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Cambridge.University.Press.Upper.Motor.Neurone.Syndrome.and.Spasticity.Clinical.Management.and.Neurophysiology.Jun.2008.
This page intentionally left blank Upper Motor Neurone Syndrome and Spasticity Second Edition Upper Motor Neurone Syndrome and Spasticity Clinical Management and Neurophysiology Second Edition Edited by Michael P Barnes Professor of Neurological Rehabilitation Walkergate Park International Centre for Neurorehabilitation and Neuropsychiatry Newcastle upon Tyne, UK Garth R Johnson Professor of Rehabilitation Engineering Centre for Rehabilitation and Engineering Studies (CREST) School of Mechanical and Systems Engineering Newcastle University Newcastle upon Tyne, UK CAMBRIDGE UNIVERSITY PRESS Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo Cambridge University Press The Edinburgh Building, Cambridge CB2 8RU, UK Published in the United States of America by Cambridge University Press, New York www.cambridge.org Information on this title: www.cambridge.org/9780521689786 © Cambridge University Press 2008 This publication is in copyright Subject to statutory exception and to the provision of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press First published in print format 2008 ISBN-13 978-0-511-39699-1 eBook (NetLibrary) ISBN-13 paperback 978-0-521-68978-6 Cambridge University Press has no responsibility for the persistence or accuracy of urls for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate Contents List of Contributors Preface to the second edition page vii ix An overview of the clinical management of spasticity 12 Michael P Barnes Neurophysiology of spasticity Management of spasticity in children 214 Rachael Hutchinson and H Kerr Graham Index 241 Geoff Sheean The measurement of spasticity 64 Garth R Johnson and Anand D Pandyan Physiotherapy management of spasticity 79 Roslyn N Boyd and Louise Ada Seating and positioning 99 Craig A Kirkwood and Geoff I Bardsley Orthoses, splints and casts 113 Paul T Charlton and Duncan W N Ferguson Pharmacological management of spasticity 131 Anthony B Ward and Sajida Javaid Chemical neurolysis in the management of muscle spasticity 150 A Magid O Bakheit Spasticity and botulinum toxin 165 Michael P Barnes and Elizabeth C Davis 10 Intrathecal baclofen for the control of spinal and supraspinal spasticity 181 David N Rushton 11 Surgical management of spasticity 193 Patrick Mertens and Marc Sindou v Contributors Louise Ada Paul T Charlton Associate Professor Discipline of Physiotherapy University of Sydney Sydney, Australia Senior Orthotist J C Peacock & Son Newcastle upon Tyne, UK A Magid O Bakheit Professor of Neurological Rehabilitation Department of Rehabilitation Medicine Mount Gould Hospital Plymouth, UK Elizabeth C Davis Consultant in Rehabilitation Medicine Walkergate Park International Centre for Neurorehabilitation and Neuropsychiatry Newcastle upon Tyne, UK Geoff I Bardsley Duncan W N Ferguson Senior Rehabilitation Engineer Wheelchair & Seating Service Tayside Rehabilitation Engineering Services Ninewells Hospital Dundee, UK Senior Orthotist J C Peacock & Son Newcastle upon Tyne, UK Michael P Barnes Professor of Neurological Rehabilitation Walkergate Park International Centre for Neurorehabilitation and Neuropsychiatry Newcastle upon Tyne, UK Roslyn N Boyd Associate Professor Scientific Director Queensland Cerebral Palsy and Rehabilitation Research Centre Department of Paediatrics and Child Health University of Queensland Brisbane, Australia H Kerr Graham Professor of Orthopaedic Surgery Royal Children’s Hospital Melbourne, Australia Rachael Hutchinson Consultant Paediatric Orthopaedic Surgeon Norfolk and Norwich University Hospital NHS Trust Norfolk, UK Sajida Javaid Specialist Registrar in Rehabilitation Medicine North Staffordshire Rehabilitation Centre University Hospital of North Staffordshire Stoke-on-Trent, UK vii viii Contributors Garth R Johnson David N Rushton Professor of Rehabilitation Engineering Centre for Rehabilitation and Engineering Studies (CREST) School of Mechanical and Systems Engineering Newcastle University Newcastle upon Tyne, UK Consultant in Neurological Rehabilitation Frank Cooksey Rehabilitation Unit Kings College Hospital London, UK Craig A Kirkwood Senior Rehabilitation Engineer Wheelchair & Seating Service Tayside Rehabilitation Engineering Services Ninewells Hospital Dundee, UK Patrick Mertens Professor of Neurosurgery Hˆ pital Neurologique et Neuro-Chirurgical Pierre o Wertheimer Lyon, France Geoff Sheean Professor Department of Neurosciences University of California – San Diego Medical Centre San Diego, California, USA Marc Sindou Professor of Neurosurgery Hˆ pital Neurologique et Neuro-Chirurgical Pierre o Wertheimer Lyon, France Anthony B Ward Anand D Pandyan School of Health & Rehabilitation/Institute for Life Course Studies Keele University Staffordshire, UK Consultant in Rehabilitation Medicine North Staffordshire Rehabilitation Centre University Hospital of North Staffordshire Stoke-on-Trent, UK Management of spasticity in children Spira, R (1971) Management of spasticity in cerebral palsied children by peripheral nerve block with phenol Dev Med Child Neurol, 13: 164–73 Staheli, L T., Duncan, W R & Schaefer, E (1968) Growth alterations in the hemiplegic child Clin Orthop, 60: 205– 12 Stanley, F J & Alberman, E (1984) The Epidemiology of the Cerebral Palsies Philadelphia: J B Lippincott Stefko, R M., De Swart, R J., Dodgin, D A et al (1998) Kinematic and kinetic analysis of distal derotation osteotomy of the leg in children with cerebral palsy J Paediatr Orthop, 18: 81–7 Steinbok, P., Reiner, A M., Beauchamp, R et al (1997) A randomized clinical trial to compare selective posterior rhizotomy plus physiotherapy with physiotherapy alone in children with spastic diplegic cerebral palsy Dev Med Child Neurol, 39: 178–84 Stoffel, A (1913) The treatment of spastic contractures Am J Orthop Surg, 10: 611–44 Tardieu, G., Centaur, S & Delarue, R (1954) A la recherche d’une technique de mesure de la spasticite ‘imprime’ avec le periodique Rev Neurol, 91: 143–4 Utili, R., Boitnott, J K & Zimmerman, H J (1977) Dantrolene-associated hepatic injury: incidence and character Gastroenterology, 72: 610–16 Van Schaeybroeck P., Nuttin, B., Lagae, L et al (2000) Intrathecal baclofen for intractable cerebral palsy spasticity: a prospective placebo-controlled, doubleblind study Neurosurgery, 46: 603–12 VanWinkle, W B (1976) Calcium release from skeletal muscle sarcoplasmic reticulum: site of action of dantrolene sodium? Science, 193: 1130–1 Vaughan, C L., Berman, B & Peacock, W J (1988) Gait analysis of spastic children before and after selective lumbar rhizotomy Paediatr Neurosci, 14: 297–300 Vaughan, C L., Berman, B & Peacock, W J (1991) Cerebral palsy and rhizotomy A three year follow-up and evaluation with gait analysis J Neurosurg, 74: 178–84 Walsh, E G (1988) Assessment of human hemiplegic spasticity by a resonant frequency method Clin Biomech, 3: 173–8 Waterman, P M., Albin, M S & Smith, R B (1980) Malignant hyperthermia: a case report Anesth Analg, 59: 220–1 Wei, S., Su-Juan, W., Yuan-Gui, L et al (2006) Reliability and validity of the GMFM-66 in to year old children with cerebral palsy Am J Phys Med Rehab, 85: 141–7 Wilkinson, S P., Portman, B & Williams, R (1979) Hepatitis from dantrolene sodium Gut, 20: 33–6 Wright, F V., Sheil, E M H., Drake, J M., Wedge, J H & Naumann, S (1988) Evaluation of selective dorsal rhizotomy for the reduction of spasticity in cerebral palsy: a randomized control trial Dev Med Child Neurol, 40: 239–47 Young, R R & Delwaide, P J (1981a) Drug therapy: spasticity (first of two parts) N Engl J Med, 304: 28–33 Young, R R & Delwaide, P J (1981b) Drug therapy: spasticity (second of two parts) N Engl J Med, 304: 96–9 Zieglgansberger, W., Howe, J R & Sutor, B (1988) The neuropharmacology of baclofen In: Muller, H., Zierski, J & Penn, R D (eds.), Local-Spinal Therapy of Spasticity New York: Springer-Verlag, pp 37–49 Ziv, I., Blackburn, N., Rang, M & Koreska, J (1984) Muscle growth in normal and spastic mice Dev Med Child Neurol, 26: 941–84 RECOMMENDED READING Dormans, J P & Pellegrino, L (eds.) (1998) Caring for Children with Cerebral Palsy: A Team Approach Baltimore: Paul H Brookes Miller, G & Clark, G D (eds.) (1988) The Cerebral Palsies: Causes, Consequences and Management Boston: Butterworth-Heinemann Sussman, M D (ed.) (1992) The Diplegic Child Rosemont, IL: American Academy of Orthopaedic Surgeons 239 Index ablative procedures, 193–203, 209 Achilles tendon, surgical lengthening of, 218 active function, antispastic agents and, 131 active stiffness, definition of, 79 activities of daily living, scale of, 134 activity limitations definition of, 79 physiotherapy interventions, 86–7 spasticity as determinant of, 80–1 activity timed walking test, 133, 134 adductors, hip, motor point injections of, 158 age factors See also pediatric spasticity effect on spasticity, 82–4, 228 agonist/antagonist co-contractions, 3–4 Aircast ankle stirrup, 121, 122 alcohol intramuscular wash, 157–8 pharmacology, 152–3 side effects of, 160 alcohol nerve blocks, dosage and concentration, 159–60 indications, 132–3 intrathecal, 161–2, 202–3 pediatric use of, 223–4 therapeutic effects of, 159 alignment effect of muscle overactivity and length on, 89–90 orthotic correction of, 114 alpha motoneurone excitability electrophysiologic studies of, 47–8, 49 measurement of, 49 animal studies See also specific animal age factors affecting spasticity, 84 botulinum toxin, 226–7 241 242 Index animal studies (cont.) contractures, 81 flexor reflex afferents, 28–30 motor pathways, 10 tonic stretch reflexes, 20–1, 24–5 ankle brace, 121, 122 ankle clonus medial popliteal nerve blocks for, 151–2 pathophysiology of, 17 ankle dorsiflexion, in children, 215, 217–19 ankle foot orthosis (AFO), 121–4 aim of, 114 assessment for, 117 design of, 116, 121–2, 123 dynamic, 122–3 ground reaction, 123, 124 hinged, 123, 124 pediatric use of, 223 types of, 122–4 ankle plantaflexion orthotic correction of, 115–16 pathophysiology of, 25–6 ankle stirrups, 118, 121, 122 anterior horn cell excitability, effects of intrathecal baclofen on, 183 antibody formation, botulinum toxin, 166, 169–70 antispastic agents, See also pharmacological therapy; specific drug versus chemical neurolysis, 150 combined use of, 133 contraindications to, 131 dose titration, 133 electrophysiologic monitoring of, 39, 52, 53 indications, 132–3, 135 pediatric use of, 221–3 selection of, 131 anxiety, in children with spasticity, 222 arm See upper limb arthrodesis, 209 Ashworth scales, 65–6, 69 hypertonia measured with, 81 level of measurement, 66–7 pediatric use of, 217 recommendations, 68–9, 76 reliability of, 67–8 versus Tardieu scale, 85 associated reactions, 3–4, 33–4 botulinum toxin for, 175–6 diagnostic use of, 33 pathophysiology of, 33, 34 axon terminals, sprouting of, 15 Babinski sign See extensor plantar response backrest, in seating system, 102–3 baclofen, 135–8 antinociceptive effects of, 181–2 chemical structure, 135–6 clinical efficacy, 136–7 in combined modality therapy, 92 versus diazepam, 139 dosage and administration, 137 in drug combinations, 133 indications, 132–3 intrathecal See intrathecal baclofen (ITB) mechanism of action, 136, 222–3 overdosage, 190 pediatric use of, 221, 222–3 pharmacology, 136, 181–2, 222–3 side effects, 137–8, 222–3 Barthel ADL Index, 134 Becker intelligent knee ankle foot orthosis, 124, 126 benzodiazepines, 138–9 See also specific drug in drug combinations, 133 mechanism of action, 138 biofeedback, in seating support, 105 biological clock, in cerebral palsy, 84, 215 biomechanical approaches equinus assessment, 89–90 orthoses, 115–16, 117, 118 spasticity measurement, 71–4, 76 in children, 219 indirect, 73–4, 76 birthday syndrome, 93 bladder control loss, after intrathecal blocks, 162 blood–brain barrier, intrathecal baclofen and, 182 Bobath concept of normal movement, 113 body suits, 113 BOTOX® , 166, 168, 169, 171, 173, 176, 230 botulinum toxin (BoNT-A), 7, 165 advantages of, 176 adverse effects of, 166, 170, 176 clinical trials, 172–4, 227–30 in combined modality therapy, 171–2, 176, 215, 223, 231–2 commercial formulations, 166–7, 176, 230 cost of, 170–1 delay in onset of clinical effects, 166 dilution, 168 Index dosage, 168–9, 230 in drug combinations, 133 guidelines for use, 168 immunoresistance, 166, 169–70 indications, 132–3, 174–6, 184, 231 injection technique, 168–9, 228 versus intrathecal baclofen, 184 long-term efficacy and safety of, 169–70 mechanism of action, 165, 167 orthoses combined with, 118, 125 pediatric use, 174, 215, 219, 223, 224, 226–7, 229, 232 pharmacology, 165–7 spasticity assessment prior to, 167–8 therapeutic effect of, 167, 169–70 for upper limb spasticity, 152, 228–9 botulinum toxin (BoNT-A) clinics, 176 botulinum toxin type A (BoNT-A), 165 clinical trials, 172–4 in combined modality therapy, 92, 93 commercial formulations, 166, 176 cost of, 170–1 dilution, 168 dosage, 168–9 for equinus gait, 91–2 immunoresistance, 166, 169–70 versus muscle lengthening techniques, 91 botulinum toxin type B (BoNT-B), 165 commercial formulations, 166–7, 176 immunoresistance, 166, 169–70 botulinum toxin type C, 165 botulinum toxin type F, 165, 166 bowel control loss, after intrathecal blocks, 162 brachial plexus neurotomies, 196–7 bracing, functional, to prevent muscle stiffness, 89 brainstem areas controlling spinal reflexes, 11, 12, 14 motor pathways descending from, 12, 13 bulbar problems, bulbospinal motor pathways, in associated reactions, 34 bupivacaine, 152 calf shortening, dynamic, 214 calf spasticity, in children, 215, 223 cannabis, 135, 143–4 caregivers education of, quality of life assessment, 135 stress prevention, casting, 119–20 age factors affecting, 84 botulinum toxin combined with, 171 in children, 223, 229–30 definition of, 113 serial See serial casting cat alpha motoneurone excitability in, 47–8 decerebrate See decerebrate cat model extension responses in, 32 flexor reflex afferents in, 28 flexor withdrawal reflexes in, 30, 31 Ib nonreciprocal inhibition in, 43 positive support reaction in, 38 recurrent inhibition in, 45 catheterization, for intrathecal baclofen, 185, 187, 189 central alpha-2 adrenergic receptor agonists, 141–3 See also clonidine; tizanidine central nervous system, plasticity of, 15 cerebellar stimulation, 184, 193 cerebral lesions, spasticity caused by, versus spinal cord lesions, 14–15 cerebral palsy See also pediatric spasticity biological clock in, 84, 215 muscle growth in, 215, 220, 225 outcome measures, 220 seating concerns See seating cerebrospinal fluid, intrathecal baclofen in, 182 cerebrospinal fluid leakage, from ITB pumps, 190 cervical orthoses, 125–6, 127 Cesament See nabilone chemical neurolysis, 150 See also motor point injections; nerve blocks in children, 223–4 in combined modality therapy, 150–1 complications of, 160 diagnostic use of, 152 dosage and concentration, 159–60 goals of, 151 indications for, 150, 151 versus oral antispastic agents, 150 procedures, 153–9 therapeutic effects of, 159 children See cerebral palsy; pediatric spasticity chlorocresol, 152, 153 clasp-knife phenomenon, 16, 21, 22, 23 clawed hand, botulinum toxin for, 175 clonazepam, 136, 139 243 244 Index clonidine, 141–2 clinical efficacy, 142 mechanism of action, 13, 141 pharmacokinetics, 141 clonus, 1–2 ankle, 17, 151–2 induction of, 17 pathophysiology of, 17 clorazepate, 139 co-contraction, 34–5 versus hyperactive stretch reflex, 35, 36 pathophysiology of, 34–5, 43 coerulospinal tract, 13 collars, cervical, 125–6, 127 collateral sprouting, 15 combined modality therapy botulinum toxin in, 171–2, 176, 215, 223, 231–2 chemical neurolysis in, 150–1 for children with spasticity, 221, 224, 233–4 intrathecal baclofen in, 189 orthoses in, 113, 223 pharmacological agents in, 131 physiotherapy in, 92–3 positioning in, 99–100 surgical management in, 200, 201 communication, difficulty with, confidence factor, 118 contoured seating, 109 contractures age factors affecting, 84 botulinum toxin for, 91–2 characteristic features of, 2–3, 214 in children, 214, 215–17 dynamic, 214, 215–17 fixed, 215–17, 218–19 myostatic, 214, 218–19 pathophysiology of, 27–8, 81 prevention of casting, 119–20 orthoses, 114–15 physiotherapy, 89–90, 91 stretching, 2, 101 stretch reflex hyperexcitability and, 25 surgical release of, Cordis Secor pump, 190 cortical control of excitatory area, 12 of inhibitory centre, 11 of motor function, 10–11 cortico-reticular drive, 14 cost botulinum toxin, 170–1 intrathecal baclofen, 183 crawling, surgical management and, 209–11 cresol, 152 crossed extensor reflex, 28, 32 crouch gait, orthotic treatment of, 123 cushions, seat, 107 custom moulded seating, 109 cutaneous reflexes, 16, 28 See also specific reflex Dantrium See dantrolene sodium dantrolene sodium, 139–41 clinical efficacy, 136, 140 dosage and administration, 140 in drug combinations, 133 indications, 132–3, 222 mechanism of action, 139–40, 222 pediatric use of, 221, 222 pharmacokinetics, 140, 222 side effects, 141, 222 decerebrate cat model, 10 flexor reflexes in, 28 group II afferents in, 50 stretch reflex hyperexcitability in, 24–5 tonic vibration reflex in, 50 decorticate posture See hemiplegic posture deep brain stimulation, 193 deep tendon reflex, 16 delta-9-tetrahydroccabinol (THC), 143–4 descending motor pathways pathophysiology of, 10–11, 12 in spinal cord, 12, 13–14 dexterity, loss of, diazepam, 138–9 versus baclofen, 139 clinical efficacy, 136, 138–9 dosage and administration, 139 indications, 222 pediatric use, 221–2 pharmacology, 138, 221–2 rebound phenomenon, 222 side effects, 139, 221–2 diplegia, contracture prevention in, 215–17 disability, global scales of, 135 dorsal reticulospinal tract, 13–14 flexor reflexes inhibited by, 28, 29 Index dorsal rhizotomy See selective dorsal rhizotomy (SDR) dorsal root entry zone (DREZ), surgery in, 203–4, 205–6, 207, 208, 209 Dr Berrhill jacket, 127, 128 dronabinol, 143 dynamic ankle foot orthoses, 122–3 dynamic contractures, 214, 215–17 dynamic insoles, 114, 118, 122–3 dynamic range of motion testing, in children, 217–19 dynamic seating, 107, 109 dysaesthesiae, neurolytic agent-induced, 160 Dysport® , 166, 168–9, 173, 176, 230 dystonia, 3, 35–8 definition of, 35–7, 79 effect of stretching on, 37 management of, 37–8 elbow extension, loss of, 217–19 elbow flexors, static tonic stretch reflexes in, 22, 23 electrical stimulation botulinum toxin combined with, 171, 172 nerve blocks using, 153–4 electromyography (EMG) for botulinum injection guidance, 169 intraoperative, 200 in spasticity assessment, 84 electrophysiologic studies, 39 correlation with clinical signs, 39, 52, 75–6 drug monitoring using, 39, 52, 53 excitatory system, 47–8, 51 H reflexes, 38–40 Ia presynaptic inhibition, 40–2 Ia reciprocal inhibition, 42, 43 Ib nonreciprocal inhibition, 43–4, 45 of recurrent inhibition, 45–6, 47 spinal inhibitory mechanisms, 38 spinal reflexes, 38 epidural spinal stimulator implants, 184 equinus assessment of, biomechanical approaches to, 89–90 botulinum toxin A for, 91–2, 229–30 management of, 223, 229, 230 medial popliteal nerve blocks for, 151–2 ergonomics, seating systems and, 106 ethyl alcohol See alcohol excitatory interneurone hyperexcitability, electrophysiologic studies of, 49 excitatory system, 11–13, 14 effect of inhibitory drive reduction on, 14–15 electrophysiologic studies of, 47–8, 51 extensor plantar response, 31–2 evocation of, 31 extensor reflexes, 32–3 extensor spasms, 32–3 characteristic features of, functional advantage of, 33 fixed contractures, in children, 215–17, 218–19 flaccid foot, orthotic correction of, 115–16 flexion reflex excitability, effects of intrathecal baclofen on, 182 flexor reflex, 23 flexor reflex afferents (FRAs), 28–9, 30 electrophysiologic studies of, 50–1 supraspinal control of, 28–9, 30, 32 flexor spasms, 30–1 characteristic features of, pathophysiology of, 13, 14, 15 flexor withdrawal reflexes, 30 demonstration of, 30, 31 flu-like symptoms, botulinum toxin-related, 170 focal techniques, foot deformities functional electrical stimulation for, 128–9 medial popliteal nerve blocks for, 151–2 orthotic correction of, 115–16 tibial neurotomy for, 197, 199 footplates See insoles footwear See shoes functional electrical stimulation (FES), 128–9 Functional Independence Measure (FIM), 183 Functional Mobility Scale, 220 functional posterior rhizotomy, 200 functional sitting position, 104 fusimotor drive theory, 24–5, 28 F waves, 49, 75, 183 gabapentin, 144 gait ankle dorsiflexion during, 215, 217–19 ankle plantaflexion during orthotic correction of, 115–16 pathophysiology of, 25–6 crouch, orthotic treatment of, 123 difficulty with, modulation of stretch reflexes during, 24 245 246 Index gait (cont.) nonreciprocal inhibition during, 43–5 scissoring, obturator nerve blocks for, 152 surgical management and, 209–11 gait analysis, 73–4, 76 in children, 219 in drug monitoring, 134 in orthotic assessment, 114, 117, 129 ␥ -amino butyric acid (GABA), 181 gastrocnemius-soleus motor point injections of, 151–2, 158 reflex contraction induced in, 17 shortening of, 217–18 spasticity in, knee casting for, 223 gate control theory of pain, 193 general anesthesia, prior to botulinum toxin injection, 169, 227–8 global scales of disability, 135 Golgi tendon organs, role in clasp-knife phenomenon, 21, 23 goniometry, 135 grasp dynamometer testing, 134 Gross Motor Function Classification System (GMFCS), 220 Gross Motor Function Measure (GMFM), 220 ground reaction ankle foot orthosis, 123, 124 group II afferents, role in spasticity, 23 group II polysynaptic excitatory pathways, electrophysiologic studies of, 50–1 guided injection techniques, for botulinum toxin, 169 hip deformities, obturator nerve blocks for, 152 hip flexion spasticity, botulinum toxin for, 175 hip flexors, motor point injections, 158–9 hip integrity, seating and, 101–2, 103, 120–1 hip knee ankle foot orthosis (HKAFO), 124 hip orthoses, 124 hip surgery, proper positioning after, 102 Hmax/Mmax ratio, 49, 75 horseback riding posture, 106 H reflex(es), 17 diagnostic use of, 75 electrophysiological studies of, 38–40 reciprocal inhibition of, 43 vibratory inhibition of, 40–1 H-reflex amplitudes, 49 H-reflex conditioning technique, 45 H-reflex recovery curves, 51 hygiene, hand orthoses and, 128 hygiene scale, 134 hyperreflexia, definition of, 79 hypertonia age factors and, 84 assessment of, 82, 84–5 biomechanical components of, 2–3, 25–7, 28, 82, 84–5 definition of, 64, 79 measurement of, 81 neural component of, 2–3, 26, 27, 82, 84–5 versus spasticity, 81 hypotonia, seating and, 99 hysteresis loop, 72 hamstrings botulinum toxin injections to, 230 neurotomy at, 196 stretching of, in seating support, 101 hand deformities botulinum toxin for, 175 peripheral neurotomies for, 197–8 hand orthoses, 127–8 hemiplegia contracture prevention in, 215–17 movement therapy for, 88–9 hemiplegic posture, 3, 33, 35 pathophysiology of, 34, 37 hemiplegic shoulder botulinum toxin for, 175, 228–9 orthotic management of, 126–7, 128 hinged ankle foot orthoses, 123, 124 hip abduction orthoses, seating support with, 102 hip adductors, motor point injections of, 158 Ia polysynaptic excitatory pathways, electrophysiologic studies of, 49–50 Ia presynaptic inhibition, electrophysiologic studies of, 40–2 Ia reciprocal inhibition electrophysiologic studies of, 42, 43 impairment of, co-contraction caused by, 34–5, 43 Ib nonreciprocal (autogenic) inhibition, electrophysiologic studies of, 43–4, 45 immobilization age factors affecting, 84 effect on muscle length and stiffness, 26–7, 90 immunoresistance, to botulinum toxin, 166, 169–70 impairment, definition of, 79 infants, seating systems for, 108–9 infection at ITB pump implants, 190 at site of nerve block injection, 160 Infusaid pumps, 190 inhibitory system, 11, 14 Index disruption of, 14–15 insoles, 121 dynamic, 114, 118, 122–3 International Standards Organization orthosis definition, 113 seating standards, 108 inter(intra)-rater reliability Ashworth scales, 67–8 Tardieu method, 70, 71, 85, 86 intrathecal baclofen (ITB), 7, 181 alternatives to, 184 versus botulinum toxin, 184 in cerebrospinal fluid, 182 in combined modality therapy, 189 complications of, 189–90 cost–benefit analysis, 183 dose–response relationship, 181 effects on function and quality of life, 183 excretion of, 182 indications, 184, 209 localization of, 182 neurophysiological effects of, 182–3 overdosage, 190 patient selection, 183–5 pediatric use, 188–9, 222–3, 225–6 pharmacokinetics of, 182 pump failure, 189 therapeutic effects of, 186–9 trial dose, 184–5 intrathecal baclofen (ITB) pumps CSF leakage from, 190 dosage adjustments, 186, 187, 188 failure of, 189 implant infection, 190 implant surgery, 185 pediatric use, 225–6 refills, 186, 187, 188 types of, 190 intrathecal chemical rhizotomies, 202–3 intrathecal nerve blocks, 7, 161–2 complications, 162 indications, 161, 202–3 procedures, 161–2 therapeutic effect of, 161–2 irradiation, reflex, 16, 17 joint stabilization, in children, 233 ketazolam, 139 knee ankle foot orthosis (KAFO), 121, 123–4, 125 assessment for, 117 intelligent, 124, 126 knee block, seating support with, 102, 103, 106, 109 knee casting, for gastrosoleus spasticity, 223 knee hyperextension, orthotic correction of, 116, 118, 119, 123–4, 125 knee locks, 124 knee orthoses, 123–4 Lance, J W., definition of spasticity, 9, 79 lateral vestibular nucleus, 12–13 leg See lower limb limb garments, 113 Lioresal See baclofen local anaesthetics, diagnostic use, 152 locus coeruleus, 13 longitudinal myelotomy, 203 long-latency response (LLR), 50–1 loss of dexterity, lower extremity telescopic orthosis (LETHOR), 117 lower limb, peripheral neurotomies in, 194–5, 196, 197, 199 lower limb plaster back slabs, full-length, 120 lumbar spinal nerve blocks, 157, 160 lycra orthoses, 113 lyrica See pregabalin Malleolock ankle brace, 121, 122 marijuana See cannabis Marinol See dronabinol measurement scales See spasticity measurement scales; specific scale medial popliteal nerve blocks, 151–2, 154, 155 medial reticulospinal tract, 13–14 median neurotomy, 196, 197–8 medical history-taking, in seating assessment, 100 medium-latency response (MLR), 50 Medtronic SynchroMed© pumps, 186, 187, 188, 190 microDREZotomy (MDT), 203–4, 205–6, 207, 208, 209 mobility limitations, surgical management and, 209–11 modified Ashworth scale level of measurement, 66–7 recommendations, 68–9, 76 reliability of, 67–8 motor control, descending pathways in, pathophysiology of, 10–11, 12 motor function, effect of peripheral neurotomies on, 197–8 motor learning, 87–8, 89, 90–1 targeted, orthoses for, 115 247 248 Index motor point injections, 157–9 complications, 160 gastrosoleus muscles, 151–2, 158 hip adductors, 158 hip flexors, 158–9 intramuscular alcohol wash in, 157–8 versus nerve blocks, 157 pediatric use of, 223–4 motricity index, 133 movement See also gait abnormal, orthotic prevention of, 114 normal Bobath concept of, 113 orthotic promotion of, 114 M-response, 75 multidisciplinary care See combined modality therapy multiple sclerosis, intrathecal baclofen for, 186–7 muscle activation, tonic stretch reflexes during, 23–5 muscle activity, unnecessary, elimination of, 87 muscle belly vibration, electrophysiologic studies of, 40, 41, 49–50 muscle contractions, as associated reactions, 3–4 muscle growth, in children with cerebral palsy, 215, 220, 225 muscle length immobilization and, 26–7, 90 posture and, 90–1 muscle lengthening techniques, 90, 208–9, 215 in children, 232–3 muscle overactivity definition of, 79 peripheral causes of, 132 voluntary, versus spasticity, 81–2, 83 muscle resonant frequency measurement, 219, 228 muscle spasms characteristic features of, effects of intrathecal baclofen on, 182 extensor See extensor spasms flexor See flexor spasms frequency scale, 134 muscle stiffness in children, 214, 219, 228 immobilization and, 26–7, 90 physiotherapy techniques for, 89–91 thixotropic, 28 muscle tone clinical testing of, 17–18 loss of, after intrathecal blocks, 162 muscle torque, measurement of, 219 muscle training, 87–8, 89 in combined modality therapy, 92 orthoses for, 115 to prevent contractures, 89–90, 91 muscle weakness, botulinum toxin-related, 170 musculocutaneous nerve block, 157 musculocutaneous neurotomy, 196, 197 myelotomy, longitudinal, 203 Myobloc® , 166–7 myometer, 72 myostatic contractures, 214, 218–19 nabilone, 143 natural reciprocal inhibition, 43 nausea, botulinum toxin-related, 170 needle placement, for nerve blocks, 153–4 neonates, seating systems for, 108–9 nerve blocks, alcohol See alcohol nerve blocks complications of, 160 diagnostic use, 152 dosage and concentration, 159–60 intrathecal See intrathecal nerve blocks lumbar spinal, 157, 160 medial popliteal, 151–2, 154, 155 versus motor point injections, 157 musculocutaneous, 157 needle placement, 153–4 obturator, 152, 154–6, 157 open, 153 pediatric use, 223–4 phenol See phenol nerve blocks procedure, 153–9 sciatic, 157 therapeutic effects of, 159, 160 for upper limb muscle spasticity, 152 neuro-ablative procedures, 193–203, 209 NeuroBloc® , 166–7, 168, 176 neurolytic agents See also chemical neurolysis; specific agent dosage and concentration, 159–60 pharmacology, 152–3 side effects of, 160 neuropharmacology, 39, 52 See also pharmacological therapy neurophysiological approaches, to spasticity measurement, 74–6 neurostimulation procedures, 193 neurotomy See peripheral neurotomies; specific technique nine hole peg test, 133, 134 Index nociceptive reflexes, 16, 28 See also specific reflex nonreciprocal inhibition, electrophysiologic studies of, 43–4, 45 North American Taskforce, definitions, 79, 82 Nottingham Health Profile, 133 noxious stimuli, reduction of, in seating, 105 nursing problems, obturator nerve blocks, 152, 154–6, 157 obturator neurotomy, 194, 195, 224 open nerve blocks, 153 Ortholen, 121 orthopaedic surgery, 208, 209 in children, 226, 232–3 orthoses, 113 See also specific orthosis aim of, 113, 114, 115 assessment for, 114, 117, 119, 129 botulinum toxin combined with, 118, 125, 171 classification of, 121 in combined modality therapy, 91, 92, 93, 223 contraindications to, 118 definition of, 113 design of, 115–17, 129 patient compliance with, 119 patient selection for, 116, 117–19, 120 pediatric use, 113, 120–1, 223 plastic versus metal, 116–17, 129 seating, 102, 114, 124 sensory element of, 113 simulating effect of, 117 timing of use, 120 types of, 121–8 Orthotics Research and Locomotor Assessment Unit (ORLAU), video vector technique, 73–4 orthotist, role of, 5–7 osteotomies, 209, 233 outcome measurement, pediatric, 220 pharmacological therapy, 133–4 pain, 4–5 baclofen for, 181–2 at botulinum toxin injection site, 170 in children with spasticity, 222, 231–2 gate control theory of, 193 neurolytic agent-induced, 160 pain assessment scales, 135 paraplegia-in-extension, 15, 33 paraplegia-in-flexion, 15, 33 parapyramidal tracts inhibitory area in, 11 motor pathways in, 11 disruption of, 11, 14 Parawalker, 124 partial posterior rhizotomy, 200 participation restriction, definition of, 79 passive motion antispastic agents and, 131 resistance to, quantification of, 65, 73, 84 passive stiffness, definition of, 79 patient compliance, with orthoses, 119 patient education, pharmacological therapy, 133 patient selection chemical neurolysis, 151 intrathecal baclofen, 183–5 orthoses, 116, 117–19, 120 pediatric, 220 peripheral neurotomies, 196 pharmacological therapy, 133 role of physiotherapy in, 92 selective dorsal rhizotomy, 225 patient transfer, to seating system, 106 pediatric spasticity, 214 botulinum toxin for, 174, 215, 219, 223, 224, 226–7, 229, 232 casting for, 223, 229–30 causes of, 214, 215 chemical neurolysis for, 223–4 versus contractures, 214, 215–17 gait analysis, 219 growth and, 82–4, 215, 220, 225 intrathecal baclofen for, 188–9, 222–3, 225–6 management of, 219–33 classification of, 220–1 failure of, 220 indications for, 220 measurement of, 217–19, 220 multidisciplinary care for, 221, 224, 233–4 muscle lengthening for, 90–1 muscle stiffness and, 214, 219, 228 muscle training for, 87, 88–9 orthoses for, 113, 115, 120–1, 223 osteotomies for, 209 pain in, 222, 231–2 pathology of, 214–16, 217, 218 peripheral neurotomies for, 196, 224 pharmacological management, 221–3 249 250 Index pediatric spasticity (cont.) seating systems, 108–9 selective dorsal rhizotomy for, 224–5 surgical management, 93, 200–1, 202, 209–11, 226, 232–3 pendulum test, 71–2, 76 percussion, tendon, 16–17 percutaneous thermorhizotomies, 202–3 peripheral neurotomies, 194–8 See also specific technique in children, 196, 224 indications, 196, 209 lower limbs, 194–5, 196, 197, 199 therapeutic effect of, 197–8, 199 upper limbs, 196–8 persistent inward currents (PICs), 47–8 pharmacological therapy, 131 See also antispastic agents; specific drug clinical efficacy, 136 goals of, 132 management strategy, 132–3 muscle overactivity and, 131–2 outcome measures, 133–4 patient selection for, 133 pediatric use, 221–3 role of physiotherapy in, 92–3 phasic stretch reflexes, 16–17 phenol aqueous solutions, 153, 159 dosage and concentration, 159 in drug combinations, 133 in glycerine, 153, 161–2 intramuscular wash, 157–8 intrathecal, 161–2, 184 pharmacology, 152–3 side effects of, 160, 162 phenol nerve blocks, indications, 132–3 pediatric use, 223–4 therapeutic effects of, 159, 160 physical examination, in seating assessment, 100 Physician Rating Scales, for gait analysis, 219 physiotherapist, role of, 5–7, 92–3 physiotherapy, 79 interventions, 85–93 in multidisciplinary care, 92–3 in seating support, 100 spasticity assessment in, 84–5 Pierrot-Deseilligny technique, 43, 44 plantar response, extensor, 31, 32 plaster casting, 119–20 plasticity, 15 plateau potentials, 47–8 polypropylene orthoses, 121–2, 123, 128 polysynaptic excitatory pathways, electrophysiologic studies of, 49–51 polysynaptic excitatory postsynaptic potentials (pEPSP), 15 pommels, seating support with, 102, 109 positioning, 99 See also seating orthotics for, 114 principles of, 100–6 positive support reaction, 38, 118 posterior rhizotomy, 198 functional, 200 partial, 200 sectorial, 199 selective, 198–9 therapeutic results, 200–2 postural stabilization, in seating, 104 posture dystonia and, 37 extensor spasms and, 32–3 hemiplegic See hemiplegic posture horseback riding, 106 muscle length and, 90–1 nonreciprocal inhibition and, 45 seated See seating spasticity measurement and, 69 standing, 106 tonic stretch reflexes and, 19–20 powered biomechanical systems, for spasticity measurement, 72–3 practice of muscle skills, 87–9, 90–1 precentral cortical stimulation, 193 pregabalin, 144 pressure reduction in orthoses, 115 in seating systems, 107 presynaptic inhibition, evaluation of, 40–2 pronator teres contractures, 228–9 proprioception, definition of, 16 proprioceptive reflexes, 16 psoas major, motor point injections of, 158–9 pumps See intrathecal baclofen (ITB) pumps pyramidal tracts motor pathways in, 11 disruption of, 11 plantar response linked to, 31, 32 Index quadriceps spasticity, orthotic correction for, 116 quality of life assessment of, 133, 135 effects of intrathecal baclofen on, 183 quiet zones, 118 radiofrequency rhizotomy, percutaneous, 202–3 range of motion orthotic promotion of, 114–15 restriction of, pathophysiology of, testing of, 135, 217–19 rash, botulinum toxin-related, 170 rat, alpha motor neurone excitability in, 47, 48 reciprocal gait orthosis, 124 reciprocal inhibition electrophysiologic studies of, 42, 43 impairment of, co-contraction caused by, 34–5, 43 recurrent (Renshaw) inhibition, electrophysiologic studies of, 45–6, 47 reflex irradiation, 16, 17 Relaxation Index, 71 ‘release’ effect, 15 Renshaw cell activity, electrophysiologic studies of, 45–6, 47 resonant frequency measurements, 219, 228 restraints, in seating systems, 107 reticulospinal tract, 13–14 rhizotomy, versus intrathecal baclofen, 184 intrathecal chemical, 202–3 percutaneous radiofrequency, 202–3 posterior See posterior rhizotomy selective dorsal See selective dorsal rhizotomy (SDR) rigidity, 118 rotational osteotomies, 233 R1/R2 testing, 218 rubrospinal tract, 13 SAM system, 106 sativex, 143 sciatic nerve block, 157 scissoring gait, obturator nerve blocks for, 152 scoring systems, for gait analysis, 219 seat cushions, 107 seating, 99 alternative postures for, 105–6 clinical assessment, 100 difficulty with, hip integrity maintenance in, 101–2, 103, 120–1 postural stabilization in, 104 principles of, 100–6 reduction of noxious stimuli, 105 sustained muscle stretch in, 100–1 for transportation, 109 trunk orientation in, 102–3 seating orthosis, 102, 114, 124 seating simulator, assessment using, 100 seating systems adjustable, 107–8, 109 arm restraints in, 103–4 back rests in, 102–3 choosing, 108–9 comfort of, 105, 107 custom moulded, 109 design of, 106–8 dynamic, 107, 109 ergonomics and, 106 positioning in, 106 pressure reduction in, 107 reduction of unnecessary upper limb activity, 104–5 restraints in, 103–4, 106, 107 shear forces in, 107 strength and durability of, 107 success of, evaluating, 108 sectorial posterior rhizotomy, 199 selective dorsal rhizotomy (SDR) in children, 224–5 physiotherapy in, 92–3 selective posterior rhizotomy, 198–9 self-management, serial casting, 119–20 in children, 223 in combined modality therapy, 92 to prevent contractures, 91 servomechanism theory, 233 shear forces in orthoses, 115 in seating systems, 107 shoes design of, 116–17 insoles in, 114, 118, 121, 122–3 orthotic adaptations to, 116, 121 Short Form 36 Questionnaire, 133 short-latency response (SLR), 50 shoulder, hemiplegic botulinum toxin for, 175, 228–9 orthotic management of, 126–7, 128 shunting, 118 Silfverskiold test, 217–18 silicone orthoses, 129 single event multilevel surgery (SEMLS), 93 251 252 Index sinusoidal stretch, 84, 85 sitting braces, 124 skill, lack of muscle overactivity caused by, 81–2, 83, 89 muscle training to overcome, 87–9 orthoses for, 115 soft tissue changes See also contractures biomechanical hypertonia caused by, 26–7 characteristic features of, 2–3 prevention of, 89–91 stretch reflex hyperexcitability and, 25 soft tissue injury, from nerve blocks, 160 soleus H-reflex recovery curve, 51 soleus shortening, 217–18 somatosensory cortex, 12 plasticity of, 15 spastic catch, spasticity with cerebral lesions, versus spinal cord lesions, 14–15 characteristic features of, in children See pediatric spasticity classification of, 81 definition of, 1, 9–10, 53, 64, 79, 80, 82, 214 as determinant of activity limitations, 80–1 effect of intrathecal baclofen on, 182 effect of pathology on, 82–4 functional benefits of, 131, 159, 219–20 management approach to, 5–6, maturation factors in, 82–4 neurophysiology of, versus other impairments, 81–2, 83, 214 spasticity measurement, 64 approaches to, 65 barriers to, 64 biomechanical approaches to, 71–4, 76 indirect, 73–4, 76 before botulinum toxin use, 167–8 in children, 217–9 levels of, 65, 66 neurophysiological approaches to, 74–6 in physiotherapy, 84–5 seating system evaluation and, 108 spasticity measurement scales, 66, 74 See also specific scale requirements of, 65 spastic motor overactivity, 53 treatment of, arguments against, 53–4 spastic movement disorder, 52–4 spinal catheterization, for intrathecal baclofen, 185, 187, 189 spinal cord descending pathways in, 12, 13–14 inhibitory versus excitatory tracts in, 14 stimulation of, 193 spinal cord injury (SCI), intrathecal baclofen for, 187–8 spinal cord lesions complete versus incomplete, 15 spasticity caused by, versus cerebral lesions, 14–15 spinal inhibitory mechanisms, electrophysiological studies of, 38 spinal segmental reflexes See also specific reflex brainstem areas controlling, 11, 12, 14 classification of, 16 electrophysiological studies of, 38 evocation of, 74–5 excitability of, change in, 15–16 pathophysiology of, 16 spinal shock pathophysiology of, 15–16 presynaptic inhibition in, 41 splinting, 113 botulinum toxin combined with, 171 definition of, 113 standing posture, 106 static range of motion testing, 217–9 static tonic stretch reflexes, 21–3, 50 stepping generator, 28, 32 strength-training programs, 87, 88 stretching contracture prevention with, 2, 101 effect on dystonia, 37 repeated, effect on tonic stretch reflexes, 20, 37, 69 in seating support, 100–1 stretch reflex, in range of motion testing, 218–19 stretch reflex arc, 16 stretch reflex hyperexcitability versus co-contraction, 35, 36 physiological mechanisms underlying, 24–5 stride length test, 133 supplementary motor area (SMA), 12 surgical management, 7, 193 See also specific technique in children, 200–1, 202, 209–11 in combined modality therapy, 200, 201 indications for, 209–10, 211 orthopaedic, 208, 209 personal adaptations, 200 role of physiotherapy in, 92–3 swallowing, difficulty with, Swedish knee brace, 116, 118, 119 SynchroMed® pumps, 186, 187, 188, 190 Index Tardieu method of assessment, 69–70 versus Ashworth scales, 85 level of measurement, 70 recommendations, 70, 76 reliability of, 70, 71, 85, 86 tendon jerks, 74–5, 84, 85 tendon percussion, 16–17 tendon reflex (T reflex), versus H reflex, 38–40 tendon reflex irradiation, 16, 17 tendon transfer, 209 tenotomies, 232 terazepam, 139 THC (delta-9-tetrahydroccabinol), 143–4 Therex pump, 190 thermorhizotomies, percutaneous, 202–3 thixotropy, 28 tibialis anterior, flexor withdrawal reflexes of, 30, 31 tibial neurotomy, 194–5, 196, 197, 199 tilt table, weight bearing using, 106 tizanidine, 141, 142–3 clinical efficacy, 136, 142, 222 dosage and administration, 142–3 mechanism of action, 13, 141, 222 pediatric use, 222 pharmacokinetics, 142 side effects of, 143 toe clawing, botulinum toxin for, 175 toileting, hip integrity and, 102 tone, definition of, 64, 79 tone intensity scale, 134 tonic ambulatory foot response See positive support reaction tonic stretch reflexes, 16, 17–21 effect of repeated stretching on, 20, 37, 69 length dependence of, 19–21, 22 during muscle activation, 23–5 in normal subjects, 18 pathophysiology of, 19 static, 21–3, 50 velocity dependence of, 19, 20–1, 22, 85 tonic vibration reflex (TVR), 40, 41, 49 transcutaneous electrical nerve stimulation (TENS), 41, 160 transportation, seating for, 109 traumatic brain injury (TBI), intrathecal baclofen for, 188 tricyclic antidepressants, 160 triple flexion response, 28, 32 truncal spasticity, trunk orientation, in seating, 102–3 twisters, 124 ulnar neurotomy, 197–8 ultrasound guidance, for botulinum toxin injection, 169 unskilled performance muscle overactivity in, 81–2, 83, 89 muscle training to overcome, 87–9 orthoses for, 115 upper limb musculocutaneous nerve block in, 157 peripheral neurotomies in, 196–8 upper limb activity dexterity and strength testing, 134 unnecessary, reduction of, in seating systems, 104–5 upper limb muscle spasticity botulinum toxin for, 171–2, 174, 228–9 nerve blocks for, 152 upper limb restraints, in seating systems, 103–4 upper motor neurone(s), pathophysiology of, 10–11 upper motor neurone (UMN) syndrome clinical consequences of, 4–5 definition of, 1, 9–10 management of aims of, approach to, 5–6, negative phenomena of, 1, 2, 79 neuropharmacology of, 52 pathophysiology of, 10, 14–15, 16, 214–17 positive phenomena of, 1–2, 4, 9–10, 79 Valium See diazepam ventromedial reticular formation, 11 vestibulospinal reflexes, in associated reactions, 34 vestibulospinal tract, 12–14 vibration, 40, 41, 49–50 video recording, in gait analysis, 219 video vector technique, 73–4 voluntary muscle overactivity, versus spasticity, 81–2, 83 walking See gait Wartenberg Pendulum Test, 71–2, 76 weight bearing, using tilt table, 106 wheelchairs See also seating systems powered versus manual, 104–5 transport of, 109 windsweeping, 102, 103 wrist orthoses, 127–8 Xeomin® , 166, 170, 176 253