**3.1 Rating scale for evaluating the condition of muscles**

The main scales to assess the condition of the muscles are: the scale of muscle contraction force and volume of voluntary movements (MRCS), modified Ashworth scale (MAS) and the Tardieu scale (MTS) [27–30].

The scale of muscle contraction strength and volume of voluntary movements (Medical Research Council Scale (Oxford Scale), MRCS) allows to estimate the strength of muscle contraction and amplitude of active movements in the limb.

### **Figure 16.**

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

B. To determine the increase in tone *m. Tibialis* anterior (TA), it is

the foot is the evidence of increase of its tone.

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

necessary to make a rapid flexion of the foot followed by pronation. This maneuver provokes a stretch reflex in TA. The detected tension TA (visually and by palpation) and the contour of the tendon at the back of

C. To test spasticity in *m. Tibialis* posterior (TP), it is necessary to perform a rapid extension of the foot followed by pronation. This triggers the stretch reflex to TP. The muscle is not visually controllable, but its tendon runs along the lower edge of the medial ankle. Palpation recorded muscle tension and tendon contouring indicates an increase in its tone

D.Diagnosis of spasticity in the flexors of the toes is made by performing

longus (FDL) and/or m. Flexor hallucis longus (FHL);

The main scales to assess the condition of the muscles are: the scale of muscle

The scale of muscle contraction strength and volume of voluntary movements

the strength of muscle contraction and amplitude of active movements in the limb.

• if there is simultaneous flexion of the toes during the extension of the foot, this indicates an increase in tone in m. Flexor digitorum

• 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

sequential passive flexion and extension in the ankle joint:

**3. Scales for assessing spasticity and disorders of activity and**

contraction force and volume of voluntary movements (MRCS), modified

(Medical Research Council Scale (Oxford Scale), MRCS) allows to estimate

**3.1 Rating scale for evaluating the condition of muscles**

Ashworth scale (MAS) and the Tardieu scale (MTS) [27–30].

and up with a turn inward.

*Testing of spasticity in m. Tibialis posterior.*

**Figure 15.**

(**Figure 15**).

the foot.

**participation**

**60**

*Algorithm of diagnosis and treatment of spasticity.*

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 on the rate of tendon stretching [13].

The modified Tardieu Scale (MTS) [29, 30, 32] allows the most complete assessment of all manifestations of spasticity: tone, stretch reflex (reaction to tendon stretching), and spastic co-contraction (inclusion of muscles antagonists to movement).

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 state of deep sensitivity [33].

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

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 the joint.

The speeds are selected according to the following characteristics:


In recent years, in the professional community, there is a refusal to assess the rate V2 [31, 33], which leaves two fundamental indicators (**Figure 17**):

**Figure 17.** *(A) Slow passive extension, XV1 and (B) fast passive extension, XV3.*

XV1 – angle measured at speed V1. ХV3 – the angle measured at the speed V3.

The Tardieu scale offers a flexible evaluation system that allows you to use different approaches in the diagnosis of spasticity, opens the possibility of choosing evaluation parameters, provides options for both rapid evaluations based on one or two parameters, and a full-scale study of spasticity and paresis with the calculation of indices and coefficients, which makes it possible to register the minimum rehabilitation dynamics.

(1.5–2 times or less), with severe limitation of movement in the joint indicates a worse prognosis and the need for active exercises on muscle stretching or diagnosis

**The 2nd variant of application** of MTS actually does not assume the use of the table of a point estimation and is based on variety of measurements of angles of movement in a joint and change of a scope of movements depending on manifesta-

• ХV1—angle range of passive movement of a limb at a slow speed (angle arrest);

The main calculated value in the 2nd variant of MTS application is the spasticity

As part of the diagnosis and treatment, it is also necessary to know the XN – angle of the normal volume of movement in a particular joint. This is necessary not only to understand the degree of spasticity but also to calculate the coefficients proposed in the scale and characterizing the state of the muscles. Such factors are: (1) velocity factor (C shorting) muscle CSH, (2) ratio of spasticity (spasticity C) CS; (3) the coefficient of weakness (weakness C) muscle CW; and (4) coefficient of

Measuring XA and XA15 and calculating CF and CW fill another important gap in

There is also a muscle reaction angle (x): measured as the difference between the forced position of the joint and the angle of the normal anatomical position of the

In a complete evaluation system for the Tardieu scale includes not only the motion estimation but also sensitivity. Verification of deep sensitivity disorders is achieved by measuring the proprioception angle (XP). Normally, the brain fixes the

At neurological examination, as a rule, it is considered sufficient to reveal only the fact of violation of muscular-articular feeling. But, for the prognosis of spastic-

neurology—the ability to fully quantify paresis, thereby significantly

limb and its segments (applies to all joints except the hip) [32, 34].

ity, qualitative diagnosis of proprioception disorders and evaluation of

XS ¼ ХV1 � XV3*:* (2)

• XV3—angle stop movement of the limbs at high speed (angle catch);

working the antagonist muscles spasticity (active motion));

• XA—angle muscle power (corner of the active movement in the joint by

• ХА15—angle fatigue of the muscle (measured after 15 s of working the

of joint contracture [13].

*Spasticity: Diagnosis and Treatment*

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

tions of spasticity, register:

angle (XS):

fatigue (fatigue C) CF:

1.CSH = (XN � XV1)/XN.

2.CS = (XV1 � XV3)/XV3.

3.CW = (XV1 � XA)/XV1.

4.CF = (XA � XA15)/XA.

**63**

complementing the use of MRCS [33].

angular displacement in the joints to 2–3°.

antagonist muscles spasticity).

There are two main ways to use MTS. The first of them involves taking into account the score, which reflects the characteristics of the reaction of muscles and tendons in response to their stretching, the other option is based on taking into account the angle of the movement end, without a special assessment of the nuances of the muscle reaction. It is also possible to combine the use of both options or the use of separate elements from each of them.

**In the 1st variant of MTS** application, the assessment is based on two parameters: the degree of muscle reaction (Y) in points and the angle at which the muscle reaction (X) in degrees is achieved.

To score the degree of muscle reaction (Y), a table of scores and their interpretations is used (**Table 1**).

The estimated home value of 1st version of evaluation is **Index Tardieu** (IT)—the ratio Y (point) to X (degrees) achieved at different speeds of movement in the joint:

$$\text{IT}\left(\text{V1}, \text{V2}, \text{V3}\right) = \text{Y}\left(\text{score}\right) / \text{X}\left(\text{angle in degrees}\right). \tag{1}$$

Thus, if the angle at which the reaction occurs and/or the score varies with the velocity, we get three results. For example, in the elbow joint:

1. IТV1 = 1/180 = 0.005.

2. IТV2 = 2/90 = 0.022.

3. IТV3 = 3/90 = 0.033.

ITV1 characterizes increased muscle tone outside the reaction to the stretch reflex and demonstrates the degree of shortening of the muscle. The results obtained at V2 and V3 rates characterize the degree of muscle reaction to the tendon stretching rate and are different degrees of stretch reflex provocation.

A significant difference between ITV1–V3 (2.5 times or more) may indicate the degree of dynamism of the muscle-tendon contracture or its absence, which allows us to count on a good result when using BoNT. A slight difference in the values of it


**Table 1.** *Quality of muscle reaction.* XV1 – angle measured at speed V1.

rehabilitation dynamics.

ХV3 – the angle measured at the speed V3.

or the use of separate elements from each of them.

velocity, we get three results. For example, in the elbow joint:

reaction (X) in degrees is achieved.

tations is used (**Table 1**).

1. IТV1 = 1/180 = 0.005.

2. IТV2 = 2/90 = 0.022.

3. IТV3 = 3/90 = 0.033.

**Points Interpretation**

5 Joint immobile

**Table 1.**

**62**

*Quality of muscle reaction.*

The Tardieu scale offers a flexible evaluation system that allows you to use different approaches in the diagnosis of spasticity, opens the possibility of choosing evaluation parameters, provides options for both rapid evaluations based on one or two parameters, and a full-scale study of spasticity and paresis with the calculation of indices and coefficients, which makes it possible to register the minimum

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

There are two main ways to use MTS. The first of them involves taking into account the score, which reflects the characteristics of the reaction of muscles and tendons in response to their stretching, the other option is based on taking into account the angle of the movement end, without a special assessment of the nuances of the muscle reaction. It is also possible to combine the use of both options

**In the 1st variant of MTS** application, the assessment is based on two parameters: the degree of muscle reaction (Y) in points and the angle at which the muscle

To score the degree of muscle reaction (Y), a table of scores and their interpre-

The estimated home value of 1st version of evaluation is **Index Tardieu** (IT)—the ratio Y (point) to X (degrees) achieved at different speeds of movement in the joint:

Thus, if the angle at which the reaction occurs and/or the score varies with the

ITV1 characterizes increased muscle tone outside the reaction to the stretch reflex and demonstrates the degree of shortening of the muscle. The results

obtained at V2 and V3 rates characterize the degree of muscle reaction to the tendon

A significant difference between ITV1–V3 (2.5 times or more) may indicate the degree of dynamism of the muscle-tendon contracture or its absence, which allows us to count on a good result when using BoNT. A slight difference in the values of it

1 Slight resistance throughout with no clear catch at a precise angle

stretching rate and are different degrees of stretch reflex provocation.

0 No resistance throughout passive movement

2 Clear catch at a precise angle, followed by release 3 Fatigable clonus (10 s) occurring at a precise angle 4 Unfatigable clonus (>10 s) occurring at a precise angle

IT V1, V2, V3 ð Þ¼ Y score ð Þ*=*X angle in degrees ð Þ*:* (1)

(1.5–2 times or less), with severe limitation of movement in the joint indicates a worse prognosis and the need for active exercises on muscle stretching or diagnosis of joint contracture [13].

**The 2nd variant of application** of MTS actually does not assume the use of the table of a point estimation and is based on variety of measurements of angles of movement in a joint and change of a scope of movements depending on manifestations of spasticity, register:


The main calculated value in the 2nd variant of MTS application is the spasticity angle (XS):

$$\mathbf{X\_{S}} = \mathbf{X\_{V1}} - \mathbf{X\_{V3}}.\tag{2}$$

As part of the diagnosis and treatment, it is also necessary to know the XN – angle of the normal volume of movement in a particular joint. This is necessary not only to understand the degree of spasticity but also to calculate the coefficients proposed in the scale and characterizing the state of the muscles. Such factors are: (1) velocity factor (C shorting) muscle CSH, (2) ratio of spasticity (spasticity C) CS; (3) the coefficient of weakness (weakness C) muscle CW; and (4) coefficient of fatigue (fatigue C) CF:


Measuring XA and XA15 and calculating CF and CW fill another important gap in neurology—the ability to fully quantify paresis, thereby significantly complementing the use of MRCS [33].

There is also a muscle reaction angle (x): measured as the difference between the forced position of the joint and the angle of the normal anatomical position of the limb and its segments (applies to all joints except the hip) [32, 34].

In a complete evaluation system for the Tardieu scale includes not only the motion estimation but also sensitivity. Verification of deep sensitivity disorders is achieved by measuring the proprioception angle (XP). Normally, the brain fixes the angular displacement in the joints to 2–3°.

At neurological examination, as a rule, it is considered sufficient to reveal only the fact of violation of muscular-articular feeling. But, for the prognosis of spasticity, qualitative diagnosis of proprioception disorders and evaluation of

rehabilitation dynamics is not enough. This provision has a pathophysiological justification. One version of the pathogenesis of spasticity is the activation of muscle contraction in response to afferentation insufficiency [7]. Obtaining information about the degree of proprioception impairment allows us to predict the subsequent development of spasticity, suggesting the effectiveness and assessing the dynamics of rehabilitation. That in turn makes it possible to talk about such a definition as "rehabilitation potential" and plan the volume, structure and timing of rehabilitation of the patient.

slow-speed stop (V1) occurs at the extreme point of extension in the joint 115°, which indicates the absence of muscle contractures. Stopping at a fast speed (V3) occurs at 80°, which characterizes the stretch reflex and co-contraction of the ankle

In the case where it is necessary to evaluate the extensor muscles of the joint, the

Most often, spasticity limits the following movements: flexion and retraction in the shoulder joint, extension in the elbow, wrist and wrist joints, supination of the forearm, extension/flexion of the hip and knee joints, hip abduction, extension and pronation of the foot, and extension of the toes [19, 35]. Accordingly, the reference point for measuring the volume of these movements will be located at the point of

*Measurement of MTS range of motion in the shoulder (a) and elbow (b) joints in typical spasticity patterns.*

*Measurement of range of motion of MTS in the wrist joint in extension of wrist (a) and supination of the*

stretching and flexion of the joint. The starting point is the point lying on the shin axis, but since the maximum extension of the foot reaches 115°, the movement begins only from the position 65°. The entire range of flexion in the joint is esti-

flexor muscles. The calculated spasticity angle in this case will be 35°.

maximum contraction of the muscles that prevent this movement

mated, that is, up to 135°.

*Spasticity: Diagnosis and Treatment*

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

(**Figures 19–25**) [11].

**Figure 19.**

**Figure 20.**

**65**

*forearm (b) when the typical patterns of spasticity.*

movement is carried out in the opposite direction-toward their maximum

Full use of all the features of the Tardieu scale actually allows you to make a "passport" of a certain muscle. In cases where we cannot isolate the function of a single muscle, differentiating it from the synergists, we identify the effect of spasticity of movement in the joint as a whole. An example of this is the work of the muscles of the back of the thigh, where we cannot separate the function of m. Semitendinosus and m. Semimembranosusand assess the degree of their isolated effect on movement in the joint [35].

The "passport" of spastic muscles or restrictions of movements in the joint can be presented in the form of a table:


Especially important for the use of the Tardieu evaluation system is the understanding of the principles of measuring motion in the joint, in particular, the selection of the reference point of the angle of motion. In this case, the measurement system is different from that adopted in orthopedic practice. The reference point is the point is opposite to the studied movement or, in other words, the measurement is carried out from the extreme points of flexion/extension, reduction/withdrawal, pronation/supination, that is, the points to which the cocontraction tends [11]. The point is selected along the axis of the limb segment under study, regardless of whether the segment reaches this point or not. The main task is to make a movement from the point of greatest muscle relaxation to the point of maximum muscle stretching. A good example of this is the study of the movement during the extension of the ankle joint with spasticity in its flexors (**Figure 18**) [12].

Angles are measured from the point lying on the continuation of the axis line of the shin outside the limits of possible flexion in the ankle joint, that is, the count of extension in the joint a priori begins with 45°. The entire range of extension in the joint measured from the line of continuation of the Shin, that is, to the angle of 115°, is estimated. Thus, the movement is carried out in the direction of maximum stretching of the flexors of the joint. In the presented example (**Figure 18**), the

*Measurement of the volume movements of the MTS with increasing tonus of flexors of the ankle joint.*

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

rehabilitation dynamics is not enough. This provision has a pathophysiological justification. One version of the pathogenesis of spasticity is the activation of muscle contraction in response to afferentation insufficiency [7]. Obtaining information about the degree of proprioception impairment allows us to predict the subsequent development of spasticity, suggesting the effectiveness and assessing the dynamics of rehabilitation. That in turn makes it possible to talk about such a definition as "rehabilitation potential" and plan the volume, structure and timing of rehabilita-

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

Full use of all the features of the Tardieu scale actually allows you to make a "passport" of a certain muscle. In cases where we cannot isolate the function of a single muscle, differentiating it from the synergists, we identify the effect of spasticity of movement in the joint as a whole. An example of this is the work of the muscles of the back of the thigh, where we cannot separate the function of m. Semitendinosus and m. Semimembranosusand assess the degree of their isolated

The "passport" of spastic muscles or restrictions of movements in the joint can

**Muscle/joint XV1 XV3 XS XA XA15 XP CSH CS CW CF**

Especially important for the use of the Tardieu evaluation system is the under-

contraction tends [11]. The point is selected along the axis of the limb segment under study, regardless of whether the segment reaches this point or not. The main task is to make a movement from the point of greatest muscle relaxation to the point of maximum muscle stretching. A good example of this is the study of the movement during the extension of the ankle joint with spasticity in its flexors (**Figure 18**) [12]. Angles are measured from the point lying on the continuation of the axis line of the shin outside the limits of possible flexion in the ankle joint, that is, the count of extension in the joint a priori begins with 45°. The entire range of extension in the joint measured from the line of continuation of the Shin, that is, to the angle of 115°, is estimated. Thus, the movement is carried out in the direction of maximum stretching of the flexors of the joint. In the presented example (**Figure 18**), the

standing of the principles of measuring motion in the joint, in particular, the selection of the reference point of the angle of motion. In this case, the measurement system is different from that adopted in orthopedic practice. The reference point is the point is opposite to the studied movement or, in other words, the measurement is carried out from the extreme points of flexion/extension, reduction/withdrawal, pronation/supination, that is, the points to which the co-

*Measurement of the volume movements of the MTS with increasing tonus of flexors of the ankle joint.*

tion of the patient.

**Figure 18.**

**64**

effect on movement in the joint [35].

be presented in the form of a table:

slow-speed stop (V1) occurs at the extreme point of extension in the joint 115°, which indicates the absence of muscle contractures. Stopping at a fast speed (V3) occurs at 80°, which characterizes the stretch reflex and co-contraction of the ankle flexor muscles. The calculated spasticity angle in this case will be 35°.

In the case where it is necessary to evaluate the extensor muscles of the joint, the movement is carried out in the opposite direction-toward their maximum stretching and flexion of the joint. The starting point is the point lying on the shin axis, but since the maximum extension of the foot reaches 115°, the movement begins only from the position 65°. The entire range of flexion in the joint is estimated, that is, up to 135°.

Most often, spasticity limits the following movements: flexion and retraction in the shoulder joint, extension in the elbow, wrist and wrist joints, supination of the forearm, extension/flexion of the hip and knee joints, hip abduction, extension and pronation of the foot, and extension of the toes [19, 35]. Accordingly, the reference point for measuring the volume of these movements will be located at the point of maximum contraction of the muscles that prevent this movement (**Figures 19–25**) [11].

**Figure 19.**

*Measurement of MTS range of motion in the shoulder (a) and elbow (b) joints in typical spasticity patterns.*

### **Figure 20.**

*Measurement of range of motion of MTS in the wrist joint in extension of wrist (a) and supination of the forearm (b) when the typical patterns of spasticity.*

Considering the treatment of spasticity as part of the rehabilitation process and, given that the therapeutic effect on spasticity has the ultimate goal of normalizing the life and activities of the patient, Graces recommends the following step-by-step strategy for the use of the tardier scale [33].

**Figure 21.** *Measuring the volume of movements by MTS in typical spasticity patterns in the joints of the hand.*

**Figure 22.**

*Measurement of MTS range of motion in the hip and knee joints with gluteus maximus (a) and hamstrings (b) spasticity.*

Step 1: Maximum volume of passive movement (PROM-passive range of motion) in the joint at slow speed, assessment of the degree of muscle

*Measurement of the volume of movements by MTS in the ankle joint with spasticity of Gastrocnemius (a)*

Step 2: Passive movement in the joint at fast speed, evaluation of spasticity

Step 4: Active and rapid movement in the joint for 15 s. With the subsequent

Step 5: Assessment of limb function and human activity (various activity and participation tests) (LASIS, Frenchay, 10 m walk test, etc.) = F (limb function).

shortening (angle arest) = XV1.

*Measuring the volume of movements by MTS in adductor spasticity.*

*Spasticity: Diagnosis and Treatment*

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

**Figure 25.**

**67**

**Figure 24.**

*and Soleus (b).*

(Y and/or angle catch) = XV3.

Step 3: Active joint movement, strength score = XA.

angle measurement, assessment of fatigue = XA15.

### **Figure 23.**

*Measurement of range of motion at the MTS when spasticity in the rectus (a) and lateral vastus, and medial, intermediomedialis et lateralis of m. Quadriceps femoris (b).*

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

Considering the treatment of spasticity as part of the rehabilitation process and, given that the therapeutic effect on spasticity has the ultimate goal of normalizing the life and activities of the patient, Graces recommends the following step-by-step

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

*Measuring the volume of movements by MTS in typical spasticity patterns in the joints of the hand.*

*Measurement of MTS range of motion in the hip and knee joints with gluteus maximus (a) and hamstrings*

*Measurement of range of motion at the MTS when spasticity in the rectus (a) and lateral vastus, and medial,*

*intermediomedialis et lateralis of m. Quadriceps femoris (b).*

strategy for the use of the tardier scale [33].

**Figure 21.**

**Figure 22.**

**Figure 23.**

**66**

*(b) spasticity.*

**Figure 24.** *Measuring the volume of movements by MTS in adductor spasticity.*

#### **Figure 25.**

*Measurement of the volume of movements by MTS in the ankle joint with spasticity of Gastrocnemius (a) and Soleus (b).*


Step 3: Active joint movement, strength score = XA.


The place and role of MTS in rehabilitation is demonstrated in the following algorithm of rehabilitation approach to patients with spastic paresis (**Figure 26**) [34]. It involves testing the patient, identifying the problem, selecting the rehabilitation goal, developing an intervention plan, and then analyzing the outcome with the selection of the new rehabilitation goal.

allow to sufficiently assess the effectiveness of botulinum therapy and rehabilitation

In the treatment of spasticity, the use of MTS allows us to conclude how the introduction of BoNT had an impact on the rehabilitation of the patient. The choice of a specialist drug BoNT for the treatment of spasticity is based on the experience

pharmacoeconomics. On average, the duration of various drugs BoNT in patients

Thus, the stages of application of MTS in the treatment of spasticity BoNT are:

2. testing 3–4 weeks after injection, which demonstrates the effectiveness of BoNT;

Thus, the modified Tardieu scale (MTS) is convenient for full-scale diagnosis of the main elements of the clinical picture of the central nervous system damage, such as paresis, spasticity, proprioception disorders and allows to qualitatively and

Spasticity has an extremely negative impact on daily and professional activities, severely restricts independent movement, self-service, reduces the role of the individual in the family and society. The therapeutic effect on spasticity has the ultimate goal of normalizing the life and activity of the patient and with a favorable

The Hauser walking index (HAI) and the Rivermead mobility index (RMI) are used to verify self-mobility and self-service violations. Since these scales are not sensitive enough to small changes in mobility, they should be supplemented by a quantitative test to assess walking: distance, time, and independence [36–38].

The concept of self-service includes not only movement but also its assessment should be supplemented by the analysis of the degree of influence of spasticity in the hand on daily activities. The most convenient and informative tool for this analysis is the Leeds scale of influence of spasticity of the hand on the activity

The Hauser Ambulation Index (HAI) includes the ranking of patients by 10 gradations depending on the need for external assistance, the use of devices for

Index of Rivermead mobility (Rivermead Mobility Index, RMI) [37, 38]. The value of the mobility index, developed at the Rivermead center, Cambridge Uni-

The range of values of the scale of the index can vary from 0 points (the inability to perform any of these actions on their own) to 15 points (the ability to run 10 m), which corresponds to normal human mobility. Of particular value for assessing the impact of spasticity on human activity, this test acquires due to the fact that it includes tasks similar to those performed by a person in everyday practice (that is, it

3. testing 12–20 weeks after injection of BoNT. Evaluation at this time interval shows the effectiveness of rehabilitation, as well as being a baseline assessment

and analysis of many factors, among which one of the most significant is

with spasticity reaches 12–14 weeks [11].

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

for deciding on the next injection session.

quantitatively assess the dynamics of treatment and rehabilitation.

outcome provides the return to the original standard of living [36].

movement, and the time of passing the test distance [34, 36].

versity, is the sum of the points: 1 point for each positive response.

1. testing before injection;

*Spasticity: Diagnosis and Treatment*

**3.2 Activity and participation scales**

(LASIS) [34, 39, 40].

**69**

*3.2.1 Movement assessment*

dynamics.

It is possible to use MTS in the most limited form. It is enough to measure V1 and V3 and calculate XS. Registering these three parameters and their changes will

**Figure 26.** *Algorithm of diagnosis and treatment of a patient with spastic paresis.*

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

The place and role of MTS in rehabilitation is demonstrated in the following algorithm of rehabilitation approach to patients with spastic paresis (**Figure 26**) [34]. It involves testing the patient, identifying the problem, selecting the rehabilitation goal, developing an intervention plan, and then analyzing the outcome with

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

It is possible to use MTS in the most limited form. It is enough to measure V1 and V3 and calculate XS. Registering these three parameters and their changes will

the selection of the new rehabilitation goal.

**Figure 26.**

**68**

*Algorithm of diagnosis and treatment of a patient with spastic paresis.*

allow to sufficiently assess the effectiveness of botulinum therapy and rehabilitation dynamics.

In the treatment of spasticity, the use of MTS allows us to conclude how the introduction of BoNT had an impact on the rehabilitation of the patient. The choice of a specialist drug BoNT for the treatment of spasticity is based on the experience and analysis of many factors, among which one of the most significant is pharmacoeconomics. On average, the duration of various drugs BoNT in patients with spasticity reaches 12–14 weeks [11].

Thus, the stages of application of MTS in the treatment of spasticity BoNT are:

1. testing before injection;

2. testing 3–4 weeks after injection, which demonstrates the effectiveness of BoNT;

3. testing 12–20 weeks after injection of BoNT. Evaluation at this time interval shows the effectiveness of rehabilitation, as well as being a baseline assessment for deciding on the next injection session.

Thus, the modified Tardieu scale (MTS) is convenient for full-scale diagnosis of the main elements of the clinical picture of the central nervous system damage, such as paresis, spasticity, proprioception disorders and allows to qualitatively and quantitatively assess the dynamics of treatment and rehabilitation.

### **3.2 Activity and participation scales**

Spasticity has an extremely negative impact on daily and professional activities, severely restricts independent movement, self-service, reduces the role of the individual in the family and society. The therapeutic effect on spasticity has the ultimate goal of normalizing the life and activity of the patient and with a favorable outcome provides the return to the original standard of living [36].

The Hauser walking index (HAI) and the Rivermead mobility index (RMI) are used to verify self-mobility and self-service violations. Since these scales are not sensitive enough to small changes in mobility, they should be supplemented by a quantitative test to assess walking: distance, time, and independence [36–38].

The concept of self-service includes not only movement but also its assessment should be supplemented by the analysis of the degree of influence of spasticity in the hand on daily activities. The most convenient and informative tool for this analysis is the Leeds scale of influence of spasticity of the hand on the activity (LASIS) [34, 39, 40].

### *3.2.1 Movement assessment*

The Hauser Ambulation Index (HAI) includes the ranking of patients by 10 gradations depending on the need for external assistance, the use of devices for movement, and the time of passing the test distance [34, 36].

Index of Rivermead mobility (Rivermead Mobility Index, RMI) [37, 38]. The value of the mobility index, developed at the Rivermead center, Cambridge University, is the sum of the points: 1 point for each positive response.

The range of values of the scale of the index can vary from 0 points (the inability to perform any of these actions on their own) to 15 points (the ability to run 10 m), which corresponds to normal human mobility. Of particular value for assessing the impact of spasticity on human activity, this test acquires due to the fact that it includes tasks similar to those performed by a person in everyday practice (that is, it

### *Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

has a high "environmental friendliness"). Also, this test can be used to assess the effectiveness of the use of BoNT in relation to the improvement of movement [41].

Walking assessment tests. A common feature of these tests is the lack of assessment of walking quality. Unfortunately, walking quality cannot be reliably assessed without the use of laboratory gait analysis techniques. But it must be borne in mind that it will always be more important for the patient to be able to reach the object he needs safely and quickly than to walk "beautifully." Therefore, the above scales and tests do not lose their relevance in clinical practice, despite the development of instrumental methods for diagnosing walking disorders.

### *3.2.2 Evaluation of hand productivity*

For a quick (less than 10 min) evaluation of the possibility of manipulation (capture, lifting and transfer) objects of different sizes, you must use the "Test with nine pegs" (objects with a diameter of about 1 cm), the test "Box and blocks" (box and Block Test) (cube edge 2.5 cm), the test ARAT (Action Research Arm Test) (manipulation of objects with different sizes, shapes, and weights), Frenchay test (evaluation of functional movements: fixing the ruler, manipulation of objects of different sizes, pinch grip, as well as the ability to touch the top of the head), and Leeds Arm Spasticity Impact Scale (LASIS) [42–45].

This scale was developed at the University of Leeds to measure the effect of spasticity on the functionality and care procedures for paresis of the hand [44]. The daily activities of the patient or the caregiver during the preceding 7 days shall be taken into account.

color staining is effective, but practically not required for work on the limbs and in

*Indicative ultrasound picture with symbols. Screen view of Edge (FujiFilm SonoSite Inc.'s handheld ultrasound*

**Ultrasonic sensor.** Optimal, generally accepted and convenient for muscle visualization is a linear sensor with a width of about 38–50 mm and an operating frequency of 3–16 MHz. Sensors of smaller width narrow the ultrasound picture, thereby reducing the orientation space, some key points fall out of sight. This is especially noticeable when working on large muscle arrays, such as the thigh muscles.

1.Skin and bones represent the most superficial and deepest layers obtained by ultrasound navigation. Due to their acoustic properties, they tend to be hyperechogenic, that is, look light, bright. Tendons look almost the same.

3.Arteries and veins. Anechoic (black) tubular structures. Arteries are pulsating and round, veins can be round or oval. A distinctive feature of veins is their

4.Muscle tissue is hypoechoic, compared to bones or tendons; its structure is flooded with bright spots. If these points are traced along the muscle, you can

5.Nerves. With good resolution, you can see the structure of the nerve. Due to the presence of nerve fibers, its cut is similar to a honeycomb. The nerve, as a rule, is located next to the blood vessel and is considered as part of the

**Workplace organization.** It is necessary to pay serious attention to the workplace, achieving its convenience, the correct location of the elements necessary for work.

2.Tendons are hyperechogenic. They have a characteristic fibrillar striated structure in the longitudinal and granular in the transverse section.

fact is only necessary for the ultrasound of tissues on the body and neck.

**Ultrasound picture of tissues** (**Figure 27**).

**Figure 27.**

*Spasticity: Diagnosis and Treatment*

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

*machine).*

easy compression when pressed by the sensor.

see how they come together and form tendons.

neurovascular bundle.

**71**

In each case, the respondent, the patient and/or the caregiver are asked if the action is feasible or not. The difficulty is evaluated on the scale from 0 to 4.

Modified scale Frenchay (Modified Frenchay Test MFS) allows to estimate the functional state of hands. The concept of "functional state" indicates how the sick hand is adapted to everyday life and participates in it [46].

### **4. Treatment of spasticity**

### **4.1 Methods of injection of BoNT in spasticity**

The effectiveness of treatment of spasticity BoNT depends on the accuracy of the introduction into the target muscle and thus is directly related to the skill of a particular specialist and possession of his methods of navigation [47].

### *4.1.1 Ultrasonic navigation in the treatment of spasticity*

Representations of the injection point and depth of the target muscle, based on the knowledge of anatomy, are often incorrect. The location of muscles and bones relatively to each other, their volume is individual, and the presence of vessels and nerves at the injection site is unpredictable. Only 15–20% of individual anatomical structure corresponds to that presented in the relevant atlases. Any pathology, associated with the distortion of movement, exacerbates the differences in the relative position and volume of muscles. Thus, the orientation to the generally accepted anatomical guidelines in the introduction of BoNT makes the treatment of spasticity extremely ineffective. Ultrasound scanning is the main navigation method for BoNT injections in the treatment of spasticity [17].

**Ultrasound scanner.** To navigate the muscles in botulinum therapy, it is enough to have a black and white ultrasound scanner. The use of the Doppler effect and

**Figure 27.**

has a high "environmental friendliness"). Also, this test can be used to assess the effectiveness of the use of BoNT in relation to the improvement of movement [41]. Walking assessment tests. A common feature of these tests is the lack of assessment of walking quality. Unfortunately, walking quality cannot be reliably assessed without the use of laboratory gait analysis techniques. But it must be borne in mind that it will always be more important for the patient to be able to reach the object he needs safely and quickly than to walk "beautifully." Therefore, the above scales and tests do not lose their relevance in clinical practice, despite the development of

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

For a quick (less than 10 min) evaluation of the possibility of manipulation (capture, lifting and transfer) objects of different sizes, you must use the "Test with nine pegs" (objects with a diameter of about 1 cm), the test "Box and blocks" (box and Block Test) (cube edge 2.5 cm), the test ARAT (Action Research Arm Test) (manipulation of objects with different sizes, shapes, and weights), Frenchay test (evaluation of functional movements: fixing the ruler, manipulation of objects of different sizes, pinch grip, as well as the ability to touch the top of the head), and

This scale was developed at the University of Leeds to measure the effect of spasticity on the functionality and care procedures for paresis of the hand [44]. The daily activities of the patient or the caregiver during the preceding 7 days shall be

In each case, the respondent, the patient and/or the caregiver are asked if the

Modified scale Frenchay (Modified Frenchay Test MFS) allows to estimate the functional state of hands. The concept of "functional state" indicates how the sick

The effectiveness of treatment of spasticity BoNT depends on the accuracy of the introduction into the target muscle and thus is directly related to the skill of a

Representations of the injection point and depth of the target muscle, based on the knowledge of anatomy, are often incorrect. The location of muscles and bones relatively to each other, their volume is individual, and the presence of vessels and nerves at the injection site is unpredictable. Only 15–20% of individual anatomical structure corresponds to that presented in the relevant atlases. Any pathology, associated with the distortion of movement, exacerbates the differences in the relative position and volume of muscles. Thus, the orientation to the generally accepted anatomical guidelines in the introduction of BoNT makes the treatment of spasticity extremely ineffective. Ultrasound scanning is the main navigation

**Ultrasound scanner.** To navigate the muscles in botulinum therapy, it is enough to have a black and white ultrasound scanner. The use of the Doppler effect and

particular specialist and possession of his methods of navigation [47].

method for BoNT injections in the treatment of spasticity [17].

action is feasible or not. The difficulty is evaluated on the scale from 0 to 4.

instrumental methods for diagnosing walking disorders.

Leeds Arm Spasticity Impact Scale (LASIS) [42–45].

hand is adapted to everyday life and participates in it [46].

**4.1 Methods of injection of BoNT in spasticity**

*4.1.1 Ultrasonic navigation in the treatment of spasticity*

*3.2.2 Evaluation of hand productivity*

taken into account.

**70**

**4. Treatment of spasticity**

*Indicative ultrasound picture with symbols. Screen view of Edge (FujiFilm SonoSite Inc.'s handheld ultrasound machine).*

color staining is effective, but practically not required for work on the limbs and in fact is only necessary for the ultrasound of tissues on the body and neck.

**Ultrasonic sensor.** Optimal, generally accepted and convenient for muscle visualization is a linear sensor with a width of about 38–50 mm and an operating frequency of 3–16 MHz. Sensors of smaller width narrow the ultrasound picture, thereby reducing the orientation space, some key points fall out of sight. This is especially noticeable when working on large muscle arrays, such as the thigh muscles.

**Ultrasound picture of tissues** (**Figure 27**).


**Workplace organization.** It is necessary to pay serious attention to the workplace, achieving its convenience, the correct location of the elements necessary for work.

• Musculoskeletal (Msk) mode, optimal for muscle examination.

upper limbs in adults; the average depth are the following:

• The middle and lower third of the forearm-3.3 cm.

3.Frequency (frequency/THI) – the wave frequency is directly related to the ability to penetrate into tissue. It should be remembered that the higher the frequency, the faster the tissue absorption and shallower penetration of the signal, the lower the frequency, the greater the signal immersion. On average, the optimal frequency for the muscles of the shoulder girdle, shoulder, and

forearm is 7–8 MHz, for the muscles of the hand from 10 MHz.

allowing for higher contrast and resolution of the object.

image, change its profile, remove image interference, etc.

1.Way to № 1. Transversely to the ultrasound beam.

*4.1.3 Types and methods of needle insertion under ultrasound control*

4.Focus (focus). Focus on a specific object from the overall scan pattern,

5.Brightness (gain). This is the ability to amplify all signals from the entire image. It is perceived as the increased brightness of the picture. It should be noted that with excessive amplification, tissue boundaries may be fuzzy and

In addition to the basic adjustments, there are additional ones that can be used to change the power of the ultrasonic wave, improve the quality and overview of the

The needle is inserted at an angle to the plane of the sensor and, accordingly, transversely to the plane of the ultrasonic beam. The thickness of the ultrasound beam is 2–3 mm. Therefore, when moving the needle, the researcher sees only the displacement of tissues from it and only that part of it, or the slice that passed through the beam (**Figure 29**). This method, despite the limitations of needle visibility, is convenient, easy to learn and most often used in practice.

2.Way to № 2. In the plane of the ultrasonic beam (longitudinally). Introduction of the needle from the end of the working surface of the sensor at an angle. In this case, the entire needle is in the plane of the beam and is fully visible

This method has some limitations: even a slight change in the angle of the sensor relatively to the skin or its displacement leads to the loss of the needle

• Muscles of the shoulder girdle-up to 4 cm.

• Shoulder muscles-up to 4–6 cm.

*Spasticity: Diagnosis and Treatment*

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

• Muscles of the hand-up to 2 cm.

interference may occur.

(**Figure 30**).

**73**

• Upper third of the forearm 3.3–4 cm.

2.Depth in most cases, the optimal depth is greater than the depth at which the target muscle is located. This is because when scanning, it is necessary to focus on the surrounding markers—vessel, bone, tendon, etc. for examination of the

**Figure 28.** *Example of workplace organization for injection under ultrasound control.*

The task of the doctor is not just to locate and verify the muscle, but also to make an injection. It should be borne in mind that the positioning of the limbs may be difficult due to spasticity and disturbance of the patient's consciousness. Picturing the muscles can be distorted by muscle contraction, etc. Therefore, it is preferable to use portable ultrasound scanner that allows you to easily move the machine around the patient. The most convenient location of the patient is between the doctor and the screen, the doctor does not have to turn around in order to study the ultrasound picture, and he can place all the necessary tools directly in front of him/her (**Figure 28**).
