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.

Neuromuscular partitioning of the gastrocnemius based on intramuscular nerve distribution patterns: implications for injections

Spasticity of the gastrocnemius is commonly treated with botulinum toxin injections; however, the optimal injection sites within each head have not been evaluated in relation to neuromuscular partitions. The purpose of the present study was to (1) document the intramuscular innervation patterns of the medial and lateral heads of gastrocnemius using 3 dimensional modeling; (2) determine if the medial and lateral heads of gastrocnemius are neuromuscularly partitioned; and (3) propose botulinum toxin injection strategies based on these findings. In this cadaveric study (n=24) the extramuscular and intramuscular innervation was serially dissected followed by digitization and 3D reconstruction and/or photography of the innervation pattern throughout the muscle volume. Intramuscular innervation patterns were defined to determine if the heads of gastrocnemius were neuromuscularly partitioned and based on these findings approaches for botulinum toxin injections were proposed. In all specimens except one, both heads of the gastrocnemius received independent innervation from three discrete nerve branches. Therefore, each head had three neuromuscular partitions defined by location as superior, inferomedial and inferolateral. In one specimen, the lateral head also received nerve branches via the soleus that innervated the inferolateral partition distally. Functionally, independent activation of the neuromuscular partitions of the gastrocnemius may result in differential contribution of the partitions to knee flexion and ankle plantarflexion. To capture all partitions, four injection sites into each belly were proposed. Future clinical studies are needed to determine if there is improved spasticity reduction by targeting neuromuscular partitions

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Rehabilitation medicine: 3. Management of adult spasticity.

Spasticity refers to an abnormal, velocity-dependent (i.e., how fast the joint is moved through its range) increase in muscle tone resulting from interruption of the neural circuitry regulating the muscles and is a common complication of cerebral palsy, brain injuries, spinal cord injuries, multiple sclerosis and stroke. The muscle stretch reflex is thought to play an important role in spasticity generation. Spasticity can have a significant detrimental effect on daily functions, such as feeding, dressing, hygiene, bladder and bowel control, and mobility; patients' need for support can also influence the cost of care. Thus, managing these patients appropriately or referring them to those with expertise in this area is important. In this article, I review the pathophysiology of spasticity and the evaluation and management of adult patients with the condition. Two hypothetical cases are presented to illustrate the management of spasticity.