Clinical assessment of spasticity in spinal cord injury: a multidimensional problem

Inhibitory kinesiotaping has no effect on post-stroke spasticity: Prospective, randomised, controlled study

OBJECTIVE

Motor neuron pool activity is high in spasticity. The effect of inhibitory kinesiotaping (KT) on spasticity is unclear. The aim of this study is to investigate the effect of inhibitory KT on spasticity after stroke.

METHODS

Fifty stroke patients with ankle plantarflexor spasticity were randomised to intervention (27) and control (23) groups. Inhibitory KT was applied to the triceps surae muscle in the intervention group and sham KT to the Achilles tendon in the control group. Inhibitory and sham KT were applied for 72 h with a combined conventional rehabilitation programme. Spasticity was assessed at baseline and 72 h after KT using three instruments: Modified Ashworth Scale (MAS), Homosynaptic Post-Activation Depression (HPAD) reflecting the level of motor neuron pool activity, and joint torque as a measure of resistance to passive ankle dorsiflexion.

RESULTS

The baseline MAS score, HPAD levels and dorsiflexion torque of the two groups were not significantly different. The change in MAS score was -3.7 ± 17.5 (p = 0.180) in the intervention group and 3.6 ± 33.3 (p = 0.655) in the control group. The change in dorsiflexion torque was -0.3 ± 16.1 kg m (p = 0.539) in the intervention group and 8.0 ± 24.1 kg m (p = 0.167) in the control group. The change in mean HPAD was 8.7 ± 34.7 (p = 0.911) in the intervention group and 10.1 ± 41.6 (p = 0.609) in the control group.

CONCLUSIONS

The present study showed that inhibitory KT has no antispastic effect in stroke patients.

A scoping review on muscle cramps and spasms in upper motor neuron disorder-two sides of the same coin?

Background

Muscle cramps are typically regarded as benign muscle overactivity in healthy individuals, whereas spasms are linked to spasticity resulting from central motor lesions. However, their striking similarities made us hypothesize that cramping is an under-recognized and potentially misidentified aspect of spasticity.

Methods

A systematic search on spasms and cramps in patients with Upper Motor Neuron Disorder (spinal cord injury, cerebral palsy, traumatic brain injury, and stroke) was carried out in Embase/Medline, aiming to describe the definitions, characteristics, and measures of spasms and cramps that are used in the scientific literature.

Results

The search identified 4,202 studies, of which 253 were reviewed: 217 studies documented only muscle spasms, 7 studies reported only cramps, and 29 encompassed both. Most studies (n = 216) lacked explicit definitions for either term. One-half omitted any description and when present, the clinical resemblance was significant. Various methods quantified cramp/spasm frequency, with self-reports being the most common approach.

Conclusion

Muscle cramps and spasms probably represent related symptoms with a shared pathophysiological component. When considering future treatment strategies, it is important to recognize that part of the patient's spasms may be attributed to cramps.

Evidence of Improvement of Lower Limb Functioning Using Hydrotherapy on Spinal Cord Injury Patients

BACKGROUND

Spinal cord injury (SCI) is a devastating problem for modern society, whether it affects young people in the most productive period of their lives or the elderly. The spinal cord injury is currently without curative treatment and the therapeutic intervention aims to minimize secondary complications and maximize residual function through rehabilitation medicine. The main objective of this scientific paper is to determine whether there is evidence in the literature regarding the importance and/or use of hydrotherapy, as part of the therapeutic management of the SCI patient, in order to decrease the degree of spasticity, of pain symptoms, increase or maintain range of motion, improve respiratory, cardiovascular, and metabolic status, as well as improve function and psychological benefits.

METHODS

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) procedures, the following databases were analyzed between 2000 and 2021: Pub Med, Pub Med Central, Science Direct, Scopus, and SpringerLink. Initial keywords: rehabilitation treatment, spinal cord injury. Additional keywords: hydrotherapy, aqua therapy, spasticity, human. For the scientific quality of the included articles, risk of bias was assessed using the Downs and Black Appraisal Modified Scale.

RESULTS

Our research used only four publications as per PRISMA protocol, assessed with Downs and Black Scale. The study models used in the individual studies included in the research are the following: two systematic reviews, one experimental non-randomized control, and one individual semi-structured interview. Due to the low number of studies, despite two of them being reviews, there is the necessity for a more standardized methodology to prove the benefits hydrotherapy for SCI patients for the improvement of lower limb functioning.

CONCLUSION

Hydrotherapy is an important component of the treatment of an SCI patient, despite the limited number of scientific studies that support this aspect. Clinical trials in the future are required.

Paving the way for a better management of pain in patients with spinal cord injury: An exploratory study on the use of Functional Electric Stimulation(FES)-cycling

CONTEXT/OBJECTIVE

Chronic pain is common in patients with spinal cord injury (SCI), for whom it negatively affects quality of life, and its treatment requires an integrated approach. To this end, lower limb functional electrical stimulation (FES) cycling holds promise.

OBJECTIVE

To investigate pain reduction in a sample of patients with SCI by means of lower limb rehabilitation using FES cycling.

DESIGN, SETTING AND PARTICIPANTS

Sixteen patients with incomplete and complete SCIs, attending the Neurorobotic Unit of our research institute and reporting pain at or below the level of their SCI were recruited to this exploratory study.

INTERVENTIONS

Patients undertook two daily sessions of FES cycling, six times weekly, for 6 weeks.

OUTCOME MEASURES

Pain outcomes were measured using the 0-10 numerical rating scale (NRS), the Multidimensional Pain Inventory for SCI (MPI-SCI), and the 36-Item Short Form Survey (SF-36). Finally, we assessed the features of dorsal laser-evoked potentials (LEPs) to objectively evaluate Aδ fiber pathways.

RESULTS

All participants tolerated the intervention well, and completed the training without side effects. Statistically significant changes were found in pain-NRS, MPI-SCI, and SF-36 scores, and LEP amplitudes. Following treatment, we found that three patients experienced high pain relief (an NRS decrease of at least 80%), six individuals achieved moderate pain relief (an NRS decrease of about 30-70%), and five participants had mild pain relief (an NRS decrease of less than 30%).

CONCLUSION

Our preliminary results suggest that FES cycling training is capable of reducing the pain reported by patients with SCI, regardless of American Spinal Injury Association scoring, pain level, or the neurological level of injury. The neurophysiological mechanisms underlying such effects are likely to be both spinal and supraspinal.

Quality of life and symptom burden in children with neurodegenerative diseases: using PedsQL and SProND, a new symptom-based scale

Background

Children with neurodegenerative conditions (CNDC) often suffer from severe neurodisability and high symptom burden with multisystemic involvement. However, their symptom burden and health-related quality of life (HRQOL) is not systematically documented in the literature, and there is no existing tool for such purposes. We designed our own tool for scoring of symptom burden amongst CNDCs and adopted the PedsQL generic score 4.0 to quantify the impact of overall symptom burden on children’s overall HRQOL.

Methods

The Symptom Profile for children with neurodegnerative condition (SProND) questionnaire was developed, which consisted of 14 questions grouped according to 5 categories, namely epilepsy, neurobehavioural, movement and mobility related, breathing and swallowing, and other daily activities. CNDCs were recruited during visits to the Comprehensive Neurometabolic / Neurodegenerative Program of the Duchess of Kent Children’s Hospital and Hong Kong Children’s Hospital between November 2019 and March 2020. The SProND and PedsQL 4.0 Generic Core Scales were distributed to consenting parents of CNDCs.

Results

36 CNDCs were recruited and matched with community controls. The response rate of subject and control were 99.5% and 98.7% respectively. The Cronbach alpha was 0.61 for the neurobehavioural domain and >  = 0.7 for other domains. The greater number of symptoms each subject experiences, the worse his/ her PedsQL scores. Subjects displaying hypersalivation and swallowing difficulties had average physical health summary scores of less than 30% compared with subjects without these symptoms. On the other hand, average psychosocial health summary scores of subjects with involuntary movements, joint stiffness, hypersalivation, sleep problem and anorexia were approximately 70% compared to subjects without these symptoms.

Discussion and conclusion

This is one of the first studies to look at CNDCs as a group. We propose the SProND questionnaire for evaluation of symptom profile amongst CNDCs with satisfactory internal and external validity. It demonstrates how physical symptoms impact both physical and psychosocial HRQOL, and the cumulative effect of individual symptoms on the overall HRQOL. As such, CNDCs should be systematically screened for multi-systemic symptoms as a routine part of their clinical care, and care plans should be individually catered to individual patients’ symptom burden and specific needs.

Effect of epidural spinal cord stimulation after chronic spinal cord injury on volitional movement and cardiovascular function: study protocol for the phase II open label controlled E-STAND trial

INTRODUCTION

Spinal cord injury (SCI) leads to significant changes in morbidity, mortality and quality of life (QOL). Currently, there are no effective therapies to restore function after chronic SCI. Preliminary studies have indicated that epidural spinal cord stimulation (eSCS) is a promising therapy to improve motor control and autonomic function for patients with chronic SCI. The aim of this study is to assess the effects of tonic eSCS after chronic SCI on quantitative outcomes of volitional movement and cardiovascular function. Our secondary objective is to optimise spinal cord stimulation parameters for volitional movement.

METHODS AND ANALYSIS

The Epidural Stimulation After Neurologic Damage (ESTAND) trial is a phase II single-site self-controlled trial of epidural stimulation with the goal of restoring volitional movement and autonomic function after motor complete SCI. Participants undergo epidural stimulator implantation and are followed up over 15 months while completing at-home, mobile application-based movement testing. The primary outcome measure integrates quantity of volitional movement and similarity to normal controls using the volitional response index (VRI) and the modified Brain Motor Control Assessment. The mobile application is a custom-designed platform to support participant response and a kinematic task to optimise the settings for each participant. The application optimises stimulation settings by evaluating the parameter space using movement data collected from the tablet application and accelerometers. A subgroup of participants with cardiovascular dysautonomia are included for optimisation of blood pressure stabilisation. Indirect effects of stimulation on cardiovascular function, pain, sexual function, bowel/bladder, QOL and psychiatric measures are analysed to assess generalisability of this targeted intervention.

ETHICS AND DISSEMINATION

This study has been approved after full review by the Minneapolis Medical Research Foundation Institutional Review Board and by the Minneapolis VA Health Care System. This project has received Food and Drug Administration investigational device exemption approval. Trial results will be disseminated through peer-reviewed publications, conference presentations and seminars.

TRIAL REGISTRATION NUMBER

NCT03026816.

Shared and distinct voxel-based lesion-symptom mappings for spasticity and impaired movement in the hemiparetic upper limb

Hemiparesis and spasticity are common co-occurring manifestations of hemispheric stroke. The relationship between impaired precision and force in voluntary movement (hemiparesis) and the increment in muscle tone that stems from dysregulated activity of the stretch reflex (spasticity) is far from clear. Here we aimed to elucidate whether variation in lesion topography affects hemiparesis and spasticity in a similar or dis-similar manner. Voxel-based lesion-symptom mapping (VLSM) was used to assess the impact of lesion topography on (a) upper limb paresis, as reflected by the Fugl-Meyer Assessment scale for the upper limb and (b) elbow flexor spasticity, as reflected by the Tonic Stretch Reflex Threshold, in 41 patients with first-ever stroke. Hemiparesis and spasticity were affected by damage to peri-Sylvian cortical and subcortical regions and the putamen. Hemiparesis (but not spasticity) was affected by damage to the corticospinal tract at corona-radiata and capsular levels, and by damage to white-matter association tracts and additional regions in the temporal cortex and pallidum. VLSM conjunction analysis showed only a minor overlap of brain voxels where the existence of damage affected both hemiparesis and spasticity, suggesting that control of voluntary movement and regulation of muscle tone at rest involve largely separate parts of the motor network.

Embodiment Comfort Levels During Motor Imagery Training Combined With Immersive Virtual Reality in a Spinal Cord Injury Patient

Brain-machine interfaces combining visual, auditory, and tactile feedback have been previously used to generate embodiment experiences during spinal cord injury (SCI) rehabilitation. It is not known if adding temperature to these modalities can result in discomfort with embodiment experiences. Here, comfort levels with the embodiment experiences were investigated in an intervention that required a chronic pain SCI patient to generate lower limb motor imagery commands in an immersive environment combining visual (virtual reality -VR), auditory, tactile, and thermal feedback. Assessments were made pre-/ post-, throughout the intervention (Weeks 0-5), and at 7 weeks follow up. Overall, high levels of embodiment in the adapted three-domain scale of embodiment were found throughout the sessions. No significant adverse effects of VR were reported. Although sessions induced only a modest reduction in pain levels, an overall reduction occurred in all pain scales (Faces, Intensity, and Verbal) at follow up. A high degree of comfort in the comfort scale for the thermal-tactile sleeve, in both the thermal and tactile feedback components of the sleeve was reported. This study supports the feasibility of combining multimodal stimulation involving visual (VR), auditory, tactile, and thermal feedback to generate embodiment experiences in neurorehabilitation programs.

Minimal handgrip force is needed for transcutaneous electrical stimulation to improve hand functions of patients with severe spinal cord injury

Spinal cord stimulation enhanced restoration of motor function following spinal cord injury (SCI) in unblinded studies. To determine whether training combined with transcutaneous electrical spinal cord stimulation (tSCS), with or without systemic serotonergic treatment with buspirone (busp), could improve hand function in individuals with severe hand paralysis following SCI, we assessed ten subjects in a double-blind, sham-controlled, crossover study. All treatments—busp, tSCS, and the busp plus tSCS—reduced muscle tone and spasm frequency. Buspirone did not have any discernible impact on grip force or manual dexterity when administered alone or in combination with tSCS. In contrast, grip force, sinusoidal force generation and grip-release rate improved significantly after 6 weeks of tSCS in 5 out of 10 subjects who had residual grip force within the range of 0.1–1.5 N at the baseline evaluation. Improved hand function was sustained in subjects with residual grip force 2–5 months after the tSCS and buspirone treatment. We conclude that tSCS combined with training improves hand strength and manual dexterity in subjects with SCI who have residual grip strength greater than 0.1 N. Buspirone did not significantly improve the hand function nor add to the effect of stimulation.

Foundational ingredients of robotic gait training for people with incomplete spinal cord injury during inpatient rehabilitation (FIRST): A randomized controlled trial protocol

Introduction

As technological advances allow the use of robotic exoskeleton devices with gait training, there is a critical need to establish a robotic gait training (RGT) program to meet the needs of people with spinal cord injury (SCI) during inpatient rehabilitation. The purposes of this study are to prospectively examine the efficacy of a stakeholder informed RGT program compared to usual care gait training (UC) during inpatient rehabilitation in people with incomplete SCI and compare the intensity of RGT and UC gait training during inpatient rehabilitation.

Study design

128 patients with incomplete SCI admitted to our inpatient rehabilitation facility will be screened for eligibility and randomized to either the RGT or UC group. RGT sessions will use the Ekso robotic exoskeleton [class II medical device (United States FDA)]. UC sessions will use traditional gait training approaches such as manually assisted overground gait training with walkers and orthotics and body weight–supported treadmill training (BWSTT). Our primary outcome is gait function as characterized by the Walking Index for Spinal Cord Injury–II (WISCI-II). Secondary outcomes are gait speed, Spinal Cord Independence Measure (SCIM), Numeric Pain Rating Scale (NPRS), Fatigue Severity Scale (FSS), Penn Spasm Frequency Scale (PSFS), Patient Health Questionnaire-9 (PHQ-9), General Anxiety Disorder– 7 (GAD-7), International Spinal Cord Injury Quality of Life Basic Data Set, and a Qualitative Questionnaire. Assessments of primary and secondary outcomes will occur at admission and discharge from inpatient rehabilitation. General or generalized linear models will be used to analyze differences between groups for all measures.

Clinical impact

Successful completion of this study will provide a usable, replicable, stakeholder informed RGT intervention for use with individuals with incomplete SCI during inpatient rehabilitation.

Considerations on the psychometric properties and validity of the Spinal Cord Injury Secondary Conditons Scale

STUDY DESIGN

Cross-sectional validation study.

OBJECTIVES

Explore psychometric properties of Spinal Cord Injury Secondary Conditions Scale (SCI-SCS).

SETTING

Two Scandinavian rehabilitation centres.

METHODS

Included were 224 consecutive patients attending regular follow-up at least 1 year after a traumatic SCI. Mean age was 49.6 (SD 14.9) years. SCI-SCS floor and ceiling effect examined. Construct validity was investigated by confirmatory factor analysis and correlation analysis, and reliability by Cronbach's alpha.

RESULTS

SCI-SCS showed no floor or ceiling effect. Two out of four earlier reported latent factors ("Genitourinary and bowel", "Muscle structures and pain") were confirmed. The global Cronbach's alpha of SCI-SCS was 0.65 and 0.22-0.61 for the four latent factors. The SCI-SCS sum score showed low correlation to quality of life (QoL) measured by EQ5 VAS (r_s = -0.47, p < 0.001). Likewise, the sum score correlations to QoL-general and QoL-physical health (International SCI QoL Basic Dataset) were low (r_s = -0.36, p < 0.001 and r_s = -0.37, p < 0.001, respectively). The scale item Muscle Spasms correlated moderately to ratings on Spasm Frequency (r_s = 0.59, p < 0.001) and Spasm Intensity (r_s = 0.56, p < 0.001) scales. Chronic Pain and Joint and Muscle Pain correlated to patient reported number of pain sites and level of pain (International SCI Pain Basic Dataset 1.0) (r_s = 0.31 p < 0.001 and r_s = 0.47, p < 0.001, respectively).

CONCLUSION

SCI-SCS is a relevant instrument for giving clinicians and researchers an overview of the individual recent experiences with secondary conditions. However, the instrument could benefit from a clearer definition of the construct secondary conditions, a scale revision and a consideration of whether to add other experienced secondary conditions.

Characterizing the Experience of Spasticity after Spinal Cord Injury: A National Survey Project of the Spinal Cord Injury Model Systems Centers

OBJECTIVE

To characterize the qualities that individuals with spinal cord injury (SCI) associate with their experience of spasticity and to describe the relationship between spasticity and perceived quality of life and the perceived value of spasticity management approaches.

DESIGN

Online cross-sectional survey.

SETTING

Multicenter collaboration among 6 Spinal Cord Injury Model Systems hospitals in the United States.

PARTICIPANTS

Individuals with SCI (N=1076).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Qualities of Spasticity Questionnaire, modified Spinal Cord Injury-Spasticity Evaluation Tool (mSCI-SET), and the modified Patient-Reported Impact of Spasticity Measure (mPRISM).

RESULTS

Respondents indicated that spasms most often occurred in response to movement-related triggering events. However, spontaneous spasms (ie, no triggering event) were also reported to be among the most common types. Frequency of spasms appears to decline with age. The highest frequency of spasms was reported by 56% of respondents aged <25 years and by only 28% of those >55 years. Stiffness associated with spasticity was reported to be more common than spasms (legs, 65% vs 54%; trunk, 33% vs 18%; arms, 26% vs 15%). Respondents reported negative effects of spasticity more commonly than positive effects. Based on their association with negative scores on the mSCI-SET and the mPRISM, the 5 most problematic experiences reported were stiffness all day, interference with sleep, painful spasms, perceived link between spasticity and pain, and intensification of pain before a spasm. Respondents indicated spasticity was improved more by stretching (48%) and exercise (45%) than by antispasmodics (38%).

CONCLUSIONS

The experience of spasticity after SCI is complex and multidimensional, with consequences that affect mobility, sleep, comfort, and quality of life. Stiffness, rather than spasms, appears to be the most problematic characteristic of spasticity. Physical therapeutic interventions to treat spasticity warrant in-depth investigation.

Arm activity measure (ArmA): psychometric evaluation of the Swedish version

Background

Patient Reported Outcomes Measure (PROM) are commonly used in research and essential to understand the patient experience when receiving treatment. Arm Activity Measure (ArmA) is a valid and reliable self-report questionnaire for assessing passive (section A) and active (section B) real-life arm function in patients with disabling spasticity. The original English version of ArmA has been psychometrically tested and translated into Thai.

Aims

Translate and cross-culturally adapt ArmA to Swedish language and context. Further, to evaluate the reliability, validity and sensitivity of the Swedish version of the questionnaire (ArmA-S) in patients with disabling upper limb spasticity caused by injuries to the central nervous system (CNS).

Materials and methods

ArmA was translated and cross-culturally adapted according to established guidelines. Validity and reliability were evaluated in 61 patients with disabling spasticity. Face and content validity was evaluated by expert opinions from clinicians and feedback from patients with upper limb spasticity. Internal consistency reliability was assessed with Cronbach’s alpha and test-retest reliability was assessed using the quadratic weighted kappa.

Results

ArmA-S was shown to be clinically feasible, with good face and content validity and no floor or ceiling effects. Internal consistency of ArmA-S was high and equivalent to ArmA; with Chronbach´s alpha coefficients values of 0.94 and 0.93 for section A and B, respectively. Test-retest reliability was good, with kappa values of 0.86 and 0.83 for section A and B, respectively. Some layout modifications of ArmA-S were made to further increase the user-friendliness, test-retest reliability, and responsiveness.

Conclusion

ArmA-S was shown to be a reliable and valid self-report questionnaire for use in clinical practice and research to assess improvements in passive and active upper limb function in patients with disabling spasticity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-021-00310-4.

Tonic stretch reflex threshold as a measure of spasticity after stroke: Reliability, minimal detectable change and responsiveness

OBJECTIVE

To determine inter-rater reliability, minimal detectable change and responsiveness of Tonic Stretch Reflex Threshold (TSRT) as a quantitative measure of elbow flexor spasticity.

METHODS

Elbow flexor spasticity was assessed in 55 patients with sub-acute stroke by determining TSRT, the angle of spasticity onset at rest (velocity = 0°/s). Elbow flexor muscles were stretched 20 times at different velocities. Dynamic stretch-reflex thresholds, the elbow angles corresponding to the onset of elbow flexor EMG at each velocity, were used for TSRT calculation. Spasticity was also measured with the Modified Ashworth Scale (MAS). In a sub-group of 44 subjects, TSRT and MAS were measured before and after two weeks of an upper-limb intervention.

RESULTS

The intraclass correlation coefficient was 0.65 and the 95% minimal detectable change was 32.4°. In the treated sub-group, TSRT, but not MAS significantly changed. TSRT effect size and standardized response mean were 0.40 and 0.35, respectively. Detection of clinically meaningful improvements in upper-limb motor impairment by TSRT change scores ranged from poor to excellent.

CONCLUSIONS

Evaluation of stroke-related elbow flexor spasticity by TSRT has good inter-rater reliability. Test responsiveness is low, but better than that of the MAS.

SIGNIFICANCE

TSRT may be used to complement current scales of spasticity quantification.

A review and evaluation of patient-reported outcome measures for spasticity in persons with spinal cord damage: Recommendations from the Ability Network - an international initiative

Context: Patient-reported outcome measures (PROMs) are valuable for capturing the impact of spasticity on health-related quality of life (HRQoL) in persons with spinal cord damage (SCD) and evaluating the efficacy of interventions. Objective: To provide practical guidance for measuring HRQoL in persons with spasticity following SCD. Methods: Literature reviews identified measures of HRQoL and caregiver burden, utilized in studies addressing spasticity in SCD. Identified measures were evaluated for clinical relevance and practicality for use in clinical practice and research. The PRISM, SCI-SET, EQ-5D and SF-36 instruments were mapped to the International Classification of Functioning, Disability and Health (ICF). The PRISM and SCI-SET were evaluated using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist. Results: Two spasticity-specific, five generic, and four preference-based measures were identified. ICF mapping and the COSMIN checklist supported the use of the PRISM and SCI-SET in SCD. The SF-36 is considered the most useful generic measure; disability-adapted versions may be more acceptable but further studies on psychometric properties are required. The SF-36 can be converted to a preference-based measure (SF-6D), or alternatively the EQ-5D can be used. While no measures specific to caregivers of people with SCD were identified, the Caregiver Burden Scale and the Zarit Burden Interview are considered suitable. Conclusion: Recommended measures include the PRISM and SCI-SET (condition-specific), SF-36 (generic), and Caregiver Burden Scale and Zarit Burden Interview (caregiver burden). Consideration should be given to using condition-specific and generic measures in combination; the PRISM or SCI-SET combined with SF-36 is recommended.

Painful tonic spasm in Chinese patients with neuromyelitis optica spectrum disorder: Prevalence, subtype, and features

OBJECTIVES

Painful tonic spasm (PTS) is a common symptom in patients with neuromyelitis optica spectrum disorder (NMOSD). We herein aimed to explore the prevalence, subtype, and features of PTS in Chinese Han patients with NMOSD.

METHODS

We retrospectively reviewed medical records and interviewed patients with NMOSD who were admitted to Huashan Hospital and the Jing'an District Center Hospital of Fudan University in Shanghai, China, from February 2017 to May 2019. The primary questionnaires included a Numerical Rating Scale (NRS), Spinal Cord Injury Health Questionnaire (SCI-HQ), Penn Spasm Frequency Scale (PSFS), and Patient Global Impression of Improvement (PGI-I).

RESULTS

Sixty-seven of 153 (43.79%) patients with NMOSD showed PTS, only when spinal cord was involved. PTS had a negative impact on daily life in 97.01% (65/67) of the patients, and 92.54% (62/67) of the patients needed symptomatic treatment. Pain intensity and frequency of PTS were significantly different (P = 0.018 with NRS, P = 0.045 with PSFS) among flexor tonic spasm, extensor tonic spasm, isometric tonic spasm and complex tonic spasm subtype. Forty patients (59.71%) manifested complex tonic spasms, which indicated more severe pain and frequent spasms comparing to other subtypes. The locations of PTS were significantly different among the 5 subtypes (P<0.001), i.e.,77.78% (7/9) of flexor tonic spasms appeared in the upper extremity, 100% (9/9) of extensor tonic spasm occurred in the lower extremity, and isometric tonic spasms principally occurred in the trunk (87.5%). Forty-one patients (66.13%) demonstrated good responses to the symptomatic treatments, and there were no statistical differences with respect to the therapeutic responses among the 5 PTS subtypes (P = 0.509).

CONCLUSIONS

PTS was associated with myelitis, and was a common symptom in NMOSD. Intensity, frequency and location were different among the PTS subtypes. Complex tonic spasm was the most common and serious subtype.

Structured Water Dance Intervention (SWAN) for adults with profound intellectual and multiple disabilities: study protocol

Background

People with profound intellectual and multiple disabilities (PIMD) have a combination of severe intellectual disability, extensive physical impairment, sensory impairments and medical health problems. There is, however, a lack of evidence-based physical and health-promoting interventions for people with PIMD.

Objective

Structured Water Dance Intervention (SWAN) is a new method developed to fill this gap. This paper reports a protocol for an intervention study which aims to evaluate SWAN with regard to its effects on physiological, psychological and social health-related variables as well as its cost-effectiveness and potential for implementation in health care.

Methods

The evaluation of SWAN is performed in a multi-center randomized crossover study. Data is collected through cortisol measurement, physiological assessments, proxy ratings, video observations and interviews.

Conclusions

This is the first attempt to evaluate rigorously an innovative intervention for people with PIMD, a group that is rarely considered for health promotion interventions. This study will provide important information about the efficacy, cost-effectiveness and potential to implement SWAN in health care.

Vibration attenuates spasm-like activity in humans with spinal cord injury

KEY POINTS

Cutaneous reflexes were tested to examine the neuronal mechanisms contributing to muscle spasms in humans with chronic spinal cord injury (SCI). Specifically, we tested the effect of Achilles and tibialis anterior tendon vibration on the early and late components of the cutaneous reflex and reciprocal Ia inhibition in the soleus and tibialis anterior muscles in humans with chronic SCI. We found that tendon vibration reduced the amplitude of later but not earlier cutaneous reflex in the antagonist but not in the agonist muscle relative to the location of the vibration. In addition, reciprocal Ia inhibition between antagonist ankle muscles increased with tendon vibration and participants with a larger suppression of the later component of the cutaneous reflex had stronger reciprocal Ia inhibition from the antagonistic muscle. Our study is the first to provide evidence that tendon vibration attenuates late cutaneous spasm-like reflex activity, likely via reciprocal inhibitory mechanisms, and may represent a method, when properly targeted, for controlling spasms in humans with SCI.

ABSTRACT

The neuronal mechanisms contributing to the generation of involuntary muscle contractions (spasms) in humans with spinal cord injury (SCI) remain poorly understood. To address this question, we examined the effect of Achilles and tibialis anterior tendon vibration at 20, 40, 80 and 120 Hz on the amplitude of the long-polysynaptic (LPR, from reflex onset to 500 ms) and long-lasting (LLR, from 500 ms to reflex offset) cutaneous reflex evoked by medial plantar nerve stimulation in the soleus and tibialis anterior, and reciprocal Ia inhibition between these muscles, in 25 individuals with chronic SCI. We found that Achilles tendon vibration at 40 and 80 Hz, but not other frequencies, reduced the amplitude of the LLR in the tibialis anterior, but not the soleus muscle, without affecting the amplitude of the LPR. Vibratory effects were stronger at 80 than 40 Hz. Similar results were found in the soleus muscle when the tibialis anterior tendon was vibrated. Notably, tendon vibration at 80 Hz increased reciprocal Ia inhibition between antagonistic ankle muscles and vibratory-induced increases in reciprocal Ia inhibition were correlated with decreases in the LLR, suggesting that participants with a larger suppression of later cutaneous reflex activity had stronger reciprocal Ia inhibition from the antagonistic muscle. Our study is the first to provide evidence that tendon vibration suppresses late spasm-like activity in antagonist but not agonist muscles, likely via reciprocal inhibitory mechanisms, in humans with chronic SCI. We argue that targeted vibration of antagonistic tendons might help to control spasms after SCI.

Spasticity and pain in adults with cerebral palsy

AIM

To evaluate whether spasticity measures are related to pain in adults with cerebral palsy (CP).

METHOD

This cross-sectional study recruited individuals aged 16 to 89 years with a diagnosis of CP. Participants completed the Penn Spasm Frequency Scale (PSFS), Brief Pain Inventory (BPI), and PROMIS Pain Interference measures. The Modified Ashworth Scale (MAS) and Tardieu spasticity angles of six joints were rated and summed to composite MAS and Tardieu scores for each participant. Associations between spasticity and pain measures were evaluated.

RESULTS

Forty-seven participants (27 females, 20 males) with a mean age of 35 years 7 months (range 18-77y) spanning all Gross Motor Function Classification System (GMFCS) levels were included. Twenty-six participants reported their average pain level on BPI as greater than 0 over the past week (median pain level 4.0). Median PSFS was 1.0 (range 0.0-1.0) and this correlated with average BPI and Pain Interference T scores (median 40.7; ρ=0.33 and ρ=0.31 respectively [both p=0.01]). When adjusted for pain medication use and age, MAS correlated with BPI (ρ=0.30; p=0.04). Other pain and spasticity measures, or GMFCS level, were not significantly related with pain interference or BPI rating. Age was weakly associated with BPI (slope=0.10; p<0.01).

INTERPRETATION

PROMIS Pain Interference was lower than population-based norms. Patient-rated spasm frequency demonstrated better association with pain levels and interference than physician-rated MAS and Tardieu.

WHAT THIS PAPER ADDS

Pain was not associated with Gross Motor Function Classification System level. Pain increased with age, as anticipated. Self-reported spasm scores were associated with increased pain in contrast to clinical examination scales. Adjusted, summed spasticity on the Modified Ashworth Scale was associated with pain scores on the Brief Pain Inventory. Although pain is experienced by adults with cerebral palsy, pain did not interfere with activities.

Muscle weakness and impaired motor coordination in hyperpolarization-activated cyclic nucleotide-gated potassium channel 1-deficient rats

Hyperpolarization-activated cyclic nucleotide-gated potassium channel 1 (HCN1) contribute to spontaneous rhythmic activity in different tissues, including the heart and brain. Deficiency in HCN1 function is associated with sick sinus syndrome in mice and epilepsy in humans. We recently developed Hcn1-deficient rats and found that they exhibit absence epilepsy. While rearing Hcn1-deficient rats, we noticed loose muscle tension and abnormal gait. We therefore evaluated the muscle strength and motor functions of Hcn1-deficient rats. When subjected to the wire hang test, Hcn1-deficient rats fell down more easily than control F344 rats. Grip strength of Hcn1-deficient rats was significantly smaller than F344 rats. In the inclined plane test, they exhibited a smaller maximum angle. In the rotarod test, the latency to fall was shorter for Hcn1-deficient rats than F344 rats. In the footprint analysis, Hcn1-deficient rats exhibited smaller step length and wider step width than F344 rats. Instead of poor motor coordination ability and muscle weakness, Hcn1-deficient rats exhibited normal electromyograms, muscle histology, and deep tendon reflex. These findings suggest that HCN1 channels contribute to motor coordination and muscle strength, and that the muscle weakness of Hcn1-deficient rats results from the involvement not of the peripheral but of the central nervous system.

Impact of spasticity on transfers and activities of daily living in individuals with spinal cord injury

CONTEXT/OBJECTIVE

For persons with spinal cord injury, spasticity commonly interferes with activities of daily living such as transfers. Electromyography can be used to objectively measure muscle spasms during transfers, but how electromyographic measures relate to the impact spasticity has on life, or to clinically-rated spasticity, is unclear. We aimed to characterize relationships among spasm duration and magnitude, impact of spasticity on daily life, and a clinical measure of extensor spasticity, as well as to determine reliability of the electromyographic measures.

DESIGN

Participants (N=19) underwent electromyographic measurements of involuntary muscle activity (spasm duration and magnitude) evoked in quadriceps muscles during transfers on two days. Impact of spasticity on daily life was measured with the Spinal Cord Injury Spasticity Evaluation Tool. Clinically-rated spasticity severity was measured with the Spinal Cord Assessment Tool for Spastic reflexes.

RESULTS

No significant associations were found between impact of spasticity and spasm duration, spasm magnitude, or clinical extensor spasticity score. Absolute and normalized spasm duration were positively associated with clinical extensor spasticity score (rho=0.510-0.667, P < 0.05). Spasm measures during transfers had good to excellent day-to-day reliability (rho=0.656-0.846, P < 0.05).

CONCLUSIONS

Electromyographic and clinical measures of involuntary activity in the lower extremity do not significantly relate to perceived impact of spasticity on daily life. However, quadriceps spasm duration during transfers is related to clinically-rated extensor spasticity. Electromyography is a reliable method of quantifying quadriceps spasms during transfers. Future investigations should identify factors that influence the impact of spasticity on life, which may help direct treatment strategies to reduce problematic impact.

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.

Inherited Ataxia and Intrathecal Baclofen for the Treatment of Spasticity and Painful Spasms

BACKGROUND

Intrathecal baclofen (ITB) treatment is considered a powerful tool in the management of severe spasticity in neurological conditions such as multiple sclerosis, cerebral palsy, and traumatic spinal cord and brain injury.

OBJECTIVES

The objective of this study was to assess the effectiveness of the ITB in patients with inherited ataxia suffering from severe painful spasms and/or spasticity.

METHOD

A total of 5 patients with spinocerebellar ataxia 3 or 7 or Friedreich's ataxia were included in this observational multicenter study. The patients were interviewed and completed outcome measures assessing pain (The Brief Pain Inventory), fatigue (Fatigue Severity Scale), and life satisfaction (LiSAT-9) before and 1 year after the treatment. Spasticity (Modified Ashworth Scale) and spasm frequency (SPFS) were measured objectively for each patient.

RESULTS

The mean treatment time was 1.9 years. Evaluation of established standard forms revealed symptomatic relief from spasticity, spasms, pain, and fatigue in addition to improved body posture, sleep, and life satisfaction after ITB treatment.

CONCLUSIONS

We report the potential beneficial effects of ITB treatment in patients with inherited ataxia who also suffer from spasticity/spasms. ITB treatment indication in neurological disorders allows for extension to the treatment of spasticity/ spasms in patients with hereditary ataxia.

Early predictors of developing problematic spasticity following traumatic spinal cord injury: A prospective cohort study

Objective: To identify early predictors and develop reliable, validated prediction models for development of problematic spasticity after traumatic spinal cord injury (SCI).Design: Prospective cohort study of the Rick Hansen Spinal Cord Injury Registry (RHSCIR), retrospective review of inpatient medical charts.Setting: Quaternary trauma center, rehabilitation center, community settings.Participants: Individuals with traumatic SCI between March 1, 2005, and March 31, 2014, prospectively enrolled in the Vancouver site RHSCIR.Interventions: None.Main Outcome Measure: Spasticity limiting function or requiring treatment (problematic spasticity) on the Spinal Cord Injury Health Questionnaire.Results: In 350 patients, variables documented during hospitalization that predicted the development of problematic spasticity up to 5 years post-injury included: initial Glasgow Coma Scale; age at time of injury; admission to rehabilitation center; community discharge anti-spasticity medication prescription, neurological status, Penn Spasm Frequency Scale, and pain interference with quality of life, sleep, activities; greater change in AIS motor scores between admission and discharge. The predictive models had area under the receiver operating characteristic curve of 0.80 (95% CI 0.75, 0.85) in the development set (N = 244) and 0.84 (95% CI 0.74, 0.92) in the validation set (N = 106) for spasticity limiting function and 0.81 (95% CI 0.76, 0.85) in the development set and 0.85 (95% CI 0.77, 0.92) in the validation set for spasticity requiring treatment.Conclusions: Our prediction models provide an early prognosis of risk of developing problematic spasticity after traumatic SCI, which can be used to improve clinical spasticity management and assist research (e.g. risk stratification in interventional trials).

Temporal Indices of Ankle Clonus and Relationship to Electrophysiologic and Clinical Measures in Persons With Spinal Cord Injury

BACKGROUND AND PURPOSE

Clonus arising from plantar flexor hyperreflexia is a phenomenon that is commonly observed in persons with spastic hypertonia. We assessed the temporal components of a biomechanical measure to quantify ankle clonus, and validated these in persons with spasticity due to spinal cord injury.

METHODS

In 40 individuals with chronic (>1 year) spinal cord injury, we elicited ankle clonus using a standardized mechanical perturbation (drop test). We examined reliability and construct validity of 2 components of the drop test: clonus duration (timed with a stopwatch) and number of oscillations in the first 10-second interval (measured via optical motion capture). We compared these measures to the Spinal Cord Assessment Tool for Spastic reflexes (SCATS) clonus score and H-reflex/M-wave (H/M) ratio, a clinical and electrophysiologic measure, respectively.

RESULTS

Intra- and interrater reliability of clonus duration measurement was good [intraclass correlation coefficient, ICC (2, 1) = 1.00]; test-retest reliability was good both at 1 hour [ICC (2, 2) = 0.99] and at 1 week [ICC (2, 2) = 0.99]. Clonus duration was moderately correlated with SCATS clonus score (r = 0.58). Number of oscillations had good within-session test-retest reliability [ICC (2, 1) > 0.90] and strong correlations with SCATS clonus score (r = 0.86) and soleus H/M ratio (r = 0.77).

DISCUSSION AND CONCLUSIONS

Clonus duration and number of oscillations as measured with a standardized test are reliable and valid measures of plantar flexor hyperreflexia that are accessible for clinical use. Tools for objective measurement of ankle clonus are valuable for assessing effectiveness of interventions directed at normalizing reflex activity associated with spasticity.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A179).

Treatment patterns of in-patient spasticity medication use after traumatic spinal cord injury: a prospective cohort study

STUDY DESIGN

Prospective cohort study using the Rick Hansen SCI Registry (RHSCIR) and retrospective medical chart review.

OBJECTIVE

To describe treatment patterns of in-patient anti-spasticity medication use following traumatic spinal cord injury (SCI) in acute and rehabilitation hospital settings in British Columbia, Canada.

SETTING

Quaternary trauma center, rehabilitation center.

METHODS

Individuals with traumatic SCI between 2005 and 2014 enrolled in the Vancouver RHSCIR site (N = 917) were eligible for inclusion. Oral and injectable anti-spasticity medication use were the main outcome measures.

RESULTS

In 769 participants, higher neurological level and injury severity were associated with in-patient anti-spasticity medication use (p < 0.001 for both). Of individuals with cervical and thoracic injuries (n = 589), 37% were prescribed anti-spasticity medication during hospital admission. Baclofen was the most commonly used first line oral therapy. Mean (SD) and median time from injury to Baclofen initiation was 70 (69) and 50 days, respectively. The probability of having initiated an in-patient anti-spasticity medication was 55% (95% CI (49, 60)) for individuals 6 months post-injury, and 71% (95% CI (62, 79)) for individuals 12 months post-injury. At community discharge, the prevalence of oral and injectable anti-spasticity medication use was 26 and 5%. Practice patterns of anti-spasticity medication use (2005-2009 vs. 2010-2014) have not changed significantly over time.

CONCLUSIONS

This is the first large prospective cohort study of in-patient anti-spasticity medication use following traumatic SCI. Results from our study inform clinicians and individuals of "real world" anti-spasticity medication use among individuals with traumatic SCI and may help guide care for this population in the community.

An integrated gait rehabilitation training based on Functional Electrical Stimulation cycling and overground robotic exoskeleton in complete spinal cord injury patients: Preliminary results

The aim of this study is to investigate the effects of an integrated gait rehabilitation training based on Functional Electrical Stimulation (FES)-cycling and overground robotic exoskeleton in a group of seven complete spinal cord injury patients on spasticity and patient-robot interaction. They underwent a robot-assisted rehabilitation training based on two phases: n=20 sessions of FES-cycling followed by n= 20 sessions of robot-assisted gait training based on an overground robotic exoskeleton. The following clinical outcome measures were used: Modified Ashworth Scale (MAS), Numerical Rating Scale (NRS) on spasticity, Penn Spasm Frequency Scale (PSFS), Spinal Cord Independence Measure Scale (SCIM), NRS on pain and International Spinal Cord Injury Pain Data Set (ISCI). Clinical outcome measures were assessed before (T0) after (T1) the FES-cycling training and after (T2) the powered overground gait training. The ability to walk when using exoskeleton was assessed by means of 10 Meter Walk Test (10MWT), 6 Minute Walk Test (6MWT), Timed Up and Go test (TUG), standing time, walking time and number of steps. Statistically significant changes were found on the MAS score, NRS-spasticity, 6MWT, TUG, standing time and number of steps. The preliminary results of this study show that an integrated gait rehabilitation training based on FES-cycling and overground robotic exoskeleton in complete SCI patients can provide a significant reduction of spasticity and improvements in terms of patient-robot interaction.

Clinical Assessment of Spasticity in People With Spinal Cord Damage: Recommendations From the Ability Network, an International Initiative

A thorough assessment of the extent and severity of spasticity, and its effect on functioning, is central to the effective management of spasticity in persons with spinal cord damage (SCD). These individuals however do not always receive adequate assessment of their spasticity. Inadequate assessment compromises management when the effect of spasticity and/or need for intervention are not fully recognized. Assessment is also central to determining treatment efficacy. A barrier to spasticity assessment has been the lack of consensus on clinical and functional measures suitable for routine clinical practice. To extend on existing work, a working group of the Ability Network identified and consolidated information on possible measures, and then synthesized and formulated findings into practical recommendations for assessing spasticity and its effect on function in persons with SCD. Sixteen clinical and functional measures that have been used for this purpose were identified using a targeted literature review. These were mapped to the relevant domains of the International Classification of Functioning, Disability and Health to assess the breadth of their coverage; coverage of many domains was found to be lacking, suggesting a focus for future work. The advantages, disadvantages, and usefulness of the measures were assessed using a range of criteria, with a focus on usefulness and feasibility in routine clinical practice. Based on this evaluation, a selection of measures suitable for initial and follow-up assessments are recommended. The recommendations are intended to have broad applicability to a variety of health care settings where people with SCD are managed.

Development of a clinical spasticity scale for evaluation of dogs with chronic thoracolumbar spinal cord injury

OBJECTIVE To develop a spasticity scale for dogs with chronic deficits following severe spinal cord injury (SCI) for use in clinical assessment and outcome measurement in clinical trials. ANIMALS 20 chronically paralyzed dogs with a persistent lack of hind limb pain perception caused by an acute SCI at least 3 months previously. PROCEDURES Spasticity was assessed in both hind limbs via tests of muscle tone, clonus, and flexor and extensor spasms adapted from human scales. Measurement of patellar clonus duration and flexor spasm duration and degree was feasible. These components were used to create a canine spasticity scale (CSS; overall score range, 0 to 18). Temporal variation for individual dogs and interrater reliability were evaluated. Gait was quantified with published gait scales, and CSS scores were compared with gait scores and clinical variables. Owners were questioned regarding spasticity observed at home. RESULTS 20 dogs were enrolled: 18 with no apparent hind limb pain perception and 2 with blunted responses; 5 were ambulatory. Testing was well tolerated, and scores were repeatable between raters. Median overall CSS score was 7 (range, 3 to 11), and flexor spasms were the most prominent finding. Overall CSS score was not associated with age, SCI duration, lesion location, or owner-reported spasticity. Overall CSS score and flexor spasm duration were associated with gait scores. CONCLUSIONS AND CLINICAL RELEVANCE The CSS could be used to quantify hind limb spasticity in dogs with chronic thoracolumbar SCI and might be a useful outcome measure. Flexor spasms may represent an integral part of stepping in dogs with severe SCI.

Neuropathic pain and spasticity: intricate consequences of spinal cord injury

STUDY DESIGN

The 2016 International Spinal Cord Society Sir Ludwig Guttmann Lecture.

OBJECTIVES

The aim of this review is to identify different symptoms and signs of neuropathic pain and spasticity after spinal cord injury (SCI) and to present different methods of assessing them. The objective is to discuss how a careful characterization of different symptoms and signs, and a better translation of preclinical findings may improve our understanding of the complex and entangled mechanisms of neuropathic pain and spasticity.

METHODS

A MEDLINE search was performed using the following terms: 'pain', 'neuropathic', 'spasticity', 'spasms' and 'spinal cord injury'.

RESULTS

This review identified different domains of neuropathic pain and spasticity after SCI and methods to assess them in preclinical and clinical research. Different factors important for pain description include location, onset, pain descriptors and somatosensory function, while muscle tone, spasms, reflexes and clonus are important aspects of spasticity. Similarities and differences between neuropathic pain and spasticity are discussed.

CONCLUSIONS

Understanding that neuropathic pain and spasticity are multidimensional consequences of SCI, and a careful examination and characterization of the symptoms and signs, are a prerequisite for understanding the relationship between neuropathic pain and spasticity and the intricate underlying mechanisms.

Characterization of Involuntary Contractions after Spinal Cord Injury Reveals Associations between Physiological and Self-Reported Measures of Spasticity

Correlations between physiological, clinical and self-reported assessments of spasticity are often weak. Our aims were to quantify functional, self-reported and physiological indices of spasticity in individuals with thoracic spinal cord injury (SCI; 3 women, 9 men; 19–52 years), and to compare the strength and direction of associations between these measures. The functional measure we introduced involved recording involuntary electromyographic activity during a transfer from wheelchair to bed which is a daily task necessary for function. High soleus (SL) and tibialis anterior (TA) F-wave/M-wave area ratios were the only physiological measures that distinguished injured participants from the uninjured (6 women, 13 men, 19–67 years). Hyporeflexia (decreased SL H/M ratio) was unexpectedly present in older participants after injury. During transfers, the duration and intensity of involuntary electromyographic activity varied across muscles and participants, but coactivity was common. Wide inter-participant variability was seen for self-reported spasm frequency, severity, pain and interference with function, as well as tone (resistance to imposed joint movement). Our recordings of involuntary electromyographic activity during transfers provided evidence of significant associations between physiological and self-reported measures of spasticity. Reduced low frequency H-reflex depression in SL and high F-wave/M-wave area ratios in TA, physiological indicators of reduced inhibition and greater motoneuron excitability, respectively, were associated with long duration SL and biceps femoris (BF) electromyographic activity during transfers. In turn, participants reported high spasm frequency when transfers involved short duration TA EMG, decreased co-activation between SL and TA, as well as between rectus femoris (RF) vs. BF. Thus, the duration of muscle activity and/or the time of agonist-antagonist muscle coactivity may be used by injured individuals to count spasms. Intense electromyographic activity and high tone related closely (possibly from joint stabilization), while intense electromyographic activity in one muscle of an agonist-antagonist pair (especially in TA vs. SL, and RF vs. BF) likely induced joint movement and was associated with severe spasms. These data support the idea that individuals with SCI describe their spasticity by both the duration and intensity of involuntary agonist-antagonist muscle coactivity during everyday tasks.

Reliability of the Spinal Cord Assessment Tool for Spastic Reflexes

OBJECTIVE

To assess the reliability of the Spinal Cord Assessment Tool for Spastic Reflexes (SCATS).

DESIGN

Observational reliability study of the SCATS.

SETTING

Inpatient rehabilitation unit at an education and research hospital.

PARTICIPANTS

Subjects (N=47) between the ages of 18 and 88 years with spinal cord injury (SCI) and with American Spinal Injury Association Impairment Scale grades from A to D with spasticity, who were at least 6 months postinjury.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Interrater and test-retest reliability of the SCATS.

RESULTS

The SCATS had substantial to almost perfect interrater agreement (κ=.669-1.000) between the 2 physiatrists. Test-retest agreement of the SCATS was also substantial to almost perfect (κ=.614-1.000) as well. There was a significant correlation between the SCATS clonus scores and the Modified Ashworth scores of the hip, knee, and ankle. No correlation was found between SCATS extensor spasm scores and Modified Ashworth scores. The SCATS flexor spasm scores were only correlated significantly with the ankle plantar flexor Modified Ashworth scores (P<.05).

CONCLUSIONS

The SCATS is a reliable tool for assessing spasm activity and spastic hypertonia in patients with SCI.

Pharmacological management of spasticity in multiple sclerosis: Systematic review and consensus paper

Background and objectives:

Treatment of spasticity poses a major challenge given the complex clinical presentation and variable efficacy and safety profiles of available drugs. We present a systematic review of the pharmacological treatment of spasticity in multiple sclerosis (MS) patients.

Methods:

Controlled trials and observational studies were identified. Scientific evidence was evaluated according to pre-specified levels of certainty.

Results:

The evidence supports the use of baclofen, tizanidine and gabapentin as first-line options. Diazepam or dantrolene could be considered if no clinical improvement is seen with the previous drugs. Nabiximols has a positive effect when used as add-on therapy in patients with poor response and/or tolerance to first-line oral treatments. Despite limited evidence, intrathecal baclofen and intrathecal phenol show a positive effect in severe spasticity and suboptimal response to oral drugs.

Conclusion:

The available studies on spasticity treatment offer some insight to guide clinical practice but are of variable methodological quality. Large, well-designed trials are needed to confirm the effectiveness of antispasticity agents and to produce evidence-based treatment algorithms.

The Use of Hydrotherapy for the Management of Spasticity

Introduction. Spasticity is a major problem for the rehabilitation team. Physiotherapy is a vital component of therapy. Oral medication and other modalities such as heat, cold, ultrasound, electrical stimulation, and surgery (neuro-surgical or orthopedic) can also be used. The aim of this study was to compare the effects of hydrotherapy on spasticity and Functional Independence Measure (FIM) scores of patients with spinal cord injury (SCI). Materials and Methods. This is a control case matched study. Twenty SCI patients were divided into 2 groups and matched for age, gender, injury time, Ashworth scores, oral baclofen intake, American Spinal Injury Association, and FIM scores. The control group received passive range of motion exercise twice a day and oral baclofen for 10 weeks. The study group also received passive range of motion and oral baclofen, as well as 20 min of water exercises (at 71 °F, full immersion) 3 times per week. The authors evaluated spasm severity, FIM scores, oral baclofen intake, and Ashworth scales, between groups at the beginning and at the end of the treatment period. Results. Both groups demonstrated a significant increase in FIM scores. However, the hydrotherapy group demonstrated a larger increase (P < 0.0001) than the control group. There was a statistically significant decrease in oral baclofen intake in the hydrotherapy group (P < 0.01). There was no statistical change in the control group. Spasticity was evaluated by the Ashworth scale. There was a statistical improvement in each group (P < 0.01, P < 0.02). However, when compared to the control group, the use of hydrotherapy produced a significant decrease in spasm severity (P < 0.02). Conclusion. Side effects are often seen when using oral drug treatment for spasticity. Adding hydrotherapy to the rehabilitation program can be helpful in decreasing the amount of medication required. Future studies must evaluate benefits of hydrotherapy for rehabilitation.

Early physiotherapy after injection of botulinum toxin increases the beneficial effects on spasticity in patients with multiple sclerosis

Objective : To determine whether additional physiotherapy increases botulinum toxin type A effects in reducing spasticity in patients with multiple sclerosis.

Design : A single-blind, randomized, controlled pilot trial with a 12-week study period.

Subjects : Thirty-eight patients with progressive multiple sclerosis affected by focal spasticity and who were observed at the Multiple Sclerosis Centre operating in the S. Andrea Hospital in Rome.

Interventions : For intervention all patients received botulinum toxin type A; the treatment group also received additional physiotherapy to optimize management through passive or active exercise and stretching regimens.

Main measures : To measure objective and subjective level of spasticity, patients were assessed at baseline, 2, 4 and 12 weeks post treatment by Modified Ashworth Scale and visual analogue scale.

Results : When compared with the control group, we found a significant decrease of spasticity by Modified Ashworth Scale (P < 0.01 by t-test) in the treatment group at week 2 (2.73 versus 3.22), week 4 (2.64 versus 3.33) and week 12 (2.68 versus 3.33). The mean (%) difference in Modified Ashworth Scale score between baseline and the end of follow-up was —0.95 (26.1) in the treatment group and —0.28 (7.7) in the control group (P < 0.01). The combined treatment proved also to be more effective by visual analogue scale (P < 0.01) at week 4 (6.95 versus 5.50) and at week 12 (7.86 versus 6.56) but not at week 2 (5.18 versus 5.50; P = 0.41).

Conclusions : Our data suggest that physiotherapy in combination with botulinum toxin type A injection can improve overall response to botulinum toxin.

Clinical Neurophysiological Assessment of Residual Motor Control in Post-Spinal Cord Injury Paralysis

Objective. This study was designed to characterize the rudimentary residual lower-limb motor control that can exist in clinically paralyzed spinal-cord-injured individuals. Methods. Sixty-seven paralyzed spinal-cord-injured subjects were studied using surface electromyography recorded from muscles of the lower limbs and analyzed for responses to a rigidly administered protocol of reinforcement maneuvers, voluntary movement attempts, vibration, or the ability to volitionally suppress withdrawal evoked by plantar surface stimulation. Results. Markers for the subclinical discomplete motor syndrome were found in 64% of the subjects. The tonic vibration response was recorded in 37%, volitional plantar surface stimulation response suppression in 27%, and reinforcement maneuver responses in 6% of the subjects. Three subjects, 4%, produced reliable but very low amplitude surface electromyography during the voluntary movement segment of the protocol. Surface electromyography recorded during passive leg movement was related to Ashworth scores as was the tonic vibration response marker (P < 0.05). Conclusions. Multimuscle surface electromyography patterns recorded during a rigidly administered protocol of motor tasks can be used to differentiate between clinically paralyzed spinal-cord-injured individuals using subclinical motor output to identify the translesional neural connections that remain available for intervention testing and treatment planning after spinal cord injury.

Modified Ashworth scale and spasm frequency score in spinal cord injury: reliability and correlation

STUDY DESIGN

Intra- and inter-rater reliability study.

OBJECTIVES

To assess intra- and inter-rater reliability of the Modified Ashworth Scale (MAS) and Spasm Frequency Score (SFS) in lower extremities in a population of spinal cord-injured persons, as well as correlations between the two scales.

SETTING

Clinic for Spinal Cord Injuries, Rigshospitalet, Hornbaek, Denmark.

METHODS

Thirty-one persons participated in the study and were tested four times in total with MAS and SFS by three experienced raters. Cohen's kappa (κ), simple and quadratic weighted (nominal and ordinal scale level of measurement), was used as a measure of reliability and Spearman's rank correlation coefficient for correlation between MAS and SFS.

RESULTS

Neurological level ranged from C2 to L2 and American Spinal Injury Association impairment scale A to D. Time since injury was (mean±s.d.) 3.4±6.5 years. Age was 48.3±20.2 years. Cause of injury was traumatic in 55% and non-traumatic for 45% of the participants. Antispastic medication was used by 61%. MAS showed intra-rater κsimple=-0.11 to 0.46 and κweighted=-0.11 to 0.83. Inter-rater κsimple=-0.06 to 0.32 and κweighted=0.08 to 0.74. SFS showed intra-rater κweighted=0.94 and inter-rater κweighted=0.93. Correlation between MAS and SFS showed non-significant correlation coefficients from-0.11 to 0.90.

CONCLUSION

Reliability of MAS is highly affected by the weighting scheme. With a weighted-κ it was overall reliable and simple-κ overall unreliability. Repeated tests should always be performed by the same rater and in a very standardized manner. SFS was found reliable. MAS and SFS are poorly correlated, and ratings were inversely distributed and suggest that it assesses different aspects of spasticity.

Muscle Synergies in Cycling after Incomplete Spinal Cord Injury: Correlation with Clinical Measures of Motor Function and Spasticity

Background: After incomplete spinal cord injury (iSCI), patients suffer important sensorimotor impairments, such as abnormal locomotion patterns and spasticity. Complementary to current clinical diagnostic procedures, the analysis of muscle synergies has emerged as a promising tool to study muscle coordination, which plays a major role in the control of multi-limb functional movements.

Objective: Based on recent findings suggesting that walking and cycling share similar synergistic control, the analysis of muscle synergies during cycling might be explored as an early descriptor of gait-related impaired control. This idea was split into the following two hypotheses: (a) iSCI patients present a synergistic control of muscles during cycling; (b) muscle synergies outcomes extracted during cycling correlate with clinical measurements of gait performance and/or spasticity.

Methods: Electromyographic (EMG) activity of 13 unilateral lower limb muscles was recorded in a group of 10 healthy individuals and 10 iSCI subjects during cycling at four different cadences. A non-negative matrix factorization (NNMF) algorithm was applied to identify synergistic components (i.e., activation coefficients and muscle synergy vectors). Reconstruction goodness scores (VAF and r²) were used to evaluate the ability of a given number of synergies to reconstruct the EMG signals.

A set of metrics based on the similarity between pathologic and healthy synergies were correlated with clinical scales of gait performance and spasticity.

Results: iSCI patients preserved a synergistic control of muscles during cycling. The similarity with the healthy reference was consistent with the degree of the impairment, i.e., less impaired patients showed higher similarities with the healthy reference. There was a strong correlation between reconstruction goodness scores at 42 rpm and motor performance scales (TUG, 10-m test and WISCI II). On the other hand, the similarity between the healthy and affected synergies presented correlation with some spasticity symptoms measured by Penn, Modified Ashworth and SCATS scales.

Conclusion: Overall, the results of this study support the hypothesis that the analysis of muscle synergies during cycling can provide detailed quantitative assessment of functional motor impairments and symptoms of spasticity caused by abnormal spatiotemporal muscle co-activation following iSCI.

Spasticity over time during acute rehabilitation: a study of patient and clinician scores

AIMS

The aims of this study were to describe spasticity trajectories as a function of time, gender, and diagnosis and to explore the correspondence between patient and clinician scores of spasticity.

BACKGROUND

Discrepancy between examiner assessment and patient rating of spasticity exists. Assessments that include the patient perspective are critical for patient safety. This mixed-method study provided patient descriptors of spasticity integrated with clinical scales.

METHOD

Twenty-three participants provided spasticity descriptors and rated their spasticity based on Numeric Rating Scale (NRS) scores. A clinician evaluated spasticity daily using the Modified Ashworth Scale (MAS). This resulted in 1976 points of data for analysis.

RESULTS

Spasticity was highly variable over time. The empirical correspondence between the clinician-rated MAS and the patient-rated NRS revealed that patient and examiner understanding of spasticity were diverged considerably.

CONCLUSIONS

Clinical evaluation protocols should include patient reports on spasticity. Knowledge about patient word choice can enhance patient-provider communication.

Effect of Transcutaneous Electrical Nerve Stimulation on Plantar Flexor Muscle Spasticity and Walking Speed in Stroke Patients

BACKGROUND AND PURPOSE

Spasticity is a major disabling symptom in patients post stroke. Although studies have demonstrated that transcutaneous electrical nerve stimulation (TENS) can reduce spasticity, the duration of single session TENS is a subject of debate. The purpose of this study was to determine the sustainability of the effects of TENS applied over common peroneal nerve in the reduction of ankle plantar-flexor spasticity and improving gait speed in patients post stroke.

METHODS

Thirty patients (11 women and 19 men) (mean age of 46.46 years) were randomly assigned to group 1 (task oriented exercises), group 2 (TENS for 30 min and task oriented exercises) and group 3 (TENS for 60 min and task oriented exercises) for a period of five sessions per week for 6 weeks. All patients were assessed for ankle plantar-flexor spasticity, passive ankle dorsi-flexion range of motion, clonus and timed up and go test at the time of recruitment to study, at 3 and 6 weeks of therapeutic intervention.

RESULTS

The overall results of the study suggest that there was a decrease in ankle plantar flexor spasticity, ankle clonus and timed up and go score in all the groups. A greater reduction of spasticity was seen in TENS groups (groups 2 and 3) when compared to control. No significant improvement was found in timed up and go test (TUG) scores between groups.

CONCLUSION

Both 30 min and 60 min of application of TENS are effective in reducing spasticity of ankle plantar flexors, improving walking ability and increase the effectiveness of task related training. Based on the effect size, we would recommend a longer duration application for the reduction of spasticity. Copyright © 2015 John Wiley & Sons, Ltd.

Improving Target Acquisition for Computer Users With Athetosis

Prior work has highlighted the challenges faced by people with athetosis when trying to acquire on-screen targets using a mouse or trackball. The difficulty of positioning the mouse cursor within a confined area has been identified as a challenging task. We have developed a target acquisition assistance algorithm that features transition assistance via directional gain variation based on target prediction, settling assistance via gain reduction in the vicinity of a predicted target, and expansion of the predicted target as the cursor approaches it. We evaluated the algorithm on improving target acquisition efficiency among seven participants with athetoid cerebral palsy. Our results showed that the algorithm significantly reduced the overall movement time by about 20%. Considering the target acquisition occurs countless times in the course of regular computer use, the accumulative effect of such improvements can be significant for improving the efficiency of computer interaction among people with athetosis.