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PubMed2003

[Physiotherapy for spasticity].

The aims of physiotherapy techniques used for the treatment of spasticity are to favor sensorimotor recovery and gesture relearning and to lead to an optimal independence in daily life activities. For stroke and head injury patients, there are several techniques sometimes based on opposing principles. The concept of Bobath tries to inhibit the spastic paralysis and the associated reactions to improve the voluntary motricity of limbs with the ultimate goal of enabling exercises in a functional situation, sometimes after a very long period of therapy. On the contrary, according to the concept of Brunnstom, the goal of exercise is to strengthen the spastic paralysis and the associated reactions to enable the upright position and walking as soon as possible. This technique is especially used in very severe deficiencies where the aim is to avoid the bedridden situation. Three active principles can be identified for neurological rehabilitation. Electrical stimulation is not used routinely by rehabilitation teams. It allows to reduce the spasticity of antagonist muscles working against stimulated muscles. It participates in improving the strength of contraction of weak muscles notably in subjects with incomplete paraplegia. Finally, it can be used to improve or replace a functional command (lifting the foot during walking, for example). Nevertheless, electrical stimulation cannot replace basic rehabilitation exercises.

Central Nervous System Diseases↗
PubMed2003

[Microsurgical drezotomy for spastic limbs].

A microsurgical drezotomy can be useful in some selected cases for the treatment of severe and diffuse spasticity in one or several limbs. This technique has been introduced by M. Sindou in 1972, on the basis of human anatomical studies in the dorsal root entry zone (DREZ). The aim of surgery is to interrupt preferentially the peripheral inputs sustaining myotatic and polysynaptic reflexes which are exaggerated in spasticity, and also nociceptive fibers in the lateral part of the DREZ, whilst sparing most of the medial tactile and kinestetic fibers for the dorsal funiculus. The authors report a retrospective review of 269 patients with severe spasticity in one upper limb (94 cases) treated by a cervical drezotomy, and in one (17 cases) or two lower limbs (158 cases) treated by a lumbosacral drezotomy. The place of this ablative technique inside the neurosurgical armament against spasticity is discussed.

Arm↗
PubMedDate not supplied

[Orally administered drugs in the treatment of spasticity].

Spasticity is a common problem in paediatric neurology and its management constitutes a real professional challenge. There are numerous therapeutic options available and their advantages and disadvantages should be carefully weighed up for each individual patient. It is true that we do not have one single final option, but experience and knowledge of the therapeutic possibilities favour the functional improvement of patients suffering from spasticity. In this paper, we analyse the different drugs available for oral administration in the treatment of spasticity. Special attention is given to the side effects and interactions of these drugs in multiple deficiency patients, who are usually already receiving other medication. We review the mechanism of action, the forms of presentation and dosage, the side effects and interactions of baclofen, diazepam, clonidine, tizanidine, modafilin, gabapentin and dantrolene. Finally, other drugs that may be useful in improving spasticity are also analysed.

Administration, Oral↗
PubMedDate not supplied

[Selective dorsal rhizotomy as a therapeutic option in spasticity. Indications and results].

AIMS: Spasticity, which is a very frequent sequela of neurological diseases, is useful for compensating for loss of strength and enabling the patient to stand, if it is not excessive. Otherwise, it is contraindicative and requires specific treatment. DEVELOPMENT: Spasticity is a spinal cord dysfunction triggered by the lack of upper motoneuron inhibiting afferents and, hence, its treatment can be centred either on a level above that of the lesion itself, if the descending pathways remain functional, or on the lesion, that is, on the spinal cord, by means of neurostimulation, intrathecal drugs or ablative procedures. Ablative procedures, which are essentially oriented towards reducing the afferents in order to diminish medullar reflex hyperexcitability, are indicated in children with spastic cerebral palsy. Thanks to a rigorous detailed study that is conducted beforehand, selective dorsal rhizotomy (SDR) allows us to determine which groups of muscles must be treated. Based on intraoperative neurophysiological studies and monitoring and the use of microsurgical techniques, the dorsal rhizome turns out to be very selective after the perfect identification of the rootlets that are to be preserved. Following the qualitative and quantitative valuation of diverse parameters, post operative results show significant improvements in the functional performance of the child at one year after the intervention, and these are maintained and increase in the next few years. A strict programme of physiotherapy and rehabilitation is very effective and enables patients to enjoy greater autonomy. CONCLUSIONS: The use of SDR enables us to remove excessive spasticity, correct anomalous postures and reduce collateral pain. Its successful performance is depends on the work of a multidisciplinary team and on the overall approach to the disease in each case.

Humans↗
PubMed1992

[Clinical polymorphism and genetic heterogeneity of hereditary spastic ataxia].

The authors systematized the descriptions of different ataxic degenerative syndromes associated with the development of pyramidal symptomatology. Demonstrated the genetic pleomorphism of hereditary spastic ataxias, described the clinical features characteristic of different types of inheritance of spastic ataxias. Based on the authors' observations and analysis of the reported data the following criteria for the diagnosis "spastic ataxia" are suggested: autosomal dominant inheritance type, with the onset on the 3rd-4th decade of life, cerebellar ataxia and dysarthria coupled with tendinous hyperreflexia and the rise of the muscular tone by the spastic type.

Adult↗
PubMed1992

Mechanisms of tetrazepam action on spasticity.

This investigation assessed the mechanisms of Tetrazepam action on spasticity using a battery of electromyographic methods. Thirty patients with post-stroke spastic hemiparesis treated with Tetrazepam took part in the investigation. A questionnaire for assessment of subjective improvement after treatment used a 5-point scale. The 5-point scales were used to assess muscle tone, muscle strength and tendon reflexes. A battery of electromyographic methods was used to analyse different mechanisms of spasticity: for alpha-motoneuron activity--the F-wave parameters; for gamma-motoneuron activity--the TA/H amplitude ratio; for presynaptic inhibition--the ratio of H-reflex maximal amplitudes before and after vibration on the Achilles tendon (Hvibr/Hmax); for common interneuron activity--the flexor reflex parameters. Our results revealed that Tetrazepam reduces tone in spastic muscles and has a slight effect on tendon hyperreflexia. It has no influence on muscle strength, Babinski sign and ankle clonus. Tetrazepam acts by decreasing motoneurone activity and increasing presynaptic inhibition.

Aged↗
PubMed1992

Relief of experimental spasticity and anxiolytic/anticonvulsant actions of the alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate antagonist 2,3-dihydroxy-6-nitro-7-sulfamoyl-benzo(F)quinoxaline.

Spasticity is characterized by pathological overactivity in spinal stretch reflex circuits and may be associated with disturbances in excitatory amino acid-mediated transmission in the cord. A genetically determined syndrome of spasticity in the rat permits the quantitative evaluation of the antispastic effects of drugs by recording activity in the electromyogram (EMG) from a hind limb extensor muscle. In genetically spastic rats, systemic administration of the alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA) antagonist, 2,3-dihydroxy-6-nitro-7-sulfamoyl-benzo(F) quinoxaline (NBQX), normalized pathologically increased EMG activity, whereas the AMPA agonist, alpha-amino-3-hydroxy-5-tertbutyl-4-isoxazolepropionate (ATPA), exacerbated the EMG measures of spasticity. The reflex mechanisms in the spinal cord can be studied in mice using EMG recordings from the tibial muscle (Hoffmann reflex) or from the plantar foot muscle (flexor reflex) after electrical stimulation of the tibial nerve. Systemic and i.t. administration of NBQX blocked Hoffmann reflexes in mice, leaving flexor reflexes unchanged. ATPA enhanced Hoffmann, and had no effect on flexor reflexes. The effects of NBQX on spinal reflexes were seen in doses which do not affect locomotor activity, but show anxiolytic and some antiepileptic activity in rodents. These data suggest that the design of novel muscle relaxant drugs acting at the AMPA subtype of glutamate receptors may be feasible.

Animals↗
PubMed1992

[Spastic paraparesis and sensory disturbance improved by prednisolone therapy].

We reported a 65-year-old man whose sister was suffering from HTLV-I-associated myelopathy (HAM) and who presented slowly progressive spastic paraparesis, sensory disturbance in the feet, tremors and cerebellar ataxia. He was also positive for serum anti-HTLV-I antibody. He first showed a head tremor at the age of 3 years. He developed a spastic and ataxic gait when aged 15 years, and it became difficult for him to walk at the age of 50 years. Examination at 65 years showed a spastic and ataxic gait and scanning speech. Hyper-reflexia and Bahinski's signs were observed. Sensation in the feet was decreased. The anti-HTLV-I antibody titer in the serum was 1:512 by the PA method, and Western blot analysis revealed bands of P19, P24, P28 and P32. Examination of the cerebrospinal fluid (CSF), including oligoclonal bands, gave normal results. The CSF was negative for anti-HTLV-I antibody. CT and MRI of the head showed cerebellar atrophy. His sister was 60 years old. She had developed a spastic gait at the age of 15 years. Sensory defects and bladder dysfunction developed when aged 35 years. Hyper-reflexia, Babinski's sign and foot clonus were observed. Sensation in the feet was decreased. The urinary residual volume was increased. Ataxia was not observed. The anti-HTLV-I antibody titer in the serum was 1:8,192 by the PA method, and Western blot analysis revealed bands of p24, p28 and p32. Examination of the CSF, including oligoclonal bands, gave only normal results.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1992

Increased F-wave duration in patients with spasticity.

F-wave responses of the posterior tibial nerve have been studied in 22 patients with spasticity and in 18 normal control subjects with surface EMG. Mean amplitude and mean duration of the F-waves were significantly (p less than 0.001) longer in patients with spasticity than in healthy controls. These findings could be the result of an enhanced spinal excitability in spasticity. Based on the present results F-wave recording may be used as a simple and practical technique for detection and documentation of spasticity.

Adult↗
PubMed1992

Spasticity--implications in rehabilitation.

Several features characterise spasticity which may be present in patients with lesions of the upper motor neurones of the brain and spinal cord. Spasticity gives rise to disability depending on the site and extent of the lesion. The manifestations of spasticity and its direct consequences on the locomotor system are discussed in this paper together with the factors affecting it. Management strategies in the rehabilitation of patients with spasticity are outlined, with emphasis on preserving maximum possible function in mobility and activities of daily living.

Activities of Daily Living↗
PubMed1992

Intrathecal baclofen in hereditary spastic paraparesis.

Intrathecal baclofen has not been previously evaluated for the treatment of the disabling hypertonia associated with hereditary spastic paraparesis. Muscle tone and deep-tendon reflexes were evaluated in three patients with hereditary spastic paraparesis after a double-blind, cross-over bolus injection of intrathecal baclofen. Patients underwent placement of a subcutaneous pump for continuous infusion of intrathecal baclofen. Three months after implantation the muscle tone decreased 2.04 points (p less than .0001) and the reflex score decreased 2.25 points (p less than .001). Patients initially reported subjective weakness, but muscle testing revealed either an increase or no change in voluntary motor function. Baclofen doses of 60 to 264 micrograms per day were required for effective control of muscle tone and spasticity. Much of the disability in familial spastic paraparesis may be related to the loss of suprasegmental inhibition of spinal reflexes overwhelming the residual voluntary motor function.

Baclofen↗
PubMedDate not supplied

[Intrathecal baclofen in severe spasticity due to multiple sclerosis].

Intrathecal administration of baclofen via programmable pump is a highly effective treatment method in severe spasticity resistant to oral medications. The authors describe a case of severe spasticity with tetraplegia and painful (> 10 a day) muscle spasms in the upper and lower limbs and paraspinal muscles, in a patient with clinically definite diagnosis of multiple sclerosis (MS). The 34-year-old female patient with a 15-year history of MS, suffering from lower limb spasticity with pes equinovarus since 1995, was treated with very good results with botulinum toxin injections of calf muscles (14 sessions of Dysport 1500iu till 2002). In the early 2002 she developed tetraplegia with severe, generalized and intractable spasticity. After 4 months of ineffective polytherapy (with high doses of oral baclofen, tizanidine, gabapentine, clonidine, diazepam) and the patient's enormous sufferings (she could neither sit up nor voluntarily change her position in bed), a programmable baclofen pump (Medtronic) was implanted. As soon as a few days after the surgery she could stand, sit and move voluntarily, her painful spasms disappeared, and her bladder catheter was removed. At a 6-month follow-up the effect was stable--she was able to walk a long distance outdoors with the aid of a crutch. The daily dose of the drug is 500 micrograms. No side effects of complications were noted.

Adult↗
PubMed2005

Reduction of spastic tone increase induced by peripheral repetitive magnetic stimulation is frequency-independent.

Repetitive magnetic stimulation is able to reduce spastic tone increase after applying it at the spinal cord. It was also found to induce frequency-dependent changes in H-reflex. In a small pilot investigation we stimulated a patient with severe spasticity of the lower limbs and applied different stimulation frequencies. The aim was to look for a clinical measurable effect of spastic reduction depending on the applied frequency. We were unable to show such a dependency, but could confirm the spastic-reducing effects of a peripheral repetitive magnetic stimulation using supratheshold intensities.

Evoked Potentials, Motor↗
PubMed2006

[A randomized, double blind, placebo-controlled study of the efficacy and safety of tolperisone in spasticity following cerebral stroke].

To study the efficacy and safety of tolperisone--a centrally acting muscle relaxant with membrane stabilizing activity--in the treatment of stroke-related spasticity. This was a randomized, double-blind, placebo-controlled, multicenter study with parallel groups. Treatment lasted 12 weeks and was started with a titration period of variable length (dose range 300-900 mg tolperisone daily). The degree of spasticity determined on the Ashworth Scale in the most severely affected joint area was denned as primary target parameter. Hundred and twenty patients (43 females, 77 males) in a mean age of 63,3 +/- 10,6 years were recruited and received treatment. In the majority of patients both limbs of each side were affected by the spasticity which on average had been present for 3,3 +/- 4,4 years. A 62% of the patients were treated with a daily dose >600 mg tolperisone. Tolperisone reduced the mean Ashworth Score by a mean of 1,03 +/- 0,71 compared with a mean reduction of 0,47 +/- 0,54 in the placebo group (p<0,0001). A 78,3% of the patients on tolperisone versus 45% of the placebo patients experienced a reduction by at least 1 point on the Ashworth Scale (p<0,0001). Functional and overall assessments of efficacy confirmed superior efficacy of tolperisone. Adverse events occurred less often on active treatment (n=19) than on placebo (n=26) and were mostly of mild-to-moderate intensity. No withdrawals caused by adverse events were reported in the tolperisone group. The findings of the present study demonstrate the efficacy and excellent tolerance of tolperisone in the treatment of spastic hypertonia following cerebral stroke. Study data further suggest that an individual dose titration which may exceed the recommended maximum dose of 450 mg daily results in optimized therapeutic benefit.

Adult↗
PubMed1991

Intrathecal baclofen for severe spasticity: five years experience.

Severe spasticity is a major problem in the rehabilitation of patients with dysfunction of the spinal cord or cerebral hemispheres. Oral baclofen is often effective. However, in patients with severe spasticity adequate control may not be obtained from oral therapy with the drug. Over the past 5 years we have developed a program for the use of intrathecal baclofen for severe spasticity, and in relation to this discuss patient assessment, practical aspects of drug administration, complications of therapy and patient benefits. Continuous intrathecal baclofen is a safe and effective adjunct to physical therapy in the management of patients with severe spasticity.

Adult↗
PubMed1991

Evaluation of treatment protocols on minimal to moderate spasticity in multiple sclerosis.

Thirty men and women diagnosed with definite multiple sclerosis (MS) were treated for ten weeks in a blinded, cross-over study. Patients with minimal to moderate spasticity were randomized to one of three sequences to evaluate the effects on MS-related spasticity of baclofen alone, stretching regimen with placebo, placebo alone, and stretching regimen with baclofen. The Cybex II isokinetic unit, timed gait, Ashworth scale, and subject's assessment of function were objective and subjective measures used to evaluate changes in hypertonicity. There was significant correlation between the Cybex and Ashworth as methods of measuring spasticity. Overall, treatment with baclofen alone significantly improved moderate quadriceps spasticity as measured by Cybex flexion scores. A trend, indicative of enhancing the beneficial effects of baclofen, was noted when stretching exercises were added to the treatment.

Adult↗
PubMed1991

Intrathecal baclofen for spasticity in cerebral palsy.

Seventeen patients with congenital spastic cerebral palsy and six patients with other forms of spasticity were injected intrathecally with doses of placebo or baclofen, 25 micrograms, 50 micrograms, or 100 micrograms, in a randomized, double-blind manner. Muscle tone in the upper and lower extremities was assessed by Ashworth scores both before the injections and every 2 hours afterward for 8 hours. Function of the upper extremities was evaluated before the injections and 4 hours afterward. Muscle tone in the lower extremities was significantly decreased within 2 hours after baclofen injection and remained lower than baseline 8 hours afterward. Upper extremity tone and function were not significantly affected by these single doses. Confusion and drowsiness occurred in two of the youngest children in the study after the 50-micrograms dose, but cleared within 2 hours. Our findings indicate that intrathecal baclofen reduces spasticity in children with cerebral palsy, as it does in adults with spasticity of spinal origin.

Adolescent↗
PubMed1990

Long-term morphology of spastic or flaccid muscles in spinal cord-transected rabbits.

Despite difficulty in long-term maintenance of spinalized rabbits, muscular pathologic changes in chronic spinalized rabbits could be observed for a period of four weeks. Rabbits were prepared by spinal cord transection at T10 (spastic paralysis) or by spinal cord removal below L7 (flaccid paralysis). Spastic preparations showed hind-limb spasticity and reflex incontinence one to two days after operation. Hypertrophic fibers began to appear in spastic muscles after two weeks. This hypertrophy, thought to be caused by phasic repetitive contraction, was verified by electron microscopy to be different from normal exercise hypertrophy. Flaccid preparations maintained hind-limb flaccidity and overflow incontinence. In flaccid muscle, marked muscle fiber necrosis indicated rapid atrophy. Spinal deformity and joint contracture inactivate spinalized rabbits, and cause pressure sores. However, feeding assistance and avoidance of complications make long-term maintenance possible.

Animals↗