This book aids the practitioner in understanding the difference between spasticity and muscle stiffness, weighing old and new treatment options, and developing an appropriate treatment algorithm for a given patient. Spasticity is a common and disabling condition after neurologic injury such as stroke, spinal cord injury, multiple sclerosis, traumatic brain injury and cerebral palsy. Current treatments for spasticity may exacerbate other problems. Hence, there is a great need to develop a comprehensive understanding of the pathophysiology of spasticity and muscle stiffness, its assessment, and the various treatment options available to obtain the best results to restore joint alignment, movement, and function. This book is organized into two sections: Part I of the book deals with the pathophysiology and assessment of spasticity and muscle stiffness, and Part II of the book explains the rationale, framework, considerations, and evidence for various treatments for both spasticity and muscle stiffness. This comprehensive approach will enable physiatrists, neurologists, internists, and physical and occupational therapists to achieve the best possible outcomes for their patients.
Author(s): Preeti Raghavan
Publisher: Springer
Year: 2022
Language: English
Pages: 328
City: Cham
Foreword
Preface
Contents
Contributors
Part I: Pathophysiology and Assessment
1: Neural Basis of Spasticity
Definition of Spasticity
Time Course of the Development of Spasticity
What Types of Neural Injury Lead to the Development of Spasticity?
How Does Injury to the Corticospinal Tract Lead to Spasticity?
Consequences of Excitatory-Inhibitory Imbalance in Spinal Circuitry
Conclusion
References
2: Spasticity Versus Spastic Movement Disorder
Introduction
Pathophysiology
Clinical Aspects
Functional Aspects
Implications for Treatment
Conclusion
References
3: Clinical Assessment of the Syndrome of Spastic Paresis
Introduction
Assessment of Spasticity
Ashworth-Derived Scales
The Tardieu Scale
The Syndrome of Spastic Paresis
The Non-Neural Muscle Disorder: Spastic Myopathy
The Neural Disorder
Muscle Overactivity in Antagonists
Stretch-Sensitive Paresis in Agonists
The Five-Step Assessment
Functional Step: Step 1
Technical Steps: Steps 2–5
Conclusion
References
4: Quantitative Measurement of Resistance to Passive Joint Motion in Chronic Stroke Survivors
Introduction
Quantification of Neural and Biomechanical Responses During Elbow Joint Rotation
Determination of Catch Angle and EMG Response
Occurrence of a Catch
EMG Onset Angle
Catch Angle and Reflex EMG Response as a Function of Joint Rotation Speed
Timing of the Onset of the EMG Response and the Catch Angle
Origins of the Resistance to Passive Joint Motion
Quantification of the Resistance to Passive Joint Rotation After BoNT Injections in Chronic Stroke Survivors
Conclusions
References
5: Structural Alterations in Muscle in Children with Spastic Cerebral Palsy
Skeletal Muscle Structure
Change in Muscle Structure During Postnatal Development
Muscle Adaptation
Clinical Presentation in Children with Cerebral Palsy
Sarcomere Alterations in Contractured Muscles
Extracellular Matrix
Alterations in Extracellular Matrix Content
Alterations in Passive Muscle Stiffness
Muscle Stem Cells
Satellite Cells
Change in Satellite Cells in Contractured Muscles
Metabolic Properties
Alterations in Motor Units and in the Neuromuscular Junction
Conclusion
References
6: Mechanisms of Development of Passive Mechanical Muscle Stiffness
Introduction
Three-dimensional Muscle Geometry and its Effect on Active and Passive Force Generation
The Architecture of Muscle Affects its Force Generating Capacity
The ECM Transmits Force Laterally and Facilitates Muscle Shape Changes
The Three-dimensional Nature of Muscle Contraction
Effect of Fluid-ECM Interactions on Muscle Mechanics
Role of Intramuscular Fluid on the Properties of the ECM
Intramuscular Fluid Affects the Viscosity of the Ground Substance of the ECM
Muscle Hydration, Lubrication, Viscoelasticity, and ECM Stiffness
Effect of Exercise, Immobility, and Overuse on Hyaluronan Concentration
The Hyaluronan Hypothesis of Muscle Stiffness: its Role in Spasticity, Fibrosis, and Contracture
The Hyaluronan Hypothesis of Muscle Stiffness
Spasticity Versus Muscle Stiffness
Role of Hyaluronan in the Progression to Fibrosis and Contracture
Conclusion
References
7: Symptomatic and Functional After-Effects of the Syndrome of Spastic Paresis
Introduction
Functional Consequences in the Upper Limb
Skin and Nerve Problems
Skin Problems of the Hand, at the Elbow Crease, and in the Axilla
Episodic Disruptive Symptoms
Associated Reactions
Physical Compression and Injury
Problems of Access
Access to the Hand, Fingers, and Thumb
Access to the Elbow Crease
Access to the Axilla
Grasp and Release Dysfunction
Inadequate Hand Opening Preceding Grasp
Inadequate Hand Opening During Release
Hyperextended Wrist and Finger Flexor Tenodesis
Joint and Muscle Contractures
The Intrinsic plus Hand
The Flexed Thumb
Reach Dysfunction
Inadequate Scapular Rotation
Inadequate Shoulder Movement
Inadequate Elbow Movement
Inadequate Forearm Orientation of the Hand
Inadequate Vernier Adjustments of the Wrist
Functional Consequences in the Lower Limb
Skin and Footwear Problems
Striatal Toe
Painful Toe Flexion
Problems of Limb Clearance
Stiff Knee with and without Equinovarus
Inadequate Hip Flexion
Problems of Foot Loading
Loading on the Lateral Border of the Foot
Forefoot First Loading
Problems of Limb Advancement
Insufficient Hip Flexion
Stiff Knee (Inadequate Knee Flexion in Swing Phase)
Toe Drag
Inadequate Knee Extension in Terminal Swing
Problems of Single Limb Support
Knee Flexion in Stance
Weak Knee Extensors
Painful Toe Flexors During Loading and Weightbearing
Conclusions
References
Part II: Treatment
8: Framework for the Treatment of Spasticity and Muscle Stiffness
Introduction
Rehabilitation Based on Principles of Motor Learning
Medical and Pharmacologic Treatment Algorithm
The Patient’s Experience
Spasticity Versus Muscle Stiffness
The Five-Step Assessment
Generalized and Focal Treatments
Emerging Non-Pharmacologic Treatments
Conclusion
References
9: Medical Exacerbation of Spasticity
Introduction
Pathophysiology of Autonomic Dysfunction in Individuals with Spasticity
Medical Conditions that Exacerbate Spasticity
The Genitourinary Tract
The Gastrointestinal System
Skin Conditions
Heterotopic Ossification
Venous Thromboembolism
Fractures
Management of Paroxysmal Sympathetic Hyperactivity
Miscellaneous Causes
Conclusion
References
10: Oral Spasmolytics
Introduction
GABA Agonists/GABA Mimetics
Baclofen
Mechanisms of Action
Clinical Use
Dosing
Side Effect Profile
Benzodiazepines
Mechanism of Action
Diazepam
Dosing
Side Effect Profile
Clonazepam
Dosing
Side Effect Profile
Tiagabine
Mechanism of Action
Clinical Use
Dosing
Side Effect Profile
Alpha 2 Agonists
Tizanidine
Mechanism of Action
Clinical Use
Dosing
Side Effect Profile
Clonidine
Mechanism of Action and Clinical Use
Dosing
Side Effect Profile
Dantrolene Sodium
Mechanism of Action
Clinical Use
Dosing
Side Effect Profile
Sodium and/or Calcium Channel Blocking Agents
Mechanism of Action
Sodium Channel Blocking Agents
Mechanism of Action
Clinical Use/Dosing
Calcium Channel Blocking Agents
Mechanism of Action
Clinical Use/Dosing
Combination of Sodium and Calcium Channel Blocking Agents
Mechanism of Action
Clinical Use/Dosing
Potassium Channel Blocking Agent
4-Aminopyridine
Mechanism of Action
Clinical Use
Dosing
Side Effect Profile
Serotonergic/Alpha Receptor Antagonist
Cyproheptadine
Mechanism of Action
Clinical Use
Dosing
Side Effect Profile
Cannabis
Mechanism of Action
Clinical Use/Dosing
Side Effect Profile
Medications with Unknown Mechanism of Action for Muscle Spasms
Cyclobenzaprine
Mechanism of Action
Clinical Use/Dosing
Side Effect Profile
Orphenadrine
Mechanism of Action
Clinical Use
Dosing
Side Effect Profile
Mexiletine
Mechanism of Action
Clinical Use
Dosing
Side Effect Profile
Conclusion
References
11: Intrathecal Baclofen Therapy
Introduction
Components of Intrathecal Baclofen Therapy
Patient Selection
Patient Characteristics
Advantages and Disadvantages of Intrathecal Baclofen Therapy
Intrathecal Baclofen Trial
Successful Trial
Skipping a Trial
Adverse Events During a Trial
Pump Implantation
Pump Options
Initiation of ITB Therapy
Modes of Dose Delivery
Dose Titration
Post-implant Rehabilitation
Patient and Caregiver Education
Pump Refill and Therapy Maintenance
Refill Appointments
Refill Procedure
Baclofen Withdrawal
Baclofen Overdose
Troubleshooting
Diagnosis of Pump Catheter Malfunction
Bolus Dosing
Residual Volume Mismatch
Catheter Access Port Aspiration
Imaging
Pump Replacement and Explantation
Conclusion
References
12: Treatment of Focal Muscle Overactivity Using Botulinum Toxin Injections
Introduction
Structure
Mechanism of Action
Binding
Internalization
Translocation
Cleavage
Pharmacology
Review of AAN Guidelines for the Utility of BoNT in Spasticity
Adult Upper Limb Spasticity
Adult Lower Limb Spasticity
Cerebral Palsy
Emerging Evidence
Review of Dose Recommendations
Upper Limb Spasticity
Lower Limb Spasticity
Patient and Muscle Selection for Treatment
The Preinjection Consultation
Planning the Injection
Localization of Muscles
After Injection
Measuring Outcomes
Goal Attainment
Measures of Spasticity
Caregiver Burden and Quality of Life
Conclusion
References
13: Treatment of Focal Muscle Stiffness with Hyaluronidase Injections
Introduction
Catabolism of Hyaluronan by Hyaluronidases
Pharmacology and Uses of Exogenous Hyaluronidases
Novel Off-Label Use of Hyaluronidase for Treatment of Muscle Stiffness
Upper Limb Muscle Stiffness
Safety and Preliminary Efficacy of a Single Injection Treatment
Safety and Dose-Response of Multiple Injection Treatments
Lower Limb Muscle Stiffness
Preliminary Efficacy of a Single Injection Treatment
Imaging Quantification of Hyaluronan Content in Patients with Muscle Stiffness
Accumulated Hyaluronan Traps Intramuscular Free Water in Stiff Muscles
Patient and Muscle Selection for Treatment
The Preinjection Consultation
Selection of Muscles
The Injection
After Injection
Measuring Outcomes
Conclusions
References
14: Emerging Non-Pharmacologic Treatments
Introduction
Peripheral Electrical Stimulation
Stroke
Spinal Cord Injury
Multiple Sclerosis
Cerebral Palsy
Spinal Cord Stimulation
Transcranial Direct Current Stimulation
Stroke
Cerebral Palsy
Multiple Sclerosis
Repetitive Transcranial Magnetic Stimulation
Stroke
Spinal Cord Injury
Multiple Sclerosis
Cerebral Palsy
Other Emerging Treatments
Conclusion
References
Index
