Filatov E.V., Konovalova N.G., Uryupin V.Yu., Palatkin P.P., Lyakhovetskaya V.V.
Novokuznetsk Scientific Practical Center of Medicosocial Expertise and Rehabilitation for Disabled Persons, Novokuznetsk, Russia
TIME COURSE OF SPASTIC SYNDROME IN PATIENTS WITH TRAUMATIC SPINAL CORD INJURY DURING TREATMENT AND ITS EFFECTS ON MOTOR REHABILITATION
More than 10,000 cases of spine and spinal cord
injuries, mainly in young persons of working age, are registered in the Russian
Federation each year. In 2006, the number of the persons with history of spinal
cord injury was 250 thousand in Russia [1].
Spine and spinal cord injury causes the persistent
somatic and neurogenic disorders leading to disability in 80-95 % in survived
patients. The course of spinal cord traumatic disease (SCTD) is characterized
by disordered functioning of many organs and systems. The most significant
disorders are loss or disorder of locomotor, urinary and neurotrophic
functions. Most patients after spine and spinal cord injury cannot move
independently, cannot control the function of pelvic organs and require for
constant attention and care [2].
However each patient has his/her own rehabilitation
potential, which allows forming the postural activity and movements, and
restoring the life and work skills. Particularly, even in absence of voluntary
motions below the level of spinal cord injury, the patient could be adapted to
movement in the wheel-chair and to independent walking.
Restoration, compensation and replacement of lost
functions often limit both decreasing muscular strength and such manifestations
of SCTD as neuropathic pain syndrome, bedsore wounds, infectious processes in
urinary tract and orthopedic pathology of the extremities which require for
specific treatment. Often, correction of complications of SCTD and psychological
aid go before the procedures for restoration of motion functions [3-6]. One
need to note the spastic syndrome, which is difficult to correct, but it limits
the possibilities of use of the available rehabilitation potential.
Objective
– to study the occurrence rate of spastic syndrome in patients with
traumatic spinal cord injury, its course associated with treatment and effects
of motor rehabilitation.
MATERIALS AND METHODS
The subject of the study included 884 cases of SCTD.
The patients were admitted for restorative treatment to Novokuznetsk Scientific
Practical Center of Medicosocial Expertise and Rehabilitation for Disabled
Persons. There were 699 men and 185 women. The mean age of the patients was 36.2 (95 % CI 35.4-37). The mean age of the men was 36.1 (95 % CI 35.2-37); the mean age of the
women – 36.4 (95 % CI 34.7-38.1).
The examination included the complex orthopedic
examination [2], radial diagnostics, ultrasonic examination of internal organs,
duplex scanning of vessels of the extremities. The intensity of spastic
syndrome was estimated with Ashworth scale. The degree of neurological
disorders was estimated with the scale from American Spinal Injury Association
(ASIA). The characteristics of neurogenic dysfunction of lower urinary tracts
were estimated in the complex urodynamic examination. Locomotor possibilities
were estimated according to the compensation level (CL) of the following
functions: turning in lying, sitting, standing and walking [3].
For achievement of the task, the patients were
distributed into two big groups. The main group included the patients with
spastic syndrome, the control one – without it. The main group was divided into
three subgroups according to treatment types. The first subgroup included the
patients with conservative treatment of spasticity and concurrent pathology
(remedial gymnastics, kinesitherapy, physical therapy, drug therapy). The
second subgroup included the spine and spinal cord surgery (decompressive,
stabilizing, decompressive and stabilizing) and functional neurosurgery –
epidural implantation of electrodes with subsequent electric neuromodulation of
the spinal cord, destructive methods of
functional surgery (rhizotomy, DREZ surgery, neurotomy) and chemical neuromodulation
of the spinal cord (subarachnoidal introduction of dalargin).
The third subgroup received the surgical correction
of concurrent pathology (urologic, orthopedic, surgical treatment of bedsore
wounds, minor purulent surgery).
The patients without spastic syndrome were included
into the comparison group including two subgroups. The first subgroup of the
second group included the patients who were admitted for conservative medical
rehabilitation (the same as in the first subgroup of the main group). The
second group included the patients who received the surgical treatment of
concurrent pathology (the same as in the third subgroup of the main group).
The statistical analysis of the results of the
study: χ2
test was used for comparison of relative frequencies; the correlation analysis
was conducted according to Spearman’s technique. Wilcoxon-Mann-Whitney test was
used for estimation of differences in disconnected samples. The differences were
statistically significant with p < 0.05. The statistical calculations were performed
with Statistica 10.0.1011.0 (StatSoft Inc., USA).
RESULTS
The
total amount of the patients without spastic syndrome was 228 patients (26 %).
Most patients had the injuries in the inferior thoracic spine (ITS) and in the
lumbar spine (LS). The neurological disorders of the type A were more common
for ITS, the type C – for LS.
The
patients with spastic syndrome were 74 % (656 patients). The highest number of
the patients in this group also had some neurological disorders of the types A
and C, but the spinal cord injury was more often in the cervical spine (CS) and
in the superior thoracic spine (STS).
The
table 1 shows the distribution of the patients according to a spinal injury
level and intensity of neurological deficiency. The statistical analysis of the
data from the table 1 identified the high incidence of a combination of type A
neurological disorders with ITS injury (p < 0.05) in the group of the
patients without spastic syndrome. The type C of neurological disorders was
more often in ITS and LS (p < 0.05). These comparisons were conducted in
relation to injuries to other spinal regions and types of neurological
disorders.
Table 1. Distribution of patients with spinal cord traumatic disease according to presence of spastic syndrome, level of spine injury and degree of neurological deficiency
Injury type according to ASIA |
Spinal cord injury level |
Total |
|||
Cervical |
Upper thoracic |
Lower thoracic |
Lumbar |
||
Group without spastic syndrome, n = 228 |
|||||
А |
6 |
6 |
60 |
22 |
94 |
В |
2 |
0 |
18 |
8 |
28 |
С |
0 |
0 |
37 |
34 |
71 |
D + Е |
2 |
4 |
9 |
20 |
35 |
Total |
10 |
10 |
124 |
84 |
228 |
Group with clinical course of spastic syyndrome, n = 656 |
|||||
А |
123 |
151 |
58 |
11 |
343 |
В |
54 |
18 |
10 |
9 |
91 |
С |
77 |
18 |
34 |
14 |
143 |
D + Е |
48 |
14 |
10 |
7 |
79 |
Total |
302 |
201 |
112 |
41 |
656 |
The
similar analysis of the clinical group of the patients with spastic syndrome
identified a higher incidence of type A neurological disorders and injuries in
CS and STS (p < 0.05) in comparison with other spinal parts and other types
of neurological disorders.
After
the treatment, the intensity of spastic syndrome decreased in most patients.
The table 2 shows the data of time course of amount of the patients with
different level of spasticity in dependence on the used technique of treatment.
The analysis of the table 2 showed that the conservative treatment techniques
for SCTD complicated by spastic syndrome were used more often than surgical
techniques of correction and surgical management of concurrent pathology (p
> 0.001). The choice of treatment techniques did not depend on intensity of
spastic syndrome.
Table 2. Time course of number of patients with different level of spasticity under influence of various treatment techniques, n = 656
Treatment technique |
Number of patients |
||||||
Spasticity according to Ashworth |
Total |
||||||
4 points |
3 points |
2 points and less |
|||||
1 |
2 |
1 |
2 |
1 |
2 |
||
Conservative treatment |
46 |
22 |
188 |
173 |
142 |
181 |
376 |
Functional neurosurgery, chemical neuromodulation, spinal surgery |
39 |
15 |
44 |
47 |
38 |
59 |
121 |
Surgical management of concurrent pathology |
32 |
7 |
77 |
76 |
50 |
76 |
159 |
Total |
117 |
44 |
309 |
296 |
230 |
316 |
656 |
Note: 1 – amount of patients before treatment; 2 – amount of patients after treatment.
The table 3 shows the time course of spastic syndrome, motional and locomotor values in relation to the treatment techniques. The conservative treatment decreased the number of the patients with spastic syndrome of 4 points (p < 0.05). The insignificant decrease of the patients with spastic syndrome of 3 points was observed (p > 0.05). The number of the patients with spastic syndrome of 2 points and lower increased. The use of the techniques of functional neurosurgery and chemical neuromodulation, and spinal surgeries were accompanied by the statistically significant decrease in the number of the patients with high level of spasticity (4 points, p > 0.05) and the increase in the number of the patients with spasticity ≤ 3 points. The surgical treatment of concurrent pathology resulted in the statistically significant decrease in the number of the patients with high level of spasticity (p > 0.05) and the regular increase in the number of the patients with spasticity ≤ 3 points.
Table 3. Time course of spastic syndrome, motional and locomotor scores
Treatment type |
Values |
n |
Mean score |
p |
Time course of values, abs. (%) |
|
before treatment |
after treatment |
|||||
Conservative treatment (n = 376) |
spastic syndrome |
376 |
2.7 |
2.5 |
0 |
58 (15.4 %) |
motion score |
267 |
50.5 |
52.9 |
0 |
55 (14.6 %) |
|
locomotor score |
358 |
6.7 |
7 |
0 |
76 (20.2 %) |
|
Functional neurosurgery, chemical neuromodulation, spinal surgery (n = 121) |
spastic syndrome |
121 |
3 |
2.5 |
0 |
46 (38.0 %) |
motion score |
84 |
42 |
43 |
0.012 |
8 (6.6 %) |
|
locomotor score |
111 |
4 |
4.2 |
0.001 |
25 (20.7 %) |
|
Surgical treatment of concurrent pathology (n = 159) |
spastic syndrome |
121 |
2.8 |
2.5 |
0 |
77 (27.5 %) |
motion score |
84 |
42.3 |
42.9 |
0.012 |
9 (3.2 %) |
|
locomotor score |
111 |
3.4 |
3.5 |
0.001 |
39 (13.9 %) |
Note: Here and after: n – number of patients; p – level of statistical significance of differences before and after treatment.
Simultaneously
with the decrease in intensity of spastic syndrome, the tasks of the treatment
included the extension of movement activity of the patients, which can be
estimated with the time course of motional and locomotor points. The table 3
shows that the first subgroup receiving only conservative treatment included
the patients with the highest locomotor and motional scores at admission. After
the treatment, they demonstrated the decrease in spastic syndrome, and the
statistically significant increase in motional and locomotor scores.
The
patients of the second and third subgroups with only surgical treatment
demonstrated lower motion abilities, resulting in the lower locomotor and
motional points. However the second group, which combined the patients after
functional neurosurgery and spinal surgery, demonstrated the evident increase
in locomotor and motional points after the treatment at the background of the
statistically significant decrease in spastic syndrome (p < 0.012).
The
third group with surgical management of concurrent pathology showed only the
statistically significant decrease in spastic syndrome (p < 0.0003). There
were not any evident changes in motional and locomotor points (p > 0.05).
Let’s
consider the time course of motional and locomotor points in dependence on a
treatment technique in the comparison group (the table 4) including two
subgroups. We can note the higher motional and locomotor points in both
subgroups in comparison with three subgroups of the patients with spastic
syndrome.
Among
the patients receiving the invasive treatment, one patient (1 %) showed the
decrease in motional points, 7 patients (7.1 %) – the decreasing locomotor
points. It determined the negative trends in this subgroup.
In
the subgroup of the patients without spastic syndrome who received only
conservative treatment, the mean values of motional and locomotor points
increased. After conservative treatment, the motional and locomotor points
increased in 21 patients.
The
comparison of the main group and the control one showed that the mean values of
locomotor and motional points were evidently higher in the patients without
spastic syndrome before and after treatment (p > 0.00002). It is interesting
that the degree of increase in these values is higher in the patients with
spasticity.
DISCUSSION
Regardless
of spinal and spinal cord injury levels, most patients showed the neurological
deficiency of type A. Moreover, the injuries at ITS or LS levels were rarely
complicated by spastic syndrome, whereas an injury at the higher level causes
the development of spasticity.
In
the main group, all used treatment techniques were accompanied by the
decreasing intensity of spastic syndrome, but, possibly, the causes are
different in the different groups. If the patients of the first subgroup
received the treatment for direct decrease in spasticity, then the second
subgroup, most probably, achieved the result because of normalizing activity of
the spinal cord in the process of restoration of simple, ontogenetically
determined postural and locomotor responses with participation of the parts of
the locomotor system above and lower the level of the spinal cord injury. The
trigger zones initiating the spastic reactions were removed in the patients of
the third subgroup.
The
number of the patients with increasing locomotor points was higher than the
number of the patients with increasing motional points in all subgroups of the
patients of the main group with evident spastic syndrome. In the subgroups 2
and 3 with surgical management, the number of the patients with increasing
locomotor points was 3-4 times higher than the number of the patients with increasing
motional points.
These
points show the different characteristics of neurological picture and life
quality of the patients. If the increase in motional points supposes the
decrease in depth of the spinal cord injury, then the increase in locomotor
points characterizes the ability to use the available neuromotor and
neurosensory resources for arrangement of targeted motional activity.
The
received results confirm the presence of evident neurological deficiency and apraxia
– non-ability to use the whole rehabilitation potential. Different types of
remedial gymnastics and physical therapy procedures for decrease in intensity
of spastic syndrome, improvement in blood circulation and tissue trophism and
increasing muscular strength extend the neuromotor capabilities of the patient
and help to use available recourses. This observation is confirmed by the
results of the previous study of rehabilitation potential in view of unrealized
neurosensory and neuromotor capabilities in patients with spinal injuries [2,
3, 7].
Table 4. The values of motion and locomotor scores depending on treatment technique of patients without spastic syndrome
Treatment type |
Values |
n |
Mean score |
p |
Time course of values, abs. (%) |
|
before treatment |
after treatment |
|||||
Conservative (n = 130) |
motion score |
94 |
62.6 |
63.3 |
0 |
21 (16.2 %) |
locomotor score |
120 |
8.2 |
8.5 |
0 |
21 (16.2 %) |
|
Surgical (n = 98) |
motion score |
58 |
54.5 |
53.4 |
1 |
1 (1.0 %) |
locomotor score |
75 |
4.8 |
4.5 |
0.583 |
7 (7.1 %) |
|
Total (n = 228) |
motion score |
152 |
59.1 |
59.5 |
0 |
22 (9.6 %) |
locomotor score |
195 |
6.9 |
7 |
0.011 |
28 (12.3 %) |
Why
in patients after surgical management the number of persons who improve their
motional capabilities by mean of training highly exceeds the number of persons
who have training along with regression of neurological symptoms, whereas in
persons receiving the conservative treatment the difference is not so
significant? Possibly, the conservative treatment techniques favored the
restoration of voluntary control of muscles to the greater degree than surgical
methods. Possibly, the postsurgical protective mode makes the influence, i.e.
very limited physical load. It is entirely possible that a surgical injury
makes the negative influence on segments of the spinal cord in the early
postsurgical period.
The
patients with evident spastic syndrome at admission showed the lower motional
and locomotor points than the patients without spastic syndrome who are
admitted for restorative treatment, although the patients with type A
neurological deficiency prevailed in both groups. The difference is determined
by lower level of the spine and spinal cord injury in the patents with type A
neurological deficiency – most patients had the injuries at the level of ITS
and LS.
The
decrease in intensity of “motional deficiency” in view of increasing motional
and locomotor points at the background of restorative treatment in patients
without spasticity is comparable with the patients without spastic syndrome.
It
is interesting that the subgroup of the patients with slow motional disorders
and conservative treatment demonstrated the full parallelism between increase
in locomotor and motional points. The time course is unclear in the subgroup of
the patients with surgical treatment. Possibly, the postsurgical limited
motional activity and orientation of restorative treatment to correction of the
complication (the cause of admission) exerted the influence.
The
comparison of the time trends in the subgroups of the patients who received the
surgical treatment of concurrent pathology showed the clear improvement in the
third subgroup of the main group, but such results were not found in the second
subgroup. In the first case, the decrease in intensity of spastic syndrome gave
the possibilities for voluntary control of unvoluntary motional responses
(modulation of these responses in relation to the situation). As result, the
possibilities for use of the available rehabilitation potential extended, and
it exceeded the negative effect of surgical trauma and postsurgical mode. Such
effect
was
absent
in
the
second
case.
CONCLUSION
Spastic
syndrome of 3-4 points (Ashworth) was in 74 % of the patients with spinal cord
traumatic diseases in the hospital population. Most patients had the spinal
cord injuries at the levels of the cervical spine and the superior thoracic
spine, whereas the patients with slow type of disorders had the injuries at the
inferior thoracic and lumbar levels.
The
patients received the various types of treatment: conservative management,
spinal surgery, chemical neuromodulation of the spinal cord, surgical
correction of concurrent pathology. As the result of the treatment, the
intensity of spastic syndrome decreased and the motional capabilities improved
because of increase in motional and locomotor points regardless of a type of
treatment. The increase in locomotor points was the most frequent positive
result of treatment. In patients with slow type of disorders, the increase in
locomotor points passed along with the increase in motional points. Possibly,
the decrease in intensity of spastic syndrome gives the additional motional
capabilities in view of partial control of movements that is absent in persons
with the slow type of disorders.
Information on financing and conflict of interests
The study was conducted without sponsorship.
The authors declare the absence of clear or potential
conflicts of interests relating to publishing this article.
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