Functional outcomes of spasticity-reducing surgery and rehabilitation at 1-year follow-up in 30 patients.

The effects of spasticity-reducing surgery in the upper extremity were assessed in a prospective observational study of 30 consecutive patients with stroke (n = 13), incomplete spinal cord injury (n = 9), traumatic brain injury (n = 5), cerebral palsy (n = 2), and degenerative central nervous system disease (n = 1). Surgery, which included lengthening of tendons and release of muscles, was followed by early rehabilitation at three intensity levels depending on the patients' specific needs and conditions. At 12 months follow-up there were significant improvements in all outcome measures with the following mean values: spasticity decreased by 1.4 points (Modified Ashworth Scale, 0-5), visual analogue pain score by 1.3 points, and both Canadian Occupational Performance Measures increased (performance by 3.4 and satisfaction by 3.6), and most measures of joint position or mobility improved. Hand surgery combined with early and comprehensive rehabilitation improves function, activity and patients' satisfaction in patients with disabling spasticity with improvement lasting for at least 1 year.Level of evidence: II.

Cortical activation changes and improved motor function in stroke patients after focal spasticity therapy--an interventional study applying repeated fMRI.

BACKGROUND: Impaired dominant hand function in stroke patients is a common clinical problem. Functional improvement after focal spasticity therapy is well documented but knowledge about central correlates is sparse. Brain activity was therefore followed during therapy with repeated functional magnetic resonance imaging (fMRI). The purpose was to analyse motor function and central nervous system (CNS) correlates in response to a standardized motor task in stroke patients after a comprehensive focal spasticity therapy. METHODS: Six consecutive first-time chronic stroke patients [4 women; mean age (SD) 66 (10) years] with right-sided hand paresis and spasticity were studied. Peripheral effects after focal spasticity management including intramuscular botulinum toxin type A (BoNT-A) injections were assessed on 3 occasions (baseline, 6 and 12 weeks) with functional tests. Brain effects were assessed on the same occasions by fMRI blood oxygen level dependent (BOLD) technique during a standardized motor task focusing on the motor and pre-motor cortex (Brodmann areas, BA4a, BA4p & BA6). For reference 10 healthy individuals [5 women; mean age (SD) of 51(8) years], were studied twice with ≥ 6 weeks interval. RESULTS: After therapy there was a significant reduction in spasticity and functional improvement in 5 of 6 patients. In response to the motor task there was a ~1.5 - 3% increase in brain activity in the motor and pre-motor cortex. At baseline, this increase was larger in the non-injured (ipsilateral) than in the contralateral hemisphere. Compared with healthy subjects the patients showed a significantly (2-4.5 times) higher brain activity, especially on the ipsilateral side. After therapy, there was a larger decrease in the ipsilateral and a minor decrease in the contralateral response, i.e. a clear lateralization of left-to-right in a normalizing direction in all areas. CONCLUSIONS: Comprehensive focal spasticity management was also in this study associated with brain reorganization in a "normalizing" left/right lateralization direction in addition to improved motor function. Furthermore, quantification of BOLD intensity in specified BAs showed reduced neuronal "over-activity" in the injured brain after therapy.

Short Form 36 assessed health-related quality of life after focal spasticity therapy.

OBJECTIVE: Analysis of the impact of an individualized comprehensive focal spasticity management on health-related quality of life. DESIGN: Prospective observational and interventional 12-week trial in a single-centre rehabilitation outpatient clinic. PATIENTS: Forty-one adult patients with upper motor neurone lesions (23 men), mean age 52 (standard deviation 13) years; 27 stroke, 7 cerebral palsy and 7 miscellaneous diagnoses. METHODS: Patients were assessed using the Short Form 36 (SF-36) Questionnaire before and after intramuscular injections of botulinum toxin type A combined with physical interventions. Spasticity was assessed with the Ashworth Scale (0-4). A verbal scale for patients' self-report of therapy effect was also used. RESULTS: Significant improvement was found in 3 of 8 SF-36 health scales: social (p = 0.008) and physical functioning (p = 0.026), and role physical (p = 0.048). Spasticity improved significantly (mean 1.1, p < 0.001). Improvement according to the verbal scale was observed for 57 (86%) indications (overall improvement in 36 patients, 88%). CONCLUSION: Comprehensive focal spasticity management with botulinum toxin type A intramuscular injections and physical interventions can improve patients' perceived health-related quality of life in addition to objectively and subjectively measured motor functions.

Focal spasticity therapy with botulinum toxin: effects on function, activities of daily living and pain in 100 adult patients.

OBJECTIVE: Analysis of the effects of a comprehensive focal spasticity program in adult patients. DESIGN: Retrospective study of an out-patient cohort. PATIENTS: One hundred patients were enrolled in the study (54 men and 46 women, mean age 41 years (SD 14). Cerebral palsy and stroke were equally common (80% in total). The remaining patients had miscellaneous diagnoses, including traumatic brain injury. METHODS: On average 230 units (SD 101) of botulinum toxin A Botox was given for 227 principal therapy targets chosen by the patient or the caregiver. One patient could have several targets for therapy. Administration of botulinum toxin was combined with 260 additional therapeutic interventions, most of which were forms of physical therapy. The effects were assessed after 6 weeks and compared with baseline functional abilities 1-2 weeks prior to therapy. RESULTS: Improvement was observed for 211 (93%) therapy targets, no change in 15 (7%), and impairment in 1, corresponding to an overall improvement in 90 patients (90%), 9 unchanged (9%) and worsening in 1. Spasticity assessment (Ashworth scale 0-4; 30 patients) showed a statistically significant improvement (median at baseline was 3 vs 2 after therapy, mean difference 1.2, p<0.001). CONCLUSION: Improvement was observed in >or=90% of patients and in their principal therapeutic targets in a cohort receiving their first focal spasticity treatment with botulinum toxin A and additional therapy. A strict strategy for patient selection and comprehensive management was followed.