RESUMEN
OBJECTIVE: Selective neurotomy has been suggested as a permanent treatment for focal spasticity. A systematic literature review was performed to investigate the efficacy of selective neurotomy regarding focal lower limb spasticity. METHODS: A systematic search in PubMed, Medline, Cochrane, and Embase databases was carried out. Studies were included if they reported on the following outcomes: muscle tone, muscle strength, pain, ankle range of motion and/or walking speed, after selective lower limb neurotomy in any type of upper motor neuron syndrome. RESULTS: A total of 25 non-randomized and/or uncontrolled studies and 1 randomized controlled study were selected. The included studies reported improvements in terms of leg muscle tone, pain, passive range of ankle motion, and walking speed. CONCLUSION: The results suggest that selective neurotomy is effective for reducing lower limb spasticity, without any negative effects on walking speed. However, this conclusion is primarily based on uncontrolled case series, whereas conclusions on clinical efficacy should preferably be based on comparison with a reference treatment through (randomized) controlled trials. Future studies should also include quantitative, validated functional assessment tools to further establish the efficacy of selective neurotomy as long-lasting treatment for patients with focal lower limb spasticity.
Asunto(s)
Extremidad Inferior , Espasticidad Muscular , Humanos , Espasticidad Muscular/cirugía , Espasticidad Muscular/etiología , Espasticidad Muscular/fisiopatología , Extremidad Inferior/cirugía , Resultado del Tratamiento , Rango del Movimiento Articular/fisiología , Enfermedad de la Neurona Motora/cirugía , Enfermedad de la Neurona Motora/rehabilitación , Enfermedad de la Neurona Motora/fisiopatología , Fuerza Muscular/fisiologíaRESUMEN
Neuromuscular inhibitors have been quickly advanced from being used only for aesthetic purposes to being used as a treatment for musculoskeletal pain and muscle spasticity. This phenomenon stems from the diminished force exerted by muscles, which are essential for bone remodeling. In this context, it is hypothesized that botulinum toxin (BTX) might exert a direct influence on bone resorption. Although such treatments have the potential to provide patients with significant relief, bone loss occurring due to elective muscle paralysis has yet to be examined in clinical trials. The disuse model resulting from spinal cord injury, characterized by the absence of ground reaction and muscle forces, provides an ideal context for exploring the skeletal ramifications of intramuscular BTX injection. This approach enables an investigation into the intricate interplay between muscle and bone, encompassing the impact of spasticity on bone preservation, the potential positive and negative outcomes of BTX on bone metabolism, and the involvement of the autonomic nervous system in bone remodeling regulation. This paper presents a narrative review of research findings on the disturbance of the typical balance between muscles and bones caused by acute muscle paralysis from BTX, resulting in osteopenia and bone resorption.
Asunto(s)
Toxinas Botulínicas , Espasticidad Muscular , Traumatismos de la Médula Espinal , Humanos , Traumatismos de la Médula Espinal/complicaciones , Traumatismos de la Médula Espinal/tratamiento farmacológico , Espasticidad Muscular/tratamiento farmacológico , Espasticidad Muscular/etiología , Toxinas Botulínicas/administración & dosificación , Toxinas Botulínicas/uso terapéutico , Fármacos Neuromusculares/administración & dosificación , Fármacos Neuromusculares/uso terapéutico , Animales , Huesos/efectos de los fármacos , Remodelación Ósea/efectos de los fármacos , Remodelación Ósea/fisiología , Resorción Ósea , Músculo Esquelético/efectos de los fármacos , Enfermedades Óseas Metabólicas/tratamiento farmacológicoRESUMEN
OBJECTIVE: The aim of this study was to provide a classification of the upper limb patterns in patients with upper limb spasticity due to multiple sclerosis. DESIGN: Pilot observational study. PATIENTS: Twenty-five adult patients with multiple sclerosis suffering from upper limb spasticity who underwent one segmental (i.e., proximal and distal upper limb) botulinum toxin treatment cycle were recruited. METHODS: Patients remained in a sitting position during the evaluation. Upper limb spasticity postures (i.e., postural attitude of a single joint/anatomical region) were evaluated and recorded for the shoulder (adducted/internally rotated), elbow (flexed/extended), forearm (pronated/supinated/neutral), wrist (flexed/extended/neutral) and hand (fingers flexed/thumb in palm). RESULTS: On the basis of the clinical observations, 6 patterns (i.e., sets of limb postures) of upper limb spasticity have been described according to the postures of the shoulder, elbow, forearm, and wrist. CONCLUSION: The patterns of upper limb spasticity in patients with multiple sclerosis described by this pilot study do not completely overlap with those observed in patients with post-stroke spasticity. This further supports the need to consider the features of spasticity related to its aetiology in order to manage patients appropriately.
Asunto(s)
Esclerosis Múltiple , Espasticidad Muscular , Extremidad Superior , Humanos , Espasticidad Muscular/etiología , Espasticidad Muscular/fisiopatología , Proyectos Piloto , Esclerosis Múltiple/complicaciones , Esclerosis Múltiple/fisiopatología , Femenino , Masculino , Persona de Mediana Edad , Extremidad Superior/fisiopatología , Adulto , Postura/fisiología , AncianoRESUMEN
Strokes cause spasticity via stretch reflex hyperexcitability in the spinal cord, and spastic paralysis due to involuntary muscle contraction in the hands and fingers can severely restrict skilled hand movements. However, the underlying neurological mechanisms remain unknown. Using a mouse model of spasticity after stroke, we demonstrate changes in neuronal activity with and without electrostimulation of the afferent nerve to induce the stretch reflex, measured using quantitative activation-induced manganese-enhanced magnetic resonance imaging. Neuronal activity increased within the ventral medullary reticular formation (MdV) in the contralesional brainstem during the acute post-stroke phase, and this increase was characterised by activation of circuits involved in spasticity. Interestingly, ascending electrostimulation inhibited the MdV activity on the stimulation side in normal conditions. Moreover, immunohistochemical staining showed that, in the acute phase, the density of GluA1, one of the α-amino-3 hydroxy5 methyl -4 isoxazolepropionic acid receptor (AMPAR) subunits, at the synapses of MdV neurons was significantly increased. In addition, the GluA1/GluA2 ratio in these receptors was altered at 2 weeks post-stroke, confirming homeostatic plasticity as the underlying mechanisms of spasticity. These results provide new insights into the relationship between impaired skilled movements and spasticity at the acute post-stroke phase.
Asunto(s)
Bulbo Raquídeo , Espasticidad Muscular , Formación Reticular , Animales , Espasticidad Muscular/fisiopatología , Espasticidad Muscular/etiología , Ratones , Formación Reticular/fisiopatología , Formación Reticular/diagnóstico por imagen , Bulbo Raquídeo/metabolismo , Masculino , Accidente Cerebrovascular Trombótico/fisiopatología , Imagen por Resonancia Magnética , Ratones Endogámicos C57BL , Modelos Animales de Enfermedad , Receptores AMPA/metabolismo , Reflejo de Estiramiento/fisiologíaRESUMEN
BACKGROUND: Spasticity is a common and potentially debilitating symptom of multiple sclerosis (MS) with a highly variable presentation. Understanding, quantifying, and managing MS-associated spasticity (MSS) is a challenge for research and in clinical practice. The tetrahydrocannabinol:cannabidiol oromucosal spray nabiximols has demonstrated beneficial effects in the treatment of MSS in clinical studies as well as real-world observational studies, and is approved for the treatment of MSS in 29 countries globally. Most randomized studies evaluated the efficacy of nabiximols using the change in average daily spasticity scores reported by patients using the spasticity Numeric Rating Scale as a primary endpoint. This study, RELEASE MSS1 (NCT04657666), was conducted using a prespecified primary endpoint of change in spastic muscle tone (Modified Ashworth Scale Lower Limb Muscle Tone-6 [MAS LLMT-6]) to corroborate the efficacy of nabiximols as adjunctive therapy observed with the patient-measured spasticity Numeric Rating Scale primary endpoint in the previous pivotal studies. METHODS: This was a phase 3, multicenter, randomized, double-blind, placebo-controlled, 2-treatment, 2-period, crossover trial. Because of the prevalence and functional impact of lower limb spasticity on the individual patient's overall experience of MS spasticity, the MAS LLMT-6 was derived from the clinician-rated MAS. The MAS LLMT-6 is the average transformed MAS score of 6 muscle groups (knee flexors, knee extensors, and ankle plantar flexors; all assessed bilaterally). Secondary measures included MAS LLMT-4 scores, defined as the average of the 4 individual MAS-transformed scores of knee flexors and knee extensors bilaterally. Patients had a diagnosis of MS and an untransformed MAS score of at least 2 in ≥2 of 6 LLMT-6 muscle groups despite current treatment with ≥1 of the following oral antispasticity agents: baclofen, tizanidine, or dantrolene. Eligible participants were randomly assigned to 1 of 2 treatment sequences. Each treatment sequence consisted of two treatment periods, each consisting of a 14-day dose titration phase followed by a 7-day dose maintenance phase. RESULTS: Of 68 patients enrolled, 33 were assigned to nabiximols followed by placebo and 35 were assigned to placebo followed by nabiximols. Least squares mean changes in MAS LLMT-6 scores from baseline to day 21 were -0.23 for nabiximols and -0.26 for placebo; the least squares mean treatment difference in MAS LLMT-6 scores for nabiximols versus placebo was 0.04, which was not statistically significant (P = 0.7152). Mean changes in MAS LLMT-4 scores from baseline to day 21 also were not significantly different between the nabiximols and placebo groups. Safety results in this study were consistent with the known safety profile of nabiximols in patients with MSS. CONCLUSION: Despite the established efficacy of nabiximols in MSS observed using patient-reported measures, the primary endpoint was not met in this study. The findings from this study reflect and emphasize some of the challenges in the evaluation and treatment of MS spasticity. CLINICAL TRIAL REGISTRATION NUMBER (CLINICALTRIALS.GOV): : NCT04657666.
Asunto(s)
Cannabidiol , Dronabinol , Combinación de Medicamentos , Esclerosis Múltiple , Espasticidad Muscular , Humanos , Espasticidad Muscular/tratamiento farmacológico , Espasticidad Muscular/etiología , Cannabidiol/administración & dosificación , Cannabidiol/farmacología , Dronabinol/administración & dosificación , Dronabinol/farmacología , Método Doble Ciego , Esclerosis Múltiple/complicaciones , Esclerosis Múltiple/tratamiento farmacológico , Adulto , Masculino , Vaporizadores Orales , Femenino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de SaludRESUMEN
We conducted a multicenter and retrospective study to describe the use of botulinum toxin type A (BoNT-A) to treat post-stroke spasticity (PSS). Data were extracted from free-text in electronic health records (EHRs) in five Spanish hospitals. We included adults diagnosed with PSS between January 2015 and December 2019, stratified into BoNT-A-treated and untreated groups. We used EHRead® technology, which incorporates natural language processing and machine learning, as well as SNOMED CT terminology. We analyzed demographic data, stroke characteristics, BoNT-A use patterns, and other treatments. We reviewed the EHRs of 1,233,929 patients and identified 2190 people with PSS with a median age of 69 years; in total, 52.1% were men, 70.7% had cardiovascular risk factors, and 63.2% had suffered an ischemic stroke. Among the PSS patients, 25.5% received BoNT-A at least once. The median time from stroke to spasticity onset was 205 days, and the time from stroke to the first BoNT-A injection was 364 days. The primary goal of BoNT-A treatment was pain control. Among the study cohort, rehabilitation was the most common non-pharmacological treatment (95.5%). Only 3.3% had recorded monitoring scales. In conclusion, a quarter of patients with PSS received BoNT-A mainly for pain relief, typically one year after the stroke. Early treatment, disease monitoring, and better data documentation in EHRs are crucial to improve PSS patients' care.
Asunto(s)
Toxinas Botulínicas Tipo A , Aprendizaje Automático , Espasticidad Muscular , Procesamiento de Lenguaje Natural , Accidente Cerebrovascular , Humanos , Espasticidad Muscular/tratamiento farmacológico , Espasticidad Muscular/etiología , Toxinas Botulínicas Tipo A/uso terapéutico , Masculino , Femenino , Anciano , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/tratamiento farmacológico , Estudios Retrospectivos , Persona de Mediana Edad , Registros Electrónicos de Salud , Fármacos Neuromusculares/uso terapéutico , Anciano de 80 o más AñosRESUMEN
Importance: Stroke is a leading cause of disability worldwide and is often accompanied by complications such as spasticity. Static stretching (SS) is a common physiotherapy intervention for reducing spasticity, whereas dry needling (DN) is a novel approach. However, the combined effects of DN and SS on spasticity have not been thoroughly investigated. Given the pivotal effect of spasticity on daily activities, mitigating spasticity can significantly contribute to restoring patient independence. Objective: This study will explore the impact of DN plus SS on spasticity, alpha motor neuron excitability, overall function, and quality of life in patients with chronic stroke. Design, Setting, and Population: A double-blind, randomized, sham-controlled trial will be conducted in patients with post-stroke spasticity in the plantar flexor muscles. Twentyeight participants will be randomly assigned to either an intervention or control group. The intervention group will receive DN (60s × 3 days/week; 1 week) plus SS (20 min × 5 days/ week; 1 week). The control group will undergo sham DN (60s × 3 days/week; 1 week) and SS (20 min × 5 days/week; 1 week). Exposures: DN plus SS or sham DN plus SS. Main Outcomes and Measures: Both groups will be assessed at baseline, immediately post-treatment, and after 1 week of follow-up. Outcome measures will include the Modified Modified Ashworth Scale, H-reflex latency, Hmax/Mmax ratio, active and passive ankle dorsiflexion range of motion, timed up and go test, and the EuroQol questionnaire. Results: Results from this randomized, sham-controlled study will provide evidence for the effectiveness of DN in combination with SS for spasticity. Conclusions and Relevance: The additional impact of DN in conjunction with SS, a widely used method for reducing muscle tone, remains unclear and warrants investigation. This study, with a high level of evidence, aims to address this knowledge gap.
Asunto(s)
Punción Seca , Espasticidad Muscular , Ejercicios de Estiramiento Muscular , Accidente Cerebrovascular , Humanos , Espasticidad Muscular/terapia , Espasticidad Muscular/fisiopatología , Espasticidad Muscular/etiología , Punción Seca/métodos , Accidente Cerebrovascular/complicaciones , Accidente Cerebrovascular/fisiopatología , Accidente Cerebrovascular/terapia , Método Doble Ciego , Masculino , Femenino , Persona de Mediana Edad , Enfermedad Crónica , Adulto , Calidad de Vida , AncianoRESUMEN
Acute brain injuries are caused by a variety of etiologies, each potentially disrupting neurological function. The neurologic impairments are on a spectrum of severity often creating functional barriers to completing activities of daily living. Initial treatment starts immediately upon diagnosis and requires a multimodal approach working to prevent systemic changes. Therapy, bracing treatment, injections, and pharmacologic treatments are the mainstay of early intervention. Worsening upper motor neurological impairment associated with involuntary muscle hyperactivity can lead to a spastic equinovarus foot deformity. Spastic equinovarus foot deformities secondary to anoxic brain injuries or traumatic brain injury pose a challenging situation for orthopaedic surgeons because of associated cognitive impairment, spastic tone, and extensive soft-tissue contractures prohibiting bracing treatment. Tendon releases and transfers in combination with functional bracing treatment are initially attempted, and selective fusions are performed for severe cases. Surgical indications are primarily focused on obtaining a balanced, braceable, functional lower extremity with a plantigrade foot.
Asunto(s)
Pie Equinovaro , Espasticidad Muscular , Humanos , Pie Equinovaro/terapia , Pie Equinovaro/etiología , Espasticidad Muscular/terapia , Espasticidad Muscular/etiología , Tirantes , Transferencia TendinosaRESUMEN
OBJECTIVE: To compare the effect of rectus femoris diagnostic motor nerve blocks (DNB) with anaesthetics and rectus femoris muscle botulinum toxin (BoNT-A) injection in multiple sclerosis patients with unilateral stiff-knee gait. DESIGN: Prospective observational study Subjects/Patients: Multiple sclerosis patients in stable condition. METHODS: Patients underwent evaluation before and 1 hour after the anaesthetic block, and 1 month after the botulinum injection. Assessment included a 10-m walking test, a 6-minute walking test, a timed-up-and-go (TUG) test, and a Baseline Expanded Disability Status Scale (EDSS). Post-DNB and post-BoNT-A satisfaction was measured with the global assessment of efficacy scale. RESULTS: Fourteen patients with unilateral stiff-knee gait due to multiple sclerosis underwent a DNB, among whom 13 received botulinum injections in the rectus femoris muscle after a satisfying test result. Positive post-DNB results correlated with significant functional improvements after BoNT-A. Higher EDSS and longer time from diagnosis correlated with poorer post-DNB and post-BoNT-A absolute outcomes. CONCLUSION: DNB showed predictive value for BoNT-A outcomes, especially in the case of worse functional status. It effectively predicted endurance and walking speed improvement, while TUG showed greater improvement after botulinum. In cases of uncertain therapeutic benefit, nerve blocks may provide a valuable diagnostic support, particularly in patients with lower functional status.
Asunto(s)
Toxinas Botulínicas Tipo A , Esclerosis Múltiple , Espasticidad Muscular , Bloqueo Nervioso , Fármacos Neuromusculares , Músculo Cuádriceps , Humanos , Espasticidad Muscular/etiología , Espasticidad Muscular/tratamiento farmacológico , Femenino , Esclerosis Múltiple/complicaciones , Esclerosis Múltiple/tratamiento farmacológico , Masculino , Estudios Prospectivos , Persona de Mediana Edad , Bloqueo Nervioso/métodos , Toxinas Botulínicas Tipo A/administración & dosificación , Toxinas Botulínicas Tipo A/farmacología , Adulto , Fármacos Neuromusculares/administración & dosificación , Fármacos Neuromusculares/farmacología , Resultado del Tratamiento , Trastornos Neurológicos de la Marcha/etiología , Trastornos Neurológicos de la Marcha/tratamiento farmacológicoRESUMEN
BACKGROUND: Hinged ankle foot orthoses (HAFO) are commonly prescribed for children with cerebral palsy (CP) to improve their ambulatory function. OBJECTIVES: The aim of this study was to compare the effect of vibration-HAFO with that of the same orthosis without vibration on gait, function, and spasticity in hemiplegic CP children. STUDY DESIGN: Randomized Control Trial Design (a pilot study). METHODS: Twenty-three children with hemiplegic CP participated in this study. The control group (n = 12) used HAFO, and the intervention group (n = 11) used vibration-HAFO for four weeks. Pre-post three-dimensional gait analysis was done. Calf muscle spasticity and function were also measured. RESULTS: Results showed significant differences between the two groups in the one-minute walking test (p = 0.023) and spasticity (after intervention [p = 0.022], after follow-up [p = 0.020]). Also, significant differences were detected between the two groups in the step width (p = 0.042), maximum hip abduction (p = 0.008), stance maximum dorsiflexion (p = 0.036) and mean pelvic tilt (p = 0.004) in the barefoot condition. Gait cycle time (p = 0.005), maximum hip abduction (p = 0.042), and cadence (p = 0.001) were different between groups in the braced condition. We couldn't find any significant within and between groups differences in knee kinematic parameters. The mean time of using vibration was 16.83 minutes per day. CONCLUSIONS: The vibration-hinged AFO is feasible, safe, and acceptable for children with hemiplegic CP to be integrated into practice. Temporospatial and clinical parameters, especially spasticity, were improved. There were slight trends toward improvement in pelvic and knee kinematics. Vibration-HAFO is of benefit to ambulatory CP children with mild and moderate spasticity. It improved the walking capacity of the children.
Asunto(s)
Parálisis Cerebral , Ortesis del Pié , Espasticidad Muscular , Vibración , Humanos , Parálisis Cerebral/complicaciones , Parálisis Cerebral/rehabilitación , Parálisis Cerebral/fisiopatología , Niño , Masculino , Espasticidad Muscular/etiología , Espasticidad Muscular/rehabilitación , Espasticidad Muscular/terapia , Espasticidad Muscular/fisiopatología , Femenino , Vibración/uso terapéutico , Proyectos Piloto , Trastornos Neurológicos de la Marcha/rehabilitación , Trastornos Neurológicos de la Marcha/etiología , Trastornos Neurológicos de la Marcha/fisiopatología , Trastornos Neurológicos de la Marcha/terapia , Marcha/fisiología , Diseño de Equipo , Hemiplejía/rehabilitación , Hemiplejía/etiología , Hemiplejía/fisiopatología , Resultado del Tratamiento , Adolescente , Articulación del Tobillo/fisiopatología , Fenómenos BiomecánicosRESUMEN
STUDY DESIGN: A psychometric study. OBJECTIVES: To 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. SETTING: The study was developed in the Spinal Cord Unit at University Hospital Motol and Paraple Centre in Prague, Czech Republic. METHODS: The 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. RESULTS: The 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. CONCLUSIONS: The 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.
Asunto(s)
Espasticidad Muscular , Psicometría , Traumatismos de la Médula Espinal , Traumatismos de la Médula Espinal/fisiopatología , Traumatismos de la Médula Espinal/diagnóstico , Traumatismos de la Médula Espinal/complicaciones , Humanos , Masculino , Espasticidad Muscular/fisiopatología , Espasticidad Muscular/diagnóstico , Espasticidad Muscular/etiología , Femenino , Reproducibilidad de los Resultados , Adulto , Persona de Mediana Edad , Índice de Severidad de la Enfermedad , Músculo Esquelético/fisiopatología , Anciano , Adulto JovenRESUMEN
INTRODUCTION: Poststroke spasticity (PSS) affects up to 40% of patients who had a stroke. Botulinum neurotoxin type A (BoNT-A) has been shown to improve spasticity, but the optimal timing of its application remains unclear. While several predictors of upper limb PSS are known, their utility in clinical practice in relation to BoNT-A treatment has yet to be fully elucidated. The COLOSSEO-BoNT study aims to investigate predictors of PSS and the effects of BoNT-A timing on spasticity-related metrics in a real-world setting. METHODS AND ANALYSIS: The recruitment will involve approximately 960 patients who have recently experienced an ischaemic stroke (within 10 days, V0) and will follow them up for 24 months. Parameters will be gathered at specific intervals: (V1) 4, (V2) 8, (V3) 12, (V4) 18 months and (V5) 24 months following enrolment. Patients will be monitored throughout their rehabilitation and outpatient clinic journeys and will be compared based on their BoNT-A treatment status-distinguishing between patients receiving treatment at different timings and those who undergo rehabilitation without treatment. Potential predictors will encompass the Fugl-Meyer assessment, the National Institute of Health Stroke Scale (NIHSS), stroke radiological characteristics, performance status, therapies and access to patient care pathways. Outcomes will evaluate muscle stiffness using the modified Ashworth scale and passive range of motion, along with measures of quality of life, pain, and functionality. ETHICS AND DISSEMINATION: This study underwent review and approval by the Ethics Committee of the Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy. Regardless of the outcome, the findings will be disseminated through publication in peer-reviewed journals and presentations at national and international conferences. TRIAL REGISTRATION NUMBER: NCT05379413.
Asunto(s)
Toxinas Botulínicas Tipo A , Espasticidad Muscular , Fármacos Neuromusculares , Accidente Cerebrovascular , Extremidad Superior , Femenino , Humanos , Masculino , Toxinas Botulínicas Tipo A/uso terapéutico , Toxinas Botulínicas Tipo A/administración & dosificación , Estudios Longitudinales , Espasticidad Muscular/tratamiento farmacológico , Espasticidad Muscular/etiología , Fármacos Neuromusculares/uso terapéutico , Fármacos Neuromusculares/administración & dosificación , Estudios Observacionales como Asunto , Estudios Prospectivos , Accidente Cerebrovascular/complicaciones , Rehabilitación de Accidente Cerebrovascular/métodos , Extremidad Superior/fisiopatologíaRESUMEN
BACKGROUND: Upper limb (UL) spastic paresis has been classically evaluated with assessments of passive movements with limited functional validity. The aim of this study was to assess whether a composite measure of active range of motion (AROM, or X
Asunto(s)
Rango del Movimiento Articular , Rehabilitación de Accidente Cerebrovascular , Accidente Cerebrovascular , Extremidad Superior , Humanos , Masculino , Femenino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Accidente Cerebrovascular/fisiopatología , Accidente Cerebrovascular/complicaciones , Rango del Movimiento Articular/fisiología , Extremidad Superior/fisiopatología , Anciano , Rehabilitación de Accidente Cerebrovascular/métodos , Enfermedad Crónica , Espasticidad Muscular/fisiopatología , Espasticidad Muscular/etiología , Espasticidad Muscular/rehabilitación , Evaluación de la Discapacidad , Paresia/fisiopatología , Paresia/etiología , Paresia/rehabilitación , PsicometríaRESUMEN
INTRODUCTION: The increase in the number of people with upper limb spasticity as a sequela of cerebrovascular disease, which negatively impacts their autonomy, functional independence and participation, and affects their quality of life, calls for the application of precise and objective instruments for its measurement and evaluation. OBJECTIVE: To assess the validity and reliability of the Tardieu scale in the evaluation of upper extremity spasticity in adults with cerebrovascular disease. MATERIALS AND METHODS: The search strategy was implemented in eight databases; the systematic review protocol was registered beforehand in INPLASY (with registration no. 2023110076). The evidence was synthesised in three phases: a tabular presentation of results, an evaluation of the quality of the articles, and a narrative synthesis of the findings. RESULTS: Only three of the 33 articles identified fulfilled the variables that enable the validity and reliability of the Tardieu scale to be established. The measurements of angles and velocities R1, R2 and R2-R1 were analysed. Student's t-test to assess the reliability between the measurements of R1 and R2; and angles R2 and R2-R1 showed statistical significance, which confirmed the reliability of the scale. CONCLUSIONS: The Tardieu scale proved robust. It is important to note that the sample size, the time of evolution of the disease and the age of the patients may influence the results of the scale.
TITLE: Validez y fiabilidad de la escala de Tardieu para evaluar la espasticidad en miembro superior en adultos con enfermedad cerebrovascular. Revisión sistemática.Introducción. El incremento en el número de personas con espasticidad en los miembros superiores como secuela de una enfermedad cerebrovascular, que impacta negativamente en la autonomía, la independencia funcional y la participación, y afecta a la calidad de vida de las personas, demanda la aplicación de herramientas clínicas precisas y objetivas para su medición y evaluación. Objetivo. Evaluar la validez y la fiabilidad de la escala de Tardieu en la evaluación de la espasticidad en las extremidades superiores de adultos con enfermedad cerebrovascular. Materiales y métodos. La estrategia de búsqueda se implementó en ocho bases de datos; el protocolo de revisión sistemática se registró previamente en INPLASY (registro n.o 2023110076). La síntesis de la evidencia se llevó a cabo en tres fases: presentación tabular de resultados, evaluación de la calidad de los artículos y síntesis narrativa de los hallazgos. Resultados. De los 33 artículos identificados, sólo tres cumplieron con las variables que permiten establecer la validez y la fiabilidad de la escala de Tardieu. Se analizaron las medidas de los ángulos y velocidades R1, R2 y R2-R1. La prueba de la t de Student para evaluar la fiabilidad entre las medidas de R1 y R2; los ángulos R2 y R2-R1 mostraron significancia estadística, lo que confirmó la confiabilidad de la escala. Conclusiones. La escala de Tardieu demostró robustez. Es importante considerar que el tamaño de la muestra, el tiempo de evolución de la enfermedad y la edad de los pacientes pueden influir en los resultados de la escala.
Asunto(s)
Trastornos Cerebrovasculares , Espasticidad Muscular , Extremidad Superior , Humanos , Espasticidad Muscular/etiología , Espasticidad Muscular/diagnóstico , Espasticidad Muscular/fisiopatología , Reproducibilidad de los Resultados , Trastornos Cerebrovasculares/complicaciones , Extremidad Superior/fisiopatología , AdultoRESUMEN
INTRODUCTION: Spasticity is one of the most common secondary complications following a spinal cord injury (SCI), which can significantly debilitate a patient irrespective of the severity of the injury. Intrathecal baclofen therapy can effectively reduce global spasticity in bilateral lower extremities at lower doses and allows precise dose titration to manage spasticity optimally. In complex patients with spasticity and multiple medical comorbidities, multidisciplinary teamwork is required to assess ITB safety and deliver timely intervention to prevent secondary complications of spasticity and improve quality of life. CASE PRESENTATION: A 61-year-old African American male with multiple comorbidities, including end-stage renal disease (ESRD) requiring dialysis sustained non-traumatic SCI due to epidural abscess resulting in paraplegia and severe debilitating spasticity. Spasticity gradually worsened and interfered with his ability to achieve independence with functional activities appropriate for his neurological level of injury. A multidisciplinary team approach in this complex case resulted in a successful ITB trial and subsequent ITB implantation, resulting in reduced spasticity and improved quality of life. To our knowledge, this is the first case report of the administration of intrathecal baclofen pump therapy in a person with SCI and end-stage renal disease (ESRD) dependent on hemodialysis. DISCUSSION: ITB therapy can be safely delivered in a person with SCI and multiple medical comorbidities, including ESRD, dependent on hemodialysis to manage spasticity. However, a careful evaluation and discussion among the multidisciplinary team managing the patient's morbidities and patient is required to assess the risks and benefits of ITB therapy to allow the patient to make an informed decision.
Asunto(s)
Baclofeno , Inyecciones Espinales , Fallo Renal Crónico , Relajantes Musculares Centrales , Espasticidad Muscular , Diálisis Renal , Traumatismos de la Médula Espinal , Humanos , Baclofeno/administración & dosificación , Espasticidad Muscular/tratamiento farmacológico , Espasticidad Muscular/etiología , Masculino , Persona de Mediana Edad , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/terapia , Traumatismos de la Médula Espinal/complicaciones , Relajantes Musculares Centrales/administración & dosificaciónRESUMEN
BACKGROUND: Evaluating muscle spasticity in children with cerebral palsy (CP) is essential for determining the most effective treatment strategies. This scoping review assesses the current methods used to evaluate muscle spasticity, highlighting both traditional and innovative technologies, and their respective advantages and limitations. METHODS: A search (to April 2024) used keywords such as muscle spasticity, cerebral palsy, and assessment methods. Selection criteria included articles involving CP children, assessing spasticity objectively/subjectively, comparing methods, or evaluating method effectiveness. RESULTS: From an initial pool of 1971 articles, 30 met our inclusion criteria. These studies collectively appraised a variety of techniques ranging from well-established clinical scales like the modified Ashworth Scale and Tardieu Scale, to cutting-edge technologies such as real-time sonoelastography and inertial sensors. Notably, innovative methods such as the dynamic evaluation of range of motion scale and the stiffness tool were highlighted for their potential to provide more nuanced and precise assessments of spasticity. The review unveiled a critical insight: while traditional methods are convenient and widely used, they often fall short in reliability and objectivity. CONCLUSION: The review discussed the strengths and limitations of each method and concluded that more reliable methods are needed to measure the level of muscle spasticity more accurately.
Asunto(s)
Parálisis Cerebral , Espasticidad Muscular , Humanos , Espasticidad Muscular/fisiopatología , Espasticidad Muscular/etiología , Espasticidad Muscular/diagnóstico , Parálisis Cerebral/complicaciones , Parálisis Cerebral/fisiopatología , Niño , Reproducibilidad de los Resultados , Rango del Movimiento Articular , Diagnóstico por Imagen de Elasticidad/métodosRESUMEN
OBJECTIVE: The aims of this study were to 1) assess and quantify white matter (WM) microstructural characteristics derived from diffusion tensor imaging (DTI) in children with cerebral palsy (CP) prior to selective dorsal rhizotomy (SDR), and 2) investigate potential associations between WM diffusion properties and gross motor function and spasticity in children with spastic CP who underwent SDR. METHODS: This study is a multisite study based on DT images acquired prior to SDR as well as postoperative outcome data. DTI data collected from two sites were harmonized using the ComBat approach to minimize intersite scanner difference. The DTI abnormalities between children with spastic CP and controls were analyzed and correlated with the severity of impaired mobility based on the Gross Motor Function Classification System (GMFCS). The improvement in gross motor function and spasticity after SDR surgery was assessed utilizing the Gross Motor Function Measure-66 (GMFM-66), the Modified Tardieu Scale (MTS), and the modified Ashworth scale (MAS). Alterations in these outcome measures were quantified in association with DTI abnormalities. RESULTS: Significant DTI alterations, including lower fractional anisotropy (FA) in the genu of the corpus callosum (gCC) and higher mean diffusivity (MD) in the gCC and posterior limb of the internal capsule (PLIC), were found in children in the SDR group when compared with the age-matched control group (all p < 0.05). Greater DTI alterations (FA in gCC and MD in gCC and PLIC) were associated with lower mobility levels as determined based on GMFCS level (p < 0.05). The pre- to post-SDR improvement in motor function based on GMFM-66 was statistically significant (p = 0.006 and 0.002 at 6-month and 12-month follow-ups, respectively). The SDR efficacy was also identified as improving spasticity in lower-extremity muscle groups assessed with the MTS and MAS. Partial correlation analysis presented a significant association between pre- to post-SDR MTS alteration and DTI abnormalities. CONCLUSIONS: The findings in the present study provided initial quantitative evidence to establish the WM microstructural characteristics in children with spastic CP prior to SDR surgery. The study generated data for the association between baseline DTI characteristics and mobility in children with CP prior to SDR surgery. The study also demonstrated SDR efficacy in improving motor function and spasticity based on the GMFM-66, MTS, and MAS, respectively, in association with DTI data.
Asunto(s)
Parálisis Cerebral , Imagen de Difusión Tensora , Rizotomía , Sustancia Blanca , Humanos , Parálisis Cerebral/cirugía , Parálisis Cerebral/diagnóstico por imagen , Parálisis Cerebral/complicaciones , Imagen de Difusión Tensora/métodos , Rizotomía/métodos , Niño , Masculino , Femenino , Sustancia Blanca/diagnóstico por imagen , Sustancia Blanca/cirugía , Sustancia Blanca/patología , Preescolar , Espasticidad Muscular/cirugía , Espasticidad Muscular/diagnóstico por imagen , Espasticidad Muscular/etiología , Adolescente , Resultado del Tratamiento , Anisotropía , Cuerpo Calloso/diagnóstico por imagen , Cuerpo Calloso/cirugíaRESUMEN
BACKGROUND: Around 40% of stroke survivor develop spasticity. Plantar flexors (PF) muscles are often affected, with severe functional impairment. The treatment of choice is botulinum toxin type A (BoNT-A) combined with adjuvant treatments. The temporary pharmacological effect implies periodic reassessment and reinjection. These long-term chronic programs require monitoring the functional impact of each cycle and the clinical evolution in relation to aging and repeated interventions. AIM: Evaluating changes of functional level in patients with post-stroke spasticity treated with BoNT-A by assessing the long-term maintenance of the therapeutic efficacy. DESIGN: Retrospective longitudinal observational study. SETTING: Outpatients. POPULATION: Chronic stroke survivors undergoing BoNT-A treatment and subsequent intensive rehabilitation (10 sessions in a day-hospital regime). METHODS: Medical records of the enrolled patients were consulted. The primary endpoint was the change in PF spasticity by at least 1 point on the Modified Ashworth Scale (MAS) at each cycle. Secondary endpoints were the assessment of possible trends in gait parameters (Six Minute Walking Test [6MWT]; Timed Up and Go [TUG], and 10 Meters Walking Test [10mWT]) pre- and post-injection and at each cycle. RESULTS: Thirty-six patients were enrolled. A reduction of at least one MAS point for PF was recorded after each cycle in all subjects. A time-dependent reduction in the proportion of patients reporting an improvement higher than the minimal clinically important difference (MCID) in 6MWT and 10mWT was observed. In the case of TUG, this data kept stable at all cycles. A one-point increase in the basal functional ambulation classification (FAC) score resulted in a reduction in the probability of having a TUG improvement greater than the MCID. The opposite correlation was found for 6MWT and 10mWT. CONCLUSIONS: With the proposed treatment, the clinical significance TUG improvement remains constant throughout repeated cycles and the proportion of patients with improvement in 6MWT and 10mWT tends to decline over time. The predictive value of basal FAC on the functional variables expected improvement may provide a potential treatment targeting tool. CLINICAL REHABILITATION IMPACT: These results may deliver prognostic indication allowing an optimized integration of different post-BoNT-A rehabilitation approaches, agreeing with current evidence. Adequate monitoring and treatment protocols are crucial for the stability of functional level and may prevent excessive fluctuations.
Asunto(s)
Toxinas Botulínicas Tipo A , Espasticidad Muscular , Fármacos Neuromusculares , Rehabilitación de Accidente Cerebrovascular , Accidente Cerebrovascular , Humanos , Espasticidad Muscular/tratamiento farmacológico , Espasticidad Muscular/etiología , Espasticidad Muscular/fisiopatología , Femenino , Toxinas Botulínicas Tipo A/administración & dosificación , Toxinas Botulínicas Tipo A/uso terapéutico , Masculino , Estudios Retrospectivos , Persona de Mediana Edad , Accidente Cerebrovascular/complicaciones , Anciano , Rehabilitación de Accidente Cerebrovascular/métodos , Fármacos Neuromusculares/uso terapéutico , Fármacos Neuromusculares/administración & dosificación , Estudios Longitudinales , Resultado del Tratamiento , Estudios de SeguimientoRESUMEN
BACKGROUND: Motor impairments are common consequences of traumatic brain injury (TBI). It affects the individuals' participation in activities of daily living (ADLs). Dry needling treatment (DNT) uses a specialized needle to alter cortical activity. This case study aims to examine the effects of DNT on spasticity, balance, gait, and self-independence in a single patient with TBI. CASE DESCRIPTION: A twenty-six-year-old male with a history of TBI, resulting in muscle weakness on the right side of the body, spasticity, distributed balance, and difficulties with independent gait participated in this study. The Berg balance scale (BBS), 6-min walk test (6MWT), Modified Ashworth Scale (MAS), and Functional Independence Measure (FIM) were used to evaluate balance, gait, spasticity, and functional performance, respectively. OUTCOME: After 36 DNT sessions extended over 12 weeks, the patient demonstrated improvements in spasticity, balance, gait, and functional capacity both immediately after the intervention and at the 4-week follow-up. CONCLUSION: This case study demonstrates that DNT is considered a novel intervention for treating spasticity and improving balance, gait, and functional capacity post-TBI. Further research is recommended to verify these findings.
Asunto(s)
Lesiones Traumáticas del Encéfalo , Punción Seca , Espasticidad Muscular , Equilibrio Postural , Humanos , Masculino , Lesiones Traumáticas del Encéfalo/complicaciones , Lesiones Traumáticas del Encéfalo/rehabilitación , Espasticidad Muscular/terapia , Espasticidad Muscular/rehabilitación , Espasticidad Muscular/etiología , Equilibrio Postural/fisiología , Punción Seca/métodos , Adulto , Marcha/fisiología , Actividades Cotidianas , Debilidad Muscular/rehabilitación , Debilidad Muscular/etiología , Debilidad Muscular/terapiaRESUMEN
BACKGROUND: Investigating the spatial distribution of muscle activity would facilitate understanding the underlying mechanism of spasticity. The purpose of this study is to investigate the characteristics of spastic muscles during passive stretch and active contraction by high-density surface electromyography (HD-sEMG). METHODS: Fourteen spastic hemiparetic subjects and ten healthy subjects were recruited. The biceps brachii (BB) muscle activity of each subject was recorded by HD-sEMG during passive stretch at four stretch velocities (10, 60, 120, 180Ë/s) and active contraction at three submaximal contraction levels (20, 50, 80%MVC). The intensity and spatial distribution of the BB activity were compared by the means of two-way analysis of variance, independent sample t-test, and paired sample t-test. RESULTS: Compared with healthy subjects, spastic hemiparetic subjects showed significantly higher intensity with velocity-dependent heterogeneous activation during passive stretch and more lateral and proximal activation distribution during active contraction. In addition, spastic hemiparetic subjects displayed almost non-overlapping activation areas during passive stretch and active contraction. The activation distribution of passive stretch was more distal when compared with the active contraction. CONCLUSIONS: These alterations of the BB activity could be the consequence of deficits in the descending central control after stroke. The complementary spatial distribution of spastic BB activity reflected their opposite motor units (MUs) recruitment patterns between passive stretch and active contraction. This HD-sEMG study provides new neurophysiological evidence for the spatial relationship of spastic BB activity between passive stretch and active contraction, advancing our knowledge on the mechanism of spasticity. TRIAL REGISTRATION: ChiCTR2000032245.