Open-label dose-titration safety and efficacy study of tizanidine hydrochloride in the treatment of spasticity associated with chronic stroke

A modified scoping review of interventions for global post stroke spasticity

PURPOSE

Stroke is a major global health concern, and post-stroke spasticity (PSS) can severely impair mobility and quality of life. This modified scoping review synthesizes the most current evidence up to 2024 for interventions targeting PSS, employing GRADE methodology and a packed bubble chart adapted from the Evidence Alert Traffic Light System to rigorously evaluate the state of evidence to assist global healthcare professionals and policymakers in developing context-sensitive strategies that are both effective and feasible within their specific healthcare environments.

METHODS

From a pool of 2420 studies, 53 met our inclusion criteria and were subjected to a detailed analysis, representing 44 distinct interventions.

FINDINGS

In our findings, oral medications showed limited efficacy with potential adverse effects. Therefore, prioritizing GRADE A treatments with green traffic light like low-dose botulinum toxin type A (BoNT-A) injections, early intervention, and multimodal therapies of GRADE A can significantly reduce spasticity, as well as alleviate pain and shed light to enhance functional recovery. These treatments offer the additional advantage of requiring minimal therapy duration and personnel. Intrathecal baclofen (ITB) has demonstrated efficacy in managing severe spasticity following bilateral strokes, surpassing the effectiveness of oral medicines. Nevertheless, in settings with limited resources, therapies graded from A to C and indicated by green to yellow traffic lights can still be employed to control spasticity and accomplish rehabilitation goals, even though they require daily sessions that demand substantial time and personnel.

SUMMARY

Our study provides valuable insights into efficacious therapies for PSS and highlights areas requiring additional research to enhance clinical decision-making.

Quantitative Analysis of the Multicomponent and Spectrum-Effect Correlation of the Antispasmodic Activity of Shaoyao-Gancao Decoction

Shaoyao-Gancao Decoction (SGD) is a well-known classic traditional Chinese medicine (TCM) with antispasmodic, anti-inflammatory, and analgesic effects. This preparation has been widely used to treat spasticity diseases in the clinic. To date, the material basis of SGD remains unclear, and the spectrum-effect correlation of its antispasmodic activity has not been reported yet. In this study, high-performance liquid chromatography (HPLC) was used to establish the fingerprint and determine the multiple components of SGD. The common peaks of fingerprints were evaluated by the similarity with the chromatographic fingerprints of the TCM. Meanwhile, the multiple components were quantified and analysed using the heatmap and box size analysis. Furthermore, data on the antispasmodic effect were extracted through in vitro smooth muscle contraction assay. Grey relational analysis combined with partial least square regression was used to study the spectrum-effect correlation of SGD. Finally, the potential antispasmolytic components were validated using an isolated tissue experiment. The HPLC fingerprint was established, and 20 common peaks were identified. The similarities of 15 batches of SGD were all above 0.965. The HPLC method for simultaneous determination of the multiple components was accurate and reliable. The contents of albiflorin, paeoniflorin, liquiritin, and glycyrrhizic acid were higher than the other components in SGD. The heatmap and box size also showed that X3 (albiflorin), X4 (paeoniflorin), X5 (liquiritin), X11 (liquirtigenin), and X16 (glycyrrhizic acid) could be used as quality indicators in the further establishment of quality standards. The spectrum-effect correlation results indicated that X4, X11, and X16 were highly correlated with antispasmolytic activity. Verification tests showed that paeoniflorin (11.7-29.25 μg/mL) and liquirtigenin (17.19-28.65 μg/mL) could significantly reduce the maximum contractile (P < 0.01). These compounds exerted concentration-dependent spasmolytic effects with the inhibitory response for acetylcholine (Ach)-evoked contraction. Thus, SGD had a significant antispasmodic effect, which resulted from the synergistic activity of its multiple components. These findings can be used for the pharmacodynamics study of SGD and are of great significance for the determination of quality markers and quality control.

Neural and non-neural contributions to ankle spasticity in children with cerebral palsy

AIM

To assess the neural and non-neural contributions to spasticity in the impaired ankle of children with cerebral palsy (CP).

METHOD

Instrumented tapping of the Achilles tendon was done isometrically to minimize non-neural contributions and elicit neural contributions. Robot-controlled ankle stretching was done at various velocities, including slow stretching, with minimized neural contributions. Spasticity was assessed as having neural (phasic and tonic stretch reflex torque, tendon reflex gain, contraction rate, and half relaxation rate) and non-neural origin (elastic stiffness and viscous damping) in 17 children with CP (six females and 11 males; mean age [SD] 10y 8mo [3y 11mo], range 4y-18y) and 17 typically developing children (six females and 11 males; mean age [SD] 12y 7mo [2y 9mo], range 7y-18y). All torques were normalized to weight×height.

RESULTS

Children with CP showed increased phasic and tonic stretch reflex torque (p=0.004 and p=0.001 respectively), tendon reflex gain (p=0.02), contraction rate (p=0.038), half relaxation rate (p=0.02), elastic stiffness (p=0.01), and viscous damping (p=0.01) compared to typically developing children.

INTERPRETATION

Controlled stretching and instrumented tendon tapping allow the systematic quantification of various neural and non-neural changes in CP, which can be used to guide impairment-specific treatment.

WHAT THIS PAPER ADDS

Ankle spasticity is associated with increased phasic and tonic stretch reflexes, tendon reflex gain, and contraction and half relaxation rates. Ankle spasticity is also associated with increased elastic stiffness and viscous damping.

Acupuncture therapy for poststroke spastic hemiplegia: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Hemiplegia after stroke is one of the main dysfunctions in stroke patients. Acupuncture had been widely used for poststroke spastic hemiplegia (PSSH), but the efficiency was unclear. This study aimed to examine the efficiency and safety of acupuncture for individuals with PSSH.

METHODS

We searched nine databases from their inception to 27^th July 2019. Randomized controlled trials (RCTs) of acupuncture for the treatment of PSSH met the screening criteria. The quality of methodology was evaluated by Cochrane's risk of bias tool. RevMan 5.3 was used to perform the meta-analysis. The primary outcome was the Fugl-Myer Assessment (FMA) score, and the secondary outcomes were the Ashworth Scale for Spasticity (ASS) and Barthel Index (BI) scores. To evaluated the safety of acupuncture therapy, researchers scanned the full text to collect adverse events.

RESULTS

Researchers retrieved 2452 articles in total, after screening, thirty-eight studies with 2628 participants of were included. In this meta-analysis, twenty-seven trials revealed that acupuncture therapy was associated with an increase in FMA scores compared with rehabilitation training (RT) (MD: 8.43, 95% CI, 6.57 to 10.28, p < 0.00001, I² = 75%). According to the analysis of subgroup of interventions, ten trials showed that manual acupuncture (MA) plus RT was associated with an increase in FMA compared with RT (MD: 10.84, 95% CI, 9.29 to 13.29, p < 0.00001, I² = 24%), three trials showed that electroacupuncture (EA) plus RT was associated with an improvement in FMA compared with RT (MD: 9.44, 95% CI, 1.00 to 17.88, p = 0.03, I² = 81%), twelve trials showed that MA was associated with an increase in FMA compared with RT (MD: 5.48, 95% CI, 2.07 to 8.89, p = 0.002, I² = 74%), and one trials showed that EA was associated with an improvement in FMA compared with RT (MD: 11.35, 95% CI, 5.03 to 17.67, p = 0.0004). According to the analysis of subgroup of treatment duration, four trials used acupuncture therapy for more than 1 month, revealed that acupuncture therapy was associated with an increase in FMA scores compared with RT (MD: 9.24, 95% CI, 0.42 to 18.06, p = 0.04, I² = 93%). Thirty-two trials used acupuncture therapy for less than or equal to 1 month, revealed that acupuncture therapy was associated with an increase in FMA scores compared with RT (MD: 8.32, 95% CI, 6.56 to 10.09, p < 0.00001, I² = 61%). Six trials indicated that acupuncture therapy was better than RT in terms of the ASS (MD: 0.46, 95% CI, -0.65 to -0.27, p < 0.00001, I² = 67%), twenty-four trials indicated that acupuncture therapy was better than RT in terms of the BI scores (MD: 8.32, 95% CI, 5.30 to 11.35, p < 0.00001, I² = 88%). In general, the methodologies of the RCTs were of poor quality. Two RCTs reported no adverse events, one trial reported five adverse events without severe influence, others did not mention.

CONCLUSIONS

This review discovered that acupuncture might be a safe and effective adjuvant therapy for individuals with PSSH. Nevertheless, there were methodological limitations in the included RCTs, and well-designed and large-scale studies should be carried out to confirm our results.

Flexion synergy overshadows flexor spasticity during reaching in chronic moderate to severe hemiparetic stroke

OBJECTIVE

Pharmaceutical intervention targets arm flexor spasticity with an often-unsuccessful goal of improving function. Flexion synergy is a related motor impairment that may be inadvertently neglected. Here, flexor spasticity and flexion synergy are disentangled to determine their contributions to reaching dysfunction.

METHODS

Twenty-six individuals participated. A robotic device systematically modulated shoulder abduction loading during ballistic reaching. Elbow muscle electromyography data were partitioned into windows delineated by elbow joint velocity allowing for the separation of synergy- and spasticity-related activation.

RESULTS

Reaching velocity decreased with abduction loading (p<0.001) such that velocity was 30% slower when lifting the arm at 50% of abduction strength compared to when arm weight was supported. Abnormal flexion synergy increased with abduction loading (p<0.001) such that normalized activation ranged from a median (interquartile range) of 0.07 (0.03-0.12) when arm weight was supported to 0.19 (0.12-0.40) when actively lifting (large effect size, d=0.59). Flexor spasticity was detected during reaching (p=0.016) but only when arm weight was supported (intermediate effect size, d=0.33).

CONCLUSION

Flexion synergy is the predominant contributor to reaching dysfunction while flexor spasticity appears only relevant during unnaturally occurring passively supported movement.

SIGNIFICANCE

Interventions targeting flexion synergy should be leveraged in future stroke recovery trials.

Baclofen in the Therapeutic of Sequele of Traumatic Brain Injury: Spasticity

Traumatic brain injury (TBI) is an alteration in brain function, caused by an external force, which may be a hit on the skull, rapid acceleration or deceleration, penetration of an object, or shock waves from an explosion. Traumatic brain injury is a major cause of morbidity and mortality worldwide, with a high prevalence rate in pediatric patients, in which treatment options are still limited, not available at present neuroprotective drugs. Although the therapeutic management of these patients is varied and dependent on the severity of the injury, general techniques of drug types are handled, as well as physical and surgical. Baclofen is a muscle relaxant used to treat spasticity and improve mobility in patients with spinal cord injuries, relieving pain and muscle stiffness. Pharmacological support with baclofen is contradictory, because disruption of its oral administration may cause increased muscle tone syndrome and muscle spasm, prolonged seizures, hyperthermia, dysesthesia, hallucinations, or even multisystem organ failure. Combined treatments must consider the pathophysiology of broader alterations than only excitation/inhibition context, allowing the patient's reintegration with the greatest functionality.

Adherence associated with oral medications in the treatment of spasticity

OBJECTIVE

To examine adherence to baclofen, tizanidine, and dantrolene (U.S. Food and Drug Administration-approved oral spasticity medications), and identified determinants of adherence.

DESIGN

A retrospective administrative claims data analysis that used medical and pharmacy claims data and enrollment information from a large, national U.S. health plan.

SUBJECTS AND METHODS

The subjects were commercial health plan members who initiated treatment on baclofen, tizanidine, or dantrolene from January 1, 2004, through September 30, 2009, and who had stroke, spinal cord injury, traumatic brain injury, cerebral palsy, or multiple sclerosis. Descriptive and logistic regression statistical analyses were performed.

MAIN OUTCOME MEASUREMENTS

Outcomes were adherence, measured as continuous medication possession ratio (MPR) and as a binary indicator (MPR ≥0.80, adherent; MPR <0.80, nonadherent), change in oral spasticity medication, and use of nonoral spasticity therapy.

RESULTS

The study population included 2840 subjects. Adherence overall was poor: the range of mean unadjusted MPR values was 0.10-0.50, which indicated that, at best, the subjects were adherent to their index spasticity medications for 50% of their treatment periods. Unadjusted overall MPRs for baclofen and tizanidine were 20.4% and 9.1%, respectively. Fewer than 5% of subjects changed oral spasticity medications. The results of logistic regression to identify determinants of adherence showed that subjects treated with tizanidine versus baclofen had 37.4% lower odds of adherence and that subjects with traumatic brain injury versus stroke had 77.5% lower odds of adherence. The odds of adherence increased with age and with preindex contracture or decubitus ulcer.

CONCLUSIONS

Adherence to oral spasticity medication was poor irrespective of index spasticity medication or condition. Results from this study indicated that physicians cannot assume that patients are adherent to prescribed oral spasticity medications. A more complete understanding of the reasons behind nonadherence is required.

Central Neuropathic Pain in Spinal Cord Injury

Spinal cord injury (SCI) is a devastating medical condition affecting 1.2 million people in the United States. Central neuropathic pain is one of the most common medical complications of SCI. Current treatment options include opioids, antiepileptic agents such as gabapentin, antispastic agents such as baclofen or tizanidine, and tricyclic acid. Other options include complementary, nonpharmacological treatment such as exercise or acupuncture, interventional treatments, and psychological approaches. Although these treatment options exist, central neuropathic pain in patients with SCI is still extremely difficult to treat because of its complexity. To develop and provide more effective treatment options to these patients, proper assessment of and classification tools for central neuropathic pain, as well as a better understanding of the pathophysiology, are needed. A combination of approaches, from standard general pain assessments to medically specific questions unique to SCI pathophysiology, is essential for this population. A multidisciplinary approach to patient care, in addition with a better understanding of pathophysiology and diagnosis, will lead to improved management and treatment of patients with SCI displaying central neuropathic pain. Here we summarize the most recent classification tools, pathophysiology, and current treatment options for patients with SCI with central neuropathic pain.

Potent suppression of stretch reflex activity after systemic or spinal delivery of tizanidine in rats with spinal ischemia-induced chronic spastic paraplegia

BACKGROUND

Spasticity and rigidity are serious complications associated with spinal traumatic or ischemic injury. Clinical studies show that tizanidine (Tiz) is an effective antispasticity agent; however, the mechanism of this effect is still not clear. Tiz binds not only to α2-adrenoreceptors (AR) but also to imidazoline (I) receptors. Both receptor systems (AR+I) are present in the spinal cord interneurons and α-motoneurons. The aim of the present study was to evaluate the therapeutic potency of systematically or spinally (intrathecally [IT]) delivered Tiz on stretch reflex activity (SRA) in animals with ischemic spasticity, and to delineate supraspinal or spinal sites of Tiz action.

EXPERIMENTAL PROCEDURES

Animals were exposed to 10 min of spinal ischemia to induce an increase in SRA. Increase in SRA was identified by simultaneous increase in recorded electromyography (EMG) activity and ankle resistance measured during computer-controlled ankle dorsiflexion (40°/3 s) in fully awake animals. Animals with increased SRA were divided into several experimental subgroups and treated as follows: (i) Tiz administered systemically at the dose of 1 mg kg(-1), or IT at 10 μg or 50 μg delivered as a single dose; (ii) treatment with systemic Tiz was followed by the systemic injection of vehicle, or by nonselective AR antagonist without affinity for I receptors; yohimbine (Yoh), α2A AR antagonist; BRL44408 (BRL), α2B AR antagonist; ARC239 (ARC), nonselective AR and I(1) receptor antagonist; efaroxan (Efa), or nonselective AR and I(2) receptor antagonist; idazoxan (Ida); (iii) treatment with IT Tiz was followed by the IT injection of selective α2A AR antagonist; atipamezole (Ati). In a separate group of spastic animals the effect of systemic Tiz treatment (1 mg/kg) or isoflurane anesthesia on H-reflex activity was also studied.

RESULTS

Systemic and/or IT treatment with Tiz significantly suppressed SRA. This Tiz-mediated anti-SRA effect was reversed by BRL (5 mg kg(-1)), Efa (1 mg kg(-1)), and Ida (1 mg kg(-1)). No reversal was seen after Yoh (3 mg kg(-1)) or ARC (5 mg kg(-1)) treatment. Anti-SRA induced by IT Tiz (50 μg) was reversed by IT injection of Ati (50 μg). Significant suppression of H-reflex was measured after systemic Tiz treatment (1 mg/kg) or isoflurane (2%) anesthesia, respectively. Immunofluorescence staining of spinal cord sections taken from animals with spasticity showed upregulation of α2A receptor in activated astrocytes.

CONCLUSIONS

These data suggest that α2A AR and I receptors, but not α2B AR, primarily mediate the Tiz-induced antispasticity effect. This effect involves spinal and potentially supraspinal sites and likely targets α2A receptor present on spinal neurons, primary afferents, and activated astrocytes. Further studies using highly selective antagonists are needed to elucidate the involvement of specific subtypes of the AR and I receptors in the antispasticity effect seen after Tiz treatment.

Role of oral medications in spasticity management

Oral medications are frequently used to manage spasticity. Some clinicians may believe that oral medications are a more conservative or "first-line" strategy to treat this condition. However, their use may lead to significant adverse events. Additionally, efficacy has not been well-established, in particular the ability of these medications to enhance functional outcome. The decision regarding the use of oral medications is further complicated by the fact that a number of different agents have been used for many different diagnoses. The relative dearth of well-controlled studies makes the choice of medications for a given clinical condition even more difficult. This article reviews the mechanisms of action of some of the medications that are more commonly used to treat spasticity and identifies some studies that may suggest efficacy, or lack thereof, for certain diagnoses. Because questions remain regarding the benefit of oral medications, potential side effects also are emphasized to help the reader consider both potential risks and benefits. The article is intended as a broad overview, rather than comprehensive review of the literature.

Pharmacotherapy in stroke rehabilitation

BACKGROUND

Pharmacotherapy is commonly given to patients recovering from a stroke to prevent further complications (e.g. recurrent stroke, seizures) or enhance recovery. However, some drugs may have a negative impact on neuroplasticity.

OBJECTIVES

This review examines currently used drugs that are believed to promote recovery from motor and cognitive disturbances associated with stroke.

METHODS

Literature regarding the properties, efficacy, safety, and dosing of drugs used to promote recovery after stroke was reviewed.

RESULTS

The data on pharmacotherapy are insufficient to support a claim of significantly improved rehabilitation outcomes. Moreover, a growing body of evidence indicates that some agents can impair functional reorganization and slow the recovery process. However, a few chemicals are reported to be beneficial for stroke rehabilitation. The most promising are noradrenergic and dopaminergic agents, as well as several growth factors; these should be the future focus of extensive randomized clinical trials.

CONCLUSIONS

Currently there is no drug with proven efficacy in enhancing poststroke recovery.

Update on tizanidine for muscle spasticity and emerging indications

BACKGROUND

Tizanidine hydrochloride, an alpha(2)-adrenergic receptor agonist, is a widely used medication for the treatment of muscle spasticity. Clinical studies have supported its use in the management of spasticity caused by multiple sclerosis (MS), acquired brain injury or spinal cord injury. It has also been shown to be clinically effective in the management of pain syndromes, such as: myofascial pain, lower back pain and trigeminal neuralgia. This review summarizes the recent findings on the clinical application of tizanidine.

OBJECTIVE

Our objective was to review and summarize the medical literature regarding the evidence for the usefulness of tizanidine in the management of spasticity and in pain syndromes such as myofascial pain.

METHODS

We reviewed the current medical and pharmacology literature through various internet literature searches. This information was then synthesized and presented in paragraph and table form.

RESULTS/CONCLUSION

Tizanidine hydrochloride is a very useful medication in patients suffering from spasticity caused by MS, acquired brain injury or spinal cord injury. It can also be helpful in patients suffering from chronic neck and/or lower back pain who have a myofascial component to their pain. Doses should be started at low dose and gradually titrated to effect.

A practical overview of tizanidine use for spasticity secondary to multiple sclerosis, stroke, and spinal cord injury

OBJECTIVE

Tizanidine is an imidazoline central alpha(2)-adrenoceptor agonist widely used to manage spasticity secondary to conditions such as multiple sclerosis (MS), stroke, and spinal cord injury (SCI). While there is widespread use of tizanidine in clinical practice, little practical information is available to assist prescribers with the effective use of tizanidine for spasticity management. The aim of this review is to provide an up-to-date overview of tizanidine and its use in the management of spasticity associated with acquired (SCI), static (stroke), and progressive neurological (MS) diseases.

SCOPE

An unfiltered literature search of the term 'tizanidine' was undertaken on the Medline database resulting in 311 papers. As the review focused on tizanidine clinical pharmacokinetics, efficacy, and tolerability, with comparisons limited to the oral antispastic agents baclofen, diazepam, and dantrolene, 53 articles were selected for detailed assessment.

FINDINGS

Tizanidine, an alpha(2)-adrenoceptor agonist, is a short-acting drug with larger interpatient variability, and linear pharmacokinetics that is dosage form-dependent. Clinical trials have demonstrated that the efficacy of tizanidine is comparable to that of baclofen or diazepam with global tolerability data favoring tizanidine. A clinical case presentation demonstrated the effective use of tizanidine in combination with baclofen as a logical avenue for improved spasticity control.

CONCLUSIONS

There is a large body of evidence for the effective use of tizanidine monotherapy in the management of spasticity. A case study demonstrates that combination therapy can effectively control spasticity while better managing dose-dependent adverse events, although additional studies need to be performed to confirm these results.

Improvements in healthcare and cost benefits associated with botulinum toxin treatment of spasticity and muscle overactivity

Spasticity is a widespread, disabling form of muscle overactivity affecting patients with central nervous system damage resulting in upper motor neurone syndrome. There is a range of effective therapies for the treatment of spasticity (e.g. physical, anaesthetic, chemodenervation and neurolytic injections, systemic medication and surgery), but all therapies must be based on an individualized, multidisciplinary programme targeted to achieve patient goals. Appropriate therapy should be based on the extent and severity of spasticity, but spasticity and its consequences, regardless of presentation or cause, are commonly treated with systemic agents. This may be ill-advised as systemic treatment is associated with many undesirable effects. In particular, elderly patients with post-stroke spasticity are at risk from the central adverse effects of systemic medication (e.g. sedation and gait disturbance), which make them more susceptible to falling, with an associated increased risk of fracture. The rising costs of fracture care and its sequelae are fast becoming an international problem contributing to high healthcare expenditure. Botulinum toxin type-A (BoNT-A) treatment is highly effective for some of the more common forms of spasticity and muscle overactivity, and has a favourable profile when compared with systemic agents and other focal treatments. Therefore, the clinical benefits of BoNT-A treatment outweigh the apparent high costs of this intervention, showing it to be a cost-effective treatment.

Intrathecal Baclofen Management of Poststroke Spastic Hypertonia: Implications for Function and Quality of Life

OBJECTIVES

To evaluate the impact of intrathecal baclofen (ITB) on function and quality of life (QOL) and to obtain efficacy and safety data in poststroke spastic hypertonia.

DESIGN

Prospective open-label multicenter trial with follow-up at 3 and 12 months.

SETTING

Twenty-four stroke treatment centers in the United States.

PARTICIPANTS

Ninety-four stroke participants (age range, 24-82 y) with spastic hypertonia. Seventy-four participants underwent ITB pump implantation.

INTERVENTION

Participants were implanted with an ITB pump.

MAIN OUTCOME MEASURES

FIM instrument and QOL (Sickness Impact Profile [SIP]) changes, spastic hypertonia (Ashworth Scale), and safety.

RESULTS

FIM scores improved overall in repeated-measures analysis of variance (ANOVA) (P = .005) and by 3.00 +/- 7.69 (P = .001) at 3 months and by 2.86 +/- 10.13 (P = .017) at 12 months. Significant improvements in SIP scores were noted overall (repeated-measures ANOVA, P < .001) and at 3 (P = .003) and 12 months (P < .001). The combined average Ashworth Scale score of the upper and lower limbs decreased by 1.27 +/- 0.76 (P < .001) at 3 months and by 1.39 +/- 0.73 (P < .001) at 12 months from baseline, which was significant overall (repeated-measures ANOVA, P<.001). Strength in the unaffected side did not change overall (repeated-measures ANOVA, P = .321) or at either 3 (P = .553) or 12 months (P = .462). Minimal adverse events and device complications were reported.

CONCLUSIONS

There was significant improvement in function, QOL, and spastic hypertonia at 3 and 12 months after implant, without adversely affecting muscle strength of the unaffected limbs. Data suggest that ITB therapy is a safe and efficacious treatment for spastic hypertonia resulting from stroke.

Delay in initiation and termination of tibialis anterior contraction in lower-limb hemiparesis: relationship to lower-limb motor impairment and mobility

OBJECTIVE

To assess the relationship between delays in initiation and termination of tibialis anterior contraction in the hemiplegic lower limb and clinical measures of lower-limb motor impairment and mobility.

DESIGN

Cross-sectional correlational study.

SETTING

Outpatient rehabilitation clinic of an academic medical center.

PARTICIPANTS

Convenience sample of 22 chronic stroke survivors with lower-limb hemiparesis.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Delays in initiation and termination of tibialis anterior electromyographic activity during isometric contraction, lower-limb Fugl-Meyer Assessment (FMA), and Modified Emory Functional Ambulation Profile (mEFAP).

RESULTS

The affected lower limb exhibited significantly longer delays in initiation and termination of tibialis anterior contraction relative to the unaffected limb. Delay in termination of 3-second tibialis anterior contraction of the affected limb correlated significantly with the FMA and mEFAP. However, delay in initiation of tibialis anterior contraction did not correlate with clinical measures.

CONCLUSIONS

Delay in termination of muscle activity in the hemiparetic lower limb may have important clinical implications, but delay in initiation did not correlate with clinical measures. Controlled, interventional trials are needed to demonstrate a cause and effect relationship.

Effectiveness of repeated treatment with botulinum toxin type A across different conditions

This review assessed the overall effectiveness of repeated treatments with botulinum toxin type A (BoNTA) across different conditions, as documented in the published literature. Forty-four original research articles reporting on 16 different conditions were identified that included data on the duration or efficacy of multiple treatments with BoNTA. All of the 44 studies found sustained or enhanced improvement in efficacy and/or duration over the follow-up period, which ranged from a few treatments to more than 10 years. Dosages did not change over time in 22 of the studies, increased in 4 studies, were not reported over time in 17 studies, and tended to increase then decrease in one study. Seven studies reported a statistically significant increase in the efficacy or duration of BoNTA over time. Results suggest that continued benefit with repeated BoNTA treatment is widely reported in the literature.

Treatments for stroke

Stroke is the third leading cause of death and the leading cause of disability in developed countries, yet remains a poorly treated condition. Treatments for stroke can be aimed at acutely improving blood flow or protecting brain tissue against ischaemia, enhancing stroke recovery or reducing the risk of stroke recurrence. This paper reviews each of these approaches, particularly focusing on mechanisms for which there are agents in clinical trials. There are a number of appealing neuroprotective agents in Phase II and III clinical trials. However, the majority of acute treatments are likely to suffer from a narrow therapeutic time window and hence limited patient access. Combinations of acute approaches are likely to offer the greatest benefit, but present challenges in development. Promotion of recovery following stroke offers enormous potential for successful therapeutic intervention. Excitingly, new developments in preclinical research have identified possible ways in which this may be achieved.

Neurobiology of rehabilitation

Rehabilitation aims to lessen the physical and cognitive impairments and disabilities of patients with stroke, multiple sclerosis, spinal cord or brain injury, and other neurologic diseases. Conventional approaches beyond compensatory adjustments to disability may be augmented by applying some of the myriad experimental results about mechanisms of intrinsic biological changes after injury and the effects of extrinsic manipulations on spared neuronal assemblies. The organization and inherent adaptability of the anatomical nodes within distributed pathways of the central nervous system offer a flexible substrate for treatment strategies that drive activity-dependent plasticity. Opportunities for a new generation of approaches are manifested by rodent and non-human primate studies that reveal morphologic and physiologic adaptations induced by injury, by learning-associated practice, by the effects of pharmacologic neuromodulators, by the behavioral and molecular bases for enhancing activity-dependent synaptic plasticity, and by cell replacement, gene therapy, and regenerative biologic strategies. Techniques such as functional magnetic resonance imaging and transcranial magnetic stimulation will help determine the most optimal physiologic effects of interventions in patients as the cortical representations for skilled movements and cognitive processes are modified by the combination of conventional and biologic therapies. As clinicians digest the finer details of the neurobiology of rehabilitation, they will translate laboratory data into controlled clinical trials. By determining how much they can influence neural reorganization, clinicians will extend the opportunities for neurorestoration.

Hypotension Due to Interaction Between Lisinopril and Tizanidine

OBJECTIVE

To report a case in which significant hypotension occurred after initiation of tizanidine in a patient using the antihypertensive agent lisinopril.

CASE SUMMARY

A 48-year-old woman was admitted due to cerebral hemorrhage at the midbrain and pons, with extension to the fourth ventricle. Consciousness disturbance (Glasgow coma scale 4) with a decerebrate posture improved 5 days after stroke onset. As the BP was fairly high, antihypertensive agents, including lisinopril, were initiated. Three weeks later, the decerebrate rigidity and high BP remained, and tizanidine was initiated to see whether the decrease in muscle tone could facilitate hypertension control and motor recovery. However, the BP dropped dramatically within 2 hours after the first dose of tizanidine. The tizanidine and all of the antihypertensive medications were withdrawn. Tizanidine was used again after her BP had stabilized, but did not produce similar problems.

DISCUSSION

A similar event was reported in 2000. The reaction in our patient appeared after tizanidine initiation and improved after both lisinopril and tizanidine were discontinued. According to the Naranjo probability scale, this was classified as a possible drug interaction. This kind of reaction is seldom mentioned as occurring during co-administration with tizanidine. With its characteristics, tizanidine has the potential to compromise hemodynamic stability during concomitant angiotensin-converting enzyme inhibitor use.

CONCLUSIONS

Based upon the literature review, the hypotension in this patient was possibly due to the interaction between tizanidine and lisinopril.

Stroke and neurodegenerative disorders. 3. stroke: rehabilitation management11An organization with which one or more of the authors is associated has received or will receive financial benefits from a commercial party having a direct financial interest in the results of the research supporting this article. Geis is on the advisory board and the speaker’s bureau of Allergan; she is on the speaker’s bureau of Medtronic

This self-directed learning module highlights common rehabilitation issues in stroke survivors. Topics include spasticity, constraint-induced movement therapy, partial body weight-supported treadmill training, virtual reality training, vestibular retraining, aphasia treatment, and cognitive retraining. It is part of the study chapter on stroke and neurodegenerative disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation.

OVERALL ARTICLE OBJECTIVES

(a) To identify and review the treatment options for poststroke spasticity; (b) to review the use of body weight-supported treadmill training in stroke patients; (c) to describe virtual reality training as an adjunct in stroke rehabilitation; (d) to review vestibular rehabilitation; (e) to discuss advances in aphasia treatment; (f) to discuss cognitive retraining; and (g) to provide an update on treatment of neglect syndromes.

Antispastic effect of electroacupuncture and moxibustion in stroke patients

Spasticity is a frequently observed motor impairment that develops after stroke. The objective of this study was to evaluate the efficacy of electroacupuncture (EA) and moxibustion (Mox) on spasticity due to stroke. The subjects consisted of 35 stroke patients with elbow spasticity whose mean duration of stroke was 2.97 months. Fifteen patients were randomized to the EA group, ten to Mox, and ten to control. Every other day, 30 minutes of electrical stimulation with a frequency of 50 Hz was given through four needles on the Ch'ü-Ch'ih-San-Li (LI-11-LI-10) and Wai-Kuan-Ho-Ku (TB-5-LI-4) points of the paretic side. Direct Mox was applied to Ch'ü-Ch'ih (LI-11), San-Li (LI-10), Wai-Kuan (TB-5) and Ho-Ku (LI-4) points three times a day every other day. The control group was given only the routine acupuncture therapy for stroke and range of motion (ROM) exercise, which were also applied to the EA and Mox groups. The efficacy of treatment was measured before, immediately, 1 hour, 3 hours, 1 day, 5 days, 10 days and 15 days after the start of treatment using a modified Ashworth scale (MAS). In the EA group, spasticity was significantly reduced immediately, 1 hour and 3 hours after treatment (p < 0.05). Reductions were significant on the 5th day and thereafter (p < 0.05). In the Mox group, there was no significant change in the MAS scores after the first treatment. In the Mox and control group, there was no significant change in MAS scores. This study suggests that EA can temporarily reduce spasticity due to stroke, and if applied repeatedly it can maintain reduced spasticity.

Orally Delivered Baclofen to Control Spastic Hypertonia in Acquired Brain Injury

To determine if oral/systemic delivery of baclofen can effectively decrease spastic hypertonia due to acquired brain injury (traumatic brain injury, stroke, anoxia, or encephalopathy). Tertiary care outpatient rehabilitation center directly attached to a university hospital. Patients were a convenience sample recruited consecutively who had been referred for treatment of their spastic hypertonia to our spasticity clinic over a 5-year period. The spastic hypertonia was due to an acquired brain injury by either traumatic brain injury (TBI), stroke, or anoxic brain injury. All patients were more than 6 months postinjury or illness. Retrospective review of patients before and after initiation of treatment with oral baclofen, per standardized clinical data sheets. Thirty-five patients (22 TBI patients) were started on oral baclofen and were reevaluated between 1 to 3 months after initiation of treatment. Data for motor tone (Ashworth scores), spasm scores (Penn spasm frequency score), and deep tendon reflex scores were collected on the affected upper extremity (UE) and lower extremity (LE) side(s). Normal extremities were not assessed. Differences over time were assessed via descriptive statistics and Wilcoxon signed-rank. After 1 to 3 months of treatment when subjects had reached their maximal tolerated dosage, the average LE Ashworth score in the affected lower extremities (LEs) decreased from 3.5 to 3.2 (P =.0003), the reflex score decreased from 2.5 to 2.2 (P =.0274), and there was no statistical difference in the spasm score (P >.05). When the 22 TBI patients are analyzed separately, the average LE Ashworth score decreased from 3.5 to 3.2 (P =.0044) and the reflex score decreased from 2.7 to 2.0 (P =.0003). There was no statistically significant change in UE tone, spasm frequency, or reflexes after 1 to 3 months of treatment (P >.05). The average dosage at follow-up was 57 mg/day of baclofen (range 15-120 mg/day). There was a 17% incidence of somnolence that limited the maximum daily dosage of the medication. The oral delivery of baclofen is capable of reducing LE spastic hypertonia resulting from acquired brain injury. The lack of effect upon the upper extremities may be due to receptor specificity issues. GABA-B receptors may be less involved in the modulation of UE spastic hypertonia.

Improvement in walking speed in poststroke spastic hemiplegia after intrathecal baclofen therapy: a preliminary study

OBJECTIVE

To explore whether intrathecal baclofen (ITB) therapy improves ambulation in stroke survivors.

DESIGN

Case series.

SETTING

Tertiary care center.

PARTICIPANTS

Ten adults with poststroke hemiparesis who were ambulatory at the time of pump implantation.

INTERVENTIONS

Implantation of ITB pump after inadequate control of spasticity with other interventions. Time from stroke onset to implantation averaged 28.6 months (range, 9-55mo).

MAIN OUTCOME MEASURES

Customary walking speed was measured from the time required to walk 50ft (15m) at a self-selected pace. Evaluators rated spastic hypertonia and functional mobility.

RESULTS

Statistically significant improvements occurred in walking speed, functional mobility ratings, and spasticity (P<.05) at a follow-up interval that averaged 8.9 months. Mean walking speed over 50ft improved from 36.6 to 52cm/s. Mean Modified Ashworth Scale scores in the muscles of the affected lower limb improved from 2.0 to 0.4. Normal muscle strength (5/5) was preserved in the unaffected limbs.

CONCLUSIONS

This preliminary study suggests that ITB therapy, in combination with physical therapy, may improve walking speed and functional mobility in ambulatory individuals with poststroke spastic hemiplegia.

Motor Restoration and Spasticity Management after Stroke

The treatment of stroke does not end after a 3-hour time window. Several randomized, controlled studies of focused stroke rehabilitation units showed that these units reduce disability, with treatment effects persisting for years. Although the exact reasons for the superiority of these specialized units remain uncertain, presumably some portion is related to the quality and types of therapies provided to the patients. Advances in the understanding of the brain's ability to react to injury have led to the current testing of treatments based on the neuroscience of recovery rather than simply the clinician's guess about what effective treatments might be. This chapter will provide an overview of the treatments directed towards the restoration of motor function and towards ameliorating spasticity after stroke. The data supporting the use of emerging therapies of constraint induced movement treatment and robotic treatment will be discussed.

New developments in stroke rehabilitation

There is increasing evidence that environmental and neuropharmacologic treatments enhance stroke recovery. Functional magnetic resonance imaging and transcranial magnetic stimulation have significantly broadened our understanding of the neuroanatomic relationships involved in recovery from brain injury due to stroke. These tools have also demonstrated the role for pharmacologic enhancement of cortical plasticity coupled with behavioral interventions. Robot-assisted therapy and partial body weight-supported treadmill gait training have demonstrated the role for technologic intervention in the modern neuro-rehabilitation setting. Current research using hemi-field ocular prisms and patching techniques suggest a role in the rehabilitation of hemianopsia and visual neglect. Finally, many advances have been made in the understanding of common stroke complications, such as depression, dysphagia, venous thromboembolic disease, incontinence, and spasticity.