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Thoughts and ideas from Sravani Mehta MD
Spasticity: The Complete Guide
July 24, 2019 at 12:00 AM
by Sravani Mehta MD
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Spasticity is a motor disorder affecting muscular elements of the body ultimately making movement difficult. This condition causes the continuous contractions of specific muscles resulting in tightness or stiffness of these muscles. This can interfere with the walk, speech and normal movement of the individual.

The cause is generally damage to a part of the spinal cord or brain responsible for voluntary movement. This damage changes the signal balance between the muscles and the nervous system. The imbalance results in an increase in muscle activity. This has a negative impact on the joints and muscles of the extremities.

Spasticity is caused by many disorders: Meningitis, Damage to the brain from a lack of oxygen, Brain Tumor, Encephalitis, Traumatic brain injury (TBI), Amyotrophic lateral sclerosis (Lou Gehrig's disease), Stroke, Cerebral Palsy(CP), Adrenoleukodystrophy, Spinal cord injury (SCI).

The symptoms can be mild, such as a tightness in the muscles. The severe symptoms include uncontrollable, painful spasms in the extremities. This is most common in the arms and legs. There may also be lower back pain and tightness around or centered in the joints. The other symptoms include: Muscle spasms resulting in painful and uncontrollable muscle contractions, Deformities of the joints and muscles, Crossing the legs involuntarily, Muscle fatigue. Many everyday tasks become much harder to perform.

The gradual development of this condition results from the emergence of neurophysiologic mechanisms due to an injury of the central nervous system. The spinal tracts including the rubrospinal and vestibulospinal tracts increase in activity. This condition often results from an injury to the basal ganglia, brainstem, central white matter, cortex, thalamus, cerebellum or spinal cord. The individuals impacted have a traumatic injury to the brain, cerebrovascular episodes, (MS) multiple sclerosis, or an injury to the spinal cord among other conditions. This type of muscle overactivity is triggered by a disruption of the communication between the spinal cord and the brain due to an illness or an injury to the spinal cord. The degree and development of this condition cause an immature motor pattern. This is especially prominent when a movement is in progress. This has a negative impact on normal posture, movements and balancing the torso. Ther are some benefits to this condition including helping to tone the muscles. This condition can result in numerous issues including fatigue and pain. The individual can have difficulties performing normal daily activities including sleeping, changing positions, sitting and walking.

The spinal cord is dominated by the muscle command causing the muscle to become spastic or too tense as opposed to having any weakness. Deformities in the extremities are not present when the individual is born. Any deformities are developed as time passes. The most common cause of the deformities includes a limited ability to use and stretch these muscles on a daily basis and spastic muscles. Brain Trauma Injury Spastic hypertonia is often a result when the brain stem, midbrain or cerebellum are damaged. This damage impacts the brain's reflex centers. This causes an interruption in the messages sent using the numerous nerve pathways. The resulting disruption can lead to changes in movement, the tone of the muscle, reflex and sensation. The location of the damage determines the parts of the body impacted and the resulting motor deficits. The reflex centers in the spinal cord as not nearly as complicated as those in the brain. This makes the condition a lot harder to treat when the individual has a neurological disorder or an injury to the spinal cord. A lot of individuals experience increased muscle tone after receiving a brain injury. This results in extremely rigid body posture. One of the most common positions is holding the elbows rigidly at the individual's side with the fingers clenched and the fingers and wrists bent. In most cases, the toes and ankles are flexed with the legs extended from the hips. During the recovery period, there may be a change in the nerve signals controlling the individual's motor functions. The brain's reflex center may not be reached by certain signals or too many signals can be sent by the brain resulting in an improper response from the muscles. Multiple Sclerosis This condition is extremely common among individuals with (MS) multiple sclerosis. There are two different types of spasms linked to this condition. These are extensor and flexor. Extensor is when the legs are straightened involuntarily. This encompasses the muscles located on the front of the upper thigh or the quadriceps and the muscles on the inner thigh or the adductors. The legs will remain close together with the knees and hips straight and the ankles crossed over each other. This usually concerns the hamstring muscles located on the back of the upper thigh. This does not generally affect the arms in individuals with multiple sclerosis. Flexor is when the hips or knees bend involuntarily. This usually centers on the muscles on the back of the upper thigh or the hamstrings. The knees and hips are bent upwards towards the chest. The Clinical Evaluation The clinical signs of this condition are different depending on the type of injury including progressive or sudden, the extent of the damage to the spinal cord or brain and whether the injury is incomplete or complete. If the individual suffered a localized brain injury like a stroke or an incomplete injury of the spinal cord, the increase in muscular tone will not be the same for all the joints. The positioning of the joint is also affected by the non-injured muscles. This scenario has a higher risk of the joint becoming deformed. In some instances, the repetition of the abnormal movement as time passes can cause dystonia. This is when the normal adjacent muscles develop permanent contractions in an attempt to balance the torso in an aesthetically pleasing, fast and safe motion such as walking. The clinical examination has four separate stages including the functional and static evaluation. The first stage is the clinical observation. This is observing the body of the individual when they walk into the room and while sitting in a supine position. Any muscle spasms or muscular atrophies are also noted. The second stage is when the range of the joint movements are examined such as the pathological and normal reflexes and the active movements. During this stage, the Modified Ashworth Scale, the Tardieu Scale, the motor test and the adductor tone rating are used. The third step involves a motor skill test for the upper limbs while the individual is in a sitting position. The fourth stage is examining the individual's balance while walking for a shorter and a lengthier distance. One of the major signs of movement disturbance is fatigue. This condition is not static. The condition is constantly changing as the day passes including when the individual is sleeping. The changes are dependent on irritant and pain factors including infection, inflammation, the individual's emotional state and menstruation for females. The timing of the treatment is critical for managing this condition.

The treatment is dependent on an evaluation for each individual. This is based on the age of the individual, the underlying cause and the severity of the condition. All of the available treatments have the same goals. This includes; • Providing relief for the symptoms and signs of this condition • Improving ease of care and daily living activities such as hygiene and walking • Helping ensure children achieve more normal muscle growth • Decreasing the frequency and pain of the muscle contractions • Decreasing the caregiver challenges including bathing, feeding and dressing Oral Medications Oral medications are used for the treatment of this condition when the symptoms are interfering with the individual's ability to sleep or function on a daily basis. Managing the medications effectively often necessitates the usage of more than one drug or combining another kind of treatment with oral medications. It is extremely important to work closely with the physician or create a personalized treatment plan for each individual. Depending on the individual and the class of medication, there is a possibility of side effects. The medications include dantrolene sodium, gabapentin, baclofen, imidazolines and benzodiazepines. Injections of Botulinum Toxin Botulinum toxin is often referred to as Botox or BTA. When the amount used is tiny, the injections are effective for paralyzing spastic muscles. The sites of the injections must be determined extremely carefully. Instead of causing a weakness, this condition causes the muscle to become overactive. The Botox releases acetylcholine to block the overactive muscles. This results in a relaxation of these muscles. In most cases, the effect of the injection can be seen in just a few days. The results last for approximately twelve to sixteen weeks. Eventually, the nerve endings will grow back and the muscle will recover. The functional benefits last for a much longer period of time. The number of injections the individual can receive are limited. Occupational and Physical Therapy Occupational and physical therapy is used to improve the range of mobility and motion, reduce muscle tone, improve the level of comfort and increase coordination and strength. The therapy may include temporary casts or braces, applying cold packs, biofeedback, strengthening exercises, limb positioning and electrical stimulation. Surgery There are two main neurological procedures for treating this condition, These are (SDR) selective dorsal rhizotomy and (ITB) intrathecal baclofen pumps. If the condition is severe, a pump can be implanted surgically in the abdomen of the individual for the administration of baclofen. When baclofen is directly delivered to the spinal fluid, the result is often a powerful decrease in the impact of the condition and a decrease in pain without as many side effects. This treatment has been very effective in treating the upper and lower extremities. Selective dorsal rhizotomy involves selective nerve roots being cut by a neurosurgeon. These nerve fibers are found just outside of the spinal column. The muscles can then send sensory messages to the spinal cord. This treatment is used when the condition is severe enough to interfere with positioning or movement. This decreases the stiffness in the muscles without impacting any of the other functions. This may improve the function and mobility of the muscles while helping to prevent deformities of the bone and joint and severe scarring of the muscle. This treatment is extremely effective for individuals with cerebral palsy meeting specific conditions. Individuals with certain conditions are not candidates for selective dorsal rhizotomy. This includes: • Individuals with severe scoliosis. • Individuals who have had a congenital brain infection, head trauma, meningitis, familial disease or congenital hydrocephalus separate from premature birth.

Individuals with cerebral palsy with predominant dystonia or rigidity or significant ataxia or athetosis. Surgery will not provide these individuals with any functional gains. According to controlled, random clinical trials, a large percentage of individuals with cerebral palsy have seen an improvement in function after having surgery. Surgery is not appropriate for all individuals with this condition.

Treatment for this condition generally includes a combination of several different options.

Oral medications may be prescribed to help decrease muscle issues associated with this condition.

Occupational and physical therapists teach exercises for positioning and stretching to help the individual maintain their motion range and prevent the muscles from tightening or shortening.

Intrathecal therapy is when the condition is treated using medications administered right into the fluid around the spinal cord 24 hours a day. A catheter system and implantable pump are used for the delivery of the medication.

Injections of Botox are injected into the impacted muscles to reduce the signals from the muscles causing the condition. This offers the individual complete relief enabling them to strengthen and move the muscles. The injections can be given every ninety days.

Every aspect of this condition must be analyzed to ensure the right treatment is provided at the right time. This includes the nature of the condition, the differences with other disorders involving muscle tone, the development based on the severity and site of the injury, the changes over time and during sleep, the symptoms including pain and the changes in intensity resulting from both internal and external sensory stimuli. The length of time between the injury and the treatment has to be defined. This is dependent on the clinical condition of the individual and the chosen plan for therapy. There are four different categories of treatment.

The first category is nursing care. This involves the treatment or prevention of contractures, the treatment or prevention of decubitus, positioning the torso correctly in a wheelchair or on a bed, gently catheterizing the bladder, the orthotics fitting, making arrangements for a caregiver, relieving pain and improving sleep.

The second category encompasses improving movement, accelerating the process of recovery, modifications to the immature motor pattern, guiding neuroplasticity through the use of new techniques for recovery also known as robotic rehabilitation and providing a new functional method for walking and moving.

The third category involves the activities the individual participates in for their daily routine such as putting on clothing, driving, personal hygiene, etc.

The fourth category is meant to improve the individual's quality of life including living independently and going back to their professional and social lives.

The rehabilitation team (involving a physiatrist- who is an MD such as Dr. Mehta that specialized in Physical Medicine & Rehab) and many different types of therapists) will set goals for the individual while considering not only the person but their family. The final goal is a successful outcome.