Spasticity and Muscle Stiffness: Restoring Form and Function

Description

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. 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