Spasticity after spinal cord injury Jens Bo Nielsen Department of Physical Exercise and Sport Science & Department of Neuroscience and Pharmacology Panum.

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]