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

Evaluating Community-Based Intrathecal Baclofen Therapy: Effectiveness, Safety, and Feasibility

Background: Intrathecal baclofen (ITB) is used for the treatment of intractable spasticity. The burden of traveling for ITB screening and aftercare is problematic for nursing home residents with severe spasticity and seems to result in undertreatment of spasticity. The aim of this study is to evaluate the effectiveness, safety, and feasibility of ITB for nursing home residents treated in their home, describing the selection phase, the initial trial of ITB, and aftercare up to 3 months after implantation of an ITB pump. Methods: This retrospective database study included immobile, adult nursing home residents with severe spasticity, referred to an Ambulatory Care Clinic between 2016 and 2021. When eligible, an ITB trial was performed by ITB experts in the nursing home. If a permanent pump was implanted, dose titration and aftercare were performed on location. Results: A total of 102 patients were referred; 80 underwent an ITB trial on location, and 94% improved significantly on the Modified Ashworth Scale and clonus scale pre-ITB trial versus post-ITB trial, as well as at 3 months post-implantation. There was a low incidence of adverse events, mostly procedure- and drug-related. Conclusions: This study indicates that selection, testing, and aftercare for ITB on location is effective and safe.

Management of spasticity in individuals with spinal cord injury in the era of COVID-19 pandemic societal restrictions

STUDY DESIGN

Cross-sectional telephone interviews.

OBJECTIVE

The coronavirus disease (COVID-19) pandemic placed unprecedented pressure on healthcare systems worldwide. Here, we aimed to investigate the disruptions in management of spasticity and activities of daily living (ADL) in individuals with spinal cord injury (SCI) during the COVID-19 pandemic.

SETTING

Two university hospitals in Istanbul, Turkey.

METHODS

Twenty-four individuals with SCI exhibiting moderate and severe spasticity were enroled. All participants underwent ultrasound-guided botulinum toxin type A (BoNT-A) injections at two centres. A self-rated spasticity survey prepared by the authors was conducted. We questioned whether there was an increase in spasticity and the need for new BoNT-A injections during the societal restrictions of the COVID-19 pandemic. Spasticity severity in the previous week was rated using a numeric rating scale (NRS). ADL disrupted by spasticity were assessed by asking open-ended questions.

RESULTS

In total, 75% participants reported a moderate increase in spasticity, 12.5% reported a severe increase, and 12.5% reported no difference. The mean spasticity NRS score was 6 (standard deviation = 2). Further, 87.5% (21) participants reported the need for BoNT-A treatment because of symptom re-emergence. When spasticity-induced deterioration in ADL was assessed, individuals mostly reported difficulties in walking, sitting on a wheelchair, and sleep disturbance due to spasticity.

CONCLUSIONS

Most (87.5%) individuals with SCI reported a moderate or severe increase in spasticity during COVID-19 restrictions. Individuals with disabilities are an especially sensitive group and require specialised care during extraordinary circumstances, such as pandemics, hurricanes, or earthquakes.

SPONSORSHIP

None.

Primary Care in the Spinal Cord Injury Population: Things to Consider in the Ongoing Discussion

Purpose of Review

Spinal cord injury (SCI) creates unique needs that if not recognized and addressed timely can have detrimental effects on the health and quality of life (QOL) of people living with a SCI. Primary preventive health care is shown to decrease morbidity and mortality, yet the SCI population reportedly faces challenges getting access to this care. This area in SCI health care is still largely understudied with no consensus on the ideal way or which health care provider is best to provide primary care for this population.

Findings

Preventive care is generally provided by general primary care providers, but not all primary care providers are trained in recognizing and addressing spinal cord injury-specific needs. SCI providers generally are not trained in addressing all aspects of preventive care. Knowing the recommended preventive care screenings, recognizing and managing specific conditions seen after a SCI, and seamless coordination of care between general practitioners and SCI specialists are some of the interventions to help prevent health complications, decrease morbidity and mortality, improve health outcomes, and promote QOL in this patient population.

Summary

Prioritized focus on preventive care is necessary for a positive impact on the overall health and QOL in this population. Addressing the knowledge gap reported by primary care providers and SCI providers may help increase the probability of SCI patients getting their preventive and specialty care needs addressed. We present a "cheat sheet" of recommendations for the preventive care evaluation of a person living with a SCI.

Intrathecal and Oral Baclofen Use in Adults With Spinal Cord Injury: A Systematic Review of Efficacy in Spasticity Reduction, Functional Changes, Dosing, and Adverse Events

OBJECTIVE

To examine the efficacy, dosing, and safety profiles of intrathecal and oral baclofen in treating spasticity after spinal cord injury (SCI).

DATA SOURCES

PubMed and Cochrane Databases were searched from 1970-2018 with keywords baclofen, spinal cord injury, and efficacy.

STUDY SELECTION

The database search yielded 588 sources and 10 additional relevant publications. After removal of duplicates, 398 publications were screened.

DATA EXTRACTION

Data were extracted using the following population, intervention, comparator, outcomes, and study designs criteria: studies including adult patients with SCI with spasticity; the intervention could be oral or intrathecal administration of baclofen; selection was inclusive for control groups, surgical management, rehabilitation, and alternative pharmaceutical agents; outcomes were efficacy, dosing, and adverse events. Randomized controlled trials, observational studies, and case reports were included. Meta-analyses and systematic reviews were excluded.

DATA SYNTHESIS

A total of 98 studies were included with 1943 patients. Only 4 randomized, double-blinded, and placebo-controlled trials were reported. Thirty-nine studies examined changes in the Modified Ashworth Scale (MAS; 34 studies) and Penn Spasm scores (Penn Spasm Frequency; 19 studies), with average reductions of 1.7±1.3 and 1.6±1.4 in individuals with SCI, respectively. Of these data, a total of 6 of the 34 studies (MAS) and 2 of the 19 studies (Penn Spasm Frequency) analyzed oral baclofen. Forty-three studies addressed adverse events with muscle weakness and fatigue frequently reported.

CONCLUSIONS

Baclofen is the most commonly-prescribed antispasmodic after SCI. Surprisingly, there remains a significant lack of large, placebo-controlled, double-blinded clinical trials, with most efficacy data arising from small studies examining treatment across different etiologies. In the studies reviewed, baclofen effectively improved spasticity outcome measures, with increased efficacy through intrathecal administration. Few studies assessed how reduced neural excitability affected residual motor function and activities of daily living. A host of adverse events were reported that may negatively affect quality of life. Comparative randomized controlled trials of baclofen and alternative treatments are warranted because these have demonstrated promise in relieving spasticity with reduced adverse events and without negatively affecting residual motor function.

Phenol neurolysis in people with spinal cord injury: a descriptive study

STUDY DESIGN

Descriptive study.

OBJECTIVES

The study's main objective was to describe the common targets of phenol neurolysis and review the safety and efficacy of the dose used for this spasticity management procedure in people with spinal cord injury (SCI).

SETTING

An acute rehabilitation hospital.

METHODS

Data from people with SCI who underwent phenol neurolysis procedures for spasticity management between April 2017 and August 2018 were included in this study. We collected demographics and phenol neurolysis procedure-related information.

RESULTS

A total of 66 people with SCI and spasticity underwent phenol neurolysis of 303 nerves over 102 encounters. During these encounters, 97% of procedures were performed using both electrical stimulation and ultrasound guidance. The median (IQR) total volume of 6% aqueous phenol used per encounter was 4.0 (2.0-6.0) ml with a median (IQR) of 1.5 (1.0-2.3) ml per nerve. The most frequent target was the obturator nerve (33%), followed by the pectoral nerves (23%). Immediate post-phenol neurolysis improvement or reduction in spasticity was reported for 92% of all documented encounters. There was no documentation of any post-procedure-related adverse events in this cohort during this specified time frame.

CONCLUSIONS

Our findings suggest that phenol neurolysis can be safely used to manage spasticity in people with SCI under combined electrical stimulation and ultrasound guidance. Further research is required to assess the procedure's safety, efficacy, and cost-effectiveness on patient-reported outcomes compared to other spasticity interventions.

Properties of the surface electromyogram following traumatic spinal cord injury: a scoping review

Traumatic spinal cord injury (SCI) disrupts spinal and supraspinal pathways, and this process is reflected in changes in surface electromyography (sEMG). sEMG is an informative complement to current clinical testing and can capture the residual motor command in great detail-including in muscles below the level of injury with seemingly absent motor activities. In this comprehensive review, we sought to describe how the sEMG properties are changed after SCI. We conducted a systematic literature search followed by a narrative review focusing on sEMG analysis techniques and signal properties post-SCI. We found that early reports were mostly focused on the qualitative analysis of sEMG patterns and evolved to semi-quantitative scores and a more detailed amplitude-based quantification. Nonetheless, recent studies are still constrained to an amplitude-based analysis of the sEMG, and there are opportunities to more broadly characterize the time- and frequency-domain properties of the signal as well as to take fuller advantage of high-density EMG techniques. We recommend the incorporation of a broader range of signal properties into the neurophysiological assessment post-SCI and the development of a greater understanding of the relation between these sEMG properties and underlying physiology. Enhanced sEMG analysis could contribute to a more complete description of the effects of SCI on upper and lower motor neuron function and their interactions, and also assist in understanding the mechanisms of change following neuromodulation or exercise therapy.

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.

Physiotherapy interventions for the treatment of spasticity in people with spinal cord injury: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

To determine the effectiveness of physiotherapy interventions for the treatment of spasticity in people with spinal cord injuries.

SETTING

Not applicable.

METHODS

A comprehensive search was undertaken to identify all randomised controlled trials of physiotherapy interventions that included an assessor-reported (objective) or participant-reported (subjective) measure of spasticity. Only trials that provided a physiotherapy intervention on more than one occasion were included. The susceptibility to bias of each trial was rated on the PEDro scale. Data were extracted to derive mean between-group differences (95% CI) for each trial.

RESULTS

Twenty-eight trials were identified but only 17 provided useable data. Seven trials compared a physiotherapy intervention to no intervention (or a sham intervention) and 10 trials compared one physiotherapy intervention to another physiotherapy intervention. The median (IQR) PEDro score of the 17 trials was 6/10 (6-8). The most commonly used assessor- and participant-reported measures of spasticity were the Ashworth scale and Spinal Cord Injury Spasticity Evaluation Tool, respectively. Only one trial demonstrated a treatment effect. This trial compared continuous passive motion of the ankle to no treatment on the Ashworth scale. The remaining 16 trials were either inconclusive or indicated that the treatment was ineffective for reducing spasticity.

CONCLUSIONS

There is no high-quality evidence to indicate that physiotherapy interventions decrease spasticity but this may reflect a lack of research on the topic. Future trials should focus on participant-reported measures of spasticity that distinguish between the immediate, short-term and long-term effects of any physiotherapy intervention.

Bilateral and asymmetrical contributions of passive and active ankle plantar flexors stiffness to spasticity in humans with spinal cord injury

Spasticity is one of the most common symptoms present in humans with spinal cord injury (SCI); however, its clinical assessment remains underdeveloped. The purpose of the study was to examine the contribution of passive muscle stiffness and active spinal reflex mechanisms to clinical outcomes of spasticity after SCI. It is important that passive and active contributions to increased muscle stiffness are distinguished to make appropriate decisions about antispastic treatments and to monitor its effectiveness. To address this question, we combined biomechanical and electrophysiological assessments of ankle plantarflexor muscles bilaterally in individuals with and without chronic SCI. Spasticity was assessed using the Modified Ashworth Scale (MAS) and a self-reported questionnaire. We performed slow and fast dorsiflexion stretches of the ankle joint to measure passive muscle stiffness and reflex-induced torque using a dynamometer and the soleus H reflex using electrical stimulation over the posterior tibial nerve. All SCI participants reported the presence of spasticity. While 96% of them reported higher spasticity on one side compared with the other, the MAS detected differences across sides in only 25% of the them. Passive muscle stiffness and the reflex-induced torque were larger in SCI compared with controls more on one side compared with the other. The soleus stretch reflex, but not the H reflex, was larger in SCI compared with controls and showed differences across sides, with a larger reflex in the side showing a higher reflex-induced torque. MAS scores were not correlated with biomechanical and electrophysiological outcomes. These findings provide evidence for bilateral and asymmetric contributions of passive and active ankle plantar flexors stiffness to spasticity in humans with chronic SCI and highlight a poor agreement between a self-reported questionnaire and the MAS for detecting asymmetries in spasticity across sides.NEW & NOTEWORTHY Spasticity affects a number of people with spinal cord injury (SCI). Using biomechanical, electrophysiological, and clinical assessments, we found that passive muscle properties and active spinal reflex mechanisms contribute bilaterally and asymmetrically to spasticity in ankle plantarflexor muscles in humans with chronic SCI. A self-reported questionnaire had poor agreement with the Modified Ashworth Scale in detecting asymmetries in spasticity. The nature of these changes might contribute to the poor sensitivity of clinical exams.