1. Is Spasticity causing Pain
Is Spasticity causing Pain? A Cross-sectional Survey of Patient Perception
Adil Shaikh1, 2, Chetan P. Phadke1, 2, 3, Farooq Ismail1, 2, Chris Boulias1, 2
1-Spasticity Research Program, West Park Healthcare Centre; 2-University of Toronto; 3-York University, Toronto, Ontario, CANADA
Spasticity is prevalent in upper motor neuron (UMN) disorders and can impair functional activities1. Patients with spasticity can also experience pain2 and in our clinical practice, patients with spasticity often have pain and spasms (a sudden involuntary muscle contraction). Several potential causes of pain such as spasticity, shoulder-hand syndrome, and central post-stroke pain have been identified3; however, the relationship between spasticity and pain has not been assessed in other non-stroke patient populations. For clinicians that manage patients with spasticity, further evidence, especially in relation to patient perceptions, is required to clarify the full benefit of intramuscular botulinum toxin injections.
INTRODUCTION
RESULTS
Figure 2: Patient reported pain type
Figure 1: Pain prevalence based on type of UMN disorder .
OBJECTIVES
To assess the prevalence of pain in adults with spasticity and to assess the association between the subjective experience of pain and spasticity
Step length asymmetry -
Figure 3: Relationship between pain, spasticity, and BoNTA
The majority of patients with spasticity originating from a variety of CNS-related disorders experienced pain to varying degrees.(61-88%; see Figure 1)
Pain was reported to occur more often during movement than at rest (34% vs. 21%).
Relationship between NRS and MAS was non-significant (r = 0.16; p>0.05).
This pain may be nociceptive in origin and related to movement (Figure 2)
Although the severity of spasticity did not correlate statistically with the amount of pain experienced, subjectively the pain was reported to be related to spasticity (Figure 3).
The patients perceived a decrease in their pain as a result of BoNTA injection (Figure 3).
Based on the high (64%) prevalence of pain in our patients experiencing spasticity, it appears that physicians may have to consider treatment of pain as part of spasticity management.
Further studies are needed to explore the mechanisms underpinning pain relief from BoNTA injections for limb spasticity.
DISCUSSION
Design: Prospective cross-sectional study. Setting: Outpatient clinic.
Participants: 131 participants with UMN disorders; 47% had a primary diagnosis of stroke. Other frequent etiologies included MS, CP, SCI and TBI at rates of 19%, 12%, 9% and 8%, respectively. The ages of the patients in the study ranged from 20 to 90 years - mean 57 years (standard deviation 17 years; mode 78 years); 66 were males and 65 females. Patients typically receive BoNTA injections at an interval of 3-6 months. Of all participants, 20% self-reported some degree of memory deficit. Only 3 patients reported a previous history of pain that occurred prior to the onset of neurological disorder (not relevant to patients with cerebral palsy).
Procedures: We assessed pain intensity and location, relationship between spasticity and pain perception, and perception of pain relief from botulinum toxin type-A (BoNTA) injections.
Main Outcome Measures: 1) the prevalence of pain in patients with spasticity; 2) the type of pain exhibited; 3) patient perception of the association between pain and spasticity and spasm; and 4) perception of change in pain in relation to botulinum injections. Pain was measured using a 10-point numerical rating scale (NRS) and spasticity was measured using modified Ashworth Scale (MAS) scores.
METHODS
ACKNOWLEDGMENTS
We would like to thank all our participants, the West Park Foundation, and the West Park Spasticity Management Clinic staff.
REFERENCES
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Wissel J, Manack A, M B. Toward an epidemiology of poststroke spasticity. Neurology January 2013;15(80(3 Suppl 2)):S13-9.
Lundström E, Smits A, Terént A, Borg J. Risk factors for stroke-related pain 1 year after first-ever stroke. Eur J Neurol Feburary;16(2):188-93