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PubMedDate not supplied

Treatment of muscle spasticity in patients with cerebral palsy using BTX-A: a pilot study.

This study was designed to verify the safety and efficacy of botulinum toxin type A (BTX-A) used as a neuromuscular block on spastic masticatory musculature of children with cerebral palsy. Six patients who had spastic-tetraplegic cerebral-palsy, aged 5 to 20 years were selected. All patients had spasticity of the jaw muscles, bruxism, lower lip trauma, limited mouth opening, and difficulties in cleaning the oral cavity. The patients were sedated under general anesthesia, while the dentist injected the masseter and temporalis muscles bilaterally with 150 and 75 units of BTX-A each. Clinical examinations were conducted at 7, 14, 30, and 90 days after the initial appointment. We found statistically significant decreases in muscle spasticity and bruxism (p = 0.002), improved inter-incisal opening (p = 0.002), improved oral hygiene (p = 0.031), and less lower lip trauma (p = 0.060) after the neuromuscular blocking.

Adolescent↗
PubMed2003

The relation between Ashworth scale scores and the excitability of the alpha motor neurones in patients with post-stroke muscle spasticity.

BACKGROUND: The modified Ashworth scale (MAS) is the most widely used method for assessing muscle spasticity in clinical practice and research. However, the validity of this scale has been challenged. OBJECTIVES: To compare the MAS with objective neurophysiological tests of spasticity. METHODS: The MAS was recorded in patients with post-stroke lower limb muscle spasticity and correlated with the excitability of the alpha motor neurones. The latter was evaluated by measuring the latency of the Hoffmann reflex (H reflex) and the ratio of the amplitude of the maximum H reflex (H(max)) to that of the compound action motor potential of the soleus muscle (M(max)). RESULTS: Data on 24 randomly recruited patients were analysed. Patients were divided into two groups according to their MAS score: 14 had a MAS score of 1 (group A) and 10 scored 2 (group B). The two groups were comparable with respect to age and sex, but in group A there was a longer period since the stroke. The H reflex latency was reduced and the H(max):M(max) ratio was increased in both groups. The H(max):M(max) ratio values were higher for group B but the differences were not statistically significant. CONCLUSIONS: There is a relation between the MAS scores and alpha motor neurone excitability, although it is not linear. This suggests that the MAS measures muscle hypertonia rather than spasticity.

Action Potentials↗
PubMed2002

Anatomic motor point localization for the treatment of gastrocnemius muscle spasticity.

The location of the motor point of the gastrocnemius muscle was accurately defined relative to surrounding bony landmarks to facilitate the approach to the nerve of the gastrocnemius muscle during treatment for gastrocnemius muscle spasticity. Anatomic dissection of 40 cadaver knees was undertaken for morphometric measurement. The distances from the epicondyle of the femur to the motor branch, and from the motor branch to the motor point of the nerve to the medial head of the gastrocnemius muscle were 3.68 +/- 11.44 mm, and 37.79 +/- 7.80 mm, respectively; while those of the nerve to lateral head of the gastrocnemius muscle were 4.45 +/- 11.96 mm, and 32.16 +/- 4.64 mm, respectively. The tibial nerve lay 44.57 +/- 5.45% and 56.30 +/- 4.73% from the lateral margins of the epicondyle and the fibular head, respectively. Careful consideration of the morphometry of the motor point of the gastrocnemius muscle may provide accurate anatomical guidance, and hence reduce complications during the chemical blockage of these nerves.

Humans↗
PubMed1993

Attenuation of facial muscle spasticity with intramuscular phenol neurolysis.

Intramuscular phenol neurolysis is a well-known procedure used to decrease spasticity and improve function in patients who have failed to respond to more conservative forms of intervention. Traditionally, this approach has been limited to spasticity reduction in limb muscles, and its use in managing spasticity of the facial muscles has not been described in the literature. This case report describes a new and previously unreported application of intramuscular neurolysis for managing severe unrelenting facial muscle spasticity in a postanoxic encephalopathic patient. Prior to the procedure, hypertonicity in the orbicularis oris muscle was so profound that it limited speech and affected cosmetic, hygienic, and nutritional status. After intramuscular phenol neurolysis of the orbicularis oris muscle, the patient's level of functioning improved.

Eating↗
PubMed2001

Safety profile and efficacy of botulinum toxin A (Dysport) in children with muscle spasticity.

Botulinum toxin A (BTX-A) is widely used in the management of muscle spasticity in children. However, at present the dose of BTX-A for a given patient is selected empirically. The aim of this study is to provide dosage guidelines that are based on risk/benefit assessment. This was a multicentre retrospective study of the safety profile and efficacy of BTX-A in children with chronic muscle spasticity. Data in 758 patients who received a total of 1594 treatments were analysed (mean age 7.2 years; 429 males, 329 females). Spastic cerebral palsy (CP) was the most common diagnosis (94% of the study sample). Of all treatments 7% resulted in adverse events; incidence was related to the total dose rather than the dose calculated on the basis of body weight. The highest incidence of adverse events was observed in patients who received >1000 IU of BTX-A per treatment session. The odds of an adverse event was 5.1 times greater for this group of patients than for those who had 250 IU or less (p<0.001). A good overall response to treatment was reported in 82% and treatment goals were fully or partially achieved in 3% and 94% of participants respectively. More patients in the highest dose group reported functional deterioration. Interestingly, multilevel treatments resulted in a better response than single-level treatments (odds ratio 1.7, 95% CI 1.3 to 2.2,p=0.001).

Age Factors↗
PubMed1987

Interrater reliability of a modified Ashworth scale of muscle spasticity.

We undertook this investigation to determine the interrater reliability of manual tests of elbow flexor muscle spasticity graded on a modified Ashworth scale. We each independently graded the elbow flexor muscle spasticity of 30 patients with intracranial lesions. We agreed on 86.7% of our ratings. The Kendall's tau correlation between our grades was .847 (p less than .001). Thus, the relationship between the raters' judgments was significant and the reliability was good. Although the results were limited to the elbow flexor muscle group, we believe them to be positive enough to encourage further trials of the modified Ashworth scale for grading spasticity.

Elbow Joint↗
PubMed1994

Complications of spinal opioid therapy: myoclonus, spastic muscle tone and spinal jerking.

This study was made in order to define risk factors for patients requiring spinal opioid therapy developing painful spastic muscle tone together with myoclonus and spinal jerking (MSJ). The case histories of 75 patients, all receiving morphine spinally, were retrospectively analysed and, of these, 10 suffered from the MSJ syndrome. The following were taken as evaluation criteria: age, sex, performance status, duration and dosage of previous systemic and current spinal morphine therapy, concomitant analgesic and co-analgesic medication, pretreatment of the dorsal column and neurological dysfunction due to damage either of the nerval plexus or of the medulla spinalis. As a result, high spinal morphine doses in conjunction with pathological changes within the spine were shown to be risk factors for this syndrome. Changing from spinal to systemic morphine application or reduction of spinal doses together with the addition of systemic morphine led to complete recovery from MSJ. As underlying mechanism, an imbalance between the activity of spinal and central opioid receptors and/or toxic morphine effects on the medulla spinalis are discussed. In conclusion, great care should be taken when applying morphine to the spine in patients with neurological dysfunction due to an apparent pathology of the medulla spinalis, especially if large amounts of morphine are likely to be required. Some systemic application of morphine might reduce the risk of patients developing MSJ syndrome.

Administration, Oral↗
PubMed2005

Variability and predictability of functional efficacy of botulinum toxin injection in leg spastic muscles.

Botulinum toxin injection reduces spasticity level. However, the effects on gait parameters and daily living activities remain controversial, and the prediction of results remains poorly evaluated. The aim of this open study was to investigate these effects, and the predictability of results. Forty-seven injections were given to 47 patients with stroke (males: 24; mean age: 51.7), in the soleus, gastrocnemius, tibialis posterior and anterior, and flexor digitorum longus, with a global dose of 300 U (Botox). Each was evaluated at day 1 (D1), day 15 (D15), month 2 (M2) and month 5 (M5). We observed a significant but moderate reduction in spasticity (Ashworth) of the ankle plantar flexors (0.72/5) and dorsiflexors, which was greater at D15, and an improvement in distal positioning in the upright situation. Upright balance and gait (Functional Ambulation Categories) were improved, especially at M2 and in the barefoot condition. Gait velocity and step length with usual aids (10 m) were discretely increased, and this was especially evident in about 15 patients. We also found improvement in the Rivermead Motor Assessment. Patients reported better foot positioning, facilitation in limb propulsion, and better static and dynamic balance. For each assessment, high variability in the effects was also shown. Improvement in functional tests was partially predicted by age (negative relation), delay since stroke (negative relation), gender (better in men), spasticity of hip adductors and knee extensors (negative relation), active ankle dorsiflexion (positive relation) and heel-ground distance (positive relation). In conclusion, the effects on spasticity, balance and gait were relatively modest, and with a large variability between patients. Functional improvement could be partially predicted by several general or specific factors, the knowledge of which is important in the selection of patients to be injected, and for future trials aiming to demonstrate the efficacy of botulinum toxin injection.

Adult↗
PubMed2003

[Alcohol neurolytic blocks for pain and muscle spasticity].

Peripheral nerve blockade is one of the therapeutic options for spasticity of various muscles. Percutaneous nerve stimulation allows accurate location of nerves and neurolysis can be performed using intraneural injection of 65% ethanol or 5 to 12% phenol. Spastic contraction of various muscle groups is a common source of pain and disability which prevents efficient rehabilitation. Neurolytic blocks are possible in most of motor nerves of the upper and lower limbs and main indications are spastic sequelae of stroke and spinal trauma but also of multiple sclerosis, cerebral palsy and chronic coma. The use of percutaneous nerve stimulation allows accurate location and four nerves are more frequently treated: pectoral nerve loop, median, obturator and tibial nerves. In patients with spasticity of the adductor thigh muscles, nerve blocks are performed via a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve. No complications occur and minor side effects are transient painful phenomena during injection. These approaches have proved to be accurate, fast, simple, highly successful and reproducible. Percutaneous neurolytic procedures, should be performed as early as possible, as soon as spasticity becomes painful and disabling in patients with neurological sequelae of stroke, head trauma or any lesion of the motor neurons.

Ethanol↗
PubMed2003

Botulinum toxin in the management of childhood muscle spasticity: comparison of clinical practice of 17 treatment centres.

At least two randomized controlled trials (RCTs) have shown botulinum toxin type A (BtxA) to be efficacious and safe when used in the management of muscle spasticity in children. However, the need to use standard treatment protocols in these studies obscures some aspects of routine clinical practice that may have important effect on clinical outcomes. The purpose of this study was to seek additional information on the use of BtxA that is not usually captured by RCTs. This was performed by reviewing the clinical practice of practitioners in 17 treatment centres in Europe. The details of treatment with BtxA, including the dose, site and frequency of injections and the use of anaesthesia or sedation, were abstracted from the patient's records. Information was also obtained on the response to treatment and the occurrence and severity of adverse events. The data on 758 children who received a total of 1,594 treatments in 17 different clinics in Europe were analysed. Ninety-four per cent of patients had cerebral palsy. There was a general agreement on the indications for treatment but the average dose of BtxA used varied between centres. One treatment centre used general anaesthesia (GA) prior to injections in most patients. The reported efficacy and adverse events profile was similar for all centres. The evidence from routine clinical practice for the efficacy and safety of BtxA in the management of muscle spasticity in children, as described in this study, is in agreement with that of most of the open-label and RCTs published to date. The present study also demonstrates the disagreement between clinicians on the optimal dose of BtxA for individual muscles and confirms that the injections can be carried out without GA in almost all cases.

Anesthesia↗
PubMedDate not supplied

[Relationship between decreased presynaptic inhibition and muscle spasticity in patients with a history of cerebral insult].

Stimulation electromyography was used to study inhibition of the soleus muscle H-reflex induced by stimulation of the common peroneal nerve in healthy individuals and in patients who had underwent cerebral apoplexy. Two successive inhibition waves (D1 and D2) were recorded; the first wave demonstrated the development of presynaptic inhibition of group Ia afferent fibers. In post-insult patients the depth of inhibition diminished depending on the degree of the pathologic increase of the tonus of the skeletal musculature. The role of presynaptic inhibition disorders in the pathogenesis of muscle spasticity is discussed.

Cerebrovascular Disorders↗
PubMed2006

Whole-body vibration training compared with resistance training: effect on spasticity, muscle strength and motor performance in adults with cerebral palsy.

OBJECTIVE: The aim of this study was to evaluate the effect on spasticity, muscle strength and motor performance after 8 weeks of whole-body vibration training compared with resistance training in adults with cerebral palsy. METHODS: Fourteen persons with spastic diplegia (21-41 years) were randomized to intervention with either whole-body vibration training (n=7) or resistance training (n=7). Pre- and post-training measures of spasticity using the modified Ashworth scale, muscle strength using isokinetic dynamometry, walking ability using Six-Minute Walk Test, balance using Timed Up and Go test and gross motor performance using Gross Motor Function Measure were performed. RESULTS: Spasticity decreased in knee extensors in the whole-body vibration group. Muscle strength increased in the resistance training group at the velocity 30 degrees /s and in both groups at 90 degrees /s. Six-Minute Walk Test and Timed Up and Go test did not change significantly. Gross Motor Function Measure increased in the whole-body vibration group. CONCLUSION: These data suggest that an 8-week intervention of whole-body vibration training or resistance training can increase muscle strength, without negative effect on spasticity, in adults with cerebral palsy.

Adult↗
PubMed2026

Treatment of spinal injury muscle spasticity by spinal subpial AAV9-GAD65/VGAT delivery: An efficacy and safety study in rat, pig, and NHP.

The loss in segmental inhibitory GABAergic tone plays the key role in the development of spinal injury-induced muscle spasticity. We use a subpial segment-targeted delivery of adeno-associated virus vector(s) expressing GAD65 (glutamic acid decarboxylase-65) and VGAT (vesicular GABA transporter) transgenes in rats with spinal transection-induced spasticity. In treated animals, a significant suppression in spasticity was seen at 5-8 weeks after treatment. Naive rats, pigs, and non-human primates (NHPs) injected with human equivalent dose of treatment vectors and surviving for 3 weeks to 4.5 years showed normal motor function and pinch-evoked response. A significant increase in the number of VGLUT2 terminals co-expressing GAD65 and VGAT protein in vector-injected segment was seen. This corresponded with the presence of transgene-specific rat Gad2 or human GAD2 and rat Slc32a1 or human SLC32A1 mRNA signal. No spinal toxicity was noted in NHPs at 4.5 years post vector delivery. Analysis of peripheral organs (liver, spleen, and skeletal muscle) showed minimal or no detectable transgenes in pigs and NHPs. These data demonstrate that a single-time-point spinal-segment-targeted subpial delivery of GAD65/VGAT transgenes is effective in suppressing spinal injury-induced spasticity and has a favorable long-term safety profile as defined by normal neurological function and histopathology in naive pigs and NHPs.

Animals↗
PubMed1996

Reliability of the Modified Ashworth Scale in the assessment of plantarflexor muscle spasticity in patients with traumatic brain injury.

Although the Modified Ashworth Scale (MAS) is commonly used to assess the severity of muscle spasticity for ankle plantarflexors, its reliability has only been established for elbow muscles. Interrater reliability, intrarater reliability and temporal (between-days) reliability were examined in this study. Also, interrater reliability for use of the scale with plantarflexors was compared with reported results from the measurement of elbow flexors. Thirty adult volunteers with traumatic brain injuries participated. There were 20 men and 10 women; the mean age was 28.3 years (SD = 10.8). Two physical therapists used the MAS to score the subjects independently. Measurements were repeated to yield multiple scores for intrarater reliability assessment. Twenty-one of the subjects returned individually on separate days to be measured again, so that temporal reliability could be assessed. Spearman's correlation coefficients were 0.73 for interrater reliability 0.74 and 0.55 for intrarater reliability, and 0.82 for temporal reliability. Overall, reliability of the MAS for assessing plantarflexor spasticity in patients with traumatic brain injury was found to be minimally adequate to support its continued use. However, interrater reliability was less than that which has been reported for elbow flexors, and intrarater reliability findings were mixed.

Adolescent↗
PubMed2002

Torque-EMG relationships in normal and spastic muscles.

The linearity of the relationship between torque and electromyographic (EMG) activation has been widely debated for years, yet remains unresolved. Despite limitations and possible inaccuracies, an assumption of linearity is often made to simplify the relationship between these variables for computational and descriptive purposes. Although typically derived from isometric test conditions, these relationships have also been extrapolated, perhaps invalidly, to conditions where joint velocity and length are changing. The purpose of this study was to examine the degree of linearity between hamstring and quadriceps torques and their respective EMG signals, and to compare the slopes of these relationships in normal and spastic muscles at varying muscle lengths and conditions. We hypothesized that relationships would be linear for all muscles tested in both subject groups; however, slopes would differ across the two muscles, the three muscle lengths tested, and the two subject groups. We further hypothesized that the degree of linearity during an isotonic task would be less than for the isometric one, particularly for patients with spasticity who may demonstrate abnormal responses to changes in muscle length. Results indicated that torque--EMG relationships were linear for all subjects during isometric contractions, regardless of group, muscle, or knee angle. However, the degree of linearity was significantly less in CP in both conditions; and within the CP group, was less during isotonic compared to isometric conditions. Slope values differed between muscles at some lengths, across muscle lengths in the quadriceps, and subjects with CP showed consistently lower slopes for all quadriceps values. These data in general support the robustness of the linear assumption in isometric conditions for the knee musculature, caution against extrapolation to isotonic conditions particularly for those with movement abnormalities, and suggest that slope differences may provide valuable insights into pathology and warrant further investigation.

Adolescent↗
PubMed2005

Structural and mechanical alterations in spastic skeletal muscle.

Spasticity, a neurological problem secondary to an upper motor neuron lesion, has a significant effect on skeletal muscle. The upper motor neuron lesions may be secondary to a cerebral vascular accident, head injury, spinal cord injury, or degenerative diseases such as multiple sclerosis, or perinatal brain injuries such as cerebral palsy. Functional ability in these patients can be severely compromised but the basic mechanisms underlying these deficits are not clearly understood. In this review we evaluate the current evidence in the literature that suggests that skeletal muscle tissue itself is altered in spastic conditions. Experimental studies were evaluated that included a variety of methods encompassing joint mechanics, tissue mechanics, and muscle morphology. Taken together, the literature strongly supports the assertion that 'spastic muscles' are altered in a way that is unique among muscle plasticity models and inconsistent with simple transformation due to chronic stimulation or disuse. Further studies are required to detail the intra- and extracellular modifications of skeletal muscle that occur secondary to spasticity so that novel therapeutic treatments can be developed for this impairment.

Biomechanical Phenomena↗