Spasticity Treatment
Stiffness and shortening of muscles and tendons commonly occur in the affected limbs
(arms and legs) after stroke. In addition, people with stroke may notice rhythmic
shaking of their ankles or even fingers. They may also notice that their arms and/or
legs may move in abnormal patterns (see below), sometimes seemingly beyond their control.
In some cases, these stereotyped movements can occur at night, or in certain positions,
and cause painful “spasms” of muscles. Spasticity is technically “velocity dependent
resistance to stretch” in a given muscle. However, it is the term most commonly used
to describe several negative features of Upper Motor Neuron Syndrome-a consequence
of stroke and other central nervous system disorders.
Normally, our central nervous system and muscles work together to allow smooth coordinated
movement. We have certain “hard-wired” reflexes built into the system (such as the
knee jerk when a doctor taps you with a hammer). These reflexes are used or dampened
by the central nervous system depending upon what you are trying to do.
After a stroke, the ability to control or dampen the reflexes becomes impaired, so
the reflexes become exaggerated and may interfere with normal movement. Spasticity
can explain the clonus, or shaking of the ankles, as an exaggerated reflex.
Another problem is increased muscle tone, that is independent of how fast a muscle
is stretched. The limb can be very stiff to move at all times. The primitive movement
patterns of FLEXION in the arm, elbow, fingers, wrist and EXTENSION in the leg (usually
the knee locks and the foot is pushing down and twisted inward) are also part of the
Upper Motor Neuron syndrome, and often grouped under the generic name “spasticity.”
Is all spasticity bad?
The simple answer is no.
Spasticity can be good in that it may help maintain muscle bulk in an otherwise “paralyzed”
muscle that a person can not voluntarily control. Since the muscles are over-active
and firing, it may also help prevent osteoporosis or disuse atrophy (the muscle shrinks).
Functionally, some people use that lower extremity extension patterning mentioned
above to help with transfers or standing. The extended leg gives support like a pillar,
allowing pivoting into a wheelchair or on the toilet.
The otherside of the coin is...
Spasticity more commonly causes shortening of the muscles that can lead to contractures (permanent shortening) with deformity of joints.
This can then lead to pain with even simple activities like putting on a shirt, or
interfere with hygiene.
The hyperactive muscles may cover up function in other muscles, lead to balance problems,
and increase the energy required to perform a given task.
What can you do?
The most important thing to treat spasticity is RANGE of MOTION exercises with gentle
stretching. These often only take 5-10 minutes and ideally would be done 3-4 times
a day, but once is still better than not at all.
-Often a patient with a stroke will benefit from some help from others in doing the
stretches-particularly for full range of motion at the shoulder and for the lower
extremities.
-A warm bath will often help relax the muscles prior to exercise and stretch.
-Although splints are important to maintain functional range and prevent contractures,
active gentle stretching is still the best thing.
There are oral medications to treat spasticity.
These include drugs such as Valium, Baclofen, Zanaflex, and Dantrium.
Many of these drugs can cause drowsiness or other problems, particularly after an
acquired brain injury.
However, these drugs are very good for generally reducing the severity of tone and
the reactivity of muscles to stretch (helping clonus) and can benefit several involved
limbs. So if several limbs and/or the body are involved, these oral medications can
help many body parts at one time.
Another option for the stereotyped movement patterns, hyper-reactivity and tone are
the use of either Botulinum Toxin or phenol.
These medicines are injected directly into the affected muscles and cause relaxation
of the muscles.
The advantage of the injections is that only the muscles requiring treatment are
treated and there is no general side effect on the body or its organs (like the drowsiness
of oral medicine).
The disadvantages are that if there are many muscles to be treated one may not be
able to only use botulinum (there is a limit on the dose), side effects from the use
of needles (usually not serious) and that ONLY the muscles treated are affected. Sometimes
a whole nerve block with phenol can treat several muscles with one injection. Also
the injections wear off in about 3 months (a little longer potentially for phenol).
Botulinum is very expensive (phenol is not) but both medicines are covered by most
insurance companies, including Medicare and Medicaid.
Often a doctor will perform phenol or botulinum toxin blocks prior to putting a cast
on a contracted joint or limb, or before you use special dynamic splints to correct
spastic contractures that have already formed.
Finally, here are a variety of surgeries that can be performed to reduce spasticity
or spastic contractures. These include tendon lengthening/release and the placement
of the Baclofen pump.
Surgery
-Orthopaedic surgeons can actually cut the muscle or tendon it’s attached to in order
to make it longer and release the contracture.
-Neurosurgeons may do rhizotomies: cut the nerve roots as they leave the spinal cord
thus paralyzing the muscles the nerve root goes to and making them limp.
-Both types of surgeries are permanent, however.
Baclofen Pump
The pump requires placement of a catheter in the space around the spinal cord that
is ultimately attached to a pump/reservoir under the skin of the abdomen.
The pump can be programmed to deliver medication directly to the spinal cord at various
doses during the day, depending on a given individual’s spasticity pattern and needs.
Drawbacks are that it is a surgical procedure and the patient must have the reservoir
filled every 4 to 6 weeks, among other potential problems.
Still, the effectiveness can be remarkable, though this effect is more evident in
the legs than the arms.
There are no cognitive side effects like oral baclofen since the therapeutic level
of medication is delivered directly to the spinal cord and doesn't have to circulate
through the blood and thus to the brain.
Many of the bad consequences of spasticity can be prevented with range of motion
exercise and medication (oral or injected). Like so many other things, an ounce of
prevention is worth a pound of cure-it is more difficult to correct severe contractures
that might have been prevented, than it is to have prevented them in the first place.
SO KEEP DOING THE STRETCHING EXERCISES!
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Additional Information: |
References:
Braddom, R. (2006). Physical medicine and rehabilitation (3rd ed.). Philadelphia, PA: Saunders.
National Stroke Association. (2011). Spasticity treatment. Retrieved from http://www.stroke.org/site/PageServer?pagename=spasttr
Physical medicine and rehabilitation for spasticity. (2011). Retrieved from http://emedicine.medscape.com/article/318994-overview
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Revised 2010, 2012