Botulinum toxin assessment, intervention and after-care for upper limb hypertonicity in adults: international consensus statement

Long-Term Enhancement of Botulinum Toxin Injections for Post-Stroke Spasticity by Use of Stretching Exercises-A Randomized Controlled Trial

Botulinum toxin A (BONT/A) injections play a central role in the treatment of upper limb spasticity in stroke patients. We proposed structured stretching exercises to enhance the effect of post-stroke spasticity relief of the upper limbs following BONT/A injections. A total of 43 patients who had a stroke with grade 2 spasticity or higher on the Modified Ashworth Scale (MAS) in their upper-limb muscles were randomly assigned to the intervention (n = 21) or control group (n = 22). The former received structured stretching exercises after their BONT/A injections for 20 min, 5 days per week, for 6 months at a hospital, while the others conducted self-stretching exercises at home. The outcome measures were assessed before the intervention (T0) and after three (T1) and six months (T2). Significantly greater improvements in the MAS scores of the elbows, wrists, and fingers were found in the intervention group's patients at T1 and T2. The behavioral outcome measures, including shoulder pain, activities of daily living, and quality of life, and our electrophysiological studies also showed a significantly higher enhancement in this patient group. In conclusion, the structured stretching exercises plus BONT/A injections for six months showed a superior effect in relieving post-stroke upper-limb spasticity compared to self-stretching exercises.

Effectiveness of Extracorporeal Shock Wave Therapy after Botulinum Toxin Injection for Post-Stroke Upper Extremity Spasticity: A Randomized Controlled Study

Post-stroke spasticity is a common complication that limits the functional performance of patients. Botulinum toxin (BTx) is an effective treatment for spasticity. Numerous researchers have applied extracorporeal shock wave therapy (ESWT) to address post-stroke spasticity, yielding positive clinical outcomes. We aimed to clarify the add-on effects of ESWT on BTx therapy for spasticity in patients with post-stroke. Sixteen eligible patients with upper extremity spasticity after stroke were recruited for this study. They were randomized to either a BTx with focused ESWT treatment group or a BTx alone group. Spasticity, measured using the modified Ashworth score (MAS) and modified Tardieu scale (MTS), showed statistically significant improvements in the elbow and wrist flexor muscles in both BTx + ESWT group and BTx alone groups. However, no significant differences were observed between the two groups with time flow. The BTx + ESWT group showed significantly decreased MAS of the finger flexors at follow-up and increased R1 (MTS) of the finger flexors at 3 weeks after treatment, which was not observed in the BTx alone group. This is the first study to identify the add-on effect of ESWT on BTx injections to improve post-stroke upper limb spasticity.

The Role of Botulinum Toxin Type-A in Spasticity: Research Trends from a Bibliometric Analysis

Botulinum toxin type-A (BoNT-A) has emerged as a key therapeutic agent for the management of spasticity. This paper presents a comprehensive bibliometric and visual analysis of research concerning BoNT-A treatment of spasticity to elucidate current trends and future directions in this research area. A search was conducted in the Web of Science database for articles focused on the use of BoNT-A in spasticity published between 2000 and 2022. We extracted various metrics, including counts of publications and contributions from different countries, institutions, authors, and journals. Analytical methods in CiteSpace were employed for the examination of co-citations, collaborations, and the co-occurrence of keywords. Our search yielded 1489 publications. Analysis revealed a consistent annual increase in research output. The United States, United Kingdom, and Italy were the leading contributors. The top institution in this research was Assistance Publique Hopitaux, Paris. The journal containing the highest number of relevant publications was Toxins. Key frequently occurring keywords were 'stroke', 'cerebral palsy', 'adult spasticity', and 'upper extremity'. This study identified 12 clusters of keywords and 15 clusters of co-cited references, indicating the main focus areas and emerging themes in this field. This study comprehensively analyzed and summarized trends in BoNT-A research in the field of spasticity over the past 22 years.

Ultrasound image guided injection of botulinum toxin for the management of spasticity: A Delphi study to develop recommendations for a scope of practice, competency, and governance framework

Objective

To establish a scope of practice, competency (through education) and governance framework for ultrasound image guided injection of botulinum toxin in the management of spasticity.

Design

Delphi study.

Setting

International, web-based survey.

Participants

A purposively selected multidisciplinary (physicians, physiotherapists, occupational therapists) panel of experts (n=15) in the use of ultrasound image guided injection of botulinum toxin for management of spasticity. Panel members were predominantly based in the UK (11/15).

Interventions

In round 1, open-ended questions were posed relating to potential scope of practice for 'ultrasound imaging in spasticity management'; (specifically relating to ultrasound image guided injection of Botulinum Toxin) education/competency and governance considerations. In round 2, respondents were asked to rate their level of agreement with the statements generated.

Outcome measures

5-point Likert scale used for rating the statements. Threshold for consensus agreement was set at 70% or above.

Results

Three different scopes of practice relating to ultrasound imaging in spasticity management were accepted. The primary scope of practice was the use of ultrasound imaging to guide safe and accurate delivery of botulinum toxin. Relating to this primary scope, 7 competency requirements were agreed relating to areas including image optimization and interpretation, needle visualization and safety. A singular, broad governance statement was generated.

Conclusion

Relating specifically to guided injection of botulinum toxin for management of spasticity, we present a scope of practice, competency, and governance framework. These are integrated within a framework approach to provide a mechanism for increased patient access to accurate, safe, and effective focal spasticity treatment. The framework supports focused training routes, greater inter-profession communication and wider clinical community engagement in spasticity management using this modality.

Controlling modified Tardieu scale assessment speeds to match joint angular velocities during walking impacts spasticity assessment outcomes

OBJECTIVE

To investigate whether tailoring the speed of the Modified Tardieu Scale to reflect an individual's joint angular velocity during walking influences spasticity assessment outcomes.

DESIGN

Observational trial.

SETTING

Inpatient and outpatient neurological hospital department.

SUBJECTS

Ninety adults with lower-limb spasticity.

INTERVENTIONS

N/A.

MAIN MEASURES

The Modified Tardieu Scale was used to assess the gastrocnemius, soleus, hamstrings and quadriceps. The V1 (slow) and V3 (fast) movements were completed as per standardised testing. Two additional assessments were completed, reflecting joint angular velocities during walking based on (i) a healthy control database (controlled velocity) and (ii) the individual's real-time joint angular velocities during walking (matched velocity). The agreement was compared using Cohen's and Weighted Kappa statistics, sensitivity and specificity.

RESULTS

There was poor agreement when rating trials as spastic or not spastic at the ankle joint (Cohen's Kappa = 0.01-0.17). Trials were classified as spastic during V3 and not spastic during the controlled conditions in 81.6-85.1% of trials when compared to stance phase dorsiflexion angular velocities and 48.0-56.4% when compared to swing phase dorsiflexion angular velocities. The severity of muscle reaction demonstrated poor agreement at the ankle (Weighted Kappa = 0.01-0.28). At the knee, there was a moderate-excellent agreement between the V3 and controlled conditions when rating a trial as spastic or not spastic (Cohen's Kappa = 0.66-0.84) and excellent agreement when comparing severity (Weighted Kappa = 0.73-0.94).

CONCLUSION

The speed of assessment impacted spasticity outcomes. It is possible that the standardised protocol may overestimate the impact spasticity has on walking, especially at the ankle.

Increasing the Passive Range of Joint Motion in Stroke Patients Using Botulinum Toxin: The Role of Pain Relief

By blocking the release of neurotransmitters, botulinum toxin A (BoNT-A) is an effective treatment for muscle over-activity and pain in stroke patients. BoNT-A has also been reported to increase passive range of motion (p-ROM), the decrease of which is mainly due to muscle shortening (i.e., muscle contracture). Although the mechanism of action of BoNT-A on p-ROM is far from understood, pain relief may be hypothesized to play a role. To test this hypothesis, a retrospective investigation of p-ROM and pain was conducted in post-stroke patients treated with BoNT-A for upper limb hypertonia. Among 70 stroke patients enrolled in the study, muscle tone (Modified Ashworth Scale), pathological postures, p-ROM, and pain during p-ROM assessment (Numeric Rating Scale, NRS) were investigated in elbow flexors (48 patients) and in finger flexors (64 patients), just before and 3-6 weeks after BoNT-A treatment. Before BoNT-A treatment, pathological postures of elbow flexion were found in all patients but one. A decreased elbow p-ROM was found in 18 patients (38%). Patients with decreased p-ROM had higher pain-NRS scores (5.08 ± 1.96, with a pain score ≥8 in 11% of cases) than patients with normal p-ROM (0.57 ± 1.36) (p < 0.001). Similarly, pathological postures of finger flexion were found in all patients but two. A decreased finger p-ROM was found in 14 patients (22%). Pain was more intense in the 14 patients with decreased p-ROM (8.43 ± 1.74, with a pain score ≥ 8 in 86% of cases) than in the 50 patients with normal p-ROM (0.98 ± 1.89) (p < 0.001). After BoNT-A treatment, muscle tone, pathological postures, and pain decreased in both elbow and finger flexors. In contrast, p-ROM increased only in finger flexors. The study discusses that pain plays a pivotal role in the increase in p-ROM observed after BoNT-A treatment.

Focal muscle spasticity has little impact on muscle power for walking in people with Traumatic Brain Injury

BACKGROUND

Spasticity is prevalent following Traumatic Brain Injury. 'Focal' muscle spasticity has been defined as spasticity affecting a localised muscle group, but it's impact on gait kinetics remains unclear. The aim of this study was to investigate the relationship between focal muscle spasticity and gait kinetics following Traumatic Brain Injury.

METHODS

Ninety-three participants attending physiotherapy for mobility limitations following Traumatic Brain Injury were invited to participate in the study. Participants underwent clinical gait analysis and were grouped depending on the presence or absence of focal muscle spasticity. Kinetic data was obtained for each sub-group, and participants were compared to healthy controls.

FINDINGS

Hip extensor power generation at initial contact, hip flexor power generation at terminal stance, and knee extensor power absorption at terminal stance were all significantly increased, and ankle power generation was significantly reduced at push-off when comparing Traumatic Brain Injury to healthy control populations. There were only two significant differences between participants with and without focal muscle spasticity, hip extensor power generation at initial contact was increased (1.53 vs 1.03 W/kg, P < .05) for those with focal hamstring spasticity, and knee extensor power absorption in early stance was reduced (-0.28 vs -0.64 W/kg, P < .05) for those with focal rectus femoris spasticity. However, these results should be interpreted with caution as the sub-group of participants with focal hamstring and rectus femoris spasticity was small.

INTERPRETATION

Focal muscle spasticity had little association with abnormal gait kinetics in this cohort of independently ambulant people with Traumatic Brain Injury.

Video enhanced visual analysis of hemiparetic gait muscle selection: A pilot study

This paper summarizes the use of video enhanced visual analysis (VEVA) as a muscle selection assistance method for abnormal foot postures in adults with upper motor neuron syndrome (UMNS) treated with botulinum neurotoxin (BoNT-A) in a real-world setting. This pilot study used a prospective treatment study design with persons in an outpatient, rehabilitation hospital. Participants had acquired brain injury (ABI) of >6-month duration who had a spastic ankle foot deformity amenable to treatment with botulinum toxin A and able to independently ambulate a minimum of 10 m. Participants were evaluated before abobotulinumtoxinA injection (500 U-1500 U) to the identified lower limb muscles and four to five weeks post injection. Main Outcome Measures: Temporal spatial data (self-selected and maximal walking velocities (SSWV/MWV); step length and stance time); Modified Ashworth Scale (MAS); Tardieu Scale (TS) and ankle Passive Range of Motion (PROM) change from baseline to follow-up (f/u). Data is presented on ten of the eleven consecutive participants enrolled in the study. One participant withdrew due to study unrelated opposite ankle pain before reassessment. Mean SSWV increased post treatment by 21% in the barefoot condition and 8% when walking with shoes. For the MWV condition, there was a 15% mean increase post treatment in the barefoot condition and 10% when walking with shoes. Participants showed improved symmetry in step length and stance time in both post-treatment walking conditions. Ankle MAS and TS improved with knee flexed or extended. Ankle PROM increased post treatment with knee flexed by 8° and knee extended by 11.7°. VEVA in addition to clinical evaluation appears to facilitate muscle identification and selection of ankle deformities for treatment with BoNT-A. Our findings show marked improvement in ankle MAS, TS and PROM as indicators of pharmacological activity and increase in SSWV as a marker of functional improvement.

Interhemispheric parietal cortex connectivity reflects improvement in post-stroke spasticity due to treatment with botulinum toxin-A

In post-stroke spasticity (PSS), effective treatment with botulinum neurotoxin (BoNT) is associated with transient decrease in activation of the ipsilesional superior parietal lobule (SPL) and intraparietal sulcus (IPS). We hypothesized that this would be reflected in changes in resting-state functional connectivity (rsFC) of the SPL/IPS. Our aim was therefore to assess rsFC of the ipsilesional SPL/IPS in chronic stroke patients with hemiparesis both with and without PSS and to explore the relationship between SPL/IPS rsFC and PSS severity. To this end, fourteen chronic stroke patients with upper limb weakness and PSS (the PSS group) and 8 patients with comparable weakness but no PSS (the control group) underwent clinical evaluation and 3 fMRI examinations, at baseline (W0) and 4 and 11 weeks after BoNT (W4 and W11, respectively). Seed-based rsFC of the atlas-based SPL and IPS was evaluated using a group×time interaction analysis and a correlation analysis with PSS severity (modified Ashworth scale), integrity of the ipsilesional somatosensory afferent pathway (evoked potential N20 latency), and age. In the PSS group, transient improvement in PSS was associated with increase in rsFC between the ipsilesional IPS and the contralesional SPL at W4. The interhemispheric connectivity was negatively correlated with PSS severity at baseline and with PSS improvement at W4. We propose adaptation of the internal forward model as the putative underlying mechanism and discuss its possible association with increased limb use, diminished spastic dystonia, or improved motor performance, as well as its potential contribution to the clinical effects of BoNT.

Task and ecologically based assessment of upper-limb passive function before and after botulinum injections in adults with stroke using the Upper-Limb Performance Assessment: French cross-cultural adaptation and feasibility pilot study

PURPOSE

To test feasibility of a French translation and cross-cultural adaptation of the Upper-Limb Performance Assessment (ULPA) for task and ecologically based assessment of individualized passive function of upper-limb (UL) performance in adults treated with botulinum toxin-A.

MATERIALS AND METHODS

A case series with seven adults with stroke (29-74 years) for spastic hypertonia management with passive use objectives (hygiene or positioning) established through Goal Attainment Scaling (GAS). Scores on ULPA Task Performance Mastery (TPM) were obtained through clinical and home-based performances before and after treatment.

RESULTS

Time administration per task ranged from 5-10 min. Median (range) ULPA, Task Performance Mastery (ULPA-TPM) scores pre-intervention of 58 mastery (35-71) improved to 75 (58-88). Tau-U demonstrated significant large effect sizes (≥.65) for five participants. Complementary measures demonstrated improvement of passive performance for five participants and improvements in GAS for six participants. Testing indicates excellent intra-rater (ICC = 0.90) and moderate inter-rater (ICC = 0.64) reliability, with SDC of 10.16 and 18.23%, respectively.

CONCLUSIONS

French use of ULPA is a promising standardized, objective and ecologically based assessment of passive performance in adults with stroke. Preliminary findings after TCCA support feasibility for measurement of individualized goals for UL passive use. Future studies may explore other tasks and environments. Implications for rehabilitationULPA is a performance-based, criterion-referenced and ecological measure of individualized goals based on task-analysis of upper-limb (UL) performance in real-life situations providing an interest for individualized assessment of activity and participation.The measure provides a standardized and quantitative approach, applicable to passive use of UL across environments, promoting ecological validity of assessment.Preliminary data will support clinical interpretation of change before and after botulinum injections of UL passive performance.Access to a transculturally validated French version of ULPA complements standardized assessment of UL impairment, perceived performance and goal attainment.

Technology-assisted assessment of spasticity: a systematic review

BACKGROUND

Spasticity is defined as "a motor disorder characterised by a velocity dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks". It is a highly prevalent condition following stroke and other neurological conditions. Clinical assessment of spasticity relies predominantly on manual, non-instrumented, clinical scales. Technology based solutions have been developed in the last decades to offer more specific, sensitive and accurate alternatives but no consensus exists on these different approaches.

METHOD

A systematic review of literature of technology-based methods aiming at the assessment of spasticity was performed. The approaches taken in the studies were classified based on the method used as well as their outcome measures. The psychometric properties and usability of the methods and outcome measures reported were evaluated.

RESULTS

124 studies were included in the analysis. 78 different outcome measures were identified, among which seven were used in more than 10 different studies each. The different methods rely on a wide range of different equipment (from robotic systems to simple goniometers) affecting their cost and usability. Studies equivalently applied to the lower and upper limbs (48% and 52%, respectively). A majority of studies applied to a stroke population (N = 79). More than half the papers did not report thoroughly the psychometric properties of the measures. Analysis identified that only 54 studies used measures specific to spasticity. Repeatability and discriminant validity were found to be of good quality in respectively 25 and 42 studies but were most often not evaluated (N = 95 and N = 78). Clinical validity was commonly assessed only against clinical scales (N = 33). Sensitivity of the measure was assessed in only three studies.

CONCLUSION

The development of a large diversity of assessment approaches appears to be done at the expense of their careful evaluation. Still, among the well validated approaches, the ones based on manual stretching and measuring a muscle activity reaction and the ones leveraging controlled stretches while isolating the stretch-reflex torque component appear as the two promising practical alternatives to clinical scales. These methods should be further evaluated, including on their sensitivity, to fully inform on their potential.

Prognosis prediction of the effect of botulinum toxin therapy and intensive rehabilitation on the upper arm function in post-stroke patients using hierarchical cluster analysis

PURPOSE

We analysed the effect of botulinum neurotoxin A therapy (BoNT-A) with intensive rehabilitation on the upper limb (UL) spasticity in post-stroke patients by classifying function by UL movement and examining differences in functional improvement.

MATERIALS AND METHODS

In this non-randomized, controlled study. The patient function was classified into groups from the score of the sub-categories of the Fugl-Meyer Assessment (FMA-UE) before treatment in the Intervention group by hierarchical cluster analysis.

RESULTS

A total of 139 patients in the Intervention group were classified into six groups. All groups showed a significant improvement in FMA-UE after the intervention. In the group scoring 19-31 points on the FMA-UE and with the voluntary movement of shoulder, elbow, forearm, and finger, a significant improvement was observed compared to the Control group. Further, in the group scoring 26-47 points on the FMA-UE and with the voluntary movement of shoulder, elbow, forearm, wrist, and finger, a significant improvement was observed compared to the Control group.

CONCLUSIONS

In this study, BoNT-A and intensive rehabilitation showed improvement in spasticity and UL function. A high therapeutic effect is expected in patients with moderate impairment levels who have voluntary movement in whole UL or in UL except for the wrist.IMPLICATIONS FOR REHABILITATIONHierarchical cluster analysis focusing on the Fugl-Meyer Assessment of the Upper Extremity sub-categories may be useful for studies aimed to improve the upper arm function.Botulinum Neurotoxin A therapy (BoNT-A) and intensive rehabilitation in post-stroke patients showed improvement in spasticity and upper arm function.The degree of the upper arm function before the intervention may affect the improvement effect of BoNT-A and intensive rehabilitation.In the motor function, the post-stroke patients with a moderate impairment level who have voluntary movement of the whole upper limb or upper limb except for the wrist are most likely to receive these therapeutic effects.

Linking Prioritized Occupational Performance in Patients Undergoing Spasticity-Correcting Upper Limb Surgery to the International Classification of Functioning, Disability, and Health

Background

Spasticity is generally caused by damage to the spinal cord or the areas of the brain that controls movements, which poses significant limitations in occupational tasks.

Objectives

The aims of the study were to (I) describe prioritized occupational performance problems (POPP) among patients who underwent upper limb spasticity-correcting surgery and map them to the International Classification of Function, Disability, and Health (ICF); (II) assess outcomes postsurgery; (III) assess whether the results are influenced by the diagnosis, gender, and residual muscle function; and (IV) assess correlation between changes in COPM and gains in grasp ability and grip strength.

Methods

In this retrospective study, assessments occurred pre- and postsurgery, including the Canadian Occupational Performance Measure (COPM), grip strength, and grasp ability. POPP were transformed to prioritized occupational performance goals (POPG) during subsequent rehabilitation.

Results

60 patients with a history of spinal cord injury (SCI) (n = 42; 59%), stroke (n = 25; 34%), traumatic brain injury (TBI) (n = 4; 6%), and reason unknown (n = 1; 1%) were included, with a mean age of 57 (±13) years. Of those, 11 had bilateral surgery, generating 71 COPM forms and 320 POPG. The POPG were mapped to the ICF activity and participation chapter, most often to self-care (n = 131; 41%), domestic life (n = 68; 21%), and mobility (n = 58; 18%). COPM scores were significantly increased postsurgery, irrespective of diagnosis, gender, and muscle function. No clear correlation between COPM improvement and hand function gains was shown.

Conclusion

Patients who underwent spasticity-correcting upper limb surgery identified difficulties with a wide range of occupational tasks that they considered as important to regain. Treatment-induced gains in occupational performance were significant but had no clear correlation with gains in grasp ability and hand strength. Independent of diagnosis, gender, and residual muscle function, it seems important to address the activity- and participation-specific aspects in the assessment and rehabilitation of patients.

A Practical Post-Stroke Elbow Spasticity Assessment Using an Upper Limb Rehabilitation Robot: A Validation Study

Spasticity is a motor disorder characterised by a velocity-dependent increase in muscle tone, which is critical in neurorehabilitation given its high prevalence and potential negative influence among the post-stroke population. Accurate measurement of spasticity is important as it guides the strategy of spasticity treatment and evaluates the effectiveness of spasticity management. However, spasticity is commonly measured using clinical scales which may lack objectivity and reliability. Although many technology-assisted measures have been developed, showing their potential as accurate and reliable alternatives to standard clinical scales, they have not been widely adopted in clinical practice due to their low usability and feasibility. This paper thus introduces an easy-to-use robotic based measure of elbow spasticity and its evaluation protocol. Preliminary results collected with one post-stroke patient and one healthy control subject are presented and demonstrate the feasibility of the approach.

Association of Lower Limb Focal Spasticity With Kinematic Variables During Walking in Traumatic Brain Injury

BACKGROUND AND PURPOSE

Focal muscle spasticity is defined as spasticity that affects a localized group of muscles. It is prevalent in many adult-onset neurological conditions, yet the relationship of focal muscle spasticity with walking remains unclear. Therefore, the aim of this study was to determine the relationship of focal muscle spasticity with the kinematics of walking in traumatic brain injury (TBI).

METHODS

Ninety-one participants with TBI underwent clinical gait analysis and assessment of focal lower limb muscle spasticity in a prospective cross-sectional study. A matched group of 25 healthy controls (HCs) were recruited to establish a reference dataset. Kinematic data for each person with and without focal muscle spasticity following TBI were compared with the HC cohort at a matched walking speed.

RESULTS

The TBI and HC cohorts were well matched. Only those with focal hamstring muscle spasticity walked significantly different to those without. They had significantly greater knee flexion (23.4° compared with 10.5°, P < 0.01) at initial contact. There were no other significant differences in kinematic variables between those with and without focal muscle spasticity. There was no significant association between focal muscle spasticity and walking speed.

DISCUSSION AND CONCLUSIONS

Focal muscle spasticity and abnormal kinematics whilst walking were common in this cohort of people with TBI. However, focal muscle spasticity had little relationship with kinematic variables, and no significant relationship with walking speed. This finding has implications for the treatment of focal muscle spasticity to improve walking following TBI. Focal muscle spasticity had little relationship with kinematic variables and walking speed in this cohort of people with TBI who could walk without assistance.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A381).

A Pilot Randomized Controlled Trial of Botulinum Toxin Treatment Combined with Robot-Assisted Therapy, Mirror Therapy, or Active Control Treatment in Patients with Spasticity Following Stroke

Effects of the combined task-oriented trainings with botulinum toxin A (BoNT-A) injection on improving motor functions and reducing spasticity remains unclear. This study aims to investigate effects of 3 task-oriented trainings (robot-assisted therapy (RT), mirror therapy (MT), and active control treatment (AC)) in patients with stroke after BoNT-A injection. Thirty-seven patients with chronic spastic hemiplegic stroke were randomly assigned to receive RT, MT, or AC following BoNT-A injection over spastic upper extremity muscles. Each session of RT, MT, and AC was 75 min, 3 times weekly, for 8 weeks. Outcome measures were assessed at pretreatment, post-treatment, and 3-month follow-up, involving the Fugl-Meyer Assessment (FMA), Modified Ashworth Scale (MAS), Motor Activity Log (MAL), including amount of use (AOU) and quality of movement (QOM), and arm activity level. All 3 combined treatments improved FMA, MAS, and MAL. The AC induced a greater effect on QOM in MAL at the 3-month follow-up than RT or MT. All 3 combined trainings induced minimal effect on arm activity level. Our findings suggest that for patients with stroke who received BoNT-A injection over spastic UE muscles, the RT, MT, or AC UE training that followed was effective in improving motor functions, reducing spasticity, and enhancing daily function.

Pharmacological management of muscle spasticity

Background: Muscle spasticity is a neurologic disorder, which is considered one of the positive signs of upper motor neuron diseases. Spasticity is common after brain or spinal cord injury. Since spasticity results in tendon retraction, muscle weakness, pain, ankylosis, and disability in activities of daily living, treatment is warranted.Current Concepts: Spasticity is usually assessed using the Modified Ashworth Scale or Modified Tardieu Scale. It is treated with various methods, including physical therapy, occupational therapy, orthosis, medication, and surgery. Pharmacological management should be selected according to the location and severity of the symptom and includes oral medications, chemical nerve block, and intrathecal baclofen pump insertion. Oral medications include baclofen, benzodiazepine, dantrolene, and tizanidine. Chemoneurolysis of spasticity is done with botulinum toxin or a mixture of phenol and alcohol.Discussion and Conclusion: Since muscle spasticity affects motor function and activities of daily living, understanding of this symptom and choosing an optimal treatment are necessary. Pharmacologic treatments should be administered with caution especially with the side effects. Optimal treatment of spasticity will bring the best neurological outcome for the patients.

Effect of Robot-assisted Rehabilitation to Botulinum Toxin A Injection for Upper Limb Disability in Patients with Chronic Stroke: A Case Series and Systematic Review

Combining single-joint hybrid assistive limb (HAL-SJ) with botulinum toxin A (BTX-A) therapy is novel and has great therapeutic potential for the rehabilitation of stroke patients with upper limb paralysis. The purpose of this observational case series study was to evaluate the effect of BTX-A and HAL-SJ combination therapy on different exoskeleton robots used for treating upper limb paralysis. The HAL-SJ combination received a BTX-A injection followed by HAL-SJ-assisted rehabilitation for 60 min per session, 10 times per week, during 2 weeks of hospitalization. Clinical evaluations to assess motor function, limb functions used during daily activities, and spasticity were performed prior to injection, at 2-week post-treatment intervention, and at the 4-month follow-up visit. The total Fugl-Meyer assessment-upper limb (FMA-UE), proximal FMA-UE, action research arm test (ARAT), Motor Activity Log (MAL), and Disability Assessment Scale (DAS) showed a statistically significant difference, and a large effect size. However, the FMA distal assessment at 2-week post-treatment intervention showed no significant difference and a moderate effect size. The FMA-UE scores of the extracted systematic review articles showed that our design improved upper limb function. The change in the total FMA-UE score in this study showed that, compared to previous reports in the exoskeletal robotic therapy group, our combination therapy had a higher score than five of the seven references. Our results suggest that BTX-A therapy and HAL-SJ combination therapy may improve upper limb function, similar to other treatment methods in the literature.

The cost-effectiveness of abobotulinumtoxinA (Dysport) and onabotulinumtoxinA (Botox) for managing spasticity of the upper and lower limbs, and cervical dystonia

OBJECTIVE

To evaluate the costs and benefits associated with the use of abobotulinumtoxinA (aboBoNT-A) and onabotulinumtoxinA (onaBoNT-A) for lower limb spasticity in children, upper and lower limb spasticity in adults, and cervical dystonia in adults.

METHODS

This pharmacoeconomic analysis compared aboBoNT-A with onaBoNT-A. A decision tree model with a 1-year time horizon was conducted from a UK National Health Service (NHS) perspective using data from a variety of sources: randomized controlled trials (RCTs), network meta-analyses (NMAs), observational studies, and a physician survey investigating treatment patterns and resource utilization. Four patient populations were included: pediatric patients with lower limb spasticity (PLL), and adults with upper limb spasticity (AUL), lower limb spasticity (ALL), and cervical dystonia (CD). Outcomes included costs, quality-adjusted life years (QALYs) gained, cost per responder, and incremental cost per QALY gained. The effectiveness of each treatment was evaluated as a response to treatment. The base case assumption was that all patients in the model continued to receive botulinum toxin type A (BoNT-A) treatments at regular intervals regardless of treatment response status. Scenario analysis evaluated the impact of discontinuing BoNT-A for patients without a response to the first injection.

RESULTS

The model found that aboBoNT-A resulted in greater quality-of-life and lower costs compared with onaBoNT-A for the management of spasticity and CD in all included indications. Across populations, cost savings ranged from £304 to £3,963 and QALYs gained ranged from 0.010 to 0.02 over a 1-year time horizon. Results were robust to scenario analyses and were driven by the impact of treatment response on health-related quality-of-life.

CONCLUSIONS

AboBoNT-A was associated with higher treatment response, improved quality-of-life, and reduced costs in spasticity and CD versus onaBoNT-A. These findings could help deliver more effective and efficient healthcare in the NHS.

Validity and reliability of the Modified Tardieu Scale as a spasticity outcome measure of the upper limbs in adults with neurological conditions: a systematic review and narrative analysis

PURPOSE

To evaluate published evidence on the Modified Tardieu Scale (MTS) as a tool to assess spasticity in the upper limbs of adults with neurological conditions.

DATA SOURCES

A systematic search of six electronic databases (PubMed/MEDLINE, CINAHL, EMBASE, the Cochrane Library, Web of Science and Physiotherapy Evidence Database) from inception to 31 December 2020. A search strategy was developed using key elements of the research question: population, intervention (action), outcome.

STUDY ELIGIBILITY CRITERIA

Inclusion criteria: (1) adult participants with neurological conditions; (2) upper limb muscles/joints as tested elements; (3) studies testing the MTS and (4) reliability or validity reported.

EXCLUSION CRITERIA

(1) non-English articles; (2) non-empirical articles and (3) studies testing the Tardieu Scale.

STUDY APPRAISAL

Evidence quality was evaluated using the US National Heart, Lung, Blood Institute quality assessment tool for observational cohort and cross-sectional studies.

RESULTS

Six reliability studies met the inclusion criteria. Overall, most articles reported good-to-excellent levels of inter-rater, intrarater and test-retest reliability. However, limitations, such as study design weaknesses, statistical misuses and reporting biases, undermine confidence in reported conclusions. The validity of the MTS also remained questionable based on the results of one study.

CONCLUSIONS AND IMPLICATIONS

This review did not find sufficient evidence to either support or reject the use of the MTS in assessing spasticity in the upper limbs of adults with neurological conditions. Despite the paucity of research evidence, the MTS may still remain a clinically useful tool to measure the motor aspect of spasticity. Future research would benefit from a focus on test standardisation, while the wider field would require the development of a consensual definition of spasticity.

Predictors of Clinically Important Improvements in Motor Function and Daily Use of Affected Arm after a Botulinum Toxin A Injection in Patients with Chronic Stroke

Identifying patients who can gain minimal clinically important difference (MCID) in active motor function in the affected upper extremity (UE) after a botulinum toxin A (BoNT-A) injection for post-stroke spasticity is important. Eighty-eight participants received a BoNT-A injection in the affected UE. Two outcome measures, Fugl–Meyer Assessment Upper Extremity (FMA-UE) and Motor Activity Log (MAL), were assessed at pre-injection and after 24 rehabilitation sessions. We defined favorable response as an FMA-UE change score ≥5 or MAL change score ≥0.5.Statistical analysis revealed that the time since stroke less than 36 months (odds ratio (OR) = 4.902 (1.219–13.732); p = 0.023) was a significant predictor of gaining MCID in the FMA-UE. Medical Research Council scale -proximal UE (OR = 1.930 (1.004–3.710); p = 0.049) and post-injection duration (OR = 1.039 (1.006–1.074); p =0.021) were two significant predictors of MAL amount of use. The time since stroke less than 36 months (OR = 3.759 (1.149–12.292); p = 0.028), naivety to BoNT-A (OR = 3.322 (1.091–10.118); p = 0.035), and education years (OR = 1.282 (1.050–1.565); p = 0.015) were significant predictors of MAL quality of movement. The findings of our study can help optimize BoNT-A treatment planning.

Assessment of upper limb abnormalities using the Kinect: Reliability, validity and detection accuracy in people living with acquired brain injury

Upper limb kinematic abnormalities are prevalent in people with acquired brain injury (ABI). We examined if the Microsoft Kinect for Xbox One (Kinect) reliably (test-retest) and validly (concurrent) quantifies upper limb kinematics, and accurately classifies abnormalities (sensitivity/specificity), in an ABI cohort when compared to three-dimensional motion analysis (3DMA) and a subjective rating scale. We compared 42 adults with ABI to 36 healthy control (HC) participants. Walking trials were recorded by 3DMA and Kinect at self-selected (SSWS) and fast (FWS) walking speeds. When classifying abnormalities for 3DMA and Kinect, a 95% reference range (based on HC data) was calculated using the Kinematic Deviation Score worst axis (KDSw); values outside of this range were classified abnormal. Scores ≥ 2 in the subjective rating scale, based on International Classification of Functioning, Disability and Health Framework's Qualifiers Scale, were considered abnormal. Test-retest reliability and concurrent validity were determined using intra-class correlation coefficient (Absolute ICC_2,1) and Pearson's or Spearman's correlation respectively. Fisher's Exact Test was conducted to determine sensitivity and specificity between each combination of the two methods. Strong test-retest reliability was observed for 3DMA (median(IQR) ICC:0.86(0.85-0.90)). Kinect showed overall strong SSWS test-retest reliability (ICC:0.87(0.84-0.91)) and moderate FWS test-retest reliability (ICC:0.61(0.56-0.65)). Concurrent validity between 3DMA and Kinect was overall moderate. Sensitivity and specificity between 3DMA, Kinect and subjective scores were overall modest. Our results suggest caution should be used if implementing Kinect as its validity is modest against criterion-reference 3DMA; however, given its reliability and similar sensitivity/specificity to 3DMA further responsiveness research is warranted.

Botulinum toxin treatment for difficult-to-treat finger pressure ulcers caused by severe hand flexion: case report

We report the successful treatment of two cases of difficult-to-treat pressure ulcers with botulinum toxin type A (BoNT-A). A 71-year-old male patient with Parkinson's disease presented with severe hand grip deformities of the fingers and a pressure ulcer (PU) on the right hand. He received 240U of BoNT-A into the upper limb muscles, which improved finger mobility during passive extension and resulted in resolution of the palm PU. No recurrence was noted. A 69-year-old female patient with Lewy body dementia presented with a PU on the palm side of the middle finger apex of the right hand, with exposure of the phalanx bone and dark red oedematous granulation of the tip of the finger. Severe muscle tone was noted. She received 240U of BoNT-A injected into the muscles of the upper extremities. This resulted in the disappearance of the contracture between the middle finger cusp and palm, and prompt healing of the PU. A protective finger orthosis was also used to improve hand finger grip and prevent further PUs. Although BoNT-A injection resulted in only slight improvement in the range of motion, it produced relief of pressure with consequent healing of the PU. Injection of BoNT-A into the affected muscles of the patients in this case report was effective in reducing flexor muscle tone, relief of pressure on the palm skin and healing of hand PUs.

The Effects of Distributed vs. Condensed Schedule for Robot-Assisted Training with Botulinum Toxin A Injection for Spastic Upper Limbs in Chronic Post-Stroke Subjects

Robot-assisted training (RT) combined with a Botulinum toxin A (BoNT-A) injection has been suggested as a means to optimize spasticity treatment outcomes. The optimal schedule of applying RT after a BoNT-A injection has not been defined. This single-blind, randomized controlled trial compared the effects of two predefined RT approaches as an adjunct to BoNT-A injections of spastic upper limbs in chronic post-stroke subjects. Thirty-six patients received a BoNT-A injection in the affected upper extremity and were randomly assigned to the condensed or distributed RT group. The condensed group received an intervention of four sessions/week for six consecutive weeks. The distributed group attended two sessions/week for 12 consecutive weeks. Each session included 45 min of RT using the InMotion 2.0 robot, followed by 30 min of functional training. The Fugl-Meyer Assessment, Modified Ashworth Scale, Wolf Motor Function Test, Motor Activity Log, and Stroke Self-Efficacy Questionnaire were assessed at pre-training, mid-term, post-training, and at 6 week follow-up, with the exception of the Motor Activity Log, which did not include mid-term measures. After the intervention, both groups had significant improvements in all outcome measures (within-group effects, p < 0.05), with the exception of the Wolf Motor Function Test time score. There were no significant differences between groups and interaction effects in all outcome measures. Our findings suggest that RT provided in a fixed dosage as an adjunct to a BoNT-A injection has a positive effect on participants' impairment and activity levels, regardless of treatment frequency. (ClinicalTrials.gov: NCT03321097).

Cortical somatosensory processing after botulinum toxin therapy in post-stroke spasticity

In dystonic and spastic movement disorders, abnormalities of motor control and somatosensory processing as well as cortical modulations associated with clinical improvement after botulinum toxin A (BoNT-A) treatment have been reported, but electrophysiological evidence remains controversial. In the present observational study, we aimed to uncover central correlates of post-stroke spasticity (PSS) and BoNT-A-related changes in the sensorimotor cortex by investigating the cortical components of somatosensory evoked potentials (SEPs). Thirty-one chronic stroke patients with PSS of the upper limb were treated with BoNT-A application into the affected muscles and physiotherapy. Clinical and electrophysiological evaluations were performed just before BoNT-A application (W0), then 4 weeks (W4) and 11 weeks (W11) later. PSS was evaluated with the modified Ashworth scale (MAS). Median nerve SEPs were examined in both upper limbs with subsequent statistical analysis of the peak-to-peak amplitudes of precentral P22/N30 and postcentral N20/P23 components. At baseline (W0), postcentral SEPs were significantly lower over the affected cortex. At follow up, cortical SEPs did not show any significant changes attributable to BoNT-A and/or physiotherapy, despite clear clinical improvement. Our results imply that conventional SEPs are of limited value in evaluating cortical changes after BoNT-A treatment and further studies are needed to elucidate its central actions.

Added-value of spasticity reduction to improve arm-hand skill performance in sub-acute stroke patients with a moderately to severely affected arm-hand

BACKGROUND AND OBJECTIVE:

Stroke patients with a moderately to severely affected hand may be impeded in exploiting their full arm-hand training potential during rehabilitation due to spasticity. Reducing early signs of spasticity in sub-acute stroke patients may lead to improvements in arm-hand-function and arm-hand-skill-performance.

METHODS:

Single-case-experimental-design and meta-analysis. Ten sub-acute stroke patients (Modified-Ashworth-Scale:1 + to 3) participated. Training: 2x6 weeks, using a well-described arm-hand regime (therapy-as-usual). Botulinum-toxin was administered once within 5 weeks after onset of therapy-as-usual. Measures: Action-Research-Arm-Test, ABILHAND, Fugl-Meyer-Assessment, grip-strength, Motricity-Index.

RESULTS:

At group level, after baseline trend correction, adjusting for spontaneous recovery and therapy-as-usual effects, the added-value of botulinum-toxin-A on arm-hand-function and arm-hand-skill-performance was not confirmed. However, non-detrended data revealed significant improvements over time on arm-hand-function and arm-hand-skill-performance level (p≤0.037). Conversely, at individual level, after baseline trend correction, 7/10 patients improved on arm-hand-function: Fugl-Meyer-Assessment (N = 4; p≤0.019), grip-strength (N = 3; p≤0.014), Motricity-Index (N = 4; p≤0.002), whereas 6/10 patients improved on arm-hand-skill-performance: Action-Research-Arm-Test (N = 3; p≤0.042), ABILHAND (N = 5; p≤0.034).

CONCLUSION:

Application of botulinum-toxin-A may have an added-value in a substantial part of sub-acute stroke patients suffering from spasticity early post-stroke and who, at the point of therapy admission, display no dexterity. It may improve their arm-hand performance when combined with a well– defined therapy-as-usual.

Potential contributing factors to upper limb associated reactions in people with acquired brain injury: an exploratory study

PURPOSE

To determine which potential contributing factors are associated with upper limb associated reaction (AR) expression in individuals with acquired brain injury (ABI).

METHODS

Forty-two participants underwent three-dimensional motion analysis at self-selected walking speed to generate the AR outcome measure, quantifying their upper limb kinematic deviation compared to healthy controls. Clinical assessment included: upper and lower limb hypertonicity, spasticity and strength, balance, dynamic walking stability, arm and leg function, anxiety, arm pain/discomfort, and fear of falling.

RESULTS

Significant, moderate-to-strong correlations (r = 0.42-0.74, p < 0.05) existed between upper limb ARs and both hypertonicity and spasticity of the upper limb muscles and the knee extensors. Significant, moderate correlations to ARs (r = 0.42-0.59, p < 0.05) existed for balance, dynamic stability, upper limb strength, and arm function. The severity of AR was significantly different between those with and without hypertonicity of the four tested upper limb muscles, elbow and long finger flexor spasticity, knee extensor spasticity, and reduced dynamic stability (p < 0.05; effect sizes ≥0.80). However, these contributing factors were not present in all participants.

CONCLUSIONS

Associated reactions are complex and multi-factorial. There were several significant correlations indicating that factors may influence AR severity. While positive upper motor neuron syndrome features should be prioritised for clinical assessment, these factors are not prerequisites for ARs.IMPLICATIONS FOR REHABILITATIONUpper limb associated reactions are a complex and multi-factorial phenomenon.Upper limb muscle hypertonicity and spasticity should be prioritised for assessment; however, they are not prerequisites for associated reactions.Hypertonicity and spasticity should be differentiated as they may have differing relationships to associated reactions.Knee extensor hypertonicity and spasticity, postural stability, upper limb strength, and arm function may also be contributing factors to consider.

The Use of Botulinum Toxin for Treatment of Spasticity

Spasticity is one component of the upper motor neuron (UMN) syndrome resulting from a multitude of neurologic conditions, such as stroke, brain injury, spinal cord injury, multiple sclerosis, and cerebral palsy. It is clinically recognized as a phenomenon of velocity-dependent increase in resistance, i.e., hypertonia. Recent advances in the pathophysiology of spasticity improve our understanding of mechanisms underlying this complex phenomenon and its relations to other components of UMN syndrome (weakness and disordered motor control), as well as the resultant clinical problems. This theoretical framework provides a foundation to set up treatment goals and to guide goal-oriented clinical assessment and treatment. Among a spectrum of treatment options, botulinum toxin (BoNT) therapy is the preferred treatment for focal spasticity. The evidence is very robust that BoNT therapy effectively reduces spasticity; however, it does not improve voluntary movement. In this chapter, we highlight a few issues on how to achieve the best clinical outcomes of BoNT therapy, such as dosing, dilution, guidance techniques, adjunctive therapies, early treatment, repeated injections, and central effects, as well as the ways to improve motor function in selected subgroups of patients with spasticity. We also discuss the reasons of poor responses to BoNT therapy and when not to use BoNT therapy.

The Effectiveness of Botulinum Toxin Type A (BoNT-A) Treatment in Brazilian Patients with Chronic Post-Stroke Spasticity: Results from the Observational, Multicenter, Prospective BCause Study

Botulinum toxin type A (BoNT-A) is an effective treatment for post-stroke spasticity; however, some patients cannot access treatment until ≥1 year post-stroke. This Brazilian post-marketing study (NCT02390206) assessed the achievement of person-centered goals in patients with chronic post-stroke spasticity after a BoNT-A injection. Patients had a last documented stroke ≥1 year before study entry and post-stroke upper limb (UL) spasticity, with or without lower limb (LL) spasticity. Patients received BoNT-A injections at baseline (visit 1) and visit 2 (3–6 months). Primary endpoint was responder rate (achievement of primary goal from Goal Attainment Scaling (GAS)) at visit 2. Overall, 204 patients underwent GAS evaluation at visit 2, mean (SD) age was 56.4 (13.2) years and 90.7% had LL spasticity. Median (range) time between first stroke and onset of spasticity was 3.6 (0−349) months, onset of spasticity and first injection was 22.7 (0−350) months and waiting time for a rehabilitation appointment was 9.0 (1−96) months. At visit 2, 61.3% (95% CI: 54.4, 67.7) of patients were responders, which was similar for UL and LL primary goals (57.8% [95% CI: 49.9, 65.3] vs. 64.1% [95% CI: 48.4, 77.3]). This study provides evidence to support the effectiveness of BoNT-A treatment for chronic post-stroke spasticity.

The Effects of Botulinum Toxin Injections on Spasticity and Motor Performance in Chronic Stroke with Spastic Hemiplegia

Spastic muscles are weak muscles. It is known that muscle weakness is linked to poor motor performance. Botulinum neurotoxin (BoNT) injections are considered as the first-line treatment for focal spasticity. The purpose of this study was to quantitatively investigate the effects of BoNT injections on force control of spastic biceps brachii muscles in stroke survivors. Ten stroke survivors with spastic hemiplegia (51.7 ± 11.5 yrs; 5 men) who received 100 units of incobotulinumtoxinA or onabotulinumtoxinA to the biceps brachii muscles participated in this study. Spasticity assessment (Modified Ashworth Scale (MAS) and reflex torque) and muscle strength of elbow flexors, as well as motor performance assessment (force variability of submaximal elbow flexion) were performed within one week before (pre-injection) and 3~4 weeks (3-wk) after BoNT injections. As expected, BoNT injections reduced the MAS score and reflex torque, and elbow flexor strength on the spastic paretic side. However, motor performance remained within similar level before and after injections. There was no change in muscle strength or motor performance on the contralateral arm after BoNT injections. The results of this study provide evidence that BoNT injections can reduce spasticity and muscle strength, while motor performance of the weakened spastic muscle remains unchanged.

Feasibility of single and combined with other treatments using transcranial direct current stimulation for chronic stroke: A pilot study

Objectives

This pilot study aimed to investigate the safety and efficacy of transcranial direct current stimulation (tDCS) for chronic stroke in adult and pediatric patients. We also aimed to verify the efficacy of botulinum toxin A and peripheral neuromuscular electrical stimulation combined therapy involving bilateral tDCS in adult patients with chronic stroke.

Methods

We conducted a pilot study applying an unblinded, non-randomized design. Eleven patients were recruited, and classified into three groups. Group I-a involved bilateral transcranial direct current stimulation and intensive occupational therapy for chronic stroke in adult patients. Group I-b involved bilateral tDCS and intensive occupational therapy for chronic stroke in pediatric patients. Group II involved bilateral tDCS, peripheral neuromuscular electrical stimulation, and intensive occupational therapy after botulinum toxin A injection for chronic stroke in adult patients. Clinical evaluations to assess motor function and spasticity were performed at baseline as well as in 2-week and 4-month follow-up visits. The questionnaire included questions regarding the presence of tDCS side effects, such as headache, redness, pain, itching, and fever.

Results

There were clinically meaningful changes in total Fugl-Meyer Assessment Upper Extremity (FMA-UE) scores at the 2-week follow-up and in the Action Research Arm Test (ARAT) scores at 4-month follow-up in Group I-b. In addition, Group II showed significant improvement in total FMA-UE scores in the 2-week follow-up (p < 0.05) but not on the ARAT scores (p > 0.05). However, Group II showed improvements in total Motor Activity Log scores at both follow-up visits (p < 0.05). No serious adverse events were reported.

Conclusion

The results of this study indicate that tDCS therapy is a potential treatment in pediatric patients with chronic stroke. Furthermore, our data indicate that botulinum toxin A and peripheral neuromuscular electrical stimulation combined therapy may enhance the efficacy of tDCS on motor function.

A synthesis and appraisal of clinical practice guidelines, consensus statements and Cochrane systematic reviews for the management of focal spasticity in adults and children

Objective: To identify and appraise the existing clinical practice guidelines, consensus statements and Cochrane systematic reviews for the management of adult and paediatric focal spasticity to generate a single synthesized guideline.Methods: Systematic review of 12 electronic databases. Clinical practice guidelines, consensus statements and Cochrane systematic reviews for focal spasticity in adults and children. Included studies were appraised according to the AGREE II criteria.Results: A total of 25 papers were included in this review, comprising 12 clinical practice guidelines, nine consensus statements and four Cochrane systematic reviews. The areas most strongly endorsed were: (1) management to be provided by a multi-disciplinary team, (2) therapy should be goal-directed, (3) goals to be developed in conjunction with the patient and family, and (4) importance of follow-up evaluations. There was a greater focus on activity outcomes and classification in the paediatric papers. The guidelines varied considerably in their quality, with AGREE II scores ranging from 52.8 to 97.1%.Conclusions: This systematic review has synthesized the key elements regarding principles of focal spasticity management, outcome measures, physical interventions and educational recommendations into a single, readily applied guideline available for clinical use. Despite considerable variability in the quality of the guidelines, several strong themes emerged.Implications for rehabilitationFocal spasticity management should be multi-disciplinary, patient-centred and goal-directed.Routine measurement of impairment and activity are strongly endorsed.Botulinum toxin A injection should only be provided as part of an integrated approach to focal spasticity management.

Protocol for the economic evaluation of the InTENSE program for rehabilitation of chronic upper limb spasticity

Background

Assessment of the costs of care associated with chronic upper-limb spasticity following stroke in Australia and the potential benefits of adding intensive upper limb rehabilitation to botulinum toxin-A are key objectives of the InTENSE randomised controlled trial.

Methods

Recruitment for the trial has been completed. A total of 139 participants from 6 stroke units across 3 Australian states are participating in the trial. A cost utility analysis will be undertaken to compare resource use and costs over 12 months with health-related quality of life outcomes associated with the intervention relative to a usual care comparator. A cost effectiveness analysis with the main clinical measure of outcome, Goal Attainment Scaling, will also be undertaken. The primary outcome measure for the cost utility analysis will be the incremental cost effectiveness ratio (ICER) generated from the incremental cost of the intervention as compared to the incremental benefit, as measured in quality adjusted life years (QALYs) gained. The utility scores generated from the EQ-5D three level instrument (EQ-5D-3 L) measured at baseline, 3 months and 12 months will be utilised to calculate the incremental Quality Adjusted Life Year (QALY) gains for the intervention relative to usual care using area-under the curve methods.

Discussion

The results of the economic evaluation will provide evidence of the total costs of care for patients with chronic upper limb spasticity following stroke. It will also provide evidence for the cost-effectiveness of adding evidence-based movement therapy to botulinum toxin-A as a treatment, providing important information for health system decision makers tasked with the planning and provision of services.

[Modern aspects of the pathophysiology of walking disorders and their rehabilitation in post-stroke patients]

The problem of rehabilitation of post-stroke patients with motor deficit remains relevant with growing prevalence of disability and decreasing mortality, despite all measures aimed at stroke prevention and morbidity reduction. One of the most common consequences of stroke is gait impairment as a result of spastic paresis of the lower limb (decreased gait velocity, shortened step, excessive loading of intact limb etc.), which leads to significant maladaptation, increased risk of falls, decrease in quality of life. The article presents a detailed review of motor action in normal and pathologic conditions, analysis of neuronal structures involved into a movement act in healthy individuals and in stroke patients, current aspects of gait pathophysiology, characteristics of post-stroke gait (speed and asymmetry of gain, balance control impairment). A separate paragraph is devoted to gait recovery after stroke with analysis of existing and developing strategies of rehabilitation, aimed at the improvement of vertical posture, balance control and movement, condition, tone and functioning of skeletal muscles. Authors also analyze new research information on the efficacy of botulinum toxin preparations and programs of Guided Self-Rehabilitation Contracts (GSC), present the results of clinical trials demonstrating the efficacy of combination of these two methods.

Effectiveness of AbobotulinumtoxinA in Post-stroke Upper Limb Spasticity in Relation to Timing of Treatment

Background: Recent studies of botulinum toxin for post-stroke spasticity indicate potential benefits of early treatment (i. e., first 6 months) in terms of developing hypertonicity, pain and passive function limitations. This non-interventional, longitudinal study aimed to assess the impact of disease duration on the effectiveness of abobotulinumtoxinA treatment for upper limb spasticity. Methods: The early-BIRD study (NCT01840475) was conducted between February 2013 and 2018 in 43 centers across Germany, France, Austria, Netherlands and Switzerland. Adult patients with post-stroke upper limb spasticity undergoing routine abobotulinumtoxinA treatment were followed for up to four treatment cycles. Patients were categorized by time from stroke event to first botulinum toxin-A treatment in the study (as defined by the 1st and 3rd quartiles time distribution) into early-, medium- and late- start groups. We hypothesized that the early-start group would show a larger benefit (decrease) as assessed by the modified Ashworth scale (MAS, primary endpoint) on elbow plus wrist flexors compared with the late-start group. Results: Of the 303 patients enrolled, 292 (96.4%) received ≥1 treatment and 186 (61.4%) received 4 injection cycles and completed the study. Patients in all groups showed a reduction in MAS scores from baseline over the consecutive injection visits (i.e., at end of each cycle). Although reductions in MAS scores descriptively favored the early treatment group, the difference compared to the late group did not reach statistical significance at the last study visit (ANCOVA: difference in adjusted means of 0.15, p = 0.546). Conclusions: In this observational, routine-practice study, patients in all groups displayed a benefit from abobotulinumtoxinA treatment, supporting the effectiveness of treatment for patients at various disease stages. Although the data revealed some trends in favor of early vs. late treatment, we did not find strong evidence for a significant benefit of early vs. late start of treatment in terms of reduction in MAS scores.

Individualized OnabotulinumtoxinA Treatment for Upper Limb Spasticity Resulted in High Clinician- and Patient-Reported Satisfaction: Long-Term Observational Results from the ASPIRE Study

Introduction

OnabotulinumtoxinA treatment for spasticity is dependent on numerous factors and varies according to selected treatment goals.

Objective

To examine real‐world onabotulinumtoxinA treatment utilization and effectiveness in patients with upper limb spasticity over 2 years from the Adult Spasticity International Registry (ASPIRE) study.

Design

Multicenter, prospective, observational registry (NCT01930786).

Setting

Fifty‐four international clinical sites in North America, Europe, and Asia.

Patients

Adults (naïve or non‐naïve to botulinum toxins for spasticity) with upper limb focal spasticity related to upper motor neuron syndrome across multiple etiologies.

Interventions

OnabotulinumtoxinA administered at clinician's discretion.

Main Outcome Measures

OnabotulinumtoxinA utilization, clinician and patient satisfaction.

Results

Four hundred eighty‐four patients received ≥1 treatment of onabotulinumtoxinA for upper limb spasticity. Patients were on average 55.1 years old, 50.8% male, predominantly Caucasian (72.3%), and 38.6% were naïve to botulinum toxins. Stroke was the most frequently reported underlying etiology (74.0%). Most patients (81.2%) had moderate to severe spasticity at baseline. The most commonly treated upper limb clinical presentation was clenched fist (79.1% of patients). Across all presentations, onabotulinumtoxinA doses ranged between 5‐600U. Electromyography (EMG) was most often utilized to localize muscles (≥57.0% of treatment sessions). Clinicians (92.9% of treatment sessions) and patients (85.7%) reported being extremely satisfied/satisfied that treatment helped manage spasticity, and clinicians (98.6%) and patients (92.2%) would definitely/probably continue onabotulinumtoxinA treatment. One hundred seventy‐nine patients (37.0%) reported 563 adverse events (AEs); 15 AEs in 14 patients (2.9%) were considered treatment related. Sixty‐nine patients (14.3%) reported 137 serious AEs; 3 serious AEs in 2 patients (0.4%) were considered treatment related. No new safety signals were identified.

Conclusions

ASPIRE captured the real‐world individualized nature of onabotulinumtoxinA utilization for upper limb spasticity over 2 years, with consistently high clinician‐ and patient‐reported satisfaction. Data in this primary analysis will guide clinical use of onabotulinumtoxinA, as well as provide insights to improve educational programs on spasticity management.

Efficacy and Safety of OnabotulinumtoxinA 400 Units in Patients with Post-Stroke Upper Limb Spasticity: Final Report of a Randomized, Double-Blind, Placebo-Controlled Trial with an Open-Label Extension Phase

In many countries, 400 units (U) is the maximum dose of onabotulinumtoxinA available to treat upper limb spasticity, but few studies have demonstrated the optimal use of this dose. In the double-blind phase of this randomized, controlled trial, we compared the efficacy and safety of 400 vs. 240 U onabotulinumtoxinA in patients with post-stroke upper limb spasticity. Both groups received 240 U onabotulinumtoxinA injected in the forearm. An additional 160 U onabotulinumtoxinA (400 U group) or placebo (240 U group) was injected in the elbow flexors. Both groups showed similar muscle tone reduction in the wrist, fingers, and thumb; muscle tone reduction in the elbow flexors was greater in the group treated with onabotulinumtoxinA (400 U group) compared to placebo (240 U group). Functional disabilities improved in both groups. No substantial difference was found in safety profiles. In the subsequent open-label phase, all participants received repeat injections of 400 U onabotulinumtoxinA (target muscles and doses per muscle determined by the physician). Similar efficacy and safety outcomes, as with the 400 U group in the double-blind phase, were confirmed. This final report demonstrates that injection of onabotulinumtoxinA 400 U relieves muscle tone in a wide range of areas and improves functional disabilities; generally, it was well-tolerated, and no new safety concerns were identified. The dosing data in the open-label phase will inform optimal use of onabotulinumtoxinA in clinical practice (ClinicalTrials.gov: NCT03261167).

The nature and extent of upper limb associated reactions during walking in people with acquired brain injury

BACKGROUND

Upper limb associated reactions (ARs) are common in people with acquired brain injury (ABI). Despite this, there is no gold-standard outcome measure and no kinematic description of this movement disorder. The aim of this study was to determine the upper limb kinematic variables most frequently affected by ARs in people with ABI compared with a healthy cohort at matched walking speed intention.

METHODS

A convenience sample of 36 healthy control adults (HCs) and 42 people with ABI who had upper limb ARs during walking were recruited and underwent assessment of their self-selected walking speed using the criterion-reference three dimensional motion analysis (3DMA) at Epworth Hospital, Melbourne. Shoulder flexion, abduction and rotation, elbow flexion, forearm rotation and wrist flexion were assessed. The mean angle, standard deviation (SD), peak joint angles and total joint angle range of motion (ROM) were calculated for each axis across the gait cycle. On a group level, ANCOVA was used to assess the between-group differences for each upper limb kinematic outcome variable. To quantify abnormality prevalence on an individual participant level, the percentage of ABI participants that were outside of the 95% confidence interval of the HC sample for each variable were calculated.

RESULTS

There were significant between-group differences for all elbow and shoulder abduction outcome variables (p < 0.01), most shoulder flexion variables (except for shoulder extension peak), forearm rotation SD and ROM and for wrist flexion ROM. Elbow flexion and shoulder abduction were the axes most frequently affected by ARs. Despite the elbow being the most prevalently affected (38/42, 90%), a large proportion of participants had abnormality, defined as ±1.96 SD of the HC mean, present at the shoulder (32/42, 76%), forearm (20/42, 48%) and wrist joints (10/42, 24%).

CONCLUSION

This study provides valuable information on ARs, and highlights the need for clinical assessment of ARs to include all of the major joints of the upper limb. This may inform the development of a criterion-reference outcome measure or classification system specific to ARs.

Effect of Additional Rehabilitation After Botulinum Toxin-A on Upper Limb Activity in Chronic Stroke: The InTENSE Trial

Supplemental Digital Content is available in the text.

The aim of this trial was to determine the effect of additional upper limb rehabilitation following botulinum toxin-A for upper limb activity in chronic stroke.

The Leg Activity measure, a new measure of passive and active function and impact on quality of life; informing goal setting and outcome evaluation in leg spasticity

PURPOSE

Application of the Leg Activity measure in acquired brain injury spasticity intervention to identify areas for goal setting prior to treatment, document the treatments applied and evaluate outcome.

METHODS

A prospective cohort from three specialist spasticity management centres was used. Primary outcome measures were, Leg Activity Measure, Modified Ashworth Scale and Goal Attainment Scaling - light. Measurement was completed at baseline, 6 and 12 weeks. The Leg-Therapy recording Schedule was used to record physical therapy intervention.

RESULTS

Participants (n = 64) included had a mean age of 51 (18-84) years, half (n = 32) were men. Significant changes were demonstrated over the 12-week period in MAS (X^r2 = 35.4; p < 0.001), the Leg Activity passive function scale (X^r2 = 32.2; p < 0.001) (e.g., improved ease of dressing, hygiene) and Leg Activity impact on quality of life scale (Xr2 = 32.2; p < 0.001). No change was identified in the Leg Activity active function scale. Goal achievement was demonstrated at 6 weeks and further improved at 12 weeks (Xr2 = 65.7; p < 0.001) and was associated with change in the relevant scale. Physical interventions were captured at each time-point.

DISCUSSION

Significant gains in passive-function and quality-of-life were recorded by the Leg Activity measure scales at 6 weeks, and at 12 weeks post-injection in the context of on-going physical treatment, primarily by self-management.Implications for rehabilitationThe Leg Activity measure is able to detected changes in passive function and impact on quality of life.Measurement of change in active function is also likely to be detected, but was not seen in the cohort studied.The Leg Activity measure was effective in this study in identifying problem areas to enable setting of treatment goals and planning of treatment intervention.

Cerebral palsy and bruxism: Effects of botulinum toxin injections-A randomized controlled trial

Objective

Cerebral palsy (CP) includes disturbances in muscular control caused by perinatal brain injury. Masticatory muscle involvement hampers functions such as chewing and talking. Bruxism and temporomandibular disorders are overrepresented. Neuromuscular blocks with botulinum toxin type A (BTX‐A) may alleviate problems due to muscular hyperactivity. The aim was to evaluate masticatory muscle BTX‐A injections in subjects with CP and bruxism.

Methods

A prospective, parallel, randomized, placebo‐controlled, and double‐blind trial in 12 patients with CP was performed. End points were alterations in objective and subjective oral capacities after two BTX‐A or corresponding placebo injections. Matched, healthy references were also evaluated.

Results

The reference group demonstrated stronger and more efficient oral functions compared with the CP group. Subjective and objective oral capacities appeared to vary considerably between CP patients and also over time in this patient group and were poorly correlated. No significant effect of BTX‐A compared with placebo on outcome variables was observed at group level, but continued treatment with BTX‐A was requested by the majority of the patients.

Conclusion

The evidence is unable to support the use of BTX‐A for the treatment of affected masticatory muscles in CP, but the findings are inconclusive in certain respects. Larger, more homogeneous groups of CP patients need to be evaluated in future trials.

Spasticity and Range of Motion Over Time in Stroke Patients Who Received Multiple-Dose Botulinum Toxin Therapy

OBJECTIVE

This study examined how the effects of botulinum toxin therapy changed over time by sequential evaluation of clinical improvements in spasticity and contracture in 24 chronic-stage stroke patients on repeated botulinum toxin therapy who were receiving fewer rehabilitation interventions.

METHODS

Botulinum toxin injection was administered into the spastic muscle of the paralyzed upper or lower limb 5 times with at least 3-month intervals. Modified Ashworth Scale and range of motion were measured before and 2 weeks after each dose in the extremities to compare the first measurement value with subsequent values. Each predose value was also compared with the first predose value.

RESULTS

Compared with predose scores, Modified Ashworth Scale significantly improved in all flexors after 2 weeks from the first to fifth doses. Range of motion significantly improved in wrist dorsiflexion and ankle dorsiflexion. Comparison of values before each dose versus the first predose value showed significant improvement both in the Modified Ashworth Scale score of wrist flexors, finger flexors, and ankle planter flexors, and the range of motion of elbow extension, wrist dorsiflexion, and ankle dorsiflexion.

CONCLUSION

The comparison of predose values versus 2-week postdose values indicated that the effect of botulinum toxin formulation would not lessen after repeated injections with continuous improvements of Modified Ashworth Scale and range of motion. The comparison of predose values versus the first predose value also suggested that multiple injections of botulinum toxin formulation could be more effective in reducing spasticity and increasing the range of motion than a single injection.

Association of Long-Term Treatment by Botulinum Neurotoxins and Occupational Therapy with Subjective Physical Status in Patients with Post-Stroke Hemiplegia

The short-term effects of botulinum toxin type A (BoNT-A) treatment in stroke patients with upper extremity are well established. This study examined the association between the recovery of motor function of the upper extremity with subjective physical symptoms in outpatients receiving long-term BoNT-A and occupational therapy following stroke. We also investigated the expectations of patients who elected to continue treatment. Forty-seven patients (23 men and 24 women) aged 61 years received BoNT-A treatment more than 20 times. The subjective physical status was analyzed by using the visual analogue scale score through an eight-item questionnaire. Recovery of motor function in the upper extremity was detected by calculating the change (delta) in Fugl–Mayer Assessment (FMA), and ordinal logistic modeling analysis was used to determine the association between the delta-FMA score and the subjective level of agreement for each item. When the ordinal logistic modeling fit was statistically significant, results were interpreted as having logistic probability. The logistic curves discriminating one point (strongly disagree) from five points (strongly agree) were fit in a stepwise fashion. This study suggests that patients receiving long-term BoNT-A treatment and occupational therapy experienced an increased upper extremity mitigation and decreased insomnia after injection, regardless of the recovery of motor function.

Botulinum toxin A injection in the management of shoulder muscle overactivity: A scoping review

The majority of studies examining botulinum toxin A (BTX-A) in the management of upper limb muscle overactivity and pain focus on the distal arm and hand. Research has begun to look at BTX-A efficacy in more proximal upper limb muscles, with literature showing equivocal findings. This scoping review identified 15 studies meeting inclusion criteria whose data were examined against three outcome variables: muscle overactivity, range of movement and pain. Overall, while the majority of injected participants improved on these variables, between-study methodological variability such as research design potentially underpowered studies and arbitrary decision making gave a high likelihood of influencing the interpretation of their results. Future research is warranted, with a robust focus on functional anatomy, a critical appraisal of how BTX-A may help the individual being studied and utilising individualised rather than protocol-driven research paradigms.

Botulinum Toxin Modulates Posterior Parietal Cortex Activation in Post-stroke Spasticity of the Upper Limb

Post-stroke spasticity (PSS) is effectively treated with intramuscular botulinum toxin type A (BoNT-A), although the clinical improvement is likely mediated by changes at the central nervous system level. Using functional magnetic resonance imaging (fMRI) of the brain, this study aims to confirm and locate BoNT-A-related changes during motor imagery with the impaired hand in severe PSS. Temporary alterations in primary and secondary sensorimotor representation of the impaired upper limb were expected. Thirty chronic stroke patients with upper limb PSS undergoing comprehensive treatment including physiotherapy and indicated for BoNT treatment were investigated. A change in PSS of the upper limb was assessed with the modified Ashworth scale (MAS). fMRI and clinical assessments were performed before (W0) and 4 weeks (W4) and 11 weeks (W11) after BoNT-A application. fMRI data were acquired using 1.5-Tesla scanners during imagery of finger-thumb opposition sequences with the impaired hand. At the group level, we separately modeled (1) average activation at each time point with the MAS score and age at W0 as covariates; and (2) within-subject effect of BoNT-A and the effect of time since W0 as independent variables. Comprehensive treatment of PSS with BoNT-A significantly decreased PSS of the upper limb with a maximal effect at W4. Task-related fMRI prior to treatment (W0) showed extensive activation of bilateral frontoparietal sensorimotor cortical areas, bilateral cerebellum, and contralesional basal ganglia and thalamus. After BoNT-A application (W4), the activation extent decreased globally, mostly in the bilateral parietal cortices and cerebellum, but returned close to baseline at W11. The intra-subject contrast revealed a significant BoNT-A effect, manifesting as a transient decrease in the activation of the ipsilesional intraparietal sulcus and superior parietal lobule. We demonstrate that BoNT-A treatment of PSS of the upper limb is associated with transient changes in the ipsilesional posterior parietal cortex, possibly resulting from temporarily altered sensorimotor upper limb representations.

Treatment of spasticity in spinal cord injury with botulinum toxin

CONTEXT

Spasticity is one of the most frequent complications in spinal cord injury (SCI), and is routinely managed with oral pharmacologic therapy. Botulinum toxin (BT) is not accepted as a treatment for spasticity in SCI in Spain but may be used in certain cases of focal distribution.

OBJECTIVE

To report the results with BT for treatment of spasticity in SCI.

DESIGN AND SETTING

Descriptive retrospective study conducted at a specialist SCI rehabilitation center in Spain, covering patients first treated from 2012 through 2014, and successfully followed up for a minimum of 1 year. Data were collected on the following variables: demographic and SCI characteristics (level and grade); nature of spasticity, e.g. tone, distribution, spasms, articular involvement and pain; function; application of BT; tolerance and adverse reactions.

RESULTS

The study covered 90 patients, predominantly male with incomplete injuries. Improvement in tone as measured by the modified Ashworth scale was a mean of 1.17 points. Goniometric improvement was achieved in 65.6% and improvement in pain in 38.9% of cases. There were no adverse side-effects. Patients with focal spasticity showed a significantly greater improvement in tone (P < 0.0001). The earlier the BT injection, the greater the improvement in goniometric performance (P < 0.006) and pain (P < 0.033), with the best results being obtained within the first 6 months of clinical course. ASIA D injuries showed a greater improvement in tone (P < 0.0001).

CONCLUSIONS

BT can be both an effective treatment for focal spasticity in SCI and a good coadjuvant for oral treatments in generalized spasticity.

Prevalence of upper-limb spasticity and its impact on care among nursing home residents with prior stroke

Purpose: Post-stroke spasticity can impair motor function and may cause pain, limb deformity, contracture, and difficulties with limb care. This study aimed to assess the prevalence and burden of post-stroke upper-limb spasticity among nursing home residents.Materials and methods: A multisite, cross-sectional study was conducted across three nursing home facilities. Participants included residents with a confirmed diagnosis of stroke, and nursing staff involved in their care. Residents were assessed using the Tardieu Scale, passive range-of-motion, Abbey Pain scale, Modified Rankin Scale and observation of limb position and skin condition. Nursing staff completed the Arm Activity Measure (ArmA).Results: 264 individuals were screened, 51 had a diagnosis of stroke (19.3%), and 23 consented to participate. 16 participants (70%) demonstrated upper-limb spasticity of at least one joint, median Tardieu score 2 [IQR 2-3]. Pain scores and nurse-rated passive ArmA were significantly higher for patients with spasticity compared to those without (p = 0.003 and p < 0.001, respectively). Greater spasticity correlated with higher pain (r_s =0.44) and ArmA scores (r_s =0.71).Conclusions: A high proportion (70%) of nursing home residents with stroke demonstrated upper-limb spasticity, associated with pain and passive care difficulties. These data suggest there is an unmet need for spasticity management among nursing-home residents.Implications for rehabilitationUpper-limb spasticity is prevalent among nursing home residents with prior stroke; here, observed in 70% of cases.Spasticity was associated with increased pain and more difficult passive limb care in this population.There is an unmet need for spasticity management among nursing home residents with prior stroke.Efforts should be made to improve access to multidisciplinary spasticity treatment for this vulnerable patient population.

Effects of Home-Based Robotic Therapy Involving the Single-Joint Hybrid Assistive Limb Robotic Suit in the Chronic Phase of Stroke: A Pilot Study

Introduction

Robotic therapy has drawn attention in the rehabilitation field including home-based rehabilitation. A previous study has reported that home-based therapy could be more effective for increasing upper limb activity than facility-based therapy. The single-joint hybrid assistive limb (HAL-SJ) is an exoskeleton robot developed according to the interactive biofeedback theory, and several studies have shown its effectiveness for upper limb function in stroke patients. A study of home-based robotic therapy has shown to enhance rehabilitation effectiveness for stroke patient with a paretic upper limb. However, home-based therapy involving a HAL-SJ in stroke patients with paretic upper limbs has not been investigated. The present study aimed to investigate paretic upper limb activity and function with home-based robotic therapy involving a HAL-SJ in stroke patients.

Materials and Methods

A home-based robotic therapy program involving a HAL-SJ was performed for 30 min per session followed by standard therapy for 30 min per session, 2 times a week, for 4 weeks (i.e., completion of all 8 sessions involved 8 h of rehabilitation), at home. After the intervention, patients were followed up by telephone and home visits for 8 weeks. The paretic upper limb activity and function were assessed using the Motor Activity Log (MAL; amount of use (AOU)), arm triaxial accelerometry (laterality index (LI)), the Fugl–Meyer assessment (FMA), and the action research arm test (ARAT), at baseline and week 4 and week 12 after the start of training.

Results

The study included 10 stroke patients (5 men; mean age, 61.1 ± 7.1 years). The AOU scores and LI significantly improved at week 4 after the start of training (p<0.05). However, no significant changes were observed in the LI at week 12 (p=0.161) and the FMA scores at both week 4 and week 12 (p=0.059 and p=0.083, respectively). The ARAT scores significantly improved at both week 4 and week 12 (p<0.05).

Conclusion

Home-based robotic therapy combined with conventional therapy could be a valuable approach for increasing paretic upper limb activity and maintaining paretic upper limb function in the chronic phase of stroke.

Toward Accurate Clinical Spasticity Assessment: Validation of Movement Speed and Joint Angle Assessments Using Smartphones and Camera Tracking

OBJECTIVE

To investigate whether a three-dimensional (3-D) camera (Microsoft Kinect) and a smartphone can be used to accurately quantify the joint angular velocity and range of motion (ROM) compared to a criterion-standard 3-D motion analysis system during a lower limb spasticity assessment.

DESIGN

Observational, criterion-standard comparison study.

SETTING

Large rehabilitation center.

PARTICIPANTS

A convenience sample of 35 controls, 35 patients with a neurologic condition, and 34 rehabilitation professionals (physiotherapists and rehabilitation doctors) participated (N=104).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Modified Tardieu Scale was used to assess spasticity of the quadriceps, hamstrings, soleus, and gastrocnemius. Data for each trial were collected concurrently using the criterion-standard Optitrack 3-D motion analysis (3DMA) system, Microsoft Kinect, and a smartphone. Each healthy control participant was assessed by 1 health professional and each patient with a neurological condition was assessed by 3 health professionals. Spearman correlation coefficient and intraclass correlation coefficient with 95% confidence intervals were used to report the strength of the relationships investigated.

RESULTS

The smartphone and Microsoft Kinect demonstrated excellent concurrent validity with the 3DMA system. Overall, 74.8% of the relationships investigated demonstrated a very strong (≥0.80) correlation across all of the testing parameters. The Microsoft Kinect was superior to the smartphone for measuring joint start and end angle, the smartphone was superior for measuring joint angular velocity, and the 2 systems were comparable for measuring total joint ROM.

CONCLUSIONS

These findings provide preliminary evidence that user-friendly, low-cost technologies can be used to facilitate accurate measurements of joint angular velocity and angles during a lower limb spasticity assessment in a clinical setting.