powerpoint presentation - holy cross hospital...10/10/2016 4 reason 2: clinical scales are bad at...
TRANSCRIPT
10/10/2016
1
Measuring Spasticity in people with DoC -
from the lab to the bed side
Anand Pandyan, Rasheed Meeran, Raymundo (Ray) Milay and Adam Poulter
Keele University
A plan of sorts
•Spasticity and approaches to measure this
•Is there a reason to change current clinical
approaches to measurement
•Measurement challenges in DoC
Disordered sensori-motor control, resulting from an upper motor neurone lesion, presenting as intermittent or sustained involuntary activation of muscles
Spasticity – a conceptual definition
Pandyan et al 2005 Disabili & Rehab – SPASM consortium
Spasticity (operational definition)
•Spasm (A transient but continuous muscular contraction with
cutaneous or visceral triggers)
•Clonus (A transient but intermittent rhythmic or muscle
contraction with proprioceptive and/or cutaneous triggers)
•Stretch induced muscle activity
•Abnormal movement patterns & co-contraction still
remain unresolved
Score Penn spasm frequency scale Spasm frequency score
0 No spasms No spasms
1 Mild spasms at stimulation One or fewer spasms per day
2 Irregular strong spasms less than one
time/hour
Between one and five spasms per day
3 Spasms more often than one
time/hour
Five to less than 10 spasms per day
4 Spasms more than 10 times/hour Ten or more spasms per day, or continuous
contraction
Table 4: The descriptors associated with the ordinal level scales used to quantify the frequency of
spasms.Penn RD et al 1989 Intrathecal baclofen for severe spinal spasticity. N Engl J Med, 320: 1517 – 1521. Snow BJ et al 1990
Treatment of spasticity with botulinum toxin: a double blind study. Ann Neurol, 28: 512 – 515. Biering-Sørensen et al 2005 Spasticity-assessment: a review. Spinal Cord, 44: 708 – 722.
Quality of muscle reaction (X):
0 No resistance throughout the course of the passive movement
1 Slight resistance throughout the course of the passive movement, with no clear catch at precise angle
2 Clear catch at precise angle, interrupting the passive movement, followed by release
3 Fatigable clonus (< 10 seconds when maintaining pressure) occurring at precise angle
4 Infatigable clonus (> 10 seconds when maintaining pressure) occurring at precise angle
Gracies et al., 2000, Boyd & Ada 2001, Morris 2002
Tardieu method for measuring spasticity
10/10/2016
2
Stretch induced muscle activity
Malhotra et al (2008) & personal data
Contractures – a definition (& a digression)
A pathological condition of soft tissues characterised
by stiffness and is usually associated with loss of elasticity and fixed shortening of the involved tissues
(muscle, tendon, ligament, subcutaneous tissue, skin, blood vessels and nerves) and results in loss of
movement around a joint
Harburn and Potter (1993); Teasell and Gillen (1993); Lehmann et al (1989); Botte et al (1988)
Does spasticity cause contractures?
Lessons from observing stroke patients with
sever levels of disability
• Female – 74
• Total Anterior Circulatory Infarct
• NIHSS – 17 (Arm = 4, Leg = 2)
Pre-Stroke Admission Baseline 3 Months 6 Months
Barthel 20 3 11 17 18
ARAT 57 0 0 0 0
Had no function or spasticity
EUBOSS (2012 – 2014)
…..did not develop contractures
50- 0 500
1
2
3
4
0
0.01
0.02
0.03
0.04
Angle (Deg)
Forc
e (N
)
EM
G (
mV
)0.009
100- 50- 0 500
1
2
3
4
0
0.01
0.02
0.03
0.04
Angle (Deg)
Fo
rce
(N)
EM
G (
mV
)
100- 50- 0 500
1
2
3
4
0
0.01
0.02
0.03
0.04
Angle (Deg)
Forc
e (N
)
EM
G (
mV
)0.008
50- 0 500
1
2
3
4
0
0.01
0.02
0.03
0.04
Angle (Deg)
Forc
e (N
)
EM
G (
mV
)
50- 0 500
1
2
3
4
0
0.01
0.02
0.03
0.04
Angle (Deg)
Forc
e (N
)
EM
G (
mV
)
50- 0 500
1
2
3
4
0
0.01
0.02
0.03
0.04
Angle (Deg)
Fo
rce
(N)
EM
G (
mV
)
Baseline 3 Months 6 Months
EUBOSS (2012 – 2014)
Had no function but developed spasticity
• Male - 81
• Partial Anterior Circulatory Infarct
• NIHSS – 13 (Arm = 4, Leg = 3)
Pre-Stroke Admission Baseline 3 Months 6 Months
Barthel 20 1 4 3 3
ARAT 57 0 0 0 1
EUBOSS (2012 – 2014)
10/10/2016
3
…..did develop contractures
100- 50- 0 500
1
2
3
4
0
0.01
0.02
0.03
0.04
Angle vs Force (slow)
Angle vs Flexor EMG
Angle (Deg)
Forc
e (N
)
EM
G (
mV
)
100- 50- 0 500
1
2
3
4
0
0.01
0.02
0.03
0.04
0.05
Angle vs Force (slow)
Angle vs Flexor EMG
Angle (Deg)
Forc
e (N
)
EM
G (
mV
)
100- 50- 0 500
1
2
3
4
5
0
0.01
0.02
0.03
0.04
Angle vs Force (slow)
Angle vs Flexor EMG
Angle (Deg)
Forc
e (N
)
EM
G (
mV
)
100- 50- 0 50 1000
1
2
3
4
0
0.02
0.04
Angle vs Force (slow)
Angle vs Flexor EMG
Angle (Deg)
Forc
e (N
)
EM
G (
mV
)
100- 50- 0 500
1
2
3
4
0
0.01
0.02
0.03
0.04
Angle vs Force (slow)
Angle vs Flexor EMG
Angle (Deg)
Forc
e (N
)
EM
G (
mV
)
100- 50- 0 500
1
2
3
4
0
0.02
0.04
Angle vs Force (slow)
Angle vs Flexor EMG
Angle (Deg)
Forc
e (N
)
EM
G (
mV
)
0.007 0.016 0.047
Baseline 3 Months6 Months
EUBOSS (2012 – 2014)
Forms of spasticity and links to contractures
Malhotra et al (2008) & personal data
• Spasticity may be an inevitable consequence of a neurological injury
• In patients with no functional movement atrophy is an inevitable consequence
• In patients with no functional movement and spasticity (or spastic dystonia) contractures may be inevitable
A summary of my thoughts on
spasticity and contracturesShould we measure stretch induced muscle
activity as a measure of spasticity as opposed to using clinical scales?
Altered CNS
output
Reason 1: Resistance to passive movement is a
confounded measure.
20 38 56 74 92 110 128 146 164 182 200
50
20
10
40
70
100
Pre
Lin. Reg PrePost
Linear Reg Post
Angle (Degrees)
Fo
rce (
N)
RTPM pre - 1.063
RTPM post – 1.001
20 38 56 74 92 110 128 146 164 182 200
50
20
10
40
70
100
Pre
Lin. Reg PrePost
Linear Reg Post
Angle (Degrees)
Force (
N)
RTPM Pre - 0.432 (0.674)
RTPM Post - 0.155 (0.881)
e.g. from two responders to treatment with botulinum toxin
RTPMFast = 0.26 N/deg(R2 = 0.922);
(SpeedFast = 74 deg/s)
RTPMSlow = 0.22 (R2 = 0.721)
(SpeedSlow = 8 deg/s)
0 20 40 60 80 100 120
10
10
20
RTPM pre treatment
RTPM post treatment
Angle (Degrees)
Fo
rce
(N
)
0 20 40 60 80 100 120
20
40
60
Fast Flexor EMG pre treatment
Slow Flexor EMG pre treatment
Angle (Degrees)
EM
G (
uV
)
0 20 40 60 80 100 120
10
10
20
RTPM pre treatment
RTPM post treatment
Angle (Degrees)
Fo
rce
(N
)
0 20 40 60 80 100 120
20
40
60
Fast Flexor EMG pre treatment
Slow Flexor EMG pre treatment
Angle (Degrees)
EM
G (
uV
)
Slow
moveme
nt EMG
Slow
movement
Force
Brisk
moveme
nt Force
Brisk
moveme
nt EMG
10/10/2016
4
Reason 2: Clinical scales are bad at identifying
early spasticityMAS Abnormal
muscle activity
- ive + ive
0 12 44
1 0 21
1+ 0 12
2 1 3
3 0 6
4 0 1
EMG
MAS
With Without
+ive 43 1
-ive 44 12
Sensitivity = 43/(43+44)
= 0.49
Specificity = 12/(12+1)
= 0.92
Reason 3: Treatment effects are often missed
or underestimated
Case Report 1 – Patient A
• 72 year old gentleman
• Had a left MCA infarct with subsequent
haemorrhagic transformation 3 days later
• Baseline measures taken 37 days poststroke
• No active movement of upper limb
Patient A - baseline
• Elbow - Very slight velocity dependent response
• Wrist -Marked velocity and position dependent response to passive stretch
• No pain reported
• No active movement at elbow or wrist
• ARAT = 0/57
0.1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1100
0
100
200
300
0
0.05
0.1
0.15
Slow Velocity
Fast Velocity
Slow_Flexor EMG
Fast_Flexor EMG
Slow Vs Fast (Vel & EMG)
Angle (deg)
Vel
ocit
y (d
eg/s
)
EM
G (
mV
)
281.493
6.894-
S_Vels
F_Velf
0.2
0.0
S_FEMGs
F_FEMGf
13.997- 10
3-
S_Angles S_Angle0-
PROM_slow
F_Anglef F_Angle0-
PROM_fast
S_Angles S_Angle0-
PROM_slow
F_Anglef F_Angle0-
PROM_fast
0.1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 150
0
50
100
150
200
0
0.05
0.1
0.15
Slow Velocity
Fast Velocity
Slow_Flexor EMG
Fast_Flexor EMG
Slow Vs Fast (Vel & EMG)
Angle (deg)
Vel
oc
ity
(deg/s
)
EM
G (
mV
)
194.229
15.12-
S_Vels
F_Velf
0.2
0.0
S_FEMGs
F_FEMGf
11.761- 10
3-
S_Angles S_Angle0-
PROM_slow
F_Anglef F_Angle0-
PROM_fast
S_Angles S_Angle0-
PROM_slow
F_Anglef F_Angle0-
PROM_fast
Elbow MAS=0 Wrist MAS = 1+
Patient A – Week 4
• Elbow – position dependent spasticity
• Wrist – velocity and position dependent spasticity
• Moderate pain
• No active movement
• ARAT = 0/57
• BoNtA (total Onabotulinumtoxin 400U) given 5 days after this assessment
90 80 70 60 50 40 300
10
20
30
40
50
0
0.02
0.04
0.06
0.08
Slow RP E
Fast RPE
Slow_Flexor EMG
Fast_Flexor EMG
Slow vs Fast (Force & EMG)
Angle (deg)
Fo
rce
(N)
EM
G (
mV
)
45.206
7.928
S_Force
F_Force
0.1
0.0
S_FEMG
F_FEMG
31.286-83.891- S_Angle F_Angle S_Angle F_Angle
90 80 70 60 50 40 300
10
20
30
40
50
50
0
50
100
150
Slow RP E
Fast RPE
Slow Velocity
Fast Velocity
Slow vs Fast (Force & EMG)
Angle (deg)
Fo
rce
(Kg
)
Vel
(de
g/s
)
50 40 30 20 10 0 10 20 3020
0
20
40
60
80
100
0
0.05
0.1
0.15
Slow RP E
Fast RPE
Slow_Flexor EMG
Fast_Flexor EMG
Slow vs Fast (Force & EMG)
Angle (deg)
Fo
rce
(N)
EM
G (
mV
)
81.188
0.87-
S_Force
F_Force
0.2
0.0
S_FEMG
F_FEMG
24.83543.446- S_Angle F_Angle S_Angle F_Angle
60 40 20 0 20 4050
0
50
100
100
0
100
200
300
Slow RP E
Fast RPE
Slow Velocity
Fast Velocity
Slow vs Fast (Force & EMG)
Angle (deg)
Fo
rce
(Kg
)
Vel
(de
g/s
)
Elbow MAS = 3 Wrist MAS = 3
10/10/2016
5
Patient A – Week 8 (&12)
• Elbow – no spasticity
• Wrist – position dependent spasticity
• Pain “couldn’t be any worse”
• No active movement
• ARAT 0/57
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 120
0
20
40
60
80
0
0.05
0.1
0.15
Slow Velocity
Fast Velocity
Slow_Flexor EMG
Fast_Flexor EMG
Slow Vs Fast (Vel & EMG)
Angle (deg)
Velo
cit
y (
deg
/s)
EM
G (
mV
)
65.439
12.924-
S_Vels
F_Velf
0.2
0.0
S_FEMGs
F_FEMGf
10 S_Angles S_Angle0-
PROM_slow
F_Anglef F_Angle0-
PROM_fast
S_Angles S_Angle0-
PROM_slow
F_Anglef F_Angle0-
PROM_fast
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 150
0
50
100
150
200
0
0.05
0.1
0.15
Slow Velocity
Fast Velocity
Slow_Flexor EMG
Fast_Flexor EMG
Slow Vs Fast (Vel & EMG)
Angle (deg)
Velo
cit
y (
deg
/s)
EM
G (
mV
)
152.757
7.677-
S_Vels
F_Velf
0.2
0.0
S_FEMGs
F_FEMGf
10 S_Angles S_Angle0-
PROM_slow
F_Anglef F_Angle0-
PROM_fast
S_Angles S_Angle0-
PROM_slow
F_Anglef F_Angle0-
PROM_fast
Elbow MAS = 3 Wrist MAS = 4
50 64 78 92 106 120
5
10
15
20
25
RMS Flexor EMG (Pre Botox)
RMS Flexor EMG (Post Botox)
Angle (deg)
EM
G (
mic
roV
) A non responderMAS
6 8 0
10 32 54 76 98 120
10
20
30
40
50
RMS Flexor EMG (pre Botox)
RMS Flexor EMG (post Botox)
Angle (deg)
EM
G (
mic
roV
) A responderEMG (Brisk movement)
10Mean dose 82 U
(25U – 300U)
4Mean dose 44 U
(25U – 60U)
MAS
EMG 3 7 0 10
3 1 0 4
6 8 0 14
Reason 4: Clinical interpretation of the term
spasticity is not consistent (lessons from observations on a child scheduled for SDR)
Lower limb
reflexes appear
normal pre-
surgery
Pre
Post
Upper limb
reflexes appear
normal pre-
surgery (possibly
a wind up phenomenon)
Pre
Post
10/10/2016
6
9060Lower limb pendulum (left) appear normal pre-surgery
Pre
Post
60 90Lower limb pendulum (right) appear normal pre-surgery
Pre
Post
Measuring spasticity in DoC
BACKGROUND
• Holy Cross Hospital (HxH): 40 beds - 18 are in Disorders of Consciousness (DOC).
• Majority of patients in HxH suffer with spasticity.
• Current rx….
• Modified Ashworth Scale (MAS) – measuring tool for spasticity.
• Problem –difficult to reproduce, inter-rater reliably (1).
• Lacks sensitivity – basic assessment tool for a complex issue.
AIMS/OBJECTIVES
• Is the Biometrics Ltd. DataLog MWX8 accurate, reliable, and practical in measuring spasticity in a clinical setting?
• Can these methods of measurement inform clinical decision making?
PATIENT GROUP
• Vegetative State
• Diagnosed with TBI or Hypoxic Brain Injury
• Unilateral or bilateral elbow flexor spasticity/stiffness.
• MAS score ≥ 1 elbow flexors
• Able to be seated for measurement purposes
10/10/2016
7
PATIENTS SELECTED
• A sample of 3 patients.
• Patient 1 – Botulinum Toxin A Injection
• The patient has had regular botulinum toxin injections in the past to treat the elbow flexor spasticity.
• The patient had a course of injections during the surface EMG measurement period.
• Patient 2 – Splint Intervention
• The patient has bilateral fibreglass elbow splint to control bilateral elbow flexor stiffness.
• The patient has had BoNT-A injections in the past for the elbow flexors but is 4 months post injection during the period of surface EMG measurements.
• Patient 3 – Passive stretching regime
• The patient has had BoNT-A injections in the past for the left elbow flexors but is 4 months post injection during the period of surface EMG measurements.
• The patient is only receiving manual passive stretching regime to maintain elbow range.
MEASUREMENTS
Pre-measurement protocol:
• No infection.
• Trache care/suction 30 mins prior.
• Sat out for minimum 1 hour before measurements.
• Patient should be settled and not agitated (as much as possible).
• Measurements completed in wheelchair.
• Pillows and lateral support removed.
• Electrodes applied to motor points as per BoNT-A injection manual.
• Measurements completed in the physio gym.
MEASUREMENTS CONTINUED….
Same protocol for all patients before and after intervention.
Six channels to be used:
• Channel 1: Biceps brachii EMG through metal electrodes.
• Channel 2: Brachioradialis EMG through metal electrodes.
• Channel 3: Triceps EMG through metal electrodes.
• Channel 5: Stretch force applied through force transducer.
• Channel 6: Joint angle measurements through angle sensor.
• Ground channel.
EXAMPLE OF MEASUREMENT SETUP
MEASUREMENT SETUP FOR SPLINTING CONDITION STANDARD MEASUREMENTS FOR ALL PATIENTS
• Measurement 1
• Passive slow stretch (roughly 10 seconds from resting position to end range)
• 1 minute baseline without stimulus -> slow stretch to end range-> release -> record for a further 1 minute.
• Measurement 2
• Passive fast stretch (roughly 5 seconds from resting position to end range)
• 1 minute baseline without stimulus -> fast stretch to end range-> release -> record for a further 1 minute.
• Slow stretch always completed prior to fast stretch.
10/10/2016
8
ADDITIONAL MEASUREMENTS
• Patient 1:
• Measurements obtained pre- BoNT-A injection.
• Measurements 7-14 days post BoNT-A injection and 1 month
• Patient 2:
• Measurement 1+2 pre-application of elbow splint.
• Applied splint.
• 5 min measurement of channels 1-3 (Immediately after splint application)
• 2 hourly 5 min measurements (channels 1-3) for a period of 4 hours.
• Repeat measurement 1+2 immediately after removal of splint.
• Control group:
• Measurements obtained from staff
NORMAL SUBJECTS
Le
ft Bic
ep
s B
rac
hii E
MG
0:00.000 0:20.000 0:40.000 1:00.000 1:20.000 1:40.000 2:00.000
3
-3
-2.5
-2
-1.5
-1
-0.5
(mV ) 0
0.5
1
1.5
2
2.5
Le
ft Bic
ep
s B
rac
hii E
MG
0:00.000 0:20.000 0:40.000 1:00.000 1:20.000 1:40.000 2:00.000
3
-3
-2.5
-2
-1.5
-1
-0.5
(mV ) 0
0.5
1
1.5
2
2.5
Fast stretch 17.08.16 control 1Slow stretch 17.08.16 control 1
Fast stretch control 2
Le
ft Bic
ep
s B
rac
hii E
MG
0:00.000 0:20.000 0:40.000 1:00.000 1:20.000 1:40.000 2:00.000
3
-3
-2.5
-2
-1.5
-1
-0.5
(mV ) 0
0.5
1
1.5
2
2.5
Slow stretch control 2
Le
ft Bic
ep
s B
rac
hii E
MG
0:00.000 0:20.000 0:40.000 1:00.000 1:20.000 1:40.000 2:00.000
3
-3
-2.5
-2
-1.5
-1
-0.5
(mV ) 0
0.5
1
1.5
2
2.5
NORMAL SUBJECTS
PATIENT 1 RESULTS
COMPARING PRE AND POST BOTOX Pre Botox 29/06/16 (fast
stretch)
Le
ft B
ic
ep
s B
ra
ch
ii E
MG
0:00.000 0:10.000 0:20.000 0:30.000 0:40.000 0:50.000 1:00.000 1:10.000 1:20.000 1:30.000 1:40.000 1:50.000 2:00.000 2:10.000 2:20.000 2:30.000
3
-3
-2.5
-2
-1.5
-1
-0.5
(mV ) 0
0.5
1
1.5
2
2.5
Post Botox 25/07/16 (fast stretch)
Le
ft B
ic
ep
s B
ra
ch
ii E
MG
0:00.000 0:10.000 0:20.000 0:30.000 0:40.000 0:50.000 1:00.000 1:10.000 1:20.000 1:30.000 1:40.000 1:50.000 2:00.000 2:10.000
3
-3
-2
-1
(mV ) 0
1
2
Fast stretch 29/06/16
Le
ft Bic
ep
s B
rac
hii E
MG
0:00.000 0:50.000 1:40.000 2:30.000
3
-3
-2.5
-2
-1.5
-1
-0.5
(mV ) 0
0.5
1
1.5
2
2.5
Slow stretch 29/06/16
Le
ft Bic
ep
s B
rac
hii E
MG
0:00.000 0:50.000 1:40.000
3
-3
-2.5
-2
-1.5
-1
-0.5
(mV ) 0
0.5
1
1.5
2
2.5
10/10/2016
9
Fast 10/08/16
Le
ft Bic
ep
s B
rac
hii E
MG
0:00.000 0:50.000 1:40.000
3
-3
-2.5
-2
-1.5
-1
-0.5
(mV ) 0
0.5
1
1.5
2
2.5
Slow 10/08/16
Le
ft Bic
ep
s B
rac
hii E
MG
0:00.000 0:50.000 1:40.000
3
-3
-2.5
-2
-1.5
-1
-0.5
(mV ) 0
0.5
1
1.5
2
2.5
08.06.2016 15.06.2016 06.07.2016 13.07.2016 22.07.2016 25.07.2016 10.08.2016
MvLow
-0.27 -0.18 -0.42 -0.53 -0.03 -0.21 -0.21
Mvhigh
0.31 0.31 0.3 0.4 0.02 0.15 0.37
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
Fast stretch
Mv high Mv Low
08.06.2016 15.06.2016 06.07.2016 13.07.2016 22.07.2016 25.07.2016 10.08.2016
MV low -0.28 -0.14 -0.9 -0.14 -0.39 -0.37 -0.13
MV High 0.48 0.18 0.63 0.07 0.56 0.33 0.19
-1
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
Slow stretch
MV High MV low
PATIENT 2 RESULTS
PATIENT 2 – SPLINTING INTERVENTION
08.07.16 10:00 08.07.16 12:00 08.07.16 14:00 22.07.16 10:00 22.07.16 12:00 22.07.16 14:00 25.07.16 10:00 25.07.16 12:00 25.07.16 14:00
MV high 0.17 0.31 0.17 0.14 0.23 0.09 0.33 0.17 0.58
MV Low -0.22 -0.44 -0.36 -0.13 -0.17 -0.07 -0.3 -0.11 -0.52
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
Splinting patient
MV Low MV high
20 mins with splint on reading (29/06/16) and below same patient sleeping/low arousal.
Left Biceps B
rachii EMG
0:00.000 1:40.000 3:20.000 5:00.000 6:40.000 8:20.000 10:00.000 11:40.000 13:20.000 15:00.000 16:40.000 18:20.000 20:00.000
3
-3
-2.5
-2
-1.5
-1
-0.5
(mV ) 0
0.5
1
1.5
2
2.5
Left Biceps Brachii EMG
0:00.000 0:20.000 0:40.000 1:00.000 1:20.000 1:40.000 2:00.000 2:20.000 2:40.000 3:00.000 3:20.000 3:40.000 4:00.000 4:20.000 4:40.000 5:00.000
3
-3
-2.5
-2
-1.5
-1
-0.5
(mV ) 0
0.5
1
1.5
2
2.5
10/10/2016
10
PATIENT 3 RESULTS
GRAPHS FOR PATIENT 3
13.06.16 22.06.16 29.06.16 06.07.16 25.07.16
Mv Low -0.16 -0.18 -0.13 -0.16 -0.12
Mv high 0.11 0.14 0.11 0.17 0.12
-0.2
-0.15
-0.1
-0.05
0
0.05
0.1
0.15
0.2
Fast stretching
Mv high Mv Low
13.06.16 22.06.16 29.06.16 06.07.16 25.07.16
MV low -0.15 -0.17 -0.12 -0.14 -0.14
MV High 0.12 0.14 0.11 0.14 0.22
-0.2
-0.15
-0.1
-0.05
0
0.05
0.1
0.15
0.2
0.25
Slow Stretching
MV High MV low
CONCLUSIONS
• Following injections on BoNT-A amplitude was reduced
• Not all patients are demonstrating spasticity – see patient 2, should they have had Botox?
• Low arousal demonstrates a reduced amplitude in EMG readings.
• We are not able to effectively assess splinting with the current technology.
• Can measure for 20 minutes in splinting condition – longer periods may cause marking/sores.
• Some of the background artefacts on the readings – are these due to methodology or fibrosis/adipose tissue.
• No demonstration of “catch” (patient 3) on graphs despite being rated MAS 1
LIMITATIONS
• Initially took 1 hour to complete readings.
• Extensive practice and training required for specific protocol and use of equipment.
• To monitor effect of splinting a patient’s splint had to be modified to fit electrodes without splint removal.
• Requires certain conditions to gain useful readings, i.e. patient alert, trache care completed, no coughing.
• Connectivity issues - need to use laptop to check settings before reading.
• Difficult to transfer data if collected on SD card – mostly due to IT security in hospitals (cannot use USB or card reader).
• Often if left unattended the laptop would go into standby, causing the Bluetooth signal to be lost.
IMPLICATIONS FOR PRACTICE• Reduced application to measurement time to 15-20 mins per limb
• Useful as an adjunct to MAS to review individual muscle groups.
• Can be completed in sitting with one therapist but much faster with two.
• Can give more specific results over time and give a numerical objective value.
• Useful in clinical decision making regarding BoNT-A injections – spasticity vs contracture.
• Better equipment:
• Wireless electrodes, goniometer and force transducer – facilitate set up and ease of measurement
• Bluetooth connectivity issues – loss of connection, unable to transfer data wirelessly
• Datalog software compatibility – only runs on Windows 7
FUTURE RECOMMENDATIONS
• Re-test muscle groups where there are anomalies (yawning or low arousal).
• A longer (4-6 hours) reading may be of benefit in the splinting condition, however we were limited by marking on the skin due to the electrodes.