Clinical assessment and management of spasticity: a review

Intrathecal Baclofen Therapy for Refractory Spasticity: A Case Series

BACKGROUND

Management of refractory spasticity symptoms remains a challenging task for clinicians. Intrathecal baclofen (ITB) therapy has emerged as a promising option for treating this condition. This study evaluates the effectiveness of ITB therapy in managing refractory spasticity symptoms.

METHODS

A retrospective chart review was conducted on 34 patients with refractory spasticity symptoms who underwent ITB therapy at a single institution. The patients' demographics, clinical characteristics, and dosages were recorded. The primary outcome measures were the reduction in pain, improvement in mobility, decrease in spasm frequency, and alleviation of spasticity.

RESULTS

ITB therapy successfully reduced pain, improved mobility, decreased spasm frequency, and alleviated spasticity. The mean daily administered dose was 245 μg (range: 88-510 μg, standard deviation:104). However, it was observed that the appropriate dosage of ITB therapy was patient-specific and time-sensitive. Moreover, side effects were observed when an incorrect dose was administered.

CONCLUSIONS

ITB therapy is an effective and safe option for managing refractory spasticity symptoms. However, the appropriate dosage should be individualized and monitored closely to avoid side effects. This study highlights the importance of carefully considering the potential risks and benefits of ITB therapy for each patient.

Stretching exercises in managing spasticity: effectiveness, risks, and adjunct therapies

Spasticity is a component of upper motor neuron disorders and can be seen in neurological conditions like stroke and multiple sclerosis. Although the incidence rate of spasticity is unknown, it can put pressure on the health condition of those with spasticity, and there is no absolute effective way to control it. In the past, stretching exercises were an accessible tool for physical therapists to manage and control spasticity, but opinions on the optimal dose, aftereffects, and mechanism of effects were controversial. Therefore, this article tries to provide an overview of the effectiveness and risks of stretching exercises. Furthermore, there are several adjunct therapies, such as brain stimulation and botulinum injection, that can increase the effectiveness of a simple stretch by increasing cortical excitability and reducing muscle tone and their role is evaluated in this regard. The results of this study propose that several prospective and case studies have demonstrated the benefits of stretching to control spasticity, but it seems that other methods such as casting can be more effective than a simple stretch. Therefore, it is better to use stretching in combination with other therapeutic regimes to increase its effectivity of it.

Expert consensus on the surgical evaluation and management of upper extremity spasticity in adults

In the last decade there has been incredible interest and advancement in the surgical care of adult patients with upper motor neuron (UMN) injuries. Spasticity represents a prevalent and debilitating feature of UMN syndrome, which can result from cerebral palsy, spinal cord injury, cerebrovascular accident and traumatic or anoxic brain injury. While several diagnostic tools and management strategies have been described for upper limb spasticity, evidence-based practice guidelines do not currently exist due to low patient volume and a paucity of surgeons routinely performing surgeries in UMN syndrome patients. As such, expert consensus may help provide guidance for patients, therapists and clinicians alike. In this article an expert panel was assembled, and the Delphi method was utilized to present diagnostic considerations, define operative indications, discuss surgical treatment modalities and encourage a standard set of outcome measures for patients with upper extremity spasticity.

Daily Vibrotactile Stimulation Exhibits Equal or Greater Spasticity Relief Than Botulinum Toxin in Stroke

OBJECTIVE

To test the feasibility and efficacy of the VibroTactile Stimulation (VTS) Glove, a wearable device that provides VTS to the impaired limb to reduce spastic hypertonia.

DESIGN

Prospective 2-arm intervention study-including 1 group of patients who use Botulinum toxin (BTX-A) for spasticity and 1 group of patients who do not use BTX-A.

SETTING

Participants were recruited through rehabilitation and neurology clinics.

PARTICIPANTS

Patients with chronic stroke (N=20; mean age=54 years, mean time since stroke=6.9 years). Patients who were previously receiving the standard of care (BTX-A injection) were eligible to participate and started the intervention 12 weeks after their last injection.

INTERVENTION

Participants were instructed to use the VTS Glove for 3 hours daily, at home or during everyday activities, for 8 weeks.

MAIN OUTCOME MEASURES

Spasticity was assessed with the Modified Ashworth Scale and the Modified Tardieu Scale at baseline and then at 2-week intervals for 12 weeks. Primary outcomes were the difference from baseline and at week 8 (end of VTS Glove use) and week 12 (4 weeks after stopping VTS Glove use). Patients who were receiving BTX-A were also assessed during the 12 weeks preceding the start of VTS Glove use to monitor the effect of BTX-A on spastic hypertonia. Range of motion and participant feedback were also studied.

RESULTS

A clinically meaningful difference in spastic hypertonia was found during and after daily VTS Glove use. Modified Ashworth and Modified Tardieu scores were reduced by an average of 0.9 (P=.0014) and 0.7 (P=.0003), respectively, at week 8 of daily VTS Glove use, and by 1.1 (P=.00025) and 0.9 (P=.0001), respectively, 1 month after stopping VTS Glove use. For participants who used BTX-A, 6 out of 11 showed greater change in Modified Ashworth ratings during VTS Glove use (mean=-1.8 vs mean=-1.6 with BTX-A) and 8 out of 11 showed their lowest level of symptoms during VTS Glove use (vs BTX-A).

CONCLUSIONS

Daily stimulation from the VTS Glove provides relief of spasticity and hypertonia. For more than half of the participants who had regularly used BTX-A, the VTS Glove provided equal or greater symptom relief.

Quantitative assessment of spasticity: a narrative review of novel approaches and technologies

Spasticity is a complex neurological disorder, causing significant physical disabilities and affecting patients' independence and quality of daily lives. Current spasticity assessment methods are questioned for their non-standardized measurement protocols, limited reliabilities, and capabilities in distinguishing neuron or non-neuron factors in upper motor neuron lesion. A series of new approaches are developed for improving the effectiveness of current clinical used spasticity assessment methods with the developing technology in biosensors, robotics, medical imaging, biomechanics, telemedicine, and artificial intelligence. We investigated the reliabilities and effectiveness of current spasticity measures employed in clinical environments and the newly developed approaches, published from 2016 to date, which have the potential to be used in clinical environments. The new spasticity scales, taking advantage of quantified information such as torque, or echo intensity, the velocity-dependent feature and patients' self-reported information, grade spasticity semi-quantitatively, have competitive or better reliability than previous spasticity scales. Medical imaging technologies, including near-infrared spectroscopy, magnetic resonance imaging, ultrasound and thermography, can measure muscle hemodynamics and metabolism, muscle tissue properties, or temperature of tissue. Medical imaging-based methods are feasible to provide quantitative information in assessing and monitoring muscle spasticity. Portable devices, robotic based equipment or myotonometry, using information from angular, inertial, torque or surface EMG sensors, can quantify spasticity with the help of machine learning algorithms. However, spasticity measures using those devices are normally not physiological sound. Repetitive peripheral magnetic stimulation can assess patients with severe spasticity, which lost voluntary contractions. Neuromusculoskeletal modeling evaluates the neural and non-neural properties and may gain insights into the underlying pathology of spasticity muscles. Telemedicine technology enables outpatient spasticity assessment. The newly developed spasticity methods aim to standardize experimental protocols and outcome measures and enable quantified, accurate, and intelligent assessment. However, more work is needed to investigate and improve the effectiveness and accuracy of spasticity assessment.

Multimodal assessment of spasticity using a point-of-care instrumented glove to separate neural and biomechanical contributions

Accurate assessment of spasticity is crucial for physicians to select the most suitable treatment for patients. However, the current clinical practice standard is limited by imprecise assessment scales relying on perception. Here, we equipped the clinician with a portable, multimodal sensor glove to shift bedside evaluations from subjective perception to objective measurements. The measurements were correlated with biomechanical properties of muscles and revealed dynamic characteristics of spasticity, including catch symptoms and velocity-dependent resistance. Using the biomechanical data, a radar metric was developed for ranking severity in spastic knees and elbows. The continuous monitoring results during anesthesia induction enable the separation of neural and structural contributions to spasticity in 21 patients. This work delineated effects of reflex excitations from structural abnormalities, to classify underlying causes of spasticity that will inform treatment decisions for evidence-based patient care.

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Tool to shift from subjective scales to objective metrics in spasticity evaluation

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Develop a multifaceted metric to rank severity based on biomechanical properties

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Delineate effects of hyper-reflexes and structural abnormalities in spastic muscles

Results of Intrathecal Baclofen Treatment in Sixteen Spasticity Patients According to Four Different Measurement Scales: A Retrospective Analysis

Introduction

Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes. It occurs as a result of overstimulation of the stretch reflex and is a component of the upper motor neuron syndrome. Intrathecal Baclofen (ITB) pump administration in patients with a diagnosis of spasticity may be a suitable option for reducing the complaints of the patients and increasing their quality of life. The aim of this study is to analyze clinically and statistically the diagnosis, treatment criteria, and post-treatment results of patients with spasticity who were treated in our clinic.

Materials and Method

Sixteen patients who were diagnosed with spasticity and placed on an intrathecal Baclofen pump between January 2015 and December 2020 were included in this study. An intrathecal Baclofen trial was first applied to patients who were candidates for the Baclofen pump. The spasticity levels of the patients who decided to have an intrathecal Baclofen pump were scored according to the modified Ashworth scale (MAS) and Penn spasm frequency scale (PSFS). In addition, the scaling of the patients' own conditions according to the visual analogue scale (VAS) and ambulation status according to the modified functional ambulation classification (MFAC) were recorded. All these evaluations were repeated in the preoperative, early postoperative, and follow-up periods.

Results

The sex distribution of the patients included in the study was equal to eight women and eight men. The age distribution was between 18 and 76. The average age was 40.62 (standard deviation ±17.79). The average preoperative modified Ashworth scale score was 3.73, and the average Penn spasm frequency scale score of the patients was 3.67. The average preoperative modified functional ambulation classification score was 1.87, and the average visual analogue scale score was 6.67. At the end of the second postoperative week, the average modified Ashworth scale score was 1.80 and the average Penn spasm frequency scale score was 1.67. The modified functional ambulation classification score was 2.60 and the visual analogue scale score was 4.58. The average follow-up period of the patients was 64 months. At the end of the follow-up periods, the average late-period modified Ashworth scale score was 1.87, and the Penn spasm frequency scale score was 1.67. The average modified functional ambulation classification score was 3.00, and the average visual analogue scale score was 4.50. Statistically, there was a significant difference between preoperative and postoperative results in both modified Ashworth scale and Penn spasm frequency scale scores (P<0.05). Modified functional ambulation classification preoperative and postoperative comparison results (P<0.05) and visual analogue scale results (P<0.05) were also statistically significant. No significant difference was found between the early postoperative period and the late postoperative period in all measurements (P=1.00).

Conclusion

Intrathecal Baclofen administration is one of the many treatment options for spasticity. In this way, it has been shown that greater Baclofen efficacy is achieved and its side effects are reduced. It should always be remembered that the process of this treatment is teamwork that requires the participation of more than one specialty branch. Physical therapists, neurologists, pediatricians, and neurosurgeons should be included in this teamwork.

Effects of dry needling on muscle spasticity of the upper limb in a survivor of traumatic brain injury: a case report

Background

Survivors of moderate and severe traumatic brain injury typically present with spasticity, an upper motor neuron lesion associated with hyperexcitability of the stretch reflex due to disinhibition of cortical influences on spinal cord circuits and structural and functional changes in skeletal muscle. There is growing evidence supporting the effectiveness of dry needling in abating spasticity.

Case presentation

The present case aims to quantify the effects of dry needling on upper limb spastic muscles in a survivor of severe traumatic brain injury in a 27-year-old Iranian man. The treated muscles were biceps brachii, brachialis, flexor digitorum superficialis and profundus, flexor carpi radialis, flexor carpi ulnaris, opponens pollicis, and adductor pollicis. Outcome measures were evaluated before and 1 hour after the intervention. Our results showed that the patient’s upper limb recovery stage and hand function improved one grade according to Brunnstrom recovery stages. Spasticity assessed using the Modified Modified Ashworth Scale in all movements showed one-grade abatement, except in the forearm pronator. Passive resistance force decreased in all movements except in forearm supination. Active range of motion and passive range of motion increased in all movements except in active and passive forearm supination. Hand dexterity improved in both affected and unaffected hands.

Conclusions

Results shown that dry needling could be a favorable option for reducing spasticity.

Effects of the Structured Water Dance Intervention (SWAN) on muscular hypertonia in adults with profound intellectual and multiple disabilities

This study aimed to evaluate the effect of Structured Water Dance Intervention (SWAN) on muscular hypertonia in individuals with profound intellectual and multiple disability (PIMD). Muscular hypertonia has a multitude of negative consequences for people with PIMD because it can lead to contractures, pain, mobility impairment, pressure ulcers that limits functional behavior as well as gross and fine motor function. Thirty-six individuals with PIMD in four Swedish regions were randomized to two groups in a multicenter, crossover design. Two withdrew participation, thus 34 individuals completed the intervention. The intervention was administered for 40 min once a week during a 12-week period. Outcomes related to muscular hypertonia were examined using the Modified Ashworth Scale (MAS), and based on accompanying assistants' assessments. Hypertonia decreased from baseline to the end of the intervention period, as demonstrated by a decrease in MAS score. Hypertonia also decreased during the sessions, as shown by the assistants' ratings. In conclusion, this study demonstrates that SWAN holds potential to reduce muscular hypertonia in people with PIMD and points out the importance of customized physical treatment alternatives. The study provides useful information for the design of future non-invasive, non-pharmacological interventions to reduce muscular hypertonia in PIMD.

Functional intermuscular reduction in spasticity for people with multiple sclerosis

Background

Eighty-five percent of people with multiple sclerosis (MS) incur gait impairments debilitating enough to significantly impact their function.

Objectives

The aim of this study was to determine if a novel combination of intermuscular electrical stimulation, followed by functional electrical stimulation combined with supported bodyweight treadmill training, would improve gait, decrease spasticity and fatigue, and improve muscle strength.

Methods

Using a pre-post experimental design, we implemented this combination six-week protocol in 16 individuals with MS. We completed summary statistics and longitudinal pre-post results using Wilcoxon sign rank tests with Bonferroni adjustment.

Results

Participants responded with median increases of 29.4 feet (p < 0.0001) during the Six Minute Walk Test, median decreases of 0.7 s (p = 0.0011) in the 25-Foot Walk Test, median increases of 3.8 toe taps to fatigue (p = 0.0306) and median increases of 5.0 heel raises (p = 0.0093). Significant changes were noted in the Modified Ashworth Scale, both after intermuscular electrical stimulation (median change = −0.5 p = 0.0039) and after treadmill walking (median change = −0.5, p < 0.0005).

Conclusions

Results of this novel protocol suggest this intervention combination has the potential to decrease spasticity, and improve gait speed and endurance in individuals with MS. Observed changes in mobility occurred without accompanying increases in fatigue.

Canadian Physicians' Use of Perioperative Botulinum Toxin Injections to Spastic Limbs: A Cross-sectional National Survey

Objective

To investigate the practice patterns of Canadian physicians who use perioperative botulinum toxin (BoNT) injections to improve surgical outcomes on spastic limbs.

Design

A cross-sectional national survey composed of an invitation email and an 18-item questionnaire was disseminated by a national physical medicine and rehabilitation (PMR) society to 138 physician members involved in spasticity management.

Setting

Not applicable.

Participants

Twenty-five percent of the participants (N=34) fully completed the survey.

Interventions

Not applicable.

Main Outcome Measures

Participants completed an online questionnaire that examined the practice patterns and surgical outcomes associated with perioperative BoNT injections.

Results

The majority (n=21; 84%) of Canadian physicians who inject BoNT perioperatively to improve outcomes of surgeries performed on spastic limbs are specialists in PMR practicing in academic settings. Most respondents (74%) used BoNT injections for perioperative treatment for patients with limb spasticity undergoing surgery. Of those surveyed, 65% of physicians used BoNT preoperatively, 21% used BoNT intraoperatively, and 24% used BoNT postoperatively.Of the physicians who performed BoNT injections preoperatively, 6% performed BoNT injections 7 to 12 weeks preoperatively, 32% performed BoNT injections 4 to 6 weeks preoperatively, 47% performed BoNT injections 2 to 3 weeks preoperatively, and 15% performed BoNT injections 0 to 1 week preoperatively. The majority of physicians (85%) responded that injecting BoNT perioperatively may improve a patient's surgical outcome and all of the participants (100%) stated that BoNT did not contribute to any perioperative complications or adverse effects. Qualitative responses emphasized that successful outcomes from the perioperative BoNT were linked to enhanced collaboration with surgeons and that more research is needed to determine the optimal timing of perioperative BoNT.

Conclusion

Canadian physicians, mostly PMR specialists, administer perioperative BoNT to improve outcomes of surgeries performed on spastic limbs. The optimal timing for perioperative BoNT was suggested to be 2 to 3 weeks before the surgery by 47% of survey respondents. All participating physicians responded that perioperative BoNT did not contribute to any known perioperative complications or adverse events. This study highlights the importance of conducting more robust research to better understand optimal timing for perioperative BoNT injection, enhancing collaboration between physicians and surgeons, and increasing awareness of perioperative BoNT when planning for surgeries on spastic limbs.

Pros and cons of botulinum toxin injection therapy in cerebral palsy: A qualitative study exploring caregivers' perspective

BACKGROUND

To describe and understand the experiences and beliefs of caregivers of children with cerebral palsy following botulinum toxin injection.

METHODS

A descriptive case study approach with focus group interviews was employed. A semi-structured questionnaire was conducted to collect data. Twenty-one caregivers of children (3-13 years old) with cerebral palsy were recruited with a maximum variation sampling strategy to gain insight through different perspectives. Qualitative analysis with verbatim transcripts was analysed using a thematic approach.

FINDINGS

Four themes emerged from qualitative analyses: acceptance of diagnosis, perceptions about treatment, caregivers' experiences with the health environment, and feelings and thoughts after the treatment.

CONCLUSIONS

This study highlights caregivers' requests for information about the possible long-term effect of botulinum toxin, as well as information and support to provide the best rehabilitation programme immediately after injection.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Intrathecal baclofen therapy for severe spasticity in an adult with tethered cord syndrome: a case report

Background

Patients with tethered cord syndrome often suffer severe spasticity. To the best of our knowledge, intrathecal baclofen (ITB) therapy in a patient with tethered cord syndrome has not been reported previously. We describe a case in which ITB therapy was useful for treating severe spasticity in an adult with tethered cord syndrome.

Case presentation

We present the case of a 50-year-old Japanese woman with tethered cord syndrome and related conditions suffering from severe spasticity and pain in the lower limbs. She was born with a lumbosacral myelomeningocele, which was closed in the neonatal period. For 4–5 years before this presentation, spasticity in the lower limbs had been exacerbated without any obvious cause. She received rehabilitation and pharmacotherapy from a local doctor, but symptoms were unimproved, and her previous doctor referred her to this department. A test with 50 μg of intrathecally delivered baclofen showed total relief of spasticity and pain, so a pump was implanted for continuous baclofen delivery. During 24 months of follow-up, spasticity has remained under excellent control with baclofen at 38.5–41.0 μg/day.

Conclusions

ITB therapy proved extremely effective in this adult with severe spasticity from tethered code syndrome.

Neuromodulation Therapies for Spasticity Control: Now and Beyond

Spasticity is a major cause of disability following upper motor neuron (UMN) injury. The diagnosis and treatment of spasticity has been a focus of clinicians and researchers alike. In recent years, there have been significant advances both in strategies for spasticity assessment and in the development of novel treatments. Currently, several well-established spasticity management techniques fall into the major categories of physiotherapy, pharmacotherapy, and surgical management. The majority of recent developments in all of these broad categories have focused more on methods of neuromodulation instead of simple symptomatic treatment, attempting to address the underlying cause of spasticity more directly. The following narrative review briefly discusses the causes and clinical assessment of spasticity and also details the wide variety of current and developing treatment approaches for this often-debilitating condition.

Systematic review on use and efficacy of selective dorsal rhizotomy (SDR) for the management of spasticity in non-pediatric patients

PURPOSE

Selective dorsal rhizotomy (SDR) has been used to improve mobility and reduce lower extremity spasticity in patients with a various CNS conditions. Incidentally, literature on SDR has been performed in the pediatric population as such there is a paucity of research on the use in adult patients.

METHODS

Studies describing SDR in adults were identified from Medline and Embase databases. Combinations of search terms "Selective Dorsal Rhizotomy," "Selective Posterior Rhizotomy," and "Adult" were used. Only literature in English language on patients over the age of 18 years and that included measures for lower extremity outcome (i.e., spasticity, mobility) were included. Case reports, reviews without primary data, or inaccessible publications were excluded.

RESULTS

One hundred twenty-nine publications between 1970 and 2019 were identified. Twelve of these publications fit the inclusion criteria (n = 141 patients). In series where it was reported, SDR resulted in ambulatory improvement (54%, n = 44 out of 81), reduced spasticity (75.2%, n = 106 out of 141), and minimized muscle and joint pain (74.5%, n = 64 out of 86). SDR also showed improvement in parameters of the activities of daily life. 92.3% (n = 48 out of 52) of patients post-SDR developed new lower limb paresthesia.

CONCLUSION

The success and efficacy appear durable in the short-term, but further follow-up is necessary to validate these findings. The goal of the intervention dictates the ideal adult patient for SDR. Patients seeking ambulatory improvement, any etiology of spasticity besides MS, seem favorable. Positive locomotive predictors include the ability to isolate lower extremity function, lack of contractures, lower limb strength, and post-SDR physiotherapy.

Long-Term Care Resident Awareness and Interest in Spasticity Treatments

Spasticity is common in long-term care settings (affecting up to one in three residents), yet it remains under-treated despite safe and effective, Food and Drug Administration (FDA)-approved therapies. One barrier to treatment may be lack of awareness of available therapies for long-term care residents living with spasticity. A standardized spasticity treatment awareness and interest interview was conducted with 18 nursing home residents and 11 veterans’ home residents in this cross-sectional study. Veterans’ home residents were also asked about potential barriers to receiving spasticity treatment. Many residents across both long-term care facilities were unaware of most of the treatment options for spasticity. Participants were most aware of physical/occupational therapy (83%, 95% CI: 65–93%) and least aware of intrathecal baclofen (21%, 95% CI: 9–39%). After learning about treatments, only 7% of participants (95% CI: 0–23%) were not interested in receiving any form of spasticity treatment. Among residents previously unaware of spasticity treatments, at least one quarter became interested in receiving treatment and at least one-fifth indicated possibly being interested in the treatment after learning about it. Potential barriers to receiving treatment included traveling to see a doctor and limited knowledge of insurance coverage of spasticity treatments. These results suggest that patient-centered approaches, including education and discerning patient preferences, may improve spasticity treatment in long-term care settings.

Perioperative Botulinum Toxin Injections to Enhance Surgical Outcomes in Patients With Spasticity: Preoperative, Intraoperative, and Postoperative Case Reports

Spasticity causes an array of disabilities, which in turn may lead to the need for surgical intervention. Spasticity itself may also negatively affect surgical outcomes. This report reviews the potential benefit of perioperative (before, during, or after surgery) botulinum toxin (BoNT) injections for 3 patients with spasticity due to spinal cord injury, stroke, or multiple sclerosis. We discuss perioperative BoNT in 3 time periods: preoperatively, intraoperatively, and postoperatively. The cases demonstrate the use of perioperative BoNT in decreasing pain, improving wound healing, and improving surgical outcomes. We conclude by discussing the potential use of perioperative BoNT for surgical interventions in patients with spasticity and the need for further high-quality research in this field.

Surface Electromyography Meets Biomechanics: Correct Interpretation of sEMG-Signals in Neuro-Rehabilitation Needs Biomechanical Input

Coordinated activation of muscles is the basis for human locomotion. Impaired muscular activation is related to poor movement performance and disability. To restore movement performance, information about the subject's individual muscular activation is of high relevance. Surface electromyography (sEMG) allows the pain-free assessment of muscular activation and many ready-to-use technologies are available. They enable the usage of sEMG measurements in several applications. However, due to the fact that in most rehabilitation applications dynamic conditions are analyzed, the correct interpretation of sEMG signals remains difficult which hinders the spread of sEMG in clinical applications. From biomechanics it is well-known that the sEMG signal depends on muscle fiber length, contraction velocity, contraction type and on the muscle's biomechanical moment. In non-isometric conditions these biomechanical factors have to be considered when analyzing sEMG signals. Additionally, the central nervous system control strategies used to activate synergistic and antagonistic muscles have to be taken into consideration. These central nervous system activation strategies are rarely known in physiology and are hard to manage in pathology. In this perspective report we discuss how the consideration of biomechanical factors leads to more reliable information extraction from sEMG signals and how the limitations of sEMG can be overcome in dynamic conditions. This is a prerequisite if the use of sEMG in rehabilitation applications is to extend. Examples will be given showing how the integration of biomechanical knowledge into the interpretation of sEMG helps to identify the central nervous system activation strategies involved and leads to relevant clinical information.

Spasticity distribution and severity in individuals with HTLV-1-associated myelopathy/tropical spastic paraparesis

In individuals with HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP), spasticity is one of the main symptoms. The neurological signs of the disease are well defined, but details of how spasticity appears in these individuals have not been well explored. To describe spasticity location and severity of HAM/TSP individuals. Cross-sectional study with individuals older than 18 years, diagnosed with HAM/TSP and with lower limb spasticity. Pregnant women, individuals with other associated neurological diseases, and those using antispastic drugs were not included. Spasticity was assessed by the Modified Ashworth Scale (MAS), applied to the abductor, adductor, flexor, and extensor muscles of the hips, flexors, and extensors of the knees, dorsiflexors, plantiflexors, evertors, and inverters of the foot. Thirty participants were included. The plantiflexor muscles (90%), knee extensors (80%), knee flexors (63,3%), and adductors (50%) were most frequently affected by spasticity. Twenty-three (76.7%) individuals had mixed spasticity, 5 (16.7%) with distal spasticity and 2 (6.7%) with proximal spasticity. MAS was similar between the lower limbs in at least 6 of the 10 muscle groups of each individual. Spasticity was mostly mixed in the lower limbs, with more frequently mild severity. The individuals were partially symmetrical between the lower limbs. The most affected muscle groups were the plantiflexors, knee extensors and flexors and the hip adductors, consecutively, being predominantly symmetrical.

Prevalence of Comorbid Spasticity and Urinary Incontinence in Residents of a Long-Term Care Facility

The current study evaluated the prevalence of comorbid spasticity and urinary incontinence (UI) in a long-term care facility. Medical history, presence of UI, and activities of daily living (ADL) dependency were obtained from medical records and Minimum Data Set 3.0. Quality of life was assessed with the EuroQoL-5D-5L (EQ-5D). Comorbid spasticity and UI presented in 29% of participants (14 of 49). Participants with spasticity and UI had higher ADL dependency and lower EQ-5D than participants without both conditions (4.9, 95% confidence interval [CI] [1.6, 80.], p = 0.003; -0.17, 95% CI [-0.33, 0.00], p = 0.044; respectively). More than one half of participants with lower limb spasticity had severe UI, compared to only 10% without lower limb spasticity (relative risk = 5.5; 95% CI [1.9, 15.9]; p = 0.006). Comorbid spasticity and UI may be common in the long-term care setting and negatively associated with ADL and quality of life. Further investigation is needed to confirm these findings. [Journal of Gerontological Nursing, 46(10), 35-42.].

Robot-Aided Systems for Improving the Assessment of Upper Limb Spasticity: A Systematic Review

Spasticity is a motor disorder that causes stiffness or tightness of the muscles and can interfere with normal movement, speech, and gait. Traditionally, the spasticity assessment is carried out by clinicians using standardized procedures for objective evaluation. However, these procedures are manually performed and, thereby, they could be influenced by the clinician's subjectivity or expertise. The automation of such traditional methods for spasticity evaluation is an interesting and emerging field in neurorehabilitation. One of the most promising approaches is the use of robot-aided systems. In this paper, a systematic review of systems focused on the assessment of upper limb (UL) spasticity using robotic technology is presented. A systematic search and review of related articles in the literature were conducted. The chosen works were analyzed according to the morphology of devices, the data acquisition systems, the outcome generation method, and the focus of intervention (assessment and/or training). Finally, a series of guidelines and challenges that must be considered when designing and implementing fully-automated robot-aided systems for the assessment of UL spasticity are summarized.

The Minimum Data Set: An Opportunity to Improve Spasticity Screening

Spasticity is a common movement disorder that arises from trauma or disease affecting the central nervous system. Untreated spasticity can result in limitations in completing activities of daily living, painful limb contractures, and other conditions associated with loss of mobility. In the long-term care setting, this treatable condition is prevalent, yet often unrecognized likely because of a lack of spasticity-trained practitioners. A recently published spasticity referral tool holds promise for addressing the underdiagnosis of spasticity in the long-term care population. The Minimum Data Set (MDS) would be an ideal mechanism for increasing the diagnosis and treatment of spasticity because it is a government-directed comprehensive screening tool that informs care plans for all residents residing in federally funded long-term care facilities. The MDS could easily integrate the published referral assessment to record the presence of spastic postures and muscle rigidity. We propose expanding the MDS to include 3 questions related to spasticity to improve the recognition and treatment of this prevalent and treatable condition.

Effect of music listening on hypertonia in neurologically impaired patients-systematic review

Background

As music listening is able to induce self-perceived and physiological signs of relaxation, it might be an interesting tool to induce muscle relaxation in patients with hypertonia. To this date effective non-pharmacological rehabilitation strategies to treat hypertonia in neurologically impaired patients are lacking. Therefore the aim is to investigate the effectiveness of music listening on muscle activity and relaxation.

Methodology

The search strategy was performed by the PRISMA guidelines and registered in the PROSPERO database (no. 42019128511). Seven databases were systematically searched until March 2019. Six of the 1,684 studies met the eligibility criteria and were included in this review. Risk of bias was assessed by the PEDro scale. In total 171 patients with a variety of neurological conditions were included assessing hypertonia with both clinicall and biomechanical measures.

Results

The analysis showed that there was a large treatment effect of music listening on muscle performance (SMD 0.96, 95% CI [0.29–1.63], I² = 10%, Z = 2.82, p = 0.005). Music can be used as either background music during rehabilitation (dual-task) or during rest (single-task) and musical preferences seem to play a major role in the observed treatment effect.

Conclusions

Although music listening is able to induce muscle relaxation, several gaps in the available literature were acknowledged. Future research is in need of an accurate and objective assessment of hypertonia.

Selection process for botulinum toxin injections in patients with chronic-stage hemiplegic stroke: a qualitative study

Background

Botulinum toxin (BT) injection is a new treatment for spasticity with hemiplegia after stroke. How a patient decides to receive BT injections after becoming aware of the treatment remains unclear. In this exploratory qualitative study, we aimed to investigate patients’ decision-making about treatment strategies in collaboration with family and health professionals and to identify conflicts in patients’ feelings about BT treatment.

Methods

The study included six patients with stroke sequelae. Data were collected using comprehensive interviews and were analyzed using the grounded theory approach and trajectory equifinality modeling.

Results

After patients learned about BT treatment, they clearly exhibited the following two concurrent perceptions: “the restriction of one’s life due to disabilities” and “the ability to do certain things despite one’s disabilities.” Some patients reported a “fear of not being able to maintain the status quo owing to the side effects of BT.” To alleviate this fear, timely support from family members was offered, and patients overcame anxiety through creative thinking. However, there were also expressions that revealed patients’ difficulties dealing with negative events. These factors influenced the patients’ development of “expectations of BT” or “hesitations about BT.”

Conclusions

To establish treatment strategies in collaboration with patients, healthcare professionals should show supportive attitudes and have discussions with patients and their family members to help patients resolve their conflicts and should establish treatment strategies that maintain the positive aspects of patients’ lives.

Transcutaneous Spinal Cord Stimulation Induces Temporary Attenuation of Spasticity in Individuals with Spinal Cord Injury

Epidural spinal cord stimulation (SCS) is currently regarded as a breakthrough procedure for enabling movement after spinal cord injury (SCI), yet one of its original applications was for spinal spasticity. An emergent method that activates similar target neural structures non-invasively is transcutaneous SCS. Its clinical value for spasticity control would depend on inducing carry-over effects, because the surface-electrode-based approach cannot be applied chronically. We evaluated single-session effects of transcutaneous lumbar SCS in 12 individuals with SCI by a test-battery approach, before, immediately after and 2 h after intervention. Stimulation was applied for 30 min at 50 Hz with an intensity sub-threshold for eliciting reflexes in lower extremity muscles. The tests included evaluations of stretch-induced spasticity (Modified Ashworth Scale [MAS] sum score, pendulum test, electromyography-based evaluation of tonic stretch reflexes), clonus, cutaneous-input-evoked spasms, and the timed 10 m walk test. Across participants, the MAS sum score, clonus, and spasms were significantly reduced immediately after SCS, and all spasticity measures were improved 2 h post-intervention, with large effect sizes and including clinically meaningful improvements. The effect on walking speed varied across individuals. We further conducted a single-case multi-session study over 6 weeks to explore the applicability of transcutaneous SCS as a home-based therapy. Self-application of the intervention was successful; weekly evaluations suggested progressively improving therapeutic effects during the active period and carry-over effects for 7 days. Our results suggest that transcutaneous SCS can be a viable non-pharmacological option for managing spasticity, likely working through enhancing pre- and post-synaptic spinal inhibitory mechanisms, and may additionally serve to identify responders to treatments with epidural SCS.

Spasticity, gait, and balance in patients with multiple sclerosis: A cross-sectional study

OBJECTIVE

More than 80% of people with multiple sclerosis (MS) are affected by spasticity. Spasticity is known to reduce quality of life and contribute to additional symptoms, such as pain and reduced mobility, but the association between spasticity, balance, and mobility has not yet been established. Our aim was to examine whether a relationship exists between spasticity in the lower limbs, balance, and gait, as well as to explore the involvement of different muscle groups.

METHODS

This study employed a cross-sectional design. Thirty patients with MS were included. The Modified Ashworth Scale (MAS) was used to examine spasticity in the ankle plantar flexors, knee extensors, and hip adductors. Balance was measured using the Mini-Balance Evaluation Systems Test, and gait with the 2-Minute Walk Test. The participants were tested once with no additional follow-up. Spearman's correlation, recursive partitioning, and linear regression analyses were used to explore the association.

RESULTS

A significant correlation between gait distance and spasticity in the ankle plantar flexors (ρ = -.69, p < .001) and knee extensors (ρ = -.45, p = .012) was observed. Balance significantly correlated with spasticity in ankle plantar flexors (ρ = -.69, p < .001), knee extensors (ρ = -.52, p = .003), and hip adductors (ρ = -.5, p = .005). The relationship between spasticity in ankle plantar flexors and hip adductors was significant, even from low levels of spasticity, whereas MAS score ≥ 2 was clinically correlated with a decrease in gait and balance function. Adjustments for sex, age, or years since diagnosis had only minor impact on the results.

CONCLUSIONS

This study indicates that spasticity in the lower limbs is clinically significantly associated with mobility in people with MS.

Introduction of a procedure to objectively quantify spastic movement impairment during freely performed voluntary movements

Spastic impaired limb function is a frequent result of brain lesions. Although its assessment is important for clinical and therapeutical management, it still lacks an objective measure to quantify the functionality of the affected limb. The present paper reports a procedure based on the muscular activation recorded by Surface Electromyography (sEMG), which enables the assessment of the degree of spastic impairment. 15 healthy subjects and 7 patients with impaired upper limb function due to spasticity were included in the study. SEMG was recorded from the biceps and brachioradialis during active elbow extension at different movement velocities. The spastic impairment was clinically assessed by the Tardieu-Test and the Wolf Motor Function Test. Results of the clinical assessment and parameter values quantifying the muscular activation at different joint positions and movement velocities have been set in relation to one another. The results show that spastic impairment leads to a changed correlation between the muscular activation and movement velocity as well as to a changed inter-muscular co-ordination of biceps and brachioradialis. These changes, reflected in the sEMG, can be quantified by 5 newly introduced parameters. This way could allow the assessment of spastic impairment in the context of functional everyday tasks, for the first-time.

Sine causa tetraparesis: A pilot study on its possible relationship with interferon signature analysis and Aicardi Goutières syndrome related genes analysis

Tetraparesis is usually due to cerebral palsy (CP), inborn errors of metabolism, neurogenetic disorders and spinal cord lesions. However, literature data reported that about 10% of children with tetraparesis show a negative/non-specific neuroradiological findings without a specific etiological cause. Aicardi Goutières Syndrome (AGS) is a genetic encephalopathy that may cause tetraparesis. Interferon signature is a reliable biomarker for AGS and could be performed in sine-causa tetraparesis. The aim of the study was to examine the type I interferon signature and AGS related-genes in children with sine causa tetraparesis, to look for misdiagnosed AGS. A secondary aim was to determine which aspects of the patient history, clinical picture and brain imaging best characterize tetraparesis due to an interferonopathy.Seven out of 78 patients affected by tetraparesis, characterized by unremarkable pre-peri-postnatal history and normal/non-specific brain magnetic resonance imaging (MRI) were selected and underwent anamnestic data collection, clinical examination, brain imaging review, peripheral blood interferon signature and AGS-related genes analysis.At our evaluation time (mean age of 11.9 years), all the 7 patients showed spastic-dystonic tetraparesis. At clinical onset brain MRI was normal in 4 and with non-specific abnormalities in 3; at follow-up 3 patients presented with new white-matter lesions, associated with brain calcification in 1 case. Interferon signature was elevated in one subject who presented also a mutation of the IFIH1 gene.AGS should be considered in sine-causa tetraparesis. Core features of interferonopathy-related tetraparesis are: onset during first year of life, psychomotor regression with tetraparesis evolution, brain white-matter lesions with late calcifications. A positive interferon signature may be a helpful marker to select patients with spastic tetraparesis who should undergo genetic analysis for AGS.

A Descriptive Study of Self-Reported Injury in Non-elite Adaptive Athletes

BACKGROUND

Adaptive sports programs are increasing across the country and there is a paucity of research investigating the epidemiology and sports injury risk factors in non-elite athletes.

OBJECTIVE

To assess the demographics, training regime, and injuries incurred by adaptive athletes participating in local adaptive sports clubs and to assess the athletes' type of medical care and prevalence of those with spasticity.

DESIGN

Descriptive cross-sectional study.

SETTING

Local area adaptive sports teams and programs.

PARTICIPANTS

Sixty-one athletes participating in wheelchair basketball, wheelchair rugby, sled hockey, and adaptive rowing were surveyed, with a response rate of 70.5%.

INTERVENTIONS

Completion of self-report survey.

OUTCOME

Report of injury prevalence, injury characteristics, type of medical care, and assessment of frequency and severity of spasticity using the Penn Spasm Frequency Scale.

RESULTS

Most athletes (86%) trained or competed in their main sport 9-12 months per year. Most athletes (79.1%) trained at least 4 hours per week. In the past 12 months, 39.5% of athletes surveyed sustained an injury that required them to miss practice or a competition, with 58.8% of these athletes having sustained a significant injury. Many of those injured (64.7%) had never participated in an injury prevention or conditioning program. Injury prevalence by sport was 42.9% in wheelchair rugby, 60% in sled hockey, 44% wheelchair basketball, and 0% in adaptive rowing. The most commonly injured body parts were the shoulder (52.9%) and wrist (52.9%).

CONCLUSIONS

This study shows that non-elite adaptive sports athletes sustain similar types of injuries as noted in published reports of elite athletes but could be provided with less injury prevention education and access to medical care. This area will require future study, especially investigating injury risk factors within specific sports and diagnoses.

LEVEL OF EVIDENCE

III.

Retraining Reflexes: Clinical Translation of Spinal Reflex Operant Conditioning

Neurological disorders, such as spinal cord injury, stroke, traumatic brain injury, cerebral palsy, and multiple sclerosis cause motor impairments that are a huge burden at the individual, family, and societal levels. Spinal reflex abnormalities contribute to these impairments. Spinal reflex measurements play important roles in characterizing and monitoring neurological disorders and their associated motor impairments, such as spasticity, which affects nearly half of those with neurological disorders. Spinal reflexes can also serve as therapeutic targets themselves. Operant conditioning protocols can target beneficial plasticity to key reflex pathways; they can thereby trigger wider plasticity that improves impaired motor skills, such as locomotion. These protocols may complement standard therapies such as locomotor training and enhance functional recovery. This paper reviews the value of spinal reflexes and the therapeutic promise of spinal reflex operant conditioning protocols; it also considers the complex process of translating this promise into clinical reality.

Dorsal Longitudinal T-Myelotomy (Bischof II Technique): A Useful, Antiquated Procedure for the Treatment of Intractable Spastic Paraplegia

OBJECTIVE

Dorsal longitudinal T-myelotomy is a long-established operation to treat severe spastic paraplegia. The present study aimed to report this surgical technique and investigate the efficacy of T-myelotomy for spasticity relief.

METHODS

All cases undergoing T-myelotomy for treatment of intractable spastic paraplegia during 2009-2017 were included. The severity of spasticity was evaluated with the Modified Ashworth Scale, Penn Spasm Frequency Scale, Adductor Tone Rating Scale, degree of passive range of motion, and occurrence of abdominal muscle spasms. Other clinical assessments included deep tendon reflex assessed by the National Institute of Neurological Disorders and Stroke scale, Babinski sign, healing of decubitus ulcers, and ambulatory status.

RESULTS

Fourteen patients with a mean age of 39.3 ± 13.4 years were included. The 7 patients with abdominal muscle spasms before surgery had no spasms after surgery. The Babinski sign was absent in all cases after surgery. Unhealed pressure ulcers in all 9 cases were healed after surgery. All 4 patients with a preoperative bed-bound condition were able to ambulate with a wheelchair. A statistically significant improvement in mean Modified Ashworth Scale score, degree of passive range of motion, and National Institute of Neurological Disorders and Stroke scale score was found in the subgroup and overall analyses. There was also a statistically significant improvement in the Penn Spasm Frequency Scale and Adductor Tone Rating Scale scores.

CONCLUSIONS

Dorsal longitudinal T-myelotomy remains an effective option for the treatment of intractable spastic paraplegia. It is suitable for, and may be an alternative to, intrathecal baclofen therapy for patients with complete spinal cord lesion or patients without hope of regaining motor function.

Effects of Treadmill Training Combined with Serotonergic Interventions on Spasticity after Contusive Spinal Cord Injury

Spasticity usually emerges during the course of recovery from spinal cord injury (SCI). While medications and physical rehabilitation are prescribed to alleviate spastic symptoms, the insufficiency of their effects remains an important problem to be addressed. Given the challenges associated with increasing the dose of medication, we hypothesized that a combination therapy with medication and physical rehabilitation can be effective. Therefore, we examined the effects of treadmill training (TMT) along with serotonergic medication using a spastic rat model after contusive injury. Spasticity-strong SCI rats were selected 4 weeks after SCI and received one of the following interventions for 2 weeks: only TMT, TMT with fluoxetine (a selective serotonin re-uptake inhibitor), TMT with cyproheptadine (a 5-HT₂ receptor antagonist), only fluoxetine, or only cyproheptadine. We performed the swimming test to quantify the frequency of spastic behaviors. We also evaluated hindlimb locomotor functions every week. At the end of the intervention, we examined the Hoffman reflex from the plantar muscle and the immunoreactivity of the 5-HT_2A receptor in spinal cord tissues. While the TMT group and cyproheptadine-treated groups showed decreased spastic behaviors and reduction in spinal hyperreflexia, the fluoxetine-treated group showed the opposite effect, even with TMT. Moreover, TMT suppressed the expression of the 5-HT_2A receptor in the lumbar spinal motor neurons, while cyproheptadine treatment did not change it. We did not observe any differences in locomotor functions between the groups. Taken together, our findings indicate that TMT and cyproheptadine significantly alleviated spastic symptoms, but did not show synergistic or additive effects.

Rehabilitation of Neuromotor Disabilities in Aquatic Microgravity Environment

The aquatic environment has a high potential in rehabilitation treatment of acute lesions and in chronic diseases. The Safe Bearing Back method is proposed to stimulate the reorganization of deteriorated sensory neuromotor skills. The aim of the present study was to verify the effectiveness and the long-term maintenance of the benefits of a specific thermal rehabilitation training in neuromotor and neurological disabilities. Seventy four patients were evaluated using the Functional Independence Measure (FIM), Tinetti Gait-Balance Scale (TIN), and Visual Analog Scale (VAS) for pain. In addition, a general health index was developed, conceived as a linear combination, with unit weights, of the normalized FIM, TIN, and VAS indicators. Measurements were made at T1 (baseline before treatment), T2 (after a five-month treatment, which was the end of treatment), and T3 (6 months after the end of treatment). Self-sufficiency, walking ability, and subjective pain perception were improved after the treatment. The improvement tapered off during the six-month-long follow-up, but the patients' condition remained well compared with the baseline level before the implementation of the treatment program. We conclude that hydrokinesitherapy with the Safe Bearing Back method demonstrates is clearly effective in the immediate and medium-term rehabilitation of neuromotor diseases.

Comparison of efficacy between dorsal root entry zone lesioning and selective dorsal rhizotomy for spasticity of cerebral origin

BACKGROUND

Severe spasticity adversely affects patient functional status and caregiving. No previous study has compared efficacy between dorsal root entry zone lesioning (DREZL) and selective dorsal rhizotomy (SDR) for reduction of spasticity. This study aimed to investigate the efficacy of DREZL and SDR for attenuating spasticity, and to compare efficacy between these two methods.

METHODS

All patients who underwent DREZL, SDR, or both for treatment of intractable spasticity caused by cerebral pathology at Siriraj Hospital during 2009 to 2016 were recruited. Severity of spasticity was assessed using Modified Ashworth Scale (MAS) and Adductor Tone Rating Scale (ATRS). Ambulatory status was also evaluated.

RESULTS

Fifteen patients (13 males) with a mean age of 30.3 ± 17.5 years were included. Eight, six, and one patient underwent DREZL, SDR, and combined cervical DREZL and lumbosacral SDR, respectively. Eight of ten patients with preoperative bed-bound status had postoperative improvement in ambulatory status. Spasticity was significantly reduced in the DREZL group (p < 0.001), the SDR group (p < 0.001), and in overall analysis (p < 0.001). SDR was effective in both pediatric and adult spasticity patients. A significantly greater reduction in spasticity as assessed by MAS score (p < 0.001) and ATRS score (p = 0.015) was found in the DREZL group. Transient lower limb weakness was found in a patient who underwent SDR.

CONCLUSIONS

DREZL is more effective for reducing spasticity, but is more destructive than SDR. DREZL should be preferred for bed-ridden patients, and SDR for ambulatory patients. Both operations are helpful for improving ambulatory status. Gait improvement was observed only in patients who underwent SDR. Adult patients with spasticity of cerebral origin benefit from SDR.

Measurement of post-stroke spasticity based on tonic stretch reflex threshold: implications of stretch velocity for clinical practice

PURPOSE

The most commonly used method for the clinical evaluation of spasticity is the modified Ashworth scale (MAS), which is subjective. In this regard, the spasticity assessment through the tonic stretch reflex threshold, which is an objective method, has emerged as an alternative. It is based on the value of the dynamic stretch reflex threshold, which is measured at different stretch velocities. However, by this definition, it is not possible to define the speed at which passive stretches should be performed during evaluation.

OBJECTIVE

This study aimed to evaluate whether the speed-variation sequence used to acquire the dynamic stretch reflex threshold influences the tonic stretch reflex threshold (TSRT) and, consequently, the estimation of spasticity by this method.

METHODS

Three forms of stretching-variation speed were adopted, i.e., increasing, decreasing, and randomised. The study was performed using 10 post-stroke patients.

RESULTS AND CONCLUSIONS

The results showed that the stretch protocols were not all the same and that the method of increasing was most suitable for performing manual passive stretches to evaluate TSRT in these patients. Another analysis was the correlation between MAS and tonic stretch reflex threshold; a weak correlation was observed between the increasing and decreasing methods, and moderate correlation was observed between the random methods. Implications for Rehabilitation We demonstrated that the protocol of execution of passive stretches influences in the measurement of the tonic stretch reflex threshold (TSRT). We recommend the method of increasing velocity for performing manual passive stretches. We also build software with a reliable biological data acquisition system, which makes acquisition and processing of data in real time. In this way, the TSRT is a promising quantitative measure to assess post-stroke spasticity, calculated automatically. We also we provided the use of portable instruments to facilitate the assessment of spasticity in clinical practice.

Outcomes of intrathecal baclofen therapy in patients with cerebral palsy and acquired brain injury

Intrathecal baclofen (ITB) has been known to reduce spasticity which did not respond to oral medications and botulinum toxin treatment. However, few results have been reported comparing the effects of ITB therapy in patients with cerebral palsy (CP) and acquired brain injury. This study aimed to investigate beneficial and adverse effects of ITB bolus injection and pump therapy in patients with CP and to compare outcomes to patients with acquired brain injury such as traumatic brain injury and hypoxic brain injury. ITB test trials were performed in 37 patients (19 CP and 18 acquired brain injury). Based on ambulatory function, CP patients were divided into 2 groups: 11 patients with nonambulatory CP and 8 patients with ambulatory CP. Change of spasticity was evaluated using the Modified Ashworth Scale. Additional positive or negative effects were also evaluated after ITB bolus injection. In patients who received ITB pump implantation, outcomes of spasticity, subjective satisfaction and adverse events were evaluated until 12 months post-treatment. After ITB bolus injection, 32 patients (86.5%) (CP 84.2% versus acquired brain injury 88.9%) showed a positive response of reducing spasticity. However, 8 patients with CP had negative adverse effects. Particularly, 3 ambulatory CP patients showed standing impairment and 1 ambulatory CP patient showed impaired gait pattern such as foot drop because of excessive reduction of lower extremity muscle tone. Ambulatory CP patients received ITB pump implantation less than patients with acquired brain injury after ITB test trials (P = .003 by a chi-squared test). After the pump implantation, spasticity was significantly reduced within 1 month and the effect maintained for 12 months. Seventeen patients or their caregivers (73.9%) were very satisfied, whereas 5 patients (21.7%) suffered from adverse events showed no subjective satisfaction. In conclusion, ITB therapy was effective in reducing spasticity in patients with CP and acquired brain injury. Before ITB pump implantation, it seems necessary to perform the ITB bolus injection to verify beneficial effects and adverse effects especially in ambulatory CP.

Effects of one session radial extracorporeal shockwave therapy on post-stroke plantarflexor spasticity: a single-blind clinical trial

Purpose To examine the effects of radial extracorporeal shockwave therapy (rESWT) on plantarflexor spasticity after stroke. Method Twelve patients with stroke were randomly included for this prospective, single-blind clinical trial. Patients received one rESWT session (0.340 mJ/mm², 2000 shots) on plantarflexor muscle. The Modified Modified Ashworth Scale (MMAS), H-reflex tests, ankle range of motion (ROM), passive plantarflexor torque (PPFT) and timed up and go test (TUG) were measured at baseline (T₀), immediately after treatment (T₁) and one hour after the end of the treatment (T₂). Results Patients had improved the MMAS scores for both the gastrocnemius and the soleus muscles, active and passive ROM, PPFT and TUG over time after rESWT. For the PPFT, it was greater at high velocity than at low velocity, and there was a significant three-way interaction between time, knee position (extended/flexed) and velocity (low/high). The H-reflex latency had decreased at T₁, but there was no significant effect on H_max/M_max ratio. Conclusions The rESWT improved plantarflexor spasticity, and the effects sustained for one hour, whereas it was not effective in improving spinal excitability. Implications for Rehabilitation One session radial extracorporeal shock wave therapy (rESWT) is safe and effective in improving post stroke plantarflexor spasticity, ankle active and passive range of motion, passive torque, and walking capability. The spasticity scores improved for both the gastrocnemius and the soleus muscles and persisted one hour after rESWT. The magnitude of resistive plantarflexor passive torque in the knee extended position and high velocity was larger over time suggesting greater gastrocnemius spasticity than soleus. The rESWT had no significant effects on alpha motorneuron excitability.

Relationship between muscle-tendon length, range of motion, and resistance to passive movement in children with normal and increased tone

[Purpose] The aim of this study was to quantify the resistance to passive movement by measuring changes in muscle-tendon length and joint range of motion (ROM), before and after applying a standardized 5-kilogram tension force, and to correlate and compare these changes to muscle tone. [Subjects and Methods] Children with cerebral palsy (n=29) and typically developed children (n=12) participated in this observational study. The modified Ashworth scale (MAS) was used to assess tone in the right plantarflexor muscle. An ultrasound-imaging device was used to measure Δmuscle-tendon length in the right medial gastrocnemius muscle, and a goniometer was used to measure right ankle ΔROM. [Results] Compared with the MAS, the results showed that ΔROM had the highest construct validity (convergent and discriminant) followed by Δmuscle-tendon unit length. Therefore, these parameters may be better alternatives to the MAS for the quantitative assessment of resistance to passive movement in patients with increased tone. [Conclusion] This study demonstrated that measuring the change in the passive properties of the muscle-tendon unit, as well as the corresponding change in ROM, might provide better options for assessing resistance to passive movement or muscle tone.

Current Practices of Physical and Occupational Therapists Regarding Spasticity Assessment and Treatment

Purpose: The purpose of this study was to understand current trends in rehabilitation practice regarding spasticity assessment and treatment. Method: The clinical practices of Canadian physiotherapists and occupational therapists in assessing and treating spasticity were investigated using a self-administered, Web-based questionnaire (cross-sectional design). Experienced clinicians developed the questionnaire, which surveyed socio-demographic characteristics, work environment, and clinician satisfaction with spasticity assessments and preferences for treatment. Results: A total of 317 clinicians (204 physiotherapists and 113 occupational therapists) completed the questionnaire. The majority of participants reported that using valid and reliable outcome measures to assess spasticity was important (91.1%). Most clinicians indicated using a combination of spasticity assessments, and their level of satisfaction with these assessments was very high. All clinicians believed that spasticity should be evaluated by rehabilitation professionals, and most indicated that it should be assessed by more than one professional. Although 83.8% indicated that spasticity should be tested on admission, a much lower percentage believed that it should be evaluated throughout rehabilitation. Most clinicians (92.2%) reported using multiple treatment modalities for spasticity. Conclusions: This study is the first to document clinicians' practices regarding spasticity assessment and treatment. A better understanding of current trends in physiotherapy and occupational therapy will help in tailoring strategies to improve practice.

Botulinum toxin therapy for treatment of spasticity in multiple sclerosis: review and recommendations of the IAB-Interdisciplinary Working Group for Movement Disorders task force

Botulinum toxin (BT) therapy is an established treatment of spasticity due to stroke. For multiple sclerosis (MS) spasticity this is not the case. IAB-Interdisciplinary Working Group for Movement Disorders formed a task force to explore the use of BT therapy for treatment of MS spasticity. A formalised PubMed literature search produced 55 publications (3 randomised controlled trials, 3 interventional studies, 11 observational studies, 2 case studies, 35 reviews, 1 guideline) all unanimously favouring the use of BT therapy for MS spasticity. There is no reason to believe that BT should be less effective and safe in MS spasticity than it is in stroke spasticity. Recommendations include an update of the current prevalence of MS spasticity and its clinical features according to classifications used in movement disorders. Immunological data on MS patients already treated should be analysed with respect to frequencies of MS relapses and BT antibody formation. Registration authorities should expand registration of BT therapy for spasticity regardless of its aetiology. MS specialists should consider BT therapy for symptomatic treatment of spasticity.