1. The Management of Spasticity after SCI A Systematic Review of the literature, 2000-2010

2. Systematic Review – Management of Spasticity
Compiled by the Shepherd Center Study Group in Atlanta, GA. Innovative Knowledge Dissemination & Utilization Project for Disability & Professional Stakeholder Organizations/ NIDRR Grant # (H133A050006) at Boston University Center for Psychiatric Rehabilitation.

3. Systematic Review – Management of Spasticity
A review was conducted using a system for rating the rigor and meaning of disability research (Farkas, Rogers and Anthony, 2008).
The first instrument in this system is: “Standards for Rating Program Evaluation, Policy or Survey Research, Pre-Post and Correlational Human Subjects” (Rogers, Farkas, Anthony & Kash, 2008) and “Standards for Rating the Meaning of Disability Research” (Farkas & Anthony, 2008).

4. Shepherd Center Systematic Review Group
Leadership Team:
Reviewers:
Lesley Hudson, MS
David Apple, MD
Deborah Backus, PhD, PT
Rebecca Acevedo
Leslie VanHiel, MSPT
Jennith Bernstein, PT
Amanda Gillot, OT
Ashley Kim, PT
Elizabeth Sasso, PT
Kristen Casperson, PT
Anna Berry, PT
Liz Randall, SPT
Data Coordinator:
Editor:

5. Glossary of Abbreviations
General
SCI - Spinal cord injury
ASIA – American Spinal Injury Association
AIS – ASIA Impairment Scale
ISNCSCI – International Standards for the Neurological Classification of Spinal Cord Injury Assessment (formerly ASIA exam)

6. Glossary of Abbreviations
Research Studies and Interventions
RCT – Randomized control trial
LE – Lower extremity
ROM – Range of motion
TENS – Transcutaneous electrical nerve stimulation
rTMS - Repeated transcranial magnetic stimulation
eSCS - Spinal cord electrical stimulation
FES – Functional electrical stimulation
WBV – Whole body vibration

7. Glossary of Abbreviations
Outcome Measures for Research Studies
AS – Ashworth Scale
MAS – Modified Ashworth Scale
CSS - Composite spasticity score (based on several AS scores)
VAS – Visual Analog Scale
MPSFS – Modified Penn Spasm Frequency Scale
SCATS – Spinal Cord Assessment Tool for Spastic Reflexes
SCI-SET – Spinal Cord Injury Spasticity Evaluation Tool
Hmax/Mmax – Electrophysiological ratio measure of neural excitability
EMG - Electromyography

8. Definitions of Spasticity
Involuntary muscle firing
Velocity-dependent
Increase resistance to stretch
Abnormal processing of sensory input within networks of neurons in the spinal cord networks.
There are many definitions of spasticity, but the most referenced:
Lance, 1980:
“Spasticity is a motor disorder characterized by a velocity- dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neuron syndrome.”

9. Other Definitions
Decq’s definition, 2003 : “…a symptom of the upper motor neuron syndrome characterized by an exaggeration of the stretch reflex secondary to hyperexcitability of spinal reflexes.” It separates:
Intrinsic tonic spasticity: exaggeration of the tonic component of the stretch reflex (hypertonia).
Intrinsic phasic spasticity: exaggeration of the phasic component of the stretch reflex (hyper-reflexia, clonus, velocity-dependent resistance).
Extrinsic spasticity: exaggeration of extrinsic flexion or extension spinal reflexes (spasms, withdrawal reflex).
Adams & Hicks, Spinal Cord, 2005
Don’t think we need this slide for payers

10. Positive Effects of Spasticity
Spasticity may:
Be used to help with transfers, standing, walking, and ADLs.
Help prevent muscle atrophy.
Muscles may appear to be healthier compared to those without spasticity.

11. Negative Effects of Spasticity
However, spasticity may also lead to:
Decreased range of motion (ROM)
Inability to position the limbs safely
Limited mobility
Difficulty performing personal hygiene
Discomfort and pain
andgodlaughs.blogspot.com

12. Is Treatment Necessary?
If mild, wait and see?
Questions to ask:
Does it cause pain?
Interfere with sleep?
Make function unsafe?
Cause secondary issues of -
Poor posture / asymmetric seating?
Pressure sores?
Make care difficult?
Affect hygiene?
Will treatment improve quality of life and safety?

13. Treatment Goals Relieve signs & symptoms
Decrease frequency and severity of spasticity
Improve function
Gait
Posture
Reach and grasp for ADLs
Improve ease of care

14. Patient Evaluation and Treatment Planning
Evaluate Patient:
Does spasticity/ overactivity interfere significantly with function?
Measures must include all aspects of spasticity
Will it lead to musculoskeletal deformity?
Patient Evaluation
and
Treatment Planning
No treatment necessary No
Yes
Patient and Caregiver Objectives
Identify patient and caregiver goals
Functional Objectives
Improve gait, hygiene, ADLs, pain relief, ease of care
Decrease spasm frequency & severity
Technical Objectives
Promote tone reduction, improved range of motion, joint position
Decrease spasm frequency
Decrease hyper-reflexia
Spasticity Management Program
MODIFIED from Spasticity Treatment Planning. WEMOVE.org, 2005.

15. Spasticity is an ongoing problem, despite treatment options.
Traditional and surgical treatment options are routinely used to decrease spasticity…
Yet, many persons with SCI continue to have problems related to spasticity:
More than half of all persons surveyed with chronic SCI report symptoms and sequelae of spasticity (Sköld, et al ; Maynard, et al. 1990).
Persons with cervical and motor incomplete injuries seem to have spasticity that is more frequent and more severe.

16. Conservative Treatment Options
Pharmacological Management
Baclofen – oral or pump (intrathecal)
Adjunct Dantrolene, Zanax, or Valium
Physical and Occupational Therapy
Range of motion (ROM) exercises & prolonged stretching
Casting or splinting
Electrical stimulation - transcutaneous nerve stimulation (TENS)
Acupuncture
Massage

17. If other options don’t work…
Surgery involves cutting pathways in the nervous system thought to be involved in spasticity.
However, forms of electrical stimulation to the spinal cord (epidural spinal cord stimulation) and electromagnetic stimulation to the brain (transcutaneous magnetic stimulation - TMS) may mimic the effects of surgical interventions.

18. Spasticity and its management in SCI is multi-faceted.
Spasticity is no longer just an extremity’s resistance to quick movement.
It includes spasms, overall hypertonia, hyper- reflexia, and clonus.
The optimal treatment for each of these different aspects of spasticity is not yet clear.
The literature related to spasticity has not been evaluated in terms of what is meaningful to persons with SCI.

19. Purpose of Review
To evaluate all published research from the past 10 years related to the management of spasticity after spinal cord injury (SCI) to determine which evidence may be:
Meaningful to persons with SCI who have spasticity (e.g. includes level and completeness of injury).
Related to any type of spasticity a person may experience (velocity-dependent resistance, spasms, hypertonia, clonus).

20. Definitions of types of spasticity used in this review
Velocity-dependent resistance = phasic (quick and short lasting) spasticity of resistance felt when an extremity is moved quickly
Hypertonia = tonic (longer lasting, co-contraction) spasticity of increased resistance to movement throughout range
Spasms = phasic spasticity of body movement into a flexor or extensor pattern
Clonus = phasic spasticity of repeated movement of a body part when positioned with the muscle stretched
Hyper-reflexia = increased reflex response (e.g. the knee reflex response)

21. The Review Conducted by 7 clinicians.
Included all articles published between 2000 and related to the treatment of spasticity in persons with SCI.
All articles rated on quality of the science & meaningfulness to persons with SCI, or their caregivers and clinicians, or payers.
Any article of high quality that was meaningful was considered for this summary.

22. Study Designs Accepted for Review
Experimental: Employed methods including a random assignment and a control group or a reasonably constructed comparison group.
Quasi-experimental: No random assignment, but either with a control group or a reasonably constructed comparison group.
Descriptive: Neither a control group, nor randomization, is used. These included case studies and reports, studies employing repeated measures, and pre-post designs.

23. Search Results Of 49 papers reviewed:
Seven papers met criteria of quality and meaningfulness.
Only 3 of the 7 papers defined spasticity, and these all differed.
Each of the 7 papers used different outcome measures of spasticity.
These are ongoing problems with research in this area.

24. Definition of Spasticity provided Aspect of spasticity measured
Study
Definition of Spasticity provided
Aspect of spasticity measured
Bowden & Stokic 2009
Based on Lance, 1980: “…a motor disorder characterized by a velocity-dependent increase in tonic stretch reflex with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of upper motor neuron syndrome”; “…include clonus, involuntary muscle contractions or spasms, and muscle co-contraction.”
Passive resistance to stretch
Spasm frequency & severity
Stretch reflex/hyper-reflexia
Flexion withdrawal
Kumru, et al. 2010
Based on Decq, 2003: “…a symptom of upper motor neuron syndrome, characterized by an exaggeration of the stretch reflex, spasms, and resistance to passive movement across a joint, secondary to hyperexcitability of spinal reflexes.”
Velocity-dependent resistance to stretch
Clonus
Hypertonia
Ness & Field-Foté 2009
Own definition: “…spastic hypertonia with increased reflex excitability and disordered motor output (i.e. spasticity, clonus, spastic gait patterns)…”
Stretch reflex/quadriceps hyper-reflexia

25. Definition of Spasticity provided Aspect of spasticity measured
Study
Definition of Spasticity provided
Aspect of spasticity measured
Chung & Cheng 2009
none provided
Velocity-dependent resistance to stretch
Passive resistance
Clonus
Kakebeeke TH, et al. 2005
Krause P et al. 2008
Passive resistance to stretch
Stretch reflex/quadriceps hyper-reflexia
Pinter MM, et al 2000
Spasm frequency

26. Experimental Study Design: Overview
2 of 7 studies used a randomized controlled trial (RCT).
Both of these studies used electrical stimulation for the treatment.
2 studies were longitudinal cohort designs.
1 study was a case study.
1 study used a pre-post design.
1 study used a cross-over design.

27. Experimental Study Design: RCT of TENS
Intervention
Study Design
Outcome Measures
Participant Characteristics
Chung BPH, Cheng BKK 2009
60 mins active TENS or 60 mins placebo; over the common peroneal nerve
RCT,
n=18
Composite Spasticity Score
Full range passive ankle dorsiflexion
Ankle clonus
14 male; 4 female
24-77 y.o.
C4-T12
AIS A, B, C, D
4 weeks to 364 weeks (approx. 5.5 years) post-SCI

28. Results: Reduction in Resistance and Clonus with TENS
TENS group showed significant decrease in:
Composite Spasticity Score (29.5%, p=0.017)
Resistance to full passive range at ankle dorsiflexion (31%, p=0.024)
Ankle clonus (29.6%, p=0.023)
Notes:
Anti-spasticity medications were allowed.
No significant differences between groups at baseline.
Chung & Cheng 2009

29. Experimental Study Design: RCT of TMS
Intervention
Study Design
Outcome Measures
Participant Characteristics
Kumru H, Murillo N, Samso JV, et al. 2010
Repetitive Transcranial Magnetic Stimulation (TMS)
RCT with cross- over for sham group,
n=15
MAS
VAS for pain
MPSFS
SCAT
SCI-SET
Hmax/Mmax, Reflex (reflex responses on EMG as indicators of neural excitability)
Withdrawal Reflex
12 male; female
15-68 y.o.
C4-T12
AIS C, D
2-17 months post-SCI

30. RCT of TMS: Sample Notes
11 of 15 using Baclofen
4 of 15 on no anti-spasticity meds
Not all traumatic SCIs:
4 of 15 etiology = tumor
4 of 15 etiology = myelitis
Kumru et al., 2010

31. Results: Decrease in Some Spasticity, Motor Control Still Disordered
Neurophysiological function did not change.
TMS group, but not sham group, significantly decreased:
MAS score (p<0.006)
not significantly different between those with traumatic & non- traumatic SCI
MPSFS (p=0.01)
SCATS (p<0.04)
SCI-SET (p=0.003)
MAS, SCATS, & SCI-SET results maintained one week after last session (p=0.049).
Kumru et al., 2010

32. Results (cont.):
14 of 15 reported significant improvement in pain on VAS (p<0.002).
Was maintained in 13 of 15 at end of the week after TMS (p=0.004)
No significant change in measures when sham only.
Kumru et al., 2010

33. Experimental Study Design: Summary of RCTs
In persons with acute or chronic, motor complete or incomplete, paraplegia or tetraplegia, applying electrical stimulation peripherally (i.e. at the common peroneal nerve or the nerve innervating the muscle antagonistic to the spastic muscle, Chung & Cheng, 2009), or electromagnetic stimulation centrally (i.e. over the primary motor cortex, Kumru et al., 2010) for motor incomplete injuries led to a significant reduction in several different aspects of spasticity:
Velocity-dependent resistance to stretch
Spasms
Hypertonia
Hyper-reflexia
Clonus

34. Descriptive Study Design: Longitudinal Study, Epidural E-stim
Intervention
Study Design
Outcome Measures
Participant Characteristics
Pinter et al. 2000
Epidural spinal cord electrical stimulation (eSCS)
Longitudinal,
n=8
EMG during passive stretch of LE & Pendulum Test
Ashworth Scale
Clinical rating scale
4 male; female
18-34 y.o.
C5-T6
AIS A, B, C
19-94 months post-SCI

35. Results: Epidural Stim Reduced Some Aspects of Spasticity
Significant reduction in:
EMG activity in left and right legs (p=0.004, p=0.0035, respectively).
Except for quadriceps when analyzed independently
Ashworth score (p=0.0117)
7 of 8 participants discontinued anti-spasticity medication.
Pinter et al., 2000

36. Descriptive Study Design: Case Study with Baclofen
Intervention
Study Design
Outcome Measures
Participant Characteristics
Bowden M, Stokic DS. 2009
Pharma- cologic,
intrathecal baclofen
Single subject case report
Ashworth Scale
Lower extremity strength using ISNCSCI
EMG
H-Reflex & H/M ratio (reflex responses on EMG as indicators of neural excitability)
Plantar Withdrawal Reflex
Maximal Voluntary Dorsiflexion
1 male
41 y.o.
T11, AIS D
8 years post-SCI

37. Strength Decreased, BUT Spasticity Decreased More
Dose-dependent decreases in:
Ashworth score (p<0.01)
Bilateral lower extremity strength (p<0.001)
H/M ratio
EMG amplitude and duration of the plantar withdrawal reflex
Decrease in strength was less than decrease in spasticity.
After withdrawal of medication, the rebound in spasticity was less than increase in strength.

38. Descriptive Study Design: Pre-Post with Passive LE Cycling
Intervention
Study Design
Outcome Measures
Participant Characteristics
Kakebeeke et al. 2005
30 mins passive lower extremity ergometry
Pre-Post,
n=10
Muscle strength testing using isokinetic dynamometry (torque) in sitting & lying; movements of leg at 10°/sec & 120°/sec; taken before, after, & 1 week post passive cycling session
9 male; female
23-60 y.o.
C6-T12
AIS A, B
1-25 years post-SCI

39. Results: Strength Same, BUT Reports of Reduced Spasticity
No change in elicited peak torque before, immediately after, or one week after passive cycling.
6 of 10 participants reported reduced spasticity immediately after cycling.
Kakebeeke et al., 2005

40. Descriptive Study Design: Cross-over, FES & Passive Cycling
Intervention
Study Design
Outcome Measures
Participant Characteristics
Krause P, et al. 2008
Functional electrical stimulation cycling, Passive cycling
Cross- over,
n=5
Modified AS of quads
Pendulum Test of quads. Also during Pendulum Test:
Peak Velocity (deg/s) during first swing
Relaxation Index (A1/(1.6 x A0), where A1 & A0 = degrees of first swing in flexion, then extension, respectively)
3 male; female
37-66 y.o.
T3-T7, AIS A
3-9 years post-SCI

41. Results: Both Active & Passive Cycling Show Some Effects
Greater & significant increase in relaxation index (RI) after FES cycling (68%) than after passive cycling (12%) (p=0.01).
Peak velocity (PV) significantly increased after FES cycling, unchanged after passive cycling (p=0.01).
MAS decreased significantly for both FES cycling (p<0.001) and passive cycling (p<0.05).
* Participants were not on anti-spasticity medications.

42. Descriptive Study Design: Longitudinal, Whole Body Vibration
Intervention
Study Design
Outcome Measures
SCI Participant Characteristics
Ness LL, Field-Foté EC, 2009
Whole body vibration on vibrating platform
Longitudinal,
n=16
Pendulum test
14 male; female
28-65 y.o.
C4-T8
AIS C, D
> 1 year post-SCI

43. Results: Long Lasting Effects with WBV
Significant reduction in quadriceps spasticity (p=0.005).
Significant reduction within session (range p= to for weeks 1, 2, 4).
No significant difference between those on anti- spasticity meds and those not.
Effects lasted at least 6-8 weeks post-intervention.
Ness LL, Field-Foté EC, 2009

44. Medications Varied 7 of 16 on Baclofen 1 of 16 on Tizanidine
9 of 16 on no spasticity medication
Ness LL, Field-Foté EC, 2009

45. Descriptive Study Design: Summary of Studies
These studies provide further support that:
stimulating the nervous system (e.g. electrical stimulation), OR
altering the excitability in the nervous system (e.g. Baclofen)
can lead to a reduction in spasticity in persons with complete or incomplete tetraplegia or paraplegia.

46. Methodological Considerations
Definitions of spasticity differ:
A motor disorder characterized by a velocity-dependent increase in tonic stretch reflex, exaggerated tendon jerks; includes clonus, involuntary muscle contractions or spasms, and muscle co-contraction (Lance, 1980)
Includes intrinsic tonic spasticity (i.e. the exaggeration of the tonic component of the stretch reflex, hypertonia), intrinsic phasic spasticity (i.e. the exaggeration of the phasic component of the stretch reflex or hyper-reflexia and clonus), and extrinsic spasticity, (i.e., the exaggeration of extrinsic flexion or extension spinal reflexes, spasms) (Adams & Hicks, 2005).

47. Study Limitations
Spasticity syndrome may be worse in people with cervical and incomplete injuries than those with thoracic and complete injuries.
(Kirshblum, 1999; Maynard et al, 1990; Sköld et al, 1999).
Even though studies included persons with complete and incomplete paraplegia and tetraplegia, as well as acute and chronic injuries, results were averaged and reported as a whole.
It remains unknown whether there is a differential response to the interventions.

48. Study Limitations
Studies included persons with chronic SCI, who may have musculoskeletal consequences to chronic spasticity.
Chronic spasticity has musculoskeletal effects, namely muscle shortening and contractures (Gracies et al., 1997).
Musculoskeletal parameters were not assessed in any of these studies. Improvements may have been neural or musculoskeletal or both.
Improving one and not the other may preclude maximal improvements.

49. Study Limitations There were no functional assessments.
Whether reducing spasticity is necessary and sufficient for improving motor control and function remains unclear.
There were no studies addressing the cost- effectiveness of treatments for spasticity.

50. Recommendations
Any stakeholder interested in the evidence related to the management of spasticity after SCI should consider:
Outcome measures differed across all studies.
Different aspects of spasticity may be affected by a given intervention.
For instance, if spasms are the worse aspect of spasticity, rTMS, eSCS, or baclofen (all with evidence of reducing spasms in persons with SCI) may be pursued.
Those with velocity-dependent resistance to stretch may choose TENS or rTMS, but rTMS may give the best results overall if there are multiple areas related to spasticity.

51. Recommended Future Research
Further study is warranted to determine:
the differential responses to interventions in those with varying levels of injury, classifications of injury, and times since injury.
the differential effects of interventions on neural and musculoskeletal tissues.
the effects of interventions on function.
the long-term effects of these interventions.
the cost-effectiveness of the various treatments for spasticity.

52. References
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53. References (cont.)
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