Purpose: To discuss the measurement of spasticity in the clinical and research environments, make recommendations based on the SPASM reviews of biomechanical, neurophysiological and clinical methods of measuring spasticity and indicate future developments of measurement tools. Method: Using the results of the systematic reviews of the biomechanical, neurophysiological and clinical approaches, methods were evaluated across three dimensions: (1) validity, reliability and sensitivity to change; (2) practical quality such as ease of use and (3) qualities specific to the measurement of spasticity, for example ability to be applied to different muscle groups. Methods were considered in terms of applicability to research and clinical applications. Results: A hierarchy of measurement approaches was identified from highly controlled and more objective (but unrelated to function) to ecologically valid, but less objective and subject to contamination from other variables. The lack of a precise definition of spasticity may account for the problem of developing a valid, reliable and sensitive method of measurement. The reviews have identified that some tests measure spasticity per se, some phenomena associated with spasticity or consequential to it and others the effect of spasticity on activity and participation and independence. Conclusions: Methods appropriate for use in research, particularly into the mechanism of spasticity did not satisfy the needs of the clinician and the need for an objective but clinically applicable tool was identified. A clinical assessment may need to generate more than one ‘value’ and should include evaluation of other components of the upper motor neurone syndrome. There is therefore a need for standardized protocols for ‘best practice’ in application of spasticity measurement tools and scales.

Theoretical and methodological considerations in the measurement of spasticity

Epidural electrical stimulation of posterior structures of the human lumbosacral cord: 3. Control of spasticity

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Epidural electrical stimulation of posterior structures of the human lumbosacral cord: 3. Control Of spasticity.

Purpose: To review and characterise biomechanical approaches for the measurement of spasticity as one component of the upper motor neurone syndrome. Method: Systematic literature searches based on defined constructs and a four-step review process of approaches used or described to measure spasticity, its association with function or associated phenomena. Most approaches were limited to individual joints and therefore, to reflect this trend, references were grouped according to which body joint(s) were investigated or whether it addressed a functional activity. For each joint, references were further sub-divided into the types of measurement method described. Results: A database of 335 references was established for the review process. The knee, ankle and elbow joints were the most popular, perhaps reflecting the assumption that they are mono-planar in movement and therefore simpler to assess. Seven measurement methods were identified: five involving passive movement (manual, controlled displacement, controlled torque, gravitational and tendon tap) and two involving active movement (voluntary and functional). Generally, the equipment described was in an experimental stage and there was a lack of information on system properties, such as accuracy or reliability. Patient testing was either by cohort or case studies. The review also conveyed the myriad of interpretations of the concept of spasticity. Conclusions: Though biomechanical approaches provide quantitative data, the review highlighted several limitations that have prevented them being established as an appropriate method for clinical application to measure spasticity.

Biomechanical approaches applied to the lower and upper limb for the measurement of spasticity: a systematic review of the literature.

Gravity-induced oscillations of the lower leg in normal and spastic subjects were examined with a view towards evaluating a clinical test of spasticity called the pendulum test. For passive limb motion (in which no reflex excitation occurred), a second-order linear model did not provide an adequate description of the motion for either spastic or normal legs. System equations including nonlinear mechanical properties simulating asymmetries in the swing and amplitude dependent variations in stiffness and damping provided a more accurate description. For spastic limb motion (in which reflex excitation did occur) accurate simulation required components accounting for abnormal reflex activation, coinciding with the time course of EMG activation. These included increased stiffness and damping with their gains related to reflex EMG magnitude, and changes in the rest length of the stiffness. Comparison of numerical with experimental data showed that the nonlinear model simulated the motion accurately, with the variance accounted for usually exceeding 90%. >

A quantitative analysis of pendular motion of the lower leg in spastic human subjects

In paraplegic patients with upper motor neuron lesions the signal path from the central nervous system to the muscles is interrupted. Functional electrical stimulation applied to the lower motor neurons can replace the lacking signals. A so-called neuroprosthesis may be used to restore motor function in paraplegic patients on the basis of functional electrical stimulation. However, the control of multiple joints is difficult due to the complexity, nonlinearity, and time-variance of the system involved. Furthermore, effects such as muscle fatigue, spasticity, and limited force in the stimulated muscle further complicate the control task. Mathematical models of the human musculoskeletal system can support the development of neuroprosthesis. In this article a detailed overview of the existing work in the literature is given and two examples developed by the author are presented that give an insight into model-based development of neuroprosthesis for paraplegic patients. It is shown that modelling the musculoskeletal system can provide better understanding of muscular force production and movement coordination principles. Models can also be used to design and test stimulation patterns and feedback control strategies. Additionally, model components can be implemented in a controller to improve control performance. Eventually, the use of musculoskeletal models for neuroprosthesis design may help to avoid internal disturbances such as fatigue and optimize muscular force output. Furthermore, better controller quality can be obtained than in previous empirical approaches. In addition, the number of experimental tests to be performed with human subjects can be reduced. It is concluded that mathematical models play an increasing role in the development of reliable closed-loop controlled, lower extremity neuroprostheses.

Model–based development of neuroprostheses for paraplegic patients

Goniometric records of a swinging lower leg (pendulum test) provide useful information in assessing the level of hypertonia in normals, spinal cord injured (SCI) patients and hemiparetic patients. A linearised second-order dynamic model without forcing function is proposed for a normal and hypotonic paraplegic leg Forces which appear in the quadriceps muscle in spastic patients are simulated with hypertonia torquest Th. A combined biomechanical and neural model is proposed to facilitate qualitative discussion of the observed phenomena. Large variability of goniograms in spastic patients as well as lack of detailed knowledge regarding the neurophysiology of spasticity prevents further development of realistic models which should be time varying and nonlinear.

Dynamics of spastic knee joint.

Various electrical stimuli with frequencies from 10 Hz to 1000 Hz and pulse widths from 10 μs to 1000 μs were applied to seven spinal-cord injured patients with spasticity of the knee muscle. Spasticity was assessed with the pendulum test and EMG activity in the quadriceps and hamstrings. No universal optimum combination of stimulation parameters could be established but stimuli of 100 Hz and 100 μs pulse width were more effective than other combinations. Subjective remarks of patients regarding the effects over 24 h did not always correlate with measured data obtained within one hour after stimulation.

T. Bajd

Papers

Dynamics of spastic knee joint.

Effects of stimulation parameters on modification of spinal spasticity.

Dermatome stimulation differences in paraplegic and hemiplegic spasticity