Upper Motor Neurone Syndrome and Spasticity: Clinical Management and Neurophysiology.

Upper Motor Neurone Syndrome and Spasticity: Clinical Management and Neurophysiology. Barnes MB, Johnson GR, eds. New York, NY 10011-4211, Cambridge University Press, 2001, paperback, 326 pp, illus, ISBN: 0-521-79427-7, $49.95.

The editors and the chapter authors of this book should be commended for compiling this detailed, accurate, and up-to-date reference on spasticity and upper motor neuron (UMN) syndrome. This well-written text deals with 3 major topics related to spasticity: neurophysiology, measurement, and clinical management. It also contains a section devoted to management of spasticity in children.

In the initial chapters, the authors review and distinguish between the positive and negative signs of UMN syndrome, including spasticity, clonus, clasp-knife reflex, involuntary spasms, co-contraction, weakness, and loss of dexterity. Each of these signs is defined and described in considerable detail. The pathophysiological mechanisms underlying each sign are discussed in light of available scientific literature. Consideration is given to neural as well as biomechanical factors that contribute to UMN syndrome. Readers will come away with a wealth of information about the neurophysiology of UMN syndrome as well as an appreciation for its complex, heterogeneous nature.

The chapter dealing with measurement of spasticity covers the Ashworth Spasticity Scale, pendulum test, motorized biomechanical tests, and electrophysiological tests. Citing relevant literature, the author discusses the validity and reliability of measurements, and strengths and limitations of each test. There is a brief section devoted to gait analysis. One of the strengths of this chapter is the author's accurate remarks on the absence of a clear relationship between quantitative measures and the clinical degree of spasticity.

The later portion of the book reviews the principal approaches to clinical management of UMN syndrome, including physical therapy, seating and positioning, orthoses, medication, and surgery. The chapter addressing physical therapy deals strictly with spasticity and UMN signs associated with brain lesions. The authors' thinking is up to date as shown by their emphasis on treating negative signs, such as weakness and loss of muscle control, rather than on conditioning hyperexcitable reflexes. The goals and benefits of appropriate seating and bracing for individuals with spasticity are discussed in 2 separate chapters, with emphasis on the lower extremities. Whenever possible, the authors support their claims about the effectiveness of physical interventions with scientific literature, and, in the absence of adequate data, they cite clinical experience.

In the chapter on the pharmacological management of spasticity, oral medications (baclofen, diazepam, dantrolene sodium, tizanidine, and clonidine) are considered with respect to their pharmacokinetics, mechanisms of action, clinical efficacy, side effects, and dosage. Phenol and alcohol nerve blocks, botulinum toxin injections, and intrathecal baclofen pumps are covered, with attention to indications, procedures, and efficacy. Surgical approaches--including neurostimulation of the spinal cord, peripheral neurotomies, rhizotomies, tendon transfers, and osteotomies--are discussed. The authors' multidisciplinary view of treatment of spasticity is to be applauded. The text emphasizes the importance of physical measures, such as stretching, exercise, positioning, bracing, and eliminating causal factors (ie, bladder and skin irritation), before medications or more invasive procedures are used.

In summary, this book is a comprehensive guide to spasticity and UMN syndrome with extensive bibliographical information, particularly in the area of neurophysiology. Given the complexity of the topic, this book has a broad scope with considerable depth. The fact that chapters were written by authors from different disciplines with unique expertise enhances the level of detail. However, information is sometimes repeated unnecessarily in more than one chapter. A minor shortcoming is its lack of attention to spinal spasticity, compared with spasticity caused by brain lesions. Nevertheless, this book would be a useful reference for physical therapists, physicians, engineers, and scientists interested in the pathophysiology and clinical management of spasticity and UMN syndrome.

Sheila Schindler-Ivens, PT
University of Iowa
Iowa City, Iowa

Ms Schindler-Ivens is a doctoral candidate in the rehabilitation science program. Her research focuses on spasticity.