Spasticity and Muscle Stiffness: Restoring Form and Function

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