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Femoral obturator and sciatic neurectomy with iliacus and psoas muscle section for spasticity following spinal cord injury.

The treatment of severe refractory spasticity following spinal cord injury may raise challenging therapeutic problems. Classical approaches involve various types of myelotomies, rhizotomies and intrathecal injections of neurolytic substances. Alternative approaches include percutaneous rhizotomies and, more recently, the possible use of electrical stimulation of the spinal cord. Certain cases, however, may not be amenable to commonly accepted techniques. An operative technique is presented which involves a suprapubic incision for an infraperitoneal approach to a femoral and obturator neurectomy and an incision of the iliacus and psoas muscles bilaterally. This may be followed, when indicated, by a bilateral infragluteal section of the sciatic nerves. This technique offers a viable surgical alternative to the treatment of spasticity following spinal cord injury in cases where other traditional methods are contraindicated or have failed.

Adolescent↗

The effect of intrathecal baclofen on electrical muscle activity in spasticity.

The efficacy of intrathecally administered baclofen was demonstrated in three patients with different types of muscular hypertonia (supraspinal rigidity, spasms shortly after spinal trauma, spasms for many years induced by multiple sclerosis) using integrated electromyography. Reduction of muscular electrical activity was accompanied by clinical improvement during long-term infusion via an implanted pump. The three patients have been observed for more than 1 year, during which time the antispastic activity of intrathecally infused baclofen has remained stable. Intrathecal application of baclofen may be considered as a possible alternative to surgery.

Adult↗

The role of functional electrical stimulation in the rehabilitation of patients with incomplete spinal cord injury--observed benefits during gait studies.

The benefits of a functional electrical stimulation (FES) gait programme were assessed in a group of 6 incomplete spinal cord injured subjects. Measurements were made of quadriceps spasticity, lower limb muscle strength, postural stability in standing, spatial and temporal values of gait, physiological cost of gait and independence in activities of daily living. The subjects were assessed before commencement of the programme and after a period of gait training using FES. The benefits derived as a result of the FES gait programme included a reduction in quadriceps tone, an increase in voluntary muscle strength, a decrease in the physiological cost of gait and an increase in stride length.

Activities of Daily Living↗

Radiofrequency cordotomy for the relief of spasticity in decerebrate cats.

The effectiveness of radiofrequency (RF) cordotomy of segmental motoneurone pools of the lumbosacral cord in reducing spasticity of decerebrate cats is evaluated. The need for a new form of therapy for clinical spasticity is based upon the limitations of contemporary methods, including surgical and pharmacological techniques. In man, spasticity of spinal origin may be treated effectively by intrathecal administration of hyperbaric phenol solutions. The advantages and disadvantages are described. Difficulty in controlling the lesion is emphasized. Tension and EMG-length curves of the spastic triceps surae muscle in acute and chronic animals show that RF lesions (fixed amperage and duration) of the segmental motoneurone pools reduces myotatic reflex activity in accordance with the number of segments cordotomized. Clinical examination including cinematography and electromyography complement the physiological interpretation. RF lesions of the internuncial pool induce spontaneous EMG discharges. This finding is related to similar observations of EMG discharges and alterations in muscle tone after asphyxiation of the spinal cord.

Action Potentials↗

[Voluntary activity of the neck muscles in patients with spastic torticollis].

The authors investigated the characteristics of motor disorders in patients with spastic torticollis. The study involved registration of volitional tensions of the neck muscles in isometric conditions, i.e., when the patient's head was rigidly fixed with regard to the body. Using a tensometric dynamometer the following three moments of force were measured: one responsible for bending the head forward or backward; the second, for bending the head to the right or left shoulder; and the third, for turning the head round the longitudinal axis. The electrical activity of the neck muscles was recorded with the help of surface electrodes. It has been established that the development of volitional efforts by the neck muscles under isometric conditions is difficult or impossible if directed to the side where the patient's forcible turn of the head is directed.

Chronic Disease↗

Voluntary and reflex control of the biceps brachii muscle in spastic-athetotic patients.

A cross-correlation technique of analysis was used to measure the transmission characteristics of tonic stretch reflex (TSR) pathways in spastic-athetoid subjects sustaining a voluntary contraction in the biceps brachii muscle. A comparison was made with the transmission characteristics of normal subjects measured by the same technique. It was found that gain and phase characteristics of spastic patients did not display the large resonant peaks present in normals. It is proposed that the resonant peaks in the TSR transmission of normal subjects were caused by long loop pathways. The absence of these peaks in the spastic patients supports the hypothesis that short-circuiting of long loop pathways by hyperactive spinal reflexes is part of the mechanism of spasticity.

Arm↗

Effect of muscle biomechanics on the quantification of spasticity.

The impact of muscle biomechanics on spasticity was assessed by comparison of the reflex responses of the elbow and metacarpophalangeal (MCP) flexor muscles in individuals with chronic spastic hemiplegia following stroke. Specifically, methods were developed to quantify reflex responses and to normalize these responses for comparison across different muscle groups. Stretch reflexes were elicited in the muscles of interest by constant velocity ramp-and-hold stretches at the corresponding joint. The muscles were initially passive, with the joint placed in a midrange position. Estimates of biomechanical parameters were used to convert measured reflex joint torque and joint angle into composite flexor muscle stress and stretch. We found that the stretch reflex response for the MCP muscle group had a 74% greater mean stiffness modulus than that for the elbow muscle group, and that the reflex threshold was initiated at an 80% shorter mean muscle stretch. However, we determined that initial normalized fiber length was significantly greater for the experiments involving the MCP muscles than for those involving the elbow muscles. Increasing the initial composite fiber length of the elbow flexors produced significant reduction of the reflex threshold (p<0.001), while decreasing the initial length of the MCP flexors significantly reduced their measured reflex stiffness (p<0.001). Thus, biomechanical parameters of muscle do appear to have an important effect on the stretch reflex in individuals with impairment following stroke, and this effect should be accounted for when attempting to quantify spasticity.

Aged↗

Botulinum toxin in upper limb spasticity: study of reciprocal inhibition between forearm muscles.

To establish whether botulinum A toxin (BTX-A) acts on modifying reciprocal inhibition between forearm muscles in spasticity, 20 patients with post-stroke upper limb spasticity lasting for more than 1 year were studied. Clinical examination, physiotherapeutic evaluation, standardized video-tape assessment and electrophysiological testing (flexor carpi radialis muscle M and H responses with study of reciprocal inhibition) were performed at baseline and 2 weeks, 1, 2, 3, 4 months after BTX-A treatment. BTX-A induced a significant decrease of tone and an improvement of motility and functional status, with a significant decrease of the M wave and the H reflex. The reduction in both inhibitory phases of reciprocal inhibition did not change after BTX-A treatment differently from that reported in upper limb dystonia. These findings indicate that the efficacy of BTX-A in upper limb spasticity is mainly due to peripheral effects.

Aged↗

Tail muscles become slow but fatigable in chronic sacral spinal rats with spasticity.

Paralyzed skeletal muscle sometimes becomes faster and more fatigable after spinal cord injury (SCI) because of reduced activity. However, in some cases, pronounced muscle activity in the form of spasticity (hyperreflexia and hypertonus) occurs after long-term SCI. We hypothesized that this spastic activity may be associated with a reversal back to a slower, less fatigable muscle. In adult rats, a sacral (S2) spinal cord transection was performed, affecting only tail musculature and resulting in chronic tail spasticity beginning 2 wk later and lasting indefinitely. At 8 mo after injury, we examined the contractile properties of the segmental tail muscle in anesthetized spastic rats and in age-matched normal rats. The segmental tail muscle has only a few motor units (<12), which were easily detected with graded nerve stimulation, revealing two clear motor unit twitch durations. The dominant faster unit twitches peaked at 15 ms and ended within 50 ms, whereas the slower unit twitches only peaked at 30-50 ms. With chronic injury, this slow twitch component increased, resulting in a large overall increase (>150%) in the fraction of the peak muscle twitch force remaining at 50 ms. With injury, the peak muscle twitch (evoked with supramaximal stimulation) also increased in its time to peak (+48.9%) and half-rise time (+150.0%), and decreased in its maximum rise (-35.0%) and decay rates (-40.1%). Likewise, after a tetanic stimulation, the tetanus half-fall time increased by 53.8%. Therefore the slow portion of the muscle was enhanced in spastic muscles. Consistent with slowing, posttetanic potentiation was 9.2% lower and the stimulation frequency required to produce half-maximal tetanus decreased 39.0% in chronic spinals. Interestingly, in spastic muscles compared with normal, whole muscle twitch force was 81.1% higher, whereas tetanic force production was 38.1% lower. Hence the twitch-to-tetanus ratio increased 104.0%. Inconsistent with overall slowing, whole spastic muscles were 61.5% more fatigable than normal muscles. Thus contrary to the classical slow-to-fast conversion that is seen after SCI without spasticity, SCI with spasticity is associated with a mixed effect, including a preservation/enhancement of slow properties, but a loss of fatigue resistance.

Animals↗

Increased expression of L-type calcium channels in vascular smooth muscle cells at spastic site in a porcine model of coronary artery spasm.

Coronary artery spasm is caused primarily by increased contractility of vascular smooth muscle. Excessive Ca2+ entry into vascular smooth muscle cells (VSMCs) may be one of the key mechanisms for the spasm, but no study has ever directly examined the possible alterations of Ca2+ channels in the spastic coronary artery. Here we show that L-type Ca2+ channels are excessively expressed at the spastic site of the coronary artery. In a porcine model of coronary spasm with balloon injury, both receptor-mediated stimulation of L-type Ca2+ channels by serotonin and direct stimulation of the channels by Bay K 8644 (a dihydropyridine Ca2+ channel agonist) repeatedly induced coronary spasm in vivo, which was abolished by pretreatment with nifedipine, a dihydropyridine Ca2+ channel antagonist. In a single VSMC freshly dispersed from coronary arteries in vitro, patch-clamp experiments showed that current density of L-type Ca2+ channel current was significantly increased in VSMCs from the spastic site compared with that from the control site even when the channels were maximally stimulated by Bay K 8644. There was no difference in the sensitivity of the channels to Bay K 8644. These results indicate that functionally available L-type Ca2+ channels are excessively expressed at the spastic site of the coronary artery in our porcine model, suggesting that increased expression of L-type Ca2+ channels and concomitant increase in Ca2+ entry into VSMCs through the channels may contribute, at least in part, to the pathogenesis of coronary artery spasm.

3-Pyridinecarboxylic acid, 1,4-dihydro-2,6-dimethy↗

Skeletal muscle involvement in tropical spastic paraparesis/HTLV-1-associated myelopathy.

The frequency of muscle involvement in TSP/HAM is not known, nor is the precise role that HTLV-1 and the diverse cytokines play in the genesis of HTLV-1-associated diseases. In order to better define the frequency and characteristics of the skeletal muscle involvement in TSP/HAM, we studied 11 affected patients. EMG was performed in 9 patients and muscle biopsy was performed in all 11. Muscle tissue was analyzed using: reverse transcriptase PCR for interleukin-1 in 8; PCR for HTLV-1 proviral DNA in 5; and electron microscopy for viral particles in 3. We found pathologic alterations in all 11 patients. Four patients (36%) had a neurogenic process, while a primary muscle involvement was observed in the rest (64%). Four patients (36%) had polymyositis, and 3 (27%) had a noninflammatory myopathy. Muscle weakness in the upper limbs was significantly associated with inflammation in the muscle biopsy. EMG was abnormal in only 2 of 9 patients. Reverse transcriptase PCR did not demonstrate message for interleukin-1 in any sample examined. PCR did identify HTLV-1 proviral DNA in the muscle of 3 patients. Retroviral-like particles were found, by EM, in only one biopsy. HTLV-1 may play an important role in the pathogenesis of the frequent myopathies associated with HAM/TSP.

Adult↗