INTRODUCTION:

Stroke ranks as the third most prevalent cause with the most debilitating illnesses of mortality worldwide, accounting for approximately 795,000 new occurrences or recurring cases of stroke every year. Groups at a higher risk typically encompass individuals aged 55 and above^1-4. The most frequent symptom of stroke reported by the majority of patients was a sensation of numbness or weakness with partial or complete loss of voluntary movement. Indications to be mindful of include the sudden numbness of the face, arm, or leg, especially when it affects just one side of the body. For individuals who have experienced a stroke, a decline in motor function often results in reduced trunk stability and compromised dynamic balance^5-8.With a 4–42.6% incidence, spasticity is a common post-stroke condition in stroke patients. PSS, or post-stroke spasticity, can occur in as many as 42.6% of individuals who experienced a stroke experiencing muscular paresis ranging from mild to severe⁹. Caregivers of patients with cerebrovascular accidents (CVA) face numerous psychosocial and physiological stressors, and they may encounter various potential losses and lifestyle changes. It's crucial to prioritize educating the at-risk population about stroke risk factors, warning signs, and the importance of prompt treatment^10,11. Initially spasticity was defined as a Heightened increased muscle tone that varies with velocity and excessive tendon reflexes caused by the heightened sensitivity of the stretch reflex¹²^.Later it is restricted movement accompanied by spasticity, encompassing all the positive indicators of Upper Motor Neuron (UMN) syndrome, which have been redefined. Spasticity is characterized by abnormal sensorimotor control, which manifests as sporadic or persistent muscle involuntary involvement¹³. Involuntary muscular hyperactivity in central paresis, brought on by either rapid or slow passive joint movement or sensory activation, is the new definition that has been put forth recently¹⁴. Poststroke spasticity (PSS), which is mostly caused by four typical patterns of spasticity observed in the ankle and foot, and five distinctive arm spasticity patterns, severely inhibits flexibility in the upper limbs and the capacity to walk and move freely contrasted with a stiff-knee gait^15,16. Long-term Post-Stroke Syndrome (PSS) can result in a significant decline in quality of life, primarily due to complications such as joint contractures, pressure ulcers, and pain. These issues can contribute to a fourfold increase in the burden of care^17-20. Incorrect joint postures and contractures may result from the PSS. Feared long-term effects of PSS include pain, posture abnormalities, and the consequent impaired relearning of functionally necessary behaviours happening in the aftermath of stroke^21,22. Eighty percent of people who have survived a chronic stroke have some degree of aberrant gait and impaired movement. The implementation of neurological rehabilitation intervention resulted in a decrease in the level of functional disability²³. Spasticity in the muscles of the ankle and foot is the most common cause of equinus, varus, equinovarus, and striatal toe abnormalities observed in the ankle and foot²⁴. The spectrum and hierarchy of post-stroke hemiplegic gait abnormalities reflect the mechanical effects of spasticity, muscular weakening, aberrant synergistic activation, and their combination. During walking's stance phase, the spastic muscles are cooperatively recruited to produce hip and knee extension. The knee and hip cannot be flexed to clear the feet because of the incorrect activation. In order to make up for these limitations, stroke survivors typically hike hip and perform circumduction of the impacted leg for foot clearance during the swing phase. It is hence referred to "circumductory gait.". Depending on the extent of involvement (focal, regional, or extensive) and the severity of weakness and spasticity, a broad A range of gait impairments is observed, as outlined previously²⁵. The Modified Ashworth Scale (MAS) is widely recognized as the primary and reliable scale for assessing spasticity in both upper and lower limbs. It exhibits strong inter-rater reliability, with a kappa value of 0.79, and intra-rater reliability ranging from 0.47 to 0. The MAS employs grades tailored to the muscular changes post-stroke, enabling precise determination of spasticity levels in the muscles²⁶.

The Dynamic Gait Index (DGI) is another dependable and validated scale utilized for evaluating gait outcomes in chronic stroke patients. Its inter-rater reliability, both for test-retest and inter-rater, is high at 0.96. The reliability for single-item scores ranges from moderate to good, spanning between 0.55 and 0.93. Furthermore, its concurrent construct validity, as measured by correlation with Berg's Balance Scale, ranges from r = 0.68 to 0.83²⁷. As per Rood's method, deep pressure is a proprioceptive inhibitory strategy. It has been demonstrated to decrease excitability of motor neurons in patients with the central nervous system disorders. Applying manual pressure to the insertion point of a muscle or along its extended tendons leads to a suppressive impact. It is suggested the Pacinian corpuscle plays a role in muscle inhibition²⁸. The Golgi tendon organ may also contribute to this response. Circumferential pressure involves applying strong pressure exerted by encircling the entire circumference of a limb, maintaining consistent pressure all along²⁹. Compulsory weight-bearing exercises led to enhancements in both symmetrical weight distribution and gait speed among stroke patients³⁰.

MATERIALS AND METHODS:

Study design: Experimental study

Subjects: Post stroke patients

Sampling technique: Random sampling

Sample size: 20

Inclusion criteria:

· Age of 50-70 years.

· Spasticity level of 2-3 according to MAS

· A self-reliant walking pattern with or without the assistance of walking aids.

· The post-stroke period ranging from 3 months to 1 year.

Exclusion criteria:

· Altered cognitive ability according to MMSE

· Pain or heightened sensitivity in the lower limbs.

· Injuries to the musculoskeletal system or Fractures.

· The use of medication aimed at relaxing muscles.

· Peripheral vascular disease affecting the same side.

· Any additional neurological issues.

Study procedure:

The study was conducted with 20 participants of post stroke patients at a private medical College and hospital, Participants were selected using a simple random sampling technique, adhering to predefined inclusion and exclusion criteria. The research study protocol was thoroughly clarified to the participants, and written consent was obtained from every participant before the intervention commenced. Subjects were assigned randomly to either the interventional group or the control group using the closed envelope method. Each participant received treatment sessions lasting 30 minutes.

Group A- 10 and Group B- 10. During a period of eight weeks, Group A received circumferential pressure using sphygmomanometer with the pressure of 30-50 mmhg for 30 minutes with an intermittent break after every 10 minutes for the lower limb, i.e., plantar flexors of the foot. The control group received 30 minutes of conventional physiotherapy such as inhibitory techniques like slow sustained stretch, slow stroking, slow icing, weight bearing exercises, joint approximation, etc. All participants received treatment sessions three days per week, totalling eight weeks.

Pre-treatment assessments of spasticity and gait pattern were conducted before the intervention commenced. The same measurements were repeated after 8 weeks of treatment to obtain post-treatment values.

Materials Required: Sphygmomanometer.

Outcome Measure:

· Modified Ashworth scale,

· Dynamic Gait Index.

Ethical Clearance:

Ethical clearance for the study was obtained from the Institutional Scientific Review Board. (ISRB) – 01/016/2023/ISRB/PGSR/SCPT.

Statistical Analysis:

After the treatment of 8 weeks, Group A underwent circumferential pressure using sphygmomanometer for 30 minutes, it has notable improvement with the post values of the Modified Ashworth Scale (MAS)mean value 1.3 and in Dynamic Gait Index (DGI) mean value 20.00[TABLE 1]

DYNAMIC GAIT INDEX:

Table 1: Comparison Of Dynamic Gait Index Within The Circumferential Pressure Group:

Dynamic Gait Index		Mean	Standard Deviation	T value	P Value
	Pre test	13.20	1.75	34.00	<.0001
	Post test	20.00	1.63	34.00	<.0001

In contrast, Group B showed less significant post values of the Modified Ashworth Scale (MAS)mean value 2.5 and Dynamic Gait Index (DGI) mean value 16.20 [Table 2]. Group A had a notably greater effective rate than Group B.

Table 2: Comparison of Dynamic Gait Index Within The Conventional Physiotherapy Group:

Dynamic Gait Index

Mean

Standard Deviation

T Value

P Value

Pre test

13.00

1.63

16.00

<.0001

Post test

16.20

1.75

Modified Ashworth Scale:

From observing the 10 samples selected in the experimental group A (Circumferential pressure using sphygmomanometer), six samples showed reduction of spasticity from Grade 3 to Grade 1+, and the other 4 samples showed reduction of spasticity from Grade 2 to Grade 1.

In contrast, the 10 samples in the Group B (Conventional Physiotherapy), 4 samples showed reduction of spasticity from Grade 2 to Grade 1+ and the other six samples showed reduction of spasticity from Grade 3 to Grade 2. Assuming 1+ value as (2), the mean values for the group A post-test is 1.3 and the mean value for the group B post-test is 2.5.

RESULTS:

The result of comparing Pre-test and post-test within Group A and Group B exhibited a notable disparity in mean values at P <0.0001 [Table 3].

Table 3: Comparison Of Dynamic Gait Index Post Values Between The Circumferential Pressure and Conventional Physiotherapy Group.

Dynamic Gait Index

Mean

Standard

Deviation

T Value

P Value

Group A

Post test

20.00

1.63

5.0186

<.0001

Group B

Post test

16.20

1.75

Study concludes that circumferential pressure using sphygmomanometer reduces spasticity and improves gait pattern among post stroke patients [GRAPH 1].

Graph 1: Comparison Of Dynamic Gait Index Post Values Between The Circumferential Pressure And Conventional Physiotherapy Group.

DISCUSSION:

The purpose of this research was done to evaluate the effectiveness of applying circumferential pressure using a sphygmomanometer as a tool for intervention, compared to conventional physiotherapy, in managing spasticity of the plantar flexors and enhancing motor functions such as gait in post stroke patients. Chiranjeevi Jannu, Prathap Suganthirababu³¹ conducted a study on the Efficacy of Interferential Therapy Versus Transcutaneous electrical nerve stimulation to Reduce Pain in Patients with Diabetic neuropathy which also might be a peripheral nerve lesions that affects the lower limb most commonly which involves Paresthesia involving the lower limbs (legs and feet)According to Rood's method, deep pressure is a proprioceptive inhibitory strategy, it has been shown to decrease motor neuron responsiveness in patients with central nervous system disorders. On the other hand,Odair Bacca et al³² concluded that the circumferential pressure (CP) applied by Johnstone Pressure Splint exert a constant stimulus and offers support for stabilizing the extremity when engaging in therapeutic exercise and primarily have biomechanical and neural effects, as indicated by the reduction in muscle tone and reflex activity. Circumferential pressure application by sphygmomanometer has a substantial impact on motor abilities and spasticity hand dexterity, and in reducing spasticity in stroke patients according to Shailesh Gardas et al^33. Julie Robichaud et al³⁴ reported, following the application of circumferential pressure (CP), there was a 55% decrease in the amplitude of the H-wave. Similar research conducted on children with cerebral palsy has demonstrated that the Bobath method in conjunction with CP reduces muscular tone, increases joint range of motion, and enhances joint range of motion (ROM) and improves motor function. Julie Robichaud et alstated that in this study, the application of A pneumatic splint encircling the lower leg resulted in a decrease in excitability of the soleus muscle motoneuron reflex both neurologically in both normal subjects and individuals with Cerebrovascular Accident CVAs. This reduction persisted throughout 5 minutes of pressure application. In a study conducted by Robichaud et al, it was demonstrated that applying circumferential pressure with air splints led to a decrease in the excitability of alpha motor neurons in individuals with spinal cord injury, However, this result was observed as long as the pressure persists when actively applied. Likewise, circumferential pressure is designed to offer comfort, non-invasiveness, and ease application, and proven effective in reducing alpha motor neuron excitement and muscular activity in individuals recovering from cerebrovascular accidents (CVAs). Vishnuram S et al³⁵, conducted a study on the Effect of Peripheral Nerve Mobilization and VR-Based Gait Training on Gait Parameters Among Patients with Chronic ACA Stroke and concluded that PNM and VR game-based gait training emerge as effective interventions for enhancing gait parameters in ACA stroke rehabilitation. Dhanashri N. Marathe et al³⁶concludes that Tendinous pressure is demonstrated to be more effective compared to Myofascial Release (MFR) in reducing the spasticity of stroke patients. Manual pressure exerted on the tendon insertion point of a muscle or along long tendons induces a suppressive impact. It is suggested that the Pacinian corpuscle is involved in this muscle inhibition. Furthermore, pressure application reduces the responsiveness of tactile receptors, resulting in a slower adjustment to stimuli and an increase in sensory input. The pneumatic pressure delivered by air splints has been discovered to be provide advantages in diminishing the excitability in motor neurons of the spinal cord following a cerebrovascular accident, according to Agostinucci et al³⁷. This study offers compelling indications of the anti-spastic effects of pressure applied by a sphygmomanometer on the wrist flexors and plantar flexors, as well as its beneficial impact on motor abilities such as gait, equilibrium, and hand dexterity among the stroke patients. Circumferential pressure (CP) administered via the Johnstone pressure splint (JPS) in conjunction with intervention therapy (IT) has been employed to facilitate sensory re-education and mitigate the excitability of spastic muscles in individuals recovering from stroke^38.

The limitation of this study includes less sample size and the study limits to specific region. The further recommendation of the study includes this study is, it can be done in the upper extremity spasticity and hand functions with a larger sample size and further researches can be carried out with study involving patients with a Modified Ashworth Scale grade higher than 3 and also involving the other recent outcome measures to assess spasticity.

CONCLUSION:

It has been determined from the present research that circumferential pressure using sphygmomanometer is more effective method for post stroke patients to reduce spasticity and improve gait pattern when compared with conventional physiotherapy.

CONFLICT OF INTEREST:

A conflict of interest has not been disclosed by the author.

ACKNOWLEDGEMENT:

The authors express their gratitude for the valuable assistance provided in collecting the samples to the sub urban hospitals. They also extend their appreciation to the authors of the articles referenced and cited in this study, as well as to all participants, whose contributions are highly valued.

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Received on 12.04.2024 Revised on 03.08.2024

Accepted on 09.10.2024 Published on 27.03.2025

Available online from March 27, 2025

Research J. Pharmacy and Technology. 2025;18(3):1161-1165.

DOI: 10.52711/0974-360X.2025.00167

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