Neurophysiological methods for the assessment of spasticity: the Hoffmann reflex, the tendon reflex, and the stretch reflex

Purpose: To review the literature concerning neurophysiological methods to assess spasticity with respect to mechanisms and methodology, and to describe the three most commonly used methods: the Hoffmann reflex (H-reflex), the Tendon reflex (T-reflex), and the Stretch Reflex (SR).\ud Method: A systematic internet database search was performed to identify neurophysiological measurement methods of spasticity. A systematic exclusion procedure resulted in 185 included references, completed by additional informal search. For this paper, information about the H-, T- and stretch reflexes was extracted from these references. \ud Results: Although the reflexes are basically monosynaptic, there are many supraspinal pathways which modulate the responses in terms of their amplitude and latency. As a consequence the methods are sensitive to a considerable number of experimental conditions and are characterized by a moderate reliability and sensitivity. Correlations with other (i.e. biomechanical, neurophysiological or clinical) spasticity assessment parameters are moderate to poor. Standardised and broadly accepted protocols are still largely lacking preventing an effective exchange of knowledge. \ud Conclusions: The clinical and experimental use of the three methods is restricted due to moderate reliability and sensitivity. It is recommended to perform combined neurophysiological – biomechanical assessment of spasticity during active, functional movement

Effects of Ambulant Myofeedback Training and Ergonomic Counselling in Female Computer Workers with Work-Related Neck-Shoulder Complaints: A Randomized Controlled Trial

Objective: To investigate the effects of ambulant myofeedback training including ergonomic counselling (Mfb) and ergonomic counselling alone (EC), on work-related neck-shoulder pain and disability. Methods: Seventy-nine female computer workers reporting neck-shoulder complaints were randomly assigned to Mfb or EC and received four weeks of intervention. Pain intensity in neck, shoulders, and upper back, and pain disability, were measured at baseline, immediately after intervention, and at three and six months follow-up. Results: Pain intensity and disability had significantly decreased immediately after four weeks Mfb or EC, and the effects remained at follow up. No differences were observed between the Mfb and EC group for outcome and subjects in both intervention groups showed comparable chances for improvement in pain intensity and disability. Conclusions: Pain intensity and disability significantly reduced after both interventions and this effect remained at follow-up. No differences were observed between the two intervention groups

Muscle activation patterns of knee flexors and extensors during passive and active movement of the spastic lower limb in chronic stroke patients

The aim of this study was to describe the characteristics of spasticity, quantified as muscle activity during stretch, during passive and active movement. For this cross sectional study 19 stroke patients with spasticity in the lower limb were recruited. Reflex activity was studied with surface electromyography of knee flexor and extensor muscles during passive and active movement of the lower leg.\ud \ud On both the affected and unaffected side, root mean square values of the knee extensor muscles, while stretched, were higher during active than during passive movement (p < 0.05). For the vastus lateralis (VL) the correlation was moderate (ρ = 0.54, p = 0.022), for the rectus femoris (RF) high (ρ = 0.83, p < 0.001). For the semitendinosus (ST) the correlation was low (ρ = 0.27) and not significant.\ud \ud During active movement the correlation between VL activity and activity of the antagonist ST, as an indicator for co-contraction of the affected muscles, was marked (ρ = 0.73, p = 0.001). A moderate negative correlation was found between reflex activity of RF during passive stretch and the active range of motion (ρ = −0.51, p = 0.027).\ud \ud The results show that a passive stretch test alone is insufficient either as assessment method for spasticity during active motor tasks or as a measure for motor control.\ud \ud \u

Are changes in pain as a result from myofeedback training related to changes in muscle activation patterns in patients with work related myalgia

The objective of this explorative study was to investigate to what extent changes in perceived pain, induced by myofeedback training, are correlated to changes in muscle activation patterns. Thirty subjects with work-related myalgia received myofeedback training. Before (T0), directly after (T1) and 4 weeks or, in a subset of patients, 3 months after (T2) this training, surface electromyography (sEMG) measurements of the upper trapezius muscle were performed during standardized computer tasks; a typing and a stress task. Besides this, visual analogue scales (VAS) were filled in to assess the levels of pain in the neck and shoulders. From the sEMG, root mean square (RMS) and relative rest time (RRT, i.e. the percentage of time RMS is below a certain threshold) were used for data analysis. The relationships between RRT, RMS and VAS at T0 as well as for the changes between T1–T0 and T2–T0 were investigated using Spearman correlation coefficients. The results revealed no significant correlations between VAS and RMS both at baseline (range R =−0.22 to 0.17) and for the observed changes (range R =−0.33 to 0.32). Also, for VAS and RRT, low correlations were found for baseline (range R =−0.27 to 0.21) and for changes between T1–T0 (range R =−0.02 to 0.38). However, for the changes between T2–T0, correlation coefficients for the VAS for the shoulder and the RRT of the right trapezius during both the typing and stress tasks were significant at the P =0.05 level, whereas the correlation coefficients for the VAS for the neck and both the left and right trapezii during the stress task approached significance ( P =0.05 and P =0.1, respectively). These results suggest that decreases in pain observed at long term follow up after myofeedback training might occur as a result of an increased ability to relax but not as a result of decreased muscle activation level. However, the largest correlation found was 0.6. This means that the maximal explained variance ( $R^2$) is low (36%), and that there are also other processes than the changes in muscle activation that contribute to changes in perceived pain

Prognostic factors for the effects of two interventions for work-related neck-shoulder complaints: Myofeedback training and ergonomic counselling.

Aim\ud To explore prognostic factors for the effects of two interventions (myofeedback training in combination with ergonomic counselling (Mfb/EC) and ergonomic counselling alone (EC)) on discomfort and disability in work-related neck–shoulder complaints.\ud \ud Methods\ud Thirty-six females completed the interventions. Discomfort and disability were assessed at baseline, immediately after the intervention, and at 3-month follow-up. Potential sociodemographic and psychological prognostic factors were assessed using questionnaires. Data were analysed using multiple regression and general linear modelling.\ud \ud Results\ud Changes in discomfort were best predicted by baseline discomfort levels. Changes in disability were predicted by baseline disability levels, patient profile, and coping strategy ‘ignoring sensations’. A significant difference between the Mfb/EC and EC group was found for coping strategy ‘ignoring sensations’, which appeared to be a predictor for changes in disability at 3-month follow-up in the Mfb/EC group only.\ud \ud Conclusions\ud Subjects with high levels of initial discomfort and disability and specific psychological patient profiles benefit most from interventions. Myofeedback training contributes a specific quality to those who ignore pain sensations.\ud \u

Patient ratings of spasticity during daily activities are only marginally associated with long-term surface electromyography

AIM: To investigate the association between subjective spasticity ratings and objective spasticity measurement using a new tool for spasticity assessment, that is long-term surface electromyography (sEMG) recordings during daily activities. For monitoring, processing and analysis of this long-term sEMG data, a muscle activity detection algorithm was developed. METHOD: sEMG of the rectus femoris, vastus lateralis, adductor group and semitendinosus of 14 complete spinal-cord-injured patients, in whom voluntary muscle contraction was absent, was recorded continuously during daily activities. Synchronously, subjects stored their activities in a diary and scored their experienced level of spasticity on the Visual Analogue Scale (VAS) for that particular activity. sEMG data were analysed using a high-quality burst-detection algorithm that was developed and validated within this study. Derived sEMG parameters were clustered using principal-component analysis (PCA) and used in a linear mixed model analysis to study their association with VAS. RESULTS: VAS scores appeared significantly associated with the PCA components representing the number and the duration of bursts, but not burst amplitude. Furthermore, VAS scores were associated with the activity performed. The percentage explained variance was, however, low, that is 27-35%. CONCLUSIONS: Patient ratings of the level of spasticity appear poorly associated with spasticity in terms of involuntary muscle activity assessed with long-term sEMG recordings. It is likely that other factors such as pain and cognitions are also incorporated in these patient ratings. Clinicians are therefore strongly advised to perform complementary objective assessments using long-term sEMG recordings.\ud \ud \ud \u

The receptiveness toward remotely supported myofeedback treatment

Remotely supported myofeedback treatment (RSMT) is considered to be a potentially valuable alternative to the conventional myofeedback treatment, as it might increase efficiency of care. This study was aimed at examining the receptiveness of potential end users (patients and professionals) with respect to RSMT. By doing so, protocols of RSMT can be developed which fit to the needs of end users and enhance treatment adherence. For both end-user groups, questionnaires were developed focusing on two components of the attitude–social support–self-efficacy (ASE) model. Fifteen patients with neck–shoulder complaints previously treated with conventional myofeedback and 17 professionals participated in the study. Results showed positive attitudes toward RSMT in 53% of the patients, and 67% of them were willing to participate in RSMT. Of the 17 professionals included in the present study 43% reported a positive attitude. In addition, 40% of the patients and 100% of the professionals believed their self-efficacy level to be sufficient for RSMT. In addition to e-consultations, 40% percent of the patients suggested that the optimal frequency of structural in vivo contact with their therapist would be once per 2 weeks, which is less frequent compared to the weekly in vivo contacts in the conventional myofeedback treatment. Professionals emphasized the importance of nonverbal communication and physical interaction (as in in vivo contact) in remote treatment concepts

Perceived spasticity in chronic spinal cord injured patients: Associations with psychological factors

Purpose: To explore the association between perceived spasticity and psychological factors (pain sensations, coping strategies, and illness cognitions) in chronic spinal cord injured (SCI) patients. - \ud Methods: Cross-sectional study using a set of questionnaires was designed for chronic complete patients with SCI and with self-reported leg spasticity. Outcome measures were Visual Analogue Scale for average perceived leg spasticity (VASSpasticity), VASPain for average perceived pain sensations in the leg, Utrecht Coping List (UCL) including its seven subscales, and Illness Cognition Questionnaire (ICQ) with its three subscales. Psychological factors with a bivariate correlation with VASSpasticity of p<0.2 were selected for regression analyses. - \ud Results: Nineteen patients with SCI (response rate 86%) participated. Bivariate correlations of p<0.2 were found between VASSpasticity and VASPain, UCLActive approach, UCLSeeking social support, UCLReassuring thoughts, ICQAcceptation, and ICQHelplessness. Only UCLReassuring thoughts (Beta −0.59, p=0.01) and ICQHelplessness (Beta 0.50, p=0.02) were retained in the multivariate model, explaining 44% of the variance in VASSpasticity (R2adjusted). - \ud Conclusions: Perceived spasticity appeared associated with psychological factors in complete patients with SCI: Those with higher levels of reassuring thoughts and lower levels of helplessness reported relatively lower levels of perceived spasticity. Large prospective cohort studies are recommended

Stop using the Ashworth Scale for the assessment of spasticity.

Item does not contain fulltextAIM: Many studies have been performed on the methodological qualities of the (modified) Ashworth Scale but overall these studies seem inconclusive. The aim of this study was to investigate the construct validity and inter-rater reliability of the Ashworth Scale (AS) for the assessment of spasticity in the upper and lower extremities. METHOD: A cross-sectional study on spasticity in the elbow flexors (part 1) and knee extensors (part 2) was carried out. In both parts AS was assessed while muscle activity and resistance were recorded simultaneously in patients with upper motor neuron syndrome. Each patient was measured by three raters. RESULTS: 30 patients participated, 19 in each part of the study. For elbow flexor muscles, AS was not significantly associated with electromyographic parameters, except for rater 2 (rho = 0.66, p<0.01). A significant moderate association was found with resistance (0.54< or = rho < or =0.61, p<0.05). For knee extensors, AS scores were moderately associated with muscle activity (0.56< or = rho < or =0.66, p<0.05) and also with resistance (0.55< or = rho < or =0.87, p<0.05). The intraclass correlation coefficient for absolute agreement was 0.58 for elbow flexors and 0.63 for knee extensors. In linear mixed model analysis, the factor rater appeared to be highly associated with AS. CONCLUSION: The validity and reliability of the AS is insufficient to be used as a measure of spasticity.1 januari 201

Survey of 5 European countries suggests that more elements of patient-centered medical homes could improve primary care

Item does not contain fulltextThe patient-centered medical home is a US model for comprehensive care. This model features a personal physician or registered nurse who is augmented by a proactive team and information technology. Such a model could prove useful for advanced European systems as they strive to improve primary care, particularly for chronically ill patients. We surveyed 6,428 chronically ill patients and 152 primary care providers in five European countries to assess aspects of the patient-centered medical home. Although most patients reported that they had a personal physician and no problems in contacting the practice after hours, for example, other aspects of the patient-centered medical home, such as provision of written self-management support to patients, were not as widespread. We conclude that despite strong organizational structures, European primary care systems need additional efforts to recognize chronically ill patients as partners in care and can embrace patient-centered medical homes to improve care for European patients