Spasticitet Jens Bo Nielsen Department of Physical Exercise and Sport Science & Department of Neuroscience and Pharmacology Panum Københavns Universitet E-mail: J.B.Nielsen@mfi.ku.dk

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

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

Dystoni Parese Ataxi Spasticitet

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. 1968 Mar;91(1):1-14. Evidence from human NO: Sherman et al. J Neurol Sci. 2000 Apr 15;175(2):145-55. NO: Nathan PW Effects on movement of surgical incisions into the human spinal cord. Brain. 1994 Apr;117 ( Pt 2):337-46. Yes: Paulson et al. Arch Neurol. 1986 Jan;43(1):93-5.

Hjernelæsion involverer almindeligvis mange strukturer

Pathophysiological mechanisms in spasticity Gr. II pathways Postactivation depression

Control of reciprocal inhibition in healthy human subjects

Reciprocal inhibition in patients with spasticity Crone C, Nielsen J, Petersen N, Ballegaard M & Hultborn H. (1994). Brain 117, 1161-1168. Crone C, Johnsen LL & Nielsen J (2000). Clinical neurophysiology suppl 53, 160-178 Morita H, Crone C, Christenhuis D, Petersen NT & Nielsen JB. (2001). Brain. 124(Pt 4), 826-37 Crone C, Johnsen LL, Biering-Sørensen F & Nielsen JB (2003). Appearance of reciprocal facilitation in patients with spasticity. Brain, 126(Pt 2):495-507.

Reciprocal inhibition in stroke patient Before stroke After stroke

Post-activation depression is small in patients with spasticity Nielsen J, Petersen N & Crone C. (1995) Brain. 118: 995-1004 Nielsen J, Petersen, Ballegaard M, Biering-Sørensen F & Kiehn O (1993). Experimental Brain Research 97, 173-176

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

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

Reflekser findes ikke som selvstændige fænomener – de er altid integreret med resten af nervesystemet. Problem for behandling.. j.b.nielsen@mfi.ku.dk

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

Stretch reflexes are not increased in the active spastic muscle Therefore caution when using antispastic medication: Dietz & Sinkjær Lancet Neurol. 2007 Aug;6(8):725-33.

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

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

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

Hvordan skal vi så behandle?

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

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

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

Reinforcing the right movements – phasic dopamine signals

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):1692-8.

It takes time to become an expert

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

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

The End Jens Bo Nielsen Department of Neuroscience and Pharmacology Panum University of Copenhagen E-mail: jbnielsen@sund.ku.dk

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

The End Jens Bo Nielsen Institut for Neurovidenskab og Farmakologi Kan købes på: http://www.hjerneforum.dk/ Jens Bo Nielsen Institut for Neurovidenskab og Farmakologi Panum Københavns Universitet E-mail: j.b.nielsen@mfi.ku.dk

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. 2002 Oct;83(10):1349-54. Blackburn et al. Phys Ther. 2002 Jan;82(1):25-34. Gregson et al. Arch Phys Med Rehabil. 1999 Sep;80(9):1013-6; Biering-Sørensen et al. 2006 )

Biomekanisk evaluering af spasticitet Jakob Lorentzen Hvidovre hosp.

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

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

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

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

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

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