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PubMed2003

Use of botulinum toxin type A and type B for spasticity in upper and lower limbs.

BT is likely effective in controlling spasticity in the smaller muscles of the arm and hand, although there has been only one large controlled trial. For lower limb spasticity, the outcomes are more mixed. No large randomized, controlled trials have been done, and the larger size of the muscles results in a decreased ability to treat widespread spasticity. For more focal treatment in the legs and feet, however, and when combined with other denervating agents or physical modalities, BT is probably effective. Careful analysis is warranted before performing any chemodenervation on a limb muscle or muscles.

Anti-Dyskinesia Agents↗
PubMed2001

Safety profile and efficacy of botulinum toxin A (Dysport) in children with muscle spasticity.

Botulinum toxin A (BTX-A) is widely used in the management of muscle spasticity in children. However, at present the dose of BTX-A for a given patient is selected empirically. The aim of this study is to provide dosage guidelines that are based on risk/benefit assessment. This was a multicentre retrospective study of the safety profile and efficacy of BTX-A in children with chronic muscle spasticity. Data in 758 patients who received a total of 1594 treatments were analysed (mean age 7.2 years; 429 males, 329 females). Spastic cerebral palsy (CP) was the most common diagnosis (94% of the study sample). Of all treatments 7% resulted in adverse events; incidence was related to the total dose rather than the dose calculated on the basis of body weight. The highest incidence of adverse events was observed in patients who received >1000 IU of BTX-A per treatment session. The odds of an adverse event was 5.1 times greater for this group of patients than for those who had 250 IU or less (p<0.001). A good overall response to treatment was reported in 82% and treatment goals were fully or partially achieved in 3% and 94% of participants respectively. More patients in the highest dose group reported functional deterioration. Interestingly, multilevel treatments resulted in a better response than single-level treatments (odds ratio 1.7, 95% CI 1.3 to 2.2,p=0.001).

Age Factors↗
PubMed2006

Neuromuscular electrical stimulation and dynamic bracing for the management of upper-extremity spasticity in children with cerebral palsy.

A prospective study was designed to determine whether the combined use of neuromuscular electrical stimulation (NMES) and dynamic bracing was more effective than use of either alone in reducing upper-extremity spasticity in children with spastic hemiplegic cerebral palsy. Twenty-four patients (12 males, 12 females; mean age 8y 7mo [SD 4y 2mo]; age range 3-18y) diagnosed with spastic hemiplegic CP were randomly allocated to three groups: group 1 had two 30-minute sessions of NMES a day applied on the antagonist extensors without bracing; group 2 had two 30-minute sessions of dynamic bracing per day; and group 3 had two 30-minute sessions of NMES and dynamic bracing every day. Treatment was continued for 6 months in all groups and applied only to the affected extremity. Patients were evaluated before therapy, at monthly intervals during the therapy, and 3 months after completion of the therapy. Three measures of outcome were taken: the Melbourne Assessment, grip strength, and posture evaluation with Zancolli's classification. The therapist performing the outcome assessments was blinded as to groups. Statistically significant differences were found in all three measures for only those treated with combined NMES and dynamic bracing. However, this significant effect lasted for only 2 months after discontinuation of the treatment. We conclude that the combined use of NMES and bracing is more effective than either alone but requires continuous application.

Adolescent↗
PubMed1987

Treatment of spasticity with tizanidine in multiple sclerosis.

Spasticity is a frequent and often disabling symptom in MS patients. Current drugs used as antispastic agents include Dantrolene Sodium, Baclofen and Diazepam. Tizanidine (5-chloro-4-(2imidazolin-2 yl amino)-2,1,3-benzothialdiazole) is a new antispasticity agent that has purported central action. A double blind placebo controlled trial was performed to study the efficacy of this drug in MS patients. Sixty-six patients entered an eight week therapeutic trial and fifty-nine completed the trial. Patients were assessed at 0, 2, 3 and 8 weeks of therapy for clinical effects. Electrophysiologic tests were performed at 0 and 8 weeks. A statistically significant benefit was noted in spastic muscle groups in the legs with concomitant significant reduction in hyperactive stretch reflexes and ankle clonus. Side effects most frequently cited included dry mouth and drowsiness. Two patients developed elevated liver function test that decreased with cessation of therapy. Other clinical details, side effects and electrophysiologic data will be presented. Tizanidine appears to reduce clinical spasticity and hyperreflexia in MS patients although no change in functional status was detected. Tizanidine may well serve as an alternate antispastic agent, alone or in combination with other agents.

Adolescent↗
PubMed1995

Long-term intrathecal baclofen therapy in patients with intractable spasticity.

BACKGROUND: Severe spasticity unresponsive to oral drugs may respond satisfactorily to baclofen delivered intrathecally. METHODS: Intrathecal baclofen (IB) therapy delivered by means of implanted infusion pumps was used for nine patients with severe spasticity. Six patients had multiple sclerosis, two cervical spinal cord injury, and one head injury. All were non-ambulatory. RESULTS: Patients showed improvement in many areas, including ability to transfer, seating, pain control, personal care, and liability to skin breakdown. Before IB therapy, only three of the nine patients were able to live at home in the community and six were institutionalized. At the end of our follow-up period, only one patient remained institutionalized, three lived in group homes and five lived at home in the community. In the year preceding pump implantation, the nine patients spent a total of 755 days in acute care hospitals. In the year following onset of IB therapy, they spent only 259 days in hospital. CONCLUSIONS: IB therapy can improve patient quality of life and can be cost-effective in carefully selected patients with severe spasticity and disability. The drug delivery catheter is that part of the therapeutic system most vulnerable to failure. Because of the varied expertise required to manage these patients effectively, and the potential for a variety of complications, it is essential that an IB program is supported by a well-organized multi-disciplinary medical team.

Adult↗
PubMed2000

Effect of baclofen on gait in spastic MS patients.

OBJECTIVES: To measure gait and postural stability by objective methods in spastic MS patients and to evaluate the effect of baclofen on gait and postural stability. PATIENTS AND METHODS: Fourteen spastic MS patients were examined in a placebo controlled double-blind, cross-over trial of oral baclofen treatment. The gait was measured on a computerized treadmill and postural stability was measured on a computer assisted force-plate. RESULTS: Only insignificant improvements in the clinical measurements during baclofen treatment were found. At baseline gait was characterized by low speed, short steps and unsteadiness. Postural stability was severely impaired. During baclofen treatment only vertical unsteadiness of gait diminished significantly. DISCUSSION: We conclude that patients primarily with spasticity, concomitant with hampering or painful spasms and co-contractions should be offered treatment with baclofen. Only some will experience improvement of their gait disorders, when treated with baclofen.

Adult↗
PubMed2000

Neurological and neuroradiological progression in hereditary spastic paraplegia with a thin corpus callosum.

We followed-up a Japanese man suffering from hereditary spastic paraplegia with a thin corpus callosum (HSP-TCC) by single photon emission computed tomography (SPECT) using 123IN-isopropyl-piodoamphetamine (123I-IMP) over 4 years (25 to 29 years old). Besides the initial symptoms of lower limb spasticity, mental deterioration slightly progressed and upper limb spasticity and slight cerebellar ataxia were developed, during the period. Cranial magnetic resonance imaging (MRI) revealed an extremely thin corpus callosum and medial frontal atrophy, which remained essentially unchanged during the period. 123I-IMP SPECT demonstrated that cerebral blood flow was decreased in the thalamus and the medial frontal, temporal and parietal cortices at the first examination, and that the thalamus showed further reduction but the other involved regions presented essentially no progression during the follow-up period. This is the first report referring to the longitudinal clinical and neuroradiological changes in HSP-TCC.

Adult↗
PubMed2002

Hereditary spastic paraplegia with thin corpus callosum and cataract: a clinical description of two siblings.

We report two siblings with autosomal recessive hereditary spastic paraplegia and thin corpus callosum. These patients had a similar history of progressive spastic gait, followed by mental impairment in the second decade. In addition to rigospasticity, ataxia, and foot deformity, both patients had congenital cataract on ophthalmologic examination. The association of cataract and thin corpus callosum suggests a distinct genetic disorder involving these structures in complicated spastic paraplegia.

Abnormalities, Multiple↗
PubMed1982

Percutaneous embolisation of major spinal cord artery as a treatment for intractable spasticity.

Based on the angiographic findings of the injured spinal cord percutaneous embolisation of Adamkiewicz's artery was carried out to control intractable spasticity in ten cases of late stage spinal cord paralysis. The purpose of this procedure was to interrupt the reflex arcs of the lower extremities by decreasing the blood supply to the lumbar enlargement. Results were excellent in two cases, good in five and poor in three. Major effects were found in adduction and flexion spasticity of the hip joints and bladder function was always preserved in these patients. It is speculated that occlusion of Adamkiewicz's artery mainly affected the lower thoracic and the upper lumbar segments. Anastomosis between the anterior spinal artery and the two posterior spinal arteries might have provided sufficient collateral blood circulation to the conus level. It is emphasised that the percutaneous embolisation of Adamkiewicz's artery reduced the intractable spasticity of the lower extremities without changes in the voiding function of the automatic bladder.

Adult↗
PubMed1987

Clinical and electromyographic evaluation of obturator neurectomy in severe spasticity.

Obturator neurectomy was performed in 35 patients with severe spasticity of the lower limbs. Immediate release of excessive spasticity in the adductor group of muscles was observed and confirmed by E.M.G. In most cases, a beneficial reduction of spasticity in other groups of muscles in the lower limbs was also observed. As a result, rehabilitation of the patients was improved.

Electromyography↗
PubMed1991

Continuous infusion of intrathecal baclofen: long-term effects on spasticity in spinal cord injury.

The effects of intrathecal baclofen infusion were studied in 9 spinal cord injury patients whose spasticity had been refractory to oral medications. In a two stage, placebo controlled trial, baclofen was administered into the lumbar intrathecal space and subsequent clinical and neurophysiologic changes were assessed. In stage 1, 9 patients underwent a 5 day percutaneous infusion of baclofen and placebo via an external pump. Ashworth and reflex scores were assessed at time of enrollment, after infusion of that amount of baclofen which provided optimal spasticity control and after intrathecal infusion of placebo. The mean Ashworth grade decreased from 3.78 +/- 1.34 to 1.16 +/- 0.48 (p less than 0.001) while mean reflex score decreased from 3.57 +/- 1.05 to 0.64 +/- 0.87 (p less than 0.001). These values differed significantly from those associated with placebo therapy (Ashworth grade--2.54 +/- 1.04, p less than 0.001; reflex score--2.56 +/- 1.04, p less than 0.01). Objective improvements in functional abilities and independence were noted in 8 patients, while somatosensory and brainstem auditory evoked potentials were unchanged in all patients. Urodynamic evaluation revealed increased bladder capacity in 3 patients, while in 4 no change was observed. In Stage 2, permanent programmable infusion pumps were implanted in 7 patients who demonstrated a good response during Stage 1. In this group, mean Ashworth score decreased from 3.79 +/- 0.69 to 2 +/- 0.96 (p less than 0.001) and mean reflex score decreased from 3.85 +/- 0.62 to 2.18 +/- 0.43 (p less than 0.001). Baclofen dosage increased from 182 +/- 135 to 528 +/- 266 mcg/day over the 3-22 month follow-up period. Most of the dosage increase occurred within the initial 12 months following infusion pump implantation and tended to plateau thereafter. Minor complications such as catheter dislodgement/kinking and nausea occurred infrequently while no device related infections were observed. There was no clinical evidence of any significant baclofen neurotoxicity either in Stage 1 or 2. The only ambulatory patient developed marked lower extremity weakness during Stage 1 intrathecal baclofen infusion and was temporarily unable to walk. We conclude that continuous administration of intrathecal baclofen is an effective and safe modality for spasticity control in patients who are refractory to oral medications.

Administration, Cutaneous↗
PubMed1996

The inter rater reliability of the original and of the modified Ashworth scale for the assessment of spasticity in patients with spinal cord injury.

Thirty patients with spinal cord injury (SCI) were randomly selected to participate in this study which evaluated the inter rater reliability of the original and of the modified Ashworth scale for the assessment of spasticity in the lower limbs. A doctor and a physiotherapist rated the muscle tone of hip adductors, hip extensors, hip flexors and ankle plantarflexors according to the original and to the modified Ashworth scale. The results were analyzed using a Cohen's Kappa statistical test and showed varying levels of reliability for different muscle groups and limbs. Kappa values ranged between 0.21 and 0.61 (mean 0.37). The original scale was slightly more reliable than was the modified scale. However, this difference was not significant (P > 0.05), and was not consistent between the two limbs and between different muscle groups. It was concluded that the Ashworth scale is of limited use in the assessment of spasticity in the lower limb of patients with SCI. Further work is required to establish a standardised speed of muscle stretching during the test, or to find more appropriate grades and descriptions of spasticity for this patient group. The effects of training of the raters in the use of the scales also warrants further investigation.

Adolescent↗
PubMed1999

Isokinetic assessment of spasticity in subjects with traumatic spinal cord injury (ASIA A).

OBJECTIVE: To assess resistance to passive isokinetic movements at specified speeds and range of motion, as a measure of muscular tonus. METHODS: A group of 12 subjects with complete traumatic spinal cord injury and a group of 12 able-bodied subjects were analysed, distinguishing the level of spasticity in the SCI group. Maximum eccentric peak torque was observed in passive isokinetic flexion (F) and extension (E) knee movement in displacements of 30, 60 and 120 per second. RESULTS: The Student t-test showed that the average torque in the injured group was significantly higher than in the control group (F= 120 degrees per second, P<0.001). Variance analysis showed that the lower level presented lower torque levels (E=60 and 120 degrees per second, P<0.032), while those in the higher level presented higher torque levels (F and E=60 and 120 per second, P<0.032) when compared to the control group. In the control group the Student t-test (P<0.0006) showed a significantly different muscle behavior (Flexion>Extension Torque). CONCLUSION: By using isokinetic assessment it was possible to quantify hypertonic spasticity in a group of subjects with spinal cord injury, distinguishing groups with higher and lower levels of spasticity as compared to a control group.

Adolescent↗
PubMed2000

Spastic movement disorder.

This review deals with the neuronal mechanisms underlying spastic movement disorder, assessed by electrophysiological means with the aim of first, a better understanding of the underlying pathophysiology and second, the selection of an adequate treatment. For the patient usually one of the first symptoms of a lesion within the central motor system represents the movement disorder, which is most characteristic during locomotion in patients with spasticity. The clinical examination reveals exaggerated tendon tap reflexes and increased muscle tone typical of the spastic movement disorder. However, today we know that there exists only a weak relationship between the physical signs obtained during the clinical examination in a passive motor condition and the impaired neuronal mechanisms being in operation during an active movement. By the recording and analysis of electrophysiological and biomechanical parameters during a functional movement such as locomotion, the significance of, for example, impaired reflex behaviour or pathophysiology of muscle tone and its contribution to the movement disorder can reliably be assessed. Consequently, an adequate treatment should not be restricted to the cosmetic therapy and correction of an isolated clinical parameter but should be based on the pathophysiology and significance of the mechanisms underlying the disorder of functional movement which impairs the patient.

Humans↗
PubMed2000

Epidural electrical stimulation of posterior structures of the human lumbosacral cord: 3. Control Of spasticity.

OBJECTIVES: The purpose of this study was to evaluate the effect of spinal cord stimulation (SCS) on severe spasticity of the lower limbs in patients with traumatic spinal cord injury (SCI) under close scrutiny of the site and parameters of stimulation. MATERIALS AND METHODS: Eight SCI patients (four women, four men) were included in the study. Levels of spasticity before and during stimulation were compared according to a clinical rating scale and by surface electrode polyelectromyography (pEMG) during passive flexion and extension of the knee, supplemented by a pendulum test with the stimulating device switched either on or off over an appropriate period. RESULTS: Both the clinical and the experimental parameters clearly demonstrated that SCS, when correctly handled, is a highly effective approach to controlling spasticity in spinal cord injury subjects. The success of this type of treatment hinges on four factors: (1) the epidural electrode must be located over the upper lumbar cord segment (L1, L2, L3); (2) the train frequency of stimulation must be in the range of 50 - 100 Hz, the amplitude within 2 - 7 V and the stimulus width of 210 micross; (3) the stimulus parameters must be optimized by clinically assessing the effect of arbitrary combinations of the four contacts of the quadripolar electrode; and (4) amplitudes of stimulation must be adjusted to different body positions. CONCLUSIONS: Severe muscle hypertonia affecting the lower extremities of patients with chronic spinal cord injuries can be effectively suppressed via stimulation of the upper lumbar cord segment.

Adolescent↗
PubMed2006

The treatment of spasticity with Delta9-tetrahydrocannabinol in persons with spinal cord injury.

STUDY DESIGN: Open label study to determine drug dose for a randomized double-blind placebo-controlled parallel study. OBJECTIVES: To assess the efficacy and side effects of oral Delta(9)-tetrahydrocannabinol (THC) and rectal THC-hemisuccinate (THC-HS) in SCI patients. SETTING: REHAB Basel, Switzerland. METHOD: Twenty-five patients with SCI were included in this three-phase study with individual dose adjustment, each consisting of 6 weeks. Twenty-two participants received oral THC open label starting with a single dose of 10 mg (Phase 1, completed by 15 patients). Eight subjects received rectal THC-HS (Phase 2, completed by seven patients). In Phase 3, six patients were treated with oral THC and seven with placebo. Major outcome parameters were the spasticity sum score (SSS) using the Modified Ashworth Scale (MAS) and self-ratings of spasticity. RESULTS: Mean daily doses were 31 mg with THC and 43 mg with THC-HS. Mean SSS for THC decreased significantly from 16.72 (+/-7.60) at baseline to 8.92 (+/-7.14) on day 43. Similar improvement was seen with THC-HS. We observed a significant improvement of SSS with active drug (P=0.001) in the seven subjects who received oral THC in Phase 1 and placebo in Phase 3. Major reasons for drop out were increase of pain and psychological side effects. CONCLUSION: THC is an effective and safe drug in the treatment of spasticity. At least 15-20 mg per day were needed to achieve a therapeutic effect.

Administration, Oral↗
PubMed1985

Intrinsic laryngeal muscle activity in a spastic dysphonia patient.

EMG activity from four intrinsic laryngeal muscles (thyroarytenoid, posterior cricoarytenoid, interarytenoid, and cricothyroid) was obtained from one female spastic dysphonia patient while she performed a variety of speech and nonspeech tasks. These tasks were performed before and during a period of temporary unilateral laryngeal muscle paralysis. In the nonparalyzed condition, adductory muscle activity showed intermittent sudden increases that coincided with momentary voice arrests. These muscle patterns and accompanying voice interruptions were not present either when speech was produced in falsetto register or at anytime during the paralysis condition. The data suggest that individuals with this type of spastic dysphonia have normal morphology of recurrent laryngeal nerves and intrinsic laryngeal muscles, which means that the triggering mechanism(s) for spastic dysphonia symptoms must be located at some point neurologically upstream from the larynx.

Combined Modality Therapy↗
PubMedDate not supplied

Rehabilitation of spasticity and related problems in childhood cerebral palsy.

Spasticity is one part of the upper motor neuron syndrome, but it is a widespread problem in cerebral palsy; it is debilitating, affects function and can lead to musculoskeletal complications. Significant advances have occurred in antispasticity management (and related musculoskeletal problems) in children with cerebral palsy during the past 5-10 years. Botulinum toxin A has been the most outstanding treatment advance; it is relatively long-lasting, easy to administer, reversible, has a favourable side-effect profile and is highly useful for focal spasticity. There is an emerging role for intrathecal baclofen in Australia. Despite being available and practised in North America for years, selective dorsal rhizotomy has not been popular in Australia. The use of orthopaedic surgery has significantly altered in recent years. There is still a place for oral drug treatment, including some newer agents and the potential for combination treatment with other modalities. The role of physical therapy in defining disability, assessing function, undertaking biomechanical assessment and providing mobility aids/casting/orthoses and motor training/stretching exercises is critical for the success of medical and surgical interventions. From an Australian perspective, the purpose of the present review is to provide a critical review of therapies available for spasticity associated with childhood cerebral palsy.

Administration, Oral↗