Duration of Treatment Effect Using IncobotulinumtoxinA for Upper-limb Spasticity: A Post-hoc Analysis

The efficacy and safety of incobotulinumtoxinA ≤400 U was demonstrated in subjects with post-stroke upper-limb spasticity in a randomized, double-blind Phase 3 study with an open-label extension (OLEX; EudraCT number 2005-003951-11, NCT00432666). We report a post-hoc analysis of the duration of the treatment effect. Subjects completing the placebo-controlled main period (single injection cycle with 12–20-week observation) entered the OLEX and received a maximum of five further treatments (maximum duration 69 weeks) with incobotulinumtoxinA ≤400 U at flexible intervals with a minimum duration of 12 weeks, based on clinical need. Intervals between two consecutive incobotulinumtoxinA injections, excluding treatment intervals prior to the end-of-study visit, were evaluated. Of 437 incobotulinumtoxinA treatment intervals, 415 received by 136 subjects were included in the post-hoc analysis. More than half (52.3%; 217/415) of all incobotulinumtoxinA reinjections were administered at Week ≥14, 31.1% (129/415) at Week ≥16, 19.0% (79/415) at Week ≥18, and 11.6% (48/415) at Week ≥20. The duration of effect may vary and can exceed 20 weeks or more, which was observed in at least one injection cycle in 29.4% (40/136) subjects over the course of their treatment. Data show that incobotulinumtoxinA retreatment for upper-limb spasticity may not be required at 12-week intervals and provides evidence for flexible treatment intervals beyond this time frame.

Sustained efficacy of incobotulinumtoxina repeated injections for upper-limb post-stroke spasticity: A post hoc analysis

OBJECTIVE

This post hoc analysis assessed the impact of repeated incobotulinumtoxinA injections on muscle tone, disability, and caregiver burden in adults with upper-limb post-stroke spasticity.

DESIGN

Data from the double-blind, placebo-controlled main period and three open-label extension cycles of two Phase 3, randomized, multicentre trials were pooled.

METHODS

Subjects received incobotulinumtoxinA 400 Units at 12-week intervals (±3 days) (study 3001, NCT01392300) or ≤ 400 Units at ≥12-week intervals based on clinical need (study 0410, NCT00432666). Ashworth Scale (AS) arm sumscore (sum of elbow, wrist, finger and thumb flexor, and forearm pronator AS scores), Disability Assessment Scale (DAS), and Carer Burden Scale (CBS) scores were assessed.

RESULTS

Among 465 subjects, from study baseline to 4 weeks post-injection, mean (standard deviation) AS arm sumscore improved continuously: main period, -3.23 (2.55) (placebo, -1.49 (2.09)); extension cycles 1, 2, and 3, -4.38 (2.85), -4.87 (3.05), and -5.03 (3.02), respectively. DAS principal target domain responder rate increased from 47.4% in the main period (placebo 27.2%) to 66.6% in extension cycle 3. Significant improvements in CBS scores 4 weeks post-injection accompanied improved functional disability in all cycles.

CONCLUSION

IncobotulinumtoxinA conferred sustained improvements in muscle tone, disability, and caregiver burden in subjects with upper-limb post-stroke spasticity.

IncobotulinumtoxinA Treatment in Upper-Limb Poststroke Spasticity in the Open-Label Extension Period of PURE: Efficacy in Passive Function, Caregiver Burden, and Quality of Life

BACKGROUND

Poststroke spasticity affects motor function and the ability to perform activities of daily living, with the potential to affect quality of life (QoL) and increase caregiver burden.

OBJECTIVE

To investigate the effect of repeated incobotulinumtoxinA treatment on spasticity-associated functional disability, caregiver burden, and QoL in the 36-week open-label extension of the phase 3 PURE study (NCT01392300).

DESIGN

Open-label extension period of a prospective, double-blind, placebo-controlled, randomized, multicenter study.

SETTING

Forty-six investigation sites in seven countries (Czech Republic, Germany, Hungary, India, Poland, Russia, United States).

PARTICIPANTS

Adults, aged 18-80 years, ≥12 months since last botulinum neurotoxin injection or entirely toxin naïve, with median poststroke upper-limb spasticity of >2 years' duration.

METHODS

Participants who completed the 12-week, double-blind main period could enter the open-label extension and receive up to three additional incobotulinumtoxinA treatments (fixed total dose 400 U at 12-week intervals) into the affected muscles of one upper limb.

MAIN OUTCOME MEASURES

Functional disability (Disability Assessment Scale; DAS), caregiver burden (Carer Burden Scale), and quality of life (QoL; EuroQol [EQ] 5-dimensions three-level [EQ-5D-3L]).

RESULTS

The open-label extension included 296 treated patients. Mean DAS score for the principal target domain improved significantly from the main period baseline to the end-of-study visit (P < .0001). Carer Burden Scale scores also significantly improved from the main period baseline to the end-of-study visit (P < .05 for all caregiving activities except "applying a splint"). At the end-of-study visit, versus the main period baseline, 19.7%-33.3% of patients experienced improvements for each parameter on the EQ-5D-3L, except "mobility," with significant improvement in EQ-5D visual analog scale scores (P < .001).

CONCLUSIONS

Repeated incobotulinumtoxinA treatments at 12-week intervals in participants with chronic poststroke upper-limb spasticity resulted in significant improvements in QoL, as well as significant reductions in upper-limb functional disability and caregiver burden.

IncobotulinumtoxinA Efficacy and Safety in Adults with Upper-Limb Spasticity Following Stroke: Results from the Open-Label Extension Period of a Phase 3 Study

Introduction

The objective of the study was to investigate the efficacy and safety of repeated incobotulinumtoxinA injections for the treatment of upper-limb post-stroke spasticity in adults.

Methods

Adults 18–80 years of age with post-stroke upper-limb spasticity who completed the 12-week randomized, double-blind, placebo-controlled main period (MP) of a phase 3 trial (NCT01392300) were eligible to enrol in the 36-week open-label extension period (OLEX). The OLEX included three treatment cycles at fixed 12-week injection intervals; subjects were injected with 400 U incobotulinumtoxinA into the affected upper limb. Efficacy assessments included evaluation of muscle tone using the Ashworth Scale (AS) and the Global Impression of Change Scale (GICS) assessed by the investigator, subject, and caregiver. The incidence of adverse events (AEs) was monitored throughout the OLEX.

Results

A total of 296 of 299 subjects (99.0%) who completed the MP received incobotulinumtoxinA in the OLEX, and 248 subjects completed the 36-week OLEX. The proportion of subjects with at least a 1-point improvement in AS score from each incobotulinumtoxinA treatment to the respective 4-week post-injection visit ranged by cycle from 52.3% to 59.2% for wrist flexors, 49.1% to 52.3% for elbow flexors, 59.8% to 64.5% for finger flexors, 35.5% to 41.2% for thumb flexors, and 37.4% to 39.9% for forearm pronators (P < 0.0001 for all). Over 90% of subjects were assessed by the investigator to be at least minimally improved (4 weeks post-injection) on the GICS during each injection cycle; 61.0% in the 1st cycle, 58.2% in the 2nd cycle, and 57.4% in the 3rd cycle were considered much improved or very much improved on the GICS. Three percent of subjects (9/296) reported treatment-related AEs; the most frequently reported were pain in the extremity (n = 2, 0.7%) and constipation (n = 2, 0.7%). Serious AEs were reported by 22 subjects (7.4%); however, none were considered treatment-related.

Conclusions

Repeated injections of incobotulinumtoxinA for the treatment of post-stroke upper-limb spasticity led to significant improvements in muscle tone and investigator’s global impression of change. Treatment was well tolerated, with no serious treatment-related AEs.

Funding

Merz Pharmaceuticals GmbH.

Objective assessment of functional ambulation in adults with hemiplegia using ankle foot orthotics after stroke

OBJECTIVE

To objectively evaluate the effect of ankle foot orthotics (AFOs) on functional ambulation in individuals with hemiplegia secondary to stroke using quantifiable outcome measures.

DESIGN

With-without repeated measures design.

SETTING

Rehabilitation research center.

PARTICIPANTS

Eighteen adults with stroke-related hemiplegia 6 months using a prescribed AFO.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASUREMENTS

The distance (m) and velocity (m/s) during the 6-Minute Walk Test (6MWT) and total time (s) and velocity (m/s) during the 25-ft walk (25ftW). Secondary analysis evaluated the 6MWT and 25ftW grouped by the time component of the Ambulatory Index (AI).

RESULTS

Distance walked during the 6MWT was significantly greater with AFO (228.54 +/- 103.93) than without AFO (197.49 +/- 104.13), P = .002. Time to complete the 25ftW was significantly greater without AFO (21.22 +/- 20.57) than with AFO (15.49 +/- 14.65), P = .010. There was a significant difference in average velocity between the 25ftW and 6MWT during the with AFO condition, P = .010. Secondary analysis grouped by the AI time showed that as level of function decreases, brace effect on functional ambulation increases (Group 3: 25ftW with AFO, P = .040).

CONCLUSIONS

AFO usage in hemiplegic stroke patients improves functional ambulation, particularly in individuals with a slower gait velocity. The 25ftW, with and without AFO, may be useful to the patient and clinician when determining the importance of brace utilization. Speed modulation was improved when the AFO was added to the paretic limb, and AI grouping indicated that the AFO was more beneficial in people with a slower gait velocity (>20 seconds for the 25ftW). A more definitive study is needed to more completely address this issue. As an exploratory study, the feasibility of different walking assessments was determined so that future studies can validate which objective measures can be used and easily implemented in clinical settings.

Congenital and acquired brain injury. 4. Outpatient and community reintegration

This self-directed learning module highlights the rehabilitation aspects of care for people with traumatic brain injury (TBI) after the acute phase. It focuses on issues important to community reentry, outpatient care, and return to work. It is part of the chapter on TBI medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article specifically focuses on the formulation of rehabilitation plans to address the issues of cognitive dysfunction, behavioral disturbances, and community reintegration. Topics covered include pharmacologic and nonpharmacologic approaches to cognitive and affective disorders, intimacy, social isolation, mobility, and return to work. Finally, the critical issues of legal competency and obtaining informed consent in the population with cognitive impairment are discussed.

OVERALL ARTICLE OBJECTIVE

To summarize the issues that affect outpatient care, independence, and community reentry after traumatic brain injury.

Congenital and acquired brain injury. 1. Epidemiology, pathophysiology, prognostication, innovative treatments, and prevention

This self-directed learning module reviews the current epidemiology of traumatic brain injury (TBI), its pathophysiology, prognostication after injury, currently available innovative early approaches to diagnosis and treatment, and effective methods of prevention. It is intended to provide the rehabilitation clinician with current knowledge to accurately inform patients, families, significant others, referring physicians, and payers and to aid in clinical decision making while caring for patients after TBI.

OVERALL ARTICLE OBJECTIVE

To describe current knowledge in traumatic brain injury epidemiology, pathophysiology, prognostication, acute treatment, and prevention.

MRI findings in the painful poststroke shoulder

BACKGROUND AND PURPOSE

We describe the structural abnormalities in the painful shoulder of stroke survivors and their relationships to clinical characteristics. Method- Eighty-nine chronic stroke survivors with poststroke shoulder pain underwent T1- and T2-weighted multiplanar, multisequence MRI of the painful paretic shoulder. All scans were reviewed by one radiologist for the following abnormalities: rotator cuff, biceps and deltoid tears, tendinopathies and atrophy, subacromial bursa fluid, labral ligamentous complex abnormalities, and acromioclavicular capsular hypertrophy. Clinical variables included subject demographics, stroke characteristics, and the Brief Pain Inventory Questions 12. The relationship between MRI findings and clinical characteristics was assessed through logistic regression.

RESULTS

Thirty-five percent of subjects exhibited a tear of at least one rotator cuff, biceps or deltoid muscle. Fifty-three percent of subjects exhibited tendinopathy of at least one rotator cuff, bicep or deltoid muscle. The prevalence of rotator cuff tears increased with age. However, rotator cuff tears and rotator cuff and deltoid tendinopathies were not related to severity of poststroke shoulder pain. In approximately 20% of cases, rotator cuff and deltoid muscles exhibited evidence of atrophy. Atrophy was associated with reduced motor strength and reduced severity of shoulder pain.

CONCLUSIONS

Rotator cuff tears and rotator cuff and deltoid tendinopathies are highly prevalent in poststroke shoulder pain. However, their relationship to shoulder pain is uncertain. Atrophy is less common but is associated with less severe shoulder pain.

Measuring finger flexion and activity trends over a 25 hour period using a low cost wireless device

The goal of this research was to evaluate the usefulness of a wireless custom monitor in measuring real-time finger posture over an extended period of time as the wearer goes about daily life activities. One individual wore the device for 25 continuous hours in the research facility and at home. Initial data analysis methods have been presented to explore different aspects of hand activity over time. Evaluating mean flexion over five minute intervals reveals common hand postures assumed throughout the day, while total joint excursion over longer intervals highlights periods of inactivity associated with sleep or rest, as well as periods of higher intensity activities that can be used to evaluate compliance with physical therapy and home rehabilitation instructions.

Complications of interlaminar cervical epidural steroid injections: a review of the literature

STUDY DESIGN

A comprehensive literature review.

OBJECTIVES

To review and critically evaluate the past literature focusing on incidence and clinical presentation of complications associated with interlaminar cervical epidural steroid injection (ICESI). The overall goal is to guide the direction of future research and improve clinical care by increasing awareness of complications, their presentations, and management.

SUMMARY OF BACKGROUND DATA

Although ICESI is considered a relatively safe procedure, a number of minor and major complications have been reported across the literature. Thus far, reports of complications are limited to retrospective studies, case reports, and data extrapolated from lumbar and thoracic procedures. As a result, the past literature has been of limited value with regard to facilitating both clinical care and future research efforts.

METHODS

Medical databases were searched for studies of ICESI. The bibliographies of these papers were then searched as well. Papers focusing on cervical techniques that did not involve injection into the epidural space were discarded, as were studies of thoracic and lumbar spine injections. Reports of complications associated with ICESI were further subdivided into major and minor categories.

RESULTS

The reported rate of complications associated with ICESI varied between 0 and 16.8%.

CONCLUSION

There are significant limitations in the available literature discussing the complications associated with ICESI, but they strongly suggest that ICESI is a relatively safe procedure. Numerous potential adverse reactions have been associated with ICESI, with the vast majority being minor and transient in nature. However, serious complications may also result and may be technique related. Injectionists should be aware of the clinical presentations, rates, potential consequences, and appropriate techniques to avoid these complications. More studies are needed with specific focus on cervical complication rates, standardization of injection techniques, and differentiation between complications and poor efficacy. In addition, the use of a prospective randomized blinded controlled design would be beneficial.

Formation of neutralizing antibodies in patients receiving botulinum toxin type A for treatment of poststroke spasticity: a pooled-data analysis of three clinical trials

OBJECTIVE

The purpose of this study was to investigate the incidence of neutralizing antibody (NAb) formation in patients with poststroke spasticity treated with a specific formulation of botulinum toxin type A (BoNTA).

METHODS

Data from 3 previous clinical trials of BoNTA in patients with upper and/or lower limb spasticity were pooled and evaluated. Study 1 was a randomized, double-blind, placebo-controlled, multicenter trial of BoNTA in patients aged >/=21 years who had experienced a stroke >6 months before the initiation of the study. Study 2 was an open-label extension of study 1. Study 3 was a randomized, double-blind, multicenter trial of a specific BoNTA formulation in patients aged >/= 21 years who had experienced a stroke >/=6 weeks before study entry. Patients with a fixed contracture of the studied limb were excluded from participation in studies 1 and 2. Serum samples were obtained from each patient before each BoNTA treatment and at the end of each study. The mouse protection assay (MPA) was used for detection of NAbs to BoNTA in serum.

RESULTS

A total of 235 individual patients with post-stroke spasticity were enrolled in the 3 trials, including 126, 111 (all of whom participated in study 1), and 109 in studies 1, 2, and 3, respectively. Study 1 had an equal (50.0%) distribution of male and female patients (63/63). The distribution of male and female patients was 56 (50.5%) and 55 (49.5%), respectively, in study 2, and 55 (50.5%) and 54 (49.5), respectively, in study 3. The mean (SD) ages of patients in studies 1, 2, and 3 were 61.4 (13.8), 61.5 (14.1), and 58.5 (13.9) years, respectively. The MPA was used for detection of NAbs to BoNTA in the serum samples of 191 patients, including 64 from study 1, 111 from study 2 (55 of these patients were placebo recipients and 56 received their first BoNTA injection in study 1), and 72 (a sample was not obtained for 1 patient who had not received an injection) from study 3. The median number of BoNTA treatments received by these patients was 2 (range, 1-4 treatments) over a period lasting from 12 to 42 weeks. The mean dose of BoNTA was 241 U (range, 100-400 U), with a maximum dose of 960 U in any 1 patient. NAbs to BoNTA were detected in the serum sample of 1/191 (0.5%) patient who had participated in studies 1 and 2. Based on muscle-tone scores (3 and 4 for wrist and fingers, respectively) on a 5-point Ashworth Scale (0 = none to 4 = severe), the patient did not appear to exhibit a clinical response to BoNTA at any time during the studies.

CONCLUSION

Formation of NAbs was rare (1/191) in this group of adults with poststroke spasticity from three 12- to 42-week clinical trials who received >/=1 treatment with a specific BoNTA formulation at doses ranging from 100 to 400 U.

Intramuscular Electrical Stimulation for Shoulder Pain in Hemiplegia: Does Time From Stroke Onset Predict Treatment Success?

Background. A randomized clinical has shown the effectiveness of intramuscular electrical stimulation for the treatment of poststroke shoulder pain. Objective. Identify predictors of treatment success and assess the impact of the strongest predictor on outcomes. Method. This is a secondary analysis of a multisite randomized clinical trial of intramuscular electrical stimulation for poststroke shoulder pain. The study included 61 chronic stroke survivors with shoulder pain randomized to a 6-week course of intramuscular electrical stimulation (n = 32) versus a hemisling (n = 29). The primary outcome measure was Brief Pain Inventory Question 12. Treatment success was defined as ≥ 2-point reduction in this measure at end of treatment and at 3, 6, and 12 months posttreatment. Forward stepwise regression was used to identify factors predictive of treatment success among participants assigned to the electrical stimulation group. The factor most predictive of treatment success was used as an explanatory variable, and the clinical trials data were reanalyzed. Results. Time from stroke onset was most predictive of treatment success. Subjects were divided according to the median value of stroke onset: early (<77 weeks) versus late (> 77 weeks). Electrical stimulation was effective in reducing poststroke shoulder pain for the early group (94% vs 7%, P < .001) but not for the late group (31% vs 33%). Repeated-measure analysis of variance revealed significant treatment ( P < .001), time from stroke onset ( P = .032), and treatment by time from stroke onset interaction ( P < .001) effects. Conclusions. Stroke survivors who are treated early after stroke onset may experience greater benefit from intramuscular electrical stimulation for poststroke shoulder pain. However, the relative importance of time from stroke onset versus duration of pain is not known.

Poststroke Shoulder Pain: Its Relationship to Motor Impairment, Activity Limitation, and Quality of Life

OBJECTIVE

To assess the relationship between poststroke shoulder pain, upper-limb motor impairment, activity limitation, and pain-related quality of life (QOL).

DESIGN

Cross-sectional, secondary analysis of baseline data from a multisite clinical trial.

SETTING

Outpatient rehabilitation clinics of 7 academic medical centers.

PARTICIPANTS

Volunteer sample of 61 chronic stroke survivors with poststroke shoulder pain and glenohumeral subluxation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

We measured poststroke shoulder pain with the Brief Pain Inventory question 12 (BPI 12), a self-reported 11-point numeric rating scale (NRS) that assesses "worst pain" in the last 7 days. Motor impairment was measured with the Fugl-Meyer Assessment (FMA). Activity limitation was measured with the Arm Motor Ability Test (AMAT) and the FIM instrument. Pain-related QOL was measured with BPI question 23, a self-reported 11-point NRS that assesses pain interference with general activity, mood, walking ability, normal work, interpersonal relationships, sleep, and enjoyment of life.

RESULTS

Stepwise regression analyses indicated that poststroke shoulder pain is associated with the BPI 23, but not with the FMA, FIM, or AMAT scores.

CONCLUSIONS

Poststroke shoulder pain is associated with reduced QOL, but not with motor impairment or activity limitation.

Intramuscular Electrical Stimulation for Hemiplegic Shoulder Pain

OBJECTIVE

Assess the effectiveness of intramuscular electrical stimulation in reducing hemiplegic shoulder pain at 12 mos posttreatment.

DESIGN

A total of 61 chronic stroke survivors with shoulder pain and subluxation participated in this multiple-center, single-blinded, randomized clinical trial. Treatment subjects received intramuscular electrical stimulation to the supraspinatus, posterior deltoid, middle deltoid, and upper trapezius for 6 hrs/day for 6 wks. Control subjects were treated with a cuff-type sling for 6 wks. Brief Pain Inventory question 12, an 11-point numeric rating scale was administered in a blinded manner at baseline, end of treatment, and at 3, 6, and 12 mos posttreatment. Treatment success was defined as a minimum 2-point reduction in Brief Pain Inventory question 12 at all posttreatment assessments. Secondary measures included pain-related quality of life (Brief Pain Inventory question 23), subluxation, motor impairment, range of motion, spasticity, and activity limitation.

RESULTS

The electrical stimulation group exhibited a significantly higher success rate than controls (63% vs. 21%, P = 0.001). Repeated-measure analysis of variance revealed significant treatment effects on posttreatment Brief Pain Inventory question 12 (F = 21.2, P < 0.001) and Brief Pain Inventory question 23 (F = 8.3, P < 0.001). Treatment effects on other secondary measures were not significant.

CONCLUSIONS

Intramuscular electrical stimulation reduces hemiplegic shoulder pain, and the effect is maintained for > or =12 mos posttreatment.

Pharmacological stimulant treatment of neurocognitive and functional deficits after traumatic and non-traumatic brain injury

The sequelae of a traumatic or acquired brain injury may manifest itself in many ways that include decreased attention and arousal as well as cognitive, emotional and sensorimotor deficits. The discussion that follows will serve as a review of the use of stimulants in the management of patients with strokes or traumatic brain injury. The indications discussed include treating deficits in attention and arousal, as well as facilitating functional recovery. The literature cited has been derived from various research and clinical settings. After briefly reviewing, biochemistry and neuroanatomy, the paper discusses pertinent treatment issues such as the timing of initiation and discontinuation of stimulating medication with emphasis on the varied, current clinical practices. With the complexity of the various neurochemical processes that occur as a result of secondary brain damage, it would be impossible to review all potential stimulating agents in a single article. The authors' intent was to review the most commonly used neurostimulants, various intervention strategies, potential benefits and caveats and long-term outcomes with the use of these medications.

Intramuscular neuromuscular electric stimulation for poststroke shoulder pain: A multicenter randomized clinical trial 11A commercial party with a direct financial interests in the results of the research supporting this article has or will confer a benefit on the author or 1 or more of the authors. NeuroControl Corp, Valley View, OH, intends to commercialize the device evaluated in this article and has submitted a premarket 510(K)application, which is currently pending US Food and Drug Administration review. Chae and Feldstein are consultants to NeuroControl. Walker was an employee of NeuroControl, and is now a consultant to NeuroControl. Fang is an employee of NeuroControl. During this study, Yu served as a consultant to NeuroControl and Grill was an employee of NeuroControl, but neither now has an affiliation with NeuroControl

OBJECTIVE

To assess the effectiveness of intramuscular neuromuscular electric stimulation (NMES) in reducing poststroke shoulder pain.

DESIGN

Multicenter, single-blinded, randomized clinical trial.

SETTING

Ambulatory centers of 7 academic rehabilitation centers in the United States.

PARTICIPANTS

Volunteer sample of 61 chronic stroke survivors with shoulder pain and subluxation.

INTERVENTION

Treatment subjects received intramuscular NMES to the supraspinatus, posterior deltoid, middle deltoid, and trapezius for 6 hours a day for 6 weeks. Control subjects were treated with a cuff-type sling for 6 weeks. Main outcome measure Brief Pain Inventory question 12 (BPI 12), an 11-point numeric rating scale administered in a blinded manner at the end of treatment, and at 3 and 6 months posttreatment.

RESULTS

The NMES group exhibited significantly higher proportions of success based on the 3-point or more reduction in BPI 12 success criterion at the end of treatment (65.6% vs 24.1%, P<.01), at 3 months (59.4% vs 20.7%, P<.01), and at 6 months (59.4% vs 27.6%, P<.05). By using the most stringent "no pain" criterion, the NMES group also exhibited significantly higher proportions of success at the end of treatment (34.4% vs 3.4%, P<.01), at 3 months (34.4% vs 0.0%, P<.001), and at 6 months (34.4% vs 10.3%, P<.05).

CONCLUSIONS

Intramuscular NMES reduces poststroke shoulder pain among those with shoulder subluxation and the effect is maintained for at least 6 months posttreatment.

Rehabilitation of movement disorders11A commercial party with a direct financial interest in the results of the research supporting this article has conferred or will confer a financial benefit upon the author or one or more of the authors. Elovic is on the advisory board and speaker’s bureau of Allergan

This self-directed learning module highlights several movement disorders. These include dystonia, chorea, tremors, and myoclonus. A description of the clinical presentation and associated disease processes is presented. Although the discussion on treatment focuses on pharmacologic intervention, surgical options are presented when appropriate. Other movement disorders (ie, parkinsonism) are discussed elsewhere in the Study Guide.

OVERALL ARTICLE OBJECTIVES

(a) To define the various symptoms and etiologies of dystonia; (b) to define chorea and its treatment; (c) to define tremors, including associated neurologic disorders, plus pharmacologic and potential surgical interventions; and (d) to describe the symptoms, classification, and treatment of primary and secondary myoclonus.

Acute Care Management of Post-TBI Spasticity

The management of persons with traumatic brain injury (TBI) who have acute spasticity remains a challenge. A correct stratification is essential to clinical care and determination of efficacy from proposed interventions. The secondary severe sequelae of spasticity after TBI can result in profound functional impairment. These concerns are often best addressed early in the patient's course. Limited research in the area of the acute care treatment of severe spasticity is available. The authors employ a review of the available data as well as recount their own clinical experience in the acute care management of severe spasticity to assist in developing an order for the plethora of potential treatments available to clinicians and researchers. We propose to use a case example to emphasize key clinic points in the management of spasticity in the acute care setting.

Outcome Assessment for Spasticity Management in the Patient With Traumatic Brain Injury

The objective of this article was to (1) review the engineering and medical literature to structure the available information concerning the assessment of spasticity in the neurological population; (2) to discuss the strengths and weaknesses of the different methods currently in use in spasticity assessment; and (3) make recommendations for future efforts in spasticity outcome assessment. Spasticity textbooks, Web sites, and OVID, IEEE, and Medline searches from 1966 through 2003 of spasticity, quantitative measure, or outcome assessment in the rehabilitation population were used as data sources. Over 500 articles were reviewed. Articles that discussed outcome measures used to assess interventions and evaluation of spasticity were included. Authors reviewed the articles looking at inclusion criteria, data collection, methodology, assessment methods, and conclusions for validity and relevance to this article. Issues such as clinical relevance, real-world function and lack of objectivity, and time consumed during performance are important issues for spasticity assessment. Some measures such as the Ashworth Scale remain in common use secondary to ease of use despite their obvious functional limitations. More functional outcome goals are plagued by being more time consuming and a general inability to demonstrate changes after an intervention. This may be secondary to the other factors that combine with spasticity to cause dysfunction at that level. Quantitative metrics can provide more objective measurements but their clinical relevance is sometimes problematic. The assessment of spasticity outcome is still somewhat problematic. Further work is necessary to develop measures that have real-world functional significance to both the individuals being treated and the clinicians. A lack of objectivity is still a problem. In the future it is important for clinicians and the engineers to work together in the development of better outcome measures.