Effects of Reactive and Proactive Exercises on Ankle Spasticity in Patients with Chronic Stroke: A Randomized Clinical Trial
Abstract
Background: Stroke is a leading cause of adult disability. Spasticity is a neurological condition that occurs secondary to stroke and affecting the patient's quality of life. This study designed to compare the effect of reactive and proactive exercises on spasticity in people with stroke.
Materials and methods: In this single-blind clinical trial study, 30 people with stroke were randomly divided into three groups: control, reactive, and proactive, of which 27 patients completed the study. These people were treated for 12 sessions for 4 weeks (three times a week). The control group received conventional exercises, the reactive group received conventional exercises plus reactive exercises, and the proactive group received conventional exercises plus proactive exercises. The outcomes were clinical outcome of spasticity in baseline and neural properties that respectively evaluated using the Modified Modified Ashworth Scale and H-reflex latency and Hmax/Mmax ratio. All statistical analyzes were performed using SPSS version 20.
Results: In H-reflex latency (F = 0.404, P = 0.672, ηp² = 0.033) and Hmax/Mmax ratio (F = 0.878, P = 0.429, ηp² = 0.071) there were no significant differences between groups.
Conclusions: Intergroup comparisons did not show a significant advantage in favor of the use of proactive and reactive exercises on neural properties of spasticity compared to conventional exercises alone.
1. Bonita R, Mendis S, Truelsen T, Bogousslavsky J, Toole J, Yatsu F. The global stroke initiative. Lancet Neurol. 2004;3(7):391-3. eng. [PubMed ID:15207791]. https://doi.org/10.1016/s1474-4422(04)00800-2.
2. Ghasemi E, Khademi-Kalantari K, Khalkhali-Zavieh M, Rezasoltani A, Ghasemi M, Akbarzadeh Baghban A, et al. The Effect of Functional Stretching Exercises on Neural and Mechanical Properties of the Spastic Medial Gastrocnemius Muscle in Patients with Chronic Stroke: A Randomized Controlled Trial. J Stroke Cerebrovasc Dis. 2018;27(7):1733-42. eng. [PubMed ID:29706442]. https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.01.024.
3. McLellan DL. Spasticity: disorder motor control. J Neurol Neurosurg Psychiatry. 1981 Oct;44(10):961.
4. Dressler D, Bhidayasiri R, Bohlega S, Chana P, Chien HF, Chung TM, et al. Defining spasticity: a new approach considering current movement disorders terminology and botulinum toxin therapy. J Neurol. 2018;265(4):856-62. eng. [PubMed ID:29423615]. https://doi.org/10.1007/s00415-018-8759-1.
5. Zeng H, Chen J, Guo Y, Tan S. Prevalence and Risk Factors for Spasticity After Stroke: A Systematic Review and Meta-Analysis. Front Neurol. 2020;11:616097. eng. [PubMed ID:33551975]. [PubMed Central ID:PMC7855612]. https://doi.org/10.3389/fneur.2020.616097.
6. Sommerfeld DK, Eek EU, Svensson AK, Holmqvist LW, von Arbin MH. Spasticity after stroke: its occurrence and association with motor impairments and activity limitations. Stroke. 2004;35(1):134-9. eng. [PubMed ID:14684785]. https://doi.org/10.1161/01.Str.0000105386.05173.5e.
7. Soyuer F, Oztürk A. The effect of spasticity, sense and walking aids in falls of people after chronic stroke. Disabil Rehabil. 2007;29(9):679-87. eng. [PubMed ID:17453990]. https://doi.org/10.1080/09638280600925860.
8. Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review. Lancet Neurol. 2009;8(8):741-54. eng. [PubMed ID:19608100]. https://doi.org/10.1016/s1474-4422(09)70150-4.
9. Hsu AL, Tang PF, Jan MH. Analysis of impairments influencing gait velocity and asymmetry of hemiplegic patients after mild to moderate stroke. Arch Phys Med Rehabil. 2003;84(8):1185-93. eng. [PubMed ID:12917858]. https://doi.org/10.1016/s0003-9993(03)00030-3.
10. Wei TS, Liu PT, Chang LW, Liu SY. Gait asymmetry, ankle spasticity, and depression as independent predictors of falls in ambulatory stroke patients. PLoS One. 2017;12(5):e0177136. eng. [PubMed ID:28542281]. [PubMed Central ID:PMC5441600]. https://doi.org/10.1371/journal.pone.0177136.
11. Brainin M, Norrving B, Sunnerhagen KS, Goldstein LB, Cramer SC, Donnan GA, et al. Poststroke chronic disease management: towards improved identification and interventions for poststroke spasticity-related complications. Int J Stroke. 2011;6(1):42-6. eng. [PubMed ID:21205240]. https://doi.org/10.1111/j.1747-4949.2010.00539.x.
12. Hebert D, Lindsay MP, McIntyre A, Kirton A, Rumney PG, Bagg S, et al. Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015. Int J Stroke. 2016;11(4):459-84. eng. [PubMed ID:27079654]. https://doi.org/10.1177/1747493016643553.
13. Kuo C-L, Hu G-C. Post-stroke Spasticity: A Review of Epidemiology, Pathophysiology, and Treatments. International Journal of Gerontology. 2018;12(4):280-4. https://doi.org/https://doi.org/10.1016/j.ijge.2018.05.005.
14. Saeideh F, Majid G, Keivan B, Ehsan G. Investigating the Effects of Nintendo Wii on Ankle Spasticity in Patients with Stroke: A Randomized Clinical Trial. Journal of Modern Rehabilitation. 2024;18(4). https://doi.org/10.18502/jmr.v18i4.16917.
15. Koohestani Dehaghi FU, Ghasemi MU, Emami Ardestani PU, Ghasemi EU. Investigation the Effect of Reactive and Proactive Exercises on Balance Performance and Balance Confidence in Stroke Patients: A Randomized Clinical Trial. Health Scope. 2025;14(e153550). https://doi.org/10.5812/healthscope-153550.
16. Kannan L, Vora J, Varas-Diaz G, Bhatt T, Hughes S. Does Exercise-Based Conventional Training Improve Reactive Balance Control among People with Chronic Stroke? Brain Sci. 2020;11(1).
17. Cavallari P, Bolzoni F, Bruttini C, Esposti R. The Organization and Control of Intra-Limb Anticipatory Postural Adjustments and Their Role in Movement Performance. Front Hum Neurosci. 2016;10:525. eng. [PubMed ID:27807411]. [PubMed Central ID:PMC5069406]. https://doi.org/10.3389/fnhum.2016.00525.
18. Aruin AS. Enhancing Anticipatory Postural Adjustments: A Novel Approach to Balance Rehabilitation. J Nov Physiother. 2016;6(2). eng. [PubMed ID:27335705]. [PubMed Central ID:PMC4913780]. https://doi.org/10.4172/2165-7025.1000e144.
19. Mansfield A, Aqui A, Danells CJ, Knorr S, Centen A, DePaul VG, et al. Does perturbation-based balance training prevent falls among individuals with chronic stroke? A randomised controlled trial. BMJ open. 2018;8(8):e021510.
20. Boebinger S, Payne A, Martino G, Kerr K, Mirdamadi J, McKay JL, et al. Precise cortical contributions to sensorimotor feedback control during reactive balance. PLoS Comput Biol. 2024;20(4):e1011562.
21. Shen HY, Lin JY, Chen CC, Lee HF, Chao H, Lieu FK, et al. Evaluation of post-stroke spasticity from the subacute to chronic stages: A clinical and neurophysiologic study of motoneuron pool excitability. Chin J Physiol. 2022;65(3):109-16. eng. [PubMed ID:35775529]. https://doi.org/10.4103/0304-4920.348359.
22. Schieppati M. The Hoffmann reflex: a means of assessing spinal reflex excitability and its descending control in man. Prog Neurobiol. 1987;28(4):345-76. eng. [PubMed ID:3588965]. https://doi.org/10.1016/0301-0082(87)90007-4.
23. Naghdi S, Ansari NN, Mansouri K, Olyaei GR, Asgari A, Kazemnejad A. The correlation between Modified Ashworth Scale scores and the new index of alpha motoneurones excitability in post-stroke patients. Electromyogr Clin Neurophysiol. 2008;48(2):109-15. eng. [PubMed ID:18435215].
24. Phadke CP, Robertson CT, Condliffe EG, Patten C. Upper-extremity H-reflex measurement post-stroke: reliability and inter-limb differences. Clin Neurophysiol. 2012;123(8):1606-15. eng. [PubMed ID:22277759]. https://doi.org/10.1016/j.clinph.2011.12.012.
25. In TS, Jung JH, Jang SH, Kim KH, Jung KS, Cho HY. Effects of Light Touch on Balance in Patients with Stroke. Open Med (Wars). 2019;14:259-63. eng. [PubMed ID:30997393]. [PubMed Central ID:PMC6463820]. https://doi.org/10.1515/med-2019-0021.
26. Faria CD, Teixeira-Salmela LF, Silva EB, Nadeau S. Expanded timed up and go test with subjects with stroke: reliability and comparisons with matched healthy controls. Arch Phys Med Rehabil. 2012;93(6):1034-8. eng. [PubMed ID:22381595]. https://doi.org/10.1016/j.apmr.2011.11.025.
27. Jamali S, Azad A, Taghizadeh G. Use of Functional Balance Measurement Tools to Predict the Fear of Falling in Faller and Non-Faller Chronic Stroke Patients. Function and Disability Journal. 2018;1(2):19-28. eng. https://doi.org/10.30699/fdisj.01.2.19.
28. Cabanas-Valdés R, Bagur-Calafat C, Girabent-Farrés M, Caballero-Gómez FM, Hernández-Valiño M, Urrútia Cuchí G. The effect of additional core stability exercises on improving dynamic sitting balance and trunk control for subacute stroke patients: a randomized controlled trial. Clin Rehabil. 2016;30(10):1024-33. eng. [PubMed ID:26451007]. https://doi.org/10.1177/0269215515609414.
29. Ghotbi N, Ansari NN, Naghdi S, Hasson S, Jamshidpour B, Amiri S. Inter-rater reliability of the Modified Modified Ashworth Scale in assessing lower limb muscle spasticity. Brain injury. 2009;23(10):815-9.
30. Ghotbi N, Nakhostin Ansari N, Naghdi S, Hasson S. Measurement of lower-limb muscle spasticity: intrarater reliability of Modified Modified Ashworth Scale. Journal of rehabilitation research and development. 2011;48(1):83.
31. Bakheit A, Maynard V, Shaw S. The effects of isotonic and isokinetic muscle stretch on the excitability of the spinal alpha motor neurones in patients with muscle spasticity. European journal of neurology. 2005;12(9):719-24.
32. Cuenca Zaldívar JN, Calvo S, Bravo-Esteban E, Oliva Ruiz P, Santi-Cano MJ, Herrero P. Effectiveness of dry needling for upper extremity spasticity, quality of life and function in subacute phase stroke patients. 2021;39(4):299-308. [PubMed ID:32815384]. https://doi.org/10.1177/0964528420947426.
33. Harrison RA, Field TS. Post stroke pain: identification, assessment, and therapy. Cerebrovasc Dis. 2015;39(3-4):190-201. eng. [PubMed ID:25766121]. https://doi.org/10.1159/000375397.
34. Cuenca Zaldívar JN, Calvo S, Bravo-Esteban E, Oliva Ruiz P, Santi-Cano MJ, Herrero P. Effectiveness of dry needling for upper extremity spasticity, quality of life and function in subacute phase stroke patients. Acupunct Med. 2021;39(4):299-308. eng. [PubMed ID:32815384]. https://doi.org/10.1177/0964528420947426.
35. Stevenson VL. Rehabilitation in practice: Spasticity management. Clin Rehabil. 2010;24(4):293-304. eng. [PubMed ID:20360150]. https://doi.org/10.1177/0269215509353254.
36. Zhang Y, Wang YZ, Huang LP, Bai B, Zhou S, Yin MM, et al. Aquatic Therapy Improves Outcomes for Subacute Stroke Patients by Enhancing Muscular Strength of Paretic Lower Limbs Without Increasing Spasticity: A Randomized Controlled Trial. Am J Phys Med Rehabil. 2016;95(11):840-9. eng. [PubMed ID:27088480]. https://doi.org/10.1097/phm.0000000000000512.
37. Medeiros DM, Martini TF. Chronic effect of different types of stretching on ankle dorsiflexion range of motion: Systematic review and meta-analysis. Foot (Edinb). 2018;34:28-35. eng. [PubMed ID:29223884]. https://doi.org/10.1016/j.foot.2017.09.006.
38. Chen K, Zhu S, Tang Y, Lan F, Liu Z. Advances in balance training to prevent falls in stroke patients: a scoping review. Frontiers in neurology. 2024;15:1167954.
39. Alayat MSM, Almatrafi NA, El Fiky AAR, Elsodany AM, Shousha TM, Basuodan R. The effectiveness of perturbation-based training in the treatment of patients with stroke: a systematic review and meta-analysis. Neuroscience Insights. 2022;17:26331055221114818.
40. Stokkermans M, Solis-Escalante T, Cohen MX, Weerdesteyn V. Distinct cortico-muscular coupling between step and stance leg during reactive stepping responses. Front Neurol. 2023;14:1124773.
41. Palmieri RM, HOFFMAN MA, INGERSOLL CD. Intersession reliability for H-reflex measurements arising from the soleus, peroneal, and tibialis anterior musculature. International Journal of Neuroscience. 2002;112(7):841-50.
42. Levin MF, Hui-Chan C. Are H and stretch reflexes in hemiparesis reproducible and correlated with spasticity? Journal of neurology. 1993;240(2):63-71.
43. Kim KS, Seo JH, Song CG. Portable measurement system for the objective evaluation of the spasticity of hemiplegic patients based on the tonic stretch reflex threshold. Medical engineering & physics. 2011;33(1):62-9.
44. Pizzi A, Carlucci G, Falsini C, Verdesca S, Grippo A. Evaluation of upper-limb spasticity after stroke: A clinical and neurophysiologic study. Archives of physical medicine and rehabilitation. 2005;86(3):410-5.
45. Pisano F, Miscio G, Del Conte C, Pianca D, Candeloro E, Colombo R. Quantitative measures of spasticity in post-stroke patients. Clinical Neurophysiology. 2000;111(6):1015-22.
46. Galiana L, Fung J, Kearney R. Identification of intrinsic and reflex ankle stiffness components in stroke patients. Experimental brain research. 2005;165(4):422-34.
2. Ghasemi E, Khademi-Kalantari K, Khalkhali-Zavieh M, Rezasoltani A, Ghasemi M, Akbarzadeh Baghban A, et al. The Effect of Functional Stretching Exercises on Neural and Mechanical Properties of the Spastic Medial Gastrocnemius Muscle in Patients with Chronic Stroke: A Randomized Controlled Trial. J Stroke Cerebrovasc Dis. 2018;27(7):1733-42. eng. [PubMed ID:29706442]. https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.01.024.
3. McLellan DL. Spasticity: disorder motor control. J Neurol Neurosurg Psychiatry. 1981 Oct;44(10):961.
4. Dressler D, Bhidayasiri R, Bohlega S, Chana P, Chien HF, Chung TM, et al. Defining spasticity: a new approach considering current movement disorders terminology and botulinum toxin therapy. J Neurol. 2018;265(4):856-62. eng. [PubMed ID:29423615]. https://doi.org/10.1007/s00415-018-8759-1.
5. Zeng H, Chen J, Guo Y, Tan S. Prevalence and Risk Factors for Spasticity After Stroke: A Systematic Review and Meta-Analysis. Front Neurol. 2020;11:616097. eng. [PubMed ID:33551975]. [PubMed Central ID:PMC7855612]. https://doi.org/10.3389/fneur.2020.616097.
6. Sommerfeld DK, Eek EU, Svensson AK, Holmqvist LW, von Arbin MH. Spasticity after stroke: its occurrence and association with motor impairments and activity limitations. Stroke. 2004;35(1):134-9. eng. [PubMed ID:14684785]. https://doi.org/10.1161/01.Str.0000105386.05173.5e.
7. Soyuer F, Oztürk A. The effect of spasticity, sense and walking aids in falls of people after chronic stroke. Disabil Rehabil. 2007;29(9):679-87. eng. [PubMed ID:17453990]. https://doi.org/10.1080/09638280600925860.
8. Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review. Lancet Neurol. 2009;8(8):741-54. eng. [PubMed ID:19608100]. https://doi.org/10.1016/s1474-4422(09)70150-4.
9. Hsu AL, Tang PF, Jan MH. Analysis of impairments influencing gait velocity and asymmetry of hemiplegic patients after mild to moderate stroke. Arch Phys Med Rehabil. 2003;84(8):1185-93. eng. [PubMed ID:12917858]. https://doi.org/10.1016/s0003-9993(03)00030-3.
10. Wei TS, Liu PT, Chang LW, Liu SY. Gait asymmetry, ankle spasticity, and depression as independent predictors of falls in ambulatory stroke patients. PLoS One. 2017;12(5):e0177136. eng. [PubMed ID:28542281]. [PubMed Central ID:PMC5441600]. https://doi.org/10.1371/journal.pone.0177136.
11. Brainin M, Norrving B, Sunnerhagen KS, Goldstein LB, Cramer SC, Donnan GA, et al. Poststroke chronic disease management: towards improved identification and interventions for poststroke spasticity-related complications. Int J Stroke. 2011;6(1):42-6. eng. [PubMed ID:21205240]. https://doi.org/10.1111/j.1747-4949.2010.00539.x.
12. Hebert D, Lindsay MP, McIntyre A, Kirton A, Rumney PG, Bagg S, et al. Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015. Int J Stroke. 2016;11(4):459-84. eng. [PubMed ID:27079654]. https://doi.org/10.1177/1747493016643553.
13. Kuo C-L, Hu G-C. Post-stroke Spasticity: A Review of Epidemiology, Pathophysiology, and Treatments. International Journal of Gerontology. 2018;12(4):280-4. https://doi.org/https://doi.org/10.1016/j.ijge.2018.05.005.
14. Saeideh F, Majid G, Keivan B, Ehsan G. Investigating the Effects of Nintendo Wii on Ankle Spasticity in Patients with Stroke: A Randomized Clinical Trial. Journal of Modern Rehabilitation. 2024;18(4). https://doi.org/10.18502/jmr.v18i4.16917.
15. Koohestani Dehaghi FU, Ghasemi MU, Emami Ardestani PU, Ghasemi EU. Investigation the Effect of Reactive and Proactive Exercises on Balance Performance and Balance Confidence in Stroke Patients: A Randomized Clinical Trial. Health Scope. 2025;14(e153550). https://doi.org/10.5812/healthscope-153550.
16. Kannan L, Vora J, Varas-Diaz G, Bhatt T, Hughes S. Does Exercise-Based Conventional Training Improve Reactive Balance Control among People with Chronic Stroke? Brain Sci. 2020;11(1).
17. Cavallari P, Bolzoni F, Bruttini C, Esposti R. The Organization and Control of Intra-Limb Anticipatory Postural Adjustments and Their Role in Movement Performance. Front Hum Neurosci. 2016;10:525. eng. [PubMed ID:27807411]. [PubMed Central ID:PMC5069406]. https://doi.org/10.3389/fnhum.2016.00525.
18. Aruin AS. Enhancing Anticipatory Postural Adjustments: A Novel Approach to Balance Rehabilitation. J Nov Physiother. 2016;6(2). eng. [PubMed ID:27335705]. [PubMed Central ID:PMC4913780]. https://doi.org/10.4172/2165-7025.1000e144.
19. Mansfield A, Aqui A, Danells CJ, Knorr S, Centen A, DePaul VG, et al. Does perturbation-based balance training prevent falls among individuals with chronic stroke? A randomised controlled trial. BMJ open. 2018;8(8):e021510.
20. Boebinger S, Payne A, Martino G, Kerr K, Mirdamadi J, McKay JL, et al. Precise cortical contributions to sensorimotor feedback control during reactive balance. PLoS Comput Biol. 2024;20(4):e1011562.
21. Shen HY, Lin JY, Chen CC, Lee HF, Chao H, Lieu FK, et al. Evaluation of post-stroke spasticity from the subacute to chronic stages: A clinical and neurophysiologic study of motoneuron pool excitability. Chin J Physiol. 2022;65(3):109-16. eng. [PubMed ID:35775529]. https://doi.org/10.4103/0304-4920.348359.
22. Schieppati M. The Hoffmann reflex: a means of assessing spinal reflex excitability and its descending control in man. Prog Neurobiol. 1987;28(4):345-76. eng. [PubMed ID:3588965]. https://doi.org/10.1016/0301-0082(87)90007-4.
23. Naghdi S, Ansari NN, Mansouri K, Olyaei GR, Asgari A, Kazemnejad A. The correlation between Modified Ashworth Scale scores and the new index of alpha motoneurones excitability in post-stroke patients. Electromyogr Clin Neurophysiol. 2008;48(2):109-15. eng. [PubMed ID:18435215].
24. Phadke CP, Robertson CT, Condliffe EG, Patten C. Upper-extremity H-reflex measurement post-stroke: reliability and inter-limb differences. Clin Neurophysiol. 2012;123(8):1606-15. eng. [PubMed ID:22277759]. https://doi.org/10.1016/j.clinph.2011.12.012.
25. In TS, Jung JH, Jang SH, Kim KH, Jung KS, Cho HY. Effects of Light Touch on Balance in Patients with Stroke. Open Med (Wars). 2019;14:259-63. eng. [PubMed ID:30997393]. [PubMed Central ID:PMC6463820]. https://doi.org/10.1515/med-2019-0021.
26. Faria CD, Teixeira-Salmela LF, Silva EB, Nadeau S. Expanded timed up and go test with subjects with stroke: reliability and comparisons with matched healthy controls. Arch Phys Med Rehabil. 2012;93(6):1034-8. eng. [PubMed ID:22381595]. https://doi.org/10.1016/j.apmr.2011.11.025.
27. Jamali S, Azad A, Taghizadeh G. Use of Functional Balance Measurement Tools to Predict the Fear of Falling in Faller and Non-Faller Chronic Stroke Patients. Function and Disability Journal. 2018;1(2):19-28. eng. https://doi.org/10.30699/fdisj.01.2.19.
28. Cabanas-Valdés R, Bagur-Calafat C, Girabent-Farrés M, Caballero-Gómez FM, Hernández-Valiño M, Urrútia Cuchí G. The effect of additional core stability exercises on improving dynamic sitting balance and trunk control for subacute stroke patients: a randomized controlled trial. Clin Rehabil. 2016;30(10):1024-33. eng. [PubMed ID:26451007]. https://doi.org/10.1177/0269215515609414.
29. Ghotbi N, Ansari NN, Naghdi S, Hasson S, Jamshidpour B, Amiri S. Inter-rater reliability of the Modified Modified Ashworth Scale in assessing lower limb muscle spasticity. Brain injury. 2009;23(10):815-9.
30. Ghotbi N, Nakhostin Ansari N, Naghdi S, Hasson S. Measurement of lower-limb muscle spasticity: intrarater reliability of Modified Modified Ashworth Scale. Journal of rehabilitation research and development. 2011;48(1):83.
31. Bakheit A, Maynard V, Shaw S. The effects of isotonic and isokinetic muscle stretch on the excitability of the spinal alpha motor neurones in patients with muscle spasticity. European journal of neurology. 2005;12(9):719-24.
32. Cuenca Zaldívar JN, Calvo S, Bravo-Esteban E, Oliva Ruiz P, Santi-Cano MJ, Herrero P. Effectiveness of dry needling for upper extremity spasticity, quality of life and function in subacute phase stroke patients. 2021;39(4):299-308. [PubMed ID:32815384]. https://doi.org/10.1177/0964528420947426.
33. Harrison RA, Field TS. Post stroke pain: identification, assessment, and therapy. Cerebrovasc Dis. 2015;39(3-4):190-201. eng. [PubMed ID:25766121]. https://doi.org/10.1159/000375397.
34. Cuenca Zaldívar JN, Calvo S, Bravo-Esteban E, Oliva Ruiz P, Santi-Cano MJ, Herrero P. Effectiveness of dry needling for upper extremity spasticity, quality of life and function in subacute phase stroke patients. Acupunct Med. 2021;39(4):299-308. eng. [PubMed ID:32815384]. https://doi.org/10.1177/0964528420947426.
35. Stevenson VL. Rehabilitation in practice: Spasticity management. Clin Rehabil. 2010;24(4):293-304. eng. [PubMed ID:20360150]. https://doi.org/10.1177/0269215509353254.
36. Zhang Y, Wang YZ, Huang LP, Bai B, Zhou S, Yin MM, et al. Aquatic Therapy Improves Outcomes for Subacute Stroke Patients by Enhancing Muscular Strength of Paretic Lower Limbs Without Increasing Spasticity: A Randomized Controlled Trial. Am J Phys Med Rehabil. 2016;95(11):840-9. eng. [PubMed ID:27088480]. https://doi.org/10.1097/phm.0000000000000512.
37. Medeiros DM, Martini TF. Chronic effect of different types of stretching on ankle dorsiflexion range of motion: Systematic review and meta-analysis. Foot (Edinb). 2018;34:28-35. eng. [PubMed ID:29223884]. https://doi.org/10.1016/j.foot.2017.09.006.
38. Chen K, Zhu S, Tang Y, Lan F, Liu Z. Advances in balance training to prevent falls in stroke patients: a scoping review. Frontiers in neurology. 2024;15:1167954.
39. Alayat MSM, Almatrafi NA, El Fiky AAR, Elsodany AM, Shousha TM, Basuodan R. The effectiveness of perturbation-based training in the treatment of patients with stroke: a systematic review and meta-analysis. Neuroscience Insights. 2022;17:26331055221114818.
40. Stokkermans M, Solis-Escalante T, Cohen MX, Weerdesteyn V. Distinct cortico-muscular coupling between step and stance leg during reactive stepping responses. Front Neurol. 2023;14:1124773.
41. Palmieri RM, HOFFMAN MA, INGERSOLL CD. Intersession reliability for H-reflex measurements arising from the soleus, peroneal, and tibialis anterior musculature. International Journal of Neuroscience. 2002;112(7):841-50.
42. Levin MF, Hui-Chan C. Are H and stretch reflexes in hemiparesis reproducible and correlated with spasticity? Journal of neurology. 1993;240(2):63-71.
43. Kim KS, Seo JH, Song CG. Portable measurement system for the objective evaluation of the spasticity of hemiplegic patients based on the tonic stretch reflex threshold. Medical engineering & physics. 2011;33(1):62-9.
44. Pizzi A, Carlucci G, Falsini C, Verdesca S, Grippo A. Evaluation of upper-limb spasticity after stroke: A clinical and neurophysiologic study. Archives of physical medicine and rehabilitation. 2005;86(3):410-5.
45. Pisano F, Miscio G, Del Conte C, Pianca D, Candeloro E, Colombo R. Quantitative measures of spasticity in post-stroke patients. Clinical Neurophysiology. 2000;111(6):1015-22.
46. Galiana L, Fung J, Kearney R. Identification of intrinsic and reflex ankle stiffness components in stroke patients. Experimental brain research. 2005;165(4):422-34.
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How to Cite
1.
Kouhestani Dehaghi F, Ghasemi M, Roghani T, Ghasemi E. Effects of Reactive and Proactive Exercises on Ankle Spasticity in Patients with Chronic Stroke: A Randomized Clinical Trial. jmr. 2026;(-).
