Physical therapy in patients with disorders of consciousness: Impact on spasticity and muscle contracture

Article type: Research Article

Authors: Thibaut, A.^{a; b; *} | Wannez, S.^a | Deltombe, T.^c | Martens, G.^a | Laureys, S.^a | Chatelle, C.^{a; d}

Affiliations: [a] Department of Neurology, Coma Science Group, GIGA-Consciousness, University and University Hospital of Liege, Liege, Belgium | [b] Spaulding Neuromodulation Center, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA, USA | [c] Department of Physical Medicine and Rehabilitation, CHU UCL Namur site Mont-Godinne, (Université Catholique de Louvain), Yvoir, Belgium | [d] Laboratory for NeuroImaging of Coma and Consciousness, Massachusetts General Hospital, Boston, MA, USA

Correspondence: [*] Address for correspondence: A. Thibaut, GIGA-Consciousness, B-34, Quartier Hôpital, Avenue de l’Hôpital, 11, 4000 Liège, Belgium. Tel.: +32 3668069; E-mail: athibaut@ulg.ac.be.

Abstract: BACKGROUND:Spasticity is a frequent complication after severe brain injury, which may prevent the rehabilitation process and worsen the patients’ quality of life. OBJECTIVES:In this study, we investigated the correlation between spasticity, muscle contracture, and the frequency of physical therapy (PT) in subacute and chronic patients with disorders of consciousness (DOC). METHODS:109 patients with subacute and chronic disorders of consciousness (Vegetative state/Unresponsive wakefulness syndrome – VS/UWS; minimally conscious state – MCS and patients who emerged from MCS – EMCS) were included in the study (39 female; mean age: 40±13.5y; 60 with traumatic etiology; 35 VS/UWS, 68 MCS, 6 EMCS; time since insult: 38±42months). The number of PT sessions (i.e., 20 to 30 minutes of conventional stretching of the four limbs) was collected based on patients’ medical record and varied between 0 to 6 times per week (low PT = 0–3 and high PT = 4–6 sessions per week). Spasticity was measured with the Modified Ashworth Scale (MAS) on every segment for both upper (UL) and lower limbs (LL). The presence of muscle contracture was assessed in every joint. We tested the relationship between spasticity and muscle contracture with the frequency of PT as well as other potential confounders such as time since injury or anti-spastic medication intake. RESULTS:We identified a negative correlation between the frequency of PT and MAS scores as well as the presence of muscle contracture. We also identified that patients who received less than four sessions per week were more likely to be spastic and suffer from muscle contracture than patients receiving 4 sessions or more. When separating subacute (3 to 12 months post-insult) and chronic (>12months post-insult) patients, these negative correlations were only observed in chronic patients. A logit regression model showed that frequency of PT influenced spasticity, whereas neither time since insult nor medication had a significant impact on the presence of spasticity. On the other hand, PT, time since injury and medication seemed to be associated with the presence of muscle contracture. CONCLUSION:Our results suggest that, in subacute and chronic patients with DOC, PT could have an impact on patients’ spasticity and muscles contractures. Beside PT, other factors such as time since onset and medication seem to influence the development of muscle contractures. These findings support the need for frequent PT sessions and regular re-evaluation of the overall spastic treatment for patients with DOC.

Keywords: Spasticity, hypertonicity, upper motor neuron, muscle contracture, disorders of consciousness, minimally conscious state, vegetative state/unresponsive wakefulness syndrome, non-pharmacological treatment, physical therapy

DOI: 10.3233/NRE-172229

Journal: NeuroRehabilitation, vol. 42, no. 2, pp. 199-205, 2018