Adherence associated with oral medications in the treatment of spasticity

Dry needling in multiple sclerosis: a scoping review

OBJECTIVE

Dry needling (DN) has recently been investigated as an alternative strategy to reduce muscle spasticity and improve mobility in people with multiple sclerosis (pwMS). The aim of the present review was to identify any available literature on the potential benefits of DN in pwMS.

METHODS

A systematic literature search was conducted in the PubMed, Scopus, ScienceDirect, Embase/Ovid, CINAHL, CENTRAL, Web of Science and PEDro databases and at ClinicalTrials.gov. The search results were limited to studies published between 2000 and 2023 without language restrictions. All articles reporting on the application of DN (defined as the use of a needle to target myofascial trigger point(s) without injection) in pwMS were included. Studies related to traditional medicine were excluded. Two reviewers independently investigated the quality of reporting based on Joanna Briggs Institute critical appraisal tools. Data on the effects of DN on muscle spasticity, pain intensity, mobility and other reported outcomes in pwMS were extracted and analyzed.

RESULTS

Four original articles (two case reports and two case series) and one conference paper reporting the findings of a randomized controlled trial randomized controlled trial (RCT) were included. The RCT was small (n = 16 participants) and sham-controlled with no significant differences between groups. In all four case reports/series, reduced spasticity was observed following DN treatment in pwMS. Findings with respect to other outcomes (including pain intensity, mobility, quality of life, manual dexterity and disability reduction) were mixed.

CONCLUSION

Although no firm conclusions can be drawn from these uncontrolled case reports/series, DN for pwMS appears feasible and (based on limited clinical observation) may have potential as an adjunct therapeutic method to address spasticity in pwMS. However, the quantity and quality of available data are extremely limited. There is a need for high-quality studies of DN (ideally adequately sized RCTs with a low risk of bias) to further explore its effectiveness in the MS population.

Sheffield Adaptive Patterned Electrical Stimulation (SHAPES) Therapy for Post Stroke Arm spasticity: study protocol for a 3-arm, a partially blinded, randomised controlled trial

INTRODUCTION

Post stroke elbow spasticity (PSES) affects over a third of individuals following stroke and negatively impacts on functional recovery, comfort and quality of life. Drug therapies have limited efficacy and unwanted side effects, botulinum toxin, although effective, is costly, and conventional electrical stimulation therapies are limited long term by habituation. We aim to investigate the efficacy of Sheffield Adaptive Patterned Electrical Stimulation (SHAPES), that delivers temporally and spatially varying pattern of electrical stimulation, against transcutaneous electrical stimulation (TENS) and standard care at reducing PSES.

METHODS AND DESIGN

Overall, 297 people with PSES will be randomised (1:1:1) to one of 3 arms: Standard care (no electrical stimulation), TENS (conventional patterned electrical stimulation) or SHAPES (adaptive patterned electrical stimulation). Both SHAPES and TENS are delivered using a specially designed electrical stimulation sleeve used for 60 min each day for 6-weeks. Outcome measures are completed at baseline, end of treatment (EOT 6 weeks) and then 6-weeks, 12-weeks and 24-weeks after the end of treatment. Efficacy will be determined based on the proportion of participants experiencing meaningful improvement (18%) in the 7-day Numerical Rating Scale (NRS-S) for PSES, compared between both intervention arms and standard care, and between the two intervention groups. Measures of arm motor function (Action Research Arm Test, MRC scale), and quality of life (SQoL-6D, EQ-5D) will also be measured along with a parallel health economic evaluation.

DISCUSSION

The results of the SHAPES trial will inform management of elbow spasticity after stroke. The SHAPES intervention is a low cost, self-administered intervention for the management of spasticity that can be used repeatedly, and if found to be more effective than TENS or control has the potential to be widely implemented in the UK NHS healthcare setting. Furthermore, despite the wide use of TENS in the management of spasticity, this study will provide critically required evidence regarding its efficacy. The trial has been registered with the ISRCTN registry (ISRCTN26060261).

Safety and effectiveness of thermal radiofrequency applied to the musculocutaneous nerve for patients with spasticity

Objective

Evaluate safety and effectiveness of thermal radiofrequency in the musculocutaneous nerve in patients with focal elbow flexor spasticity.

Design

Ambispective observational follow-up study. Patients with focal spasticity secondary to central nervous system injury with elbow flexor pattern who received thermal radiofrequency treatment in the musculocutaneous nerve between 2021 and 2023 were included.

Subjects

12 patients.

Methods

Ultrasound-guided thermal radiofrequency was applied to the musculocutaneous nerve at 80°C for 90 s. Effectiveness was assessed prior to thermal radiofrequency and at 6 months using scales to measure pain (VAS), spasticity (MAS), disability (DAS), quality of life (SQol-6D), patient-perceived and physician-perceived satisfaction (PIG-C, PGA), and goal attainment (GAS). Elbow joint range of motion was evaluated via goniometry. Safety was evaluated by assessing side effects.

Results

Patients had statistically significant improvements in spasticity (p = 0.003), severe elbow flexion (p = 0.02), pain (p = 0.046), functioning (p < 0.05), and spasticity-related quality of life (p < 0.05 in three sections). Furthermore, treatment goals were attained. Patient- and physician-perceived clinical improvement was achieved. Regarding side effects, two patients had dysesthesia that was self-limiting, with maximum duration of 1 month.

Conclusion

Thermal radiofrequency in the musculocutaneous nerve can be a safe, effective treatment for patients with severe spasticity with an elbow flexor pattern.

Neuromodulation and quality of life for patient with spasticity after spinal cord injury

RATIONALE

Spasticity develops in 80% of spinal cord injury cases and negatively affects the patents' quality of life. The most common method of surgical treatment for severe spasticity is a long-term intrathecal baclofen therapy (ITB). Long-term spinal cord stimulation is another possible treatment technique. This paper aims to evaluate the changes in quality of life for patients with spasticity who have been treated with neuromodulation (SCS or ITB) in 12 months after the surgery, as well to compare the changes in quality of life for patients who have been treated with spinal cord stimulation and those who received long-term intrathecal baclofen therapy.

MATERIALS AND METHODS

The influence of spasticity, experienced by the patients with a spinal cord injury, on their quality of life was analyzed before the surgery and 12 months after it. The severity of the spinal cord damage was determined with the scale of the American Spinal Injury Association (ASIA); spasticity was evaluated with the modified Ashworth scale, Penn Spasm Frequency Scale; pain levels were determined with visual analogue scale (VAS), anxiety and depression levels - with HADS. Functional activity of the patients was evaluated with the help of the Functional Independence Measure (FIM).

RESULTS

The treatment results for 33 patients (25 men and 8 women), aged from 18 to 62, are presented. After the trial stimulation, the patients were randomly assigned to either SCS or ITB group (18 and 15 people respectively). The decrease of spasticity in both experimental groups caused lower levels of pain, less functional dependency on other people, lower stress and depression rates and, as a consequence, better quality of life and social adaptation. The obtained results for SCS and ITB groups are statistically similar.

[Clinical practice guideline for the treatment of spasticity: Consensus and algorithms]

Spasticity is a complex phenomenon of extremely variable clinical expression, a dynamic and evolutionary process that can condition the activity and treatment of the patient. The current recommendation for early treatment aims to avoid progression and complications, and involves an individualized approach based on a wide range of pharmacological and non-pharmacological measures. This guide results from a forum of expert specialists who faced some frequent uncertainties in the assessment process and therapeutic approach of the spastic patient such as the suitability of initiating treatment, considerations for initiating, continuing and ceasing treatment with botulinum toxin, adjuvant treatments, pain or follow-up. The result is one algorithm of decision for the therapeutic approach of spasticity. Both scientific progress and the exchange of clinical experience on which this guide is based, can support decision-making on some areas of gloom that we find in daily practice.

The Efficacy of Cannabis on Multiple Sclerosis-Related Symptoms

Multiple sclerosis (MS) is known as an autoimmune disease that damages the neurons in the central nervous system. MS is characterized by its most common symptoms of spasticity, muscle spasms, neuropathic pain, tremors, bladder dysfunction, dysarthria, and some intellectual problems, including memory disturbances. Several clinical studies have been conducted to investigate the effects of cannabis on the relief of these symptoms in MS patients. The efficacy of Cannabis sativa (C. Sativa) in the management of MS outcomes such as spasticity, pain, tremors, ataxia, bladder functions, sleep, quality of life, and adverse effects were assessed in this review. Most clinical studies showed the positive effects of cannabinoids with their different routes of administration, such as oromucosal spray and oral form, in reducing most MS symptoms. The oromucosal spray Nabiximols demonstrated an improvement in reducing MS spasticity, pain, and quality of life with a tolerated adverse effect. Oral cannabinoids are significantly effective for treating MS pain and spasticity, while the other symptoms indicate slight improvement and the evidence is quite inconsistent. Oromucosal spray and oral cannabis are mainly used for treating patients with MS and have positive effects on treating the most common symptoms of MS, such as pain and spasticity, whereas the other MS symptoms indicated slight improvement, for which further studies are needed.

Neuromodulation as a basic platform for neuroprotection and repair after spinal cord injury

Spinal cord injury (SCI) is one of the most challenging medical issues. Spasticity is a major complication of SCI. A combination of spinal cord stimulation, new methods of neuroprotection and biomedical cellular products provides fundamentally new options for SCI treatment and rehabilitation. The paper attempts to critically analyze the effectiveness of using these procedures for patients with SCI, suggesting a protocol for a step-by-step personalized treatment of SCI, based on continuity of modern conservative and surgical methods. The study argues the possibility of using neuromodulation as a basis for rehabilitating patients with SCI.

Efficacy and safety of tolperisone versus baclofen among Chinese patients with spasticity associated with spinal cord injury: a non-randomized retrospective study

There are many medications available to treat spasticity, but the tolerability of medications is the main issue for choosing the best treatment. The objectives of this study were to compare the efficacy and adverse effects of tolperisone compared to baclofen among patients with spasticity associated with spinal cord injury. Patients received baclofen plus physical therapy (BAF+PT, n=135) or tolperisone plus physical therapy (TOL+PT, n=116), or physical therapy alone (PT, n=180). The modified Ashworth scale score, the modified Medical Research Council score, the Barthel Index score, and the Disability Assessment scale score were improved (P<0.05 for all) in all the patients at the end of 6 weeks compared to before interventions. After 6 weeks, the overall coefficient of efficacy of the intervention(s) in the BAF+PT, TOL+PT, and PT groups were 1.15, 0.45, and 0.05, respectively. The patients of the BAF+PT group reported asthenia, drowsiness, and sleepiness and those of the TOL+PT group reported dyspepsia and epigastric pain as adverse effects. When comparing drug interventions to physical therapy alone, both baclofen plus physical therapy and tolperisone plus physical therapy played a significant role in the improvement of daily activities of patients. Nonetheless, baclofen plus physical therapy was tentatively effective. Tolperisone plus physical therapy was slightly effective. In addition, baclofen caused adverse effects related to the sedative manifestation (Level of Evidence: III; Technical Efficacy Stage: 4).

Real-World Adherence to OnabotulinumtoxinA Treatment for Spasticity: Insights From the ASPIRE Study

OBJECTIVE

To identify baseline characteristics and treatment-related variables that affect adherence to onabotulinumtoxinA treatment from the Adult Spasticity International Registry (ASPIRE) study.

DESIGN

Prospective, observational registry (NCT01930786).

SETTING

International clinical sites.

PARTICIPANTS

Adults with spasticity (N=730).

INTERVENTIONS

OnabotulinumtoxinA at clinician's discretion.

MAIN OUTCOME MEASURES

Clinically meaningful thresholds used for treatment adherent (≥3 treatment sessions during 2-year study) and nonadherent (≤2 sessions). Data analyzed using logistic regression and presented as odds ratios (ORs) with 95% confidence intervals (CIs). Treatment-related variables assessed at sessions 1 and 2 only.

RESULTS

Of the total population, 523 patients (71.6%) were treatment adherent with 5.3±1.6 sessions and 207 (28.4%) were nonadherent with 1.5±0.5 sessions. In the final model (n=626/730), 522 patients (83.4%) were treatment adherent and 104 (16.6%) were nonadherent. Baseline characteristics associated with adherence: treated in Europe (OR=1.84; CI, 1.06-3.21; P=.030) and use of orthotics (OR=1.88; CI, 1.15-3.08; P=.012). Baseline characteristics associated with nonadherence: history of diplopia (OR=0.28; CI, 0.09-0.89; P=.031) and use of assistive devices (OR=0.51; CI, 0.29-0.90; P=.021). Treatment-related variables associated with nonadherence: treatment interval ≥15 weeks (OR=0.43; CI, 0.26-0.72; P=.001) and clinician dissatisfaction with onabotulinumtoxinA to manage pain (OR=0.18; CI, 0.05-0.69; P=.012). Of the population with stroke (n=411), 288 patients (70.1%) were treatment adherent with 5.3±1.6 sessions and 123 (29.9%) were nonadherent with 1.5±0.5 session. In the final stroke model (n=346/411), 288 patients (83.2%) were treatment adherent and 58 (16.8%) were nonadherent. Baseline characteristics associated with adherence: treated in Europe (OR=2.99; CI, 1.39-6.44; P=.005) and use of orthotics (OR=3.18; CI, 1.57-6.45; P=.001). Treatment-related variables associated with nonadherence: treatment interval ≥15 weeks (OR=0.42; CI, 0.21-0.83; P=.013) and moderate/severe disability on upper limb Disability Assessment Scale pain subscale (OR=0.40; CI, 0.19-0.83; P=.015).

CONCLUSIONS

These ASPIRE analyses demonstrate real-world patient and clinical variables that affect adherence to onabotulinumtoxinA and provide insights to help optimize management strategies to improve patient care.

Acupuncture treatment for spasticity after brain injury

Spasticity after brain injury is a neurological sequela caused by damage to upper motor neurons. The primary symptoms are involuntary muscle activity, decreased muscle strength, and joint contracture. Acupuncture as a therapeutic method to regulate central nervous system function has been studied widely in recent years. Many clinical experiments have proved that acupuncture has positive effects on spasticity after brain injury. In this review, we discuss recent research of acupuncture treatment and the need for large randomized controlled trials.

Evaluation of the Effectiveness of Treatment with Botulinum Toxin on Sleep Quality in Stroke-Related Spasticity

BACKGROUND AND PURPOSE

Botulinum toxin (BoNT) is a commonly used agent in the treatment of stroke-related spasticity. Sleep disorders can often be seen as a comorbidity or complication in stroke patients. Based on the data that spasticity is associated with sleep disorders, in this study, we aimed to evaluate whether sleep quality has changed in patients with stroke treated with BoNT.

METHODS

Thirty five (17 female / 18 male) stroke patients with gastrocnemius and / or soleus spasticity were included in this observational cross-sectional study. In clinical evaluation before and three months after BoNT injection; for spasticity evaluation modified Ashworth scale (MAS), pain assessment visual analog scale (VAS), functional evaluation; passive joint range of motion (ROM) measurement, functional independence measurement (FIM), lower limb Brunstrom staging, life quality assessment short form-36 (SF-36) quality of life scale, and sleep quality assessment Pittsburgh sleep quality index (PSQI) scales were used.

RESULTS

After the BoNT injection, there was a statistically significant decrease in MAS and VAS scores, a significant increase in passive ROM measurements, FIM, lower limb Brunstrom staging, and SF-36 physical function sub parameter. There was also a significant decrease in PSQI scores. Before and after treatment, there was no correlation found between PSQI values with pain and spasticity. However, there was a weak negative correlation between post-treatment PSQI values, passive ROM, SF-36 physical function and SF-36 physical role sub parameters (respectively: r: -0.335 p: 0.049, r: -0.364, 0.032, r: -0.404, p: 0.016). Conlusion: The results of our study suggest that BoNT, which is frequently used in the treatment of spasticity in stroke patients, has positive effects on sleep quality.

Caregiver Delivered Sensory Electrical Stimulation for Post Stroke Upper Limb Spasticity: A Single Blind Crossover Randomized Feasibility Study

We developed a 64 channel sensory electrical stimulator which delivers a dynamic and variable ‘Sensory Barrage’ Stimulation (SBS). Our aim was to assess the feasibility of caregivers delivering the stimulation in the community for a clinical trial comparing single channel Transcutaneous Electrical Nerve Stimulation (TENS) with SBS for post stroke upper limb spasticity. We trained caregivers of 16 participants with post stroke upper limb spasticity to sequentially administer SBS and TENS for 60 min daily for four weeks each, with a washout period of two weeks in between. Outcome measures tested were recruitment and retention rates, compliance with interventions and daily recording of Participant -reported Numerical Rating Scale (NRS). We also collected results of Action Research Arm Test (ARAT), Leeds Arm Spasticity Impact Scale (LASIS) and Modified Ashworth Scale (MAS) for spasticity. Out of 21 potential participants, 16 consented and 15 completed the protocol. Ten participants received TENS for 80% (23/28) of the intended hours. Eleven participants completed NRS for at 80% (45/56) of the study days. All participants attended all visits. The MAS reduced by at least one in five participants after SBS and in three after TENS. Minimal Clinically Important Difference (MCID) of four points increase in ARAT was seen in five participants following TENS, and in four following SBS. A MCID of 18% decrease in NRS was reported by eight participants after TENS and three after SBS. This study demonstrated the feasibility of undertaking a trial of sensory electrical stimulation for post-stroke spasticity with caregivers delivering intervention in community. The study was not powered to detect efficacy of the interventions. Trial registration number: NCT02907775.Date 20-9-2016.

Treatment of spasticity in spinal cord injury with botulinum toxin

CONTEXT

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

OBJECTIVE

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

DESIGN AND SETTING

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

RESULTS

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

CONCLUSIONS

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

Intrathecal Therapies

Intrathecal baclofen therapy is a well-established technique for spasticity management. This article briefly reviews the pharmacology of intrathecal baclofen as well as customary approach for utilization of this targeted drug delivery concept. Following these descriptions, four unusual presentations will be described, including the need for initial trialing, patient-directed boluses during chronic intrathecal baclofen therapy, use of medications other than baclofen for intrathecal therapy in spastic patients, and intraventricular baclofen delivery. These hypothetical cases are provided in an effort to expand the use of targeted drug delivery to larger population of spastic patients.

Efficacy and Safety of Botulinum Toxin Type A in Spasticity Caused by Spinal Cord Injury: A Randomized, Controlled Trial

Background

Baclofen is approved by the US FDA to treat spasticity, but its sustained use may cause drug addiction. The objective of this study was to compare the efficacy and safety of botulinum toxin type A versus baclofen in spasticity.

Material/Methods

A total of 336 patients who had spasticity caused by spinal cord injury were enrolled in a randomized (in 1: 1: 1: ratio) for placebo, controlled trial. Patients had received baclofen (BA group, n=112), local intramuscular injection of 500 U Botulinum toxin type A (BTI group, n=112), or physical therapies alone (placebo group, n=112). Modified Ashworth scale (mAS) score, disability assessment scale (DAS) score, modified medical research council (mMRC) score, the Barthel Index (BI) score, and treatment-emergent adverse effects were evaluated during the follow-up period. Wilcoxon test or one-way ANOVA/Tukey post hoc tests were performed at 95% of confidence level.

Results

Baclofen (1.504±0.045 vs. 1.53±0.06, p=0.003, q=4.068) and botulinum toxin type A (1.49±0.09 vs. 1.528±0.15, p=0.0224, q=3.5541) had improved mAS scores after 2 weeks. Baclofen had a more strongly improved DAS score than botulinum toxin type A at 4 (p=0.0496, q=3.48) and 6 (p<0.0001, q=6.48) weeks. Baclofen and botulinum toxin type A had consistently improved BI scores. Baclofen caused asthenia and sleepiness, while botulinum toxin type A caused bronchitis and elevated blood pressure.

Conclusions

Botulinum toxin type A may be an effective therapeutic option for spasticity caused by spinal cord injury.

Multiple sclerosis symptoms and spasticity management: new data

Spasticity, perceived by patients as muscle rigidity and spasms, is a common symptom in multiple sclerosis (MS). It is associated with functional impairment that can exacerbate other MS symptoms and reduce quality of life. Pharmacological treatment options are limited and frequently ineffective. Treatment adherence is a key issue to address in these patients. The efficacy and safety of 9-delta-tetrahydrocannabinol:cannabidiol (THC:CBD) oromucosal spray for treatment of MS spasticity were demonstrated in four Phase III trials. Observational studies and registry data subsequently confirmed the effectiveness and tolerability of THC:CBD oromucosal spray under everyday practice conditions. Among patients who respond to treatment, THC:CBD oromucosal spray has been shown to produce positive improvements in gait parameters and to normalize muscle fibers.

Effect of tetrahydrocannabinol:cannabidiol oromucosal spray on activities of daily living in multiple sclerosis patients with resistant spasticity: a retrospective, observational study

Aim: To examine evolution in activities of daily living (ADL) in patients with multiple sclerosis spasticity during long-term use of tetrahydrocannabinol (THC):cannabidiol (CBD) oromucosal spray. Methods: Functional impairment was assessed retrospectively (prior to start of treatment) and at the present moment using a 16-item ADL survey; results were compared. A control group without add-on THC:CBD oromucosal spray was included to investigate possible recall bias. Results: ADL was maintained or slightly improved with THC:CBD oromucosal spray across treatment time (mean 31.9 months) including significant improvement in ‘standing up’ (p < 0.05) and trends in other items. Significant improvements (p < 0.01) with THC:CBD oromucosal spray were observed in several multiple sclerosis spasticity-related symptoms. Overall, 96.9% of patients using THC:CBD oromucosal spray had a positive global impression of change during treatment. Conclusion: In this pilot study, THC:CBD oromucosal spray maintained or improved aspects of daily functioning. Further study in a larger trial is warranted.

Medical cost impact of intrathecal baclofen therapy for severe spasticity

OBJECTIVES

To evaluate the economic effects of intrathecal baclofen (ITB) for patients with severe spasticity based on costs of care before and after implantation of an intrathecal drug delivery system.

MATERIALS AND METHODS

An actuarial projection of post-implant experience in the absence of ITB intervention was used to simulate a continued conventional medical management protocol (ITB-free) by assuming a reasonable trend rate based on health-care industry standards. Cost projections were developed over a 30-year time horizon at various reimplantation rates. The model was informed by retrospective analysis of commercial administrative claims data from 409 pediatric and adult spasticity patients who received a pump implant (ITB-experienced) within a 3-year service period (January 2006 to January 2009). Common indications associated with pump implant included multiple sclerosis (N = 124), cerebral palsy (N = 131), and spinal cord injury (N = 40).

RESULTS

ITB was less costly than the conventional protocol over our baseline implantation cycle. Costs in the month of implant and in the year following were cumulatively $26,375 more than with the conventional protocol. However, ITB financial break-even occurs between the second and third years post-implant. The lifetime analysis indicates that savings for ITB are $8009 per patient per year compared with conventional therapy. Most of the savings are derived from reductions in inpatient admissions, physician office visits, and outpatient physiotherapy.

CONCLUSIONS

The results suggest that spasticity patients receiving ITB would expect to experience a reduction in cumulative future medical costs relative to anticipated costs in the absence of a pump implant. This finding complements the existing literature on the cost-effectiveness of ITB.