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The inter-rater reliability of the original and of the Modified Ashworth Scale for the assessment of spasticity in patients with spinal cord injury
Abstract
Thirty patients with spinal cord injury (SCI) were randomly selected to participate in this study which evaluated the inter rater reliability of the original and of the modified Ashworth scale for the assessment of spasticity in the lower limbs. A doctor and a physiotherapist rated the muscle tone of hip adductors, hip extensors, hip flexors and ankle plantarflexors according to the original and to the modified Ashworth scale. The results were analyzed using a Cohen's Kappa statistical test and showed varying levels of reliability for different muscle groups and limbs. Kappa values ranged between 0.21 and 0.61 (mean 0.37). The original scale was slightly more reliable than was the modified scale. However, this difference was not significant (P > 0.05), and was not consistent between the two limbs and between different muscle groups. It was concluded that the Ashworth scale is of limited use in the assessment of spasticity in the lower limb of patients with SCI. Further work is required to establish a standardised speed of muscle stretching during the test, or to find more appropriate grades and descriptions of spasticity for this patient group. The effects of training of the raters in the use of the scales also warrants further investigation.
... Population (sample size, age, health condition) Usability Score Ashworth Scale Brashear et al., 2002;Fleuren et al., 2010;Haas et al., 1996;Lee et al., 1989;Nakhostin-Ansari et al., 2006;Nuyens et al., 1994;Vattanasilp & Ada, 1999) Overall sample size: n = 136 Age (Mean, range) = 54.2, 13 -81 years Conditions: multiple sclerosis (n = 30), stroke (n = 23), spinal cord injury (n = 24), hemiplegia (n = 59). ...
... 2 Modified Ashworth Scale (Akpinar et al., 2017;Allison et al., 1996;Ansari et al., 2006;Ansari et al., 2008a;Baunsgaard et al., 2016;Blackburn et al., 2002;Bohannon & Smith, 1987;Cooper et al., 2005;Craven & Morris, 2010;Gregson et al., 1999Gregson et al., , 2000Haas et al., 1996;Kaya et al., 2011;Li et al., 2014;Mehrholz et al., 2005a, b;Nakhostin-Ansari et al., 2006;Pandyan et al., 2001Pandyan et al., , 2003Sloan et al., 1992;Tederko et al., 2007;Zurawski et al. 2019) Overall sample size: n = 747 Age (Mean, range) = 53.3, 13 -90 years Conditions: stroke (n = 278), cerebral palsy (n = 2), multiple sclerosis (n = 1), amyotrophic lateral sclerosis (n = 2), spinal cord injury (n = 163), traumatic brain injury (n = 32), hemiplegia (n = 269). ...
... Demographics Reliability Validity Overall rating* Ashworth Scale Brashear et al., 2002;Fleuren et al., 2010;Haas et al., 1996;Lee et al., 1989;Nakhostin-Ansari et al., 2006;Nuyens et al., 1994;Vattanasilp & Ada, 1999) (Akpinar et al., 2017;Allison et al., 1996;Ansari et al., 2006;Ansari et al., 2008a;Baunsgaard et al., 2016;Blackburn et al., 2002;Bohannon & Smith, 1987;Cooper et al., 2005;Craven & Morris, 2010;Gregson et al., 1999Gregson et al., , 2000Haas et al., 1996;Kaya et al., 2011;Li et al., 2014;Mehrholz et al., 2005a,b;Nakhostin-Ansari et al., 2006;Pandyan et al., 2001Pandyan et al., , 2003Sloan et Tederko et al., 2007;Zurawski et al., 2019) Re-Modified Ashworth Scale (Ansari et al., 2012;Ansari et al., 2008bAnsari et al., , 2009aGhotbi et al., 2009Ghotbi et al., , 2011Kaya et al., 2011;Mishra & Ganesh, 2014;Naghdi et al., 2007Naghdi et al., , 2008 (Abou et al., 2020;Cabanas-Valdes et al., 2016;Erol et al., 2021;Gorman et al., 2010Gorman et al., , 2014aPalermo et al., 2020;Sung et al., 2016) (Bourcier et al., 2020;Braga-Neto et al., 2010;Brandsma et al., 2017;Bürk et al., 2009;Kim et al., 2014;Salci et al., 2017;Schmitz-Hübsch et al., 2006Tan et al., 2013;Weyer et al., 2007;Winser et al., 2018;Yabe et al., 2008) (Akpinar et al., 2017;Ansari et al., 2008cAnsari et al., , 2013Azarnia et al. 2021;Ben-Shabat et al., 2013;Li et al., 2014;Mehrholz et al., 2005a;Naghdi et al., 2014Naghdi et al., , 2017Singh et al., 2011;Santos et al., 2021;Sonvane & Kumar, 2019) (Cabanas-Valdes et al., 2016;Fil Balkan et al., 2019;Lombardi et al., 2017;Monticone et al., 2017;Parlak Demir & Yildirim, 2018;Quinzanos et al., 2014;Sag et al., 2019;Seo et al., 2008;Verheyden et al., 2004Verheyden et al., , 2005Verheyden et al., , 2006aVerheyden et al., , b, 2007Zhao et al., 2021) (Aguiar et al., 2016;Akshintala et al., 2021;Aksu & Yakut, 2003;Baschung Pfister et al., 2018;Beck et al., 1999;Bohannon, 1986Bohannon, , 1992Bohannon, , 1993Bohannon, , 1995Bohannon et al., 2013;Bohannon & Andrews, 1987;Brinkmann, 1994;Busse et al., 2008;Cardin & Bohannon, 2017;Dyball et al., 2011;Eken et al., 2020;Ekstrand et al., 2015;Faria et al., 2013;Goonetilleke et al., 1994; Hayes et al., 2002;Kilmer et al., 1997;Knak et al., 2020;Larson et al., 2010;Livesley, 1992;May et al., 1997;Mentiplay et al., 2018;Moreno-Navarro et al., 2021;Morris et al., 2008;Noreau & Vachon, 1998;Riddle et al., 1989;Saygin et al., 2020;Schwartz et al., 1992;Tsai et al., 2015;van Langeveld et al., 1996;Visser et al., 2003) Inter-session: ICC = 0.94,PCC = 0.96,SEM = 0.10 Parallel Forms Reliability: PCC = 0.82 Consistency: Cronbach's Alpha = 0.95 Motricity Index (Bohannon, 1995(Bohannon, , 1999Cameron & Bohannon, 2000;Collin & Wade, 1990;Fayazi et al., 2012;Vos-Vromans et al., 2005) (Collin & Wade, 1990;Fil Balkan et al., 2019;Franchignoni et al., 1997;Parlak Demir & Yildirim, 2015) ...
The key aim of classification in Para sport is to try and ensure that competitors are grouped so that they compete against others with impairments that cause a similar level of activity limitation within a specific sport. This synthesis aimed to identify existing, valid, and reliable, impairment assessment tools to measure eligible impairments that influence an individual’s ability to compete at Para dressage. A multi-stage approach was employed, where a systematic search of professional databases of impairment assessment tools first identified 35 tools for Para dressage. Then, a search strategy was developed, based on these 35 tools, and 305 scientific articles were identified from academic databases up to September 2021. From here, impairment assessment tools were evaluated and refined in a two-stage process using known performance determinants for Para dressage and then an assessment of their reliability, validity and practical usability. This resulted in the selection of impairment assessment tools, which included measures of muscle tone, strength, coordination, sitting balance, and trunk function. From this synthesis, we present a novel process by which impairment assessment tools were selected, refined, and critically examined using knowledge of performance determinants for dressage, the views and experiences of stakeholders, and reliability and validity of tools. The processes described here could be applied to the development of evidence-based classification systems across a range of Para sports.
... Population (sample size, age, health condition) Usability Score Ashworth Scale Brashear et al., 2002;Fleuren et al., 2010;Haas et al., 1996;Lee et al., 1989;Nakhostin-Ansari et al., 2006;Nuyens et al., 1994;Vattanasilp & Ada, 1999) Overall sample size: n = 136 Age (Mean, range) = 54.2, 13 -81 years Conditions: multiple sclerosis (n = 30), stroke (n = 23), spinal cord injury (n = 24), hemiplegia (n = 59). ...
... 2 Modified Ashworth Scale (Akpinar et al., 2017;Allison et al., 1996;Ansari et al., 2006;Ansari et al., 2008a;Baunsgaard et al., 2016;Blackburn et al., 2002;Bohannon & Smith, 1987;Cooper et al., 2005;Craven & Morris, 2010;Gregson et al., 1999Gregson et al., , 2000Haas et al., 1996;Kaya et al., 2011;Li et al., 2014;Mehrholz et al., 2005a, b;Nakhostin-Ansari et al., 2006;Pandyan et al., 2001Pandyan et al., , 2003Sloan et al., 1992;Tederko et al., 2007;Zurawski et al. 2019) Overall sample size: n = 747 Age (Mean, range) = 53.3, 13 -90 years Conditions: stroke (n = 278), cerebral palsy (n = 2), multiple sclerosis (n = 1), amyotrophic lateral sclerosis (n = 2), spinal cord injury (n = 163), traumatic brain injury (n = 32), hemiplegia (n = 269). ...
... Demographics Reliability Validity Overall rating* Ashworth Scale Brashear et al., 2002;Fleuren et al., 2010;Haas et al., 1996;Lee et al., 1989;Nakhostin-Ansari et al., 2006;Nuyens et al., 1994;Vattanasilp & Ada, 1999) (Akpinar et al., 2017;Allison et al., 1996;Ansari et al., 2006;Ansari et al., 2008a;Baunsgaard et al., 2016;Blackburn et al., 2002;Bohannon & Smith, 1987;Cooper et al., 2005;Craven & Morris, 2010;Gregson et al., 1999Gregson et al., , 2000Haas et al., 1996;Kaya et al., 2011;Li et al., 2014;Mehrholz et al., 2005a,b;Nakhostin-Ansari et al., 2006;Pandyan et al., 2001Pandyan et al., , 2003Sloan et Tederko et al., 2007;Zurawski et al., 2019) Re-Modified Ashworth Scale (Ansari et al., 2012;Ansari et al., 2008bAnsari et al., , 2009aGhotbi et al., 2009Ghotbi et al., , 2011Kaya et al., 2011;Mishra & Ganesh, 2014;Naghdi et al., 2007Naghdi et al., , 2008 (Abou et al., 2020;Cabanas-Valdes et al., 2016;Erol et al., 2021;Gorman et al., 2010Gorman et al., , 2014aPalermo et al., 2020;Sung et al., 2016) (Bourcier et al., 2020;Braga-Neto et al., 2010;Brandsma et al., 2017;Bürk et al., 2009;Kim et al., 2014;Salci et al., 2017;Schmitz-Hübsch et al., 2006Tan et al., 2013;Weyer et al., 2007;Winser et al., 2018;Yabe et al., 2008) (Akpinar et al., 2017;Ansari et al., 2008cAnsari et al., , 2013Azarnia et al. 2021;Ben-Shabat et al., 2013;Li et al., 2014;Mehrholz et al., 2005a;Naghdi et al., 2014Naghdi et al., , 2017Singh et al., 2011;Santos et al., 2021;Sonvane & Kumar, 2019) (Cabanas-Valdes et al., 2016;Fil Balkan et al., 2019;Lombardi et al., 2017;Monticone et al., 2017;Parlak Demir & Yildirim, 2018;Quinzanos et al., 2014;Sag et al., 2019;Seo et al., 2008;Verheyden et al., 2004Verheyden et al., , 2005Verheyden et al., , 2006aVerheyden et al., , b, 2007Zhao et al., 2021) (Aguiar et al., 2016;Akshintala et al., 2021;Aksu & Yakut, 2003;Baschung Pfister et al., 2018;Beck et al., 1999;Bohannon, 1986Bohannon, , 1992Bohannon, , 1993Bohannon, , 1995Bohannon et al., 2013;Bohannon & Andrews, 1987;Brinkmann, 1994;Busse et al., 2008;Cardin & Bohannon, 2017;Dyball et al., 2011;Eken et al., 2020;Ekstrand et al., 2015;Faria et al., 2013;Goonetilleke et al., 1994; Hayes et al., 2002;Kilmer et al., 1997;Knak et al., 2020;Larson et al., 2010;Livesley, 1992;May et al., 1997;Mentiplay et al., 2018;Moreno-Navarro et al., 2021;Morris et al., 2008;Noreau & Vachon, 1998;Riddle et al., 1989;Saygin et al., 2020;Schwartz et al., 1992;Tsai et al., 2015;van Langeveld et al., 1996;Visser et al., 2003) Inter-session: ICC = 0.94,PCC = 0.96,SEM = 0.10 Parallel Forms Reliability: PCC = 0.82 Consistency: Cronbach's Alpha = 0.95 Motricity Index (Bohannon, 1995(Bohannon, , 1999Cameron & Bohannon, 2000;Collin & Wade, 1990;Fayazi et al., 2012;Vos-Vromans et al., 2005) (Collin & Wade, 1990;Fil Balkan et al., 2019;Franchignoni et al., 1997;Parlak Demir & Yildirim, 2015) ...
The key aim of classification in Para sport is to try and ensure that competitors are grouped so that they compete against others with impairments that cause a similar level of activity limitation within a specific sport. This synthesis aimed to identify existing, valid, and reliable, impairment assessment tools to measure eligible impairments that influence an individual's ability to compete at Para dressage. A multi-stage approach was employed, where a systematic search of professional databases of impairment assessment tools first identified 35 tools for Para dressage. Then, a search strategy was developed, based on these 35 tools, and 305 scientific articles were identified from academic databases up to September 2021. From here, impairment assessment tools were evaluated and refined in a two-stage process using known performance determinants for Para dressage and then an assessment of their reliability, validity and practical usability. This resulted in the selection of impairment assessment tools, which included measures of muscle tone, strength, coordination, sitting balance, and trunk function. From this synthesis, we present a novel process by which impairment assessment tools were selected, refined, and critically examined using knowledge of performance determinants for dressage, the views and experiences of stakeholders, and reliability and validity of tools. The processes described here could be applied to the development of evidence-based classification systems across a range of Para sports.
... The AS was developed by Ashworth in 1964, modified in 1987 by Bohannen and Smith, and validated for SCI population in 1996 [13]. Both scales ask the examiner to move a limb through its full range of movement then rate the amount of resistance felt. ...
... Table 11 summarizes the papers' authors and languages and Table 12 shows the quality of their studies. [13] ? ...
... ? [13] ? ...
The objective of this chapter is to describe and evaluate the assessment tools to evaluate neurological status in people with SCI through a systematic review of scientific literature. The systematic review was conducted in line with COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) on Pubmed, Scopus, Cinahl, and Web of Science. After removing duplicates, 3333 papers were screened, and of these 476 were included in this systematic review. Among these, 28 papers were considered for this chapter. Results show 19 assessment tools that evaluate the neurological area in persons with SCI. The most common assessment tools are the Modified Ashworth Scale (MAS) and the Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET).
... Clinical outcome assessments can be categorised as single item, where a single score is assigned to the patient (tapping speed, peg-sorting, the Modified Ashworth Scale); or multiple item, where the patient is scored on multiple elements whose scores are combined, possibly through addition (all clinical outcome measures listed above). Single item scales can be problematic because, if a patient's score is considered on the boundary of two levels, repeated measures by the same or different raters may lead to substantially different conclusions (Haas et al. 1996;Hobart et al. 2000;Hobart et al. 2007). By combining scores of multiple items, one can reduce the error associated with the measurement tool, but multiple item scales retain some problems of the single item method. ...
... Beta rhythms are also present in electroencephalographic (EEG) and magnetoencephalography (MEG) recordings of the motor cortex during maintained isometric contraction (Penfield 1954). Simultaneous surface recordings from hand musculature correlate with brain recordings within this frequency band, suggesting a periodic interaction between brain and muscle Halliday et al. 1998). It has been proposed, then, that beta rhythms in hand musculature reflect the influence of cortical drive. ...
... The frequency range of shared input may have a functional basis. As reviewed in the introduction, alpha rhythms may correspond with the frequency range of neurogenic tremor (Elble and Randall 1976), whilst beta rhythms are believed to reflect cortical drive to muscles Halliday et al. 1998). Together, these results indicate that both E.B. and H.W. have shared input to left and right muscles of the distal upper limb that may be due to branching, descending motor pathways, although due to the lag duration it is not possible to identify the point of branching. ...
Hemispherectomy is a surgical procedure for treating intractable epilepsy, involving the removal or disconnection of a cerebral hemisphere. Prior to surgery, patients have weakness along one side of their body and disruptions to their motor control. These impairments can be further exacerbated by the operation. This thesis provides an investigation into upper limb movement after surgery in terms of gross motor control and ipsilateral descending motor pathways for distal function. A neurophysiological assessment was used to identify the pathway driving the distal muscles of the paretic upper limbs. The results support the findings of previous studies that suggest superior function is likely to be dependent on a common, branching corticospinal pathway to the left and right sides. In addition, one patient without evidence of a common pathway had some use of the paretic wrist suggesting the presence of a distinct ipsilesional – possibly corticoreticulospinal – pathway. Upper limb kinematics during functional unimanual and bimanual reaching was also assessed. Unimanual deficits were identified and abnormalities in inter-limb coordination were found. These include a tendency to perform bimanual reaches as sequential unimanual reaches and reduced spatial interference in the trajectories of the two limbs. Whilst there were significant differences between the comparison and patient groups for these measures, there was also significant variance between the patients, underlining the heterogeneity of this cohort.
... In Studies I and II, the Manual Muscle Test (MMT) [195] and in Study II the MMT and the lower extremity motor score (LEMS) of the standard AIS [50] were evaluated. In Study I and II, the same physiotherapist evaluated spasticity by employing the Modified Ashworth Scale (MAS) [196]. The participants' sensory function was assessed by a physician utilizing the AIS sensory score [50]. ...
... Stimulation methods [126], [216], [217], neurophysiological measurements [122], [125], [185], [218], clinical inventory [49], [195], [196], functional tests [198], [200], and the self-reports [197] used in this thesis were shown to be reliable and can be recommended for use by researchers further developing PAS stimulation protocols and for health care professionals using long-term PAS as a novel treatment. The stimulation protocol was tested to induce LTPlike plasticity in a wide range of ISIs between TMS and PNS [13], [14]. ...
Spinal cord injury (SCI) is a devastating condition and consequent loss of motor control remains one of the main causes of disability. Motor recovery after SCI depends on the amount of spared and restored neural connections in the spinal cord. Most SCIs are incomplete and even neurologically complete injuries possess some spared neural connections. Damaged motor pathways can be reactivated by external stimulation. However, current treatment approaches are mainly palliative, such as assisting adaptation to impairments. Thus, there is a need for novel therapies to induce neuroplasticity in the spinal cord and strengthen weak and disrupted neural connections. In this thesis, paired associative stimulation (PAS) was applied as a long-term treatment for chronic incomplete SCI of traumatic origin. PAS is a noninvasive neuromodulation paradigm where descending volleys induced by transcranial magnetic stimulation (TMS) of the motor cortex are timed to coincide with antidromic volleys elicited by peripheral nerve electrical stimulation (PNS). The stimulation protocol was designed to coincide TMS and PNS-induced volleys at the cortico-motoneuronal synapses in the spinal cord. Continuous pairing of TMS and PNS stimuli can change synaptic efficacy and produce long-term potentiation (LTP)-like plasticity in the corticospinal tract. Augmentation of synaptic strength at the spinal level has clear therapeutic value for SCI, as it can enhance motor control over paralyzed
muscles. The aim of the thesis was to investigate the possible therapeutic effects of
long-term PAS on hand and leg motor function in individuals with chronic incomplete SCI of traumatic origin. Study I explored long-term PAS therapeutic potential by providing long-term PAS until full recovery of hand muscle strength or until improvements ceased. The PAS protocol was designed to coincide TMS- and PNS-induced volleys in the cervical spinal cord, which is both the location of the stimulated lower motor neuron cell bodies and the site of the injury. Improvements up to normal values of hand muscle strength (Manual Muscle Test [MMT]) and increased amplitude of motor evoked potentials (MEPs) were obtained after more than 1-year stimulation in a participant with SCI. The participant regained almost complete self-care of the upper body. This was the first demonstration of restoring normal strength and range of movement of individual hand muscles by means of long-term PAS. The effect persisted over 6 months of follow up. Study II probed the effects of long-term PAS on leg muscle strength and walking in a group of five people with SCI. The PAS protocol was designed to coincide TMS- and PNS-induced volleys in the lumbar spinal cord but the site of the injury was in the cervical spinal cord. Long-term PAS delivered for 2 months significantly increased the total lower limb MMT score. This effect was stable over a 1-month follow up. Walking speed increased after 2 months of PAS in all participants. This study was the first demonstration that long-term PAS may significantly increase leg muscle strength and affect walking. The MMT score prior to the intervention was a good predictor of changes in walking speed. Study III developed a novel technique that enables probing neural excitability at the cervical spinal level by utilizing focal magnetic coil and anatomy-specific models for re-positioning of the coil. The technique enabled recording of highly reproducible MEPs and was suitable for accurate
maintenance and retrieval of the focal coil position at the cervical level. In summary, this thesis contributes to the understanding of therapeutic efficacy of long-term PAS for restoration of motor control over hand and leg muscles after chronic SCI. This work challenges the view that chronic SCI is an irreversible pathologic condition and demonstrates the possibility of restoring neurological function many years postinjury when spontaneous recovery is extremely rare. The increased amplitude of MEPs, sustainable
motor improvements, and the effects observed regardless of injury location indicate that PAS induces stable changes in the corticospinal pathways.
... In fact, the definition of spasticity has been broadened and challenged over the years, opening the consideration of including symptoms of upper motor neuron lesion when referring to spasticity (Pandyan et al. 2005). Clinical exams commonly used to assess spasticity in individuals with SCI include the Modified Ashworth Scale (MAS; Bohannon and Smith 1987) and the Tardieu Scale (Ansari et al. 2013) both based on subjective quantifications, of which the validity and reliability have been questioned (Akpinar et al. 2017;Alhusaini et al. 2010;Alibiglou et al. 2008;Blackburn et al. 2002;Fleuren et al. 2010;Haas et al. 1996). ...
... On the other side, we found the self-reported questionnaire detected asymmetries in spasticity across sides in 96% of participants, suggesting that this outcome might be more useful to determine the more or less spastic side. The validity and reliability of the MAS have been questioned (Akpinar et al. 2017;Blackburn et al. 2002;Fleuren et al. 2010;Haas et al. 1996;Platz et al. 2005). We argue that the bilateral and asymmetrical increases in passive muscle stiffness and active spinal reflex mechanisms make it more difficult for the MAS to accurately assess spasticity. ...
Spasticity is one of the most common symptoms present in humans with spinal cord injury (SCI), however, its clinical assessment remains underdeveloped. The purpose of the study was to examine the contribution of passive muscle stiffness and active spinal reflex mechanisms to clinical outcomes of spasticity after SCI. It is important that passive and active contributions to increased muscle stiffness are distinguished to make appropriate decisions about anti-spastic treatments and to monitor its effectiveness. To address this question, we combined biomechanical and electrophysiological assessments of ankle plantarflexor muscles bilaterally in individuals with and without chronic SCI. Spasticity was assessed using the Modified Ashworth Scale (MAS) and a self-reported questionnaire. We performed slow and fast dorsiflexion stretches of the ankle joint to measure passive muscle stiffness and reflex-induced torque using a dynamometer and the soleus H-reflex using electrical stimulation over the posterior tibial nerve. All SCI participants reported the presence of spasticity. While 96% of them reported higher spasticity on one side compared with the other, the MAS detected differences across sides in only 25% of the them. Passive muscle stiffness and the reflex-induced torque were larger in SCI compared with controls more on one side compared with the other. The soleus stretch reflex, but not the H-reflex, was larger in SCI compared with controls and showed differences across sides, with a larger reflex in the side showing a higher reflex-induced torque. MAS scores were not correlated with biomechanical and electrophysiological outcomes. These findings provide evidence for bilateral and asymmetric contributions of passive and active ankle plantar flexors stiffness to spasticity in humans with chronic SCI and highlight a poor agreement between a self-reported questionnaire and the MAS for detecting asymmetries in spasticity across sides.
... Signals were processed according to previous reports on patient frailty. 37 The following variables were assessed: gait velocity (time in seconds to cover the distance of 20 m); step variability; root mean squared (RMS) of acceleration; 38,39 and RMS of lineal Jerk. 40 The RMS of acceleration was expressed as intensity during gait, with high values related to poorer trunk control. ...
... 40 The RMS of acceleration was expressed as intensity during gait, with high values related to poorer trunk control. 38,39 RMS of Jerk was expressed as the smoothness of trunk control during gait, with lower values reflecting better trunk control. 40 All accelerometer data were analyzed in the Matlab software (MathWorks Inc, Natick, MA, USA). ...
Context:
Spasticity in neurological disorders (i.e. stroke patients and cerebral palsy) is positively improved by dry needling. However, reports are scarce regarding the potential effects of dry needling in reducing spasticity and improving functionality in patients with an incomplete spinal cord injury. The aim of this case report was to study the immediate, short-term effects of dry needling treatment (10 weeks) on spasticity, dynamic stability, walking velocity, self-independence, and pain in a single patient with an incomplete spinal cord injury.
Findings:
The dry needling treatment resulted in immediate, short-time effects on basal spasticity in the upper (reduction from 2 to 0 point median) and lower (reduction from 2 to 0 point median) limbs, as measured by the modified Ashworth Scale. Dynamic-stability, assessed by trunk accelerometry, improved more than 50% (Root Mean Squared of acceleration, Root Mean Squared of Jerk and step variability), and gait speed improved by 24.7 s (i.e. time to walk 20 m). Self-independence and pain were respectively scored by the Spinal Cord Independence Measure (21 points improvement) and visual analog scale (4 points improvement).
Conclusions:
This case report demonstrates that dry needling treatment can have positive effects on spasticity, dynamic stability, walking velocity, self-independence, and pain in patients with incomplete spinal cord injury. Further research is needed in a larger patient population to deeply understand the mechanism(s) associated with the obtained results and regarding the clinical significances of dry needling treatment for incomplete spinal cord injury.
... Furthermore, the increased muscle tone may alter the musculoskeletal development of children with CP, leading to muscle shortening (passive muscle stiffness), torsional deformities, joint dislocations, and scoliosis. Measurement of spasticity is a complex and vexed issue; methods that are easily used in practice are clinical ordinal scales, such as the Ashworth Scale (AS), the Modified Ashworth Scale (MAS) [3], the Tardieu Scale and the Modified Tardieu Scale, that still lack reliability and do not allow to distinguish between active and passive muscle stiffness. Dynamometry is an objective way to measure the force required to move a joint, so it could be suggestive of passive muscular stiffness; however, dynamometry is a complex technique and is affected by stiffness of soft tissues others than muscles [4][5][6]. ...
... The exclusion criteria were: (1) previous ankle or knee surgery; (2) pharmacological treatment of spasticity in the past 6 months or during the study (BTX-A injections, GABAergic medications, benzodiazepines, or muscle relaxants); (3) walking inability (assisted or unassisted). Children with cerebral palsy were compared to a group of 21 typically developing children (11 males and 10 females; age range [3][4][5][6][7][8][9][10][11][12][13][14]. ...
Purpose:
Cerebral palsy (CP) is a disorder characterized by an increased muscle stiffness that can be contingent on both neurological and biomechanical factors. The neurological aspects are related to hyper-excitability of the stretch reflex, while the biomechanical factors are related to modifications in muscle structure. We used smart-shear wave elastography (S-SWE) to analyze muscle properties and to compare shear wave speed in soleus muscles of patients affected by CP and typically developing children.
Methods:
We enrolled 21 children (15 males and 6 females; age range 3-16) with spastic hemiplegia CP and 21 healthy children (11 males and 10 females; age range 3-14). Measurements of soleus S-SWE were performed using a Samsung RS80A ultrasound scanner with Prestige equipment (Samsung Medison Co. Ltd., Seoul, Korea), with a convex array transducer (CA1-7; Samsung Medison Co. Ltd., Seoul, Korea). For each CP child clinical assessment included Modified Ashworth Scale (MAS) score.
Results:
Children with CP showed greater S-SWE values than the healthy ones (p < 0.001). Our data suggest a significant correlation between the S-SWE values and the MAS scores (Spearman correlation coefficient 0.74; p < 0.001 at Kruskal-Wallis test) in children with CP.
Conclusions:
Measuring muscle properties with SWE, a non-invasive and real-time technique, may integrate the physical exam. SWE may be a reliable clinical tool for diagnosis and longitudinal monitoring of muscle stiffness, as well as particularly suitable for grading and for assessing the response to treatments.
... The MAS is an easy-to-administer tool, which has been adopted for assessing spasticity in a variety of indications, including SCI. 9,24 It is a five-point ordinal scale that subjectively assesses muscle tone. The MAS scores were collected from the right hip adductor and extensor muscles, right knee extensor and flexor muscles and right plantar flexor muscles of the participants. ...
... The multidimensional nature of spasticity has also been put forward as a consideration when selecting outcome measures for spasticity. 9 Patients with SCI often experience exaggerated muscle reflex responses, such as clonus, flexor spasms and extensor spasms. The Spinal Cord Assessment Tool for Spastic Reflexes, developed by Benz et al., 34 is suggested as a valid and reliable tool for assessment of spasm activity in patients with SCI. ...
Study design:
Psychometrics study.
Objectives:
To assess the reliability of the Modified Ashworth Scale (MAS) and Modified Tardieu Scale (MTS) in patients with spinal cord injuries (SCIs).
Setting:
Inpatient rehabilitation clinics at two state hospitals.
Methods:
The study included 65 participants aged between 18 and 88 years with SCI with spasticity. All participants were at least 6 months after injury and had an American Spinal Injury Association Impairment Scale grade of A-D. The MAS and MTS scores were collected from the right hip adductor and hip extensor muscles, right knee extensor and knee flexor muscles and right plantar flexor muscles. Each participant was assessed twice by two experienced physiatrists 1 week apart. The raters were blinded to each other's scores.
Results:
Inter-rater and test-retest agreement for the MAS scores (κ=0.531-0.774) was moderate to substantial. Inter-rater and test-retest agreement for the MTS X scores (κ=0.692-0.917) was substantial to almost perfect. Inter-rater reliability and test-retest reliability of the MTS R2-R1 was excellent (intra-class correlation coefficient (ICC) 0.874-0.973, confidence interval (CI): 0.79-0.98) for all muscles tested. Inter-rater reliability of the MTS R2 for the hip adductor and knee extensor muscles was poor (ICC 0.248, CI: -0.00 to 0.47 and ICC 0.094, CI: -0.16 to 0.34, respectively). The test-retest reliability of the MTS R2 was also poor for the knee extensor muscles (ICC 0.318, CI: -0.06 to 0.53).
Conclusion:
MAS has adequate reliability for determining lower-extremity spasticity in patients with SCI. The demonstration of excellent inter-rater reliability and test-retest reliability of the MTS R2-R1 suggests its utility as a complementary tool for informing treatment decisions in patients with SCI.Spinal Cord advance online publication, 9 May 2017; doi:10.1038/sc.2017.48.
... Para avaliação da espasticidade dos flexores plantares foi utilizada a Escala de Ashworth Modificada, com pontuação que varia de 0 a 4 (HAAS et al., 1996). O Protocolo de Desempenho Físico de Fugl-Meyer -FM -seção de função motora da extremidade inferior -foi aplicado e sua pontuação varia de 0 a 34 (pior e melhor função motora, respectivamente) (MAKI et al. 2006). ...
Resumo O reflexo tônico flexor dos dedos-RTFD-pode ocorrer em hemiparéticos após acidente vascular encefálico-AVE-e se caracteriza por flexão, adução e elevação dos artelhos. O objetivo do estudo foi relatar um caso de RTFD em paciente com hemiparesia crônica à esquerda. Para confirmar a presença do RTFD, o paciente foi orientado a manter o ortostatismo por 1 minuto com os pés descalços. Foram realizados: teste de marcha de 10; Escala de Ashworth Modificada e o Protocolo de Fugl-Meyer-FM (extremidade inferior). Foi observado o RTFD após um minuto na posição ortostática. O paciente apresentou velocidade de 0,3 m/s e cadência de 94 passos/min; pontuação 29 na seção extremidade inferior do FM e espasticidade grau 2 em flexores plantares. O paciente apresentou o RTFD na posição ortostática associado a alterações na velocidade e cadência da marcha, hipertonia elástica em flexores plantares e comprometimento da função motora de membro inferior esquerdo. Palavras-chave: Acidente Cerebral Vascular. Paresia. Marcha. Equilíbrio Postural. Hipertonia Muscular. Abstract The tonic toe flexion reflex-TTFR-may occur in hemiparetic patients after cerebro vascular accident-CVA-and it is characterized by flexion, adduction and elevation of the toes. The aim of this study was to report a case of tonic toe flexor reflex in patients with left chronic hemiparesis. To confirm the presence of TTFR the patient was instructed to maintain the orthostatism position for 1 minute barefoot. 10-meters gait test and the Modified Ashworth Scale (plantiflexors muscles); Fugl-Meyer Assessment-FMA (lower extremity section) were performed;. The TTFR was observed after one minute in the orthostatism position. The patient presented at 0.3 m/s cadence of 94 steps/min; score 29 of FMA and plantiflexors' spasticity was level 2. The patient presented TTFR in the orthostatism position with changes in speed and cadence of gait, plantiflexors' elastic hypertonia and impaired motor function of the left lower limb. 1 Introdução O reflexo tônico flexor dos dedos-RTFD, também conhecido como reflexo dos dedos em garra, é um reflexo anormal que pode ocorrer como resultado de uma lesão cerebral associada à hemiparesia e alterações na postura e marcha (BRAIN; CURRAN, 1950; COHEN; IANNONE; ALTO, 1967; GOLDSTEIN, 1938). É descrito como uma flexão extrema, adução e elevação dos dedos do pé em relação ao solo associada à inversão do pé. Estudos relatam que o RTFD é usualmente observado durante a marcha, justificado pelos estímulos cutâneos e proprioceptivos repetitivos na superfície plantar (BRAIN;). O RTFD parece resultar da ausência da inibição do reflexo primitivo controlada pelos centros supra-espinhais (COHEN; IANNONE; ALTO, 1967; MANFREDI; SACCO; SIDERI, 1975). Nos recém-nascidos o reflexo aparece após estímulo aparente na sola do pé sem a necessidade de contato com o solo, já o reflexo anormal surge após um estímulo mais forte e mais estável (LANDAU; CLARE, 1996; RICHTER; HINES, 1932). O RTFD é considerado normal até aproximadamente quatorze meses de vida (FLEHMIG, 2005), porém a sua persistência indica possível comprometimento no lobo frontal contralateral ou em fibras do trato córtico-espinhal com origem nesse sítio. Estudos prévios indicaram através da eletromiografia que o aparecimento do RTFD durante a marcha poderia ocorrer devido à atividade excessiva da musculatura intrínseca do pé, assim como dos flexores dos dedos. Observaram ainda que a ativação de outros músculos dos membros inferiores, como tibial anterior, tríceps sural e isquiotibiais também poderiam estar associados com o RTFD
... The motor dysfunction was assessed using the BBB (Table A1) and the Ashworth (Table A2) scores in some experiments for around 5 months, followed by acute H-reflex recordings carried out in each animal tested. Whilst the BBB scoring is routinely used [34][35][36][37], the Ashworth test remains less often implemented in animal studies [38,39], unlike human diagnostics [40,41]. Nevertheless, the Ashworth and the BBB scores in rodents are strongly correlated, based on the earlier [17] and present studies; moreover, a correlation was found between both of the two tests and changed H-reflex. ...
Motor disability is a common outcome of spinal cord injury (SCI). The recovery of motor function after injury depends on the severity of neurotrauma; motor deficit can be reversible, at least partially, due to the innate tissue capability to recover, which, however, deteriorates with age. Pain is often a comorbidity of injury, although its prediction remains poor. It is largely unknown whether pain can attend motor dysfunction. Here, we implemented SCI for modelling severe and moderate neurotrauma and monitored SCI rats for up to 5 months post-injury to determine the profiles of both motor deficit and nociceptive sensitivity. Our data showed that motor dysfunction remained persistent after a moderate SCI in older animals (5-month-old); however, there were two populations among young SCI rats (1 month-old) whose motor deficit either declined or exacerbated even more over 4–5 weeks after identical injury. All young SCI rats displayed changed nociceptive sensitivity in thermal and mechanical modalities. The regression analysis of the changes revealed a population trend with respect to hyper- or hyposensitivity/motor deficit. Together, our data describe the phenotypes of motor deficit and pain, the two severe complications of neurotrauma. Our findings also suggest the predictability of motor dysfunction and pain syndromes following SCI that can be a hallmark for long-term rehabilitation and recovery after injury.
... [44] In spinal cord injury patients, there was fair-to-moderate agreement for AS and generally fair agreement for MAS when assessing the lower extremities. [45] However, moderateto-substantial interrater reliability of the MAS was shown in the elbow flexors of stroke patients; this was better than seen in assessments of the ankle plantar flexors in these patients. ...
This module discusses the pathophysiology of spasticity and the lesions underlying the condition. It considers the clinical presentation of spasticity and outlines the relevant clinical history that should be documented. The positive and negative signs of spasticity are explained. Clinical presentations of spasticity are discussed, and an illustrated table of spastic limb postures details how the muscles involved in each individual's condition may be identified. The main systems for assessing the severity of the condition, the Ashworth Scale, the modified Ashworth scale, and the Tardieu Scale, are explained. The likelihood of spasticity developing following a stroke and the probable long-term outcomes are considered. The value of involving patients in their own treatment regimens, by defining and setting goals, using the SMARTER system is explained, and the need to continually assess and refine treatment with time as the condition progresses is also discussed.
... The principal clinical outcome measure for spasticity has been the long-established Modified Ashworth Scale (MAS) [47,48]. Previous literature investigating the MAS reported poor inter-rater reliability [49][50][51][52] and a poor correlation with self-rated assessments of spasticity [53]. Joint contractions further decrease the reliability of the MAS [52]. ...
Background
The pathological mechanism in acute spinal cord injury (SCI) is dual sequential: the primary mechanical lesion and the secondary injury due to a cascade of biochemical and pathological changes initiated by the primary lesion. Therapeutic approaches have focused on modulating the mechanisms of secondary injury. Despite extensive efforts in the treatment of SCI, there is yet no causal, curative treatment approach available.
Extracorporeal shock wave therapy (ESWT) has been successfully implemented in clinical use. Biological responses to therapeutic shock waves include altered metabolic activity of various cell types due to direct and indirect mechanotransduction leading to improved migration, proliferation, chemotaxis, modulation of the inflammatory response, angiogenesis, and neovascularization, thus inducing rather a regeneration than repair.
The aim of this clinical study is to investigate the effect of ESWT in humans within the first 48 h after an acute traumatic SCI, with the objective to intervene in the secondary injury phase in order to reduce the extent of neuronal loss.
Methods
This two-arm three-stage adaptive, prospective, multi-center, randomized, blinded, placebo-controlled study has been initiated in July 2020, and a total of 82 patients with acute traumatic SCI will be recruited for the first stage in 15 participating hospitals as part of a two-armed three-stage adaptive trial design. The focused ESWT (energy flux density: 0.1–0.19 mJ/mm ² , frequency: 2–5 Hz) is applied once at the level of the lesion, five segments above/below, and on the plantar surface of both feet within the first 48 h after trauma.
The degree of improvement in motor and sensory function after 6 months post-injury is the primary endpoint of the study. Secondary endpoints include routine blood chemistry parameters, the degree of spasticity, the ability to walk, urological function, quality of life, and the independence in everyday life.
Discussion
The application of ESWT activates the nervous tissue regeneration involving a multitude of various biochemical and cellular events and leads to a decreased neuronal loss. ESWT might contribute to an improvement in the treatment of acute traumatic SCI in future clinical use.
Trial registration
ClinicalTrials.gov NCT04474106
... Traqueostomía: es la apertura de un ostoma en la tráquea, con el fin de establecer una vía aérea artificial para asegurar la ventilación del paciente (21) . 3 = aumento considerable en el tono muscular, el movimiento pasivo es difícil, y 4 = parte afectada se encuentra rígida en flexión o extensión (23) . Diabetes: defecto determinado y transmitido genéticamente en el metabolismo de los carbohidratos, a menudo precedido o acompañado de microangiopatía u obesidad y producida por la falta de acción efectiva de la insulina (24) . ...
Introducción: El accidente cerebrovascular (ACV) representa el 87% de todas las muertes en países de bajos y medianos ingresos como Argentina. Los estudios epidemiológicos en este país, en sujetos con ACV, son escasos.
Objetivo: Describir las características clínicas, demográficas y de la recuperación motora de los sujetos internados con secuela de ACV a su ingreso al Hospital de Rehabilitación Manuel Rocca (HRMR) durante el año 2018.
Método: El diseño fue descriptivo, retrospectivo. Las variables clínico demográficas fueron extraídas de las hojas de ingreso de las historias clínicas.
Resultados: La muestra final se compuso de 38 sujetos. Las mujeres representaron el 42,1% de la muestra, con una mediana de edad 56 años (rango intercuartílico-RIQ-48,5-78,5). El ACV isquémico representó el 78,9% de la muestra, de los cuales el 65,8% tenían un compromiso de la circulación anterior. Con una media al ingreso de 49,08 puntos (desvío estándar 19,47) en la escala Functional Independence Measure (FIM) y una mediana de 66,5 días (RIQ 34-129,25) a la fecha de ingreso de ocurrido el evento.
Conclusión: El presente estudio permite las características clínicas, demográficas y de la recuperación motora de los sujetos internados con secuela de ACV a su ingreso al HRMR durante el año 2018.
Palabras claves: accidente cerebrovascular, terapia física, Argentina, estudio epidemiológico, estudio retrospectivo
... The (modified) Ashworth (MAS) scale is the most widely used clinical spasticity scale. It was established to measure the course and the intensity of spasticity and the effect of therapy (Malhotra et al., 2008) for various clinical conditions such as stroke (Bakheit et al., 2003), spinal cord injuries (Akpinar et al., 2017), traumatic brain injuries (Allison et al., 1996), or multiple sclerosis (Haas et al., 1996). Because of its general definition and limitations, e.g., the nominal levels of the scale (Pandyan et al., 1999), the MAS has been criticized (Fleuren et al., 2010). ...
Although spasticity is one of the most common causes of motor disability worldwide, its precise definition and pathophysiology remain elusive, which to date renders its experimental targeting tricky. At least in part, this difficulty is caused by heterogeneous phenotypes of spasticity-causing neurological disorders, all causing spasticity by involving upper motor neurons. The most common clinical symptoms are a series of rapid muscle contractions (clonus), an increased muscle tone (hypertonia), and augmented tendon reflex activity (hyperreflexia). This muscle overactivity is due to disturbed inhibition of spinal reflexes following upper motor neuron dysfunction. Despite a range of physical and pharmacological therapies ameliorating the symptoms, their targeted application remains difficult. Therefore, to date, spasticity impacts rehabilitative therapy, and no therapy exists that reverses the pathology completely. In contrast to the incidence and importance of spasticity, only very little pre-clinical work in animal models exists, and this research is focused on the cat or the rat spastic tail model to decipher altered reflexes and excitability of the motor neurons in the spinal cord. Meanwhile, the characterization of spasticity in clinically more relevant mouse models of neurological disorders, such as stroke, remains understudied. Here, we provide a brief introduction into the clinical knowledge and therapy of spasticity and an in-depth review of pre-clinical studies of spasticity in mice including the current experimental challenges for clinical translation.
... Participants underwent an evaluation to collect sociodemographic and clinical data using a semi-structured questionnaire, including sex, age, disease duration, and physical exercise practice. Spasticity was assessed using the modified Ashworth scale (MAS), a 6-point ordinal scale that evaluates muscle tone through a passive movement of the limb up to its maximum amplitude at a standard speed, verifying the resistance degree felt to the movement (Haas et al. 1996;Akpinar et al. 2017). MAS has good reliability, especially for assessing spasticity in the lower limbs of individuals with spinal cord injury (Bohannon and Smith 1987;Ghotbi et al. 2011). ...
In individuals with HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP), spasticity is one of the main symptoms. The neurological signs of the disease are well defined, but details of how spasticity appears in these individuals have not been well explored. To describe spasticity location and severity of HAM/TSP individuals. Cross-sectional study with individuals older than 18 years, diagnosed with HAM/TSP and with lower limb spasticity. Pregnant women, individuals with other associated neurological diseases, and those using antispastic drugs were not included. Spasticity was assessed by the Modified Ashworth Scale (MAS), applied to the abductor, adductor, flexor, and extensor muscles of the hips, flexors, and extensors of the knees, dorsiflexors, plantiflexors, evertors, and inverters of the foot. Thirty participants were included. The plantiflexor muscles (90%), knee extensors (80%), knee flexors (63,3%), and adductors (50%) were most frequently affected by spasticity. Twenty-three (76.7%) individuals had mixed spasticity, 5 (16.7%) with distal spasticity and 2 (6.7%) with proximal spasticity. MAS was similar between the lower limbs in at least 6 of the 10 muscle groups of each individual. Spasticity was mostly mixed in the lower limbs, with more frequently mild severity. The individuals were partially symmetrical between the lower limbs. The most affected muscle groups were the plantiflexors, knee extensors and flexors and the hip adductors, consecutively , being predominantly symmetrical.
... It is important to use outcome measures in clinical evaluation; however, it is always challenging to maintain a balance between test simplicity and speed with its reliability and validity [5], so different tests and methods have been suggested with respect to the disease diagnosis. In this book, we recommend the outcome measure of the National Hospital of Neurology and Neurosurgery (NHNN) in London with a few modifications [2], which is typically used for patients with moderate to severe spasticity (Appendix 2). ...
... Assessments are completed at the different assessment times to collect outcomes characterizing the following: Scale [78]. ...
Background:
In wheelchair users with a spinal cord injury (WUSCI), prolonged non-active sitting time and reduced physical activity-typically linked to this mode of mobility-contribute to the development or exacerbation of cardiorespiratory, musculoskeletal, and endocrine-metabolic health complications that are often linked to increased risks of chronic pain or psychological morbidity. Limited evidence suggests that engaging in a walking program with a wearable robotic exoskeleton (WRE) may be a promising physical activity intervention to counter these detrimental health effects.
Objective:
This study's overall goals are to determine: 1) the effects of a 16-week WRE-assisted walking program on organic systems, functional capacities, and multifaceted psychosocial factors, and 2) self-reported satisfaction and perspectives with regard to the intervention and the device.
Methods:
Twenty WUSCI (>18 months) will complete an overground WRE-assisted walking program (34 sessions; 60 min/session), supervised by a physiotherapist, during a 16-week period (1-3 sessions/week). Data will be collected 1-month prior, at the beginning, at the end, and 2 months after completing the program. Assessments will characterize sociodemographic characteristics; anthropometric parameters; sensorimotor impairments; pain; lower extremity range of motion and spasticity; wheelchair abilities; cardiorespiratory fitness; upper extremity strength; bone architecture and mineral density at the femur, tibia and radius; total and regional body composition; health-related quality of life; and psychological health. Interviews and an online questionnaire will be conducted to measure users' satisfaction and perspectives at the end of the program. Differences across measurement times will be verified using appropriate parametric or nonparametric analyses of variance for repeated measures.
Results:
This study is currently underway with active recruitment in Montréal, Québec, Canada. Results are expected in 2021 (spring).
Conclusions:
The results from this study will be essential to guide the development, implementation, and evaluation of future evidence-based WRE-assisted walking programs offered in the community, and to initiate a reflection regarding the use of WRE during initial rehabilitation following a spinal cord injury.
Clinicaltrial:
U.S. National Library of Medicine (clinicaltrials.gov), NCT03989752. Registered on June 7, 2019.
... Assessments are completed at the different assessment times to collect outcomes characterizing the following: Scale [78]. ...
BACKGROUND
In wheelchair users with a spinal cord injury (WUSCI), prolonged non-active sitting time and reduced physical activity—typically linked to this mode of mobility—contribute to the development or exacerbation of cardiorespiratory, musculoskeletal, and endocrine-metabolic health complications that are often linked to increased risks of chronic pain or psychological morbidity. Limited evidence suggests that engaging in a walking program with a wearable robotic exoskeleton (WRE) may be a promising physical activity intervention to counter these detrimental health effects.
OBJECTIVE
This study’s overall goals are to determine: 1) the effects of a 16-week WRE-assisted walking program on organic systems, functional capacities, and multifaceted psychosocial factors, and 2) self-reported satisfaction and perspectives with regard to the intervention and the device.
METHODS
Twenty WUSCI (>18 months) will complete an overground WRE-assisted walking program (34 sessions; 60 min/session), supervised by a physiotherapist, during a 16-week period (1–3 sessions/week). Data will be collected 1-month prior, at the beginning, at the end, and 2 months after completing the program. Assessments will characterize sociodemographic characteristics; anthropometric parameters; sensorimotor impairments; pain; lower extremity range of motion and spasticity; wheelchair abilities; cardiorespiratory fitness; upper extremity strength; bone architecture and mineral density at the femur, tibia and radius; total and regional body composition; health-related quality of life; and psychological health. Interviews and an online questionnaire will be conducted to measure users’ satisfaction and perspectives at the end of the program. Differences across measurement times will be verified using appropriate parametric or nonparametric analyses of variance for repeated measures.
RESULTS
This study is currently underway with active recruitment in Montréal, Québec, Canada. Results are expected in 2021 (spring).
CONCLUSIONS
The results from this study will be essential to guide the development, implementation, and evaluation of future evidence-based WRE-assisted walking programs offered in the community, and to initiate a reflection regarding the use of WRE during initial rehabilitation following a spinal cord injury.
CLINICALTRIAL
U.S. National Library of Medicine (clinicaltrials.gov), NCT03989752. Registered on June 7, 2019.
... Modified Ashworth Scale (MASH) is a common clinical scale that measures spasticity and muscle tone using a 0-to 4-point scale (0, normal muscle tone, to 4, rigid). In our study, we evaluated MASH according to shoulder internal rotator and adductor spasticity [13,14]. ...
Introduction This study aims to investigate the effect of botulinum toxin-A (BoNT-A) injection into pectoralis major and teres
major muscles and suprascapular nerve block (SSNB) on pain, range of motion (ROM), and upper extremity function for
(hemiplegic shoulder pain) HSP, and to compare the effectiveness of these two methods.
Materials and methods Sixty patients with HSP were randomly assigned into 2 groups. The Group 1 (n = 30) received BoNT-A
injection into the pectoralis major and teres major, and the Group 2 (n = 30) received SSSB. Patients were evaluated just before
the start of the study, and 2 and 6 weeks after the start of the study with visual analog scale (VAS), Modified Ashworth Scale
(MASH), the passive ROM, and the Fugl-Meyer Scale (FMS) arm section.
Results In Group 1, statistically significant improvement was found in all evaluation parameters on 2th and 6th week. Group 2
showed significant improvement in all parameters on week 2 (p < 0.05), and significant improvement was observed in MASH
and pain in abduction in the 6th week (p < 0.05). When the groups were compared with each other, a statistically significant
difference was observed inMASH, ROM, and FMS parameters on week 2 in favor of Group 1; in all evaluation parameters, there
was a statistically significant difference in favor of Group 1 on week 6 (p < 0.05).
Conclusion We concluded that BoNT-Ainjection into the pectoralismajor and teres majormuscles for HSP was equal in the short
term and more effective in the middle term compared with SSNB treatment in improving pain, ROM, and function.
Keywords Hemiplegic shoulder pain . Botulinumtoxin-A . Suprascapular nerve block
Introduction
Hemiplegic shoulder pain (HSP) is one of the most common
post-stroke complications, and the reported prevalence
ranges from 16 to 84%. Symptoms may develop
within the first 2 weeks but persist for more than
6 months in 20% of the cases and may become permanent
[1].
... Para la valoración de la espasticidad y afectación neuromuscular del paciente con EM, se recomienda el uso de las tres escalas, ya que se complementan entre ellas: escala de Ashworth modificada, escala 0-10 de la Numeric Rating Scale (NRS) y escala de espasmos de Penn (NE 4; GR D/√): -Escala de Ashworth y versión modificada. La utilización del método de valoración de la espasti-cidad, denominado escala de Ashworth modificada, versión modificada (MMAS), se recomienda en la evaluación de la espasticidad, en pacientes con esclerosis múltiple, ya que ha demostrado su utilidad en la práctica clínica [40][41][42][43][44][45][46][47][48][49][50][51][52] (NE 2+; GR C/√). -Escala NRS de 0-10. ...
... La evidencia sugiere, además, que la fiabilidad interobservador de la EAM es mayor cuando se emplean en el examen extremidades menos pesadas (miembro superior) y músculos más distales [18]. En cuanto a la fiabilidad intraobservador, los resultados han sido bastante variables en función de la articulación valorada y la patología subyacente [19][20][21]. Debido a la variabilidad de estos resultados, una nueva versión de la EAM, denominada EAM-modificada, ha sido descrita recientemente; sus propiedades métricas están siendo estudiadas en la actualidad con resultados preliminares prometedores [22]. La mayor crítica a las escalas de Ashworth es la subjetividad de términos como 'ligero incremento' , 'mínima resistencia' o 'considerable aumento' [9], así como el hecho de no definir la velocidad de la movilización, aunque en el ámbito clínico se utiliza habitualmente un segundo para realizar el recorrido articular completo [9]. ...
... Spasticity can contribute to functional impairment by slowing voluntary movements, causing abnormal synergistic movement patterns, and limiting agonist muscle force, all of which can lead to gait deviations and increase risk of falling (Gregson et al., 1999;Nuygens et al., 1994;Sloan, Sinclair, Thompson, Taylor, & Pentland, 1992). The Modified Ashworth Scale (MAS) is the most frequently cited clinical rating scale for spasticity, although it has been shown to have inconsistent reliability for different muscle groups (Sloan et al., 1992;Gregson et al., 2000;Allison, Abraham, & Petersen, 1996;Haas, Bergstrom, Jamous, & Bennie;Pandyan et al., 1999). Its use in measuring spasticity in people with ALS has also not been documented in the literature. ...
Background:
Persons diagnosed with Amyotrophic Lateral Sclerosis (ALS) often demonstrate neurological deficits that predispose them to repeated falls and associated adverse consequences. Determining contributing factors to falls in this population is critical to improve safety and patient outcomes.
Objective:
The purpose of this study was to correlate clinical measures of gait speed, balance, strength, spasticity, and a self-reported rating scale of function with fall incidence in individuals with ALS.
Methods:
Thirty-one participants with a confirmed ALS diagnosis were recruited from an outpatient clinic. Each participant performed the following tests: timed gait speed, Berg Balance Scale (BBS), manual muscle testing (MMT) for lower extremity (LE) strength, Modified Ashworth Scale (MAS) for LE spasticity, and the ALS Functional Rating Scale-Revised (ALSFRS-R). Each participant reported number of falls that occurred in the past three months. Pearson correlation coefficients were calculated to determine correlations between variables.
Results:
Significant correlation was found between fall incidence and composite LE strength score (rp = 0.385, p = 0.032).
Conclusions:
There is a relationship between LE weakness and number of falls in the ALS population. Preventing disuse-related LE muscle weakness and education of need for external support may decrease the number of falls experienced by individuals with ALS.
... In the case of Post-Traumatic Stress Disorder (PTSD) research, the PTSD Checklist [39] was used twice to measure symptom severity, with three other scales used for this purpose as well. Motor outcomes in different settings, including Multiple Sclerosis (MS), spinal cord injury and stroke were commonly measured using the Berg Balance Scale (BBS) [40], the Tinetti Performance-Oriented Mobility Assessment (POMA) [41], and the Ashworth Scale [42]. A single study on patients with schizophrenia was retrieved, in which the Social-Adaptive Functioning Evaluation [43] was used to measure outcomes (Table 2). ...
Animal-assisted therapies have become widespread with programs targeting a variety of pathologies and populations. Despite its popularity, it is unclear if this therapy is useful. The aim of this systematic review is to establish the efficacy of Animal assisted therapies in the management of dementia, depression and other conditions in adult population. A search was conducted in MEDLINE, EMBASE, CINAHL, LILACS, ScienceDirect, and Taylor and Francis, OpenGrey, GreyLiteratureReport, ProQuest, and DIALNET. No language or study type filters were applied. Conditions studied included depression, dementia, multiple sclerosis, PTSD, stroke, spinal cord injury, and schizophrenia. Only articles published after the year 2000 using therapies with significant animal involvement were included. 23 articles and dissertations met inclusion criteria. Overall quality was low. The degree of animal interaction significantly influenced outcomes. Results are generally favorable, but more thorough and standardized research should be done to strengthen the existing evidence.
... The Modified Ashworth Scale (MAS) was used to evaluate the degree of muscular resistance to passive movement, being used only the lower section member. The score of each item ranges from 0-4, with 0 representing normal tone and 4 rigidity due to hypertonia (13) . ...
Background: It is estimated that the prevalence of cerebrovascular accident (CVA) increases significantly as a result of the increase in the elderly population, leading to dependence and care. Interventions with physical exercises are essential for patients with chronic CVA and hemiparesis to contribute to functional motor recovery. The gait of the hemiparetic patients is very impaired, including decreased speed, unipodal support in the abbreviated paretic limb, increased step length, decreased hip flexion, increased knee flexion and plantar flexion and involves compensatory strategies to deal with deficits of the affected limb. Rehabilitation programs of patients with CVA should focus on the restoration of the individual’s independence and ability to move. Objective: To analyze the effects of the addition of a load on a lower limb not affected in the discharge of weight and motor function of paretic lower limb. Method: Experimental, randomized, double-blind study conducted at the Physiotherapy and Occupational Therapy Outpatient Clinic of the Hospital das Clínicas (HC) - UNICAMP. Participants were assessed by the Confidence and Balance Scale, Fugl-Meyer Assessment of Physical Performance (FMA), Modified Ashworth Scale (MAS), Postural Stroke Scale for post-stroke patients (PSS), Time up and go test (TUG), 10-Meter gait test, Stroke Scale Barthel and weight transfer in the affected lower limb. Participants were treated in 12 walking training sessions on the treadmill with 1 kg added to the ankle of the lower limb. Results: There were variations between the 3 times for gait time (p= 0.005), FMA (p= 0.002), Activities-specific Balance Confidence Scale (ABC scale) (p= 0.007) and EAPA (p= 0.042). Conclusion: Treadmill therapy and weight addition in the healthy limb revealed improvement in motor function, balance in orthostatism and walking speed.
... The participant completed the Modified Functional Reach Test (mFRT), Activity-based Balance Level Evaluation (ABLE) scale, and Modified Ashworth scale. 21 The mFRT (i.e. seated reach) 22,23 was used to examine the changes in the participant's ability to maintain control over his upright posture during forward reach, without any assistance. ...
Objective: To examine the biomechanical and neuromuscular effects of a longitudinal multi-muscle electrical stimulation (submaximal intensities) training of the lower limbs combined with/without activity-based stand training, on the recovery of stability and function for one individual with spinal cord injury (SCI).
Design: Single-subject, longitudinal study.
Setting: Neuroplasticity laboratory.
Participant: A 34-year-old male, with sensory- and motor-complete SCI (C5/C6).
Interventions: Two consecutive interventions: 61 hours of supine, lower-limb ES (ES-alone) and 51 hours of ES combined with stand training using an overhead body-weight support system (ST + ES).
Outcome Measures: Clinical measures, trunk stability, and muscle activity were assessed and compared across time points. Trunk Stability Limit (TSL) determined improvements in trunk independence.
Results: Functional clinical values increased after both interventions, with further increases post ST + ES. Post ES-alone, trunk stability was maintained at 81% body-weight (BW) loading before failure; post ST + ES, BW loading increased to 95%. TSL values decreased post ST + ES (TSLA/P=54.0 kg.cm, TSLM/L=14.5 kg.cm), compared to ES-alone (TSLA/P=8.5 kg.cm, TSLM/L=3.9 kg.cm). Trunk muscle activity decreased post ST + ES training, compared to ES-alone.
Conclusion: Neuromuscular and postural trunk control dramatically improved following the multi-muscle ES of the lower limbs with stand training. Multi-muscle ES training paradigm of the lower limb, using traditional parameters, may contribute to the functional recovery of the trunk.
... Upper-extremity motor function for persons with stroke was assessed using the upper extremity section of the Fugl-Meyer Assessment (FMA) (Fugl-Meyer et al., 1975;Gladstone et al., 2002). Hypertonicity was measured using the Modified Ashworth Scale (Bohannon and Smith, 1987;Haas et al., 1996). Hemiparetic severity (mean FMA 44.13 out of 66 points) and stroke chronicity (mean 8.15 years) indicated a wide range of stroke-related upper-extremity impairments. ...
Modulating visual feedback may be a viable option to improve motor function after stroke, but the neurophysiological basis for this improvement is not clear. Visual gain can be manipulated by increasing or decreasing the spatial amplitude of an error signal. Here, we combined a unilateral visually guided grip force task with functional MRI to understand how changes in the gain of visual feedback alter brain activity in the chronic phase after stroke. Analyses focused on brain activation when force was produced by the most impaired hand of the stroke group as compared to the non-dominant hand of the control group. Our experiment produced three novel results. First, gain-related improvements in force control were associated with an increase in activity in many regions within the visuomotor network in both the stroke and control groups. These regions include the extrastriate visual cortex, inferior parietal lobule, ventral premotor cortex, cerebellum, and supplementary motor area. Second, the stroke group showed gain-related increases in activity in additional regions of lobules VI and VIIb of the ipsilateral cerebellum. Third, relative to the control group, the stroke group showed increased activity in the ipsilateral primary motor cortex, and activity in this region did not vary as a function of visual feedback gain. The visuomotor network, cerebellum, and ipsilateral primary motor cortex have each been targeted in rehabilitation interventions after stroke. Our observations provide new insight into the role these regions play in processing visual gain during a precisely controlled visuomotor task in the chronic phase after stroke.
... Each animal was evaluated before lesion, on day The Ashworth scale. The Ashworth rating scale was used for the assessment of muscle tone and hindlimb rigid post-SCI according to the adapted Ashworth scale for rats 56,57 . We evaluated positioning of hindlimb ipsilateral to the hemisected side as described in details in Table 1. ...
Spasticity, a common complication after spinal cord injury (SCI), is frequently accompanied by chronic pain. The physiological origin of this pain (critical to its treatment) remains unknown, although spastic motor dysfunction has been related to the hyperexcitability of motoneurons and to changes in spinal sensory processing. Here we show that the pain mechanism involves changes in sensory circuits of the dorsal horn (DH) where nociceptive inputs integrate for pain processing. Spasticity is associated with the DH hyperexcitability resulting from an increase in excitation and disinhibition occurring in two respective types of sensory interneurons. In the tonic-firing inhibitory lamina II interneurons, glutamatergic drive was reduced while glycinergic inhibition was potentiated. In contrast, excitatory drive was boosted to the adapting-firing excitatory lamina II interneurons while GABAergic and glycinergic inhibition were reduced. Thus, increased activity of excitatory DH interneurons coupled with the reduced excitability of inhibitory DH interneurons post-SCI could provide a neurophysiological mechanism of central sensitization and chronic pain associated with spasticity.
... The MAS does not represent the entire picture of spasticity in subjects with SCI. Also, studies 12,[14][15][16] that examined the reliability of the MAS have yielded conflicting results. The SCATS is a more comprehensive clinical scale that may have advantages over the MAS, because it measures mul- tijoint spastic motor behaviors in SCI. ...
Objective:
To assess the reliability of the Spinal Cord Assessment Tool for Spastic Reflexes (SCATS).
Design:
Observational reliability study of the SCATS .
Setting:
Inpatient rehabilitation unit at an education and research hospital.
Participants:
This study included 47 subjects between the ages of 18 and 88 years with spinal cord injury, American Spinal Injury Association (ASIA) impairment scale grades from A to D with spasticity, and at least 6 months post injury.
Interventions:
Not applicable.
Main outcome measures:
Inter-rater and test-retest reliability of the SCATS.
Results:
The SCATS had substantial to almost perfect inter-rater agreement (κ=0.669-1.000) between the 2 physiatrists. Test-retest agreement of the SCATS was also substantial to almost perfect (κ=0.614-1.000) as well. There was a significant correlation between the SCATS clonus scores and the Modified Ashworth scores of the hip, knee, and ankle. No correlation was found between SCATS extensor spasm scores and Modified Ashworth scores. The SCATS flexor spasm scores were only correlated significantly with the ankle plantar flexor Modified Ashworth scores (p<0.05).
Conclusion:
The SCATS is a reliable tool for assessing spasm activity and spastic hypertonia in patients with spinal cord injury.
Hypertonia describes abnormally increased muscle tone caused by upper motor neuron pathology in the brain or spinal cord. Clinically, hypertonia can manifest in either spasticity, dystonia, rigidity, or a combination of these subtypes. In most cases, hypertonia reflects a static pathologic process, but rarely it can be a sign of a progressive neurologic disorder. Multiple scoring systems exist to evaluate patients with hypertonia. The most common and recognizable childhood disease that manifests with hypertonia is spastic cerebral palsy. Hypertonia management is dependent on the pathology and functionality of the individual patient and includes physical therapy, oral medications, intramuscular injections, and surgical procedures. This chapter discusses the definition of hypertonia, its different clinical subtypes, clinical examination findings, scaling systems, pathophysiology, and finally the different treatment modalities.
Spasticity can cause serious problems in the activity and participation of people with spinal cord injuries. It can also be a significant challenge for rehabilitation. Spasticity is usually defined as a velocity-dependent increase in the tonic stretch reflex (muscle tone) with exaggerated tendon jerks, clonus, and spasms, resulting from the hyperexcitability of the stretch reflex. Current management approaches, including new drugs and technologies, can provide significant benefits for people with spinal cord injuries. This chapter aims to provide an overview of spasticity in spinal cord injuries, including definition, pathophysiology, and management.KeywordsSpasticityUpper motor neuron lesionSpinal cord injuries
Introduction
Spinal cord injury (SCI) is a devastating condition with immediate impact on the individual’s health and quality of life. Major functional recovery reaches a plateau 3–4 months after injury despite intensive rehabilitative training. To enhance training efficacy and improve long-term outcomes, the combination of rehabilitation with electrical modulation of the spinal cord and brain has recently aroused scientific interest with encouraging results. The mesencephalic locomotor region (MLR), an evolutionarily conserved brainstem locomotor command and control centre, is considered a promising target for deep brain stimulation (DBS) in patients with SCI. Experiments showed that MLR-DBS can induce locomotion in rats with spinal white matter destructions of >85%.
Methods and analysis
In this prospective one-armed multi-centre study, we investigate the safety, feasibility, and therapeutic efficacy of MLR-DBS to enable and enhance locomotor training in severely affected, subchronic and chronic American Spinal Injury Association Impairment Scale C patients in order to improve functional recovery. Patients undergo an intensive training programme with MLR-DBS while being regularly followed up until 6 months post-implantation. The acquired data of each timepoint are compared with baseline while the primary endpoint is performance in the 6-minute walking test. The clinical trial protocol was written in accordance with the Standard Protocol Items: Recommendations for Interventional Trials checklist.
Ethics and dissemination
This first in-man study investigates the therapeutic potential of MLR-DBS in SCI patients. One patient has already been implanted with electrodes and underwent MLR stimulation during locomotion. Based on the preliminary results which promise safety and feasibility, recruitment of further patients is currently ongoing. Ethical approval has been obtained from the Ethical Committee of the Canton of Zurich (case number BASEC 2016-01104) and Swissmedic (10000316). Results will be published in peer-reviewed journals and presented at conferences.
Trial registration number
NCT03053791 .
Background: The pathological mechanism in acute spinal cord injury (SCI) is dual sequential: the primary mechanical lesion and the secondary injury due to a cascade of biochemical and pathological changes initiated by the primary lesion. Therapeutic approaches have focused on modulating the mechanisms of secondary injury. Despite extensive efforts in the treatment of SCI, there is yet no causal, curative treatment approach available.
Extracorporeal shock wave therapy (ESWT) has been successfully implemented in clinical use. Biological responses to therapeutic shock waves include altered metabolic activity of various cell types due to direct and indirect mechanotransduction leading to improved migration, proliferation, chemotaxis, modulation of the inflammatory response, angiogenesis and neovascularization thus inducing rather a regeneration than repair.
Objective: The aim of this clinical study is to investigate the effect of ESWT in humans within the first 48 hours after an acute traumatic SCI, with the objective to intervene in the secondary injury phase in order to reduce the extent of neuronal loss.
Study design: Two-arm three-stage adaptive, prospective, multi-center, randomized, double-blind, placebo-controlled study.
Methods: The study has been initiated in July 2020 and a total of 82 patients with acute traumatic SCI will be recruited for the first stage in 15 participating hospitals as part of a two-armed three-stage adaptive trial design. The focused ESWT (energy flux density: 0.1 - 0.19 mJ/mm2, Frequency: 2-5 Hz) is applied once at the level of the lesion, five segments above / below and on the plantar surface of both feet within the first 48 hours after trauma.
The degree of improvement between the follow-up examinations over six months in motor and sensory function is the primary endpoint of the study. Secondary endpoints include routine blood chemistry parameters, the degree of spasticity, the ability to walk, urological function, quality of life, and the independence in everyday life.
Hypothesis: The application of ESWT activates the nervous tissue regeneration involving a multitude of various biochemical and cellular events and leads to a decreased neuronal loss. ESWT might contribute to an improvement in the treatment of acute traumatic SCI in future clinical use.
ClinicalTrials.gov identifier: NCT04474106
Spasticity is a neurological disorder which results in disordered sensorimotor control owing to an upper motor neuron lesion. The muscles are continuously contracted which causes stiffness in the muscle which hinders the movement of muscle from their natural movement. It is mainly caused due to an injury to the central nervous system. Commonly used assessment methods of spasticity like the Ashworth and modified Ashworth scales do not quantify the degree of spasticity in the patients as they simply make available a semi quantitative degree of the force applied by the foot as resistance to passive movement with restricted inter-rater reliability. Electromechanical methods like isokinetic dynamometers can be used only when an objective quantitative weigh is available for the resistance to passive motion. Electrophysiological methods are valuable for the understanding of the pathophysiological procedures tangled in spasticity. But none of the methods are easy and reliable.
Key points:
Damage to corticospinal axons have implications for the development of spasticity following spinal cord injury (SCI). Here, we examined to which extent residual corticospinal connections and spasticity are present in muscles below the injury (quadriceps femoris and soleus) in humans with motor complete thoracic SCI. We found three distinct sub-groups of people: participants with spasticity and corticospinal responses in the quadriceps femoris and soleus, participants with spasticity and corticospinal responses in the quadriceps femoris only, and participants with no spasticity or corticospinal responses in either muscle. Spasticity and corticospinal responses were present in the quadriceps but never only in the soleus muscle, suggesting a proximal to distal gradient of symptoms of hyperreflexia. These results suggest that concomitant patterns of residual corticospinal connectivity and spasticity exist in humans with motor complete SCI and that a clinical exam of spasticity might be a good predictor of residual corticospinal connectivity.
Abstract:
The loss of corticospinal axons has implications for the development of spasticity following spinal cord injury (SCI). However, the extent to which residual corticospinal connections and spasticity are present across muscles below the injury remains unknown. To address this question, we tested spasticity using the Modified Ashworth Scale and transmission in the corticospinal pathway by examining motor evoked potentials elicited by transcranial magnetic stimulation over the leg motor cortex (cortical MEPs) and by direct activation of corticospinal axons by electrical stimulation over the thoracic spine (thoracic MEPs), in the quadriceps femoris and soleus muscles, in 30 individuals with motor complete thoracic SCI. Cortical MEPs were also conditioned by thoracic electrical stimulation at intervals allowing their summation or collision. We found three distinct sub-groups of participants: 47% showed spasticity in the quadriceps femoris and soleus muscle, 30% showed spasticity in the quadriceps femoris muscle only, and 23% showed no spasticity in either muscle. While cortical MEPs were present only in the quadriceps in participants with spasticity, thoracic MEPs were present in both muscles when spasticity was present. Thoracic electrical stimulation facilitated and suppressed cortical MEPs, showing that both forms of stimulation activated similar corticospinal axons. Cortical and thoracic MEPs correlated with the degree of spasticity in both muscles. These results provide the first evidence that related patterns of residual corticospinal connectivity and spasticity exist in muscles below the injury after motor complete thoracic SCI and highlight that a clinical exam of spasticity can predict residual corticospinal connectivity after severe paralysis. This article is protected by copyright. All rights reserved.
Objective
To determine if functional measures of ambulation can be accurately classified using clinical measures, demographics, personal, psychosocial, and environmental factors (PPEF), and limb accelerations (LA) obtained during sleep, among individuals with chronic, motor incomplete spinal cord injury (SCI) in an effort to guide future, longitudinal predictions models.
Design
Cross-sectional, 1-5 days of data collection
Setting
Community-based data collection
Participants
Adults with chronic (>1 year), motor incomplete SCI (n=27)
Interventions
Not applicable
Main Outcome Measures
Ambulatory ability based on the 10-Meter (10mWT) or 6-Minute Walk Tests (6MWT) categorized as non-ambulatory, household ambulator (0.01-0.44m/s, 1-204m) or community ambulator (>0.44m/s, >204m). A random forest model classified ambulatory ability using input features including: clinical measures of strength, sensation, and spasticity; demographics; PPEF including pain, environmental factors, health, social support, self-efficacy, resilience, and sleep quality; LA measured during sleep. Machine learning methods were employed explicitly to avoid overfitting and minimize the possibility of biased results.
Results
The combination of LA, clinical, and demographic features resulted in the highest classification accuracies for both functional ambulation outcomes (10mWT=70.4%, 6MWT=81.5%). Adding LA, PPEF, or both increased the accuracy of classification compared to the clinical/demographic features alone. Clinical measures of strength and sensation (especially knee flexion strength), LA measures of movement smoothness, and presence of pain and comorbidities were among the most important features selected for the models.
Conclusions
The addition of LA and PPEF features increased functional ambulation classification accuracy in a population with incomplete SCI for whom improved prognosis for mobility outcomes is needed. These findings provide support for future longitudinal studies that use LA, PPEF, and advanced analyses to improve clinical prediction rules for functional mobility outcomes.
One of the common disorders in people with quadriplegia is having a weak grip strength that can affect activities of daily living (ADL). This study presents the design of a soft robotic glove via pneumatic actuators and feasibility according to a range of motion (ROM) of proximal interphalangeal (PIP) joint and user friendly.
The soft robotic glove includes a neoprene cockup, two pumps, a controller that adjusts the pressure of the pumps, two-direction parts, and two silicone tubes placed on an index and middle fingers. A total of seven subjects (2healthy, 5quadriplegia patients) participated in this project. Performance of the device was verified through assessment in healthy participants first and then spinal cord injury (SCI) participants. The device evaluated the range of motion (ROM) of a proximal interphalangeal (PIP) joint. Then, subjects completed a satisfaction questionnaire.
Results showed the ROM of the PIP joint (p value= 0.042) increased by using the robotic glove. The average score of the satisfaction questionnaire was 4.24 which was beyond the desirable threshold. In conclusion, the glove obtained ROM requirements to the grip usual objects and underlined the potential for assisting SCI participants in ADLs. Providing motion in all fingers should be investigated and developed in the future.
Electrical stimulation has been used to treat spasticity in children with cerebral palsy. Building on the benefits of electrical stimulation, a new assistive device, electro-suit Mollii® with imbedded electrodes has been tested. The aim of the study was to evaluate the possible effect of Mollii® on body function, activity and participation in self-selected activities.
Methods: Six children, five to ten years of age, used the electro-suit for one hour, every other day for three months. The impact was evaluated after four weeks and after three months by measuring passive range of motion (ROM), muscle tone, pain, gross motor function and participation.
Results: All participants improved in the total score for Canadian Occupational Performance Measure (COPM), three of them showed significant clinical improvements. Pain was reduced for children who estimated pain when the study started. There were also small changes in ROM and muscle tone and gross motor function.
Conclusion: Electro-suit Mollii® had a positive impact on activity and participation in self-selected activities among the children in this study. Further studies with more children over a longer time are necessary to evaluate the impact and usefulness over time.
Post-stroke spasticity seriously affects patients’ quality of life. Spasticity is considered to involve both neural and non-neural factors. Current clinical scales, such as the Modified Ashworth Scale and the Modified Tardieu Scale, lack reliability and reproducibility. These scales are also unable to identify the neural and non-neural contributions to spasticity. Surface electromyography and biomechanical and myotonometry measurement methods for post-stroke spasticity are discussed in this report. Surface electromyography can provide neural information, while myotonometry can estimate muscular properties. Both the neural and non-neural contributions can be estimated by biomechanical measurement. These laboratory methods can quantitatively assess spasticity. They can provide more valuable information for further study on treatment and rehabilitation than clinical scales.
Spasticity, which indicates an abnormal stretch reflex behavior, is a disabling component of upper motor neuron lesion including spinal cord injury. The upper motor neuron system consists of all the pathways above the anterior horn cell, including the brain, brainstem, and spinal cord. Spasticity includes a wide range of abnormal motor behavior due to upper motor neuron lesion. This causes increased muscle tone, increased muscle reactivity, reduced precision of voluntary muscle control, and the emergence of involuntary motor output. All of these effects can show time-dependent differences in static versus dynamic conditions, flexor versus extensor movements, and many other permutations. Clinically, spasticity can be easily recognized, but can be difficult to quantify and treat. The pathophysiology of spasticity is complex and controversial. There are many subtle considerations in the management of spasticity, and sometimes the clinician has to negotiate with the patient when adjusting the spasticity.
La rehabilitación de los lesionados medulares es un proceso largo cuyo punto de partida es la evaluación rigurosa y completa del paciente y de las consecuencias que tiene la lesión medular sobre su organismo. Los resultados de esta evaluación permitirán describir la situación clínica del paciente, predecir su estado en el futuro y hacer un seguimiento de los avances o retrocesos de su salud. En resumen, la evaluación permitirá elegir la mejor estrategia terapéutica y adaptarla a medida que sea necesario. Para que la exploración esté lo más exenta posible de errores y para no correr el riesgo de instaurar un tratamiento en el mejor de los casos ineficaz y en el peor de los casos perjudicial, se recomienda utilizar instrumentos de medida calibrados, es decir, fiables y válidos.
La riabilitazione dei pazienti con lesioni midollari è un processo lungo, il cui punto di partenza è la valutazione rigorosa e completa del paziente, così come delle conseguenze della lesione midollare sul suo corpo. I risultati di questa valutazione permettono di descrivere lo stato di salute del paziente, di predire il suo stato futuro e di monitorare i miglioramenti o i peggioramenti della sua salute. In sintesi, questa valutazione deve consentire di scegliere e di adattare a mano a mano la migliore strategia terapeutica. Affinché questa valutazione sia il più possibile esente da errori e per evitare il rischio di instaurare un trattamento nella migliore delle ipotesi inefficace e, nella peggiore, dannoso, si raccomanda di utilizzare strumenti di misurazione calibrati, vale a dire affidabili e validi.
Background and purpose: The aim of this study was to evaluate heterotopic ossification (HO) prevalence after stroke, describing clinical features and investigating predictors of HO and its severity. Methods: A cross-sectional study was carried out in 7 rehabilitation centers (Sarah Network) from 2004 to 2013. Results: Among 17,794 stroke cases, 235 patients (1.3%) presented clinical and radiological evidence of HO. A log-binomial model with robust variance estimated the prevalence ratio of 1.3% in 10 years. A multinomial logistic regression was performed to investigate the predictors of HO and its severity. The presence of hemorrhagic stroke (prevalence ratio [PR] = 4.75; 95% confidence interval [CI] PR = 3.38; 6.68) and ischemic stroke with hemorrhagic transformation (PR = 3.08; 95% CI PR = 1.63; 5.81), male sex (PR = 1.60; 95% CI PR = 1.16; 2.22), spasticity (PR = 13.78; 95% CI PR = 8.59; 22.10), and cognitive impairment (PR = 1.88; 95% CI PR = 1.36; 2.60) were independently associated with HO. Patients with HO were younger (P <.0001) and presented a shorter time of disease (P =.013). Young adult patients were more likely to develop severe HO (odds ratio = 2.80, 95% CI 1.09; 7.20) than were elderly patients. Severe HO was also related to heavy alcohol consumption (2.45; 1.03-5.84) and involved 2 or more joints (5.34; 1.85-15.36). There was an association with use of invasive ventilation (6.30; 2.13-18.63) at the acute stroke phase and patients were dependent on activities of daily living after stroke (3.90; 1.00-15.19). Conclusions: Despite the small prevalence of HO after stroke, this 10-year multicenter study was able to identify several associated factors related to the management and severity of stroke as well as the hemorrhagic subtype.
Reliable assessment is essential for the management of spasticity, one of the most frequent complication of various neurological diseases. For the spasticity assessment, several clinical tools have been developed and widely used in clinics. The most popular one is modified Ashworth scale (MAS). It has a simple protocol, but is subjective and qualitative. To improve its reliability, quantitative measurement and consistent training would be needed. This study presents an elbow spasticity simulator which mimics spastic response of adult post stroke survivors. First, spastic responses (i.e. resistance and joint motion) from patients with a stroke were measured during conventional MAS assessment. Each grade of MAS was quantified by using three parameters representing three characteristics of the spasticity. Based on the parameters, haptic models of MAS were developed for implementing repeatable and consistent haptic training of novice clinicians. Two experienced clinicians participated in preliminary evaluation of the models.
Objective:
To determine whether the integration of dynamic weight shifting into treadmill training would improve the efficacy of treadmill training in humans with spinal cord injury (SCI).
Design:
Sixteen humans with SCI were randomly assigned to receive robotic or treadmill only training, and underwent 6 weeks of training. A force was applied to the pelvis for facilitating weight shifting and to the legs for assisting with leg swing for participants in the robotic group. No assistance force was applied for participants in the treadmill only group. Outcome measures consisted of overground walking speed, 6-minute walking distance, and other clinical measures, and were assessed pre, post 6 weeks of training, and 8 weeks after the end of training.
Results:
A greater improvement in 6-minute walking distance was observed after robotic training than that after treadmill only training (p = 0.03), but there was not a significant difference between the two groups in improvements in walking speed. However, a greater improvement was observed for the participants who underwent robotic training than those who underwent treadmill only training (i.e., 15% vs. 2%).
Conclusion:
Applying a pelvis assistance force for facilitating weight shifting during treadmill training may improve locomotor function in humans with SCI.
Background and purpose:
Clonus arising from plantar flexor hyperreflexia is a phenomenon that is commonly observed in persons with spastic hypertonia. We assessed the temporal components of a biomechanical measure to quantify ankle clonus, and validated these in persons with spasticity due to spinal cord injury.
Methods:
In 40 individuals with chronic (>1 year) spinal cord injury, we elicited ankle clonus using a standardized mechanical perturbation (drop test). We examined reliability and construct validity of 2 components of the drop test: clonus duration (timed with a stopwatch) and number of oscillations in the first 10-second interval (measured via optical motion capture). We compared these measures to the Spinal Cord Assessment Tool for Spastic reflexes (SCATS) clonus score and H-reflex/M-wave (H/M) ratio, a clinical and electrophysiologic measure, respectively.
Results:
Intra- and interrater reliability of clonus duration measurement was good [intraclass correlation coefficient, ICC (2, 1) = 1.00]; test-retest reliability was good both at 1 hour [ICC (2, 2) = 0.99] and at 1 week [ICC (2, 2) = 0.99]. Clonus duration was moderately correlated with SCATS clonus score (r = 0.58). Number of oscillations had good within-session test-retest reliability [ICC (2, 1) > 0.90] and strong correlations with SCATS clonus score (r = 0.86) and soleus H/M ratio (r = 0.77).
Discussion and conclusions:
Clonus duration and number of oscillations as measured with a standardized test are reliable and valid measures of plantar flexor hyperreflexia that are accessible for clinical use. Tools for objective measurement of ankle clonus are valuable for assessing effectiveness of interventions directed at normalizing reflex activity associated with spasticity.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A179).
As has been said of certain forms of art, spasticity is difficult to define, but “You know it when you see it.” After upper motoneuron damage due to spinal cord injury, spinal circuitry receives unbalanced input from peripheral afferent fibers and segmental interneuronal circuits relative to descending supraspinal pathways. This results in a mostly detrimental clinical syndrome of distorted motor control that contributes as much as frank weakness does to hindering execution of activities of daily living. In this chapter, we elaborate on our current understanding of the physiological mechanisms underlying post-SCI spasticity in humans, its evolution, its assessment, and a spectrum of clinical interventions. We end by discussing future directions of investigation that could position clinicians to help patients reestablish volitional control over the altered circuitry that underlies 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.
A study of 30 patients with multiple sclerosis was undertaken to determine the inter-rater reliabilty of the Ashworth scale for the clinical assessment of spasticity in the lower limbs. Scores of two physiotherapists were compared. Kendall's tau correlation coefficients higher than 0.60 were found for M soleus, M gastrocnemius and for the M psoas. For the adductors and the internal rotators of the hip, the interrater reliability according to Kendall's tau was lower than 0.55. For the M quadriceps and the flexors of the knee, Kendall's tau correlations were higher on the left side than on the right side. No explanation could be found for this inconsistent finding. It was concluded that the Ashworth scale may be used as a reliable scale for some muscles but not for others. More research is needed to find out if differences in ratings could be explained by fluctuations or differences in the clinical assessment of the muscle tone.
The Wartenberg pendulum test is an objective quantitative method for the assessment of muscle tone. We have compared the results of measurements of muscle tone using this method with traditional clinical assessments graded on the Ashworth scale. Two indices (R1 and R2) were measured from the Wartenberg test. Both were related to readings from the Ashworth scale. The ratio R2 (the ratio of the amplitude of the first swing to the difference in angle between the start and finish positions), however, showed a linear relationship throughout the range of spasticity tested in contrast to the curvilinear relationship shown by R1 (the ratio of the amplitude of the first swing to the difference between the rebound angle and the start angle). Significant changes in the ratio R2 without any corresponding change in the Ashworth grading were observed. It is concluded that the Wartenberg ratio R2 and the Ashworth scale assess similar features of the muscle and/or its motor control, but that the pendulum test provides a more finely graded observer- independent measurement.
In September 1992, the Executive Committee of the Consortium of Multiple Sclerosis Centers selected members for the physical therapy specialty panel. The group's responsibility was to review current literature and clinical practice on spasticity and balance in multiple sclerosis care. This task was achieved through individual work and conference calls and the results were reported at the multidisciplinary "What Do We Know About MS?" conference in June 1993. With input from forty other health care professionals experienced with MS care, two research questions were generated by the physical therapy panel. The question for balance was "Which of the three clinical measurement tools—Tinetti, Berg, or Functional Reach—is the best predictor of falls in the MS client, and how do they correlate with an experienced clinician's subjective evaluation?" The question for spasticity was "Will a daily stretching program result in decreased spasticity severity and improved functional mobility in ambulatory MS clients?" The findings from the spasticity question will provide a scientific basis for a common clinical practice in MS. The findings from the balance question will validate reliable clinical tools that may assess risk for falling in MS clients. The experience and findings were shared at the annual Consortium meeting in Victoria in September 1993.
Equipment has been constructed which provides quantification of spasticity with ease. The instrument is mobile, and may be used in outpatient clinics or on wards to monitor progress of treatment. The methods of measurement have proven to be reliable, although at the low torque encountered it may be advantageous to measure the torque directly from the output shaft in order to reduce the noise from the worm gearing. Patient acceptance has been good, and the instrument is in routine clinical use for the assessment of treatment. The method of fixation of the arm and positioning of the machine has proved effective. Future developments planned include the provision of an on-line microprocessor to compute the areas of the curves and give indices of spasticity. This work will follow after further clinical trials. Details of the equipment and clinical data may be obtained from the authors.
Spasticity is an important cause of neurological disability, and many new treatments are emerging to treat it. To assess any therapy, a consistent and reproducible method of measuring spasticity is required. The Ashworth Scale, in which each passive movement is graded between 1 (normal) and 5 (immovable), has been used in recent studies, and has the advantage over other methods of being simple to use and applicable over a wide range of arm and leg movements. We have studied the Ashworth Scale's reliability within and among four observers (two physicians, an occupational therapist, and a physical therapist) in 12 patients with moderate to severe spasticity. Total spasticity scores ranged from 22 to 66 (mean, 44.5). Coefficient of repeatability for intrarater variability was between 7.2 and 9.4. Interobserver error measured by Kendall's coefficient of concordance was 0.92. Given that small fluctuations in spasticity occur normally, these results indicate that the Ashworth Scale is a reliable and reproducible method of evaluating spasticity.
SummaryWith the implementation of the Government's document ‘Health of the Nation’ there appears to be an increased need for objective evaluation and quantification of outcome in rehabilitation. Spasticity is a clinical feature and a physiological phenomenon that has often been considered complex and difficult to measure. However, the literature has highlighted the need for a quantitative measurement of this impairment caused by an increase in muscle tone within the clinical setting. The development of such a measurement has been affected by a lack of understanding of the underlying mechanisms of Spasticity. A variety of measurements for Spasticity are available and can be divided into subjective measurements (such as tendon jerks, rating scales and associated reactions) and objective measurements (including EMG, pendulum tests and isokinetic measurements) but few are actually used. The measurement of spasticity is seen as part of the overall assessment process and it is proposed that more energy should be devoted to evaluating the reliability and validity of already existing clinical assessment scales.
The measurement of impairment and disability can improve patient care and is now essential in clinical audit. Practical, useful measures are slowly being developed, both for use in specific diseases and for more general use. This review discusses both new measures and new work on more well-established measures.
To develop a reliable and objective technique for quantifying spastic hypertonia, ten chronically hemiplegic patients with varying degrees of spasticity were studied on three occasions during several weeks. The modified Ashworth scale, a clinical assessment of extremity tone, was performed before and after each of the following objective tests: (1) torque and EMG measurements during ramp and hold angular displacement about the elbow, (2) pendulum test of the lower extremity, and (3) H/M ratio studies of upper and lower extremities. Subject motor function was also quantified using the Fugl-Meyer motor assessment scale. A regression analysis was performed to determine how successfully each of the objective measures correlated with the clinical yardstick, the modified Ashworth scale. A similar correlation between the objective measures and the Fugl-Meyer motor assessment scale was performed. Temporal reproducibility of a test for a given subject was evaluated by performing an ANOVA of repeated measures for each test over the three study sessions in a given subject. We conclude that (1) both the ramp and hold threshold measurements and pendulum test offer acceptable objective measures of spastic hypertonia since they correlate closely with clinical perception, (2) the Fugl-Meyer motor assessment scale also correlates closely with the severity of spastic tone, and (3) objective measures of spastic hypertonia are often surprisingly reproducible when repeatedly applied to a selected group of chronic hemiplegic patients with long-standing spasticity.
Spasticity develops after supraspinal or spinal lesions of descending motor systems, with obligate involvement of the corticospinal tract. Spasticity is characterized by an increase in muscle tone, which, in contrast to many other types of enhanced muscle tone, shows a marked velocity-dependent increase when the muscle is passively stretched. The pathophysiological mechanisms underlying this spastic muscle tone remain obscure. Three major causes are currently considered possible: (1) changes in the excitability of spinal interneurones; (2) receptor hypersensitivity; (3) formation of new synapses by sprouting. The latter mechanism could account for the long time course over which spastic muscle tone develops in hemiplegic or paraplegic patients, but there is no experimental evidence for this hypothesis. The electromyographic (EMG) gait analysis of patients with spasticity has thrown doubt on the common belief that the velocity-dependent increase in spastic muscle tone is evoked by stretch reflex activity and has led to the idea that spastic muscle tone resides in the muscle fibres themselves. While such a mechanism may contribute to the slowness of active movements in spastic patients, recent experiments on patients with spastic arm paresis have confirmed the classical view that the spastic muscle tone is related to the EMG activity evoked in the passively stretched muscle. This pathological EMG activity is seen during the entire range of the dynamic phase of the stretch, during which a normal muscle exhibits only an early, phasic burst at the highest stretch velocities employed. For the pharmacological treatment of spasticity, substances with different central or peripheral actions are available. Their assumed receptor actions are described, together with their main indications and side-effects.(ABSTRACT TRUNCATED AT 250 WORDS)
Thirty men and women diagnosed with definite multiple sclerosis (MS) were treated for ten weeks in a blinded, cross-over study. Patients with minimal to moderate spasticity were randomized to one of three sequences to evaluate the effects on MS-related spasticity of baclofen alone, stretching regimen with placebo, placebo alone, and stretching regimen with baclofen. The Cybex II isokinetic unit, timed gait, Ashworth scale, and subject's assessment of function were objective and subjective measures used to evaluate changes in hypertonicity. There was significant correlation between the Cybex and Ashworth as methods of measuring spasticity. Overall, treatment with baclofen alone significantly improved moderate quadriceps spasticity as measured by Cybex flexion scores. A trend, indicative of enhancing the beneficial effects of baclofen, was noted when stretching exercises were added to the treatment.
Spastic hypertonia has been 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, as one component of the upper motor neuron syndrome. Heightened muscle tone may be the result of changes intrinsic to the muscle or to altered reflex properties. Increased motoneuronal excitability and/or enhanced stretch-evoked synaptic excitation of motoneurons are mechanisms that might enhance stretch reflexes. Two distinct parameters may be altered in the pathologic stretch reflex--the "set point," or angular threshold of the stretch reflex, and the reflex "gain," or the amount of force required to extend the limb in proportion to the increasing joint angle. Earlier studies fail to dissociate the contributions of reflex threshold and reflex gain. Recent investigations suggest that spastic hypertonia may be the result of a decrease in stretch reflex threshold without significant increase in reflex gain, as was previously believed. Various clinical scales, biomechanical paradigms, pendulum models, and electrophysiologic studies have been used to quantify spastic hypertonia. Biomechanical methods seem to correlate most closely with the clinical state. Spastic hypertonia is but one component of the upper motor neuron syndrome, whose features also include loss of dexterity, weakness, fatigability, and various reflex release phenomena. These other features of the upper motor neuron syndrome may well be more disabling to the patient than changes in muscle tone.
I undertook this study to determine the test-retest variability and reliability of the pendulum test for muscle spasticity performed with the Cybex II isokinetic dynamometer. Thirty patients, with intracranial lesions and hemiplegia of 15 days' to 3 years' duration, were tested four times, consecutively. With the patients lying supine, the angle of flexion, at which the knee first reversed direction after the leg was dropped, was measured on each goniogram from the dynamometer chart recorder. The mean differences between the angles of reversal and the angles of maximum possible knee flexion (the relative angle of reversal) for the first through the fourth trials were 27.2, 27.0, 26.3, and 25.6 degrees, respectively. The relative angle of reversal did not differ significantly between trials. The mean difference between the largest and smallest relative angle of reversal for each of the subject's trials was 6.1 degrees. The intraclass correlation coefficient between the relative angle of reversal for the four trials was .96. Because the test variability was not significant and because the correlation between trials was high, the test may merit broader application to patients with intracranial lesions. Further investigation of variability across days and after treatments is advised.
Spasticity indicates that the muscle stretch reflex has become isolated from its supraspinal inhibitory modulation system, so that the alpha and dynamic fusimotor (spindle) neurons are abnormally excitable. In spastic lower limbs, the stretch reflex shows 2 main features: flexor and extensor excitation dependent on stretch velocity, and flexor excitation and extensor inhibition dependent on the lengthening of the muscle during stretch (clasp knife phenomenon). In the upper limbs patients with cerebral palsy show a length dependent inhibition of the biceps and excitation of the triceps, whereas patients with either hemiplegia or Parkinson's disease show excitation of both muscles as the fibers stretch. The situation is complicated by abnormal responsiveness to vibration; percussion over a tendon or a bony prominence starts a chain of reflex contractions as the vibration wave spreads through limbs or trunk.
Six hundred and twelve patients with closed spinal injuries are described. The incidence of various types of fracture and fracture-dislocation and the degree of reduction achieved by postural reduction is analysed in relation to the initial and late neurological lesions. The average time that the patients were kept in bed is given for the various types of skeletal injury. Only 4 patients developed late instability of the spine.
In spite of the different uses of the term "spasticity", hyperactivity of skeletal muscle stretch reflexes is the one common factor and we therefore need to know how this is produced by lesions within the central nervous system and what are its consequences to the initiation and execution of voluntary movement, not only initially but also chronically. The alpha motoneurone is directly responsible for the initiation of skeletal muscle contraction and final integration of excitatory and inhibitory nervous input normally takes place on its surface. In spasticity there is not only loss of descending direct excitatory and inhibitory control of motoneurones, but also loss of the control of spinal interneurones which would normally regulate (principally by inhibition) segmental spinal reflexes, including the stretch reflexes, especially those concerned with antigravity muscles. Gamma motoneurones may also have a reduction inhibitory control with consequent increase of muscle spindle sensitivity to stretch, and this may be further exaggerated by changes in the physical properties of affected muscles. The peripheral disorders of function are more accessible to study and to pharmacological and physical treatment, but with the increasing knowledge of inhibitory mechanisms and their pharmacology there is hope that some degree of influence may be possible within the central nervous system, by therapy with drugs that mimic or prolong the action of inhibitory transmitters.
Simple and inexpensive instrumentation required for pendulum testing of spasticity is described. It is based on the use of an electrogoniometer and tachometer. Eight parameters are extracted from the goniogram and the tachogram to evaluate the degree of spasticity. The correlation coefficients are calculated to determine the parameters relevant for the estimation of spasticity. Spasticity was assessed in the knee extensors of ten spinal cord injury patients and in five hemiplegics. The described instrumentation and evaluation of the pendulum test provide an effective spasticity testing in the clinical environment.
The aim of this investigation was to develop a clinically applicable method for quantitative evaluation of spasticity about the knee and to determine the minimum instrumentation necessary for a quick and simple estimation of spasticity. Skeletal muscle spasticity is assessed by physical therapists as increased resistance of a particular muscle group to manually induced passive movement. In this study the passive movement was produced by the force of gravity while the resistance was observed from the joint goniogram. Spasticity of the knee extensors was measured on patients with spinal cord injuries. Records of severe, moderate, and slight spasticity are presented in the paper. A mathematical model has been developed describing the behaviour of healthy and spastic extremity.
This study was conducted to determine the feasibility of quantifying spasticity by measuring the resistance to passive movement using an isokinetic dynamometer. A quantifiable method was developed by determining the summation of the four consecutive resisting torque amplitudes during flexion and extension of the knee at specified speeds and range of motion. A more rigorous assessment was made by finding the slope of the linear regression curve of torque-velocity data. Although the values of maximum torque were higher in the spastic group than in the normal group, the difference was statistically significant only when the sum of the torque amplitudes was considered (P < 0.0028). Values of the maximum torque as well as the sum of the torque amplitudes increased in a linear fashion (r > 0.75) with increasing velocity. The slopes of the torque-velocity curves were greater in spastic subjects than in normal subjects. The sensitivity to the rate of stretch was statistically greater (P < 0.0004) for the spastic group than normals only when the sum of torque amplitudes was considered. The corresponding data obtained during the flexion and extension of the knee were not statistically different (P > 0.05). Serial summation of torque amplitudes and measurement of slope in the torque-velocity curve are sensitive and repeatable methodologies for the measurement of spasticity assessment.
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