The management of focal spasticity

Riluzole for treating spasticity in patients with chronic traumatic spinal cord injury: Study protocol in the phase ib/iib adaptive multicenter randomized controlled RILUSCI trial

BACKGROUND

Satisfactory treatment is often lacking for spasticity, a highly prevalent motor disorder in patients with spinal cord injury (SCI). Low concentrations of riluzole potently reduce the persistent sodium current, the post-SCI increase in which contributes to spasticity. The repurposing of this drug may therefore constitute a useful potential therapeutic option for relieving SCI patients suffering from chronic traumatic spasticity.

OBJECTIVE

RILUSCI is a phase 1b-2b trial designed to assess whether riluzole is a safe and biologically effective means of managing spasticity in adult patients with traumatic chronic SCI.

METHODS

In this multicenter double-blind trial, adults (aged 18-65 years) suffering from spasticity after SCI (target enrollment: 90 participants) will be randomly assigned to be given either a placebo or a recommended daily oral dose of riluzole for two weeks. The latter dose will be previously determined in phase 1b of the study by performing double-blind dose-finding tests using a Bayesian continuous reassessment method. The primary endpoint of the trial will be an improvement in the Modified Ashworth Score (MAS) or the Numerical Rating Score (NRS) quantifying spasticity. The secondary outcomes will be based on the safety and pharmacokinetics of riluzole as well as its impact on muscle spasms, pain, bladder dysfunction and quality of life. Analyses will be performed before, during and after the treatment and the placebo-controlled period.

CONCLUSION

To the best of our knowledge, this clinical trial will be the first to document the safety and efficacy of riluzole as a means of reducing spasticity in patients with chronic SCI.

TRIAL REGISTRATION

The clinical trial, which is already in progress, was registered on the ClinicalTrials.gov website on August 9, 2016 under the registration number NCT02859792.

TRIAL SPONSOR

Assistance Publique-Hôpitaux de Marseille.

Spasticity and preservation of skeletal muscle mass in people with spinal cord injury

STUDY DESIGN

Cross-sectional OBJECTIVE: To investigate the association between skeletal muscle mass and spasticity in people with spinal cord injury (SCI).

SETTING

Tertiary level hospital in Seoul, Korea METHODS: Spasticity was evaluated in 69 participants with SCI using the spasticity sum score (SSS), Penn Spasm Frequency Scale (PSFS), and Spinal Cord Assessment Tool for Spastic Reflexes (SCATS). Skeletal muscle mass was measured using a dual-energy X-ray absorptiometry scanner, and skeletal muscle index was calculated by dividing skeletal muscle mass by height squared. Laboratory parameters including hemoglobin, albumin, creatinine, fasting glucose, and cholesterol were measured. Spearman's correlation analysis was performed to assess the association between the skeletal muscle mass and spasticity scales. Multiple linear regression analysis was used to present the independent association between them.

RESULTS

The participants' mean age was 41.8 years; 54 (78.3%) were male, and 46 (66.7%) were tetraplegic. Skeletal muscle index of lower extremities was significantly correlated with all spasticity scales. Spearman's correlation coefficients were 0.468, 0.467, 0.555, 0.506, and 0.474 for SSS, PSFS, SCATS clonus, SCATS flexor, and SCATS extensor with p-values < 0.001, respectively. After adjustment for age, sex, level of injury, body mass index, and serum creatinine, all spasticity scales were significantly associated with skeletal muscle index of lower extremities in multiple regression analysis. Standardized coefficients were 0.228, 0.274, 0.294, 0.210, and 0.227 for SSS, PSFS, SCATS clonus, SCATS flexor, and SCATS extensor.

CONCLUSIONS

Spasticity was significantly correlated with the skeletal muscle mass even after adjusting for possible confounders. Spasticity may need to be considered as an influencing factor in interventions such as electrical stimulation to preserve skeletal muscle mass.

Comparison of transcutaneous electrical nerve stimulation (TENS) and functional electrical stimulation (FES) for spasticity in spinal cord injury - A pilot randomized cross-over trial

OBJECTIVE

Spasticity following spinal cord injury (SCI) can impair function and affect quality of life. This study compared the effects of transcutaneous electrical nerve stimulation (TENS) and functional electrical stimulation (FES) on lower limb spasticity in patients with SCI.

DESIGN

Double blind randomized crossover design.

SETTING

Neuro-rehabilitation unit, Manipal University, India.

PARTICIPANTS

Ten participants (age: 39 ± 13.6 years, C1-T11, 1-26 months post SCI) with lower limb spasticity were enrolled in this study.

INTERVENTIONS

Participants were administered electrical stimulation with TENS and FES (duration - 30 minutes) in a cross over manner separated by 24 hours.

OUTCOME MEASURES

Spasticity was measured using modified Ashworth scale (MAS) [for hip abductors, knee extensors and ankle plantar flexors] and spinal cord assessment tool for spastic reflexes (SCATS). Assessments were performed at baseline, immediately, 1 hour, 4 hours, and 24 hours post intervention.

RESULTS

A between group analysis did not show statistically significant differences between FES and TENS (P > 0.05). In the within group analyses, TENS and FES significantly reduced spasticity up to 4 hours in hip adductors and knee extensors (P < 0.01). SCATS values showed significant reductions at 1 hour (P = 0.01) following TENS and 4 hours following FES (P = 0.01).

CONCLUSION

A single session of electrical stimulation with FES and TENS appears to have similar anti-spasticity effects that last for 4 hours. The findings of this preliminary study suggest that both TENS and FES have the potential to be used as therapeutic adjuncts to relieve spasticity in the clinic. In addition, FES may have better effects on patients presenting with spastic reflexes.

Cerebral palsy: Influence of TheraTogs ® on gait, posture and in functional performance

Abstract Introduction: For children with cerebral palsy, orthoses take an important role in improving posture, gait, functional performance and preventing secondary musculoskeletal disorders. Objective: To evaluate the influence of TheraTogs® on the posture, distribution of plantar pressure during gait and functional performance of a child with spastic diplegia cerebral palsy. Methods: A quantitative evaluation was carried out on a case study in which an 11-year-old child diagnosed with diplegic cerebral palsy underwent postural assessment through the Postural Assessment Software (PAS), plantar pressure distribution assessment during barefoot gait through the Emed-X system, before and after the intervention period of 8 weeks and functional assessment (Pediatric Evaluation of Disability Inventory - PEDI), with and without TheraTogs®. Results: In posture, TheraTogs® had greater influence on hip extension and this change was greater during its use. In the plantar pressure distribution assessment, an increase in posteriorization of plantar pressure occurred in the initial contact, the performance of the push-off phase and initial swing phase improved. In functionality, the child showed improvements in mobility, however, their self-care ability with TheraTogs® was reduced. Conclusion: Although improvements in posture, gait and functionality were verified with the use of TheraTogs®, the excessive heat, difficulties in toileting and self-care were disadvantages in wearing TheraTogs®.

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.

Clinical assessment of spasticity in individuals with spinal cord injury

Objective

To evaluate the effect of neuromuscular electrical stimulation on spasticity in patients with spinal cord injury.

Methods

The study included eleven subjects with spinal cord injuries (C4 to T5). The modified Ashworth scale and pendulum test, which is accomplished through the Pendular Test Device - PTD (equipment which has a quartz crystal transducer accelerometer and optic fiber flexible electrogoniometer measuring the tensions and angular displacements). Patients underwent neuromuscular electrical stimulation (NMES) to the quadriceps muscle from fibular nerve, and the tests were administered before and after therapy.

Results

The data show a decrease in spasticity after NMES, with features such as increased variation between maximum and minimum peaks, i.e. increased amplitude of the curves. Furthermore, data from the subjective scale, and modified Ashworth scale after neuromuscular electrical stimulation also showed a reduction in the values of spasticity.

Conclusion

The data suggest that NMES is effective in reducing spasticity immediately after completion. Level of Evidence II, Therapeutic Studies-Investigating the Results of Treatment.

Evaluation of interadductor approach in neurolytic blockade of obturator nerve in spastic patients

BACKGROUND

Spasticity is a syndrome associated with a persistent increase in involuntary reflex activity of a muscle in response to stretch. Adductor muscle spasticity is a common complication of spinal cord and brain injury. It needs to be treated if it interferes with activities of daily living and self-care. Obturator neurolytic blockade is one of the cost-effective therapeutic possibilities to treat spasticity of adductor group of muscles. In this study, we assessed the efficacy of interadductor approach in alleviating the spasticity.

METHODS

Obturator neurolysis using 8-10 ml 6% phenol was given with the guidance of a peripheral nerve stimulator in 20 spastic patients. Technical evaluation included number of attempted needle insertions, time to accurate location of the nerve, depth of needle insertion, and success rate. Pain, spasticity, hip abduction range of motion (ROM), number of spasms, gait, and hygiene were evaluated at 1(st) hour, 24(th) hour, end of the 1(st) week, and in the 1(st), 2(nd), and 3(rd) months following the intervention.

RESULTS

The success rate was 100% with mean time to accurate nerve location 4.9±2.06 min. Average depth of needle insertion was 2.91±0.32 cm. Compared with the scores measured immediately before the block, all studied parameters improved significantly. An increase in the Modified Ashworth Scale values was observed in the 2(nd) and 3(rd) months, but they did not reach their initial values.

CONCLUSION

The interadductor approach proved to be accurate and fast, with a high success rate. Phenol blockade is an efficient and cost-effective technique in patients with adductor spasticity. It led to a decrease in spasticity and pain with an increase in the ROM of the hip and better hygiene, with an efficacy lasting for about 3 months.

The spinal cord injury spasticity evaluation tool: development and evaluation

OBJECTIVE

To develop and assess the reliability and validity of a new scale designed to measure the impact of spasticity on daily life in people with spinal cord injury (SCI).

DESIGN

Scale development and assessment.

SETTING

General community.

PARTICIPANTS

Community-dwelling persons with chronic SCI and spasticity participated in study 1 (n=9), study 2 (n=19), and study 3 (n=61).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Study 1: participant definitions of spasticity and list of scale items. Study 2: scale refinement, face validity, and time to complete. Study 3: internal consistency, test-retest reliability, and construct validity.

RESULTS

The Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET) is a 7-day recall self-report questionnaire that takes into account both the problematic and useful effects of spasticity on daily life in people with SCI. The scale exhibited good face validity and required 6.8+/-2.6 minutes to complete. The internal consistency (alpha) and intraclass correlation coefficient of the SCI-SET were .90 and .91, respectively. Construct validity was supported by correlations (r range, -.48 to .68; P<.01) between SCI-SET scores and theoretically meaningful constructs.

CONCLUSIONS

The SCI-SET fills a need for a reliable and valid self-report measure of the impact of spasticity on daily life in people with SCI, taking into account both the problematic and useful effects of spasticity.

Spasticity after spinal cord injury

Symptoms of spasticity are often experienced by individuals with spinal cord injury (SCI) following a period of spinal shock and, in many cases, these symptoms negatively affect quality of life. Despite its prevalence, spasticity as a syndrome in the SCI population is not always managed effectively. This is likely due to the fact that the syndrome can have various presentations, each with their own specific etiology. This overview summarizes the symptoms and pathophysiology of the various presentations of spasticity in the SCI population and discusses the currently accepted management techniques. There is a need for a better understanding of the syndrome of spasticity as well as the development of a valid and reliable assessment tool.

Image-guided HIFU neurolysis of peripheral nerves to treat spasticity and pain

Spasticity, a major complication of central nervous system disorders, signified by uncontrollable muscle contractions, is very difficult to treat effectively. We report on the use of ultrasound (US) image-guided high-intensity focused US (HIFU) to target and suppress the function of the sciatic nerve complex of rabbits in vivo, as a possible treatment of spasticity. The image-guided HIFU device included a 3.2-MHz spherically curved transducer and an intraoperative imaging probe. A focal acoustic intensity of 1480 to 1850 W/cm(2), applied using a scanning method, was effective in achieving complete conduction block in 100% of 22 nerve complexes with HIFU treatment times of 36 +/- 14 s (mean +/- SD). Gross examination showed blanching of the nerve at the HIFU treatment site and lesion volumes of 2.8 +/- 1.4 cm(3) encompassing the nerve complex. Histologic examination indicated axonal demyelination and necrosis of Schwann cells as probable mechanisms of nerve block. With accurate localization and targeting of peripheral nerves using US imaging, HIFU could become a promising tool for the suppression of spasticity.

Metallic taste: an unusual reaction to botulinum toxin A

BACKGROUND

Botulinum neurotoxin formulations are safe and effective agents for the treatment of facial rhytides.

OBJECTIVES

A patient is described who complained of metallic taste after each treatment with botulinum toxin A (BTX-A).

RESULTS

The sensation of metallic taste diminished after successive treatments with BTX-A, despite adequate dosing for cosmetic purposes.

CONCLUSION

Metallic taste is associated with the use of numerous medications; however, the pathogenesis remains unclear. Alteration in zinc metabolism, which may occur with BTX-A administration, has been suggested as a possible mechanism. Although this is the first known report of dysgeusia after BTX-A, physicians and patients may be reassured that the taste alteration was self-limited and was not significantly problematic for the patient in our case.