Severity Of Spasticity Research Articles

Comparing the acute effect of myofascial release techniques and passive stretching on hind foot dynamic loading in patients with multiple sclerosis: A cohort-blinded study

Summary Study aim: It is important for therapists to incorporate new practical methods into therapy programs when they have demonstrable efficacy in the treatment of multiple sclerosis. Investigating the acute effects of myofascial release techniques (MFR) and passive stretching (PS) on hind foot loading and the severity of spasticity in individuals with multiple sclerosis (MS) was the aim of the study. Material and methods: Following the initial evaluation, 10 participants with MS (n = 20 feet) were given MFR for the plantar flexor muscle group. After the day following the first visit, participants were asked to come again and PS was applied to the plantar flexor muscle groups after the evaluation. The severity of spasticity was assessed with the Modified Ashworth Scale (MAS). Dynamic loading parameters of the hind foot – medial and lateral maximum pressure (N/cm2), active contact areas (cm2), contact percentiles (%) – were evaluated with dynamic pedobarography. Participants of the study were evaluated four times: (1) at the initial evaluation, (2) after MFR application, (3) 24 hours after the initial evaluation (pre-PS), (4) after PS. Results: There were no differences in MAS (p > 0.05) according to time-dependent analyses (p > 0.05). After MFR, the maximum pressure of the medial heel and active contact area were increased (p < 0.05) and there was a carryover effect on the maximum pressure of the right foot. Conclusions: This study showed that MFR was an effective method for management of plantar flexor spasticity in patients with multiple sclerosis in the short term and there was a carryover effect in favor of MFR. There was no additional effect of PS.

The beneficial aspects of spasticity in relation to ambulatory ability in mice with spinal cord injury.

Experimental study with mice. Spasticity is a common complication after spinal cord injury (SCI) and has detrimental aspects, such as persistent pain and involuntary muscle spasms. This study aimed to assess the influence of antispastic therapy on locomotor function after SCI. University-based laboratory in Fukuoka, Japan. A mouse model of spasticity was developed by producing incomplete SCI at the 9th thoracic level. At 8 weeks after SCI, an antispastic drug, baclofen, was intraperitoneally administered to six injured and two sham-operated mice. The severity of spasticity was evaluated by the modified Ashworth scoring (MAS) system, and locomotor function was evaluated by the Basso-Beattie-Bresnahan (BBB) scale/Basso mouse score (BMS). The administration of baclofen significantly improved spasticity in the SCI mice and the mean MAS decreased to from 6.2 to 2.8. However, at the same time, it significantly exacerbated the locomotor dysfunction of the SCI mice and the mean BMS decreased from 4.7 to 2.3. The time-course of the changes in locomotor function coincided with the time-course of the spasticity score. We also confirmed that the administration of baclofen was not associated with any changes in either locomotor function or spasticity of the sham-operated control mice. Our results suggest that spasticity has a certain beneficial effect on ambulation ability. It is important to note that antispastic treatments may be associated with a risk of impairing the preserved function of chronic SCI patients.

Spasticity and Pain after Spinal Cord Injury: Impact on Daily Life and the Influence of Psychological Factors.

Spasticity and pain frequently co-occur in persons with spinal cord injury (SCI), yet, how these sequelae interact in daily life is unclear. Additionally, little is known about how psychological factors relate to the perception of spasticity and its impacts on daily life. (1) Characterize relationships between spasticity and chronic pain with regard to perceived severity, difficulty dealing, and life interference. (2) Determine the extent to which perceived spasticity severity and physiological, psychological, and pain-related factors contribute to impacts of spasticity on daily life (difficulty in dealing, life interference). (3) Determine the effects of painful spasticity on aspects of chronic pain and spasticity (severity, life interference, interference with sleep, and spasm duration). Observational study. University laboratory. Twenty participants with SCI and lower extremity spasticity. Measures included International SCI Pain Basic Data Set, Pain and Spasticity Inventories, Difficulty Dealing with Pain/Spasticity, SCI-Spasticity Evaluation Tool, Connor-Davidson Resilience and Moorong Self-Efficacy Scales, Spinal Cord Assessment Tool for Spastic Reflexes, spasm duration, and injury-related and demographic factors. Bivariate correlations, multiple regression analyses, and pairwise comparisons were performed. Spasticity and chronic pain were directly related, with respect to perceived severity, difficulty dealing, and life interference (rho = 0.514-0.673, P < .05). Shorter injury duration, greater perceived spasticity severity, and greater difficulty dealing with pain explained 61% of variance in difficulty dealing with spasticity. Greater perceived spasticity severity and lower resilience explained 72% of variance in life interference of spasticity. Spasm duration was not significantly associated with perceived spasticity severity. Participants with painful spasticity had significantly greater chronic pain severity (P = .02) and sleep-related impact of spasticity (P = .03) than participants without painful spasticity. Perceived severity of spasticity, injury duration, ability to deal with chronic pain, resilience, and painful spasms appear to play important roles in the negative impacts of spasticity on life after SCI. III.

Thermography assessment of spastic lower limb in patients after cerebral stroke undergoing rehabilitation

Stroke contributes to disability in adulthood. The assessment of the degree of spasticity is one of the basic methods of patient examination after stroke and is used for monitoring rehabilitative outcomes; however, no optimal scale for the unambiguous assessment of spasticity exists. Our study aimed to assess the usefulness of thermography in measuring the effects of rehabilitation in stroke patients’ spastic hemiparesis. In this prospective, single-center study, 40 stroke patients with a mean age of 60.6 ± 5.5 years were enrolled. All suffered from hemiparesis. Surface temperature of the shank was assessed with infrared thermography; degree of independence with the Barthel Index; and muscle tone with the Modified Ashworth Scale. A comparison of temperature between the spastic and non-spastic posterior part of the shank was conducted. Temperature changes, severity of spasticity, and gait pattern were evaluated and compared at baseline and after 6 weeks of rehabilitation. All patients completed a rehabilitation program. The baseline temperature in the spastic extremity was significantly lower than in the normal extremity (mean temperature 28.93 °C vs 30.20 °C; p = 0.0001). After rehabilitation, the temperature in the spastic extremity increased significantly; however, the significant difference between the two extremities persisted (mean temperature 29.76 °C vs 30.54 °C; p = 0.0001). After rehabilitation, spasticity in affected extremity decreased significantly (p > 0.001). Additionally, an improvement in gait pattern was observed. We conclude that thermography proved to be useful in the assessment of rehabilitation effects in stroke patients with spastic hemiparesis; thus, it can be considered an additional tool for determining impaired muscle tone in patients with spasticity.

A clinical study to assess the influence of acupuncture at \u201cWang\u2019s Jiaji\u201d acupoints on limb spasticity in patients in convalescent stage of ischemic stroke: study protocol for a randomized controlled trial

BackgroundStroke is characterized by high morbidity, high mortality, and high disability. Spasticity, one of the most common complications after stroke, may reduce the potential success of rehabilitation and has a detrimental effect on stroke patients’ daily function and quality of life. Moreover, the long-term management of spasticity is a financial burden to patients and increases societal costs. The current treatments, mainly including physical therapy, oral drugs, drug injection therapy, and surgical interventions, have been used to reduce spasticity. However, every conventional approach has its limitations. Acupuncture at the “Wang’s Jiaji” acupoints, based on the experience of the famous old doctor of traditional Chinese medicine (TCM) Le Ting Wang in treating post-stroke limb spasm, has been widely practiced in our department. This intervention has effectively avoided the controversy around acupuncture at local acupoints on the limbs, and is easy to apply without side effects. Our previous studies had found that acupuncture at the “Wang’s Jiaji-points” can reduce the occurrence and severity of spasticity occurring after stroke in the early stage (the first 21 days). In this study, we chose patients in the convalescent stage, 1–6 months after stroke, so as to study the efficacy and the specific intervention time of “Wang’s jiaji” in the convalescent stage after stroke.MethodsThis is a randomized, controlled, and single-blind study. Patients in the convalescent stage within 1–6 months of ischemic stroke will be selected as subjects. A total of 100 subjects will be randomly assigned to two groups. The acupuncture group will be given acupuncture treatment five times a week; the medicine group will be given 10mg baclofen three times a day. These two groups will continue to receive current usual care for the prevention and treatment of cerebrovascular diseases, but drugs that affect muscle tone will not be allowed. The treatment will last for 2 weeks. The primary outcome measurement is the simplified Fugl-Meyer Assessment. The secondary outcome measurements are the Modified Ashworth Scale, Modified Barthel Scale, and the H-reflex, F response, and H/M ratios of electromyography. All outcome measurements are assessed at baseline, 2 weeks, 4 weeks, and 12 weeks after first treatment except the electromyography, which is assessed at baseline and 2 weeks after first acupuncture.DiscussionThis trial aims to evaluate the effects and the specific intervention time of “Wang’s Jiaji” acupoints on spasticity after stroke.Trial registrationISRCTN registry, ISRCTN31511176. Registered on 29 August 2017.Version number of protocol 2016-2-1161Version date of protocol: 2016-1

Residual descending motor pathways influence spasticity after spinal cord injury.

Spasticity is one of the most common symptoms manifested in humans with spinal cord injury (SCI). The neural mechanisms contributing to its development are not yet understood. Using neurophysiological and imaging techniques, we examined the influence of residual descending motor pathways on spasticity in humans with SCI. We measured spasticity in 33 individuals with motor complete SCI (determined by clinical examination) without preservation of voluntary motor output in the quadriceps femoris muscle. To examine residual descending motor pathways, we used magnetic and electrical stimulation over the leg motor cortex to elicit motor evoked potentials (MEPs) in the quadriceps femoris muscle and structural magnetic resonance imaging to measure spinal cord atrophy. We found that 60% of participants showed symptoms of spasticity, whereas the other 40% showed no spasticity, demonstrating the presence of 2 clear subgroups of humans with motor complete SCI. MEPs were only present in individuals who had spasticity, and MEP size correlated with the severity of spasticity. Spinal cord atrophy was greater in nonspastic compared with spastic subjects. Notably, the degree of spared tissue in the lateral regions of the spinal cord was positively correlated with the severity of spasticity, indicating preservation of white matter related to motor tracts when spasticity was present. These results support the hypothesis that preservation of descending motor pathways influences spasticity in humans with motor complete SCI; this knowledge might help the rehabilitation and assessment of people with SCI. ANN NEUROL 2019.

When does spasticity in the upper limb develop after a first stroke? A nationwide observational study on 861 stroke patients

This study investigated the time taken for upper extremity spasticity to develop and its regional difference after first-ever stroke onset in a nationwide multicenter study in South Korea. The retrospective observational study included 861 individuals with post-stroke spasticity in the upper limbs. Spasticity in the upper extremity joints was defined as a modified Ashworth Scale score ≥1. The median time to develop upper limb spasticity after stroke onset was 34 days. 12% of post-stroke spasticity cases developed between 2 months and 3 months and 13% developed after 3 months from onset. At the time of diagnosis of spasticity, most patients showed only a slight increase in muscle tone, which was observed most frequently in the elbow, followed by the wrist, and fingers. Younger stroke survivors were more spastic, and the severity of spasticity increased with time. Approximately half of the patients with post-stroke spasticity developed spasticity during the first month. However, post-stroke spasticity can develop more than 3 months after stroke onset. Therefore, it is important to assess spasticity, even in the chronic state.

Clinically practical formula for preoperatively estimating the cutting rate of the spinal nerve root in a functional posterior rhizotomy.

A functional posterior rhizotomy (FPR) ideally involves minimal cutting of the posterior root while providing maximal reduction of disabling spasticity. However, the ideal cutting rate has yet to be determined. It was hypothesized that the cutting rate of the posterior root would negatively correlate with preoperative motor function in children with spasticity. Children who underwent an FPR between March 1996 and March 2017 and whose pre- and postoperative data were followed more than a year were enrolled. The preoperative Gross Motor Function Measure (GMFM) score and the overall cutting rate of the posterior root were plotted on a scatter plot, and a simple linear regression analysis was performed. The rationale for the cutting rate of the posterior root was tested by postoperative chronological changes in the GMFM score up to 5years after the FPR. The Gross Motor Function Classification System (GMFCS) was used to group the children. The postoperative and preoperative GMFM were compared at each GMFCS level. One hundred thirty-seven children (aged 2 to 19years old, mean 5.9years old) met the selection criteria. The cutting rate of the posterior root ranged from 17 to 83%, (mean 48.3%). A scatter plot was then made using GMFM scores between 10 and 90. The formula for the simple linear regression analysis was y = - 0.5539x + 73.896 (x, GMFM score; y, overall cutting rate (%)). The formula was further approximated based on the scatter plot findings as y = 100 - x. The postoperative GMFM showed an improved average score for all GMFCS levels although statistically significant improvement at postoperative 5years was confirmed in only the GMFCS level 1 group. The findings of this study supported the hypothesis of the negative correlation of the cutting rate of the posterior root with preoperative motor function in children with spasticity. The amount of posterior nerve root/rootlet cutting during FPR negatively correlated with the preoperative GMFM score. The approximated formula is simple, practical for clinical use, and helpful for preoperatively estimating the required overall cutting rate for the posterior root. The suggested cutting rate induced by the approximated formula should be used as a reference value and be modified according to preoperative motor function, severity and distribution of spasticity, the result of intraoperative neurophysiology, and other factors.

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.

Daily Practice Managing Resistant Multiple Sclerosis Spasticity With Delta-9-Tetrahydrocannabinol: Cannabidiol Oromucosal Spray: A Systematic Review of Observational Studies.

Background/purpose:Spasticity is one of the most common symptoms in people with multiple sclerosis (MS). Conventional anti-spasticity agents have limitations in their efficacy and tolerability. Delta-9-tetrahydrocannabinol: cannabidiol (THC:CBD) spray, a cannabinoid-based medicine, is approved as an add-on therapy for MS spasticity not adequately controlled by other anti-spasticity medications. The results from randomized controlled trials (RCTs) have demonstrated a reduction in the severity of spasticity and associated symptoms. However, RCTs do not always reflect real-life outcomes. We systematically reviewed the complementary evidence from non-interventional real-world studies.Methods:A systematic literature review was conducted to identify all non-RCT publications on THC:CBD spray between 2011 and 2017. Data on study design, patient characteristics, effectiveness, and safety outcomes were extracted from those publications meeting our inclusion criteria.Results:In total, we reviewed 14 real-world publications including observational studies and treatment registries. The proportion of patients reaching the threshold of minimal clinical important difference (MCID), with at least a 20% reduction of the spasticity Numeric Rating Scale (NRS) score after 4 weeks ranged from 41.9% to 82.9%. The reduction in the mean NRS spasticity score after 4 weeks was maintained over 6-12 months. The average daily dose was five to six sprays. Delta-9-tetrahydrocannabinol: cannabidiol was well tolerated in the evaluated studies in the same way as in the RCTs. No new or unexpected adverse events or safety signals were reported in everyday clinical practice.Conclusions:The data evaluated in this systematic review provide evidence for the efficacy and safety of THC:CBD in clinical practice and confirm results obtained in RCTs.

Predictors of Response to 4-Aminopyridine in Chronic Canine Spinal Cord Injury.

4-Aminopyridine (4AP), a potassium channel antagonist, can improve hindlimb motor function in dogs with chronic thoracolumbar spinal cord injury (SCI); however, individual response is variable. We hypothesized that injury characteristics would differ between dogs that do and do not respond to 4AP. Our objective was to compare clinical, electrodiagnostic, gait, and imaging variables between dogs that do and do not respond to 4AP, to identify predictors of response. Thirty-four dogs with permanent deficits after acute thoracolumbar SCI were enrolled. Spasticity, motor and sensory evoked potentials (MEPs, SEPs), H-reflex, F-waves, gait scores, and magnetic resonance imaging (MRI) with diffusion tensor imaging (DTI) were evaluated at baseline and after 4AP administration. Baseline variables were assessed as predictors of response; response was defined as ≥1 point change in open field gait score. Variables were compared pre- and post-4AP to evaluate 4AP effects. Fifteen of 33 (45%) dogs were responders, 18/33 (55%) were non-responders and 1 was eliminated because of an adverse event. Pre-H-reflex threshold <1.2 mA predicted non-response; pre-H-reflex threshold >1.2 mA and Canine Spasticity Scale overall score <7 were predictive of response. All responders had translesional connections on DTI. MEPs were more common post-4AP than pre-4AP (10 vs. 6 dogs) and 4AP decreased H-reflex threshold and increased spasticity in responders. 4-AP impacts central conduction and motor neuron pool excitability in dogs with chronic SCI. Severity of spasticity and H-reflex threshold might allow prediction of response. Further exploration of electrodiagnostic and imaging characteristics might elucidate additional factors contributing to response or non-response.

Assessment of quality of life in relation to spasticity severity and socio-demographic and clinical factors among patients with spinal cord injury

Objective: To assess the impact of spasticity severity as well as socio-demographic and clinical factors on quality of life (QOL) and to identify factors predicting poor QOL among patients with spinal cord injury (SCI)Design: Descriptive cross-sectional study.Setting: Tertiary care clinic in Istanbul, Turkey.Participants: A total of 110 patients with SCI (mean (SD) age: 43.8 (14.7) years, 58.2% were males) were enrolled.Assessments: The American Spinal Injury Association (ASIA) Impairment Scale (AIS), Modified Ashworth Scale (MAS) and Turkish version of the World Health Organization Quality of life questionnaire (WHOQOL-BREF) were utilized to determine the SCI category, severity of spasticity and QOL scores, respectively.Outcome measures: The WHOQOL-BREF scores were evaluated with respect to the severity of spasticity, aetiology and duration of SCI, AIS category and method of bladder management.Results: The mean (SD) physical health (41.9 (15.3) vs. 46.5 (10.9), P = 0.029), social relationships (45.6 (20.2) vs. 53.8 (17.3), P = 0.025) and total WHOQOL-BREF scores were significantly lower in patients with more severe spasticity. Multivariate linear regression analysis revealed that severity of spasticity was a significant predictor of decreased WHOQOL-BREF total scores, physical domain scores and social relations domain scores by 11.381 (P = 0.007), 11.518 (P = 0.005) and 17. 965 (P = 0.004), respectively.Conclusion: In conclusion, addressing QOL in relation to severity of spasticity for the first time among Turkish SCI patients, our findings revealed a negative impact of the spasticity severity on the WHOQOL-BREF scores, particularly for physical health and social relationship domains.

Does acupuncture help patients with spasticity? A narrative review.

Spasticity is a motor disorder encountered after upper motor neuron lesions. It adversely affects quality of life in most patients and causes long-term burden of care and has significant financial implications. The effect of conventional therapies for spasticity including physical therapy, surgery, and pharmacotherapy are not always satisfying because of the short-term effects or side effects in some patients. Acupuncture is a part of traditional medicine originating from China. It has been used to resolve functional recovery problems after central nervous system injury for many years in Asian countries and is increasingly popular in western countries. Some researches suggest that acupuncture has therapeutic potential to help improve limb movement function and decrease the severity of spasticity. This review synthesizes studies involving stroke, brain injury, spinal cord injury, cerebral palsy, and multiple sclerosis to give an overall picture of the effect and potential mechanisms of acupuncture on spasticity occurring after upper motor neuron lesions. Moderate-quality evidence suggests that electroacupuncture combined with conventional routine care (pharmacological/rehabilitation) could reduce spasticity and improve motor function and activities in daily living after stroke. However, there is not enough evidence to conclude that acupuncture (including electroacupuncture) could reduce spasticity with other central nervous system diseases.

Interaction between muscle tone, short-range stiffness and increased sensory feedback gains explains key kinematic features of the pendulum test in spastic cerebral palsy: A simulation study.

The pendulum test is a sensitive clinical assessment of spasticity where the lower leg is dropped from the horizontal position and features of limb motion are recorded. Three key kinematic features are associated with the degree of severity of spasticity in children with cerebral palsy: decreased initial limb excursion, reduced number of limb oscillations, and a non-vertical resting limb angle. While spasticity is attributed to increased velocity-dependent resistance to motion, prior models simulating increased sensorimotor feedback of muscle velocity fail to explain the key pendulum test kinematic outcomes in spastic individuals. Here we hypothesized that increased muscle tone, causing a transient increase in muscle force, i.e. short-range stiffness, could account for reduced first swing excursion and non-vertical resting limb angle. We further hypothesized that hyperreflexia modeled based on muscle fiber force, and not velocity, feedback would be necessary to reduce the number of oscillations because of its interaction with transiently increased muscle force due to short-range stiffness. We simulated the lower leg as a torque-driven single-link pendulum. Muscle tone was modeled as a constant baseline joint torque, short-range stiffness torque was dependent on the level of muscle tone, and delayed sensory feedback torque to simulate reflex activity was based on either muscle velocity or force. Muscle tone and transient short-range stiffness were necessary to simulate decreased initial swing excursion and non-vertical resting leg angle. Moreover, the reduction in the number of oscillations was best reproduced by simulating stretch reflex activity in terms of force, and not velocity, feedback. Varying only baseline muscle torque and reflex gain, we simulated a range of pendulum test kinematics observed across different levels of spasticity. Our model lends insight into physiological mechanisms of spasticity whose contributions can vary on an individual-specific basis, and potentially across different neurological disorders that manifest spasticity as a symptom.

Managing Spasticity in a Pregnant Woman with Spinal Cord Injury: a Review

This paper aims to review the available treatment options for spasticity management that can be used for pregnant women with spinal cord injury (SCI). There are extensive reviews exploring the approach to care for the parturient with SCI. These often include a discussion on common medications used and their potential impact on pregnancy and lactation. However, there are no specific guidelines on managing spasticity in pregnancy. Existing review articles show a low level of evidence for commonly utilized physical interventions in spasticity management. There are several case reports on the use of intrathecal baclofen and focal injections with botulinum neurotoxin during pregnancy. The approach to management should recognize the interaction of pregnancy with secondary complications of SCI. Treatment decisions should be based on severity of spasticity, patient goals, and education of potential risks and benefits of different options with regard to pregnancy, lactation, maternal, and fetal outcomes.

Association Between Spasticity and Functional Impairments During the First Year After Stroke in Korea: The KOSCO Study.

The aim of the study was to investigate the correlation between spasticity severity and functional outcomes during the first year after stroke. The Korean Stroke Cohort for Functioning and Rehabilitation is a large, multicenter, prospective cohort study of all patients with acute first-ever stroke admitted to participating hospitals in nine Korean areas. To investigate the correlation between spasticity severity and functional status measured by using the Institutes of Health Stroke Scale (NIHSS), Modified Barthel Index (MBI), Functional Independence Measurement (FIM), Fugl-Meyer Assessment (FMA), Functional Ambulatory Category (FAC), modified Rankin scale (mRS), and American Speech-Language Hearing Association National Outcome Measurement System Swallowing Scale (ASHA-NOMS), data were analyzed at 3, 6, and 12 mos after the occurrence of stroke. A total of 7359 stroke patients, 3056 were finally included. Prevalence rates of spasticity in patients after stroke were 6.8% at 3 mos, 6.9% at 6 mos, and 7.6% at 12 mos. The scores of mRS and NIHSS were higher and those of K-MBI, FIM, FMA, and ASHA-NOMS were lower in more severe spastic patients, indicating poorer functional outcomes (P < 0.05). This study demonstrated the coexistence of spasticity and poor functional outcome during the first year after first-ever stroke patients.

P40. Delta-9-Tetrahydrocannabinol-cannabidiol (THC/CBD) oromucosal spray for the treatment of spasticity in ALS – Assessment of patient reported outcomes

Background Treatment of spasticity poses a major challenge in ALS patient management. Antispasticity medication may be limited due to side effects or to exacerbation of muscle weakness. Delta-9-tetrahydrocannabinol (THC)/cannabidiol (CBD) oromucosal spray (Sativex®), approved for multiple sclerosis spasticity second line treatment, might be an off-label treatment option in ALS patients with resistant spasticity. Although THC/CBD is known to be used in a subgroup of ALS patients few systematic investigations have been reported. Methods A retrospective observational study investigated patients with ALS, spasticity and prescribed THC/CBD treatment, who were registered on the internet platform Ambulanzpartner Versorgungsportal (www.ambulanzpartner.de). The survey addressed the region and severity of spasticity (numeric rating scale), dosage of THC/CBD, treatment satisfaction as assessed by the Net Promoter Score (NPS) and the 9-item treatment satisfaction questionnaire for medication (TSQM9). Results 68 patients with ALS, spasticity and prescribed THC/CBD were identified. 44 patients responded to the survey (64%). The median age of participants was 58 years (27–87 years). Most commonly, spasticity was located in the lower limbs (95%; n = 42). THC/CBD was used in male and female patients alike (ratio 43%/57%). Most patients (78%; n = 25) reported at least one application per day (daily use), whereas 22% of patients used it less often (13% weekly, 9% monthly). There was a wide range in the dosage of THC/CBD in ALS ( Fig. 1 ). The median dosage was 6 oromucosal spray applications per day (2.7 mg THC/ 2.5 mg CBD each). 25% of patients report 1–2 applications per day (infrequent use) whereas another 25% of patients report more than 10 applications per day (frequent use). The NPS assessment revealed a good satisfaction of ALS patients with THC/CBD (NPS sum score: +4.9). Analysis of TSQM9 demonstrated high treatment satisfaction for several TSQM9 subdomains including ‘effectiveness’ (70,5), ‘convenience’ (76.6) and ‘overall satisfaction’ (75.0). Discussion THC/CBD was used in a wide range of ALS patients regarding age and clinical presentation. The mean dosage of THC/CBD in ALS with resistant spasticity was well comparable with the dosage in the approved MS spasticity indication. The wide dosage distribution underlines that THC/CBD dosage was adjusted to the individual needs of symptom control. Patient reported outcome scores demonstrated high treatment satisfaction. However, prospective studies on THC/CBD in ALS-related spasticity and comparative investigations to other oral antispasticity medications are of interest to address the effectiveness of THC/CBD in the domains of spasticity, pain, muscle cramps, and other ALS-related symptoms. Acknowledgement This work was supported by a grant of Almirall Hermal GmbH to Ambulanzpartner Soziotechnologie GmbH.

Objective Assessment of Spasticity With a Method Based on a Human Upper Limb Model.

This paper presents a method based on a human upper limb model that assesses the severity of spasticity in patients with stroke objectively. The kinematic model consists of four moving segments connected by four joints. The joint torques are computed using inverse dynamics with measurements from three inertial measurement units (IMUs) attached to the participant's upper limb. The muscle activations are estimated using the joint torques via a musculoskeletal model which consists of 22 muscles. The severity of spasticity is then quantified by measuring the tonic stretch reflex threshold (TSRT) of the participant. 15 patient participants participated in the experiments where they were assessed by two qualified therapists using modified Ashworth scale (MAS), and their motions and EMG signals were captured at the same time. Using the upper limb model, the TSRT of each patient was measured and ranked. The estimated muscle activation profiles have a high correlation (0.707) to the EMG signal profiles. The null hypothesis that the rankings of the severity using the model and the MAS assessment have no correlation has been tested, and was rejected convincingly ( ). These findings suggest that the model has the potential to complement the existing practices by providing an alternative evaluation method.

Spasticity severity after stroke and relation to hand motor recovery and corticospinal tract integrity

Spasticity of muscles controlling the hand is common after stroke, however, its impact on hand motor recovery and its neural correlates are poorly understood. This longitudinal observational study investigated hand spasticity after stroke in relation to motor recovery, secondary complications and lesion location. Sixty-one patients were assessed at three weeks (T1), three (T2) and six months (T3) after stroke. Neural (NC) and viscoelastic (EC and VC) stretch-resistance in wrist and finger flexors were quantified with the NeuroFlexor method. Clinical evaluation included Fugl–Meyer (FMA-HAND), Box and Block Test (BBT), passive range of movement (ROM) and pain (FMA-subscale). Magnetic Resonance Imaging data were analyzed for weighted corticospinal tract lesion load (wCST-LL) and voxel-based lesion symptom mapping (VLSM). Four spasticity subgroups were defined: early severe (SS, n = 10), early moderate (MS, n = 10), late developing (LS, n = 17) and no spasticity (NS, n = 24). All groups except SS improved in FMA-HAND to T3. SS and LS had no recovery in BBT. SS showed a larger loss of ROM and more frequent arm pain at T3. wCST-LL predicted NC at T3, also when including FMA-HAND and lesion volume as covariates. VLSM showed that lesioned white matter below the cortical hand knob correlated positively with spasticity. Severe hand spasticity impairs motor recovery, ROM and may increase risk for development of arm pain. This study provides the first data showing that spasticity is related to lesion load of the CST. The significance of early quantification of spasticity for prediction of motor outcome and rehabilitation planning will be discussed.

Dorsal Longitudinal T-Myelotomy (Bischof II Technique): A Useful, Antiquated Procedure for the Treatment of Intractable Spastic Paraplegia

Dorsal longitudinal T-myelotomy is a long-established operation to treat severe spastic paraplegia. The present study aimed to report this surgical technique and investigate the efficacy of T-myelotomy for spasticity relief. All cases undergoing T-myelotomy for treatment of intractable spastic paraplegia during 2009-2017 were included. The severity of spasticity was evaluated with the Modified Ashworth Scale, Penn Spasm Frequency Scale, Adductor Tone Rating Scale, degree of passive range of motion, and occurrence of abdominal muscle spasms. Other clinical assessments included deep tendon reflex assessed by the National Institute of Neurological Disorders and Stroke scale, Babinski sign, healing of decubitus ulcers, and ambulatory status. Fourteen patients with a mean age of 39.3±13.4 years were included. The 7 patients with abdominal muscle spasms before surgery had no spasms after surgery. The Babinski sign was absent in all cases after surgery. Unhealed pressure ulcers in all 9 cases were healed after surgery. All 4 patients with a preoperative bed-bound condition were able to ambulate with a wheelchair. Astatistically significant improvement in mean Modified Ashworth Scale score, degree of passive range of motion, and National Institute of Neurological Disorders and Stroke scale score was found in the subgroup and overall analyses. There was also a statistically significant improvement in the Penn Spasm Frequency Scale and Adductor Tone Rating Scale scores. Dorsal longitudinal T-myelotomy remains an effective option for the treatment of intractable spastic paraplegia. It is suitable for, and may be an alternative to, intrathecal baclofen therapy for patients with complete spinal cord lesion or patients without hope of regaining motor function.