[Spasticity-correcting surgery can have long-lasting effects]. / Spasticitetskorrigerande kirurgi kan ge långvariga förbättringar.

Spasticity is a common secondary complication after injuries to the central nervous system (CNS). Spasticity may severely impair arm and hand function, and consequently, affect an individual's function, resulting in disabilities or limiting activities and participation. Today, there is conflicting evidence regarding the effectiveness of available spasticity treatments. The population of adults with spasticity problems due to a CNS injury is heterogenic. A multidisciplinary approach is essential in customizing treatment to individual needs. The planning of treatment should consider the remaining upper limb functions and the patient's potential to improveme. Spasticity-correcting surgery is an option that seems underutilized. This article describes a structured and standardized program for the preoperative assessment, the surgical technique and the postoperative rehabilitation of patients undergoing upper limb spasticity-correcting surgery.

Análise da ativação muscular em indivíduos com paralisia cerebral através de manuseios do conceito bobath: uma revisão crítica / Analysis of muscle activation in individuals with Cerebral Palsy through handling the Bobath Concept: a critical review

O objetivo desse artigo foi analisar criticamente a literatura a respeito da ativação muscular pelo uso do Conceito Bobath em indivíduos com Paralisia Cerebral. As bases de dados consultadas foram Pubmed, Science Direct, Scielo, Lilacs, PEDro e ResearchGate, não limitando o período de publicação, sendo incluídos artigos publicados até maio de 2020. Foram encontrados na literatura 827 estudos, destes apenas cinco foram incluídos nessa revisão. Os artigos inclusos, a partir de critérios pré-estabelecidos, avaliaram através da eletromiografia diferentes musculaturas pelo uso de manuseios do Conceito Bobath. As musculaturas avaliadas estão relacionadas ao controle de cervical e de tronco, além dos músculos oblíquo interno, transverso do abdome e reto abdominal. A ativação muscular foi avaliada nas posturas de decúbito lateral, decúbito ventral e sedestação. Os artigos revisados identificaram através da eletromiografia que ocorre ativação muscular durante alguns manuseios do Conceito Bobath em indivíduos com paralisia cerebral, contudo as pesquisas são escassas, já que os estudos apresentam limitações nos desenhos experimentais e amostras pequenas. Isso reforça a importância de ampliar a investigação acerca da ativação muscular durante os manuseios com esta abordagem, o que poderá contribuir efetivamente na tomada de decisão dos profissionais que atuam nesta área, visando maior eficácia no tratamento e qualidade de vida desta população.AU)

The aim of this article was to critically analyze the literature on muscle activation by the use of the Bobath Concept in individuals with Cerebral Palsy. The databases consulted were Pubmed, Science Direct, Scielo, Lilacs, PEDro and ResearchGate, not limiting the publication period, including articles published until May 2020. A total of 827 studies were found in the literature, and of these only five were included in this review. The included articles, based on pre-established criteria, evaluated through electromyography different muscles using the Bobath Concept handling. The muscles evaluated are related to cervical and trunk control, in addition to the internal oblique, transverse muscles of the abdomen and rectum. Muscle activation was evaluated in lateral decubitus postures, ventral decubitus and sedestation. The reviewed articles identified, through electromyography, that muscle activation occurs during some handling of the Bobath Concept in individuals with cerebral palsy, however research is scarce, since studies have limitations in experimental designs and small samples. This reinforces the importance of expanding the investigation about muscle activation during handling with this approach, which can effectively contribute to the decision making of professionals working in this area, aiming at greater efficiency in the treatment and quality of life of this population.(AU)

Efeitos da crioterapia associada à cinesioterapia e da estimulação elétrica em pacientes hemiparéticos espásticos / Efectos de la crioterapia asociada a la cinesioterapia y de la estimulación eléctrica en pacientes hemiparéticos espásticos / Effects of cryotherapy associated with kinesiotherapy and electrical stimulation on spastic hemiparetic patients

RESUMO A espasticidade causada pelo acidente vascular encefálico (AVE) é uma das principais causas de incapacidade funcional no membro superior. O objetivo do estudo foi verificar o efeito da crioterapia associada à cinesioterapia e da estimulação elétrica na capacidade de preensão palmar do membro espástico de pacientes com AVE na fase crônica. Participaram do estudo 40 pacientes com idade média de 60,5 (±9,45) anos e hemiparesia espástica, divididos aleatoriamente em grupo A (GA): submetidos à crioterapia nos músculos flexores de punho e cinesioterapia nos músculos flexores e extensores de punho; e grupo B (GB): submetidos à estimulação elétrica nos músculos extensores de punho. A capacidade de preensão palmar foi avaliada por meio de um dinamômetro de bulbo antes, depois de 16 atendimentos e um mês após o término do tratamento. Os resultados demonstraram que houve aumento da capacidade de preensão palmar no GA (p=0,0244) e GB (p=0,0144) após o tratamento, com manutenção um mês após seu término (p=0,6002 e 0,3066 respectivamente), sem diferença estatística entre estes. Os achados apontam que ambos os recursos terapêuticos foram eficazes para o aumento da capacidade de preensão palmar dos participantes do estudo.

RESUMEN La espasticidad causada por el accidente cerebrovascular (ACV) es una de las principales causas de incapacidad funcional en el miembro superior. El objetivo del estudio fue verificar el efecto de la crioterapia asociada a la cinesioterapia y de la estimulación eléctrica en la capacidad de prensión palmar del miembro espástico de pacientes con ACV en fase crónica. Participaron del estudio 40 pacientes con edad media de 60,5 (±9,45) años y hemiparesia espástica, divididos aleatoriamente en grupo A (GA) -sometidos a la crioterapia en los músculos flexores del puño y cinesioterapia en los músculos flexores y extensores del puño - y grupo B (GB) - sometidos a la estimulación eléctrica en los músculos extensores del puño. Se evaluó la capacidad de prensión palmar por medio de un dinamómetro neumático antes del tratamiento, después de 16 atendimientos y un mes después del término del tratamiento. Los resultados demostraron un aumento de la capacidad de prensión palmar en el GA (p=0,0244) y en el GB (p=0,0144) después del tratamiento, con mantenimiento un mes después de su término (p=0,6002 y 0,3066 respectivamente), sin diferencia estadística entre éstos. Los hallazgos apuntan que ambos recursos terapéuticos fueron eficaces para aumentar la capacidad de prensión palmar de los participantes del estudio.

ABSTRACT Spasticity caused by stroke is a cause of functional disability of the upper extremity. The aim of this study was to check the effect of cryotherapy associated with kinesiotherapy and electrical stimulation on the palmar grip strength of the spastic limb of stroke patients in the chronic phase. Forty patients whose mean age was 60.5 (±9.45) years old and who had spastic hemiparesis participated in the study, having been randomly sorted into group A (GA): submitted to cryotherapy on the wrist flexors and kinesiotherapy on the wrist flexors and wrist extensors, and Group B (GB): submitted to electrical stimulation on the wrist extensors. Palmar grip strength was evaluated by a bulb dynamometer before, after 16 sessions and one month after the end of treatment. The results showed that there was an increase in palmar grip strength in GA (p=0.0244) and GB (p=0.0144) after treatment, with maintenance one month after its completion (p=0.6002 and 0.3066, respectively), and no statistical difference was observed between them. The findings indicate that both therapeutic resources were effective in increasing the study participants' palmar grip strength.

Feasibility and effectiveness of a newly modified protocol-guided selective dorsal rhizotomy via single-level approach to treat spastic hemiplegia in pediatric cases with cerebral palsy.

PURPOSE: It still remains challenging to treat CP cases with spastic hemiplegia using SDR via a single-level approach when guided by the traditional EMG response grading system. Our aim was to assess the feasibility and effectiveness of a newly modified protocol-guided single-level laminectomy SDR to treat such pediatric patients. METHODS: A retrospective cohort review was conducted in the CP cases with spastic hemiplegia undergone our newly modified protocol-guided single-level approach SDR since May 2016 to October 2017, and followed by intensive rehabilitation program for at least 12 months in both Shanghai Children's Hospital and Shanghai Rehabilitation and Vocational Training Center for the Disabled. Inclusion and exclusion criteria were set for the selection of patients in the current study. Our study focused on the setup, EMG recording interpretation, and outcome measures for this newly modified rhizotomy scheme. RESULTS: Eleven cases were included in the current study. Based on our new rhizotomy protocol, a total of 34 rootlets over our 11 cases were cut (2 in 4, 3 in 4, 4 in 1, and 5 rootlets in 2 cases, respectively). After SDR and the following rehabilitation program at a mean duration of 19 months, muscle tone of those "target muscles" in affected lower extremities which identified during pre-op assessment decreased by a mean of 1.4 degrees (Modified Ashworth Scale) in our cases. Strength of those target muscles and ROM of joints involved in their lower limbs were reported to have improved significantly as well. All cases showed major progress with regard to their motor function. A mean of about 10-point increase of GMFM-66 score was reported, and five of six cases who were with GMFCS level II preoperatively improved their GMFCS level at the last assessment. Kinematics of joints of hip, knee, and ankle on the affected side in our cases demonstrated a major correction, along with improvement of their foot pressure patterns to the ground during their gait cycles. Surgery-related complications, such as cerebral-spinal fluid leak/infection, long-term hypoesthesia, or urinary/bowel incontinence were not recorded in the current study. CONCLUSION: Single-level SDR when guided by our simplified rhizotomy protocol is feasible and effective to treat pediatric CP cases with spastic hemiplegia.

Orthopaedic surgery for patients with central nervous system lesions: Concepts and techniques.

Since ancient times, the aim of orthopedic surgery has been to correct limb and joint deformities, including those resulting from central nervous system lesions. Recent developments in the treatment of spasticity have led to changes in concepts and management strategies. The increase in life expectancy has increased the functional needs of patients. Orthopedic surgery, along with treatments for spasticity, improves the functional capacity of patients with neuro-orthopaedic disorders, improving their autonomy. In this paper, we describe key moments in the history of orthopedic surgery regarding the treatment of patients with central nervous system lesions, from poliomyelitis to stroke-related hemiplegia, from the limbs to the spine, and from contractures to heterotopic ossification. A synthesis of the current surgical techniques is then provided, and the importance of multidisciplinary evaluation and management is highlighted, along with indications for medical, rehabilitation and surgical treatments and their combinations. We explain why it is essential to consider patients' expectations and to set achievable goals, particularly before surgery, which is by nature irreversible. More recently, specialized surgical teams have begun to favor the use of soft-tissue techniques over bony and joint procedures, except for spinal disorders. We highlight that orthopedic surgery is no longer the end-point of treatment. For example, lengthening a contractured muscle improves the balance around a joint, improving mobility and stability but may be only part of the problem. Further medical treatment and rehabilitation, or additional surgery, are often necessary to continue to improve the function of the limb. Despite the recognized effectiveness of orthopedic surgery for neuro-orthopedic disorders, few studies have formally evaluated them. Hence, there is a need for research to provide evidence to support orthopedic surgery for treating neuro-orthopedic disorders.

Trial of Contralateral Seventh Cervical Nerve Transfer for Spastic Arm Paralysis.

BACKGROUND: Spastic limb paralysis due to injury to a cerebral hemisphere can cause long-term disability. We investigated the effect of grafting the contralateral C7 nerve from the nonparalyzed side to the paralyzed side in patients with spastic arm paralysis due to chronic cerebral injury. METHODS: We randomly assigned 36 patients who had had unilateral arm paralysis for more than 5 years to undergo C7 nerve transfer plus rehabilitation (18 patients) or to undergo rehabilitation alone (18 patients). The primary outcome was the change from baseline to month 12 in the total score on the Fugl-Meyer upper-extremity scale (scores range from 0 to 66, with higher scores indicating better function). Results The mean increase in Fugl-Meyer score in the paralyzed arm was 17.7 in the surgery group and 2.6 in the control group (difference, 15.1; 95% confidence interval, 12.2 to 17.9; P<0.001). With regard to improvements in spasticity as measured on the Modified Ashworth Scale (an assessment of five joints, each scored from 0 to 5, with higher scores indicating more spasticity), the smallest between-group difference was in the thumb, with 6, 9, and 3 patients in the surgery group having a 2-unit improvement, a 1-unit improvement, or no change, respectively, as compared with 1, 6, and 7 patients in the control group (P=0.02). Transcranial magnetic stimulation and functional imaging showed connectivity between the ipsilateral hemisphere and the paralyzed arm. There were no significant differences from baseline to month 12 in power, tactile threshold, or two-point discrimination in the hand on the side of the donor graft. RESULTS: The mean increase in Fugl-Meyer score in the paralyzed arm was 17.7 in the surgery group and 2.6 in the control group (difference, 15.1; 95% confidence interval, 12.2 to 17.9; P<0.001). With regard to improvements in spasticity as measured on the Modified Ashworth Scale (an assessment of five joints, each scored from 0 to 5, with higher scores indicating more spasticity), the smallest between-group difference was in the thumb, with 6, 9, and 3 patients in the surgery group having a 2-unit improvement, a 1-unit improvement, or no change, respectively, as compared with 1, 6, and 7 patients in the control group (P=0.02). Transcranial magnetic stimulation and functional imaging showed connectivity between the ipsilateral hemisphere and the paralyzed arm. There were no significant differences from baseline to month 12 in power, tactile threshold, or two-point discrimination in the hand on the side of the donor graft. CONCLUSIONS: In this single-center trial involving patients who had had unilateral arm paralysis due to chronic cerebral injury for more than 5 years, transfer of the C7 nerve from the nonparalyzed side to the side of the arm that was paralyzed was associated with a greater improvement in function and reduction of spasticity than rehabilitation alone over a period of 12 months. Physiological connectivity developed between the ipsilateral cerebral hemisphere and the paralyzed hand. (Funded by the National Natural Science Foundation of China and others; Chinese Clinical Trial Registry number, 13004466 .).

[Post-stroke spasticity management including a chosen physiotherapeutic methods and improvements in motor control - review of the current scientific evidence.]

Cerebrovascular diseases based on stroke etiology concern millions of people worldwide, and annual rates of disease are still increasing. In the era of an aging society and suffering from a number of risk factors, in particular those modifiable, strokes and muscles' spastic paresis, subsequently resulting in damage of upper motor neuron structures will become a serious problem for the entire health care system. Effective management and physiotherapy treatment for post-stroke spasticity persisted, both in the acute and chronic, is still a significant medical problem in the interdisciplinary aspect. Care procedures for this type of patient becomes a kind of challenge for specialists in neurology, internal medicine, cardiology, dermatology or neurosurgery, but also for physiotherapists in their everyday clinical practice. The aim of this paper is to present the issues of cerebral stroke and resulting spastic hypertonia in terms of current pharmacological treatment and surgery, and primarily through the use of effective physiotherapy methods, the use of which was confirmed in the way of reliable scientific research in accordance with the principles of Evidence Based Medicine and Physiotherapy (EBMP).

Resultados funcionales de corto plazo en rizotomía dorsal selectiva para el tratamiento de espasticidad en niños con parálisis cerebral / Short-term functional outcomes of selective dorsal rhizotomy for the treatment of spasticity in children with cerebral palsy

Introduction: selective dorsal rhizotomy (SDR) is a neurosurgical, non-reversible intervention to treat disabling spasticity in children with cerebral palsy (CP), improving their motor function and general performance. Objective: to assess functional outcomes of SDR in CP patients at Institutos teletón Chile, 6 and 12 months post-surgery. Patients and Method: Clinical records of all patients that underwent a SDR procedure between November 2010 and November 2013 were reviewed. Eighteen cases (spastic diplegia; age 7.5 +/- 2.9 years) were found, and their relevant pre-, peri- and post operative data after 6 and 12 months, were analyzed, as: clinical history, physical examination, evidence of preventricular leukomalacia (PVL), aspects related to surgery, and functional outcomes, including Gross Motor Function Measurement (GMFM)-66 and -88, Pediatric Evaluation Disability Inventory (PEDI) and gait lab (GL) using Gait Deviation Index (GDI). Results: Fifty percent of the subjects were classified as GMFCS II-III and the other 50 percent as GMFCS IV. A clinical important reduction in lower limb spasticity, particularly in triceps surae and hip flexors was observed in all patients, as well as improved muscular strength in many of them. GMFM-66 and GMFM-88 scores improved (p < 0.01). A trend towards improvement, without significant differences was observed in PEDI scores (GMFCS IV patients), and a significant improvement in GDI in ambulant patients (p < 0.015). Conclusions: SDR is a valid option to achieve long-lasting control of spasticity, 12 months after surgery, in children with spastic cerebral palsy, improving also functional capacity.

Introducción: la rizotomía dorsal selectiva (RDS) es una intervención neuro-quirúrgica irreversible para tratarla espasticidad discapacitante en niños con parálisis cerebral (PC). Su finalidad es mejorar la función motora y funcionalidad global de los pacientes. Objetivo: Evaluar los resultados funcionales de la RDS en los pacientes de Institutos teletón Chile con PC a los 6 y 12 meses postoperatorio. Pacientes y Método: Se revisan las fichas clínicas de los pacientes operados de RDS entre noviembre de 2010 y noviembre de 2013. Se encuentran 18 casos (diplejia espástica; edad 7,5 +/- 2,9 años), cuyos datos clínicos relevantes pre, peri y postoperatorios a 6 y 12 meses, fueron analizados: historia y examen físico; presencia de leucomalacia periventricular (LMPV); aspectos quirúrgicos y resultados funcionales de: Gross Motor Function Measurement (GMFM)-66 y 88, Pediatric Evaluation Disability Inventory (PEDI) y en laboratorio de marcha (LM), el Gait Deviation Index (GDI). Resultados: 50 por ciento correspondieron a pacientes GMFCS II-III y 50 por ciento a GMFCS IV. Se obtuvo importante reducción clínica de espasticidad de extremidades inferiores, especialmente plantiflexores de tobillo y flexores de cadera en todos los pacientes y en muchos un aumento de la fuerza muscular. Hubo mejoría en función motora gruesa evaluado con GMFM-66 (p < 0,001) y GMFM-88 (p < 0,001). tendencia a mejoría, sin diferencias significativas en PEDI (pacientes GMFCS IV) y mejoría significativa de GDI en pacientes ambulantes (p < 0,015). Conclusiones: La RDS es una opción válida para el control duradero de la espasticidad, a 12 meses, en niños con parálisis cerebral espástica, proporcionando además mejorías funcionales.

Feasibility of a shorter Goal Attainment Scaling method for a pediatric spasticity clinic - The 3-milestones GAS.

BACKGROUND: Goal Attainment Scaling (GAS) is a method for writing personalized evaluation scales to quantify progress toward defined goals. It is useful in rehabilitation but is hampered by the experience required to adequately "predict" the possible outcomes relating to a particular goal before treatment and the time needed to describe all 5 levels of the scale. Here we aimed to investigate the feasibility of using GAS in a clinical setting of a pediatric spasticity clinic with a shorter method, the "3-milestones" GAS (goal setting with 3 levels and goal rating with the classical 5 levels). Secondary aims were to (1) analyze the types of goals children's therapists set for botulinum toxin treatment and (2) compare the score distribution (and therefore the ability to predict outcome) by goal type. METHODS: Therapists were trained in GAS writing and prepared GAS scales in the regional spasticity-management clinic they attended with their patients and families. The study included all GAS scales written during a 2-year period. GAS score distribution across the 5 GAS levels was examined to assess whether the therapist could reliably predict outcome and whether the 3-milestones GAS yielded similar distributions as the original GAS method. RESULTS: In total, 541 GAS scales were written and showed the expected score distribution. Most scales (55%) referred to movement quality goals and fewer (29%) to family goals and activity domains. CONCLUSION: The 3-milestones GAS method was feasible within the time constraints of the spasticity clinic and could be used by local therapists in cooperation with the hospital team.

Effects of low-level laser therapy (LLLT 808 nm) on lower limb spastic muscle activity in chronic stroke patients.

A cerebrovascular accident (CVA) may affect basic motor functions, including spasticity that may be present in the upper extremity and/or the lower extremity, post-stroke. Spasticity causes pain, muscle force reduction, and decreases the time to onset of muscle fatigue. Several therapeutic resources have been employed to treat CVA to promote functional recovery. The clinical use of low-level laser therapy (LLLT) for rehabilitation of muscular disorders has provided better muscle responses. Thus, the aim of this study was to evaluate the effect of the application of LLLT in spastic muscles in patients with spasticity post-CVA. A double-blind clinical trial was conducted with 15 volunteer stroke patients who presented with post-stroke spasticity. Both males and females were treated; the average age was 51.5 ± 11.8 years old; the participants entered the study ranging from 11 to 48 months post-stroke onset. The patients participated in three consecutive phases (control, placebo, and real LLLT), in which all tests of isometric endurance of their hemiparetic lower limb were performed. LLLT (diode laser, 100 mW 808 nm, beam spot area 0.0314 cm(2), 127.39 J/cm(2)/point, 40 s) was applied before isometric endurance. After the real LLLT intervention, we observed significant reduction in the visual analogue scale for pain intensity (p = 0.0038), increased time to onset of muscle fatigue (p = 0.0063), and increased torque peak (p = 0.0076), but no significant change in the root mean square (RMS) value (electric signal in the motor unit during contraction, as obtained with surface electromyography). Our results suggest that the application of LLLT may contribute to increased recruitment of muscle fibers and, hence, to increase the onset time of the spastic muscle fatigue, reducing pain intensity in stroke patients with spasticity, as has been observed in healthy subjects and athletes.

Rehabilitation After Spasticity-Correcting Upper Limb Surgery in Tetraplegia.

OBJECTIVE: To describe the early active rehabilitation concept developed for spasticity-correcting surgery in tetraplegia and to report the outcomes in grip ability and change of performance and satisfaction in patients' prioritized activities 1 year postoperatively. DESIGN: Retrospective case-control study. SETTING: Nonprofit rehabilitation unit. PARTICIPANTS: All patients who underwent surgeries for correction of spasticity in tetraplegic hands between 2009 and 2013 in the studied unit (N=37). INTERVENTIONS: Spasticity-correcting upper limb surgery with early active rehabilitation to restore grip ability in tetraplegia. MAIN OUTCOME MEASURES: Grasp and release test (GRT) and modified Canadian Occupational Performance Measure (COPM). RESULTS: All patients could accomplish the early active rehabilitation concept. The complication rate related to the treatment was low. Compared with preoperatively, all evaluated individuals experienced improvements in grasp ability and activity performance and satisfaction at 1-year follow-up. The performance in prioritized activities, as measured by the COPM, improved by 2.6 scale steps. Satisfaction with performance improved 3.0 scale steps postoperatively (n=21). The grasp ability, measured by the GRT, improved significantly, from 80 preoperatively to 111 (n=10). CONCLUSIONS: The surgery, combined with the early active rehabilitation protocol, is a reliable and safe procedure. The ability to use the hand improved, and gains were maintained at least 1 year after surgery in all patients with respect to both the objective grasp ability and patients' subjective rating of their performance and satisfaction in their prioritized activities. The procedure should therefore be considered as an adjunct to other treatments of upper limb spasticity in spinal cord injury.

Perfil de dispensação da toxina botulínica para tratamento da espasticidade: dados nacionais brasileiros / Dispensing profile of botulinum toxin for treating spasticity: Brazilian national data

Os fisiatras especializados no tratamento de espasticidade foram reunidos para um painel de discussão a respeito do uso de toxina botulínica (TB) na rede pública de diferentes estados do Brasil. Os dados analisados durante a discussão do Datasus demonstram um baixo perfil de demanda desse produto dispensado pelo Sistema Único de Saúde (SUS), com uma heterogeneidade na distribuição da TB nos estados brasileiros. Esse quadro parece se configurar principalmente por falta de uma política pública devidamente planejada, como a falta de unificação e normatização dos centros de distribuição, pela falta ou inadequação da remuneração do procedimento de aplicação da TB aos centros de tratamento, de modo padronizado pela tabela SUS e escassez de médicos capacitados para realizá-lo junto à falta de centros de reabilitação multidisciplinar habilitados. O uso de toxina botulínica com finalidade terapêutica no Brasil teve início nos anos 90, para tratamento de distonia e de espasticidade. Atualmente, é empregada em diferentes condições clínicas, porém, apesar da crescente demanda e indicações ao longo dos anos, há poucos relatos ou publicações sobre seu uso e benefício para pacientes atendidos pela Sistema Único de Saúde (SUS). Para abordar esse tema, em maio de 2015, na cidade de São Paulo, fisiatras de diferentes estados do Brasil se encontraram e discutiram a relevância da toxina botulínica no tratamento de espasticidade

The physiatrists specialized in treating spasticity were brought together for a panel discussion about the use of botulinum toxin (BT) in the public system in different states of Brazil. The data analyzed during the discussion of Datasus demonstrate a low-demand profile of the product dispensed by the Unified Health System (SUS), with heterogeneity in the distribution of TB in the Brazilian states. This scenario seems to be set up mainly for lack of a properly planned public policy, such as lack of unification and standardization of distribution centers, the lack or inadequacy of TB compensation proceeding to treatment centers, in a standardized manner by SUS and shortage of trained doctors to do it together with the lack of qualified multidisciplinary rehabilitation centers. The use of botulinum toxin for therapeutic purposes in Brazil began in the 90s, to treat dystonia and spasticity. It is currently employed in different clinical conditions; however, despite growing demand and indications over the years, there are few reports or publications on its use and benefit to patients served by the Unified Health System (SUS). To address this issue, in May 2015, in São Paulo, physiatrists from different states of Brazil met and discussed the relevance of botulinum toxin in treating spasticity

[The results of single-event multilevel orthopedic surgeries and the early rehabilitation used in complex with botulinum toxin treatment in patients with spastic forms of cerebral palsy].

OBJECTIVE: To evaluate motor possibilities of patients with children spastic palsy (CSP) one year after single-event multilevel orthopedic low extremity surgeries in combination with early rehabilitation treatment including botulinum toxin treatment. MATERIAL AND METHODS: Authors studied the results of operative orthopedic treatment in 55 patients with CSP, aged from 5 to 17 years (mean 11.9 ± 2.5 years), who underwent multilevel surgeries with early functional rehabilitation using 1.5 treatment courses with 6-8 week treatment-free periods during 9-12 months in combination with a single injection of disport in the post-operative period. We performed 74 surgeries 140 episodes of botulinum toxin treatment using average doses of Botulinum toxin 10 U per kg of body mass injected into low extremity muscles. RESULTS: In the post-operative period, authors recorded a significant reduction in pain syndrome, assessed with a pain intensity scale, from 8.6 ± 1.2 to 4.3 ± 1.1 scores (p < 0.001). An analysis of gait demonstrated an improvement of gait patterns in all patients able to move independently. An increase in motor abilities, measured with the Gillette Functional Assessment Questionnaire, by 1 level was identified in 28 (50.9%) patients, by 2 levels in 2 (3.6%) patients, no changes were observed in 25 (45.5%) patients. CONCLUSION: Single-event multilevel orthopedic surgeries in children with CSP reduce a number of repeated surgeries. The effective control over pain syndrome in patients with CSP using multilevel botulinum toxin treatment in the post-operative period promotes the functional rehabilitation, increases rates of loading during training sessions and the motivation of CSP patients to restore the lost activity.

Neuroplasticidade na reabilitação de pacientes acometidos por AVC espástico / Neuroplasticity in the rehabilitation of patients affected by spastic stroke

O Acidente Vascular Cerebral (AVC) é uma das principais causas de incapacidades no mundo, tendo como um dos principais prejuízos a sequela de espasticidade. A partir dopotencial de neuroplasticidade cerebral, a reabilitação desenvolve técnicas como a Terapia de Restrição e Indução do Movimento, que visa a melhora o desempenho motor. O objetivo desteestudo é analisar os resultados benéficos de estudos baseados noprincípio da neuroplasticidade como mecanismo de reabilitação em pacientes com AVC espástico. O estudo constituiu-se através de revisão de literatura impressa e digital com publicações nacionais e internacionais, a qual foi consultada em bases como SciELO, portal de periódicos da Capes, PubMed e em acervos da biblioteca dainstituição de ensino. Foram utilizadas as palavras chaves Acidente Vascular Cerebral; Espasticidade; Neuroplasticidade e a buscavisou publicações entre 2000 e 2013. Dos 38 artigos pesquisados apenas 4 contemplaram o objetivo do trabalho, e apresentaram resultados positivos sobre a utilização da Terapia de Restrição eIndução do Movimentos que promove a reorganização cortical.

Stroke (CVA) is one of the leading causes of disability in the world, having as one of the major losses torehab the sequel of spasticity. From the known potential of neuroplasticity, the rehabilitation with techniques that use this principle, as the restriction and induction Therapy, improve engineperformance. The aim of this study is to analyze the beneficial results of works that use the neuroplasticity the rehabilitation mechanism in patients with spastic STROKE. This study consisted in a literature review from searches in databases the Virtual Health Library, SciELO, portal de periodicos Capes and PubMed, withpublication dates between 2000 and 2013, as well as in books. Of the 38 articles surveyed “seal only 4 had the objective of this work, and showed positive results in relation to the benefi ts of Movement induction and restriction Therapy which promotesthe cortical reorganization. However it is necessary to fi nd more directly the effectiveness of this technique in the re-establishment of DLAS. Therefore, there is a vast area of occupational therapist to the closest possible rehabilitation of functional independence.

Management of stroke patients submitted to botulinum toxin type A therapy: a Delphi survey of an Italian expert panel of specialist injectors.

BACKGROUND: Spasticity is a common disabling symptom of several neurological conditions including stroke. Botulinum toxin type A (BTX-A) injection represents the gold standard therapy for focal spasticity. Post-stroke management of patients receiving BTX-A therapy has been variously investigated, but general agreement on how and when to implement rehabilitation is lacking. AIM: To perform a national survey of experts on the most appropriate rehabilitation procedures after BTX-A therapy for the focal treatment of spasticity. DESIGN: The study employed the Delphi technique through the COSMO project (Consensus on Post-Injection Management in Post-stroke Spasticity). METHODS: Italian neurologists and physiatrists with experience in BTX-A therapy were selected to participate in the survey. Their anonymous opinions on key issues in treatment strategies in post-stroke spasticity were collected in three sequential rounds facilitated by a web platform. Consensus on a given issue was defined as agreed opinion by at least 66% of the survey participants. RESULTS: In all, 44 Italian experts were involved. Positive consensus was reached on the need to start rehabilitation during the first week after BTX-A injection therapy, with a rehabilitation program comprising both stretching combined with electrical stimulation and exercise therapy. Functional surgery may be considered only after 12-24 months in cases of BTX-A therapy failure. The use of commercial or custom-made orthoses in selected cases was recommended. The appropriate time interval between two BTX-A injections is 3-6 months, and clinical assessment should be performed 1 month after injection. CONCLUSION: The results of this national survey confirm that clinical experts on the use of BTX-A therapy for spasticity after stroke agree on the need to initiate rehabilitation treatment immediately after BTX-A injection: muscle stretching exercises, eventually combined with neuromuscular electrical stimulation, may enhance the effect of BTX-A therapy. Outcome after BTX-A therapy should be assessed at repeated follow-up visits. CLINICAL REHABILITATION IMPACT: This expert panel survey can provide guidance for clinicians in the assessment of patients treated with BTX-A therapy.

Spasticity after stroke: physiology, assessment and treatment.

BACKGROUND: Spasticity following a stroke occurs in about 30% of patients. The mechanisms underlying this disorder, however, are not well understood. METHOD: This review aims to define spasticity, describe hypotheses explaining its development after a stroke, give an overview of related neuroimaging studies as well as a description of the most common scales used to quantify the degree of spasticity and finally explore which treatments are currently being used to treat this disorder. RESULTS: The lack of consensus is highlighted on the basis of spasticity and the associated absence of guidelines for treatment, use of drugs and rehabilitation programmes. CONCLUSIONS: Future studies require controlled protocols to determine the efficiency of pharmacological and non-pharmacological treatments for spasticity. Neuroimaging may help predict the occurrence of spasticity and could provide insight into its neurological basis.

The effects of whole-body vibration therapy on bone turnover, muscle strength, motor function, and spasticity in chronic stroke: a randomized controlled trial.

BACKGROUND: Whole-body vibration (WBV) has been used in older adults to improve bone health and neuromuscular function, and may have potential applications for stroke patients. AIM: To investigate the effects of WBV on bone turnover, leg muscle strength, motor function, and spasticity among chronic stroke patients. DESIGN: Randomized controlled trial (RCT). SETTING: Community. POPULATION: Eighty-two chronic stroke patients. METHODS: The experimental group underwent exercise training with WBV stimulation for a maximum of 15 minutes, 3 days per week for 8 weeks. The controls received the same exercises without WBV. Participants were evaluated for isokinetic knee muscle strength, serum levels of bone formation and resorption markers, spasticity and motor function of the paretic leg at baseline, immediately after the 8-week training period, and 1-month follow-up. RESULTS: Intention-to-treat analysis revealed no significant changes in levels of bone turnover markers and motor function of the paretic leg over time in both groups. Muscle strength outcomes showed no significant group×time interaction, with similar significant improvements found in both groups. Spasticity of the paretic knee was significantly reduced in the experimental group (P=0.005), but not in controls (P=0.465). No serious adverse events were reported. CONCLUSION: The WBV protocol used in this study did not induce additional effects on bone turnover, knee muscle strength and paretic leg motor function among chronic stroke patients. WBV may have potential to modulate spasticity, but this requires further investigation. CLINICAL REHABILITATION IMPACT: More study on WBV is required before it can be recommended as an adjunct treatment in rehabilitation of chronic stroke patients.

Single Event Multilevel Surgery in children with bilateral spastic cerebral palsy: a 5 year prospective cohort study.

BACKGROUND: Single Event Multilevel Surgery (SEMLS) is considered the standard of care to improve gait and function in children with bilateral spastic cerebral palsy (BSCP). We have demonstrated in a randomized controlled trial (RCT) of SEMLS, that gait was improved at 12 months after surgery and gross motor function at 24 months after surgery. The question addressed in this study, was to determine if improvements in gait and function, would be maintained at 5 year follow-up. METHODS: Nineteen children with BSCP, GMFCS levels II (14 children) and III (5 children), mean age 9.7 years (range 7.7-12.2 years) participated in a prospective cohort study following participation in a RCT, with follow-up to 5 years. Outcome measures were Gait Profile Score (GPS), Gillette Gait Index (GGI), Gait Deviation Index (GDI), Gross Motor Function Measure (GMFM66) and Functional Mobility Scale (FMS). RESULTS: Eighteen children have completed follow-up, with interval analysis at 1, 2 and 5 years post SEMLS. One child was excluded because of neurological deterioration and his diagnosis was revised to Hereditary Spastic Paraparesis (HSP). GPS improved by 5.29° and GMFM66 by 3.3% at 5 years post SEMLS. Differences between outcome measures at 1 versus 5 years and 2 versus 5 years (except GMFM66) were not significant, indicating that improvements in gait and gross motor function were stable over time. CONCLUSIONS: SEMLS results in clinically and statistically significant improvements in gait and function, in children with BSCP, which were maintained at 5 years after surgery.