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Objective: The objective of this study is to determine the physical evaluations and assessment tools used by a group of Canadian healthcare professionals treating adults with spasticity. Methods: A cross-sectional web-based 19-question survey was developed to determine the types of physical evaluations, tone-related impairment measurements, and assessment tools used in the management of adults with spasticity. The survey was distributed to healthcare professionals from the Canadian Advances in Neuro-Orthopedics for Spasticity Congress database. Results: Eighty study participants (61 physiatrists and 19 other healthcare professionals) completed the survey and were included. Nearly half (46.3%, 37/80) of the participants reported having an inter- or trans-disciplinary team managing individuals with spasticity. Visual observation of movement, available range of motion determination, tone during velocity-dependent passive range of motion looking for a spastic catch, spasticity, and clonus, and evaluation of gait were the most frequently used physical evaluations. The most frequently used spasticity tools were the Modified Ashworth Scale, goniometer, and Goal Attainment Scale. Results were similar in brain- and spinal cord-predominant etiologies. To evaluate goals, qualitative description was used most (37.5%). Conclusion: Our findings provide a better understanding of the spasticity management landscape in Canada with respect to staffing, physical evaluations, and outcome measurements used in clinical practice. For all etiologies of spasticity, visual observation of patient movement, Modified Ashworth Scale, and qualitative goal outcomes descriptions were most commonly used to guide treatment and optimize outcomes. Understanding the current practice of spasticity assessment will help provide guidance for clinical evaluation and management of spasticity.

Anecdotal clinical experience shows that patients often indicate that their spasticity improves on the day of treatment with intramuscular botulinum injection. Previous research shows that compound motor action potentials (CMAPs) decrease 48 h post-injection. However, no studies to date have assessed the neurophysiological changes less than 48 h post-injection.Fifteen healthy control subjects (10 F; mean age 41 ± 11 years) participated in this randomized double-blind study. We injected 10 units of either onabotulinumtoxinA or incobotulinumtoxinA in the extensor digitorum brevis (EDB) muscle, one in each foot. We performed serial CMAP assessments using nerve conduction study of the peroneal nerve at following time intervals after botulinum injection - 2, 4, 6, 24, 26, 28, 30, 48, 72 h and 6 days post-injection. We used an ANOVA with repeated measures separately for each type of toxin.Post-hoc tests using the Bonferroni correction revealed that there was a statistically significant decrease in the mean EDB CMAP amplitude from baseline starting at 24 h post-injection in the incobotulinumtoxinA group (p 0.05) and 4 h post-injection in the onabotulinumtoxinA group (p 0.05).We conclude that both toxin formulations tested in this study exert a significant decrease in EDB CMAP amplitude in the period of48 h post-injection.

Introduction In patients taking warfarin, the level of anticoagulation status using the International Normalized Ratio (INR) is one consideration before botulinum toxin type-A (BoNTA) injections; however, there is wide diversity in physician approaches and preferences in using INR status and the INR cut-off values to determine suitability of anticoagulated patients for BoNTA injections. There is no standard approach for treating spasticity with BoNTA injections in patients who are on warfarin or direct anticoagulants (DOACs). Objective: Our objective was to review the challenges in the use of BoNTA in patients who are receiving anticoagulants and to present highlights of the Canadian Delphi Study on the management of anticoagulated patients with limb spasticity. Methods We present a hypothetical case of a patient with focal spasticity who is also receiving anticoagulants. Results The results when injecting BoNTA in anticoagulated patients were as follows: 1) BoNTA injections should not be withheld purely because a patient is anticoagulated and other factors need to be considered. 2) A 25G (or higher) needle should be used when injecting into the deepleg compartment muscles. 3) The INR level ≤3.5 should be used when injecting the deep posterior leg compartment muscles. 4) The concern regarding bleeding when using DOACs remain the same as with warfarin when INR is in the therapeutic range. 6) The dose and scheduling of DOACs need not be altered prior to BoNTA injections. Conclusions The Canadian consensus statements assist clinicians by providing a framework for consideration to navigate the challenges when injecting BoNTA in anticoagulated patients with spasticity.

BACKGROUND Adjunct therapies are nonpharmacological treatments used with botulinum toxin (BoNT) injection that may improve spasticity outcomes. It has been suggested that physicians consider adjunct therapies as a part of comprehensive spasticity management. It is unclear which adjunct therapies are used by physicians in clinical practice. OBJECTIVE To determine physician practice patterns and perceptions of use of adjunct therapies following BoNT injection for limb spasticity. DESIGN Cross-sectional national survey of current clinical practice using a 22-item questionnaire developed by the authors. SETTING Not applicable. PARTICIPANTS Survey respondents were physicians actively administering BoNT injections for limb spasticity management across Canada (N = 48). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Types of adjunct therapies used by physicians; physician opinions on barriers to adjunct therapy use, patient preferences, and future research priorities. RESULTS Most physicians prescribe home stretching programs, home active exercise programs, and splinting; however, many physicians perceive that these same adjunct therapies are unwanted by patients. A minority of physicians prescribe electrical stimulation (ES), transcutaneous electrical nerve stimulation (TENS), casting, and extracorporeal shockwave therapy; financial limitations and perceived lack of evidence were identified as barriers to their use. Significantly more physicians practicing in academic settings compared with nonacademic, community, and private practice settings used functional ES (59% vs 11%) and TENS (41% vs 0%) as adjunct therapies (P

Background: Passive leg cycling is an important clinical tool available for rehabilitation after spinal cord injury (SCI). Passive cycling can be used to derive exercise-related benefits in patients with poor motor control. There have been a number of studies examining the effects of passive cycling on a variety of outcomes. There is need for a systematic assessment of the cycling parameters and the associated clinical changes in cardiovascular, neuromuscular, and musculoskeletal outcomes after passive cycling. Objectives: To assess the effectiveness of passive leg cycling interventions on cardiovascular, neuromuscular, and musculoskeletal outcomes post SCI, and to describe intensity, duration, and type of passive leg cycling post SCI. Methods: PRISMA guided systematic review of literature based on searches in the following databases: PubMed/MEDLINE, PEDro, EMBASE, Cochrane Library, and Google Scholar. Peer-reviewed publications that were written in English were included if they described the effects of a single session or multiple sessions of passive leg cycling in persons post SCI. Results: Eleven papers were included: two were randomized controlled trials (RCTs), one was a crossover trial, and the rest were pre-post single-group designs. Three studies (including two RCTs) reported statistically significant benefits of multiple sessions of passive cycling on leg blood flow velocity, spasticity, reflex excitability and joint range of motion, and markers of muscle hypertrophy. About half of the single session studies showed statistically significant improvement in acute responses. Conclusion: Multiple sessions of passive leg cycling showed benefits in three categories – cardiovascular, musculoskeletal, and neurological – with medium to large effect sizes.

Purpose: Goal Attainment Scaling (GAS) is used to assess functional gains in response to treatment. Specific characteristics of the functional goals set by individuals receiving botulinum toxin type A (BoNTA) injections for spasticity management are unknown. The primary objectives of this study were to describe the characteristics of the goals set by patients before receiving BoNTA injections using the International Classification of Functioning, Disability and Health (ICF) and to determine whether the pattern of spasticity distribution affected the goals set. Methods: A cross-sectional retrospective chart review was carried out in an outpatient spasticity-management clinic in Toronto. A total of 176 patients with a variety of neurological lesions attended the clinic to receive BoNTA injections and completed GAS from December 2012 to December 2013. The main outcome measures were the characteristics of the goals set by the participants on the basis of ICF categories (body functions and structures, activity and participation) and the spasticity distribution using Modified Ashworth Scale scores. Results: Of the patients, 73% set activity and participation goals, and 27% set body functions and structures goals (p0.05). Conclusion: Our results show that patients receiving BoNTA treatment set a higher percentage of activity and participation goals than body functions and structures goals. Goal classification was not affected by type of spasticity distribution or type of UMN disorder.

Objective To conduct a systematic review of the literature that examined the effect of botulinum toxin type A on clonus. Data Sources A literature search of multiple databases (PubMed, Cochrane, Google Scholar, Embase) was performed to identify articles published in English in the past 30 years (1986–2016). Study Selection Two reviewers independently applied the following inclusion criteria: (1) any adult patients older than 18 years with upper motor lesion; (2) any location and duration of clonus; and (3) subjective and objective measurements of clonus tested at least 2 weeks after botulinum toxin injection. Data Extraction Two reviewers independently extracted the data and assessed the methodological quality. A consensus method was used to solve disagreements. Data Synthesis The systematic review resulted in 164 articles, of which 14 met the inclusion criteria: 3 were randomized controlled trials, 1 was nonrandomized, and 6 were case series and 3 case studies. All studies (181 patients) showed improvement in clonus: 6 of 14 results were statistically significant. Different scales were used for clonus measurement, such as clonus score, patient diaries, clonus spasm score, and electromyogram duration. Conclusions Overall, there was preliminary evidence indicating improvement in clonus after botulinum injection. The major drawback with studies reviewed here was a large variation in the type of clonus assessment tools, which also lacked validity, reliability, and sensitivity to small changes in clonus.

Purpose: The purpose of this study was to estimate the interrater reliability of the Modified Ashworth Scale (MAS) using consistent movement speeds guided by a metronome when measuring wrist flexor and ankle plantar flexor spasticity in patients with an upper motor neuron (UMN) lesion. The MAS has been found to have inconsistent interrater reliability for scoring the degree of spasticity. Method: This quantitative cross-sectional pilot study occurred in the outpatient spasticity clinic of a community rehabilitation hospital. Participants were a convenience sample of 20 patients with UMN lesions receiving botulinum toxin type A injections for focal spasticity. For each of the muscle groups tested, different pairs of evaluators scored spasticity on the MAS at a velocity of 130° per second. Evaluators were physical therapy students trained by an experienced physical therapist in MAS assessment. Weighted κ values were calculated to measure interrater reliability for each muscle group. Results: The weighted κ values for the wrist flexors and ankle plantar flexors were, respectively, moderate (κw = 0.54; 95% CI: 0.21, 0.87) and slight (κw = 0.08; 95% CI: −0.34, 0.50). Conclusion: Using consistent movement velocity, novice evaluators were able to score spasticity with reasonable interrater reliability when assessing the wrist flexors but not the ankle plantar flexors.

Water-based exercises have been used in the rehabilitation of people with stroke, but little is known about the impact of this treatment on balance. This study examined the effect of water-based exercises compared to land-based exercises on the balance of people with sub-acute stroke.In this single-blind randomized controlled study, 32 patients with first-time stroke discharged from inpatient rehabilitation at West Park Healthcare Centre were recruited. Participants were randomized into W (water-based + land; n = 17) or L (land only; n = 15) exercise groups. Both groups attended therapy two times per week for six weeks. Initial and progression protocols for the water-based exercises (a combination of balance, stretching, and strengthening and endurance training) and land therapy (balance, strength, transfer, gait, and stair training) were devised. Outcomes included the Berg Balance Score, Community Balance and Mobility Score, Timed Up and Go Test, and 2 Minute Walk Test.Baseline characteristics of groups W and L were similar in age, side of stroke, time since stroke, and wait time between inpatient discharge and outpatient therapy on all four outcomes. Pooled change scores from all outcomes showed that significantly greater number of patients in the W-group showed improvement post-training compared to the L-group (p 0.05). More patients in W-group showed change scores exceeding the published minimal detectable change scores.A combination of water- and land-based exercises has potential for improving balance. The results of this study extend the work showing benefit of water-based exercise in chronic and less-impaired stroke groups to patients with sub-acute stroke.

The purpose of this study was to assess the prevalence of compartment syndrome or major bleeding episodes and compare compartment syndrome, patient and intervention characteristics in 110 patients with stroke (treated with Warfarin, new oral anticoagulants, antiplatelet, or no anticoagulants) treated for spasticity in deep leg compartment muscles with botulinum toxin injections [onabotulinumtoxinA (n = 77); incobotulinumtoxinA (n = 33)]. We reviewed 674 injection cycles (range 1–25 cycles per patient) and found no cases of compartment syndrome in any patient groups.

Objective:The adverse events (AEs) with botulinum toxin type-A (BoNTA), used for indications other than spasticity, are widely reported in the literature. However, the site, dose, and frequency of injections are different for spasticity when compared to the treatment for other conditions and hence the AEs may be different as well. The objective of this study was to summarize the AEs reported in Canada and systematically review the AEs with intramuscular botulinum toxin injections to treat focal spasticity.Methods: Data were gathered from Health Canada (2009-2013) and major electronic databases.Results: In a 4 year period, 285 AEs were reported. OnabotulinumtoxinA (n=272 events): 68% females, 53% serious, 18% hospitalization, and 8% fatalities. The type of AEs reported were – muscle weakness (19%), oropharyngeal (14%), respiratory (14%), eye related (8%), bowel/bladder related (8%), and infection (5%). IncobotulinumtoxinA (n=13): 38% females, 62% serious, and 54% hospitalization. The type of AEs reported were – muscle weakness (15%), oropharyngeal (15%), respiratory (38%), eye related (23%), bowel/bladder related (15%), and infection (15%). Commonly reported AEs in the literature were muscle weakness, pain, oropharyngeal, bowel/bladder, blood circulation, neurological, gait, and respiratory problems.Conclusion:While BoNTA is useful in managing spasticity, future studies need to investigate the factors that can minimize AEs. A better understanding of the underlying mechanisms of the AEs can also improve guidelines for BoNTA administration and enhance outcomes.

Amaç: Antikoagulan tedavi almakta olan hastalarda botulinum toksin (BTX) uygulamaları ile ilgili ulusal veya uluslararası rehberlerin olmaması, klinisyenlerin farklı yaklaşımlar sergilemesine neden olmaktadır. Bu araştırmada, klinisyenlerin bu grup hastalarda BTX uygulama yaklaşımlarının ortaya konması amaçlanmıştır. Gereç ve Yöntemler: Türkiye'de spastisite tedavisinde BTX uygulayan klinisyenlere yönelik elektronik anket çalışması gerçekleştirildi. Bulgular: Ankete 80 klinisyen katıldı. Rutin pratikte kullanılan BTX enjeksiyon teknikleri açısından klinisyenlar arasında belirgin farklılıklar saptandı. Ankete katılan klinisyenlerin %7'si antikoagulan kullanan hastalarda asla BTX enjeksiyonu yapmadığını, %4'ü International Normalized Ratio (INR) değerini kontrol etmeksizin enjeksiyonu gerçekleştiridiğini, geriye kalan %89'u ise, enjeksiyonları INR kontrolü ile gerçekleştirdiğini belirtti. Güvenli INR değeri, %45'i tarafından, Objective: In the absence of national or international guidelines, physician approaches to administer botulinum toxin (BTX) injections in patients on an anticoagulant therapy may be variable. We aimed to document the preferences and attitudes of physicians for controlling the bleeding risk of BTX injections in anticoagulated patients. Material and Methods: An electronic survey of physicians across Turkey who practice BTX administration for spasticity management was conducted.Results: In total, 80 physicians participated in the survey. There was a wide variance regarding the type of guidance and needle they used for injecting BTX in their routine practice. Among the respondents, only 7% reported refusing to administer BTX injections in anticoagulated patients, whereas 4% reported performing the injections without controlling the International Normalized Ratio (INR) value. Of the remaining respondents, the safe INR value for BTX injections was reported as

Purpose: To describe the nature, extent, and impact of spasticity; determine factors that are perceived to influence its severity; and examine the relationship between time since diagnosis and impact of spasticity on daily activities in people with stroke and multiple sclerosis (MS) who are receiving botulinum toxin injection treatments. Methods: After a cross-sectional telephone survey, descriptive statistics and correlations were analyzed separately for the stroke and MS groups. Results: A total of 29 people with stroke and 10 with MS were surveyed. Both groups perceived increased spasticity with outdoor cold (69% stroke, 60% MS), muscle fatigue (59% stroke, 80% MS), and mental stress (59% stroke, 90% MS). No statistically significant correlations were found between time since diagnosis and perceived impact of spasticity on function in the stroke (r=0.07, p=0.37) or MS (r=0.16, p=0.33) groups. The MS group experienced bilateral and more severe perception of spasticity in the legs than the stroke group and identified more factors as worsening their spasticity (p

Background. Balance impairments, falls, and spasticity are common after stroke, but the effect of spasticity on balance control after stroke is not well understood.Methods. In this cross-sectional study, twenty-seven participants with stroke were divided into two groups, based on ankle plantar flexor spasticity level. Fifteen individuals with high spasticity (Modified Ashworth Scale (MAS) score of ≥2) and 12 individuals with low spasticity (MAS score Results. The high spasticity group demonstrated greater ML COP velocity, trunk roll velocity, trunk roll velocity frequency amplitude at 3.7 Hz, and trunk roll velocity frequency amplitude at 4.9 Hz, particularly in the eyes closed condition (spasticitybyvisioninteraction). ML COP MPF was greater in the high spasticity group.Conclusion. Individuals with high spasticity after stroke demonstrated greater impairment of balance control in the frontal plane, which was exacerbated when vision was removed.

Spasticity and clonus are common clinical signs of upper motor neuron lesions poststroke. Intramuscular botulinum toxin-A injections have been shown to reduce spasticity and to improve quality of life. Upper extremity clonus can have a significant impact upon activities of daily living and can pose challenges to comfort, self-care, hygiene, and appearance. Although less common than in the ankle, it is important to understand how upper extremity clonus management may be beneficial to patients presenting with this finding. The majority of previous reports have focused on management of clonus in the lower extremity, but very few have addressed the management of upper extremity clonus. We present a case of poststroke upper extremity clonus with marked improvements following intramuscular botulinum toxin-A injections.

Objective The aims of this study were to systematically identify and summarize the literature examining the impact of physiologic and psychologic triggers on spasticity and discuss the evidence supporting various types of triggers. Design PubMed, EMBASE, CINAHL, and PEDro databases were searched using specific keyword combinations. Only studies using clinical tests or self-reports of spasticity were included. Results A total of 1152 articles were scanned for relevance, and of 44 relevant articles, 24 were reviewed. Pregnancy, posture, cold, circadian rhythm, and skin conditions increased spasticity and were measured using objective clinical tests. Self-reports of spasticity suggest that triggers such as bowel- and bladder-related issues, menstrual cycle, mental stress, and tight clothing can all increase spasticity. No literature evidence of increase in spasticity in response to heterotopic ossification, hemorrhoids, deep vein thrombosis, fever, and sleep patterns was found. Conclusions Although self-reports indicate a strong possibility of increasing spasticity, without objective examination, the true effects of these triggers on spasticity remain inconclusive. Most studies reviewed here were performed in the spinal cord injury population; therefore, it is not known whether these triggers induce similar effects in persons with other neurologic etiologies.

Botulinum toxin, frequently used to manage focal limb spasticity, has been reported to affect both extrafusal and intrafusal fibers of the injected muscle. Since most studies have used spinal reflexes, it is difficult to isolate the intrafusal effects from extrafusal and central effects. In a paper by On et al. [7], both stretch and H-reflexes were used to examine the intrafusal effects of botulinum toxin injections. Revisiting the data from On et al. [7] presented a unique opportunity to describe a novel method of measuring the effect of botulinum toxin-A on muscle spindle activity in patients with spasticity. H-reflex, maximum M-wave, and Achilles tendon reflex were serially assessed in ten patients with stroke pre-, 2, 4, and 12 weeks post-botulinum. In order to assess the intrafusal effects, we subtracted the %change in H-reflex amplitude from baseline (representing extrafusal and central effects) from the %change in Achilles tendon reflex amplitude from baseline (representing intrafusal, extrafusal and central effects). Using this formula, our results suggest that botulinum induces significant chemodenervation of the intrafusal muscle fibers (33% decreases). Intrafusal effects were greatest at 2 weeks, but tapered off by 12 weeks post-botulinum (p0.017). We found a significant positive correlation between the intrafusal effects of botulinum toxin and changes in modified Ashworth scale. Our method of assessing the effects of botulinum toxin shows significant effect on intrafusal fibers, which correlates with clinical manifestation of spasticity. Future studies need to investigate ways to maximize intrafusal effects and minimize extrafusal effects of botulinum therapy.

Purpose: We investigated the best position for shoulder retractor strengthening exercise to maximize middle trapezius activity and minimize rhomboid major activity. Although both trapezius and rhomboids are scapular retractors, rhomboids also act as downward rotators of the scapula, which can worsen subacromial impingement. Methods: Twelve healthy participants (age 30 [SD 6] y) with no history of shoulder pain were recruited for this study, which used fine-wire electromyography to examine maximal muscle activation of the middle trapezius and rhomboid major muscle fibres in four different positions: with the shoulder in 90° abduction with elbow completely extended and (1) shoulder internal rotation, (2) shoulder neutral rotation, (3) shoulder external rotation, and (4) rowing (shoulder neutral rotation and elbow flexed 90°). The ratio of trapezius to rhomboid muscles was compared with Wilcoxon signed-rank tests. Results: Muscle activation ratio during shoulder retraction exercise was significantly lower by 22% (i.e., rhomboid was more active than middle trapezius) when performed with the shoulder in rowing position (elbow flexed) than with the shoulder in external rotation (elbow extended) position (p=0.031). All four positions produced coactivation of trapezius and rhomboids. Discussion: Rowing position may not be the best position for shoulder retractor strengthening in patients with impingement syndrome. The preferable position for maximizing middle trapezius activity and minimizing rhomboid activity may be shoulder external rotation with elbow extended.

To conduct a systematic review of the literature that examined the effect of botulinum toxin type A on clonus.A literature search of multiple databases (PubMed, Cochrane, Google Scholar, Embase) was performed to identify articles published in English in the past 30 years (1986-2016).Two reviewers independently applied the following inclusion criteria: (1) any adult patients older than 18 years with upper motor lesion; (2) any location and duration of clonus; and (3) subjective and objective measurements of clonus tested at least 2 weeks after botulinum toxin injection.Two reviewers independently extracted the data and assessed the methodological quality. A consensus method was used to solve disagreements.The systematic review resulted in 164 articles, of which 14 met the inclusion criteria: 3 were randomized controlled trials, 1 was nonrandomized, and 6 were case series and 3 case studies. All studies (181 patients) showed improvement in clonus: 6 of 14 results were statistically significant. Different scales were used for clonus measurement, such as clonus score, patient diaries, clonus spasm score, and electromyogram duration.Overall, there was preliminary evidence indicating improvement in clonus after botulinum injection. The major drawback with studies reviewed here was a large variation in the type of clonus assessment tools, which also lacked validity, reliability, and sensitivity to small changes in clonus.

To understand physician preferences and bleeding complication rates of intramuscular botulinum neurotoxin type A injections for spasticity management in anticoagulated patients, questionnaires were mailed to 138 physicians across Canada. The international normalized ratio comfort range for injections was

Fung S, Phadke CP, Kam A, Ismail F, Boulias C. Effect of topical anesthetics on needle insertion pain during botulinum toxin type A injections for limb spasticity. Objective To compare pain perception using 3 anesthetics (eutectic mixture of local anesthetics [EMLA], vapocoolant spray, and ice) compared with a control (no anesthetic) during botulinum toxin type A (BTX-A) injections for lower limb spasticity. Design A placebo-controlled, single-blinded study where each study patient served as their own control. Setting Spasticity clinic. Participants Subjects (N=30) with ankle spasticity who visited the clinic for BTX-A injections in the gastrocnemius muscle were consecutively sampled. Intervention The gastrocnemius muscle was divided into 4 quadrants and 1 of the 3 different anesthetic agents was applied to each quadrant with 1 quadrant using no anesthetic, control. Main Outcome Measures Numerical Rating Scale (NRS) and the Wong-Baker FACES scale. Results Pain perception using the NRS and FACES scale was significantly lower using ice and EMLA compared with control and spray conditions ( P Conclusions Pain relief offered by EMLA and ice was comparable, suggesting that ice is a more convenient option because of brief application time (compared with EMLA). Spray may have made the patients more sensitive to pain and alternative approaches for using vapocoolant should be considered.

Objective: To assess the prevalence of pain in adults with spasticity and to assess the association between the subjective experience of pain and spasticity.Design: Cross-sectional study.Setting: outpatient spasticity management clinic of a rehabilitation centre.Patients: Patients with upper motor neuron lesions and spasticity (n=131) were recruited.Methods: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: Pain perception rated on a 10-point numerical rating scale and pain quality.Results:65% of the patients with spasticity reported presence of pain and 60% described it as an aching pain. More patients reported pain with movement (34%) compared to rest (21%). There was a statistically poor correlation between the severity of pain and spasticity (r=0.16; p>0.05). Most patients (80%) believed that their pain was related to spasticity and 62% reported that BoNTA injections decreased their pain.Conclusions:The high incidence of pain noted within our sample suggests that physicians may have to consider pain management as part of spasticity treatment. Participants reported that their pain was related to their spasticity, and that it decreased after BoNTA treatment. Further study is needed to explore the relationships between objective measures of spasticity and pain.

To determine the impact of cognitive interference on foot pedal reaction time among stroke survivors with right- (RH) or left-hemiplegia (LH).Cross-sectional comparison without randomization.10 patients post-stroke with RH, 10 with LH; 10 age-matched controls.Foot pedal response times were measured using three different reaction time (RT) paradigms: simple RT, dual-task RT (counting backward by serial 3 seconds), and choice RT (correct response contingent on stimuli to eliminate pre-programing). RH and LH used the non-paretic leg for all trials. Three 3 (RT task) × 3 (group) mixed-model factorial ANOVAs were used to compare RT, movement time (MT), total response time (TRT).Overall controls demonstrated faster RT than RH (332 ± 73 versus 474 ± 144 ms, P 0.001) or LH (402 ± 127 ms, P 0.05); LH group demonstrated faster RT than those with RH (P 0.05). Control subjects demonstrated significantly faster RT than RH for all RT conditions (P 0.05 for all). In contrast, controls achieved significantly faster RT than LH for the choice RT condition only (P 0.05), but not for the simple (P = 0.12) or dual-task RT conditions (P = 0.25).Compared to controls, response time was significantly impaired among LH and RH when the response could not be pre-programmed. While current simple RT testing commonly employed by driver rehab specialists may be sufficient for detecting RT deficits in patients with RH, simple or dual-task RT tests alone may fail to detect RT deficiencies among LH, even when testing the non-paretic limb. Choice RT should be added to post-stroke driver fitness assessment, particularly for patients with LH.

Purpose: In this case report, we describe the type and duration of a physical therapy and botulinum toxin type A (BoNTA) intervention directed at lower limb spasticity and the gait and balance improvement in a patient post-stroke. Treatment of focal spasticity with BoNTA intramuscular injections combined with physical therapy is recommended by rehabilitation experts. However, the optimal type and duration of physical therapy intervention to optimize any functional gains that follow chemodenervation induced by BoNTA has not been established. Method: One individual with chronic stroke who received BoNTA injections for upper and lower extremity spasticity was included. Physical therapy intervention consisted of 45- to 60-min sessions twice weekly for 12 weeks, based on the Bobath–neurodevelopmental therapy approach, and an activity-based home program. Results: After BoNTA injections and physical therapy, the patient made clinically significant improvements in balance and gait speed and became more independent with his ambulation. Conclusions: This case report demonstrates that physical therapy after BoNTA injections can result in significant functional improvements for individuals with spasticity after chronic stroke that may not be possible with BoNTA injections alone.

Boulias C, Meikle B, Pauley T, Devlin M. Return to driving after lower-extremity amputation. Objectives To study driving behaviors after major lower-extremity amputations and to determine which factors influence return to driving after amputation. Design A cross-sectional study. Setting Data were collected from patients attending an outpatient amputee and prosthetics clinic between February 2001 and September 2001. Participants A convenience sample (N=123). Inclusion criteria were: age greater than 18 years, unilateral or bilateral major lower-extremity amputation, minimum 1 year since prosthetic fitting, and active automobile driver within 6 months prior to amputation. Subjects had an average age of 63.4±12.1 years and were on average 6.8±8.3 years since amputation. Common causes for amputation were peripheral vascular disease (73.2%), trauma (13.8%), and tumor (12.2%). Interventions Not applicable. Main Outcome Measure Driving habits after lower-extremity amputation. Results Overall, 80.5% of participants were able to return to driving an average of 3.8 months after amputation, although the majority reported a decreased driving frequency. Female sex (odds ratio [OR]=.08; 95% confidence interval [CI], .02–.34), age of 60 years or greater (OR=.16; 95% CI, .03–.74), right-sided amputation (OR=.13; 95% CI, .03–.52), and preamputation driving frequency of less than every day (OR=.18; 95% CI, .05–.69) were all significantly related to a reduced likelihood of return to driving postamputation. Items that did not have a statistically significant association with return to driving included level of amputation, reason for amputation, preamputation automobile transmission, and accessibility to public transit. Subjects with left-sided amputation had significantly fewer concerns about driving, while those with a right amputation frequently required vehicle modifications (40.6%) or switch to a left-foot driving style for braking (81.3%) and accelerating (65.6%). Common barriers to return to driving included preference not to drive, fear and/or lack of confidence, and related medical conditions. Conclusions The majority of subjects with major lower-extremity amputation were able to return to driving after major lower-extremity amputation. Major automobile modifications are commonly performed by right-sided amputees. Several predictors of return to driving and barriers preventing return to driving were identified.

Meikle B, Boulias C, Pauley T, Devlin M. Does increased prosthetic weight affect gait speed and patient preference in dysvascular transfemoral amputees? Arch Phys Med Rehabil 2003;84:1657–61. Objectives To determine if increased prosthetic weight affects gait speed in dysvascular transfemoral amputees and to see if there is any patient preference for lighter versus heavier prostheses. Design Randomized prospective double-blind crossover trial. Setting Outpatient, tertiary care, amputee clinic in Ontario, Canada. Participants A convenience sample of 10 subjects with unilateral transfemoral amputations because of peripheral vascular disease. All subjects were independent community ambulators over 50 years old. Intervention Seemingly identical weights of 150g (placebo weight), 770g, and 1625g were added to the prosthesis 14cm below the knee joint. Main outcome measures Two-minute walk test (2MWT) and subject preference. Results The 2MWT results were not significantly influenced by weight added (mean, 53.4±28.4m, 55.1±28.9m, and 52.8±26.7m for 150g, 770g, and 1625g of added weight, respectively). Subject preference revealed that more than half preferred a weighted prosthesis over the "placebo" weight (5 subjects preferred 770g added, 4 subjects preferred 150g added, 1 preferred 1625g added). Conclusions Short-term intervention with increased prosthetic mass had no significant adverse affect on gait speed, and more than half of the subjects preferred an added mass condition.

When isolated myelin membranes were ADP-ribosylated by [32P]NAD+ either in the absence of toxin (by the membrane ADP-ribosyltransferase) or in the presence of cholera toxin, the same proteins were ADP-ribosylated in both cases and myelin basic protein (MBP) was the major radioactive product. Therefore, cholera toxin was considered a good model for ADP-ribosylation of myelin proteins. Although purified human MBP migrates as a single band on sodium dodecyl sulfate-polyacrylamide gel electrophoresis with a molecular mass of 20 kDa, the microheterogeneity that is masked under these conditions can be clearly demonstrated on alkaline-urea gels at pH 10.6. At this pH, MBP is resolved into several components that differ one from the other by a single charge (charge isomers). These charge isomers can be resolved on CM52 columns at pH 10.6, and several can be ADP-ribosylated. Component 1 (C-1), the most cationic charge isomer, incorporated 1.79 mol of ADP-ribose/mol of protein. C-2 and C-3 (which differ from C-1 by the loss of one and two positive charges, respectively) incorporated slightly less at 1.67 and 1.63 mol of ADP-ribose/mol of protein, respectively, whereas C-8, the least cationic, incorporated less than 0.11 mol/mol of protein. In the presence of neutral hydroxylamine, the ADP-ribosyl bond was shown to have a half-life of about 80 min, suggesting an N-glycosidic linkage between ADP-ribose and an arginyl residue of the protein.(ABSTRACT TRUNCATED AT 250 WORDS)

Although falls, balance impairment, and spasticity are common post-stroke, their interrelationship remains unclear. We review the literature for a) a relationship between spasticity and balance and b) the effect of botulinum toxin injections on balance. Electronic databases were searched based on two criteria: a) studies assessing balance in subjects with spasticity and b) studies examining the effect of botulinum toxin on balance. The primary findings were a) balance is impaired in subjects with spasticity, but only one study assessed relationship between spasticity and balance; and b) four studies reported that balance improves following botulinum treatment for limb spasticity. Persons with spasticity demonstrate impaired balance, but the correlation between spasticity and balance has not been adequately assessed in the literature. Evidence for balance changes following botulinum toxin is weak because of lack of randomization, control group comparison, objective balance assessment measures, and standard clinical scales.

Although inpatient stroke rehabilitation provides clinicians with the opportunity to prepare patients for continuation of prestroke activities, little is known about the patients' ability to safely resume driving at the point of discharge to the community.To compare foot pedal response times of 20 stroke patients with right hemiplegia (RH) or left hemiplegia (LH) and 10 controls.A cross-sectional design was used. Response times were measured using 3 foot pedal operation techniques: (1) right-sided accelerator with right leg operating accelerator and brake, (2) right-sided accelerator with left leg operating accelerator and brake, and (3) left-sided accelerator with left leg operating accelerator and brake. Outcomes included reaction time (RT), movement time (MT), and total response time (TRT).Controls demonstrated faster RT than patients with RH (263 vs 348 ms; P.001) or LH (316 ms; P.05) for all conditions, as well as faster MT than patients with RH (P.05 for all) but not LH when using the right leg (258 vs 251 ms; P = .82). Controls demonstrated faster TRT than patients with RH (P.001 for all) but not LH when using the right leg (515 vs 553 ms; P = .44).When using the nonparetic leg, patients with LH had braking response times comparable to controls, but patients with RH demonstrated significant impairment of both the paretic and nonparetic legs.

Subscapularis muscle spasticity is commonly treated with botulinum toxin injections; however, there are challenges in determining optimal injection sites within the muscle. The purpose of this study was to document the intramuscular innervation patterns of the subscapularis (1) to determine how the muscle is neuromuscularly partitioned and (2) to identify a strategy for botulinum toxin injection based on neuromuscular partitioning. In 50 formalin-embalmed cadaveric specimens, the extramuscular and intramuscular innervation was (1) serially dissected, digitized, and reconstructed in 3 dimensions (n=7); or (2) serially dissected and photographed (n=43). Intramuscular innervation patterns were compared among specimens to identify neuromuscular partitions. Variation was observed in the number (2-5) and origin of extramuscular nerve branches to the subscapularis. Despite variation in extramuscular innervation, the intramuscular innervation was consistent. Based on intramuscular innervation patterns, the subscapularis had 3 neuromuscular partitions (superior, middle, inferior) in 78% of specimens, and 2 partitions (superior, inferior) in 22% of specimens. The superior and middle partitions were most commonly innervated by branch(es) from the posterior cord, and the inferior partition by branch(es) from the axillary nerve. Injection of botulinum toxin into each partition may help to optimize results in the treatment of shoulder spasticity, and may be achieved by a combination of medial and inferior approaches. Clinical studies are required to determine whether the combination approach is more effective than any single approach and whether the number of partitions injected correlates with clinical outcomes.