Spasticity Management Teams, Evaluations, and Tools: A Canadian Cross-Sectional Survey.

OBJECTIVE: The objective of this study is to determine the physical evaluations and assessment tools used by a group of Canadian healthcare professionals treating adults with spasticity. METHODS: A cross-sectional web-based 19-question survey was developed to determine the types of physical evaluations, tone-related impairment measurements, and assessment tools used in the management of adults with spasticity. The survey was distributed to healthcare professionals from the Canadian Advances in Neuro-Orthopedics for Spasticity Congress database. RESULTS: Eighty study participants (61 physiatrists and 19 other healthcare professionals) completed the survey and were included. Nearly half (46.3%, 37/80) of the participants reported having an inter- or trans-disciplinary team managing individuals with spasticity. Visual observation of movement, available range of motion determination, tone during velocity-dependent passive range of motion looking for a spastic catch, spasticity, and clonus, and evaluation of gait were the most frequently used physical evaluations. The most frequently used spasticity tools were the Modified Ashworth Scale, goniometer, and Goal Attainment Scale. Results were similar in brain- and spinal cord-predominant etiologies. To evaluate goals, qualitative description was used most (37.5%). CONCLUSION: Our findings provide a better understanding of the spasticity management landscape in Canada with respect to staffing, physical evaluations, and outcome measurements used in clinical practice. For all etiologies of spasticity, visual observation of patient movement, Modified Ashworth Scale, and qualitative goal outcomes descriptions were most commonly used to guide treatment and optimize outcomes. Understanding the current practice of spasticity assessment will help provide guidance for clinical evaluation and management of spasticity.

A Delphi-Based Consensus Statement on the Management of Anticoagulated Patients With Botulinum Toxin for Limb Spasticity.

OBJECTIVE: To create a consensus statement on the considerations for treatment of anticoagulated patients with botulinum toxin A (BoNTA) intramuscular injections for limb spasticity. DESIGN: We used the Delphi method. SETTING: A multiquestion electronic survey. PARTICIPANTS: Canadian physicians (N=39) who use BoNTA injections for spasticity management in their practice. INTERVENTIONS: After the survey was sent, there were e-mail discussions to facilitate an understanding of the issues underlying the responses. Consensus for each question was reached when agreement level was ≥75%. MAIN OUTCOME MEASURES: Not applicable. RESULTS: When injecting BoNTA in anticoagulated patients: (1) BoNTA injections should not be withheld regardless of muscles injected; (2) a 25G or smaller size needle should be used when injecting into the deep leg compartment muscles; (3) international normalized ratio (INR) level should be ≤3.5 when injecting the deep leg compartment muscles; (4) if there are clinical concerns such as history of a fluctuating INR, recent bleeding, excessive or new bruising, then an INR value on the day of injection with point-of-care testing or within the preceding 2-3 days should be taken into consideration when injecting deep compartment muscles; (5) the concern regarding bleeding when using direct oral anticoagulants (DOACs) should be the same as with warfarin (when INR is in the therapeutic range); (6) the dose and scheduling of DOACs should not be altered for the purpose of minimizing the risk of bleeding prior to BoNTA injections. CONCLUSIONS: These consensus statements provide a framework for physicians to consider when injecting BoNTA for spasticity in anticoagulated patients. These consensus statements are not strict guidelines or decision-making steps, but rather an effort to generate common understanding in the absence of evidence in the literature.

Treatment patterns of in-patient spasticity medication use after traumatic spinal cord injury: a prospective cohort study.

STUDY DESIGN: Prospective cohort study using the Rick Hansen SCI Registry (RHSCIR) and retrospective medical chart review. OBJECTIVE: To describe treatment patterns of in-patient anti-spasticity medication use following traumatic spinal cord injury (SCI) in acute and rehabilitation hospital settings in British Columbia, Canada. SETTING: Quaternary trauma center, rehabilitation center. METHODS: Individuals with traumatic SCI between 2005 and 2014 enrolled in the Vancouver RHSCIR site (N = 917) were eligible for inclusion. Oral and injectable anti-spasticity medication use were the main outcome measures. RESULTS: In 769 participants, higher neurological level and injury severity were associated with in-patient anti-spasticity medication use (p < 0.001 for both). Of individuals with cervical and thoracic injuries (n = 589), 37% were prescribed anti-spasticity medication during hospital admission. Baclofen was the most commonly used first line oral therapy. Mean (SD) and median time from injury to Baclofen initiation was 70 (69) and 50 days, respectively. The probability of having initiated an in-patient anti-spasticity medication was 55% (95% CI (49, 60)) for individuals 6 months post-injury, and 71% (95% CI (62, 79)) for individuals 12 months post-injury. At community discharge, the prevalence of oral and injectable anti-spasticity medication use was 26 and 5%. Practice patterns of anti-spasticity medication use (2005-2009 vs. 2010-2014) have not changed significantly over time. CONCLUSIONS: This is the first large prospective cohort study of in-patient anti-spasticity medication use following traumatic SCI. Results from our study inform clinicians and individuals of "real world" anti-spasticity medication use among individuals with traumatic SCI and may help guide care for this population in the community.

Intra-rater and inter-rater reliability of the Penn Spasm Frequency Scale in People with chronic traumatic spinal cord injury.

STUDY DESIGN: Psychometric study. OBJECTIVES: Evaluate the intra-rater and inter-rater reliability of the Penn Spasm Frequency Scale (PSFS) in people with chronic traumatic spinal cord injury (SCI). SETTING: Community setting. METHODS: Participants with chronic traumatic SCI were administered the PSFS, a self-reported spasticity measure in which the individual documents the frequency (Part 1) and severity (Part 2) of their muscle spasms. One rater administered the PSFS at baseline, 5 to 10 days, and 4 to 6 weeks after baseline. The second rater administered the PSFS within 3 days of the first rater. RESULTS: Reliability was assessed using weighted-kappa (95% confidence interval) statistics. In 61 participants, the intra-rater reliability between 5 to 10 days and 4 to 6 weeks after baseline was 0.822 (0.709, 0.935) and 0.734 (0.586, 0.883), respectively, for PSFS Part 1. With the addition of Part 2, the intra-rater reliabilities were 0.812 (0.705, 0.919) and 0.729 (0.586, 0.872) for 5 to 10 days and 4 to 6 weeks, respectively. The PSFS inter-rater reliability within a 3-day time interval was 0.862 (0.759, 0.965) for Part 1 and 0.857 (0.762, 0.952) with the addition of Part 2. CONCLUSIONS: PSFS Part 1 intra-rater and inter-rater reliability weighted-kappa statistics are in the "almost perfect" category, with lower confidence bounds in the "substantial" range. By adding Part 2 the reliability decreases, but the kappa statistics remain "substantial," with a lower confidence bound in the "moderate" range. The PSFS is probably a reliable outcome measure to assess self-reported spasticity after chronic traumatic SCI.

Prevalence and Effect of Problematic Spasticity After Traumatic Spinal Cord Injury.

OBJECTIVE: To evaluate the prevalence and effect of spasticity after traumatic spinal cord injury (SCI). DESIGN: Prospective cohort study of the Rick Hansen Spinal Cord Injury Registry (RHSCIR) and retrospective review of inpatient medical charts. SETTING: Quaternary trauma center, rehabilitation center, and community settings. PARTICIPANTS: Individuals (N=860) with a traumatic SCI between March 1, 2005, and March 31, 2014, prospectively enrolled in the Vancouver site RHSCIR were eligible for inclusion. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Questionnaires (Penn Spasm Frequency Scale, Spinal Cord Injury Health Questionnaire) and antispasticity medication use. RESULTS: In 465 patients, the prevalence of spasticity at community discharge was 65%, and the prevalence of problematic spasticity (defined as discharged on antispasticity medication) was 35%. Problematic spasticity was associated with cervicothoracic neurologic level and injury severity (P<.001). In community follow-up, the prevalence of patients reporting any spasticity treatment (ie, problematic spasticity) was 35% at 1 year, 41% at 2 years, and 31% at 5 years postinjury. Interference with function caused by spasticity was reported by 27% of patients at 1 year, 25% at 2 years, and 20% at 5 years postinjury. Patients with American Spinal Injury Association Impairment Scale grade C injuries had the highest prevalence of ongoing spasticity treatment and functional limitation. CONCLUSIONS: Spasticity is a highly prevalent secondary consequence of SCI, particularly in patients with severe motor incomplete cervicothoracic injuries. It is problematic in one third of all patients with SCI up to 5 years postinjury. One in 5 patients will have ongoing functional limitations related to spasticity, highlighting the importance of close community follow-up and the need for further research into spasticity management strategies.

Does the method of botulinum neurotoxin injection for limb spasticity affect outcomes? A systematic review.

OBJECTIVE: To systematically review randomized controlled trials of botulinum neurotoxin for limb spasticity to determine whether different injection techniques affect spasticity outcomes. METHODS: MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials electronic databases were searched for English language human randomized controlled trials from 1990 to 13 May 2016. Studies were assessed in duplicate for data extraction and risk of bias using the Physiotherapy Evidence Database scale and graded according to Sackett's levels of evidence. RESULTS: Nine of 347 studies screened met selection criteria. Four categories of botulinum neurotoxin injection techniques were identified: (1) injection localization technique; (2) injection site selection; (3) injectate volume; (4) injection volume and site selection. There is level 1 evidence that: ultrasound, electromyography, and electrostimulation are superior to manual needle placement; endplate injections improve outcomes vs. multisite quadrant injections; motor point injections are equivalent to multisite injections; high volume injections are similar to low volume injections; and high volume injections distant from the endplate are more efficacious than low volumes closer to the endplate. CONCLUSION: Level 1 evidence exists for differences in treatment outcomes using specific botulinum neurotoxin injection techniques. Findings are based on single studies that require independent replication and further study.

Worldwide Survey of Clinician Practice on use of Adjunctive Therapies Following Botulinum Toxin Injection for Spasticity.

OBJECTIVE: Non-pharmacological adjunctive therapies can be used alongside botulinum toxin injection to enhance its efficacy. The objective of this global study was to determine the current practice and perception among clinicians of the use of adjunctive therapies after botulinum toxin injections for the treatment of limb spasticity. METHODS: A questionnaire with 22 questions on clinical practice demographics, self-reported use and clinician opinion on barriers to the use of complementary therapies, and priorities for future research was translated into 7 languages and distributed worldwide through national and international professional associations concerning (neuro)rehabilitation. RESULTS: A total of 527 clinicians from 52 countries responded to the survey. Most commonly used physical interventions were: active exercise programmes at home (81%), stretching programmes at home (81%), and splinting (70%), followed by active movement exercises (65%) and within 30 min of botulinum toxin injection and constraint induced movement therapy (63%). The main barriers reported by clinicians to provision of these interventions were clinicians' lack of time, limited financial resources, and lack of evidence. Future research should focus primarily on immediate active movement exercises and passive stretching. CONCLUSION: Worldwide, clinicians often recommend adjunctive therapies after a botulinum toxin injection to reduce spasticity. The most commonly used physical interventions among clinicians were active exercises at home, stretching at home, and splinting. Lack of evidence, time and financial constraints were identified as barriers to providing these interventions.

Practice Patterns of Physicians Using Adjunct Therapies with Botulinum Toxin Injection for Spasticity: A Canadian Multicenter Cross-Sectional Survey.

BACKGROUND: Adjunct therapies are nonpharmacological treatments used with botulinum toxin (BoNT) injection that may improve spasticity outcomes. It has been suggested that physicians consider adjunct therapies as a part of comprehensive spasticity management. It is unclear which adjunct therapies are used by physicians in clinical practice. OBJECTIVE: To determine physician practice patterns and perceptions of use of adjunct therapies following BoNT injection for limb spasticity. DESIGN: Cross-sectional national survey of current clinical practice using a 22-item questionnaire developed by the authors. SETTING: Not applicable. PARTICIPANTS: Survey respondents were physicians actively administering BoNT injections for limb spasticity management across Canada (N = 48). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Types of adjunct therapies used by physicians; physician opinions on barriers to adjunct therapy use, patient preferences, and future research priorities. RESULTS: Most physicians prescribe home stretching programs, home active exercise programs, and splinting; however, many physicians perceive that these same adjunct therapies are unwanted by patients. A minority of physicians prescribe electrical stimulation (ES), transcutaneous electrical nerve stimulation (TENS), casting, and extracorporeal shockwave therapy; financial limitations and perceived lack of evidence were identified as barriers to their use. Significantly more physicians practicing in academic settings compared with nonacademic, community, and private practice settings used functional ES (59% vs 11%) and TENS (41% vs 0%) as adjunct therapies (P < .05). Research priorities included determining the effectiveness of immediate postinjection application of adjunct therapies (eg, injected muscle activation with ES or stretching) and nutraceuticals. CONCLUSIONS: Canadian physicians frequently use adjunct therapies in combination with BoNT injection to treat spasticity. Financial and time constraints are identified as barriers to implementation of adjunct therapies that are currently supported by research, and patient preferences may also affect compliance. Future research should focus on adjunct therapies that overcome these barriers.

Early predictors of developing problematic spasticity following traumatic spinal cord injury: A prospective cohort study.

Objective: To identify early predictors and develop reliable, validated prediction models for development of problematic spasticity after traumatic spinal cord injury (SCI).Design: Prospective cohort study of the Rick Hansen Spinal Cord Injury Registry (RHSCIR), retrospective review of inpatient medical charts.Setting: Quaternary trauma center, rehabilitation center, community settings.Participants: Individuals with traumatic SCI between March 1, 2005, and March 31, 2014, prospectively enrolled in the Vancouver site RHSCIR.Interventions: None.Main Outcome Measure: Spasticity limiting function or requiring treatment (problematic spasticity) on the Spinal Cord Injury Health Questionnaire.Results: In 350 patients, variables documented during hospitalization that predicted the development of problematic spasticity up to 5 years post-injury included: initial Glasgow Coma Scale; age at time of injury; admission to rehabilitation center; community discharge anti-spasticity medication prescription, neurological status, Penn Spasm Frequency Scale, and pain interference with quality of life, sleep, activities; greater change in AIS motor scores between admission and discharge. The predictive models had area under the receiver operating characteristic curve of 0.80 (95% CI 0.75, 0.85) in the development set (N = 244) and 0.84 (95% CI 0.74, 0.92) in the validation set (N = 106) for spasticity limiting function and 0.81 (95% CI 0.76, 0.85) in the development set and 0.85 (95% CI 0.77, 0.92) in the validation set for spasticity requiring treatment.Conclusions: Our prediction models provide an early prognosis of risk of developing problematic spasticity after traumatic SCI, which can be used to improve clinical spasticity management and assist research (e.g. risk stratification in interventional trials).

Implementing a self-management mobile app for spinal cord injury during inpatient rehabilitation and following community discharge: A feasibility study.

Objective: To determine the feasibility of implementing and evaluating a self-management mobile app for spinal cord injury (SCI) during inpatient rehabilitation and following community discharge. Design: Pilot feasibility study. Setting: Rehabilitation hospital and community. Participants: Inpatients from rehabilitation hospital following admission for their first SCI. Intervention: A mobile app was developed to facilitate self-management following SCI. The app consisted of 18 tools focusing on goal setting, tracking various health aspects, and identifying confidence regarding components of self-management. In-person training and follow-up sessions were conducted during inpatient rehabilitation and follow-up calls were provided after participants were discharged into the community. Main outcome measures: Participants completed outcome measures at baseline, community discharge, and 3-months post discharge. This study focused on feasibility indicators including recruitment, retention, respondent characteristics, adherence, and app usage. Additionally, participants' self-management confidence relating to SCI (e.g. medication, skin, bladder, pain) was evaluated over time. Results: Twenty participants (median age 39, IQR: 31 years, 85% male) enrolled in the study. Participants' Spinal Cord Injury Independence Measure (SCIM-III) median score was 23 and IQR was 33 (range: 7-84), which did not correlate with app usage. Retention from admission to discharge was 85% and 70% from discharge to 3-months post discharge. Individuals in the study who used the app entered data an average of 1.7x/day in rehabilitation (n = 17), and 0.5x/day in the community (n = 7). Participants' bowel self-management confidence improved between admission and discharge (P < 0.01). Conclusions: Feasibility indicators support a larger clinical trial during inpatient rehabilitation; however, there were challenges with retention and adherence following community discharge.

Early adjunct treatment with topical lidocaine results in improved pain and function in a patient with complex regional pain syndrome.

Complex regional pain syndrome (CRPS) is a pain disorder characterized by sensory, motor, trophic and autonomic dysfunction. The hallmark of the disorder is pain out of proportion of the inciting event. CRPS is difficult for clinicians to manage as there is no gold standard for diagnosis or treatment. Patients with CRPS are at risk of developing contractures, tissue atrophy, joint dislocation and severe chronic pain. While CRPS is thought to be due to peripheral and central nervous system dysfunction, there is limited understanding of the pathophysiology of CRPS. The proposed mechanisms are multifactorial and consequently, so are the proposed treatments. These treatments can be invasive, such as intrathecal drug delivery or sympathectomy, which have poor evidence for efficacy. Thus, highlighting the need for a safe, effective, and early intervention. We present a case of topical 5% lidocaine ointment as a non-invasive, inexpensive and effective adjunct treatment in the management of pain in a spinal cord injured patient presenting with early CRPS. The clinically important effect of topical lidocaine for reducing severe allodynia allowed the patient to participate in rehabilitation strategies to further manage the debilitating consequences of her CRPS, including decreased range of motion (ROM) and function. The immediate pain relief from topical lidocaine allowed the patient to tolerate physical therapy sessions directed at her CRPS. A successful outcome was measured subjectively and objectively by our patient's reduction in symptoms and improvement in ROM and function, respectively. This case study provides preliminary support for improved pain and functional outcome with early adjunct treatment of CRPS with topical lidocaine.