The influence of contractures and variation in measurement stretching velocity on the reliability of the Modified Ashworth Scale in patients with severe brain injury

Factors affecting occupational therapy services for patients with traumatic brain injury

Background

Traumatic brain injury (TBI) is one of the top causes of disability in the younger population worldwide. Rehabilitation services should be accessible to all citizens to achieve universal health coverage.

Objectives

This study aimed to explore the barriers and facilitators influencing the provision of rehabilitation for patients with TBI from occupational therapists' perspectives in Gauteng, South African healthcare facilities. It further explored the perceived strategies that would strengthen the delivery and provision of TBI rehabilitation.

Method

An exploratory qualitative research design was used in this study. A total of 16 occupational therapists were in focus groups either face-to-face or on an online platform. Thematic analysis was used to analyse the raw data.

Results

There were three themes that emerged from the study, namely, 'Not a recipe', 'Toolbox', and 'Lost in the cracks'. These themes highlighted the various aspects affecting the rehabilitation of patients with TBI.

Conclusion

There are factors that both enhance and hinder service delivery for patients with TBI rehabilitation. Strategies to overcome barriers to TBI rehabilitation need to be considered to improve service provision for patients with TBI.

Contribution

This article provides recommendations to improve occupational therapy services for patients with TBI in South Africa. The findings can contribute to policy development and education requirements for TBI.

Spastic muscle stiffness evaluated using ultrasound elastography and evoked electromyogram in patients following severe traumatic brain injury: an observational study

OBJECTIVE

To determine the relationship between muscle stiffness assessed using ultrasound shear wave elastography, spinal motor neuron excitability assessed using the F wave, and clinical findings of spasticity in patients with spastic muscle overactivity following severe traumatic brain injury.

METHODS

This study enrolled 17 inpatients with severe traumatic brain injury and 20 healthy volunteers. Biceps brachii muscle stiffness was then evaluated using ultrasound shear wave speed. Spinal motor neuron excitability was evaluated using the F/M ratio recorded from abductor pollicis brevis muscle. Clinical parameters, such as the modified Ashworth scale and modified Tardieu scale, were assessed in the patient with traumatic brain injury.

RESULTS

The patients with traumatic brain injury group had a significantly higher shear wave speed and F/M ratio compared with the healthy group. A higher shear wave speed was correlated with higher clinical spastic severity in patients with traumatic brain injury. The F/M ratio was not significantly correlated with clinical spastic severity.

CONCLUSION

Ultrasound shear wave elastography might be helpful for assessing muscle stiffness in patients with spastic muscle overactivity following severe traumatic brain injury. Further studies comprising larger cohorts are warranted.

Revisiting Excitotoxicity in Traumatic Brain Injury: From Bench to Bedside

Traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality. Consequences vary from mild cognitive impairment to death and, no matter the severity of subsequent sequelae, it represents a high burden for affected patients and for the health care system. Brain trauma can cause neuronal death through mechanical forces that disrupt cell architecture, and other secondary consequences through mechanisms such as inflammation, oxidative stress, programmed cell death, and, most importantly, excitotoxicity. This review aims to provide a comprehensive understanding of the many classical and novel pathways implicated in tissue damage following TBI. We summarize the preclinical evidence of potential therapeutic interventions and describe the available clinical evaluation of novel drug targets such as vitamin B12 and ifenprodil, among others.

The Assessment of Upper-Limb Spasticity Based on a Multi-Layer Process Using a Portable Measurement System

Spasticity is a common disabling complication caused by the upper motor neurons dysfunction following neurological diseases such as stroke. Currently, the assessment of the spastic hypertonia triggered by stretch reflexes is manually performed by clinicians using perception-based clinical scales, however, their reliability is still questionable due to the inter-rater and intra-rater variability. In order to objectively quantify the complex spasticity phenomenon in post-stroke patients, this study proposed a multi-layer assessment system based on a novel measurement device. The exoskeletal device was developed to synchronously record the kinematic, biomechanical and electrophysiological information in sixteen spastic patients and ten age-matched healthy subjects, while the spastic limb was stretched at low, moderate and high velocities. The mechanical impedance of the elbow joint was identified using a modified genetic algorithm to quantify the alterations in viscoelastic properties underlying pathological resistance. Simultaneously, the time-frequency features were extracted from the surface electromyography (sEMG) signals to reveal the neurophysiological mechanisms of the spastic muscles. By concatenating these single-layer decisions, a support vector regression (SVR)-based fusion model was developed to generate a more comprehensive quantification of spasticity severity. Experimental results demonstrated that the stiffness and damping components of the spastic arm significantly deviated from the nonspastic baseline, and strong correlations were observed between the proposed spasticity assessment and the severity level measured by clinical scales ( R = 0.86, P = 1.67e - 5 ), as well as the tonic stretch reflex threshold (TSRT) value ( R = - 0.89, P = 3.54e - 6 ). These promising results suggest that the proposed assessment system holds great potential to support the clinical diagnosis of motor abnormalities in spastic patients, and ultimately enables optimal adjustment of treatment protocols.

Translation and cross-cultural adaptation to Brazilian Portuguese of the Modified Tardieu Scale for muscle tone assessment among patients with spinal cord injury

BACKGROUND

Assessment of muscle tone is of great importance for evaluating people with spinal injuries.

OBJECTIVE

To translate and adapt the Modified Tardieu Scale (MTS) to Brazilian Portuguese and validate its use for evaluating patients with spinal cord injury.

METHODS

The translation and adaptation of the "Escala de Tardieu Modificada" went through the steps of translation, translation synthesis, back-translation and expert committee meeting. Two evaluators rated the tone of the elbow flexors/extensors, wrist extensors, knee flexors/extensors and ankle plantar flexors of 51 patients with spinal cord injury. These patients were reevaluated after one week. Validation included intra and inter-rater reliability (ICC) and internal and external consistency. The Modified Ashworth Scale (MAS) was used in the evaluations, to investigate the correlations.

RESULTS

The Brazilian Portuguese version of the MTS is presented in this study. ICCs ranged from 0.60 to 0.99 (intra and inter-examiner) and there was a moderate to strong correlation with MAS.

CONCLUSIONS

The MTS proved to be adequate for assessing the muscle tone of people with spinal cord injury in Brazil.

Selective peripheral neurotomy (SPN) as a treatment strategy for spasticity

Spasticity can be caused by central nervous system dysfunction, such as cerebral palsy and stroke. The accepted pathogenesis of spasticity is that the muscles are in the state of uninhibited stretch reflex without enough control of central nervous system. So far, there is no ideal way about how to repair central nervous system. However, the uninhibited stretch reflex can be reduced, targeting the posterior root of the spinal cord and peripheral nerves innervating the limbs, which are called selective posterior rhizotomy (SPR) and selective peripheral neurotomy (SPN), respectively. SPN is indicated for focal or multifocal spasticity, which is well accepted due to its low invasiveness and ease of use. How does the operation work? What do we do before and during this operation? Is there any risk to the patients? Our review summarizes the mechanism, indications, preoperative assessments, techniques, and complications of SPN. We hope that the spastic patients, such as pediatric cerebral palsy patients and older stroke patients, will benefit from this surgery.

Spasticity Measurement Based on the HHT Marginal Spectrum Entropy of sEMG Using a Portable System: A Preliminary Study

To facilitate stretch reflex onset (SRO) detection and improve accuracy and reliability of spasticity assessment in clinical settings, a new method to measure dynamic stretch reflex threshold (DSRT) based on Hilbert-Huang transform marginal spectrum entropy (HMSEN) of surface electromyography (sEMG) signals and a portable system to quantify modified Ashworth scale (MAS) for spasticity assessment were developed. The sEMG signals were divided into frames using a fixed-length sliding window, and the HMSEN of each frame was calculated. An adaptive threshold was set to measure the DSRT. The HMSEN based method can quantify muscle activity through time-frequency and nonlinear dynamics analysis, therefore providing deeper insight about the spastic muscle mechanisms during stretching and a reliable SRO detection method. Experimental results revealed that the HMSEN based method could reliably detect the SRO and measure the DSRT (recognition rate: 95.45%), and could achieve improved performance over the time-domain based method. There was a strong correlation ( to -0.900) between the MAS scores and the DSRT index, and the test-retest reliability was high. Additionally, limitations of the MAS were analyzed. This paper indicates that the presented framework can provide a promising tool to measure DSRT and a clinical quantitative approach for spasticity assessment.

Spasticity assessment based on the Hilbert-Huang transform marginal spectrum entropy and the root mean square of surface electromyography signals: a preliminary study

BACKGROUND

Most of the objective and quantitative methods proposed for spasticity measurement are not suitable for clinical application, and methods for surface electromyography (sEMG) signal processing are mainly limited to the time-domain. This study aims to quantify muscle activity in the time-frequency domain, and develop a practical clinical method for the objective and reliable evaluation of the spasticity based on the Hilbert-Huang transform marginal spectrum entropy (HMSEN) and the root mean square (RMS) of sEMG signals.

METHODS

Twenty-six stroke patients with elbow flexor spasticity participated in the study. The subjects were tested at sitting position with the upper limb stretched towards the ground. The HMSEN of the sEMG signals obtained from the biceps brachii was employed to facilitate the stretch reflex onset (SRO) detection. Then, the difference between the RMS of a fixed-length sEMG signal obtained after the SRO and the RMS of a baseline sEMG signal, denoted as the RMS difference (RMSD), was employed to evaluate the spasticity level. The relations between Modified Ashworth Scale (MAS) scores and RMSD were investigated by Ordinal Logistic Regression (OLR). Goodness-of-fit of the OLR was obtained with Hosmer-Lemeshow test.

RESULTS

The HMSEN based method can precisely detect the SRO, and the RMSD scores and the MAS scores were fairly well related (test: χ2 = 8.8060, p = 0.2669; retest: χ2 = 1.9094, p = 0.9647). The prediction accuracies were 85% (test) and 77% (retest) when using RMSD for predicting MAS scores. In addition, the test-retest reliability was high, with an interclass correlation coefficient of 0.914 and a standard error of measurement of 1.137. Bland-Altman plots also indicated a small bias.

CONCLUSIONS

The proposed method is manually operated and easy to use, and the HMSEN based method is robust in detecting SRO in clinical settings. Hence, the method is applicable to clinical practice. The RMSD can assess spasticity in a quantitative way and provide greater resolution of spasticity levels compared to the MAS in clinical settings. These results demonstrate that the proposed method could be clinically more useful for the accurate and reliable assessment of spasticity and may be an alternative clinical measure to the MAS.

A historical review of the evolution of the Tardieu Scale

There are many clinical assessment tools that can be used to quantify spasticity, one feature of the Upper Motor Neurone (UMN) syndrome. The focus of this short paper is on three; the Tardieu Scale, the Modified Tardieu Scale and the Australian Spasticity Assessment Scale, because a fundamental concept of these tests is their velocity dependent nature. Other bedside assessments such as the Modified Ashworth Scale examine hypertonicity, another feature of the UMN syndrome, but in this instance, the stretching movement is not velocity dependent. The Tardieu Scale, while not officially named until 1997, was conceived in the 1950s and since that time it has been revised by multiple authors and it is these additions that will be discussed in this article. The advantages and disadvantages of these assessment tools will be discussed with the ultimate aim of identifying one that has greater clinical utility.

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.

Is digital photography an accurate and precise method for measuring range of motion of the hip and knee?

BACKGROUND

Accurate measurements of knee and hip motion are required for management of musculoskeletal pathology. The purpose of this investigation was to compare three techniques for measuring motion at the hip and knee. The authors hypothesized that digital photography would be equivalent in accuracy and show higher precision compared to the other two techniques.

METHODS

Using infrared motion capture analysis as the reference standard, hip flexion/abduction/internal rotation/external rotation and knee flexion/extension were measured using visual estimation, goniometry, and photography on 10 fresh frozen cadavers. These measurements were performed by three physical therapists and three orthopaedic surgeons. Accuracy was defined by the difference from the reference standard, while precision was defined by the proportion of measurements within either 5° or 10°. Analysis of variance (ANOVA), t-tests, and chi-squared tests were used.

RESULTS

Although two statistically significant differences were found in measurement accuracy between the three techniques, neither of these differences met clinical significance (difference of 1.4° for hip abduction and 1.7° for the knee extension). Precision of measurements was significantly higher for digital photography than: (i) visual estimation for hip abduction and knee extension, and (ii) goniometry for knee extension only.

CONCLUSIONS

There was no clinically significant difference in measurement accuracy between the three techniques for hip and knee motion. Digital photography only showed higher precision for two joint motions (hip abduction and knee extension). Overall digital photography shows equivalent accuracy and near-equivalent precision to visual estimation and goniometry.

Acupuncture Reduces Excitability of Spinal Motor Neurons in Patients with Spastic Muscle Overactivity and Chronic Disorder of Consciousness Following Traumatic Brain Injury

BACKGROUND AND OBJECTIVE

Spastic hypertonia usually occurs in patients with chronic disorders of consciousness (DOC) following severe traumatic brain injury (TBI). Spinal motor neuron excitability has been reported to increase in patients with brain damage. The aim of this study was to evaluate the immediate effects of acupuncture on spinal motor neuron excitability in patients with DOC following TBI by using evoked electromyography.

SETTING AND PARTICIPANTS

Eleven male patients (mean age, 33 ± 14 years) with refractory muscle spasticity of the upper extremity accompanying chronic DOC following TBI and admitted to Chubu Medical Center for Prolonged Traumatic Brain Dysfunction were included.

DESIGN

A crossover study design was used. Changes in variables in the acupuncture session were compared with those in the control session in the same patients.

INTERVENTION

Acupuncture treatment was performed at GV 26, Ex-HN 3, bilateral LI 4, and ST 36 for 10 minutes.

OUTCOME MEASURES

F-wave was recorded from the abductor pollicis brevis muscle. The main outcome measure was F/M amplitude ratio (F-wave amplitude/M-wave amplitude), calculated as an index for spinal motor neuron excitability. F-waves were recorded before treatment (baseline), 10 minutes after needle insertion (phase 1), and 10 minutes after needle removal (phase 2). The same procedure was followed in the control session without acupuncture on a separate day.

RESULTS

F/M ratio was significantly reduced from baseline to phase 1 (p < 0.001) and phase 2 (p < 0.001) in the acupuncture session, whereas no significant changes were observed in the control session. Changes in F/M ratio from baseline to phase 1 and phase 2 were greater in the acupuncture session than the control session (p = 0.001 and <0.001, respectively).

CONCLUSION

The excitability of the spinal motor neurons in patients with DOC following TBI was reduced after acupuncture treatment, suggesting that it is beneficial for reducing spastic muscle hypertonia in these patients.

Reliability of the Modified Tardieu Scale and the Modified Ashworth Scale in adult patients with severe brain injury: a comparison study

Objective: To assess and to compare the reliability of the Modified Tardieu Scale with the Modified Ashworth Scale in patients with severe brain injury and impaired consciousness.

Design: Cross-sectional observational comparison study.

Setting: An early rehabilitation centre for adults with neurological disorders.

Subjects: Thirty patients with impaired consciousness due to severe cerebral damage of various aetiologies.

Measurement protocol: Four experienced physical therapists rated each patient in a randomized order once daily for two consecutive days. Shoulder, elbow, wrist, hip, knee and ankle spasticity were assessed by the use of Modified Tardieu Scale and Modified Ashworth Scale data collection procedures.

Main outcome measures: Test - retest and inter-rater reliability (k=kappa value) of the Modified Tardieu Scale and the Modified Ashworth Scale.

Results: The test-retest reliability of the Modified Ashworth Scale was moderate to good (k = 0.47-0.62) and of the Modified Tardieu Scale moderate to very good (k = 0.52-0.87). Test - retest reliability was significantly higher within the Modified Tardieu Scale in comparison with the Modified Ashworth Scale (Z<1.96; p<0.05) except for shoulder extensor and internal rotator muscles (Z<1.96; p<0.05). Although inter-rater reliability of both scales was poor to moderate (Modified Ashworth Scale: k = 0.16-0.42; Modified Tardieu Scale: k = 0.29-0.53), significantly higher k-values were revealed with the Modified Tardieu Scale for all tested muscle groups (Z<1.96; p<0.05) except for wrist extensors (Z<1.96; p<0.05).

Conclusion: In patients with severe brain injury and impaired consciousness the Modified Tardieu Scale provides higher test-retest and inter-rater reliability compared with the Modified Ashworth Scale and may therefore be a more valid spasticity scale in adults.

Assessment of robotic patient simulators for training in manual physical therapy examination techniques

Robots that simulate patients suffering from joint resistance caused by biomechanical and neural impairments are used to aid the training of physical therapists in manual examination techniques. However, there are few methods for assessing such robots. This article proposes two types of assessment measures based on typical judgments of clinicians. One of the measures involves the evaluation of how well the simulator presents different severities of a specified disease. Experienced clinicians were requested to rate the simulated symptoms in terms of severity, and the consistency of their ratings was used as a performance measure. The other measure involves the evaluation of how well the simulator presents different types of symptoms. In this case, the clinicians were requested to classify the simulated resistances in terms of symptom type, and the average ratios of their answers were used as performance measures. For both types of assessment measures, a higher index implied higher agreement among the experienced clinicians that subjectively assessed the symptoms based on typical symptom features. We applied these two assessment methods to a patient knee robot and achieved positive appraisals. The assessment measures have potential for use in comparing several patient simulators for training physical therapists, rather than as absolute indices for developing a standard.

Effects of Extracorporeal Shock Wave Therapy on Spasticity in Patients after Brain Injury: A Meta-analysis

[Purpose] The purpose of this meta-analysis was to assess the effects of extracorporeal shock wave therapy (ESWT) on reducing spasticity immediately and 4 weeks after application of ESWT. [Subjects and Methods] We searched PubMed, TCL, Embase, and Scopus from their inception dates through June 2013. The key words "muscle hypertonia OR spasticity" were used for spasticity, and the key words "shock wave OR ESWT" were used for ESWT. Five studies were ultimately included in the meta-analysis. [Results] The Modified Ashworth Scale (MAS) grade was significantly improved immediately after ESWT compared with the baseline values (standardized mean difference [SMD], -0.792; 95% confidence interval [CI], -1.001 to -0.583). The MAS grade at four weeks after ESWT was also significantly improved compared with the baseline values (SMD, -0.735; 95% CI, -0.951 to -0.519). [Conclusion] ESWT has a significant effect on improving spasticity. Further standardization of treatment protocols including treatment intervals and intensities needs to be established and long-term follow up studies are needed.

The effect of a hand-stretching device during the management of spasticity in chronic hemiparetic stroke patients

Objective

To describe a hand-stretching device that was developed for the management of hand spasticity in chronic hemiparetic stroke patients, and the effects of this device on hand spasticity.

Methods

Fifteen chronic hemiparetic stroke patients with finger flexor spasticity were recruited and randomly assigned to an intervention group (8 patients) or a control group (7 patients). The stretching device consists of a resting hand splint, a finger and thumb stretcher, and a frame. In use, the stretched state was maintained for 10 minutes per exercise session, and the exercise was performed twice daily for 4 weeks. Spasticity of finger flexor muscles in the two groups was assessed 3 times, 4 weeks apart, using the Modified Ashworth Scale (MAS). Patients in the intervention group were assessed twice (pre-1 and pre-2) before and once (post-1) after starting the stretching program.

Results

Mean MAS (mMAS) scores at initial evaluations were not significantly different at pre-1 in the intervention group and at 1st assessment in the control group (p>0.05). In addition, no significant differences were observed between mMAS scores at pre-1 and pre-2 in the intervention group (p>0.05). However, mMAS scores at post-1 were significantly lower than that at pre-2 in the intervention group (p<0.05). Within the control group, no significant changes in mMAS scores were observed between 1st, 2nd, and 3rd assessments (p>0.05). In addition, mMAS scores at post-1 in the intervention group were significantly decreased compared with those at the 3rd assessment in the control group (p<0.05).

Conclusion

The devised stretching device was found to relieve hand spasticity effectively in chronic hemiparetic stroke patients.

Accuracy and reliability of haptic spasticity assessment using HESS (Haptic Elbow Spasticity Simulator)

Clinical assessment of spasticity tends to be subjective because of the nature of the in-person assessment; severity of spasticity is judged based on the muscle tone felt by a clinician during manual manipulation of a patient's limb. As an attempt to standardize the clinical assessment of spasticity, we developed HESS (Haptic Elbow Spasticity Simulator), a programmable robotic system that can provide accurate and consistent haptic responses of spasticity and thus can be used as a training tool for clinicians. The aim of this study is to evaluate the accuracy and reliability of the recreated haptic responses. Based on clinical data collected from children with cerebral palsy, four levels of elbow spasticity (1, 1+, 2, and 3 in the Modified Ashworth Scale [MAS]) were recreated by HESS. Seven experienced clinicians manipulated HESS to score the recreated haptic responses. The accuracy of the recreation was assessed by the percent agreement between intended and determined MAS scores. The inter-rater reliability among the clinicians was analyzed by using Fleiss's kappa. In addition, the level of realism with the recreation was evaluated by a questionnaire on "how realistic" this felt in a qualitative way. The percent agreement was high (85.7±11.7%), and for inter-rater reliability, there was substantial agreement (κ=0.646) among the seven clinicians. The level of realism was 7.71±0.95 out of 10. These results show that the haptic recreation of spasticity by HESS has the potential to be used as a training tool for standardizing and enhancing reliability of clinical assessment.

Development of a Haptic Elbow Spasticity Simulator (HESS) for improving accuracy and reliability of clinical assessment of spasticity

This paper presents the framework for developing a robotic system to improve accuracy and reliability of clinical assessment. Clinical assessment of spasticity tends to have poor reliability because of the nature of the in-person assessment. To improve accuracy and reliability of spasticity assessment, a haptic device, named the HESS (Haptic Elbow Spasticity Simulator) has been designed and constructed to recreate the clinical "feel" of elbow spasticity based on quantitative measurements. A mathematical model representing the spastic elbow joint was proposed based on clinical assessment using the Modified Ashworth Scale (MAS) and quantitative data (position, velocity, and torque) collected on subjects with elbow spasticity. Four haptic models (HMs) were created to represent the haptic feel of MAS 1, 1+, 2, and 3. The four HMs were assessed by experienced clinicians; three clinicians performed both in-person and haptic assessments, and had 100% agreement in MAS scores; and eight clinicians who were experienced with MAS assessed the four HMs without receiving any training prior to the test. Inter-rater reliability among the eight clinicians had substantial agreement (κ = 0.626). The eight clinicians also rated the level of realism ( 7.63 ± 0.92 out of 10) as compared to their experience with real patients.

Early use of Xeomin neurotoxin for local anti-spasticity therapy for pes equines after acquired brain injury (ABI)

PRIMARY OBJECTIVE

The acute management of spasticity following ABI is challenging. Contractures can occur during the acute phases of illness. The joints most affected are the shoulders and the ankles.

RESEARCH DESIGN

A case study of a 48-year-old female patient who received local chemoneurolytic anti-spasticity therapy following a severe subarachnoid haemorrhage for pes equines deformity is presented to illustrate the role of focal neurotoxin therapy.

METHODS AND PROCEDURES

The increasing spasticity in her legs was observed and could not be effectively treated with oral anti-spasticity agents or intensive physiotherapy. As spasticity increased (Modified Ashworth Scale 4), mobility of the right foot continued to deteriorate, leading to indication for local anti-spasticity treatment with Xeomin neurotoxin. The spastic pes equinus was injected with Xeomin® using a total dose of 150 U.

MAIN OUTCOMES AND RESULTS

On the 6th day after injection, a gradual reduction in spasticity was observed in the injected muscle (Modified Ashworth Scale 1-2) and an increasing improvement in joint mobility.

CONCLUSIONS

Early local anti-spasticity treatment with Xeomin is effective treatment. The cost of the intervention would appear to be high, but if one compares it with the costs of conservative treatment, it is not more expensive.

Clinical measurement of limb spasticity in adults: state of the science

Spasticity is a neuromuscular dysfunction characterized by tight or stiff muscles. Spasticity occurs across the spectrum of upper motor neuron disease and complicates the course and quality of life of those affected. Accurate and precise assessment of spasticity is the first step in providing safe and effective treatments to patients for management of spasticity. Examiner evaluations (Ashworth Scale, Modified Ashworth, and Visual Analog Scale) and patient self-reports (Visual Analog Scale and Numeric Rating Scale) are used to assess spasticity in clinical practice. We reviewed the biology of spasticity and summarized research that assessed properties of scores obtained from clinical scales when used in a variety of upper motor neuron diseases. The definition of spasticity was inconsistent. Rater reliability or agreement on clinical scales varied widely. Correspondence with electromyogram results was mixed. There was dissimilarity in patient reports and examiner assessments. Scores from clinical scales are responsive (decrease after initiation of treatment with known effectiveness), but the utility of scores for indexing individual change associated with the natural history of upper motor neuron disease is unknown. Future research incorporating patient reports and examiner findings over time will help to clarify the definition and capture the essence of spasticity.

Contractures and involuntary muscle overactivity in severe brain injury

PRIMARY OBJECTIVE

The aim of the present study was to evaluate the association of contractures with an increase or reduction of non-spastic muscle overactivity due to severe cerebral damage.

METHODS AND PROCEDURES

Forty-five patients with tetraparesis after severe cerebral damage were investigated. Three groups were defined based on the presence of spasticity (revealed as resistance to passive stretch (= hypertonia)), and the presence of contracture of the relevant knee joint: Group(s) (17 patients with hypertonia without contracture), Group(s+c) (20 patients with hypertonia and contracture), and Group(c) (eight patients without hypertonia and with contracture). In all groups spontaneous involuntary muscle activity was assessed continuously over a 12-hour period through isometric measurement of knee joint flexion torque. A mathematical algorithm differentiated an hourly muscle activity spectrum (PI(h)). The frequency of peaks (peaks(h)) from the activity spectrum was determined.

MAIN OUTCOMES AND RESULTS

We revealed that Group(s) had higher PI(h) and more frequent peaks(h) compared with Group(s+c) and Group(c) (p<0.05). Group(c) had comparable PI(h) and peaks(h) compared with Group(s+c) (p>0.05).

CONCLUSION

The presence of contractures was associated with lower involuntary muscle overactivity in terms of lower PI(h) and less frequent peaks(h), indicating that contractures may be associated with reduced non-spastic positive features of the upper motor neurone syndrome in patients with severe brain damage.

Comparison of orthostatic reactions of patients still unconscious within the first three months of brain injury on a tilt table with and without integrated stepping. A prospective, randomized crossover pilot trial

OBJECTIVE

To determine whether passive leg movement during tilt table mobilization reduces the incidence of orthostatic dysfunction in mobilization of patients being comatose or semi-comatose early after brain injury.

DESIGN

Randomized crossover pilot trial using sequential testing.

SETTING

Neurorehabilitation hospital.

SUBJECTS

Nine patients still unconscious within the first three months of brain injury (5 men, 4 women; age 51 +/- 20 years).

INTERVENTION

Patients were subjected once to a conventional tilt table and once to a tilt table with an integrated stepping device.

MAIN OUTCOME MEASURE

The number of syncopes/presyncopes (orthostatic hypotension, tachypnoea, increased sweating) during interventions.

RESULTS

One patient had presyncopes on both devices, six patients had presyncopes on the conventional tilt table but not on the tilt table with integrated stepping, and two patients did not exhibit presyncopal symptoms on either device. There were significantly more incidents on the tilt table without than on the one with an integrated stepping device (P < 0.05) at tilts of 50 or 70 degrees respectively.

CONCLUSION

Patients tolerate greater degrees of head-up tilt better with simultaneous leg movement.

Direct isolation of neural stem cells in the adult hippocampus after traumatic brain injury

Recently, we have manipulated endogenous neural stem/progenitor cells (NSCs) in situ in the adult mouse to undergo neurogenesis and anatomic circuit re-formation de novo in the neocortex, where it does not normally occur, by using a highly targeted brain injury model. However, how the NSCs respond to injury in the adult mouse brain is poorly understood. While studying the molecular mechanisms that regulate NSC fates after brain injury, it is important to develop a strategy to identify NSCs in niches and isolate them directly from fresh tissue after brain injury. Here we report that we directly isolated NSCs from adult brains after traumatic brain injury by genetically labeling NSCs with EGFP combined with fluorescence-activated cell sorting (FACS) technique without an intervening cell culture and with high concentrations of growth factors. The isolated EGFP-positive cells can self-renew and have the potential to differentiate into both neurons and glia in vitro, confirming that the FACS-sorted EGFP-positive cells are NSCs. This unique approach provides a useful tool to isolate large amounts of endogenous NSCs in situ for identifying the critical molecules that regulate fate decision and neurogenesis in the adult brain after injury.

Selective death of newborn neurons in hippocampal dentate gyrus following moderate experimental traumatic brain injury

Memory impairment is one of the most significant residual deficits following traumatic brain injury (TBI) and is among the most frequent complaints heard from patients and their relatives. It has been reported that the hippocampus is particularly vulnerable to TBI, which results in hippocampus-dependent cognitive impairment. There are different regions in the hippocampus, and each region is composed of different cell types, which might respond differently to TBI. However, regional and cell type-specific neuronal death following TBI is not well described. Here, we examined the distribution of degenerating neurons in the hippocampus of the mouse brain following controlled cortical impact (CCI) and found that the majority of degenerating neurons observed were in the dentate gyrus after moderate (0.5 mm cortical deformation) CCI-TBI. In contrast, there were only a few degenerating neurons observed in the hilus, and we did not observe any degenerating neurons in the CA3 or CA1 regions. Among those degenerating cells in the dentate gyrus, about 80% of them were found in the inner granular neuron layer. Analysis with cell type-specific markers showed that most of the degenerating neurons in the inner granular neuron layer are newborn immature neurons. Further quantitative analysis shows that the number of newborn immature neurons in the dentate gyrus is dramatically decreased in the ipsilateral hemisphere compared with the contralateral side. Collectively, our data demonstrate the selective death of newborn immature neurons in the hippocampal dentate gyrus following moderate injury with CCI in mice. This selective vulnerability of newborn immature dentate neurons may contribute to the persistent impairment of learning and memory post-TBI and provide an innovative target for neuroprotective treatment strategies.

Inter- and intrarater reliability of the Modified Modified Ashworth Scale in patients with knee extensor poststroke spasticity

Muscle spasticity is a common motor disorder following upper motor neuron syndrome. A reliable and valid clinical tool is essential to document the effect of therapeutic interventions aimed to improve function by reducing spasticity. The Modified Ashworth Scale (MAS) is the most widely used and accepted clinical scale of spasticity. The MAS has been recently modified. The aim of this investigation was to determine the interrater and intrarater reliability of clinical test of knee extensor post-stroke spasticity graded on a Modified Modified Ashworth Scale (MMAS). Two raters scored the muscle spasticity of 15 patients with ischaemic stroke. For the inter- and intrarater reliability, two raters agreed on 80.1% and 86.6%, respectively. The Kappa values were good (kappa=0.72, SE=0.14, p<0.001) between raters and very good (kappa=0.82, SE=0.12, p<0.001) within one rater. The values of Kendall tau-b correlation were acceptable for clinical use with 0.87 (SE=0.06, p<0.001) between raters and 0.92 (SE=0.05, p<0.001) within one rater. The MMAS demonstrated reliable measurements for a single rater and between raters for measuring knee extensor post-stroke spasticity. The results encourage further study on the reliability and the validity of the scale.