Long-term outcome in severe traumatic brain injury is significantly influenced by brainstem involvement

Individualized spectral filters alleviate persistent photophobia, headaches and migraines in active duty military and Veterans following brain trauma

PURPOSE

Consistent with association between photophobia and headache, growing evidence suggests an underlying causal relationship between light sensitivity and central pain. We investigated whether an intervention to regulate light sensitivity by filtering only wavelengths causing difficulties for the specific individual could alleviate headaches/migraines resulting from traumatic brain injury (TBI).

METHODS

Secondary data analysis of a clinical database including N = 392 military personnel (97% men, 3% women), ranging in age from 20 to 51 years, diagnosed with TBI, persistent headaches/migraines, and light sensitivity. The average elapsed time from TBI diagnosis to intervention was 3 years. Headache/migraine severity, frequency, medication use, and difficulties related to daily functioning were assessed pre and 4-12 weeks post-intervention with individualized spectral filters.

RESULTS

Monthly migraine frequency decreased significantly from an average of 14.8 to 1.9, with 74% reporting no migraines post-intervention. Prescription and over-the-counter medication use decreased by more than 70%. Individuals also reported significant improvement in light sensitivity, headaches/migraine severity, and physical and perceptual symptoms.

CONCLUSIONS

Wearing individualized spectral filters was associated with symptom relief, increased subjective quality of reported health and well-being, and decreased objective medication use for TBI-related persistent headaches/migraines. These results support a suggested relationship between dysregulated light sensitivity and central regulation of pain.

Spinal Cord Boundary Conditions Affect Brain Tissue Strains in Impact Simulations

Brain and spinal cord injuries have devastating consequences on quality of life but are challenging to assess experimentally due to the traumatic nature of such injuries. Finite element human body models (HBM) have been developed to investigate injury but are limited by a lack of biofidelic spinal cord implementation. In many HBM, brain models terminate with a fixed boundary condition at the brain stem. The goals of this study were to implement a comprehensive representation of the spinal cord into a contemporary head and neck HBM, and quantify the effect of the spinal cord on brain deformation during simulated impacts. Spinal cord tissue geometries were developed, based on 3D medical imaging and literature data, meshed, and implemented into the GHBMC 50th percentile male model. The model was evaluated in frontal, lateral, rear, and oblique impact conditions, and the resulting maximum principal strains in the brain tissue were compared, with and without the spinal cord. A new cumulative strain curve metric was proposed to quantify brain strain distribution. Presence of the spinal cord increased brain tissue strains in all simulated cases, owing to a more compliant boundary condition, highlighting the importance of the spinal cord to assess brain response during impact.

Paired associative stimulation on the soleus H-Reflex using motor point and peripheral nerve stimulation

Paired associative stimulation (PAS) has been shown to modulate the corticospinal excitability via spike timing dependent plasticity (STDP). In this study, we aimed to suppress the spinal H-Reflex using PAS. We paired two stimulation modalities, i.e., peripheral nerve stimulation (PNS) and motor point stimulation (MPS). We used PNS to dominantly activate the Ia sensory axon, and we used MPS to dominantly activate the α-motoneuron cell body antidromically. Thus, we applied both PNS and MPS such that the α-motoneuron cell body was activated 5 ms before the activation of the Ia sensory axon ending at the Ia-α motoneuron synapse. If the spinal reflexes can be modulated by STDP, and a combination of MPS and PNS is timed appropriately, then the H-Reflex amplitude will decrease while no change in H-Reflex amplitude is expected for MPS or PNS only. To test this hypothesis, six young healthy participants (5M/1F: 26.8 ± 4.1 yrs) received one of the three following conditions on days separated by at least 24 hr: 1) PAS, 2) MPS only or 3) PNS only. The H-Reflex and M-wave recruitment curves of the soleus were measured immediately prior to, immediately after, 30 min and 60 min after the intervention. The normalized H-Reflex amplitudes were then compared across conditions and times using a two-way ANOVA (3 conditions × 4 times). No main effects of condition or time, or interaction effect were found. These results suggest that relying solely on STDP may be insufficient to inhibit the soleus H-Reflex.

Characterization of the blood oxygen level dependent hemodynamic response function in human subcortical regions with high spatiotemporal resolution

Subcortical brain regions are absolutely essential for normal human function. These phylogenetically early brain regions play critical roles in human behaviors such as the orientation of attention, arousal, and the modulation of sensory signals to cerebral cortex. Despite the critical health importance of subcortical brain regions, there has been a dearth of research on their neurovascular responses. Blood oxygen level dependent (BOLD) functional MRI (fMRI) experiments can help fill this gap in our understanding. The BOLD hemodynamic response function (HRF) evoked by brief (<4 s) neural activation is crucial for the interpretation of fMRI results because linear analysis between neural activity and the BOLD response relies on the HRF. Moreover, the HRF is a consequence of underlying local blood flow and oxygen metabolism, so characterization of the HRF enables understanding of neurovascular and neurometabolic coupling. We measured the subcortical HRF at 9.4T and 3T with high spatiotemporal resolution using protocols that enabled reliable delineation of HRFs in individual subjects. These results were compared with the HRF in visual cortex. The HRF was faster in subcortical regions than cortical regions at both field strengths. There was no significant undershoot in subcortical areas while there was a significant post-stimulus undershoot that was tightly coupled with its peak amplitude in cortex. The different BOLD temporal dynamics indicate different vascular dynamics and neurometabolic responses between cortex and subcortical nuclei.

Reasons and Determinants of BoNT-A Treatment Discontinuation in Patients Living with Spasticity: A 10-Year Retrospective Analysis

BACKGROUND

The present study aimed to evaluate the reasons and determinants of BoNT-A discontinuation in patients with stroke, multiple sclerosis, spinal cord injury, and traumatic brain injury.

METHODS

It is a retrospective study of 56 discontinuer patients treated with botulinum toxin between January 2011 and December 2021. Discontinuation rates and their predictors were estimated using Kaplan-Meier, Log rank test, and Cox's regression method of analyses.

RESULTS

The mean age was 56.54 years, 53.57% were affected by post-stroke spasticity, 17.86% by spinal cord injury, 12.5% and 16.07% by traumatic brain injury and multiple sclerosis, respectively. The median discontinuation time was 5 months. The main reason for discontinuation were logistic problems (37%) and orthopedic surgeries or intrathecal baclofen (27%). Discontinuers were more likely to have severe spasticity (R = 1.785), have no pain (HR = 1.320), no access to rehabilitation services (HR = 1.402), and have cognitive impairment (HR = 1.403).

CONCLUSIONS

The main reasons for discontinuation are related to logistic issues (due to distance or the absence of an adequate caregiver) and surgical interventions for spasticity, including intrathecal baclofen. It is crucial to identify possible predictors of discontinuation to improve the effectiveness of a multidisciplinary management. The study confirms the crucial role of rehabilitation and caregivers in achieving better long-term outcomes.

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.

The Use of Botulinum Toxin for Treatment of Spasticity

Spasticity is one component of the upper motor neuron (UMN) syndrome resulting from a multitude of neurologic conditions, such as stroke, brain injury, spinal cord injury, multiple sclerosis, and cerebral palsy. It is clinically recognized as a phenomenon of velocity-dependent increase in resistance, i.e., hypertonia. Recent advances in the pathophysiology of spasticity improve our understanding of mechanisms underlying this complex phenomenon and its relations to other components of UMN syndrome (weakness and disordered motor control), as well as the resultant clinical problems. This theoretical framework provides a foundation to set up treatment goals and to guide goal-oriented clinical assessment and treatment. Among a spectrum of treatment options, botulinum toxin (BoNT) therapy is the preferred treatment for focal spasticity. The evidence is very robust that BoNT therapy effectively reduces spasticity; however, it does not improve voluntary movement. In this chapter, we highlight a few issues on how to achieve the best clinical outcomes of BoNT therapy, such as dosing, dilution, guidance techniques, adjunctive therapies, early treatment, repeated injections, and central effects, as well as the ways to improve motor function in selected subgroups of patients with spasticity. We also discuss the reasons of poor responses to BoNT therapy and when not to use BoNT therapy.

High clinician- and patient-reported satisfaction with individualized onabotulinumtoxinA treatment for spasticity across several etiologies from the ASPIRE study

Etiology-specific onabotulinumtoxinA utilization to manage spasticity is largely unknown. In this 1-year interim analysis, we evaluated real-world onabotulinumtoxinA utilization and effectiveness across several etiologies from the Adult Spasticity International Registry (ASPIRE) study. ASPIRE is a multicenter, prospective, observational registry (NCT01930786) examining stroke, multiple sclerosis [MS], cerebral palsy [CP], traumatic brain injury [TBI], and spinal cord injury [SCI] patients with spasticity treated with onabotulinumtoxinA at the clinician's discretion. Assessments included onabotulinumtoxinA utilization (each session), clinician (subsequent session)/patient (5±1 weeks post-treatment) satisfaction, and the Disability Assessment Scale (DAS; subsequent session). 730 patients received ≥1 onabotulinumtoxinA treatment, with 37% naïve to botulinum toxin(s) for spasticity. The most common etiology was stroke (n=411, 56%), followed by MS (N=119, 16%), CP (N=77, 11%), TBI (N=45, 6%), and SCI (N=42, 6%). The total body mean cumulative dose (±SD) of onabotulinumtoxinA per session ranged from 296 U (±145) in CP to 406 U (±152) in TBI. The most commonly treated upper limb presentations were clenched fist (stroke, MS, and SCI), flexed wrist (CP), and flexed elbow (TBI). Equinovarus foot was the most commonly treated lower limb presentation in all etiologies. Stroke patients showed improved DAS scores for nearly all subscales in both limbs, indicative of improved global function. All etiologies showed improved lower limb mobility DAS scores. Across all sessions, clinicians (range: 87.4% [SCI]-94.2% [CP]) and patients (range: 67.6% [TBI]-89.7% [SCI]) reported extreme satisfaction/satisfaction that onabotulinumtoxinA helped manage spasticity, and clinicians (range: 94.6% [TBI]-98.8% [CP]) and patients (range: 88.4% [stroke]-91.2% [TBI]) would definitely/probably continue treatment. Treatment-related adverse events (TRAEs) and treatment-related serious adverse events (TRSAEs) were reported as follows: stroke: 10 TRAEs (2.2% patients), 3 TRSAEs (0.5%); MS: 5 TRAEs (4.2%), 0 TRSAEs; CP: 0 TRAEs, 0 TRSAEs; TBI: 1 TRAEs (2.2%), 0 TRSAEs; SCI: 0 TRAEs, 0 TRSAEs. No new safety signals were identified. High clinician- and patient-reported satisfaction were observed following individualized onabotulinumtoxinA treatment, as well as improved global function. Interim results from ASPIRE demonstrate etiology-specific similarities and differences in clinical approaches to manage spasticity.

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ASPIRE found etiology-specific similarities and differences in real-world onabotulinumtoxinA utilization for spasticity.

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Across all etiologies, there was high clinician- and patient-reported satisfaction with onabotulinumtoxinA treatment.

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In DAS, all etiologies showed improved global function in lower limb mobility following onabotulinumtoxinA treatment.

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Adverse event data varied by etiology of spasticity; however, no new safety signals were identified.

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ASPIRE data may guide clinical strategies and educational programs to improve onabotulinumtoxinA spasticity management.

Upper limb surgery for severe spasticity after acquired brain injury improves ease of care

For individuals with acquired brain injury and severe upper limb spasticity, personal care is often difficult, time-consuming and painful. Previous studies on outcomes after surgery for upper limb spasticity have focused on functional gain, pain, hygiene and appearance. We operated on 38 non-communicative patients (45 limbs, 535 procedures) with severe spasticity and a non-functional upper limb(s). The surgical goals were to provide opening of the fingers and thumb, wrist stability and, if required, to release muscles around the elbow and shoulder. We used the Carer Burden Score as a relevant outcome measure. Preoperatively and 3 months postoperatively, the carer rated the degree of difficulty in cleaning the palm, cutting the fingernails, cleaning the axilla and dressing the upper body on a 5-point Likert scale. Surgery significantly improved the ease of care, which has implications not only for the patient but also for carers and associated health costs. Level of evidence: IV.

Considerations in the Management of Upper Extremity Spasticity

Spasticity is a movement disorder characterized by a velocity-dependent increase in muscle tone and a hyperexcitable stretch reflex. Common causes of spasticity include cerebral palsy, spinal cord injury, and stroke. Surgical treatment plans for spasticity must be highly individualized and based on the characteristics of patients and the spasticity in order to maximize functional gains. Candidates for surgery must be carefully selected. In this article, the authors review the pathophysiology of spasticity and discuss general considerations for surgical management with an emphasis on patient factors and spasticity characteristics. Specific considerations for the common causes of spasticity are presented.

Common Etiologies of Upper Extremity Spasticity

Spasticity is a motor disorder that manifests as a component of the upper motor neuron syndrome. It is associated with paralysis and can cause significant disability. The most common causes leading to spasticity include stroke, traumatic brain injury, multiple sclerosis, spinal cord injury, and cerebral palsy. This article discusses the pathophysiology and clinical findings associated with each of the most common etiologies of upper extremity spasticity.

Retraining Reflexes: Clinical Translation of Spinal Reflex Operant Conditioning

Neurological disorders, such as spinal cord injury, stroke, traumatic brain injury, cerebral palsy, and multiple sclerosis cause motor impairments that are a huge burden at the individual, family, and societal levels. Spinal reflex abnormalities contribute to these impairments. Spinal reflex measurements play important roles in characterizing and monitoring neurological disorders and their associated motor impairments, such as spasticity, which affects nearly half of those with neurological disorders. Spinal reflexes can also serve as therapeutic targets themselves. Operant conditioning protocols can target beneficial plasticity to key reflex pathways; they can thereby trigger wider plasticity that improves impaired motor skills, such as locomotion. These protocols may complement standard therapies such as locomotor training and enhance functional recovery. This paper reviews the value of spinal reflexes and the therapeutic promise of spinal reflex operant conditioning protocols; it also considers the complex process of translating this promise into clinical reality.

Interventions for managing skeletal muscle spasticity following traumatic brain injury

BACKGROUND

Skeletal muscle spasticity is a major physical complication resulting from traumatic brain injury (TBI), which can lead to muscle contracture, joint stiffness, reduced range of movement, broken skin and pain. Treatments for spasticity include a range of pharmacological and non-pharmacological interventions, often used in combination. Management of spasticity following TBI varies from other clinical populations because of the added complexity of behavioural and cognitive issues associated with TBI.

OBJECTIVES

To assess the effects of interventions for managing skeletal muscle spasticity in people with TBI.

SEARCH METHODS

In June 2017, we searched key databases including the Cochrane Injuries Group Specialised Register, CENTRAL, MEDLINE (Ovid), Embase (Ovid) and others, in addition to clinical trials registries and the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cross-over RCTs evaluating any intervention for the management of spasticity in TBI. Only studies where at least 50% of participants had a TBI (or for whom separate data for participants with TBI were available) were included. The primary outcomes were spasticity and adverse effects. Secondary outcome measures were classified according to the World Health Organization International Classification of Functioning, Disability and Health including body functions (sensory, pain, neuromusculoskeletal and movement-related functions) and activities and participation (general tasks and demands; mobility; self-care; domestic life; major life areas; community, social and civic life).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Data were synthesised narratively; meta-analysis was precluded due to the paucity and heterogeneity of data.

MAIN RESULTS

We included nine studies in this review which involved 134 participants with TBI. Only five studies reported between-group differences, yielding outcome data for 105 participants with TBI. These five studies assessed the effects of a range of pharmacological (baclofen, botulinum toxin A) and non-pharmacological (casting, physiotherapy, splints, tilt table standing and electrical stimulation) interventions, often in combination. The studies which tested the effect of baclofen and tizanidine did not report their results adequately. Where outcome data were available, spasticity and adverse events were reported, in addition to some secondary outcome measures.Of the five studies with results, three were funded by governments, charities or health services and two were funded by a pharmaceutical or medical technology company. The four studies without useable results were funded by pharmaceutical or medical technology companies.It was difficult to draw conclusions about the effectiveness of these interventions due to poor reporting, small study size and the fact that participants with TBI were usually only a proportion of the overall total. Meta-analysis was not feasible due to the paucity of data and heterogeneity of interventions and comparator groups. Some studies concluded that the intervention they tested had beneficial effects on spasticity, and others found no difference between certain treatments. The most common adverse event was minor skin damage in people who received casting. We believe it would be misleading to provide any further description of study results given the quality of the evidence was very low for all outcomes.

AUTHORS' CONCLUSIONS

The very low quality and limited amount of evidence about the management of spasticity in people with TBI means that we are uncertain about the effectiveness or harms of these interventions. Well-designed and adequately powered studies using functional outcome measures to test the interventions used in clinical practice are needed.

Benefits of repetitive transcranial magnetic stimulation (rTMS) for spastic subjects: clinical, functional, and biomechanical parameters for lower limb and walking in five hemiparetic patients

Introduction. Spasticity is a disabling symptom resulting from reorganization of spinal reflexes no longer inhibited by supraspinal control. Several studies have demonstrated interest in repetitive transcranial magnetic stimulation in spastic patients. We conducted a prospective, randomized, double-blind crossover study on five spastic hemiparetic patients to determine whether this type of stimulation of the premotor cortex can provide a clinical benefit. Material and Methods. Two stimulation frequencies (1 Hz and 10 Hz) were tested versus placebo. Patients were assessed clinically, by quantitative analysis of walking and measurement of neuromechanical parameters (H and T reflexes, musculoarticular stiffness of the ankle). Results. No change was observed after placebo and 10 Hz protocols. Clinical parameters were not significantly modified after 1 Hz stimulation, apart from a tendency towards improved recruitment of antagonist muscles on the Fügl-Meyer scale. Only cadence and recurvatum were significantly modified on quantitative analysis of walking. Neuromechanical parameters were modified with significant decreases in H max⁡ /M max⁡ and T/M max⁡ ratios and stiffness indices 9 days or 31 days after initiation of TMS. Conclusion. This preliminary study supports the efficacy of low-frequency TMS to reduce reflex excitability and stiffness of ankle plantar flexors, while clinical signs of spasticity were not significantly modified.

Orthopedic evaluation and surgical treatment of the spastic shoulder

The spastic shoulder can often result from brain injury that causes disruption in the upper motor neuron inhibitory pathways. Patients develop dyssynergic muscle activation, muscle weakness, and contractures and often present with fixed adduction and internal rotation deformity to the limb. This article reviews the importance of a comprehensive preoperative evaluation and discusses appropriate treatment strategies based on preoperative evaluation.

Evidence-based review and assessment of botulinum neurotoxin for the treatment of adult spasticity in the upper motor neuron syndrome

Botulinum neurotoxin (BoNT) can be injected to achieve therapeutic benefit across a large range of clinical conditions. To assess the efficacy and safety of BoNT injections for the treatment of spasticity associated with the upper motor neuron syndrome (UMNS), an expert panel reviewed evidence from the published literature. Data sources included English-language studies identified via MEDLINE, EMBASE, CINAHL, Current Contents, and the Cochrane Central Register of Controlled Trials. Evidence tables generated in the 2008 Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (AAN) review of the use of BoNT for autonomic disorders were also reviewed and updated. The panel evaluated evidence at several levels, supporting BoNT as a class, the serotypes BoNT-A and BoNT-B, as well as the four individual commercially available formulations: abobotulinumtoxinA (A/Abo), onabotulinumtoxinA (A/Ona), incobotulinumtoxinA (A/Inco), and rimabotulinumtoxinB (B/Rima). The panel ultimately made recommendations on the effectiveness of BoNT for the management of spasticity, based upon the strength of clinical evidence and following the AAN classification scale. While the prior report by the AAN provided recommendations for the use of BoNT as a class of drug, this report provides more detail and includes recommendations for the individual formulations. For the treatment of upper limb spasticity, the evidence supported a Level A recommendation for BoNT-A, A/Abo, and A/Ona, with a Level B recommendation for A/Inco; there was insufficient evidence to support a recommendation for B/Rima. For lower limb spasticity, there was sufficient clinical evidence to support a Level A recommendation for A/Ona individually and BoNT-A in aggregate; the clinical evidence for A/Abo supported a Level C recommendation; and there was insufficient information to recommend A/Inco and B/Rima (Level U). There is a need for further comparative effectiveness studies of the available BoNT formulations for the management of spasticity.

Use of injectable spasticity management agents in a cancer center

PURPOSE

This study aims to analyze the utilization and effectiveness of injectable spasticity medications by the physiatry team at a referral-based tertiary cancer center.

METHODS

A retrospective review and analysis of patient and injection characteristics were obtained from patients who had received onabotulinum toxin or phenol nerve block injections from December 1, 2007 through January 31, 2012. Out of 3,724 physiatry consultations during this period, 20 (less than 1 %) different cancer patients received a total of 54 total procedures.

RESULTS

The majority of patients (17/20, 85 %) had a positive response to the injection. A positive response to the injection was defined by: (1) if the patient qualified to receive and was given another injection or (2) if there is a record of improvement if they did not receive another injection. A total of ten of 20 (50 %) patients received only one injection. Of these, seven of ten (70 %) reported a positive response to the injected agent. Those with only one injection tended to live farther away and die sooner. Four of 54 (7 %) injection procedures resulted in undesirable reported side effects (two for phenol, two for botulinum toxin). Nine of 54 (17 %) procedures occurred while the patients were on a chemotherapy protocol. All patients were injected at least 1 year out from initial diagnosis.

Morphometric MRI findings in the thalamus and brainstem in children after moderate to severe traumatic brain injury

Generalized whole brain volume loss is well documented in moderate to severe traumatic brain injury. Whether this atrophy occurs in the thalamus and brainstem has not been systematically studied in children. Magnetic resonance imaging (MRI) quantitative analysis was used to investigate brain volume loss in the thalamus and brainstem in 16 traumatic brain injury subjects (age range 9-16 years) compared with 16 age and demo-graphically matched controls. Based on multiple analysis of covariance, controlling for age and head size, reduced volume in the thalamus and the midbrain region of the brainstem were found. General linear model analyses revealed a relation between processing speed on a working memory task and midbrain and brain stem volumes. Reduced volume in thalamic and brainstem structures were associated with traumatic brain injury. Reduction in midbrain and thalamic volume is probably a reflection of the secondary effects of diffuse axonal injury and reduction in cortical volume from brain injury.