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PubMed2002

Clinical neurokinesiology of spastic gait.

Locomotor control requires a spatiotemporal coordination of passive and active forces across the movement system. Both anticipatory and reactive strategies operate in locomotor control. Mammalian locomotion is based on a rhythmic, "pacemaker" activity of spinal stepping generators. Reflex modification of the gait cycle is task-, context- and especially phase-dependent. In spasticity, together with disturbed supraspinal control, the phase-dependent reflex modulation of the gait cycle is severely impaired and there is altered modulation and timing of muscle activation and relaxation during voluntary movement. There is also a poor correlation between EMG activity and tension development in the spastic muscle. The tension increases without sufficient muscle activation and disconnection and dyscoordination between muscle activation, tension development and motor performance develops. The pattern of muscle activation and the development of increased muscle tone in patients with spasticity may be dramatically different in active movement from that observed in clinical testing of the passive muscles. Strategies used in the functional treatment of spasticity should be aimed at training and activating residual motor function, suppression of pathological and unfavourable movement and postural patterns and preventing secondary complications. In the 1990s a number of new specific instrumental methods and technical equipment supporting gait rehabilitation in patients with CNS lesions were developed: rhythmic auditory stimulation and other types of rhythmic stimulation, partial body support, usually with treadmill walking, complex orthotic support of bipedal locomotion, multichannel functional electrical stimulation, usually with programmable computer control, and advanced gait trainers. In therapy of spastic gait, the functional goals should be clearly determined from the kinesiological point of view of the impairment, and the impact on disability and handicap should be considered and a multidisciplinary approach is essential. (Ref. 139.)

Central Nervous System Diseases↗

PubMedDate not supplied

Non-drug induced spasticity reduction achieved by coordination dynamic therapy in CNS injury.

In two patients with severe central nervous system (CNS) lesions it could be demonstrated that spasticity reduction can be achieved by the coordination dynamic therapy method without administration of spasmolytic drugs. The reduction of spasticity in the short- and long-term memory was measured with the coordination dynamic recording method. When performing rhythmic coordinated movements, the mainly extensor spasticity reduced in the first case in the short-term memory within 35 min of assisted exercising by approximately 68% (easy treatable case). In the second case spasticity reduced in the short-term memory within 58 min of exercising by 15 up to 28% and in the long-term memory within 6 months by 16% (difficult treatable case) as judged by the improvement of the coordination dynamics when exercising on the special coordination dynamic therapy device. Reduction of spasticity without administration of drugs could be achieved in all of the more than 100 patients undergoing coordination dynamic therapy.

Adolescent↗

PubMedDate not supplied

[Posterior partial rhizotomy and a new technique, posterior partial radiclotomy, in the treatment of tonic spasticity (author's transl)].

A comparison between G r o s' technique and a new personal technique, performed in 24 patients suffering from spastic syndromes, offers an opportunity for a reappraisal of Foerster's method of treating spasticity. The best results were obtained in patients with postural spastic disorders. Because the posterior partial rhizotomy did not result in a complete preservation of deep sensation in all patients operated on, it seems questionable whether this technique should be performed in spastic patients who are acquiring (or have already acquired) an independent standing position of deambulation. The technique which we propose, the posterior partial radiclotomy, did not cause any sensory disorder and appears of therapeutic value also and especially in patients suffering from spastic syndromes of moderate degree.

Adolescent↗

PubMed2003

[Pathophysiology of spasticity].

Lance's definition of spasticity focuses on the exaggeration of the tonic stretch reflex as one component of the upper motor neuron syndrome. In daily practice, many different symptoms are referred to as spasticity. Experimental studies stress the particular role of the premotor cortex and the medial reticular formation for the genesis of spasticity. Physiological studies clearly demonstrate the two components, phasic and tonic, of the stretch reflex. Whatever the pathology, the clinical picture of spasticity seems to depend less upon the etiology of the lesion and more upon its location in the neuraxis. There is a regional organisation of the spinal circuitry according to the function of the segmental nerves and, therefore, a particular clinical presentation related to each spinal segment. The muscular efferents are also heterogeneous and linked to function. This is the fundamental base of focal treatment of spasticity.

Animals↗

PubMed2003

[Pathology of spastic muscles. Study of 26 patients].

Spastic hypertonia is observed in various central neurological diseases. Pathology of spastic muscle is not well known. Tibial selective microsurgical neurotomy is used for the spastic foot treatment. Twenty-six hemiplegic patients, spastic since more than one year, underwent selective tibial microsurgical neurotomy. Biopsies of soleus, lateral and medial gastrocnemius muscles were performed during surgical treatment, after free patient consent and ethical committee approval. The aim of this study was to describe histopathological lesions of spastic muscles, with histological and histoenzymatic techniques. Histological studies revealed myogenic atrophy, concerning both types of fibers or only type II fibers. They also showed type I (slow fibers) to type II (fast fibers) transformation, in the three studied muscles. These results are similar to those described in the literature.

Adolescent↗

PubMed2003

[Clinical evaluation of spasticity].

Spasticity is one component of the upper motor neurone syndrome. Unlike motor deficit and co-contraction, spasticity is responsive to treatment. Thus it receives more attention than the other features of the upper motor neuron syndrome. In order to treat correctly the patients, we need to know expectations of the patient and family. Detailed clinical evaluation including functional analysis is necessary to determine whether the objectives are reasonable. This evaluation is not always very easy because of complex clinical features. Simply aiming to reduce spasticity is not a final treatment goal. There must be a purpose behind it. It is actually very difficult to evaluate functional effect of spasticity treatments. Few studies show a real functional improvement. Yet patients are satisfied with the results and the goals are often achieved. One explanation is that functional scales usually used do not fit to the spasticity problem.

Humans↗

PubMed2003

[Spastic gait analysis. Contribution of the motion lab].

Etienne-Jules Marey introduced gait motion analysis at the end of the XIXth century. It was rapidly adopted by clinicians and Charcot used it at the beginning of the XXth century in La Salpêtrière. Motion analysis was widely used after the first optoelectronic system was built by Furné in 1968. The optoelectronic system calculates the orientation of each body segment in the space after the determination of the space co-ordinates of cutaneous markers placed over them. It is particularly useful for spastic gait. Many disturbances of kinematics and kinetics have been described during spastic gait. They are the consequences of spasticity and other motor and sensory deficits of central nervous system lesions. Motion analysis must be coupled with electromyographic recording of spastic muscles activity which, with kinetic analysis, enables distinguishing the mechanisms underlying gait disturbances. Motion analysis provides clinicians with an indispensable tool for understanding spasticity and evaluating therapeutic efficacy.

Biomechanical Phenomena↗

PubMed2003

[Alcohol neurolytic blocks for pain and muscle spasticity].

Peripheral nerve blockade is one of the therapeutic options for spasticity of various muscles. Percutaneous nerve stimulation allows accurate location of nerves and neurolysis can be performed using intraneural injection of 65% ethanol or 5 to 12% phenol. Spastic contraction of various muscle groups is a common source of pain and disability which prevents efficient rehabilitation. Neurolytic blocks are possible in most of motor nerves of the upper and lower limbs and main indications are spastic sequelae of stroke and spinal trauma but also of multiple sclerosis, cerebral palsy and chronic coma. The use of percutaneous nerve stimulation allows accurate location and four nerves are more frequently treated: pectoral nerve loop, median, obturator and tibial nerves. In patients with spasticity of the adductor thigh muscles, nerve blocks are performed via a combined approach using fluoroscopy and nerve stimulation to identify the obturator nerve. No complications occur and minor side effects are transient painful phenomena during injection. These approaches have proved to be accurate, fast, simple, highly successful and reproducible. Percutaneous neurolytic procedures, should be performed as early as possible, as soon as spasticity becomes painful and disabling in patients with neurological sequelae of stroke, head trauma or any lesion of the motor neurons.

Ethanol↗

PubMedDate not supplied

[Palliative surgical treatment of spastic paralysis in the upper extremity].

AIMS: In this paper we review the main studies conducted on therapy applied to the bony and soft parts in spastic paralysis of the upper extremity. DEVELOPMENT: Spasticity presents muscular hypertonia and hyperexcitability of the stretch reflex, which are typical of upper motoneuron syndrome. Physiopathologically, spasticity is due to the medullar and supramedullar alteration of the afferent and efferent pathways. Treatment is multidisciplinary and involves the collaboration of rehabilitators, neurophysiologists, neurologists, paediatricians, orthopaedic surgeons and psychologists, who all contribute with their different therapeutic aspects and characteristics (which can be pharmacological, peripheral neurological blockages, surgical, etc.). The characteristic posture of the upper extremities in spastic cerebral palsy is the inward rotation of the shoulder, flexion of the elbow and pronated forearm, and the deformity of the fingers (swan-neck and thumbs-in-palm). The primary objectives in these patients will be to improve communication with their surroundings, perform activities of daily living, increase mobility and walking. CONCLUSIONS: The surgical treatment applied by orthopaedic surgeons in the upper extremities are aimed at achieving an enhanced adaptive functionality rather than morphological normality. Factors to be taken into account include age, voluntary control over muscles and joints, level of severity of the spasticity (Ashworth scale) and stereognostic sensitivity. In general, on soft parts we will use procedures such as dehiscence or lengthening of the flexor muscles of the shoulder and elbow or of the adductor of the thumb; transfer of the pronators in order to adopt the supinating function or of the flexors so as to reinforce the extensors of the forearm, and capsulodesis or tenodesis in the hand. The bony procedures will consist in derotational osteotomies of the humerus and radius and arthrodesis in the wrist or in the metacarpophalangeal joints of the thumb, depending on whether there is greater rigidity or age in the former cases or instability in the latter.

Humans↗

PubMed2003

Rehabilitation medicine: 3. Management of adult spasticity.

Spasticity refers to an abnormal, velocity-dependent (i.e., how fast the joint is moved through its range) increase in muscle tone resulting from interruption of the neural circuitry regulating the muscles and is a common complication of cerebral palsy, brain injuries, spinal cord injuries, multiple sclerosis and stroke. The muscle stretch reflex is thought to play an important role in spasticity generation. Spasticity can have a significant detrimental effect on daily functions, such as feeding, dressing, hygiene, bladder and bowel control, and mobility; patients' need for support can also influence the cost of care. Thus, managing these patients appropriately or referring them to those with expertise in this area is important. In this article, I review the pathophysiology of spasticity and the evaluation and management of adult patients with the condition. Two hypothetical cases are presented to illustrate the management of spasticity.

Cervical Vertebrae↗

PubMedDate not supplied

[Guidelines for the treatment of spasticity in adults using Botulinum toxin].

AIMS: The introduction of Botulinum toxin type A (BTA) in the treatment of spasticity in adults was a large step forward in neurology and it is currently seen as the first choice treatment in focal spasticity. In an attempt to achieve the optimisation of this therapeutic resource, different clinical guidelines have been drawn up which include reviews of the evidence available about the indications and use of BTA. Spasticity is characterised by the presence of involuntary muscular hyperactivity that is often associated to pain, deformity and functional disability. From the clinical point of view, the advantages of BTA are obvious (ease of use and dosage determination, long lasting effects, reversibility should the response be inappropriate, etc.) and far outweigh its drawbacks. It can only be used after a proper selection of patients, of the therapeutic aims and of the muscular areas to be treated, and a tailor-made programme of rehabilitation must also be drawn up. Increasing experience in its use suggests that its early administration is effective in preventing or reducing the complications arising from spasticity. CONCLUSIONS: BTA is effective in the treatment of spasticity and plays a significant role if the clinical objectives involve functional aspects. At present a large amount of well-documented experience concerning its indications, effects and safety in clinical practice is already available.

Adult↗

PubMed2004

[Spasticity in multiple sclerosis].

Already in 1860, the great neurologist Charcot described the symptom spasticity in patients affected by "sclerose en plaque". Spasticity is one of the most common symptoms of multiple sclerosis MS). The consequences of spasticity are very disadvantages because it hinders the functional mobility and overburden disability. Moreover, in the later stages of MS spasticity may be complicated by seating problems, pressure sores, fibrous contractures and poor perineal hygiene. In this article, the therapeutical management of MS spasticity, in all its components (pharmacological, rehabilitative, surgical) is reviewed.

Humans↗

PubMed2001

[Measuring outcome in spasticity rehabilitation].

Spasticity is a frequent consequence of upper motor neuron lesion and is associated with a variety of symptoms such as pain, muscle stiffness and reflex patterns that interfere with activities of daily living, dexterity and gait. As therapy strategies in managing spasticity-associated problems have been evolving there is an increasing need for a practicable documentation system which describes spasticity and related symptoms on different levels in order to evaluate especially the level of functioning. In daily routine the single-case-design reflects a useful technique to evaluate the status in terms of technical, functional and individual goals for treatment. However, there is no single tool to measure the different types of changes due to treatment, therefore a variety of selecting tests, based on the functional changes expected from the selected treatment, is recommended. The sensitivity of the selected tests should match the range of expected improvements related to the specific treatment. Technical goals should be evaluated by validated spasticity rating scales. As changes in technical measures of spasticity such as muscle tone, muscle length, range of motion or repetitive voluntary movements may not correlate with clinical improvements, individual functional goals should be defined. Those functional goals should reflect the patients' and care-givers' individual perception of the actual problem. A treatment diary is a useful tool to document subjective perception of changes over time. Some practical issues are adressed below. Reliable outcome measures enable patients and doctors to select further treatment strategies and gives health care providers information on treatment expectations in return for their investments.

Activities of Daily Living↗

PubMedDate not supplied

[The usefulness of tizanidine. A one-year follow-up of the treatment of spasticity in infantile cerebral palsy].

INTRODUCTION: The cerebral palsy has the first place of physical handicap in children (type spastic, 88%). Tizanidine imidazole derivative is centrally acting as a a2-adrenergic agonist. AIM: To demonstrate clinically the effectiveness of tizanidine in the decrease of the spasticity. PATIENTS AND METHODS: We assigned randomly in a double blind study 10 children treated with tizanidine (0.05 mg/kg/day) and 30 with placebo for a 6-month period, after which they were unified in the group of tizanidine. The dependent variables were spasticity, Ashworth scale, posture tone scale, reflex scale and liver function test. RESULTS: The spasticity and the reflex decreased in the group of tizanidine an 78.85% in comparison with a 7.64% in the group of placebo (p = 0.0001); in the monitoring of 6 months 35 patients reduced this to 78.2% (p= 0.0001). The duration of effectiveness of tizanidine in four patients was two months and they never returned to their appraisal basal. Without reported adverse effects, the liver function test remains normal. CONCLUSION: Tizanidine produces a significant reduction of the spasticity in children without adverse effects, having a high percentage of acceptance to the prescribe dose.

Adolescent↗

PubMed1990

[Selective limited posterior rhizotomy at 3 dorsal levels. A variant for the neurosurgical treatment of spasticity].

INTRODUCTION: Selective posterior rhizotomy (SPR) is effective for reducing spasticity associated to infantile cerebral palsy (ICP). To avoid excessive muscular hypotone a different surgical technique is proposed. PATIENTS AND METHODS: Sixteen children with spasticity secondary to ICP were evaluated before and after rhizotomy. The degree of spasticity was compared in the lower an in the upper limbs. Dorsal roots of levels L4, L5, and S1 were analyzed and sectioned according to the results yielded by intraoperative electrical stimulation. RESULTS: Spasticity was reduced in all the muscular groups analyzed. One of the patients had bladder incontinence. CONCLUSIONS: The limited surgical procedure is sufficient for reducing spasticity.

Afferent Pathways↗

PubMed1989

Spasticity: quantitative measurements as a basis for assessing effectiveness of therapeutic intervention.

Spasticity, a common problem in upper motor neuron lesions, frequently results in uncontrolled involuntary motion that interferes with function. A quantifiable method related to the mechanical output of the muscle is needed to test and improve therapeutic intervention. A sinusoidal displacement of 5 degrees was used to measure elastic and viscous stiffness around the ankle at frequencies from 3 to 12Hz. To isolate viscoelastic response, the influences of inertia and equipment drag were eliminated. Test-retest correlation values were 0.953 for elastic and 0.992 for viscous stiffness. The elastic stiffness in 13 spastic subjects under nerve block was significantly higher than that of 13 healthy subjects (p less than or equal to 0.05), indicating early changes associated with contracture. Elastic and viscous response is expressed by the total stiffness vector containing both components, the Nyquist diagram. This diagram's pathlength from 3 to 12Hz was calculated and showed high test-retest reliability in healthy subjects. The median pathlength value for the spastic group was 98 Newton-meters/radian (N-m/rad) and, for the normal group, 24N-m/rad, a statistically significant difference (p less than or equal to 0.0001). A mathematical model of the spastic response shows that the Nyquist diagram's pathlength relates to reflex loop gain and is independent of the shift in passive properties. The model predicts a shift in passive properties during spastic responses relative to responses measured during nerve block. Thus, subtraction of passive responses measured during nerve block may not isolate the remaining reflex response, but the pathlength measure relating to the reflex response gain was unaffected, allowing evaluation of therapeutic intervention effectiveness.

Adult↗

PubMed1988

Management of the spastic upper extremity in the neurologically impaired adult.

Spasticity that interferes with upper extremity function is common in adults following stroke, brain injury, or anoxia. During the period of neurologic recovery definitive surgical procedures are avoided. Techniques to temporarily reduce spasticity include the implantation of a MicroPort reservoir and catheter for repeated branchial plexus blocks and phenol nerve blocks, which provide longer lasting relief of noxious muscle tone. Percutaneous blocks of the musculocutaneous and recurrent median nerves and motor point blocks of the pectoralis major, the brachioradialis, and forearm flexor muscles are easily performed at bedside. The motor branch of the ulnar nerve can be injected surgically with phenol to diminish intrinsic spasticity. When neurologic recovery has plateaued, hand placement can be improved in many patients following proximal release of the brachioradialis muscle and lengthening of the biceps and branchialis tendons. Hand function is enhanced by fractional lengthening of spastic wrist and finger flexors. Intrinsic spasticity must be addressed at the same time by phenol block or intrinic release. When extensor function is lacking, a tenodesis of the wrist extensors is helpful. The thumb-in-palm deformity requires proximal release of the thenar muscles as well as lengthening of the flexor pollicis longus. Contracture releases in the nonfunctional arm improve hygiene and ease care.

Adult↗

PubMed1985

[Treatment of spastic foot by selective neurotomy of the tibial nerve. Results of a series of 31 cases].

A large number of patients suffering from various neurological diseases remain disabled because of spastic disorders in their foot. These disorders--which are responsible for abnormal postures and painful disturbances for walking and standing--can be corrected by an effective procedure: the so-called Selective Neurotomy of the Tibial Nerve (T.N.), developed in its modern form by Gros in 1972. The procedure aims at sectioning the T.N. branches corresponding to the muscles, the spasticity of which is considered harmful, i.e. the soleus (and/or gastrocnemius) nerves for equinus and ankle clonus, the posterior tibialis branch for varus, and the flexor fascicles for tonic flexion of the toes. After dissection of each T.N. branches at the lower part of the popliteal region and their identification with bipolar electro-stimulation, the selected nerves are sectioned partially (about two-third of their caliber) under the operative microscope. The present series consists of 37 operations--performed 25 times unilaterally and 6 bilaterally--in 31 patients, 17 to 68 year old (39 on average). In 11 patients spasticity was from spinal cord origin and in the 20 others from vascular or traumatic cerebral damages. The spastic disorders--installed for 2 to 17 years (4 on average)--were due to one, several or all the following components: equinus, ankle clonus, varus, flexion of the toes. Surgery obtained complete suppression of the disabling spastic components, total pain relief and consequently improvement of the residual voluntary movements by achieving balance between agonist and antagonist muscles, in 33 out of the 37 cases, i.e. in 91% of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗