A Possible Pharmacotherapy-Avoiding Break-Through in Physical

Therapy Treatment during Early Rehabilitation of Patients with High

Muscle Tone after Thalamus Hemorrhage

OLAF R. VAN LOON1,a,*, A. J. (TOM) VAN LOON2,b

1Privat Klinik im Park, Therapy Department,

Badstrasse 50, CH-5116 Schinznach-Bad,

SWITZERLAND

2Shandong University of Science and Technology,

Qingdao 266590,

CHINA

aORCiD: 0000-0002-2833-7575

bORCiD: 0000-0002-8906-1728

*Corresponding Author

Abstract: - Deep dry needling (DDN) treatments were given during early rehabilitation to a 48-year-old male

subject who suffered from brain hemorrhage with the objective to diminish hypertension. DDN treatment at such

an early stage of recovery has not been well documented until now. It is new in, among some other aspects, that it

avoids the commonly applied pharmacotherapy that is intended to decrease the hypertension, but that often appears

hardly effective or not effective at all, or sometimes possibly even counter-effective. A pre-intervention test was

performed to record baseline values, and the same aspects were measured again, directly after, and approximately

one hour after the intervention. The results for the range of movement (ROM) of the subject’s right-side extremities

were assessed through the Tardieu scale. It could be deduced that DDN did not result in a long-lasting reduction of

the tension, but that the ROM values for the elbow joints within the treated muscles improved significantly during

and immediately after the treatment, allowing better alignment and more active movement. It thus appeared that the

DDN-induced temporarily improved ROM facilitated treatment and allowed the subject to exercise in a better

alignment and more effectively during treatment. The experience with the subject makes it likely that DDN during

early rehabilitation makes a post-stroke subject more comfortable (because of reduced spasticity/hypertension) and

helps making physical therapy treatment of post-stroke patients more effective although no spasticity-reducing

pharmacotherapy need be given, thus also increasing the cost-effectiveness of the treatment.

Key-Words: - brain hemorrhage, DDN, dry needling, early rehabilitation, hypertension, physical therapy, spasticity.

Received: April 22, 2024. Revised: October 11, 2024. Accepted: November 14, 2024. Published: December 20, 2024.

1 Introduction

Treatments in the form of medicines were given

already in prehistoric times, based on empirical

results. The positive results in the course of time in

ever more and ever more effective medicines. It is

now increasingly recognized in the medical

community, however, that the ‘classical’ prescription

of medicines to treat specific physical malfunctioning

is not always the best cure: although medicines still

play a major role in the treatments of patients,

pharmacotherapy occasionally has not the expected

result, or maybe even counter-effective.

Consequently, ever more practice-oriented research

is aimed at finding out how the biological

functioning can be repaired, while avoiding possible

negative side-effects of pharmacotherapy.

An example is the case where post-stroke

patients are treated by physical therapists. Such

treatments may include several techniques [1],

including ‘classical’ ones such as medicines [2] and

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advanced techniques such as brain-computer

interfaces, robot-assisted and virtual reality, brain

stimulation, and cell therapies, [3]. Such treatments

may be given at different times, [4]. Not all

treatments are equally successful [5], and physical

therapy therefore still plays a major role.

One of the major problems for the physical

therapy treatment of such patients is that they suffer

commonly from hypertension, often due to a

perceptivity problem. It should be noticed here that

hypertension because of a perceptivity problem is

fairly frequently confused with spasticity, because

the symptoms are commonly much alike. The

hypertension causes that the patient tends to raise his

muscle tone to get the joints in an exceptional

position that will help him/her to feel his/her position

better. This can concern flexion or extension, and the

positions thus taken are often the same as those

during spasticity.

Such an unnatural, forced position of arms and/or

legs may, obviously, hamper optimization of physical

therapy treatment during early rehabilitation, because

the treatment is uncomfortable for the patient and

requires more effort and time from the physical

therapists. Consequently, the physical therapy

treatment of such patients takes, as a rule, relatively

much time. It would therefore be helpful if a method

could be developed that makes the physical therapy

treatments of such patients during early rehabilitation

more efficient and effective. Earlier experiences with

the effect of deep dry needling (DDN) indicated that

this technique might be helpful, [6], [7]. It was

therefore decided to apply this technique to a patient

where physical therapy posed a problem for the

above reasons.

In the case dealt with here, it was agreed among

all professionals involved, after several treatments

and repeated assessment of the results, that the

patient, who had brain hemorrhage, suffered from

hypertension and not from spasticity. The main

argument was that the patient showed during

treatments that he was able to move both his right-

side arm and leg out of the typical spasticity pattern,

which is atypical for spasticity.

The reason for the massive flexion of his arm and

leg was a perception problem; this made him feel his

arm or leg only in extreme flexion. This problem can

commonly be reduced by pharmacological therapy,

but such a therapy can easily interfere with the

physical and occupational therapies. Deep dry

needling, which is an emerging non-pharmacological

technique which can be applied to reduce spasticity

and hypertension without the side effects of

pharmacotherapy, was therefore applied with the sole

intention to reduce the patient’s hypertension so that

an immediately following standard physical therapy

would be more comfortable for the patient, and

would make the work easier for the physical and

occupational therapists. Such a treatment has not

been documented thus far for therapy during early

rehabilitation of patients with cerebral hemorrhage.

2 Material and Methods

The present study concerns a 48-year-old male

patient who suffered from a thalamus hemorrhage,

which, because of a midline shift and the resulting

increased brain pressure, had to be relieved by

craniotomy. In addition to his left-side hemorrhage,

the patient suffered from subluxation to anterior of

his right humerus, extreme hypertension of the right-

side extremities in flexion, and a severe perception

deficit, in combination with loss of his capability to

speak. This resulted in decreased muscle length in

flexion muscles, and consequently a decrease in

ROM in extension (particularly of the biceps brachii,

the flexion muscles of the forearm and the fingers,

the adductor muscles of the right hip, the ischiocrural

muscles, the gastrocnemius and the soleus).

2.1 Therapies and Clinical Course

Before early rehabilitation started, the patient had

extreme flexion positions in both his right arm and

leg, particularly when lying in bed or sitting in a

wheelchair. He was treated according to standard

care during early rehabilitation at the ANR (early

rehabilitation) Department of Zurzach Care (Baden,

Switzerland). This included minimally two hours per

day of direct therapeutic treatment as well as two

hours of therapeutic care, divided over 15-45 minute

periods. The direct therapeutic treatment consisted of

at least two interventions a day, commonly in the

form of team treatment by two physical therapists or

a physical and an occupational therapist; additional

therapy was provided by a speech/dysphagia

therapist.

After the transfer from the acute hospital to the

early rehabilitation unit, still with the partly removed

skull, moderate but increasingly severe hypertension

became apparent, predominantly in his right forearm

and fingers and his semitendinosus,

semimembranosus, biceps and gastrocnemius.

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Treatment with antispastic agents had only limited

effect and was consequently stopped after two weeks.

Early rehabilitation included deep dry needling

(DDN); it started in the third week after transfer to

the early rehabilitation department, exclusively with

the intention to reduce what was initially considered

as spasticity (only later it was agreed by the treating

professionals that the term “hypertension” was more

appropriate) and to increase the passive range of

motion (ROM) without the sedative side effects of

antispastic medication. Tolerability of DDN was

assessed by motoric and verbal reactions. Once

established, the frequency of DDN treatment was

three times a week (about 25 minutes per session),

for a duration of seven weeks.

The spasticity therapies included mobilization,

both at bedside and in a passive wheelchair, on a

treatment table and subsequently also in a functional

standing frame [8], as well as additional muscle-tone

reducing measures by both the physical and the

occupational therapists.

For objectively measuring the results of the DDN

treatment regarding the extension of the elbow, we

used the Tardieu scale [9], [10] and ROM values to

determine the spasticity and passive ROM, [11].The

ROM of the elbow and wrist was measured using a

goniometer.

For the purpose, a pretest-posttest (pre-treatment)

evaluation was designed with assessment at 2-4

points for one arm after baseline measurements had

been performed (Table 1). Since it appeared soon that

a decrease in muscle tone occurred for all treated

muscles directly after treatment, but that there was no

clear improvement at the longer term, the original

assessment protocol was changed to before treatment

(T0) directly after treatment (T1), and 1 hour after

treatment (T2). All measurements were performed

under the same conditions.

2.2 Intervention

Dry needling was performed for 45-60 s at all points

with severe high tone/spasticity, particularly of the

taught bands. The duration of the total treatment

period was seven weeks. During this time, re-

implementation of the removed part of his skull

occurred at the university hospital of Zürich.

Before the actual DDN treatment started, one

place in the right biceps brachii and one place in the

right gastrocnemius were treated with DDN to test

for both tolerability and local response to this type of

treatment. These muscles were chosen because they

are easily accessible and had the highest tone. The

fast reduction of the muscle tension and the absence

of negative effects made the therapist decide, in

consultation with the neurologist, to follow-up this

test by a more extensive treatment.

This actual treatment started within the first week

with three days (separated from each other by one

day of rest) of DNN treatment of the biceps brachii,

the brachioradialis and the forearm flexors, in

addition to the daily therapy treatments according to

standard care. The treatment regime was re-assessed

and adapted after two weeks when it had become

clear that the patient suffered from hypertension

rather than from spasticity.

The results directly after treatment showed a

decrease in muscle tone for all treated muscles. After

consultation with the Head of the Department, the

assessment protocol was therefore changed to before,

directly after and one hour after treatment.

During the final two weeks, the DNN treatment

was similar again as in the first week: treatments

during three days per week (separated by one day of

rest). The treatment involved the biceps brachii, the

flexor muscles of the lower right arm, and the

ischiocrural muscles and calf muscles of the right

leg..

Table 1. Baseline measurements regarding the right-

side elbow ROM of the patient before start of the

treatment period

ROM

flexion quality (Q)*

elbow ROM

(extension/flexion)

V1**

(extension)

V3**

(extension)

25°-25°/145°

70° / Q = 2

catch at 110° /

Q = 2

* Flexion quality was determined following the Tardieu scale. Q

= 2: clear catch at a precise angle followed by release.

** V1 = moving as slowly as possible, in this case from extension

to flexion; V3 = at a fast rate, faster than gravitational pull.

Note: V2 (speed of the limb segment falling with gravitational

pull) could not be measured because the arm could not fall down

against the hypertonia.

3 Results

After the first week (three treatments of the triceps

and of two forearm flexors and the brachioradialis,

each with two needles), the right arm had become

more relaxed. There was less tension directly after

the treatment; moreover, the ROM in the elbow, the

hand and the fingers had improved as compared to

the baseline values (Table 1). The elbows could be

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extended farther. It seemed that all joints in the right

arm were somewhat more rigid than before, but

accurate measurement with a goniometer was

impossible because of sudden increases in muscle

tone. A movement of 10-15° directly after treatment

seemed possible, but one hour later, the ROM was

again comparable to before the treatment.

After including a re-assessment one hour after

treatment, the planning of the treatments was also

changed back to the standard care: physical and

occupational therapy were given directly after the

DDN treatment two out of the three times a week that

DDN was applied. Physical and occupational

therapists then noticed that treatment directly after

DDN could start more easily with a more extended

position of both the arm as the leg and that it was

possible to do more weight-bearing because of a

better posture und better extended joints: therapy

immediately after DDN made it possible for the

patient to stand in a better upright position and to

keep this position for a longer time. This implies that

the objectives of the practice-oriented study had been

reached completely: more comfortable treatment for

the patient, easier and more effective treatment by the

physical and occupational therapists, and quicker

results than could be obtained with standard care.

4 Discussion

This is the first case describing the results of DDN

for a post-stroke patient with extensive muscle tone

during early rehabilitation with assessments before,

immediately after and one hour after the DDN

treatment. It should be mentioned in this context that

DDN is a relatively new technique that has shown to

be effective not only for reducing the general pain of

post-stroke patients [12], but also for reduction of

pressure-induced pain, [13]. It has been found that

DDN appears particularly effective in the case of

neurological conditions. This was already well

known for babies with cerebral palsy, [14], [15] and

the relationship between DDN and the brain was also

indicated by DDN treatment for spinal cord injury,

[16], [17]. This explains why DDN may also be

effective in the treatment of post-stroke patients with

a high muscle tone. The medical community in some

Kantons of Switzerland has therefore decided that

DDN is allowed in rehabilitation if a patient suffers

from high muscle tone. Such DDN treatments were

for many years typically started only in the course of

the rehabilitation process, particularly for treatment

of pain [18], [19], [20] and normal hypertensia [21],

[22]. DDN treatment in neurology [23] has, however,

been successfully applied in later phases of

rehabilitation of post-stroke patients [13], but has

thus far not been applied in an early rehabilitation

setting.

Because better treatment with standard physical

therapy appears possible after a DDN treatment –

either or not in combination with other types of

treatment (e.g., [24] – and because of the resulting

improved ROM and alignment of joints, it seems

worthwhile to start more extensive studies in order to

determine whether our findings are generically valid,

or whether they represent a more or less exceptional

case. The reason why we did not carry out such a

study ourselves is that no such patients were present

in our hospital at the time. Yet, such an extended

study would be important because it might deepen

the insight into the effect of DDN on spasticity and

hypertension. To assess the effects, systematic

baseline measurements should be followed by

measurements directly after treatment and a specific

time afterwards.

Another reason for such a study is that it cannot

be decided on the basis of our observations whether

our approach was optimal. Nor can it be deduced

whether there are long-term effects. It is obvious,

however, that our patient tolerated the DDN

treatment well with distinct reduction of the

hypertension, in spite of significant reduction of

antispastic pharmacotherapy. Further studies might

well contribute to the development of a practice-

based, optimized DNN treatment to be used for

severely injured patients with brain damage.

5 Conclusions

A patient with severe hemorrhage and craniotomy

has been treated with DDN in an early stage of

rehabilitation, with the sole objective to reduce

muscle tone just before standard treatment by

physical and occupational therapists.

This would make the standard physical therapy

more comfortable for the patient and easier for the

physical and occupational therapists, in spite of the

lack of the commonly given pharmacotherapy. The

DDN treatment was well tolerated and without

complications. A significant increase of the ROM of

the various joints occurred directly after treatment.

The tone of the treated muscles decreased following

the Tardieu scale (Table 2, Appendix).

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The implications of the new approach for

rehabilitation of post-stroke patients suffering from

spasticity or hypertension can be summarized as

follows:

* the spasticity/hypertension causes that they feel

their arm or leg only in extreme flexion;

* this hampers effective and efficient physical

therapy significantly;

* deep dry needling shortly before the standard

physical therapy reduces the spasticity or

hypertension;

* this makes the physiotherapy more comfortable for

the patient and requires less time and effort from

the physical or occupational therapist;

* a side effect is that the more efficient treatment

may reduces the total period of treatment and thus

the cost.

Since no comparable studies have ever been

documented, even better results might be obtained by

adaptations of our approach, but our results show that

DDN is well tolerated and probably helpful for the

rehabilitation of severely injured patients with brain

hemorrhage who suffer from severe tone, particularly

if treatments of the standard care are given directly

after the DDN treatment. Although the absence of

other studies with a comparable early-rehabilitation

DDN treatment prevent drawing definite generic

conclusions our approach seems to represent a break-

through for the physical therapy treatment during

early rehabilitation of patients with severe brain

damage. The new approach may well help to reduce

the negative side-effects that are not uncommon if

pharmacotherapy is given to such patients, and

avoids the exceptionally high costs that are involved

in advanced techniques such as brain stimulation

sand cell therapy.

Acknowledgements:

We thank the patient and his family for permission to

publish the case, including the above mentioned

details. We also thank the Head of the Rehabilitation

Department of Zurzach Care, Prof. Peter S. Sándor,

for permission to publish these results of the

treatment that was given in his department.

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The authors equally contributed in the present

research, at all stages from the formulation of the

problem to the final findings and solution.

Sources of Funding for Research Presented in a

Scientific Article or Scientific Article Itself

No funding was received for this study.

Conflict of Interest

The authors have no conflicts of interest to declare

that are relevant to the content of this article.

The treatment of the client and the reporting are in

accordance with the Declaration of Helsinki.

All relevant data underlying the present contribution

are provided in the two tables.

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(Attribution 4.0 International, CC BY 4.0)

This article is published under the terms of the

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WSEAS TRANSACTIONS on BIOLOGY and BIOMEDICINE

DOI: 10.37394/23208.2024.21.39

Olaf R. Van Loon, A. J. (Tom) Van Loon

E-ISSN: 2224-2902

391

Volume 21, 2024

APPENDIX

Table 2. Changes in ROM of the patient’s right elbow joint and quality according to the Tardieu scale before (T0),

directly after (T1) and 1 hour after treatment (T2) during the successive days of treatment

ROM

flexion

quality (Q)*

ROM

flexion

quality

ROM

flexion quality

V1**

110°

85°

105°

110°

90°

110°

85°

105°

110°

80°

105°

85°

95°

* Flexion quality was determined following the Tardieu scale. Q = 1: slight resistance throughout, without a clear catch at a precise angle;

Q = 2: clear catch at a precise angle followed by release.

** V1 = flexing as slowly as possible; V3 = at a fast rate, faster than gravitational pull. Note: V2 (speed of the limb segment falling with

gravitational pull) could not be measured because the arm could not fall down against the hypertonia.

WSEAS TRANSACTIONS on BIOLOGY and BIOMEDICINE

DOI: 10.37394/23208.2024.21.39

Olaf R. Van Loon, A. J. (Tom) Van Loon

E-ISSN: 2224-2902

392

Volume 21, 2024