[Spasticity in neurological pathologies. An update on the pathophysiological mechanisms, advances in diagnosis and treatment]. / Espasticidad en la patología neurológica. Actualización sobre mecanismos fisiopatológicos, avances en el diagnóstico y tratamiento.

INTRODUCTION: Spasticity is a frequent clinical sign in people with neurological diseases that affects mobility and causes serious complications: pain, joint limitation, muscular contractions and bed sores, which have a significant effect on the individual's functionality and quality of life. AIM: To review the integration, description and critical interpretation of the most recent scientific evidence on the clinical variability of spasticity and associated symptoms, the different pathophysiological mechanisms and their relevance in the diagnostic and therapeutic approach. DEVELOPMENT: A search was conducted in the scientific publications on the different aspects of spasticity grouped into two main categories: cerebral and spinal cord pathologies. The epidemiological, clinical and pathophysiological aspects, clinical and instrumental diagnoses, and the physiotherapeutic, pharmacological and surgical approach to spasticity in each group of pathologies were all reviewed. CONCLUSION: Spasticity is related to structural lesions and maladaptive neuroplastic changes that determine an important variability in its clinical expression. Although its diagnosis presents important limitations, the use of clinical and neurophysiological diagnostic tools aimed at achieving different approaches in cases of neurological pathologies originating in the brain and in the spinal cord could optimise the effectiveness of spasticity therapies.

TITLE: Espasticidad en la patología neurológica. Actualización sobre mecanismos fisiopatológicos, avances en el diagnóstico y tratamiento.Introducción. La espasticidad es un signo clínico frecuente en personas con enfermedades neurológicas que afecta a la movilidad y causa graves complicaciones: dolor, limitación articular, contracturas y úlceras por presión, que conllevan una afectación significativa de la funcionalidad del individuo y de su calidad de vida. Objetivo. Revisar la integración, la descripción y la interpretación crítica de la evidencia científica más reciente sobre la variabilidad clínica de la espasticidad y los síntomas asociados, los distintos mecanismos fisiopatológicos y su relevancia en el abordaje diagnóstico y terapéutico. Desarrollo. Se realizó una búsqueda de las publicaciones científicas sobre los distintos aspectos de la espasticidad agrupados en dos categorías magistrales: patologías cerebral y medular; y se revisaron aspectos epidemiológicos, clínicos y fisiopatológicos, el diagnóstico clínico e instrumental, y el abordaje fisioterapéutico, farmacológico y quirúrgico de la espasticidad en cada grupo de patologías. Conclusión. La espasticidad se relaciona con lesiones estructurales y cambios neuroplásticos maladaptativos que determinan una importante variabilidad en su expresión clínica. Aunque su diagnóstico presenta importantes limitaciones, el uso de herramientas de diagnóstico clínico y neurofisiológico encaminadas al abordaje diferencial en las patologías neurológicas de origen cerebral y medular podría optimizar la eficacia de las terapias de la espasticidad.

Terapia robótica con el exoesqueleto H2 en la rehabilitación de la marcha en pacientes con lesión medular incompleta. Una experiencia clínica / Robot therapy with the H2 exoskeleton for gait rehabilitation in patients with incomplete spinal cord injry. A clinical experience

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Baclofeno intratecal en daño cerebral y recuperación de estado vegetativo persistente. A propósito de un caso / Intrathecal baclofen therapy in brain injury and recovery of persistent vegetative state. Apropos of a case

Pacientes con daño cerebral y espasticidad son candidatos a terapia de baclofeno intratecal (ITB) cuando dosis máximas de antiespásticos orales no son efectivas. Algunos autores describen una mejora en el nivel de consciencia en pacientes con daño cerebral y alteraciones del nivel de consciencia. Presentamos el caso de una paciente de 43 años con daño cerebral, espasticidad y estado vegetativo persistente que presentó mejora del nivel de consciencia tras administrar ITB para el manejo de la espasticidad. Durante la prueba de infusión de baclofeno intratecal monitorizamos la espasticidad según la Escala modificada de Ashworth y el nivel de consciencia mediante Coma Recovery Scale-Revised. Tras observar mejoría en Escala modificada de Ashworth y en Coma Recovery Scale-Revised, decidimos implantar la bomba de ITB y la paciente emergió de estado vegetativo persistente a estado de mínima consciencia. Sugerimos el beneficio añadido de ITB sobre el nivel de consciencia en pacientes con daño cerebral, alteraciones del nivel de consciencia y espasticidad, no existiendo evidencia suficiente para prescribirlo en el tratamiento de alteraciones del nivel de consciencia

Patients with brain injury and spasticity are candidates for intrathecal baclofen therapy (ITB) when maximal doses of oral antispastic drugs fail. Some authors have described an improvement in the level of consciousness in patients with brain injury and disorder of consciousness treated with ITB for spasticity. We present the case of a 43-year-old patient with brain injury, spasticity, and permanent vegetative state (PVS) who showed an improvement in the level of consciousness after ITB for spasticity. We performed an ITB infusion test, assessing the spasticity with the Modified Ashworth Scale (MAS) and level of consciousness with the Coma Recovery Scale-Revised (CRS-R) and observed an improvement in the spasticity and the level of consciousness. Consequently, the ITB pump was implanted and the patient recovered from PVS to minimal conscious state (MCS). We conclude that ITB is indicated in patients with brain injury and spasticity. We suggest the improvement in the level of consciousness as a possible additional benefit. There is a lack of evidence to recommend ITB in patients with altered level of consciousness

[Intrathecal baclofen therapy in brain injury and recovery of persistent vegetative state. Apropos of a case]. / Baclofeno intratecal en daño cerebral y recuperación de estado vegetativo persistente. A propósito de un caso.

Patients with brain injury and spasticity are candidates for intrathecal baclofen therapy (ITB) when maximal doses of oral antispastic drugs fail. Some authors have described an improvement in the level of consciousness in patients with brain injury and disorder of consciousness treated with ITB for spasticity. We present the case of a 43-year-old patient with brain injury, spasticity, and permanent vegetative state (PVS) who showed an improvement in the level of consciousness after ITB for spasticity. We performed an ITB infusion test, assessing the spasticity with the Modified Ashworth Scale (MAS) and level of consciousness with the Coma Recovery Scale-Revised (CRS-R) and observed an improvement in the spasticity and the level of consciousness. Consequently, the ITB pump was implanted and the patient recovered from PVS to minimal conscious state (MCS). We conclude that ITB is indicated in patients with brain injury and spasticity. We suggest the improvement in the level of consciousness as a possible additional benefit. There is a lack of evidence to recommend ITB in patients with altered level of consciousness.

[Robot therapy with the H2 exoskeleton for gait rehabilitation in patients with incomplete spinal cord injry. A clinical experience]. / Terapia robótica con el exoesqueleto H2 en la rehabilitación de la marcha en pacientes con lesión medular incompleta. Una experiencia clínica.

BACKGROUND AND OBJECTIVE: Robotic exoskeletons have emerged as a promising tool in gait rehabilitation in patients with a spinal cord injury. The aim of this study was to assess the clinical applicability of a new robotic exoskeleton model (Exo H2) in the rehabilitation of people with incomplete spinal cord injury. MATERIAL AND METHODS: Exo H2 exoskeleton training was performed for 15 sessions in patients with incomplete subacute spinal cord injury. We analysed the appearance of undesirable events and the patient's perception of pain, fatigue and comfort. In addition, a pilot test was carried out on the possible effectiveness of the device by analysing gait characteristics before and after treatment measured by the 10mWT, the 6mWT, the TUG, the WISCI-II, and the impact on the SCIM III scale. RESULTS: Of a group of 8 patients recruited, we were able to analyse data from 4. No undesirable effects were reported. The VAS value was 2.28±1.55 for pain, 3.75±1.55 for fatigue and 4.17±1.68 for comfort. All values improved on the WISCI-I and the TUG and almost all in the 10MWT and in the 6MWT. CONCLUSIONS: The performance of the Exo H2 exoskeleton was robust during a clinical protocol for gait rehabilitation. The treatment was safe, without undesirable effects and with good patient tolerance. These results might justify the performance of clinical trials with an adequate sample size.

[Spinal cord injury due to suicide attempt, psychiatric profile and functional disability]. / Lesion medular por intento de suicidio, perfil psiquiatrico y discapacidad funcional.

INTRODUCTION: Studies published in other countries indicate that 1.6-3% of spinal cord injuries are acquired due to suicide attempt, the majority being produced by precipitation in patients with previous psychiatric disorders. AIMS: To determine the frequency of attempted suicide as a cause of spinal cord injuries in a neurorehabilitation hospital and to describe the characteristics of these patients in psychiatric terms and functional disability. PATIENTS AND METHODS: Retrospective study in which all patients with spinal cord injuries due to suicide attempt in a period of 15 years in a neurorehabilitation hospital were reviewed. RESULTS: Suicide attempt caused 2% (n = 61) of spinal cord injuries in our population. Although 93% of the patients were diagnosed with psychiatric pathology, 60% were linked to mental health facilities and only three consulted for emergency the days before the precipitation. Six attempts were made in the context of psychiatric services and 26% of patients had made previous attempts. The most frequent medical diagnosis was paraplegia associated with fractures in the lower extremities and chest trauma. CONCLUSIONS: Precipitation due to suicide attempt causes 2% of spinal cord injuries, with depression and psychotic disorders being the most prevalent psychiatric disorders. After the rehabilitation period, this population requires special attention from the mental health teams since they combine risk factors to commit suicide such as the history of previous attempts and the presence of a chronic disabling condition.

TITLE: Lesion medular por intento de suicidio, perfil psiquiatrico y discapacidad funcional.Introduccion. Estudios realizados en otros paises señalan que el 1,6-3% de las lesiones medulares se adquieren por intento de autolisis, y la mayoria se producen por precipitacion. Objetivos. Determinar la frecuencia de intento de suicidio como causa de lesion medular en un hospital de neurorrehabilitacion y describir las caracteristicas de estos pacientes en terminos psiquiatricos y de discapacidad funcional. Pacientes y metodos. Estudio retrospectivo en el que se revisaron todos los pacientes con lesion medular por intento de autolisis en un periodo de 15 años en un hospital de neurorrehabilitacion. Resultados. El intento de autolisis ocasiono el 2% de las lesiones medulares en la muestra (n = 61). El 93% de los pacientes estaba diagnosticado de patologia psiquiatrica y el 26% habia realizado tentativas previas. Aunque el 60% estaba vinculado a salud mental, solo tres consultaron por urgencias dias antes de la precipitacion y seis realizaron la tentativa en el contexto de servicios psiquiatricos. El diagnostico mas frecuente fue la paraplejia asociada a fracturas en las extremidades inferiores y traumatismos toracicos. Conclusiones. La precipitacion por intento de autolisis provoca el 2% de las lesiones medulares, y la depresion y los trastornos psicoticos son las patologias psiquiatricas previas mas prevalentes. Tras el periodo de rehabilitacion, esta poblacion requiere especial atencion por parte de los equipos de salud mental, ya que combina factores de riesgo para cometer suicidio, como la historia de tentativas previas, y la presencia de una condicion cronica discapacitante.

Consenso sobre la profilaxis y tratamiento de la enfermedad tromboembólica venosa en la lesión medular y en el daño cerebral adquirido / Prevention and treatment of venous thromboembolism in spinal cord injury and acquired brain injury

La enfermedad tromboembólica venosa es un proceso patológico que abarca tanto la trombosis venosa profunda como el tromboembolismo pulmonar. Son muchos los estudios que recogen la alta incidencia de esta enfermedad en pacientes afectos de lesiones neurológicas como la lesión medular, el traumatismo craneoencefálico o el ictus, todos ellos pacientes susceptibles de ingreso en centros de rehabilitación. En la literatura publicada existe controversia acerca de la necesidad de screening de enfermedad tromboembólica venosa en estos pacientes, el tiempo de mantenimiento de la profilaxis o los fármacos a utilizar tanto en la profilaxis como una vez se establece la sospecha o el diagnóstico definitivo de dicha enfermedad. Con esta revisión de la literatura pretendemos hacer un consenso para intentar aclarar dudas y establecer unas directrices de sospecha, diagnóstico y tratamiento que nos ayuden en la práctica clínica diaria

Venous thromboembolism is a disease that includes both deep vein thrombosis and pulmonary embolism. Many studies reflect the high incidence of this disease in patients with neurological injuries such as, spinal cord injury, traumatic brain injury, or stroke, and all these patients are candidates for admission to rehabilitation centres. There is controversy in the published literature on the need for screening of deep vein thrombosis in these patients, time on prophylaxis drug maintenance or the drugs to use for prophylaxis once suspected or when the definite diagnosis of this disease is established. A review of the literature is presented in order to attempt to clarify these doubts and establish guidelines for suspicion, diagnosis and treatment to help us in daily clinical practice

Multiple sclerosis following a spinal cord injury: a rare and unfortunate case.

This is a case report and review of literature with the objective report of the case of a young man with physical disability following a traumatic spinal cord injury (SCI) who was later newly diagnosed with multiple sclerosis (MS) in an inpatient SCI rehabilitation center. (Barcelona, Spain). A 24-year-old male sustained a traumatic spinal cord lesion (T9 AIS A) as the result of a motorcycle accident. He completed his rehabilitation process without complications and returned to the community having adjusted to his new disability. Two and a half years after his initial injury, he attended the clinic after experiencing 2 months of paresthesias in his left hand, progressing to his right upper limb, and difficulty with fine hand movements. An magnetic resonance imaging (MRI) was arranged and although post-traumatic syringomyelia was ruled out, demyelinating areas in the cervical spinal cord were found. A brain MRI revealed multiple demyelinating lesions suggestive of MS. The diagnosis of MS was confirmed by a neurologist and treatment was started with daily doses of glatiramer acetate. At this time the patient was still independent in transfers, activities of daily living and wheelchair management. In young patients with SCI, adequate follow-up is important to detect subsequent complications that may lead to clinical and functional deterioration with a view to uncommon causes such as MS.

H reflex modulation by transcranial magnetic stimulation in spinal cord injury subjects after gait training with electromechanical systems.

STUDY DESIGN: Prospective longitudinal study. OBJECTIVES: The aim of this study was to examine the effects of transcranial magnetic stimulation (TMS) on the soleus H reflex in patients with spinal cord injury (SCI) before and after locomotion training. SETTING: Neurorehabilitation hospital in Barcelona, Spain. METHODS: H reflex was elicited in 29 incomplete patients with SCI at 20, 50 and 80 ms after single vertex TMS, and compared with 13 healthy subjects. Patients were subdivided in two groups according to time since injury (<3 months, 3-12 months), and all received training with electromechanical systems. The H reflex modulation pattern to TMS was reassessed and the results were analyzed as a function of change in the patient clinical score. RESULTS: Healthy subjects showed a significant H reflex facilitation at 20 ms (186.1%) and at 80 ms (190.6%) compared with the control H reflex. In patients, the H reflex facilitation at 20 ms was significantly reduced before training (142.5%, P=0.039) compared with healthy subjects. After training, patients with <3 months exhibited an increase in H reflex facilitation at 20 ms (170.7%, P=0.04), a greater gait velocity (P=0.014) and a positive correlation with the walking index for spinal cord injury (WISCI II) scale (P=0.050), compared with those with >3 months. CONCLUSIONS: TMS-induced H reflex modulation may help in the assessment of changes in the descending control of leg reflexes. Our results suggest that the changes on reflex modulation in patients with SCI occur within the first 3 months after injury.

[Characteristics of chronic neuropathic pain and their relationship with psychological well-being in spinal cord injury patients]. / Características del dolor neuropático crónico y su relación con el bienestar psicológico en pacientes con lesión medular.

AIMS: To determine the prevalence of neuropathic pain (NP) in a sample of patients with spinal cord injury (SCI), to examine the relation between clinical, demographic and psychological characteristics with the prevalence of NP after SCI and the different types of NP, and to study predictive factors. PATIENTS AND METHODS: Transversal observational study of 260 patients who attended their annual revision. Main outcome measures included presence/absence of NP, psychological well-being index, detailed pain history and 0-10 numerical rating scale of average pain intensity. RESULTS: 93 patients (36%) with SCI had NP. Of the patients with NP, 35% showed pain at level, while 65% showed NP below the level of injury. The only variable with a predictive value on the prevalence of NP was older age at the time of SCI. Statistically significant differences were observed between the prevalence of NP and the perception of psychological well-being; patients with NP were the ones with more psychological distress. As for the different types of NP, the variables with predictive value on the classification of NP were early onset of pain at level, and incompleteness of the lesion in the below level NP. CONCLUSION: The results of this study show that NP appears frequently after SCI being more prevalent in patients who suffered the injury at more advanced ages. NP has a negative impact on the perception of psychological well-being.

Características del dolor neuropático crónico y su relación con el bienestar psicológico en pacientes con lesión medular / Characteristics of chronic neuropathic pain and their relationship with psychological well-being in spinal cord injury patients

Objetivos. Determinar la prevalencia del dolor neuropático (DN) en una muestra de pacientes con lesión medular (LM), examinar la relación entre las características clínicas, demográficas y psicológicas con la prevalencia del DN después de una LM y a su vez con los diferentes tipos de DN, y estudiar el valor predictivo de los factores más significativos. Pacientes y métodos. Estudio transversal observacional de un total de 260 pacientes que acudieron a una revisión anual. Las principales medidas de resultados incluyeron presencia/ausencia de DN, índice de bienestar psicológico, historia detallada del dolor y escala de puntuación numérica de 0-10 para la media de intensidad del dolor. Resultados. 93 pacientes (36%) con LM tenían DN. De los pacientes que presentaron DN, un 35% mostró dolor a nivel de la lesión, mientras que un 65% presentó DN por debajo. La única variable con capacidad predictiva sobre la prevalencia del DN fue la edad en el momento de la LM. Se observaron diferencias estadísticamente significativas entre la prevalencia del DN y la percepción de bienestar psicológico; el grupo de pacientes con DN fue el que tuvo proporcionalmente un malestar psicológico mayor. En cuanto a los diferentes tipos de DN, las variables con capacidad predictiva sobre la clasificación del DN eran el inicio temprano del dolor en el DN a nivel y el hecho de que la lesión sea incompleta en el DN por debajo. Conclusión. El DN aparece con frecuencia después de la LM y se da de forma más común en aquellos pacientes que han sufrido la lesión a edades más avanzadas. El DN tiene un impacto negativo en la percepción de bienestar psicológico

Aims. To determine the prevalence of neuropathic pain (NP) in a sample of patients with spinal cord injury (SCI), to examine the relation between clinical, demographic and psychological characteristics with the prevalence of NP after SCI and the different types of NP, and to study predictive factors. Patients and methods. Transversal observational study of 260 patients who attended their annual revision. Main outcome measures included presence/absence of NP, psychological wellbeing index, detailed pain history and 0-10 numerical rating scale of average pain intensity. Results. 93 patients (36%) with SCI had NP. Of the patients with NP, 35% showed pain at level, while 65% showed NP below the level of injury. The only variable with a predictive value on the prevalence of NP was older age at the time of SCI. Statistically significant differences were observed between the prevalence of NP and the perception of psychological well-being; patients with NP were the ones with more psychological distress. As for the different types of NP, the variables with predictive value on the classification of NP were early onset of pain at level, and incompleteness of the lesion in the below level NP. Conclusion. The results of this study show that NP appears frequently after SCI being more prevalent in patients who suffered the injury at more advanced ages. NP has a negative impact on the perception of psychological well-being