1. Spasticity after spinal cord injury
Jens Bo Nielsen
Department of Physical Exercise and Sport Science
&
Department of Neuroscience and Pharmacology
Panum
Københavns Universitet

2. Center for Research in Spasticity and Neurorehabilitation
Purpose: Coordination of research activities in danish laboratories devoted to research in Spasticity and Neurorehabilitation
By:
1) Facilitate transfer of knowledge from basic neurobiology to clinic
2) Facilitate development of new evaluation and rehabilitation techniques with a neuroscientific basis
Center for Research in Spasticity and Neurorehabilitation
Rigshospitalet
Panum
Hans Hultborn
Kurt Jørgensen
Jens Bo Nielsen
Jørgen E. Nielsen
Nicolas Petersen
Fin Biering-Sørensen
Clarissa Crone
Christian Krarup
Mads Ravnborg
Hvidovre hospital
Terry Jernigan
Søren Anker Pedersen
Egill Rostrup
Stig Sonne-Holm
Jesper Bencke
Thomas Sinkjær
Jørgen Feldbæk Nielsen 2

3. Spasticity – short history
1841 – Marshall Hall: Decapitated frogs. Automatic movements in paretic limbs – called reflexes (introduced by Willis). Tone: Certain degree of firmness. Tone caused by reflexes
1863 – Sechenev: release of reflex function from cerebral inhibition
1880: Brissaud differentiates reflex mediated stiffness and contracture with the use of ischemia (blocks reflex)
1885: Gowers argues that stretch reflex and tone are related
1890: Haidenhain concludes that tone is a reflex which depends on resistance
: Sherrington describes reflexes and points out that muscle tone is complex and should be carefully described when mentioned.

4. Definition of spasticity
Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (’muscle tone’) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neuron syndrome.
Lance, Spasticity: Disordered Motor Control 1980

5. But in the clinic ”spasticity” is used more broadly:
Increased muscle tone
Multiple sclerosis
Stroke
Spinal cord injury
Amyotrophic lateral sclerosis
Traumatic brain injury
Cerebral palsy
Tumors
Hereditary spastic paraparesis
(Neurolatyrism)
(hyperekplexia (startle disease)?)
Hyperexcitable tendon jerks
(stretch reflexes)
Spasms
Spastic gait
Babinski
Increased flexor reflexes
and contractures

6. Different pathophysiological mechanisms are involved
Lance´s definition
Velocity dependent resistance to stretch. Increased stretch reflexes
Spasms – sustained activity after input. Role of flexor reflexes, role of Mn properties?
Spontaneous muscle activity at ´rest´. = increased muscle tone at rest. Lesion of basal ganglia?
Contractures. Alteration of passive muscle properties
Spastic Gait ??

7. Does lesion of the corticospinal tract lead to spasticity?
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.

8. Spasticity is not seen immediately after lesion but develops over several months
From Ashby 1973

9. Pathophysiological mechanisms in spasticity

10. Control of reciprocal inhibition in healthy human subjects

11. 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):

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

13. SInkjær et al Clin Neurophysiol. 1999 May;110(5):951-9.NB
Decreased contribution from afferent feedback to the soleus muscle during walking in patients with spastic stroke. Mazzaro et al. J Stroke Cerebrovasc Dis Jul-Aug;16(4):135-44

14. Reduced reflex modulation during bicycling in strokeNB
Schindler et al. 2007

15. Reciprocal inhibition is increased following explosive strength training. Increased ability of producing force quickly.
Geertsen et al.; indsendt til J Appl Physiol 15

16. How to evaluate spasticity?
Ashworth scale has generally been found to be reliable for the upper arm, but NOT for the lower limb
(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): )

17. Biomechanical evaluation of spasticity
Jakob Lorentzen
Hvidovre hosp.

18. Larger resistance to stretch in spastic muscle
“False” positive
“False” negative
Healthy range

19. Evaluation of muscle resistance by handheld dynamometer is well correlated to resistance measures by stationary device
R2:0,711

20. Reasonable intra- and interrater reliability

21. But not significantly larger resistance measured by handheld device in patients with spasticity according to Ashworth scale

22. The End Jens Bo Nielsen Institut for Neurovidenskab og Farmakologi
Panum
Københavns Universitet