Archives 1992-2013

Objective. To present electrophysiological methods of spasticity assessment.

Review. Spasticity is one of the core clinical signs of lesions within the central nervous system. In medicine there have been so far no objective, widely used methods of assessing and comparing spasticity. Three groups of methods are used to evaluate spasticity: clinimetric, biomechanical and electrophysiological. Electrophysiological techniques are the most objective ones, but they are also time-consuming and require both appropriate equipment and trained staff. In the pathogenic chain of spasticity electrophysiological methods are focused on the evaluation of only some elements, such as alpha-motor neurons excitability, presynaptic inhibition, Renshaw cells feedback inhibition, polysynaptic activity and reciprocal inhibition. Alpha-motor neurons activity is most frequently evaluated by analysing various aspects of the Hoffmann reflex (H reflex) and F wave, which is extensively discussed in the article.

Aim. In this report methods most commonly used in the of assessment patients suffering from severe spasticity are presented.

Review. "Measurement" of spasticity is necessary for the evaluation of new treatment methods. This could be made directly or indirectly – in the latter case the sequels of spasticity are measured. In this article both subjective and objective methods of examination of spasticity are described. The tone intensity scales, spasm frequency scores, global scales of motor impairment, ADL scales, upper extremity dexterity and strength testing, examination techniques and maneuvres differentiating rectus femoris from iliopsoas and gastrocnemius from soleus tightness, clinical gait scores, EMG and the goniometric pendulum test are reviewed.

Aim. A review of the goniometric assessment in modern rehabilitation of patients with movement disorders is presented by the authors.

Review. The construction and principle of operation of the digital goniometer applied to pendulum testing of the lower extremities with pathologically changed muscle lone, are described. An electro-optical transducer transmits a digitised time-dependent function of an angle between the patient's thigh and leg axes via an interface to a special computer programme. The function is registered, some coefficients describing the extremity motion in the joint are determined and the patient is assigned to an appropriate rehabilitation group by the designed programme. Normal values of the pendulum test coefficients in asymptomatic subjects are presented

Aim. To analyse some aspects of spasticity and to introduce current knowledge about the assessment and physiotherapy of the condition.

Review. The process of rehabilitation is prolonged and more difficult when spasticity occurs. It is difficult to evaluate treatment methods. Application of reflex activity (tonic neck reflexes and associated reactions) and movement strategies to relieve muscle tension after CNS lesions was proposed. Pathological patterns of movement were analysed. A three-dimensional cinematic system for spasticity assessment Vicon using visualization of associated reactions was introduced. The goal of physiotherapy after the CNS damage consists in re-education of impaired functions, also by regaining the normal muscle lane.

Aim. The authors present a brief review of the most popular pharmacological approaches to the therapy of spasticity.

Review. The treatment of spastic paresis is a difficult task for neurologists and physiotherapists. No uniform principles of pharmacological treatment have been developed so far. Basic pharmaceuticals administered locally, orally or intrathecally in the treatment of spasticity are discussed. The aims and principles of such treatment are outlined, as welt as recommendations for selection of appropriate drugs, and their effects.

Aim. To present basic data on botulinum toxin type A (BTX-A) in the treatment of cerebral palsy.

Review. BTX-A is nowadays a widely used treatment for spasticity due to cerebral palsy (CP). It is a registered therapy in the majority of European countries and Australia. Before the year 2001 156 studies were published on its usefulness and safety in CP. Nevertheless, there are only few studies regarding the short and long-term functional gains following BTX-A therapy. Recently published data suggest that BTX-A may trigger and produce a better functional outcome in CP patients, despite its transitory effect on muscle lone or passive range of motions. BTX-A seems to be especially useful in younger children (2-6 years old) with mild/moderate focal spasticity, without fixed contractures.

Aim. There are different therapeutic approaches to the neurorehabilitation of spasticity which will be addressed in this paper.

Review. The term "spasticity" is used for velocity-dependent muscle tone increase, but also for enhanced ten don reflexes with positive Babinski's sign, exaggerated cutaneous and autonomic reflexes, involuntary flexor and extensor spasms, clonus, impaired movement execution, enhanced muscular resistance against passive movement, abnormal limb postures, clumsiness, enhanced fatigability and paresis. The definition of the term spasticity has changed in the last decades. First it referred only to the velocity-dependent increase in muscle tone, more recently all the above-mentioned phenomena are summarized as the upper motor neurone syndrome. These different definitions serve not an academic purpose but are of practical importance. Most pharmacological studies dealing with drug treatment of spasticity use stretch reflex excitability and/or clonus intensity as parameters to assess the efficacy of antispastic treatment. Velocity-dependent muscle tone and enhanced stretch reflexes have only little functional significance for the patient as the intensity of stretch reflex responses and of clonus hardly corresponds to the quality of movement execution. Dyssynergic patterns of muscle activation with co-activation of agonists and antagonists, paresis and loss of dexterity together with fatigability are much more important for the functional outcome. Increased muscle tone has a potential value. Extensor hypertonicity can provide the rigidity for weight-bearing stance. Spasticity should be treated however if it interferes with nursing, contributes to contractures, causes painful spasms or hampers movements.

Conclusions. The first step is to exclude any noxious and enhancing stimulus like urinary tract infections, pain, bowel and bladder distensions, pressure sores etc. Physiotherapy, physical stimuli (ice, electrical stimulation), pharmacotherapy, chemical blocks or neurosurgical interventions should be selected or combined according to the individual status of the patient.

Aim. To present main methods of surgical intervention in the treatment of spasticity.

Review. Spasticity seems to be one of the major obstacles on the way to provide good nursing care and rehabilitation to patients with injuries of the central nervous system (CNS). The essential therapeutic procedures in spasticity are physiotherapy and drug therapy. Nevertheless, surgical treatment still remain useful in particular cases of severe, persistent spasticity with co-existent, undesirable complications like muscle and ligament contractures and various pain syndromes. Basic groups of surgical treatment methods are presented in the review: (1) surgical procedures on the spinal cord: myelotomies and cordectomies, (2) surgical procedures on the peripheral nervous system: posterior rhisotomy, damaging entry-areas of posterior nerve roots, anterior rhisotomy, cuts through nerve roots of cauda equina and peripheral nerves, (3) surgical procedures on ligaments and muscles: elongation of tendons and muscles, tenotomies, transitions of tendons.

Aim. Severe spasticity of paretic limbs in patients after stroke aggravates impairment of their mobility functions, making rehabilitation and nursing care more difficult. This paper presents the results of treatment for spasticity of the upper limb and hand in patients after stroke, rehabilitated in the Department with new methods, i.e. botulin toxin and cryotherapy.

Subjects and method. Botulin toxin was administered to the upper limb and hand muscles affected by spasticity in 44 patients after stroke, while local cryotherapy with nitrogen vapors was applied to 80 patients. The treatment outcomes were evaluated using the Modified Ashworth Scale, the Brunnström scale, and the Barthel Index.

Results. Application of botulin toxin and cryotherapy resulted in a reduction of the upper limb and hand spasticity as assessed by the Ashworth scale.

Conclusion. A favourable effect of the botulin toxin treatment and of cryotherapy on the functional status of the paretic limb was noted.

Aim. Botulinum toxin type A (BTX-A) application in the treatment of post-stroke spasticity or the upper limb was presented.

Review. BTX-A is a valuable tool in the treatment of spasticity due to cerebral palsy, cerebral injuries and stroke. Since the first publication in 1989 many open-label uncontrolled trials have evidenced BTX-A efficacy in decreasing muscle tone, associated pain and muscle spasms, increasing the passive range of motions, facilitating the hygiene, dressing, and in same studies also improving the upper limb function. However, placebo-controlled studies published so far have not revealed any clear impact of BTX-A injections on the complex functions of the upper limb. This may result from too strict protocols, insufficient sensitivity of outcome measures, or too late recruitment to the study (the risk of contractions). The treatment goals, best candidate characteristics, common patterns of spasticity with muscles involved, dose ranges, dose modifiers and the technique of infection under EMG guidance are discussed in the article.

Aim. In the paper the treatment of spasticity with traditional pharmacological methods, i.e. phenol and ethanol injections was discussed.

Review. Spasticity is one of the most common and important problems in neurology, since the degree of spasticity may reflect the severity of disability in neurological patients with the upper motor neuron injury (due to stroke, multiple sclerosis, or trauma). Phenol and ethanol are the long-lasting local blocking agents used traditionally to treat spasticity.

Conclusions. Irrespective of clinical advantages, the main problems with this kind of treatment include correct patient selection, appropriate selection of involved muscles, and drawbacks related to unpleasant side effects (painful injections, chronic pain, and dysthesias).

Aim. To present the principles and applications of intrathecal baclofen treatment for spasticity of various origin.

Review. Intrathecal baclofen (ITB) introduced for the first time in 1984, is widely used in the treatment of severe spasticity of various origin. Baclofen is delivered via an intrathecal catheter from an implantable pump that allows to control the dosage over many years. Numerous reports have evidenced beneficial effects of the treatment in patients with spasticity of spinal, cerebral, or mixed origin. Significantly positive treatment outcomes were noted also in patients suffering from conditions other than the classical recommendations, i.e. sclerosis multiplex, spinal cord injury, cerebral trauma, cerebral palsy, or dystonia. Neurogenic dysfunction of the urinary bladder; locomotion and mobility should be assessed both in the testing stage and over a long period of time. Undesirable side-effects are seldom reported.

Aim. The management of spasticity and its clinical consequences requires continuous research with a view to developing new strategies. The aim of this paper is to present the author's experience with intrathecal baclofen ill fusion in the treatment of children with the spastic bilateral form of cerebral palsy.

Subjects and methods. Ten patients (aged from 12 to 21 years) with implanted baclofen pumps underwent clinical (the Ashworth scale), functional (GMFM) and neurophysiological (EMG tests) assessment before and at the time of baclofen infusion. The technical procedure of the pump implantation and methods of monitoring the patients are presented. The follow-up period varied from 6 to 20 months.

Results. In all the patients a statistically significant reduction of spasticity was found on the basis of clinical and neurophysiological observations. Spasticity reduction appeared at first in the lower leg muscles, and later on in upper legs. The optimal time for the establishing the final baclofen dose ranged from 3 to 6 months.

Conclusion. The presented results suggest that clinical effectiveness of intrathecal baclofen is very promising.

Aim. To review several studies on botulinum toxin in the treatment of post-stroke patients.

Review. Ten studies (out of which 9 were randomised controlled trials) on botulinum toxin type A (BTX-A) treatment in post-stroke patients were analysed. Both homogeneity of the patient group in terms of the diagnosis and the patients' comparability in terms of their functional prognosis and other sources of bias were generally unsatisfactory. BTX-A treatment effectiveness could not be convincingly demonstrated as regards improvement of functional abilities. Larger-scale controlled studies are needed to assess BTX-A, and special attention should be paid to individual goal assessment, duration of functional benefits, co-treatment, side effects, and cost effectiveness.