J Rehabil Med 2010; 42: 801–807

EDUCATIONAL REVIEW

HOW TO CLINICALLY ASSESS AND TREAT MUSCLE OVERACTIVITY IN SPASTIC PARESIS*

Alain P. Yelnik, MD1, Olivier Simon, MD, PhD2, Bernard Parratte, MD, PhD3 and Jean Michel Gracies, MD, PhD4 From the Physical Medicine and Rehabilitation Departments, 1AP-HP, G. H. Lariboisière-F.Widal, University Paris 7, 2AP-HP, GH Bichat, University Paris 7, Paris, 3CHU Besançon, University Franche Comté, Besançon and 4AP-HP, CHU H. Mondor, University UPEC, Créteil, France

Objective: This educational paper aims to describe, in adult quired lesions, traumatic, vascular, tumoural or infectious, lead patients, the different aspects of muscle overactivity after a to spastic paresis, i.e. paresis associated with stretch-sensitive central nervous system lesion, including spasticity, spastic muscle overactivity. “Spasticity” is a term that is often used dystonia and spastic co-contraction, the assessment of their beyond its definition, to refer to various types of muscle over- symptoms and consequences, and therapeutic options. activity. The term “muscle overactivity” is more appropriate Discussion and Conclusion: Clinical evaluation involves the and should be used preferentially. This article describes the assessment of passive range of motion, angle of catch or different aspects of muscle overactivity after a CNS lesion, the clonus, active range of motion, rapid alternating movements means of clinical evaluation of its consequences, the different and functional consequences. A number of scales have been therapeutic options, the usual need for a multidisciplinary ap- developed to assess patients with spastic paresis, involving proach, and the need for a scheduled follow-up. both patient and caregivers. Not all persons with spasticity This paper has 4 main educational objectives: (i) to explain require treatment, which is considered only when muscle the pathophysiology of spastic paresis and the definition of the overactivity is disabling or problematic. A list of personal different types of spastic muscle overactivity; (ii) to describe objectives may be proposed for each patient, which will drive assessment and treatment. Prior to treatment the pa- the means of assessing spastic paresis and the consequences tient must be informed of the intended benefits and possible of muscle overactivity; (iii) to describe how to disentangle adverse events. Clinical evaluation may be supported by the the roles played by various types of muscle overactivity, mus- use of transient neuromuscular blocks and/or instrumental culoskeletal complications and other neurological disorders analysis. Physical therapies usually represent the mainstay potentially associated with spastic paresis; and (iv) to describe of treatment. Self-rehabilitation with stretching and active the different treatments available and their value. exercises, intramuscular injections of botulinum toxin, al- cohol or phenol injections, oral or intrathecal drugs, and PATHOPHYSIOLOGY OF SPASTIC PARESIS surgery comprise the treatment options available to the cli- nician. Follow-up must be scheduled in order to assess the Three fundamental phenomena occur after a lesion to the cen- benefits of treatment and possible adverse events. tral motor pathways assigned to motor command execution. Key words: spastic paresis; muscle overactivity; assessment; treatment. Paresis J Rehabil Med 2010; 42: 801–807 After an acquired brain injury causing a lesion to the cortico­ spinal pathways, the central execution of motor command is Correspondence address: Alain P. Yelnik, AP-HP, G. H. Lari- boisière-F. Widal, University Paris 7, Physical Medicine and disrupted, resulting in immediate paresis (1). Paresis is defined Rehabilitation Department, 200 rue du Faubourg Saint Denis, as the quantitative lack of command directed to agonist muscles FR-75010 Paris, France. E-mail: [email protected] when attempting to generate force or movement. This lack of command can occur through an insufficient number of motor Submitted December 28, 2009; accepted July 26, 2010 units synchronously recruited and/or an insufficient discharge frequency of the recruited motor units. INTRODUCTION The aim of this educational paper is to set out the essential Soft tissue contracture and changes in contractile muscle points of management of spasticity in patients with spastic properties paresis, for Physical and Rehabilitation Medicine specialists The relative immobilization of the paretic body parts leaves and other physicians. Many central nervous system (CNS) ac- some of the muscles and their surrounding soft tissues immo- bilized in a shortened position. Plasticity subsequently causes the soft tissue to shorten and adapt to its new length. This phe- *This is an educational review which is produced in collaboration with nomenon leads to soft tissue contracture, which is defined by: UEMS European Board of Physical and Rehabilitation Medicine. (i) physical shortening; and (ii) reduction in extensibility of soft © 2010 The Authors. doi: 10.2340/16501977-0613 J Rehabil Med 42 Journal Compilation © 2010 Foundation of Rehabilitation Information. ISSN 1650-1977 802 A. P. Yelnik et al. tissue, including muscles, tendons, ligaments, joint capsules, der can stay internally rotated and adducted with a flexed and skin, vessels and nerves (1). This process begins with gene pronated elbow and flexed wrist and fingers. In the lower limb, changes and transcriptional events, leading to protein synthesis spastic dystonia may often involve the plantar flexors and cause reduction a few hours after the onset of immobilization, and equinovarus deformity and/or toe flexors, causing toe clawing only intensifies in the days, weeks and months that follow if that can be painful and disabling during walking. insufficient preventative treatment is implemented (2, 3). In addition, changes in contractile muscle properties (particularly Spastic co-contraction. Spastic co-contraction is defined as slow-to-fast) are observed depending on the initial motor unit an “unwanted, excessive, level of antagonistic muscle activ- type and duration of disuse (3). ity during voluntary command on an agonist muscle, which is aggravated by tonic stretch in the co-contracting muscle” (2, Muscle overactivity 8). Spastic co-contraction in patients with spastic paresis is a descending phenomenon, most probably due to misdirection Lesion- and activity-dependent adaptive changes subsequently of the supraspinal drive. It may be facilitated by increased occur within the higher centres and the spinal cord (2). Brainstem recurrent inhibition, causing loss of reciprocal inhibition dur- descending pathways (rubro-, tecto-, reticulo-, vestibulospinal ing voluntary command (2, 9). Thus, the primary triggering pathways) are increasingly recruited (with potential disinhibi- factor for spastic co-contraction is voluntary command on an tion due to frontal disconnections in brain lesions) to take over agonist, and spastic co-contraction is detected and measured some of the execution of motor command following disruption during voluntary effort. of the corticospinal pathway. Most of these brainstem descending In patients with good or fairly good motor control, spastic pathways tend to be constantly active, thus generating permanent co-contraction is likely to be the most disabling form of muscle muscle activity. At the spinal cord level, lower motor neurons overactivity in spastic paresis, as it impedes generation of force are now deprived of their regular descending excitation from or movement: range of active motion is diminished and rapid the corticospinal pathway and release growth factors locally alternating movements are slowed. In the upper limb spastic co- (4). These tend to promote local sprouting from neighbouring contraction may often be observed in the flexors during attempts interneurons, thus creating conditions for the formation of new at elbow, wrist or finger extension. Thus, reaching becomes dif- abnormal synapses between these interneurons and the somatic ficult as well as opening the hand to grab an object or drop it. In membrane of the deprived motor neurons, thus leading to the the lower limb during the swing phase of walking, spastic co- creation of new abnormal or exaggerated reflex pathways (5). contraction of the hip extensors may restrict active hip flexion; Spasticity. Spasticity is the most commonly recognized manifes- in the knee flexors and extensors it may restrict knee motion; tation among these gradually occurring changes. The definition of similarly, spastic co-contraction of the ankle plantar flexors may spasticity has been simplified as anincrease in velocity-dependent restrict active dorsiflexion in the swing phase (10). stretch reflexes (2, 6), which is clinically manifested at rest by excessive responses to muscle stretch or tendon taps. Stretch- Other types of muscle overactivity. Other types of muscle over- induced contraction at rest occurs at a lower threshold, and with activity exist, which have not been shown to be stretch-sensitive. an increased amplitude in patients with spastic paresis compared Pathological extra-segmental co-contraction (also known, with normal subjects. Thus, the primary triggering factor for depending on its pattern, as syncinesia, associated reactions, spasticity is phasic stretch, and this phenomenon is detected and choreic or athetotic movements) is an unwanted, abnormal level measured at rest. Spasticity is unlikely to be a disabling form of of activity in muscles that are distant (at a different segmental muscle overactivity, except when clonus interferes with posture level) from the agonist involved in the voluntary command (2). or movement. Clonus can be triggered by passive movement Excessive cutaneous or nociceptive responses and other forms during nursing, dressing or washing, or simply during attempts of inappropriate muscle recruitment during yawning, breathing to maintain a relaxed seated position, causing discomfort or diffi- or coughing are also common in spastic paresis. culty in keeping the feet on the footplates of a wheelchair. Clonus Factors causing variation. The time of day and the position can also be triggered by active movements, with a potentially of other joints, including the neck, may impact on the differ- negative impact on prehension or walking. ent types of stretch-sensitive muscle overactivity. Thus, when Spastic dystonia. The term “spastic dystonia” was coined by assessing muscle overactivity in spastic paresis, the clinician Denny-Brown to represent tonic chronic muscle activity that must make every effort to repeat assessments at a similar is present in the context of spasticity (2, 7). Thus, spastic dys- time of the day and in the same body position. Other common tonia is spontaneous overactivity at rest for which there is no factors in variation are stress level, external temperature and primary triggering factor. It is the type of muscle overactivity any nociceptive factor. The mere measurement of spasticity that is most easily recognizable when looking only at patients in a patient at rest is far from fully reflects the impact of the with spastic paresis, as spastic dystonia deforms joints and condition during movement. body postures and is a major cause of disfigurement and social handicap in these patients. CLINICAL EVALUATION In hemiparetic patients after or traumatic brain injury various types of spastic dystonia may be observed, leading to Whatever the different aspects and terms in use to describe abnormal postures. For example, in the upper limb the shoul- muscle overactivity, what is important is to determine its real J Rehabil Med 42 Muscle overactivity in spastic paresis 803 impact, and this requires a careful clinical evaluation. This Scales intended for caregivers or patients evaluate difficulties assessment can then be used to argue the need for a treatment during nursing, discomfort or disfigurement. A tool has been and will be the basis of the required follow-up. proposed by Bhakta et al. (14); the patient’s disability (PD) and the carer burden rating scale (CBRS). These scales have been Passive range of motion developed to measure upper limb activity limitation in patients For each movement evaluated, the clinician stretches the cor- with no active function in the arm. The PD consists of 8 items, responding muscles and joints at a very slow speed (called V1, such as cleaning the palm, cutting fingernails, putting the paretic slow velocity) that is kept below the threshold for eliciting a arm through sleeves, etc. The CBRS consists of 4 items: cleaning stretch reflex. The angle at which soft tissue offers a maximum the palm, cutting the fingernails, dressing and cleaning under the resistance is defined as the passive range of motion for that armpit. With a similar approach, Brashear et al. (15) proposed joint. A common and important clinical issue is to distinguish the Disability Assessment Scale, which assesses 4 domains of retraction from severe dystonia, which may require transient potential disability: hygiene, dressing, limb position, and pain. motor blocks (see below). The patient, together with the physiatrist, selects one of the 4 domains as the principal target of treatment. Angle of catch or clonus and spasticity grade However, when motor control is strongly impaired, overactiv- For each movement evaluated, the clinician should stretch the ity in some muscles may be functionally useful. In the lower corresponding muscles and joints at the fastest speed possible limb, patients with severe paresis may sometimes stand using for the examiner (V3, fast velocity). According to the Tardieu quadriceps overactivity; in the upper limb, elbow flexor overac- scale, two parameters are then determined: the angle at which tivity may allow the patient to carry a purse or bag. The patient catch or clonus occurs represents the threshold to elicit the must be evaluated keeping in mind the potential usefulness of reflex, and the type of muscle reaction occurring at that angle muscle overactivity in some areas before a decision is reached defines the spasticity grade (11, 12). on treatment. Assessing function in patients with fairly good motor con- Active range of motion trol. Paresis, soft tissue contracture, spastic co-contraction, For each passive movement evaluated, the clinician asks the dystonia, and clonus may interfere with active movement. patient to perform an active movement as far as possible along Evaluating the real impact of overactivity on active movement the range, until the active force produced by the agonist is bal- is required to determine the need for and type of treatment. anced by the passive resistance from the stretched structures Different levels of assessment can be used, measuring motor together with the spastic co-contraction in the antagonist. This control, limb function or global independence. third angle is the active range of motion. Generic personal functional scales, such as the Barthel Index after stroke, Expanded Disability Status Scale in multiple Rapid alternating movement frequency sclerosis or the Functional Independence Measure, may be The patient performs the same active movements over the useful in clinical practice. However, as Wade et al. (16) noted, maximal range as measured above then returns to the starting these activities of daily living (ADL) scales measure the ability position again, as many times as possible in a limited period of to perform tasks without necessarily involving the affected arm. time (e.g. 15 s). The number of movements performed indicates They may therefore rate mainly adaptive strategies learned by the ability of the subject to repeat fast active movements (13), patients, and are not designed to measure the consequences of which is required for some everyday activities, but moreover overactivity and the effects of treatment. is a good way, in our experience, to reveal spastic dystonia or Emphasis may be put specifically on the assessment of the co-contraction during a simple examination. motor impairment of the affected limb (17, 18), which involves comprehensive testing of active abilities of the paretic limbs. Function: consequences of paresis, contracture and muscle The limitations of extensive impairment scores, such as the overactivity Fugl-Meyer, include time consumption and the absence of Individualized, patient specific outcomes may be considered, real-life tasks tested. Its sensitivity may be insufficient to using a goal-setting process. To describe the tools that can be observe change after treatment with botulinum toxin (BTX) used to assess function, including the consequences of muscle (19). Upper limb function has been assessed using different overactivity, patients can be divided into two approximate main scales (e.g. Rivermead Motor Assessment, Frenchay arm test, categories according to the magnitude of impairment. Motor Activity Log) and by motor impairment tests, such as the box-and-block test or the nine-hole peg test. However, these Assessing function in patients with severe paresis. Contrac- standard scales for upper limb function are not usually sensitive tures and/or spastic dystonia may lead to abnormal joint posi- enough to demonstrate efficacy of treatment, and contradic- tions, causing disfigurement, pain, discomfort, impairment in tory results have been published (20–23). With the purpose of washing, dressing, urinary function, sitting position, walking improving sensitivity, reliability and validity in the functional impairment with potential consequences on perineal hygiene assessment of the upper limb, a modified Frenchay Arm Test, or a risk of bed sores. Clonus may also bear functional impact, termed the Modified Frenchay Scale has been proposed (24). assessed on: spontaneous position (sitting or standing), passive This tool involves 10 real-life uni- and bi-manual tasks, which motion, active motion (reaching, walking). are videotaped and rated on a visual analogue scale. J Rehabil Med 42 804 A. P. Yelnik et al.

Many authors have used a global assessment of the result, pro- Muscle overactivity is probably the only motor disorder posed to patients, caregivers or investigators in research studies. that can benefit from a drug treatment, but it is not the only While negative in some studies (22), in most this global assess- motor disturbance in spastic paresis. Paresis can be treated ment of benefit showed positive effects of BTX treatment (15, by motor training. Soft tissue shortening can be treated by 19–21, 25). Such a global assessment may be based on previous aggressive stretch programmes. The following 3 questions goals for the treatment, previously specified with the patient. must be addressed: The main function of the lower limb is walking. Clinical • Is muscle overactivity problematic and, if so, in what re- functional scales, such as the Functional Ambulation Classifi­ spects? Only a detailed analysis of the impact of overactivity cation, do not have sufficient sensibility. To rate actual function in all its passive and active functional aspects enables the in the lower limb, walking tests can be performed (10 metres clinician to decide on the appropriateness of a given treat- walking, 2-min or 6-min endurance test) as well as tests of ment and to set reasonable patient objectives. stair-climbing performance and walking on uneven ground. • Is muscle overactivity the main cause of the disability or only Walking speed and step length can be measured, as well as the one of the causes? In the latter case, which components are physiological cost index, which is the speed divided by the dif- involved? It is important to specify quality of motor control ference between the heart rate before and after the effort (26). and hypoesthesia. If muscle overactivity is considered to be The quality of the movement is difficult to assess clinically and an important culprit for the motor deficiency, then its treat- can be usefully completed by instrumental analysis (notably ment is likely to be helpful to the patient (32). kinematic analysis) especially when surgery is considered. • Is the problematic muscle overactivity limited to one muscle group or is it more widely spread? The correct treatment Other evaluations depends on the answer. Combined assessment of soft tissue contracture and spastic dystonia. Tools such as the Ashworth and the Modified Ash- Transient motor blocks worth scales have been widely used in clinical trials under Transient neuromuscular blocks by intramuscular injections the initial assumption that they measure spasticity (27, 28). (motor point injections) or by perineural injections (trunk nerve However, it is now established that these instruments evaluate anaesthesia) using local anaesthetic drugs may be performed a combination of soft tissue contracture and spastic dystonia, prior to treatment in order to address the following issues (28): in addition to spasticity itself (12, 29). (i) How severe is muscle contracture? If it is severe, it is obvi- ous that drug treatment of overactivity alone or physiotherapy Assessment of pain. Pain directly related to muscle over­activity cannot aim to restore the normal range of motion; (ii) How is possible, due to prolonged muscle contractions, but also to could the patient manage functionally (walking, reaching, tendon lesions and abnormal postures. Pain may be an impor- grasping) after local weakening treatment?; (iii) Is there any tant component of the patient’s difficulties. Apart from scales active command available in the antagonist muscles that can in which pain assessment is included, as in the Disability be trained or what will be unwanted? This information may be Assessment Scale (15), pain can be assessed non-specifically fundamental when surgery is considered (33, 34) but the motor using visual analogue scales when it is deemed necessary. block has a transient effect, too short to allow the patient to adjust to a new motor pattern, thus the latter two issues may TREATMENT be incompletely solved. In the upper limb, the following blocks can be carried out Indications for treatment easily: pectoral nerve loop to examine the role of pectoralis The treatment of muscle overactivity may be considered when major and minor in the adduction and medial rotation; mus- the condition is disabling. Whatever its aetiology, muscle culocutaneus nerve to release the elbow flexors except for overactivity usually has a negative impact on motor command, brachioradialis; ulnar and median nerves to release wrist and and this justifies treatment of the symptom itself, i.e. independ- finger flexors. In the lower limb, the obturator nerve can be ent of the aetiological context, as a function of the patient’s blocked to release hip adductors, posterior tibialis nerve and neuro­logical disorders (30, 31). However, not all spastic pa- its branches can be separately blocked to examine the roles of tients necessarily require treatment for muscle overactivity. gastrocnemius, soleus, tibialis posterior and toe flexors. Treating muscle overactivity must only be considered after Anaesthetic drugs available include lidocaine, ropivacaine rigorous clinical analysis, in order to determine the severity and bupivacaine. Apart from potential allergic reactions, the of the condition, its true consequences and distribution. This main risks are toxic dose-related effects, such as hypotension, careful assessment often requires a multidisciplinary approach, bradycardia and cardiac arrest. The clinician must therefore varying from patient to patient, including physician, physical have emergency equipment available. These complications therapist, occupational therapist, nurse or caregiver. A list of are fortunately rare. personal, separately measurable objectives may be proposed for each patient, to drive therapeutic strategy. The follow-up Treatment of nociceptive triggering factors must be scheduled to document benefits and possible adverse Potential nociceptive triggering factors must be treated before events. treating muscle overactivity, bearing in mind that the patient

J Rehabil Med 42 Muscle overactivity in spastic paresis 805 may be unaware of them because of hypoesthetic areas. particularly in children, but this technique has not been evaluated Common factors are: bed sores, urinary infection or lithiasis, against electrical stimulation for its efficiency. constipation, haemorrhoids, fractures or ingrown toenails. No immediate post-injection complications have been re- Muscle overactivity is sometimes associated with these fac- ported (except for slight pain at the injection site). Patient and tors, especially with sores and pain, and treatment of one may caregivers must be warned of a low risk of adverse effects that help the other. For example, intrathecal baclofen infusion via may occur during the first 3 weeks after each injection (swal- a transient catheter may be help with large bedsores in spastic lowing disorders and botulism-like syndrome) and should be paraparesis, leading to a reduction in abnormal posture. encouraged to consult if any doubt. The results of the therapy may be assessed 1–6 weeks after Treatment options the injection on the basis of the personalized objectives decided The therapeutic programme may combine, in various propor- before treatment. Repeat injections are often justified due to the tions, physical therapy, occupational therapy, self-rehabilita- transient effect of the toxin, but a long-lasting effect is possible. tion, the use of orthoses and assistive devices, drug treatment, No repeated treatment must be conducted without accurate as- orthopaedic surgery and neurosurgery. sessment. When needed, a minimum delay of 2–3 months be- tween injections is usually recommended, although no scientific Physical therapies. Physiotherapy is the basic treatment for all evidence backs up any specific delay (30, 31). Each subsequent patients with spasticity (35, 36). It may help to limit muscle con- injection should be followed by an evaluation of the achievement tractures and reduce overactivity for a short period. Physio­therapy of pre-therapeutic defined objectives, as well as tolerance, with is essential to help patients to adapt to changes, and sometimes a review of the dose and treated muscles. Repeat injections can drug-induced reduction in overactivity can allow a new rehabili- be continued as long as beneficial effects are observed. tation programme to be started. In all cases, physiotherapy must Alcohol and phenol. Alcohol or phenol have often been be considered as complementary to drugs and surgery. Maintained injected perineurally. This treatment should be used prefer- stretch must remain a mainstay in a physiotherapy session, as ably in nerves with a low sensory activity and a high motor its efficacy has been largely demonstrated (37). Heat or cold predominance (obturator, musculocutaneous, etc.). Intramus- applications have also been proposed, as well as positional inter­ cular (motor point) injections may also be performed with the ventions, such as inhibitory casting. Electrical stimulation has potential disadvantage of being painful at injection, but the been shown to allow spasticity reduction in muscles antagonist advantage of avoiding the risk of post-injection dysesthaesia. to the stimulated muscles (38). One interesting use of electri- This focal treatment by chemical neurolysis is usually not cal stimulation is the stimulation of hand and fingers extensors used as a first-line therapy, except in the case of particularly during prehension training, mixing overactive flexor inhibition problematic overactivity affecting a large number of areas. with extensor activation (39). Finally, one of the most important Alcohol or phenol can be used for large muscles by chemical parts of overactivity treatment and contracture prevention is self- block of a whole nerve trunk (adductor muscles for example), rehabilitation with stretching postures, active exercises taught to while BTX is used for some other muscles because of the patients and caregivers and sometimes orthoses. maximum permitted doses of BTX (30). Injection is performed using electrical stimulation. A transient motor block may be Drugs. This section refers mainly to the recommendations of performed initially in order to indicate whether chemical neu- France’s drug authority (Agence Francaise de Securite des rolysis might be effective. The benefits of alcohol or phenol Produits de Sante) (30, 31). treatment must be weighed up initially, relative to those of Botulinum toxin. A double-blind study comparing BTX, surgery (alcohol or phenol induce tissue fibrosis, which may tizanidine and placebo after stroke or traumatic brain injury has render subsequent surgeries difficult). recently established BTX type A as the first-line treatment of Oral drugs. Baclofen and tizanidine have reduced tone on multifocal muscle overactivity, for both better efficacy and bet- Ashworth scores with a dose-dependent response in some ter tolerance than systemic treatment (40). The efficacy of BTX studies, but there is no evidence on reducing the functional type A has been documented in self-care improvement (washing impact of spasticity (45, 46). Tizanidine has been shown to be and dressing) (15) and active movements in the leg with gait no more effective than placebo in reducing tone and improv- improvement (41, 42). No improvement in active arm function ing perceived function in the upper limb (40). Poor tolerance, has been demonstrated to date except using kinematic analysis with insidious adverse events, such as sedation, fatigability, (43). An effect on pain reduction has also been demonstrated. drowsiness and reduction in seizure threshold, have led these There are currently 4 forms of BTX available in Europe: 3 type to be considered as second-line therapies in stroke patients A (Botox®, Allergan, Dysport®, Ipsen-Pharma, Xeomin®, Merz) (30, 31). Introduction, dose adjustment and withdrawal must and 1 type B (Neurobloc®, Elan-Pharma), and it must be kept be performed gradually. All long-term treatments must be reap- in mind that the units of these toxins are different, specific for praised (e.g. for therapeutic windows, and dose changes) with each brand. We strongly recommend using electrical stimulation a periodicity that depends on condition and time since onset. to localize injection sites, as using anatomical markers alone Other drugs, such as dantrolene, have no sufficient evidence may lead to inaccurate targeting (30, 31, 44). There is interest in the literature to recommend their use. A combination of oral in the use of ultrasound guidance to help to identify muscles, therapies is not recommended (30, 31).

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Intrathecal baclofen. Intrathecal baclofen (ITB) is a long- Conclusion term treatment with continuous, intra-spinal administration via an implanted pump that reduces spasticity, especially in Treatment of muscle overactivity should be considered only spinal injury patients and in (47, 48). ITB after careful evaluation of its consequences, often using a has been used in patients whose leg muscle overactivity was multidisciplinary approach, in terms of active and passive considered diffuse. It should be reserved for severely disabled function, pain, discomfort and other symptoms. Not all patients patients whose muscle overactivity interferes with posture, with spasticity require treatment. Different scales may be used nursing, rest, personal independence or causes pain (30). according to the goals, but none of them replaces personal ob- Grave (potentially lethal) complications have occurred with jectives elaborated for and with each patient. The indication for this treatment and detailed information on the expected benefits and the choice of treatment among physical therapy, drug and and risks, notably in terms of potential loss of motor function surgery usually requires a multidisciplinary approach. Regard- (which can be reversed at withdrawal) must be provided to the less of their value, focal treatments by chemical weakening patients and his or her caregiver and family (49). should only be considered as an adjunct to physical therapies. Several assessments are usually performed before definitive Follow-up must be scheduled in order to assess the benefits or pump implantation by after simple injection via lumbar puncture possible adverse events of the treatment. or via a temporary access device. Efficacy may be evaluated in the following 3–4 h. The usually recommended first test dose is 50 µg in adults, with a maximum dose of 150 µg that should be Learning objectives reached after 3 days. Caution should be exercised particularly To understand the pathophysiology of spastic paresis and the with respect to the risk of overdosing, paying particular attention definition of the different types of spastic muscle overactivity: spasticity, spastic dystonia, and spastic co-contractions. to vigilance and respiratory disorders. Thus, monitoring of vital To know how to assess spastic paresis and to understand the signs by a specialized team must be performed during the 4 h consequences of muscle overactivity. following the test. Then, if the treatment is well-tolerated and To be able to distinguish between the assessment of muscle deemed effective, the team may decide to implant the pump, and overactivity and the assessment of its consequences. to monitor and follow up the treatment. It is critical to ensure To understand the different scales, their usefulness and their limits. maintenance, notably to detect hazards related to the procedure To be able to assess with the patient and in a multidisciplinary (displacement of the catheter, infection, etc.) and to prevent the approach the real consequences of muscle overactivity in activities occurrence of a withdrawal syndrome. and participation. Surgery. Surgery may play an important role in the treatment To know how to disentangle the roles played by various types of chronic muscle overactivity, but it is not the first-line treat- of muscle overactivity, musculoskeletal complications and other ment. Because of its potential adverse events and its remaining neurological disorders potentially associated with spastic paresis. effects, surgical techniques must be strictly adapted to different To understand the different types of treatment available and their goals: hygiene, standing, transferring, walking, use of assistive value. devices (e.g. shoes, orthoses, canes, wheelchair). It involves To be able to assess the benefits and possible adverse events of the different treatments. neurosurgery and orthopaedic surgery. Surgical procedures To be able to determine personal objectives for each patient before may include one or more of techniques described below. commencing treatment. Peripheral neurotomy (selective or hyperselective) consists in partial and segmental resection, involving motor collateral branches to overactive muscles. The goal of selective periph- eral neurotomy is to balance agonists and antagonists without References abolishing “useful” tone. For the lower limb, common targets 1. Gracies JM. Pathophysiology of spastic paresis. I: Paresis and soft are collateral branches of the posterior tibial nerves (e.g. an- tissue changes. Muscle Nerve 2005; 31: 535–551. kle clonus, equinus, inversion of the foot) (50) and obturator 2. Gracies JM. Pathophysiology of spastic paresis. II: Emergence of nerves. In the upper limb, good results have been reported muscle overactivity. Muscle Nerve 2005; 31: 552–571. 3. Baptista IL, Leal ML, Artioli GG, Aoki MS, Fiamoncini J, Turri with neurotomy of the musculo-cutaneous, median and ulnar AO, et al. Leucine attenuates skeletal muscle wasting via inhibition nerves (48). Other nerve surgeries, such as rhizotomies, have of ubiquitin ligases. Muscle Nerve 2010; 41: 800–808. also been used but have potential complications. 4. Maier IC, Baumann K, Thallmair M, Weinmann O, Scholl J, Schwab Musculoskeletal surgery is treatment of the consequences of ME. Constraint induced movement therapy in the adult rat after uni- muscle overactivity, contracture and joint deformities, performed lateral corticospinal tract injury. J Neurosci 2008; 28: 9386–9403. 5. Raineteau O, Schwab ME. Plasticity of motor systems after incom- on the muscle or the tendon itself. Tendon transfers (e.g. tibialis plete . Nat Rev Neurosci 2001; 2: 263–273. anterior) or lengthening are conservative treatments commonly 6. Lance JW, Feldman RG, Young RR, Koeller C. Spasticity: disorder of proposed (51). Tenotomy may be considered in the case of mus- motor control. Chicago, IL: Year Book Medical; 1980, p. 485–494. cle contracture without active functional objectives. Osteotomies 7. Denny-Brown D. The cerebral control of movement. Liverpool: are sometimes proposed to correct hip displacements and foot University Press; 1966, p. 124–143. 8. Gracies JM, Wilson L, Gandevia SC, Burke D. Stretched position deformities. 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