Characterizing the Experience of Spasticity after Spinal Cord Injury: A National Survey Project of the Spinal Cord Injury Model Systems Centers

ObjectiveTo characterize the qualities that individuals with spinal cord injury (SCI) associate with their experience of spasticity and to describe the relationship between spasticity and perceived quality of life and the perceived value of spasticity management approaches.DesignOnline cross-sectional survey.SettingMulticenter collaboration among 6 Spinal Cord Injury Model Systems hospitals in the United States.ParticipantsIndividuals with SCI (N=1076).InterventionsNot applicable.Main Outcome MeasuresQualities of Spasticity Questionnaire, modified Spinal Cord Injury–Spasticity Evaluation Tool (mSCI-SET), and the modified Patient-Reported Impact of Spasticity Measure (mPRISM).ResultsRespondents indicated that spasms most often occurred in response to movement-related triggering events. However, spontaneous spasms (ie, no triggering event) were also reported to be among the most common types. Frequency of spasms appears to decline with age. The highest frequency of spasms was reported by 56% of respondents aged <25 years and by only 28% of those >55 years. Stiffness associated with spasticity was reported to be more common than spasms (legs, 65% vs 54%; trunk, 33% vs 18%; arms, 26% vs 15%). Respondents reported negative effects of spasticity more commonly than positive effects. Based on their association with negative scores on the mSCI-SET and the mPRISM, the 5 most problematic experiences reported were stiffness all day, interference with sleep, painful spasms, perceived link between spasticity and pain, and intensification of pain before a spasm. Respondents indicated spasticity was improved more by stretching (48%) and exercise (45%) than by antispasmodics (38%).ConclusionsThe experience of spasticity after SCI is complex and multidimensional, with consequences that affect mobility, sleep, comfort, and quality of life. Stiffness, rather than spasms, appears to be the most problematic characteristic of spasticity. Physical therapeutic interventions to treat spasticity warrant in-depth investigation.     

Use of intrathecal baclofen in a pediatric cerebral palsy patient with refractory hemiplegia to maintain orthopaedic surgery gains

Spasticity, a common symptom accompanying cerebral palsy (CP), can severely affect patients' function and cause disability in childhood. Intrathecal baclofen (ITB) therapy is a widely used treatment to reduce spasticity in quadriparetic CP patients. Likewise, adults sustaining strokes and subsequent spastic hemiplegic have proven excellent candidates as well from ITB therapy. However, data on ITB treatment in pediatric patients with hemiplegic CP are lacking. This is the first report to present such a case. A nine-year old girl with spastic hemiplegic CP failed chemical denervation and serial casting of lower extremity spasticity and an associated equinovarus contracture. An ITB bolus test revealed an improvement in her Ashworth score from a mean of 2.8 to 1.2 on the involved side, whereas the unaffected side stayed constant from a mean of 1.3 to 1.2. The patient was subsequently treated with continuous ITB with improvement of Ashworth scores from a mean of 2.8 at baseline to 1.1 at 17 months after implantation of the ITB pump. Subsequent surgery was performed to correct the residual ankle deformity resulting in improvements in passive range of motion, gait function and brace tolerance. Hemiplegic CP pediatric patients can be successfully treated with ITB to reduce spasticity, improve function, and retain postoperative surgical correction without affecting the normal side.     

Onset,time course and prediction of spasticity after stroke or traumatic brain injury

ObjectiveTo describe spasticity from the onset of acquired brain injury, time course over the first year and factors associated with prediction of the development of spasticity.MethodsRecent relevant literature known to the authors, along with a complementary search yielding a total of 9 articles, represented the base for this scoping review.ResultsSpasticity can be seen in the first week after brain injury and is more common in the upper than lower extremity. The severity of upper-limb impairment is a major factor in the development of spasticity during the first year after stroke. The prevalence of severe spasticity seems to increase during the first year. The combination of reduced arm motor function and spasticity in an early phase (4 weeks post-stroke) is an important predictor of the development of severe spasticity after 12 months. Spontaneous reduction in spasticity was seldom reported but may occur, especially in mild forms of spasticity.ConclusionSigns of spasticity can often be noted within the first 4 weeks after brain injury and is more common in the upper than lower extremity. Impaired sensorimotor function is a predictor. These findings highlight the importance to follow up patients with increased risk of developing severe spasticity to be able to start adequate spasticity treatment and prevent the negative consequences of spasticity. Understanding spasticity onset and progression also provides a basis for the development of effective therapies.     

Spasticity in head trauma and CVA patients: etiology and management

Spasticity is a common problem in patients following head trauma and cerebral vascular accident (CVA). Spasticity interferes with mobility and self-care activities which are critical for successful rehabilitative outcomes. While a patient with a spastic muscle about a joint may be able to voluntarily contract the muscle, relaxation of the muscle may be impossible. Severe spasticity can result in joint contractures which further impair function. Shearing movements due to spastic responses precipitate skin breakdown and may disrupt pressure sore repair. In addition, the inability to perform functional activities produces frustration and anxiety for patients and their significant others. The purpose of this article is to review the pathophysiologic basis of spasticity, outline treatment methods used to decrease spasticity, and suggest clinical management strategies for the nurse working with head trauma and CVA patients who exhibit spasticity.     

Increased spasticity in a chronic spinal cord injury patient after scabies infestation: A case report

Spasticity is a common feature of spinal cord injury (SCI). Spasticity exacerbation is commonly encountered with nociceptive and exteroceptive stimuli including bladder and bowel dysfunction, pressure sores, contracture, tight-fitting leg bags and clothing, and ingrown toenail. This report describes a patient with chronic SCI (T4 level) who complained of increasing spasticity of bilateral lower extremities for 5 weeks. He also had skin lesions on different parts of his body, accompanied by itching above the spinal cord lesion level. A clinical diagnosis of scabies was made and pharmacologic treatment was initiated. Following treatment, spasticity was significantly reduced and the skin rash with itching faded out. This report is the first of scabies skin infestation lesions triggering exacerbation of spasticity in an SCI patient.     

脊髓损伤后肌痉挛机制与治疗

肌痉挛是脊髓损伤所致截瘫患者中常见并发症之一。痉挛常可导致患者肢体酸胀疼痛、关节挛缩、畸形，进而影响行走及在轮椅上保持姿势的能力，并增加异位骨化和骨折的发生率，从而严重影响患者日常生活及康复治疗效果。目前痉挛的治疗方法很多，如药物治疗、运动疗法和物理治疗、神经阻滞疗法、手术治疗等。但单一的治疗方法效果往往不理想，故目前联合应用多种方法来治疗肌痉挛在临床上较受欢迎。本文通过复习文献，就脊髓损伤后肌痉挛的发生机制、症状特点、评定方法进行简要介绍，并针对其临床治疗进行讨论。     

Spasticity after traumatic spinal cord injury: nature, severity, and location

OBJECTIVE: To assess spasticity in a prevalence population of persons with traumatic spinal cord injury (SCI), and determine the degree of correspondence between self-reported spasticity and investigator-elicited spasticity using the modified Ashworth scale. DESIGN: Survey of a near total (88%) prevalence population. SETTING: Outpatient clinic of a university hospital. PATIENTS: A total of 354 individuals with SCI. MAIN OUTCOME MEASURES: The survey includes self-reported symptoms, neurologic examination (American Spinal Injury Association [ASIA] classification), physical therapy examination, range of motion (ROM), and complications. RESULTS: Presence of problematic spasticity was significantly correlated with cervical incomplete (ASIA B-D) injury. Reports of beneficial effects of spasticity were significantly less common in women. Self-reported problematic spasticity was significantly correlated with extensor spasticity. Spasticity was elicitable by movement provocation in 60% of the patients reporting spasticity. Significant correlations were found between elicitable spasticity and limited ROM. CONCLUSION: Flexion, extension, and abduction movements performed with the patient placed in a standardized supine test position are suitable both for test of ROM and degree of spasticity. Spasticity was not elicitable by movement provocation on physical examination in 40% of the patients who reported spasticity, thus indicating that the patient's self-report is an important complement to the clinical assessment. A significant association between spasticity and contractures (reduced ROM) was seen.     

Measuring outcome in spasticity rehabilitation

Spasticity is a frequent consequence of upper motor neuron lesion and is associated with a variety of symptoms such as pain, muscle stiffness and reflex patterns that interfere with activities of daily living, dexterity and gait. As therapy strategies in managing spasticity-associated problems have been evolving there is an increasing need for a practicable documentation system which describes spasticity and related symptoms on different levels in order to evaluate especially the level of functioning. In daily routine the single-case-design reflects a useful technique to evaluate the status in terms of technical, functional and individual goals for treatment. However, there is no single tool to measure the different types of changes due to treatment, therefore a variety of selecting tests, based on the functional changes expected from the selected treatment, is recommended. The sensitivity of the selected tests should match the range of expected improvements related to the specific treatment. Technical goals should be evaluated by validated spasticity rating scales. As changes in technical measures of spasticity such as muscle tone, muscle length, range of motion or repetitive voluntary movements may not correlate with clinical improvements, individual functional goals should be defined. Those functional goals should reflect the patients' and care-givers' individual perception of the actual problem. A treatment diary is a useful tool to document subjective perception of changes over time. Some practical issues are adressed below. Reliable outcome measures enable patients and doctors to select further treatment strategies and gives health care providers information on treatment expectations in return for their investments.     

Systematic review of the influence of spasticity on quality of life in adults with chronic neurological conditions

Objective: To conduct a systematic review of the published evidence on the relationship between spasticity and quality of life (QOL) in chronic neurological conditions in adults. Data sources: MEDLINE, Embase, CINAHL and PsycINFO databases. Methods: The databases were searched from inception to October 2014 using keywords ‘spasticity’ and ‘quality of life’ for publications in English language. Cross-sectional and longitudinal studies reporting quantitative analyses on the association between spasticity and QOL were included. Appraisal of the studies and data extraction were conducted in accordance with Strengthening the Reporting of Observational Studies in Epidemiology guidance. Results: 17/652 studies (total of 27 827 patients) met inclusion criteria for review. These examined the relationship between spasticity and QOL in multiple sclerosis (MS), spinal cord injury (SCI) and stroke. Spasticity was found to be associated with significantly lower scores on health status measures, namely SF-12, SF-36 and EQ-5D, in MS and SCI, but less so in stroke. Spasticity was associated with considerably lower scores on physical components of the health status questionnaires, but with only marginally lower scores on mental components. The studies that employed global QOL measures, such as the World Health Organisation Quality of Life – BREF, found no significant relationship between spasticity and QOL. Spasticity was often associated with pain, sleep problems, fatigue and urinary dysfunction. Conclusions: Spasticity is associated with worse health status, however its relationship with overall QOL is not established. The relationship between spasticity and QOL is confounded by other impairments and requires multivariate analysis.

• Implications for Rehabilitation

• Effective management of spasticity may result in significant improvements in HRQOL.

• It is important to address multiple factors in the management of spasticity including pain, bladder problems, fatigue and sleep, as the interplay of these may have significant negative effects on HRQOL.

• Clinician-administered methods for measuring spasticity, such as the Ashworth scale, may not provide comprehensive assessment of spasticity.

• Incorporation of patient-reported measures for spasticity is pivotal in the assessment of therapeutic interventions.

     

Managing spasticity with drugs

Spasticity is a common symptom observed after pyramidal system lesion. The treatment of spasticity has considerably changed during last years, notably with the generalization of Botulinum toxin use. However, the treatment of spasticity should consider all therapeutic possibility in accordance with patient status and objective. Drugs are only a part of the treatment and physical therapy must always be used. Others treatments such as surgery, orthosis, occupational therapy must also be discussed individually. Several guidelines are now available for Botulinum toxin treatment but only the French guidelines consider all drug therapies. This review addresses the different drugs commonly used on the basis of an extensive review of literature. Some facts are clearly established by randomized controlled trials but a certain number of questions remains unclear and only clinical experience and consensus can guide injectors.     

A novel robot training system designed to supplement upper limb physiotherapy of patients with spastic hemiparesis

Spasticity is velocity and acceleration dependent, and it is therefore important to execute physiotherapeutic exercises at a relatively low and constant velocity. This can be more accurately managed by a robot than by a person when such exercises are administered continuously for more than 15-20 min. The purpose of this project was to construct a robot-mediated system that could support upper limb physiotherapy of patients with spastic hemiparesis. The system, unlike any known robotic therapeutic system, uses unmodified industrial robots to carry out passive physiotherapy on the upper limb (including the movements of the shoulder and the elbow). An initial trial was executed in order to assess its safety and to gain experience of the robot-mediated therapy. Four healthy subjects and eight patients with spastic hemiparesis were included. Each subject received 30-min-long robotic physiotherapy sessions over 20 consecutive workdays. The 12 participants received, in total, 240 robot-mediated physiotherapeutic sessions. No dangerous situation or considerable technical problem occurred; the robots executed the therapy programme as intended. Investigation of the effectiveness of this kind of therapy was not an aim of this initial trial; however, the patients' clinical status was followed and some favourable changes were found regarding the spasticity of elbow flexors and shoulder abductors. According to the experiences of the first clinical investigation, the programming interface and the mechanical interface device between the patient and the robots had been improved. A controlled clinical study is under way to assess the effectiveness of the REHAROB movement therapy.     

Evaluation and primary management of spasticity

Spasticity is often a lifelong manifestation of central nervous system damage in adults with upper motor neuron lesions. Practitioners who initiate the management of spasticity when damage occurs are more likely to offer the patient a life without permanent joint deformity. Spasticity may be helpful or harmful to the patient, but in either event warrants a careful assessment and management plan based upon current health care concepts. Two general intervention principles and three specific intervention measures, including the use of medication, are discussed.     

Selective dorsal rhizotomy in cerebral palsy spasticity-a newly established operative technique in Slovenia: A case report and review of literature

BACKGROUND Spasticity affects a large number of children,mainly in the setting of cerebral palsy,however,only a few paediatric neurosurgeons deal with this problem.This is mainly due to the fact that until 1979,when Fasano has published the first series of selective dorsal rhizotomy(SDR),neurosurgeons were able to provide such children only a modest help.The therapy of spasticity has made a great progress since then.Today,peroral drugs,intramuscular and intrathecal medicines are available,that may limit the effects of the disease.In addition,surgical treatment is gaining importance,appearing in the form of deep brain stimulation,peripheral nerve procedures and SDR.All these options offer the affected children good opportunities of improving the quality of life.CASE SUMMARY A 15-year old boy is presented that was surgically treated for spasticity as a result of cerebral palsy.Laminotomy at L1 level was performed and L1 to S1 nerve roots were isolated and divided in smaller fascicles.Then,the SDR was made.CONCLUSION We describe a patient report and surgical technique of SDR that was performed in Slovenia for the first time.     

Relationship between static muscle strength deficits and spasticity in stroke patients with hemiparesis

The purpose of this retrospective investigation was to determine whether a relationship exists between static strength deficits in the shoulder medial (internal) rotator and elbow flexor muscles and spasticity in these muscles or their antagonists. We reviewed the records of the first 50 stroke patients with hemiparesis who met the entry criteria for the study and who were admitted over a four-month period of time. Static muscle strength was measured by hand-held dynamometry. Spasticity was graded on the Ashworth scale. Kendall's tau correlations were calculated between static muscle strength deficits and spasticity. Static strength deficits of the shoulder medial rotator and elbow flexor muscles were correlated (p less than .01) with the agonist muscles' spasticity, but not with the antagonist muscles' spasticity. Muscle group spasticity and strength deficits, therefore, appear to be covarying manifestations of cerebrovascular accidents. Clinicians, thus, may interpret an agonist muscle's capacity for force production in light of its own tone rather than that of its antagonist.     

Characteristics of associated reactions in people with hemiplegic cerebral palsy

Purposes. To investigate the relationship between associated reactions and a) spasticity, b) contracture and c) coordination. Methods. Associated reactions were measured as magnitude of muscle activity in the affected limb during a 50% maximum voluntary contraction of muscles in the unaffected limb. Spasticity was measured as hyper‐reflexia during passive muscle stretch, coordination as performance during a tracking task, and contracture as loss of range of motion. Chi‐square analysis was used to examine the association between associated reactions and spasticity, and linear regression to examine the relationship between associated reactions and spasticity, coordination and contracture. Results. Twenty‐three people with hemiplegic cerebral palsy aged from 15 to 47 years (mean [SD]: 29 years [9]) participated. Thirteen participants exhibited spasticity, and six participants exhibited associated reactions. Five of the six participants with associated reactions also had spasticity (χ² = 2.37, p = 0.12). Associated reactions were highly correlated with spasticity (r = 0.77, p = 0.001), but not with contracture (r = 0.35, p = 0.29) or coordination (r = ?0.31, p = 0.30). Conclusions. Although 27% of participants exhibited associated reactions, and these were mostly small, associated reactions appear to be an expression of spasticity in hemiplegic cerebral palsy. Copyright © 2010 John Wiley & Sons, Ltd.     

Development and validation of Patient Reported Impact of Spasticity Measure (PRISM)

Persons with spinal cord injury (SCI) may experience a range of symptoms typically labeled "spasticity." Previous efforts to develop assessment tools that measure spasticity have failed to represent the experiences of persons who live with the condition. The purpose of this multicenter study was to develop an instrument that measures the impact of spasticity on quality of life. Based on 24 semistructured interviews, a developmental form of the Patient Reported Impact of Spasticity Measure (PRISM) was constructed. The developmental PRISM was administered to 180 persons at five sites. Subscales were developed based on factor analytic results. Evidence for the reliability and validity of the scores was evaluated. Seven subscales were developed, including one that measures the positive effects of spasticity. Results of reliability and validity assessments indicate that the PRISM subscale scores effectively measure the impact of spasticity in the population of veterans with SCI.     

Reduction in post-spinal cord injury spasticity by combination of peripheral nerve grafting and acidic fibroblast growth factor infusion in monkeys

ObjectiveSpasticity is a frequent complication after spinal cord injury (SCI), but the existing therapies provide only limited relief and are associated with adverse reactions. Therefore, we aimed to develop a novel strategy to ameliorate the spasticity induced by SCI.MethodsThis nonrandomized controlled study used a repeated measurement design. The study involved four monkeys, two of which served as controls and only underwent spinal cord hemisection surgery at the T8 spine level. The other two monkeys underwent transplantation of sural nerve segments into the injured sites and long-term infusion of acidic fibroblast growth factor (aFGF). All monkeys received postoperative exercise training and therapy.ResultsThe combined therapy substantially reduced the spasticity in leg muscle tone, patella tendon reflex, and fanning of toes. Although all monkeys showed spontaneous recovery of function over time, the recovery in the controls reached a plateau and started to decline after 11 weeks.ConclusionsThe combination of peripheral nerve grafting and aFGF infusion may serve as a complementary approach to reduce the signs of spasticity in patients with SCI.