Abstract

Purpose:

To compare the effects of botulinum toxin injection with and without needle electromyographic guidance for the treatment of spasticity. Method: A randomized controlled study was conducted in a tertiary university hospital. Twenty-seven adult hemiplegic patients with spasticity due to brain or spinal cord damage were included. Spastic muscles were injected with botulinum toxin with or without EMG guidance. The modified Ashworth scale and modified Barthel index in each patient pre- and post-injection were documented.

Results:

In group A, which consisted of 15 patients (55.55%), the injection was administered with needle electromyographic guidance, while in 12 patients (44.44%) of group B without electromyographic guidance with the use of anatomic landmarks only. The follow-up period was 3 months. At 3 weeks post-injection, spasticity was decreased (p < 0.05) in all patients and the mean (SD) reduction of spasticity was higher (p < 0.05) in group A (1.67 (0.5)) than group B (1.25 (0.46)). Similarly, the mean (SD) functional modified Barthel index improved statistically significantly (p < 0.001) post-injection (45.37 (8.43)) than pre-injection (54.07 (9.610), especially in group A (p < 0.05).

Conclusion:

The effectiveness of intramuscular botulinum toxin injection for the treatment of spasticity in hemiplegic patients is superior when performed with needle electromyographic guidance than without electromyography. Implications for Rehabilitation It is recommended that botulinum toxin muscle injections of hemiplegic limbs be performed with EMG guidance More spasticity reduction and functional improvement at 3 months post-injection was observed in patients injected with botulinum toxin by the use of combined EMG guidance and anatomic landmarks EMG guidance might also save amount of botulinum toxin due to less spasticity observed during injection than when injection is performed with anatomic landmarks only.

Stroke is often characterized by disturbance in balance and mobility among the survivors with its attendant rehabilitation potentials. Static balance serves as a foundation for attainment of functions in patients with stroke, yet its determinants are usually under-estimated.This study was therefore designed to determine the influence of some clinical and demographic factors on static balance in stroke survivors.Eighty (80) hemiparetic stroke survivors participated in this cross-sectional survey. Demographic variables include age, height, weight and body mass index (BMI) whilst knee range of motion, (ROM) duration of stroke, levels of disability and spasticity of the paretic lower limbs of the participants were the clinical variables. Universal Goniometer, Barthel Index, and Modified Ashworth Scale were used to assess ROM, disability and spasticity levels respectively. The outcome measure for static balance was Functional Reach Test. Pearson's correlation coefficient analysis was performed to establish the correlations between some selected variables and the static balance. Level of significance was set at p<0.05.The mean age of the participants was 56.7+/-12.8 years. They comprised 37(46.2%) right hemiparetic and 43 (53.8%) left hemiparetic patients. Significant positive correlation was observed between functional reach scores and knee ROM, spasticity and disability levels (r=0.3; r=0.5; 0.2) respectively. However, the mean age, weight, height and BMI of the participants were not significantly correlated with functional reach scores.Joint range of motion, spasticity and disability levels were the main determinants of static balance in stroke survivors. These factors should be considered whilst priotizing goals during rehabilitation of stroke survivors.

In this paper possible mechanism of improvement of the functional state of the brain areas, maintaining movement, visual, auditory, and higher functions of the brain during correction of generalized spastic syndrome (botulinotherapy with Xeomin) in patients in a vegetative state (VS) is discussed. If to consider the vegetative state as stable pathological condition (SPC) of the brain, then from the perspective of the theory of structural and functional organization of the brain with systems with rigid and flexible elements (N.P. Behtereva), the therapy led to an unbalance of SPC, "functional release" of neurons and redistribution of their functions to provide other activities, the formation of new interneuronal connections. Taking into account the functional variability of neurons (S.V. Medvedev), blocking neuromuscular transmission in spastic muscles leads to a reduction of abnormal afferent and efferent hyperactivity of motor and sensory neuronal circuits, which releases the brain for other activities. This allows to consider botulinotherapy of pharmacoresistant muscle spasticity in patients in VS and minimal consciousness, not only as a symptomatic treatment, but also as a "indirect neuroprotection".

Existing functional evaluation tools do not accurately reveal the improved function following botulinum toxin A (BTX-A) injection for post-stroke upper limb spasticity. With the aim of developing an alternate method of measuring functional improvement following BTX-A injection, this study tested the feasibility, validity and reliability of video clip analysis performed by the clinicians. Seventy-nine patients administered BTX-A due to post-stroke upper limb spasticity, were retrospectively evaluated using video clip analysis. Pre- and post-injection video clips recorded at 1-month intervals were randomly allocated and sent to three blinded physician evaluators who were asked to choose the one that seemed more improved in terms of hand motion and associated upper limb reaction during gait. The three physicians chose the post-injection video clip as depicting improved hand motion (82.3%, 79.7%, and 72.2%) and associated upper limb reaction during gait (73.4%, 70.9%, and 70.9%). Kappa and intraclass correlation coefficient as a measure of interrater reliability among the three physicians was 0.86 and 0.79 for the hand, and 0.92 and 0.92 for associated upper limb reaction during gait, respectively. The percent overall agreement of the physicians was 78.1% and 71.7% for hand function and associated upper limb reaction, respectively. Retrospective pre- and post-BTX-A injection video clip analyses is a clinically feasible alternative method to evaluate the improvement following BTX-A injection for post-stroke upper limb spasticity, especially in busy clinical practice setting.

A 4-year-old boy presented with progressive neurodegeneration, mild coarsening of facies and spasticity. The classical neuroimaging guided the subsequent investigation of enzyme assay which confirmed the diagnosis of fucosidosis.

We report a female with infantile onset of systemic lupus erythematosus secondary to C1q deficiency, in whom we identified a novel homozygous mutation in C1qB. The patient developed a progressive encephalopathy associated with spasticity, and suffered several arterial ischaemic strokes. Cerebral imaging demonstrated acquired intracranial calcification and a cerebral vasculopathy reminiscent of moyamoya. This case demonstrates overlap with some features of Aicardi-Goutières syndrome which, like C1q deficiency, is a monogenic cause of inflammation involving dysregulation of the innate immune system and stimulation of a type I interferon response.

Neurobrucellosis is chronic brucellosis affecting the nervous system. It may mimic many neurological diseases but it rarely presents as polyradiculopathy. Brucellar radiculopathy was diagnosed in 6 patients who presented with weakness of the lower extremities. Five patients had lumbar puncture, 4 had magnetic resonance imaging of lumbar spine and 4 had nerve conduction studies. Five patients had areflexia and weakness; one had areflexia with proprioceptive ataxia. All patients had positive Brucella serology; cerebrospinal fluid showed lymphocytic pleocytosis, elevated protein, normal-low glucose; brucella serology was positive in all specimens. Nerve conduction studies showed absent F-wave in 2 patients and polyradiculopathy with secondary motor axonopathy in 2 patients; motor conduction velocity was normal in all. Magnetic resonance imaging with gadolinium injection showed enhancement of lumbar nerve root in 3 patients, and no enhancement in one. All patients improved after treatment with antibiotics and lumbar root enhancement disappeared. Symptoms of myelopathy were unmasked after radiculopathy had resolved in one patient. In endemic areas, brucella infection should be considered in the differential diagnosis of radiculopathy. Radiculopathy is probably due to inflammation of the meninges and the intrathecal portion of the roots. The pathogenesis of myelopathy may involve demyelination as spasticity persists or worsens after radiculopathy improves.

To describe the clinical profile, and identify its risk factors, of cerebral palsy (CP) as seen in a cohort of consecutive Saudi children aged between one and 3 years of age prospectively over a one-year period.Saudi children aged 1-3 years with CP (diagnosis based on specified criteria) were selected from children presenting to the Neurology service at the King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia with delayed milestones, seizures, mental retardation and difficulty with walking and evaluated at 3-monthly intervals for one year from January to December 2000. Information on gestation duration, labor and delivery, birth weight and the medical history of the mothers was obtained. Cranial computerized tomography and electroencephalography were carried out in addition to baseline investigations (toxoplasmosis, other, rubella, cytomegalovirus, and herpes simplex virus serology, serum lactate, pyruvate, amino acid screen, thyroid function tests, and chromosome analysis). Somatosensory, molecular genetics and muscle biopsy for histopathologic and histochemical studies were not performed in any of the patients.One hundred and eighty-seven children with CP were seen during the study period: 109 males (mean age 20.3 +/- 8.69 months); 78 females (mean age 20.6 +/- 8.55 months). Seventy-three had microcephaly (<5th percentile) with a mean head circumference of 44.5 +/- 3.69 cms for males and 43.0 +/- 4.16 for females. The main symptoms were inability to walk independently (54%), delayed speech (52%) and seizures (45%). The main neurologic features were motor weakness (85%), spasticity (60%), language dysfunction (42%), mental retardation (31%) and head lag (30%). A history of previous CP in the family was obtained in 8 patients (4%) but none of them had other features of hereditary spastic paraplegia. Electroencephalography abnormalities, present in 113 (73%) were more frequent in those without seizures than with seizures. Cranial computerized tomography abnormalities were mainly cerebral atrophy (60%) and hydrocephalus (53.7%). Twenty-five percent were from twin pregnancies; 56 (34%) were of low birth weight, 20% were pre-term deliveries, birth asphyxia was present in 165 and breech presentation was encountered in 8%.The main risk factors identified were twin pregnancy, pre-term delivery, prolonged labor, low birth weight and a history of previous CP in the family. Our findings suggest that improved maternal and childcare particularly in the ante and perinatal periods may reduce the incidence of CP in this environment.

Spasticity is common in patients with a variety of central nervous system disorders. It can lead to significant disability or cause complications that may result in severe morbidity. In such patients, treatment of spasticity is warranted. Several oral and parenteral medications are available for use in the treatment of spasticity. This article reviews the pharmacological properties and therapeutic effectiveness of these medications to provide a practical objective guide for physicians who may be involved in the management of spasticity.

OBJECTIVE:

Lack of adherence to medications for chronic conditions is a pervasive problem. This study examined adherence to baclofen, tizanidine, and dantrolene (FDA-approved oral spasticity medications) and identified determinants of adherence.

DESIGN:

Retrospective administrative claims data analysis, employing medical and pharmacy claims data and enrollment information from a large, national US health plan.

SUBJECTS:

and

Methods:

Subjects were commercial health plan members who: initiated treatment on baclofen, tizanidine, or dantrolene from January 1, 2004 through September 30, 2009; and had stroke, spinal cord injury (SCI), traumatic brain injury (TBI), cerebral palsy (CP), or multiple sclerosis (MS). Descriptive and logistic regression statistical analyses were performed. MAIN OUTCOME

MEASUREMENTS:

Outcomes were: adherence, measured as continuous medication possession ratio (MPR) and as a binary indicator (MPR ≥ 0.80 = adherent; MPR < 0.80 = non-adherent); change in oral spasticity medication; and use of non-oral spasticity therapy.

RESULTS:

The study population included 2,840 subjects. Adherence overall was poor: the range of mean unadjusted MPR values was 0.10 to 0.50, indicating that at best, subjects were adherent to their index spasticity medications for 50% of their treatment periods. Unadjusted overall MPRs for baclofen and tizanidine were 20.4% and 9.1%, respectively. Less than 5% of subjects changed oral spasticity medications. Results of logistic regression to identify determinants of adherence showed that subjects treated with tizanidine versus baclofen had 37.4% lower odds of adherence and those with TBI versus stroke had 77.5% lower odds of adherence. The odds of adherence increased with age and with pre-index contracture or decubitus ulcer.

CONCLUSIONS:

Adherence to oral spasticity medication adherence was poor irrespective of index spasticity medication or condition. Results from this study indicate that physicians cannot assume that patients are adherent to prescribed oral spasticity medications. A more complete understanding of the reasons behind non-adherence is required.