TIME COURSE OF SPASTIC SYNDROME IN PATIENTS WITH TRAUMATIC SPINAL CORD INJURY DURING TREATMENT AND ITS EFFECTS ON MOTOR EHABILITATION 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
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 | |||||
| À | 6 | 6 | 60 | 22 | 94 |
| Â | 2 | 0 | 18 | 8 | 28 |
| Ñ | 0 | 0 | 37 | 34 | 71 |
| D+Å | 2 | 4 | 9 | 20 | 35 |
| Total | 10 | 10 | 124 | 84 | 228 |
| Group with clinical course of spastic syyndrome, n = 656 | |||||
| À | 123 | 151 | 58 | 11 | 343 |
| Â | 54 | 18 | 10 | 9 | 91 |
| Ñ | 77 | 18 | 34 | 14 | 143 |
| D+Å | 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 | ||||||
| Ashworth 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 4 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.
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 %) | |
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].
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.