Spasticity after spinal cord injury
Jens Bo Nielsen
Department of Physical Exercise and Sport Science
&
Department of Neuroscience and Pharmacology
Panum
Københavns Universitet
E-mail: [email protected]
Center for Research in Spasticity and
Neurorehabilitation
• Hans Hultborn• Kurt Jørgensen• Jens Bo Nielsen• Jørgen E. Nielsen• Nicolas Petersen
• Fin Biering-Sørensen• Clarissa Crone• Christian Krarup• Mads Ravnborg
• Thomas Sinkjær• Jørgen Feldbæk Nielsen
• Terry Jernigan• Søren Anker Pedersen• Egill Rostrup• Stig Sonne-Holm• Jesper Bencke
Purpose: Coordination of research activities in danish laboratories devoted to research in Spasticity and NeurorehabilitationBy: 1) Facilitate transfer of knowledge from basic neurobiology to clinic 2) Facilitate development of new evaluation and rehabilitation techniques with a neuroscientific basis
RigshospitaletPanum
Hvidovre hospital
Spasticity – short history
• 1841 – Marshall Hall: Decapitated frogs. Automatic movements in paretic limbs – called reflexes (introduced by Willis). Tone: Certain degree of firmness. Tone caused by reflexes
• 1863 – Sechenev: release of reflex function from cerebral inhibition
• 1880: Brissaud differentiates reflex mediated stiffness and contracture with the use of ischemia (blocks reflex)
• 1885: Gowers argues that stretch reflex and tone are related
• 1890: Haidenhain concludes that tone is a reflex which depends on resistance
• 1890-1910: Sherrington describes reflexes and points out that muscle tone is complex and should be carefully described when mentioned.
Definition of spasticity
Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (’muscle tone’) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neuron syndrome.
Lance, Spasticity: Disordered Motor Control 1980
But in the clinic ”spasticity” is used more broadly:
Increased muscle tone
Spastic gait
Hyperexcitable tendon jerks(stretch reflexes)
Babinski
Spasms
and contractures
• Multiple sclerosis• Stroke• Spinal cord injury• Amyotrophic lateral sclerosis• Traumatic brain injury• Cerebral palsy• Tumors• Hereditary spastic paraparesis• (Neurolatyrism)• (hyperekplexia (startle disease)?)Increased flexor reflexes
Different pathophysiological mechanisms are involved
• Velocity dependent resistance to stretch. Increased stretch reflexes
• Spasms – sustained activity after input. Role of flexor reflexes, role of Mn properties?
• Spontaneous muscle activity at ´rest´. = increased muscle tone at rest. Lesion of basal ganglia?
• Contractures. Alteration of passive muscle properties
• Spastic Gait ??
Lance´s definition
Does lesion of the corticospinal tract lead to spasticity?
• Evidence from monkeys• NO: Towers 1940• NO: Lawrence & Kuypers. The functional
organization of the motor system in the monkey. I. The effects of bilateral pyramidal lesions. Brain. 1968 Mar;91(1):1-14.
• Evidence from human• NO: Sherman et al. J Neurol Sci. 2000 Apr
15;175(2):145-55. • NO: Nathan PW Effects on movement of
surgical incisions into the human spinal cord. Brain. 1994 Apr;117 ( Pt 2):337-46.
• Yes: Paulson et al. Arch Neurol. 1986 Jan;43(1):93-5.
Spasticity is not seen immediately after lesion but develops over several months
From Ashby 1973
Pathophysiological mechanisms in spasticity
Control of reciprocal inhibition in healthy human subjects
Reciprocal inhibition in patients with spasticity
Conditioning-test in terval (ms)
Siz
e o
f co
ndi
tione
d re
flex
(% o
f co
ntr
ol r
efle
x)
0 2 4 6 8 10 12
70
80
90
100
110
120
130
Healthy subjects (n=25)Hem iplegic patients (n=11)Paraplegic patients (n=11)MS patients (n=30)
Crone C, Nielsen J, Petersen N, Ballegaard M & Hultborn H. (1994). Brain 117, 1161-1168.Crone C, Johnsen LL & Nielsen J (2000). Clinical neurophysiology suppl 53, 160-178 Morita H, Crone C, Christenhuis D, Petersen NT & Nielsen JB. (2001). Brain. 124(Pt 4), 826-37Crone C, Johnsen LL, Biering-Sørensen F & Nielsen JB (2003). Appearance of reciprocal facilitation in patients with spasticity. Brain, 126(Pt 2):495-507.
Stretch reflexes are not increased in the active spastic muscle
Therefore caution when using antispastic medication:Dietz & Sinkjær Lancet Neurol. 2007 Aug;6(8):725-33.
The stretch reflex during spastic walking
EM G[µV ]
0
20
40
60
80
100
0 500 1000 1500 2000Ti me [ms]
0
50
100
150
200Stretch ref l ex ampl i tude[µV]
0
20
40
60
80
100
0 500 1000 1500 2000Ti me [ms]
EM G[µV ]
0
50
100
150
200Stretch ref l ex ampl i tude[µV]
PATIENT CONTROL
SO L TA SO L TA
Decreased contribution from afferent feedback to the soleus muscle during walking in patients with spastic stroke.Mazzaro et al. J Stroke Cerebrovasc Dis. 2007 Jul-Aug;16(4):135-44
SInkjær et al Clin Neurophysiol. 1999 May;110(5):951-9.
NB
Reduced reflex modulation during bicycling in stroke
Schindler et al. 2007
NB
Reciprocal inhibition is increased following explosive strength training. Increased ability of
producing force quickly.
Geertsen et al.; indsendt til J Appl Physiol
How to evaluate spasticity?
Ashworth scale has generally been found to be reliable for the upper arm, but NOT for the lower limb (Brashear et al. Arch Phys Med Rehabil. 2002 Oct;83(10):1349-54. Blackburn et al. Phys Ther. 2002
Jan;82(1):25-34. Gregson et al. Arch Phys Med Rehabil. 1999 Sep;80(9):1013-6 )
Biomechanical evaluation of spasticity
Jakob LorentzenHvidovre hosp.
Larger resistance to stretch in spastic muscle
Resistive torque (% of max torque)
0 20 40 60 80 100 120 140 160
Mus
cle
tone
(sc
ore
on t
he A
shw
orth
sca
le)
0
1
2
3
4
5
Healthy range
“False” negative
“False” positive
Evaluation of muscle resistance by handheld dynamometer is well correlated to resistance
measures by stationary device
Torque total norm. to Mmax
Torque total norm. to Mmax
0 20 40 60 80 100 120
Impe
danc
e an
kle
fast
0,00
0,05
0,10
0,15
0,20
0,25
0,30
0,35
Reasonable intra- and interrater reliability
Intrarater RA1 ankle fast
Impedance day 2
0,0 0,1 0,2 0,3 0,4
Imp
edan
ce d
ay 1
0,0
0,1
0,2
0,3
0,4
Intrarater RA1 ankle fast
Impedance day 2
0,0 0,1 0,2 0,3 0,4
Impe
danc
e da
y 1
0,0
0,1
0,2
0,3
0,4
Interrater RA1 ankle fast
Impedance rater 2
0,0 0,1 0,2 0,3 0,4
Impe
danc
e ra
ter
1
0,0
0,1
0,2
0,3
0,4
But not significantly larger resistance measured by handheld device in patients with spasticity
according to Ashworth scaleMAS / RA1
MAS ankle 0 and 1-4
1 2
Impe
danc
e an
kle
fast
0,0
0,1
0,2
0,3
0,4
0,5
0,6
The End
• Jens Bo Nielsen• Institut for Neurovidenskab og Farmakologi• Panum• Københavns Universitet• E-mail: [email protected]