*2.1.2 Lower limb muscle testing*

While a professional consensus has been formed on the upper limb spasticity patterns based on the work of H. Hefter, a consolidated opinion on the lower limb spasticity patterns has not been developed, and the question of determining target muscles and BoNT dosages still remains open [11].

The peculiarity of the lower limb patterns is the ambiguity of their distribution among clinical nosological forms. This fact and the remaining unclear features of the pathogenesis of spasticity is that it does not allow you to choose and apply to the patterns of the lower limb a single classification principle. We can only say about the predominant frequency of occurrence of a particular pattern in any nosology.

Thus, we can distinguish:

1.Spasticity patterns in cerebral palsy.


*Spasticity: Diagnosis and Treatment DOI: http://dx.doi.org/10.5772/intechopen.91046*

	- Adduction.
	- Flexion or extension of the hip.
	- Of equinus.
	- Flexion or extension of the knee.
	- "Triple flexion".
	- Flexion of the ankle joints.
	- Adduction.
	- Flexion of the toes.

4.Patterns of spasticity in stroke and brain injury.


Testing of the muscles of the lower limb is carried out in the supine position, on both limbs, consistently comparing flexion in the joints (to identify poor muscle extensibility not associated with spasticity) [18].

There are two main types of lower limb spasticity patterns in patients undergoing stroke: dynamic pattern (DP) and static pattern (SP), as well as their possible combinations with flexion of the toes and hip reduction. Patterns are proposed based on the principle of visual assessment of the limb position at rest and when walking [19].

In case DP manifestations of spasticity are determined only in the process of movement. In the resting position, the legs do not differ from healthy and its normal statics is kept (limb are visually full length, the joints are in the middle position, and toes are separated), the position of the fingers most often corresponds with the finger of these intact side. Walking is characterized by a peculiar pattern, in which in the phase of hip transfer and knee extension, before lowering the foot to the surface, there are oscillatory movements of the shin from side to side with possible flexion of the fingers. The cause of DP is increased tone and muscle-tendon contraction in the muscles of the back of the thigh (hamstrings), mm. Semitendinosus (S/t), Semimembranosus (S/m), Biceps femoris (BF) and in *M. gracilis* (G).

Gait peculiarity in this type of spasticity is associated with the phylogenetic foundations of neurophysiology of movement in providing the act of walking and is

*2.1.2 Lower limb muscle testing*

**Figure 10.**

**Figure 9.**

*M. Flexor pollicis longus spasticity testing.*

Thus, we can distinguish:

• equinus.

**56**

1.Spasticity patterns in cerebral palsy.

• Flexion of hip and knee joints.

• Internal rotation and the tibia adducci.

muscles and BoNT dosages still remains open [11].

*(C) m. Adductor pollicis, and (D) m. Opponens pollicis.*

While a professional consensus has been formed on the upper limb spasticity patterns based on the work of H. Hefter, a consolidated opinion on the lower limb spasticity patterns has not been developed, and the question of determining target

*Patterns in spasticity of the muscles of the hand. (A) m. Flexor pollicis longus, (B) m. Flexor pollicis brevis,*

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

The peculiarity of the lower limb patterns is the ambiguity of their distribution among clinical nosological forms. This fact and the remaining unclear features of the pathogenesis of spasticity is that it does not allow you to choose and apply to the patterns of the lower limb a single classification principle. We can only say about the predominant frequency of occurrence of a particular pattern in any nosology.

realized through segmental connections, leading, in part, to its automatism [20–22]. As a result, the paretic limb, which tends to step of the same characteristics as the intact one, encounters hamstrings contraction, which leads to a push of the hip and knee backward and medially, stopping the inertia of the limb forward, shortening the step and, sometimes, bringing the hip and shin oscillatory movements [23–25].

SP is characterized primarily by equinecom and equinovarus that can be observed in standing and lying down. There may also be curvature of the pelvic position due to changes in limb length, and/or knee flexion. But more often there is flexion in the ankle joint with a possible compensatory tension of the anterior muscle group of the thigh. The gait in this case becomes circulatory with a slope contralateral to the paresis. This result toning any of the four muscles: m. Soleus (S), m. Gastrocnemius (G/c), m. Tibialis posterior (TP), m. Tibialis anterior (TA).

An additional phenomenon in SP and DP can be flexion of the toes, which is responsible for spasticity mm. Flexor digitorum longus (FDL), Flexor hallucis longus (FHL), Flexor digitorum brevis (FDB), and Flexor hallucis brevis (FHB).

	- A. For the differential diagnosis of posterior thigh muscle hypertonicity, the patient's straight leg is bent at the hip joint. At the limit of extensibility of spastic muscles, involuntary flexion of the leg in the knee joint is fixed. Fixing the leg at this level, use palpation and visually determine tense muscles of the back of the thigh. In difficult cases, for verification of spastic muscles, ultrasound diagnosis should be carried out.
	- B. To test spasticity in the inner thigh muscles (adductors, G and m. Sartorius (Srt)), the leg is retracted to the tensile limit. After that spastic muscles are examined by palpation, visually, and optionally using ultrasonic equipment (**Figure 12**). To differentiate the tone increase in adductors and G, a gracilis test was also performed (**Figure 13**). To identify limitations in the diversion of the leg, it is made bending at the knee (the test must be performed on the edge of the couch). The ability to perform further hip abduction after flexion-indicates spasticity in G. The Lack of response to knee flexion indicates an increase in tone in the adductors.
	- A. To differentiate spasticity in m. Soleus (S) and in the heads of m. Gastrocnemius (G/c), a Silfverskiold test should be performed (**Figure 14**) [26].

During the test, the angle of flexion of the foot is consistently determined with the leg straightened and bent at the knee. No change in the position of the ankle joint in response to flexion of the knee and the foot clonus testify the increase of tone in S. Marked decrease of the bending angle up to 80° or less while you straighten the legs indicates spasticity in G/c. Supination of the foot of any severity in the last phase of the rectification of the foot manifests the increased tone only in the medial head G/c. As an additional test when the leg is straightened, should be a passive extension of the foot

*Sequential test execution Silverskiold's to identify spasticity in m. Gastrocnemius and m. Soleus.*

**Figure 13.**

**Figure 12.**

**Figure 14.**

**59**

*Testing of spasticity in m. Gracilis (gracilis test).*

*Testing of spasticity in the hip adductor muscles.*

*Spasticity: Diagnosis and Treatment*

*DOI: http://dx.doi.org/10.5772/intechopen.91046*

*Spasticity: Diagnosis and Treatment DOI: http://dx.doi.org/10.5772/intechopen.91046*

realized through segmental connections, leading, in part, to its automatism [20–22]. As a result, the paretic limb, which tends to step of the same characteristics as the intact one, encounters hamstrings contraction, which leads to a push of the hip and knee backward and medially, stopping the inertia of the limb forward, shortening the step and, sometimes, bringing the hip and shin oscillatory movements [23–25]. SP is characterized primarily by equinecom and equinovarus that can be observed in standing and lying down. There may also be curvature of the pelvic position due to changes in limb length, and/or knee flexion. But more often there is flexion in the ankle joint with a possible compensatory tension of the anterior muscle group of the thigh. The gait in this case becomes circulatory with a slope contralateral to the paresis. This result toning any of the four muscles: m. Soleus (S), m. Gastrocnemius (G/c), m. Tibialis posterior (TP), m. Tibialis anterior (TA). An additional phenomenon in SP and DP can be flexion of the toes, which is responsible for spasticity mm. Flexor digitorum longus (FDL), Flexor hallucis longus (FHL), Flexor digitorum brevis (FDB), and Flexor hallucis brevis (FHB).

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

A. For the differential diagnosis of posterior thigh muscle hypertonicity, the patient's straight leg is bent at the hip joint. At the limit of extensibility of spastic muscles, involuntary flexion of the leg in the knee joint is fixed. Fixing the leg at this level, use palpation and visually determine tense muscles of the back of the thigh. In difficult cases, for verification of

B. To test spasticity in the inner thigh muscles (adductors, G and m. Sartorius (Srt)), the leg is retracted to the tensile limit. After that spastic muscles are

equipment (**Figure 12**). To differentiate the tone increase in adductors and G, a gracilis test was also performed (**Figure 13**). To identify limitations in the diversion of the leg, it is made bending at the knee (the test must be performed on the edge of the couch). The ability to perform further hip abduction after flexion-indicates spasticity in G. The Lack of response to

spastic muscles, ultrasound diagnosis should be carried out.

examined by palpation, visually, and optionally using ultrasonic

knee flexion indicates an increase in tone in the adductors.

A. To differentiate spasticity in m. Soleus (S) and in the heads of m. Gastrocnemius (G/c), a Silfverskiold test should be performed

*Spasticity testing in posterior thigh muscles (mm. Semitendinosus, Semimembranosus, Biceps femoris, and Gracilis).*

1.Assessment of DP (**Figure 11**):

2.Assessment of SP:

**Figure 11.**

**58**

(**Figure 14**) [26].

**Figure 12.** *Testing of spasticity in the hip adductor muscles.*

**Figure 13.** *Testing of spasticity in m. Gracilis (gracilis test).*

**Figure 14.** *Sequential test execution Silverskiold's to identify spasticity in m. Gastrocnemius and m. Soleus.*

> During the test, the angle of flexion of the foot is consistently determined with the leg straightened and bent at the knee. No change in the position of the ankle joint in response to flexion of the knee and the foot clonus testify the increase of tone in S. Marked decrease of the bending angle up to 80° or less while you straighten the legs indicates spasticity in G/c. Supination of the foot of any severity in the last phase of the rectification of the foot manifests the increased tone only in the medial head G/c. As an additional test when the leg is straightened, should be a passive extension of the foot

**Figure 15.** *Testing of spasticity in m. Tibialis posterior.*

with simultaneous sharp proanation. Visually and by palpation fixed tension of medial head G/c confirms the increase of its tone. The presence of spasticity only in the medial head G/c leads to tension of the medial part of the Achilles tendon, which is manifested by pulling the heel bone back and up with a turn inward.

The modified Ashworth Scale (MAS) serves to objectify muscle tone and is the most used to evaluate the effectiveness of treatment of spasticity of BoNT [31]. MAS allows, without resorting to special measuring tools and calculations, to assess the degree of mobility of the joints, associated with increased muscle tone when performing passive movement. At the same time, MAS does not reveal the nuances of spasticity, such as muscle reactivity, the dependence of its contraction

The modified Tardieu Scale (MTS) [29, 30, 32] allows the most complete assess-

The capabilities inherent in the MTS assessment system allow not only to verify spasticity in more detail, but also to quantify muscle weakness, fatigue, and the

The following algorithm is used to diagnose and treat spasticity (**Figure 16**) [11]: The measurement system incorporated in MTS is performed by a goniometer and must be performed at the same time of the day, and the tested limb must be

The peculiarity of MTS application is the assessment of changes in muscle tone and angles of movement in the joint in response to the provocation of spastic cocontraction (activation of muscles antagonists to movement) and stretch reflex (reaction to tendon stretching) obtained at different speeds of passive movement in

• speed equal to the speed of fall of a limb moving under the action of gravity (V2);

• as soon as possible (V3) (faster than the speed of natural fall of the limb

In recent years, in the professional community, there is a refusal to assess the

ment of all manifestations of spasticity: tone, stretch reflex (reaction to tendon stretching), and spastic co-contraction (inclusion of muscles antagonists to

placed in the same position during repeated testing (**Figure 17**) [11].

The speeds are selected according to the following characteristics:

rate V2 [31, 33], which leaves two fundamental indicators (**Figure 17**):

*(A) Slow passive extension, XV1 and (B) fast passive extension, XV3.*

on the rate of tendon stretching [13].

*Algorithm of diagnosis and treatment of spasticity.*

*DOI: http://dx.doi.org/10.5772/intechopen.91046*

*Spasticity: Diagnosis and Treatment*

state of deep sensitivity [33].

• as slowly as possible (V1);

segment under gravity).

movement).

**Figure 16.**

the joint.

**Figure 17.**

**61**

	- if there is simultaneous flexion of the toes during the extension of the foot, this indicates an increase in tone in m. Flexor digitorum longus (FDL) and/or m. Flexor hallucis longus (FHL);
	- maintaining your posture of flexion, regardless of movements in the ankle joint demonstrates increased tone in m. Flexor digitorum brevis (FDB) and/or m. Flexor hallucis brevis (FHB). Tension in them can also be seen with palpation of the arch of the foot.
