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PubMed2001

Scientific basis of spasticity: insights from a laboratory model.

A variety of central nervous system injuries, diseases, and developmental deficits can lead to motor disorders that present complex mixtures of symptoms. Those that have a fundamental similarity characterized by the appearance of exaggerated velocity-dependent resistance to the lengthening of skeletal muscles are called spasticity. Reports based on clinical observations of motor disorders have and continue to provide the essential database of information regarding the range and distribution of unifying and discordant features of spasticity. Laboratory investigations employing animal models of motor disorders following experimental lesions of the central nervous system have reproduced some of the neurophysiologic changes that accompany injury of the central nervous system in humans. Those experimental lesions produced by spinal cord contusion/compression reproduce many of the histopathologic features displayed in traumatic injury of the human spinal cord as well. Studies using this model have revealed not only changes in reflex threshold and amplitude but also alterations in fundamental rate-modulation processes that regulate reflex excitability during repetitive stimulation. This report characterizes insights obtained from a laboratory investigation in search of fundamental mechanisms that contribute to the development of spasticity and provides a vantage point for understanding therapeutic strategies for treatment of spasticity.

Animals↗
PubMed2002

Open-label study of botulinum toxin for upper limb spasticity in cerebral palsy.

The objective of this study was to assess the efficacy of botulinum toxin for upper limb spasticity in cerebral palsy. An open-label study was conducted in 11 children with cerebral palsy. Post-botulinum toxin assessment was conducted in weeks 1, 4, and 16, with averaged scores being analyzed. The Clinical Global Impression Scale of the mothers showed marked, moderate, and mild improvement in five, four, and two cases, respectively. The Modified Ashworth Spasticity Scale score showed a statistically significant decrease in the mean spasticity score (P < .003). Other tests were performed depending on the cognition of the child. Increase in joint motion occurred in all five children assessed using web space (P = .043). For the Jebson Hand Function Test, improvement occurred in all five cases assessed (P < .03). Four of five (80%) children could perform tasks that they failed before they were given botulinum toxin. Botulinum toxin is useful in decreasing spasticity and improving the upper limb function of young children with cerebral palsy with normal cognition. Motivated families should be selected with a specific target of using botulinum toxin as an adjunct in a habilitation program.

Adolescent↗
PubMed2003

The effect of transcutaneous electrical nerve stimulation on spasticity in multiple sclerosis patients: a pilot study.

The aim of this study was to examine the effects of transcutaneous electrical nerve stimulation on spasticity in patients with multiple sclerosis. The study was carried out in the Hacettepe University School of Physical Therapy and Rehabilitation. The subjects in the study were 10 clinically definite, primary and secondary progressive type multiple sclerosis outpatients with mild to moderate spasticity in the plantar flexor muscles of the ankle. Stimuli of frequency 100 Hz and pulse width 0.3 msec were used 20 minutes per day for 4 weeks. Patients were assessed by electromyography, Modified Ashworth Scale, and Ambulation Index. Electromyography was performed before and after the daily treatment of spastic muscles with transcutaneous electrical nerve stimulation in order to assess the effect on muscle relaxation. The Modified Ashworth Scale and Ambulation Index were used before and after 4 weeks' treatment. After 4 weeks of treatment, there were statistically significant reductions in spasticity of both extremities as assessed by myoelectric activity and the Modified Ashworth Scale (P < 0.05). Ambulation Index level was not improved significantly (P > 0.05).

Adult↗
PubMed2004

The use of hydrotherapy for the management of spasticity.

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

Activities of Daily Living↗
PubMed2006

Oral baclofen and clonidine for treatment of spasticity in children.

Few data exist in the literature to support the use of high dosages of oral baclofen and clonidine that are frequently required to treat children with spasticity. This study was a retrospective chart review of baclofen and clonidine dosages used in children diagnosed with cerebral palsy or traumatic brain injury. The primary objective was to calculate the mean dosages of baclofen and clonidine based on the duration of spasticity postinjury. Secondary objectives included determining correlations between dosage and age, injury type, location of spasticity, comorbid seizures, or concomitant antispasticity medications. Eighty-seven children receiving baclofen and/or clonidine were included in this study. Mean dosages of 40 mg/day (n = 86) and 0.4 mg/day (n = 31) were required for baclofen and clonidine, respectively. The maximum dosage was 240 mg/day for baclofen and 3.6 mg/day for clonidine. Duration postinjury, age, and concomitant antispasticity medications were the most predictive variables for baclofen dosage as a model (r = .522; P = .000). Duration postinjury and location of spasticity were the most predictive variables for clonidine dosage as a model (r = .523; P = .000). The average dosages of baclofen and clonidine used in this population of children with cerebral palsy or traumatic brain injury were similar to those reported in the literature, with higher maximum dosages found in this investigation.

Administration, Oral↗
PubMed2001

Quantifying associated reactions in the paretic arm in stroke and their relationship to spasticity.

OBJECTIVES: (1) To present a measurement protocol for assessing associated reactions (AR) in the paretic arm and (2) to use it to investigate the pattern of AR and its association with spasticity. SETTING: Inpatient rehabilitation unit. DESIGN: Associated reactions in 49 adults with stroke were measured in terms of force generated, electrical muscle activity and wrist movement in the paretic arm using hand dynamometry, surface electromyography and electrogoniometry respectively. Simultaneous recording of the effort used to elicit the associated reaction was made using a second hand dynamometer. The magnitude and persistence of AR was compared with the clinical assessment of spasticity (using the modified Ashworth Scale, MAS). RESULTS: There was poor correlation between peak AR and MAS, suggesting that AR are not confined to patients with severe spasticity. Co-activation of forearm flexors and extensors was evident during the AR. AR fluctuated during a single period of effort in some patients. Only 12 out of 31 patients who maintained uniform effort over the measurement period produced a uniform AR. AR often persisted for some time after effort had ceased. Eight were classified as minimal (median AR 0.23 N), 25 as mild (median AR 2.7 N), 11 as moderate (median AR 6.4 N) and 3 as severe (median AR 11.0 N). AR tended to persist in patients with higher MAS although this result was not statistically significant. CONCLUSION: The magnitude, profile and persistence of AR varied considerably between individuals. Associated reactions were present in people with minimal spasticity. As this technique allows the magnitude of AR to be quantified in relation to effort it has the potential to be a useful outcome measure in clinical trials evaluating the treatments (e.g. physiotherapy) directed at reducing associated reactions.

Activities of Daily Living↗
PubMed2002

Intramuscular neurolysis with alcohol to treat post-stroke finger flexor spasticity.

OBJECTIVE: To evaluate the effectiveness of intramuscular neurolysis with alcohol for the treatment of finger flexor spasticity in individuals with stroke. DESIGN: Case series. SETTING: Outpatient clinic of a tertiary rehabilitation facility. SUBJECTS: Thirty patients with a mean age of 60.2 years and post-stroke duration of 8.3 months with finger flexor spasticity. INTERVENTIONS: Intramuscular neurolysis or motor point blocks of the finger flexors of the hemiplegic upper extremity with 50% ethyl alcohol. MAIN OUTCOME MEASURES: The severity of spasticity as measured by the Modified Ashworth Scale (MAS) and the passive range of motion of the proximal interphalangeal joints of the second to fifth digits. RESULTS: The mean baseline MAS score was 4.0 +/- 0.5 and this improved to 2.0 +/- 0.6, 2.2 +/- 0.6 and 2.6 +/- 0.6 at four weeks, three months and six months post neurolysis respectively. The gains in range of motion were 18.5 +/- 6.7, 17.5 +/- 6.4 and 14.9 +/- 4.8 degrees at four weeks, three months and six months post neurolysis respectively. These improvements were statistically significant (p < 0.05). Two subjects developed temporary dysesthetic pain of the forearm and palm. CONCLUSION: Intramuscular neurolysis with alcohol provides good relief of finger flexor spasticity in hemiplegic individuals.

Ethanol↗
PubMed1998

Botulinum toxin type A and short-term electrical stimulation in the treatment of upper limb flexor spasticity after stroke: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To investigate whether the combined approach of botulinum toxin type A (BtxA) and electrical stimulation was more effective than the toxin alone in the treatment of chronic upper limb spasticity after stroke. DESIGN: Randomized, placebo-controlled study with four treatment groups: 1000 units BtxA (Dysport) + electrical stimulation (A), 1000 units BtxA (B), placebo + electrical stimulation (C) and placebo (D). SETTING: A neurological rehabilitation clinic. SUBJECTS: Twenty-four stroke patients with chronic upper limb spasticity after stroke, six patients in each treatment group. INTERVENTIONS: Intramuscular injection of either toxin or placebo into six upper imb flexor muscles. In group A and C additional electrical stimulation of the injected muscles with surface electrodes, three times half an hour each day for three days. MAIN OUTCOME MEASURES: Muscle tone rated with the modified Ashworth score, limb position at rest and difficulties encountered during three upper limb motor tasks assessed before and 2, 6 and 12 weeks after injection. RESULTS: Most improvements were observed in patients of group A. Cleaning the palm (p = 0.004) differed across groups. Pairwise comparison for this target variable showed that group A differed from group B and D (p <0.01), but not from C. Indicative across-group differences were obtained for elbow spasticity reduction (p = 0.011), and improvement of putting the arm through a sleeve (p = 0.020). CONCLUSIONS: The placebo-controlled trial favours the concept that electrical stimulation enhances the effectiveness of BtxA in the treatment of chronic upper limb flexor spasticity after stroke.

Activities of Daily Living↗
PubMed2002

Clinical effectiveness of oral treatments for spasticity in multiple sclerosis: a systematic review.

Spasticity is a common disabling feature of multiple sderosis. A variety of drugs are in regular use as oral treatment induding badofen, dantrolene, tizanidine, and diazepam. Published evidence of effectiveness is limited. Most trials are of small size, of short duration, and have not reported on functional outcomes. Studies have been published which suggest that badofen, tizanidine, and diazepam are all effective in reducing dinical measures of spasticity, but there is little evidence that they lead to an improvement in patient function. There is no evidence to suggest any difference in effectiveness between them. The evidence that dantrolene has any effect on spasticity is of poor quality. Diazepam and dantrolene are associated with more side effects than baclofen and tizanidine. There is evidence for the effectiveness of gabapentin in reducing spasticity and improving function in the short term, though longer-term studies are needed to establish its true value. One randomized controlled trial of threonine does not support its effectiveness.

Administration, Oral↗
PubMed1991

Reciprocal inhibition between forearm muscles in spastic hemiplegia.

We studied reciprocal inhibition of H-reflexes in the forearm flexor and extensor muscles in 14 patients with spastic hemiplegia secondary to a focal cerebral lesion and 14 normal volunteers. In the spastic limb, the Hmax/Mmax ratio was increased in both flexor and particularly extensor wrist muscles. The 3 normal inhibitory phases of reciprocal inhibition between extensor and flexor forearm muscles were markedly reduced on the spastic side of patients. The early disynaptic phase showed the greatest alteration. Reduced or absent inhibition between forearm muscles associated with increased spinal motoneuron excitability may be typical to spastic hemiplegia.

Brain Diseases↗
PubMed1995

Botulinum toxin A for spasticity, muscle spasms, and rigidity.

We studied the effects of botulinum toxin A in 12 patients with spasticity and in eight patients with rigidity. The study design was a double-blind, placebo-controlled crossover trial with botulinum toxin A versus saline. Using the Ashworth Scale for spasticity and the Unified Parkinson's Disease Rating Scale for rigidity, we gave the patients a tone grade before and 2 weeks after treatment. Improvement in tone by two grades or more was considered clinically significant. In the spasticity group, botulinum toxin A reduced the tone of all patients significantly, improved functionality and nursing care in eight of 12 patients, and alleviated painful spasms in five of five patients. In the rigidity group, muscle tone was decreased in seven of eight patients, functionality improved in four of seven, and joint and muscle pain decreased in four of five. We conclude that botulinum toxin A is effective against the disabling effects of spasticity and rigidity. The treatment was well tolerated.

Adolescent↗
PubMed1996

Botulinum toxin type A in the treatment of upper extremity spasticity: a randomized, double-blind, placebo-controlled trial.

Spasticity is a disorder of excess muscle tone associated with CNS disease. We hypothesized that botulinum toxin, a neuromuscular blocking agent, would reduce tone in spastic muscles after stroke. This randomized, double-blind, placebo-controlled, multicenter clinical trial evaluated the safety and efficacy of botulinum toxin type A (BTXA) in the treatment of chronic upper limb spasticity after stroke. Thirty-nine patients received IM injections of a total dose of either 75, 150, or 300 units of BTXA or placebo into the biceps, flexor carpi radialis, and flexor carpi ulnaris muscles. At baseline, patients demonstrated a mean wrist flexor tone of 2.9 and elbow flexor tone of 2.6 on the Ashworth Scale (0 to 4). Treatment with the 300-unit BTXA dose resulted in a statistically and clinically significant mean decrease in wrist flexor tone of 1.2 (p = 0.028), 1.1 (p = 0.044), and 1.2 (p = 0.026) points and elbow flexor tone of 1.2 (p = 0.024), 1.2 (p = 0.028), and 1.1 (p = 0.199) at weeks 2, 4, and 6 postinjection. In the placebo group, tone reduction at the wrist was 0.3, 0.2, and 0.0 and at the elbow was 0.3, 0.3, and 0.6 at weeks 2, 4, and 6 postinjection. BTXA groups reported significant improvement on the physician and patient Global Assessment of Response to Treatment at weeks 4 and 6 postinjection. There were no serious adverse effects. In this 3-month study, BTXA safely reduced upper extremity muscle tone in patients with chronic spasticity after stroke.

Adult↗
PubMed1985

Control of spasticity by implantable continuous flow morphine pump.

Continuous flow pumps are being used for the delivery of morphine sulfate to the intrathecal and epidural space for control of pain. We have encountered several patients who had a combination of pain and spasticity or who had spasticity so intense that it was the source of pain. One to two milligrams of intrathecal morphine dramatically relieved their spasticity and pain. Three such patients have subsequently undergone pump implantation with prolonged control of their spasticity. This has initiated a formal clinical investigation directed at determining the physiological mechanism of this phenomenon, as well as its long term efficacy.

Adult↗
PubMed1982

Respiratory distress after recurrent laryngeal nerve sectioning for adductor spastic dysphonia.

Adductor spastic dysphonia is a voice sign associated with various neurologic and psychologic disorders. Treatment of spastic dysphonia in selected patients is unilateral recurrent laryngeal nerve sectioning. Except for voice change or, in some patients, return of phonatory spasticity, there have been no long-term sequelae or complications of this treatment. We describe three patients with adductor spastic dysphonia who underwent recurrent laryngeal nerve sectioning and who, 3 to 38 months later, suffered respiratory distress that required tracheostomy. The respiratory distress in all three patients was due to episodic jerky vocal cord hyperadductions that caused stridor during inspiration and expiration. These repetitive laryngospasms during respiration and phonation were progressive. Two patients needed an arytenoidectomy to achieve a useful voice, and all three required a permanent tracheostomy to alleviate inspiratory laryngeal obstruction.

Aged↗
PubMed1977

Dantrolene sodium: a review of its pharmacological properties and therapeutic efficacy in spasticity.

Dantrolene sodium or dantrolene1 is 1([5-(nitrophenyl)furfurylidend] amino) hydantoin sodium hydrate. It is indicated for use in chronic disorders characterised by skeletal muscle spasticity, such as spinal cord injury, stroke, cerebral palsy and multiple sclerosis. Dantrolene is believed to act directly on the contractile mechanism of skeletal muscle to decrease the force of contraction in the absence of any demonstrated effects on neural pathways, on the neuromuscular junction, or on the excitable properties of the muscle fibre membranes. Controlled trials have demonstrated that dantrolene is superior to placebo in adults or children with spasticity from various causes, as evidenced by clinical assessments of disability and daily activities, and by muscle and reflex responses to mechanical and electrical stimulation. It is somewhat less effective in patients with multiple sclerosis than in those with spasticity from other causes. There has been a general clinical impression in controlled trials that dantrolene caused less sedation than would have been expected from therapeutically comparable doses of diazepam. In 2 controlled trials, there was no significant difference between dantrolene and diazepam in terms of reductions in spasticity, clonus, and hyperreflexia, but side-effects such as drowsiness and inco-ordination occurred significantly more frequently on diazepam. Long-term studies have indicated continuing benefit for patients taking dantrolene, though the incidence of side-effects has often been high and there has been a suggestion of exacerbation of seizures in children with cerebral palsy. Dantrolene may be of value in the medical treatment of spasm of the external urethral sphincter due to neurological and non-neurological disease, and animal studies suggest a potential use in the management of malignant hyperpyrexia. Chemical evidence of liver dysfunction may occur in 0.7 to 1% of patients on long-term treatment with dantrolene, with symptomatic hepatitis in 0.35 to 0.5% and fatal hepatitis in 0.1 to 0.2%. The drug commonly causes transient drowsiness, dizziness, weakness, general malaise, fatigue and diarrhoea at the start of therapy. Muscle weakness may be the principal limiting side-effect in ambulant patients, particularly in those with multiple sclerosis, and therapy could be hazardous in patients with pre-existing bulbar or respiratory weakness. The dosage of dantrolene has been fixed in most controlled trials, though long-term studies have indicated the need for individualisation of dosage. The initial dose is usually 25mg once daily, increasing to 25mg two, three or four times daily, and then by increments of 25mg up to as high as 100mg two, three or four times daily. The lowest dose compatible with optimal response is recommended.

Adult↗
PubMed1986

Dantrolene. A review of its pharmacodynamic and pharmacokinetic properties and therapeutic use in malignant hyperthermia, the neuroleptic malignant syndrome and an update of its use in muscle spasticity.

Dantrolene sodium acts primarily by affecting calcium flux across the sarcoplasmic reticulum of skeletal muscle. Recently, dantrolene has been used very successfully in the treatment of several rare hypercatabolic syndromes which have previously been associated with high mortality rates. In malignant hyperthermia, where early diagnosis and treatment usually with intravenous dantrolene in association with other supportive measures (and often subsequent dantrolene therapy) is performed, recovery is seen in virtually 100% of patients. There is a rapid resolution of hyperthermia, dysrhythmias, muscle rigidity, tachycardia, hypercapnia, mottled or cyanotic skin, and metabolic acidosis, and a slower normalisation of myoglobinuria and elevated serum creatine phosphokinase levels. In patients with family history or previous episodes of malignant hyperthermia, prophylactic treatment with dantrolene prior to anaesthesia prevents the syndrome occurring in most cases. Where malignant hyperthermia has developed patients have been successfully treated with further dantrolene therapy. Dantrolene has also been used successfully in the treatment of a few cases of heat stroke and the neuroleptic malignant syndrome--both of which have many similarities to malignant hyperthermia. Dantrolene is well established in the treatment of patients with muscle spasticity where it generally improves at least some of the components of spasticity (i.e. hyper/hypotonia, clonus, muscle cramps and spasms, resistance to stretch and flexor reflexes, articular movement, neurological and motor functions and urinary control). However, in some patients, particularly those with multiple sclerosis, dantrolene may not be effective, and in many cases muscular strength may diminish. Long term dantrolene therapy has been associated with hepatic toxicity and may cause problems in patients treated for disorders of muscle spasticity. Thus, dantrolene offers a unique advance in the therapy available for the treatment of hypercatabolic disorders and is also useful in the treatment of muscle spasticity of various aetiology.

Animals↗
PubMed1984

Effect of electrical stimulation on spasticity in hemiparetic patients.

Cyclical electrical stimulation has been applied to 10 hemiparetic patients with clinical signs of knee joint spasticity. The programme included 30 minutes of stimulation to the hamstrings followed by another 30 minutes of stimulation to the hamstrings and quadriceps. None of the patients experienced increased spasticity. The reduction in spasticity ranged from none to substantial with some other beneficial side-effects. No conclusions could be drawn as to whether hamstring stimulation is preferred to combined stimulation or to quadriceps stimulation alone. It is suggested that small portable stimulators be introduced for chronic use in spastic patients after an optimum stimulation regimen is individually established for each patient.

Adolescent↗
PubMed1998

A study of the effectiveness of botulinum toxin type A (Dysport) in the management of muscle spasticity.

Severe muscle spasticity is common in patients with neurological disease. It is often associated with pain and distressing spasms, and frequently leads to functional motor disability. Antispasticity drugs usually result in systemic adverse effects, and peripheral nerve blocks have some disadvantages such as sensory loss and painful dysaesthesiae. In recent years botulinum toxin type A (BT/A) has been advocated for the treatment of muscle spasticity. We studied, using a functional assessment scale, the effects of BT/A on the patients' symptoms and the functional disability due to spasticity in five children and eight adults who were referred for treatment. In 10 patients the treatment goals were achieved, and children generally had a better and more sustained response than adults. There were no adverse effects reported. The present study suggests that BT/A is safe and effective in improving the motor functional disability which is often associated with severe localized muscle spasticity.

Adolescent↗