must have the article approved by the instructor prior to submission of the annotated bibliography. The instructor will approve the article based on a peer reviewed journal not content or relevance to the topic. Students will then be required to write an annotated bibliography on the approved article. Date: Students need to email a copy of the complete research article for approval on no later than The Final assignment will be submitted on google classroom. Instructions: Students will construct an annotated bibliography. An annotated bibliography is a list of citations of articles, books, and other publications on a particular topic. Each citation is followed by a relatively brief paragraph that summarizes the source’s argument and other relevant material including its intended audience, sources of evidence, and methodology. The assignment will be completed individually and out of class. The annotated bibliography consists of two elements: 1. The citation in current AMA style format 2. The Annotation - The annotation should consist of one paragraph using whole complete sentences in the third person and should be approximately 150-200 words in length. The assignment should be typed, double spaced, in Times New Roman 12 font, 1” margin. The annotation should include most, if not all, of the following: · Explanation of main purpose · Description of content · Focus of article · Relevance of topic · Type of intended audience · Evaluate its method, conclusion and/or reliability · Strengths / weaknesses or biases · Your own brief impression of the work Assessment: The assignment will be assessed according to the criteria identified in the grading rubric on the attached page. *Once all of the annotated bibliographies are turned in the instructor will be responsible for compiling a comprehensive annotated bibliography, which will be given to the students. Student Name PTA 1401: Applied Anatomy and Kinesiology with Lab L.I.R.N. assignment: annotated bibliography Sample This is a sample of an annotated bibliography. 1. Waters, Eric. Suggestions From the Field for Return to Sports Participation Following Anterior Cruciate Ligament Reconstruction. J Orthop Sports Phys Ther. 2012; 42.4. 326-36. Retrieved From http://www.jospt.org/issues/articleID.2737,type.2/article_detail.asp Eric Waters’s, in his 2012 article “Suggestions From the Field for Return to Sports Participation Following Anterior Cruciate Ligament Reconstruction” concentrates on the treatment of ACL injuries. He supports this by setting examples of specific exercises that treat or prevent ACL injuries. His purpose is to show how treatment works with an ACL injury and explain how to prevent it, in order for others to educate themselves with the study that he has done. His intended audience is physical therapists, doctors, physicians, and athletes. Water’s article is relevant to my topic because he focuses on rehabilitation of athletes. Stating, “Preparing a basketball player for an effective return to play requires that the final and most functional phase of the rehabilitation program encompass a thorough protocol based on exercises that maintain proper lower extremity alignment throughout all the conceivable scenarios of a basketball game,” (333) he exemplifies that it is important to perform certain exercises in order to compete at the best ability. A. Manca, PhD, PT, Department of Biomedical Sciences, University of Sassari, Sassari, Italy. G. Martinez, BSc, PT, Department of Biomedical Sciences, University of Sassari. E. Aiello, MD, Department of Medical, Surgical and Experimental Sciences, University of Sassari. L. Ventura, MSc, PT, Department of Biomedical Sciences, University of Sassari. F. Deriu, MD, PhD, Department of Biomedical Sciences, University of Sassari, Viale S. Pietro 43/b, 07100 Sassari, Italy. Address all correspondence to Dr Deriu at: [email protected] [Manca A, Martinez G, Aiello E, Ventura L, Deriu F. Effect of eccentric strength training on elbow flexor spasticity and muscle weakness in people with multiple sclerosis: proof-of-concept single-system case series. Phys Ther. 2020;100:1142–1152.] © 2020 American Physical Therapy Association Published Ahead of Print: April 7, 2020 Accepted: December 20, 2019 Submitted: June 9, 2019 Post a comment for this article at: https://academic.oup.com/ptj Original Research Effect of Eccentric Strength Training on Elbow Flexor Spasticity and Muscle Weakness in People With Multiple Sclerosis: Proof-of-Concept Single-System Case Series Andrea Manca, Gianluca Martinez, Elena Aiello, Lucia Ventura, Franca Deriu Objective. To date, no attention has been devoted to the employment of eccentric contractions to manage spasticity in multiple sclerosis. This single-system case series aimed to explore the effects of eccentric training on spasticity-related resistance to passive motion in people with multiple sclerosis with elbow flexor spasticity. Methods. Six people with multiple sclerosis (median Expanded Disability Status Scale score = 4.8, range = 2.0–5.5; Modified Ashworth Scale [MAS] score ≤ 3) underwent a 6-week eccentric strength training of the spastic muscles. Before and after the intervention, the following outcomes were assessed: resistive peak torque (RPT), isometric strength, resting limb position, passive range of motion and active range of motion, severity of hypertonia by MAS, and numerical rating scale. At baseline, the primary outcome (RPT) was tested over 3 time points to ensure a stable measurement. The 2-SD method was used to test pre-post training effects at individual level. Group-level analyses were also performed. Results. Following the intervention RPT decreased by at least 2 SDs in all participants but 1, with a significant reduction at group level of 41.6 (29.6)\%. Four people with multiple sclerosis reported a reduction in perceived spasticity severity. No changes in MAS score were detected. Group-level analyses revealed that maximal strength increased significantly in the trained elbow flexors (+30.9 [9.1]\%). Elbow flexion at rest was found to be significantly reduced (−35.5 [12.4]\%), whereas passive range of motion (+4.6\%) and active range of motion (+11.8\%) significantly increased. Conclusion. Eccentric training is feasible and safe to manage spasticity in people with multiple sclerosis. Preliminary data showed that this protocol can reduce resistance to passive motion, also improving strength, spasticity-free range of motion, and limb positioning. Impact. Patients with multiple sclerosis–related spasticity and moderate-to-severe dis- ability can benefit from adding slow submaximal eccentric contractions to the conventional management of spasticity. 1142 Physical Therapy Volume 100 Number 7 2020 D ow nloaded from https://academ ic.oup.com /ptj/article/100/7/1142/5816579 by A P TA M em ber A ccess user on 13 S eptem ber 2021 Eccentric Training to Manage Spasticity I t is estimated that 60\% to 90\% of people with multiplesclerosis experience spasticity,1 a debilitating symptomusually associated with weakness, spasms, and pain. Spasticity negatively impacts a person’s participation in family, work, and social life and, consequently, quality of life.2 Moreover, patients with spasticity display tissue alterations, including contractures and connective changes in muscles, tendons, and joints, which can further impair limb positioning, movement, and function.3 Beyond pharmacological treatments, for which only short-term effectiveness is established, several nonpharmacological interventions are also used, such as physical modalities and structured exercise programs. A Cochrane Database review found “low-level” evidence of beneficial effects for exercise-based approaches given alone or in conjunction with physical modalities.4 In regard to rehabilitation programs, to our knowledge, no attention has so far been devoted to the employment of eccentric contractions (ie, the motion of an active muscle while it is lengthening under load)5 to specifically manage spasticity in multiple sclerosis. Compared with other training regimens, eccentric contractions have been extensively reported in healthy populations to induce the highest gains in maximal force generation and muscle capability to maintain force over the range of motion.6 ,7 Additionally, these effects are obtained at a reduced energy cost, which is of critical importance to people with multiple sclerosis, who exhibit muscle weakness and low reserves of energy and are exposed to early-onset fatigue.8 In addition, lengthening eccentric actions can lead to a better positioning of the affected limb and can reduce the spasticity-associated active and passive muscular insufficiencies in the spastic muscle and in its nonspastic agonist, respectively, which prevent multijoint muscles from achieving the optimal production of strength.9 Overall, these properties were shown to have therapeutic implications in orthopedic conditions, especially for tendon disorders,5 and in neurological conditions characterized by muscle weakness and spasticity-induced contractures. In particular, eccentric protocols were found to increase strength without exacerbating spasticity in children and adolescents with cerebral palsy10 and in stroke survivors.11 In people with multiple sclerosis, eccentric contractions have been previously employed to manage lower limb muscle weakness, with controversial findings ranging from significant increases in strength12 to no additional effect when eccentric training was added to standard concentric exercise.13 These studies, however, only employed lengthening contractions to manage muscle weakness and, to the best of our knowledge, no studies have so far investigated whether an eccentric training protocol can reduce spastic hypertonia. Based on the above rationale, the primary hypothesis of this study was that the employment of a program of eccentric training of the spastic elbow flexor muscles would: (1) prove feasible and safe in people with multiple sclerosis; (2) reduce resistance to passive motion; (3) increase the spasticity-free range of motion (ROM), and (4) improve muscle strength of the spastic elbow flexors. Therefore, this study proposed to explore in people with multiple sclerosis with focal limb spasticity the effects of eccentric training of the spastic muscle(s) on their objective and subjective resistance to passive motion as well as muscle weakness, active/passive ROM, and resting limb positioning. Methods Participants A convenience sample of 6 people with multiple sclerosis with a moderate-to-severe degree of spasticity was selected within the framework of a larger randomized controlled trial (NCT02010398) for which a degree of spasticity equal to or greater than moderate was set as exclusion criterion. The study was conducted according to the Declaration of Helsinki and approved by the institutional Bioethics Committee of the Local Health Authority (ASL n.1-Sassari, Italy; Prot. number 2420/CE 2016). Participants were given an informative note regarding all the modalities and timing of the study and were required to sign an informed consent form before enrollment. All data are stored and protected at the Department of Biomedical Sciences, University of Sassari, Sassari, Italy. Inclusion criteria were: (1) definite diagnosis of multiple sclerosis according to 2017 revision of diagnostic criteria14; (2) Expanded Disability Status Scale (EDSS) score less than or equal to 6.5 with a Pyramidal Functional System score of 2 to 4; (3) unilateral spasticity of the upper limb shown by excessive flexor or extensor muscle tone score less than or equal to 3 as measured by the Modified Ashworth Scale (MAS); (4) compliance with the study instructions; and (5) age greater than 18 years. Criteria for exclusion or discontinuation were: (1) any medical condition contraindicating participation in resistance training exercises; (2) disability and comorbidities caused by medical conditions other than multiple sclerosis; (3) fixed contracture or relevant atrophy in the affected limb; (4) previous or current treatment with any botulin toxin serotype, or phenol, or cannabinoids, or surgery in the previous 6 months; (5) current casting for spasticity of the limb of interest; (6) occurrence of relapses or variations in disease-modifying drugs or symptomatic treatment within 6 months prior to recruitment; (7) major depression (assessed with Beck Depression Inventory scale, cutoff for exclusion ≥ 28); (8) clinically relevant cognitive deficits (assessed with Frontal Assessment Battery scale, cutoff for exclusion ≥ 14; and with the Trail Making Test A and B, cutoffs for exclusion Trail Making Test A ≥ 78 seconds and Trail Making Test B 2020 Volume 100 Number 7 Physical Therapy 1143 D ow nloaded from https://academ ic.oup.com /ptj/article/100/7/1142/5816579 by A P TA M em ber A ccess user on 13 S eptem ber 2021 Eccentric Training to Manage Spasticity Figure 1. Time line of the study. PRE: baseline assessments (phase A of the AB design) with test-retest procedures consisting of 3 bilateral measurements (test, 1-day and 1-week retests) of the resistance to passive mobilization (isokinetic resistive spastic moment, primary outcome) from the spastic and nonspastic limbs; in this phase, baseline measures of dynamometric and clinical-functional outcomes were also performed (secondary outcomes). Intervention: 6-week eccentric training of the spastic elbow flexors (phase B of the AB design). Each arrow indicates 1 training session (total sessions = 18). Post: posttraining test-retest of the primary outcome and posttraining test of secondary outcomes. ≥ 273 seconds); and (9) participation in rehabilitative or training programs in the previous 6 months. Participants deemed eligible underwent clinical and dynamometric assessments within 1 week. Participants were asked to refrain from any other exercise activity for the entire duration of the study. Design A single-system case series study was chosen because it is acknowledged as an appropriate methodology to observe changes in a participant’s performance over time, providing clinically relevant information about individuals.15 ,16 The study design was implemented by carrying out multiple pretests at baseline to control for the familiarization/learning effect, which is frequently associated with strength testing protocols,17 and to control for the high variability in muscle performance observed in people with multiple sclerosis.8 ,18 Multiple baseline assessments were also performed to establish the reliability of the measurements. A series of 6 case studies was completed employing a pretest-posttest design.19 It is also known as AB design, where A represents the multiple baseline assessments, and B refers to the intervention phase followed by the postintervention assessment. The timeline of the study is detailed in Figure 1. Baseline Assessments Dynamometric assessments. All dynamometric tests were performed using an isokinetic device (Kinetic Communicator; KinCom, Chattanooga, TN, USA). The test was carried out in the affected limb first. The unaffected side was also assessed for intraparticipant comparisons. The participant was asked to sit on the dynamometer seat, positioned according to the joint and muscle group under test, and stabilized using custom straps and harnesses. The axis of rotation was aligned with the center of rotation of the elbow joint. Resistance to motor-driven passive mobilization. The isokinetic resistive peak torque (RPT) was set as the primary outcome of the study because it allows quantification of the amount of resistance opposed by the spastic muscle group to passive movement.20 ,21 In the affected side, RPTs were measured during passive elbow extensions to quantify passive resistance to limb movement opposed by the flexor muscles. The participant’s elbow joint was mobilized at increasing angular velocities (from 5 to 240◦/s), according to the participant’s comfort and tolerability. In particular, for angular speeds greater than 180◦/s the flexibility, rigidity, and self-reported perception of discomfort were carefully checked for each participant. During the procedure to measure the RPTs, participants were instructed to relax while the dynamometer was moving the limb throughout the predefined comfortable ROM, which was kept constant from baseline to postintervention assessments to ensure consistency and comparability. Passive torques obtained throughout the full ROM at the angular speed of 5◦/s were used to correct for the effects of gravity and limb weight and to detect the amount of stiffness from the soft tissues, which detracts from the actual torque produced by the flexor muscles.22 ,23 The lowest angular velocity found to elicit the spastic reflex was used for pre-post comparisons in RPT. 1144 Physical Therapy Volume 100 Number 7 2020 D ow nloaded from https://academ ic.oup.com /ptj/article/100/7/1142/5816579 by A P TA M em ber A ccess user on 13 S eptem ber 2021 Eccentric Training to Manage Spasticity Given the high variability in neuromuscular performance observed in people with multiple sclerosis,8 the RPT was measured over 3 time points by means of test-retest procedures (test; 1-day retest; 1-week retest) for reliability purposes, to obtain a stable baseline, avoid potential effects of residual fatigue or muscle soreness, and minimize the presence of ongoing performance-based gains, which can reduce the ability to track the real changes from baseline following the intervention. Of the RPTs recorded over the 3 sessions, the highest was retained for analysis as the baseline value. Offline data analyses were then conducted to establish the RPT for each participant, which was obtained as the difference between the torque recorded from the unaffected and from the spastic elbow flexors. Maximal strength. Maximal voluntary isometric contractions from the affected and unaffected elbow flexor muscles were measured at the optimal muscle length (intermediate ROM). Three trials, each lasting approximately 5 seconds, were collected. Each trial was followed by a 1-minute rest period. Electrogoniometric assessments. The resting limb position and passive and active ROM were measured by electrogoniometry (DataLog Twin Axis, Biometrics Ltd, Newport, United Kingdom). Clinical assessments. These included: (1) the severity of spastic hypertonia, as assessed by the clinician-reported MAS24; and (2) the variations in patient-reported perception of spasticity burden in the trained muscles, as assessed by the numerical rating scale (NRS), with a score from 0 (“no interference of spasticity”) to 10 (“unable to move the spastic joint”). Intervention In general, throughout the training period special attention was devoted to the monitoring of the delayed onset of muscular soreness, which has been associated with eccentric contractions, although levels of soreness diminish with repeated bouts of eccentric exercise because muscle remodeling increases the muscle length.25 Participant-reported delayed muscular soreness relating to a training session was estimated via NRS at the beginning of the following session. The eccentric intervention was performed on the same isokinetic device employed for the dynamometric assessments. People with multiple sclerosis underwent a 6-week eccentric training program targeting the spastic elbow flexors. Each participant was provided with an individually adapted eccentric training regimen tailored according to the strength level recorded at baseline. Participants were required to actively resist (ie, “brake”) with the spastic muscles the forced elbow extension driven by the isokinetic device, which was preset to move at a slow angular velocity (30◦/s). The workload was adjusted to match 70\% of the maximum level of strength recorded at baseline. The training schedule consisted of 3 training sessions per week, each session consisting of 6 to 8 sets of 6 to 10 repetitions (increased on a weekly basis), with a complete recovery of 3 minutes between sets. The training schedule was planned and developed by 1 of the authors, a clinical exercise physiologist and physical therapist with a specific background in testing and training procedures for populations with neurological conditions. Each session was supervised in a 1:1 ratio by a physical therapist with a 5-year expertise with people with multiple sclerosis. Postintervention Assessments Postintervention assessments of the primary and secondary outcomes were performed within 1 week from the end of the training (Fig. 1). Statistical Analysis Data analysis was performed using the SPSS software for Windows, version 18.0 (SPSS Inc, Chicago, IL, USA). The assessment of measurements’ consistency was performed to determine the reliability of the primary outcome, the RPT, which has been previously reported as highly variable.21 ,23 According to Lexell and Downham,26 test-retest reproducibility was estimated by calculating the consistency of the RPT measurements at baseline. The intraclass correlation coefficient (ICC) was calculated over 3 time points using a 2-way random ICC2,1 for average measures. The ICC coefficients were calculated taking a value of less than 0.4 as an index of poor reliability, 0.4 to 0.75 as fair to good reliability, and greater than 0.75 as excellent reliability.27 ICC determination also established the responsiveness of the changes from baseline. Accordingly, the standard error of measurement (SEm) was also calculated using the formula: SEm = SD√(1 − ICC).28 Based on the SEm, the smallest real difference at the individual level (SRDi)26 was calculated using the following formula:29 SRDi = 2.77 SEm√2. To assess the individual-level effects of the eccentric training, the 2-SD band method was employed to quantify the amount of change in RPT from baseline.19 A 2-SD band method was calculated for each participant based on the baseline measurements of RPT over 3 time points. Even though the design of this study was set as single-system, changes from baseline in the amount of resistance to passive motion following the intervention were also analyzed at the group level by running 2-tailed paired t tests for continuous data expressed as mean (SD) (RPT, maximal strength, resting limb position, active ROM, passive ROM), or the nonparametric Wilcoxon signed-rank test for ordinal data (MAS and NRS scores), with significance set at P < .05. 2020 Volume 100 Number 7 Physical Therapy 1145 D ow nloaded from https://academ ic.oup.com /ptj/article/100/7/1142/5816579 by A P TA M em ber A ccess user on 13 S eptem ber 2021 Eccentric Training to Manage Spasticity Table 1. Demographic and Clinical Features of the Participants at the Study Entrya Participants Variable 1 2 3 4 5 6 Age, y 55 38 30 54 29 35 Disease, y 12 13 11 13 14 10 EDSS 4.5 5.0 4.5 5.0 2.0 5.0 MAS 1+ 2 2 1+ 1 1 Walking aids None None None None Walking stick AFO aAFO = ankle foot orthosis; EDSS = Expanded Disability System Status; MAS = Modified Ashworth Scale. Role of the Funding Source Fondazione Italiana Sclerosi Multipla (FISM 2018/R/9) and a grant for Multiple Sclerosis Innovation (GMSI 2018) supported this work. The funders played no role in the design, conduct, or reporting of this study. Results All the participants (6 women; 40.2 [11.6] years old; mean weight: 60.4 [12.3] kg) had a definite diagnosis of relapsing remitting multiple sclerosis with a mean disease duration of 12.2 [1.5] years. They had moderate to severe disability (median EDSS: 4.8; range 2–5.5), normal cognitive functions, and depression ranging from minimal to mild, with the exception of participant #5, who exhibited a Beck Depression Inventory score of 22 (moderate to severe depression). All participants were receiving antispastic pharmacological treatment (baclofen orally) throughout the entire duration of the study, during which no relapses or changes in medications occurred. The intervention was well tolerated, with 100\% adherence to the scheduled program and no adverse events reported by the participants. Overall, a delayed onset of muscular soreness in the trained muscles was reported in the 48 hours following the training sessions of the first week of intervention (median NRS score 4/10; range 2–5). However, none of the participants had to take pain medication or delay the following session due to muscular soreness. Main demographic and clinical features of the participants are reported in Table 1. Resistance to Motor-Driven Passive Motion Data on RPT are reported at 90◦/s of angular velocity, which was found to be the lowest speed able to elicit the spastic reflex in all participants. Regarding the multiple assessments of RPT at baseline (Tab. 2), the ICC values calculated over the 3 assessment sessions at baseline were 0.98 (95\% CI: 0.93–0.99), 0.99 (95\% CI: 0.96–1.00) when comparing sessions 1 and 2, and 0.96 (95\% CI: 0.70–0.99) when comparing sessions 1 versus 3 and session 2 versus 3. The SEm ranged from 7\% to 25\%, with a median value of 15\%, and the SRD ranged from 25.8\% to 31\%. Each participant had therefore to exceed this range of improvement for the observed training-induced change in the resistive peak torque to be considered as meaningful and not due to a measurement error. Individual- and group-level results of the reliability analyses are reported for the RPT in Table 2. Following the eccentric training, the amount of resistance opposed by the spastic muscle(s) against the passive motion carried out by the isokinetic dynamometer, that is, the RPT, was found reduced in all the participants but 1 (Tab. 3). Figure 2 displays for each of the 6 participants the torque/angle isokinetic curve during passive mobilization at 90◦/s of angular velocity at baseline (PRE) and after the 6-week eccentric training (POST) carried out on the isokinetic device both for the unaffected and for the spastic limb. The graphs show that, at baseline, the unaffected limb is linearly moved by the isokinetic device throughout the predefined range of motion. By contrast, the spastic limb opposes a certain amount of resistance to passive motion, as shown by the opposite direction taken by the curve (downward rather than upward trend). The difference between the patterns exhibited by the 2 limbs was reduced following the 6-week eccentric training. When appraising the results through visual inspection, based on the 2-SD band method, the posttraining curves of 5 participants (#1, #2, #3, #4, and #6) were found to be at least 2 SDs below the baseline values, thus indicating a significant reduction at the individual level in the amount of resistance to passive mobilization. For participant #5, a nonsignificant reduction in the RPT was observed. Comparing the training-induced percentage change in the resistive peak torque with the SRDi range calculated at baseline (25.8\%–31\%), 5 participants (#1, #2, #3, #4, and #6) of the 6 participants were found to exceed this threshold, whereas 1 patient (#5) did not. Resistance to Manual Passive Mobilization Following the 6-week eccentric training, 5 of the participants (#1, #2, #3, #4, and #6) reported a subjective reduction in self-perceived severity of spasticity, as 1146 Physical Therapy Volume 100 Number 7 2020 D ow nloaded from https://academ ic.oup.com /ptj/article/100/7/1142/5816579 by A P TA M em ber A ccess user on 13 S eptem ber 2021 Eccentric Training to Manage Spasticity Table 2. Reliability of the Resistive Peak Torque Measured During Passive Isokinetic Extensions of the Affected Elbow Flexors at Baseline Resistive Peak Torque,a Nm Participants Test 1-Day Retest 1-Week Retest 1 12.9 (9.2) 12.2 (8.9) 12.3 (9.0) 2 17.4 (11.9) 17.0 (12.1) 17.2 (11.5) 3 22.5 (14.0) 20.7 (12.6) 17.0 (11.6) 4 8.7 (5.8) 6.2 (4.2) 8.5 (5.9) 5 6.5 (3.6) 6.4 (4.0) 6.5( 4.1) 6 11.0 (6.2) 10.3 (6.2) 9.8 (5.7) 1–6 13.2 (6.2) 12.1 (5.8) 11.9 (4.5) aThe resistive peak torque was calculated as the difference between the torques recorded from the nonspastic and spastic elbow flexors, respectively. Values are means (SD) in newton meters (Nm); all torques recorded at 90◦/s of isokinetic angular velocity. Table 3. Resistive Peak Torques Measured During Passive Isokinetic Extension of the Nonspastic and Spastic Elbow Flexors Before (PRE) and After (POST) the 6-Week Period of Eccentric Traininga PRE POST Participants Nonspastic Torque, Nm Spastic Torque, Nm RPT, Nm Nonspastic Torque, Nm Spastic Torque, Nm RPT, Nm RPT PRE to POST Change, \% 1 18.3 (5.7) 5.4 (3.7) 12.9 (9.2) 16.9 (6.1) 9.8 (1.9) 7.1 (5.4) −45\%b , c 2 18.0 (5.7) 0.6 (6.5) 17.4 (11.9) 17.0 (6.5) 10.6 (2.5) 6.5 (5.3) −62.7\%b , c 3 18.7 (5.6) −4.2 (8.4) 22.5 (14) 18.2 (6.1) 11.6 (2.6) 6.6 (4.7) −70.7\%b , c 4 16.0 (5.5) 7.3 (1.5) 8.7 (5.8) 15.2 (6.1) 10.1 (2.8) 5.1 (3.7) −41.4\%b , c 5 18.9 (3.2) 12.4 (1.9) 6.5 (3.6) 18.2 (3.5) 10.8 (1.3) 7.4 (2.2) 13.8\% 6 17.1 (5.6) 6.1 (1.6) 11.0 (6.2) 16.3 (6.3) 10.1 (2.8) 6.2 (3.9) −43.6\%b , c 1–6d 17.8 (1.1) 4.5 (5.8) 13.2 (5.9) 17 (1.2) 10.5 (0.7) 6.5 (0.8) −41.6 (29.6) P = .018 aValues are means (SD) in newton meters (Nm). All torques recorded at 90◦/s of isokinetic angular velocity. RPT = resistive peak torque calculated as the difference between the torques recorded from the nonspastic and spastic elbow flexors, respectively. bPRE to POST change in resistive peak torque exceeding the smallest real difference (SRDi) cutoff for clinically meaningful change. cSignificant change from baseline according to the 2-SD band method calculated for each participant at baseline over 3 time points. d1–6 = group-level results as assessed by 2-tailed paired t tests; significance set at P < .05. assessed by the 0 to 10 NRS. Participants #1, #2, #3, and #4 reported a reduction by at least 1 point. No change was detected in the clinician-rated MAS scores (Tab. 4). Maximal Strength Following the eccentric training, maximal voluntary isometric strength of the elbow flexors measured at the optimal muscle length (intermediate ROM) increased in all the participants (+30.9 [9.1]\%; 95\% CI: 20.3-41.4; P = .0006; Tab. 4). Resting Limb Position, Passive and Active ROM Table 4 summarizes data by participant and at the group level. At the POST-evaluation, electrogoniometry of the spastic side revealed reduced flexion at rest in the spontaneous position of the upper limb in all participants. At the group-level analysis, resting limb position was found significantly improved (−35.5 [12.4]\%; 95\% CI: 23.8-49.8; P = .0008). Both passive ROM (+4.6\%; P = .005) and active ROM (+11.8\%; P = .009) were found to be significantly increased (Tab. 4). Discussion To our knowledge, the present proof-of-concept single-system case series employed eccentric training for the first time primarily to modulate spastic hypertonia, unlike previous studies in neurological populations that used similar protocols to increase muscle strength in stroke survivors11 and in children with cerebral palsy.10 We 2020 Volume 100 Number 7 Physical Therapy 1147 D ow nloaded from https://academ ic.oup.com /ptj/article/100/7/1142/5816579 by A P TA M em ber A ccess user on 13 S eptem ber 2021 Eccentric Training to Manage Spasticity Figure 2. Effects of a 6-week eccentric training on the isokinetic spastic resistive moment recorded bilaterally: individual results. Moment/angle isokinetic curve at 90◦/s of angular velocity is shown for each participant at baseline (PRE, left panels) and after the 6-week eccentric training (POST, right panels) carried out on the isokinetic device. Data are reported for the unaffected limb (continuous line) and the affected limb (dotted line). Graph axes are optimized for each case. 1148 Physical Therapy Volume 100 Number 7 2020 D ow nloaded from https://academ ic.oup.com /ptj/article/100/7/1142/5816579 by A P TA M em ber A ccess user on 13 S eptem ber 2021 Eccentric Training to Manage Spasticity Table 4. Muscle Strength, Goniometric and Qualitative Measures of Muscle Hypertonia in Persons With Multiple Sclerosis Presenting Spasticity of Elbow Flexors Before and After 6 Weeks of Eccentric Training of the Spastic Musclesa Participants Outcomes Assessed 1 2 3 4 5 6 1–6 Spastic elbow flexors MVIC, (Nm) PRE 27.4 33.9 40.6 30.2 48.2 37.6 36.3 (7.5) (95\% CI: 28.4 to 44.2) POST 38.8 46.3 48.5 41.1 58.1 49.4 47.0 (6.8) (95\% CI: 39.8 to 54.2) P .0006 Resting limb position, (deg) PRE 17 24 30 12 18 17 19.7 (6.3) (95\% CI: 13.0 to 26.3) POST 9 14 22 7 15 9 12.7 (5.5) (95\% CI: 6.9 to 18.5) P .001 PROM, (deg) PRE 110 102 105 107 111 114 108.2 (4.3) (95\% CI: 103.6 to 112.7) POST 113 109 113 110 113 121 113.2 (4.2) (95\% CI: 108.7 to 117.6) P .005 AROM, (deg) PRE 87 74 90 92 101 101 90.5 (9.7) (95\% CI: 80.3 to 100.7) POST 104 93 101 99 103 103 101.2 (4.8) (95\% CI: …