Spasticity : an elusive problem after spinal cord injury

Abstract

The aim of this thesis was to characterize spasticity in individuals and in a near total prevalence population with traumatic spinal cord (SCI) injury by assessment of: Article I) Relation between Self-reporting of symptoms, neurologic examination (ASIA), physical therapy examination, ROM and complications; Article II) Repeated self-rating (VAS), and the relation between movement- provoked MAS rating and self-rating after a repetitive passive movement intervention; Article III) Correlation between movement-provoked MAS rating during simultaneous recording of EMG thigh muscle activity; Article IV) Correlation between Isokinetic movement-provoked resistive torque measurements during recording of EMG thigh muscle activity; and Article V) FES induced changes in body composition evaluated by CT and in spasticity by using the methods from articles II-IV.

Article I comprised the near-total prevalence population (n=354) of individuals with traumatic SCI in Stockholm. Article II comprised 45 individuals with various levels and degrees of injury. Articles III- V comprised 15 male individuals with a cervical motor complete SCI. Problematic spasticity was significantly more common in individuals with a cervical incomplete (ASIA B-D) injury. Reports of beneficial effects of spasticity were significantly less common in females and in subgroups with duration of injury less than 4 years. Spasticity was elicitable by movement provocation in only 60% of the individuals reporting spasticity. Spasticity of SCI subjects with a cervical injury fluctuated significantly (p<0.05) during time of the day, unlike spasticity of SCI subjects with thoracic injury. Immediately after intervention with passive movements, spasticity ratings (VAS) in SCI patients with a thoracic motor complete injury decreased by 11-14 mm (90%, p<0.001) as self-rated on VAS and by 1-2 grades (50%, p<0.001) as measured with MAS.

Spasticity was provoked in 50% of the subjects. while correlations between MAS grades and EMG values were calculated both including and excluding the MAS 0-grade ratings. 80% of spasticity MAS ratings (0-grades included) correlated significantly (p<0.05) with simultaneous EMG values. The flexion movement correlated significantly (p<0.05) irrespective of side and regardless whether O-grades were included or excluded as opposed to extension movement. Significantly higher isokinetic resistance (p=0.049) was provoked for extension movement compared to that of flexion. Contrary, the maximum EMG thigh muscle activity was significantly higher (p=0.009) during flexion provocation compared to that during extension. No change in FES induced spasticity (evaluated as in studies II-IV) was seen in the training group when compared with the control group. The training group increased their leg muscle volume by an average of 1300 cm3 (p<0.001) as compared to the control group who experienced no change. No significant changes were found in the subject's lower extremity or abdomen with regard to subcutaneous and visceral adipose tissue (AT).

This thesis has highlighted in subjective and objective data sets of spasticity in SCI man, the elusive nature of this prevalent symptom. Careful comparisons of self-assessments, clinical assessments, and in occasional systematic studies objective measures are recommended.