The Efficacy of Functional Electrical Stimulation of the Abdominal Muscles in the Treatment of Chronic Constipation in Patients with Multiple Sclerosis: A Pilot Study.

Chronic constipation in patients with multiple sclerosis (MS) is common and the current methods of treatment are ineffective in some patients. Anecdotal observations suggest that functional electrical stimulation (FES) of the abdominal muscles may be effective in the management of constipation in these patients. Patients and Methods. In this exploratory investigation we studied the effects of FES on the whole gut transit time (WGTT) and the colonic transit time (CTT). In addition, we evaluated the treatment effect on the patients' constipation-related quality of life and on the use of laxatives and the use of manual bowel evacuation. FES was given for 30 minutes twice a day for a period of six weeks. Four female patients were studied. Results. The WGTT and CTT and constipation-related quality of life improved in all patients. The patients' use of laxatives was reduced. No adverse effects of FES treatment were reported. Conclusion. The findings of this pilot study suggest that FES applied to the abdominal muscles may be an effective treatment modality for severe chronic constipation in patients with MS.

Predictive analysis for identifying potentially undiagnosed post-stroke spasticity patients in United Kingdom.

PURPOSE OF THE RESEARCH: Spasticity is one of the well-recognized complications of stroke which may give rise to pain and limit patients' ability to perform daily activities. The predisposing factors and direct effects of post-stroke spasticity also involve high management costs in terms of healthcare resources, and case-control designs are required for establishing such differences. Using 'The Health Improvement Network' (THIN) database, such a study would not provide reliable estimates since the prevalence of post-stroke spasticity was found to be 2%, substantially below the most conservative previously reported estimates. The objective of this study was to use predictive analysis techniques to determine if there are a substantial number of potentially under-recorded patients with post-stroke spasticity. METHODS: This study used retrospective data from adult patients with a diagnostic code for stroke between 2007 and 2011 registered in THIN. Two algorithm approaches were developed and compared, a statistically validated data-trained algorithm and a clinician-trained algorithm. RESULTS: A data-trained algorithm using Random Forest showed better prediction performance than clinician-trained algorithm, with higher sensitivity and only marginally lower specificity. Overall accuracy was 75% and 72%, respectively. The data-trained algorithm predicted an additional 3912 records consistent with patients developing spasticity in the 12months following a stroke. CONCLUSIONS: Using machine learning techniques, additional unrecorded post-stroke spasticity patients were identified, increasing the condition's prevalence in THIN from 2% to 13%. This work shows the potential for under-reporting of PSS in primary care data, and provides a method for improved identification of cases and control records for future studies.

Budget impact analysis of botulinum toxin A therapy for upper limb spasticity in the United Kingdom.

BACKGROUND: Botulinum toxin A (BoNT-A) is an effective treatment for patients with upper limb spasticity (ULS), which is a debilitating feature of upper motor neuron lesions. BoNT-A preparations available in the UK are associated with different costs. METHODS: We developed a budget impact model to assess the effect of changing market shares of different BoNT-A formulations - abobotulinumtoxinA, onabotulinumtoxinA, and incobotulinumtoxinA - and best supportive care, from the UK payer perspective, over a 5-year time horizon. Epidemiological and resource use data were derived from published literature and clinical expert opinion. One-way sensitivity analyses were performed to determine parameters most influential on budget impact. RESULTS: Base-case assumptions showed that an increased uptake of abobotulinumtoxinA resulted in a 5-year savings of £6,283,829. Treatment with BoNT-A costs less than best supportive care per patient per year, although treating a patient with onabotulinumtoxinA (£20,861) and incobotulinumtoxinA (£20,717) cost more per patient annually than with abobotulinumtoxinA (£19,800). Sensitivity analyses showed that the most influential parameters on budget were percentage of cerebral palsy and stroke patients developing ULS, and the prevalence of stroke. CONCLUSION: Study findings suggest that increased use of abobotulinumtoxinA for ULS in the UK could potentially reduce total ULS cost for the health system and society.

The pharmacological management of post-stroke muscle spasticity.

Muscle hypertonia following upper motor neurone lesions (referred to here as 'spasticity') is a common problem in patients with neurological disease, and its management is one of the major challenges in clinical practice. Understanding the pathogenesis and clinical course of spasticity is essential for the effective management of this condition. The hypertonia initially results from increased excitability of the alpha motor neurones due to an imbalance between the excitatory and inhibitory influences of the vestibulospinal and reticulospinal tracts. This is the 'neural component' of muscle hypertonia. However, usually within 3-4 weeks, changes in the structure and mechanical properties of the paralysed muscles and the effect of thixotropy also contribute to the hypertonia. The selection of the optimal treatment option is often influenced by whether the neural or the non-neural component is more pronounced. Muscle spasticity often interferes with motor function or causes distressing symptoms, such as painful muscle spasms. If untreated, spasticity may also lead to soft tissue shortening (fixed contractures). However, spasticity can also be beneficial to patients. For example, despite severe leg muscle weakness, most hemiplegic patients are able to walk because the spasticity of the extensor muscles braces the lower limb in a rigid pillar. Other reported benefits of spasticity include the maintenance of muscle bulk and bone mineral density and possibly a reduced risk of lower limb deep vein thrombosis. Several factors, such as skin pressure sores, faecal impaction, urinary tract infections and stones in the urinary bladder, can aggravate muscle spasticity. These factors should always be looked for as their adequate treatment is often sufficient to reduce muscle tone without the need for specific antispasticity medication. Therefore, a careful evaluation of the patient's symptoms and their impact on function, and the setting of clear and realistic therapy goals are important prerequisites to treatment. The best treatment outcomes are usually achieved when pharmacological and non-pharmacological treatment modalities are used in tandem. Different drugs are available for the management of spasticity, including oral muscle relaxants, anticonvulsant drugs, intrathecal baclofen, cannabis extract, phenol and alcohol (for peripheral nerve blocks) and botulinum toxin injections. Similarly, there is a range of non-pharmacological methods of treatment, e.g. regular muscle stretching, the use of splints and orthoses, electrical stimulation, etc. Although these are not discussed here, this should not detract from the importance of combining them with antispasticity drugs in order to maximize the clinical benefit of treatment.

Classification of posture in poststroke upper limb spasticity: a potential decision tool for botulinum toxin A treatment?

A significant percentage of patients suffering from a stroke involving motor-relevant central nervous system regions will develop a spastic movement disorder. Hyperactivity of different muscle combinations forces the limbs affected into abnormal postures or movement patterns. As muscular hyperactivity can effectively and safely be treated with botulinum toxin type A (BoNT-A), we present a classification of spastic arm movement patterns to support BoNT-A therapy of arm spasticity. A few characteristic patterns can be distinguished that may be relevant for BoNT-A treatment. On the basis of a differentiated posture and arm movement analysis, five characteristic arm spasticity patterns (ASP I-V) were defined with respect to the position of the shoulder, elbow, forearm, and wrist joints. These patterns were verified using data from a worldwide noninterventional Upper Limb International Survey. By clinical observation, spastic arm postures in 94% of 665 poststroke patients could be assigned to one of these five ASPs. The most frequent pattern of arm spasticity was ASP III (41.8%) with internal rotation and adduction of the shoulder and flexion at the elbow coupled with a neutral positioning of the forearm and wrist, not the typical Wernicke-Mann position. These five different arm position patterns (ASP I-V) form the foundation of a common terminology and facilitate quick and understandable exchange of information with other physicians. Furthermore, utilization of these patterns may improve the dosing, goal setting, and outcome of the BoNT-A treatment of arm spasticity.

The effect of total cumulative dose, number of treatment cycles, interval between injections, and length of treatment on the frequency of occurrence of antibodies to botulinum toxin type A in the treatment of muscle spasticity.

A large cumulative dose of botulinum toxin type A (BoNT-A), frequent injections, a short interval between treatment cycles, and a long duration of treatment have all been suggested, but not confirmed, to be associated with a high incidence of neutralizing antibodies to the neurotoxin. The aim of this study was to investigate whether these variables predispose to BoNT-A neutralizing antibody formation. A mouse protection (neutralization) bioassay was used for the detection of BoNT-A antibodies in 17 patients who received large doses of BoNT-A, over at least 10 consecutive treatment cycles or for 5 years or more. BoNT-A antibodies were not detected in any of the study patients. The study findings did not confirm an association between the above-mentioned variables and BoNT-A antibody formation.

Spasticity or reversible muscle hypertonia?

BACKGROUND AND OBJECTIVE: The increase in resistance to passive muscle stretch in a paretic limb due to an upper motor neurone lesion is often referred to as muscle spasticity. However, this terminology is inaccurate and does not take into account the complex pathogenesis of the condition or describe the factors that contribute to the clinically observed changes in muscle tone. In this report we propose an alternative terminology and explain the reasons for doing so.

The profile of patients and current practice of treatment of upper limb muscle spasticity with botulinum toxin type A: an international survey.

To document the current practice in relation with the treatment of patients with upper limb spasticity with botulinum toxin type A to inform future research in this area. We designed an international, cross-sectional, noninterventional survey of current practice. Nine hundred and seventy-four patients from 122 investigational centres in 31 countries were studied. Most patients were over 40 years old and had a stroke. Improvement of active function was the most frequent treatment goal in the first 3 months after the onset of upper limb spasticity, but was less common than passive function in the chronic stage. Pain relief was a common goal in both the stages. As a rule, clinicians intended to assess the effectiveness of treatment with impairment level scales. Functional outcome measures seem to be rarely used in clinical practice. The use of these measures should be encouraged to assess whether the reduction in muscle tone translates into functional benefit to patients and their caregivers.

The use of botulinum toxin for the treatment of muscle spasticity in the first 2 years of life.

Although there are sound theoretical reasons for the use of botulinum toxin (Btx) as early as possible in the management of severe childhood muscle spasticity, the experience with its safety in children younger than 2 years of age is limited and information about its possible effects on the development and maturation of the human motor system is still scarce. This study discusses the rationale and the potential pitfalls of the use of Btx in the first 2 years of the child's life. It also reviews the currently available evidence on the efficacy and safety of Btx in this age group. It concludes by suggesting a framework for studies of the optimal time to start treatment of childhood spasticity with Btx.

Creating the optimal conditions for rehabilitation research.

Current evidence suggests that productivity in biomedical research depends on the support that the research group enjoys from its parent institution, the composition of the group and the personal attributes of its members and leader. Supportive institutions provide adequate physical resources and allow substantial uninterrupted time for research. The effectiveness of the research group asa whole is also strongly influenced by the group's structure, the professional competence of the group leader, his leadership style and his ability to foster collaboration with other research groups and organizations. There is a good case for a flexible leadership style that is modelled on the situational theory of leadership. In addition, the personal characteristics of the individual members of the research group influence the quality and quantity of the research output. Effective groups are made of motivated individuals with research training and skills that are relevant to the objectives of the research group. Rehabilitation research is fundamentally different from traditional biomedical research. This study discusses how the factors that influence productivity of biomedical research relate to rehabilitation science and practice and examines the conditions that are necessary to create and maintain an academic environment that is conducive to large volume,high-quality research in rehabilitation medicine.