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Spasticitet

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.

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Spasticitet

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  1. 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

  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. 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.

  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, 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.

  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: 995-1004 Nielsen J, Petersen, Ballegaard M, Biering-Sørensen F & Kiehn O (1993). Experimental Brain Research 97, 173-176

  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.. j.b.nielsen@mfi.ku.dk

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

  16. 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.

  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 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

  23. 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):1692-8.

  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 • E-mail: jbnielsen@sund.ku.dk

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

  31. The End 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

  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. 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 )

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

  37. Force (N) Ang Disp (deg) 0 0 Ang Vel (deg/s) 0 10 20 30 40 Time (s) 10 20 30 40 50 0 10 20 30 40 50 Måling af muskelstivhed 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 Maria Willerslev-Olsen

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