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Query: UMLS:C0026838 (spasticity)
 6,471 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Studies published from January 1966 until October 2000 on the clinical effects of focal neuronal and neuromuscular blockade in post stroke upper limb spasticity were identified. Twelve studies were included and evaluated on 13 methodological criteria. Ten studies on Botulinum toxin type A (BTX-A) treatment were found (of which 4 were randomised controlled trials (RCTs) and 6 were uncontrolled observational studies) as well as one uncontrolled observational study on phenol blockade of the subscapular muscle and one on alcohol blockade of the musculocutaneus nerve. The homogeneity of the patient groups with regard to diagnosis and their comparability with regard to functional prognosis and other sources of bias were generally unsatisfactory. Only two RCTs met predetermined criteria of minimal validity. There is evidence of effectiveness of BTX-A treatment on reducing muscle tone (varying between 0.8 and 2.0 points on the modified Ashworth scale) and improving passive range of motion at all arm-hand levels in chronic stroke patients for approximately 3-4 months. There is also preliminary evidence of a synergistic effect of concomitant electrostimulation. Taking into account a critical maximum dose of 100 MU Botox" (300-500 MU Dysport) for preserving active finger flexion, BTX-A treatment seems to be a safe focal spasmolytic treatment. Effectiveness of BTX-A treatment on improving functional abilities could not be convincingly demonstrated, although two subgroups may be identified that might specifically benefit at a functional level: (1) patients with mild spasticity and a potential for voluntary extensor activity and (2) patients with severe spasticity suffering from problems with positioning and taking care of the affected arm and hand. Larger controlled studies are needed to compare the effectiveness of BTX-A with other focal spasmolytic techniques paying special attention to individual goal assessment, the (duration of) functional benefits, co-treatment and aftercare, side-effects and cost-effectiveness.
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PMID:Treatment of upper extremity spasticity in stroke patients by focal neuronal or neuromuscular blockade: a systematic review of the literature. 1201 80

A 48-year-old women was admitted to our hospital because of gradually developed spastic gait. She showed spasticity of the lower extremities with mild weakness. Laboratory tests disclosed decreased WBC and platelet counts and mild increases of transaminase and total bilirubin. Blood manganese level was markedly increased (6.0 micrograms/dl). Abdominal ultrasound showed splenomegaly, and abdominal angiography showed a dilatation of the portal and paraumbilical veins. T1-weighted MR images showed high signal intensities at the bilateral globus pallidus and cerebral peducles, and T2-weighted images showed high signal intensities at the bilateral deep white matter, posterior limbs of the internal capsule and right upper cervical spinal cord. Following the diagnosis of IPH, splenectomy was performed. The blood level of manganese decreased thereafter and her neurological deficits gradually improved. Hepatic diseases often show high signal intensities at the basal ganglia on T1-weighted images, and this seemed to be due to accumulation of manganese in our case. Because demyelination or axonal injury of the spinal cord are found in hepatic disease, we speculate that the high signal intensities at the spinal cord on T2-weighted images of our case reflect hepatic myelopathy, which may also be caused by high blood levels of manganese.
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PMID:[A case of idiopathic portal hypertension (IPH) with hypermanganemia presenting as spastic gait]. 1271 91

Peripheral nerve blockade is one of the therapeutic options for spasticity of various muscles. Percutaneous nerve stimulation allows accurate location of nerves and neurolysis can be performed using intraneural injection of 65% ethanol or 5 to 12% phenol. Spastic contraction of various muscle groups is a common source of pain and disability which prevents efficient rehabilitation. Neurolytic blocks are possible in most of motor nerves of the upper and lower limbs and main indications are spastic sequelae of stroke and spinal trauma but also of multiple sclerosis, cerebral palsy and chronic coma. The use of percutaneous nerve stimulation allows accurate location and four nerves are more frequently treated: pectoral nerve loop, median, obturator and tibial nerves. In patients with spasticity of the adductor thigh muscles, nerve blocks are performed via a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve. No complications occur and minor side effects are transient painful phenomena during injection. These approaches have proved to be accurate, fast, simple, highly successful and reproducible. Percutaneous neurolytic procedures, should be performed as early as possible, as soon as spasticity becomes painful and disabling in patients with neurological sequelae of stroke, head trauma or any lesion of the motor neurons.
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PMID:[Alcohol neurolytic blocks for pain and muscle spasticity]. 1274

This review of the long-term management of spasticity addresses some of the clinical dilemmas in the management of patients with chronic disability. As it is important for clinicians to have clear objectives in patient treatment, the available treatment strategies are set out. Why is it important to treat spastic patients and what treatment does one use? When should one consider a change in the strategy and why is it necessary to have a clear discharge policy from the service to avoid serious logistic problems? The review reiterates the role of physical treatment in the management and thereafter the maintenance of patients with spasticity. There are now a number of good papers on the use of botulinum toxin in spasticity, but this review sets out their context in clinical management and briefly mentions the use of phenol nerve blockade and intrathecal baclofen in clinical practice. Finally, how does one justify the use of an agent regarded as expensive? It is important to use outcome measures that are valid and sensitive to change, and an example is given of ways of demonstrating benefit.
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PMID:Long-term modification of spasticity. 1281 59

Combined 5% phenol-glycerol has been used to treat cancer pain or spasticity and as sympathetic blocks. The major clinical problems have been the unpredictable effects on pain and on the duration of the blocks. Previously we have shown that intraneurally injected phenol induces haemorrhagic necrosis as well as dissolving of the nerve fibres. Glycerol, on the other hand, induces dispersion of nerve fibre debris into the endoneurium. We have now studied the effects of a combination of these two chemically different agents. The endoneurial and epineurial responses of rat peripheral nerve were followed after intraneural and perineural injections. Samples for electron microscopic and immunohistochemical studies were taken at 1-26 weeks after the injection. The intraneural phenol-glycerol injection resulted in gross endoneurial damage with partly or totally dissolved nerve fibres. Totally dissolved nerve fibres showed empty, collapsed basal lamina tubes and partly dissolved nerve fibres showed breaching of remaining degenerative debris into the endoneurial space. Axonal regeneration was delayed and was observed first after 2 weeks and it took 4 months before most of the nerve fibres were myelinated. The perineural injections resulted in partial subperineurial damage of the endoneurium morphologically similar to the results caused by the intraneural injection. An initial high accumulation of epineurial macrophages was noted at 1 and 2 weeks. An invasion of macrophages into the endoneurium occurred within 1 week after the intraneural and perineural injections and the number of endoneurial macrophages remained high for up to 6 months. The present study shows that glycerol added to phenol diminishes the necrotizing effect of phenol after an intraneural injection. Combined phenol-glycerol-induced nerve injury is reversible and the axons regenerate but residual morphological changes can be observed even after 6 months.
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PMID:The effect of combined neurolytic blocking agent 5% phenol-glycerol in rat sciatic nerve. 1285 32

Neuromuscular blockade via injection of alcohol, phenol, or botulinum toxin reduces the tone of overactive muscles in order to restore the appropriate balance between agonists and antagonists. Such a restoration allows improved stretch and increased resting length and can reduce the likelihood of contracture. Alcohol or phenol, injected onto the motor nerve, denatures proteins and promotes axonal degeneration. The onset of action is within hours, whereas the duration of action is variable, ranging from 2 weeks to 6 months and beyond. The advantages of alcohol or phenol chemodenervation lie in their low cost and lack of antigenicity. The disadvantages include the technical difficulty of the injections and significant risk for pain as a result of treatment. Botulinum toxins, purified forms of Clostridium botulinum exotoxins, are injected directly into muscle, where they cleave one or more vesicle fusion proteins, thus blocking release of acetylcholine at the neuromuscular junction. Three commercial products--two of serotype A and one of B--are available. Each differs in its unit potency, side effects, and duration of action. On average, botulinum toxin has a clinical onset of action approximately 12 to 72 hours after injection, with a peak effect at 1 to 3 weeks. Effects then plateau for 1 to 2 months, with patients often requiring reinjection approximately every 3 months. Side effects may include local discomfort at the site of the injection and excessive weakness of the injected or nearby muscles, although more distant effects may occur. Antibody formation is a significant clinical concern and eventually obviates treatment benefit in approximately 5% of patients. Switching serotypes may be effective, at least temporarily. Consensus dosing guidelines have been developed and are presented within. Numerous studies have suggested that botulinum toxin has a role in the care of children with spasticity or dystonia related to cerebral palsy, and may improve equinus, gait, upper extremity use, comfort, and care. Evidence of functional improvement remains equivocal in the severely impaired child; however, there is evidence for improvement in less impaired children. The optimal candidate for injectable neuromuscular blockade is one who has a limited number of muscles that need treatment, who does not have fixed contracture, and who retains selective motor control. The ultimate goal of treatment for the hypertonic child is to maximize function, comfort, and independence. Hypertonia is only one aspect of the upper motoneuron syndrome, which includes both positive and negative symptoms. The treatment program, in which chemodenervation is only one tool, requires a multidisciplinary evaluation and individualized plan to address the whole patient.
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PMID:Injectable neuromuscular blockade in the treatment of spasticity and movement disorders. 1367 71

Intrathecal baclofen (ITB) therapy is a widely recognized management technique for severe, disabling spasticity in individuals with cerebral palsy and spinal and brain injuries. Its utility in the stroke population has only been recognized recently. Unlike the aforementioned patient populations, many stroke survivors are ambulatory and are able to maintain a certain degree of functional independence through compensatory use of the uninvolved limbs. Clinicians often fail to recognize the potential enhancement in the function of these individuals if they gain better control of their spastic limbs. Other spasticity treatments, such as oral medications and neurolytic procedures, offer the advantage of being nonsurgical; however, not every stroke patient will respond well to them. Some patients may not tolerate the systemic side effects of oral medications, such as drowsiness and sedation. In patients with severe multilimb spasticity, phenol and even high doses of botulinum toxin may not adequately control spasticity. ITB therapy offers the advantage of effectively decreasing severe, diffuse spasticity without causing untoward effects on arousal and cognition. This article will review the efficacy of ITB therapy in treating spasticity and enhancing function in stroke survivors.
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PMID:Intrathecal baclofen therapy for stroke-related spasticity. 1452 50

Chemodenervation with botulinum toxin (BTX) and chemical neurolysis with phenol can be used alone or in combination to effectively manage focal spasticity after a stroke. As with other treatments, these interventions must be done the right way, at the right time, in the right patient, and for the right reason. The proper use of these treatments requires careful patient assessment and realistic goals, knowledge of the peripheral functional anatomy, and an understanding of how these treatments work and how to best to administer them. This article reviews how BTX and phenol can be used in the management of poststroke spasticity.
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PMID:Effective use of chemodenervation and chemical neurolysis in the management of poststroke spasticity. 1452 51

As one component of the upper motor neuron syndrome, spasticity can have a significant functional impact on the child with cerebral palsy. Treatment planning requires the determination that excess tone interferes with some aspect of function, comfort, or care, and takes into consideration carefully devised goals that meet the needs of the patient and the caregiver. Treatment options include physical therapy, oral medications, chemodenervation with botulinum toxin or phenol, rhizotomy, intrathecal baclofen, and orthopedic surgery. The uses and limitations of each is discussed, and evidence for efficacy in cerebral palsy is reviewed.
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PMID:Management of spasticity in children with cerebral palsy. 1513 54

Cerebral palsy, a range of non-progressive syndromes of posture and motor impairment, is a common cause of disability in childhood. The disorder results from various insults to different areas within the developing nervous system, which partly explains the variability of clinical findings. Management options include physiotherapy, occupational and speech therapy, orthotics, device-assisted modalities, pharmacological intervention, and orthopaedic and neurosurgical procedures. Since 1980, modification of spasticity by means of orally administered drugs, intramuscular chemodenervation agents (alcohol, phenol, botulinum toxin A), intrathecally administered drugs (baclofen), and surgery (neurectomy, rhizotomy) has become more frequent. Family-directed use of holistic approaches for their children with cerebral palsy includes the widespread adoption of complementary and alternative therapies; however, the prevalence of their use and the cost of these options are unknown. Traditional medical techniques (physiotherapy, bracing, and orthopaedic musculoskeletal surgery) remain the mainstay of treatment strategies at this time. This seminar addresses only the musculoskeletal issues associated with cerebral palsy and only indirectly discusses the cognitive, medical, and social issues associated with this diagnosis.
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PMID:Cerebral palsy. 1523 52


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