Management Of Spasticity Research Articles

Effective management of spasticity and impacts on weight change and resting energy expenditure in a female with spinal cord injury: a case report

The impact of muscle spasticity on weight change and energy expenditure after spinal cord injury (SCI) is not well understood. This case study reports changes to body weight and resting energy expenditure (REE) in a 36-year-old female (T3 AIS A SCI; 80 kg; body mass index=28 kg m-2 at injury) requiring escalating therapies to manage severe spasticity. Body weight, spasticity medications and fasted REE (measured using indirect calorimetry, canopy hood) were recorded at 4, 16, 17, 20 and 44 months post injury. Spasticity was assessed at each time point using the Modified Ashworth Scale (MAS). At 4 months post injury, REE was high (1710 kcal per day) corresponding with severe spasticity in the lower limbs (4 on the MAS). Over the following 12 months, the patient experienced an 8 kg weight loss, visible lower limb muscle wasting and a 30% reduction in REE while requiring increasing drug therapies for spasticity. With insertion of an intrathecal Baclofen pump at 17 months and cessation of other medications, spasticity improved markedly and weight increased by 6 kg in 27 months without any significant change to REE (mean=1260 kcal±2%). Effective management of spasticity with intrathecal Baclofen appears to be associated with weight gain but not REE. Without body composition and activity energy expenditure data, this observation is difficult to explain. Regardless, routine weight monitoring with appropriate dietary counselling should be considered in this patient group to help prevent unintentional weight gain.

The effect of aquatic exercise on spasticity, quality of life, and motor function in cerebral palsy.

The primary aim of this study was to compare the effects of aquatic exercises and land-based exercises on spasticity, quality of life, and motor function in children with cerebral palsy (CP). The secondary aim was to assess the morphology of spastic muscle using ultrasonography. Thirty-two children (17 boys, 15 girls; mean age 9.7±2.7 years; range 4 to 17 years) with CP were enrolled in this study. The patients were randomly assigned to two groups to receive 30 sessions of an aquatic or a land-based exercise program. The patients were assessed for the impairment level, functional measures, and quality of life before and after therapy. Ultrasonographic assessment of spastic gastrocnemius muscle was also performed. Both group showed significant improvements in most functional outcome measures. There were no significant differences in the percentage changes of the scores for functional outcome measures between the two groups. However, aquatic exercise produced a higher improvement in quality of life scores than the land-based exercises. Post-treatment ultrasonographic assessment of spastic gastrocnemius muscle showed a significant improvement in the compressibility ratio in the aquatic exercise group. The modified Ashworth Scale score of spastic gastrocnemius muscle in patients with CP showed a negative and weak-to-moderate correlation with the compressibility ratio based on the ultrasonographic evaluation. Our study results suggest that the aquatic exercises are as effective as land-based exercises for spasticity management and motor function improvement in children with CP. Aquatic exercise can result in a higher level of improvement in quality of life scores than the land- based exercises. Ultrasonographic muscle compressibility ratio may be used to evaluate muscle elasticity in children with CP.

Systematic Review of the Costs and Benefits of Prescribed Cannabis-Based Medicines for the Management of Chronic Illness: Lessons from Multiple Sclerosis.

Cannabis-based medicines (CBMs) may offer relief from symptoms of disease; however, their additional cost needs to be considered alongside their effectiveness. We sought to review the economic costs and benefits of prescribed CBMs in any chronic illness, and the frameworks used for their economic evaluation. A systematic review of eight medical and economic databases, from inception to mid-December 2016, was undertaken. MeSH headings and text words relating to economic costs and benefits, and CBMs were combined. Study quality was assessed using relevant checklists and results were synthesised in narrative form. Of 2514 identified records, ten studies met the eligibility criteria, all for the management of multiple sclerosis (MS). Six contained economic evaluations, four studies reported utility-based quality of life, and one was a willingness-to-pay study. Four of five industry-sponsored cost-utility analyses for MS spasticity reported nabiximols as being cost-effective from a European health system perspective. Incremental cost-effectiveness ratios per quality-adjusted life-year (QALY) gained for these five studies were £49,257 (UK); £10,891 (Wales); €11,214 (Germany); €4968 (Italy); and dominant (Spain). Nabiximols for the management of MS spasticity was not associated with statistically significant improvements in EQ-5D scores compared with standard care. Study quality was moderate overall, with limited inclusion of both relevant societal costs and discussions of potential bias. Prescribed CBMs are a potentially cost-effective add-on treatment for MS spasticity; however, this evidence is uncertain. Further investment in randomised trials with in-built economic evaluations is warranted for a wider range of clinical indications. PROSPERO Registration Number: CRD42014006370.

Therapeutic benefit of uncobotulinum toxin A for spasticity of the triceps surae in patients with multiple sclerosis: An observational study on gait spatiotemporal parameters

Few data are available on the use of botulinum toxin for spasticity treatment in multiple sclerosis (MS). In a previous study we found that one of the main therapeutic goals in patients suffering from spasticity of the triceps surae was improvement in walking. In this pilot observational study, we assessed the benefit of an injection of incobotulinumtoxinA in patients with MS suffering from spasticity of the triceps surae. This study enrolled MS patients with Expanded Disability Status Scale (EDSS) scores < 6 who required botulinum toxin for focal spasticity of the triceps surae. Treatment consisted of 200 IU of incobotulinumtoxinA (Xeomin) (100 units in 3 milliliters) injected into the triceps surae at 5 sites. A second injection was allowed, but after a 3 months delay. Outcome measures were assessed before injection, and at 6 weeks and 3 months post-injection, using the Goal Attainment Scale (GAS), Twelve Item MS Walking (MSWS-12) Scale, Timed Up and Go (TUG) Test, and 6 Minute Walk Test (6MWT). Spatiotemporal gait data were obtained by GAITRite. Twenty-two patients with a mean age of 48.2 ± 12 years and a mean EDSS of 4.2 (median 4.7). At 6 weeks, spatiotemporal parameters and the results of the 6MWT were not significantly different even though we observed a significant improvement for the GAS, the MSWS-12 score ( P = 0.015), and the TUG Test ( P = 0.003). However, at 3 months, there was a significant benefit on injected (0.005) and non-injected (0.01) step length measured by GaitRITE but not on support distribution (0.18; 0.38). This may explain the decrease in gait fatigability and the increase of speed on the 6MWT (0.02), although neither the TUG Test nor the MSWS-12 Scale showed improvement. Eighty percent of patients had reached their objective on GAS. These results confirm the interest of toxin as a treatment for focal spasticity of the triceps surae with a significant improvement of gait. Further studies are needed to clarify guidelines for administration (dosage, intervals). The best results on gait parameters are obtained after 3 months, confirmation of the hypothesis of central effect of toxin. Botulinum toxin should probably be discussed early in the management of spasticity in MS patients.

Medical management of spasticity using botulinum toxin in France: Etiologies and evolution of practices

Spasticity is a frequent complication of various central nervous system (CNS) pathologies. Botulinum toxin (BoNT) is one of the treatments of spasticity when it causes a patient discomfort. This analysis explores the evolution of hospital care for spasticity treated with BoNT in France between 2009 and 2014 and describes the main etiologies. Data were extracted from the national Programme Médical de Systemes d’Information (PMSI) database, Médecine-Chirurgie-Obstétrique (MCO) and Soins de Suite et de Réadaptation (SSR) chained 2009–2014. This analysis describes the evolution of the number of patients diagnosed with spasticity and their management using BoNT in MCO and SSR. Etiologies of spasticity were investigated among 33 groups of pathologies (using ICD-10 Codes) described in the literature as etiology of spasticity. Over the period, the number of patients coded as having spastic paresis increased by 35%. The main causes of spasticity were stroke (45%), spinal cord damage (SCD: 8%), multiple sclerosis (MS: 8%), traumatic brain injury (TBI: 4%) and CNS tumours (4%). The etiology of spasticity could not be identified in 17% patients, and 2 different etiologies could result in spasticity for 5% patients. Between 2009 and 2014, the number of BoNT injections for spastic paresis increased by 90% (from 19,033 to 36,167). At the same time, the number of annual injections per patient remained relatively stable (+3%). The increase in injections was more pronounced in MCO (+128%) than SSR (+52%). In 2014, 60% of injections were performed in MCO medical units. Among patients with an identified etiology, over the period 2009–2014, 18.5% were treated at least once with BoNT. The proportion of patients treated was higher for patients with TBI (29%) and MS (22%) than for stroke (17%) or SCD (14%). Management of spasticity using BoNT increased in France between 2009 and 2014. This was mainly due to the increased number of spastic patients diagnosed and subsequently treated. The future reimbursement measures for SSR medical units are likely to lead to a continued increase in the number of patients treated, and an increase of those treated within SSR units.

Study regarding the effectiveness of extracorporeal shock wave therapy on spasticity

Stroke and its clinical and functional consequences are the leading causes for long-term disability in Europe, offering an everyday challenge for all rehabilitation specialists. Every month, our clinic welcomes 10 to 15 post-stroke patients in the post-acute to chronic stage and more than half of them face an increase in spasticity leading to an augmentation of the disability level and a decline of their quality of life. For a better approach they must be involved in a complex spasticity management program. We have studied the effect of extracorporeal shock wave therapy in the spasticity management for 25 in-patients between January and March 2017 after a stroke within the last 3 years. They came for assessment and treatment of pain, spasticity and limitations in their daily activities. We used Ashworth scale to assess spasticity, Visual Analog Scale to measure the pain and Activities of Daily Living score for evaluation before and after the rehabilitation program. The therapy was applied two times a week for 2 weeks on the palmar flexors for the upper limb and the muscular junction of the gastrocnemius muscle for the lower limb. Statistical data was analyzed using SPSS for Windows version 10.0 and Epi Info 7. Data analysis was given in mean ± standard deviation, minimum and maximum. The correlation test and paired t -test were used for the comparison of parametric and non-parametric results. P -values of less than 0.01 were considered statistically significant. Short-term results for most patients showed improvement in pain, especially a decrease in spasticity followed by better tolerance to the physical therapy program, but with no major changes in ADL score. The limits of the study are given by the small number of patients included, a lack of a medium and long-term assessment of the therapeutic effect evaluation and the absence of a placebo controlled group.

Time to retreatment with botulinum toxin A in upper limb spasticity management: Initial data from the Upper Limb International Spasticity (ULIS)-III study

The ongoing ULIS-III study aims to describe real-life clinical practice and assess patient-centered goal attainment with integrated upper limb spasticity (ULS) management that includes repeated botulinum toxin A (BoNT-A) injections. This interim analysis evaluates BoNT-A reinjection rates within rehabilitation management. ULIS-III is a 2-year longitudinal, prospective, observational, cohort study ( NCT02454803 ), which is expected to involve 58 centers (14 countries) and to enroll > 1000 adults with ULS receiving repeated BoNT-A injections. This analysis involved 44 centers (13 countries) and 335 patients (reflective of ULIS-III recruitment stage). Primary endpoint of ULIS-III is goal attainment, using Goal Attainment Scaling-Evaluation of Outcome for ULS to evaluate change following BoNT-A and concomitant treatments. BoNT-A preparation type, total dose, number of injections, and injection intervals will be recorded, as well as physical treatments, economic and quality-of-life data. Recruitment began January 2015. Patients with data for ≥ 2 injections ( n = 335), had a mean (SD) time between first and second injections of 154.9 (58.6), 137.8 (60.5), and 124.4 (41.0) days for abobotulinumtoxinA ( n = 203), onabotulinumtoxinA ( n = 94), and incobotulinumtoxinA ( n = 38), respectively. Of these patients, 177 received ≥ 3 injections. Mean (SD) time between second and third injection was 146.4 (48.5), 131.8 (36.9), and 116.3 (32.3) days for abobotulinumtoxinA ( n = 110), onabotulinumtoxinA ( n = 48), and incobotulinumtoxinA ( n = 19), respectively. The mean (SD) change in time between first and second injection intervals for these 177 patients was −5.8 (68.1), 2.3 (37.9), and 0.9 (23.3) days for abobotulinumtoxinA, onabotulinumtoxinA, and incobotulinumtoxinA, respectively. Initial ULIS-III injection interval data suggest differences in time to retreatment with different BoNT-A preparations. Longer injection intervals may reduce patient and carer burden. However, the clinical significance and generalizability of the findings reported here are as yet undetermined and the current sample as well as other variables may influence reinjection. Further ULIS-III data will provide additional clarity to these preliminary analyses. This is an encore of the original abstract submitted to AAPM&R 2017 (Turner-Stokes et al.).

Poster 57: Time to Retreatment with Botulinum Toxin A in Upper Limb Spasticity Management: Initial Data from the Upper Limb International Spasticity (ULIS)-III Study

Poster 57: Time to Retreatment with Botulinum Toxin A in Upper Limb Spasticity Management: Initial Data from the Upper Limb International Spasticity (ULIS)-III Study

Botulinum toxin for treatment of spasticity in patients with primary lateral sclerosis

Primary lateral sclerosis:(PLS) is a rare motoneuronal disease resulting in pyramidal and bulbar syndrome. The clinical pattern mimics amyotrophic lateral sclerosis (ALS). Nevertheless, PLS evolution resembles hereditary spastic paraplegia and most of the patients have a good life expectancy. Spasticity is a major symptom of the disease. Despite the rarity of the disease, many patients with PLS are referred to our department. This study describes spasticity management and outcome in patients with PLS using botulinum toxin injections. Between 2009 and 2015, 55 patients suffering from PLS with either paraparesis or tetraparesis were referred to the specialized consultation in physical rehabilitation medicine department in Hospital Pitié-Salpêtrière in Paris, in order to manage their spasticity. Their medical charts were retrospectively analyzed, to determine the effects of botulinum toxin therapy. Among the 55 patients, 44 patients received botulinum toxin injections, preceded by motor block for 16 patients. Injections were mostly performed in lowers limbs in order to ameliorate comfort, or ambulation. The treatment was uncomplicated. Among the 44 patients treated with botulinum toxin injections, 28 patients (63.6%) were satisfied by the treatment. Twenty-two patients (50%) underwent botulinum toxin therapy for at least a year, 6 patients (13.6%) for more than 3 years. This study confirms the interest of botulinum toxin for the treatment of spasticity in patients with PLS as it provided clinical improvement of spasticity in almost two thirds of our patients. PLS evolutes slowly, this treatment could be reiterated in a long-term approach.

Outcome of selective motor fasiculotomy in the management of lower limb spasticity due to cerebral palsy (a prospective cohort study in 23 children)

Outcome of selective motor fasiculotomy in the management of lower limb spasticity due to cerebral palsy (a prospective cohort study in 23 children)

Is spasticity always the same? An observational study comparing the features of spastic equinus foot in patients with chronic stroke and multiple sclerosis

Spasticity is common in stroke and multiple sclerosis. To treat spasticity we have a wide range of interventions, whose application may depend not only on the severity of spasticity but also on its etiology. Consequently, a better understanding of muscle spasticity in different neurological diseases may inform clinicians as to the more appropriate therapeutic approach. Our aim was to compare the clinical and ultrasonographic features of spastic equinus in patients with chronic stroke and multiple sclerosis. Thirty-eight patients with secondary progressive multiple sclerosis and 38 chronic stroke patients with spastic equinus were evaluated at the affected ankle according to the following outcomes: modified Ashworth scale, Tardieu scale, passive range of motion, spastic gastrocnemius muscle echo intensity and thickness. Affected calf muscles tone was significantly greater in patients with chronic stroke (modified Ashworth scale P=0.008; Tardieu scale angle P=0.004) as well as spastic gastrocnemius muscle echo intensity (P<0.001). Affected ankle range of motion was significantly greater in patients with multiple sclerosis (P<0.001) as well as spastic gastrocnemius muscle thickness (medialis: P=0.003; lateralis: P=0.004). Our findings evidenced that the same pattern of spasticity (equinus foot) has some different features according to its etiology. This may help the management of spasticity.

Development of elbow spasticity model for objective training of spasticity assessment of patients post stroke.

Reliable assessment is essential for the management of spasticity, one of the most frequent complication of various neurological diseases. For the spasticity assessment, several clinical tools have been developed and widely used in clinics. The most popular one is modified Ashworth scale (MAS). It has a simple protocol, but is subjective and qualitative. To improve its reliability, quantitative measurement and consistent training would be needed. This study presents an elbow spasticity simulator which mimics spastic response of adult post stroke survivors. First, spastic responses (i.e. resistance and joint motion) from patients with a stroke were measured during conventional MAS assessment. Each grade of MAS was quantified by using three parameters representing three characteristics of the spasticity. Based on the parameters, haptic models of MAS were developed for implementing repeatable and consistent haptic training of novice clinicians. Two experienced clinicians participated in preliminary evaluation of the models.

Assessment of elbow spasticity with surface electromyography and mechanomyography based on support vector machine.

The Modified Ashworth Scale (MAS) is the gold standard in clinical for grading spasticity. However, its results greatly depend on the physician evaluations and are subjective. In this study, we investigated the feasibility of using support vector machine (SVM) to objectively assess elbow spasticity based on both surface electromyography (sEMG) and mechanomyography (MMG). sEMG signals and tri-axial accelerometer mechanomyography (ACC-MMG) signals were recorded simultaneously on patients' biceps and triceps when they extended or bended elbow passively. 39 post-stroke patients participated in the study, and were divided into four groups regarding MAS level (MAS=0, 1, 1+ or 2). The three types of features, root mean square (RMS), mean power frequency (MPF), and median frequency (MF), were calculated from sEMG and MMG signal recordings. Spearman correlation analysis was used to investigate the relationship between the features and spasticity grades. The results showed that the correlation between MAS and each of the five features (MMG-RMS of the biceps, MMG-RMS of the triceps, the EMG-RMS of the biceps, EMG-RMS of the triceps, EMG-MPF of the triceps) was significant (p<;0.05). The four spasticity grades were identified with SVM, and the classification accuracy of SVM with sEMG, MMG, sEMG-MMG were 70.9%, 83.3%, 91.7%, respectively. Our results suggest that using the SVM-based method with sEMG and MMG to assess elbow spasticity would be suitable for clinical management of spasticity.

Successful long-term management of spasticity in patients with multiple sclerosis using a software application (APP): A pilot study

BackgroundSpasticity is a very common syndrome in patients with multiple sclerosis (pwMS), but available treatments lead to sufficient symptom control only in one third. ObjectiveTo investigate the impact of an individualized training program on improving spasticity in a prospective pilot trial in pwMS suffering from moderate spasticity (defined as ≥ 4 on a normative rating scale; NRS). MethodsPwMS were familiarized with predefined exercises targeting spasticity while undergoing inpatient rehabilitation (IR). After IR, 20 pwMS were 1:1 randomized either to a newly designed APP-based home therapy program providing suitable exercises on a daily basis or to a paper-based home therapy program for 3 months. At month 3, all patients received the APP-based home program for another 3 months. Degree of spasticity was rated on the NRS. ResultsUndergoing inpatient rehabilitation for a mean of 32 days led to a significant reduction in spasticity in pwMS (p = 0.00). Further self-training with the APP-based home program for 3 months led to 1.2 lower mean NRS as compared to training with the conventional paper-based program (p = 0.09). Spasticity was found to be on low levels again in both groups after 6 months. ConclusionIn pwMS, an individually tailored anti-spasticity program delivered by a software APP is a feasible tool for increasing long-term adherence to self-training thereby positively impacting spasticity in pwMS.

Goals Set by Patients Using the ICF Model before Receiving Botulinum Injections and Their Relation to Spasticity Distribution.

Purpose: Goal Attainment Scaling (GAS) is used to assess functional gains in response to treatment. Specific characteristics of the functional goals set by individuals receiving botulinum toxin type A (BoNTA) injections for spasticity management are unknown. The primary objectives of this study were to describe the characteristics of the goals set by patients before receiving BoNTA injections using the International Classification of Functioning, Disability and Health (ICF) and to determine whether the pattern of spasticity distribution affected the goals set. Methods: A cross-sectional retrospective chart review was carried out in an outpatient spasticity-management clinic in Toronto. A total of 176 patients with a variety of neurological lesions attended the clinic to receive BoNTA injections and completed GAS from December 2012 to December 2013. The main outcome measures were the characteristics of the goals set by the participants on the basis of ICF categories (body functions and structures, activity and participation) and the spasticity distribution using Modified Ashworth Scale scores. Results: Of the patients, 73% set activity and participation goals, and 27% set body functions and structures goals (p<0.05). In the activity and participation category, 30% of patients set moving and walking goals, 28% set self-care and dressing goals, and 12% set changing and maintaining body position goals. In the body functions and structures category, 18% set neuromuscular and movement-related goals, and 8% set pain goals. The ICF goal categories were not related to the patterns of spasticity (upper limb vs. lower limb or unilateral vs. bilateral spasticity) or type of upper motor neuron (UMN) lesion (p>0.05). Conclusion: Our results show that patients receiving BoNTA treatment set a higher percentage of activity and participation goals than body functions and structures goals. Goal classification was not affected by type of spasticity distribution or type of UMN disorder.

Effects of a group spasticity management program versus usual care in people with multiple sclerosis: A randomized controlled pilot trial (P3.354)

Effects of a group spasticity management program versus usual care in people with multiple sclerosis: A randomized controlled pilot trial (P3.354)

Spasticity, Motor Recovery, and Neural Plasticity after Stroke.

Spasticity and weakness (spastic paresis) are the primary motor impairments after stroke and impose significant challenges for treatment and patient care. Spasticity emerges and disappears in the course of complete motor recovery. Spasticity and motor recovery are both related to neural plasticity after stroke. However, the relation between the two remains poorly understood among clinicians and researchers. Recovery of strength and motor function is mainly attributed to cortical plastic reorganization in the early recovery phase, while reticulospinal (RS) hyperexcitability as a result of maladaptive plasticity, is the most plausible mechanism for poststroke spasticity. It is important to differentiate and understand that motor recovery and spasticity have different underlying mechanisms. Facilitation and modulation of neural plasticity through rehabilitative strategies, such as early interventions with repetitive goal-oriented intensive therapy, appropriate non-invasive brain stimulation, and pharmacological agents, are the keys to promote motor recovery. Individualized rehabilitation protocols could be developed to utilize or avoid the maladaptive plasticity, such as RS hyperexcitability, in the course of motor recovery. Aggressive and appropriate spasticity management with botulinum toxin therapy is an example of how to create a transient plastic state of the neuromotor system that allows motor re-learning and recovery in chronic stages.

Imaging three-dimensional innervation zone distribution in muscles from M-wave recordings

Objective. To localize neuromuscular junctions in skeletal muscles in vivo which is of great importance in understanding, diagnosing and managing of neuromuscular disorders. Approach. A three-dimensional global innervation zone imaging technique was developed to characterize the global distribution of innervation zones, as an indication of the location and features of neuromuscular junctions, using electrically evoked high-density surface electromyogram recordings. Main results. The performance of the technique was evaluated in the biceps brachii of six intact human subjects. The geometric centers of the distributions of the reconstructed innervation zones were determined with a mean distance of 9.4 ± 1.4 cm from the reference plane, situated at the medial epicondyle of the humerus. A mean depth was calculated as 1.5 ± 0.3 cm from the geometric centers to the closed points over the skin. The results are consistent with those reported in previous histology studies. It was also found that the volumes and distributions of the reconstructed innervation zones changed as the stimulation intensities increased until the supramaximal muscle response was achieved. Significance. Results have demonstrated the high performance of the proposed imaging technique in noninvasively imaging global distributions of the innervation zones in the three-dimensional muscle space in vivo, and the feasibility of its clinical applications, such as guiding botulinum toxin injections in spasticity management, or in early diagnosis of neurodegenerative progression of amyotrophic lateral sclerosis.

Do flexible inter-injection intervals improve the effects of botulinum toxin A treatment in reducing impairment and disability in patients with spasticity?

In patients treated with botulinum toxin-A (BoNT-A), toxin-directed antibody formation was related to the dosage and frequency of injections, leading to the empirical adoption of minimum time intervals between injections of 3months or longer. However, recent data suggest that low immunogenicity of current BoNT-A preparations could allow more frequent injections. Our hypothesis is that a short time interval between injections may be safe and effective in reducing upper limb spasticity and related disability. IncobotulinumtoxinA was injected under ultrasound guidance in spastic muscles of 11 subjects, who were evaluated just before BoNT-A injection (T0), and 1month (T1), 2months (T2) and 4months (T3) after injecting. At T1, in the case of persistent disability related to spasticity interfering with normal activities, patients received an additional toxin dose. Seven subjects received the additional dose at T1 because of persistent disability; 4 of them had a decrease of disability 1month later (T2). Rethinking the injection scheme for BoNT-A treatment may have a major impact in the management of spasticity and related disability. Future studies with larger sample sizes are warranted to confirm that injection schedules with short time intervals should no longer be discouraged in clinical practice.

Management of Spasticity in Moderate and Severe Traumatic Brain Injury: Evaluation of Clinical Practice Guidelines

Moderate to severe traumatic brain injury (TBI) can result in development of spasticity, which adversely affects function and quality of life. Given the foundation of optimal clinical practice is use of the best available evidence, we aimed to identify, describe, and evaluate methodological quality of evidence-based spasticity clinical practice guidelines (CPGs). A comprehensive search for CPGs encompassed electronic databases and online sources. Eligible CPGs were evaluated using the validated Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Five CPGs were eligible for review; 2 were specific to acquired brain injury and 1 to TBI. The 3 brain injury-specific CPGs contained 423 recommendations overall, but only 8 spasticity recommendations. On the basis of AGREE appraisals, all CPGs performed well in the areas of reporting scope and purpose; clearly presenting recommendations; including various stakeholders in the CPG development process; and reporting conflict of interest. However, only one CPG performed adequately on describing facilitators and barriers to implementation, advice, and tools on how to implement recommendations and provision of audit criteria. Intraclass correlation coefficient (ICC) for agreement between raters showed high agreement (ICC > 0.80) for most guidelines. Given the unique etiological features and treatment challenges associated with managing spasticity after TBI, more TBI-specific spasticity CPGs are required. These should incorporate information on the facilitators and barriers to implementation, advice on implementing recommendations, and audit criteria.