Interventions for managing skeletal muscle spasticity following traumatic brain injury

Abstract

Background Skeletal muscle spasticity is a major physical complication resulting from traumatic brain injury (TBI), which can lead to muscle contracture, joint stiffness, reduced range of movement, broken skin and pain. Treatments for spasticity include a range of pharmacological and non-pharmacological interventions, often used in combination. Management of spasticity following TBI varies from other clinical populations because of the added complexity of behavioural and cognitive issues associated with TBI. Objectives To assess the effects of interventions for managing skeletal muscle spasticity in people with TBI. Search methods In June 2017, we searched key databases including the Cochrane Injuries Group Specialised Register, CENTRAL, MEDLINE (Ovid), Embase (Ovid) and others, in addition to clinical trials registries and the reference lists of included studies. Selection criteria We included randomised controlled trials (RCTs) and cross-over RCTs evaluating any intervention for the management of spasticity in TBI. Only studies where at least 50% of participants had a TBI (or for whom separate data for participants with TBI were available) were included. The primary outcomes were spasticity and adverse effects. Secondary outcome measures were classified according to the World Health Organization International Classification of Functioning, Disability and Health including body functions (sensory, pain, neuromusculoskeletal and movement-related functions) and activities and participation (general tasks and demands; mobility; self-care; domestic life; major life areas; community, social and civic life). Interventions for managing skeletal muscle spasticity following traumatic brain injury (Review)

Management of Spasticity After Traumatic Brain Injury in Children

“…In a 2017 Cochrane review of post TBI spasticity treatment, there was insufficient evidence to report on the efficacy of the non-pharmacologic strategies (splinting, casting, physiotherapy, tilt table use and electrical stimulation) as well as the pharmacological strategies used (Baclofen and Tizanidine) in treating or preventing spasticity in patients after TBI (54). The review specifically mentioned that the studies looking at Baclofen in TBI-related spasticity, did not report their results adequately, so the role of Baclofen in TBI could not be evaluated (54).…”

“…Oral Baclofen (43,44) Performs better at reducing lower limb spasticity than upper limb (47) Intrathecal Baclofen Animal studies shows great benefit if early use (1st week), compared to at week 4 (39) Intrathecal Baclofen Early use safe, safe in children (48)(49)(50)(51) Dantrolene Poor evidence, high risk (40,45) Benzodiazepines High dose needed, good adjunct (45) Clonidine May dampen neural recovery (46) Clonidine Good adjunct treatment, low side effect profile (40) Gabapentin Good adjunct (40) Cannabinoids, SSRI's, Glycine agonists, Kynurenic acid All experimental (53) In a Cochrane review (54) All above has no strong evidence for or against in TBI Botox Very good clinical studies and effect (54,55) None of the lesioning techniques have been well studied in clinical TBI-related spasticity studies…”

Which interventions are useful for managing muscle spasticity in individuals who sustained traumatic brain injury? – A Cochrane Review summary with commentary

“…The authors (Synnot et al, 2017) concluded that there is significant uncertainty about the effectiveness or harms of these interventions in the management of post-TBI spasticity due to the very low quality and limited amount of evidence of the studies. One of the main reasons of this low quality was the poor report of the results of the studies that tested the effectiveness of baclofen and tizanidine.…”

Epidemiological Burden of Lower Limb Spasticity in Adults: A Systematic Review

“…[3] Spasticity can affect the entire body, [4] but LLS is generally worse because it affects mobility, balance, and independence along with adding burden on the carers. [5] Spasticity can lead to muscle contracture, joint stiffness, reduced range of movement, broken skin, and pain [6] and can significantly restrict patients' mobility and functional ability, their activities of daily living and can diminish their quality of life. [7] The incidence and prevalence of LLS vary geographically that its severity is associated with falls in persons with MS. [8] Distal paresis of the lower limb is considered an early predictor of spasticity in adults with ischemic stroke.…”

“…It is significantly different in patients with TBI due to behavioral and cognitive issues that affect their ability to participate in, or tolerate, treatment (e.g., their ability to follow instructions, monitor use of a spastic limb, or tolerate a cast). [6] The treatment of spasticity requires a multi-disciplinary approach and usually starts with physiotherapeutic approaches. However, a direct effect on abnormal muscle activity can only be achieved by pharmacological interventions.…”