Jpn J Rehabil Med 2013 ; : Pathophysiology of Spasticity Yoshihisa MASAKADO Abstract : Spasticity is a frequent and often disabling feature of

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1 Jpn J Rehabil Med 2013 ; : Pathophysiology of Spasticity Yoshihisa MASAKADO Abstract : Spasticity is a frequent and often disabling feature of neurological disease encountered in Rehabilitation Medicine. The core feature of the spastic state is the exaggeration of stretch reflexes, which manifest as hypertonus. The stretch reflex threshold is reduced, and its gain may be increased. The result is a velocity-dependent increase in the resistance of a passively stretched muscle. Spasticity is traditionally ascribed to damage to the pyramidal tract. However, studies in animals clearly implicate additional motor tracts in the pathophysiology of spasticity. In cerebral lesions some of the drive on the inhibitory center in the caudal brainstem is lost resulting in a spastic hemiplegia. Partial spinal lesions usually involve the lateral corticospinal and dorsal reticulospinal tracts, as most commonly seen in multiple sclerosis. Investigations have been conducted to ascertain which alterations in spinal reflex transmission could be responsible for the increased stretch reflex activity. Many spinal reflex pathways may increase or decrease the effect of the monosynaptic excitation : muscle spindle group II afferent, Ib inhibition, recurrent inhibition, presynaptic inhibition of Ia afferent terminals, reciprocal inhibition from muscle spindle Ia afferents from the antagonist muscles, fusimotor drive, post activation depression, plateau potentials, etc. Many of the factors mentioned above may contribute differently to the degree of the spasticity, depending on the location of the lesion spinal or cerebral, disease, the extent of the lesion, etc. Gaining a more detailed understanding of the mechanisms underlying the development of spasticity will increase the possibilities of developing more optimal and differentiated methods of treatment and rehabilitation. Jpn J Rehabil Med. Key words : pathophysiologyspasticitytonic stretch reflex phasic stretch reflex Department of Rehabilitation Medicine, Tokai University School of Medicine masakado@is.icc.u-tokai.ac.jp Jpn J Rehabil Med VOL. 50 NO

2 spasticity Lance Lance Jpn J Rehabil Med VOL. 50 NO

3 2 7 9 Broadman area Area phasic stretch reflex 2 10 tonic stretch reflex Jpn J Rehabil Med VOL. 50 NO

4 2 2 A B C D 2 Reflex-mediated stiffness non-reflex passive intrinsic mediated stiffness 508 Jpn J Rehabil Med VOL. 50 NO

5 2 1 2 g Ia Ia a a g g g 2 g 2 g microneurography Ia 19 g g Ia 2 Ia Ia Ib post-activation depression 20 plateau potential plateau potential synaptic excitation plateau potential spinal cord Jpn J Rehabil Med VOL. 50 NO

6 plateau potential Mayer NH : Clinicophysiologic concepts of spasticity and motor dysfunction in adults with an upper motoneuron lesion. Muscle Nerve Suppl 1997 ; : S 1.S13 2 : ; : Lance JW : Symposium synopsis. in Spasticity : disordered motor control ed by Feldman RG, Young RR, Koella WP. Year Book Medical Chicago 1980 ; pp , :. J Clin Rehabil 2002 ; : Gracies JM : Pathophysiology of impairment in patients with spasticity and use of stretch as a treatment of spastic hypertonia. Phys Med Rehabil Clin N Am 2001 ; : , :..,, 2010 ; pp Sheehan G : Neurophysiology of spasticity. in Upper Motor Neurone Syndrome and Spasticity ed by Barnes MP, Johnson GR. 2nd Ed, Cambridge, University press, UK, 2008 ; pp Sheean G : The pathophysiology of spasticity. Eur J Neurol Suppl 2002 ; : Brown P : Pathophysiology of spasticity. J Neurol Neurosurg Psychiatry 1994 ; : Corcos DM, Gottlieb GL, Penn RD, Myklebust B, Agarwal GC : Movement deficits caused by hyperexcitable stretch reflexes in spastic humans. Brain 1986 ; : Burke D : Spasticity as an adaptation to pyramidal tract injury. Adv Neurol 1988 ; : : 3.,, Dvir Z, Penturin E, Prop I : The effect of graded effort on the severity of associated reactions in hemiplegic patients. Clin Rehabil 1996 ; : Dickstein R, Heffes Y, Abulaffio N : Electromyographic and positional changes in the elbows of spastic hemiparetic patients during walking. Electroencephalogr Clin Neurophysiol 1996 ; : Honaga K, Masakado Y, Oki T, Hirabara Y, Fujiwara T, Ota T, Kimura A, Liu M : Associated reaction and spasticity among patients with stroke. Am J Phys Med Rehabil 2007 ; : : ; : : ; : Dietz V, Sinkjaer T : Spastic movement disorder : impaired reflex function and altered muscle mechanics. Lancet Neurol 2007 ; : Wilson LR, Gandevia SC, Inglis JT, Gracies J, Burke D : Muscle spindle activity in the affected upper limb after a unilateral stroke. Brain 1999 ; : : ; : Bennett DJ, Li Y, Harvey PJ, Gorassini M : Evidence for plateau potentials in tail motoneurons of awake chronic spinal rats with spasticity. J Neurophysiol 2001 ; : Gorassini MA, Knash ME, Harvey PJ, Bennett DJ, Yang JF : Role of motoneurons in the generation of muscle spasms after spinal cord injury. Brain 2004 ; : Jpn J Rehabil Med VOL. 50 NO

7 Jpn J Rehabil Med 2013 ; : Botulinum Toxin Type A for Upper and Lower Limb Spasticity Poststroke Tetsuo OTA Abstract : More than two years have passed since Botulinum toxin type A BoNT-A was approved for upper and lower limb spasticity after stroke. BoNT-A works well for spasticity, so it is one of the most effective treatments for spastic paresis in stroke patients. We usually treat elbow flexors, wrist flexors and finger flexors in the upper limb, and hip adductors, knee flexors and ankle plantar flexors in the lower limb in order to improve motor function, maintain sanitary conditions and reduce the burden of care. We often use motor point block with 5 phenol for the treatment of spasticity. Though BoNT-A treatment has some weak points including its cost, the risk of antibody production and dosage limitation, this treatment is easier than phenol block in the technique of injection. Additionally, injection with electrical stimulation or ultrasonography will be helpful to insert the needle into the targeted muscle more accurately. Jpn J Rehabil Med. Key words : strokespasticityabotulinum toxin type A A ROM Department of Physical Medicine & Rehabilitation, Asahikawa Medical University Hospital tetsuota@asahikawa-med.ac.jp Jpn J Rehabil Med VOL. 50 NO

8 IP 5 motor point block 5 motor point motor point motor point block 512 Jpn J Rehabil Med VOL. 50 NO

9 motor point motor point block motor point Jpn J Rehabil Med VOL. 50 NO

10 QOL 1 :.,, Picelli A, Tamburin S, Bonetti P, Fontana C, Barausse M, Dambruoso F, Gajofatto F, Santilli V, Smania N : Botulinum toxin type A injection into the Gastrocnemius muscle for spastic equinus in adults with stroke, Am J Phys Med Rehabil 2012 ; : Jpn J Rehabil Med VOL. 50 NO

11 Jpn J Rehabil Med 2013 ; : Botulinum Toxin Injections in the Treatment of Upper Limb Spasticity Takayo CHUMA Abstract : Spasticity in patients with upper neuron syndrome is significant problems. It causes difficulties with activities of daily living, interferes with voluntary movement, and causes pain, depression, and dependence on caregivers. One of the treatments for limb spasticity is botulinum toxin-a BTX-A therapy. BTX-A therapy improves muscle tone in upper and lower limb spasticity, and is safe and effective. We use BTX-A therapy to control spastic upper limbs targeting the shoulder, elbow, wrist, and finger joints. Following treatment, improved ROM, voluntary movement of fingers and the lessoning of pain, improved ADL, and improved hand function are expected. A multidisciplinary team approach is best. In such an environment, BTX injections can yield additional medical benefit by combining BTX treatment with rehabilitation. Jpn J Rehabil Med. Key words : BTXspasticityupper limb rehabilitation Babinski ADL QOL Department of Rehabilitation Medicine, Shiga Medical Center chuuma@mdc.med.shiga-pref.jp Jpn J Rehabil Med VOL. 50 NO

12 3 3 BTX clenched hand Management strategy 3 Prevention of aggravating factors pain constipation infection tight clothing poor postural management Physical treatments posture management, physiotherapy, splint Treatment options Generalised spasticity Oral agents Multi-focal and focal spasticity Intramuscular botulinum toxin Orthopedic surgery Phenol nerve muscle blockade Regional spasticity Intrathecal baclofen Neurosurgery Intrathecal phenol 516 Jpn J Rehabil Med VOL. 50 NO

13 Key steps to treatment of spasticity with botulinum toxin 3 Step 1 Before considering BT Appropriate physical programme in place Step 2 Patient selection Focal or multi-focal spasticity Demonstrable muscle over activity Clearly identified goals for treatment Step 3 Agree with multidisciplinary team Strategy for spasticity management Priority target muscles for treatment Step 4 Prior to injection Provide appropriate information Informed consent Recorded baseline Step 5 BT injection Using EMG or nerve muscle stimulator, or imaging Step 6 Follow up 7.14 days to review need for splinting orthotics 4.6 weeks to assess effect and patient status 3.4 months to assess functional outcome and plan further treatment Step 7 Documentation to include Modified Ashworth scale ROM range of motion10 m 6 VAS NGRS Numeric Graphic Rating ScaleADL FIM Functional Independence MeasureBI Barthel index 1 Modified Ashworth Scale ROM range of motionadl Ashford Jpn J Rehabil Med VOL. 50 NO

14 16 Modified Ashworth Scale Goal Attainment Scaling 4 Lim 5 Esquenazi 6 Meythaler 7 Sun modified constraint-induced movement therapy 6 8 ROM BTX A 1 : 2009,,,,.,, :.,,,, 2010 ; pp Spasticity in adults : management using botulinum toxin. National guidelines Royal College of Physicians, Ashford S, Turner-Stokes L : Management of shoulder and proximal upper limb spasticity using botulinum toxin and concurrent therapy interventions : A preliminary analysis of goals and outcomes. Disabil Rehabil 2009 ; : Lim JY, Koh JH, Paik NJ : Intramuscular botulinum tox- 518 Jpn J Rehabil Med VOL. 50 NO

15 in-a reduces hemiplegic shoulder pain : a randomized, double-blind, comparative study versus intraarticular triamcinolone acetonide. Stroke 2008 ; : Esquenazi A, Mayer N, Garreta R : Influence of botulinum toxin type A treatment of elbow flexor spasticity on hemiparetic gait. Am J Phys Med Rehabil 2008 ; : Meythaler JM, Vogtle L, Brunner RC : A preliminary assessment of the benefits of the addition of botulinum toxin A to a conventional therapy program on the function of people with longstanding stroke. Arch Phys Med Rehabil 2009 ; : Sun SF, Hsu CW, Sun HP, et al : Combined botulinum toxin type A with modified constraint-induced movement therapy for chronic stroke patients with upper extremity spasticity : a randomized controlled study. Neurorehabil Neural Repair 2010 ; : Jpn J Rehabil Med VOL. 50 NO

16 Jpn J Rehabil Med 2013 ; : Improving Upper Limb Function in Stroke Patients Yasuyuki MATSUSHIMA, Akiko HACHISUKA, Kenji HACHISUKA Abstract : Botulinum toxin type A BTXA injections are effective for treating upper limb spasticity after stroke. Treatment has been shown to reduce muscle tone and improve basic upper limb activities such as hand hygiene and facilitation of dressing. However, the evidence on the effect of BTXA injections on active function such as reaching or grasping is unclear. Rehabilitation should be combined with BTXA injection to improve upper limb function after stroke. We experienced two cases with spastic upper limb hemiparesis where upper limb function improved after combined application of BTXA injections, robotic therapy and intensive occupational therapy. Their ability to reach and grasp improved and they were able to participate in social activities. To evaluate upper limb function, the Wolf Motor Function Test and Motor Activity Log were especially useful because these scores were correlated with the degree of patient satisfaction. Combined therapeutic application of BTXA injections and new therapeutic strategies such as repetitive transcranial magnetic stimulation, transcranial direct current electrical stimulation, constrainedinduced movement therapy, and robotic-assisted therapy may be useful to improve active function for paralytic upper limbs after stroke. Jpn J Rehabil Med. Key words : botulinumupper limb functionparticipation robotic therapy 2009 A 1 passive active 2 passive Department of Rehabilitation Medicine, University of Occupational and Environmental Health, Japan y-matsu@med.uoeh-u.ac.jp 520 Jpn J Rehabil Med VOL. 50 NO

6 CI constrained-induced movement therapy 7 fmri 8 9 1 333 1 1 2 4 4 3 3 3 4 1 3 12 Action Research Arm Test ARAT ARAT 0 3 4 56 1 1 1 2 3 Arm Trainer Bi- Manu-Track 1 20 Arm Trainer passive-passive

17 6 CI constrained-induced movement therapy 7 fmri Action Research Arm Test ARAT ARAT Arm Trainer Bi- Manu-Track 1 20 Arm Trainer passive-passive mode active passive active-passive mode Arm Trainer Bi-Manu-Track Modified Asworsh Scale MAS Wolf Motor Function Test WMFT Fugl-Meyer Motor Activity Log MAL 1 58 Brunnstrom stage MAS Jpn J Rehabil Med VOL. 50 NO

Modified Asworsh Scale MAS Wolf Motor Function Test WMFT Functional Ability Score Fugl-Meyer Motor Activity Log MAL MAS 1 2 MAS 3 2 1 Fugl-Meyer

18 Modified Asworsh Scale MAS Wolf Motor Function Test WMFT Functional Ability Score Fugl-Meyer Motor Activity Log MAL MAS 1 2 MAS Fugl-Meyer Fugl-Meyer 1 3 WMFT MAL 1 2 Visual analoge scale 1 Visual analoge scale MAS Fugl-Meyer WMFT MAL Jpn J Rehabil Med VOL. 50 NO

19 2 26 Brunnstrom stage MAS MAL MAS 3 1 Fugl-Meyer WMFT MAL MAL CI rtms MAS Fugl-Meyer MAL tdcs Arm Trainer Fugl- Meyer MAL 11 Arm trainer 12 1 CI WMFT MAL rtms tdcs 1,,,, : 2009.,, : ; : Fridman EA, Crespo M, Gomez Argüello S, Degue L, Villarreal M, Bohlhalter S, Wheaton L, Hallett M : Kinematic improvement following Botulinum Toxin-A injection in upper-limb spasticity due to stroke. J Neurol Neurosurg Psychiatry 2010 ; : Bhakta BB, O Connor RJ, Cozens JA : Associated reactions after stroke : a randomized controlled trial of the effect of botulinum toxin type A. J Rehabil Med 2008 ; : Esquenazi A, Mayer N, Garreta R : Influence of botulinum toxin type A treatment of elbow flexor spasticity on hemiparetic gait. Am J Phys Med Rehabil 2008 ; : Meythaler JM, Vogtle L, Brunner RC : A preliminary assessment of the benefits of the addition of botulinum toxin a to a conventional therapy program on the function of people with longstanding stroke. Arch Phys Med Jpn J Rehabil Med VOL. 50 NO

20 Rehabil 2009 ; : Sun SF, Hsu CW, Sun HP, Hwang CW, Yang CL, Wang JL : Combined botulinum toxin type A with modified constraint-induced movement therapy for chronic stroke patients with upper extremity spasticity : a randomized controlled study. Neurorehabil Neural Repair 2010 ; : Diserens K, Ruegg D, Kleiser R, Hyde S, Perret N, Vuadens P, Fornari E, Vingerhoets F, Seitz RJ : Effect of repetitive arm cycling following botulinum toxin injection for poststroke spasticity : evidence from fmri. Neurorehabil Neural Repair 2010 ; : Shaw LC, Price CI, van Wijck FM, Shackley P, Steen N, Barnes MP, Ford GA, Graham LA, Rodgers H, Investigators B : Botulinum Toxin for the Upper Limb after Stroke BoTULS Trial : effect on impairment, activity limitation, and pain. Stroke 2011 ; : Kakuda W, Abo M, Momosaki R, Yokoi A, Fukuda A, Ito H, Tominaga A, Umemori T, Kameda Y : Combined therapeutic application of botulinum toxin type A, low-frequency rtms, and intensive occupational therapy for post-stroke spastic upper limb hemiparesis. Eur J Phys Rehabil Med 2012 ; : Ochi M, Saeki S, Oda T, Matsushima Y, Hachisuka K : Effects of anodal and cathodal transcranial direct current stimulation combined with robotic therapy on severely affected arms in chronic stroke patients. J Rehabil Med 2013 ; : Hesse S, Schulte-Tigges G, Konrad M, Bardeleben A, Werner C : Robot-assisted arm trainer for the passive and active practice of bilateral forearm and wrist movements in hemiparetic subjects. Arch Phys Med Rehabil 2003 ; : Jpn J Rehabil Med VOL. 50 NO

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