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PubMed2003

Spinal cord injury and use of botulinum toxin in reducing spasticity.

Spasticity is commonly seen after spinal cord injury, and a large percentage of patients with spinal cord injury will need treatment to control it. Although oral medications do a fair job of controlling spasticity in most patients, some patients will need additional forms of treatment. In many cases, oral medications alone do not adequately control spasticity or the patient cannot tolerate the side effects. In these instances, botulinum toxin may help control the spasticity for approximately 3 months after injection. The amount of botulinum toxin and the injection sites can be tailored to meet individual patient needs. Botulinum toxins can reduce spasticity, improve function, and reduce the amount of needed assistance.

Anti-Dyskinesia Agents↗
PubMed2000

Time-course analysis of stretch reflexes in hemiparetic subjects using an on-line spasticity measurement system.

Spasticity after a stroke is usually assessed in a score form by subjectively determining the resistance of a joint to an externally imposed passive movement. This work presents a spasticity measurement system for on-line quantifying the stretch reflex of paretic limbs. Four different constant stretch velocities in a ramp-and-hold mode are used to elicit the stretch reflex of the elbow joint in spastic subjects. The subjects are tested at supine position with the upper limb stretched towards the ground, in contrast with the horizontally stretched movement used in other studies. By subtracting the baseline torque, reflex torque measured at a selected low stretch velocity of 5 deg/sec, the influence of gravity torque and inertial in vertical stretching mode can be minimized. The averaged speed-dependent reflex torque (ASRT), defined as the measured torque deviated from the baseline torque, is used for quantifying the spastic hypertonia. Four subjects having incurred cerebrovascular accident (CVA) are recruited for time-course study in which the measurements are taken at 72 hours, one week, one month, three months, and six months after onset of stroke. During the development of spasticity, the changes of ASRT and velocity sensitivity of ASRT of the involved and the intact elbow joints are discussed.

Elbow Joint↗
PubMed2003

Spasticity of the pelvic floor mimicking an obstructive anomaly.

STUDY OBJECTIVE: Hematocolpos or hydrocolpos in menstruating women raises suspicion of a partial uterine or vaginal obstruction. The study objective is to report two unusual cases of a spastic pelvic floor leading to urine collecting in the vagina and mimicking an outflow obstruction. DESIGN, SETTING, PARTICIPANTS: The study took place at a tertiary care university's Reproductive Health Care Clinic for Women with Developmental Disabilities and involved two patients with spastic quadriplegic cerebral palsy and developmental disabilities who presented with irregular menses and abdominal pain and whose radiological evaluations were suspicious for an outflow obstruction. Medical records, including clinic visits, radiological findings, and surgical findings, were reviewed. INTERVENTIONS: Both patients underwent ultrasound and MRI evaluation of their reproductive tracts that demonstrated fluid collections in the vagina. An examination under anesthesia was performed in one patient to rule out an obstruction. In the second patient, a pelvic examination under ultrasound observation revealed initial vaginal distension with urine, which resolved after placement of a speculum. RESULTS: In both cases, the pseudo-obstruction was felt to be a urine-distended vagina due to a spastic pelvic floor. CONCLUSION: A spastic pelvic floor in an incontinent patient with spastic quadriplegia may result in urine accumulation in the vagina, mimicking an outflow tract obstruction. If the history, pelvic examination, and radiological images are inconsistent, performing an ultrasound-guided examination may assist with diagnosis.

Adolescent↗
PubMed2002

Reciprocal Ia inhibition in patients with asymmetric spinal spasticity.

OBJECTIVES: Previous studies on reciprocal Ia inhibition in spinal spasticity were contradictory, probably due to differences in the etiology, severity, and the course of recovery from the disease. The purpose of the present study was to establish a correlation between Ia inhibition and clinical abnormalities in spasticity following a spinal cord injury (SCI). METHODS: We studied reciprocal Ia inhibition in bilateral soleus muscles in five SCI patients with marked asymmetry of spasticity and functional recovery for the right and left legs. Reciprocal Ia inhibition was determined from the short latency suppression of the soleus H-reflex by conditioning stimulation of the peroneal nerve. RESULTS: In all the patients, Ia inhibition was asymmetric. Ia inhibition in the legs with good recovery and less spasticity was pronounced, but Ia inhibition in the more spastic legs was small or absent. Facilitation was seen only on the sides with poor recovery in two patients. In the healthy subjects the amount of Ia inhibition varied, but no side-to-side difference was found. CONCLUSIONS: These results suggest that reciprocal Ia inhibition varies according to the functional recovery. Pronounced Ia inhibition may be related to good functional recovery in patients with SCI.

Adult↗
PubMed2000

Sensitivity of the pendulum test for assessing spasticity in persons with cerebral palsy.

The sensitivity of the pendulum test to variation in spasticity in persons with spastic cerebral palsy (CP) was tested in 30 participants with CP and 10 participants without CP (controls) (mean age 13.8 years). The participants with CP were classified into three groups, with normal (mean age 15.9 years), mild/moderate (13.0 years), or severe (23.0 years) muscle tone, as assessed clinically using a modified Ashworth scale. Joint motion during the pendulum test was measured with an electrogoniometer. Muscle relaxation was confirmed using surface EMG. Outcome measures from the pendulum test were (1) number of oscillations, (2) duration of oscillations, (3) excursion of the first backward swing, and (4) relaxation index (first swing excursion/difference between the starting and resting angles). Data were assessed using one-way analysis of variance. Outcome measures 1 to 3 differed significantly between control participants and participants with CP (p<0.05). The first swing excursion was the best predictor of the degree of spasticity in persons with CP, being significantly different between all groups (p<0.05). The number of oscillations and their duration differentiated between control participants and all participants with CP (p<0.05) but not between participants with CP who had mild/moderate versus severe spasticity (p>0.05). The relaxation index was not a sensitive measure (p>0.05 between most study groups). We conclude that the pendulum test is a valid tool for assessing spasticity in persons with CP and that the first swing excursion is the most sensitive outcome measure.

Adolescent↗
PubMed2004

Lumbar repetitive magnetic stimulation reduces spastic tone increase of the lower limbs.

STUDY DESIGN: Comparison of spinal lesion subjects and normal subjects. OBJECTIVE: To investigate the effects of a paravertebral repetitive magnetic stimulation on spastic tone increase of the lower limbs. SETTING: Munich, Germany. METHODS: We compared the effects in 15 patients with different spinal lesions and in 16 healthy subjects. The spastic tone increase was evaluated clinically with the Ashworth scale and apparatively with the pendulum test, both at fixed times before and after stimulation. Unilateral stimulation was applied to the lumbar nerve roots L3 and L4 of the clinically more spastic leg. RESULTS: The spastic tone decreased significantly in the interval between 4 and 24 h after stimulation. This effect was slightly more pronounced in the contralateral extremity. Furthermore, the stimulation motor threshold of the patients was significantly raised. CONCLUSION: Repetitive magnetic unilateral stimulation has a positive effect on spastic tone increase due to spinal lesions, causing a decrease that lasts for about 1 day not only on the ipsilateral but also on the contralateral side.

Adult↗
PubMed1981

Adductor spastic dysphonia as a sign of essential (voice) tremor.

Adductor spastic dysphonia may not be one disorder but a voice sign of several different neurologic and psychiatric syndromes. This study evaluates whether rhythmic voice arrests, often components of "spastic dysphonia," are signs of essential tremor, a neurologic disorder. Data on 22 patients originally diagnosed as having spastic dysphonia, who had tremor-like or rhythmic voice arrests, were compared with data on two groups of patients who had essential (voice) tremor. The frequency of voice arrest on vowel prolongation in the group labeled spastic dysphonia was compared with the frequency of voice tremor in the groups with essential tremor. The median frequencies of 5.7, 5.0, and 5.5 Hz were not significantly different among the three groups. Patients in all three groups had tremor in other parts of the body, other scattered neurologic signs, and histories of life stress associated with the onset of their voice disorders. Although the results do not prove conclusively that the patients diagnosed as having spastic dysphonia in this study actually had essential tremor, the similarities to that disorder strongly suggest a linkage.

Adult↗
PubMed2002

The surgical management of spasticity.

Neurosurgery is only considered for severe spasticity following the failure of noninvasive management (adequate medical and physical therapy). The patients are carefully selected, based on rigorous multidisciplinary clinical assessment. In this we evaluate the contribution of the spasticity to the disability and any residual voluntary motor function. The goals for each patient are: (a) improvement of function and autonomy; (b) control of pain; and (c) prevention of orthopaedic disorders. To achieve these objectives, the surgical procedure must be selective and reduce the excessive hypertonia without suppressing useful muscle tone and limb functions. The surgical procedures are: (1) Classical neuro-ablative techniques (peripheral neurotomies, dorsal rhizotomies) and their modern modifications using microsurgery and intra-operative neural stimulation (dorsal root entry zone: DREZotomy). These techniques are destructive and irreversible, with the reduced muscle tone reflecting the nerve topography. It is mainly indicated when patients have localized spasticity without useful mobility. (2) Conservative techniques based on a neurophysiological control mechanism. These procedures are totally reversible. The methods involve chronic neurostimulation of the spinal cord or the cerebellum. There are only a few patients for whom this is indicated. Conversely, chronic intrathecal administration of baclofen, using an implantable pump, is well established in the treatment of diffuse spasticity of spinal origin. From reports in the literature, we critically review the respective indications in terms of function, clinical progression and the topographic extent of the spasticity.

Baclofen↗
PubMed2005

Complicated hereditary spastic paraplegia with thin corpus callosum (HSP-TCC) and childhood onset.

The hereditary spastic paraplegias (HSPs) are a group of rare disorders with the predominant clinical feature of progressive spastic paraplegia. They are subdivided into pure and complicated forms according to whether the disorder is associated with other neurological abnormalities. We report on two unrelated female Caucasian patients with complicated HSP, aged 16 and 24 years, who showed progressive gait disturbance with spasticity and ataxia as well as cognitive impairment. Onset of symptoms was at age 3 and 10 years, respectively. MRI revealed mild diffuse non-progressive T (2)-signal alterations of cerebral white matter and thinning of the body and genu of the corpus callosum. Some similarity of clinical symptoms and MRI patterns with the phenotype of Mast syndrome prompted a mutation analysis of the SPG21 gene, encoding maspardin, which revealed a wild-type sequence in both patients. Clinical and neuroradiological features in our patients are diagnostic for complicated autosomal recessive hereditary spastic paraplegia with thin corpus callosum (HSP-TCC, SPG11). This disorder, characterized by a typical MRI pattern and a progressive spastic paraplegia that may be associated with dementia and ataxia, may have an onset in early childhood and probably is one of the more common forms of complicated HSP.

Adolescent↗
PubMedDate not supplied

Spasticity in children with cerebral palsy: a retrospective review of the effects of intrathecal baclofen.

The administration of baclofen by intrathecal pump is a new technique used to reduce spasticity for individuals with upper motor neuron system injuries. Children with cerebral palsy often have difficulty in mobility because of this form of spasticity. The purpose of this study was to assess the functional outcomes of intrathecal baclofen pump therapy with spasticity in children with cerebral palsy. A retrospective review of medical records for pediatric cerebral palsy patients receiving intrathecal baclofen for intractable spasticity was performed. Of 23 sequential medical records meeting requirements for inclusion in the study, 17 subjects had sufficient recorded data to be included in the study. Data from the medical records included Ashworth scores, therapy complications, and changes in mobility and independence. Although no significant changes in the upper extremities with intrathecal baclofen occurred at one and three months, the trial bolus showed statistically significant changes in mean Ashworth scores. The pre- and posttrial bolus Ashworth scores for the lower extremities showed statistically significant decreases in the posttrial scores and at one and three months when compared with the pretrial scores (p < .001). Complications were resolved with conservative management without long-term sequelae. No infections, respiratory depressions, or deaths occurred as a result of intrathecal baclofen therapy in this study. Although intrathecal baclofen had a significant effect in reducing lower extremity spasticity in children with cerebral palsy, further prospective studies are needed to determine the effects of intrathecal baclofen on such indicators as activities of daily living.

Adolescent↗
PubMed2002

The management of pain in spasticity.

Pain is a common feature of spasticity and muscle spasms and the reasons for this are discussed in this article. However, the causes of this spasticity have to be determined and for successful management, knowing the underlying mechanisms, which produce spasticity, is necessary. In addition to knowing the range of available treatments, one has to know their particular contribution to the overall management of the patient. The assessment and management of the spastic patient is multi-disciplinary and painful spasticity changes over time. This therefore requires repeated assessments and the direction of the treatment may also change. Pain may be a dominant feature, but is rarely the sole symptom. This article looks at a strategy for the overall management of the patient with the focus on managing pain.

Administration, Oral↗
PubMed2006

A systematic review of the Tardieu Scale for the measurement of spasticity.

BACKGROUND: The Tardieu Scale has been suggested a more appropriate clinical measure of spasticity than the Ashworth or modified Ashworth Scales. It appears to adhere more closely to Lance's definition of spasticity as it involves assessment of resistance to passive movement at both slow and fast speeds. OBJECTIVE: To review the available literature in which the Tardieu Scale has been used or discussed as a measure of spasticity, with a view to determining its validity and reliability. STUDY DESIGN: A systematic review of all literature found related to the Tardieu Scale (keywords: Tardieu scale, spasticity) from Pubmed and Ovid databases, including medline, CINAHL, EMBASE, Journals at Ovid full text, EBM reviews and Cochrane database of systematic reviews. Hand searching was also used to track the source literature. CONCLUSIONS: In theory, we can acknowledge that the Tardieu Scale does, in fact, adhere more closely to Lance's definition of spasticity. However, there is a dearth of literature investigating validity and reliability of the scale. Some studies have identified the Tardieu Scale to be more sensitive than other measures, to change following treatment with botulinum toxin. Further studies need to be undertaken to clarify the validity and reliability of the scale for a variety of muscle groups in adult neurological patients.

Disability Evaluation↗
PubMedDate not supplied

Relation between spasticity, weakness and contracture of the elbow flexors and upper limb activity after stroke: an observational study.

PURPOSE: Understanding the relationship between the motor impairments and their impact on physical activity will allow rehabilitation after stroke to be based on scientific principles. The aims of this study were to determine: (i) the relative contribution of weakness and spasticity to contracture, and (ii) the relative contribution of all three impairments to limitations in physical activity during the first 12 months after stroke. METHOD: This longitudinal observational study charted the evolution of weakness (loss of maximal force), spasticity (stretch-evoked EMG) and contracture (loss of joint range) of the elbow flexors and limitations in upper limb activity (Motor Assessment Scale) for a year after stroke in 27 subjects who had suffered a first stroke. Spasticity was measured as abnormal reflex activity, weakness was measured as loss of maximum isometric torque, contracture was measured as the difference in range of motion between the affected and intact side, and limitations in physical activity were measured on a clinical scale. RESULTS: The major independent contributors to contracture were spasticity for the first four months after stroke (p = 0.0001 - 0.10) and weakness thereafter (p = 0.01 - 0.05). However, the major and only independent contributor to limitations in physical activity throughout the year was weakness (p = 0.0001 - 0.05). CONCLUSIONS: For the first time, from a longitudinal study, the findings show that spasticity can cause contracture after stroke, consistent with the prevailing clinical view. However, weakness is the main contributor to activity limitations.

Adult↗
PubMed2005

Baclofen pump intervention for spasticity affecting pulmonary function.

INTRODUCTION: Muscle spasticity may adversely affect pulmonary function after spinal cord injury (SCI). However, there is limited information regarding the treatment of spasticity as a determinant of pulmonary function. This study presents the case of a man with C4 tetraplegia who had severe spasticity and difficulty weaning from ventilatory support. METHODS: Case presentation. RESULTS: Severe spasticity likely contributed to respiratory compromise in this patient. Successful and rapid weaning from the ventilator occurred within 3 weeks of baclofen pump placement. CONCLUSIONS: Randomized clinical trials among SCI patients with significant spasticity are needed to determine whether intervention with a baclofen pump facilitates earlier ventilatory weaning.

Baclofen↗
PubMed2005

Cost-effectiveness of botulinum toxin type a in the treatment of post-stroke spasticity.

OBJECTIVE: Treatment strategies for post-stroke spasticity include oral anti-spastic drugs, surgery, physiotherapy and botulinum toxin type A injection. The objective of this study was to compare the cost-effectiveness and outcomes of oral therapy vs. botulinum toxin type A treatment strategies in patients with flexed wrist/clenched fist spasticity. METHODS: Treatment outcome and resource use data were collected from an expert panel experienced in the treatment of post-stroke spasticity. A decision tree model was developed to analyse the data. RESULTS: Thirty-five percent of patients receiving oral therapy showed an improvement in pre-treatment functional targets which would warrant continuation of therapy, compared with 73% and 68% of patients treated with botulinum toxin type A first- and second-line therapy, respectively. Botulinum toxin type A treatment was also more cost-effective than oral therapy with the "cost-per-successfully-treated month" being 942 pounds, 1387 pounds and 1697 pounds for botulinum toxin type A first-line, botulinum toxin type A second-line and oral therapy, respectively. CONCLUSION: In conclusion, botulinum toxin type A is a cost-effective treatment for post-stroke spasticity.

Administration, Oral↗
PubMed2006

Whole-body vibration training compared with resistance training: effect on spasticity, muscle strength and motor performance in adults with cerebral palsy.

OBJECTIVE: The aim of this study was to evaluate the effect on spasticity, muscle strength and motor performance after 8 weeks of whole-body vibration training compared with resistance training in adults with cerebral palsy. METHODS: Fourteen persons with spastic diplegia (21-41 years) were randomized to intervention with either whole-body vibration training (n=7) or resistance training (n=7). Pre- and post-training measures of spasticity using the modified Ashworth scale, muscle strength using isokinetic dynamometry, walking ability using Six-Minute Walk Test, balance using Timed Up and Go test and gross motor performance using Gross Motor Function Measure were performed. RESULTS: Spasticity decreased in knee extensors in the whole-body vibration group. Muscle strength increased in the resistance training group at the velocity 30 degrees /s and in both groups at 90 degrees /s. Six-Minute Walk Test and Timed Up and Go test did not change significantly. Gross Motor Function Measure increased in the whole-body vibration group. CONCLUSION: These data suggest that an 8-week intervention of whole-body vibration training or resistance training can increase muscle strength, without negative effect on spasticity, in adults with cerebral palsy.

Adult↗
PubMed1994

Disynaptic reciprocal inhibition of ankle extensors in spastic patients.

The soleus Hoffmann-reflex (H-reflex) was conditioned by a preceding stimulation of the common peroneal nerve in 74 healthy control subjects and 39 patients with spasticity in the lower extremities due to multiple sclerosis. At a conditioning-test interval of 1-3 ms a decrease of the size of the soleus H-reflex was seen in the healthy subjects. The decrease was most likely caused by disynaptic reciprocal Ia inhibition (Crone et al., 1987). In the spastic patients a similar short-latency inhibition was rarely seen. On the contrary, in several patients a facilitation was seen at a conditioning-test interval of 3-4 ms. A short-latency inhibition as pronounced as in healthy subjects was seen in four patients. These four patients did not differ from the other patients regarding the degree of spasticity or any other clinical parameter. However, they all used an external peroneal nerve stimulator daily as a walking aid. It is suggested that the lack of short-latency reciprocal inhibition reflects a deficient control of the interneurons which mediate this inhibitory spinal mechanism between antagonistic muscles in man. This might contribute to the pathophysiology of spasticity and it might be related to the frequent occurrence of co-contraction of functionally antagonistic muscles during gait in spastic patients. The existence of a pronounced reciprocal inhibition in patients receiving frequent stimulation of the peroneal nerve may suggest that regular activation of peripheral nerves is of importance for the maintenance of the activity in spinal pathways.

Adult↗
PubMedDate not supplied

Acute care management of post-TBI spasticity.

The management of persons with traumatic brain injury (TBI) who have acute spasticity remains a challenge. A correct stratification is essential to clinical care and determination of efficacy from proposed interventions. The secondary severe sequelae of spasticity after TBI can result in profound functional impairment. These concerns are often best addressed early in the patient's course. Limited research in the area of the acute care treatment of severe spasticity is available. The authors employ a review of the available data as well as recount their own clinical experience in the acute care management of severe spasticity to assist in developing an order for the plethora of potential treatments available to clinicians and researchers. We propose to use a case example to emphasize key clinic points in the management of spasticity in the acute care setting.

Acetates↗