Penn Spasm Frequency Scale Research Articles

Muscle Excitability Scale for the assessment of spastic reflexes in spinal cord injury: development and evaluation

Study designA psychometric study.ObjectivesTo introduce a novel simple tool designed to evaluate the intensity of the phasic (dynamic) component of spastic motor behavior in spinal cord injury (SCI) people and to assess its reliability and validity.SettingThe study was developed in the Spinal Cord Unit at University Hospital Motol and Paraple Centre in Prague, Czech Republic.MethodsThe Muscle Excitability Scale (MES) is designed to rate muscle motor response to exteroceptive and proprioceptive stimuli. The impairment rating ranges from zero muscle/muscle group spasm or clonus to generalized spastic response. The selected 0 to 4 scale allows for comparing the MES results with those of the Modified Ashworth Scale (MAS). After long-term use and repeated revisions, a psychometric analysis was conducted. According to the algorithm, two physiotherapists examined 50 individuals in the chronic stage after SCI.ResultsThe inter-rater reliability of MES for both legs showed κ = 0.52. The intra-rater reliability of MES for both legs showed κ = 0.50. The inter-rater reliability of simultaneously assessed MAS for both legs was higher, with κ = 0.69. The intra-rater reliability of MAS for both legs showed κ = 0.72. Spearman’s rank correlation coefficient between MES and spasm frequency of Penn Spasm Frequency Scale (PSFS) was low, while the correlation coefficient between MES and the severity part of PSFS was moderate.ConclusionsThe MES is a complementary tool for assessing the dynamic component of spastic motor behavior in SCI people. It allows a more comprehensive clinical characterization of spastic reflexes when used along with the MAS.

Assessment of pain relief after four botulinum toxin A injection cycles in patients with post-stroke lower limb spasticity: A prospective, observational study

IntroductionSpasticity is common after a stroke and is an independent risk factor for developing pain. BotulinumtoxinA injection is the treatment of choice for focal spasticity. We examined the effect of intramuscular botulinumtoxinA on pain relief in patients in routine clinical practice who were experiencing pain as a primary complaint associated with post-stroke lower limb spasticity. MethodsProspective, multicentre, post-marketing observational study. The study period was 16 months. The primary effectiveness variable was the mean change from baseline on the pain 0–10 Numerical Rating Scale after four botulinumtoxinA injection cycles. Secondary endpoints included changes from baseline on the pain 0–100 Visual Analogue Scale, Goal Attainment Scale, modified Ashworth Scale, 10-Meter Walk Test, Penn Spasm Frequency Scale, and 36-item Short-Form Health Survey. ResultsOf 186 enrolled patients, 180 (96.8%) received botulinumtoxinA at least once. The mean (standard deviation) pain 0–10 Numerical Rating Scale score decreased significantly (p<0.0001) from 4.9 (2.2) at baseline to 2.5 (2.1) at study end, representing a 50% decrease in pain severity. Relief of pain due to spasticity was supported by improvement from baseline in all secondary variables except the 10-Meter Walk Test. Two adverse events (erysipelas and phlebitis) in one patient were considered likely to be related to botulinumtoxinA injection. ConclusionBotulinumtoxinA appears to provide pain relief as an additional benefit of local treatment in patients with post-stroke lower limb spasticity for whom pain relief is a primary therapeutic goal (a Lay Abstract has been provided as Appendix A).

Effectiveness of Intradialytic Leg Ergometry and Stretching Exercises on Fatigue and Muscle Cramps Among Patients Subjected to Hemodialysis at Tertiary Care Hospitals of Sikkim

significant impact on patients' health-related quality of life and are common in chronic hemodialysis patients. The purpose of this study was to see how effective intradialytic leg ergometry and stretching exercises were at reducing fatigue and muscle cramps in hemodialysis patients at tertiary care hospitals.A quasi-experimental study conducted among 58 patients undergoing hemodialysis, randomly selected experimental and control group. Experimental group received intradialytic leg ergometry and stretching exercises during the first 2 hrs of dialysis session for a total duration of 4 weeks. Data on fatigue and muscle cramps were assessed using Multidimensional Assessment of Fatigue Scale (MAF) and PENN Spasm Frequency Scale (PSFS) respectively, at the beginning prior to implementation of intervention and re assessed during the 4th week. The study finding showed that the mean posttest score of fatigue in the experimental group was 26.86±8.228 was lesser than mean posttest score in control group 32.40±8.726, where the differences between the two groups was statistically significant at p&lt;0.05 level. Similarly with regard to muscle cramps the mean posttest score in experimental group was 1.21±0.491 was lesser than mean posttest score in control group 2.07±0.884 where the differences between the two groups was statistically significant at p&lt;0.05 level. The findings concluded that intradialytic leg ergometry and stretching exercises were beneficial in reducing fatigue and muscle cramps in hemodialysis patient. Keywords: [Hemodialysis, Fatigue, Muscle Cramps, Intradialytic ergometry]

Phenol vs. botulinum toxin A injection for managing lower limb spasticity in adult patients with upper motor lesions: A randomized clinical trial

Background: Phenol and botulinum toxin type A (BTX-A) injections are two options for treating spasticity with the ability to select a specific spastic muscle and determine the dosage based on spasticity degree. This study intends to compare the efficacy of BTX-A vs. phenol blockade in treating lower limb spasticity and to evaluate the performance improvement in gross motor functional outcomes among adult patients with upper motor neuron (UMN) lesions. Methods: This randomized, double-blind clinical trial of 28 spastic lower limb adult patients with UMN was diagnosed between March 1, 2017, to April 30, 2019. Patients were randomized in a 1:1 ratio to a “BTX-A injections” or a “Phenol injections” group. The outcomes were measured through assessment spasticity by the Modified Ashworth Scale (MAS), active range of motion (AROM) of lower limb joint by a goniometer, Verbal Rating Scale (VRS), Visual Analog Scale (VAS), and Penn Spasm Frequency Scale (PSFS) as a baseline and post-injection follow-up at 24 hours, 3 weeks, and 3 months. Results: All 28 randomized patients were analyzed. No significant difference between the two study arms, neither in demographic characteristics nor in MAS, AROM, VRS, VAS, and PSFS parameters prior to the procedures. AROM showed a significant decrease from baseline throughout the study in the phenol group. While in the BTX-A group, they improved significantly at 3 weeks; no more improvement was observed at 3 months, and the differences were statistically significant (p &lt; 0.05). The reduction in MAS, VRS, VAS, and PSFS was statistically significant in each group at 24 hours, 3 weeks, and 3 months after the injection (p &lt; 0.05). However, the differences were not significant between the phenol and BTX-A groups (p &gt; 0.05), except for PSFS at the 3 months of follow-up in the Phenol group (p = 0.01). The need for re-injection at 6 months and 9 months was that 5 patients vs. 0 patients (p = 0.01) and 8 patients vs. 3 patients (p = 0.04) in the BTX-A and phenol groups, respectively, were statistically significant. Conclusion: Phenol injection showed superior treatment effects in AROM, decreased spasm degree based on PSFS at 3 months, and less-frequent re-injection rate compared to BTX-A injections in adult patients with UMN lesions. However, both phenol and BTX-A injections effectively reduce spasticity without significant differences in efficacy and adverse effects. Future studies must be conducted with a longer duration of follow-up, and larger sample sizes better to compare both drugs’ effectiveness and side effects. Trial registration: The study protocol was registered as a clinical trial under registration IRCT20170826035914N2 at the Iranian Registry of Clinical Trials (http://www.irct.ir).

Neuromodulation and quality of life for patient with spasticity after spinal cord injury.

Spasticity develops in 80% of spinal cord injury cases and negatively affects the patents' quality of life. The most common method of surgical treatment for severe spasticity is a long-term intrathecal baclofen therapy (ITB). Long-term spinal cord stimulation is another possible treatment technique. This paper aims to evaluate the changes in quality of life for patients with spasticity who have been treated with neuromodulation (SCS or ITB) in 12 months after the surgery, as well to compare the changes in quality of life for patients who have been treated with spinal cord stimulation and those who received long-term intrathecal baclofen therapy. The influence of spasticity, experienced by the patients with a spinal cord injury, on their quality of life was analyzed before the surgery and 12 months after it. The severity of the spinal cord damage was determined with the scale of the American Spinal Injury Association (ASIA); spasticity was evaluated with the modified Ashworth scale, Penn Spasm Frequency Scale; pain levels were determined with visual analogue scale (VAS), anxiety and depression levels - with HADS. Functional activity of the patients was evaluated with the help of the Functional Independence Measure (FIM). The treatment results for 33 patients (25 men and 8 women), aged from 18 to 62, are presented. After the trial stimulation, the patients were randomly assigned to either SCS or ITB group (18 and 15 people respectively). The decrease of spasticity in both experimental groups caused lower levels of pain, less functional dependency on other people, lower stress and depression rates and, as a consequence, better quality of life and social adaptation. The obtained results for SCS and ITB groups are statistically similar.

Neurophysiological and clinical outcome measures of the impact of electrical stimulation on spasticity in spinal cord injury: Systematic review and meta-analysis.

This systematic review and meta-analysis aims to determine whether non-invasive electrical stimulation (ES) is effective at reducing spasticity in people living with spinal cord injury (SCI). PubMed, Web of Science, Scopus and Cochrane Central Register of Controlled Trials databases were searched in April 2022. Primary outcome measures were the Ashworth scale (AS), Modified Ashworth scale (MAS), Pendulum test and the Penn spasm frequency scale (PSFS). Secondary outcomes were the Hoffman (H)- reflex, motor-evoked potentials (MEPs) and posterior-root reflexes (PRRs). A random-effects model, using two correlation coefficients, ( , ) determined the difference between baseline and post-intervention measures for RCTs. A quantitative synthesis amalgamated data from studies with no control group (non-RCTs). Twenty-nine studies were included: five in the meta-analysis and 17 in the amalgamation of non-RCT studies. Twenty studies measured MAS or AS scores, 14 used the Pendulum test and one used the PSFS. Four measured the H-reflex and no studies used MEPs or PRRs. Types of ES used were: transcutaneous electrical nerve stimulation (TENS), transcutaneous spinal cord stimulation (TSCS), functional electrical stimulation (FES) cycling and FES gait. Meta-analyses of 3 studies using the MAS and 2 using the Pendulum test were carried out. For MAS scores, non-invasive ES was effective at reducing spasticity compared to a control group (p = 0.01, ; p = 0.002, ). For Pendulum test outcomes, there was no statistically significant difference between intervention and control groups. Quantitative synthesis of non-RCT studies revealed that 22 of the 29 studies reported improvement in at least one measure of spasticity following non-invasive ES, 13 of which were statistically significant (p < 0.05). Activation of the muscle was not necessary to reduce spasticity. Non-invasive ES can reduce spasticity in people with SCI, according to MAS scores, for both RCT and non-RCT studies, and Pendulum test values in non-RCT studies. This review could not correlate between clinical and neurophysiological outcomes; we recommend the additional use of neurophysiological outcomes for future studies. The use of TSCS and TENS, which did not induce a muscle contraction, indicate that activation of afferent fibres is at least required for non-invasive ES to reduce spasticity.

Safety and Potential Efficacy of Selective Dorsal Rhizotomy in Adults with Spinal Cord Injury-Induced Spasticity: An Open-Label, Non-Randomized, Single-Arm Trial

Despite the abundant literature on the use of selective dorsal rhizotomy (SDR) in spastic cerebral palsy, no investigation has evaluated its use in adult patients with chronic spinal cord injury (SCI)-induced spasticity. The present investigation aimed to evaluate the safety and potential efficacy of SDR in chronic SCI-induced spasticity for the first time. In this open-label, single-arm, non-randomized clinical trial, all patients were assigned to the single study intervention arm and underwent SDR. The primary outcome measure was the safety profile of SDR. Secondary outcome measures were Modified Ashworth Scale, Penn Spasm Frequency Scale, visual analog scale for spasticity, Spinal Cord Injury Spasticity Tool, Spinal Cord Independence measure version III, and Short Form 36 Health Survey Questionnaire. Six patients with cervical SCI and 4 with thoracic SCI were allocated to the single study intervention arm. No adverse event attributable to the SDR was found. Moreover, all secondary outcome measures of the study improved significantly over the study period (P < 0.001). Multiple regression analysis also found a significant association between level of injury and changes in average Modified Ashworth Scale scores (P= 0.041), Spinal Cord Injury Spasticity Tool score (P= 0.013), and Spinal Cord Independence measure version III total (P= 0.002) and mobility domain scores (P= 0.004) at 12-month postoperatively. This clinical trial indicated that SDR is a safe and potentially effective procedure in patients with severe and intractable SCI-induced spasticity. However, future clinical trials with larger sample sizes and adequate power are required to validate our findings regarding efficacy.

Results of Intrathecal Baclofen Treatment in Sixteen Spasticity Patients According to Four Different Measurement Scales:A Retrospective Analysis.

IntroductionSpasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes. It occurs as a result of overstimulation of the stretch reflex and is a component of the upper motor neuron syndrome. Intrathecal Baclofen (ITB) pump administration in patients with a diagnosis of spasticity may be a suitable option for reducing the complaints of the patients and increasing their quality of life. The aim of this study is to analyze clinically and statistically the diagnosis, treatment criteria, and post-treatment results of patients with spasticity who were treated in our clinic.Materials and MethodSixteen patients who were diagnosed with spasticity and placed on an intrathecal Baclofen pump between January 2015 and December 2020 were included in this study. An intrathecal Baclofen trial was first applied to patients who were candidates for the Baclofen pump. The spasticity levels of the patients who decided to have an intrathecal Baclofen pump were scored according to the modified Ashworth scale (MAS) and Penn spasm frequency scale (PSFS). In addition, the scaling of the patients' own conditions according to the visual analogue scale (VAS) and ambulation status according to the modified functional ambulation classification (MFAC) were recorded. All these evaluations were repeated in the preoperative, early postoperative, and follow-up periods.ResultsThe sex distribution of the patients included in the study was equal to eight women and eight men. The age distribution was between 18 and 76. The average age was 40.62 (standard deviation ±17.79). The average preoperative modified Ashworth scale score was 3.73, and the average Penn spasm frequency scale score of the patients was 3.67. The average preoperative modified functional ambulation classification score was 1.87, and the average visual analogue scale score was 6.67. At the end of the second postoperative week, the average modified Ashworth scale score was 1.80 and the average Penn spasm frequency scale score was 1.67. The modified functional ambulation classification score was 2.60 and the visual analogue scale score was 4.58. The average follow-up period of the patients was 64 months. At the end of the follow-up periods, the average late-period modified Ashworth scale score was 1.87, and the Penn spasm frequency scale score was 1.67. The average modified functional ambulation classification score was 3.00, and the average visual analogue scale score was 4.50. Statistically, there was a significant difference between preoperative and postoperative results in both modified Ashworth scale and Penn spasm frequency scale scores (P<0.05). Modified functional ambulation classification preoperative and postoperative comparison results (P<0.05) and visual analogue scale results (P<0.05) were also statistically significant. No significant difference was found between the early postoperative period and the late postoperative period in all measurements (P=1.00).ConclusionIntrathecal Baclofen administration is one of the many treatment options for spasticity. In this way, it has been shown that greater Baclofen efficacy is achieved and its side effects are reduced. It should always be remembered that the process of this treatment is teamwork that requires the participation of more than one specialty branch. Physical therapists, neurologists, pediatricians, and neurosurgeons should be included in this teamwork.

Clinical and rehabilitative considerations in a complex case of spastic tetraplegia, mixed aphasia, secondary encephalopathy – post severe traumatic brain injury with hemorrhagic and is-chemic lesions – with favorable late evolution and post-symptomatic status after SARS-COV-2 infection

The traumatic brain injury remains a current research topic considering the severity and the in-creased incidence of this pathology. Both physical and neuro-psychological sequelae require a complex rehabilitation program. Material and methods. We describe the evolution of a 20-year-old case, victim of a severe traumatic brain injury due to physical aggression, with spastic te-traplegia, extended ischemia in the left cerebral hemisphere, mixed aphasia, post-traumatic en-cephalopathy, left eyelid ptosis, right paresis of nerve III, post remitted status of left subdural hematoma, post remitted status of right fronto-parietal subarachnoid hemorrhage, severe joint stiffness (right elbow and fist, bilateral hips and knees), cachexia and SARS-COV-2 infection. In our clinic the patient followed medical, complex kinetotherapeutic treatments and was functio-nally assessed using the following scales: modified Ashworth, Penn Spasm Frequency Scale ( Penn), Life Quality Assessment ( QOL ), Montreal Cognitive Assessment ( MoCA ), FAC Interna-tional Scale, Glasgow Outcome Scale-Extended (GOS-E), modified Rankin scale (mRS ). Results. During the hospitalization, the patient presented a favorable late evolution with a great impro-vement of motor and neurological deficit, aphasia in remision, improvement of eyelid ptosis and joint stiffness, fact also confirmed by the increasing scores from the evaluated scales. Con-clusions. Consequently in traumatic brain injury the proper medication, personalized rehabilita-tion program, ergotherapy, speech therapy, a great deal of involvement and documentation of current information is required to improve the patient's quality of life. Keywords: traumatic brain injury, neuro-rehabilitation program, spastic tetraplegia

Features of complex therapeutical rehabilitation management with favorable evolution in a patient with right hemiplegia, mixed aphasia and optic atrophy post surgical removal of be-nign intraventricular tumor (central neurocytoma)

Central neurocytoma (CN) is a benign brain tumor located intraventricularly and classified as grade II by the World Health Organization in 2000 (classification of tumours of the central nerv-ous system). CN is frequently found in young adults and may increase intracranial pressure causing obstructive hydrocephalus, manifested by neurological symptoms such as headaches and vision problems. CN has a relatively good prognosis, provided a complete surgical resec-tion is performed. Materials and Methods: In this presentation, we describe the case of a 21-year-old patient with a personal history of headache, vomiting and decreased visual acuity in both eyes, who was admitted to the Neurosurgery Clinic III of THEBA. Following clinical and para-clinical assesements, the patient was diagnosed with a left lateral ventricular tumor with exten-sion in the right lateral ventricle and the third ventricle. The neurosurgery team decided a total resection of the tumor would be the best approach in this case. The biopsy report revealed that it was a central neurocytoma. After the surgery the patient’s neurological status improved and she was admitted in the Neuromuscular Rehabilitation CinicalDivision with flaccid right hemi-plegia and mixed aphasia. The patient was functionally assessed using the following scales: Functional Independence Measure (FIM), Montreal Cognitive Assessment (MOCA), modified Ashworth, Penn Spasm Frequency Scale (Penn), Life Quality Assessment (QOL), FAC Interna-tional Scale, Glasgow Outcome Scale-Extended (GOS-E), modified Rankin scale (mRS), Aphasia Screening Test (AST-Whurr). Results: The patient showed a favorable evolution with remitted aphasia and walking traing with self-support in tertrapod walking stick. At the same time, the patient can use the plegic upper limb in performing feeding activities. Conclusion: It should be noted that neurosurgical intervention and pharmacological treatment, associated with an indi-vidual rehabilitation program consisting of: physical, occupational and speech therapies and al-so rehabilitation nursing interventions in a patient diagnosed with flaccid right hemiplegia and mixed aphasia after total surgical resection of the intraventricular central neurocytoma has im-proved the control of symptoms and the patient's quality of life. Keywords: benign brain tumor, central neurocytoma, hemiplegia, rehabilitation

The effects of spasticity on glucose metabolism and soft tissue body composition in patients with spinal cord injury.

Objectives The aim of this study was to assess the effects of spasticity on glucose metabolism and percentage of fat-free mass (FFM%) in patients with spinal cord injury (SCI). Patients and methods A total of 33 patients (22 males, 11 females; mean age: 38.6±12.5 years; range, 20 to 64 years) with SCI defined by the American Spinal Injury Association Impairment Scale Grades A to D were included between September 2014 and May 2018. We assessed spasticity with the Modified Ashworth Scale (MAS) and evaluated spasms with the Penn Spasm Frequency Scale (PSFS). We assessed the glucose metabolism by calculating the Matsuda and HOMA-IR index, and measured FFM% by dual-energy X-ray absorptiometry. Results Fourteen patients had motor complete, and 19 had motor incomplete SCI. The neurological injury levels of the patients were C4-T12. There was a positive correlation between hip adductor muscle MAS and trunk, android, and gynoid FFM% and between hip extensor muscle MAS and android FFM% in patients with motor complete SCI. Hip extensor and knee flexor muscle MAS showed a negative correlation with the HOMA-IR. Hip adductor and extensor muscle MAS, as well as knee flexor and extensor muscle MAS, had a positive correlation with the Matsuda index in these patients. There was a positive correlation between knee extensor muscle MAS and gynoid FFM% and between PSFS and arms, trunk, gynoid, and total FFM% in patients with motor incomplete SCI. There was a negative correlation between hip adductor and extensor muscle MAS, PSFS, and level of fasting glucose in these patients. Conclusion This study supports the notion that spasticity has positive effects on the FFM% and glucose metabolism in patients with motor complete and incomplete SCI.

Effect of pelvic laparoscopic implantation of neuroprosthesis in spinal cord injured subjects: a 1-year prospective randomized controlled study

Study design1-year prospective RCT.ObjectiveExamine the effect of implantable pulse generator and low-frequency stimulation of the pelvic nerves using laparoscopic implantation of neuroprosthesis (LION) compared with neuromuscular electrical stimulation (NMES) in SCI.MethodsInclusion criteria: traumatic spinal cord injury (SCI), age 18–55 years, neurological level-of-injury Th4–L1, time-since-injury >1 year, and AIS-grades A–B. Participants were randomized to (A) LION procedure or (B) control group receiving NMES. Primary outcome measure: Walking Index for Spinal Cord Injury (WISCI-II), which is a SCI specific outcome measure assessing ability to ambulate. Secondary outcome measures: Spinal Cord Independence Measure III (SCIM III), Patient Global Impression of Change (PGIC), Penn Spasm Frequency Scale (PSFS), severity of spasticity measured by Numeric Rating Scale (NRS-11); International Spinal Cord Injury data sets-Quality of Life Basic Data Set (QoLBDS), and Brief Pain Inventory (BPI).ResultsSeventeen SCI individuals, AIS grade A, neurological level ranging from Th4–L1, were randomized to the study. One individual was excluded prior to intervention. Eight participants (7 males) with a mean age (SD) of 35.5 (12.4) years were allocated to the LION procedure, 8 participants (7 males) with age of 38.8 (15.1) years were allocated to NMES. Significantly, 5 LION group participants gained 1 point on the WISCI II scale, (p < 0.013; Fisher´s exact test). WISCI II scale score did not change in controls. No significant changes were observed in the secondary outcome measures.ConclusionThe LION procedure is a promising new treatment for individuals with SCI with significant one-year improvement in walking ability.

Nabiximols and botulinum toxin injections for patients with multiple sclerosis: efficacy on spasticity and spasms in a single-centre experience.

Spasticity is a common and disabling symptom in patients with multiple sclerosis (PwMS): as highlighted by many epidemiological studies, it is often a severe and not well treated. Despite the availability of evidence-based spasticity management guidelines, there is still great variability in everyday therapeutic approach, especially for the most complex cases. In our single-centre study, we retrospectively evaluated PwMS-treated nabiximols and botulinum toxin injections (BTI) from July 2015 to April 2019. Clinical and demographic data were collected. The severity of spasticity and spasms was recorded by modified Ashworth Scale (mAS) and Penn Spasm Frequency Scale (PSFS) at baseline and after 1 month of treatment. We evaluated 64 treatments for MS-related spasticity: 28 patients were treated with BTI and 36 patients with nabiximols. We found that both BTI and nabiximols are effective in reducing mAS (nabiximols, BTI: p < 0.001), PSFS frequency (nabiximols: p = 0.001, BTI: p = 0.008) and intensity (nabiximols: p = 0.001, BTI p = 0.016). No differences were found when directly comparing the efficacy of the two treatments, except for a statistical trend favouring BTI on spasms intensity (p = 0.091). Eleven patients were treated with both BTI and nabiximols, and only four patients continued both treatments. All dropouts were due to inefficacy of at least one of the two therapies. Our single-centre experience highlights that both BTI and nabiximols are effective in treating multiple sclerosis-related spasticity; however, BTI treatment may be more effective on spasms intensity. Combined nabiximols and BTI treatment could represent a therapeutic option for severe spasticity.

Very complex and difficult rehabilitation process in a post traumatic SCI (Spinal Cord Injury) complete tetraplegic patient with intense and refractory spasticity and frequency of spasm with presacral pressure sores (successfully operated)- case report

Introduction. Spinal cord injury (SCI) is the injury of the spinal cord from the foramen magnum to the cauda equina which occurs as a result of compulsion, incision or contusion.(1) As a result of the injury, the functions performed by the spinal cord are interrupted at the distal level of the injury. SCI causes serious disability among patients.(2) The treatment and rehabilitation period is long, expensive and exhausting in SCI. The results of SCI bring not only damage to independence and physical function, but also include many complications from the injury. Neurogenic bladder and bowel, urinary tract infections, pressure ulcers, orthostatic hypotension, fractures, deep vein thrombosis, spasticity, autonomic dysreflexia, pulmonary and cardiovascular problems, and depressive disorders are frequent complications after SCI.(3) Material and method. Having the patient’s consent and The Teaching Emergency Hospital “Bagdasar-Arseni” Ethics Committee’s approval, a 48 years old patient, complete tetraplegic with intense and refractory spasticity and frequency of spasm with presacral pressure sores (successfully operated) post traumatic spinal cord injury. The patient was functionally assessed using the following scales: : Glasgow Outcome Scale Extended, Modified Rankin Scale, Modified Ashworth, Penn Spasm Frequency Scale Functional Independence Measure, FAC International Scale, Quality of Life Assessment. Conclusions. Spasticity is a common secondary impairment after SCI characterized by hypertonus, increased intermittent or sustained involuntary somatic reflexes (hyperreflexia), clonus and painful muscle spasms. Severe spasticity may contribute to increased functional impairment, contractures, ulcers, posture disorders and pain. Treatment should start as soon as possible to prevent such negative effects. Keywords: tetraplegia, spinal cord injury, spasticity, pressure sores, traumatism, rehabilitation,

Painful tonic spasm in Chinese patients with neuromyelitis optica spectrum disorder: Prevalence, subtype, and features

ObjectivesPainful tonic spasm (PTS) is a common symptom in patients with neuromyelitis optica spectrum disorder (NMOSD). We herein aimed to explore the prevalence, subtype, and features of PTS in Chinese Han patients with NMOSD. MethodsWe retrospectively reviewed medical records and interviewed patients with NMOSD who were admitted to Huashan Hospital and the Jing'an District Center Hospital of Fudan University in Shanghai, China, from February 2017 to May 2019. The primary questionnaires included a Numerical Rating Scale (NRS), Spinal Cord Injury Health Questionnaire (SCI-HQ), Penn Spasm Frequency Scale (PSFS), and Patient Global Impression of Improvement (PGI-I). ResultsSixty-seven of 153 (43.79%) patients with NMOSD showed PTS, only when spinal cord was involved. PTS had a negative impact on daily life in 97.01% (65/67) of the patients, and 92.54% (62/67) of the patients needed symptomatic treatment. Pain intensity and frequency of PTS were significantly different (P = 0.018 with NRS, P = 0.045 with PSFS) among flexor tonic spasm, extensor tonic spasm, isometric tonic spasm and complex tonic spasm subtype. Forty patients (59.71%) manifested complex tonic spasms, which indicated more severe pain and frequent spasms comparing to other subtypes. The locations of PTS were significantly different among the 5 subtypes (P<0.001), i.e.,77.78% (7/9) of flexor tonic spasms appeared in the upper extremity, 100% (9/9) of extensor tonic spasm occurred in the lower extremity, and isometric tonic spasms principally occurred in the trunk (87.5%). Forty-one patients (66.13%) demonstrated good responses to the symptomatic treatments, and there were no statistical differences with respect to the therapeutic responses among the 5 PTS subtypes (P = 0.509). ConclusionsPTS was associated with myelitis, and was a common symptom in NMOSD. Intensity, frequency and location were different among the PTS subtypes. Complex tonic spasm was the most common and serious subtype.

Gait Training Using a Wearable Robotic Device for Non-Traumatic Spinal Cord Injury: A Case Report

Introduction:We aimed to report the clinical evaluation results of gait training with the Honda Walking Assist Device® (HWAT) in a patient with spinal cord injury (SCI).Patients and Methods:A 63-year-old male with SCI (grade D on the American Spinal Injury Association Impairment Scale) underwent 20 HWAT sessions over 4 weeks. The self-selected walking speed (SWS), mean step length, cadence, 6-minute walking test (6MWT), Walking Index for SCI score, SCI Functional Ambulation Inventory gait score, American Spinal Injury Association Impairment Scale grade, neurological level, upper and lower extremity motor scores, modified Ashworth Scale, Penn Spasm Frequency Scale, and Spinal Cord Independence Measure version III were measured on admission, at the start of HWAT, at 2 and 4 weeks post-HWAT, and at discharge. Three-dimensional kinematic gait analysis and electromyographic assessments were performed before and after HWAT.Results:The patient safely completed 20 HWAT sessions. We found improvements above the clinically meaningful difference in SWS and 6MWT as well as increased hip extension, ankle plantar- and dorsi-flexion range of motion and increased hip extensor, abductor, adductor, and ankle plantar flexor muscle activity.Discussion:The SWS improved more markedly during the HWAT intervention, exceeding the minimal clinically important difference (0.10 to 0.15 m/s) in walking speed for people with SCI until discharge. Moreover, the 6MWT results at 2 weeks after the start of HWAT exceeded the cutoff value (472.5 m) for community ambulation and remained at a similar value at discharge.Conclusion:The walking distance (6MWT) and the walking speed (SWS) both demonstrated clinically important improvements following 20 treatment sessions which included HWAT.

Spasticity and pain in adults with cerebral palsy.

To evaluate whether spasticity measures are related to pain in adults with cerebral palsy (CP). This cross-sectional study recruited individuals aged 16 to 89years with a diagnosis of CP. Participants completed the Penn Spasm Frequency Scale (PSFS), Brief Pain Inventory (BPI), and PROMIS Pain Interference measures. The Modified Ashworth Scale (MAS) and Tardieu spasticity angles of six joints were rated and summed to composite MAS and Tardieu scores for each participant. Associations between spasticity and pain measures were evaluated. Forty-seven participants (27 females, 20 males) with a mean age of 35years 7months (range 18-77y) spanning all Gross Motor Function Classification System (GMFCS) levels were included. Twenty-six participants reported their average pain level on BPI as greater than 0 over the past week (median pain level 4.0). Median PSFS was 1.0 (range 0.0-1.0) and this correlated with average BPI and Pain Interference T scores (median 40.7; ρ=0.33 and ρ=0.31 respectively [both p=0.01]). When adjusted for pain medication use and age, MAS correlated with BPI (ρ=0.30; p=0.04). Other pain and spasticity measures, or GMFCS level, were not significantly related with pain interference or BPI rating. Age was weakly associated with BPI (slope=0.10; p<0.01). PROMIS Pain Interference was lower than population-based norms. Patient-rated spasm frequency demonstrated better association with pain levels and interference than physician-rated MAS and Tardieu. Pain was not associated with Gross Motor Function Classification System level. Pain increased with age, as anticipated. Self-reported spasm scores were associated with increased pain in contrast to clinical examination scales. Adjusted, summed spasticity on the Modified Ashworth Scalewas associated with painscores on the Brief Pain Inventory. Although pain is experienced by adults with cerebral palsy, pain did not interfere with activities.

Effectiveness of electrical stimulation after administration of botulinum toxin in children with spastic diplegic cerebral palsy: A prospective, randomized clinical study.

The aim of the study was to investigate the effectiveness of electrical stimulation to agonist muscles after injection of Botulinum toxin A (BTX-A) in children with spastic diplegic cerebral palsy (SDCP). Between October 2009 and October 2010, 38 patients with SDCP (19 males, 19 females; mean age 6.3 years; range, 4 to 10 years) were included. The patients were able to walk independently or with minimal assistance by foot equine and had spasticity in the calf muscles between Grades 1+ and 3 according to the Modified Ashworth Scale (MAS). The patients received either BTX-A injection + electrical stimulation (Group 1, n=19) or BTX-A injection alone (Group 2, n=19). All patients were evaluated using the MAS, Penn Spasm Frequency Scale (PSFS), Gross Motor Function Measure-88 (GMFM-88) (Dimensions D and E), and walking velocity. A decrease in spasticity was evident for the right, left, and bilateral lower extremities for both groups (p<0.05). There were no statistically significant differences in the MAS, PSFS, GMFM-88 (Dimensions D and E), and walking velocity between the groups. Our study results showed that both patient groups benefited from the treatment and the administration of electrical stimulation to the gastrocnemius motor points produced no additional benefit for patients with SDCP.

A Descriptive Study of Self-Reported Injury in Non-elite Adaptive Athletes.

Adaptive sports programs are increasing across the country and there is a paucity of research investigating the epidemiology and sports injury risk factors in non-elite athletes. To assess the demographics, training regime, and injuries incurred by adaptive athletes participating in local adaptive sports clubs and to assess the athletes' type of medical care and prevalence of those with spasticity. Descriptive cross-sectional study. Local area adaptive sports teams and programs. Sixty-one athletes participating in wheelchair basketball, wheelchair rugby, sled hockey, and adaptive rowing were surveyed, with a response rate of 70.5%. Completion of self-report survey. Report of injury prevalence, injury characteristics, type of medical care, and assessment of frequency and severity of spasticity using the Penn Spasm Frequency Scale. Most athletes (86%) trained or competed in their main sport 9-12 months per year. Most athletes (79.1%) trained at least 4 hours per week. In the past 12 months, 39.5% of athletes surveyed sustained an injury that required them to miss practice or a competition, with 58.8% of these athletes having sustained a significant injury. Many of those injured (64.7%) had never participated in an injury prevention or conditioning program. Injury prevalence by sport was 42.9% in wheelchair rugby, 60% in sled hockey, 44% wheelchair basketball, and 0% in adaptive rowing. The most commonly injured body parts were the shoulder (52.9%) and wrist (52.9%). This study shows that non-elite adaptive sports athletes sustain similar types of injuries as noted in published reports of elite athletes but could be provided with less injury prevention education and access to medical care. This area will require future study, especially investigating injury risk factors within specific sports and diagnoses. III.

The Effect of Repetitive Transcranial Magnetic Stimulation on Spasticity in Patients with Multiple Sclerosis.

Background and PurposeThis randomized controlled study examined the effect of repetitive transcranial magnetic stimulation (rTMS) on spasticity in patients with multiple sclerosis (MS).MethodsThis study included 16 patients with a history of MS and spasticity in the adductor hip muscles according to the Modified Ashworth Scale (MAS). The participants were randomized into the active group (n=10) and control group (n=6), in which active rTMS and sham rTMS were applied in 10 sessions, respectively. A physical therapy and rehabilitation program was applied along with rTMS sessions in both groups. The evaluation parameters were assessed at baseline and then 1 week and 1 month after applying rTMS.ResultsStatistical analyses with post-hoc correction revealed statistically significant improvements in the active group compared to the control group in the bilateral MAS score, Penn Spasm Frequency Scale score, patient satisfaction, amount of urine leakage, actual health status, perceived health status, energy and fatigue, role limitations due to physical problems, social function, overall quality of life, cognitive functioning, physical health composite score, mental health composite score, and total score on the Multiple Sclerosis Quality of Life-54 (MSQOL-54) (p<0.05). Statistically significant changes were detected in the MSQOL-54 social function and physical health composite scores of patients in the control group (p<0.05).ConclusionsActive rTMS combined with a physical therapy program reduced spasticity in MS patients compared to the control group that received only physical therapy. Further comprehensive and more advanced studies are needed to confirm the present findings.