Management of spasticity in individuals with spinal cord injury in the era of COVID-19 pandemic societal restrictions.

STUDY DESIGN: Cross-sectional telephone interviews. OBJECTIVE: The coronavirus disease (COVID-19) pandemic placed unprecedented pressure on healthcare systems worldwide. Here, we aimed to investigate the disruptions in management of spasticity and activities of daily living (ADL) in individuals with spinal cord injury (SCI) during the COVID-19 pandemic. SETTING: Two university hospitals in Istanbul, Turkey. METHODS: Twenty-four individuals with SCI exhibiting moderate and severe spasticity were enroled. All participants underwent ultrasound-guided botulinum toxin type A (BoNT-A) injections at two centres. A self-rated spasticity survey prepared by the authors was conducted. We questioned whether there was an increase in spasticity and the need for new BoNT-A injections during the societal restrictions of the COVID-19 pandemic. Spasticity severity in the previous week was rated using a numeric rating scale (NRS). ADL disrupted by spasticity were assessed by asking open-ended questions. RESULTS: In total, 75% participants reported a moderate increase in spasticity, 12.5% reported a severe increase, and 12.5% reported no difference. The mean spasticity NRS score was 6 (standard deviation = 2). Further, 87.5% (21) participants reported the need for BoNT-A treatment because of symptom re-emergence. When spasticity-induced deterioration in ADL was assessed, individuals mostly reported difficulties in walking, sitting on a wheelchair, and sleep disturbance due to spasticity. CONCLUSIONS: Most (87.5%) individuals with SCI reported a moderate or severe increase in spasticity during COVID-19 restrictions. Individuals with disabilities are an especially sensitive group and require specialised care during extraordinary circumstances, such as pandemics, hurricanes, or earthquakes. SPONSORSHIP: None.

Spasticity following brain and spinal cord injury: assessment and treatment.

PURPOSE OF REVIEW: Spasticity is a common sequela of brain and spinal cord injury and contributes to disability, reduces quality of life, and increases economic burden. Spasticity is still incompletely recognized and undertreated. We will provide an overview of recent published data on the definition, assessment, and prediction, therapeutic advances, with a focus on promising new approaches, and telemedicine applications for spasticity. RECENT FINDINGS: Two new definitions of spasticity have been recently proposed, but operational criteria should be developed, and test-retest and inter-rater reliability should be explored. Cannabinoids proved to be effective in spasticity in multiple sclerosis, but evidence in other types of spasticity is lacking. Botulinum neurotoxin injection is the first-line therapy for focal spasticity, and recent literature focused on optimizing its efficacy. Several pharmacological, interventional, and nonpharmacological therapeutic approaches for spasticity have been explored but low-quality evidence impedes solid conclusions on their efficacy. The recent COVID-19 pandemic yielded guidelines/recommendations for the use of telemedicine in spasticity. SUMMARY: Despite the frequency of spasticity, robust diagnostic criteria and reliable assessment scales are required. High-quality studies are needed to support the efficacy of current treatments for spasticity. Future studies should explore telemedicine tools for spasticity assessment and treatment.

How Did the Lockdown Imposed Due to COVID-19 Affect Patients With Cerebral Palsy?

BACKGROUND: The novel coronavirus infection (SARS-CoV-2) caused disruption of the treatment and follow-up evaluations of children with cerebral palsy. AIM: The change in mobility, pain, functional status, and spasticity was investigated who were followed in a pediatric rehabilitation unit after the lockdown. METHODS: One hundred ten children were evaluated. Pain, severity of spasticity, botulinum toxin administration dates, and continuity of home exercises were recorded. The functional status was evaluated with the Functional Independence Measure for Children (WeeFIM). RESULTS: The WeeFIM self-care and mobility subscale scores and total scores were significantly worse. Only 5 of the participants had pain in the previous evaluations; in the last evaluation, 29 had pain complaints. The pain and spasticity severity of the participants whose botulinum toxin administration was delayed were significantly increased. CONCLUSIONS: The children with cerebral palsy should be followed with telemedicine at short intervals, and when necessary, in the hospital.

Atypical cutaneous and musculoskeletal manifestation of SARS-CoV-2: 'COVID-19 toes' and spasticity in a 48-year-old woman.

Establishing accurate symptomatology associated with novel diseases such as COVID-19 is a crucial component of early identification and screening. This case report identifies an adult patient with a history of clotting dysfunction presenting with rare cutaneous manifestations of COVID-19, known as 'COVID-19 toes'', previously described predominantly in children. Additionally, this patient presented with possible COVID-associated muscle spasticity of the lower limbs, as well as a prolonged and atypical timeline of COVID-19 infection. The rare occurrence of 'COVID-19 toes'' in this adult patient suggests that her medical history could have predisposed her to this symptom. This supports the coagulopathic hypothesis of this manifestation of COVID-19 and provides possible screening questions for patients with a similar history who might be exposed to the virus. Additionally, nervous system complaints associated with this disease are rare and understudied, so this novel symptom may also provide insight into this aspect of SARS-CoV-2.

Consensus recommendations for botulinum toxin injections in the spasticity management of children with cerebral palsy during COVID-19 outbreak

Spasticity is the most common motor disturbance in cerebral palsy (CP). Lockdown in the COVID-19 outbreak has profoundly changed daily routines, and similarly caused the suspension of spasticity treatment plans. Besides, the delay in botulinum toxin (BoNT) injection, which is important in the management of focal spasticity, led to some problems in children. This consensus report includes BoNT injection recommendations in the management of spasticity during the COVID-19 pandemic in children with CP. In order to develop the consensus report, physical medicine and rehabilitation (PMR) specialists experienced in the field of pediatric rehabilitation and BoNT injections were invited by Pediatric Rehabilitation Association. Items were prepared and adapted to the Delphi technique by PMR specialists. Then they were asked to the physicians experienced in BoNT injections (PMR specialist, pediatric orthopedists, and pediatric neurologists) or COVID-19 (pediatric infectious disease, adult infectious disease). In conclusion, the experts agree that conservative management approaches for spasticity may be the initial steps before BoNT injections. BoNT injections can be administered to children with CP with appropriate indications and with necessary precautions during the pandemic.

Discontinuation of botulinum neurotoxin type-A treatment during COVID-19 pandemic: an Italian survey in post stroke and traumatic brain injury patients living with spasticity.

BACKGROUND: The COVID-19 pandemic has affected health-care systems worldwide, including the outpatient spasticity care with botulinum neurotoxin toxin type A (BoNT-A). AIM: The aim of this study was to investigate the impact of discontinuation of BoNT-A treatment on patients living with spasticity during the COVID-19 quarantine. DESIGN: A multicentric cross-sectional study. SETTING: Outpatients setting. POPULATION: Patients with spasticity after stroke and traumatic brain injury treated with BoNT-A. METHODS: A phone-based survey was conducted from March to May, 2020. Based on the International Classification of Functioning, Disability and Health (ICF), an ad hoc questionnaire CORTOX (CORonavirus TOXin survey) was developed to investigate patients' experiences following the discontinuation of their usual treatment for spasticity due to the lockdown and its implication on their health perception. It assessed patients' condition and explored different ICF domains related to spasticity: unpleasant sensations, mobility, self-care, facilitators and psychosocial factors. The sum of those represented the CORTOX score (Max 142). The questionnaire also collected data about the impact of COVID-19 on patients' wellbeing (mood, sleep, relationships, community life, motivation). RESULTS: A total of 151 participants completed the survey. Most participants (72.2%) experienced a worsening in perceived spasticity, 53% got worse in independence and 70.9% had a negative impact on quality of life. The mean CORTOX score was 52.85±27.25, reflecting a perceived worsening in all ICF domains investigated. Moderate to strong correlations were found between different sub-scores of the questionnaire and severity of spasticity (P<0.001). COVID-19 psychosocial related factors were associated with loss of independence (P<0.05) but only mood was associated with worsening of spasticity (P<0.001). The lack of rehabilitation therapy was significantly associated with the worsening of independence but not with the worsening of spasticity. Finally, respondents reported that BoNT-A was useful to their condition and should not be discontinued. CONCLUSIONS: The discontinuation of BoNT-A treatment was associated with worsening of activities and participation and perceived spasticity. COVID-19 related problems and rehabilitation showed an association with loss of independence. CLINICAL REHABILITATION IMPACT: This study will provide useful information in the field of spasticity management using a patient's centred approach, with consistent quantitative and qualitative information.