Spasticity in spinal cord injury:: Self- and clinically rated intrinsic fluctuations and intervention-induced changes

Objectives: (1) To determine patterns of intrinsic fluctuations in spasticity, using repeated self-ratings, in subjects with spinal cord injury (SCI); and (2) To determine the relation between self-ratings of spasticity using a visual analogue scale (VAS) and clinical ratings of spasticity using the Modified Ashworth Scale (MAS) before and after spasticity-reducing treatment. Design: Part I: observational, prospective cross-sectional study; part II: experimental, prospective longitudinal study. Setting: Outpatient clinic of the Karolinska Hospital, Stockholm, Sweden. Patients: Forty-five persons with SCI (39 men, 6 women); mean age at injury, 26 yrs; mean time since injury, 11 yrs. Intervention: Repetitive passive movements of standardized range of motion in three different body positions, performed by two motorized tables. Main Outcome Measures: VAS ratings of spasticity, every other hour when awake, and of movement-provoked spasticity, rated before and after each treatment session, and MAS ratings of movement-provoked spasticity, before and after each treatment session. Results: The spasticity of cervical SCI subjects fluctuated significantly (p < .05) during the day, unlike the spasticity of thoracic SCI subjects. Immediately after intervention with passive movements, spasticity ratings in thoracic motor complete SCI patients decreased by 11 to 14 mm (90%, p < .001) as self-rated on VAS and by 1 to 2 grades (50%, p < .001) as measured with MAS. A 30% (p < .018) decrease in VAS values of intrinsic pattern of spasticity was maintained over time when treatment was given regularly and was maintained for at least 1 week after discontinuation of treatment. VAS ratings correlated significantly with MAS ratings (r = .44 to .62, p < .001). Conclusion: Repetitive passive movement intervention decreased spasticity when performed regularly, as assessed by VAS and MAS ratings. VAS and MAS ratings were significantly correlated. It is recommended that SCI patients repeatedly rate their spasticity to establish a baseline before and to track changes after interventions aimed at reducing spasticity The time of day when spasticity is measured seems more important in cervically injured individuals, because of their mon pronounced intrinsic fluctuations.