CASE REPORTS

Changes in Muscle Spasticityin Patients With Cerebral PalsyAfter Spinal Manipulation: Case Series

Oleh Kachmar, MD, PhD,aTaras Voloshyn, MD,band Mykhailo Hordiyevych, MDb

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ABSTRACT

Objective: The purpose of this case series was to report quantitative changes in wrist muscle spasticity in childrenwith cerebral palsy after 1 spinal manipulation (SM) and a 2-week course of treatment.
Methods: Twenty-nine patients, aged 7 to 18 years, with spastic forms of cerebral palsy and without fixed contractureof the wrist, were evaluated before initiation of treatment, after 1 SM, and at the end of a 2-week course of treatment.Along with daily SM, the program included physical therapy,massage,reflexotherapy,extremity joint mobilization,mechanotherapy, and rehabilitation computer games for 3 to 4 hours’duration. Spasticity of the wrist flexor was measuredquantitatively using a Neuroflexor device, which calculates the neural component (NC) of muscle tone, representing truespasticity, and excluding nonneural components, caused by altered muscle properties: elasticity and viscosity.
Results: Substantial decrease in spasticity was noted in all patient groups after SM. The average NC values decreasedby 1.65 newtons (from 7.6 ± 6.2 to 5.9 ± 6.5) after 1 SM. Another slight decrease of 0.5 newtons was noted after a 2-weekcourse of treatment. In the group of patients with minimal spasticity, the decrease in NC after the first SM was almost twofold—from3.93 ± 2.9 to 2.01 ± 1.0. In cases of moderate spasticity, NC reduction was noted only after the 2-week course of intensive treatment.
Conclusions: In this sample of patients with cerebral palsy, a decrease in wrist muscle spasticity was noted after SM.Spasticity reduction was potentiated during the 2-week course of treatment. (J Chiropr Med 2016;15:299-304)Key Indexing Terms:Spinal Manipulation; Muscle Spasticity; Cerebral Palsy

INTRODUCTION

The termcerebral palsy(CP) refers to a group ofpermanent disorders of the development of movement andposture, which cause activity limitations and are attributedto nonprogressive disturbances of a developing brain.1Itis the most common motor disorder among children,affecting approximately 2 children per 1000 births. One in5 children with CP (20%) has a severe intellectual deficitand is unable to walk.2
Muscle spasticity is a clinical syndrome of CP resultingfrom upper motor neuron lesions, and the reduction of theselesions is an important therapeutic target for optimizingmotor performance. The treatment program for a child withspasticity may include different options: exercises, casting,constraint-induced therapy, oral medications, chemodenerva-tion, intrathecal baclofen, selective dorsal rhizotomy, andorthopedic surgery.3Because of the limited efficiency of“traditional”treatments, a wide range of complementary andalternative therapies are used for muscle tone management inpatients with CP, including spinal manipulation (SM).4,5
Spinal manipulation could possibly be used as aseparate intervention in CP treatment and as part of anintegrated treatment program called theintensive neuro-physiologic rehabilitation system, which includesdifferent treatment modalities: physical and occupationaltherapy, extremity joint mobilization, reflexotherapy,body massage, and mechanotherapy. This treatment maybe performed in intensive 2-week courses lasting 3 to4 hours daily.6
Descriptive studies of this rehabilitation approach havereported improvements in gross motor functions7and adecrease in muscle spasticity in 94% of the cases.8However, these studies had methodologic limitations, andspasticity was measured using the Modified AshworthScale,9whose validity and reliability have been questionedby many authors.10

a) Innovative Technologies Department, International Clinic of Rehabilitation, Truskavets, Ukraine.
b) Rehabilitation Department, International Clinic of Rehabili-tation, Truskavets, Ukraine.Corresponding author: Oleh Kachmar, MD, PhD, 37, Pomir-etska Street, Truskavets, 82200, Ukraine. Tel.: +38 067 3537 927.(e-mail:au.vivl.aher.ci%40ramhcako).
Paper submitted April 26, 2016; in revised form June 24,2016; accepted July 31, 2016.1556-3707© 2016 National University of Health Sciences.http://dx.doi.org/10.1016/j.jcm.2016.07.003

A more precise quantitative evaluation of spasticity ispossible using the Neuroflexor device, developed by theSwedish company Aggero MedTech AB (Stockholm,Sweden) and validated by a research team from theKarolinska Institute (Solna, Sweden). 11 Recent studieshave indicated that Neuroflexor is a reliable measurementtool with high test–retest and interrater reliability, 12 and itssensitivity is good enough to measure changes in spasticityduring CP treatment.13
The purpose of this case series is to describe thequantitative changes in wrist muscle spasticity in childrenwith CP after 1 SM and after a 2-week course of treatment

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METHODS

Patient Selection

Patients were selected for this prospective case seriesaccording to the established inclusion criteria and evaluated3 times. Initial evaluation was followed by SM in 10 to 15minutes, and the second evaluation was carried out after 15minutes. The third evaluation was performed at the end ofthe 2-week course of treatment. All procedures wereperformed in accordance with the ethical standards of theinstitutional committee on human experimentation and theHelsinki Declaration of 1975, as revised in 2000; writteninformed consent was obtained from all patients included inthe study. Research work was approved by the MedicalEthics Commission of the International Clinic of Rehabilitation, located in Truskavets, Ukraine.

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A total of 30 children admitted to the RehabilitationClinic took part in the study. Inclusion criteria were asfollows: unilateral and bilateral forms of spastic CP, age 7to 18 years, and Manual Ability Classification Scale levelsI–IV. Exclusion criteria were as follows: ataxic ordyskinetic form of CP, fixed contractures of the wristwith less than 50° of passive wrist extension, and inabilityto understand and comply with instructions. The clinicaldiagnosis was confirmed by a child neurologist before thesubjects were included in the study.

One patient failed to participate in the final evaluationbecause of somatic disease and was excluded fromthe study; analysis was carried out in 29 children.

The demographic characteristics of the group are presentedin Table 1.Patients were divided into 3 groups according tothe spasticity level: minimal spasticity (“1” by the ModifiedAshworth scale), 10 children; mild spasticity (“1+” by theModified Ashworth scale), 10 children; moderate spasticity(“2” by the Modified Ashworth scale), 9 children.

Intervention

Spinal manipulation was performed by an orthopedicmedical doctor certified in Manual Therapy. After manualevaluation, high-velocity low-amplitude SM was carriedout in all regions of the spine, including thoracicadjustments in the prone position, lumbar manipulation inlateral recumbent position, and cervical manipulation insitting position.
Spinal manipulation was repeated every day, with a totalof 12 manipulations during the 2-week period. The programfor children with CP also included daily sessions ofphysical therapy, massage, reflexotherapy, extremity jointmobilization, mechanotherapy, and rehabilitation computergames with average daily duration of 3 to 4 hours. A detailed description of the treatment is provided in themanual. 6 No side effects were detected by the researcher and doctor in charge or reported by the patients ortheir parents.

Illustration

Fig 2. Neural component values before intervention (NC-1), after 1 spinal manipulation (NC-2), and after the 2-week course oftreatment (NC-3). Data presented for the whole group, for patients with minimal spasticity (“1” by the Modified Ashworth scale), forpatients with mild spasticity (“1+” by the Modified Ashworth scale), and for patients with moderate spasticity (“2” by the ModifiedAshworth scale). The NC values are given in newtons on the vertical axis.

Evaluation Procedure

aluation ProcedureMuscle tone was measured using the Neuroflexordevice. This instrument extends the wrist and stretchesthe muscles at 2 different constant velocities, whilethe force transducers measure resistance during movements(Fig 1).
Total movement resistance testifies to true spasticity,called the neural component (NC) of muscle tone, which isinduced by the stretch reflex, and nonneural components,caused by altered muscle properties: inertia, elasticity, andviscosity. One test session consisted of 5 slow movementsand 10 fast movements; dedicated software was used toseparate total resistance into its elastic, viscous, and neuralcomponents. Lower NC values correspond to lowerspasticity levels.
A Modified Ashworth Scale score of wrist spasticity wasobtained with the child seated with the elbow flexed to 90° andthe forearm pronated.9 The children’s gross motor functionswere evaluated according to the Gross Motor FunctionClassification System. 14 Hand function was evaluatedaccording to the Manual Ability Classification System.15

Results

Measurement results are summarized in Fig 2 andTable 2, which present NC values before intervention(NC-1), after 1 SM (NC-2), and after the 2-week course oftreatment (NC-3).
Data are presented for the whole group, for patients withminimal spasticity (“1” by the Modified Ashworth scale),for patients with mild spasticity (“1+” by the Modified Ashworth scale), and for patients with moderate spasticity(“2” by the Modified Ashworth scale).
Differences between NC-1 and NC-2 indicate changes inspasticity that occurred after 1 SM; differences betweenNC-1 and NC-3 show changes after the 2-week course oftreatment that included daily SM.Substantial decrease in spasticity was noted both after 1SM and after the 2-week course of treatment. The averagevalues of spasticity decreased by 1.65 newtons (from 7.6 ±6.2 to 5.9 ± 6.5) after 1 SM. After a 2-week course ofintensive treatment with daily SM, there was another slightdecrease in spasticity by 0.5 newtons.
In the group of patients with minimal spasticity, theNC decrease after the first SM was almost twofold—from3.93 ± 2.9 to 2.01 ± 1.0. During the course of treatment,there was a small “rebound” effect, with NC values returningto 2.27 ± 1.4.In cases of mild spasticity, changes in NC were alsonoted after the first SM (from 5.35 ± 3.4 to 3.64 ± 2.4) withsubsequent stabilization at 3.57 ± 2.0.In the moderate spasticity group, changes in NC after thefirst SM were not substantial (from 14.16 ± 3.3 to 12.88 ±7.6), but spasticity levels continued to decrease to 11.23 ±7.5 newtons during the course of treatment.

Discussion

Spinal manipulation is a common treatment modality formusculoskeletal problems, and in many cases, it is used fornonmusculoskeletal conditions.16 There is growing evidence from research studies of the effectiveness ofchiropractic and osteopathic manipulation for nonmusculoskeletal conditions, especially in patients with migraineand headache, 17,18 hypertension, 19,20 chronic obstructive pulmonary disease, 21 and different pediatric conditions,22including CP.23-2

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Our study was aimed at evaluating changes in wristmuscle spasticity in children with CP after 1 SM and a2-week intensive rehabilitation program with daily SMtogether with other treatment modalities: physical therapy,massage, reflexotherapy, extremity joint mobilization,mechanotherapy, and rehabilitation computer games.
In our case series, reduction in spasticity was noted afterthe first manipulation—the NC values of muscle tonedecreased from 7.6 ± 6.2 newtons to 5.9 ± 6.5. After the2-week course of intensive treatment with daily SM, therewas another small decrease in spasticity by 0.5 newtons.
The most pronounced decrease in spasticity after 1 SMwas observed in children with minimal spasticity. In casesof moderate spasticity, NC reduction after 1 SM was lesspronounced but became more prominent after the 2-weekcourse of treatment.
Because decrease in spasticity was noted after 1 SM andthis effect was potentiated by a multicomponent treatmentcourse, we can formulate the hypothesis that SM mighthave an impact on muscle tone regulation.
The influence of SM on muscle spasticity is not fullyunderstood at present. However, an experimental body ofevidence indicates that SM could impact primary afferentneurons from paraspinal tissues and influence musclespindle afferents and Golgi tendon organs,27,28 which aredirectly involved in muscle tone regulation.
The literature points to the influence of SM on spinalcord neural circuits 29,30 possibly modifying stretchreflexes. Interesting information about neural responses toSM has been included in reports of studies on animalmodels. 31,32 Studies have also indicated that SM has aninfluence on the H-reflex,33,34 which is a direct electrophysiologic equivalent for spasticity measurement.This explorative study describes decrease in spasticityafter SM in a group of children with CP.

Luminations

As this was a case series, there was no control group withrandomized allocation or blind testing of participants orexaminers, and the sample size was small. Therefore, wecan only note observed phenomena and cannot calculateinferential statistics or draw conclusions on causation. Thefindings of this study may not necessarily be replicable forother patients with CP or spasticity. Future randomizedcontrolled trials are required to evaluate this effect. Theauthors aim to conduct double-blind randomized clinicaltrials comparing SM and “sham” manipulation to investigatethe possible influence of SM on spasticity.

Conclusions

Decrease in wrist muscle spasticity after SM in patientswith CP was reported in this sample of young patients.Reduction in spasticity was further potentiated during the2-week course of treatment.

Funding sources and conflicts of interest

No funding sources or conflicts of interest were reportedfor this study.

Contributorship information

Concept development (provided idea for the research):O.K., T.V., M.H.
Design (planned the methods to generate the results): O.K.,T.V., M.H.Supervision (provided oversight, responsible fororganization and implementation, writing of themanuscript):O.K.Data collection/processing (responsible for experiments,patient management, organization, or reporting data):T.V., M.H.
Analysis/interpretation (responsible for statisticalanalysis, evaluation, and presentation of the results):O.K., T.V.
Literature search (performed the literature search):O.K., T.V.
Writing (responsible for writing a substantive part of themanuscript):O.K.
Critical review (revised manuscript for intellectual content,this does not relate to spelling and grammar checking):O.K., T.V., M.H.

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