|Year : 2021 | Volume
| Issue : 2 | Page : 51-57
2019 Sidney Licht lecture: Spasticity and related neuro-orthopedic deformities: A core topic in physical and rehabilitation medicine
Department of Physical and Rehabilitation Medicine; Euromov Digital Health in Motion, Montpellier University, France
|Date of Submission||19-Mar-2020|
|Date of Decision||15-Nov-2020|
|Date of Acceptance||19-Nov-2020|
|Date of Web Publication||08-Jun-2021|
Prof. Isabelle Laffont
Department of PRM, Montpellier University Hospital, 191, Boulevard du Doyen Gaston Giraud, 34295, Montpellier Cedex 05
Source of Support: None, Conflict of Interest: None
Neuro-orthopedics refers to limb and spine deformities related to various neurological diseases, mostly in a context of spastic disorders. Physical and rehabilitation medicine (PRM) specialists are familiar with these deformities that often lead to functional consequences. It is crucial in our specialty to focus on their prevention and management. A better understanding of the musculoskeletal and neurological physiopathology underlying these phenomena has enabled physicians to improve their prevention and treatment approaches. The clinical assessment of spastic and neuro-orthopedic deformities, based on a rigorous anatomical and physiological knowledge, is deeply rooted in our PRM clinical examination. The evaluation of their functional consequences relies on a patient-centered approach including detailed analysis of gait and upper limb function. There is an increased relevance of motor nerve blocks, dynamic electromyography, and motion analysis in these indications. The treatment of spasticity and its sequelae is emblematic of PRM care due to an integrative multimodal approach including rehabilitation, pharmacological treatments, local management like botulinum toxin injections, and microinvasive or conventional surgery in a multidisciplinary perspective. Finally, spasticity and neuro-orthopedics represent an incredible field of research for the future of PRM, covering basic science, nonpharmacological and pharmacological studies, surgical procedure improvements, and technological developments (neuromodulation, functional electrical stimulation, and robotics).
Keywords: Assessment, medical intervention, musculoskeletal disorders, rehabilitation, spasticity
|How to cite this article:|
Laffont I. 2019 Sidney Licht lecture: Spasticity and related neuro-orthopedic deformities: A core topic in physical and rehabilitation medicine. J Int Soc Phys Rehabil Med 2021;4:51-7
|How to cite this URL:|
Laffont I. 2019 Sidney Licht lecture: Spasticity and related neuro-orthopedic deformities: A core topic in physical and rehabilitation medicine. J Int Soc Phys Rehabil Med [serial online] 2021 [cited 2021 Jun 13];4:51-7. Available from: https://www.jisprm.org/text.asp?2021/4/2/51/317954
| Introduction|| |
Spasticity and orthopedic-related disorders are an incredibly meaningful and growing field in our specialty of physical and rehabilitation medicine (PRM). The term “spasticity,” or “muscle overactivity,” commonly includes various muscle tone and motor disorders in patients with neurological diseases. The term “neuro-orthopedics” refers to the musculoskeletal and joint consequences of muscle tone or motor disorders after neurological lesions. In clinical practice, we know that in neurological conditions, muscle tone disorders and their orthopedic sequelae are deeply interconnected.
The clinical description of limb deformities in neurological patients has significantly evolved over the last 60 years, along with explanation of their underlying pathophysiology. These deformities are related to three different phenomena that may be overlap:
- Direct neural mechanisms, including muscle tone and other motor disorders, may frequently lead to limb and trunk deformities. The most common neural mechanism is spasticity, first described by Lance 40 years ago, consisting of an increased muscle tone due to the disrupted balance between supraspinal inhibitory and excitatory sensory inputs directed to the spinal cord, and leading to a disinhibition of the stretch reflex. Other neurological disorders, such as spastic dystonia described by Denny Brown, spastic co-contractions, spasms, and extrapyramidal dysfunction including paratonia, may also contribute to the development of these deformities
- These neural mechanisms are interlinked with “non-neural” musculoskeletal mechanisms, some of them being under neural control. Among them, the most important ones are the connective tissues changes that led to a substantial number of recent publications, muscular structural changes described as the “spastic myopathy,” and heterotopic ossifications
- Aggravating factors constitute the additional mechanisms that can contribute to the worsening of functional impairments by increasing muscle stiffness and joint deformities., Part of them stem from neurological origin like secondary motor or cognitive decline, sensory loss, or pain. Others are due to external factors including acute medical conditions, immobility from various origins, physical restraints, or drugs.
These three mechanisms intertwine in a single patient over time, potentially leading to a vicious circle where the functional status can be worsened by secondary aggravating factors. Muscle tone disorders and motor weakness are the most deleterious, leading to loss of mobility, potential secondary contractures, and joint deformities. This may cause pain, discomfort and worsening of spasticity, and sometimes leads to behavioral disorders or motor and functional decline. Unfortunately, these symptoms may lead to the prescription of medication or physical restraints and can promote the caregivers' burden and directly or indirectly increase medical costs. Preventing and breaking this escalating cascade is mandatory. PRM teams can have an essential role to play in these conditions.
| Spasticity and Related Neuro-orthopedic Disorders are Becoming a Global Health Problem|| |
Muscle tone disorders and their musculoskeletal consequences have become a global health issue. With increasing life expectancy worldwide and population growth, more and more people are reaching ages where neurological disorders prevail. The burden of neurological disorders has substantially increased over the past 25 years, becoming one of the leading causes of disability. Between 1990 and 2015, the number of deaths from neurological disorders increased by 36.7% and the Daily Adjusted Life Years by 7.4%.
Stroke remains the largest contributor to the global burden. The incidence of stroke was 16 million people in 2005 and is expected to increase to an estimated 23 million by 2030. There was an estimated prevalence of 62 million stroke survivors worldwide in 2005, with projections to reach 77 million by 2030. Considering that 30%–40% of stroke patients must cope with significant spasticity and/or related orthopedic consequences, one may extrapolate that the absolute number of patients suffering from neuro-orthopedic disorders has also significantly increased. Direct costs for stroke survivors with spasticity are almost four times higher than their counterparts without spasticity, thus contributing to the overall burden.
Additionnally, many patients with other neurological diseases experience muscle tone disorders and limb deformities, including multiple sclerosis, cerebral palsy (CP), brain injury and spinal cord injury. As a result, the incidence of spasticity and its consequences have become more frequent worldwide.
| Spasticity and Related Neuro-orthopedic Disorders are Deeply Rooted in Our Physical and Rehabilitation Medicine History|| |
The first description and definition of spasticity was provided by James Waldo Lance and published in neurology in 1980. Lance was an Australian neurologist who moved to Wales (UK). His main research domain was on spasticity, muscle tone, and movement disorders. His founding works have been published in neurology journals between 1960 to the present time. One of his earliest works on the mechanisms of spasticity was published in the Archives of Physical Medicine and Rehabilitation in 1974, anchoring this topic in the history of PRM medical practices. Today, it is accepted that PRM physicians are experts at managing spasticity, both in research and in daily clinical practices.
The evaluation and treatments of orthopedic deformities related to neurological diseases were first described in poliomyelitis, a typically non-spastic medical condition. As the treatment and study of poliomyelitis was the keystone that founded our medical specialty during the past century across world, we can say that our basic collective knowledge was inherited from poliomyelitis:
- Poliomyelitis laid the foundation for our biomechanical approach of the human musculoskeletal system
- We learned from polio that in humans, the lower limb muscles operate in a closed chain when the foot is in contact with the floor. For example, the triceps surae is not only a plantar flexor of the ankle but also a knee extensor during the stance phase of gait. Similarly, based on this reverse biomechanical principle, we learned that the main cause of genu recurvatum in stroke patients lies in spasticity and/or contracture of the triceps surae
- The poliomyelitis epidemics led to the founding principles of rehabilitation of neurological patients and the orthopedic treatments of joint and spine deformities mainly based on orthoses and braces
- Finally, poliomyelitis gave birth to the main surgical techniques applied to musculoskeletal deformities used in neurological disorders: arthrodesis, tendon lengthening, and tendon transfer. In France, we recognize that most of the current principles of surgical treatment of deformities were first described in young poliomyelitis patients.,
| Spasticity and Related Neuro-orthopedic Disorders: A Specific Medical and Surgical Reasoning|| |
The assessment and treatment of spasticity and neuro-orthopedic deformities requires clinical reasoning based on the International Classification of Functioning (ICF) model, focusing first on the functional impairment and the physical capacity and then analyzing spastic or neuro orthopedic disorders, at the body level.
The decision to treat relies firstly on analyzing the patient's needs. When focusing on the deformity, the clinical reasoning is then based on strict biomechanical and neurophysiological examination including the neurological and the orthopedic features. Achieving a functional goal in a patient-centered process remains the primary objective.
- A severe deformity may be tolerated with little impact on quality of life or on daily function. Such deformities should be respected. For example, surgical correction of a fixed flexed wrist due to tendons contractures in CP should be respected until it causes pain or functional impairments (for example dressing)
- A severe deformity can be adapted to a useful purpose, and its medical or surgical correction can worsen the patient's function. There are numerous examples of orthopedic disorders, in which correction should be considered with caution in neurological patients: pes equinus in patients with weak knee extensors, hip adduction in adult CP patients with weak knee extensors, shoulder adduction in “thoracobrachial prehension,” elbow flexion or clawed fingers used for passively carrying objects [Picture 1].
| Spasticity and Related Neuro-Orthopedic Disorders Encompass the Most Representative Assessment Tools in Physical and Rehabilitation Medicine|| |
The assessment of limb deformities and their functional consequences in neurologically impaired patients are representative of the comprehensive evaluation strategy made by PRM teams, based on the ICF conceptual framework. These evaluation methods include specific and non specific clinical and instrumental tools that have became essential to our medical and/or medicosurgical practices. This includes modern and evidence-based PRM techniques such as selective motor nerve blocks (SMNBs) or motion analysis and dynamic electromyographic recordings.
Selective motor nerve blocks
The use of peripheral motor nerve blocks in PRM to assess spastic patients was described more than 50 years ago. SMNBs consist of a percutaneous injection of a local anesthetic drug around a peripheral nerve, usually Lidocaine® or Ropivacaine®, under ultrasonographic and/or electrostimulation guidance.
- The SMNBs are key in differentiating muscle spasticity or dystonia from muscle contracture: when the deformity disappears after the motor block, we can conclude that it is from spastic or dystonic origin. In these cases, a focal medical treatment or a neurosurgical procedure is required. In the other cases, a tendon lengthening may be proposed.
- SMNBs may also be used as a diagnostic tool as they can predict the outcome and functional relevance of long-lasting medical or surgical therapies such as neurotomy, phenol blockage, or botulinum toxin injections (BTIs)
- In frail patients, SMNBs may help in predicting potential unwanted detrimental effects of local spasticity treatment: for example, a distal branch of the femoral nerve block to assess its effect on unlocking of the knee before BTI into the rectus femoris or vastus intermedius in MS patients
- SMNBs may contribute to defining surgical treatment strategies by predicting the amount of voluntary motor control in muscles that are antagonist to the spastic deformity.
There are numerous sites to target SMNBs in PRM practices. In the lower limb, the motor block of the distal branches of the femoral nerve, helps in refining medical or surgical targets to decrease knee extension spasticity/dystonia, especially in stiff-knee gait patterns. SMNB of the obturator nerve is regularly used in France for the assessment of hip adduction. MNB of the trunk or tibial nerve branches is widely used to assess pes equinovarus and claw toe: in these cases, blocking the distal branches of the tibial nerve (distal to the knee) should prevent sensory disturbance and allows the analysis of its benefits on transfers or gait when the lower leg muscles are temporarily relaxed. Blocking the distal tibialis posterior nerve in its retromalleolar position can help improve our understanding of claw toes. In the upper limb, the trunk of the pectoralis nerve can be blocked to examine the role of pectoralis major and minor in the adduction and medial rotation of the shoulder. Blocking the trunk and/or the branches of the musculocutaneous nerve allows for an assessment of elbow flexors spasticity or contracture differentiating the respective role of the three different elbow flexors (biceps brachii, brachialis, and brachioradialis) and the role of accessory elbow flexors such as the bi articular forearm muscles. Distally, a SMNB of the trunk and branches of the median and ulnar nerves can help the understanding of hand and fingers deformities, including analyzing the respective participation of the intrinsic and/or extrinsic muscles in these deformities.
The SMNB in our practice is now a mandatory PRM step in determining the most appropriate medical or surgical treatment for spastic deformities in complex situations.
Motion analysis and dynamic electromyography
Motion analysis includes kinematics, kinetics, and electromyographic movement recordings. It has been used for several decades ago for gait analysis, as well as in the assessment of postural and prehension disorders' in neurological patients. In the exploration of spasticity and neuro-orthopedic disorders, it started with children with CP on whom medical and surgical treatments can only be determined based on the results of these assessments. Its use in neurologically impaired adult patients, especially for upper limb assessment, remains rare, but constitutes a growing field of interest, both in research and in clinical practice.
Motion analysis may include simple and easy-to-use devices such as instrumented treadmills, wearable devices, or video recording. This analysis allows clinicians to assess patients in an instrumental and quantifiable way in addition to routine clinical assessments such as clinical score and questionnaires. They are widely used in PRM clinical practice. More complex systems exist, such as tridimensional kinematic analysis devices, yielding more complex information for therapeutic or research purposes. The number of PRM studies that include such approaches in the field of spasticity and related orthopedic disorders is rapidly expanding.
| Spasticity and Related Neuro-orthopedic Disorders are Covering All Fields of Physical and Rehabilitation Medicine Treatments|| |
The treatment of muscle overactivity and its orthopedic consequences is emblematic of PRM care as it is based on an integrative multimodal approach including rehabilitation, pharmacological management, local treatments such as BTIs, and microinvasive or conventional surgery in a multidisciplinary perspective.
Systemic treatments of muscle disorders are recommended for generalized spasticity. Many medications have been proposed in these indications: baclofen, benzodiazepines (diazepam, clonazepam), tizanidine, gabapentin, dantrolene sodium, and cannabinoids. However, adverse effects (drowsiness, sedation, hypotension, and weakness) usually occur at doses lower than those required to reduce spasticity, which limits treatment benefits. The potential deleterious effects of these drugs on brain plasticity limit their use in patients with severe brain injury. Their effectiveness in managing muscle overactivity has been evidenced at body level, but their relevance in improving functioning and activities remains debated.
Local pharmacological treatments include BTI and neurolytic agent's administration. Available in 95 countries worldwide, botulinum toxin type A (BT-A) acts on the neuromuscular junctions, inhibiting the exocytosis of acetylcholine from presynaptic nerve endings. The adverse effects of BT-A injections are local pain, fever, fatigue, transient dysphagia, and exceptionally, botulism-like syndrome due to its dissemination to other body parts. However, several reviews have concluded that BT-A injection is safe and effective in reducing spasticity. Its effectiveness on active and passive function was evidenced for lower limb and upper limb treatments. BTIs are currently the first-line treatment for focal muscle overactivity in patients with neurological injuries.
First described by Tardieu, chemodenervation with alcohol and phenol was extensively used before the development of BT-A and functional neurosurgery. Alcohol and phenol denature proteins and injure nerve cells, producing nonselective neuronal degeneration and surrounding fibrosis. Due to the risk of neuropathic pain, injections in nerves with sensory contingent should be avoided, reserving this treatment to the distal collateral motor nerve branches only. Several uncontrolled studies demonstrated a decreased in spasticity after motor nerve blocks with alcohol and phenol, with a wide range of spasticity reduction and duration of action.
The two main approaches for nonpharmacological management of spasticity consist of the removal of noxious stimuli that can drive hypertonicity and implementing physical modalities with various effects on muscles fibers, neuro-muscular spindles, and neuronal control of muscle tone. Although a broad range of nonpharmacological approaches have been the object of various clinical trials on spasticity in different neurological cohorts, there is limited high-quality evidence for their effectiveness. The methodological quality and evidence in systematic reviews vary.
These approaches include thermotherapy, cryotherapy, instrumental postures by splinting or orthosis, kinesiotaping, electrotherapy, biofeedback, vibrations, shock waves, central or peripheric neuromodulation, acupuncture, walking exercises with bodyweight support, robotic rehabilitation, stretching, motor reinforcement, aerobic exercises, and neurodevelopmental therapy, among others. Shock wave therapy is the most promising method. Since none of the other approaches have yielded proof of their effectiveness, it seems that associations between methods might be promising.
Surgery has an important role to play in the treatment of spastic muscle overactivity and related orthopedic disorders. Orthopedic surgery applied to this field includes tendon lengthening, tendon transfers, arthrodesis, osteotomies, and heterotopic ossification removal. Its main objective is to correct limb/joint deformities and rebalance the muscular control of the joints. By changing muscle functioning and modifying the tension-length muscle relationship, the other consequence of orthopedic surgery is to decrease muscle tone and thus efficiently treat muscle tone disorders. Neurosurgical surgery is also frequently proposed, aiming at decreasing muscle tone. A large variety of techniques are available; however, the level of evidence of these surgical methods is yet to be established, especially regarding their functional benefits: neurotomy or neurectomy, radiculotomy, dorsal root entrance zone rhizotomy, intrathecal baclofen pump implantation, and deep brain stimulation.
The interdisciplinary approach between surgeons and PRM physicians is essential. We must work hand in hand with surgical teams, keeping in mind that balanced treatments including both medical and surgical approaches should regularly be proposed to our patients. We must work with surgeons on a shared timeline, considering that surgery is no longer a last-chance treatment, but could be considered as a rehabilitation tool in the care pathway of patients with neurological impairments.
Depending on the objectives of the treatment, on the underlying pathology, and on the results of the multidisciplinary assessment of the patients, medical or surgical treatments will be proposed. The general strategy is summarized in [Figure 1] and [Figure 2].
|Figure 1: Treatment strategies for upper limb deformities in the context of spastic disorders. For shoulder and elbow, medical treatments are the most prevalent (in grey): Botulinum toxin injections, intra articular injections, neurolysis and percutaneous tenotomies. Surgical treatments are more frequent for wrist and hand deformities and are represented by the size of the red triangle at the bottom of the picture: tendon lengthening, neurotomies, arthrodesis, and sometimes tendon transfers|
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|Figure 2: Treatment strategies for lower limb deformities in the context of spastic disorders. Except for patients requiring intrathecal baclofen pump implantation or removal of a heterotopic ossification, medical treatments are the most prevalent (in grey): Botulinum toxin injections, intra articular injections, neurolysis and percutaneous tenotomies. Surgical treatments are very frequent for ankle and foot deformities and are represented by the size of the red triangle at the bottom of the picture: tendon lengthening, neurotomies, arthrodesis, and frequent tendon transfers|
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| Spasticity and Related Neuro-orthopedic Disorders Cover the Main Physical and Rehabilitation Medicine Research Domains|| |
Basic science and clinical research in PRM constitute a growing field, highlighting the maturity and dynamism of our medical specialty. Research on muscle overactivity and related orthopedic disorders is emblematic of our innovation capacity in the care management of disabled patients. It also illustrates the evolution of PMR medical practices, from the historical empirical approaches to our modern evidence-based medicine.
Improving knowledge in basic science is mandatory for understanding the underlying pathophysiological mechanisms of SNO. Some of some groups currently working on the neurophysiological mechanisms driving the onset and worsening of spasticity after neurological insult,, with the idea that understanding the diversity of muscle tone disorders will help refine the optimal medical treatment, far beyond our currently available pharmacological treatments. Other PRM teams are conducting biochemical/biological research studies on connective tissues disorders and others, on heterotopic ossifications in a neurological context. This research is very promising for the future of dedicated medical, pharmacological, or physical treatments. Finally, progresses in understanding the biomechanical mechanisms of motor control adaptation after neurological lesions will undoubtedly help in building our future reasoning applied to limbs/trunk deformities for functional improvements.
Clinical research in the field comprises methodological research on the metrological properties of the tools and scales widely used to assess muscle tone disorders and their consequences on the musculoskeletal system. There is also an increasing amount of research on the use of three-dimensional movement analysis in the follow-up of spastic patients, sometimes provided through robotic devices and proposed for spasticity evaluation. Evaluation-relating innovations also include the emerging technics of intramuscular anesthetics blockages, the dramatical increasing use of ultrasounds to assess muscles structure and function, and the widespread use of functional multichannel dynamic electromyography. Implementing these technologies could greatly enhance the decision-making.
Clinical research also includes clinical trials for the validation of various treatments for muscle overactivity and musculoskeletal disorders or prevention. Many recent and promising improvements in PRM care apply to this field: Evolution in BTI indications, preventive pharmacological or non pharmacological treatments of contractures, microinvasive procedures such as percutaneous tenotomy or neurotomy performed by PRM physicians [Picture 2], noninvasive brain stimulation, and new surgical procedures.
| Conclusion|| |
Spasticity and related musculoskeletal deformities evaluation and treatment are an emblematic field of our specialty:
- PRM physicians share the same clinical reasoning based on a CIF approach that historically underlined our therapeutic approach for such disorders
- This topic covers the main PRM domains, leading to the fact that improvements in PRM care in this field will benefit the main domains of our specialty
- Research in muscle overactivity and related neuro-orthopedics disorders covers the most important fields of PRM research: from basic science to clinical research and technological developments
- This domain highligths highlights the urgent need for close cooperation with other medical specialists, surgeons, and other rehabilitation professionals.
This field is also emblematic of a modern and promising PRM specialty, emphasizing the medical side of our specialty. Preventing and treating muscle tone disorders and related deformities directly contributes to the reduction of disability worldwide.
I acknowledge Pr Olivier Dizien, Dr. Denormandie, Dr. Flavia Coroian, Dr. Anthony Gelis, Dr. François Feuvrier, Pr Denis Mottet, and Pr Bertrand Coulet, who helped me in constructing my clinical and research experience in this field on a daily basis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]