Upper Motor Neurone Syndrome and Spasticity: Clinical Management and Neurophysiology (Cambridge Medicine (Paperback))

Spasticity is a disabling problem for many adults and children with a variety of neurological disorders such as multiple sclerosis, stroke, cerebral palsy and traumatic brain injury. A practical guide for clinicians involved in the management of spasticity, this book covers all aspects of upper motor neurone syndrome from basic neurophysiology and measurement techniques to practical therapy and the use of orthoses. Surgical techniques are also covered, as well as the particular problems of management of spasticity in childhood. In the second edition of this key text, all chapters have been thoroughly updated, with additional coverage of new techniques and new drugs and therapies, whilst continuing the format that has made the first edition the core text in its field. This guide will be invaluable to physicians, physiotherapists, surgeons, orthotists, clinical engineers and health professionals. 9780521689786 Half-title 3 Title 5 Copyright 6 Contents 7 Contributors 9 Preface to the second edition 11 1 An overview of the clinical management of spasticity 13 Definitions of spasticity and the upper motor neurone syndrome 13 Negative phenomena of the UMN syndrome 13 Positive phenomena of the UMN syndrome 13 Spasticity 14 Soft tissue changes and contractures 14 Flexor and extensor spasms 15 Spastic dystonia and associated reactions 15 Clinical consequences 16 Mobility 16 Loss of dexterity 16 Bulbar and trunk problems 16 Pain 16 Carers and nursing problems 17 An approach to management 17 Aims of treatment 17 Self-management 17 The physiotherapist and the orthotist 17 Oral medication 19 Focal techniques 19 Intrathecal and surgical techniques 19 REFERENCES 20 2 Neurophysiology of spasticity 21 Introduction 21 Definition 21 Chapter overviews 22 Descending pathways: upper motor neurones 22 Brainstem areas controlling spinal reflexes 23 Inhibitory system 23 Excitatory system 23 Other motor pathways descending from the brainstem 25 Rubrospinal tract 25 Coerulospinal tract 25 Descending motor pathways in the spinal cord 25 Clinicopathological correlation 26 Mechanism of the change in excitability of the spinal reflexes 27 Spinal segmental reflexes 28 Proprioceptive reflexes 28 Phasic stretch reflexes 28 Tonic stretch reflexes 29 The clasp-knife phenomenon 33 Static tonic stretch reflexes 33 Tonic stretch reflexes during muscle activation 35 The physiological mechanisms underlying stretch reflex hyperexcitability 36 Nonreflex contributions to hypertonia: biomechanical factors 37 Nociceptive/cutaneous reflexes 40 Flexor withdrawal reflexes and flexor spasms 40 Flexor reflex afferents 40 Flexor withdrawal reflexes 42 Flexor spasms 42 The extensor plantar response 43 Extensor reflexes and spasms 44 Other UMN phenomena 45 Associated reactions 45 Spastic co-contraction 46 Spastic dystonia 47 Positive support reaction 50 Electrophysiological studies of spinal reflexes in spasticity 50 Spinal inhibitory mechanisms 50 H reflexes 50 Ia Presynaptic inhibition 52 Ia Reciprocal inhibition 54 Ib Nonreciprocal (autogenic) inhibition 55 Recurrent (Renshaw) inhibition 57 Excitatory spinal activity 59 Alpha motoneurone excitability 59 Excitatory interneurone hyperexcitability 61 Ia Polysynaptic excitatory pathways 61 Group II polysynaptic excitatory pathways 62 H-reflex recovery curves 63 Conclusion regarding spinal mechanisms in the UMN syndrome 63 Neuropharmacology of the UMN syndrome 64 The spastic movement disorder 64 REFERENCES 66 3 The measurement of spasticity 76 Introduction 76 Approaches to measurement 77 Use of scales to measure spasticity 77 Requirements of measurement scales 77 Level of measurement 77 The Ashworth scales 77 Ashworth and modified Ashworth scales – level of measurement 78 Reliability of the Ashworth scales 79 Original Ashworth scale 79 Modified Ashworth scale 79 Comparison of the Ashworth and modified Ashworth scales 80 Ashworth scales – conclusions and recommendations 80 The Tardieu method of assessment 81 Tardieu method of assessment – level of measurement 82 Reliability of the Tardieu method of assessment 82 The Tardieu method of assessment – conclusions and recommendations 82 Biomechanical approaches 83 Wartenberg test 83 Powered systems 84 Indirect biomechanical approaches – gait analysis 85 Neurophysiological approaches to measurement 86 Tendon jerks 86 H Reflexes 87 F waves 87 Overall conclusions 88 Acknowledgements 88 REFERENCES 88 4 Physiotherapy management of spasticity 91 What is spasticity? 91 How important a determinant of activity limitations is spasticity? 92 Confusion between spasticity and other impairments 93 Effect of pathology and maturation on spasticity 94 Assessment of spasticity 96 Intervention 97 Elimination of unnecessary activity 99 Training of appropriate muscles 99 Prevention of adaptive soft tissue changes 101 Pharmacological and surgical options 104 Conclusion 106 REFERENCES 106 5 Seating and positioning 111 Introduction 111 Clinical assessment 112 Principles of seating and positioning 112 Sustained muscle stretch 112 Maintenance of hip integrity 113 Trunk orientation 114 Restraint of arm movement 115 Restraint of nondominant arm 116 Restraint of both arms 116 Postural stabilization 116 Reduction of unnecessary upper limb activity 116 Reduction of noxious stimuli 117 Alternative postures 117 Horseback riding 118 SAM system 118 Standing 118 Positioning in the seat 118 Position of tasks 118 Seat design and spasticity 118 Strength and durability 119 Pressure reduction 119 Shear forces 119 Restraining movement – safety aspects 119 Adjustability 119 Evaluating success of seating systems 120 Choosing seating systems 120 Conclusion 121 REFERENCES 122 6 Orthoses, splints and casts 125 Introduction 125 Orthotic aims 126 Reduce or inhibit an abnormal pattern by positioning 126 Prevent abnormal movement 126 Promote normal alignment and movement 126 Preventing contractures and maintaining or increasing joint ranges 126 Targeted motor learning 127 Biomechanics and materials 127 Plastic or metal orthosis? 128 Assessment 129 Casting 131 Timing of orthotic intervention 132 When to wear an orthosis 132 Orthotics in paediatric management 132 Types of orthoses 133 Classification 133 Footwear and adaptations to shoes 133 Ankle-foot orthoses 133 Types of ankle-foot orthoses 134 Dynamic insoles and dynamic ankle-foot orthoses (DAFOs) 134 Hinged ankle-foot orthoses 135 Ground-reaction ankle-foot orthoses 135 Knee orthoses and knee-ankle-foot orthoses 135 Hip and hip-knee-ankle-foot orthoses (HKAFOs) 136 Cervical orthoses and the cervical spine 137 The hemiplegic shoulder 138 The hand and wrist 139 Functional electrical stimulation (FES) 140 Future developments 141 Conclusion 141 REFERENCES 141 7 Pharmacological management of spasticity 143 Introduction 143 Goals of treatment 144 Management strategy 144 Patient types 145 Combination treatment 145 Outcome measures 145 Specific treatments 147 Baclofen 147 Mechanism of action 148 Pharmacokinetics 148 Clinical efficacy 148 Dosage and administration 149 Side effects 149 Benzodiazepines 150 Mechanism of action 150 Diazepam 150 Pharmacokinetics 150 Clinical efficacy 150 Dosage and administration 151 Side effects 151 Other benzodiazepines 151 Dantrolene sodium 151 Mechanism of action 151 Pharmacokinetics 152 Clinical efficacy 152 Dosage and administration 152 Side effects 153 Central alpha-2 adrenergic receptor agonists 153 Mechanism of action 153 Clonidine 153 Pharmacokinetics 153 Clinical efficacy 154 Tizanidine 154 Pharmacokinetics 154 Clinical efficacy 154 Dosage and administration 154 Side effects 155 Cannabis 155 Gabapentin 156 Conclusion 156 REFERENCES 156 8 Chemical neurolysis in the management of muscle spasticity 162 Introduction 162 Indications for treatment 163 Indications for medial popliteal nerve blocks 163 Indications for obturator nerve blocks 164 Nerve blocks for upper limb muscle spasticity 164 The diagnostic use of nerve blocks 164 The pharmacological properties of neurolytic agents 164 Procedure of peripheral nerve blocks 165 Nerve blocks 165 Medial popliteal nerve block 166 Obturator nerve blocks 166 Sciatic nerve block 169 Block of the musculo-cutaneous nerve of the arm 169 Lumbar spinal nerve blocks 169 Motor point injections 169 Motor point injections of the gastrosoleus muscles 170 Motor point injections of the hip adductors 170 Motor point blocks of the hip flexors 170 The therapeutic effects of chemical neurolysis 171 The optimal concentration and dosage of the neurolytic agents 171 Complications of peripheral nerve blocks 172 Intrathecal block 173 Procedure of intrathecal block 173 Complications of lumbar intrathecal block 174 Summary 174 REFERENCES 175 9 Spasticity and botulinum toxin 177 Introduction 177 Clinical pharmacology 177 Botulinum toxin as a therapy for spasticity 179 Assessment 179 The injection technique 180 Dilution 180 Dosage 180 Injection guidance 181 Long-term efficacy and safety 181 Economics 182 Botulinum alone or in combination? 183 Clinical trials 184 Other spasticity indications 186 Toe clawing 187 Spastic shoulder 187 Clawed hand 187 Hip flexion spasticity 187 Associated reactions 187 Conclusions 188 REFERENCES 189 10 Intrathecal baclofen for the control of spinal and supraspinal spasticity 193 Introduction 193 Intrathecal baclofen (ITB) 193 Pharmacology of baclofen 193 Baclofen and 193 γ-amino butyric acid (GABA) 193 Baclofen and pain 193 Pharmacokinetics of intrathecal baclofen 194 Baclofen in cerebrospinal fluid (CSF) 194 Localization of ITB 194 Excretion of ITB 194 Neurophysiological effects of ITB 194 Spasticity score 194 Spasm score 194 Flexion reflex excitability 194 Anterior Horn Cell Excitability 195 Effects of ITB on function and quality of life 195 Functional independence measure (FIM) 195 Quality of Life (QoL) 195 Cost-benefit analysis 195 Indications and patient screening tests for ITB 195 General considerations 195 Indications for ITB 196 Alternatives to ITB in widespread spasticity 196 Indications for botulinum toxin 196 Trial dose 196 Implant surgery 197 Postoperative procedure 198 Follow-up organization and procedures 198 Dosage adjustments 198 Pump refills 198 Results in clinical practice 198 Multiple sclerosis (MS) 198 Spinal cord injury (SCI) 199 Traumatic brain injury (TBI) 200 Cerebral palsy (CP) 200 ITB and the rehabilitation team 201 Complications of ITB 201 Catheter failure 201 Effects of pump or catheter failure 201 Baclofen overdosage 202 CSF leakage 202 Implant infection 202 Implant limitations 202 REFERENCES 202 11 Surgical management of spasticity 205 Introduction 205 Neuro-stimulation procedures 205 Neuroablative procedures 205 Peripheral neurotomies (PNs) 206 Lower limbs 206 Upper limbs 208 Improvement of motor function 209 Posterior rhizotomies 210 Posterior selective rhizotomy 210 Sectorial posterior rhizotomy 211 Partial posterior rhizotomy 212 Functional posterior rhizotomy 212 Personal technique 212 The results of posterior rhizotomies 212 Percutaneous thermorhizotomies and intrathecal chemical rhizotomies 214 Longitudinal myelotomy 215 Surgery in the dorsal root entry zone 215 Orthopaedic surgery 220 Indications for surgery 221 In adults 221 In children with cerebral palsy 221 Conclusion 223 REFERENCES 223 12 Management of spasticity in children 226 Introduction 226 Causes of spasticity in children 226 The pathology of spasticity 226 Measuring spasticity in children: clinical 229 The Ashworth scale 229 The dynamic and static joint range of motion 229 Measuring spasticity in children: instrumented 231 Managing spasticity in children 231 The spasticity team and the spasticity clinic 233 Oral medications: generalized temporary 233 Diazepam 233 Dantrolene 234 Tizanidine 234 Baclofen 234 Casting and orthoses: temporary/focal 235 Intramuscular injections: chemoneurolysis: temporary/focal 235 Peripheral neurectomy: permanent/focal 236 Selective dorsal rhizotomy: permanent/generalized 236 Intrathecal baclofen (ITB): semipermanent/generalized 237 Botulinum toxin A (BoNT-A): focal/temporary 238 RCT 1: hemiplegic upper limb 240 RCT 2: BoNT-A vs casting for dynamic equinus 241 RCT 3: hamstring injection 242 BoNT-A doses in children 242 Orthopaedic surgery 244 Conclusion 245 REFERENCES 246 Index 253 Half-title......Page 3 Title......Page 5 Copyright......Page 6 Contents......Page 7 Contributors......Page 9 Preface to the second edition......Page 11 Positive phenomena of the UMN syndrome......Page 13 Soft tissue changes and contractures......Page 14 Spastic dystonia and associated reactions......Page 15 Pain......Page 16 The physiotherapist and the orthotist......Page 17 Intrathecal and surgical techniques......Page 19 REFERENCES......Page 20 Definition......Page 21 Descending pathways: upper motor neurones......Page 22 Excitatory system......Page 23 Descending motor pathways in the spinal cord......Page 25 Clinicopathological correlation......Page 26 Mechanism of the change in excitability of the spinal reflexes......Page 27 Phasic stretch reflexes......Page 28 Tonic stretch reflexes......Page 29 Static tonic stretch reflexes......Page 33 Tonic stretch reflexes during muscle activation......Page 35 The physiological mechanisms underlying stretch reflex hyperexcitability......Page 36 Nonreflex contributions to hypertonia: biomechanical factors......Page 37 Flexor reflex afferents......Page 40 Flexor spasms......Page 42 The extensor plantar response......Page 43 Extensor reflexes and spasms......Page 44 Associated reactions......Page 45 Spastic co-contraction......Page 46 Spastic dystonia......Page 47 H reflexes......Page 50 Ia Presynaptic inhibition......Page 52 Ia Reciprocal inhibition......Page 54 Ib Nonreciprocal (autogenic) inhibition......Page 55 Recurrent (Renshaw) inhibition......Page 57 Alpha motoneurone excitability......Page 59 Ia Polysynaptic excitatory pathways......Page 61 Group II polysynaptic excitatory pathways......Page 62 Conclusion regarding spinal mechanisms in the UMN syndrome......Page 63 The spastic movement disorder......Page 64 REFERENCES......Page 66 Introduction......Page 76 The Ashworth scales......Page 77 Ashworth and modified Ashworth scales – level of measurement......Page 78 Modified Ashworth scale......Page 79 Ashworth scales – conclusions and recommendations......Page 80 The Tardieu method of assessment......Page 81 The Tardieu method of assessment – conclusions and recommendations......Page 82 Wartenberg test......Page 83 Powered systems......Page 84 Indirect biomechanical approaches – gait analysis......Page 85 Tendon jerks......Page 86 F waves......Page 87 REFERENCES......Page 88 What is spasticity?......Page 91 How important a determinant of activity limitations is spasticity?......Page 92 Confusion between spasticity and other impairments......Page 93 Effect of pathology and maturation on spasticity......Page 94 Assessment of spasticity......Page 96 Intervention......Page 97 Training of appropriate muscles......Page 99 Prevention of adaptive soft tissue changes......Page 101 Pharmacological and surgical options......Page 104 REFERENCES......Page 106 Introduction......Page 111 Sustained muscle stretch......Page 112 Maintenance of hip integrity......Page 113 Trunk orientation......Page 114 Restraint of arm movement......Page 115 Reduction of unnecessary upper limb activity......Page 116 Alternative postures......Page 117 Seat design and spasticity......Page 118 Adjustability......Page 119 Choosing seating systems......Page 120 Conclusion......Page 121 REFERENCES......Page 122 Introduction......Page 125 Preventing contractures and maintaining or increasing joint ranges......Page 126 Biomechanics and materials......Page 127 Plastic or metal orthosis?......Page 128 Assessment......Page 129 Casting......Page 131 Orthotics in paediatric management......Page 132 Ankle-foot orthoses......Page 133 Dynamic insoles and dynamic ankle-foot orthoses (DAFOs)......Page 134 Knee orthoses and knee-ankle-foot orthoses......Page 135 Hip and hip-knee-ankle-foot orthoses (HKAFOs)......Page 136 Cervical orthoses and the cervical spine......Page 137 The hemiplegic shoulder......Page 138 The hand and wrist......Page 139 Functional electrical stimulation (FES)......Page 140 REFERENCES......Page 141 Introduction......Page 143 Management strategy......Page 144 Outcome measures......Page 145 Baclofen......Page 147 Clinical efficacy......Page 148 Side effects......Page 149 Clinical efficacy......Page 150 Mechanism of action......Page 151 Dosage and administration......Page 152 Pharmacokinetics......Page 153 Dosage and administration......Page 154 Cannabis......Page 155 REFERENCES......Page 156 Introduction......Page 162 Indications for medial popliteal nerve blocks......Page 163 The pharmacological properties of neurolytic agents......Page 164 Nerve blocks......Page 165 Obturator nerve blocks......Page 166 Motor point injections......Page 169 Motor point blocks of the hip flexors......Page 170 The optimal concentration and dosage of the neurolytic agents......Page 171 Complications of peripheral nerve blocks......Page 172 Procedure of intrathecal block......Page 173 Summary......Page 174 REFERENCES......Page 175 Clinical pharmacology......Page 177 Assessment......Page 179 Dosage......Page 180 Long-term efficacy and safety......Page 181 Economics......Page 182 Botulinum alone or in combination?......Page 183 Clinical trials......Page 184 Other spasticity indications......Page 186 Associated reactions......Page 187 Conclusions......Page 188 REFERENCES......Page 189 Baclofen and pain......Page 193 Flexion reflex excitability......Page 194 General considerations......Page 195 Trial dose......Page 196 Implant surgery......Page 197 Multiple sclerosis (MS)......Page 198 Spinal cord injury (SCI)......Page 199 Cerebral palsy (CP)......Page 200 Effects of pump or catheter failure......Page 201 REFERENCES......Page 202 Neuroablative procedures......Page 205 Lower limbs......Page 206 Upper limbs......Page 208 Improvement of motor function......Page 209 Posterior selective rhizotomy......Page 210 Sectorial posterior rhizotomy......Page 211 The results of posterior rhizotomies......Page 212 Percutaneous thermorhizotomies and intrathecal chemical rhizotomies......Page 214 Surgery in the dorsal root entry zone......Page 215 Orthopaedic surgery......Page 220 In children with cerebral palsy......Page 221 REFERENCES......Page 223 The pathology of spasticity......Page 226 The dynamic and static joint range of motion......Page 229 Managing spasticity in children......Page 231 Diazepam......Page 233 Baclofen......Page 234 Intramuscular injections: chemoneurolysis: temporary/focal......Page 235 Selective dorsal rhizotomy: permanent/generalized......Page 236 Intrathecal baclofen (ITB): semipermanent/generalized......Page 237 Botulinum toxin A (BoNT-A): focal/temporary......Page 238 RCT 1: hemiplegic upper limb......Page 240 RCT 2: BoNT-A vs casting for dynamic equinus......Page 241 BoNT-A doses in children......Page 242 Orthopaedic surgery......Page 244 Conclusion......Page 245 REFERENCES......Page 246 Index......Page 253

this Is A Thorough, Practical Reference And Guide For All Health Professionals Involved In The Management Of Spasticity.

doody Review Services

reviewer:laurie Lundy-ekman, Phd, Pt(pacific University)
description:this Is An Impressive Guide To The Contemporary Understanding Of Upper Motoneuron Syndromes And Spasticity. Among The Book's Many Strengths Are The Clarity And Organization Of The Material, The Scientific Basis Of The Presentation, And The Thorough Coverage Of Management Of The Impairments And Functional Limitations Associated With Upper Motoneuron Syndromes.
purpose:the Authors' Purpose Is To Provide A Practical Guide And Reference To Improve The Management Of Spasticity And Other Effects Of Upper Motoneuron Syndrome. This Book Is An Exceptionally Important Contribution To The Field, Because The Authors Have Primarily Used An Evidence-based Approach, Covering All Aspects Of The Clinical Management Of People With Upper Motoneuron Syndrome. The Readability And Applicability Of The Information Ensure Its Usefulness To Clinicians And Researchers.
audience:the Book Is Written For Physicians, Surgeons, Therapists, Orthotists, And Engineers. I Believe That Students, Residents, And Practitioners In These Fields Also Would Benefit From This Book. The Authors Are Established Experts In Their Fields.
features:the Complete Neurophysiology And Management Of Upper Motoneuron Syndrome Is Thoroughly Discussed. An Algorithm For Clinical Decision Making Is Presented In The First Chapter, And The Subsequent Chapters Provide Essential Information For Making The Decisions. The Chapter On Physiotherapy Management Is Especially Strong, Providing Up-to-date Evidence On Management Techniques. Unfortunately, Some Chapters Perpetuate The Myth That Significant Muscular Exertion Increases Spasticity. Although This Outdated Concept Is Debunked In Other Chapters, This Inconsistency May Lead To Confusion And To Harmful Interventions. Specifically, Prohibiting Significant Muscular Exertion Produces Increasing Paresis, Loss Of Function, And Deconditioning. Similarly, The Concept Of Antagonist Restraint Post-stroke Is Not Placed In Context As A Relatively Rare Phenomenon, But Is Misrepresented As A Common Impairment Limiting Function.
assessment:this Book Is A Major Improvement Over Other Books In The Field, Which Tend To Persist In Advocating Disproven Rationales And Interventions For The Management Of Upper Motoneuron Syndrome. A Consistent Evidence-based Approach Would Further Strengthen The Usefulness Of This Book.

"Spasticity is a disabling problem for many adults and children with a variety of neurological disorders such as multiple sclerosis, stroke, cerebral palsy and traumatic brain injury. This is a practical reference and guide for clinicians interested in the management of spasticity. The book covers all aspects of the upper motor neurone syndrome from basic neurophysiology and measurement techniques to practical therapy and the use of orthoses."--BOOK JACKET