Spasticity-assessment: a review

Modification of spasticity by transcutaneous spinal cord stimulation in individuals with incomplete spinal cord injury

CONTEXT/OBJECTIVE

To examine the effects of transcutaneous spinal cord stimulation (tSCS) on lower-limb spasticity.

DESIGN

Interventional pilot study to produce preliminary data.

SETTING

Department of Physical Medicine and Rehabilitation, Wilhelminenspital, Vienna, Austria.

PARTICIPANTS

Three subjects with chronic motor-incomplete spinal cord injury (SCI) who could walk ≥10 m.

INTERVENTIONS

Two interconnected stimulating skin electrodes (Ø 5 cm) were placed paraspinally at the T11/T12 vertebral levels, and two rectangular electrodes (8 × 13 cm) on the abdomen for the reference. Biphasic 2 ms-width pulses were delivered at 50 Hz for 30 minutes at intensities producing paraesthesias but no motor responses in the lower limbs.

OUTCOME MEASURES

The Wartenberg pendulum test and neurological recordings of surface-electromyography (EMG) were used to assess effects on exaggerated reflex excitability. Non-functional co-activation during volitional movement was evaluated. The timed 10-m walk test provided measures of clinical function.

RESULTS

The index of spasticity derived from the pendulum test changed from 0.8 ± 0.4 pre- to 0.9 ± 0.3 post-stimulation, with an improvement in the subject with the lowest pre-stimulation index. Exaggerated reflex responsiveness was decreased after tSCS across all subjects, with the most profound effect on passive lower-limb movement (pre- to post-tSCS EMG ratio: 0.2 ± 0.1), as was non-functional co-activation during voluntary movement. Gait speed values increased in two subjects by 39%.

CONCLUSION

These preliminary results suggest that tSCS, similar to epidurally delivered stimulation, may be used for spasticity control, without negatively impacting residual motor control in incomplete SCI. Further study in a larger population is warranted.

Lower limb spasticity assessment using an inertial sensor: a reliability study

Spasticity is a common motor impairment in patients with neurological disorders that can prevent functional recovery after rehabilitation. In the clinical setting, its assessment is carried out using standardized clinical scales. The aim of this study was to verify the applicability of inertial sensors for an objective measurement of quadriceps spasticity and evaluate its test-retest and inter-rater reliability during the implementation of the Wartenberg pendulum test. Ten healthy subjects and 11 patients in vegetative state with severe brain damage were enrolled in this study. Subjects were evaluated three times on three consecutive days. The test-retest reliability of measurement was assessed in the first two days. The third day was devoted to inter-rater reliability assessment. In addition, the lower limb muscle tone was bilaterally evaluated at the knee joint by the modified Ashworth scale. The factorial ANOVA analysis showed that the implemented method allowed us to discriminate between healthy and pathological conditions. The fairly low SEM and high ICC values obtained for the pendulum parameters indicated a good test-retest and inter-rater reliability of measurement. This study shows that an inertial sensor can be reliably used to characterize leg kinematics during the Wartenberg pendulum test and provide quantitative evaluation of quadriceps spasticity.

Passive muscle properties are altered in children with cerebral palsy before the age of 3 years and are difficult to distinguish clinically from spasticity

AIM

Clinical determination of spasticity is confounded by the difficulty in distinguishing reflex from passive contributions to muscle stiffness. There is, therefore, a risk that children with cerebral palsy (CP) receive antispasticity treatment unnecessarily. To investigate this, we aimed to determine the contribution of reflex mechanisms to changes in the passive elastic properties of muscles and tendons in children with CP.

METHOD

Biomechanical and electrophysiological measures were used to determine the relative contribution of reflex and passive mechanisms to ankle muscle stiffness in 35 children with spastic CP (21 males, 14 females; mean age 9 y, SD 3 y 4 mo; range 3-15 y) and 28 control children without CP (19 males, nine females; mean age 8 y 11 mo, SD 2 y 10 mo; range 3-15 y). Twenty-seven children were diagnosed as having spastic hemiplegia, six with spastic diplegia, and two with spastic tetraplegia. According to the Gross Motor Function Classification System, 31 children were classified in level I, two in level II, and two in level III.

RESULTS

Only seven children with spastic CP showed reflex stiffness outside the range of the control children. In contrast, 20 children with spastic CP showed abnormal passive muscle stiffness (p<0.001). No correlation between increased reflex or increased passive muscle stiffness and age was observed within the age range studied.

INTERPRETATION

These data suggest that increased reflex-mediated muscle stiffness is difficult to distinguish clinically from changes in passive muscle stiffness and that signs of changes in muscle properties are already present from the age of 3 years in children with CP. This emphasizes the importance of accurately distinguishing different contributions to muscle stiffness to avoid unnecessary antispasticity treatment.

A clinical measurement to quantify spasticity in children with cerebral palsy by integration of multidimensional signals

Most clinical tools for measuring spasticity, such as the Modified Ashworth Scale (MAS) and the Modified Tardieu Scale (MTS), are not sufficiently accurate or reliable. This study investigated the clinimetric properties of an instrumented spasticity assessment. Twenty-eight children with spastic cerebral palsy (CP) and 10 typically developing (TD) children were included. Six of the children with CP were retested to evaluate reliability. To quantify spasticity in the gastrocnemius (GAS) and medial hamstrings (MEH), three synchronized signals were collected and integrated: surface electromyography (sEMG); joint-angle characteristics; and torque. Muscles were manually stretched at low velocity (LV) and high velocity (HV). Spasticity parameters were extracted from the change in sEMG and in torque between LV and HV. Reliability was determined with intraclass-correlation coefficients and the standard error of measurement; validity by assessing group differences and correlating spasticity parameters with the MAS and MTS. Reliability was moderately high for both muscles. Spasticity parameters in both muscles were higher in children with CP than in TD children, showed moderate correlation with the MAS for both muscles and good correlation to the MTS for the MEH. Spasticity assessment based on multidimensional signals therefore provides reliable and clinically relevant measures of spasticity. Moreover, the moderate correlations of the MAS and MTS with the objective parameters further stress the added value of the instrumented measurements to detect and investigate spasticity, especially for the GAS.

Comparison of the effect of baclofen and transcutaneous electrical nerve stimulation for the treatment of spasticity in multiple sclerosis

OBJECTIVE

The aim of this study was to compare the relative efficacy of baclofen and self-applied transcutaneous electrical nerve stimulation (TENS) for the treatment of spasticity in the lower extremities in multiple sclerosis (MS).

METHODS

A randomized controlled clinical trial was conducted from September 2010 to June 2011. Fifty-two patients with MS presenting muscle spasm in the leg at 20-50 years of age were randomly allocated to receive a four-week treatment course of either baclofen (10 mg twice daily, increasing over three weeks to 25 mg) or self-applied TENS. Response to treatment was assessed at four weeks after commencement of the intervention by modified Ashworth scale (MAS).

RESULTS

Spasticity decreased in both groups. Of the 26 people treated with TENS, the mean (standard deviation (SD)) MAS decreased from 1.77 (0.29) at baseline to 0.73 (0.70) at the four-week follow-up (P < 0.001). Correspondingly, in the 26 people treated with baclofen, the mean (SD) MAS decreased from 1.73 (0.38) to 1.15 (0.63) (P < 0.001). The mean difference in MAS score at the four-week follow-up was significantly lower in the TENS group than the baclofen group (mean difference -0.42; 95% CI, -0.79, -0.05; P < 0.05).

DISCUSSION

This study demonstrates that both baclofen and TENS can be effective in reducing MS-related spasticity. The mean MAS score was significantly lower in the TENS group. However given the side-effect profile of baclofen, TENS may have some benefits over baclofen.

Clinical assessment of ankle plantarflexor spasticity in adult patients after stroke: inter-and intra-rater reliability of the Modified Tardieu Scale

PRIMARY OBJECTIVE

To evaluate the reliability of the Modified Tardieu Scale (MTS) in the measurement of ankle plantarflexor spasticity in patients after stroke.

RESEARCH DESIGN

Inter- and intra-rater reliability study.

INTERVENTIONS

Not applicable.

METHODS AND PROCEDURES

Adult patients after stroke participated. Patients were tested by two raters for inter-rater reliability. Patients were re-tested by one rater at least 1 week later for intra-rater reliability. The plantarflexors on the hemiparetic side were tested.

MAIN OUTCOMES AND RESULTS

The ICCs of inter and intra-rater reliability across all components of MTS were moderate and moderately high (range 0.40-0.71). Inter- and intra-rater reliability for the dynamic component of spasticity (R2-R1) were moderate (ICC = 0.57 and 0.40, respectively). The difference between the two raters for R2 was statistically significant (p = 0.001).

CONCLUSIONS

The reliability of the Modified Tardieu Scale in the measurement of ankle plantarflexor spasticity in adult patients after stroke was insufficient for routine use in clinical settings and research.

Manual linear movements to assess spasticity in a clinical setting

In a clinical setting, where motor-driven systems are not readily available, the major difficulty in the assessment of the stretch reflex lies in the control of passive limb displacement velocity. A potential approach to this problem arises from the use of manual sinusoidal movements (made by continuous alternating flexions and extensions) paced by an external stimulus. Unfortunately, there are conditions in which sinusoidal movements induce interfering phenomena such as the shortening reaction or postactivation depression. In the present paper, a novel manual method to control the velocity of passive linear movements is described and the results obtained from both healthy subjects and spastic patients are reported. This method is based on the synchronisation of movements with tones played by a metronome at different speeds. In a first set of experiments performed in healthy subjects, we demonstrated consistent control of velocity during passive limb movements using this method. Four joints usually examined during muscle tone assessment were tested: wrist, elbow, knee and ankle joints. Following this, we conducted a longitudinal assessment of the stretch reflex amplitude in wrist flexor muscles in patients with spasticity treated with botulinum toxin type A. The evaluators were not only able to vary the movement velocity based on the metronome speed, but also could reproduce the respective speeds two weeks later, despite the changing degree of hypertonia. This method is easy to perform in a clinical setting and hardware requirements are minimal, making it an attractive and robust procedure for the widespread clinical assessment of reflex hypertonia.

Activation of 5-HT2A receptors upregulates the function of the neuronal K-Cl cotransporter KCC2

In healthy adults, activation of γ-aminobutyric acid (GABA)(A) and glycine receptors inhibits neurons as a result of low intracellular chloride concentration ([Cl(-)](i)), which is maintained by the potassium-chloride cotransporter KCC2. A reduction of KCC2 expression or function is implicated in the pathogenesis of several neurological disorders, including spasticity and chronic pain following spinal cord injury (SCI). Given the critical role of KCC2 in regulating the strength and robustness of inhibition, identifying tools that may increase KCC2 function and, hence, restore endogenous inhibition in pathological conditions is of particular importance. We show that activation of 5-hydroxytryptamine (5-HT) type 2A receptors to serotonin hyperpolarizes the reversal potential of inhibitory postsynaptic potentials (IPSPs), E(IPSP), in spinal motoneurons, increases the cell membrane expression of KCC2 and both restores endogenous inhibition and reduces spasticity after SCI in rats. Up-regulation of KCC2 function by targeting 5-HT(2A) receptors, therefore, has therapeutic potential in the treatment of neurological disorders involving altered chloride homeostasis. However, these receptors have been implicated in several psychiatric disorders, and their effects on pain processing are controversial, highlighting the need to further investigate the potential systemic effects of specific 5-HT(2A)R agonists, such as (4-bromo-3,6-dimethoxybenzocyclobuten-1-yl)methylamine hydrobromide (TCB-2).

Position-dependent, hyperexcitable patellar reflex dynamics in chronic stroke

OBJECTIVES

To quantify tendon tap response (TTR) properties and their position dependence using multiple neuromechanical parameters, and to analyze correlations among neuromechanical and clinical measures.

DESIGN

Hyperexcitable dynamics of TTR were investigated in a case-control manner. An instrumented hammer was used to induce the patellar deep tendon reflex (DTR), with reflex-mediated electromyography and torque responses measured across a range of knee flexion.

SETTING

Research laboratory in a rehabilitation hospital.

PARTICIPANTS

Chronic hemiplegic stroke survivors (n=9) and healthy subjects (n=13).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Neuromechanical measures (system gain, contraction rate, half-relaxation rate, reflex loop delay, peak reflex torque, peak reflex electromyography, and reflex threshold in tapping force) were measured to characterize neuromuscular properties of patellar TTR. Clinical measurements were taken using the DTR scale and the Modified Ashworth Scale.

RESULTS

The system gain, contraction rate, half-relaxation rate, and peak reflex-mediated torque in the stroke group were generally higher, whereas the reflex threshold in the stroke group was significantly lower than their counterparts in the control group across 45° to 90° of knee flexion (P<.05). The 4 parameters were significantly higher at 60° and 75° of flexion than at 15°, 30°, 45°, and 90°, and their correlations with the 2 clinical scales at 60°, 75°, and 90° of flexion were also significantly higher than those at 15°, 30°, and 45° (P<.05).

CONCLUSIONS

The results showed hyperexcitability of TTR in stroke, quantified using a number of neuromechanical measures. Those measures peak around 60° to 75° of knee flexion and were correlated with clinical scales.

International spinal cord injury musculoskeletal basic data set

OBJECTIVES

To develop an International Spinal Cord Injury (SCI) Musculoskeletal Basic Data Set as part of the International SCI Data Sets to facilitate consistent collection and reporting of basic musculoskeletal findings in the SCI population.

SETTING

International.

METHODS

A first draft of an SCI Musculoskeletal Basic Data Set was developed by an international working group. This was reviewed by many different organizations, societies and individuals over 9 months. Revised versions were created successively.

RESULTS

The final version of the International SCI Musculoskeletal Basic Data Set contains questions on neuro-musculoskeletal history before spinal cord lesion; presence of spasticity/spasms; treatment for spasticity within the last 4 weeks; fracture(s) since the spinal cord lesion; heterotopic ossification; contracture; the location of degenerative neuromuscular and skeletal changes due to overuse after SCI; SCI-related neuromuscular scoliosis; the method(s) used to determine the presence of neuromuscular scoliosis; surgical treatment of the scoliosis; other musculoskeletal problems; if any of the musculoskeletal challenges above interfere with activities of daily living. Instructions for data collection and the data collection form are freely available on the International Spinal Cord Society (ISCoS) website (www.iscos.org.uk).

CONCLUSION

The International SCI Musculoskeletal Basic Data Set will facilitate consistent collection and reporting of basic musculoskeletal findings in the SCI population.

Clinical trial of a method for confirming the effects of spinal anesthesia in patients with spinal cord injury

In this case series study, we prospectively examined whether it might be possible to check the effect of spinal anesthesia (SA), based on the disappearance of lower extremity reflexes and spasticity, in patients with spinal cord injury (SCI), in whom the effect cannot be confirmed by the pinprick test or by using the Bromage scale. In 40 patients with chronic, clinically complete cervical SCI who were scheduled to receive SA, pre-anesthetic examination revealed that the Babinski sign, patellar tendon reflex, and spasticity (assessed using the Ashworth scale) were all positive in 31 patients, while two of these three pre-anesthetic assessment parameters were positive in eight patients. The effect of SA in these 39 patients (97.5 %) was confirmed by demonstrating the absence of both the Babinski sign and patellar tendon reflex and loss of spasticity after SA. Our results suggested that the effect of SA can be confirmed by the disappearance of the Babinski sign and patellar tendon reflex and loss of spasticity in most patients with complete cervical SCI, although determination of the level of the block is difficult. In conclusion, loss of the Babinski sign, patellar tendon reflex, and spasticity might be useful for checking the effect of SA in cervical SCI patients.

Complications of intrathecal baclofen pump: prevention and cure

Increasingly, spasticity is managed with surgically implanted Intrathecal Baclofen pumps. Intrathecal Baclofen pump revision surgery unrelated to programmable pump end-of-life is not uncommon, requiring special attention during pre-, intra-, and postoperative management. We aimed to identify and describe complications of Intrathecal Baclofen pump as well as to report avoidance and management of complications. Methods and Materials. Through 2002–2006, at the department of neurosurgery, Henry Ford and Oakwood Health Systems, Intrathecal Baclofen pumps were implanted in 44 patients: 24 children versus 20 adults; 30 “primary-implant-patients”; 14 “revision-only patients”. We evaluated reasons for revision surgeries and diagnostic workup requirements. Results. Eight primary-implant-patients required 14 revisions and 7 of revision-only patients needed 13 procedures. Seven patients with slowly increasing baclofen-resistant spasticity had either (i) unsuspected pump-catheter connector defects, (ii) an X-ray-documented pump-catheter connector defect, (iii) X-ray-demonstrated fractured catheter with intrathecal fragment. Implant infections occurred in 4 cases. Scintigraphy revealed occult CSF leakage N=1 and intrinsic pump failure N=1. Conclusion. Intrathecal Baclofen pumps, although very gratifying, have a high, technique-related complication incidence during implant life. Meticulous technique, high clinical suspicion, appropriate workup, and timely surgical management can reduce surgical complications of Intrathecal Baclofen pump implantation.

A report of anticipated benefits of functional electrical stimulation after spinal cord injury

BACKGROUND

Functional electrical stimulation (FES) has been regularly used to offset several negative body composition and metabolic adaptations following spinal cord injury (SCI). However, the outcomes of many FES trials appear to be controversial and incoherent.

OBJECTIVE

To document the potential consequences of several factors (e.g. pain, spasms, stress and lack of dietary control) that may have attenuated the effects on body composition and metabolic profile despite participation in 21 weeks of FES training.

PARTICIPANT

A 29-year-old man with T6 complete SCI participated in 21 weeks of FES, 4 days per week.

METHODS

Prior to and following training, the participant performed arm-crank-graded exercise testing to measure peak VO(2). Tests conducted included anthropometrics and dual energy X-ray absorptiometry body composition assessments, resting energy expenditure, plasma lipid profiles and intravenous glucose tolerance tests.

RESULTS

The participant frequently reported increasing pain, stress and poor eating habits. VO(2) peak decreased by 2.4 ml/kg/minute, body mass increased by 8.5 kg, and body mass index increased from 25 to 28 kg/m(2). Waist and abdominal circumferences increased by 2-4 cm, while %fat mass increased by 5.5%. Absolute increases in fat mass and fat-free mass of 8.4 and 1 kg, respectively, were reported. Fasting and peak plasma glucose increased by 12 and 14.5%, while lipid panel profiles were negatively impacted.

CONCLUSION

Failure to control for the listed negative emerging factors may obscure the expected body composition and metabolic profile adaptations anticipated from FES training.

The relationship between spasticity and muscle volume of the knee extensors in children with cerebral palsy

PURPOSE

The purpose of this study was to examine the relationship between spasticity and muscle volume in children with cerebral palsy (CP), using isokinetic dynamometry and magnetic resonance imaging.

METHODS

A retrospective sample of 8 children with diplegic CP was analyzed. One set of 10 passive knee flexion movements was completed at a velocity of 180° per second with concurrent surface electromyography of the medial hamstrings (MH) and vastus lateralis (VL) to assess knee extensor spasticity. Magnetic resonance imaging was used to measure maximum cross-sectional area and muscle volume of the quadriceps femoris.

RESULTS

The quadriceps femoris muscle volume was positively correlated with MH reflex activity, VL reflex activity, MH/VL co-contraction, and peak knee extensor passive torque (P < .05).

CONCLUSION

The present findings suggest that higher levels of knee extensor muscle spasticity are associated with greater quadriceps muscle volume in children with spastic diplegic CP.

Assessment of a portable device for the quantitative measurement of ankle joint stiffness in spastic individuals

OBJECTIVE

Spasticity is a common complication with neurological diseases and CNS lesions. Instrumented systems to evaluate spasticity often cannot provide an immediate result, thus limiting their clinical usefulness. In this study we investigated the accuracy and reliability of the portable Neurokinetics RA1 Ridgidity Analyzer to measure stiffness of the ankle joint in 46 controls, 14 spinal cord injured (SCI) and 23 multiple sclerosis (MS) participants.

METHODS

Ankle stiffness measures were made twice by two raters, at speeds above and below the expected stretch reflex threshold. Ankle torque was measured with the portable device and a stationary torque motor. Inter- and intra-rater reliability was assessed with the intra-class correlation coefficient (ICC).

RESULTS

Stiffness measures with the portable and stationary devices were significantly correlated for controls and MS participants (p < 0.01). Intra-rater reliability for the portable device ranged from 0.60-0.89 (SCI) and 0.63-0.67 (control) and inter-rater reliability ranged from 0.70-0.73 (SCI) and 0.61-0.77 (control). Ankle stiffness measures in SCI and MS participants were significantly larger than in controls for both slow (p < 0.05) and fast movements (p < 0.01), with stiffness being larger for fast compared to slow movements in SCI and MS participants (p < 0.05), but not in controls (p = 0.5).

CONCLUSION

The portable device correlated well with measures obtained by a torque motor in both controls and MS participants, showed high intra- and inter-rater reliability for the SCI participants, and could easily distinguish between stiff and control ankle joints. However, the device, in its current form, may be less accurate during rapid movements when inertia contributes to stiffness and the shape of the air-filled pads did not provide a good interface with the foot.

SIGNIFICANCE

This study demonstrates that a portable device can potentially be a useful diagnostic tool to obtain reliable information of stiffness for the ankle joint.

Treatment of rat spinal cord injury with the neurotrophic factor albumin-oleic acid: translational application for paralysis, spasticity and pain

Sensorimotor dysfunction following incomplete spinal cord injury (iSCI) is often characterized by the debilitating symptoms of paralysis, spasticity and pain, which require treatment with novel pleiotropic pharmacological agents. Previous in vitro studies suggest that Albumin (Alb) and Oleic Acid (OA) may play a role together as an endogenous neurotrophic factor. Although Alb can promote basic recovery of motor function after iSCI, the therapeutic effect of OA or Alb-OA on a known translational measure of SCI associated with symptoms of spasticity and change in nociception has not been studied. Following T9 spinal contusion injury in Wistar rats, intrathecal treatment with: i) Saline, ii) Alb (0.4 nanomoles), iii) OA (80 nanomoles), iv) Alb-Elaidic acid (0.4/80 nanomoles), or v) Alb-OA (0.4/80 nanomoles) were evaluated on basic motor function, temporal summation of noxious reflex activity, and with a new test of descending modulation of spinal activity below the SCI up to one month after injury. Albumin, OA and Alb-OA treatment inhibited nociceptive Tibialis Anterior (TA) reflex activity. Moreover Alb-OA synergistically promoted early recovery of locomotor activity to 50 ± 10% of control and promoted de novo phasic descending inhibition of TA noxious reflex activity to 47 ± 5% following non-invasive electrical conditioning stimulation applied above the iSCI. Spinal L4-L5 immunohistochemistry demonstrated a unique increase in serotonin fibre innervation up to 4.2 ± 1.1 and 2.3 ± 0.3 fold within the dorsal and ventral horn respectively with Alb-OA treatment when compared to uninjured tissue, in addition to a reduction in NR1 NMDA receptor phosphorylation and microglia reactivity. Early recovery of voluntary motor function accompanied with tonic and de novo phasic descending inhibition of nociceptive TA flexor reflex activity following Alb-OA treatment, mediated via known endogenous spinal mechanisms of action, suggests a clinical application of this novel neurotrophic factor for the treatment of paralysis, spasticity and pain.

Treating spastic equinus foot from cerebral palsy with botulinum toxin type A: what factors influence the results?: an analysis of 189 consecutive cases

OBJECTIVE

The aim of this study was to determine the variables that improve spastic equinus foot caused by cerebral palsy when treated with botulinum toxin type A.

DESIGN

We reviewed all patients treated for spastic equinus foot using botulinum toxin type A (Botox) in the triceps suralis during a 3 1/2-yr period and analyzed the results after the first injection. There were 117 patients (72 diplegic and 45 hemiplegic patients) and a total of 189 triceps suralis treated. Variables analyzed included age, total dose per session, total dose per kilogram for each session, total dose per triceps, triceps dose per kilogram, type of cerebral palsy, cognitive level, botulinum toxin dilution, and physiotherapy. Assessments of efficacy were done using a Global Assessment Scale rated independently by parents, therapists, and a neurologist; the Modified Ashworth Scale; and the Modified Physician Rating Koman scale.

RESULTS

Improvement was observed in all scales (P < 0.001). The change of foot position during walking was the best parameter for measuring improvement. There was correlation between the grade of improvement and the dose per kilogram for each triceps suralis (P < 0.001). Patient age was inversely correlated with improvement (P = 0.043). Diplegic and hemiplegic patients improved similarly, but the hemiplegic patients required higher doses for each muscle (P < 0.001). The most effective dose for diplegic patients was 3-4 IU/kg for each triceps, compared with 4-6 IU/kg for hemiplegic patients. Different dilutions of Botox (100, 50, and 40 U/ml) resulted in similar outcomes. No better results were achieved when 2-3 sessions/wk of physiotherapy was added to a daily program of exercises at home to enhance foot dorsiflexion.

CONCLUSIONS

The dose per kilogram of Botox injected into triceps suralis and the patient age influence the results. The most effective dose is different between diplegic and hemiplegic patients. The concentration of botulinum toxin type A does not play a significant role in the outcome.

Measurement of passive ankle stiffness in subjects with chronic hemiparesis using a novel ankle robot

Our objective in this study was to assess passive mechanical stiffness in the ankle of chronic hemiparetic stroke survivors and to compare it with those of healthy young and older (age-matched) individuals. Given the importance of the ankle during locomotion, an accurate estimate of passive ankle stiffness would be valuable for locomotor rehabilitation, potentially providing a measure of recovery and a quantitative basis to design treatment protocols. Using a novel ankle robot, we characterized passive ankle stiffness both in sagittal and in frontal planes by applying perturbations to the ankle joint over the entire range of motion with subjects in a relaxed state. We found that passive stiffness of the affected ankle joint was significantly higher in chronic stroke survivors than in healthy adults of a similar cohort, both in the sagittal as well as frontal plane of movement, in three out of four directions tested with indistinguishable stiffness values in plantarflexion direction. Our findings are comparable to the literature, thus indicating its plausibility, and, to our knowledge, report for the first time passive stiffness in the frontal plane for persons with chronic stroke and older healthy adults.

The animal model of spinal cord injury as an experimental pain model

Pain, which remains largely unsolved, is one of the most crucial problems for spinal cord injury patients. Due to sensory problems, as well as motor dysfunctions, spinal cord injury research has proven to be complex and difficult. Furthermore, many types of pain are associated with spinal cord injury, such as neuropathic, visceral, and musculoskeletal pain. Many animal models of spinal cord injury exist to emulate clinical situations, which could help to determine common mechanisms of pathology. However, results can be easily misunderstood and falsely interpreted. Therefore, it is important to fully understand the symptoms of human spinal cord injury, as well as the various spinal cord injury models and the possible pathologies. The present paper summarizes results from animal models of spinal cord injury, as well as the most effective use of these models.

Clinical assessment and management of spasticity: a review

Spasticity is a sign of upper motor neurone lesion, which can be located in the cerebrum or the spinal cord, and be caused by stroke, multiple sclerosis, spinal cord injury, brain injury, cerebral paresis, or other neurological conditions. Management is dependent on clinical assessment. Positive and negative effects of spasticity should be considered. Ashworth score and the modified Ashworth score are the most used scales for assessment of spasticity. These and other spasticity scales are based on assessment of resistance during passive movement. The main goal of management is functional improvement. A novel 100-point score to assess disability, function related to spasticity (Rekand disability and spasticity score) is proposed. Management of spasticity should be multimodal and should always include physiotherapy or exercise. Oral medications such as baclofen and tizanidine have limited efficacy and considerable side effects, but are easiest to use. Botulinum toxin combined with physiotherapy and/or orthopaedic surgery is effective treatment of localized spasticity. Treatment with intrathecal baclofen via programmable implanted pump is effective in generalized spasticity, particularly in the lower extremities. Neurosurgical and orthopaedic procedures may be considered in intractable cases.

Evaluation of spasticity in children with cerebral palsy using Ashworth and Tardieu Scales compared with laboratory measures

The content validity of the Tardieu Scale and the Ashworth Scale was assessed in 27 independently ambulant children with cerebral palsy (gender: 17 males, 10 females; age: 5-9 years; Gross Motor Function Classification: level I and II). Ashworth and Tardieu Scale scores and laboratory measures of spasticity and contracture were collected from the plantarflexor muscles by 2 examiners who were blinded to the results. The Tardieu Scale was more effective than the Ashworth Scale in identifying the presence of spasticity (88.9%, kappa = 0.73; P = .000), the presence of contracture (77.8%, kappa = 0.503; P = .008) and the severity of contracture (r = 0.49; P = .009). However, neither scale was able to identify the severity of spasticity. The Tardieu Scale can provide useful information in children with cerebral palsy because it differentiates spasticity from contracture. However, a more comprehensive clinical method of testing neural and non-neural contributions to impairments and function is needed.

Spinal-, brainstem- and cerebrally mediated responses at- and below-level of a spinal cord contusion in rats: evaluation of pain-like behavior

Pain is a frequent consequence of spinal cord injury (SCI) which may profoundly impair the patients' quality of life. Valid experimental models and methods are therefore desirable in the search for better treatments. Usually, experimental pain assays depend on stimulus-evoked withdrawal responses; however, this spinal-mediated reflex response may be particularly problematic when evaluating below-level SCI pain due to the development of hyperactive reflex circuitries. In this study, we applied and compared assays measuring cold (acetone), static (von Frey filaments), and dynamic mechanical (soft brush) hypersensitivity at different levels of the neuroaxis at and below the level of injury in a rat model of SCI. We induced an experimental SCI (MASCIS 25 mm weight-drop) and evaluated the development of spinal reflexes (withdrawal), spinal-brainstem-spinal reflexes (licking, guarding, struggling, vocalizing, jumping, and biting) and cerebral-dependent behavior (place escape/avoidance paradigm (PEAP)). We demonstrated increased brainstem reflexes and cerebrally mediated aversive reactions to stimuli applied at the level of SCI, suggesting development of at-level evoked pain behavior. Furthermore, stimulation below-level increased innate reflex responses without increasing brainstem reflexes or aversive behavior in the PEAP, suggesting development of the spasticity syndrome rather than pain-like behavior. While spinal reflex measures are acceptable for studying changes in the spinal reflex pathways and spinal cord, they are not suited as nociceptive behavioral measures. Measuring brainstem organized responses eliminates the bias associated with the spastic syndrome, but pain requires cortical involvement. Methods depending on cortical structures, as the PEAP, are therefore optimal endpoints in animal models of central pain.

Transcriptional regulation of gene expression clusters in motor neurons following spinal cord injury

Background

Spinal cord injury leads to neurological dysfunctions affecting the motor, sensory as well as the autonomic systems. Increased excitability of motor neurons has been implicated in injury-induced spasticity, where the reappearance of self-sustained plateau potentials in the absence of modulatory inputs from the brain correlates with the development of spasticity.

Results

Here we examine the dynamic transcriptional response of motor neurons to spinal cord injury as it evolves over time to unravel common gene expression patterns and their underlying regulatory mechanisms. For this we use a rat-tail-model with complete spinal cord transection causing injury-induced spasticity, where gene expression profiles are obtained from labeled motor neurons extracted with laser microdissection 0, 2, 7, 21 and 60 days post injury. Consensus clustering identifies 12 gene clusters with distinct time expression profiles. Analysis of these gene clusters identifies early immunological/inflammatory and late developmental responses as well as a regulation of genes relating to neuron excitability that support the development of motor neuron hyper-excitability and the reappearance of plateau potentials in the late phase of the injury response. Transcription factor motif analysis identifies differentially expressed transcription factors involved in the regulation of each gene cluster, shaping the expression of the identified biological processes and their associated genes underlying the changes in motor neuron excitability.

Conclusions

This analysis provides important clues to the underlying mechanisms of transcriptional regulation responsible for the increased excitability observed in motor neurons in the late chronic phase of spinal cord injury suggesting alternative targets for treatment of spinal cord injury. Several transcription factors were identified as potential regulators of gene clusters containing elements related to motor neuron hyper-excitability, the manipulation of which potentially could be used to alter the transcriptional response to prevent the motor neurons from entering a state of hyper-excitability.

Voluntary ankle flexor activity and adaptive coactivation gain is decreased by spasticity during subacute spinal cord injury

Although spasticity has been defined as an increase in velocity-dependent stretch reflexes and muscle hypertonia during passive movement, the measurement of flexor muscle paresis may better characterize the negative impact of this syndrome on residual motor function following incomplete spinal cord injury (iSCI). In this longitudinal study Tibialis Anterior (TA) muscle paresis produced by a loss in maximal voluntary contraction during dorsiflexion and ankle flexor muscle coactivation during ramp-and-hold controlled plantarflexion was measured in ten patients during subacute iSCI. Tibialis Anterior activity was measured at approximately two-week intervals between 3-5 months following iSCI in subjects with or without spasticity, characterized by lower-limb muscle hypertonia and/or involuntary spasms. Following iSCI, maximal voluntary contraction ankle flexor activity was lower than that recorded from healthy subjects, and was further attenuated by the presence of spasticity. Furthermore the initially high percentage value of TA coactivation increased at 75% but not at 25% maximal voluntary torque (MVT), reflected by an increase in TA coactivation gain (75%/25% MVT) from 2.5+/-0.4 to 7.5+/-1.9, well above the control level of 2.9+/-0.2. In contrast contraction-dependent TA coactivation gain decreased from 2.4+/-0.3 to 1.4+/-0.1 during spasticity. In conclusion the adaptive increase in TA coactivation gain observed in this pilot study during subacute iSCI was also sensitive to the presence of spasticity. The successful early diagnosis and treatment of spasticity would be expected to further preserve and promote adaptive motor function during subacute iSCI neurorehabilitation.

Down-regulation of the potassium-chloride cotransporter KCC2 contributes to spasticity after spinal cord injury

Hyperexcitability of spinal reflexes and reduced synaptic inhibition are commonly associated with spasticity after spinal cord injury (SCI). In adults, the activation of gamma-aminobutyric acid(A) (GABAA) and glycine receptors inhibits neurons as a result of low intracellular chloride (Cl-) concentration, which is maintained by the potassium-chloride cotransporter KCC2 (encoded by Slc12a5). We show that KCC2 is downregulated after SCI in rats, particularly in motoneuron membranes, thereby depolarizing the Cl- equilibrium potential and reducing the strength of postsynaptic inhibition. Blocking KCC2 in intact rats reduces the rate-dependent depression (RDD) of the Hoffmann reflex, as is observed in spasticity. RDD is also decreased in KCC2-deficient mice and in intact rats after intrathecal brain-derived neurotrophic factor (BDNF) injection, which downregulates KCC2. The early decrease in KCC2 after SCI is prevented by sequestering BDNF at the time of SCI. Conversely, after SCI, BDNF upregulates KCC2 and restores RDD. Our results open new perspectives for the development of therapeutic strategies to alleviate spasticity.

The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy

An interdisciplinary European group of clinical experts in the field of movement disorders and experienced Botulinum toxin users has updated the consensus for the use of Botulinum toxin in the treatment of children with cerebral palsy (CP). A problem-orientated approach was used focussing on both published and practice-based evidence. In part I of the consensus the authors have tabulated the supporting evidence to produce a concise but comprehensive information base, pooling data and experience from 36 institutions in 9 European countries which involves more than 10,000 patients and over 45,000 treatment sessions during a period of more than 280 treatment years. In part II of the consensus the Gross Motor Function Measure (GMFM) and Gross Motor Function Classification System (GMFCS) based Motor Development Curves have been expanded to provide a graphical framework on how to treat the motor disorders in children with CP. This graph is named "CP(Graph) Treatment Modalities - Gross Motor Function" and is intended to facilitate communication between parents, therapists and medical doctors concerning (1) achievable motor function, (2) realistic goal-setting and (3) treatment perspectives for children with CP. The updated European consensus 2009 summarises the current understanding regarding an integrated, multidisciplinary treatment approach using Botulinum toxin for the treatment of children with CP.

Modified Ashworth scale reliability for measurement of lower extremity spasticity among patients with SCI

STUDY DESIGN

Observational study.

OBJECTIVES

To report the intra-rater (one rater), inter-rater (two raters) and inter-session (one subject, sessions 1-5) reliability of lower extremity modified Ashworth scale (MAS) scores among patients with chronic spinal cord injury (SCI).

SETTING

Tertiary Academic Rehab Centre in Toronto, Canada.

METHODS

MAS scores of 20 subjects with chronic SCI (C5-T10 AIS A-D>12 months) were recorded for the hip abductors and adductors, knee flexors and extensors, and ankle plantar and dorsiflexors. MAS scores were assessed by two blinded raters (A and B) at the same time of day, weekly for 5 weeks using standardized test positions, a one-cycle per second metronome, with ratings recorded on the second cycle. MAS score reproducibility [intra-rater, inter-rater] were calculated using Cohen's Kappa. Intraclass correlation coefficients (ICCs) were calculated to determine inter-session (trials 1-5) reliability; Kappa values >or=0.81 and ICC values >or=0.75 were desired.

RESULTS

Intra-rater reliability was fair to almost perfect (0.2<kappa<1.0) and differed between raters. Inter-rater reliability was poor-to-moderate (kappa<0.6) for all muscle groups. Inter-session reliability for a single rater was fair-to-good (0.4<ICC<0.75) for all muscle groups.

CONCLUSIONS

MAS was not reliable as an intra-rater tool for all raters, and showed poor inter-rater and modest inter-session reliability. MAS has inadequate reliability for determining lower extremity spasticity between raters (inter-rater) or over time (inter-session). It is recommended that the rehabilitation science community seek alternative measures for quantifying spasticity.

Efficacy and tolerability of eperisone and baclofen in spastic palsy: a double-blind randomized trial

INTRODUCTION

Few trials have compared different central muscle relaxants in the treatment of spastic palsy. This head-to-head phase 3 trial compares oral eperisone, a central muscle relaxant with a promising activity in spasticity therapy, and oral baclofen.

METHODS

Patients (>18 years) with moderate to severe spastic palsy were eligible in this double-blind, randomized study; they received eperisone 300 mg/ day or baclofen 60 mg/day for 6 weeks. The efficacy evaluations included: functional analysis (Pedersen's scale, muscular tone, joint range of motion, 10-meter walking time); physiological and pathological reflexes; and electromyography (Hmax/Mmax amplitude ratio and the Wartenberg test). Physicians and patients globally assessed treatment efficacy.

RESULTS

Both eperisone (n=40) and baclofen (n=40) significantly improved functionality of lower limbs versus baseline (eperisone: -9.1%, P<0.01; baclofen: -8.3%, P<0.05), but only eperisone improved this parameter in the upper limbs (-7.8%, P<0.01 vs. -6.3%, P=NS). Both drugs reduced muscular tone from week 2. Only eperisone improved the joint range of motion (-32.5%, P<0.01 vs. -14.6%, P=NS). Both treatments reduced the 10-meter walking time (eperisone: -20.2%, P<0.01; baclofen: -24.0%, P<0.01); this effect was evident at week 2 with eperisone only. Both drugs improved reflexes. Eperisone and baclofen decreased the Hmax/Mmax amplitude ratio (eperisone: -30.0%, baclofen: -18.6%; P<0.01 for both). Eperisone increased the number of leg oscillations at the Wartenberg test (P<0.05) while baclofen increased the velocity of leg falling (P<0.01). For tolerability, no differences were observed between eperisone and baclofen in any parameters. Eperisone was judged as "good" by a higher number of physicians and patients than baclofen. Eighteen adverse events, most of mild intensity, were reported with eperisone and 27 with baclofen.

CONCLUSION

Eperisone 300 mg/day and baclofen 60 mg/day, administered orally, are effective and well-tolerated drugs in the treatment of spastic palsy. However, eperisone might be associated with some additional clinical benefits when compared with baclofen.

Knee resistance during passive stretch in patients with hypertonia

The aims of the study were to determine by a portable method (1) whether velocity-dependent changes in knee resistance in patients with spastic paresis differ from those in non-disabled subjects, and (2) whether biomechanical measures of resistance can differentiate between neural and other factors that contribute to hypertonia (increased resistance). Biomechanical (hand-hold dynamometer, electrogoniometer) and bioelectrical (EMG) measures of resistance were evaluated under static (slow stretch) and dynamic (fast stretch) conditions in twenty patients with hypertonia and 19 non-disabled subjects. Measures calculated for non-disabled subjects (control limbs) were compared to those calculated for patients (spastic limbs). Biomechanical measures of resistance did not differ strongly between groups of spastic and control limbs and between spastic limbs having different origins of knee hypertonia (neural vs. other), due to substantial variability. In contrary the static and dynamic bioelectrical measures of muscles activation were substantially larger in spastic limbs than in control limbs (p<0.05). The variability of biomechanical measures of resistance was due to varied patterns of muscle activation in response to stretch. We concluded that the biomechanical measures of hypertonia did not discriminate spastic patients from non-disabled subjects. To classify various types of knee hypertonia, the portable method should include not only analysis of biomechanical but also EMG characteristics of hypertonia. It is expected that the functional status of patients would be better predicted using clinical and quantitative measures of impairment if different classes of hypertonia (defined by different patterns of activation) were analyzed separately rather than analyzing the heterogeneous patient population as a whole.

Validity, reliability, and clinical importance of change in a 0-10 numeric rating scale measure of spasticity: a post hoc analysis of a randomized, double-blind, placebo-controlled trial

BACKGROUND

The measurement of spasticity as a symptom of neurologic disease is an area of growing interest. Clinician-rated measures of spasticity purport to be objective but do not measure the patient's experience and may not be sensitive to changes that are meaningful to the patient. In a patient with clinical spasticity, the best judge of the perceived severity of the symptom is the patient.

OBJECTIVES

The aim of this study was to assess the validity and reliability, and determine the clinical importance, of change on a 0-10 numeric rating scale (NRS) as a patient-rated measure of the perceived severity of spasticity.

METHODS

Using data from a large,randomized, doubleblind, placebo-controlled study of an endocannabinoid system modulator in patients with multiple sclerosis-related spasticity, we evaluated the test-retest reliability and comparison-based validity of a patient-reported 0-10 NRS measure of spasticity severity with the Ashworth Scale and Spasm Frequency Scale. We estimated the level of change from baseline on the 0-10 NRS spasticity scale that constituted a clinically important difference (CID) and a minimal CID (MCID) as anchored to the patient's global impression of change (PGIC).

RESULTS

Data from a total of 189 patients were included in this assessment (114 women, 75 men; mean age, 49.1 years). The test-retest reliability analysis found an interclass correlation coefficient of 0.83 (P < 0.001) between 2 measures of the 0-10 NRS spasticity scores recorded over a 7- to 14-day period before randomization. A significant correlation was found between change on 0-10 NRS and change in the Spasm Frequency Scale (r = 0.63; P < 0.001), and a moderate correlation was found between the change on 0-10 NRS and the PGIC (r = 0.47; P < 0.001). A reduction of approximately 30% in the spasticity 0-10 NRS score best represented the CID and a change of 18% the MCID.

CONCLUSIONS

The measurement of the symptom of spasticity using a patient-rated 0-10 NRS was found to be both reliable and valid. The definitions of CID and MCID will facilitate the use of appropriate responder analyses and help clinicians interpret the significance of future results.

Roles of reflex activity and co-contraction during assessments of spasticity of the knee flexor and knee extensor muscles in children with cerebral palsy and different functional levels

BACKGROUND AND PURPOSE

Spasticity is a common impairment in children with cerebral palsy (CP). The purpose of this study was to examine differences in passive resistive torque, reflex activity, coactivation, and reciprocal facilitation during assessments of the spasticity of knee flexor and knee extensor muscles in children with CP and different levels of functional ability.

SUBJECTS

Study participants were 20 children with CP and 10 children with typical development (TD). The 20 children with CP were equally divided into 2 groups: 10 children classified in Gross Motor Function Classification Scale (GMFCS) level I and 10 children classified in GMFCS level III.

METHODS

One set of 10 passive movements between 25 and 90 degrees of knee flexion and one set of 10 passive movements between 90 and 25 degrees of knee flexion were completed with an isokinetic dynamometer at 15 degrees /s, 90 degrees /s, and 180 degrees /s and concurrent surface electromyography of the vastus lateralis and medial hamstring muscles.

RESULTS

Children in the GMFCS level III group demonstrated significantly more peak knee flexor torque with passive movements at 180 degrees /s than children with TD. Children in the GMFCS level I and level III groups demonstrated significantly more repetitions with medial hamstring muscle activity, vastus lateralis muscle activity, and co-contraction than children with TD during the assessment of knee flexor spasticity at a velocity of 180 degrees /s.

DISCUSSION AND CONCLUSION

Children with CP and more impaired functional mobility may demonstrate more knee flexor spasticity and reflex activity, as measured by isokinetic dynamometry, than children with TD. However, the finding of increased reflex activity with no increase in torque in the GMFCS I group in a comparison with the TD group suggests that reflex activity may play a less prominent role in spasticity.

Spasticity measurement based on tonic stretch reflex threshold in stroke using a portable device

OBJECTIVES

We investigated intra- and inter-evaluator reliability to quantify spasticity based on the tonic stretch reflex threshold (TSRT) and the correlation between TSRT and resistance to stretch.

METHODS

Spasticity was evaluated in 20 subjects with chronic stroke-related spasticity using a portable device and the Modified Ashworth Scale (MAS). Evaluations were done on 2 days, by three evaluators. Biceps brachii EMG signals and elbow displacement were recorded during 20 elbow stretches applied at different velocities for each evaluation. Velocity-dependent dynamic stretch reflex thresholds (angle where EMG signal increased in the biceps for a given velocity of stretch) were recorded. These values were used to compute TSRT (excitability of motoneurons at 0 degrees /s). Spasticity was also measured with MAS.

RESULTS

Reliability was moderately good for subjects with moderate to high spasticity (intra-evaluator: 0.46-0.68, and inter-evaluator: 0.53-0.68). The TSRT measure of spasticity did not correlate with resistance to stretch (MAS).

CONCLUSIONS

TSRT may be a more representative measure for subjects with moderate to high spasticity. Further improvements are suggested for the portable device in order to quantify all the levels of spasticity.

SIGNIFICANCE

TSRT may be an alternative clinical measure to current clinical scales.

Changes in sensory-evoked synaptic activation of motoneurons after spinal cord injury in man

Following spinal cord injury (SCI), prolonged muscle spasms are readily triggered by brief sensory stimuli. Animal and indirect human studies have shown that a substantial portion of the depolarization of motoneurons during a muscle spasm comes from the activation of persistent inward currents (PICs). The brief (single pulse) sensory stimuli that trigger the PICs and muscle spasms in chronically spinalized animals evoke excitatory post-synaptic potentials (EPSPs) that are broadened to more than 500 ms, the duration of depolarization required to activate a PIC in the motoneuron. Thus, in humans, we investigated if post-synaptic potentials (PSPs) evoked from brief (<20 ms) sensory stimulation are changed after SCI and if they are broadened to > or =500 ms to more readily activate motoneuron PICs and muscle spasms. To estimate both the shape and duration of PSPs in human subjects we used peristimulus frequencygrams (PSFs), which are plots of the instantaneous firing frequency of tonically active single motor units that are time-locked to the occurrence of the sensory stimulus. PSFs in response to cutaneomuscular stimulation of the medial arch or toe of the foot, a sensory stimulus that readily triggers muscle spasms, were compared between non-injured control subjects and in spastic subjects with chronic (>1 year), incomplete SCI. In non-injured controls, a single shock or brief (<20 ms) train of cutaneomuscular stimulation produced PSFs consisting of a 300 ms increase in firing rate above baseline with an interposed period of reduced firing. Parallel intracellular experiments in motoneurons of adult rats revealed that a 300 ms EPSP with a fast intervening inhibitory PSP (IPSP) reproduced the PSF recorded in non-injured subjects. In contrast, the same brief sensory stimulation in subjects with chronic SCI produced PSFs of comparatively long duration (1200 ms) with no evidence for IPSP activation, as reflected by a lack of reduced firing rates after the onset of the PSF. Thus, unlike non-injured controls, the motoneurons of subjects with chronic SCI are activated by very long periods of pure depolarization from brief sensory activation. It is likely that these second-long EPSPs securely recruit slowly activating PICs in motoneurons that are known to mediate, in large part, the many seconds-long activation of motoneurons during involuntary muscle spasms.

Visual Analogue Scale to score the effects of Botulinum Toxin A treatment in children with cerebral palsy in daily clinical practice

OBJECTIVE

This study examined the reliability and efficiacy of the Visual Analogue Scale (VAS) in evaluating spasticity treatment in an outpatient setting.

PATIENTS AND METHODS

We used a parent-reported VAS device for evaluating the effects of Botulinum Toxin A (BTX-A). Data were collected on 55 children with cerebral palsy. Individual goals of treatment were formulated in close consultation with the caregivers. The categories of treatment options were improvement of pain, problems with nursing, sitting position, standing and walking.

RESULTS

Seventy-four interventions were performed in 55 children. A statistically significant effect was found for improvement of nursing, standing and walking. No statistically significant effect for pain was found, probably because of small numbers. In seven children there was no effect at all. Side effects were observed in five children.

CONCLUSION

In using a VAS instrument, beneficial effects were found for nursing, standing and walking after BTX-A treatment. A positive (not significant) correlation was found between the VAS and the Modified Tardieu for those children who also underwent a gait analysis. Evaluating spasticity treatment with the use of the VAS has an important advantage because it is a quick and easy method for evaluating individually defined treatment goals in an outpatient setting, in which time-consuming evaluations are not an option.

Outcomes of a home cycling program using functional electrical stimulation or passive motion for children with spinal cord injury: a case series

BACKGROUND/OBJECTIVE

Children with spinal cord injury (SCI) are at risk for musculoskeletal and cardiovascular complications. Stationary cycling using functional electrical stimulation (FES) or passive motion has been suggested to address these complications. The purpose of this case series is to report the outcomes of a 6-month at-home cycling program for 4 children with SCI.

METHODS

Two children cycled with FES and 2 cycled passively at home for 1 hour, 3 times per week.

OUTCOME MEASURES

Data collected included bone mineral density of the left femoral neck, distal femur, and proximal tibia; quadriceps and hamstring muscle volume; stimulated quadriceps and hamstring muscle strength; a fasting lipid profile; and heart rate and oxygen consumption during incremental upper extremity ergometry testing.

RESULTS

The 2 children cycling with FES and 1 child cycling passively exhibited improved bone mineral density, muscle volume, stimulated quadriceps strength, and lower resting heart rate. For the second child cycling passively, few changes were realized. Overall, the lipid results were inconsistent, with some positive and some negative changes seen.

CONCLUSIONS

This case series suggests that cycling with or without FES may have positive health benefits and was a practical home exercise option for these children with SCI.

Examination of spasticity of the knee flexors and knee extensors using isokinetic dynamometry with electromyography and clinical scales in children with spinal cord injury

BACKGROUND/OBJECTIVE

To examine the role of reflex activity in spasticity and the relationship between peak passive torque, Ashworth Scale (AS), and Spasm Frequency Scale (SFS) of the knee flexors and extensors during the measurement of spasticity using an isokinetic dynamometer in children with spinal cord injury (SCI).

METHODS

Eighteen children with chronic SCI and 10 children of typical development (TD) participated. One set of 10 passive movements was completed using an isokinetic dynamometer at 15, 90, and 180 degrees per second (deg/s) while surface electromyographic data were collected from the vastus lateralis (VL) and medial hamstrings (MH). Spasticity was clinically assessed using the AS and SFS.

RESULTS

There were no significant differences in peak passive torque of the knee flexors and extensors at any velocity for children with SCI compared to children with TD. Children with TD demonstrated significantly more reflex activity of the MH during the assessment of knee flexor spasticity at all movement velocities than did children with SCI. Children with TD demonstrated significantly more reflex activity of the VL during the assessment of knee-extensor spasticity with movements at 180 deg/s. The relationship between peak passive torque, AS, and SFS was significant during movements at a velocity of 90 deg/s only.

CONCLUSIONS

The role of increased reflexes in spasticity needs further examination. Isokinetic dynamometry may be measuring a different aspect of spasticity than the AS and SFS do in children with SCI.