Clinical assessment of upper limb hypertonia in central neurological diseases.

The clinical assessment of a hypertonic upper limb in central neurological diseases should be analytical, systematic (shoulder, elbow, extrinsic and intrinsic hand) and focused on the patient or caregiver's wishes and on the expected objectives (esthetic, hygienic, functional). Nerve blocks can help to separate mixed contractures, show the existence of antagonist muscles or find a starter muscle in dystonia patterns. The etiology (especially the evolving nature of the disease), general health condition (especially in older adults), associated deficits (cerebellar, sensory and cognitive; hemineglect) are considered together to arrive at a contract with patients and/or caregivers.

SpES: A new portable device for objective assessment of hypertonia in clinical practice.

Spasticity is a motor disorder that affects millions around the world. It is a particular type of hypertonia characterized by the speed-dependent increase of the muscle stretch reflex, where its correct evaluation is essential for rehabilitation. The preferred method for this assessment is the Modified Ashworth Scale (MAS), a rank derived from clinical observations. Currently, few methods can quantify this disorder objectively. Tonic Stretch Reflex Threshold (TSRT) is a parameter speed-dependent obtained from electromyographic (EMG) measurements and angular signals. Therefore, the objective was to develop portable equipment for quantitative assessments of hypertonia based on TSRT. To this end, we designed an instrument composed of single-channel EMG, flexible optical goniometer, and software for the online computing of TSRT from acquired signals. The new equipment named SpES (Spasticity Evaluation System) was applied to measuring hypertonia of the biceps brachii in twenty-two participants. The experiment was performed during manual passive stretching of the affected limb at predefined speeds. The results provided by SpES presented a satisfactory coefficient of determination (0.70) and a strong correlation with MAS (0.79). In summary, while MAS depends on precise clinical observations, SpES has the TSRT quantitative method embedded for reaching an objective assessment of hypertonia in clinical practice.

Incidence of complications in the management of non-ambulatory neuromuscular early-onset scoliosis with a rib-based growing system: high- versus low-tone patients.

PURPOSE: The purpose of this study is to evaluate whether patients with high-tone neuromuscular early-onset scoliosis have different surgical outcome and complication rate, when compared to patients with low-tone neuromuscular early-onset scoliosis treated with a rib-to-pelvis rib-based dual growing system. METHODS: This is a retrospective cohort study of 67 neuromuscular early-onset scoliosis patients, collected from a multicenter database, treated with a rib-to-pelvis rib-based dual growing system. All patients were divided into two groups: high tone and low tone. Pre-, intra- and postoperative data were compared between both groups. Complications were reported by a standardized system. RESULTS: Twenty-six high-tone and 41 low-tone patients were found homogeneous regarding gender, age at surgery, weight, height, estimated blood loss and surgery time. High-tone group (19/26 = 73.1%) experiences more postoperative complications than low-tone group (22/41 = 53.7%). Most common complications were infection, device migration, death and hardware failure. Permanent abandonment of rib-based growing technique and device removal was required in 21% of high-tone patients (P < 0.001). None of the low-tone patients required abandonment. CONCLUSION: High-tone patients had more complications than those with low tone in management of neuromuscular early-onset scoliosis treated with a rib-to-pelvis rib-based dual growing system. A different surgical approach may be required to treat the high-tone neuromuscular early-onset scoliosis.

Hypertonia Assessment Tool.

The Hypertonia Assessment Tool is a 7-item instrument that discriminates spasticity, dystonia, and rigidity on 3 levels: item scores, subtype, and hypertonia diagnosis for each extremity. We quantified the inter- and intrarater reliability using Kappa statistics, Gwet's first-order agreement coefficient (both with 95% confidence interval), and percentage agreement for all levels. For validity, we compared the Hypertonia Assessment Tool subtype with the clinical diagnosis provided by the physicians. Two physiotherapists tested 45 children with neuromotor disorders. The interrater reliability (n = 45) of the Hypertonia Assessment Tool subtype was moderate to substantial whereas the intrarater reliability (n = 42) was almost perfect. The Hypertonia Assessment Tool showed good agreement in detecting spasticity. On the contrary, there was a higher presence of dystonia of 24% to 25% tested with the Hypertonia Assessment Tool compared to the clinical diagnosis. Even some individual items showed lower agreement between raters; the Hypertonia Assessment Tool subtypes and diagnosis were reliable. Validity of the Hypertonia Assessment Tool to test spasticity is confirmed, whereas, for dystonia and rigidity, further studies are needed.

Further evaluation of the scoring, reliability, and validity of the Hypertonia Assessment Tool (HAT).

We assessed the impact of videotape analysis on scoring of the Hypertonia Assessment Tool (HAT) that discriminates between hypertonia subtypes. The HAT was administered to 28 children with cerebral palsy (mean age 9 years, range 4-17 years, 61% male). HAT examinations were videotaped; scores were assigned before and after videotape review. Neurological examination provided the gold standard diagnosis. Interrater reliability, criterion validity and individual item validation were assessed using prevalence and bias-adjusted kappa (PABAK). Videotape review did not significantly change the HAT item scores or diagnoses. Item validation eliminated 1 dystonia item. Interrater reliability was moderate for dystonia (PABAK = 0.43) and excellent for spasticity and rigidity (PABAK = 0.86-1.0). Criterion validity was substantial for spasticity (PABAK = 0.71), moderate for dystonia (PABAK = 0.43-0.57) and excellent for the absence of rigidity (PABAK = 1.0). The HAT can be administered without videotape review. Dystonia item 1 did not change the HAT hypertonia diagnosis and will be removed from the HAT.

[Evaluation and quantification of spasticity: a review of the clinical, biomechanical and neurophysiological methods]. / Valoracion y cuantificacion de la espasticidad: revision de los metodos clinicos, biomecanicos y neurofisiologicos.

INTRODUCTION: Spasticity is a sensory-motor disorder that affects about 85% of the patients with multiple sclerosis and between 65-78% of those with spinal cord injury, among other neurological conditions. Although hypertonia is generally easy to recognise clinically, quantifying it is quite a complex matter. The large number of clinical scales that exist and their subjectivity, the discrepancy between the spasticity perceived by the patient and the clinical measurement, as well as the lack of a general correlation between the neurophysiological measures and hypertonia, all make it especially difficult, in methodological terms, to perform a valid, reliable measurement of the degree of spasticity presented by the patient. AIMS: To review the main methods of evaluating spasticity published in the scientific literature and to carry out a description and critical analysis of their advantages, shortcomings and metric properties in patients with a neurological pathology. DEVELOPMENT: The different methods described for evaluating spasticity are reviewed and classified in three broad groups, namely, clinical scales specifically designed for such a purpose, biomechanical tests and neurophysiological methods. CONCLUSIONS: There is little agreement on the definition of spasticity and the need for the evaluators' training and experience when it comes to evaluating it. We recommend using a combination of the different evaluation instruments, such as the scales, biomechanical methods and neurophysiological measures reported in this study, to carry out a general diagnosis of the degree of spasticity present in the patient.

Poststroke hypertonicity: upper limb assessment and treatment.

Hypertonicity is common in patients with upper limb dysfunction following hemiplegic stroke and is associated with greater impairment, worse function, and lower health-related quality of life. In addition to increased rest activity, abnormal patterns of muscle activation, such as spastic co-contraction, may contribute to disability. In the upper limb, flexor muscles are more commonly involved distally, and at the shoulder, spasticity of adductors, flexors, and internal rotators is most often observed. Prior to interventions, a history regarding prior interventions, comorbid diagnoses, and limitations imposed by abnormal tone should be elicited. Commonly used scales to assess hypertonicity include the Modified Ashworth, the Modified Tardieu, the Spasm Frequency, the Disability Assessment, the Fugl-Meyer, and the Motor Assessment Scales. Treatment interventions for upper limb hypertonicity include stretching, splinting, strengthening of antagonist muscles, oral medications, and focal injections (phenol or botulinum toxins). Intrathecal baclofen may also impact upper limb tone. For focal injections, correct identification of muscles contributing to problematic tone is evaluated by eliciting resistance to movement at rest and observation of patterns of tightness as the limb is used functionally. The botulinum toxins have been shown to decrease tone in stroke survivors and improve active and passive functioning. Because secondary changes such as contractures and weakness may occur with prolonged hypertonicity, therapy to improve range of motion, strengthen weakened muscles, and incorporate use of the limb should be considered following focal injections, oral medications, or intrathecal pump placement.

Biomechanical and electromyographic assessment of spastic hypertonus in motor complete traumatic spinal cord-injured individuals.

STUDY DESIGN: Between-groups design with repeated measures. OBJECTIVE: To quantify spastic hypertonia in spinal cord-injured (SCI) individuals. SETTING: Rehabilitative Center, Italy. SUBJECTS: 29 individuals with a motor complete SCI (American Spinal Injury Association impairment scale grade A or B) and 22 controls. METHODS: According to the modified Ashworth scale (MAS), patients were subgrouped as SCI-1 (MAS=1, 1+) and SCI-2 (MAS=2, 3). Passive flexo-extensions of the knee were applied using an isokinetic device (LIDO Active) at 30°, 60°, 90° and 120° s(-1). We measured the peak torque, mean torque (MT) and work. Simultaneous electromyography (EMG) was recorded from leg muscles. RESULTS: At the speed of 120° s(-1) all SCI-2 patients presented EMG reflex activities in the hamstring muscle. All biomechanical parameter values increased significantly according to speed, but analysis of variance revealed a significant interaction between the angular velocity and group (F(d.f. 6, 138) = 8.89, P < 0.0001); post hoc analysis showed significantly greater torque parameter values in the SCI-2 group compared with the SCI-1 group and the control group at 90° and 120° s(-1). Receiver operating characteristic curves showed that using peak torque values the probability of correctly classifying a patient into SCI-1 and SCI-2 was 95%, compared with 70% for MT and 68% for work. CONCLUSIONS: The isokinetic device is useful for distinguishing individuals with a high level of spastic hypertonus. Examination of EMG activity may help ascertain whether increased muscle tone is caused by reflex hyper excitability and to determine whether muscle spasm is present. Peak torque and simultaneous EMG assessment should be considered for the evaluation of individuals with SCI in the rehabilitative context, that is, in measuring therapeutic interventions.

Botulinum toxin assessment, intervention and follow-up for paediatric upper limb hypertonicity: international consensus statement.

The primary objective of this paper was to evaluate the published evidence of efficacy and safety of botulinum neurotoxin (BoNT) injections in paediatric upper limb hypertonia (PULH). Secondary objectives included the provision of clinical context, based on evidence and expert opinion, in the areas of assessment, child and muscle selection, dosing, and adjunctive treatment. A multidisciplinary panel of authors systematically reviewed, abstracted, and classified relevant literature. Recommendations were based on the American Academy of Neurology (AAN) evidence classification. Following a literature search, 186 potential articles were screened for inclusion, and 15 of these met the criteria and were reviewed. Grade A evidence was found to support the use of BoNT to reach individualized therapeutic goals for PULH. There is grade B evidence (probably effective) for tone reduction following BoNT injections and grade U evidence (inconclusive) for improvement in upper limb (UL) activity and function. BoNT injections were generally found to be safe and well tolerated with the most common side effect identified as a transient decrease in grip strength.

Development of the Hypertonia Assessment Tool (HAT): a discriminative tool for hypertonia in children.

AIM: The aim of this study was to develop a tool to identify paediatric hypertonia subtypes. METHOD: Items generated by experts were subscaled (spasticity, dystonia, rigidity). The tool was administered to 34 children (19 males, 15 females, mean age 8y 2mo, range 2y 5mo-18y 7mo) with hypertonia and cerebral palsy (CP) in Gross Motor Function Classification System (GMFCS) levels: I, n=7; II, n=5; III, n=7 level IV, n=7; and level V, n=8 level. Kuder-Richardson Formula 20 determined internal consistency. To assess reliability, two physicians administered the tool to 25 additional children with CP (15 males, 10 females; mean age 10y 8 mo; GMFCS levels I, n=4; II, n=3; III, n=7; IV, n=4; and V, n=7) on two occasions, 2 weeks apart. To evaluate validity, a third physician diagnosed the hypertonia by neurological examination. RESULTS: The internal consistency of the spasticity items was moderate (alpha = 0.58), and dystonia was high (a=0.79). Item reduction eliminated seven of the 14 original items. The agreement of the spasticity and rigidity subscales was adequate (prevalence-adjusted bias-adjusted kappa [PABAK] ranging from moderate [0.57] to excellent [1.0]) for validity, test-retest reliability, and interrater reliability. For dystonia agreement was lower, with PABAK ranging from fair (0.30) to good (0.65). Eighty-seven per cent had spasticity and 78% had dystonia. INTERPRETATION: The Hypertonia Assessment Tool has good reliability and validity for identifying spasticity and the absence of rigidity, and moderate findings for dystonia.

Diagnosing paratonia in the demented elderly: reliability and validity of the Paratonia Assessment Instrument (PAI).

BACKGROUND: Paratonia is one of the associated movement disorders characteristic of dementia. The aim of this study was to develop an assessment tool (the Paratonia Assessment Instrument, PAI), based on the new consensus definition of paratonia. An additional aim was to investigate the reliability and validity of the PAI. METHODS: A three-phase cross-sectional survey was conducted. In the first two phases, the PAI was developed and validated. In the third phase, the inter-observer reliability and feasibility of the instrument was tested. RESULTS: The original PAI consisted of five criteria that all needed to be met in order to make the diagnosis. On the basis of a qualitative analysis, one criterion was reformulated and another was removed. Following this, inter-observer reliability between the two assessors resulted in an improvement of Cohen's kappa from 0.532 in the initial phase to 0.677 in the second phase. This improvement was substantiated in the third phase by two independent assessors with Cohen's kappa ranging from 0.625 to 1. CONCLUSION: The PAI is a reliable and valid assessment tool for diagnosing paratonia in elderly people with dementia that can be applied easily in daily practice.

Preliminary communication: urodynamic assessment of donepezil hydrochloride in patients with Alzheimer's disease.

BACKGROUND AND AIMS: Donepezil hydrochloride, a central cholinergic drug, is widely used for improving cognitive decline in Alzheimer's disease (AD). We investigated whether donepezil might affect the lower urinary tract (LUT) function in AD. METHODS: Alzheimer's Disease Assessment Scale cognitive subscale (ADAS-cog) (0-70, increase as impairment), urinary questionnaire, and electromyography (EMG)-cystometry were performed in eight patients with AD before and after treatment with 5 mg/day of donepezil. RESULTS: The first assessment (before donepezil) showed moderate cognitive decline in the patients as a mean ADAS-cog score of 27.0 (range: 17-35) (normal < 15). Seven patients had urinary symptoms including urinary urgency incontinence in five. EMG-cystometry revealed neurogenic detrusor overactivity in seven with a mean detrusor pressure of 44.9 cm H(2)O (20-101), mean bladder capacity of 202 ml (20-412), and post-void residuals in none. The second assessment (3 months after donepezil) showed a decrease in the ADAS-cog score to 23.3 (11-35) though without statistical significance. Urinary incontinence disappeared in one and none had a new onset of incontinence. EMG-cystometry revealed an increase in the detrusor pressure on overactivity to 54.1 cm H(2)O (20-122), but also an increase in the bladder capacity to 234 ml (80-400), and post-void residuals in one (40 ml). CONCLUSION: Although the number of our patients was small, it seems possibly that donepezil could ameliorate cognitive function without serious adverse effects on the LUT function in patients with AD.

Noninvasive assessment of bladder contractility in men.

PURPOSE: Preoperative assessment of detrusor function by pressure flow study (PFS) improves outcome from prostatectomy but is invasive and uncomfortable for the patient. We report on a large scale validation of a novel noninvasive assessment of detrusor contractility. MATERIALS AND METHODS: A flexible cuff placed around the penis was inflated automatically during voiding until flow interruption. Cuff pressure at interruption (pcuff.int) reflects isovolumetric bladder pressure (pves.isv), a measure of detrusor contractility. For comparison 151 symptomatic men performed the cuff test with simultaneous PFS monitoring. Test/retest agreement was assessed in 91 subjects who performed a cuff test without PFS on 2 occasions. RESULTS: For the 117 (77%) subjects with an acceptable cuff pressure flow trace, Bland Altman analysis showed that pcuff.int overestimated pves.isv by a mean (s.d.) of 16.4 (27.5) cm H2O, predominantly due to the cuff being positioned below the bladder. For test/retest analysis 52 (57%) of the men who were able to attend twice provided acceptable cuff data on both occasions with a mean (s.d.) difference in pcuff.int of -3.3 (32.0) cm H2O, improving to 0.0 (20.3) cm H2O in a subgroup of 39 subjects who voided more than 150 ml. On questionnaire assessment 121 (80%) subjects preferred the cuff test to PFS. CONCLUSIONS: The cuff test gives a valid and reproducible estimate of isovolumetric bladder pressure in a manner acceptable to patients, although test failure and variability of agreement require improvement. The test may be of value in the assessment of urinary symptoms and may aid in patient selection for prostatectomy.

Distinguishing neurogenic from non-neurogenic detrusor overactivity: a urodynamic assessment of lower urinary tract symptoms in patients with and without Parkinson's disease.

OBJECTIVES: To examine the urodynamic (UDS) attributes of detrusor overactivity (DO) in patients with Parkinson's disease in comparison to DO in men without neurologic disease, in whom DO is presumably outlet obstruction induced. METHODS: The UDS database was reviewed for three groups of patients: group 1, men with lower urinary tract symptoms (LUTS) and no known neurologic condition with DO (n = 22); group 2, men with Parkinson's disease and LUTS (n = 39); and group 3, women with Parkinson's disease and LUTS (n = 18). Statistical analysis was used to compare the UDS parameters and diagnoses among the groups and to test for associations between Parkinson's disease duration, Hoehn and Yahr score, and UDS findings. RESULTS: Patients with Parkinson's disease had a significantly lower median volume at first detrusor contraction than those with non-neurogenic DO. The percentage of group 1 patients with urge incontinence was significantly lower than that found in the other two groups (9.1% versus 53.8% and 55.6%, P <0.001 and 0.002, respectively). No statistically significant correlation between the duration or severity of Parkinson's disease and UDS parameters was found. CONCLUSIONS: Men with non-neurogenic LUTS are less likely to have urge incontinence on UDS than either men or women with Parkinson's disease. DO owing to Parkinson's disease occurs earlier during filling compared with non-neurogenic DO, especially in women. The duration and severity of Parkinson's disease are not predictive of the nature or severity of UDS abnormalities.

Prospective assessment of tizanidine for spasticity due to acquired brain injury.

OBJECTIVE: To determine if orally delivered tizanidine will control spastic hypertonia due to acquired brain injury. DESIGN: Randomized, double-blind, placebo-controlled, crossover design, with 2 8-week treatment arms separated by a 1-week washout period at baseline. Patients were randomly assigned to receive tizanidine or a matching placebo. SETTING: Tertiary care outpatient and inpatient rehabilitation center attached to a university hospital. PARTICIPANTS: Seventeen persons recruited in a consecutive manner, 9 of whom had suffered a stroke and 8 a traumatic brain injury, and had more than 6 months of intractable spastic hypertonia. INTERVENTION: Over a 6-week period, subjects were slowly titrated up to their maximum tolerated dose (up to 36 mg/d). Following a 1-week drug taper and 1-week period in which no study drug was administered, patients were then crossed over to the other study medication following an identical titration regime. MAIN OUTCOME MEASURES: Subjects were evaluated for dose and effect throughout the trial as well as for side effects. Data for Ashworth rigidity scores, spasm scores, deep tendon reflex scores, and motor strength were collected on the affected upper extremity (UE) and lower extremity (LE). Differences over time were assessed via descriptive statistics, Friedman's analysis, and Wilcoxon's signed-rank. Data are reported as the mean +/- 1 standard deviation. RESULTS: Following 4 weeks of treatment when subjects reached their maximal tolerated dosage, the average LE Ashworth score on the affected side decreased from 2.3 +/- 1.4 to 1.7 +/- 1.1 (p <.0001). The spasm score decreased from 1.0 +/- 0.9 to 0.5 +/- 0.8 (p =.0464), while the reflex score was not statistically significant decreasing from 2.2 +/- 1.0 to 2.0 +/- 1.1 (p =.0883). The average UE Ashworth score on the affected side decreased from 1.9 +/- 1.1 to 1.5 +/- 0.9 (p <.0001). There was no significant change in the UE spasm and reflex scores. While there were positive placebo effects on motor tone, the active drug was still significantly better than placebo for decreasing LE tone (p =.0006) and UE tone (p =.0007). With a reduction in motor tone, there was an increase in motor strength (p =.0089). The average dosage at 4 weeks was 25.2mg/d. CONCLUSION: Tizanidine is effective in decreasing the spastic hypertonia associated with acquired brain injury, which is dose-dependent. There are limitations on its use due to side effects related to drowsiness.

Effects of surface spinal cord stimulation on spasticity and quantitative assessment of muscle tone in hemiplegic patients.

Spasticity after a stroke interferes with the normal function of a limb. Electric stimulation has been used in a variety of ways to decrease spasticity. The purposes of this study were (1) to quantify the effectiveness of electric stimulation on decreasing ankle spasticity and (2) to develop a quantitative assessment of muscle tone, which could be replicated in the clinic. Ten patients with hemiparesis resulting from ischemic stroke participated in the study according to the selection criteria. Their mean age was 57 yr, with a mean stroke interval of 12.5 months. Patients received electric stimulation for 45 min through surface electrodes applied to the skin in the 12th thoracic and 1st lumbar areas. All patients received five electric stimulation treatment sessions. The electrical pulses were amplitude modulated frequency beat with a carry frequency of 2500 Hz and a stimulation frequency of 20 Hz. The stimulation intensity was adjusted to each patient to produce a sensory stimulation. The pre- and posttreatment evaluation included surface electromyography activity during passive ankle dorsiflexion, passive ankle dorsiflexion resistance at different angular velocities, as measured by an isokinetic machine and the modified Ashworth scale. Our results indicate that the surface spinal cord stimulation with middle frequency modulated to low frequency for sensory stimulation on the skin of 12th thoracic and first lumbar area is effective in reducing calf muscle spasticity of hemiplegic patients. The isokinetic torque measures for spasticity are a sensitive tool to document the effects of the treatment.

Electromyographic assessment of neonatal muscle tone.

A new psychiatric research method for measuring infant muscle tone using quantified electromyography is described. Muscle tone was assessed electromyographically from the arms and legs of 44 neonates; 18 offspring of drug abusing women, 26 control infants. Infants from the drug group had higher muscle tone than control infants. There was also a tendency for smaller infants and females to have higher muscle tone. Electromyographic assessments of tone were correlated with examiners' clinical assessments, but tended to be more sensitive to tone in specific muscle groups.