The Spinal Cord Injury Spasticity Evaluation Tool: A Persian adaptation and validation study

OBJECTIVE

To adapt the Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET) into the Persian language (SCI-SETp) and to examine the reliability and validity of the SCI-SETp in patients with spinal cord injury (SCI).

DESIGN

A cross-sectional and prospective cohort validation study.

SETTING

University Neurological Physiotherapy Clinic.

PARTICIPANTS

Adult patients with SCI.

MAIN OUTCOME MEASURES

SCI-SET.

RESULTS

There was no missing data. No floor or ceiling effect was observed. Cronbach's α coefficient was 0.862. Factor analysis suggested 1 factor structure (Eigenvalue = 8.49) explained 24.27% of the total variance. The ICC_agreement for test-retest reliability was 0.84. The standard error of measurement and the smallest detectable change was 0.30 and 0.82, respectively. The divergent relationships demonstrated the SCI-SETp uniqueness construct.

CONCLUSION

The results support the reliability and validity of the SCI-SETp for assessing the impact of spasticity on daily life of patients with SCI.

Classification of spastic hemiplegic cerebral palsy in children

BACKGROUND

The Winter classification of spastic hemiplegic cerebral palsy (CP) is based on sagittal kinematic data from 3-dimensional gait analysis used in preoperative decision making and postoperative evaluation. Our goal was to investigate how well children with spastic hemiplegic CP can be classified using Winter criteria. Second, we assessed if patients move between groups over time and/or with surgical intervention.

METHODS

One hundred twelve patients with spastic hemiplegic CP with a mean age of 8.1 years were included. Medical records and the full gait analysis data were reviewed. Patients were classified using Winter criteria, and an independent sample t test was used to compare groups.

RESULTS

We found 26 patients (23%) that could not be classified according to Winter criteria. We defined these patients as group 0. This group showed the least deviation from normal values. Each of the 5 groups in our study showed a higher mean velocity of gait and were younger than any of the groups from the Winter study. In regard to rotational alignment, kinetic variables, and, to a certain extent, muscle tone, group 0 showed the least deviation from normal values; however, most differences were subtle. When reclassifying patients after a mean of 3 years, 8 of 15 had deteriorated in the nonsurgical group, moving to a higher numbered group, whereas 19 of 31 surgically treated patients had improved.

CONCLUSIONS

The Winter classification failed to classify 23% (26/112) of our spastic hemiplegic CP children. We suggest that the classification be complemented with the less involved group 0. In this way, all patients can be classified, and thus, treatment plans can be established for all patients. The classification can be divided into ankle, knee, and hip joint involvement. The ankle involvement can be further divided into 3 separate groups. Treating physicians should be aware of the possibility that patients may move into another classification group over time.

LEVEL OF EVIDENCE

Diagnostic level 4. See instructions to authors for a complete description of levels of evidence.

Measurement of plantarflexor spasticity in traumatic brain injury: correlational study of resistance torque compared with the modified Ashworth scale

OBJECTIVES

To examine the usefulness of a biomechanical measure, resistance torque (RT), in quantifying spasticity by comparing its use with a clinical scale, the modified Ashworth scale (MAS), and quantitative electrophysiological measures.

DESIGN

This is a correlational study of spasticity measurements in 34 adults with traumatic brain injury and plantarflexor spasticity. Plantarflexor spasticity was measured in the seated position before and after cryotherapy using the MAS and also by strapping each subject's foot and ankle to an apparatus that provided a ramp and hold stretch. The quantitative measures were (1) reflex threshold angle (RTA) calculated through electromyographic signals and joint angle traces, (2) Hdorsiflexion (Hdf)/Hcontrol (Hctrl) amplitude ratio obtained through reciprocal inhibition of the soleus H-reflex, (3) Hvibration (Hvib)/Hctrl ratio obtained through vibratory inhibition of the soleus H-reflex, and (4) RT calculated as the time integral of the torque graph between the starting and ending pulses of the stretch.

RESULTS

Correlation coefficients between RT and MAS scores in both pre-ice (0.41) and post-ice trials (0.42) were fair (P = 0.001). The correlation coefficients between RT scores and RTA scores in both the pre-ice (0.66) and post-ice trials (0.75) were moderate (P <or= 0.001).

CONCLUSION

RT is a measure of the cumulative torque during an imposed stretch. The MAS is a subjective measure of the cumulative resistance perceived by the clinician during an imposed stretch. RT seems to be a fair quantitative correlate of the MAS in assessing spasticity.

Quantifying spasticity in a clinical setting

We describe a technique specifically designed for use in a clinical setting to quantify the spastic reflex response. Spasticity, which manifests as a hyperactive stretch reflex response, is the major component of cerebral palsy (CP) that interferes with normal function. Clinically, a patient's spasticity is monitored and subjectively graded by an examiner while moving the joint throughout its range of motion. Grading of the abnormal resistance is classified by clinical scales. The subjective clinical scales, however, tend to have poor inter-rater reliability and often poor correlation with functional improvements. Although objective measures of spasticity exist, their use has been limited to research laboratories, they have not been applied to the CP population, and their usefulness is determined by their correlation with subjective clinical measures. We describe a technique to quantify spasticity in a clinical setting. This technique, termed CATCH (Computer Assisted Technique to Characterize Hypertonia) integrates measurement of joint kinematics and muscle electromyography to quantify the spastic reflex response in CP. Three clinical cases are presented. These preliminary examples from the clinic suggest that this technique provides an improved method to monitor spasticity.

A systematic review of the Tardieu Scale for the measurement of spasticity

BACKGROUND

The Tardieu Scale has been suggested a more appropriate clinical measure of spasticity than the Ashworth or modified Ashworth Scales. It appears to adhere more closely to Lance's definition of spasticity as it involves assessment of resistance to passive movement at both slow and fast speeds.

OBJECTIVE

To review the available literature in which the Tardieu Scale has been used or discussed as a measure of spasticity, with a view to determining its validity and reliability.

STUDY DESIGN

A systematic review of all literature found related to the Tardieu Scale (keywords: Tardieu scale, spasticity) from Pubmed and Ovid databases, including medline, CINAHL, EMBASE, Journals at Ovid full text, EBM reviews and Cochrane database of systematic reviews. Hand searching was also used to track the source literature.

CONCLUSIONS

In theory, we can acknowledge that the Tardieu Scale does, in fact, adhere more closely to Lance's definition of spasticity. However, there is a dearth of literature investigating validity and reliability of the scale. Some studies have identified the Tardieu Scale to be more sensitive than other measures, to change following treatment with botulinum toxin. Further studies need to be undertaken to clarify the validity and reliability of the scale for a variety of muscle groups in adult neurological patients.

The guidelines for the diagnosis and treatment of spasticity

Spasticity is a predominant clinical sign appearing in different neurological diseases. It is always flanked by various degrees of muscle weakness. The clinical evaluation of a spastic patient is score according to varius internationally approved evaluation scales (Ashworth scale, muscle spasms scale, and FIM disability scale). The treatment of spasticity is mostly a symptomatic treatment aimed to relief muscle hypertonus thus increasing both motor performance and improving nursing. Many molecules are frequently being used orally with poor results or with the onset of undesired side effects. In fact oral baclofen, diazepam and tizanidine often have poor effect on spasticity and bring frequently to the appearance of undesired side effects caused by the concentration of these molecule at the brain level. Intrathecal baclofen is a good option to treat diffuse spasticity through the infusion of baclofen into the spinal CSF space. When baclofen is administered intrathecally at the spinal level it distributes with a concentration-gradient between caudal and rostral level of the spine that was calculated as 4:1 thus avoiding its concentration at the brain level when given at a therapeutical dosage. This fact avoids any undesired side effect due to the action of baclofen at the brain level. Botulinum toxin as well as peripheral neurotomies are very helpful in those cases in whom spasticity is mainly restricted to few muscular groups. A correct flow-chart to diagnose and treat the patient is mandatory to achieve the best results for each patient according to his spasticity and residual motor ability.

Spasticity-assessment: a review

STUDY DESIGN

Review of the literature on the validity and reliability of assessment of spasticity and spasms.

OBJECTIVES

Evaluate the most frequently used methods for assessment of spasticity and spasms, with particular focus on individuals with spinal cord lesions.

SETTING

Clinic for Spinal Cord Injuries, Rigshospitalet, University Hospital of Copenhagen, and Department of Medical Physiology, University of Copenhagen, Denmark.

METHODS

The assessment methods are grouped into clinical, biomechanical and electrophysiological, and the correlation between these is evaluated.

RESULTS

Clinical methods: For assessment of spasticity, the Ashworth and the modified Ashworth scales are commonly used. They provide a semiquantitative measure of the resistance to passive movement, but have limited interrater reliability. Guidelines for the testing procedures should be adhered to. Spasm frequency scales seem not to have been tested for reliability. Biomechanical methods such as isokinetic dynamometers are of value when an objective quantitative measure of the resistance to passive movement is necessary. They play a minor role in the daily clinical evaluation of spasticity. Electrophysiological methods: These techniques have provided valuable insight to the pathophysiological mechanisms involved in spasticity, but none of these techniques provide an easy and reliable assessment of spasticity for use in the daily clinic.

CONCLUSION

A combination of electrophysiological and biomechanical techniques shows some promise for a full characterization of the spastic syndrome. There is a need of simple instruments, which provide a reliable quantitative measure with a low interrater variability.

Hip displacement in cerebral palsy

BACKGROUND

Hip displacement is considered to be common in children with cerebral palsy but the reported incidence and the proposed risk factors vary widely. Knowledge regarding its overall incidence and associated risk factors can facilitate treatment of these children.

METHODS

An inception cohort was generated from the Victorian Cerebral Palsy Register for the birth years 1990 through 1992, inclusive, and multiple data sources pertaining to the cohort were reviewed during 2004. Gross motor function was assessed for each child and was graded according to the Gross Motor Function Classification System (GMFCS), which is a valid, reliable, five-level ordinal grading system. Hip displacement, defined as a migration percentage of >30%, was measured on an anteroposterior radiograph of the pelvis with use of a reliable technique.

RESULTS

A full data set was obtained for 323 (86%) of 374 children in the Register for the birth years 1990 through 1992. The mean duration of follow-up was eleven years and eight months. The incidence of hip displacement for the entire birth cohort was 35%, and it showed a linear relationship with the level of gross motor function. The incidence of hip displacement was 0% for children with GMFCS level I and 90% for those with GMFCS level V. Compared with children with GMFCS level II, those with levels III, IV, and V had significantly higher relative risks of hip displacement (2.7, 4.6, and 5.9, respectively).

CONCLUSIONS

Hip displacement is common in children with cerebral palsy, with an overall incidence of 35% found in this study. The risk of hip displacement is directly related to gross motor function as graded with the Gross Motor Function Classification System. This information may be important when assessing the risk of hip displacement for an individual child who has cerebral palsy, for counseling parents, and in the design of screening programs and resource allocation.

Reliability of elbow stretch reflex assessment in chronic post-stroke hemiparesis

OBJECTIVE

To establish reliability of quantitative measures of elbow joint spastic hypertonia in post-stroke hemiparesis.

METHODS

Nine subjects with post-stroke hemiparesis (mn duration: 42 months) were tested on three separate days. Biceps brachii and brachioradialis EMG were recorded during passive ramp-and-hold extensions applied at seven speeds between 30 and 210 degrees /s. EMG burst duration, onset position threshold, and burst intensity were used to evaluate reflex activity. Torque at 40 degrees of elbow flexion was used as a mechanical indicator of spastic hypertonia.

RESULTS

Across speeds ICCs were consistent, means ranged between 0.63 and 0.85. Thus, relative reliability was fair to excellent for all parameters. Absolute reliability, determined using standard error of measurement expressed as a percentage of the mean score (%SEM), improved at higher speeds (> or = 120 degrees/s).

CONCLUSIONS

These results establish reliability of reflex and mechanical measures of elbow spastic hypertonia post-stroke. The data demonstrate greater reflex detection at high speeds, indicating greater potential to document meaningful changes in these distinct aspects of spastic hypertonia following intervention.

SIGNIFICANCE

Based on findings of this study, reliability was demonstrated using four parameters of reflex EMG and torque indicating measurement consistency across sessions. These observations motivate determination of requisite effect sizes for clinical trials that evaluate treatment outcome.

Spastic wrist flexors are more severely affected than wrist extensors in children with cerebral palsy

Morphological properties of skeletal muscle were compared between wrist flexors and extensors within the same children (n = 8, six females, two males; age range 4 to 9y, median age 7 y) with wrist muscle imbalance secondary to spastic cerebral palsy (CP). Five patients had hemiplegic CP, two diplegic CP, and one patient had tetraplegic CP. Muscle biopsies were taken during either tendon transfer or tendon lengthening procedures. Analyses included distribution of muscle fibre types, fibre sizes, and expression of developmental myosins. Extensor fibre area was significantly greater than flexor fibre area for type 2A fibres and type 2B fibres but not for type 1 fibres. Coefficient of variation (CV) of fibre size for all three fibre types was greater for flexors compared with extensors. The greatest CV was observed for the type 2A fibres in flexors (39.5 [3.6%]). A wide variation was observed for expression of developmental myosin with the magnitude of the expression being greater, but not statistically significant, in flexors compared with extensors (5.4/mm2 vs 0.53/mm2). These data demonstrate that significant secondary myopathy of wrist flexor muscles results from CP.

Multiple Sclerosis and Spasticity

Spasticity is a common impairment in MS. It can result in significant medical complications and is associated with increased disability. Treatment strategies include skilled rehabilitation strategies, neuromuscular blocks, oral agents, intrathecal management, and surgery. Rehabilitation strategies are central, whereas other strategies are added based on the level of impairment and functional loss. Treatment strategies for spasticity management are far from optimal and are complicated in MS as a result of lesions in the brain and the spinal cord. Pharmaceutical management in MS is complicated by the numerous secondary impairments in MS and its associated polypharmacy.Head-to-head studies of the various agents are rare. The studies that exist are small and do not point to any one strategy over another. Although management is difficult, it is essential for the health, functional status, and well-being of the individual who has MS. Providers must use well-developed clinical skills to arrive at optimal individualized treatment programs and monitor them frequently. For spasticity that is unresponsive, referral to a MS Center with a spasticity program is ideal.

The influence of contractures and variation in measurement stretching velocity on the reliability of the Modified Ashworth Scale in patients with severe brain injury

OBJECTIVE

To determine the influence of contractures and different stretching velocities on the reliability of the Modified Ashworth Scale (MAS) in patients with severe brain injury and impaired consciousness.

DESIGN

Cross-section observational study.

SETTING

A rehabilitation centre for adult persons with neurological disorders.

SUBJECTS

Fifty patients with impaired consciousness due to severe cerebral damage of various aetiologies. MEASUREMENT PROTOCOL: Three experienced and trained medical professionals rated each patient in a randomized order once daily for two consecutive days. Shoulder, elbow, wrist, knee and ankle spasticity were assessed by the use of the MAS with different stretching velocities. The presence of contractures was assessed by a goniometer.

MAIN OUTCOME MEASURES

Retest and inter-rater reliability (k(w) = weighted kappa) of the MAS.

RESULTS

The retest reliability of the MAS was good (shoulder joints (k(w) 0.74), elbow joints (k(w) 0.74), wrist joints (k(w) 0.72), knee joints (k(w) 0.72), ankle joints (k(w) 0.77)) and the inter-rater reliability was moderate (shoulder joints (k(w) 0.49), elbow joints (k(w) 0.52), wrist joints (k(w) 0.51), knee joints (k(w) 0.54) ankle joints (k(w) 0.49)). The presence of contractures significantly influenced the reliability of MAS in shoulder and wrist joints. No influence of stretching velocity on the reliability of the MAS was found.

CONCLUSION

In patients with impaired consciousness due to severe brain injury the MAS has good retest, but only limited inter-rater, reliability. The presence of contractures may influence reliability of the MAS, but stretching velocity does not.

Evaluation of upper-limb spasticity after stroke: A clinical and neurophysiologic study

OBJECTIVES

To assess upper-limb spasticity after stroke by means of clinical and instrumental tools and to identify possible variables influencing the clinical pattern.

DESIGN

Descriptive measurement study of a consecutive sample of patients with upper-limb spasticity after stroke.

SETTING

Neurorehabilitation hospital.

PARTICIPANTS

Sixty-five poststroke hemiplegic patients.

INTERVENTIONS

Not applicable. Main outcome measures Upper-limb spasticity, as assessed clinically (Modified Ashworth Scale [MAS], articular goniometry) and neurophysiologically (maximum H-reflex [Hmax], maximum M response [Mmax], Hmax/Mmax ratio).

RESULTS

Poorer MAS scores were associated with lower passive range of motion (PROM) values at the wrist ( P =.01) and elbow ( P =.002). The flexor carpi radialis Hmax/Mmax ratio correlated directly with MAS scores at the wrist ( P =.005) and correlated inversely with PROM. The presence of pain in the fingers, wrist, and elbow was significantly associated only with lower PROM values at the wrist.

CONCLUSIONS

Upper-limb spasticity is involved in the development of articular PROM limitation after a stroke. Pain appears to be related to PROM reduction as well, but the exact causal relationship between these 2 factors is still unclear. The MAS and the Hmax/Mmax ratio correlated when evaluating poststroke spasticity; they characterize 2 different aspects of spasticity, clinical and neurophysiologic, respectively, and they could be used as an integrated approach to study and follow poststroke patients.

Comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions: a systematic review

Skeletal muscle relaxants are a heterogeneous group of medications used to treat two different types of underlying conditions: spasticity from upper motor neuron syndromes and muscular pain or spasms from peripheral musculoskeletal conditions. Although widely used for these indications, there appear to be gaps in our understanding of the comparative efficacy and safety of different skeletal muscle relaxants. This systematic review summarizes and assesses the evidence for the comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions. Randomized trials (for comparative efficacy and adverse events) and observational studies (for adverse events only) that included oral medications classified as skeletal muscle relaxants by the FDA were sought using electronic databases, reference lists, and pharmaceutical company submissions. Searches were performed through January 2003. The validity of each included study was assessed using a data abstraction form and predefined criteria. An overall grade was allocated for the body of evidence for each key question. A total of 101 randomized trials were included in this review. No randomized trial was rated good quality, and there was little evidence of rigorous adverse event assessment in included trials or observational studies. There is fair evidence that baclofen, tizanidine, and dantrolene are effective compared to placebo in patients with spasticity (primarily multiple sclerosis). There is fair evidence that baclofen and tizanidine are roughly equivalent for efficacy in patients with spasticity, but insufficient evidence to determine the efficacy of dantrolene compared to baclofen or tizanidine. There is fair evidence that although the overall rate of adverse effects between tizanidine and baclofen is similar, tizanidine is associated with more dry mouth and baclofen with more weakness. There is fair evidence that cyclobenzaprine, carisoprodol, orphenadrine, and tizanidine are effective compared to placebo in patients with musculoskeletal conditions (primarily acute back or neck pain). Cyclobenzaprine has been evaluated in the most clinical trials and has consistently been found to be effective. There is very limited or inconsistent data regarding the effectiveness of metaxalone, methocarbamol, chlorzoxazone, baclofen, or dantrolene compared to placebo in patients with musculoskeletal conditions. There is insufficient evidence to determine the relative efficacy or safety of cyclobenzaprine, carisoprodol, orphenadrine, tizanidine, metaxalone, methocarbamol, and chlorzoxazone. Dantrolene, and to a lesser degree chlorzoxazone, have been associated with rare serious hepatotoxicity.

Cerebral palsy rates among low-birthweight infants fell in the 1990s

Using a population-based register, this study sought to ascertain changes in the rate and severity of cerebral palsy (CP) in a geographically defined area of the UK among infants weighing less than 1500 g and born between 1984 and 1995. There were 417414 live births in the area, which included Berkshire, Buckinghamshire, Northamptonshire, and Oxfordshire. Of the 898 children with CP (526 males, 372 females), 194 (21.6%) weighed less than 1500 g at birth. The overall CP rate for neonatal survivors fell from 2.5 out of every 1000 in 1984 to 1986 to 1.7 in 1993 to 1995. The rate for those weighing less than 1000 g rose to 90 out of every 1000 neonatal survivors in 1987 to 1989 and then fell to 57 in 1993 to 1995. A similar pattern is seen among infants weighing 1000 to 1499 g at birth, the rate rising to 77 in 1987 to 1988 and then falling to 40 in 1993 to 1995. The rate of severe motor disability among infants weighing less than 1500 g also decreased (24.6 in 1984-1986 to 12.5 in 1993-1995). The relation of these findings to changes in perinatal care in the early 1990s is not known.

The effect of spasticity on cortical somatosensory-evoked potentials: changes of cortical somatosensory-evoked potentials after botulinum toxin type A injection

OBJECTIVE

To evaluate the changes in cortical somatosensory-evoked potentials (SEPs) after botulinum toxin type A injection to determine what effect spasticity has on cortical SEPs.

DESIGN

Intervention study and before-after trial.

SETTING

University-affiliated hospital in Korea.

PARTICIPANTS

Twelve children with spastic hemiplegic cerebral palsy (CP), 7 children with spastic diplegic CP, and 8 patients with traumatic brain injury.

INTERVENTION

All participants had botulinum toxin type A injected into the muscles of the spastic limb.

MAIN OUTCOME MEASURES

SEPs were recorded before and 7 days after the botulinum toxin type A injection. Spasticity of the affected spastic limb was also measured. The short latency and amplitude of waves in SEPs were measured. The SEP results were divided into 3 groups: flat (no evoked potential), abnormal (evoked but delayed in latency), and normal (clear waveform with normal latency).

RESULTS

The normal response of cortical SEP increased after injection. The SEPs exhibited more frequent improvement in the limbs, with greater improvement of spasticity in grade (>1.0 grade) and in patients of younger age (<3y) after injection (P<.05).

CONCLUSION

The observed improvement of cortical SEPs with associated reduction of spasticity that occurred after the botulinum toxin type A injection indicates that spasticity itself can be considered a factor affecting cortical SEPs.

[Evaluation of pendulum testing of spasticity]

OBJECTIVES

To identify valid measurements of spasticity derived from the pendulum test of the leg in a representative population of spastic patients.

MATERIAL AND METHODS

Pendulum testing was performed in 15 spastic and 10 matched healthy subjects. The reflex-mediated torque evoked in quadriceps femoris, as well as muscle mechanical parameters (viscosity and elasticity), were calculated using mathematical modelling. Correlation with the two main measures derived from the pendulum test reported in the literature (the Relaxation Index and the area under the curve) was calculated in order to select the most valid.

RESULTS, DISCUSSION

Among mechanical parameters, only viscosity was found to be significantly higher in the spastic group. As expected, the computed integral of the reflex-mediated torque was found to be larger in spastics than in healthy subjects. A significant non-linear (logarithmic) correlation was found between the clinically-assessed muscle spasticity (Ashworth grading) and the computed reflex-mediated torque, emphasising the non-linear behaviour of this scale. Among measurements derived from the pendulum test which are proposed in the literature for routine estimation of spasticity, the Relaxation Index exhibited an unsuitable U-shaped pattern of variation with increasing reflex-mediated torque. On the opposite, the area under the curve revealed a linear regression, which is more convenient for routine estimation of spasticity.

CONCLUSION

The pendulum test of the leg is a simple technique for the assessment of spastic hypertonia. However, the measurement generally used in the literature (the Relaxation Index) exhibits serious limitations, and would benefit to be replaced by more valid measures, such as the area under the goniometric curve, especially for the assessment of therapeutics.

Spastic hypertonia. Appendix

This appendix reviews the most commonly used clinical methods for assessing the clinical treatment of spastic hypertonia. The definitions and rating scales shown often are accepted by the Food and Drug Administration for pharmaceutical and investigational trials to obtain a clinical indication for use in spasticity clinic.

Classification of gait patterns in spastic hemiplegia and spastic diplegia: a basis for a management algorithm

Classifications of gait and postural patterns in spastic hemiplegia and spastic diplegiía are presented, based on the work of previous authors. The classifications are used as a biomechanical basis, linking spasticity, musculoskeletal pathology in the lower limbs, and the appropriate intervention strategies. The choice of target muscles for spasticity management, the muscle contractures requiring lengthening and the choice of orthotics are then linked to the underlying gait pattern.

Prospective assessment of tizanidine for spasticity due to acquired brain injury

OBJECTIVE

To determine if orally delivered tizanidine will control spastic hypertonia due to acquired brain injury.

DESIGN

Randomized, double-blind, placebo-controlled, crossover design, with 2 8-week treatment arms separated by a 1-week washout period at baseline. Patients were randomly assigned to receive tizanidine or a matching placebo.

SETTING

Tertiary care outpatient and inpatient rehabilitation center attached to a university hospital.

PARTICIPANTS

Seventeen persons recruited in a consecutive manner, 9 of whom had suffered a stroke and 8 a traumatic brain injury, and had more than 6 months of intractable spastic hypertonia.

INTERVENTION

Over a 6-week period, subjects were slowly titrated up to their maximum tolerated dose (up to 36 mg/d). Following a 1-week drug taper and 1-week period in which no study drug was administered, patients were then crossed over to the other study medication following an identical titration regime.

MAIN OUTCOME MEASURES

Subjects were evaluated for dose and effect throughout the trial as well as for side effects. Data for Ashworth rigidity scores, spasm scores, deep tendon reflex scores, and motor strength were collected on the affected upper extremity (UE) and lower extremity (LE). Differences over time were assessed via descriptive statistics, Friedman's analysis, and Wilcoxon's signed-rank. Data are reported as the mean +/- 1 standard deviation.

RESULTS

Following 4 weeks of treatment when subjects reached their maximal tolerated dosage, the average LE Ashworth score on the affected side decreased from 2.3 +/- 1.4 to 1.7 +/- 1.1 (p <.0001). The spasm score decreased from 1.0 +/- 0.9 to 0.5 +/- 0.8 (p =.0464), while the reflex score was not statistically significant decreasing from 2.2 +/- 1.0 to 2.0 +/- 1.1 (p =.0883). The average UE Ashworth score on the affected side decreased from 1.9 +/- 1.1 to 1.5 +/- 0.9 (p <.0001). There was no significant change in the UE spasm and reflex scores. While there were positive placebo effects on motor tone, the active drug was still significantly better than placebo for decreasing LE tone (p =.0006) and UE tone (p =.0007). With a reduction in motor tone, there was an increase in motor strength (p =.0089). The average dosage at 4 weeks was 25.2mg/d.

CONCLUSION

Tizanidine is effective in decreasing the spastic hypertonia associated with acquired brain injury, which is dose-dependent. There are limitations on its use due to side effects related to drowsiness.

[Spasticity and physical methods for controlling it]

Spasticity is one of the greatest difficulties in patients with central nervous system injuries and diseases. Severe spasticity makes treatment, rehabilitation and care of patient very difficult and sometimes even impossible. It has been sought for many years for an objective method to evaluate the degree of spasticity, necessary to establish the results of treatment and rehabilitation. In this study we present subjective and objective methods of evaluating the spasticity in order to classify every patient to adequate therapeutic group. The authors present physical methods that not only contribute to control of spasticity together with pharmacotherapy and surgical treatment, but can be used alone. The big advantage of this therapy is a low invasiveness and the very few side effects.

Ankle spasticity and strength in children with spastic diplegic cerebral palsy

Ankle spasticity and strength in 27 children with spastic diplegic cerebral palsy (CP) (mean age 9 years, range 3 to 18 years) and a group of 12 children without CP (comparison group) (mean age 9 years, range 5 to 18 years) were observed. To measure spasticity, a KinCom dynamometer dorsiflexed the passive ankle at five different speeds and recorded the resistive plantarflexion torques. Work values for the torque-angle data were calculated at each speed. Using this data, linear regression was used to measure spasticity. To measure strength, the dynamometer rotated the ankle from maximum dorsiflexion to maximum plantarflexion at a speed of 10 degrees/s while the child performed a maximum plantarflexion concentric contraction. The movement was reversed to record maximum dorsiflexion. Maximum torques and work by the plantarflexors and dorsiflexors were calculated. The group with CP had significantly more spasticity in the plantarflexors and significantly less strength in the plantarflexors and dorsiflexors than the group without CP. Results provide objective information quantifying ankle spasticity and strength in children with CP.

Spasticity after traumatic spinal cord injury: nature, severity, and location

OBJECTIVE

To assess spasticity in a prevalence population of persons with traumatic spinal cord injury (SCI), and determine the degree of correspondence between self-reported spasticity and investigator-elicited spasticity using the modified Ashworth scale.

DESIGN

Survey of a near total (88%) prevalence population.

SETTING

Outpatient clinic of a university hospital.

PATIENTS

A total of 354 individuals with SCI.

MAIN OUTCOME MEASURES

The survey includes self-reported symptoms, neurologic examination (American Spinal Injury Association [ASIA] classification), physical therapy examination, range of motion (ROM), and complications.

RESULTS

Presence of problematic spasticity was significantly correlated with cervical incomplete (ASIA B-D) injury. Reports of beneficial effects of spasticity were significantly less common in women. Self-reported problematic spasticity was significantly correlated with extensor spasticity. Spasticity was elicitable by movement provocation in 60% of the patients reporting spasticity. Significant correlations were found between elicitable spasticity and limited ROM.

CONCLUSION

Flexion, extension, and abduction movements performed with the patient placed in a standardized supine test position are suitable both for test of ROM and degree of spasticity. Spasticity was not elicitable by movement provocation on physical examination in 40% of the patients who reported spasticity, thus indicating that the patient's self-report is an important complement to the clinical assessment. A significant association between spasticity and contractures (reduced ROM) was seen.

A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity

BACKGROUND

The Ashworth Scale and the modified Ashworth Scale are the primary clinical measures of spast city. A prerequisite for using any scale is a knowledge of its characteristics and limitations, as these will play a part in analysing and interpreting the data. Despite the current emphasis on treating spasticity, clinicians rarely measure it.

OBJECTIVES

To determine the validity and the reliability of the Ashworth and modified Ashworth Scales.

STUDY DESIGN

A theoretical analysis following a structured literature review (key words: Ashworth; Spasticity; Measurement) of 40 papers selected from the BIDS-EMBASE, First Search and Medline databases.

CONCLUSIONS

The application of both scales would suggest that confusion exists on their characteristics and limitations as measures of spasticity. Resistance to passive movement is a complex measure that will be influenced by many factors, only one of which could be spasticity. The Ashworth Scale (AS) can be used as an ordinal level measure of resistance to passive movement, but not spasticity. The modified Ashworth Scale (MAS) will need to be treated as a nominal level measure of resistance to passive movement until the ambiguity between the '1' and '1+' grades is resolved. The reliability of the scales is better in the upper limb. The AS may be more reliable than the MAS. There is a need to standardize methods to apply these scales in clinical practice and research.

Beyond Ashworth. Electrophysiologic quantification of spasticity

Spasticity is a hallmark of upper motor neuron lesion, which is easily identified but is difficult to quantify and treat. The Ashworth scale lacks reliability. Available biomechanical and electrophysiologic studies offer a more reliable measure of spastic hypertonia but have limited clinical utility. A uniformly acceptable, reliable, and practical measure of spasticity continues to elude the clinician. This chapter reviews the basic neuroanatomy and physiology of the stretch reflex and the pathophysiology of the spasticity. Current biomechanical and electrophysiological techniques are used to quantify spasticity.

Simultaneous Ashworth measurements and electromyographic recordings in tetraplegic patients

OBJECTIVE

A recent prevalence study of 353 spinal cord injured (SCI) individuals in the greater Stockholm area showed problematic spasticity in 30% of this population. To treat spasticity, the evaluation becomes crucial. The modified Ashworth scale (MAS) is the clinically most-used scale to grade degree of spasticity. This study evaluated whether the MAS correlated with electromyographic (EMG) recordings of muscle activity.

STUDY DESIGN

This cross-sectional study was performed at an outpatient clinic that has the responsibility to do a standardized, yearly follow-up of all SCI patients in the greater Stockholm area. Thirty-eight SCI individuals met the inclusion criteria; 15 of the 38 were randomly selected for the study. They were all motor-complete tetraplegic men; mean age was 33 years and mean time since injury was 9 years. Spasticity evaluation was performed by flexing and extending the knees during simultaneous EMG recordings and MAS assessment of the thigh muscle activity.

RESULTS

Eighty percent of the individual EMG recordings correlated significantly with the corresponding Ashworth measurements. The spastic resistance, as measured both clinically and electromyographically, was stronger and lasted longer during extension than flexion movements. Spearman coefficients for correlation of quantitative spasticity measures with MAS grades were calculated. EMG and clinical measures of spasticity were more closely correlated for flexion movements. Among EMG parameters, duration of movement-associated electrical activity invariably correlated significantly with the MAS grades (p < .05). Furthermore, Ashworth measurements of movement-associated spasticity showed a positive correlation with the EMG parameters mean, peak, and start to peak of electrical activity. Each increasing grade on the MAS corresponded to increasing myoelectric activity levels for each movement.

CONCLUSION

EMG parameters were significantly positively correlated with simultaneous MAS measurements of the spastic muscle contraction. The Ashworth scale may therefore accurately reflect the movement-provoked spasticity in motor-complete tetraplegic patients.

[A new classification of the motor disorders in patients who have had a stoke]

A new classification is substantiated of motor syndromes in patients with hemispheric cerebral insult. The classification is represented by six syndromes, it takes advantage of the degree of upper and lower monoparesis, relation between the two, condition of muscular tone, ability of people to help themselves, to cope in their homes, and other items. Correctness of the classification has been confirmed by the method of correlation analysis and parameters of stimulation electromyography. The use of the classification will, we believe, help in administering the relevant rehabilitative therapy treatments in a more efficient way.

Relating clinical and neurophysiological assessment of spasticity by machine learning

Spasticity following spinal cord injury (SCI) is most often assessed clinically using a five-point Ashworth score (AS). A more objective assessment of altered motor control may be achieved by using a comprehensive protocol based on a surface electromyographic (sEMG) activity recorded from thigh and leg muscles. However, the relationship between the clinical and neurophysiological assessments is still unknown. In this paper we employ three different classification methods to investigate this relationship. The experimental results indicate that, if the appropriate set of sEMG features is used, the neurophysiological assessment is related to clinical findings and can be used to predict the AS. A comprehensive sEMG assessment may be proven useful as an objective method of evaluating the effectiveness of various interventions and for follow-up of SCI patients.

Quantitative clinical measure of spasticity in children with cerebral palsy

OBJECTIVE

This investigation developed an objective measure to quantify the degree of spasticity.

DESIGN

Specifications included a single variable that integrated key elements characterizing spasticity: velocity, range of motion, and resistance to passive motion. A dynamometer at a children's hospital quantified the passive resistance of the hamstrings to knee extension for a range of motion at 4 different speeds for the prospective descriptive investigation.

PATIENTS

A convenience sample of six children with able bodies and 17 children with spastic diplegic cerebral palsy volunteered. DATA PROCESSING: Torque-angle data were processed to calculate the work done by the machine on the children for each speed and then determine the slope of the work-velocity curves. This slope was considered to be the measure of spasticity and it was hypothesized that children with cerebral palsy would have a greater slope than children with able bodies. An independent test determined whether a significant difference existed between groups (p < .05).

RESULTS

Torque-angle data for children with able bodies indicated little change in passive resistance as a function of speed. Similar data for children with cerebral palsy indicated larger resistive torques with increasing speed. Slope from the work-velocity data was close to zero for children with able bodies [.003 J/(degrees/sec)], while the corresponding slope for children with cerebral palsy was approximately 10 times greater [.031 J/(degrees/sec)] and significantly different (p < .05).

CONCLUSION

The slope of the work-velocity data integrates three major components characterizing spasticity, it is a single number that can easily be evaluated and interpreted in a clinical setting, and it utilizes a machine that is available at many centers.

Reliability of the Modified Ashworth Scale in the assessment of plantarflexor muscle spasticity in patients with traumatic brain injury

Although the Modified Ashworth Scale (MAS) is commonly used to assess the severity of muscle spasticity for ankle plantarflexors, its reliability has only been established for elbow muscles. Interrater reliability, intrarater reliability and temporal (between-days) reliability were examined in this study. Also, interrater reliability for use of the scale with plantarflexors was compared with reported results from the measurement of elbow flexors. Thirty adult volunteers with traumatic brain injuries participated. There were 20 men and 10 women; the mean age was 28.3 years (SD = 10.8). Two physical therapists used the MAS to score the subjects independently. Measurements were repeated to yield multiple scores for intrarater reliability assessment. Twenty-one of the subjects returned individually on separate days to be measured again, so that temporal reliability could be assessed. Spearman's correlation coefficients were 0.73 for interrater reliability 0.74 and 0.55 for intrarater reliability, and 0.82 for temporal reliability. Overall, reliability of the MAS for assessing plantarflexor spasticity in patients with traumatic brain injury was found to be minimally adequate to support its continued use. However, interrater reliability was less than that which has been reported for elbow flexors, and intrarater reliability findings were mixed.

Management of the unbalanced wrist in cerebral palsy by tendon transfer

Over a 25-year period, 60 children with spasticity of the upper extremity mainly resulting from cerebral palsy underwent surgical reconstruction of the unbalanced wrist. A detailed classification of the deformity is described on the basis of the functional anatomy of the unbalanced wrist in cerebral palsy, which was divided into three groups. In retrospective analysis of the long-term results, this classification has proved helpful in selecting an option for the treatment of this difficult deformity. In addition, the described classification has aided us in keeping accurate follow-up records in predicting the progress of the patient, and in coordinating the postoperative treatment.

[Treatment of deformities of the locomotor system in hemiplegia]

In spastic hemiplegia mainly one side of the body is affected. In both the upper and the lower extremity the distal parts (hand and foot) are more severely involved than the proximal region. In cases of minor involvement the goal of treatment in the upper extremity is to achieve functional improvement by means of splinting and surgery. In cases of severe alterations cosmetic improvement without much functional gain is all that can be expected. Gait analysis has demonstrated that there are four basic patterns that can be related to the severity of involvement. In type I muscle imbalance exists without a contracture. In type II there is contracture of the muscles of the posterior compartment of the calf. In type III, in addition to the changes around the ankle joint, contractures around the knee are present, and in type IV also hip problems. Functional improvement can be achieved by means of splinting and surgery in all types. Basic principles of treatment have developed as a result of the application of gait analysis and dynamic electromyography. Specific examples of such treatment principles have recently been presented by Gage.

Cerebral palsy: survival rates, associated handicaps, and distribution by clinical subtype (Rochester, MN, 1950-1976)

We identified 64 cases of cerebral palsy (CP) born to Rochester residents in 1950-76. The majority (73%) had one of the spastic syndromes. Ataxic and dyskinetic syndromes constituted 16% and 6%, respectively. Survival follow-up was available through 1980 birthdates. Using life-table methods, we calculated survival rates for the first 10 years of life. For severely or profoundly retarded children, survival was 68% at 5 years and 54% at 10 years. All others survived through their 1980 birthday. Follow-up of CP resolution was available through the seventh birthday. Cases born in 1968-76 had the highest resolution rate (30%). For mild CP, the 1968-76 resolution rate was 86%.

Genetic approaches to the nosology of nervous system defects

The significance of genetics to the nosology of nervous system diseases has been shown in spastic paraplegias and spinocerebellar ataxias. At least about 60 different genetic types have been recognized to date. In most diseases, the genetic exploration and discrimination of types has been possible only by clinical, pathologic and simple genetic criteria like transmission. Further differentiation of genetic entities will be done especially through biochemical investigation.