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Spasticity Treatment

spasticityStiffness 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?

spasticity2The 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.

surgerySurgery

-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!

Additional Information:

The following web site provides you with more information about dealing with spasticity and preventing contractures:

Worldwide Education And Awareness for Movement Disorders


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

Developed in 2003 by Lawrence Horn, MD at The University of Toledo for Caring~Web©.

Revised 2010, 2012

Last Updated: 12/16/13