Effect of Transcutaneous Spinal Cord Stimulation on Spasticity, Mobility, Pain and Sleep in Community Dwelling Individuals Post-Stroke A single case withdrawal design Belinda Chenery Thesis for the degree of Master of Science in Movement Science June 2019 Effect of Transcutaneous Spinal Cord Stimulation on Spasticity, Mobility, Pain and Sleep in Community Dwelling Individuals Post-Stroke A single case withdrawal design Belinda Chenery Thesis for the degree of Master of Science in Movement Science Number of credits: 60 ECTS Supervisor: Anestis Divanoglou Masters committee: Anestis Divanoglou, Kristín Briem, Þórður Helgason Department of Physical Therapy Faculty of Medicine School of Health Sciences June 2019 Áhrif raförvunar mænu með yfirborðsskautum á síspennu, hreyfigetu, verki og svefn einstaklinga sem hafa fengið heilaslag og búa heima Einliðavendisnið Belinda Chenery Ritgerð til meistaragráðu í hreyfivísindum Fjöldi eininga: 60 ECTS Umsjónarkennari: Anestis Divanoglou Meistaranámsnefnd: Anestis Divanoglou, Kristín Briem, Þórður Helgason Námsbraut í sjúkraþjálfun Læknadeild Heilbrigðisvísindasvið Háskóla Íslands Júní 2019 Thesis for master’s degree in Physiotherapy at the University of Iceland. No part of this publication may be reproduced in any form without the prior permission of the copyright holder. © Belinda Chenery, 2019 Prentun: Háskólaprent Reykjavík, Ísland, 2019 Abstract Effective treatment modalities for alleviating spasticity and pain and enhancing mobility and sleep are limited post-stroke. Some evidence suggests that techniques of transcutaneous spinal cord stimulation (tSCS) may be beneficial. However, these are typically small pretest-posttest studies with high risk of bias. To date, there are no studies that evaluate the effects of tSCS in stroke. The aim of the current study was to evaluate the effects of daily home-treatment with tSCS on spasticity, mobility, pain and sleep in community dwelling individuals post-stroke. Four cases were included in a single-subject withdrawal research design comprised of two alternating baseline and intervention phases (ABAB). Each phase consisted of three measurement sessions. Clinical, biomechanical and self-report data were collected and analysed with visual and statistical techniques, suitable for single-subject design. The intervention consisted of daily home application of tSCS for three weeks. Treatment efficacy was disparate between participants. For one out of the four cases, the results revealed large effect sizes for spasticity, mobility, pain and sleep when using tSCS the first time. Maintenance of effect size from the first baseline to second intervention phase was statistically significant for mobility, pain and sleep. In the other three cases, apart from an improvement on two occasions for mobility measures, there were no improvements. Repetition of a positive effect size was not demonstrated in any case. The results of the study indicate that tSCS may be a useful tool in post-stroke rehabilitation for alleviating spasticity and pain and enhancing mobility and sleep in some community dwelling individuals post-stroke. This inexpensive, non-invasive and easily accessible home-treatment method may be a suitable tool for some individuals. iii Ágrip Árangursrík meðferðarform sem miða að því að draga úr síspennu og verkjum og bæta hreyfigetu og svefn eru af skornum skammti fyrir þá sem fengið hafa heilaslag. Vísbendingar eru um að raförvun mænu með yfirborðsrafskautum (tSCS) geti verið gagnleg, en flestar rannsóknir á þessu sviði eru einfaldar tilviksrannsóknir, með tilheyrandi hættu á skekkjum. Ekki eru til neinar kerfisbundnar rannsóknir þar sem áhrif tSCS eru könnuð á einstaklinga sem fengið hafa heilaslag. Markmið þessarar rannsóknar var að kanna áhrif daglegrar tSCS heimameðferðar á síspennu, verki, hreyfigetu og svefn meðal einstaklinga sem fengið höfðu heilaslag og búa heima. Fjórir þátttakendur tóku þátt í rannsókninni. Notast var við einliðavendisnið sem samanstóð af tveimur grunnlínum og tveimur inngripsskeiðum (ABAB snið). Hvert skeið innihélt þrjár mælingalotur. Klínískt mat, lífaflsfræðilegar mælingar og huglægt mat þátttakenda var notað til að meta áhrif íhlutunar. Í samræmi við aðferðafræði einliðasniðsrannsókna var notast við sjónrænar greiningar og viðeigandi tölfræði í greiningu niðurstaðna. Íhlutun gekk út á daglega notkun á tSCS í þrjár vikur. Reiknaðar voru áhrifastærðir til að meta hvort íhlutun hafði áhrif umfram grunnlínu. Niðurstöður voru mismunandi eftir þátttakendum. Í einu tilvikanna sýndu áhrifastærðir töluverð áhrif á síspennu, hreyfigetu, verki og svefn í fyrstu íhlutun. Einnig var tölfræðilega marktækur munur á milli fyrsta grunnlínuskeiðs og seinni íhlutunar á hreyfigetu, verkjum og svefni. Áhrifin sem komu fram í fyrri íhlutun virðast hafa haldið sér inn í seinna grunnlínuskeið, sem bendir til að tíminn á milli hafi ekki verið nægur. Hjá hinum þremur þátttakendunum reyndist ekki munur á milli íhlutunar og grunnlínu, nema í tveimur tilvikum í mælingum á hreyfigetu. Niðurstöður benda til að tSCS geti verið gagnlegt inngrip í endurhæfingu þeirra sem fengið hafa heilaslag í þeim tilgangi að draga úr áhrifum síspennu og verkja, ásamt því að bæta hreyfigetu og svefn. Um er að ræða ódýrt, einfalt og aðgengilegt inngrip sem kann að vera gagnlegt í sumum tilvikum. iv Acknowledgements and Funding Firstly, I would like to express my sincere gratitude to my supervisor, Dr. Anestis Divanoglou, for his encouragement, constructive guidance and insightful suggestions for this research project and dissertation. Your exceptional skills as a supervisor not only kept me afloat and guided me in the right direction but inspired me to reach new potentials and most importantly, enjoy the process. My deepest gratitude goes to Dr. Þórður Helgason, for his unwavering support and invaluable contribution to the implementation of this project and for his contribution to my Master´s Committee. I gratefully acknowledge the constructive guidance of Dr. Kristín Briem in my Master´s Committee and for her contribution in introducing me to this project. This research project and thesis would not have evolved without the ambitious research team from Grensás, Rehabilitation Unit of Landspitali - National University Hospital of Iceland: Gígja Magnúsdóttir and Vilborg Guðmundsdóttir, physiotherapists and Guðbjörg Ludvigsdóttir M.D. I am deeply indebted to you and Dr. Þórður Helgason for inaugurating research on tSCS in Iceland, warmly introducing me to your research team and unselfishly participating in formulating and conducting this research project. Your clinical expertise and ongoing search for rehabilitation tools that extend the boundaries of neurological rehabilitation were inspiring and deserve my deepest respect. I will miss our research time together! I cannot thank Halldór Kárason enough for his large and essential contribution in collecting, processing, analysing and presenting data. Thank you Halldór for your exceptional work, prompt responses and patience. Good luck in your future studies in Biomedical Engineering! An immense thank you is due to the Health Technology Centre of Reykjavík University for a successful collaboration and access to your fine facilities and research equipment. I would like to extend my sincere thanks to Milan R. Dimitrijevic, José Luis Vargas Luna, Winfried Mayr and Matthias Krenn, from the University Hospital in Vienna, for their advice and contribution in teaching the research team and myself methods of tSCS application and biomechanical methods of assessing spasticity. An extended gratitude to José and Winfried for welcoming me to your workplace in Vienna and opening my eyes to the clinical possibilities of tSCS. A very special gratitude goes out to the Icelandic Physiotherapy Association and the National University Hospital of Iceland for their financial support. Also, to the Student Innovation Fund of Rannis for funding preliminary pilot studies on tSCS which helped in preparation of research methods and data processing. Last, but by no means least, I would like to thank my family: my husband, daughter and son-in-law for their encouragement, practical assistance in data analysis and technical issues and my two teenage sons for their exceptional patience and understanding. v Table of contents Abstract.................................................................................................................................................... iii Ágrip ........................................................................................................................................................ iv Table of contents ..................................................................................................................................... vi List of tables .......................................................................................................................................... viii List of figures ......................................................................................................................................... viii Abbreviations ........................................................................................................................................... ix 1 Introduction .......................................................................................................................................... 1 1.1 Stroke Epidemiology ..................................................................................................................