Spasticity/tone

February 9, 2010 by afp


I would venture to say many of us have issues with spasticity or tone. What is this, what does it mean, and what is the difference? My, oh, my, I was confused when they would mention these two different terms, and then I decided to dig. I found out it was more confusing trying to express the meanings.

I did find out that spasticity seems to react differently for each of us. Spasticity and tone affects us with weird mannerisms. Some do well on medications, some do not. Some have pain associated with this, where some do not. Some are assisted by physical therapy, whereupon reading further, it shall be detailed.

　

Overview of spasticity

The most common causes of spasticity are lack of oxygen to the brain before, during, or after birth (cerebral palsy); physical trauma (brain or spinal cord injury); blockage of or bleeding from a blood vessel in the brain (stroke); multiple sclerosis (MS); or infection of the brain (encephalitis) or the covering of the brain and spinal cord (meningitis).

When damage that causes the eventual spasticity first occurs, the muscles are usually flaccid before they become spastic. Spasticity may not be present all the time—it may be related to a trigger, or stimulus, such as pain, pressure sores, a urinary tract infection, ingrown toenails, tight clothing, or constipation.

Spasticity may be painful, especially if it pulls joints into abnormal positions and or prevents a normal movement of the joints. Spasticity may range from slight muscle stiffness to permanent shortening of the muscle. When the muscle is permanently shortened, the joint becomes misshapen. This is called a contracture and is one of the most significant consequences of spasticity. Another closely related problem with muscles in many people who have spasticity is clonus, or rapid repeated muscle spasms.

While spasticity may affect any muscle group, there are some common patterns. When spasticity affects one or both arms, flexed (bent) elbow, flexed wrist, and clenched fist may result. These can all affect the person’s ability to dress, eat, or write or may interfere with balance, thereby causing difficulties with walking. Spasticity of the legs can cause flexed hip, adducted (or scissoring) thigh, stiff knee, flexed knee, equinovarus foot, and hyperextended great toe (which is also called the hitchhiker’s toe). Spasticity of one or both legs may interfere with the ability to walk, position in bed, sit, transfer, or stand.

　

Epidemiology

Overall, spasticity affects about 500,000 people in the United States, and more than 12 million people throughout the world. The number of people affected depends upon the cause of the spasticity. In the United Kingdom, approximately 100,000 people have a first-time stroke every year, and an additional 30,000 have a repeated stroke. Stroke afflicts almost 2,000 out of every 1 million people per year worldwide. Almost 40 percent of people who have a stroke continue to have spasticity one year later.

One year later? Ha! I bet, besides myself, many still have it years later.

　

Clinical examination

A standard evaluation of the nervous system forms the basis of the clinical examination in spasticity. Strength and reflexes are both assessed in this examination. The clinician asks the patient to relax and then moves the joints through their full range of motion at various speeds. Spastic muscles may have a “spastic catch,” exhibit the “clasped knife” phenomenon, or both. Observing the person with spasticity perform activities such as walking, drinking from an open cup, and moving from one position to another often yields valuable information.

The clinical examination also includes an evaluation of deep tendon reflexes. The most commonly used method of testing these reflexes is the tapping technique. With the patient sitting on the examination table and his or her legs hanging freely, the examiner gently but firmly taps below the knee (testing the patellar reflex), first on one leg and then the other.

The responses should be the same in the two legs. Similar techniques may be used to test reflexes in the Achilles tendon (behind the ankle), and reflexes may also be checked in the biceps, triceps, and brachioradialis muscles of the arms.

　

The Spasticity Management Team

The best treatment of spasticity usually includes an active patient or advocate and caregivers working with several health-care professionals from various medical backgrounds. Members of this team may include one or more of the following people.

Neurologist
A neurologist is a medical doctor trained in disorders of the nervous system. The neurologist may diagnose the neurologic problem; prescribe treatments, including medications and physical and occupational therapy; and refer the patient for surgical evaluation if necessary. The neurologist may also inject the chemodenervation treatments (see the section on treatment that follows).

Physiatrist
A physiatrist is a medical doctor who specializes in physical medicine and rehabilitation. The physiatrist may design the rehabilitation program, working with other team members to maximize the patient’s function and minimize the disabling aspects of the neurologic injury. The physiatrist may also prescribe medications and administer chemodenervation treatments.

Physical Therapist
A physical therapist is a healthcare professional who is responsible for the physical aspects of treatment. The physical therapist may perform or direct another person to perform the exercises that are necessary to assist in maintaining the range of motion of limbs affected by spasticity. The physical therapist may also apply and fit braces, splints, or casts that may be prescribed by the physiatrist or other treating physician.

In addition, the physical therapist may direct training to improve the patient’s ability to walk or move and may instruct patients and caregivers on how to position affected arms and legs to help reduce spasticity. A physical therapist often works closely with an occupational therapist to design changes in the home and equipment that might be necessary to accommodate the patient’s needs.

Occupational therapist
An occupational therapist is a healthcare professional who specializes in adaptation of the physical environment to meet the patient’s needs. The occupational therapist may teach modifications for dressing, feeding, and grooming to the patient and caregiver. This therapist may also offer expertise on adaptive devices such as wheelchairs and bath equipment and may advise on home and workplace modifications to increase accessibility and ease of use. The occupational therapist is usually the medical professional who advises the school on issues such as seating, writing, and use of facilities.

Neurosurgeon
A neurosurgeon is a medical doctor who is specially trained to perform surgical procedures related to the nervous system. For example, when a patient with severe spasticity has a positive response to a screening test (intrathecal baclofen bolus) and is then recommended to receive continuous intrathecal baclofen (ITBTM Therapy), the neurosurgeon may implant the baclofen delivery pump.

Neurosurgeons may also perform an operation to destroy selected sensory nerves at their entry point into the spinal cord (selective dorsal rhizotomy) when other treatments cannot offer adequate spasticity relief. When a patient requires exposure of a target nerve for chemodenervation, the neurosurgeon is usually the physician who performs that operation; a neurologist or physiatrist then usually performs the chemodenervation.

Orthopedic surgeon
An orthopedic surgeon is a medical doctor who is specially trained to perform operations related to bones, joints, muscles, and surrounding connective tissue. These types of procedures may help to reduce or correct contractures that lead to abnormal positioning of joints. Orthopedic operations often involve reconstruction or revision of tendons and bones. The orthopedic surgeon may also assist with the fitting of braces and assessing growth and development.

Spasticity treatment
In some patients with mild spasticity, the best treatment may be no treatment, with a watch-and-wait strategy. Typically, treatment is reserved for spasticity that causes pain, interferes with activities of daily living or sleep, or leads to increasing levels of functional disability.

Some key questions that should be answered before beginning any treatment for spasticity include:
1. Is treatment necessary?
2. Do the patient and caregiver have the time and resources necessary to put the treatment into action?
3. Will the treatment improve the patient’s or the caregiver’s quality of life?

　

Treatment goals

Patient and family expectations regarding the possibilities of treatments and outcomes may be realistic or unrealistic. Inappropriate expectations about the effectiveness of treatment may lead to disappointment regarding relief of symptoms and pain. Therefore, ongoing communication and agreement by the patient, caregivers, and healthcare professionals regarding the goals of treatment are extremely important. The following list includes goals that are commonly developed in the treatment of spasticity.
· Relieve the signs and symptoms of spasticity
· Reduce pain, frequency of spasms, or irritating stimuli
· Improve gait, hygiene, activities of daily living, or ease of care
· Reduce problems with passive function, that is, the functions provided by the caregiver, such as dressing, feeding, transfer, and bathing
· Improve voluntary active motor function, that is, the behaviors and functions that are under the patient’s control, such as reaching for, grasping, moving, and releasing an object

　

Types of treatment

A combination of various types of treatment is usually required to attain the specific goals of treatment for a particular patient. Most people with spasticity require physical and occupational therapy to improve or maintain the range of motion in their spastic limbs.

Description of types of therapies: You can follow this at the following web link: www.wemove.org/spa/spa_pot.html.

　

Physical and occupational therapy

Although physical therapy is a mainstay of treatment for spasticity, there has been surprisingly little research conducted to support the use of these techniques. Physical therapy for spasticity refers to a range of physical (as opposed to drug or surgical) treatments. These treatments of spastic muscles are designed to reduce muscle tone, maintain or improve range of motion and mobility, increase strength and coordination, and improve care and comfort.

The choice of treatments is individualized to meet the needs of the person with spasticity. Physical therapy is the most common form of treatment for spasticity in children. The success of the therapy is often based upon the motivation of the person with spasticity and the caregiver, as well as the physical therapist’s skills.

Please note the last paragraph. Team effort is a must. The success of therapy is often based upon motivation of the person and the caregiver. If you are alone, the team may be you and the therapist. It will not work unless you have motivation. I refer it as “attitude.” I have written about “attitude” in previous articles. Get one !!! Never give up, I improve everyday despite two brainstem strokes.

Here are some additional sites for more info:
- www.webmd.com/pain-management/pain-management-spasticity
- www.geocities.com/aneecp/terms.htm
- www.ninds.nih.gov/disorders/spasticity/spasticity.htm