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Thursday, 04 May 2017 18:36

What is spasticity?

Spasticity is one of the many secondary health effects caused by paralysis. People with a spinal cord injury, stroke, cerebral palsy, and multiple sclerosis most often have trouble with spasticity, but it can affect anyone with an upper motor neuron lesion. That includes a wide range of neurological disorders and injuries, and it means that millions of people are affected by spasticity.

When most people think of spasticity, they imagine simple muscle spasms, where a muscle twitches involuntarily. However, spasticity, also known as spastic hypertonia, can be more accurately defined as “disordered sensori-motor control, resulting from an upper motor neuron lesion, presenting as intermittent or sustained involuntary activation of muscles’’ [1], and the effects of spasticity can range from slight muscle stiffness to intense, uncontrollable muscle spasms that can literally launch someone out of their chair.

What causes spasticity?

Upper motor neuron lesions cause spasticity in much the same way that they cause paralysis and loss of feeling – by disrupting communication between the brain, the spinal cord, muscles, and the sensory system (sensory organs in the skin, muscles, tendons, etc.). Normally, if you want to relax a muscle, you only have to think about it, and your brain will communicate with your muscles through your spinal cord to make them relax. But if your brain or spinal cord is damaged, your muscles never get the message to relax. For this reason, if anything tells your muscles to activate, like a reflex that makes you pull away from something hot, the activation is often exaggerated or never stops. Spasticity can be triggered by movement, pain, discomfort, posture, and even other medical problems like urinary tract infections and pressure sores.

What does spasticity look like?

Many people with spasticity have increased muscle tone, meaning that some of their muscles never relax fully and are always somewhat contracted. This increased tone, also known as hypertonia, can range from mild and uncomfortable to severe and debilitating, like rigidity. Hypertonia is most commonly seen affecting the upper limb, resulting in a constantly flexed elbow, bent wrist, and/or clenched fist.

hands and spasicity

Figure 1: Presentation of spasticity in the upper limb.

The other common presentation of spasticity is hyperreflexia (exaggerated reflexes). When a reflex arc is activated in someone with spasticity, like when the patellar tendon is struck or you touch a hot stove and recoil, oftentimes the reflex will be exaggerated. In extreme cases, the reflex will repeat itself over and over again, echoing through the nervous system, which is known as clonus. Check out this video to see what hyperreflexia and clonus look like.

Pros and cons of spasticity

While spasticity is a symptom of a neurological disorder, it’s not always a bad thing. The table below lists some of the pros and cons of spasticity.

Pros Cons
Stiff muscles can help with some activities, like transferring from a wheelchair  Stiff muscles can hinder other activities, like getting dressed or brushing your teeth
     Controlled reflex spasms can help with some activities, like standing & grasping                       Uncontrolled reflex spasms can hinder other activities and lead to injury                  
   Hypertonia and spasms work the muscles, preventing atrophy & bone density loss                              Spasticity can be uncomfortable and even painful
     Metabolic requirements of spasms can improve blood circulation and breathing           Extreme hypertonia can lead to joint contractures and pressure sores
      Spasticity can be a warning sign that something else is wrong, like an infection                Extreme hyperreflexia can lead to injuries from collisions and falls

 

For more on the pros and cons of spasticity, check out this video from the University of Washington.

Managing spasticity

If the cons of spasticity outweigh the pros, then treatment may be necessary. There are several options for managing spasticity, each with its own pros and cons:

  • Surgery
    • Surgery is sometimes used as a last resort to release contractures, lengthen muscles, or reshape joints.
    • Pros: Permanent solution
    • Cons: Irreversible, painful, potentially dangerous, expensive
  • Implanted pump
    • An intrathecal pump can be implanted in the body and programmed to automatically deliver anti-spasm medication right where it’s needed.
    • Pros: Precise and low-dose so reduced side effects, reversible, refillable
    • Cons: Requires surgery, can malfunction, may cause infections, expensive
  • Injections
    • Chemicals can be injected directly into the muscle to block nerves and eliminate spasticity.
    • Pros: Only needed once every few months, directly targets the spastic muscles
    • Cons: Effectiveness diminishes over time, expensive
  • Medications
    • Medications can be taken orally or transdermally (through a patch) to manage spasticity.
    • Pros: Non-invasive, easy to manage, more affordable
    • Cons: Requires higher doses and affects the whole body with increased side effects
  • Stretching and exercise
    • The majority of time in inpatient rehab following a spinal cord injury is spent on range of motion (stretching) and strengthening exercises [2], which have a positive effect on spasticity.
    • Pros: Easy to do for some people, strengthening can improve function, most affordable
    • Cons: Time-consuming, can be difficult without assistance or special equipment
  • Electrical stimulation
    • Electrical stimulation can activate paralyzed muscles, enabling someone to exercise muscles that they otherwise could not.
    • Pros: Reduces number of spasms, best way to exercise paralyzed muscles, can have beneficial side effects, can be done without much time and effort, affordable options available
    • Cons: Can strengthen muscles, making spasms stronger; may not work well for everyone; can be expensive and complicated

Electrical stimulation and spasticity

There is a lot of confusion out there as to how electrical stimulation can be used to manage spasticity. Arjan van der Salm, a researcher from the Netherlands who wrote his doctoral dissertation on managing spasticity with electrical stimulation, provides a great analysis in his journal paper published in 2006 [3]. He demonstrated that electrical stimulation does not reduce spasticity, but it does relax spasms, meaning that the muscle will spasm less for a period of time, usually for several hours after stimulation. This can be achieved by either stimulating the spastic muscle itself, or by stimulating its antagonist. For example, if a person’s calf muscles (triceps surae) are spastic, electrical stimulation can be applied to the calf muscle or to the shin muscles (tibialis anterior), and either will relax the spasms. Van der Salm showed that stimulating the spastic muscle itself was most effective in relaxing spasms, probably because the stimulation fatigues the muscle and improves blood circulation to the muscle.

The takeaway here is that electrically stimulating a muscle can prevent spasms for several hours afterwards, so it can be used as needed to manage spasticity.

Final thoughts

There are many different factors to consider when choosing how to manage spasticity. The cause of spasticity, your situation and medical condition, and other factors like financing and support can all affect your decision. At the end of the day, a combination of methods will probably be best. For example, many people are fine with a low dose of medications combined with regular stretching and strengthening. It’s always best to consult your physician to find out what approach will be best for you.

For more information about spasticity, check out the resources below.

If you know someone who could use some help in managing spasticity, please share this article with them using the social media links at the top of the post.

The MyoCycle combines electrical stimulation with range of motion and strengthening exercise and is cleared by the FDA for general rehab for:

  1. Relaxation of muscle spasms
  2. Prevention or retardation of disuse atrophy
  3. Increasing local blood circulation
  4. Maintaining or increasing range of motion

To learn more about managing spasticity with the MyoCycle, click here.

Resources

WebMD: Spasticity

Cleveland Clinic: Spasticity

National MS Society: Spasticity

MedlinePlus: Caring for muscle spasticity or spasms

UAB-SCIMS: Spastic Hypertonia Spasticity following SCI

CareCure: FAQ about implanted baclofen pumps for managing spasticity

References

[1] Pandyan AD, Gregoric M, Barnes MP, Wood D, Van Wijck F, Burridge J, Hermens H, Johnson GR. Spasticity: clinical perceptions, neurological realities and meaningful measurement. Disability and Rehabilitation 2005;27(1/2):2-6.

[2] Taylor-Schroeder S, LaBarbera J, McDowell S, Zanca JM, Natale A, Mumma S, Gassaway J, Backus D. The SCIRehab project: physical therapy treatment time during inpatient spinal cord injury rehabilitation. The Journal of Spinal Cord Medicine 2011; 34(2):149-161.

[3] van der Salm A, Veltink PH, Ijzerman MJ, Groothius-Oudshoorn KC, Nene AV, Hermens HJ. Comparison of electric stimulation methods for reduction of triceps surae spasticity in spinal cord injury. Arch Phys Med Rehabil 2006; 87:222-228.

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Stationary cycling combined with electrical stimulation applied to the leg muscles (FES-cycling) is commonly used by people with spinal cord injury to maintain good health of their paralyzed limbs. Recent studies have highlighted the fact that FES-cycling is beneficial for people with other neurological disorders, especially stroke and multiple sclerosis (MS). An upcoming post will discuss the benefits for people with stroke, while this post will focus on the benefits for people with MS.

A recent pilot study conducted by Deborah Backus, PhD, PT, and her team at the Shepherd Center assessed the effects of FES-cycling on outcomes for people with MS [1]. Previous studies on the outcomes of FES-cycling training for ambulatory people with MS have demonstrated improvements in strength, walking endurance and speed, and even mental health and quality of life [2]. However, the effects of FES-cycling training for non-ambulatory people with MS haven’t been adequately studied, so Backus and her team set out to do just that.

Fourteen people (8 men and 6 women) with MS participated in the study. Participants ranged from 31 to 70 years old, and had been diagnosed with MS from 3 to 28 years ago. Only non-ambulatory people with MS could participate, meaning that they had to be unable to walk more than 70 feet at a time and has to use a wheelchair outside their homes. Participants completed 12 30-minute FES-cycling sessions over four weeks.

The results of the FES-cycling training indicate that not only is FES-cycling safe for non-ambulatory people with MS, but also that such training provides physical benefits and improved quality of life to people with moderate to severe MS. All the participants were able to increase their cycling time and/or resistance over the course of the training, suggesting that their ability to cycle improved as a result of the FES-cycling training. While the training had little effect on muscle strength or spasticity, the study participants reported that transfers and walking at home were easier after the FES-cycling training, suggesting that the training had functional benefits for the study participants. Perhaps most importantly, the participants reported that the social aspects of their life had improved as a result of the study, suggesting that the FES-cycling training had a positive effect on the participants’ quality of life.

Despite the fact that this was only a 4-week pilot study, the outcomes are promising for people with moderate to severe MS. More in-depth research is needed to learn more about the potential benefits of FES-cycling training for people with MS. To that end, a team of researchers at the University of Illinois at Urbana-Champaign is embarking on a 6 month clinical study to examine the effects of FES-cycling training on walking performance and physiological function among people with severe MS [3]. Based on the pilot data from the Shepherd Center, the results of this longer study are expected to be positive.

While FES-cycling is typically associated with spinal cord injury, its benefits extend to people with other neurological disorders, especially stroke and MS. These benefits include:

  • Improved walking and cycling ability
  • Increased muscle strength
  • Improved physical, mental, and social well-being
  • Better quality of life

Exciting research into the benefits of FES-cycling for people with MS is being conducted at places like the Shepherd Center and the University of Illinois at Urbana-Champaign. If you or someone you love has MS and is interested in FES-cycling, contact us today to learn how the MyoCycle Home can meet your needs!

References

[1] Deborah Backus, Blake Burdett, Laura Hawkins, Christine Manella, Kevin K. McCully, and Mark Sweatman (2016) Pilot Study of Outcomes After Functional Electrical Stimulation Cycle Training in Individuals with Multiple Sclerosis Who Are Nonambulatory. International Journal of MS Care.

[2] John N. Ratchford, Wendy Shore, Edward R. Hammond, Gregory J. Rose, Robert Rifkin, Pingting Nie, Kevin Tan, Megan E. Quigg, Barbara J. de Lateur, and Douglas A. Kerr (2010) A pilot study of functional electrical stimulation cycling in progressive multiple sclerosis. NeuroRehabilitation.

[3] Lara A. Pilutti, Robert W. Motl, Thomas A. Edwards, and Kenneth R. Wilund (2016) Rationale and design of a randomized controlled clinical trial of functional electrical stimulation cycling in persons with severe multiple sclerosis. Contemporary Clinical Trials Communications.

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