The spinal cord injury spasticity evaluation tool: development and evaluation

Motor and autonomic concomitant health improvements with neuromodulation and exercise (MACHINE) training: a randomised controlled trial in individuals with spinal cord injury

INTRODUCTION

Motor and autonomic dysfunctions are widespread among people with spinal cord injury (SCI), leading to poor health and reduced quality of life. Exercise interventions, such as locomotor training (LT), can promote sensorimotor and autonomic recovery post SCI. Recently, breakthroughs in SCI research have reported beneficial effects of electrical spinal cord stimulation (SCS) on motor and autonomic functions. Despite literature supporting the independent benefits of transcutaneous SCS (TSCS) and LT, the effect of pairing TSCS with LT is unknown. These therapies are non-invasive, customisable and have the potential to simultaneously benefit both sensorimotor and autonomic functions. The aim of this study is to assess the effects of LT paired with TSCS in people with chronic SCI on outcomes of sensorimotor and autonomic function.

METHODS AND ANALYSIS

Twelve eligible participants with chronic (>1 year) motor-complete SCI, at or above the sixth thoracic segment, will be enrolled in this single-blinded, randomised sham-controlled trial. Participants will undergo mapping for optimisation of stimulation parameters and baseline assessments of motor and autonomic functions. Participants will then be randomly assigned to either LT+TSCS or LT+Sham stimulation for 12 weeks, after which postintervention assessments will be performed to determine the effect of TSCS on motor and autonomic functions. The primary outcome of interest is attempted voluntary muscle activation using surface electromyography. The secondary outcomes relate to sensorimotor function, cardiovascular function, pelvic organ function and health-related quality of life. Statistical analysis will be performed using two-way repeated measures Analysis of variance (ANOVAs) or Kruskal-Wallis and Cohen's effect sizes.

ETHICS AND DISSEMINATION

This study has been approved after full ethical review by the University of British Columbia's Research Ethics Board. The stimulator used in this trial has received Investigation Testing Authorisation from Health Canada. Trial results will be disseminated through peer-reviewed publications, conference presentations and seminars.

TRIAL REGISTRATION NUMBER

NCT04726059.

Safety and Potential Efficacy of Selective Dorsal Rhizotomy in Adults with Spinal Cord Injury-Induced Spasticity: An Open-Label, Non-Randomized, Single-Arm Trial

BACKGROUND

Despite the abundant literature on the use of selective dorsal rhizotomy (SDR) in spastic cerebral palsy, no investigation has evaluated its use in adult patients with chronic spinal cord injury (SCI)-induced spasticity. The present investigation aimed to evaluate the safety and potential efficacy of SDR in chronic SCI-induced spasticity for the first time.

METHODS

In this open-label, single-arm, non-randomized clinical trial, all patients were assigned to the single study intervention arm and underwent SDR. The primary outcome measure was the safety profile of SDR. Secondary outcome measures were Modified Ashworth Scale, Penn Spasm Frequency Scale, visual analog scale for spasticity, Spinal Cord Injury Spasticity Tool, Spinal Cord Independence measure version III, and Short Form 36 Health Survey Questionnaire.

RESULTS

Six patients with cervical SCI and 4 with thoracic SCI were allocated to the single study intervention arm. No adverse event attributable to the SDR was found. Moreover, all secondary outcome measures of the study improved significantly over the study period (P < 0.001). Multiple regression analysis also found a significant association between level of injury and changes in average Modified Ashworth Scale scores (P = 0.041), Spinal Cord Injury Spasticity Tool score (P = 0.013), and Spinal Cord Independence measure version III total (P = 0.002) and mobility domain scores (P = 0.004) at 12-month postoperatively.

CONCLUSIONS

This clinical trial indicated that SDR is a safe and potentially effective procedure in patients with severe and intractable SCI-induced spasticity. However, future clinical trials with larger sample sizes and adequate power are required to validate our findings regarding efficacy.

Combined selective peripheral neurotomy in the treatment of spastic lower limbs of spinal cord injury patients

Objective

To explore the therapeutic effect of combined selective peripheral neurotomy (cSPN) on the spasm of the lower limbs after spinal cord injury.

Methods

A prospective intervention (before-after trial) with an observational design was conducted in 14 spinal cord injury patients with severe lower limbs spasticity by cSPN. Given the severe spasm of hip adductor, triceps surae, and hamstring muscles in these patients, a total of 26 obturator nerve branches, 26 tibia nerve branches, and 4 sciatic nerve branches partial neurotomy were performed. The modified Ashworth scale, composite spasticity scale, surface electromyography, gait analysis, functional ambulation category, spinal cord independence measure, and modified spinal cord injury–spasticity evaluation tool were used before and after surgery.

Results

Compared with preoperative, the spasm of the hip adductor, triceps surae, and hamstrings of the lower limbs in the postoperative patients decreased significantly. The abnormal gait of knee flexion and varus in the standing stage were significantly reduced. The grading of walking ability and activities of daily living were significantly improved.

Conclusions

Combined selective peripheral neurotomy can significantly reduce the spasm of lower limbs post spinal cord injury, improve abnormal gait, and improve motor function and activities of daily living.

Trial registration

ChiCTR1800019003 (2018–10-20).

The effect of extracorporeal shock wave therapy in acute traumatic spinal cord injury on motor and sensory function within 6 months post-injury: a study protocol for a two-arm three-stage adaptive, prospective, multi-center, randomized, blinded, placebo-controlled clinical trial

Background

The pathological mechanism in acute spinal cord injury (SCI) is dual sequential: the primary mechanical lesion and the secondary injury due to a cascade of biochemical and pathological changes initiated by the primary lesion. Therapeutic approaches have focused on modulating the mechanisms of secondary injury. Despite extensive efforts in the treatment of SCI, there is yet no causal, curative treatment approach available.

Extracorporeal shock wave therapy (ESWT) has been successfully implemented in clinical use. Biological responses to therapeutic shock waves include altered metabolic activity of various cell types due to direct and indirect mechanotransduction leading to improved migration, proliferation, chemotaxis, modulation of the inflammatory response, angiogenesis, and neovascularization, thus inducing rather a regeneration than repair.

The aim of this clinical study is to investigate the effect of ESWT in humans within the first 48 h after an acute traumatic SCI, with the objective to intervene in the secondary injury phase in order to reduce the extent of neuronal loss.

Methods

This two-arm three-stage adaptive, prospective, multi-center, randomized, blinded, placebo-controlled study has been initiated in July 2020, and a total of 82 patients with acute traumatic SCI will be recruited for the first stage in 15 participating hospitals as part of a two-armed three-stage adaptive trial design. The focused ESWT (energy flux density: 0.1–0.19 mJ/mm², frequency: 2–5 Hz) is applied once at the level of the lesion, five segments above/below, and on the plantar surface of both feet within the first 48 h after trauma.

The degree of improvement in motor and sensory function after 6 months post-injury is the primary endpoint of the study. Secondary endpoints include routine blood chemistry parameters, the degree of spasticity, the ability to walk, urological function, quality of life, and the independence in everyday life.

Discussion

The application of ESWT activates the nervous tissue regeneration involving a multitude of various biochemical and cellular events and leads to a decreased neuronal loss. ESWT might contribute to an improvement in the treatment of acute traumatic SCI in future clinical use.

Trial registration

ClinicalTrials.govNCT04474106

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06161-8.

Overground robotic training effects on walking and secondary health conditions in individuals with spinal cord injury: systematic review

Overground powered lower limb exoskeletons (EXOs) have proven to be valid devices in gait rehabilitation in individuals with spinal cord injury (SCI). Although several articles have reported the effects of EXOs in these individuals, the few reviews available focused on specific domains, mainly walking. The aim of this systematic review is to provide a general overview of the effects of commercial EXOs (i.e. not EXOs used in military and industry applications) for medical purposes in individuals with SCI. This systematic review was conducted following the PRISMA guidelines and it referred to MED-LINE, EMBASE, SCOPUS, Web of Science and Cochrane library databases. The studies included were Randomized Clinical Trials (RCTs) and non-RCT based on EXOs intervention on individuals with SCI. Out of 1296 studies screened, 41 met inclusion criteria. Among all the EXO studies, the Ekso device was the most discussed, followed by ReWalk, Indego, HAL and Rex devices. Since 14 different domains were considered, the outcome measures were heterogeneous. The most investigated domain was walking, followed by cardiorespiratory/metabolic responses, spasticity, balance, quality of life, human–robot interaction, robot data, bowel functionality, strength, daily living activity, neurophysiology, sensory function, bladder functionality and body composition/bone density domains. There were no reports of negative effects due to EXOs trainings and most of the significant positive effects were noted in the walking domain for Ekso, ReWalk, HAL and Indego devices. Ekso studies reported significant effects due to training in almost all domains, while this was not the case with the Rex device. Not a single study carried out on sensory functions or bladder functionality reached significance for any EXO. It is not possible to draw general conclusions about the effects of EXOs usage due to the lack of high-quality studies as addressed by the Downs and Black tool, the heterogeneity of the outcome measures, of the protocols and of the SCI epidemiological/neurological features. However, the strengths and weaknesses of EXOs are starting to be defined, even considering the different types of adverse events that EXO training brought about. EXO training showed to bring significant improvements over time, but whether its effectiveness is greater or less than conventional therapy or other treatments is still mostly unknown. High-quality RCTs are necessary to better define the pros and cons of the EXOs available today. Studies of this kind could help clinicians to better choose the appropriate training for individuals with SCI.

The impact of upper limb spasticity-correcting surgery on the everyday life of patients with disabling spasticity: a qualitative analysis

PURPOSE

The aim of this study was to explore the patient perspective of their experiences of daily life after spasticity-correcting surgery for disabling upper limb (UL) spasticity after spinal cord injury (SCI) and stroke.

MATERIALS AND METHODS

Eight patients with UL spasticity resulting from SCI (n= 6) or stroke (n= 2) were interviewed 6-9 months after spasticity-correcting surgery. A phenomenographic approach was used to analyze the interviews.

RESULTS

Five themes emerged from the interviews: (1) bodily changes, such as increased muscle strength, range of motion, and reduced muscle-hypertonicity; (2) improved occupational performance, facilitating tasks, mobility, and self-care; (3) regained control, explicating the perception of regaining bodily control and a more adaptable body; (4) enhanced interpersonal interactions, entailing the sense of being more comfortable undertaking social activities and personal interactions; and (5) enhanced psychological well-being, including having more energy, increased self-esteem, and greater happiness after surgery.

CONCLUSIONS

The participants experienced improvements in their everyday lives, including body functions, activities, social life, and psychological well-being. The benefits derived from surgery made activities easier, increased occupational performance, allowed patients regain their roles and interpersonal interactions, and enhanced their psychological well-being.Implications for rehabilitationSpasticity-correcting surgery benefits patients by improving bodily functions, which in turn, enable gains in activities, social life, and psychological well-being.Patients' experiences of increased body functions, such as enhanced mobility and reduced muscle hypertonicity, appear to increase the sense of bodily control.The surgery can increase participation and psychological well-being, even for patients whose functional or activity level did not improve after the treatment.The benefits expressed by the individuals in this study can be used to inform, planning, and in discussion with patients and other healthcare professionals about interventions targeting spasticity.

Characterizing the Experience of Spasticity after Spinal Cord Injury: A National Survey Project of the Spinal Cord Injury Model Systems Centers

OBJECTIVE

To characterize the qualities that individuals with spinal cord injury (SCI) associate with their experience of spasticity and to describe the relationship between spasticity and perceived quality of life and the perceived value of spasticity management approaches.

DESIGN

Online cross-sectional survey.

SETTING

Multicenter collaboration among 6 Spinal Cord Injury Model Systems hospitals in the United States.

PARTICIPANTS

Individuals with SCI (N=1076).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Qualities of Spasticity Questionnaire, modified Spinal Cord Injury-Spasticity Evaluation Tool (mSCI-SET), and the modified Patient-Reported Impact of Spasticity Measure (mPRISM).

RESULTS

Respondents indicated that spasms most often occurred in response to movement-related triggering events. However, spontaneous spasms (ie, no triggering event) were also reported to be among the most common types. Frequency of spasms appears to decline with age. The highest frequency of spasms was reported by 56% of respondents aged <25 years and by only 28% of those >55 years. Stiffness associated with spasticity was reported to be more common than spasms (legs, 65% vs 54%; trunk, 33% vs 18%; arms, 26% vs 15%). Respondents reported negative effects of spasticity more commonly than positive effects. Based on their association with negative scores on the mSCI-SET and the mPRISM, the 5 most problematic experiences reported were stiffness all day, interference with sleep, painful spasms, perceived link between spasticity and pain, and intensification of pain before a spasm. Respondents indicated spasticity was improved more by stretching (48%) and exercise (45%) than by antispasmodics (38%).

CONCLUSIONS

The experience of spasticity after SCI is complex and multidimensional, with consequences that affect mobility, sleep, comfort, and quality of life. Stiffness, rather than spasms, appears to be the most problematic characteristic of spasticity. Physical therapeutic interventions to treat spasticity warrant in-depth investigation.

A review and evaluation of patient-reported outcome measures for spasticity in persons with spinal cord damage: Recommendations from the Ability Network - an international initiative

Context: Patient-reported outcome measures (PROMs) are valuable for capturing the impact of spasticity on health-related quality of life (HRQoL) in persons with spinal cord damage (SCD) and evaluating the efficacy of interventions. Objective: To provide practical guidance for measuring HRQoL in persons with spasticity following SCD. Methods: Literature reviews identified measures of HRQoL and caregiver burden, utilized in studies addressing spasticity in SCD. Identified measures were evaluated for clinical relevance and practicality for use in clinical practice and research. The PRISM, SCI-SET, EQ-5D and SF-36 instruments were mapped to the International Classification of Functioning, Disability and Health (ICF). The PRISM and SCI-SET were evaluated using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist. Results: Two spasticity-specific, five generic, and four preference-based measures were identified. ICF mapping and the COSMIN checklist supported the use of the PRISM and SCI-SET in SCD. The SF-36 is considered the most useful generic measure; disability-adapted versions may be more acceptable but further studies on psychometric properties are required. The SF-36 can be converted to a preference-based measure (SF-6D), or alternatively the EQ-5D can be used. While no measures specific to caregivers of people with SCD were identified, the Caregiver Burden Scale and the Zarit Burden Interview are considered suitable. Conclusion: Recommended measures include the PRISM and SCI-SET (condition-specific), SF-36 (generic), and Caregiver Burden Scale and Zarit Burden Interview (caregiver burden). Consideration should be given to using condition-specific and generic measures in combination; the PRISM or SCI-SET combined with SF-36 is recommended.

The Swedish SPinal Cord Injury Study on Cardiopulmonary and Autonomic Impairment: Methodology, Cohort Demographics, and Initial Results

OBJECTIVE

The aim of the study was to present the methodology, cohort demographics, and initial results of the Swedish SPinal Cord Injury Study on Cardiopulmonary and Autonomic Impairment (SPICA).

DESIGN

The SPICA is based on the Swedish CArdioPulmonary BioImage Study, a study on cardiopulmonary diseases in a cohort of 30,000 people. The assessments in the SPICA cover the structure and function of the cardiopulmonary and autonomic systems using bioimaging and functional analyses, together with a study-specific questionnaire and generic and spinal cord injury-specific assessment tools. The inclusion criteria were as follows: age 50-65 yrs, traumatic spinal cord injury of 5 yrs or more, and injury levels C1-T6, American Spinal Injury Association Impairment Scale A-C.

RESULTS

Of 38 potential participants, 25 comprised the final sample (20% women, mean age 58 yrs, mean time since injury 28 yrs). Eight percent had sustained a cardiovascular event, and 72% were classified as a high risk for cardiovascular disease. Asthma was previously diagnosed in only 8%, and none had chronic obstructive pulmonary disease.

CONCLUSIONS

The risk for cardiovascular disease in people with severe high-level spinal cord injury is a major clinical concern. Forthcoming studies in the SPICA will provide new knowledge of cardiopulmonary health in this cohort, which can guide future research and be used to develop long-term management.

Daily acute intermittent hypoxia to improve walking function in persons with subacute spinal cord injury: a randomized clinical trial study protocol

BACKGROUND

Restoring community walking remains a highly valued goal for persons recovering from traumatic incomplete spinal cord injury (SCI). Recently, studies report that brief episodes of low-oxygen breathing (acute intermittent hypoxia, AIH) may serve as an effective plasticity-inducing primer that enhances the effects of walking therapy in persons with chronic (> 1 year) SCI. More persistent walking recovery may occur following repetitive (weeks) AIH treatment involving persons with more acute SCI, but this possibility remains unknown. Here we present our clinical trial protocol, designed to examine the distinct influences of repetitive AIH, with and without walking practice, on walking recovery in persons with sub-acute SCI (< 12 months) SCI. Our overarching hypothesis is that daily exposure (10 sessions, 2 weeks) to AIH will enhance walking recovery in ambulatory and non-ambulatory persons with subacute (< 12 months) SCI, presumably by harnessing endogenous mechanisms of plasticity that occur soon after injury.

METHODS

To test our hypothesis, we are conducting a randomized, placebo-controlled clinical trial on 85 study participants who we stratify into two groups according to walking ability; those unable to walk (non-ambulatory group) and those able to walk (ambulatory group). The non-ambulatory group receives either daily AIH (15, 90s episodes at 10.0% O2 with 60s intervals at 20.9% O2) or daily SHAM (15, 90s episodes at 20.9% O2 with 60s intervals at 20.9% O2) intervention. The ambulatory group receives either 60-min walking practice (WALK), daily AIH + WALK, or daily SHAM+WALK intervention. Our primary outcome measures assess overground walking speed (10-Meter Walk Test), endurance (6-Minute Walk Test), and balance (Timed Up & Go Test). For safety, we also measure levels of pain, spasticity, systemic hypertension, and autonomic dysreflexia. We record outcome measures at baseline, days 5 and 10, and follow-ups at 1 week, 1 month, 6 months, and 12 months post-treatment.

DISCUSSION

The goal of this clinical trial is to reveal the extent to which daily AIH, alone or in combination with task-specific walking practice, safely promotes persistent recovery of walking in persons with traumatic, subacute SCI. Outcomes from this study may provide new insight into ways to enhance walking recovery in persons with SCI.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02632422 . Registered 16 December 2015.

The impact of early spasticity on the intensive functional rehabilitation phase and community reintegration following traumatic spinal cord injury

Context/Objectives: To determine the impact of spasticity presenting during the acute care hospitalization on the rehabilitation outcomes following a traumatic spinal cord injury (TSCI). Design: Retrospective cohort study. Setting: A single Level 1 trauma center specialized in SCI care. Participants: 150 individuals sustaining an acute TSCI. Interventions: Not applicable. Outcome Measures: The total inpatient functional rehabilitation length of stay. The occurrence of medical complications and the discharge destination from the inpatient functional rehabilitation facility were also considered. Results: 63.3% of the cohort presented signs and/or symptoms of spasticity during acute care. Individuals with early spasticity developed medical complications during acute care and during intensive functional rehabilitation in a higher proportion. They were also hospitalized significantly longer and were less likely to return home after rehabilitation than individuals without early spasticity. Early spasticity was an independent factor associated with increased total inpatient rehabilitation length of stay. Conclusion: The development of signs and symptoms of spasticity during acute care following a TSCI may impede functional rehabilitation outcomes. In view of its association with the occurrence of early spasticity, higher vigilance towards the prevention of medical complications is recommended. Early assessment of spasticity during acute care is recommended following TSCI.

Cannabinoids and an anti-inflammatory diet for the treatment of neuropathic pain after spinal cord injury (The CATNP Study): study protocol for a randomized controlled trial

STUDY DESIGN

Multicenter, randomized, double-blind, placebo controlled, clinical trial.

OBJECTIVE

The objective of this paper is to evaluate the effectiveness of cannabinoids and an anti-inflammatory diet, alone and in combination, for the management of neuropathic pain (NP) after spinal cord injury (SCI).

SETTING

Two Canadian SCI rehabilitation centers.

METHODS

A sample of 144 individuals with SCI will receive either an anti-inflammatory diet, cannabinoids or a placebo for 6 weeks. Following this, a combined effect of these treatments will be evaluated for a further 6 weeks. The primary outcome measure will be the change in NP as assessed by the numeric rating scale (NRS). Secondary outcomes will include changes in inflammation, mood, sleep, spasticity, cost-effectiveness, and function.

CONCLUSION

This study will assess the efficacy of an anti-inflammatory diet and cannabinoids (individually and in combination) for the treatment of NP following SCI. Results may reveal a cost-effective, side-effect free intervention strategy which could be utilized for the long-term management of NP following SCI.

The positive and the negative impacts of spasticity in patients with long-term neurological conditions: an observational study

PURPOSE

To describe the positive and negative impacts of spasticity across different neurological disorders using the Patient Reported Impact of Spasticity Measure (PRISM), deduce any associations between severity of spasticity and its impact, and assess for differences across diagnostic subgroups.

MATERIALS AND METHODS

PRISM, a spasticity-specific quality of life questionnaire validated in patients with spinal cord injuries, was given to 97 follow-up patients attending a spasticity clinic prior to symptom assessment using the REsistance to PAssive movement Scale (REPAS).

RESULTS

Patients described a minor level of positive impact and a marked negative impact in the domains of "Psychological Agitation," "Daily Activities," "Need for Assistance/Positioning" and "Social Avoidance/Anxiety." Spasticity severity was, in general, a poor predictor of perceived impact, although severity and localisation of spasticity was modestly correlated with "Need for Assistance/Positioning" and "Social Embarrassment" levels. Despite comparable levels of spasticity severity, people with MS expressed a more substantial impact across some PRISM domains than did patients in other groups.

CONCLUSION

PRISM can be useful to assess the impact of spasticity in various neurological conditions although further validation studies are needed.Implications for RehabilitationThe localisation of spasticity in both legs or the right arm can produce a significant impact on 'Need for Assistance/Positioning' and 'Social Embarrassment'.People with MS may experience a greater impact of spasticity than those with other neurological conditions, particularly in the domains of Social Avoidance/Anxiety and Psychological Agitation.Coexisting factors such as anxiety, depression, fatigue and pain should be investigated together with spasticity.PRISM can assist in goal setting and treatment of people with spasticity secondary to different neurological conditions.

Pediatric telerehabilitation medicine: Making your virtual visits efficient, effective and fun

The COVID-19 pandemic has accelerated many changes in medicine including the transition from providing care in person to providing care via technology enabled telemedicine. The benefits of telemedicine visits with a Pediatric Rehabilitation Medicine (PRM) provider, also known as telerehabilitation medicine visits, are numerous. Telerehabilitation medicine provides an opportunity to deliver timely, patient and family-centric rehabilitation care while maintaining physical distance and reducing potential COVID-19 exposure for our patients, their caregivers and medical providers. Telerehabilitation medicine also allows for access to PRM care in rural areas or areas without medical specialty, virtual in-home equipment evaluation, and reduced travel burden. Because of these and many other benefits, telerehabilitation medicine will likely become part of our ongoing model of care if barriers to telemedicine continue to be lowered or removed. This paper is intended to establish a foundation for pediatric telerehabilitation medicine visit efficiency and effectiveness in our current environment and into the future.

Repeated transspinal stimulation decreases soleus H-reflex excitability and restores spinal inhibition in human spinal cord injury

Transcutaneous spinal cord or transspinal stimulation over the thoracolumbar enlargement, the spinal location of motoneurons innervating leg muscles, modulates neural circuits engaged in the control of movement. The extent to which daily sessions (e.g. repeated) of transspinal stimulation affects soleus H-reflex excitability in individuals with chronic spinal cord injury (SCI) remains largely unknown. In this study, we established the effects of repeated cathodal transspinal stimulation on soleus H-reflex excitability and spinal inhibition in individuals with and without chronic SCI. Ten SCI and 10 healthy control subjects received monophasic transspinal stimuli of 1-ms duration at 0.2 Hz at subthreshold and suprathreshold intensities of the right soleus transspinal evoked potential (TEP). SCI subjects received an average of 16 stimulation sessions, while healthy control subjects received an average of 10 stimulation sessions. Before and one or two days post intervention, we used the soleus H reflex to assess changes in motoneuron recruitment, homosynaptic depression following single tibial nerve stimuli delivered at 0.1, 0.125, 0.2, 0.33 and 1.0 Hz, and postactivation depression following paired tibial nerve stimuli at the interstimulus intervals of 60, 100, 300, and 500 ms. Soleus H-reflex excitability was decreased in both legs in motor incomplete and complete SCI but not in healthy control subjects. Soleus H-reflex homosynaptic and postactivation depression was present in motor incomplete and complete SCI but was of lesser strength to that observed in healthy control subjects. Repeated transspinal stimulation increased homosynaptic depression in all SCI subjects and remained unaltered in healthy controls. Postactivation depression remained unaltered in all subject groups. Lastly, transspinal stimulation decreased the severity of spasms and ankle clonus. The results indicate decreased reflex hyperexcitability and recovery of spinal inhibitory control in the injured human spinal cord with repeated transspinal stimulation. Transspinal stimulation is a noninvasive neuromodulation method for restoring spinally-mediated afferent reflex actions after SCI in humans.

Exploring the relationship between self-reported urinary tract infections to quality of life and associated conditions: insights from the spinal cord injury Community Survey

STUDY DESIGN

Descriptive study OBJECTIVES: Urinary tract infections (UTIs) are one of the most frequent types of infections following spinal cord injury (SCI). Here we assess the relationship between frequency of UTIs and activity level/overall quality of life (QOL) measures, determine the frequency of temporally associated conditions associated with UTI and identify factors associated with frequent UTIs.

SETTING

Canada METHODS: The Spinal Cord Injury Community Survey was developed to assess major dimensions of community living and health outcomes in persons with chronic SCI in Canada. Participants were stratified by self-reported UTI frequency. The relationship between UTI frequency and QOL, health resource utilization, and temporally associated conditions were assessed. Results were analysed with cross tabulations, χ² tests, and ordinal logistic regression.

RESULTS

Overall 73.5% of participants experienced at least one self-reported UTI since the time of injury (mean 18.5 years). Overall QOL was worse with increasing frequency of these events. Those with frequent self-reported UTIs had twice as many hospitalizations and doctors' visits and were limited in financial, vocational and leisure situations, physical health and ability to manage self-care as compared with those with no UTIs. Self-reported UTIs were associated with higher incidence of temporally associated conditions including bowel incontinence, constipation, spasticity, and autonomic dysreflexia. Individuals who were younger and female were more likely to have frequent UTIs and those with constipation and autonomic dysreflexia had worse QOL.

CONCLUSIONS

Higher frequency self-reported UTIs is related to poor QOL of individuals with long-term SCI. These findings will be incorporated into SCI UTI surveillance and management guidelines.

Impact of spasticity on transfers and activities of daily living in individuals with spinal cord injury

CONTEXT/OBJECTIVE

For persons with spinal cord injury, spasticity commonly interferes with activities of daily living such as transfers. Electromyography can be used to objectively measure muscle spasms during transfers, but how electromyographic measures relate to the impact spasticity has on life, or to clinically-rated spasticity, is unclear. We aimed to characterize relationships among spasm duration and magnitude, impact of spasticity on daily life, and a clinical measure of extensor spasticity, as well as to determine reliability of the electromyographic measures.

DESIGN

Participants (N=19) underwent electromyographic measurements of involuntary muscle activity (spasm duration and magnitude) evoked in quadriceps muscles during transfers on two days. Impact of spasticity on daily life was measured with the Spinal Cord Injury Spasticity Evaluation Tool. Clinically-rated spasticity severity was measured with the Spinal Cord Assessment Tool for Spastic reflexes.

RESULTS

No significant associations were found between impact of spasticity and spasm duration, spasm magnitude, or clinical extensor spasticity score. Absolute and normalized spasm duration were positively associated with clinical extensor spasticity score (rho=0.510-0.667, P < 0.05). Spasm measures during transfers had good to excellent day-to-day reliability (rho=0.656-0.846, P < 0.05).

CONCLUSIONS

Electromyographic and clinical measures of involuntary activity in the lower extremity do not significantly relate to perceived impact of spasticity on daily life. However, quadriceps spasm duration during transfers is related to clinically-rated extensor spasticity. Electromyography is a reliable method of quantifying quadriceps spasms during transfers. Future investigations should identify factors that influence the impact of spasticity on life, which may help direct treatment strategies to reduce problematic impact.

Multimodal cortical and subcortical exercise compared with treadmill training for spinal cord injury

BACKGROUND AND PURPOSE

Spared fibers after spinal cord injury (SCI) tend to consist predominantly of subcortical circuits that are not under volitional (cortical) control. We aim to improve function after SCI by using targeted physical exercises designed to simultaneously stimulate cortical and spared subcortical neural circuits.

METHODS

Participants with chronic motor-incomplete SCI enrolled in a single-center, prospective interventional crossover study. Participants underwent 48 sessions each of weight-supported robotic-assisted treadmill training and a novel combination of balance and fine hand exercises, in randomized order, with a 6-week washout period. Change post-intervention was measured for lower extremity motor score, soleus H-reflex facilitation; seated balance function; ambulation; spasticity; and pain.

RESULTS

Only 9 of 21 enrolled participants completed both interventions. Thirteen participants completed at least one intervention. Although there were no statistically significant differences, multimodal training tended to increase short-interval H-reflex facilitation, whereas treadmill training tended to improve dynamic seated balance.

DISCUSSION

The low number of participants who completed both phases of the crossover intervention limited the power of this study to detect significant effects. Other potential explanations for the lack of significant differences with multimodal training could include insufficient engagement of lower extremity motor cortex using skilled upper extremity exercises; and lack of skill transfer from upright postural stability during multimodal training to seated dynamic balance during testing. To our knowledge, this is the first published study to report seated posturography outcomes after rehabilitation interventions in individuals with SCI.

CONCLUSION

In participants with chronic incomplete SCI, a novel mix of multimodal exercises incorporating balance exercises with skilled upper extremity exercises showed no benefit compared to an active control program of body weight-supported treadmill training. To improve participant retention in long-term rehabilitation studies, subsequent trials would benefit from a parallel group rather than crossover study design.

Optimizing the Management of Spasticity in People With Spinal Cord Damage: A Clinical Care Pathway for Assessment and Treatment Decision Making From the Ability Network, an International Initiative

The recognition, evaluation, and management of disabling spasticity in persons with spinal cord damage (SCD) is a challenge for health care professionals, institutions, health systems, and patients. To guide the assessment and management of disabling spasticity in individuals with SCD, the Ability Network, an international panel of clinical experts, developed a clinical care pathway. The aim of this pathway is to facilitate treatment decisions that take into account the effect of disabling spasticity on health status, individual preferences and treatment goals, tolerance for adverse events, and burden on caregivers. The pathway emphasizes a patient-centered, individualized approach and the need for interdisciplinary coordination of care, patient involvement in goal setting, and the use of assessment and outcome measures that lend themselves to practical application in the clinic. The clinical care pathway is intended for use by health care professionals who provide care for persons with SCD and disabling spasticity in various settings. Barriers to optimal spasticity management in these people are also discussed. There is an urgent need for the clinical community to clarify and overcome barriers (knowledge-based, organizational, health system) to optimizing the management of spasticity in people with SCD.

Reliability and cross-cultural adaptation of the Turkish version of the Spinal Cord Injury Spasticity Evaluation Tool

The Spinal Cord Injury Spasticity Evaluation Tool is a 7-day recall self-reported questionnaire that assesses the problematic and useful effects of spasticity on daily life in patients with spinal cord injury (SCI). We aimed to determine the reliability and cross-cultural validation of the Turkish translation of the Spinal Cord Injury Spasticity Evaluation Tool (SCI-SETT). After translation and back translation of the Spinal Cord Injury Spasticity Evaluation Tool, 66 patients between the ages of 18 and 88 years with SCI, American Spinal Injury Association impairment scale grades from A to D with spasticity, and at least 6 months after injury were assessed. Participants rated the SCI-SETT at the same time period of the day, 1 week apart, and test-retest agreement was investigated. Also, the Penn Spasm Frequency Scale, self-assessment of spasticity severity, self-assessment of spasticity impact, Functional Independence Measure motor subscale, and 36-Item Short Form Health Survey were assessed for the evaluation of the convergent validity. There were 45 participants with tetraplegia and 21 patients with paraplegia. The test-retest reliability for the SCI-SETT was good. The intraclass correlation coefficient was 0.80 at 95% confidence interval. There were no significant correlations between the SCI-SETT scores and Functional Independence Measure motor subscale and Penn Spasm Frequency Scale scores. There was a significant correlation between the SCI-SETT scores and vitality scores of the 36-Item Short Form Health Survey. The SCI-SETT showed statistically significant correlations with other measures including self-assessed spasticity severity and self-assessed spasticity impact (P<0.05). The SCI-SETT is a reliable self-rating tool for assessing spasticity in patients with SCI in the Turkish population.

Use of clinical measures to document the effect of passive cycling on knee extensor spasticity and the ability to perform activities of daily living in spinal cord injury: a case report

The effects, on spasticity-related clinical measure results [initial knee flexion velocity during the pendulum test (F1-VEL); Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET) scores], of a 5-week passive cycling program were assessed in a 67-year-old man with chronic, complete, thoracic-level SCI. Three weekly evaluations were performed before and after training, at the start, middle, and end of the training (ET), and 24 h following ET. The F1-VEL increased significantly from baseline, from ET to the 2-week follow-up evaluation. A trend was found for an improvement from baseline in SCI-SET scores, from middle of training onwards. These findings, which can inform clinical decisions and clinical trial development, suggest that the F1-VEL pendulum test result may be used to document the effect on knee extensor spasticity of a passive cycling program in chronic, complete, thoracic-level SCI. Whether this is also true for the SCI-SET requires future confirmation.

Development of a clinical spasticity scale for evaluation of dogs with chronic thoracolumbar spinal cord injury

OBJECTIVE To develop a spasticity scale for dogs with chronic deficits following severe spinal cord injury (SCI) for use in clinical assessment and outcome measurement in clinical trials. ANIMALS 20 chronically paralyzed dogs with a persistent lack of hind limb pain perception caused by an acute SCI at least 3 months previously. PROCEDURES Spasticity was assessed in both hind limbs via tests of muscle tone, clonus, and flexor and extensor spasms adapted from human scales. Measurement of patellar clonus duration and flexor spasm duration and degree was feasible. These components were used to create a canine spasticity scale (CSS; overall score range, 0 to 18). Temporal variation for individual dogs and interrater reliability were evaluated. Gait was quantified with published gait scales, and CSS scores were compared with gait scores and clinical variables. Owners were questioned regarding spasticity observed at home. RESULTS 20 dogs were enrolled: 18 with no apparent hind limb pain perception and 2 with blunted responses; 5 were ambulatory. Testing was well tolerated, and scores were repeatable between raters. Median overall CSS score was 7 (range, 3 to 11), and flexor spasms were the most prominent finding. Overall CSS score was not associated with age, SCI duration, lesion location, or owner-reported spasticity. Overall CSS score and flexor spasm duration were associated with gait scores. CONCLUSIONS AND CLINICAL RELEVANCE The CSS could be used to quantify hind limb spasticity in dogs with chronic thoracolumbar SCI and might be a useful outcome measure. Flexor spasms may represent an integral part of stepping in dogs with severe SCI.

The Spinal Cord Injury Spasticity Evaluation Tool: A Persian adaptation and validation study

OBJECTIVE

To adapt the Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET) into the Persian language (SCI-SETp) and to examine the reliability and validity of the SCI-SETp in patients with spinal cord injury (SCI).

DESIGN

A cross-sectional and prospective cohort validation study.

SETTING

University Neurological Physiotherapy Clinic.

PARTICIPANTS

Adult patients with SCI.

MAIN OUTCOME MEASURES

SCI-SET.

RESULTS

There was no missing data. No floor or ceiling effect was observed. Cronbach's α coefficient was 0.862. Factor analysis suggested 1 factor structure (Eigenvalue = 8.49) explained 24.27% of the total variance. The ICC_agreement for test-retest reliability was 0.84. The standard error of measurement and the smallest detectable change was 0.30 and 0.82, respectively. The divergent relationships demonstrated the SCI-SETp uniqueness construct.

CONCLUSION

The results support the reliability and validity of the SCI-SETp for assessing the impact of spasticity on daily life of patients with SCI.

Severe spasticity in lower extremities is associated with reduced adiposity and lower fasting plasma glucose level in persons with spinal cord injury

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To investigate the effects of severe lower extremity spasticity on anthropometric dimensions, body composition and metabolic profiles in persons with chronic motor complete spinal cord injury (SCI).

SETTING

Outpatient clinic.

METHODS

Fifty-five of the 61 participants were divided into two groups (no or mild spasticity group, 28; severe spasticity group, 27) based on the assessment of the extensor muscle spasticity according to the modified Ashworth scale. Anthropometric dimensions (waist circumference (WC), waist-to-height ratio (WtHR)), body composition (fat mass (FM), body fat percentage (BFP), fat-free mass (FFM), fat-free mass percentage (FFMP), bone mineral density (BMD)) and metabolic profiles (leptin, total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglyceride (TG), fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1c)) were compared between the two groups with different degree of spasticity.

RESULTS

Spasticity of the extensor muscle group negatively correlated with BFP (r=-0.458, P<0.001). Patients with severe spasticity showed a lower WC and WtHR than those in the no or mild spasticity group (P=0.038, P=0.006, respectively). The FM, BFP, leptin and FPG of the severe spasticity group were significantly lower than those of the patients in the no or mild spasticity group (P=0.003, P<0.001, P<0.001 and P=0.037, respectively). However, no differences in BMD, total cholesterol, LDL, HDL, TG and HbA1c were observed between the groups.

CONCLUSIONS

The results of this study suggest that severe spasticity in lower extremities is associated with reduced adiposity and lower FPG levels in persons with chronic motor complete SCI.

Optimizing the Management of Disabling Spasticity Following Spinal Cord Damage: The Ability Network-An International Initiative

Optimizing the treatment of disabling spasticity in persons with spinal cord damage is hampered by a lack of consensus regarding the use of acceptable definitions of spasticity and disabling spasticity, and the relative absence of decision tools such as clinical guidelines and concise algorithms to support decision-making within the broader clinical community. Many people with spinal cord damage are managed outside specialist centers, and variations in practice result in unequal access to best practice despite equal need. In order to address these issues, the Ability Network-an international panel of clinical experts-was initiated to develop management algorithms to guide and standardize the assessment, treatment, and evaluation of outcomes of persons with spinal cord damage and disabling spasticity. To achieve this, consensus was sought on common definitions through facilitated, in-person meetings. To guide patient selection, an in-depth review of the available tools was performed and expert consensus sought to develop an appropriate instrument. Literature reviews are guiding the selection and development of tools to evaluate treatment outcomes (body functions, activity, participation, quality of life) as perceived by people with spinal cord damage and disabling spasticity, and their caregivers and clinicians. Using this approach, the Ability Network aims to facilitate treatment decisions that take into account the following: the impact of disabling spasticity on health status, patient preferences, treatment goals, tolerance for adverse events, and in cases of totally dependent persons, caregiver burden.

Identifying and classifying quality of life tools for assessing spasticity after spinal cord injury

OBJECTIVE

To identify and classify tools for assessing the influence of spasticity on quality of life (QOL) after spinal cord injury (SCI).

METHODS

Electronic databases (MEDLINE/PubMed CINAHL and PsycInfo) were searched for studies published between 1975 and 2012. Dijkers's theoretical framework on QOL was used to classify tools as either objective or subjective measures of QOL.

RESULTS

Sixteen studies met the inclusion criteria. Identified objective measures that were used to assess the influence of spasticity on QOL included the Short Form-36 (SF-36) the Sickness Impact Profile (SIP) and the Health Utilities Index-III (HUI-III). Subjective measures included the Quality of Life Index-SCI Version III (QLI-SCI) Life Situation Questionnaire-Revised (LSQ-R) Reciprocal Support Scale (RSS) Profile of Mood States (POMS) Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET) and the Patient Reported Impact of Spasticity Measure (PRISM). A number of tools proved either to be insensitive to the presence of spasticity (QLI-SCI) or yielded mixed (SF-36) or weak (RSS LSQ-R) results. Tools that were sensitive to spasticity had limited psychometric data for use in the SCI population (HUI-III SIP POMS) although 2 were developed specifically for assessing spasticity on daily life post SCI (SCI-SET PRISM).

CONCLUSIONS

Two condition-specific subjective measures the SCI-SET and PRISM emerged as the most promising tools for the assessment of spasticity impact on QOL after SCI. Further research should focus on establishing the psychometric properties of these measures for use in the SCI population.Key words: outcome measurement quality of life spasticity spinal cord injury.

Does regular standing improve bowel function in people with spinal cord injury? A randomised crossover trial

STUDY DESIGN

A randomised crossover trial.

OBJECTIVES

To determine the effects of a 6-week standing programme on bowel function in people with spinal cord injury.

SETTING

Community, Australia and the United Kingdom.

METHODS

Twenty community-dwelling people with motor complete spinal cord injury above T8 participated in a 16-week trial. The trial consisted of a 6-week stand phase and a 6-week no-stand phase separated by a 4-week washout period. Participants were randomised to one of two treatment sequences. Participants allocated to the Treatment First group stood on a tilt table for 30 min per session, five times per week for 6 weeks and then did not stand for the next 10 weeks. Participants allocated to the Control First group did the opposite: they did not stand for 10 weeks and then stood for 6 weeks. Participants in both groups received routine bowel care throughout the 16-week trial. Assessments occurred at weeks 0, 7, 10 and 17 corresponding with pre and post stand and no-stand phases. The primary outcome was Time to First Stool. There were seven secondary outcomes reflecting other aspects of bowel function and spasticity.

RESULTS

There were three dropouts leaving complete data sets on 17 participants. The mean (95% confidence interval) between-intervention difference for Time to First Stool was 0 min (-7 to 7) indicating no effect of regular standing on Time to First Stool.

CONCLUSION

Regular standing does not reduce Time to First Stool. Further trials are required to test the veracity of some commonly held assumptions about the benefits of regular standing for bowel function.

Identifying and classifying quality-of-life tools for assessing pressure ulcers after spinal cord injury

CONTEXT

Although pressure ulcers may negatively influence quality of life (QoL) post-spinal cord injury (SCI), our understanding of how to assess their impact is confounded by conceptual and measurement issues. To ensure that descriptions of pressure ulcer impact are appropriately characterized, measures should be selected according to the domains that they evaluate and the population and pathologies for which they are designed.

OBJECTIVE

To conduct a systematic literature review to identify and classify outcome measures used to assess the impact of pressure ulcers on QoL after SCI.

METHODS

Electronic databases (Medline/PubMed, CINAHL, and PsycInfo) were searched for studies published between 1975 and 2011. Identified outcome measures were classified as being either subjective or objective using a QoL model.

RESULTS

Fourteen studies were identified. The majority of tools identified in these studies did not have psychometric evidence supporting their use in the SCI population with the exception of two objective measures, the Short-Form 36 and the Craig Handicap Assessment and Reporting Technique, and two subjective measures, the Life Situation Questionnaire-Revised and the Ferrans and Powers Quality of Life Index SCI-Version.

CONCLUSION

Many QoL outcome tools showed promise in being sensitive to the presence of pressure ulcers, but few of them have been validated for use with SCI. Prospective studies should employ more rigorous methods for collecting data on pressure ulcer severity and location to improve the quality of findings with regard to their impact on QoL. The Cardiff Wound Impact Schedule is a potential tool for assessing impact of pressure ulcers-post SCI.

Spasticity changes in SCI following a dynamic standing program using the Segway

STUDY DESIGN

A pilot prospective pre- and post-intervention study.

OBJECTIVES

To determine whether a dynamic standing program using the Segway Personal Transporter results in any measurable physiological effects in individuals with spinal cord injury (SCI) using both qualitative and quantitative measures of spasticity, pain and fatigue.

SETTING

International Collaboration of Repair Discoveries (ICORD) Research Centre, Vancouver, BC, Canada.

METHODS

Eight individuals with SCI ASIA (American Spinal Injury Association) A-D, who could stand with or without the assistance of bracing or supports, participated in a 4-week dynamic standing program using a Segway (3 per week, 30-min sessions). The main outcome was spasticity as measured by the Modified Ashworth Scale (MAS). Secondary measures included the SCI-Spasticity Evaluation Tool, Pain Outcomes Questionnaire, and Fatigue Severity Scale.

RESULTS

The dynamic standing sessions were associated with immediate improvements in spasticity (MAS) (P<0.001) and self-reported pain (P<0.05). Fatigue levels decreased, however this was not significant. There is little evidence to suggest that these beneficial outcomes may have lasting effects.

CONCLUSIONS

Dynamic standing on the Segway may be effective for short-term spasticity reduction and decreased pain and fatigue. Future work should examine a larger sample size and help to propose mechanisms for potential reductions in spasticity.

Comparison of the effects of body-weight-supported treadmill training and tilt-table standing on spasticity in individuals with chronic spinal cord injury

OBJECTIVE

Determine the effects of body-weight-supported treadmill training (BWSTT) and tilt-table standing (TTS) on clinically assessed and self-reported spasticity, motor neuron excitability, and related constructs in individuals with chronic spinal cord injury (SCI).

DESIGN

Random cross-over.

METHODS

Seven individuals with chronic SCI and spasticity performed thrice-weekly BWSTT for 4 weeks and thrice-weekly TTS for 4 weeks, separated by a 4-week wash-out. Clinical (Modified Ashworth Scale, Spinal Cord Assessment Tool for Spinal reflexes) and self-report (Spinal Cord Injury Spasticity Evaluation Tool, Penn Spasm Frequency Scale) assessments of spasticity, quality of life (Quality of Life Index Spinal Cord Injury Version - III), functional mobility (FIM Motor Subscale), plus soleus H-reflex were measured at baseline, after the first training session and within 2 days of completing each training condition.

RESULTS

In comparison with TTS, a single session of BWSTT had greater beneficial effects for muscle tone (effect size (ES) = 0.69), flexor spasms (ES = 0.57), and the H/M ratio (ES = 0.50). Similarly, flexor spasms (ES = 0.79), clonus (ES = 0.66), and self-reported mobility (ES = 1.27) tended to benefit more from 4 weeks of BWSTT than of TTS. Participation in BWSTT also appeared to be favorable for quality of life (ES = 0.50). In contrast, extensor spasms were reduced to a greater degree with TTS (ES = 0.68 for single session; ES = 1.32 after 4 weeks).

CONCLUSION

While both BWSTT and TTS may provide specific benefits with respect to spasticity characteristics, data from this pilot study suggest that BWSTT may result in a broader range of positive outcomes.

Gait characteristics, range of motion, and spasticity changes in response to massage in a person with incomplete spinal cord injury: case report

PURPOSE

Our study set out to measure the effect of a specific routine of massage on gait characteristics, range of motion, and spasticity in a person with incomplete spinal cord injury.

METHODS

This descriptive, pre-post case study, conducted at the outpatient program of a rehabilitation facility, used neuromuscular techniques in massage for a 42-year-old man with incomplete chronic C5 spinal cord injury. The massage was applied to the iliopsoas, triceps surae, and hamstring muscle groups for 3 consecutive days.

MAIN OUTCOME MEASURES

Pre- and post-intervention testing included standard goniometric measurement of joint range of motion in the lower extremities, spasticity evaluation using the modified Ashworth scale, and evaluation of gait characteristics using GAITRite Walkway (CIR Systems, Havertown, PA, USA) pressure mapping for ambulation time, cadence, velocity, stride length, base of support, and single- and double-limb support.

RESULTS

AFTER THE THERAPEUTIC INTERVENTION, THE FOLLOWING GAIT CHANGES WERE DEMONSTRATED: increase in velocity and cadence of gait, decrease in ambulation time, increase in stride length, and improvements in the percentages of the swing and stance phases of the gait cycle.

CONCLUSIONS

Specific application of massage therapy influenced gait speed, stride length, and swing and stance phase percentages in one person with incomplete spinal cord injury. Further study is warranted to determine the extent to which massage may affect musculoskeletal and neural impairments that limit gait in people with incomplete spinal cord injury, and the method or routine whose application will yield the most benefit.

Perception of lower limb spasticity in patients with spinal cord injury

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To study the manifestation of spasticity in daily life of the patients with spinal cord injury, their perception of spasticity and spasticity-related discomfort.

SETTING

Rehabilitation center in the Netherlands.

METHODS

Twenty-six patients with motor complete spinal cord injury (SCI) and spasticity in the lower limbs completed a questionnaire. The following outcome measures were used: manifestation of spasticity, activities during which spasticity occurs, perceived degree of spasticity and resulting discomfort, measured with visual analog scale (VAS) and Borg scale, respectively.

RESULTS

In general, spasticity manifested as extensor spasms (84.6%), flexor spasms and/or clonus (both 69.2%), and less often as continuous tension (57.7%). The registered activities were categorized into five main groups: 'changing position' was the largest group (22.0%) with a median VAS of 6.8 (range: 2.5-9.5) and median Borg scale of 3.0 (range: 1.0-7.0). Other groups of activities were 'making a transfer' (20.7%), 'activities of daily living' (17.1%), 'being active' (17.1%) and 'stable body position' (12.2%). The overall correlation between VAS and Borg was moderate (Spearman's rho=0.53, P=0.005).

CONCLUSIONS

Patients with complete SCI experienced several manifestations of spasticity, extensor spasms being the most common. Many daily life activities elicited different manifestations of spasticity. The experienced discomfort was only moderately related to the perceived degree of spasticity during an activity. Possibly, the discomfort is influenced by other factors than the perceived spasticity alone.

Spasticity outcome measures in spinal cord injury: psychometric properties and clinical utility

STUDY DESIGN

Comprehensive review and systematic analyses.

OBJECTIVES

Assess published psychometric evidence for spinal cord injury (SCI) spasticity outcome measures. Considerations about the influence of spasticity on function have also been identified to understand treatment effects and guide service delivery.

SETTING

London, Ontario and Vancouver, British Columbia, Canada.

METHOD

Review of measures was based on availability of psychometric data, application in clinical settings and evaluated in SCI patients.

RESULTS

Ashworth and Modified Ashworth Scales (AS, MAS), Penn Spasm Frequency Scale (PSFS), Spinal Cord Assessment Tool for Spasticity (SCATS), Visual Analogue Scale self-rated scale of spasticity (VAS) and the Wartenberg Pendulum Test (WPT) were included in this review. The most frequently used tools for SCI spasticity measurement include the AS, MAS, PSFS and VAS, of which the latter two are self-report spasticity measures. The SCATS has been partially validated for SCI, but is not widely used. The WPT has been minimally validated despite its use in a large-scale SCI spasticity randomized controlled trial.

CONCLUSIONS

Since spasticity is multidimensional, focusing on one or two spasticity outcome measures can misrepresent the extent and influence of spasticity on SCI patients. Different scales measure different aspects of spasticity and individual tools correlate weakly with each other. Spasticity may be better measured with an appropriate battery of tests, including the AS or MAS, along with PSFS. These tools would benefit from further reliability and responsiveness testing. Tools that assess the influence of spasticity on patient activities, participation and quality of life are important, but lacking.