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PubMed1996

[Selective peripheral neurotomy of the hamstring branches of the sciatic nerve in the treatment of spastic flexion of the knee. Apropos of a series of 11 patients].

BACKGROUND: A series of 11 patients (9 adults and 2 children) were operated on by selective peripheral neurotomy for spastic knee in flexion. The objective of surgery was to restore bipodal stance and therefore walking for the adult patients and to improve walking for the diplegic children. METHODS: Spasticity was secondary to stroke or cranial trauma for the adult patients. The two children presented with Little disease. The delay between onset and surgery was on the average of 2 years. All the patients had a passive flexum of the knee of 20 degrees, and an excessive spasticity of the hamstrings (average Held score of 4.55). Peripheral selective neurotomies consist of a partial section of the spastic muscle's motor fascicles. The partial section concerns the afferent fibers to the spinal cord whose interruption leads to the disappearance of spasticity. The section also involves the motoneurones' axons and thus leads to partial denervation. RESULTS: The spasticity of the treated muscles disappeared in the 11 patients. Average follow-up was 16 months. The neurotomies led to improvement of walking without splint for 3 walking patients, and restored walking with a splint for 5 patients. One patient failed to walk. The two children had a dramatic improvement of their walk. CONCLUSION: Our results incite us to increasingly indicate this type of neurotomy in the treatment of the spastic lower limb.

Adolescent↗
PubMed1981

Biofeedback in rehabilitation: a review of principles and practices.

Modern biofeedback is the technique of using electronic equipment to reveal instantaneously to patients and therapists certain physiologic events and to teach the patients to control these otherwise involuntary events by manipulating the displayed signals (usually visual and/or acoustic). Diagnostic EMG and research on the fine control of motor units led to clinical EMG biofeedback. In rehabilitation it has gained a firm place in the treatment of upper motor neuron lesions, particularly in retraining muscles and inducing relaxation of spastic muscles of stroke patients. In cerebral palsy and musculoskeletal disturbances, additional feedback transducers (electrogoniometers, pressure-sensitive and position-sensing devices) are gaining wider use. Spasmodic torticollis has proved to be particularly suitable for behavioral methods of treatment including EMG feedback.

Biofeedback, Psychology↗
PubMed1980

Dynamic bracing: elastics for patients with cerebral palsy, muscular dystrophy and myelodysplasia.

Conventional bracing places constraints on the determinants of gait, which in the borderline patient, may derange gait as much or more than the postural deformity being treated. A small number of children with cerebral palsy, spina bifida, and muscular dystrophy were treated with below-knee orthoses (BKO) along with elastic bracing of the remainder of the limb. The elastics were used to augment muscle power in weakness, oppose spastic muscles, supply antagonism to unopposed muscle, and improve function. The key elements in this system include proximal attachment of elastics to the below-knee orthosis resultin in effective knee action independent of foot control; variable 2-joint function of elastics; and emphasis on a BKO-shoe combination, which positions the knee in front of the ankle at midstance. Because a small number of components are employed to produce a variety of actions, an understanding of the mechanics fo gait is needed for the rational application of this method of treatment as well as for the selection of suitable patients.

Adolescent↗
PubMed2002

Systematic muscle building exercises in the rehabilitation of stroke patients.

The effects of targeted strength training in patients with muscle weakness of central origin following cerebrovascular accidents has hardly been investigated to date. This prospective non-randomized study of 56 patients was designed to shed light on the effects of strength building exercises on muscle tone and on the gain in muscle strength achieved with them. All patients underwent a full residential neurologic rehabilitation program for 4 weeks, which included an exercise program for restoring the extensor strength of the legs and the supporting strength of the arms by leg and arm presses. Throughout the rehabilitation program muscle spasticity was evaluated clinically and maximal muscle strength on completion of the exercise program was compared to baseline. The extensor strength of the legs increased by 31.0 (+/- 26.7)% by 40.2 (+/- 15)%. significant for both variables. The extent of strength gain was positively correlated with the intensity and the number of exercising units. Muscle tone, which was abnormally high at baseline, did not further increase in any one case. The results of this study showed that targeted strength training significantly increased muscle power in patients with muscle weakness of central origin without any negative effects on spasticity.

Adult↗
PubMedDate not supplied

[Selective cooling of the spinal cord and spinal nerve roots in patients with spastic and pain syndromes].

Selective cooling of the spinal cord and its roots was applied in 26 patients with a high degree of muscle spasticity of various genesis and in 12 of those with various pain syndromes. Hypothermia was conducted by the open and closed (puncture) methods. The subarachnoid space was cooled to 11--7.5 degrees C. Spasticity diminished to grade I--II in 15 patients and to grade III in 9; in 2 patients it did not change. In 3 of 12 patients the sensation of phantom and pain were completely relieved, marked improvement occurred in 6 patients, while in 3 patients the effect proved short-lived or doubtful.

Evoked Potentials↗
PubMed1996

Clinical measurement of spasticity using the pendulum test: comparison of electrogoniometric and videotape analyses.

OBJECTIVE: To compare pendulum test data obtained using an electrogoniometer with data obtained by videotape. The issue of video digitization error was also addressed. DESIGN: The study compared pendulum test relaxation indices determined from data simultaneously collected using (1) a video (VID) camera and (2) an electrogonimeter (EG). SETTING: A spinal cord injury rehabilitation center. SUBJECTS: Three persons with a spinal cord injury (SCI) exhibiting mild, moderate, and severe spasticity, respectively, and a fourth, non-SCI subject. MAIN OUTCOME MEASURE: Relaxation index as a descriptor of lower limb muscle spasticity measured using the pendulum test. RESULTS: Multiple-digitization of VID data did not affect the reliability of this technique. It was noted that reflective markers located on body landmarks resulted in more reliable data as opposed to markers placed on the EG. Both EG and VID data were accurate and reliable. CONCLUSIONS: In the VID method, using one digitization by a single operator is sufficient. The appropriate placement of light reflector markers are on body points. EG and VID are both reliable, highly correlated, and interchangeable in measuring spasticity using the pendulum test.

Adult↗
PubMed2007

Control of spasticity in a multiple sclerosis model is mediated by CB1, not CB2, cannabinoid receptors.

BACKGROUND AND PURPOSE: There is increasing evidence to suggest that cannabis can ameliorate muscle-spasticity in multiple sclerosis, as was objectively shown in experimental autoimmune encephalomyelitis models. The purpose of this study was to investigate further the involvement of CB1 and CB2)cannabinoid receptors in the control of experimental spasticity. EXPERIMENTAL APPROACH: Spasticity was induced in wildtype and CB1-deficient mice following the development of relapsing, experimental autoimmune encephalomyelitis. Spastic-hindlimb stiffness was measured by the resistance to flexion against a strain gauge following the administration of CB1 and CB2 agonists. KEY RESULTS: As previously suggested, some CB2-selective agonists (RWJ400065) could inhibit spasticity. Importantly, however, the anti-spastic activity of RWJ400065 and the therapeutic effect of non-selective CB1/CB2 agonists (R(+)WIN55,212-2 and CP55, 940) was lost in spastic, CB1-deficit mice. CONCLUSIONS AND IMPLICATIONS: The CB1 receptor controls spasticity and cross-reactivity to this receptor appears to account for the therapeutic action of some CB2 agonists. As cannabinoid-induced psychoactivity is also mediated by the CB1 receptor, it will be difficult to truly dissociate the therapeutic effects from the well-known, adverse effects of cannabinoids when using cannabis as a medicine. The lack of knowledge on the true diversity of the cannabinoid system coupled with the lack of total specificity of current cannabinoid reagents makes interpretation of in vivo results difficult, if using a purely pharmacological approach. Gene knockout technology provides an important tool in target validation and indicates that the CB1 receptor is the main cannabinoid target for an anti-spastic effect.

Animals↗
PubMed1987

Variability and reliability of the pendulum test for spasticity using a Cybex II isokinetic dynamometer.

I undertook this study to determine the test-retest variability and reliability of the pendulum test for muscle spasticity performed with the Cybex II isokinetic dynamometer. Thirty patients, with intracranial lesions and hemiplegia of 15 days' to 3 years' duration, were tested four times, consecutively. With the patients lying supine, the angle of flexion, at which the knee first reversed direction after the leg was dropped, was measured on each goniogram from the dynamometer chart recorder. The mean differences between the angles of reversal and the angles of maximum possible knee flexion (the relative angle of reversal) for the first through the fourth trials were 27.2, 27.0, 26.3, and 25.6 degrees, respectively. The relative angle of reversal did not differ significantly between trials. The mean difference between the largest and smallest relative angle of reversal for each of the subject's trials was 6.1 degrees. The intraclass correlation coefficient between the relative angle of reversal for the four trials was .96. Because the test variability was not significant and because the correlation between trials was high, the test may merit broader application to patients with intracranial lesions. Further investigation of variability across days and after treatments is advised.

Adult↗
PubMed2002

The effects of botulinum toxin treatment on associated reactions of the upper limb on hemiplegic gait--a pilot study.

PURPOSE: The involuntary movements of the paretic arm during ambulation and other motor activities are known as associated upper limb reactions (ARs). ARs occur in 80% of stroke patients with spastic hemiplegia and often interfere with balance and safe mobilization. It is hypothesized that the treatment of localized muscle spasticity with botulinum toxin type A (BtxA) would abolish the ARs and improve balance and mobility. METHOD: This hypothesis will need to be tested in a randomized controlled trial (RCT). The aim of the present pilot study is to obtain preliminary data to inform the design of a future RCT. Eight patients received a single injection of 500 units of BtxA (Dysport((R)) Ipsen, Ltd) into the biceps brachii of the paretic arm. The patients' balance and mobility were assessed before and 2, 4 and 6 weeks after treatment using observational gait analysis and other subjective assessment scales. RESULTS: There was a significant reduction of the ARs after treatment but this did not appear to improve the patients' balance or mobility as assessed by the clinicians. Interestingly, seven out of the eight patients reported improvement in their walking. CONCLUSION: The discrepancy between the observed and reported effects of treatment could be due to the poor sensitivity of the outcome measures used in this study.

Adult↗
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↗
PubMed1998

Selective musculocutaneous fasciculotomy for spastic elbow in cerebral palsy: a preliminary study.

Three hundred and ten people with cerebral palsy who had spasticity in one or more limbs underwent selective motor fasciculotomy (SMF) of the nerves supplying the harmful spastic muscles with the aim of achieving useful tone and to improve voluntary movements. Among them, 52 people (average age 9.5 years) had 75 spastic elbows who were considered fit cases to undergo SMF of the musulocutaneous nerve (MCN). The nerve was dissected in the upper 1/3rd of the arm. Bipolar current was used to stimulate the component fascicles and to detect those carrying excessive impulses. Some of the hyperactive fascicles were ablated according to preoperative grading of the spasticity, etc. Total relief in spasticity was achieved in 47 (62.66%) elbows. Whereas, in the remaining 28 (37.33%) elbows some degree of spasticity persisted. There were overall beneficial effects of SMF on the motor functions and the flexed elbow posture. There were no side effects and recurrence of spasticity. The results were observed for an average period of 17 months. It must be noted that, 5 people who had involuntary elbow flexion on activity, like walking, also developed normal posture and the to & fro swinging movements following surgery. In conclusion, SMF of MCN is an effective and safe procedure for achieving longlasting useful tone and voluntary movements in the harmful spastic elbow of people with cerebral palsy. The present report is an account of the largest number of cerebral palsy people in the world literature to date.

Adolescent↗
PubMed2001

Improvement of sleep apnea in a patient with cerebral palsy.

Intrathecal baclofen (ITB) can reduce spasticity in adults and children with cerebral palsy. Benefits of ITB therapy include improved Ashworth scores, activities of daily living, and mobility. The impact of ITB therapy on sleep apnea in patients with cerebral palsy has not been reported. This case report describes a 29-yr-old female with mixed spastic athetoid quadriparetic cerebral palsy with dystonia, gross motor function IV, who had sleep apnea, requiring nightly continuous positive airway pressure. She received ITB with the goal to improve her wheelchair positioning and decrease her excessive movements. After the initiation of the ITB, reduction of her spasticity and dystonia was noted, as well as improvement of her sleep apnea. This case suggests that ITB therapy may improve respiratory function through reduction of respiratory muscle spasticity.

Adult↗
PubMedDate not supplied

Computer modeling of the pathomechanics of spastic hip dislocation in children.

Spastic muscles about the hip cause subluxation, dislocation, and lead to acetabular dysplasia. Spastic hip disease occurs when the muscles about the hip exert forces that are too high or in the wrong direction or both. To determine the role of the hip forces in the progression of spastic hip disease and the effect of both muscle-lengthening and bony reconstructive surgeries, a computerized mathematical model of a spastic hip joint was created. The magnitude and direction of the forces of spastic hips undergoing surgery were analyzed preoperatively and postoperatively to determine which procedure is best suited for the treatment of spastic hip disease. The muscle-lengthening procedures included (a) the adductor longus, (b) the psoas, iliacus, gracilis, adductor brevis, and adductor longus, and (3) the psoas, iliacus, gracilis, adductor brevis, adductor longus, semimembranosus, and semitendinosus. The bony reconstructive and muscle-lengthening procedures included (a) lengthening the psoas, iliacus, gracilis, adductor brevis, adductor longus, semimembranosus, and semitendinosus combined with changing femoral neck anteversion from 45 to 10 degrees , (b) lengthening of the psoas, iliacus, gracilis, adductor brevis, adductor longus, semimembranosus, and semitendinosus combined with changing neck-shaft angle from 165 to 135 degrees , and (c) lengthening of the psoas, iliacus, gracilis, adductor brevis, adductor longus, semimembranosus, and semitendinosus combined with changing femoral neck anteversion from 45 to 10 degrees and neck-shaft angle from 165 to 135 degrees . Results show that a child with spastic hip disease has a hip-force magnitude 3 times that of the a child with a normal hip in the normal physiologic position. Based on this mathematical model the best to normalize the magnitude of the hip-joint reaction force, the muscles to be lengthened should include the psoas, iliacus, gracilis, adductor brevis, and the adductor longus. To normalize the direction of the hip force, the extremity should be positioned in the normal physiologic position. The impact of decreasing the femoral anteversion or femoral neck-shaft angle or both had little additional effect on the direction or magnitude of hip forces.

Biomechanical Phenomena↗
PubMed2000

[Botulinum toxin. Use in the treatment of spasticity in children].

The medical treatment of spasticity has improved since the introduction of botulinum toxin type A (BTA) for intramuscular injection into spastic muscles. Two not directly comparable preparations are on the market: Botox and Dysport. Botox is four times as potent as Dysport. BTA is especially used for spasticity in legs, arms, and the paravertebral musculature. Surface analgesic cream is applied and an oral or rectal sedative is given after which BTA is injected locally according to strict instructions. In the motor end plate, BTA blocks the release into the synaptic cleft of acetylcholine from vesicles in the terminal nerve fibres, thereby bringing about paralysis of muscle fibre. Blockade lasts for about four months. The treatment must therefore be repeated. Because the treatment is local, side effects are few, mild, and acceptable.

Botulinum Toxins↗
PubMed2005

Simple pharmacological test battery to assess efficacy and side effect profile of centrally acting muscle relaxant drugs.

INTRODUCTION: Centrally muscle relaxants (CMRs) are used mainly for treating muscle spasticities of neurological origin, and painful muscle spasms due to rheumatologic conditions. Their use is frequently associated with dose-limiting adverse effects. New drugs with improved side-effect characteristics are badly needed. However, there is no general agreement in the pharmacological literature on what methods are adequate to assess CMR effect and side effects in behaving rodents, which may hinder the development of new drugs. Here we report on the establishment of a simple pharmacological test battery, which was used to compare efficacies and side effect profiles of 11 compounds with central muscle relaxant action, in mice (intraperitoneal application). METHODS: For measuring muscle relaxant activity, (1) a new tremor model (GYKI 20039-induced tremor) and (2) the morphine-induced Straub-tail assay were used. The former, newly developed method has advantages over harmaline- or LON-954-induced tremor. For detecting side effect liability (ataxia, sedation, impairment of voluntary motor functions), (1) the rota-rod test, (2) measurement of spontaneous motility, (3) the weight-lifting test and (4) the thiopental sleep test were used. RESULTS: Among the 11 muscle relaxant compounds tested (tolperisone, eperisone, silperisone, diazepam, baclofen, tizanidine, afloqualon, mephenesin, zoxazolamine, memantine and carisoprodol), the calculated safety ratios (i.e. ID50 for side effect/ID50 for muscle relaxant effect) varied in a wide range. Silperisone seems to have the most advantageous profile (safety ratios range between 1.7 and 3.3 in the different pairs of assays) compared to the other tested drugs with lower (one or more ratios below 1.5, and often far below 1) and more varying ratios. DISCUSSION: Therapeutic indices calculated from the results of these in vivo experiments for the clinically used muscle relaxants are in agreement with their adverse effect profiles in humans. Thus the present test battery seems to be suitable for predicting the possible clinical utility of newly synthesized compounds.

Animals↗
PubMed2001

Botulinum toxin type a neuromuscular blockade in the treatment of equinus foot deformity in cerebral palsy: a multicenter, open-label clinical trial.

BACKGROUND: Focal spasticity of the gastrocnemius-soleus muscles causes equinus gait in children with cerebral palsy (CP). Botulinum toxin type A (BTX-A), a neuromuscular blocking agent, reduces muscle tone/overactivity in dystonia, stroke, and CP. OBJECTIVE: A prospective, open-label, multicenter clinical trial evaluated the long-term safety and efficacy of repeated intramuscular injections of BTX-A on equinus gait in CP children. METHODS: Nine centers enrolled 207 children. BTX-A injections (4 U/Kg) were given approximately every 3 months (maximum dose 200 U per treatment). Outcome measures included a Physician Rating Scale of gait, ankle range of motion measurements, and the incidence and profile of adverse events. RESULTS: One hundred fifty-five (75%) of 207 children completed at least 1 year with a total of 302 patient years of BTX-A treatment. The mean duration of BTX-A exposure was 1.46 years per patient. Dynamic gait pattern on the Physician Rating Scale improved in 46% of patients (86/185) at first follow-up. The response was maintained in 41% to 58% of patients for 2 years. Both gait pattern and ankle position improved at every visit. The most common treatment-related adverse events included increased stumbling, leg cramps, leg weakness, and calf atrophy in 1% to 11% of patients. No treatment-related serious adverse events were reported. Only 6% (7/117) of patients with pre- and postantibody samples had both detectable antibodies and a subsequent treatment failure. CONCLUSION: BTX-A proved both safe and effective in the chronic management of focal muscle spasticity in children with equinus gait.

Adolescent↗
PubMed2000

Short-term effects of dynamic lycra splints on upper limb in hemiplegic patients.

OBJECTIVE: To assess acceptability, effects on swelling, resting posture, spasticity, and active (AROM) and passive range of motion (PROM) of individually tailored upper limb Lycra garments, designed as dynamic splints to exert directional pull on certain limb segments, when worn for 3 hours by hemiplegic patients. DESIGN: Crossover trial. SETTING: Outpatient and inpatient rehabilitation center. PATIENTS: Convenience sample of 16 patients with hemiparesis and upper limb spasticity caused by a stroke more than 3 weeks before the study. INTERVENTIONS: Assessments performed at the start and end of a 3-hour period during a standard rehabilitation day when the patients were and were not wearing the garment. MAIN OUTCOME MEASURES: (1) Comfort assessed by questionnaire; (2) circumference of each limb segment; (3) resting posture at elbow and wrist; (4) spasticity at shoulder, elbow, and wrist using the Tardieu scale; and (5) AROM and PROM at shoulder, elbow, and wrist measured using a goniometer; (6) elbow proprioception using McCloskey's method; (7) visual neglect syndrome using the line bisection test. Differences between changes occurring with and without the garment were compared using Wilcoxon's signed rank test for ordinal variables (spasticity grading) and Student's t test for continuous variables (all other data). RESULTS: During 3 hours, garments worn on the arm by patients with hemiplegia (1) were comfortable, (2) improved wrist posture and reduced wrist and finger flexor spasticity, (3) reduced swelling in patients with swollen limbs (digit circumference decreased by 4%; p<.01), (4) improved PROM at shoulder (mean increase in range, 4.1 degrees +/- 13.0 degrees per shoulder movement; p<.01); and (5) impaired ability to flex fingers (range of voluntary flexion of digit III reduced from 107.3 degrees +/-79.6 degrees to 91.4 degrees +/-74.1 degrees; p<.05). CONCLUSION: Lycra garments, designed to produce continuous stretch of spastic muscles when worn for several hours each day, have rapid splinting and antispastic effects on wrist and fingers in patients with hemiplegia. These garments may help severely affected patients with major spasticity or painful swollen limbs.

Adult↗