*1.5.4 Outcome measure*

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

The term "spastic dystonia" was coined by Denny-Brown in 1966 to define tonic-chronic muscle activity that is present in a spasticity pattern, during rest [15]. Thus, spastic dystonia could be described as a spontaneous overactivity at rest, not induced by a primary triggering factor [14–16]. It is easy to recognise it in patients with spastic paresis, as spastic dystonia causes specific bad postures in joints and body. For example, in the upper limb, the shoulder can stay internally rotated and adducted with a flexed and pronated elbow and flexed wrist and fingers. Equinovarus deformity represents a specific spastic dystonia in the lower limb, and it is characterised by plantar flexors and/or toe flexors, which may be painful and

Spastic co-contraction is defined as an "unwanted, excessive, level of antagonistic muscle activity during voluntary command on an agonist muscle, which is aggravated by tonic stretch in the co-contracting muscle" [13]. Spastic co-contraction in spasticity pattern is a descending phenomenon, most probably due to misdirection of the supraspinal drive. It may be caused by loss of reciprocal inhibition during voluntary command [9, 10]. So, voluntary command of an agonist muscle is the first step, which induces spastic co-contraction. In patients with good or fairly good motor control, spastic co-contraction is certainly the most disabling form of muscle overactivity, because it obstacles muscle physiological muscle voluntary

For each movement evaluated, the corresponding muscles and joints are stretched at a very slow speed, in order to keep below the threshold for eliciting a stretch reflex. The angle at which soft tissue offers a maximum resistance is defined

For each movement evaluated, the clinician should stretch the corresponding muscles and joints as fast as possible for the examiner. The spasticity grade is determined by the joint angle at which catch or clonus appears, according to Tardieu

For each passive movement evaluated at first, the clinician asks the patient to carry out an active movement at maximal range, until the active movement produced by the agonist muscles is contrasted by the passive resistance together with the spastic co-contraction of antagonist ones. This angle measure is the effective

• Velocity-dependent.

• Length-dependent.

disabling during walking.

**1.4 Spastic co-contraction**

recruitment.

**1.5 Clinical evaluation**

*1.5.1 Passive range of motion*

*1.5.3 Active range of motion*

active range of motion [18].

as the passive range of motion for that joint [17].

*1.5.2 Angle of catch or clonus and spasticity grade*

**1.3 Spastic dystonia**

**116**

scale [18].

Tardieu score is a scale realised to measure spasticity that evaluates resistance to passive movement at both slow and fast speed. Individuals are evaluated both in in sit and supine position. There are two types of measures:


The quality of muscle reaction is scored as follows (range 0–4):


In order to consider joint angle, speed movement has to be defined:


Regarding the joint angle, modified Tardieu describes:


The angle of full ROM (R2) is defined at a very slow speed (V1). The angle of muscle reaction (R1) is detected when a catch or clonus appears during a quick stretch (V3) [19].

Ashworth scale, original version (1964), is a test which quantifies resistance to passive movement, with respect to a joint and with varying degrees of velocity. Scores range from 0 to 4:

0.No increase in tone.


3.Considerable increase in tone, passive movement difficult.

4.Limb rigid, sometimes fixed in flexion or extension.

The modified Ashworth scale (Bohannon & Smith, 1987) is similar to the original one, except for a 1+ scoring category to indicate resistance through less than half of the movement [20].
