Toning It Down: Selecting Outcome Measures for Spasticity Management Using a Modified Delphi Approach

Spasticity evaluation and management tools

Spasticity is a complex and often disabling symptom for patients with upper motor neuron syndromes. Although spasticity arises from neurological disease, it often cascades into muscle and soft tissue changes, which may exacerbate symptoms and further hamper function. Effective management therefore hinges on early recognition and treatment. To this end, the definition of spasticity has expanded over time to more accurately reflect the spectrum of symptoms experienced by persons with this disorder. Once identified, clinical and research quantitative assessments of spasticity are hindered by the uniqueness of presentations both for individuals and for specific neurological diagnoses. Objective measures in isolation often fail to reflect the complex functional impact of spasticity. Multiple tools exist to quantitatively or qualitatively assess the severity of spasticity, including clinician and patient-reported measures as well as electrodiagnostic, mechanical, and ultrasound measures. A combination of objective and patient-reported outcomes is likely required to better reflect the burden of spasticity symptoms in an individual. Therapeutic options exist for the treatment of spasticity along a broad spectrum from nonpharmacologic to interventional procedures. Treatment strategies may include exercise, physical agent modalities, oral medications, injections, pumps, and surgery. Optimal spasticity management most often requires a multimodal approach, combining pharmacological management with interventions that match the functional needs, goals, and preferences of the patient. Physicians and other healthcare providers who manage spasticity must be familiarized with the full array of spasticity interventions and must frequently reassess results of treatment to ensure the patient's goals of treatment are met.

Access to Focal Spasticity Care: A Cross Canada Survey of Physiatrists

Successful management of focal spasticity requires access to botulinum toxin type A (BoNT-A) injections, physiotherapy, occupational therapy, and orthoses/bracing. To assess the quality of focal spasticity care across Canada, we sent a survey consisting of 22 questions to physiatrists involved in the management of outpatient spasticity. Thirty-four physiatrists from all 10 provinces responded to the survey. Wait time for BoNT-A treatment averaged 12.7 weeks from time of referral across Canada. More than 75% of patients faced barriers to obtaining physical therapy and orthoses. Access to best quality care for spasticity patients across Canada varies widely.

Defining the content of a minimal dataset for acquired brain injury using a Delphi procedure

Background

The lack of consistency in outcome measurement within the field of acquired brain injury (ABI) leads to incomparability of collected data and, consequently, reduced generalisation of findings. We aim to develop a set of standardised measures which can be used to obtain the minimum amount of data necessary to characterise ABI-patients across all healthcare sectors and disciplines and in every stage of recovery; i.e., an ABI-specific minimal dataset (MDS-ABI). The current study was conducted to identify the core outcome domains for adults with ABI (what to measure?) and to select the most suitable measurements within these domains (how to measure it?).

Methods

An initial comprehensive set of outcome domains and measurement instruments relevant for measuring the consequences of ABI was identified by a literature study. The selection of relevant domains was based on the International Classification of Functioning, Disability and Health framework. Measurement instruments were included in the Delphi procedure when they met pre-set requirements. A three-round Delphi study was conducted among Dutch experts (n = 48) using iterative web-based surveys to prioritise the proposed domains and instruments for the MDS-ABI. Throughout all rounds, participants could recommend additional or alternative domains and measurement instruments, and were fed back the collated group responses of the previous round.

Results

Response rates ranged from 89 to 100%. After three rounds, the expert panel reached consensus (≥51%) on the inclusion of 12 outcome domains (demographics, injury characteristics, comorbidity, cognitive functioning, emotional functioning, energy, mobility, self-care, communication, participation, social support and quality of life), measured with six measurement instruments, two screening questions and a registry of demographic- and injury information. No consensus was reached on how to measure quality of life.

Conclusions

The current study achieved consensus on the content of a minimal dataset for patients with ABI. The current version of the MDS-ABI will be evaluated and optimised if necessary in the near future.

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.

Management of intrathecal baclofen therapy for severe acquired brain injury: consensus and recommendations for good clinical practice

Although widespread in the treatment of generalised spasticity due to severe acquired brain injury, clinical use of intrathecal baclofen administered through an implanted catheter is not yet supported by full scientific evidence. The aim of the study is to provide recommendations for good clinical practice regarding intrathecal baclofen therapy. We used a modified RAND Delphi method to develop consensus-based medical guidelines, involving clinicians who use intrathecal baclofen therapy throughout Italy. The clinicians were asked 38 questions grouped in six areas (patient selection, contraindications for implant, tests prior to implant, method of implant and management of therapy, efficacy evaluation and goal setting, and management of complications). To establish consensus, 75% agreement was required in answers to every question. Consensus was reached on the second round of the Delphi process on 27/38 questions (71%), specifically those regarding identification of objectives, efficacy evaluation, and method of implant and management of therapy, whereas management of complications and contraindications for implant remained critical areas. Despite the limits of our method, a set of recommendations was drawn up for clinical practice in this sector. The study also revealed residual critical areas and indicated future lines of research necessary to reach evidence-based consensus.

Evaluation of upper extremity neurorehabilitation using technology: a European Delphi consensus study within the EU COST Action Network on Robotics for Neurorehabilitation

BACKGROUND

The need for cost-effective neurorehabilitation is driving investment into technologies for patient assessment and treatment. Translation of these technologies into clinical practice is limited by a paucity of evidence for cost-effectiveness. Methodological issues, including lack of agreement on assessment methods, limit the value of meta-analyses of trials. In this paper we report the consensus reached on assessment protocols and outcome measures for evaluation of the upper extremity in neurorehabilitation using technology. The outcomes of this research will be part of the development of European guidelines.

METHODS

A rigorous, systematic and comprehensive modified Delphi study incorporated questions and statements generation, design and piloting of consensus questionnaire and five consensus experts groups consisting of clinicians, clinical researchers, non-clinical researchers, and engineers, all with working experience of neurological assessments or technologies. For data analysis, two major groups were created: i) clinicians (e.g., practicing therapists and medical doctors) and ii) researchers (clinical and non-clinical researchers (e.g. movement scientists, technology developers and engineers).

RESULTS

Fifteen questions or statements were identified during an initial ideas generation round, following which the questionnaire was designed and piloted. Subsequently, questions and statements went through five consensus rounds over 20 months in four European countries. Two hundred eight participants: 60 clinicians (29 %), 35 clinical researchers (17 %), 77 non-clinical researchers (37 %) and 35 engineers (17 %) contributed. At each round questions and statements were added and others removed. Consensus (≥69 %) was obtained for 22 statements on i) the perceived importance of recommendations; ii) the purpose of measurement; iii) use of a minimum set of measures; iv) minimum number, timing and duration of assessments; v) use of technology-generated assessments and the restriction of clinical assessments to validated outcome measures except in certain circumstances for research.

CONCLUSIONS

Consensus was reached by a large international multidisciplinary expert panel on measures and protocols for assessment of the upper limb in research and clinical practice. Our results will inform the development of best practice for upper extremity assessment using technologies, and the formulation of evidence-based guidelines for the evaluation of upper extremity neurorehabilitation.

Improvement of spasticity following intermittent theta burst stimulation in multiple sclerosis is associated with modulation of resting-state functional connectivity of the primary motor cortices

Background:

Intermittent theta burst stimulation (iTBS) of the primary motor cortex improves transiently lower limbs spasticity in multiple sclerosis (MS). However, the cerebral mechanisms underlying this effect have never been investigated.

Objective:

To assess whether modulation of spasticity induced by iTBS is underlined by functional reorganization of the primary motor cortices.

Methods:

A total of 17 patients with MS suffering from lower limbs spasticity were randomized to receive real iTBS or sham iTBS during the first half of a 5-week indoor rehabilitation programme. Spasticity was assessed using the Modified Ashworth Scale and the Visual Analogue Scale at baseline, after the stimulation session and at the end of the rehabilitation programme. Resting-state functional magnetic resonance imaging (fMRI) was performed at the three time points, and brain functional networks topology was analysed using graph-theoretical approach.

Results:

At the end of stimulation, improvement of spasticity was greater in real iTBS group than in sham iTBS group ( p = 0.026). iTBS had a significant effect on the balance of the connectivity degree between the stimulated and the homologous primary motor cortex ( p = 0.005). Changes in inter-hemispheric balance were correlated with improvement of spasticity (rho = 0.56, p = 0.015).

Conclusion:

This longitudinal resting-state fMRI study evidences that functional reorganization of the primary motor cortices may underlie the effect of iTBS on spasticity in MS.