Mechanisms of Spasticity and its Assessment

Czech version

Authors: I. Štětkářová
Published in: Cesk Slov Neurol N 2013; 76/109(3): 267-280
Category: Minimonography

Overview

Spasticity is one of the complex motor system disorders and is a sign of central motor neuron disorder caused by trauma, ischemia or haemorrhage, inflammation, degenerative process or tumour. Spasticity is a symptom associated with a lesion within the central motor neuron. In addition to increased muscle activity, muscle contraction and paresis also occurs. Voluntary movement is associated with co-contractions and synkinesis, adversely affecting dexterity and muscle strength. Flexor and extensor spasms also have a negative effect. There are two types of spasticity: cerebral and spinal. Cerebral lesions occur either above the level of brainstem or at the level of brainstem. Due to these lesions, cerebral cortex looses its control over the inhibitory structures of the brainstem. Spinal lesions lead to severe spastic dystonia with predominant involvement of flexors. An objective examination is required to assess the type and degree of spasticity. An objective examination should be performed at the start of treatment and it is the main parameter determining further management. Routine clinical practice mainly relies on clinical evaluation scales. Neurophysiological, physical and biochemical methods are used less frequently and mainly at specialised centres. Rather than complete amelioration of spasticity, the aim of treatment is to alleviate its negative effects on activities that limit the patient. Achievable aims should be set by the patient and the physician at the initiation of treatment. Rehabilitation has a crucial role in the treatment of patients with spasticity. Pharmacotherapy is used, also due to uncomplicated application. Owing to its high efficacy and low incidence of adverse effects, botulinum toxin has an exclusive place in the treatment of focal spasticity. Administration of baclofen via intrathecal pump systems has been proven as highly effective in patients with severe generalized spasticity. New technologies and new treatment modalities, including advanced use of robots, are being developed.

Key words:
spasticity – pathophysiological mechanisms – central motor neuron syndrome – evaluation of spasticity – rehabilitation – botulinum toxin – intrathecal baclofen

Sources

1. Sheean G. The pathophysiology of spasticity. Eur J Neurol 2002; 9 (Suppl 1): 3– 9.

2. Barnes MP, Johnson GR. Upper motor neurone syndrome and spasticity. Cambridge: Cambridge University Press 2001.

3. Kaňovský P. Patofyziologie spasticity v dospělosti. In: Kaňovský P, Bareš M, Dufek J et al (eds). Spasticita, mechanismy, diagnostika a léčba. Praha: Maxdorf 2004: 83– 88.

4. Brashear A, Elovic E. Spasticity. Diagnosis and Management. New York: Demos Medical Publishing, LLC 2011.

5. Ward AB. A literature review of the pathophysiology and onset of post‑stroke spasticity. Eur J Neurol 2012; 19(1): 21– 27.

6. Lance JW. Symposium synopsis. In: Feldman RG, Young RR, Koella WP (eds). Spasticity: disordered motor control. Chicago: Yearbook Medical 1980: 485– 449.

7. Elbasiouny SM, Moroz D, Bakr MM, Mushahwar VK. Management of spasticity after spinal cord injury: current techniques and future directions. Neurorehabil Neural Repair 2010; 24(1): 23– 33.

8. Pandyan AD, Gregoric M, Barnes MP, Wood D, Van Wijck F, Burridge J et al. Spasticity: clinical perceptions, neurological realities and meaningful measurement. Disabil Rehabil 2005; 27(1– 2): 2– 6.

9. Gracies JM, Bayle N, Vinti M, Alkandari S, Vu P, Loche CM et al. Five‑ step clinical assessment in spastic paresis. Eur J Phys Rehabil Med 2010; 46(3): 411– 421.

10. Stevenson V, Jarrett L. Spasticity management: a practical multidisciplinary guide. London: Informa Healthcare 2006.

11. Gracies JM. Pathophysiology of spastic paresis. II: Emergence of muscle overactivity. Muscle Nerve 2005; 31(5): 552– 571.

12. Gracies JM. Pathophysiology of spastic paresis: I: Paresis and soft tissue changes. Muscle Nerve 2005; 31(5): 535– 551.

13. Pierrot‑ Deseilligny E, Burke D. The circuity of the human spinal cord. Cambridge: Cambridge University Press 2005: 63– 112.

14. Brown P. Pathophysiology of spasticity. J Neurol Neurosurg Psychiatry 1994; 57(7): 773– 777.

15. Hinderer SR, Dixon K. Physiologic and clinical monitoring of spastic hypertonia. Phys Med Rehabil Clin N Am 2001; 12(4): 733– 746.

16. Zafonte R, Elovic EP, Lombard L. Acute care management of post‑TBI spasticity. J Head Trauma Rehabil 2004; 19(2): 89– 100.

17. Wissel J, Manack A, Brainin M. Toward an epidemiology of poststroke spasticity. Neurology 2013; 80 (3 Suppl 2): S13– S19.

18. Rizzo MA, Hadjimichael OC, Preiningerova J, Vollmer TL. Prevalence and treatment of spasticity reported by multiple sclerosis patients. Mult Scler 2004; 10: 589– 595.

19. Noreau L, Proulx P, Gagnon L, Drolet M, Laramee MT. Secondary impairments after spinal cord injury: a population‑based study. Am J Phys Med Rehabil 2000; 79(6): 526– 535.

20. Balakrishnan S, Ward AB. The diagnosis and management of adults with spasticity. Handb Clin Neurol 2013; 110: 145– 160.

21. Burke D, Wissel J, Donnan GA. Pathophysiology of spasticity in stroke. Neurology 2013; 80 (3 Suppl 2):S20– S26.

22. Woolsey CN. Discussion on experimental hypertonia in the monkey: interruption of pyramidal or pyramidal‑ extra pyramidal cortical projections. Trans Am Neurol Assoc 1971; 96: 164– 166.

23. Bourbonnais D. Quantification of upper limb synkinesis in hemiparetic subject. Rehabilitation R and D Progress Report 1994, Dept of Veteran Affairs 1995; 32: 118– 119.

24. Dewald IP, Rymer WZ. Factors underlying abnormal posture and movement in spastic hemiparesis. In: Thilmann AF, Burke DJ, Rymer WZ (eds). Spasticity: mechanisms and management. Berlin: Springer‑ Verlag 1933: 123– 138.

25. Černý R, Opavský J. Neurologické aspekty bolesti. In: Rokyta R et al (eds). Bolest. Praha: Tigis 2006: 253– 266.

26. Francisco GE, Tan H, Green M. Do botulinum toxins have a role in the management of neuropathic pain: a focused review. Am J Phys Med Rehabil 2012; 91(10): 899– 909.

27. OʼDonnell MJ, Diener HC, Sacco RL, Panju AA, Vinisko R, Yusuf S. PRoFESS Investigators. Chronic Pain Syndromes After Ischemic Stroke: PRoFESS Trial. Stroke 2013; 44(5): 1238– 1243.

28. Wissel J, Müller J, Dressnandt J, Heinen F, Naumann M, Topka H et al. Management of spasticity associated pain with botulinum toxin A. J Pain Symptom Manage 2000; 20(1): 44– 49.

29. Truini A, Galeotti F, La Cesa S, Di Rezze S, Biasiotta A, Di Stefano G et al. Mechanisms of pain in multiple sclerosis: a combined clinical and neurophysiological study. Pain 2012; 153(10): 2048– 2054.

30. Kalichman L, Ratmansky M. Underlying pathology and associated factors of hemiplegic shoulder pain. Am J Phys Med Rehabil 2011; 90(9): 768– 780.

31. Ronco E, Denys P, Bernede‑ Bauduin C, Laffont I, Martel P, Salomon J et al. Diagnostic criteria of urinary tract infection in male patients with spinal cord injury. Neurorehabil Neural Repair 2011; 25(4): 351– 358.

32. Telles SC, Alves RC, Chadi G. Periodic limb movements during sleep and restless legs syndrome in patients with ASIA A spinal cord injury. J Neurol Sci 2011; 303(1– 2): 119– 123.

33. Biering‑ Sørensen F, Nielsen JB, Klinge K. Spasticity‑ assessment: a review. Spinal Cord 2006; 44(12): 708– 722.

34. Rekand T. Clinical assessment and management of spasticity: a review. Acta Neurol Scand Suppl 2010; 190: 62– 66.

35. Pierrot‑ Deseilligny E. Electrophysiological assessment of the spinal mechanisms underlying spasticity. In: Rossini PM, Mauguiere F (eds). New trends and advanced techniques in clinical neurophysiology (EEG Suppl. 41). Amsterdam: Elsevier Science Publishers 1990: 264– 273.

36. Wood DE, Burridge JH, van Wijck FM, McFadden C, Hitchcock RA, Pandyan AD et al. Biomechanical approaches applied to the lower and upper limb for the measurement of spasticity: a systematic review of the literature. Disabil Rehabil 2005; 27(1– 2): 19– 32.

37. Ghotbi N, Nakhostin Ansari N, Naghdi S, Hasson S. Measurement of lower‑limb muscle spasticity: intrarater reliability of Modified Ashworth Scale. J Rehabil Res Dev 2011; 48(1): 83– 88.

38. Ashworth B. Preliminary trial of carisoprodol in multiple sclerosis. Practitioner 1964; 192: 540– 542.

39. Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987; 67(2): 206– 207.

40. Tardieu G, Shentoub S, Delarue R. A la recherche d’une technique de mesure de la spasticite imprime avec la periodique. Rev Neurol 1954; 91(2): 143– 144.

41. Haugh AB, Pandyan AD, Johnson GR. A systematic review of the Tardieu Scale for the measurement of spasticity. Disabil Rehabil 2006; 28(15): 899– 907.

42. Patrick E, Ada L. The Tardieu Scale differentiates contracture from spasticity whereas the Ashworth Scale is confounded by it. Clin Rehab 2006; 20(2): 173– 182.

43. Boyd RN, Graham HK. Objective measurement of clinical findings in the use of botulinum toxin A in the management of children with cerebral palsy. Eur J Neurol 1999; 6 (Suppl 4): S23– S35.

44. Snow BJ, Tsui JK, Bhatt MH, Varelas M, Hashimoto SA, Calne DB. Treatment of spasticity with botulinum toxin: a double‑blind study. Ann Neurol 1990; 28(4): 512– 515.

45. Štětkářová I, Ehler E. Hodnocení spasticity. In: Štětkářová I, Ehler E, Jech R (eds). Spasticita a její léčba. Praha: Maxdorf 2012: 33– 58.

46. Skinner A, Turner‑ Stokes L. The use of standardized outcome measures in rehabilitation centres in the UK. Clin Rehabil 2006; 20(7): 609– 615.

47. Turner‑ Stokes L. Goal attainment scaling (GAS) in rehabilitation: a practical guide. Clin Rehabil 2009; 23(4): 362– 370.

48. Medical Research Council of the UK. Memorandum No.45. London: Pendragon House 1976: 6– 7.

49. Podsiadlo D, Richardson S. The timed „Up & Go“: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991; 39(2): 142– 148.

50. Yablon SA, Stokic DS. Neurophysiologic evaluation of spastic hypertonia: implications for management of the patient with the intrathecal baclofen pump. Am J Phys Med Rehabil 2004; 83 (Suppl 10): S10– S18.

51. Kumru H, Stetkarova I, Schindler C, Vidal J, Kofler M. Neurophysiological evidence for muscle tone reduction by intrathecal baclofen at the brainstem level. Clin Neurophysiol 2011; 122(6): 1229– 1237.

52. Leis AA, Stetkarova I, Beric A, Stokic DS. The relative sensitivity of F wave and H reflex to changes in motoneuronal excitability. Muscle Nerve 1996; 19(10): 1342– 1344.

53. Stetkarova I, Kofler M. Differential effect of baclofen on cortical and spinal inhibitory circuits. Clin Neurophysiol 2013; 124(2): 339– 345.

54. Kumru H, Kofler M, Valls‑ Solé J, Portell E, Vidal J. Brainstem reflexes are enhanced following severe spinal cord injury and reduced by continuous intrathecal baclofen. Neurorehabil Neural Repair 2009; 23(9): 921– 927.

55. Stokic DS, Yablon SA, Hayes A. Comparison of clinical and neurophysiologic responses to intrathecal baclofen bolus administration in moderate‑ to‑ severe spasticity after acquired brain injury. Arch Phys Med Rehabil 2005; 86(9): 1801– 1806.

56. Dressnandt J, Auer C, Conrad B. Influence of baclofen upon the alpha‑ motoneuron in spasticity by means of F‑ wave analysis. Muscle Nerve 1995; 18(1): 103– 107.

57. Hoskovcová M, Gál O. Rehabilitace a spasticita. In: Štětkářová I, Ehler E, Jech R (eds). Spasticita a její léčba. Praha: Maxdorf 2012: 177– 212.

58. Comella CL, Pullman SL. Botulinum toxins in neurological disease. Muscle Nerve 2004; 29(5): 628– 644.

59. Ranoux D, Gury C. Practical handbook on botulinum toxin. Marseille: SOLAL 2007.

60. Jankovic J, Albanese A, Attassi MZ, Dolly JO, Hallet M, Mayer NH. Botulinum toxin. Therapeutic clinical practice and science. Philadelphia: Saunders Elsevier 2009.

61. Ehler E, Štětkářová I. Botulotoxin v léčbě spasticity. Cesk Slov Neurol N 2009; 72/ 105(4): 317– 321.

62. Ehler E. Použití botulotoxinu v neurologii. Cesk Slov Neurol N 2013; 76/ 109(1): 7– 21.

63. Bareš M, Kaňovský P. Praktické použití botulotoxinu A v léčbě spasticity dospělé populace. Cesk Slov Neurol N 2002; 65/ 98(6): 421– 425.

64. Kaňovský P, Bareš M, Severa S, Benetin J, Kraus J,Richardson A et al. Functional benefit of botulinum toxin (Dysport) in the treatment of dynamic equinus cerebral palsy spasticity: a prospective, multicentre, double‑blind, placebo controlled study. Cesk Slov Neurol N 2004; 67/ 100(1): 16– 23.

65. Kaňovský P, Bareš M, Severa S, Richardson A. Long‑term efficacy and tolerability of 4- monthly versus yearly botulinum toxin type A treatment for lower‑limb spasticity in children with cerebral palsy. Dev Med Child Neurol 2009; 51(6): 436– 445.

66. Ehler E, Vaňásková E, Štětkářová I. Standard komplexní léčby spasticity po cévní mozkové příhodě. Cesk Slov Neurol N 2009; 72/ 105(2): 179– 181.

67. Kanovsky P, Slawek J, Denes Z, Platz T, Comes G, Grafe S et al. Efficacy and safety of treatment with incobotulinumtoxin A (botulinum neurotoxin type a free of from complex proteins; Nt 201) in post‑stroke upper limb spasticity. J Rehab Med 2011; 43(6): 486– 492.

68. Lapeyre E, Kuks JB, Meijler WJ. Spasticity: revisiting the role and the individual value of several pharmacological treatments. NeuroRehabilitation 2010; 27(2): 193– 200.

69. Simon O, Yelnik AP. Managing spasticity with drugs. Eur J Phys Rehabil Med 2010; 46(3): 401– 410.

70. Taricco M, Pagliacci MC, Telaro E, Adone R. Pharmacological interventions for spasticity following spinal cord injury: results of a Cochrane systematic review. Eura Medicophys 2006; 42(1): 5– 15.

71. Montané E, Vallano A, Laporte JR. Oral antispastic drugs in nonprogressive neurologic diseases: a systematic review. Neurology 2004; 63(8): 1357– 1363.

72. Olvey EL, Armstrong EP, Grizzle AJ. Contemporary pharmacologic treatments for spasticity of the upper limb after stroke: a systematic review. Clin Ther 2010; 32(14): 2282– 2303.

73. Feldman RG, Kelly‑ Hayes M, Conomy JP, Foley JM. Baclofen for spasticity in multiple sclerosis. Double‑blind crossover and three‑year study. Neurology 1978; 28(11): 1094– 1098.

74. Penn RD, Kroin JS. Intrathecal baclofen alleviates spinal cord spasticity. Lancet 1984; 1(8385): 1078.

75. Coffey R, Cahill D, Steers W. Intrathecal baclofen for intractable spasticity of spinal origin: results of a long‑term multicenter study. J Neurosug 1993; 78(2): 226– 232.

76. Ordia JI, Fischer E, Adamski E, Spatz EL. Chronic intrathecal delivery of baclofen by a programmable pump for the treatment of severe spasticity. J Neurosurg 1996; 85(3): 452– 457.

77. Zahavi A, Geertzen JH, Middel B, Staal M, Rietman JS. Long term effect (more than five years) of intrathecal baclofen on impairment, disability, and quality of life in patients with severe spasticity of spinal origin. J Neurol Neurosurg Psychiatry 2004; 75(11): 1553– 1557.

78. Štětkářová I, Šroubek J, Vrba I, Peregrin J, Havrdová E. Jednorázové intratékální podání baklofenu a následné zavedení pumpového systému v léčbě těžké spasticity u osob s roztroušenou sklerózou. Cesk Slov Neurol N 2007; 70/ 103(2): 190– 195.

79. Perez MA, Field‑ Fote EC, Floeter MK. Patterned sensory stimulation induces plasticity in reciprocal ia inhibition in humans. J Neurosci 2003; 23(6): 2014– 2018.

80. Jurkiewicz MT, Mikulis DJ, Fehlings MG, Verrier MC. Sensorimotor cortical activation in patients with cervical spinal cord injury with persisting paralysis. Neurorehabil Neural Repair 2010; 24(2): 136– 140.

81. Fung J, Richards CL, Malouin F, McFadyen BJ, Lamontagne A. A treadmill and motion coupled virtual reality system for gait training post‑stroke. Cyberpsychol Behav 2006; 9(2): 157– 162.

82. Jaffe DL, Brown DA, Pierson‑ Carey CD, Buckley EL, Lew HL. Stepping over obstacles to improve walking in individuals with poststroke hemiplegia. J Rehabil Res Dev 2004; 41(3A): 283– 292.

83. Centonze D, Koch G, Versace V, Mori F, Rossi S, Brusa L et al. Repetitive transcranial magnetic stimulation of the motor cortex ameliorates spasticity in multiple sclerosis. Neurology 2007; 68(13): 1045– 1050.

84. Khedr EM, Ahmed MA, Mohamed KA. Motor and visual cortical excitability in migraineurs patients with or without aura: transcranial magnetic stimulation. Neurophysiol Clin 2006; 36(1): 13– 18.

85. Nowak DA, Grefkes C, Dafotakis M, Eickhoff S, Küst J, Karbe H et al. Effects of low‑ frequency repetitive transcranial magnetic stimulation of the contralesional primary motor cortex on movement kinematics and neural activity in subcortical stroke. Arch Neurol 2008; 65(6): 741– 747.

86. Senkárová Z, Hlustík P, Otruba P, Herzig R, Kanovský P. Modulation of cortical activity in patients suffering from upper arm spasticity following stroke and treated with botulinum toxin A: an fMRI study. J Neuroimaging 2010; 20(1): 9– 15.