Moreover, interpreting the results would have been strengthened by a better description of work environment and patient characteristics. Welmer AK, von Arbin M, Widn Holmqvist L, Sommerfeld DK. Des cliniciens d'exprience ont prpar le questionnaire, qui sondait les caractristiques sociodmographiques, le milieu de travail et la satisfaction des cliniciens l'gard des valuations de la spasticit et des prfrences thrapeutiques. Tilton A, Vargus-Adams J, Delgado MR. Pharmacologic treatment of spasticity in children. Objectif: comprendre les tendances actuelles des pratiques de radaptation en matire d'valuation et de traitement de la spasticit. When possible, reminders were sent twice, using FluidSurveys, to those who had not completed the survey. It . Spasticity can be defined as a tightening or stiffness of the muscle due to increased muscle tone, and is often made worse when muscles are quickly stretched or moved. Background Nabiximols (THC/CBD Oromucosal Spray, Sativex) is used as an add-on therapy to treat moderate to severe spasticity of Multiple Sclerosis (MS). The average completion time was 10.2 minutes (excluding 3 outliers, who completed the questionnaire in >1 h). Despite oral baclofen's ability to cross the blood-brain barrier due to its lipophilic nature, the efficacy is limited at lower doses and with severe spasticity.31 Thus a method was developed to supply baclofen intrathecally via an intrathecal catheter. Treatments of Spasticity Used in Clinical Practice. These results are consistent with the Canadian Best Practice Recommendations for Stroke Care.16 Despite the lack of evidence to support the effectiveness of positioning, ROM exercises, stretching, and splinting, these modalities are recommended to treat or prevent spasticity and contractures.16 In this study, most clinicians indicated that they used a combination of interventions for individuals with spasticity; this is consistent with the literature because of the complexity of the mechanisms underlying spasticity and the variability of the clinical symptoms.8,36. Thompson AJ, Jarrett L, Lockley L, et al.. Canadian Institute for Health Information (CIHI). It can also greatly increase fatigue however exercise, properly done, is vital in managing spasticity. In the private sector, clinicians had a greater tendency to use TENS (25.0% vs. 8.8%; z=2.14, p=0.032). However, the reliability of angle measurement in the modified TS is inconsistent.28 The TS also focuses on the perceived resistance to passive movement, which is a consequence of spasticity and may not reflect its neurological origin. Verrotti A, Greco R, Spalice A, Chiarelli F, Iannetti P. Pharmacotherapy of spasticity in children with cerebral palsy. Occupational therapy: exercises that focus on small muscle groups to improve strength and coordination allowing for improved performance of daily tasks. Most participants (83.8%) believed that it should be assessed when a patient is admitted to rehabilitation services (see Figure 3). sharing sensitive information, make sure youre on a federal The limited capacity of the current clinical measurements to detect changes in spasticity may explain this result.32 It is also possible that clinicians use spasticity assessment as a diagnostic tool rather than as an outcome measure to evaluate the effect of a treatment. In light of this, several clinical practice guidelines have recommended using valid and reliable tools to assess spasticity.12,15,16 However, whether these guidelines have been implemented in clinical practice and what effect their implementation may have on patient care is unknown. government site. Selective dorsal rhizotomy in children with cerebral palsy. A better understanding of the current trends in physiotherapy and occupational therapy in Canada will help to tailor strategies to promote the implementation of recommendations from clinical practice guidelines and improve practice. Concerning the work environment, the majority of respondents reported working in the public health care system (92.4%), and almost half (48.9%) worked, more specifically, in a rehabilitation centre. HHS Vulnerability Disclosure, Help However, there is conflicting evidence about which physical treatment modality is the most effective in reducing spasticity. It can be triggered at any time through a variety of stimuli. Spasticity can be a feature of a single traumatic insult or from chronic neurological conditions.5 Some examples of upper motor neuron pathology include spinal cord injury (SCI), cerebral palsy, stroke, amyotrophic lateral sclerosis, and multiple sclerosis (MS). Spasticity: pathophysiology, evaluation and management. Cochrane Database of Systemic Reviews: plain language summaries. In all, 204 physiotherapists and 113 occupational therapists completed the questionnaire (see Table 1). Intrathecal baclofen for spasticity management: a comparative analysis of spasticity of spinal vs cortical origin. The lower percentage of clinicians who indicated that spasticity should be assessed at other time points (interim, discharge, and follow-up) rather than at admission could mean that some clinicians do not expect spasticity to change over time. We calculated the percentage of responses to each question on the basis of the number of participants who answered each question. Abstract. Thus, more extensive studies are recommended to accurately demonstrate ITB's effectiveness. and transmitted securely. Spasticity is defined as a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone') with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex.2(p.485) It is estimated that 12 million people around the world are affected by spasticity. Few studies showed that using electrical stimulation in conjunction with botulinum toxin A increased ankle flexibility and improved gait in children with cerebral palsy65 as well as spastic foot drop after a stroke in adults.66,67 Another study alluded to the use of Botox as an adjunct to ITB to alleviate focal spasticity.61 However, research involving the treatment options discussed in this article is warranted for more definitive results. Bethesda, MD 20894, Web Policies A widely used therapy for children is botulinum neurotoxin injections. In all, 8,617 individuals were sent an email inviting them to fill out the questionnaire. Galen S, Wiggins L, McWilliam R, Granat M. A combination of botulinum toxin A therapy and functional electrical stimulation in children with cerebral palsya pilot study. Marinelli L, Trompetto C, Mori L, et al.. Manual linear movements to assess spasticity in a clinical setting, The Tardieu Scale differentiates contracture from spasticity whereas the Ashworth Scale is confounded by it, Test-retest reliability and inter-rater reliability of the Modified Tardieu Scale and the Modified Ashworth Scale in hemiplegic patients with stroke, Psychometric evidence of spasticity measurement tools in cerebral palsy children and adolescents: a systematic review, The spinal pathophysiology of spasticityfrom a basic science point of view, Essential competency profile for physiotherapists in Canada. The goal of treatment for spasticity is to allow for increased movement and reduce symptom severity. A practical overview of tizanidine use for spasticity secondary to multiple sclerosis, stroke, and spinal cord injury. Nabilone is the medication that was studied for spasticity control in patients with MS.6 The proposed mechanism of action is through the stimulation of the CB1 receptors expressed in the output neurons of the substantia nigra pars reticulata and globus pallidus, thus suppressing excessive motor output and muscle spasms.53 However, it has been shown that cannabinoids work both centrally and peripherally.54 Evidence of the efficacy of this medication has been equivocal: One study showed that it may reduce symptoms of spasticity in patients with multiple sclerosis.55 Another study states that cannabinoids for MS did not have a beneficial effect on spasticity in objective measurements, but there was support for a treatment effect on pain and spasticity in subjective measurements.56 In theory, it may also reduce spasticity by reducing the input from noxious stimuli by reducing pain overall. Background: Muscle spasticity is a common sequela of spinal cord injury (SCI) that may impact daily function. Assessment: botulinum neurotoxin for the treatment of spasticity (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Spasticity is a velocity-dependent increase in muscle tone and uncontrolled, repetitive, involuntary contractions of skeletal muscles. Symposium synopsis In: Feldman RG, Young RR, Koella WP, editors. Only a small proportion of respondents had a PhD (1.3%). The results of this study showed that only a small proportion of clinicians (14.0%) are using the Tardieu Scale (TS), either the original or the modified version, even though it has been suggested as a more valid alternative for spasticity assessment.27 Unlike the MAS, the TS takes into consideration the velocity-dependent aspect of the stretch reflex response because it is performed at both slow and fast velocities. In this article we discuss mechanisms, indications, efficacy, and side effects of the most accepted current treatments. Baclofen is considered the first-line treatment for spasticity, especially in adult SCIs.5 It works pre- and postsynaptically as a gamma aminobutylic acid (GABA) B agonist at the spinal level14 and binds to its receptors, leading to membrane hyperpolarization. Poststroke Spasticity Management. Gabapentin is often prescribed when patients describe symptoms that are consistent with neuropathic pain along with spasticity.16 A study by Gruenthal et al.29 showed that using gabapentin alone, compared to a placebo, demonstrated a reduction in the Ashworth scale and in the spasticity Likert scale scores. The goal is to relieve spasticity-associated pain and limited function. Spasticity management involves diverse approaches including physiotherapy (PT) interventions, transcranial magnetic stimulation, and antispastic medications as Baclofen (by oral or intrathecal administration), and botulinum toxin A. FOIA 8600 Rockville Pike However, gabapentin is not a first-line treatment for spasticity and is rarely used as a monotherapy. neurological rehabilitation, neurology, occupational therapy, spasticity, survey, symptom assessment, ergothrapie, valuation des symptmes, neurologie, radaptation neurologique, sondage, spasticit. They were also asked to read a brief case study about an individual who had sustained a stroke and then indicate whether they would assess spasticity in that patient. Thus, our results may have overestimated the percentage of clinicians who believed that using outcome measures was important. It can be triggered at any time through a variety of stimuli. In the past, much of the controversy about the management of spasticity has been due to a lack of commonly accepted definitions of the disorder, the difficulty in measuring spasticity as well as the changing nature of the motor activity limitations with growth and maturation. The aim of this study was to investigate the current practices of physiotherapists and occupational therapists working with individuals with neurological disorders in assessing and treating spasticity using a self-administered, Web-based questionnaire. Neurological rehabilitation and management of spasticity. Poststroke spasticity (PSS) is a common complication associated with other signs and symptoms of the upper motor neuron syndrome, including agonist/antagonist co-contraction, weakness, and lack of coordination. Penn RD, Savoy SM, Corcos D, Latash M, Gottlieb G, Parke B, Kroin JS. Bayram S, Sivrioglu K, Karli N, Ozcan O. Low-dose botulinum toxin with short-term electrical stimulation in poststroke spastic drop foot: a preliminary study. In general, oral agents are more inexpensive in the short term and easier to use, but they have unwanted systemic effects, which can outweigh the potential benefits they may provide.12,13 At the same time, these systemic drugs may be better for patients with generalized spasticity.5 On the other hand, interventional therapies pose the problem of procedural errors, difficulty in finding a provider who is trained to perform the procedure, and further complications.4 However, it may provide greater control of spasticity with fewer systemic side effects if patients are compliant and can tolerate the procedures. 3,9 Spasticity can also have functionally limiting and painful sequelae, including diminished joint mobility, decreased muscle flexibility, and sleep disorders secondary . Among these questionnaires, 317 were complete, 106 were incomplete, and 2 had been terminated (consent not given). Crit Rev Phys Rehabil Med. This allows a higher CNS concentration of the drug at the spinal cord level at lower doses while avoiding the vast systemic side effects that oral baclofen induces. Acute intrathecal baclofen withdrawal: a brief review of treatment options. Before Note: Percentages were based on the total number of clinicians who treat patients with spasticity in their practice. Download Free PDF. Tous les cliniciens ont mentionn que la spasticit devrait tre value par des professionnels de la radaptation, et la plupart ont prcis qu'elle devrait l'tre par plus d'un professionnel. Awaad Y, Rizk T, Siddiqui I, Roosen N, Mcintosh K, Waines GM. Simon O, Yelnik AP. Download Free PDF. Objectives To examine the impact of physiotherapy (PT) programs on effectiveness and persistence of nabiximols treatment in people with MS-related spasticity. In the last 3 decades, selective posterior rhizotomy (SPR) has been used in the management of these patients for reduction of spasticity which may result in an improvement of their active functional mobility. Sheehan L. Spasticity can be assessed at different times during rehabilitation. Simpson DM, Gracies JM, Graham HK, Miyasaki JM, Naumann M, Russman B, Simpson LL, So Y Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Killestein J, Uitdehaag BM, Polman CH. Spasticity is a disruption in muscle movement patterns that causes certain muscles to contract all at once when you try to move or even at rest. ROM=range of motion; MAS=Modified Ashworth Scale; DTR=deep tendon reflexes; FS=functional scales; AS=Ashworth Scale; TM=torque measurements; TS=Tardieu Scale; CST=clinical score of tone; SFS=Spasm Frequency Scale; CSI=Composite Spasticity Index. Physical therapy is one part of the armoury in the fight against this disabling symptom of the upper motor neurone syndrome. Shevell MI, Dagenais L, Hall N; REPACQ CONSORTIUM*. This unexpected result may also be related to clinicians' perceptions about which spasticity assessments are valid and reliable. Abbruzzese G. The medical management of spasticity. Stempien L, Tsai T. Intrathecal baclofen pump use for spasticity: a clinical survey. All questions were mandatory. The most commonly indicated treatments for spasticity, in descending order, were positioning, prolonged muscle stretching, splinting, motor-level stimulation, other treatment modalities (options not listed), vibration, transcutaneous electrical nerve stimulation (TENS), traction, and prolonged icing (see Table 2). Spasticity following spinal cord injury In: Eng JJ, Teasell RW, Miller WC, et al., editors. In their daily practice, clinicians are using a combination of assessments; however, most of these are only indirect methods of measuring spasticity. *Data obtained from the Canadian Institute for Health Information. Complications of intrathecal baclofen pump: prevention and cure. Francisco GE, Yablon SA, Schiess MC, Wiggs L, Cavalier S, Grissom S. Consensus panel guidelines for the use of intrathecal baclofen therapy in poststroke spastic hypertonia. Percentage of respondents using spasticity assessment in their daily practice: (a) all participants and (b) physical and occupational therapists separately. Abstract. Because of the significant impact of spasticity on activities of daily living, managing spasticity is an important component of neurological rehabilitation. The appropriate modifications were then made to obtain the final version of the questionnaire. Responses also differed among clinicians from the private and public sectors. Pandyan AD, Johnson GR, Price CI, et al.. A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity, Ashworth scales are unreliable for the assessment of muscle spasticity. Spasticity presents as upper motor neuron symptoms in patients with central nervous system pathology such as stroke, spinal cord injury, brain injury, or multiple sclerosis. Romijn JA, Van Lieshout JJ, Velis DN. Conclusions: la prsente tude est la premire porter sur les pratiques des cliniciens en matire d'valuation et de traitement de la spasticit. Further studies should be done to elaborate these findings. There was also a paucity of data to validate clinical practice. being able to get an erection sometimes, but not every time you want to have sex. Because of the possible risks and benefits of each treatment, it is important to assess a patient's medical history to determine which treatment option is best. It was part of a larger study that aimed to gain a better understanding of the current trends in rehabilitation practice in managing spasticity in different countries, such as India. Physiotherapy management of spasticity. . Purpose: The purpose of this study was to understand current trends in rehabilitation practice regarding spasticity assessment and treatment. Flex dosing is indicated when patients demonstrate a suboptimal response in spasticity control or the infusion rate reaches the daily dose of 200300 g59,60 without optimal control of spasticity. Spasticity is a neurological condition affecting movement which can cause muscle stiffness, pain, loss of joint range and loss of function. The study sample also included a large proportion of clinicians from the province of Quebec. Difficulties for patients include problems maintaining personal hygiene and independent dressing. Positioning, prolonged muscle stretching, splinting, and motor-level stimulation were indicated as modalities most commonly used by clinicians to manage spasticity. La majorit des participants (91,1%) ont dclar qu'il tait important d'utiliser des mesures de rsultats valides et fiables pour valuer la spasticit. The relationship of cerebral palsy subtype and functional motor impairment: a population-based study, Poststroke spasticity: sequelae and burden on stroke survivors and caregivers, The Stockholm Spinal Cord Injury Study: 2. [11] The aims of treatment should be the following: 1. Physiotherapists are part of the rehabilitation team involved in the management of adult spasticity. Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. An official website of the United States government. The oral form of baclofen is rapidly absorbed and crosses the blood-brain barrier.4 However, penetration of the blood-brain barrier is not very efficient, which explains the limited efficacy of oral baclofen in low doses (the efficacy of oral baclofen increases with higher doses). Surgical treatments include selective dorsal rhizotomy and neurectomy. Although most provinces have residents whose spoken language is mainly English, the large number of respondents from Quebec may explain the distribution. Physiotherapy management of spasticity. Baguley IJ, Bailey KM, Slewa-Younan S. Prolonged anti-spasticity effects of bolus intrathecal baclofen. First, although it revealed that the majority of clinicians believed it was important to use valid and reliable outcome measures to assess spasticity, these results may not reflect clinicians' overall perception because this group constituted only a proportion of the targeted population. Spasticity, resulting in involuntary and sustained contractions of muscles, may evolve in patients with stroke, cerebral palsy, multiple sclerosis, brain injury, and spinal cord injury (SCI). More physiotherapists indicated using clonus, the MAS, and deep tendon reflexes to evaluate spasticity, and more occupational therapists indicated using functional scales and torque measurements (see Figure 5b). Introduction. Upper motor neurone syndrome and spasticity: clinical management and neurophysiology (Cambridge medicine). Nance PW, Shears AH, Nance DM. Potential adverse effects are related to central nervous effects as well as the development of tolerance, thereby requiring extremely high doses.30, Neurectomies (the removal of a peripheral nerve) are procedures that interrupt nerve signal transduction to reduce spasms and pain. It has shown significant reduction in spasticity in children, although the outcomes may be variable, and orthopedic complications, such as subluxation of the hips, may not be prevented.47,48 A study by Oki et al.49 concluded that all the pediatric participants with spastic hemiparesis included in the study had a reduction of tone after SDR, as measured by a modified Ashworth scale, and showed an improvement in gait. Physiotherapists were more inclined than occupational therapists to select muscle stretching and motor-level stimulation, a practice that may reflect the different role of each profession in spasticity management. Chou R, Peterson K, Helfand M. Comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions: a systematic review. Berger JR. Functional improvement and symptom management in multiple sclerosis: clinical efficacy of current therapies. FOIA Physical therapy: stretching and strengthening exercises focusing on large muscle groups to improve range of motion and mobility. Grabb PA, Guin-Renfroe S, Meythaler JM. At all time points (admission, interim, discharge, and follow-up), the proportions differed significantly between clinicians working in a rehabilitation centre and those working in other clinical settings. Intrathecal baclofen for severe spinal spasticity. An official website of the United States government. Midthoracic catheter tip placement for intrathecal baclofen administration in children with quadriparetic spasticity. Federal government websites often end in .gov or .mil. Spasticity can be incapacitating. Preliminary results have been published in abstract form.17. Abrupt withdrawal from intrathecal baclofen: recognition and management of a potentially life-threatening syndrome. To properly manage spasticity, a treatment plan must be based on an accurate clinical assessment of the patient. A comprehensive search was . Spasticity dynamically varies and is an important physiologic response to illness or other stressors. There were no exclusion criteria. Abstract. Some limitations were also identified with the questionnaire. Reversible coma due to intrathecal baclofen. The majority of the participants believed that using valid and reliable outcome measures to assess spasticity was important. Accessibility The sample was representative of the current profile of Canadian physiotherapists and occupational therapists37,39 except for the distribution of clinicians across the country. AImS oF SPAStIcItY mAnAgement When the patient presents a pattern of spasticity that implies on functional or postural loss, management of spasticity must be considered within a progressive approach - from the most conservative to the most invasive therapy. Chronic intrathecal delivery of baclofen by a programmable pump for the treatment of severe spasticity. government site. The majority of participants (92.2%) identified multiple modalities when questioned about which spasticity treatment they would typically use. 4 Physiotherapy management of spasticity 79 Roslyn N. Boyd and Louise Ada 5 Seating and positioning 99 Craig A. Kirkwood and Geoff I. Bardsley 6 Orthoses, splints and casts 113 By the end of the data collection period, we had received 425 questionnaires from physiotherapists and occupational therapists. Objective: The aim of the study was to examine the effectiveness of physiotherapy (PT) interventions on spasticity in people with multiple sclerosis. Spasticity can be incapacitating. Optimum management of spasticity isdependent on an understanding of itsunderlying physiology, an awareness ofits natural history, an appreciation ofthe impact on the patient, and a com-prehensive approach to minimising thatimpact which is both multidisciplinaryand consistent over time. Results: A total of 317 clinicians (204 physiotherapists and 113 occupational therapists) completed the questionnaire. Spasticity can, conversely, be beneficial to help patients transfer, stand, ambulate, and maintain muscle bulk. Coffey RJ, Edgar TS, Francisco GE, Graziani V, Meythaler JM, Ridgely PM, Sadig SA, Turner MS. Cannabinoids in multiple sclerosis: do they have a therapeutic role? Among the 291 clinicians who indicated that they worked with individuals with spasticity, 94.8% reported that they would assess spasticity in the case study patient (Section 4 of online Appendix 1). Spasticity is a condition in which there is an abnormal increase in muscle tone or stiffness of muscle, which might interfere with movements, gait and speech while causing discomfort or pain. Many adults who had SDR as children highly recommend the procedure as well.50. There has not been much research investigating the effectiveness of combination therapy using multiple medications or interventional therapies in conjunction. A convenience sample of six additional expert clinicians piloted the questionnaire independently. The aims of physiotherapy techniques used for the treatment of spasticity are to favor sensorimotor recovery and gesture relearning and to lead to an optimal independence in daily life activities. The site is secure. If respondents indicated that they would not, the questionnaire was terminated. Note: Respondents could select more than one option. encourage muscle growth in . Botulinum toxin type A (BTX-A) is increasingly being used for the treatment of childhood spasticity, particularly cerebral palsy. Spasticity affects a patient's independence in activities of daily living such as hygiene, dressing, self-comfort, ambulation, and sleep.10 Later it may lead to significant pain, contractures, joint subluxations or dislocations, peripheral neuropathy, and pressure ulcers.11 Therefore, treatment of this condition is imperative to improve quality of life and minimize medical complication. Systematic review. For ITB, there are currently 2 predominant philosophies of dosing: simple continuous infusion and flex dosing/periodic bolus infusion. The placement of the catheter tip for optimal management has not undergone rigorous clinical study. Most patients with ITB pumps initiate their therapy with continuous infusion. This resulted in a response rate of approximately 5.0% and a completion rate of 74.6%. Barriers to implementation of stroke rehabilitation evidence: findings from a multi-site pilot project. Radiofrequency applications to dorsal root ganglia: a literature review. These high concentrations are essentially injected perineurally to irreversibly destroy the nerve causing spasticity.4,5,17 This procedure is not commonly used as a first-line treatment because it is nonselective and has a variable duration of effect ranging from days to years8 because of partial nerve regeneration and sprouting following the treatment.4,5 This procedure is used mainly to help with gait, posture, and hygiene.44 However, this is an effective treatment for patients with spasticity refractory to all other therapies5,16 and should be reserved for patients with a complete loss of sensation and/or no functional movement in their lower body.3 Caution must be taken because there can be potential adverse effects concerning the bladder, bowel, and sexual function.5 Other adverse effects include transient flushing4 and neuropathic pain.9 In current practice, this therapy is starting to be replaced by Botox injections.8, Spasticity does unfortunately affect children, especially those with cerebral palsy and anoxic brain injuries, but treatment options are more restrictive compared to adults because of unfavorable side effects that are not tolerated well by children. There is still a need to develop spasticity assessments based on neurophysiological measures that are feasible to use in clinical settings. National Library of Medicine Theory Imbalance between descending excitatory and inhibitory impulse to the alpha motor neuron: -Spasticity of cerebral origin results from lack of descending inhibitory input from subcortical nuclei in the brain ED is often a symptom of another health problem or health-related factor. We identified the therapists who met the inclusion criteria by obtaining the associations' member lists, either from their Web sites or by contacting the associations themselves and filtering the lists to find professionals who were working with neurological populations. Physical therapy is one part of the armoury in the fight against this disabling symptom of the upper motor neurone syndrome. As a library, NLM provides access to scientific literature. 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