Studies on Spasticity from an Interventional Perspective

This thesis focuses on interventional aspects of spasticity, but has a very holistic approach, grounded in the specialty of Rehabilitation medicine. This means capturing the effects of spasticity, on such a complex biological system as the human being, living in a psychosocial context affecting the situation. When evaluating spasticity there are a number of levels of evidence. The first of course, understanding what we mean with spasticity, where there unfortunately is no consensus. The second level is to study if our treatments affect spasticity in a positive direction. The third is to grasp if a decrease in spasticity improve or normalize patient’s movement patterns. The fourth level investigates if improvement in movement patterns improve patient’s ability to perform activities; and the fifth level, comprising whether this intervention improves life satisfaction. Finally, on a societal level, we wish to investigate whether the improvement in life satisfaction or health related quality of life would motivate society to fund the intervention. Paper I on Goal Attainment Scaling pointed out necessary aspects to consider when using this instrument. This relates, among other things, to the need of learning (“the art of”) goal setting and deciding the purpose of the measurements. Research and clinical use puts different demands on the instrument, for the latter time-efficiency and simplicity to use being most important. For research, it is important to be able to register deterioration, and this can be achieved using the 6-step version. In paper II, concerning validation of the portable motion system, we showed this system to be valid for short-term measurements and that the use of Exposure Variation Analysis (EVA) seems to be a valuable tool for graphically elucidating different movements. The equipment needs further development in handling long-term measurements (which is effectuated), and norms for normal movements in different activities has to be produced. The discriminative value of EVA needs confirmation in coming studies. For the future, there is the intriguing possibility of long-term measurements in patients’ every-day life, thereby getting objective measures on how our patients use their abilities, thus capturing the difference between what you can do and what you actually do. The results from paper III demonstrated a large inequality in Sweden regarding the accessibility of BoNT-A treatment for spasticity. We could also show that treatment with BoNT-A is sound from a health-economic perspective, accounting for the uncertainty of data via the sensitivity analysis. For the future, we need to explore if this inequality also exists for other modes of spasticity treatments, e.g. multidisciplinary spasticity treatment and ITB pumps, and in other countries. In paper IV evaluating multifocal TES, the results could not confirm efficacy with the treatment according to the protocol of the manufacturer. The results have to be interpreted with care, as low compliance and frequent adverse events made deduction not captured in the RCT study. Further studies are needed in a number of areas, e.g. what is the optimal stimulation frequency, what patients can gain from the treatment and how should adjunct treatment be organized. In this thesis, I have had the privilege to explore different methods of evaluating spasticity interventions from a multimodal perspective as a starting point in an effort to understand more of this intriguing phenomenon. Some of the research questions above are already in the “pipeline” for coming studies; others are to be planned by our research group and others