The effect of body position, leg dominance, and automatic releasing mechanism on quadriceps muscle tone assessed by Pendulum Test in able-bodied persons.

Background and purpose:

Quadriceps femoris muscle spasticity is commonly measured by the Wartenberg pendulum test. It is generally assumed that lower values of the number of swings of the leg and lower relaxation indexes are associated with higher muscle tone and more spasticity. Still, there is incoherence regarding the test’s applications with various body positions and starting mechanisms. This study aims to investigate the influence of body position, leg dominance, and automatic leg-releasing mechanism on muscle tone measured by pendulum test in healthy population whose muscle tone is often compared to the spastic muscle tone of patients with neurologic disorders. 

15 healthy adults (age: 19-32 years, 9 males, 6 females) participated in this study. A Zebris 3D ultrasound-based motion analysis system was used to record kinematic data during the pendulum test. The number of swings of the leg and the relaxation index were computed from the collected data. The pendulum test was completed in eight conditions: in supine and semi-supine positions on the dominant and non-dominant leg separately and with investigator-release and automata-release mechanisms. Paired t-tests and Wilcoxon test with the significance level of .05 were applied in comparison of pairs of the pendulum test condition.

1) Applying automata-release mode, in the non-dominant leg the number of swings (p=0.03) and the relaxation index (p<0.001) were significantly higher in semi-supine than in supine position. 2) The non-dominant leg had significantly more swings than the dominant leg in both body positions with automata-release mode (p=0.009, p<0.001). In investigator-release mode this occurred in supine position (p<0.001). 3). Regarding the number of swings in investigator-release versus automata-release mode, no significant differences were found in any test condition, but the relaxation index showed significant difference for the non-dominant leg (p=0.01, p=0.009). 4) The values of the relaxation index didn’t support in all test conditions the results what the number of swings provided about the muscle tone. In automata-release mode, the dominant leg has a lower number of swings and a higher relaxation index than the non-dominant leg.

The effect of body position on the quadriceps muscle tone can be assessed by applying the pendulum test with an automatic leg-releasing mechanism even when the application of conventional investigator-release mode does not show a significant effect. The pendulum test is more sensitive to assess spasticity with automatic-release than with investigator-release mode. 

The dose effectiveness of extracorporeal shockwave on plantar flexor spasticity of ankle in stroke patients: a randomized controlled trial.

BACKGROUND: Extracorporeal shockwave therapy (ESWT) has been proven beneficial for post-stroke spasticity (PSS) of ankle plantar flexor muscles. This study aims to investigate the dose-response effectiveness of focused-ESWT and the duration of its effect on the treatment of ankle PSS in stroke patients. METHODS: In this double-blinded randomized controlled trial, stroke patients diagnosed with PSS in the ankle plantar flexor muscles were randomly assigned to two groups. The experimental group received double-dose ESWT (4000 pulses per session) targeting spastic calf muscles, while the control group received half the dose (2000 pulses per session). Both groups underwent four sessions over two weeks. The outcomes, including modified Ashworth Scale (MAS), modified Tardieu Scale (MTS), passive range of motion (PROM) of the ankle, Timed Up and Go (TUG) Test, Barthel index and strain elastography were evaluated at baseline, 1st, 4th, 12th, and 24th week after ESWT. RESULTS: Within-group analysis revealed significant improvements in MAS, PROM, TUG Test, and Barthel index for the double-dose ESWT group and improvements in Barthel index for the control group. Between-group analysis revealed greater improvements in TUG Test, Barthel Index and strain elastography for the double-dose ESWT group. Generalized estimating equations analysis indicated that the double-dose ESWT group achieved superior outcomes in the TUG Test, Barthel Index, and strain elastography across various time points and groups. CONCLUSIONS: Double-dose ESWT showed better functional improvement and elastography compared to the control group. ESWT demonstrated dose-response effectiveness for PSS of ankle-equinus. TRIAL REGISTRATION: NCT05878223.

Particularities of spasticity in myelomeningocele patients.

OBJECTIVE: Myelomeningocele (MMC), a congenital neural tube defect, is the most common developmental anomaly of the central nervous system (CNS). Spasticity is among the main disabling factors in these patients, affecting up to 1/5 of children. The purpose of this article is to review the current knowledge regarding spasticity in MMC patients, mainly focusing on its manifestations and management. METHODS: A literature search was conducted using the PubMed database for the terms "myelomeningocele" and "spasticity." Data were collected by 5 independent investigators and then synthesized in a scoping format. RESULTS: Causes of spasticity in these patients include hydrocephalus, tethered cord syndrome (TCS), syringomyelia, CNS infection, and associated congenital brain and spine anomalies. Clinical manifestations include limb spasticity and neurogenic bladder. Spasticity primarily affects muscles below the neurological level and contributes to gait impairment. Besides walking ability, spasticity also severely affects functional mobility in general, self-care, and quality of life. The majority of MMC patients experience neurogenic bladder. Treatment of spasticity can be symptomatic or target its cause. Medical and surgical options are available for both limb and bladder spasticity. Regular physiotherapy and orthotics are used to prevent contractures and the early introduction of orthoses is the cornerstone of a gait training program. Neurosurgical treatment options for spasticity include nonablative and ablative procedures such as selective dorsal rhizototmy. The urodynamic pattern guides treatment strategies, with intermittent catheterization being the best treatment option for patients with underactive detrusor and overactive sphincter muscles. CONCLUSION: Given the particularities of spasticity in MMC patients, a multidisciplinary team approach and early rehabilitation programs are keys for their optimal management.

Intrathecal baclofen obviating the need for bladder stimulator use in a patient with secondary dystonia: illustrative case.

BACKGROUND: Children with cerebral palsy often have neurogenic bladders. Bladder function is further affected by complex medical management and multifactorial disease processes, leading to worsened function and poorer quality of life. Intrathecal baclofen (ITB) therapy has been used to treat hypertonia and spasticity, but implications in neurogenic bladder management have not been well described. OBSERVATIONS: A 20-year-old female with a history of cerebral palsy and neurogenic bladder treated with sacral neuromodulation underwent ITB therapy and subsequently experienced improvement in bladder control, obviating the need for bladder stimulator use. LESSONS: ITB improves hypertonia and can effectively obviate the need for neurostimulation to treat neurogenic bladder in patients with cerebral palsy. Further research is necessary to discern mechanisms. https://thejns.org/doi/10.3171/CASE24364.

Intrathecal baclofen therapy as treatment for spasticity and dystonia: Review of cases in a pediatric palliative care unit.

INTRODUCTION: Patients managed in the Pediatric Palliative Care Integral Unit (PPCIU) have serious neurological conditions that involve significant damage at central nervous system level. The movement disorder is a very common clinical problem and for the patients where an adequate control of muscle tone is not achieved with usual techniques or drugs, intrathecal baclofen therapy (IBT) should be considered. MATERIALS AND METHODS: Descriptive retrospective study based on the review of clinical records of patients who received IBT being followed by the PPCIU of Madrid Autonomous Region in the timeframe between September 2012 and February 2021. RESULTS: IBT was implanted in 8 patients affected by infantile cerebral palsy (ICP) with a Gross Motor Function Scale (GMFCS) IV-V, 3 patients was a Pantothenate kinase deficit-associated neurodegeneration (PKAN), 2 had Acquired Brain Damage, and the remaining 3 had, respectively, 2 glutaric aciduria type I (GA-1), and poly-malformative syndrome. In all patients we observed a period of clinical stability after IBT, we call this period "honeymoon". Two patients died while in the honeymoon period, at 24.9 and 19.6 months from implantation of the pump; the median of duration of the honeymoon period in the remaining 14 was 14.4 months (IQ: 8.3-25.8). CONCLUSIONS: IBT was not only used in patients with non-progressive diseases, but also in the group of patients with neurodegenerative or progressive diseases. In all of them, after implantation of the device, we have objectified a period of clinical stability and a better control of muscle tone disorders.

Intramuscular neural distribution of the vastus medialis for botulinum neurotoxin injection: application to spasticity.

PURPOSE: A comprehensive understanding of neural distribution within the vastus medialis is crucial for the effective administration of botulinum neurotoxin injections to manage spasticity. The aim of this study was to develop an anatomically informed approach to guide the administration of botulinum neurotoxin injections into the vastus medialis muscle. METHODS: Using a modified Sihler's method, we examined the vastus medialis muscles (20 specimens) to delineate the distribution of nerves relative to a transverse line extending from the anterior superior iliac spine to the base of patella. The vastus medialis muscle was divided into 10 areas from top to bottom. Then, using two fresh cadavers, ultrasonography-guided injections were performed based on the distribution of nerves within the vastus medialis. Each specimen was subsequently dissected to verify if the dye was accurately directed to the most densely innervated regions of the vastus medialis and to assess the precision of the injections. RESULTS: The intramuscular nerve distribution within the vastus medialis muscle showed distinct patterns, particularly in areas between 6 and 9. Four injections were successfully administered on each side, targeting the regions between 6 and 9 of the vastus medialis. Upon dissection of the cadavers, the dye was found to be distributed along the muscle fiber. CONCLUSION: We recommend targeting botulinum neurotoxin injections toward regions displaying a prominent nerve distribution, specifically focusing on areas between 6 and 9. By adhering to these guidelines, clinicians can minimize doses and mitigate potential adverse effects, such as gait disturbances, antibody development, and bruising, resulting from multiple injections. Furthermore, these findings can be incorporated into electromyography practices.

Canadian Physicians' Use of Ultrasound in Spasticity Treatment: A National Cross-Sectional Survey.

Objective: To identify potential barriers and obstacles preventing clinicians from adopting ultrasound for spasticity management. Design: A prospective, cross-sectional national survey. Setting: Web-based platform. Participants: Thirty-six physicians and surgeons from across Canada. Interventions: Survey completion. Main Outcome Measures: The use of ultrasound in clinical spasticity practice, perceived barriers, and risks associated with its implementation. Results: In total, 36 Canadian physicians and surgeons responded. A total of 91% reported using the US in their practice. Nearly all of them used ultrasonography (US) to guide injections and reported using more than 1 guidance technique for their injections. Less than half of the survey respondents reported using the US for muscle architecture assessment or longitudinal evaluation of muscle echo intensity. A total of 47% of survey respondents reported that they believe there are disadvantages associated with US use in spasticity practice. Disadvantages included increased time requirements resulting in discomfort for the injector and patient, the risk of infection after the procedure, and the risk of needle-stick injury. The most important barrier identified was the increased time demands of US compared with other guidance techniques. Other barriers included a lack of feedback on identifying a spastic muscle compared with electrical guidance techniques, a lack of additional remuneration to complete injections under ultrasound guidance, and a lack of adequate training. Conclusions: Future educational efforts should address clinicians' lack of familiarity with US purposes outside of injection guidance. This survey has highlighted the need for a curriculum shift in spasticity education to improve physician's scanning and injection technique, to address concerns about increased time requirements for injecting under ultrasound guidance and to address perceived disadvantages from clinicians.

The 4S of spinal astrocytoma: specific location, syrinx, spasticity and score on Modified Mccormick Scale (MMS) predict long term outcomes in patients undergoing surgical resection of intramedullary spinal astrocytomas.

OBJECTIVES: The aim of this study was to explore the factors that could predict long term clinical outcomes in SA. METHODS: A retrospective study was conducted wherein SA patients undergoing surgical resection with a minimum follow up of 12 months were included in this study. Modified Mccormick Scale (MMS) was utilized to record the neurological status of the patients both preoperatively and at last follow up. Outcomes were assessed as: long term neurological status, that is final MMS grade and neurological deterioration, defined as increase in MMS score as compared to preoperative MMS score. Survival analysis was performed using the kaplan meier curves. RESULTS: 71 patients were included in this study with mean age of 33.07years. At a mean follow up of 57 months, preoperative MMS was the single independent predictor for moderate-severe neurological deficit (MMS III to V) on multivariate analysis (OR: 30.2, p < 0.001) and had an outstanding AUC of 0.91. Six patients had neurological deterioration at long term follow up. Absence of spasticity (p = 0.028), thoracic-thoracolumbar tumors (p = 0.006), low MMS score (p = 0.01) and hypointense T1 weighted MRI (p = 0.009) were significant predictors of long term neurological deterioration. The median overall survival was 48 months and was significantly higher in low grade tumors (p < 0.001). CONCLUSION: The study highlights the efficacy of clinical features as a predictor of long term functional outcomes in SA patients. Role of spasticity as a prognostic factor was explored for the first time in this study.

Excitation-contraction coupling inhibitors potentiate the actions of botulinum neurotoxin type A at the neuromuscular junction.

BACKGROUND AND PURPOSE: Botulinum neurotoxin type A1 (BoNT/A) is one of the most potent neurotoxins known. At the same time, it is also one of the safest therapeutic agents used for the treatment of several human disorders and in aesthetic medicine. Notwithstanding great effectiveness, strategies to accelerate the onset and prolong BoNT/A action would significantly ameliorate its pharmacological effects with beneficial outcomes for clinical use. EXPERIMENTAL APPROACH: Here, we combined BoNT/A with two fast-acting inhibitors of excitation-contraction coupling inhibitors (ECCI), either the µ-conotoxin CnIIIC or dantrolene, and tested the effect of their co-injection on a model of hind-limb paralysis in rodents using behavioural, biochemical, imaging and electrophysiological assays. KEY RESULTS: The BoNT/A-ECCI combinations accelerated the onset of muscle relaxation. Surprisingly, they also potentiated the peak effect and extended the duration of the three BoNT/A commercial preparations OnabotulinumtoxinA, AbobotulinumtoxinA and IncobotulinumtoxinA. ECCI co-injection increased the number of BoNT/A molecules entering motoneuron terminals, which induced a faster and greater cleavage of SNAP-25 during the onset and peak phases, and prolonged the attenuation of nerve-muscle neurotransmission during the recovery phase. We estimate that ECCI co-injection yields a threefold potentiation in BoNT/A pharmacological activity. CONCLUSIONS AND IMPLICATIONS: Overall, our results show that the pharmacological activity of BoNT/A can be combined and synergized with other bioactive molecules and uncover a novel strategy to enhance the neuromuscular effects of BoNT/A without altering the neurotoxin moiety or intrinsic activity, thus maintaining its exceptional safety profile.

Comparative effect of oral drugs in improving spasticity of different etiology: a network meta-analysis.

INTRODUCTION: Spasticity, a prevalent manifestation of various neurological conditions, significantly impacts the quality of life of patients. Research on the effects of oral drugs on spasticity has produced controversial results. Thus, the aim of this network meta-analysis was to compare the efficacy of oral drugs for improving spasticity in patients with different etiologies. METHODS: We searched four different databases from their inception to 30 November 2023. A network meta-analysis using a frequentist perspective was conducted to assess the effects of different oral drugs on spasticity, evaluated by the modified Ashworth scale. RESULTS: Our findings showed that, in a frequentist network meta-analysis, eperisone, diazepam, and baclofen had significantly greater spasticity, as measured by the modified Ashworth scale, than did the placebo (MD: -0.80; 95% CIs: -1.42, -0.18; MD: -0.68; 95% CIs: -1.28, -0.09; MD: -0.58; 95% CIs: -1.11, -0.06, respectively). CONCLUSION: In summary, our study confirmed that eperisone, diazepam, and baclofen could be effective approaches for reducing spasticity of different etiologies and could be useful approaches for improving patient quality of life. Key messages What is already known on this topic: The impact of oral drugs, such as baclofen, gabapentin, tizanidine, and dantrolene, in the treatment of spasticity has been documented. What this study adds: This study determines which of the oral drugs aimed at treating spasticity is the most effective across different etiologies. How this study might affect research, practice, or policy: This study suggests tailored treatment strategies for spasticity based on its etiology.

Long-Term Management of Post-Stroke Spasticity with Botulinum Toxin: A Retrospective Study.

Stroke-induced spasticity is a prevalent condition affecting stroke survivors, significantly impacting their quality of life. Botulinum Toxin A injections are widely used for its management, yet the long-term effects and optimal management strategies remain uncertain. This retrospective study analyzed medical records of 95 chronic stroke patients undergoing long-term BoNT-A treatment for spasticity. Demographic data, treatment duration, dosage variability, and dropout rates were assessed over a period ranging from 2 to 14 years. The study revealed a notable extension of the interval between BoNT-A injections throughout the treatment duration. Dropout rates peaked during the initial 5 years of treatment, perhaps due to perceived treatment ineffectiveness. Additionally, a trend of escalating dosage was observed across all groups, indicating a potential rise in the severity of spasticity or changes in treatment response over time. BoNT-A injections emerged as the predominant treatment choice for managing post-stroke spasticity. The delayed initiation of BoNT-A treatment underscores the need for heightened awareness among healthcare providers to recognize and manage spasticity promptly post-stroke. Patients' expectations and treatment goals should be clearly defined to optimize treatment adherence, while the observed escalation in dosage and treatment intervals emphasizes the dynamic nature of spasticity and underscores the importance of monitoring long-term treatment outcomes.

Do Diagnostic Nerve Blocks Affect the Starting Dose of Botulinum Neurotoxin Type A for Spasticity? A Case-Control Study.

One of the aims of diagnostic nerve blocks is to identify the overactive muscles that lead to a specific spasticity pattern. However, to date, there is no evidence on how nerve blocks may affect botulinum neurotoxin-A (BoNT-A) dose in patients with spasticity. This case-control study aims to assess the role of diagnostic nerve block in defining BoNT-A starting dose at first treatment. Patients with upper and lower limb spasticity treated for the first time with BoNT-A were retrospectively divided into two groups: Group 1 (n = 43) was evaluated with clinical assessment and diagnostic nerve block; Group 2 (n = 56) underwent clinical assessment only. Group 1 was injected with higher BoNT-A doses in some muscles (i.e., flexor digitorum profundus, soleus), and received a higher BoNT-A cumulative dose with a larger number of injected muscles for some spasticity patterns (i.e., "clenched fist", "flexed fingers", "adducted thigh"). Diagnostic nerve block may help the clinician to optimize and personalize the BoNT-A dose since the first BoNT-A treatment.

PAK1 inhibition with Romidepsin attenuates H-reflex hyperexcitability after spinal cord injury.

Hyperreflexia associated with spasticity is a prevalent neurological condition characterized by excessive and exaggerated reflex responses to stimuli. Hyperreflexia can be caused by several diseases including multiple sclerosis, stroke and spinal cord injury (SCI). Although we have previously identified the contribution of the RAC1-PAK1 pathway underlying spinal hyperreflexia with SCI-induced spasticity, a feasible druggable target has not been validated. To assess the utility of targeting PAK1 to attenuate H-reflex hyperexcitability, we administered Romidepsin, a clinically available PAK1 inhibitor, in Thy1-YFP reporter mice. We performed longitudinal EMG studies with a study design that allowed us to assess pathological H-reflex changes and drug intervention effects over time, before and after contusive SCI. As expected, our results show a significant loss of rate-dependent depression - an indication of hyperreflexia and spasticity - 1 month following SCI as compared with baseline, uninjured controls (or before injury). Romidepsin treatment reduced signs of hyperreflexia in comparison with control cohorts and in pre- and post-drug intervention in SCI animals. Neuroanatomical study further confirmed drug response, as romidepsin treatment also reduced the presence of SCI-induced dendritic spine dysgenesis on α-motor neurons. Taken together, our findings extend previous work demonstrating the utility of targeting PAK1 activity in SCI-induced spasticity and support the novel use of romidepsin as an effective tool for managing spasticity. KEY POINTS: PAK1 plays a role in contributing to the development of spinal cord injury (SCI)-induced spasticity by contributing to dendritic spine dysgenesis. In this study, we explored the preclinical utility of inhibiting PAK1 to reduce spasticity and dendritic spine dysgenesis in an SCI mouse model. Romidepsin is a PAK1 inhibitor approved in the US in 2009 for the treatment of cutaneous T-cell lymphoma. Here we show that romidepsin treatment after SCI reduced SCI-induced H-reflex hyperexcitability and abnormal α-motor neuron spine morphology. This study provides compelling evidence that romidepsin may be a promising therapeutic approach for attenuating SCI-induced spasticity.

Comparison of the Efficacy of 2 Different Botulinum Toxin Injection Techniques in Gastrocnemius Muscle Spasticity in Hemiplegic Patients: A Randomized Double-Blind Controlled Study.

OBJECTIVE: To compare the efficacy of the innervation zone-targeted injection technique (EUROMUSCULUS/USPRM (Ultrasound Study Group of the International Society of Physical and Rehabilitation Medicine) spasticity approach) and the injection technique along the muscle length. DESIGN: A double-blind randomized controlled trial. SETTING: Department of rehabilitation medicine of a medical center. PARTICIPANTS: One hundred patients with stroke experiencing ankle plantar flexor spasticity. INTERVENTIONS: In addition to conventional rehabilitation, eligible patients were randomly assigned to 2 groups. The experimental group was injected with botulinum toxin along the length of the muscle, whereas the control group was injected with the same dose and volume of botulinum toxin 25%-35% proximal to the medial head and 20%-30% proximal to the lateral aspect of the head of the gastrocnemius muscle. MAIN OUTCOME MEASURES: Modified Ashworth scale, modified Tardieu scale, ankle range of motion measurement, and 10-meter walk test were used before and 1 month after injection. RESULTS: The study was completed by 60 participants with a mean age of 59.96±12.15 years. Both injection methods were found to be effective on range of motion, spasticity level, ambulation, and walking speed. There was no statistically significant difference between injection methods. CONCLUSIONS: Both injection methods of botulinum toxin A produce similar clinical effects.

Multimodal therapy and use of adjunctive therapies to BoNT-A in spasticity management: defining terminology to help enhance spasticity treatment.

Spasticity management should be provided within the context of a comprehensive person-centered rehabilitation program. Furthermore, active goal setting for specific spasticity interventions is also important, with a well-established "more is better" approach. It is critical to consider adjunctive therapy and multimodal approaches if patients are not attaining their treatment goals. Often used interchangeably, there may be confusion between the terms adjunctive and multimodal therapy. Yet it is imperative to understand the differences between these approaches to achieve treatment goals in spasticity management. Addition of a secondary pharmacologic or non-pharmacologic treatment to optimize the efficacy of the initial modality, such as adding electrical stimulation or casting to BoNT-A, is considered an adjunctive therapy. Adjunctive therapy is time-specific and requires the added therapy be initiated within a specific period to enhance the primary treatment; usually within 2 weeks. Multimodal therapy is an integrated, patient-centric program of pharmacologic and non-pharmacologic strategies utilized in a concurrent/integrated or sequential manner to enhance the overall treatment effect across a variety of spasticity-associated impairments (e.g., neural and non-neural components). Moreover, within a multimodal approach, adjunctive therapy can be used to help enhance the treatment effect of one specific modality. The objectives of this paper are to clarify the differences between adjunctive and multimodal therapies, provide a brief evidence-based review of such approaches, and highlight clinical insights on selecting multimodal and adjunctive therapies in spasticity management.

Selective dorsal rhizotomy after baclofen intrathecal pump removal: a single-center experience and review of the literature.

PURPOSE: Selective dorsal rhizotomy (SDR) and intrathecal baclofen (ITB) pump placement are two surgical options in children affected by spasticity secondary to cerebral palsy 1. The latest literature is an enlarging indication for SDR in case of ITB failure in non-ambulant patients as an alternative to pump reimplantation to reduce spasticity and facilitate patients' care. METHODS: A retrospective single-center study has screened all children diagnosed with spastic tetraparesis who underwent in the last 10 years SDR and had previously ITB pump implanted. A cohort of six patients was pooled out. Furthermore, pertinent literature has been reviewed. RESULTS: Indication for pump removal was pump pocket infection, parents' decision, and poor response to ITB. Patients' amount of lifetime with the pump implanted has been 6.9 years. The preoperative and postoperative Ashworth scores were statistically different in both procedures (p = 0.005 and p = 0.,02). CONCLUSIONS: Only two studies investigated the pediatric population undergoing SDR in the occurrence of ITB pump removal. Authors are offering SDR to all children, regardless of GMFCS groups and previous ITB pump placement. In conclusion, SDR represents a valid tool in neurosurgeon's hands to help ameliorate patients' long-lasting quality of life, reducing the severity of the spasticity and leading to better management by caregivers.

Extracorporeal Shock Wave Therapy (eSWT) in Spinal Cord Injury-A Narrative Review.

BACKGROUND: Injury of the spinal cord causes motor and sensory dysfunction as well as pathological reflexes, leading to paraplegia or tetraplegia. The sequelae of traumatic spinal cord injury (SCI) are a significant burden and impact on healthcare systems. Despite constant progress in medicine, traumatic SCI still remains irreversible. To date, no satisfying treatment that can enable neuronal regeneration and recovery of function at the damaged level has been found. Hundreds of experiments have been conducted on various possibilities of influencing spinal regeneration; some of them have yielded promising results, but unfortunately, the successes obtained in experimental animals have not translated into humans. METHODS: This narrative review article presents the application of extracorporeal shock wave therapy (eSWT) in patients with SCI. The article has been divided into parts: 1) use of extracorporeal shock wave therapy for regeneration of the spinal cord after traumatic spinal cord injury; 2) application of extracorporeal shock wave therapy in spasticity after spinal cord injury. In both cases, the hypotheses of possible mechanisms of action will be described. RESULTS AND CONCLUSIONS: A small number of clinical trials have demonstrated the potential of eSWT to influence the regeneration of the spine, as an innovative, safe, and cost-effective treatment option for patients with SCI. Some reports have shown that eSWT can improve spasticity, walking ability, urological function, quality of life, and independence in daily life.

Dronabinol Is Not a Game Changer in Pediatric Palliative Care: Results from a Retrospective Study.

BACKGROUND/OBJECTIVES: Patients with life-limiting conditions (LLCs) often suffer from restlessness, spasticity, pain, and seizures. Dronabinol (DRB) may have a relieving effect; however, data on the effectiveness of DRB in children with LLCs are limited to outpatients. The aim of this study was to assess the efficacy and safety of DRB. METHODS: Retrospective analysis of inpatients. RESULTS: From 2011 to 2021, 1219 patients were admitted. Of these, 63 patients (63.5% male, age: 10.4 (SD = 6.3) years) were treated with DRB; 96.8% had a neurological disease, and 26 patients were started on DRB (group A), while 37 were admitted with existing DRB (group B). The effective doses were 0.21 (SD = 0.11) in group A and 0.48 (SD = 0.5) mg/kg/BW/day in group B (p = 0.01). Subjective response rates to DRB in both groups (good/moderate effect) were 9.5%/38.1% for spasticity and 1.6%/25.4% for restlessness. However, no reduction in seizures, restlessness, or demand medication was observed in 24 h protocols when patients started DRB in group A. Three patients experienced severe side effects (e.g., respiratory depression). Other side effects included fatigue (22.2%) and behavioral problems (14.3%). CONCLUSIONS: Subjective positive effects could not be confirmed by more objective data. Side effects can be severe. Thus, DRB should be started in a well-monitored setting and only with clear indications.

Neglecting Bone Health: A Critical Gap in Management of Muscle Spasticity with Botulinum Toxin in Spinal Cord Injury.

Neuromuscular inhibitors have been quickly advanced from being used only for aesthetic purposes to being used as a treatment for musculoskeletal pain and muscle spasticity. This phenomenon stems from the diminished force exerted by muscles, which are essential for bone remodeling. In this context, it is hypothesized that botulinum toxin (BTX) might exert a direct influence on bone resorption. Although such treatments have the potential to provide patients with significant relief, bone loss occurring due to elective muscle paralysis has yet to be examined in clinical trials. The disuse model resulting from spinal cord injury, characterized by the absence of ground reaction and muscle forces, provides an ideal context for exploring the skeletal ramifications of intramuscular BTX injection. This approach enables an investigation into the intricate interplay between muscle and bone, encompassing the impact of spasticity on bone preservation, the potential positive and negative outcomes of BTX on bone metabolism, and the involvement of the autonomic nervous system in bone remodeling regulation. This paper presents a narrative review of research findings on the disturbance of the typical balance between muscles and bones caused by acute muscle paralysis from BTX, resulting in osteopenia and bone resorption.

Disease-Modifying Symptomatic Treatment (DMST) Potential of Cannabinoids in Patients with Multiple Sclerosis.

With the recent introduction of a number of highly effective disease-modifying treatments (DMTs) and the resulting almost complete prevention of acute relapses in many patients with multiple sclerosis (MS), the interest of MS clinicians has gradually shifted from relapse prevention to counteraction of disease progression and the treatment of residual symptoms. Targeting the cannabinoid system with nabiximols is an approved and effective strategy for the treatment of spasticity secondary to MS. Recently, the concept of spasticity plus syndrome (SPS) was introduced to account for the evidence that spasticity often appears in MS patients in clusters with other symptoms (such as pain, bladder dysfunction, sleep, and mood disorders), where cannabinoids can also be effective due to their broader action on many immune and neuronal functions. Interestingly, outside these symptomatic benefits, extensive pre-clinical and clinical research indicated how the modulation of the cannabinoid system results in significant anti-inflammatory and neuroprotective effects, all potentially relevant for MS disease control. This evidence makes nabiximols a potential disease modifying symptomatic treatment (DMST), a concept introduced in an attempt to overcome the often artificial distinction between DMTs and symptomatic therapies (STs).