Spasticitet Jens Bo Nielsen

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1 Spasticitet Jens Bo Nielsen
Department of Physical Exercise and Sport Science & Department of Neuroscience and Pharmacology Panum Københavns Universitet

2 Muskeltonus forandringer
Spasticitet: Hastighedsafhængig forøgelse af modstand mod passivt stræk af muskel. Refleksaktivering af musklen Dystoni: Vedvarende tonus forandring pga central neural aktivering af musklen (basal kerne affektion) Kontrakturer: Passive forandringer i muskelvæv Spasmer: Længere varende muskelaktivitet efter forudgående sensorisk input Rigiditet: Tandhjulsagtig modstand mod passiv bevægelse af led (Parkinson) Blandes i klinikken ofte sammen og kaldes samlet for spasticitet

3 Behandling afhænger af symptom
Spasticitet: Behandling nødvendig/hensigtsmæssig.? Fysioterapi, træning, antispastisk medicinering (ikke botox!) Dystoni: Muligvis Botox, men langsigtet virkning ikke klart dokumenteret Kontrakturer: Udstrækning , gipsning, men dokumentation for langsigtet effekt mangler Spasmer: Behandling nødvendig/Hensigtsmæssig? Antispastisk medicinering

4 Dystoni Parese Ataxi Spasticitet

5 Spasticitet skyldes ikke læsion af pyramidebanen
Evidence from monkeys NO: Towers 1940 NO: Lawrence & Kuypers. The functional organization of the motor system in the monkey. I. The effects of bilateral pyramidal lesions. Brain Mar;91(1):1-14. Evidence from human NO: Sherman et al. J Neurol Sci Apr 15;175(2): NO: Nathan PW Effects on movement of surgical incisions into the human spinal cord. Brain Apr;117 ( Pt 2): Yes: Paulson et al. Arch Neurol Jan;43(1):93-5.

6 Hjernelæsion involverer almindeligvis mange strukturer

7 Pathophysiological mechanisms in spasticity
Gr. II pathways Postactivation depression

8 Control of reciprocal inhibition in healthy human subjects

9 Reciprocal inhibition in patients with spasticity
Crone C, Nielsen J, Petersen N, Ballegaard M & Hultborn H. (1994). Brain 117, Crone C, Johnsen LL & Nielsen J (2000). Clinical neurophysiology suppl 53, Morita H, Crone C, Christenhuis D, Petersen NT & Nielsen JB. (2001). Brain. 124(Pt 4), Crone C, Johnsen LL, Biering-Sørensen F & Nielsen JB (2003). Appearance of reciprocal facilitation in patients with spasticity. Brain, 126(Pt 2):

10 Reciprocal inhibition in stroke patient
Before stroke After stroke

11 Post-activation depression is small in patients with spasticity
Nielsen J, Petersen N & Crone C. (1995) Brain. 118: Nielsen J, Petersen, Ballegaard M, Biering-Sørensen F & Kiehn O (1993). Experimental Brain Research 97,

12 Stretch evoked torque is only increased in spastic patients
when tested by stretches every 1 s, but not with 10s between stretches Stretch Stretch evoked torque

13 Skal vi altid behandle spasticitet?
Er spasticitet en fordel eller en ulempe – hvornår behandling – og hvilken?

14 Reflekser findes ikke som selvstændige fænomener – de er altid integreret med resten af nervesystemet. Problem for behandling..

15 Muskel aktivitet under gang tilpasses automatisk omgivelserne på basis af sensorisk information
af Klint, Grey, SInkjær, Nielsen J Physiol 2008 15

16 Stretch reflexes are not increased in the active spastic muscle
Therefore caution when using antispastic medication: Dietz & Sinkjær Lancet Neurol Aug;6(8):

17 Medicinsk behandling er effektiv men ofte uhensigtsmæssig
Diazepam acts here - and here Tizanidine acts here -here Baclofen acts here -and here Dantrolene and botox act here

18 Motorisk indlæring og antispastisk medicinering
07/04/2010 Maria Willerslev-Olsen

19 Strækrefleksen forøges efter 1-2 uger immobilisering
Before After Lundbye & Nielsen, JAP

20 Hvordan skal vi så behandle?

21 Reduced reflex modulation during bicycling in stroke
NB Schindler et al. 2007

22 Reciprocal inhibition of plantarflexors is increased following explosive strength training of dorsiflexors. Increased ability to produce force quickly. Geertsen et al. JAP 2008 22

23 Unconscious improvement in motor performance
Unconscious improvement in motor performance. You don´t need to know it – to learn it Lundbye-Jensen, Leukel & Nielsen 2009

24 Reinforcing the right movements – phasic dopamine signals

25 The time it takes to induce plasticity as compared to the time we can offer patients following injury Monkeys perform 600 reaching movements pr session for 6-12 month Cats perform 2000 steps pr session every day for 3-4 month Stroke patients perform 30 movements pr session. Repeated 1-2 times pr week Spinal cord injured patients perform 300 steps pr session. Repeated 2-3 times pr week for 3-4 month Lang et al. (2009) Arch Phys Med Rehabil. 90(10):

26 It takes time to become an expert

27 Uridine and DHA are important for the cell membrane and stimulate production of synapses

28 Rats who eat uridine and DHA are better at finding their way

29 The End Jens Bo Nielsen Department of Neuroscience and Pharmacology
Panum University of Copenhagen

30 Stretch reflex is increased in healthy subjects following immobilisation – significance for pathophysiology of spasticity? Before After Lundbye & Nielsen, JAP

31 The End Jens Bo Nielsen Institut for Neurovidenskab og Farmakologi
Kan købes på: Jens Bo Nielsen Institut for Neurovidenskab og Farmakologi Panum Københavns Universitet

32 Spasticitet er svær til umulig at evaluere klinisk
Ashworth Score Criteria:         0 No increase in tone         1 Slight increase in tone, giving a “catch” when the limb is moved in flexion or extension         2 More marked increase in tone, but limb easily flexed         3 Considerable increase in tone; passive movement difficult         4 Limb rigid in flexion or extension Ashworth skalaen har vist en vis validitet for armen men IKKE for benet (Brashear et al. Arch Phys Med Rehabil Oct;83(10): Blackburn et al. Phys Ther Jan;82(1): Gregson et al. Arch Phys Med Rehabil Sep;80(9):1013-6; Biering-Sørensen et al )

33 Biomekanisk evaluering af spasticitet
Jakob Lorentzen Hvidovre hosp.

34 Måling af muskelstivhed
Healthy subject Spastic patient Max Torque Max Torque Passive Torque Passive Torque Stretch reflex threshold Stretch reflex threshold

35 How good are we at separating passive and active muscle properties?
Reflex mediated stiffness Trained neurologist only correctly indicated increased reflex mediated stiffness in 60 % of subjects ´False positive´ Lorentzen et al 2010

36 Forbedre den kliniske diagnostik – ved brug af alternative metoder?
Hvad kan vi gøre? Forbedre den kliniske diagnostik – ved brug af alternative metoder?

37 Måling af muskelstivhed
Force (N) Ang Disp (deg) Ang Vel (deg/s) 10 20 30 40 50 Time (s) Time (s)

38 Hånd-holdt dynamometer resultater
Hånd holdt/ stationært dynamometer Raske / spastiske Lorentzen et al 2010

39 Motorisk indlæring og antispastisk medicinering
Control Baclofen Diazepam All needs to be said is that he hits the mechanical stops of the orthosis because he is too poor at compensating under drug conditions (specially for Diazepam) and that the increased variability under drugs is another indication of the inability to properly control the ankle. The peak plantarflexion graph is really nice I think for this subject under the 3 conditions 07/04/2010 Maria Willerslev-Olsen