Well shit, spasticity does not need to be solved per the infuriating opinion of Dr. William M. Landau!
Spasticity After Stroke: Why Bother? Aug. 2004)
Yeah, Bruce Dobkin is a superstar stroke researcher but I think this letter is nit-picking.
Quit discussing spasticity AND JUST FUCKING CURE IT!
Does Spasticity Itself Raise the Cost of Stroke Care 4-Fold?
To the Editor:
The report from Lundstrom et al1
headlines a relationship between spasticity and higher direct costs of
stroke care over the first year after onset. The authors seem to be
putting the cart’s contents, 1 of which is spasticity, before the horse
of sensorimotor impairment. The authors used a modified Ashworth Score
of ≥1 in any 1 of 7 arm and leg joints as the measure of spasticity. The
modified Ashworth Score is a 6-point ordinal scale of resistance to
passive movement across a joint, which can arise from reflexive
clasp-knife resistance and from changes in connective tissues of the
joint associated with severity of paresis, nonuse, and contracture. It
is often used in studies, but its validity and reliability may be less
than necessary to reflect a physiologically meaningful measure.2
Clinicians involved in the care of patients with chronic stroke would
not consider a modified Ashworth Score in any 1 joint of <3 to
suggest a clinically important problem. No evidence exists that the
modified Ashworth Score cutoff used for this study’s retrospective,
database-driven findings could be detrimental after stroke. So what
underlies the relationship described?
The
authors found a significantly higher National Institutes of Health
Stroke Scale score in the group considered to have any degree of
spasticity. It would seem, then, that they would want to examine for a
correlation between cost of care and level of impairment based on the
National Institutes of Health Stroke Scale. They did show that poorer
modified Rankin Scale scores (which intermix aspects of impairment and
disability) were significantly related to higher costs. If indeed,
greater resistance to passive movement across a singe joint has a
relationship to cost, the primary relationship is probably to the degree
of sensorimotor impairment that induces greater disability and, in
turn, higher in-hospital costs from complications of greater impairment
such as immobility.
The discussion from the
authors seems to repudiate the primacy of their correlation. If “our
study does not provide evidence that spasticity as such is responsible
for the (4-fold) increase of costs” and “spasticity reflects a more
severe motor disorder,” how can the authors suggest that their data
offer, at best, a baseline for “the cost-effectiveness of interventions,
including botulinum toxin” … ? This particular intervention is likely
to drive up costs if injected into patients with a modified Ashworth
Score <3 but will not alter sensorimotor impairments. From a
healthcare priority point of view, their findings suggest the need for
more outpatient physiotherapy, which was provided to only 4% of their
subjects. A rehabilitation intervention to maintain range of motion,
prevent painful contractures and dystonic postures, and to improve motor
control and skills might reduce disability, costs, and burden of care
for those who are most impaired by paresis.
No comments:
Post a Comment