What is muscle spasticity and how is it treated?

Spasticity is an as increased muscle tone, which increases with tension and causes resistance during passive movement. This symptom is accompanied by muscle weakness, spasms, increased tendon reflexes, and partial or complete loss of ability to move the affected body part.

The most frequent cause of its appearance is a violation of the connection of the brain with the spinal cord, which can occur as a result of stroke, spine injury, brain injury, meningitis, encephalitis, and multiple sclerosis. It also develops in around 70% of people with cerebral palsy. If spasticity is not treated, dystrophic changes develop in the joints, tendons and muscles, and the risk of falls and injury increases. Osteoporosis and osteoarthritis progress.

Treatment and rehabilitation

When discussing approaches to treating spasticity, it should be borne in mind that it is a very dynamic phenomenon. Thus, the chosen therapy should be not only individual and carefully planned, but also constantly monitored and changed if needed. Treatment is usually complex. Specialists of both medical profile and social workers and relatives of the patient take part in its implementation.

The treatment of spasticity is mainly symptomatic, i.e. it cannot be cured but only symptoms can be alleviated. This means that it is necessary first of all to set the goals of therapy.  The first question that should be decided is whether it is necessary to treat these disorders at all, since often spasticity can be functionally useful, allowing the patient to move around and dress. Apparently, in this situation, spasticity should not be treated, although from a neurophysiological point of view, it is a pathological phenomenon. But the therapy can immobilize the patient and worsen their quality of life.

In cases where rehabilitation measures are necessary, the doctor should discuss the goals and possible results of the therapy with the patient.  The most common goals are to improve the ability to move, reduce the intensity of pain, and prevent the formation of soft tissue contractures (a condition in which the limb cannot be fully bent or unbent in one or more joints, caused by cicatricial contraction of the skin, tendons, diseases of the muscles, joints, pain reflex and other reasons). The specific objectives of the therapy should be clearly explained to the patient, since they must be an active participant in their implementation and aim at a certain result.

Patients with spastic paresis require long-term treatment, therefore, it is necessary to regularly revise the goals and objectives of therapy, to define new boundaries and clarify old ones. This is especially important in the case of long-term use of muscle relaxants, since often the negative effects can outweigh the positive results. These medicines such as Tizanidine are the first-line drugs for spasticity but taking them for too long without breaks can worsen many health aspects.

For a more successful rehabilitation, it is crucial that the patients and their family members have a certain level of knowledge about the mechanisms of the condition and possible treatment outcomes. It is necessary to inform the patient about some factors that can aggravate their condition, for example, inappropriate position of the paretic limb, poorly fitted shoes, heavy blanket, too soft bed. Knowing the negative potential of these or other similar situations allows the patient to prevent or alleviate many functional problems. It is also important that the patient is informed about such factors that increase motor deficits as urological infections (primarily of the bladder) and constipation.

Physical methods of treatment play a significant role in the rehabilitation strategy of patients with spastic paresis. It is important to start treatment as early as possible. There are many potential opportunities for such patients, ranging from simple passive movement exercises to more complex physiotherapy procedures. A physiotherapist may recommend symptomatic treatment with heat, water procedures, and prescribe fixation of paralyzed limbs in a certain position. Taking into account the latter circumstance, it is advisable to connect to the treatment of an orthopedist, since many functional problems can be resolved as a result of using an adequate orthopedic device. International practice shows that the active participation of a physiotherapist and orthopedist in the process of rehabilitation of patients with spastic paresis makes it possible to achieve many goals before the transition to drug or local invasive treatment.

The main treatment for spastic muscle hypertension is medication. In this case, muscle relaxants can be used both as monotherapy and as part of a general rehabilitation strategy (the latter approach is used more often). These drugs provide a useful baseline effect that allows, for instance, placing the paralyzed limb in the most comfortable position or adequately using a brace. Sometimes, especially with mild spasticity, the use of muscle relaxants can be effective as monotherapy to reduce functional problems such as seizures. But antispastic agents also have negative effects (intolerance and increased general weakness). Spasticity is often a local problem, while muscle relaxants are systemic, i.e. they affect the whole body. In this situation, the paretic muscles can relax excessively and the overall functional effect can enhance motor neurological deficits. That is why the goal and objectives of treatment require detailed discussion, strict use of medicines according to indications and monitoring.

The first medicines prescribed for the condition are benzodiazepines and benzothiadiazoles: Tizanidine (Sirdalud, Zanaflex), diazepam, and others. They can inhibit polysynaptic reflexes with less effect on monosynaptic ones.

Muscle relaxers prescribed for muscle spasticity

Often patients with spasticity and restricted movement suffer from changes in muscle tone  mainly in one or several muscle groups. For example, in the case of spastic dystonia. In this situation, the systemic effect of oral muscle relaxants is undesirable, therefore, local methods of influencing spasticity are preferred. Several years ago in the world, much attention was paid to such local technologies as phenolic and alcoholic blockade of peripheral nerves. Recently, local/topical injections of type A botulinum toxin have been used for this purpose.

Occasionally, spasticity may be resistant to oral muscle relaxants and botulinum toxin type A. In this case, intrathecal baclofen is used. For this, a special pump injecting the dosage of the medication is implanted. This therapeutic approach is not dangerous, although undesirable effects associated with pump failure or a violation in the catheter system are possible. The main limitation of this technology is the high cost of the implantable system.

There are surgical methods for spasticity treatment, for instance, rhizotomy, but at present it is practically not used. But for such undesirable effects of spastic hypertension as soft tissue contractures, this method can be considered.

Movement disorders (paresis, spasticity) often lead to immobilization of joints and the development of capsulitis, bursitis and tendonitis in them. Cramps, spasms and severe muscle tone also cause discomfort to patients. The inability to change body position leads to constant pressure on the skin, bones and joints, which also causes pain. The pain can be localized in the neck, back, limbs, is dull, burning, or resembles an electric current.

The main method of pain therapy is physiotherapy. As drug therapy, analgesics are prescribed, including non-steroidal anti-inflammatory medicines (Voltaren, etc.), anticonvulsants (Tegretol, etc.) and tricyclic antidepressants. The combination of these drugs is especially effective.

Patients with spastic paresis, regardless of the reasons for their development (acute or chronic diseases and lesions of the central nervous system), may develop symptoms such as fear, anxiety, depression. First of all, in such a situation, psychological support is required both from the medical staff and the participation of relatives of patients.

From pharmacotherapy, drugs from the benzodiazepine group are more often prescribed, since they have a lower risk of drug dependence and subsequent withdrawal syndrome. For patients with dominant depressive syndrome, antidepressants are recommended.

Conclusion

Thus, to solve the main problem of treatment and rehabilitation of patients with spastic paresis (increase in physical activity and the possibility of self-care), careful planning and monitoring of this process is necessary.  Along with medications for the treatment of the underlying disease and symptomatic therapy of spasticity, various types of exercises and physiotherapy methods should be used. In addition, various auxiliary adaptive equipment is used to fix certain parts of the body, to increase the ability to move, as well as various devices for patient self-care. The management of these patients requires a multidisciplinary approach, and in the process of treatment and rehabilitation, it is necessary to include not only a neurologist, physiotherapist and orthopedist, but also a social worker, the patients themselves and their family.

Post by: Natalie Keller, M.D. General Health Centre, Minneapolis, Minnesota