Physical and Rehabilitation Medicine Service, Unit of Neurore-education, Henri Mondor University Hospital, Créteil, France.
Eur J Phys Rehabil Med. 2010 Sep;46(3):411-21.
Among the three main factors of motor impairment that emerge in chronological order following a lesion to central motor pathways, the last two antagonize movement: 1) stretch-sensitive paresis, a reduction of agonist motor unit recruitment upon voluntary command, worsened by antagonist stretch; 2) soft tissue contracture, and 3) muscle overactivity. Types of muscle overactivity include 1) spasticity, an increase in the velocity-dependent response to muscle stretch, measured at rest; 2) spastic dystonia, i.e., chronic tonic muscle activity at rest, sensitive to stretch of the dystonic muscle and 3) spastic co-contraction, an inappropriate degree of antagonistic contraction during voluntary agonist command, sensitive to stretch of the co-contracting muscle. A five-step clinical assessment may closely parallel this phenomenology, in which the first four steps aim at quantifying the antagonistic potential of each muscle group. Step-1 measures passive range of motion, i.e., the angle of arrest upon slow stretch of the muscle group assessed (minimizing spastic dystonia), which provides insight on soft tissue length and extensibility. Step-2 measures the angle of catch or clonus upon fast passive stretch of the muscle group assessed, which provides insight on stretch reflex excitability. Step-3 measures the range of active motion against the muscle group assessed, a net result of agonist recruitment minus the combined resistance from passive soft tissue stiffness and spastic co-contraction in the muscle group assessed. Step-4 measures the maximal frequency of rapid alternating movements along the maximal active range of motion, evaluating Step-3 performance repeatability. Step-5 evaluates active function, using for example a walking test (10 m or 2 min) for lower limb and the Modified Frenchay Scale for upper limb assessment, and perceived function through patient global subjective assessment.
在中枢运动通路损伤后按时间顺序出现的运动障碍的三个主要因素中，后两个对抗运动：1）拉伸敏感的无力，即主动运动指令下的拮抗剂拉伸时，运动单位募集减少；2）软组织挛缩；3）肌肉过度活动。肌肉过度活动的类型包括：1）痉挛，即肌肉拉伸时的速度依赖性反应增加，在休息时测量；2）痉挛性张力障碍，即休息时的慢性紧张性肌肉活动，对痉挛性肌肉的拉伸敏感；3）痉挛性协同收缩，即在主动兴奋指令时拮抗收缩的程度不当，对协同收缩的肌肉拉伸敏感。五步临床评估可能与这种现象学密切相关，其中前四步旨在量化每个肌肉群的拮抗潜力。步骤 1 测量被动运动范围，即评估的肌肉群在缓慢拉伸时的停顿角度（最小化痉挛性张力障碍），这提供了软组织长度和伸展性的信息。步骤 2 测量评估的肌肉群快速被动拉伸时的捕获或阵挛角度，这提供了伸展反射兴奋性的信息。步骤 3 测量主动运动范围，减去评估的肌肉群中被动软组织僵硬和痉挛性协同收缩的综合阻力，这是评估的肌肉群的主动运动范围的净结果。步骤 4 测量在最大主动运动范围内快速交替运动的最大频率，评估步骤 3 的性能重复性。步骤 5 通过例如下肢的 10 米或 2 分钟步行测试以及上肢评估的改良 Frenchay 量表评估主动功能，并通过患者整体主观评估评估感知功能。
