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{{ClinPsy}}
 
{{ClinPsy}}
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''Clonus''' (from the Greek for "violent, confused motion") is a series of involuntary, [[rhythmic]], [[muscular contraction]]s and relaxations. Clonus is a sign of certain [[neurological]] conditions, particularly associated with [[upper motor neuron]] [[lesion]]s involving descending motor pathways, and in many cases is, accompanied by [[spasticity]] (another form of [[hyperexcitability]]).<ref name="Reference 2" /> Unlike small, spontaneous twitches known as [[fasciculation]]s (usually caused by [[lower motor neuron]] pathology), clonus causes large motions that are usually initiated by a [[reflex]]. Studies have shown clonus beat [[frequency]] to range from 3–8 [[Hertz|Hz]] on average, and may last a few seconds to several minutes depending on the patient’s condition.<ref name="Reference 2" />
   
'''Clonus''' (from the Greek for "violent, confused motion") is a series of involuntary [[muscular contraction]]s due to sudden stretching of the muscle. Clonus is a sign of certain [[neurological]] conditions, and is particularly associated with so-called [[upper motor neuron]] [[lesion]]s such as [[stroke]], [[multiple sclerosis]] or [[Spinal cord | spinal cord damage]]. Unlike the small, spontaneous twitching known as [[fasciculation]]s (usually caused by [[lower motor neuron]] pathology), clonus causes large motions that are usually initiated by a [[reflex]].
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==Susceptibility==
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Clonus is typically seen in patients with [[stroke]], [[multiple sclerosis]], [[spinal cord | spinal cord damage]] and [[hepatic encephalopathy]].<ref name="Reference 1" /> Clonus has also appeared after ingesting potent serotonergic drugs, where ingestion strongly predicts imminent serotonin toxicity ([[serotonin syndrome]]).
   
Clonus is most common in the [[ankle]]s, where it is tested by rapidly flexing back (dorsiflexing) the relaxed ankle. It can also be tested in the [[knees]] by rapidly pushing the [[patella]] towards the toes.
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== Mechanism of clonus ==
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===Two proposed mechanisms===
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''1) Self re-excitation of [[hyperactive]] stretch reflexes:''<ref name="Reference 2" />
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The self re-excitation of hyperactive stretch reflexes theory involves a repetitive contract- relax cycle in the affected muscle, which creates oscillatory movements in the affected limb.<ref name="Reference 2" /> In order for self re-excitation to exist, both an increase in [[motor neuron]] excitability and [[nerve]] signal delay are required.<ref name="Reference 2" /> Increased [[motor neuron]] excitability is likely accomplished by alterations to the net inhibition of neurons occurring as a result of injury to the [[Central nervous system|CNS]] ([[stroke]]/ [[spinal cord]] injury).<ref name="Reference 2" /> This lack of inhibition biases neurons to a net excitatory state, therefore increasing total signal conduction.<ref name="Reference 2" /> Signaling delay is present due to an increased nerve conduction time.<ref name="Reference 2" /> Long delays are primarily due to long reflex pathways, which are common in [[distal]] [[joint]]s and [[muscles]].<ref name="Reference 2" /> This may therefore explain why clonus is typically found in [[distal]] structures like the ankle.<ref name="Reference 2" /> [[Frequency]] of clonus beats have been found to be directly proportional to the length of the reflex pathway it is found in.<ref name="Reference 2" />
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''2) Presence of a central oscillator:''<ref name="Reference 2" />
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Clonus, with respect to the presence of a central oscillator, functions on the theory that when the central oscillator is turned on by a [[peripheral]] event, it will continue to rhythmically excite [[motor neurons]]; therefore creating clonus.<ref name="Reference 2" />
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Although the two proposed mechanisms are very different in [theory] and are still debated, some studies now propose the potential of both mechanisms co-existing to create clonus.<ref name="Reference 2" /> It is thought that the [[stretch reflex]] pathway may be stimulated first, and through its events, cause a decreased [[synaptic]] current [[Threshold potential|threshold]].<ref name="Reference 2" /> This decreased [[synaptic]] current threshold would enhance [[motor neuron]] excitability as [[nerve impulse]]s would be more readily conducted, and thus turn on this central oscillator.<ref name="Reference 2" /> This theory is still being investigated.<ref name="Reference 2" />
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===Clonus and Spasticity===
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Clonus tends to co-exist with [[spasticity]] in many cases of [[stroke]] and [[spinal cord injury]] likely due to their common physiological origins. <ref name="Reference 2" /> Some consider clonus as simply an extended outcome of [[spasticity]].<ref name="Reference 2" /> Although closely linked, clonus is not seen in all patients with [[spasticity]].<ref name="Reference 2" /> Clonus tends to not be present with [[spasticity]] in patients with significantly increased [[muscle tone]], as the [[muscle]]s are constantly active and therefore not engaging in the characteristic on/off cycle of clonus.<ref name="Reference 2" /> Clonus results due to an increased [[motor neuron]] excitation (decreased [[action potential]] [[Threshold potential|threshold]]) and is common in [[muscle]]s with long conduction delays, such as the long [[reflex]] tracts found in [[distal]] [[muscle]] groups.<ref name="Reference 2" /> Clonus is commonly seen in the ankle but may exist in other distal structures as well.<ref name="Reference 1" />
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==Clonus locations==
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* Ankle (medial [[gastrocnemius]])<ref name="Reference 1" />
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* [[Patella]] ([[knee cap]])
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* [[Triceps surae]]<ref name="Reference 1" /> <ref name="Reference 4" />
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* [[Biceps brachii]]<ref name="Reference 4" />
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Clonus is most commonly found at the ankle, specifically with a dorsiflexion/plantarflexion movement (up and down).<ref name="Reference 1" /> Some case studies have also reported clonus in the finger, toe, and [[Lateral (anatomy)|laterally]] in the ankle (as opposed to the typical up and down motion).<ref name="Reference 3" /> <ref name="Reference 4" />
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== Eliciting Clonus (Testing) ==
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Clonus at the [[ankle]] is tested by rapidly flexing the foot into dorsiflexion (upward), inducing a stretch to the [[gastrocnemius]] muscle.<ref name="Reference 2" /> Subsequent beating of the foot will result, however only a sustained clonus (5 beats or more) is considered abnormal. Clonus can also be tested in the [[knees]] by rapidly pushing the [[patella]] (knee cap), towards the toes.
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==Video Demonstrations==
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*[http://www.youtube.com/watch?v=YppNNYt5Cbc] Clonus at the ankle
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*[http://www.youtube.com/watch?v=7XqC5OMdpKY] Clonus at the knee (patella)
   
 
== See also ==
 
== See also ==
 
* [[Myoclonus]]
 
* [[Myoclonus]]
 
* [[Tonic-clonic seizure]]
 
* [[Tonic-clonic seizure]]
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* [[Deep tendon reflex|Deep tendon (stretch) reflex]]
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== External links ==
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* [http://www.psychotropical.com/index.php/serotonin-toxicity Dr. Gilman on Serotonin Toxicity]
   
 
==References==
 
==References==
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<references>
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{{cite journal|last=Douglas|first=Wallace M.|coauthors=Bruce H Ross, Christine K. Thomas|title=Motor unit behaviour during clonus|journal=Journal of Applied Physiology|date=Aug 25|year=2005|volume=99|issue=6|pages=2166–2172|url=http://jap.physiology.org/content/99/6/2166.short|accessdate=May 6, 2012}}<ref name="Reference 1">">{{cite journal|last=Douglas|first=Wallace M.|coauthors=Bruce H Ross, Christine K. Thomas|title=Motor unit behaviour during clonus|journal=Journal of Applied Physiology|date=Aug 25|year=2005|volume=99|issue=6|pages=2166–2172|url=http://jap.physiology.org/content/99/6/2166.short|accessdate=May 6, 2012}}</ref>
   
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<ref name="Reference 2">{{cite journal|last=Hilder|first=Joseph M.|coauthors=Zev W. Rymer|title=A Stimulation Study of Reflex Instability in Spasticity: Origins of Clonus|journal=IEEE Transactions on Rehabilitation Engineering|date=September|year=1999|volume=7|issue=3|pages=327–340|url=http://ieeexplore.ieee.org/xpl/login.jsp?tp=&arnumber=788469&url=http%3A%2F%2Fieeexplore.ieee.org%2Fxpls%2Fabs_all.jsp%3Farnumber%3D788469|accessdate=May 6, 2012}}</ref>
   
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{{cite journal|last=Mitchell|first=John K.|title=Two unusual forms of clonus: toe clonus and lateral ankle clonus|journal=Journal of Nervous and Mental Disease|date=May|year=1902|volume=29|issue=5|pages=260–261|url=http://journals.lww.com/jonmd/Citation/1902/05000/Two_Unusual_Forms_of_Clonus__Toe_Clonus_and.2.aspx|accessdate=May 6, 2012}}<ref name="Reference 3">{{cite journal|last=Mitchell|first=John K.|title=Two unusual forms of clonus: toe clonus and lateral ankle clonus|journal=Journal of Nervous and Mental Disease|date=May|year=1902|volume=29|issue=5|pages=260–261|url=http://journals.lww.com/jonmd/Citation/1902/05000/Two_Unusual_Forms_of_Clonus__Toe_Clonus_and.2.aspx|accessdate=May 6, 2012}}</ref>
   
== External links ==
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{{cite journal|last=Weisenburg|first=Theodore H|title=Triceps, Biceps and Finger Clonus|journal=Journal of Nervous and Mental Diseases|date=November|year=1903|volume=30|issue=11|pages=681–683|url=http://journals.lww.com/jonmd/Citation/1903/11000/Triceps,_Biceps,_and_Finger_Clonus.3.aspx|accessdate=May 6, 2012}}<ref name="Reference 4">{{cite journal|last=Weisenburg|first=Theodore H|title=Triceps, Biceps and Finger Clonus|journal=Journal of Nervous and Mental Diseases|date=November|year=1903|volume=30|issue=11|pages=681–683|url=http://journals.lww.com/jonmd/Citation/1903/11000/Triceps,_Biceps,_and_Finger_Clonus.3.aspx|accessdate=May 6, 2012}}</ref>
* [http://www.harkema.ucla.edu/p95x_clonus.MPG Video demonstration of clonus]
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</references>
   
[[Category:Epilepsy]]
 
 
[[Category:Medical signs]]
 
[[Category:Medical signs]]
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[[Category:Seizure types]]
   
   
:de:Klonus
 
 
{{enWP|Clonus}}
 
{{enWP|Clonus}}

Latest revision as of 19:29, August 13, 2013

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Clonus' (from the Greek for "violent, confused motion") is a series of involuntary, rhythmic, muscular contractions and relaxations. Clonus is a sign of certain neurological conditions, particularly associated with upper motor neuron lesions involving descending motor pathways, and in many cases is, accompanied by spasticity (another form of hyperexcitability).[1] Unlike small, spontaneous twitches known as fasciculations (usually caused by lower motor neuron pathology), clonus causes large motions that are usually initiated by a reflex. Studies have shown clonus beat frequency to range from 3–8 Hz on average, and may last a few seconds to several minutes depending on the patient’s condition.[1]

SusceptibilityEdit

Clonus is typically seen in patients with stroke, multiple sclerosis, spinal cord damage and hepatic encephalopathy.[2] Clonus has also appeared after ingesting potent serotonergic drugs, where ingestion strongly predicts imminent serotonin toxicity (serotonin syndrome).

Mechanism of clonus Edit

Two proposed mechanismsEdit

1) Self re-excitation of hyperactive stretch reflexes:[1]

The self re-excitation of hyperactive stretch reflexes theory involves a repetitive contract- relax cycle in the affected muscle, which creates oscillatory movements in the affected limb.[1] In order for self re-excitation to exist, both an increase in motor neuron excitability and nerve signal delay are required.[1] Increased motor neuron excitability is likely accomplished by alterations to the net inhibition of neurons occurring as a result of injury to the CNS (stroke/ spinal cord injury).[1] This lack of inhibition biases neurons to a net excitatory state, therefore increasing total signal conduction.[1] Signaling delay is present due to an increased nerve conduction time.[1] Long delays are primarily due to long reflex pathways, which are common in distal joints and muscles.[1] This may therefore explain why clonus is typically found in distal structures like the ankle.[1] Frequency of clonus beats have been found to be directly proportional to the length of the reflex pathway it is found in.[1]

2) Presence of a central oscillator:[1]

Clonus, with respect to the presence of a central oscillator, functions on the theory that when the central oscillator is turned on by a peripheral event, it will continue to rhythmically excite motor neurons; therefore creating clonus.[1]

Although the two proposed mechanisms are very different in [theory] and are still debated, some studies now propose the potential of both mechanisms co-existing to create clonus.[1] It is thought that the stretch reflex pathway may be stimulated first, and through its events, cause a decreased synaptic current threshold.[1] This decreased synaptic current threshold would enhance motor neuron excitability as nerve impulses would be more readily conducted, and thus turn on this central oscillator.[1] This theory is still being investigated.[1]

Clonus and SpasticityEdit

Clonus tends to co-exist with spasticity in many cases of stroke and spinal cord injury likely due to their common physiological origins. [1] Some consider clonus as simply an extended outcome of spasticity.[1] Although closely linked, clonus is not seen in all patients with spasticity.[1] Clonus tends to not be present with spasticity in patients with significantly increased muscle tone, as the muscles are constantly active and therefore not engaging in the characteristic on/off cycle of clonus.[1] Clonus results due to an increased motor neuron excitation (decreased action potential threshold) and is common in muscles with long conduction delays, such as the long reflex tracts found in distal muscle groups.[1] Clonus is commonly seen in the ankle but may exist in other distal structures as well.[2]

Clonus locationsEdit

Clonus is most commonly found at the ankle, specifically with a dorsiflexion/plantarflexion movement (up and down).[2] Some case studies have also reported clonus in the finger, toe, and laterally in the ankle (as opposed to the typical up and down motion).[4] [3]

Eliciting Clonus (Testing) Edit

Clonus at the ankle is tested by rapidly flexing the foot into dorsiflexion (upward), inducing a stretch to the gastrocnemius muscle.[1] Subsequent beating of the foot will result, however only a sustained clonus (5 beats or more) is considered abnormal. Clonus can also be tested in the knees by rapidly pushing the patella (knee cap), towards the toes.

Video DemonstrationsEdit

  • [1] Clonus at the ankle
  • [2] Clonus at the knee (patella)

See also Edit

External links Edit

ReferencesEdit

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 Hilder, Joseph M., Zev W. Rymer (September). A Stimulation Study of Reflex Instability in Spasticity: Origins of Clonus. IEEE Transactions on Rehabilitation Engineering 7 (3): 327–340.
  2. 2.0 2.1 2.2 2.3 2.4 ">Douglas, Wallace M., Bruce H Ross, Christine K. Thomas (Aug 25). Motor unit behaviour during clonus. Journal of Applied Physiology 99 (6): 2166–2172.
  3. 3.0 3.1 3.2 Weisenburg, Theodore H (November). Triceps, Biceps and Finger Clonus. Journal of Nervous and Mental Diseases 30 (11): 681–683.
  4. Mitchell, John K. (May). Two unusual forms of clonus: toe clonus and lateral ankle clonus. Journal of Nervous and Mental Disease 29 (5): 260–261.


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