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a National Hospital for Neurology and Neurosurgery, b Department of Neuropathology, c MRC Human Movement and Balance Unit, Institute of Neurology,
London WC1N 3BG, UK
Correspondence to: Dr P Brown, MRC Human Movement and Balance Unit, Institute of Neurology, London WC1N 3BG, UK. Telephone 0171 837 3611; fax 0171 829 8720.
Received 27
January1998 and in revised form 13 May 1998;
Accepted 15 May
1998
OBJECTIVE
To investigate whether the stiff limb
syndrome may be separated from the stiff man syndrome and progressive
encephalomyelitis with rigidity on simple clinical grounds, and whether
such a distinction has implications for aetiology, treatment, and prognosis.
METHODS Twenty three patients referred over a 10 year period with rigidity and spasms in association with continuous
motor unit activity, but without evidence of neuromyotonia,
extrapyramidal or pyramidal dysfunction or focal lesions of the spinal
cord were reviewed. The patients were divided into those with an acute
or subacute illness, leading to death within 1 year, and those with a
chronic course. The latter were divided into those in whom rigidity and spasms dominated in the axial muscles, or in one or more distal limbs,
at the time of their first assessment.
RESULTSThis simple division identified three
distinct groups of patients. (1) Progressive encephalomyelitis with
rigidity: two patients had a rapidly progressive condition
characterised by widespread rigidity which resulted in death within 6 and 16 weeks. One patient had negative anti-GAD and anti-neuronal
antibodies, but had markedly abnormal CSF and widespread denervation.
The principal pathological findings in this case were a subacute
encephalomyelitis which primarily affected the grey matter. In the
remaining patient anti-GAD antibodies were not tested, and postmortem
was refused. (2) Stiff man syndrome: eight patients had rigidity and
painful spasms of the lumbar paraspinal, abdominal, and occasionally
proximal leg muscles associated with a lumbar hyperlordosis. There was
no involvement of the upper limbs, distal lower limbs, sphincters or
cranial nerves. Seven had anti-GAD antibodies and most had additional evidence of autoimmune disease. Neurophysiologically there was continuous motor unit activity with abnormal exteroceptive
reflexes, but a normal interference pattern during spasms. The patients all responded to baclofen/diazepam and remained ambulant. (3) Stiff
limb syndrome: thirteen patients had rigidity, painful spasm, and
abnormal postures of the distal limb, usually the leg. About half went
on to develop sphincter or brainstem involvement. Generalised myoclonic
jerks were not a feature. Only two had truncal rigidity, and another
two had anti-GAD antibodies. Most had no evidence of autoimmune
disease. Neurophysiologically they had continuous motor
unit activity in the affected limb, abnormal exteroceptive reflexes,
and abnormally segmented EMG activity during spasms. The disease ran a
protracted course, and most patients had only a partial response to
baclofen or diazepam. About half became wheelchair bound.
CONCLUSIONSThe stiff limb syndrome seems distinct
from the stiff man syndrome or progressive encephalomyelitis with
rigidity, and is an important cause of rigidity and spasm in the
setting of continuous motor unit activity.
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