ON SPASTICITY IN SPINAL CORD INJURY: THE CHALLENGE OF MEASUREMENT AND THE ROLE OF NOVEL INTERVENTION (SEGWAY) by Grace Anne Boutilier B.KinH., Acadia University, 2003 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF APPLIED SCIENCE in The Faculty of Graduate Studies (Experimental Medicine) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) December 2009 © Grace Anne Boutilier, 2009 ABSTRACT Spasticity is a common sequale of spinal cord injury (SCI), and can have both beneficial and detrimental effects on mobility, functional independence and self-esteem. Clinical measurement of spasticity suffers from questions of credibility and contextual isolation. Recently self-report measures of spasticity have gained recognition as a viable alternative to independent examiner techniques. This pilot study endeavored to discern whether agreement was present between the clinical ‗gold standard‘ measure (the modified Ashworth scale or MAS) and a recently validated self-report tool (the Spinal Cord Injury Spasticity Evaluation Tool or SCI-SET). Spearman rank correlational analysis of measurement of spasticity using MAS and SCI-SET demonstrated some agreement, particularly with respect to the upper extremity musculature (ρ=.564, p=0.001). This relationship was much weaker comparing the lower extremity (ρ=.249, p=.161). They appear to measure similar, yet distinct aspects of the patients‘ spasticity. While the MAS is quick and offers an objective interpretation, perhaps the SCI-SET better reflects the multifaceted nature of spasticity and how it affects the individual, and may enable some interpretation regarding the upper and lower extremities. This information is helpful for clinicians to compile a more comprehensive picture of spasticity as it affects the individual. The Segway Personal Transporter® is a novel, yet practical mobility tool which has yet to garner widespread support in the SCI population. It requires minimal functional ability to operate, and is appropriate for use in individuals with disabilities. Previous work suggests a possible link between the Segway and physiologic benefits to spasticity, pain and fatigue. A one month intervention program targeted these outcome ii measures to determine (1) if they exist and (2) whether the effects are immediate or long-term in nature. The Segway provides evidence for short term reductions in clinical ratings of spasticity (p=.001) and self-report pain (p=.027). Self-evaluations of fatigue approached significance (p=.12). There is some evidence to suggest that these beneficial outcomes may have lasting effects. The Segway may provide an adjunct to current therapy options for treating spasticity by introducing a stimulus to the system which overrides some underlying mechanism(s). As this was pilot work, further investigation of a longitudinal nature with a larger sample size is required to substantiate these findings. iii TABLE OF CONTENTS ABSTRACT ....................................................................................................................... ii TABLE OF CONTENTS ................................................................................................ iv LIST OF TABLES .......................................................................................................... vii LIST OF FIGURES ...................................................................................................... viii ACKNOWLEDGEMENTS .............................................................................................. ix DEDICATION .................................................................................................................. x CHAPTER 1- INTRODUCTION .................................................................................. 1 1.1 Overview of Thesis ................................................................................................... 1 1.2 Purpose ...................................................................................................................... 1 1.3 Introduction to Spinal Cord Injury ............................................................................ 2 1.3.1 Spinal Cord Injury.............................................................................................. 2 1.3.2 Incidence of SCI ................................................................................................ 2 1.3.3 Cost .................................................................................................................... 3 1.3.4 Classification Schemes: Traumas, Plegias, and Impairments ............................ 3 1.3.5 Spasticity in SCI ................................................................................................ 5 1.4 Measurement of Spasticity ...................................................................................... 19 1.4.1 Introduction to Measurement of Spasticity ...................................................... 19 1.4.2 The Ashworth Scale: A Closer Look ............................................................... 28 1.4.3 The Spinal Cord Injury-Spasticity Evaluation Tool ........................................ 35 1.4.4 Measurement Summary ................................................................................... 37 1.5 Other complications of SCI .................................................................................... 38 1.5.1 Pain .................................................................................................................. 38 1.5.2 Fatigue.............................................................................................................. 40 1.5.3 Other Impacts (Depression) ............................................................................. 42 1.5.4 The Role of Physical Activity .......................................................................... 43 1.6 Mobility................................................................................................................... 44 1.6.1 SCI and Upright Standing ................................................................................ 44 1.6.2 Current Options in Mobility............................................................................. 46 1.6.3 The Segway Personal Transporter ................................................................... 50 1.7.Summary ................................................................................................................. 52 1.8 Research Questions ................................................................................................. 53 1.8.1 Research Questions #1 (Chapter 2).................................................................. 53 1.8.2 Research Questions #2 (Chapter 3).................................................................. 54 1.9 Significance............................................................................................................. 54 1.10 References ............................................................................................................. 56 CHAPTER 2 –SPASTICITY: THE CHALLENGE OF MEASUREMENT ............ 66 2.1 Introduction: Measurement of Spasticity ................................................................ 66 2.1.2 The modified Ashworth Scale ......................................................................... 68 2.1.3 The Spinal Cord Injury-Spasticity Evaluation Tool ........................................ 69 2.2 Purpose and Objectives ........................................................................................... 71 2.3 Hypothesis............................................................................................................... 71 2.4 Methods................................................................................................................... 72 iv 2.4.1 Study Design .................................................................................................... 72 2.4.2 Eligibility and Recruitment .............................................................................. 72 2.4.3 Data Collection ................................................................................................ 73 2.4.4 Modified Ashworth Testing ............................................................................. 73 2.4.5 SCI-SET ........................................................................................................... 74 2.5 Data Analysis Procedures ...................................................................................... 75 2.6 Results ..................................................................................................................... 75 2.6.1 Correlational Agreement .................................................................................. 76 2.7 Discussion ............................................................................................................... 78 2.8 Limitations .............................................................................................................. 81 2.9 Bridging Summary .................................................................................................. 82 2.10 References ............................................................................................................. 83 CHAPTER 3- THE ROLE OF NOVEL INTERVENTION (SEGWAY) ................ 85 3.1 Introduction ............................................................................................................. 85 3.1.1 Spasticity