International Journal of

Environmental Research
and Public Health

Case Report

Botulinum Toxin and Dynamic Splint Restore Grasping
Function after Stroke: A Case Report
Denis Moskiewicz 1,2 , Małgorzata Mraz 1
1
2

*

and Dagmara Chamela-Bilińska 1, *

Department of Physiotherapy, Wroclaw University of Health and Sport Sciences, 51-612 Wrocław, Poland
Rehabilitation Department, T. Marciniak Lower Silesian Specialist Hospital, Emergency Medicine Center,
54-049 Wrocław, Poland
Correspondence: dagmara.chamela-bilinska@awf.wroc.pl

Abstract: Evidence on the effectiveness of upper extremity rehabilitation post-stroke is inconclusive.
We evaluated a tailored therapeutic program with dynamic splint and botulinum toxin injections
for the treatment of upper extremity muscle spasticity. A case of a 43-year-old woman with chronic
spastic hemiparesis after ischemic stroke with significant mobility impairment in the left upper
extremity was described. A 16-week program consisted of three 50-min sessions daily and focused on
grasping and releasing with and without the splint. The patient was evaluated before botulinum toxin
injection and after 6, 12 and 16 weeks according to the International Classification of Functioning,
Disability and Health, and included the following scales: Fugl-Meyer Upper Extremity Assessment
(FMA-UE), Modified Ashworth Scale, Numerical Rating Scale (NRS), MyotonPro, Stroke Impact Scale,
Box and Blocks. Photographic documentation made before and after the experiment was compared.
Motor functions improved by 19.7% on FMA-UE, spasticity was reduced by one degree and pain at
rest and during activity decreased by one score on NRS. A reduction in the oscillation frequency of
the relaxed muscle and the stiffness of the examined muscles was observed. The patient regained
grasping function. Health-related quality of life was systematically improving with a 35% increase
at week 16 compared to the baseline. The combination treatment for spasticity based on botulinum
toxin and SaeboFlex® dynamic splint in a patient with chronic spastic hemiparesis reduces disability
and improves quality of life. However, further research is needed to investigate the treatment results.
Citation: Moskiewicz, D.; Mraz, M.;
Chamela-Bilińska, D. Botulinum

Keywords: rehabilitation; grip; hand; orthosis; SaeboFlex; spasticity

Toxin and Dynamic Splint Restore
Grasping Function after Stroke: A
Case Report. Int. J. Environ. Res.
Public Health 2023, 20, 4873. https://
doi.org/10.3390/ijerph20064873
Academic Editor: Paweł
Wańkowicz
Received: 2 February 2023
Revised: 28 February 2023
Accepted: 7 March 2023
Published: 10 March 2023

Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).

1. Introduction
People with spastic hemiparesis after a stroke experience functional limitations on
many levels. Limited daily activity, primarily due to spasticity, is the most common
complication [1], which determines the patient’s ability to live independently [2]. Regaining
the grasping function of the hand is a very difficult goal to achieve, but obtaining even
the slightest improvement can be very helpful in restoring the patient’s independence [3].
For humans, grasping is so important that the hand has gained the name of the grasping
organ in some anthropology and evolutionary sciences [4,5]. In a large study, Nakajeme
et al. showed that only 5% of patients after a stroke regain the functionality of the upper
limb; however, after 3 months still as many as 20% do not make any movements. Spasticity
of the upper extremity contributes to difficulties in dressing, maintaining hygiene and
reduces independence in everyday activities by disturbing the grasping function [6]. The
recommended first-line treatment in local post-stroke spasticity is the injection of botulinum
toxin (BoNT) [7]. Guidelines recommend multidisciplinary rehabilitation after BoNT
injections; however, the evidence supporting the effectiveness of such rehabilitation is
inconclusive [8]. The limited effectiveness of the therapies used so far results in the constant
search and testing of innovative approaches to reduce the level of disability and improve
the functional efficiency of patients after stroke [9].

Int. J. Environ. Res. Public Health 2023, 20, 4873. https://doi.org/10.3390/ijerph20064873

https://www.mdpi.com/journal/ijerph

Int. J. Environ. Res. Public Health 2023, 20, 4873

2 of 13

One of the solutions for people after a stroke with moderate and severe disability
of the upper extremity is the SaeboFlex® dynamic splint (Saebo, Charlotte, NC, USA).
In a process called “agonist retraining”, the patient uses resistance on the fingers and
thumb by using the extension spring system. This makes it possible to voluntarily contract
and relax the finger flexor muscles, which results in an assisted, functional grip and
release [10]. Multiple repetitions of grasping and releasing activities improve volitional
motor control of the finger flexor muscles [11–14]. Pooyania et al. [15] compared the effects
of the combined use of the SaeboFlex® dynamic splint and BoNT injections to the use
of the splint only in patients with spastic post-stroke hemiparesis. In their study, some
patients achieved a functional improvement of the upper extremity, likely due to functional
improvement resulting from using the splint for repeated grasp-release training. However,
it was not possible to demonstrate a more beneficial effect of using the splint after BoNT
administration, so further research was recommended.
A review of the literature encourages using BoNT and the SaeboFlex® dynamic splint
in rehabilitation programs to improve functional outcomes in people with chronic spastic
paresis of the upper extremity. Thus, we described the case of a woman with local poststroke spasticity of the upper extremity and evaluated the use of BoNT and the SaeboFlex®
dynamic splint in the tailored rehabilitation program for chronic post-stroke spastic hemiparesis. We assumed that a program based on repeated grasp-release activities and BoNT
effect will improve the grasping function of the hand.
The aim of this study is to evaluate of the use of BoNT in the treatment of local poststroke spasticity of the upper extremity in combination with an individual rehabilitation
program based on the use of the SaeboFlex® dynamic splint. This research addressed the
following research questions:

•

•

•

Will the applied treatment and rehabilitation program using the SaeboFlex® dynamic
splint improve the motor functions of the upper extremity based on the Fugl-Meyer
Upper Extremity Assessment scale?
Will local treatment of spasticity with BoNT and exercise with SaeboFlex reduce pain?
Will the applied treatment and rehabilitation program with the use of the SaeboFlex
orthosis affect the normalization of torso muscle tone?
Is it possible to achieve self-grip following local treatment of spasticity with BoNT and
exercise with the SaeboFlex® dynamic splint?

2. Case Description
2.1. Patient
In 2020, a 42-year-old woman had an ischemic stroke in the right hemisphere of the
brain, caused by thromboembolic material in the right middle artery of the brain. Before
the stroke, the patient was not treated for any chronic disease; she regularly participated in
periodic examinations required in the workplace. The factor that could affect the outcome
was that despite the rapid thrombolysis (up to 1 h after the first symptoms of stroke), it
was not possible to remove the thromboembolic material from the right middle cerebral
artery, which resulted in mechanical thrombectomy. Due to imminent cerebral edema, she
was inducted into temporary analgosedation. At discharge from the neurology department
(on day 29 after the stroke), the patient was conscious, in logical contact, with the presence
of a moderately severe syndrome of hemispatial neglect, using a wheelchair and requiring
assistance in changing places (based on the neuropsychology consultation). The functional
status according to the modified Barthel Index [16] was 30/100. Profound left hemiparesis
with a predominance in the upper extremity and pathologically increased muscle tone was
observed (internal rotators of the shoulder joint MAS = 1, elbow extensors MAS = 1, elbow
flexors MAS = 1+, wrist flexors MAS = 1, finger flexors MAS = 1). Spasticity is caused by
caused by damage to the upper motor neuron [17–19]. As such, the patient was admitted
to the Rehabilitation Department of the T. Marciniak Lower Silesian Specialist Hospital,
Emergency Medicine Center, Wrocław, Poland, where comprehensive therapy was applied.

Int. J. Environ. Res. Public Health 2023, 20, 4873

3 of 13

It included physiotherapy, occupational therapy and therapy with a neuropsychologist and
a neurologopedist.
After a 12-week stay in the rehabilitation department, the patient gained independence
to walk on a flat surface and up the stairs. The patient still had paresis of the left upper
extremity with spastic muscle tone, without grasping function and with an incomplete
range of motion in the peripheral joints (shoulder joint, elbow joint, wrist joint). The
functional status according to the Barthel Index was 80/100.
2.2. Screening and Justification of the Selection of a Research Participant
The patient was selected with the intention of gaining knowledge about the effectiveness of rehabilitation using the SaeboFlex® dynamic splint in combination with BoNT
treatment of upper extremity muscle spasticity in a comprehensively documented manner.
There was no expectation of the magnitude of the improvement achieved. The experimental procedures were approved by the Senate Committee for Research Ethics at Academy
of Physical Education in Wrocław and comply with the standards of the Declaration of
Helsinki. The patient signed informed consent to participate in the study.
The patient met the criteria for the application of BoNT and the use of the splint. For
botulinum toxin [20] therapy, the patient was qualified based on the assessment of poststroke spasticity according to the Modified Ashworth Scale (MAS); a score was ≥2 in at
least one muscle group. For therapy with the SaeboFlex® dynamic splint (Saebo, Charlotte,
NC, USA), the patient was qualified according to manufacturer recommendations [21],
which required having a passive range of 15◦ of extension movement in the radiocarpal
joint with maintaining extension in the finger joints, 1/4 of a range of active flexion in the
finger joints, 1/4 of a range of active foreflexion in the shoulder joint and 1/4 of a range of
active flexion in the elbow joint. The Mini-Mental State Examination score was 27 points.
The patient was aware of her motor deficit, which consisted mainly of a lack of grasping
function. She was strongly motivated to participate in the program, had family support,
and did not have medical complications. The patient walked on her own, but at longer
distances, she used a cane for support. All those conditions made it possible for her to
participate in the program.
2.3. Methods
The study design excluded the possibility of bias and conflicts of interest. The research was carried out by four physiotherapists who were not the authors of the researchtherapeutic program. Their experience should exclude interpretation of the test results’ bias.
BoNT was administered by a neurologist at multiple points (except for small muscles) in
dose ranges consistent with the summary of product characteristics and with the published
recommendations of the Polish Neurological Society expert group. The study design is
presented in Figure 1.
2.4. Tests and Measures
The tests and measurements were selected to assess the patient’s functional state in
agreement with the International Classification of Functioning, Disability, and Health [22].
This classification includes the following subsequent components: functions/structure,
activity and participation, thanks to which, it is possible to analyze the results of the applied
intervention not only in the context of improving the grasping function of the hand, but
also its impact on disability and social participation.

Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW

4 of 14

Int. J. Environ. Res. Public Health 2023, 20, 4873

4 of 13

Figure
Figure1.1. Study
Studydesign.
design. Created
Created in
in Photoshop
Photoshoprelease
release24.1.1
24.1.1(Adobe,
(Adobe,San
SanJose,
Jose,CA,
CA,USA).
USA).

2.4.1. Functions/Structure
2.4. Tests and Measures
1.
Level of motor functions of the upper extremity affected by spastic paresis was
The tests and measurements were selected to assess the patient’s functional state in
described using the Fugl-Meyer Upper Extremity Assessment (FMA-UE) [23,24].
agreement with the International Classification of Functioning, Disability, and Health
Assessment of the spasticity of selected muscle groups was performed using MAS [25].
2.
[22]. This classification includes the following subsequent components: functions/struc3.
Pain sensation was scored on a standard Numerical Rating Scale (NRS) [26] from
ture, activity and participation, thanks to which, it is possible to analyze the results of the
0 (no pain) to 10 (worst pain imaginable), at rest and during the activity of reaching for
applied
intervention
not
only inofthe
context
ofthe
improving
the grasping
function
of the
an object
placed at
a height
60 cm
above
floor (patient
in a standing
position).
hand,
but
also
its
impact
on
disability
and
social
participation.
4.
Recording of natural muscle oscillations with the MyotonPRO 2013 device [27] (Myoton AS, Tallinn, Estonia) included an acceleration signal and determination of voltage
2.4.1.state
Functions/Structure
parameters, as well as biomechanical and viscoelastic properties of soft tissues.
1. The
Level
of motormuscles
functions
of assessed:
the upperbiceps
extremity
affected
by spastic
waspars
defollowing
were
brachii,
latissimus
dorsi,paresis
trapezius
scribed usingflexor
the Fugl-Meyer
Upper
Extremity
(FMA-UE)
[23,24].flexor
descendens,
carpi radialis,
flexor
pollicisAssessment
longus, flexor
carpi ulnaris,
2. digitorum
Assessment
of the spasticity
of selected
groups
performed
MAS
superficialis
and pronator
teres.muscle
Measured
withwas
MyotonPro,
theusing
oscillation
[25].
frequency
f [Hz] of a muscle in a relaxed state (at rest, without volitional stimulation
3. of
Pain
was scored
on a standard
Numerical
Rating
Scale tone.
(NRS)At[26]
from
thesensation
muscle) indicates
intramuscular
pressure
and resting
muscle
very
high0
pain)for
to 10
(worstmuscle,
pain imaginable),
during
thebe
activity
of reaching
for
f(no
values
a given
blood flowat
inrest
theand
muscles
may
limited,
which may
result
in, for
e.g.,at
faster
fatigue.
is athe
biomechanical
of a tissue
that
an object
placed
a height
of 60Stiffness
cm above
floor (patientproperty
in a standing
position).
resistance
of a muscle
(tissue)
to the
contraction
or to 2013
a deformation
force
s
4. represents
Recording the
of natural
muscle
oscillations
with
MyotonPRO
device [27]
(My[N/m],
this case,
to the force
with an
which
the MyotonPro
probe
hits/presses against
oton AS,inTallinn,
Estonia)
included
acceleration
signal and
determination
of voltthe
[28].
age muscle
state parameters,
as well as biomechanical and viscoelastic properties of soft tissues. The following muscles were assessed: biceps brachii, latissimus dorsi, trapezius
2.4.2. pars
Activity
and Participation
descendens,
flexor carpi radialis, flexor pollicis longus, flexor carpi ulnaris,
1.
Stroke
Impact Scale
(SIS) version
3.0pronator
[29] wasteres.
used Measured
to determine
health-related
flexor digitorum
superficialis
and
with
MyotonPro,quality
the osof
life (test/re-test
0.79infor
general state
health
after stroke
and
cillation
frequency freliability
[Hz] of awas
muscle
a relaxed
(atreturn
rest, without
volitional
0.98
for cognition)
[30].
stimulation
of the muscle)
indicates intramuscular pressure and resting muscle tone.
Unilateral
dexterity
of blood
fine motor
skills
checked
using
the
2.
At very high
f valuesand
for coordination
a given muscle,
flow in
the were
muscles
may be
limited,
Box
and
Block
Test
[31].
The
test
enables
assessing
functional
grip
and
its
use
in
which may result in, for e.g., faster fatigue. Stiffness is a biomechanical property the
of a
activity.
The
test uses the
a wooden
box,ofdivided
by(tissue)
a partition
into two chambers
and
tissue that
represents
resistance
a muscle
to contraction
or to a defor150
blocks
of the
same size.
The
patient’s
is to
move
the maximum
number
of
mation
force
s [N/m],
in this
case,
to thetask
force
with
which
the MyotonPro
probe
blocks
one
by
one
from
one
compartment
of
the
box
to
another
within
60
s.
hits/presses against the muscle [28].
2.4.3. Visual Assessment
2.4.2. Activity and Participation
Photographic documentation and visual assessment were used to evaluate the degree
1. Stroke Impact Scale (SIS) version 3.0 [29] was used to determine health-related qualof severity of the associated reactions of the upper extremity while maintaining the standing
ity of life (test/re-test reliability was 0.79 for general health return after stroke and
position (after 20 s of maintaining the position); it is the test at the beginning of the
0.98 for cognition) [30].
experiment and after its completion (examination I and IV).

2.4.3. Visual Assessment
Photographic documentation and visual assessment were used to evaluate the degree of severity of the associated reactions of the upper extremity while maintaining the
position (after 20 s of maintaining the position); it is the test at the beginning
of
Int. J. Environ. Res. Public Health 2023, standing
20, 4873
5 of 13
the experiment and after its completion (examination I and IV).
2.4.4. Minimal Clinically Important Difference
2.4.4. Minimal Clinically Important Difference
Minimal clinically important difference (MCID) was considered for FMA-UE, NRS,
Minimal clinically important difference (MCID) was considered for FMA-UE, NRS,
SIS
and
MAS scales [32–35].
SIS and MAS scales [32–35].
2.5.Therapeutic
TherapeuticIntervention
Intervention
2.5.
therapeuticprogram
programwith
withSaeboFlex
SaeboFlex®®dynamic
dynamicsplint
splintaccording
accordingto
toButler
Butler[36]
[36]was
was
AAtherapeutic
conductedby
byaaphysiotherapist.
physiotherapist.The
The16-week
16-weekprogram
programfocused
focusedon
ongrasping
graspingand
andreleasing
releasing
conducted
® dynamic splint con® dynamic
exerciseswith
withand
andwithout
without
splint
(Figure
2) [37].
SaeboFlex
exercises
thethe
splint
(Figure
2) [37].
TheThe
SaeboFlex
splint consists
sists
of
a
part
that
includes
the
forearm
shell
and
a
dorsal
hand
piece
which
is a platform
of a part that includes the forearm shell and a dorsal hand piece which is a platform
that
that
stabilizes
the
palm
attached
to
it.
Digit
caps
for
individual
fingers
from
V the
and
stabilizes the palm attached to it. Digit caps for individual fingers from II to II
V to
and
the thumb
are attached
to dorsal
the dorsal
hand
piece.
individual
digit
caps
attached
thumb
are attached
to the
hand
piece.
TheThe
individual
digit
caps
areare
attached
to to
a
a line
made
a durable
polymer
provides
assistance
during
extension
movement
of
line
made
of aofdurable
polymer
thatthat
provides
assistance
during
extension
movement
of the
the fingers.
The splint
is additionally
stabilized
with [38].
Velcro
The arrangement
of
fingers.
The splint
is additionally
stabilized
with Velcro
The[38].
arrangement
of springs
springs
can be to
adapted
to theabilities
currentofabilities
of theThe
patient.
The
patient
used thefor
orthosis
can
be adapted
the current
the patient.
patient
used
the orthosis
about
2for
h aabout
day (75%
the(75%
therapy).
splint was
theused
patient
as partonly
of exercise;
2 h aofday
of theThe
therapy).
The used
splintbywas
by only
the patient
as part
®
® dytherefore,
she
did not use
fornot
other
Weactivities.
used the We
SaeboFlex
splint
of exercise;
therefore,
she itdid
useactivities.
it for other
used thedynamic
SaeboFlex
because
it is the
only splint
the Polish
rehabilitation
market.
Other researchers
namic splint
because
it is available
the only on
splint
available
on the Polish
rehabilitation
market.
confirm
the high quality
and
effectiveness
thiseffectiveness
device [10,37,39].
Other researchers
confirm
the
high qualityofand
of this device [10,37,39].

Figure2.2.Patient’s
Patient’supper
upperextremity
extremityin
inthe
theSaeboFlex
SaeboFlex®® dynamic
dynamicsplint.
splint.
Figure

1.1.

2.

3.

Exercise
Exerciseprogram
programaccording
accordingtotoButler
Butler[36]:
[36]:
Repeated
exercises for
foraasingle
singlemuscle
muscle
group
using
splint
(e.g.,
biceps
brachii
Repeated exercises
group
using
thethe
splint
(e.g.,
biceps
brachii
durduring
lifting the
the hand
the mouth);
improvement
of strength
neuromusing lifting
handtowards
towards
the mouth);
improvement
of and
strength
and
cular control in a single muscle group, through the use of concentric, isometric and
eccentric muscle contraction.
Repetitive exercises involving multiple muscle groups using the splint (e.g., pectoralis
major/triceps brachii during reaching and retrieving the upper extremity); improvement of the strength and neuromuscular control of agonist and antagonist muscles
through concentric, isometric and eccentric muscle contraction. Reaching exercises
were carried out both in sitting and standing positions. The patient’s task was to reach
for an object (a ball) on the table and put it in another place. The height of the table
was variable, which was aimed to diversify the activity. Recreation/creation of new
movement engrams by repeating the same tasks.
Repetitive grasp-release exercises of objects using the splint; improvement of volitional
motor control of the finger flexor muscles through the use of a phenomenon called
“agonist retraining”. The use of resistance imposed by a spring system on the fingers
and thumb, which results in the patient performing voluntary muscle contraction and

Int. J. Environ. Res. Public Health 2023, 20, 4873

4.

6 of 13

relaxation of the flexor muscles of the fingers and thumb. During the exercises, the
type of objects and their location were changed.
Repetitive grasp-release exercises without the splint; objective: to consolidate the
upper limb functions obtained with the splint by repeated grasping and releasing
tasks of various objects placed in different locations.

The total number of repetitions of all exercises was approximately 400–600 as such a
number of repetitions of difficult functional tasks such as grasping during daily activities
can lead to brain reorganization [40]. Experimental models on animals have shown that
400–600 repetitions per day are needed to provoke changes in the nervous system [41]. Task
form exercises are the most effective as they require the patient to concentrate and make an
effort to reach or grasp objects. The task should not be too difficult, but it should not be too
easy—it should be a challenge for the patient. Research suggests that intensive task-based
training with a large number of repetitions improves the upper extremity function [42].
Research on neuroplasticity has shown that repeated repetition of tasks can affect changes
in cortical organization [43].
3. Results
Examinations II to IV showed an improvement in motor function compared to examination I. After completion of the program, motor function of the upper extremity
increased by 19.7%, pain sensation by 8.3%, and passive range of motion by 16.7%, while
arthralgia decreased by 12.5%. Changes in the wrist and hand motor skills as well as coordination/velocity were noticed only during examinations III and IV. Sensation changed
only slightly during examination IV, while arthralgia decreased gradually starting from
examination II.
Spasticity was reduced by one score on average in all the muscle groups. The greatest
change in spasticity was observed during examination II, which resulted from the effect
of BoNT.
Pain at rest and during activity decreased only by one score but remained at a fairly
high level.
Oscillation frequency and stiffness gradually decreased starting from examination II
particular drop was observed during the active treatment with 7BoNT
Int. J. Environ. Res. Public Health 2023,(Figure
20, x FOR3).
PEERAREVIEW
of 14
(muscles 1–6, examination II). The trunk muscles (muscles 7–10) were not subjected to
treatment with BoNT but responded to treatment during examinations II to IV.

The direction
direction of characteristic
characteristic changes
changes in
in muscle
muscle tone
tone of selected muscles
muscles of the upper
Figure 3. The
extremity
and
trunk
in
a
standing
position
during
examinations
I
to
IV.
(A).
Oscillation
frequency
extremity
trunk
standing position during examinations I to IV.
of
flexor
digitorum
superficialis.
(B).
Stiffness
of
flexor
digitorum
superficialis.
(C).
Oscillation
freof flexor digitorum superficialis. (B). Stiffness of flexor digitorum superficialis. (C). Oscillation
quency
of
latissimus
dorsi.
(D).
Stiffness
of
latissimus
dorsi.
frequency of latissimus dorsi. (D). Stiffness of latissimus dorsi.

The total SIS score increased by 20%, while the HRQoL-physical domain improved
by 15%. Dexterity and coordination of fine motor skills changed during the study. During
examinations I and II, there were no fine motor skills. The grasping function was achieved
after 12 weeks of therapy and improved further at 16 weeks. The results are presented in
Table 1.

Int. J. Environ. Res. Public Health 2023, 20, 4873

7 of 13

The total SIS score increased by 20%, while the HRQoL-physical domain improved by
15%. Dexterity and coordination of fine motor skills changed during the study. During examinations I and II, there were no fine motor skills. The grasping function was achieved after 12 weeks of therapy and improved further at 16 weeks. The results are presented in Table 1.
Table 1. Results of structure/function measurements, oscillation frequency and stiffness of selected
muscles during examinations I to IV.
Test

Examination I

Examination II

Examination III

Examination IV

Structure/function measurements
Fugl-Meyer Upper Extremity Assessment
(A–D, max 66)
Upper extremity (max 36)
Wrist (max 10)
Hand (max 14)
Coordination/velocity (max 6)
Pain sensation (max 12)
Passive range of motion (max 24)
Arthralgia (max 24)
Modified Ashworth Scale
Elbow flexors
Elbow extensors
Wrist flexors
Finger flexors
Thumb flexors
Numerical Rating Scale
At rest (max 10)
During activity (max 10)

21/31.8%

24/36.4%

33/50%

34/51.5%

18
0
3
0
8
12
6

21
0
3
0
8
13
9

25
1
6
1
8
15
9

25
2
6
1
9
16
9

3
2
1
2
2

1
0
0
1
1

1+
1
1
1
1

1+
1
1+
1+
1

8
9

7
8

7
8

7
8

Oscillation frequency [Hz] and stiffness [N/m] of selected muscles
1. Pronator teres
Oscillation frequency
Stiffness
2. Flexor carpi ulnaris
Oscillation frequency
Stiffness
3. Flexor carpi radialis
Oscillation frequency
Stiffness
4. Flexor pollicis longus
Oscillation frequency
Stiffness
5. Flexor digitorum superficialis
Oscillation frequency
Stiffness
6. Biceps brachii
Oscillation frequency
Stiffness
7. Latissimus dorsi
Oscillation frequency
Stiffness
8. Trapezius, descending part
Oscillation frequency
Stiffness
9. Latissimus dorsi (standing position)
Oscillation frequency
Stiffness
10. Trapezius, descending part (standing position)
Oscillation frequency
Stiffness

14
229

10.7
119

10.9
124

11.5
188

19
403

15.5
294

16.5
310

16.9
329

13.5
218

10.7
124

12.4
190

12.6
198

17
316

15.2
227

16
296

16.3
301

15.5
308

14.5
259

14.8
272

15
285

16.2
295

14.8
259

15.2
265

15.5
270

15.8
305

14.4
249

13.5
199

12.4
129

15.5
291

13.6
247

12.9
240

12.8
251

16.7
241

16.1
209

15.2
174

14.3
125

19
375

18.3
352

18.3
328

17.9
377

Int. J. Environ. Res. Public Health 2023, 20, 4873

8 of 13

Table 1. Cont.
Test

Examination I

Examination II

Examination III

Examination IV

48
91
71
97
74
82
36
58
68
73
1

52
91
76
97
76
84
40
65
71
77
2

Activity and participation
Stroke Impact Scale (0–100%)
Strength
Memory and thinking
Emotions
Communication
ADL/IADL
Mobility
Hand function
Role and social function
Physical domain (1, 5, 6, 7)
Total (1–8)
Box and Block Test

40
62
42
86
54
78
24
40
56
57
0

40
91
71
94
70
82
32
43
64
69
0

ADL/IADL, activities of daily living/instrumental activities of daily living.

The MCID of 18.8% for FMA-UE met by the patient as the difference between examination I and IV was 19.7%. The MCID of one score for MAS was met as such a difference
and was achieved for three of five muscle groups. For NSR, MCID is considered to be a one
score or 15% difference, which was achieved by the patient both at rest and during activity.
For the SIS questionnaire, the MCID values of 9.2 for strength, 5.9 for ADL/IADL, and 4.5
for mobility were met. For the hand function, the MCID was close to the reference value of
17.8 as the difference achieved was 16 (Table 1).
The visual assessment (Figure 4) of the severity of the associated reactions of the
patient’s upper extremity at a standing position showed a significant change in the position
of the upper extremity. It was positioned closer to the patient’s body (increased adduction
Int. J. Environ. Res. Public Health 2023, 20, x FOR PEER REVIEW
9 of 14
and external rotation of the shoulder joint). The elbow and finger joints showed a smaller
flexion position together with the elongation of the patient’s trunk on the left side.

Figure4.
4. Patient
(A)
and
thethe
patient
after
a 16Figure
Patient before
before treatment
treatmentfor
forspasticity
spasticitywith
withbotulinum
botulinumtoxin
toxin
(A)
and
patient
after
a
® dynamic splint combined treatment for
week
tailored
therapeutic
program
using
the
SaeboFlex
®
16-week tailored therapeutic program using the SaeboFlex dynamic splint combined treatment for
spasticity with botulinum toxin (B). Vertical arrow shows the difference in the torso: shortened
spasticity with botulinum toxin (B). Vertical arrow shows the difference in the torso: shortened trunk
trunk (A) vs. elongated trunk (B). Horizontal arrow shows the distance between the trunk and the
(A) vs. elongated trunk (B). Horizontal arrow shows the distance between the trunk and the upper
upper limb: large distance (A) vs. distance reduced (B). No side effects were observed.
limb: large distance (A) vs. distance reduced (B). No side effects were observed.

4. Discussion
According to the literature, the presented case report and the experiment used are
innovative, and its effects encourage the use of such a therapy program in a larger group
of stroke patients with spastic paresis of the upper extremity. The effects of the experiment
were evaluated according to ICF standards, which is a strength of this report. In our case

Int. J. Environ. Res. Public Health 2023, 20, 4873

9 of 13

4. Discussion
According to the literature, the presented case report and the experiment used are
innovative, and its effects encourage the use of such a therapy program in a larger group of
stroke patients with spastic paresis of the upper extremity. The effects of the experiment
were evaluated according to ICF standards, which is a strength of this report. In our
case report, we showed that a 16-week program using BoNT treatment for spasticity
and exercises with dynamic splint improved functional grip and release. Furthermore, it
improved the functional status of a patient with chronic, moderate mobility impairment
resulting from stroke caused by the presence of thromboembolic material in the right
middle artery of the brain.
Physiotherapy for post-stroke patients aimed at recovering lost functions appears to
be the most effective form of neurological rehabilitation [44]. Its main goal is to regain
as much independence as possible in everyday activities, resulting in an improvement
in HRQoL. Continuously growing knowledge of post-stroke rehabilitation confirms its
central role. Obtaining more evidence for the effectiveness of rehabilitation of post-stroke
patients and facilitating the transition to clinical practice requires a better understanding of
the neurophysiological mechanisms that support recovery after stroke and the impact of
physiotherapeutic interventions on these mechanisms.
Physiotherapeutic practice shows that post-stroke rehabilitation focuses mainly on
gait re-education, while restoring/improving the function of the upper extremity is often
overlooked. Lang et al. showed that during a single therapeutic session, the most frequently
practiced activity is walking with 357 steps on average [45]. On the other hand, Kimberley
et al. depicted that the average number of repetitions of activity for the upper extremity
during a single treatment session is only 23–32 [41]. These show the imperfections of the
therapeutic process and also certain habits of the therapists. Therefore, we proposed a
program that can be beneficial in setting the goals for therapy.
Wade proved that spasticity is a common complication after stroke that limits voluntary movements [46], which can lead to reduced effectiveness of rehabilitation. Nasb
et al. demonstrated the high effectiveness of combination therapies in reducing spasticity
associated with the return of motor functions in the upper extremity [47]. The authors compared the effects of constrain-induced movement therapy combined with BoNT to intensive
conventional therapy also combined with BoNT in patients with partial, active extension
in the wrist, finger and thumb joints. Both modalities improved motor functioning and
activities of daily living in post-stroke patients.
The evidence on the efficacy of combination treatments with BoNT in patients with
greater motor deficits is limited. To meet the needs of these patients, we developed a
16-week program in which the SaeboFlex® dynamic splint and BoNT are used. Previously,
Pooyania et al. [15] showed a 12% improvement in motor function in patients in the chronic
period after stroke treated with SaeboFlex® dynamic splint and BoNT. Our results are in
line with this study; however, the improvement in FMA UE was greater, by 19.7%, and
highlights the benefits of the tailored program. To our knowledge, the program is novel
and encourages its use in a larger group of post-stroke people with spastic paresis of the
upper extremity, particularly due to its compliance with the standards of the International
Classification of Functioning, Disability, and Health.
Our report showed favorable changes in the functional status of the patient. The
final result of the FMA UE test showed that the patient achieved more than 50% of the
motor function of the upper extremity affected by spastic paresis. This translates into a 20%
improvement in impaired motor function of the entire extremity. Although the dynamic
splint stimulates grasping and releasing movements, a favorable change was observed in
other joints, i.e., in the elbow and shoulder joints. This confirms that the performance of the
grasping task stimulated by the splint was conducted as a functional model of the extremity
and as such serves as an example of a motor learning principle applied in therapy, which
is based on intensity, task, variability, increasing difficulty, goal orientation and a large
number of repetitions. The principles of motor learning stimulation in the treatment of

Int. J. Environ. Res. Public Health 2023, 20, 4873

10 of 13

stroke patients were presented by Maier et al. [48]. Thus, the proposed program meets the
principles of therapy based on stimulating motor learning. This effect is also confirmed by
the Box and Blocks test result, which showed the return of independent grasping function
already after 12 weeks of therapy and further functional grip improvement after 16 weeks
of therapy.
Regaining the grasping function of the hand is a very difficult goal to achieve; however,
obtaining even the slightest improvement can be very helpful in restoring the patient’s
independence [3]. According to the guidelines for treating spasticity with BoNT described
by Sławek, the peak of BoNT activity occurs in the second week after injection, while after
12 weeks, the effect of the drug wears off [49]. We considered this effect and confirmed it in
practice. Thus, during examination II, the resolution of spasticity was observed together
with the highest changes in oscillation frequency and muscle stiffness. Despite the fact
that after 12 weeks, the effect of BoNT ceased, muscle tone was lower than before the
experiment. This should be considered a beneficial effect of the applied therapy in reducing
the level of spasticity and regulating muscle tone.
Park and Chung reviewed the literature to summarize the effectiveness of treating
neuropathic pain with BoNT [50]. They demonstrated that BoNT is effective and reduces
pain in the shoulder joint in patients after stroke. However, this effect was not observed in
the presented case. No significant reduction in pain was achieved, both as a result of BoNT
(examination II) and in the following weeks of therapy.
The improvement in the Box and Blocks test result is very important. After 6 weeks, the
patient still showed no grasping function. However, after 12 weeks, the patient obtained a
functional grip, which improved by 100% after 16 weeks. These results suggest a beneficial
effect of the program on the grasping function of the hand, but the time needed for
improvement must be longer (12 weeks). Furthermore, a noticeable further improvement
was visible at a time when BoNT was no longer active.
The muscle tone of the trunk muscles in the supine and standing positions showed
improvement at each subsequent measurement. From examinations II to IV, the oscillation
frequency and muscle stiffness decreased. This indicates the normalization of trunk muscle
tone as a result of the gradual change in the patient’s postural compensation strategies.
The activity of the trunk muscles during reaching movement was described by
Marchesi et al. [51]. They showed that reaching movement requires the employment of
various kinematic strategies. The greatest activation was exerted by the latissimus dorsi
muscle and obliquus externus abdominis muscles. Cabanas-Valdes et al. proved that additional training of the trunk muscles improves core control, balance in sitting and standing
positions, walking and performing activities of everyday life in patients in the subacute
phase after stroke [52]. Proper core stability and proper control of the trunk muscles are
fundamental for most daily activities such as standing up, sitting down, walking and stabilizing the distal parts of the extremities. Dean et al. demonstrated that both of these factors
are necessary to maintain a stable posture and shift body weight when performing activities
such as reaching movements [53]. The authors observed that depending on the reaching
distance, there a relationship appears between the movement of the trunk and arm, the tone
of the lower extremities and the increase in the activity of individual segments of the trunk
and feet. Bending the trunk to extend the range increases the postural requirements because
the position of the center of gravity of the body changes during reaching movements.
Chern et al. showed that repeated training with a variable velocity which consisted of
bending and reaching for objects located in different places can stimulate the activity of
postural control systems [54]. The authors compared the effect of those activities between
healthy people and stroke survivors. They showed that the changing location of the target
and difficulty level have an impact on the displacement of the center of gravity of the body
and are good tools for training postural control.
De Baets et al. showed that correct activation of the trapezius muscle by ascending a
part at the beginning of the movement is key for the proper function of the arm [55]. The
conclusions of Chern et al. [54] and De Baets et al. [55] are in line with our report, in which

Int. J. Environ. Res. Public Health 2023, 20, 4873

11 of 13

muscle tone of the latissimus dorsi and the descending part of the trapezius decreased.
Furthermore, changes seen in the visual assessment suggest that improving the stability of
the lower extremity support phase is related to reaching movements and grasping objects
during exercises with the splint.
Hartley et al. demonstrated that rehabilitation of post-stroke people has a beneficial
effect on HRQoL [56]. The authors conclude that psychological support and simultaneous
pain treatment are very important in therapy. Our results are in line with these findings as
the patient was shown to systematically improve her HRQoL.
In the case of a novel treatment with limited evidence, in addition to effectiveness, the
patient’s perspective is important. The patient and her family confirmed improvements in
the patient’s functional state and upper extremity function each week as they recovered
grasping function. The patient was critical of the duration of exercise both during the day
and throughout the experiment. Despite positive effects, the program required commitment
and effort.
5. Conclusions
The results of the experiment show a positive effect on treating spasticity of the
upper extremity with BoNT in combination with a tailored therapeutic program using
the SaeboFlex® dynamic splint in a patient after stroke at all levels of the International
Classification of Functioning, Disability, and Health. After 16 weeks of therapy, muscle
tone normalized as a result of a reduction in spasticity as well as frequency oscillations and
muscle stiffness within the upper extremity and trunk. The motor function of the upper
extremity improved, and the grasping function was regained. Although pain remained
almost at the same level, the patient’s quality of life improved. The positive effects of the
treatment translated into the patient’s self-esteem and the effects on her daily functioning
were noticed by her family. The combined treatment with thed BoNT and SaeboFlex®
dynamic splints can improve functional status in post-stroke patients. The conducted
experiment is a pilot study. The result obtained encourages the authors to undertake
further research on a well-characterized and fairly homogeneous group of people after a
stroke. The results of further research will allow conclusions regarding the population of
people post-stroke to be drawn.
Author Contributions: Conceptualization, D.M., M.M., D.C.-B.; methodology, D.M., M.M., D.C.-B.;
software, D.M., M.M., D.C.-B.; validation, M.M., D.C.-B.; formal analysis, M.M.; investigation, D.M.;
resources, D.M.; data curation, D.M.; writing—original draft preparation, D.M., M.M., D.C.-B.;
writing—review and editing, M.M.; visualization, D.M., M.M.; supervision, M.M.; project administration, D.C.-B.; funding acquisition, D.M., M.M., D.C.-B. All authors have read and agreed to the
published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki, and approved by the Senate Committee for Research Ethics at Academy of Physical
Education in Wrocław (protocol no 6/2022 and approved on 14 February 2022).
Informed Consent Statement: Informed consent was obtained from the subject involved in the study.
Written informed consent has been obtained from the patient to publish this paper.
Data Availability Statement: Data available from the corresponding author on request.
Conflicts of Interest: The authors declare no conflict of interest.

References
1.
2.

Kuo, C.-L.; Hu, G.-C. Post-stroke Spasticity: A Review of Epidemiology, Pathophysiology, and Treatments. Int. J. Gerontol. 2018,
12, 280–284. [CrossRef]
Schiemanck, S.K.; Kwakkel, G.; Post, M.W.; Kappelle, L.J.; Prevo, A.J. Predicting long-term independency in activities of daily
living after middle cerebral artery stroke: Does information from MRI have added predictive value compared with clinical
information? Stroke 2006, 37, 1050–1054. [CrossRef] [PubMed]

Int. J. Environ. Res. Public Health 2023, 20, 4873

3.
4.
5.
6.
7.

8.
9.
10.
11.
12.

13.
14.

15.
16.
17.
18.
19.
20.

21.
22.
23.
24.
25.
26.
27.

28.
29.
30.
31.

12 of 13

Krakauer, J.W. Motor learning: Its relevance to stroke recovery and neurorehabilitation. Curr. Opin. Neurol. 2006, 19, 84–90.
[CrossRef] [PubMed]
Marzke, M.W. Evolutionary development of the human thumb. Hand Clin. 1992, 8, 1–8. [CrossRef]
Fernández, P.J.; Mongle, C.S.; Leakey, L.; Proctor, D.J.; Orr, C.M.; Patel, B.A.; Almécija, S.; Tocheri, M.W.; Jungers, W.L. Evolution
and function of the hominin forefoot. Proc. Natl. Acad. Sci. USA 2018, 115, 8746–8751. [CrossRef] [PubMed]
Nakayama, H.; Jørgensen, H.S.; Raaschou, H.O.; Olsen, T.S. Recovery of upper extremity function in stroke patients: The
Copenhagen Stroke Study. Arch. Phys. Med. Rehabil. 1994, 75, 394–398. [CrossRef] [PubMed]
Esquenazi, A.; Albanese, A.; Chancellor, M.B.; Elovic, E.; Segal, K.R.; Simpson, D.M.; Smith, C.P.; Ward, A.B. Evidence-based
review and assessment of botulinum neurotoxin for the treatment of adult spasticity in the upper motor neuron syndrome.
Toxicon 2013, 67, 115–128. [CrossRef]
Demetrios, M.; Khan, F.; Turner-Stokes, L.; Brand, C.; McSweeney, S. Multidisciplinary rehabilitation following botulinum toxin
and other focal intramuscular treatment for post-stroke spasticity. Cochrane Database Syst. Rev. 2013, CD009689. [CrossRef]
van der Lee, J.H.; Wagenaar, R.C.; Lankhorst, G.J.; Vogelaar, T.W.; Devillé, W.L.; Bouter, L.M. Forced use of the upper extremity in
chronic stroke patients: Results from a single-blind randomized clinical trial. Stroke 1999, 30, 2369–2375. [CrossRef]
Hoffman, H.B.; Blakey, G.L. New design of dynamic orthoses for neurological conditions. NeuroRehabilitation 2011, 28, 55–61.
[CrossRef]
Bütefisch, C.; Hummelsheim, H.; Denzler, P.; Mauritz, K.H. Repetitive training of isolated movements improves the outcome of
motor rehabilitation of the centrally paretic hand. J. Neurol. Sci. 1995, 130, 59–68. [CrossRef] [PubMed]
Eroğlu, M.; Karapolat, H.; Atamaz, F.; Tanıgör, G.; Kirazlı, Y. Occupational therapy assessment and treatment approach in
patients with subacute and chronic stroke: A single-blind, prospective, randomized clinical trial. Turk. J. Phys. Med. Rehabil. 2020,
66, 316–328. [CrossRef] [PubMed]
Sun, Y.; Ledwell, N.M.H.; Boyd, L.A.; Zehr, E.P. Unilateral wrist extension training after stroke improves strength and neural
plasticity in both arms. Exp. Brain Res. 2018, 236, 2009–2021. [CrossRef] [PubMed]
Daly, J.J.; McCabe, J.P.; Holcomb, J.; Monkiewicz, M.; Gansen, J.; Pundik, S. Long-Dose Intensive Therapy Is Necessary for Strong,
Clinically Significant, Upper Limb Functional Gains and Retained Gains in Severe/Moderate Chronic Stroke. Neurorehabil. Neural
Repair 2019, 33, 523–537. [CrossRef] [PubMed]
Pooyania, S.; Semenko, B. Botulinum toxin type-A (BoNTA) and dynamic wrist-hand orthoses versus orthoses alone for the
treatment of spastic-paretic upper extremity in chronic stroke patients. Open J. Ther. Rehabil. 2014, 2, 12–18. [CrossRef]
Mahoney, F.I.; Barthel, D.W. Functional evaluation: The Barthel Index. Md. State Med. J. 1965, 14, 61–65.
Katoozian, L.; Tahan, N.; Zoghi, M.; Bakhshayesh, B. The Onset and Frequency of Spasticity After First Ever Stroke. J. Natl. Med.
Assoc. 2018, 110, 547–552. [CrossRef]
Lundström, E.; Smits, A.; Terént, A.; Borg, J. Time-course and determinants of spasticity during the first six months following
first-ever stroke. J. Rehabil. Med. 2010, 42, 296–301. [CrossRef]
Burke, D.; Wissel, J.; Donnan, G.A. Pathophysiology of spasticity in stroke. Neurology 2013, 80, S20–S26. [CrossRef]
Brashear, A.; Zafonte, R.; Corcoran, M.; Galvez-Jimenez, N.; Gracies, J.-M.; Gordon, M.F.; McAfee, A.; Ruffing, K.; Thompson, B.;
Williams, M.; et al. Inter- and intrarater reliability of the Ashworth Scale and the Disability Assessment Scale in patients with
upper-limb poststroke spasticity. Arch. Phys. Med. Rehabil. 2002, 83, 1349–1354. [CrossRef]
SaeboFlex. Available online: https://uk.saebo.com/shop/saeboflex/ (accessed on 15 November 2022).
International Classification of Functioning, Disability and Health (ICF). WHO. Available online: https://www.who.int/standards/
classifications/international-classification-of-functioning-disability-and-health (accessed on 30 September 2022).
Fugl-Meyer, A.R.; Jääskö, L.; Leyman, I.; Olsson, S.; Steglind, S. The post-stroke hemiplegic patient. 1. a method for evaluation of
physical performance. Scand. J. Rehabil. Med. 1975, 7, 13–31. [PubMed]
Sanford, J.; Moreland, J.; Swanson, L.R.; Stratford, P.W.; Gowland, C. Reliability of the Fugl-Meyer assessment for testing motor
performance in patients following stroke. Phys. Ther. 1993, 73, 447–454. [CrossRef] [PubMed]
Morris, S. Ashworth And Tardieu Scales: Their Clinical Relevance For Measuring Spasticity In Adult And Paediatric Neurological
Populations. Phys. Ther. Rev. 2002, 7, 53–62. [CrossRef]
Lundeberg, T.; Lund, I.; Dahlin, L.; Borg, E.; Gustafsson, C.; Sandin, L.; Rosén, A.; Kowalski, J.; Eriksson, S.V. Reliability and
responsiveness of three different pain assessments. J. Rehabil. Med. 2001, 33, 279–283. [CrossRef] [PubMed]
Ianieri, G.; Saggini, R.; Marvulli, R.; Tondi, G.; Aprile, A.; Ranieri, M.; Benedetto, G.; Altini, S.; Lancioni, G.E.; Goffredo, L.; et al.
New approach in the assessment of the tone, elasticity and the muscular resistance: Nominal scales vs MYOTON. Int. J.
Immunopathol. Pharm. 2009, 22, 21–24. [CrossRef] [PubMed]
Jaskólska, A.; Jaskólski, A. Właściwości fizjologiczne i mechaniczne mi˛eśni szkieletowych—Czy sa˛ takie same w różnych
mi˛eśniach i u wszystkich osób? Kosmos 2021, 69, 739–756. [CrossRef]
Duncan, P.W.; Wallace, D.; Lai, S.M.; Johnson, D.; Embretson, S.; Laster, L.J. The stroke impact scale version 2.0. Evaluation of
reliability, validity, and sensitivity to change. Stroke 1999, 30, 2131–2140. [CrossRef]
Vellone, E.; Savini, S.; Fida, R.; Dickson, V.V.; Melkus, G.D.; Carod-Artal, F.J.; Rocco, G.; Alvaro, R. Psychometric evaluation of the
Stroke Impact Scale 3.0. J. Cardiovasc. Nurs. 2015, 30, 229–241. [CrossRef]
Desrosiers, J.; Bravo, G.; Hébert, R.; Dutil, E.; Mercier, L. Validation of the Box and Block Test as a measure of dexterity of elderly
people: Reliability, validity, and norms studies. Arch. Phys. Med. Rehabil. 1994, 75, 751–755. [CrossRef]

Int. J. Environ. Res. Public Health 2023, 20, 4873

32.
33.

34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.

46.
47.

48.
49.
50.
51.
52.

53.
54.
55.
56.

13 of 13

Hiragami, S.; Inoue, Y.; Harada, K. Minimal clinically important difference for the Fugl-Meyer assessment of the upper extremity
in convalescent stroke patients with moderate to severe hemiparesis. J. Phys. Ther. Sci. 2019, 31, 917–921. [CrossRef]
Meseguer-Henarejos, A.B.; Sánchez-Meca, J.; López-Pina, J.A.; Carles-Hernández, R. Inter- and intra-rater reliability of the
Modified Ashworth Scale: A systematic review and meta-analysis. Eur. J. Phys. Rehabil. Med. 2018, 54, 576–590. [CrossRef]
[PubMed]
Salaffi, F.; Stancati, A.; Silvestri, C.A.; Ciapetti, A.; Grassi, W. Minimal clinically important changes in chronic musculoskeletal
pain intensity measured on a numerical rating scale. Eur. J. Pain 2004, 8, 283–291. [CrossRef] [PubMed]
Lin, K.C.; Fu, T.; Wu, C.Y.; Wang, Y.H.; Liu, J.S.; Hsieh, C.J.; Lin, S.F. Minimal detectable change and clinically important difference
of the Stroke Impact Scale in stroke patients. Neurorehabil. Neural Repair 2010, 24, 486–492. [CrossRef] [PubMed]
Butler, A.; Blanton, S.; Rowe, V.; Wolf, S. Attempting to improve function and quality of life using the FTM Protocol: Case report.
J. Neurol. Phys. Ther. 2006, 30, 148–156. [CrossRef] [PubMed]
Stuck, R.A.; Marshall, L.M.; Sivakumar, R. Feasibility of SaeboFlex upper-limb training in acute stroke rehabilitation: A clinical
case series. Occup. Ther. Int. 2014, 21, 108–114. [CrossRef]
Walawender, I.; Roczniak, W.; Nowak, D.; Skowron, M.; Waliczek, M.; Rogalska, A.; Nowak, P.G. Applicability of the Numeric
Scale for Anxiety Evaluation in Patients Undergoing Dental Treatment. Dent. Med. Probl. 2015, 52, 205–214.
Andriske, L.; Verikios, D.; Hitch, D. Patient and Therapist Experiences of the SaeboFlex: A Pilot Study. Occup. Ther. Int. 2017,
2017, 5462078. [CrossRef]
Chau, C.; Barbeau, H.; Rossignol, S. Early locomotor training with clonidine in spinal cats. J. Neurophysiol. 1998, 79, 392–409.
[CrossRef]
Kimberley, T.J.; Samargia, S.; Moore, L.G.; Shakya, J.K.; Lang, C.E. Comparison of amounts and types of practice during
rehabilitation for traumatic brain injury and stroke. J. Rehabil. Res. Dev. 2010, 47, 851–862. [CrossRef]
de Sousa, D.G.; Harvey, L.A.; Dorsch, S.; Glinsky, J.V. Interventions involving repetitive practice improve strength after stroke: A
systematic review. J. Physiother. 2018, 64, 210–221. [CrossRef]
Scrivener, K.; Sherrington, C.; Schurr, K.; Treacy, D. Many participants in inpatient rehabilitation can quantify their exercise
dosage accurately: An observational study. J. Physiother. 2011, 57, 117–122. [CrossRef]
Veerbeek, J.M.; van Wegen, E.; van Peppen, R.; van der Wees, P.J.; Hendriks, E.; Rietberg, M.; Kwakkel, G. What is the evidence
for physical therapy poststroke? A systematic review and meta-analysis. PLoS ONE 2014, 9, e87987. [CrossRef] [PubMed]
Lang, C.E.; Macdonald, J.R.; Reisman, D.S.; Boyd, L.; Jacobson Kimberley, T.; Schindler-Ivens, S.M.; Hornby, T.G.; Ross, S.A.;
Scheets, P.L. Observation of amounts of movement practice provided during stroke rehabilitation. Arch. Phys. Med. Rehabil. 2009,
90, 1692–1698. [CrossRef] [PubMed]
Wade, D.T. Stroke: Rehabilitation and long-term care. Lancet 1992, 339, 791–793. [CrossRef]
Nasb, M.; Li, Z.; S A Youssef, A.; Dayoub, L.; Chen, H. Comparison of the effects of modified constraint-induced movement
therapy and intensive conventional therapy with a botulinum-a toxin injection on upper limb motor function recovery in patients
with stroke. Libyan J. Med. 2019, 14, 1609304. [CrossRef] [PubMed]
Maier, M.; Ballester, B.R.; Verschure, P. Principles of Neurorehabilitation After Stroke Based on Motor Learning and Brain Plasticity
Mechanisms. Front. Syst. Neurosci. 2019, 13, 74. [CrossRef] [PubMed]
Sławek, J. (Ed.) Zastosowanie toksyny botulinowej w leczeniu spastyczności kończyny górnej u dorosłych. In Spastyczność—Od
Patofizjologii do Leczenia, 2nd ed.; Via Medica: Gdańsk, Poland, 2013; pp. 181–194.
Park, J.; Chung, M.E. Botulinum Toxin for Central Neuropathic Pain. Toxins 2018, 10, 224. [CrossRef]
Marchesi, G.; Ballardini, G.; Barone, L.; Giannoni, P.; Lentino, C.; De Luca, A.; Casadio, M. Modified Functional Reach Test:
Upper-Body Kinematics and Muscular Activity in Chronic Stroke Survivors. Sensors 2021, 22, 230. [CrossRef]
Cabanas-Valdés, R.; Bagur-Calafat, C.; Girabent-Farrés, M.; Caballero-Gómez, F.M.; 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, 1024–1033. [CrossRef]
Dean, C.; Shepherd, R.; Adams, R. Sitting balance I: Trunk-arm coordination and the contribution of the lower limbs during
self-paced reaching in sitting. Gait Posture 1999, 10, 135–146. [CrossRef]
Chern, J.S.; Lo, C.Y.; Wu, C.Y.; Chen, C.L.; Yang, S.; Tang, F.T. Dynamic postural control during trunk bending and reaching in
healthy adults and stroke patients. Am. J. Phys. Med. Rehabil. 2010, 89, 186–197. [CrossRef] [PubMed]
De Baets, L.; Van Deun, S.; Monari, D.; Jaspers, E. Three-dimensional kinematics of the scapula and trunk, and associated scapular
muscle timing in individuals with stroke. Hum. Mov. Sci. 2016, 48, 82–90. [CrossRef] [PubMed]
Hartley, T.; Burger, M.; Inglis-Jassiem, G. Post stroke health-related quality of life, stroke severity and function: A longitudinal
cohort study. Afr. J. Disabil. 2022, 11, 947. [CrossRef] [PubMed]

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual
author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to
people or property resulting from any ideas, methods, instructions or products referred to in the content.