Spasticity, how do we manage it?

Spasticity, how do we manage it?

Spasticity is often associated with neurological difficulties. 65-78% of those who have suffered a spinal injury will experience symptoms of spasticity in the first year after their accident (1). Following a stroke, the incidence of spasticity will be 4-27% in the first three months, 19-43% between months 3 to 6, and after 6 months, 20-38% (2). For those with Multiple Sclerosis, 84% will experience symptoms of spasticity (1). These are but examples, not to mention cerebral palsy, cranial trauma, and many others.

 

Alright, but what exactly is spasticity?

Spasticity is an exaggeration of the deep tendon reflex, something we all have. When we walk, if our ankle turns in unintentionally, our body will trigger this reflex to contract the muscles and stop the movement before the ankle twists too far, thus preventing an injury. On the other hand, when the reflex is too sensitive, it becomes spastic. When we attempt to simply stretch out our arm, and the reflex to bend our elbow is triggered, this can cause problems. Do not get upset; your body is merely trying to prevent you from injuring yourself. Be careful not to confuse spasticity with rigidity. The deep tendon reflex is triggered by a rapid, involuntary movement. Spasticity is also triggered by a rapid movement, but it depends on the speed of the movement. The faster the movement, the greater the resistance. This is not the case with rigidity. The level of rigidity will remain the same no matter how rapid the movement. It is common in diseases like Parkinson’s.

 

Problematic? Tell me about it! It’s downright painful!

Spasticity is not always painful, but it can be. It can also cause spasms (involuntary movements), balance problems which create a risk of falling, or can prevent us from moving the way we want to. It depends on how bad it gets. It can be more or less incapacitating or painful.

 

Alright, now how can we get rid of it ?

Get rid of it? Maybe we do not have to. Spasticity can actually help you out. It can improve muscle tone during transfers or help you stand up straight even if your muscles are weak. When spasticity is diminished, we may feel like we are weaker. Therefore, we do not want to get rid of it, rather we want to manage it when it becomes too incapacitating or painful. We want to decrease its negative effects without depriving ourselves of its benefits.

 

OK then, how do we manage spasticity?

 We are not without choices, as there are many studies available on this very topic.

 

Medication: Your doctor may prescribe oral medication such as baclofen or tizanidine, two molecules which have proven beneficial. If you are affected by paralysis, baclofen can also be given through a pump (3).

Also, Botox (botulinum toxin) has also been proven effective for Multiple Sclerosis (4) and for a few months after suffering a stroke (5). Caution is necessary though, as treating spasticity too quickly after a stroke can hinder recovery (3).

 

Cannabis: Consuming cannabis seems to show a decrease in spasticity and spasms. The benefits vary from person to person, as do possible side-effects in those with Multiple Sclerosis or paralysis (1). It is a current and interesting area of research, even more so with impending legislation. We will be speaking more in detail about this in a future blog.

 

Acupuncture: Acupuncture and electroacupuncture have also undergone evaluations. Preliminary results show positive effects among the post-stroke patient population (6) (7).

 

Functional Electric Stimulation: The much-touted electrodes that help our muscles contract are referred to as “functional” because they are used in real-life movements like on a bicycle or a robot that helps with walking. How can contracting muscles help decrease spasticity? Stein et al. (2015)(8) explain that this happens with increased activation of muscle fibres which influence inhibition of the antagonistic muscles (which happens when a spasm prevents from doing a desired movement) and when there is an increase in sensorial stimulation on the skin. This is also effective for strokes (8) and for spinal injuries, as well as other neurological conditions.

 

Whole-body vibration machines: Generally speaking, it is a platform where one would stand. The machine causes our body to vibrate. This has proven beneficial for people with cerebral palsy (9). Short-term benefits have also been shown for those who have spinal cord injuries (10). Positive effects for other conditions remain unproven.

 

Passive Movement: Next, we have more recent, less tested treatments such as robotic devices for movement therapy. After undergoing robotic movement therapy for the arms, participants have shown less spasticity in the forearm and fingers (11). The same benefits are noticeable with the usage of exoskeletons. Participants with spinal cord injuries report a decrease in spasticity and discomfort after their walking sessions on the exoskeleton (12). Mechanical or motor-powered bikes providing passive movement can also provide similar benefits (13).

 

Constraint-Induced Movement Therapy: This therapy is geared at those having suffered a stroke. The movement of the unaffected arm is restrained and the affected arm is used for 6 hours a day, five days a week for 2 weeks. This technique not only improves spasticity, it improves general motor ability through better use of the affected arm (14).

 

Yes, this all sounds good, but what can I do about it?

Exercise programs (especially stretching) seem to be beneficial. However, they are more effective when we consult (a professional). Discussing and choosing exercises best suited for us, having guidance for adapting them – it makes a world of difference compared to someone who tries to sort through all of the available documentation on their own (15).

 

Otherwise, limited information is available to help learn how do decrease spasticity! Knowing that a reflex is triggered by a rapid movement, it only seems logical to choose a more fitting, slower movement. Start by using the slowest possible movement, gently and gradually increasing the speed. Maybe activities like Tai Chi will be beneficial? This area still needs further study. As for its feasibility, it seems that when too much spasticity is present (post stroke), it is near impossible to do Tai Chi (16). Doing Yoga seems to help those with Multiple Sclerosis, but its impact is yet to be clearly defined (17).

 

Team Work:

In the end, you will hear that you have to stay hydrated, avoid infections, breathe through your nose…..there’s nothing magic about it. We must remember that teamwork is better when facing a problem, and that we must try several ways of doing something before we discover the one that is best for us. But, we mustn’t remain alone with our spasticity!

 

For more information, consult our bibliography!

(1)da Rovare, V. P., Magalhães, G. P., Jardini, G. D., Beraldo, M. L., Gameiro, M. O., Agarwal, A., & … El Dib, R. (2017). Cannabinoids for spasticity due to multiple sclerosis or paraplegia: A systematic review and meta-analysis of randomized clinical trials. Complementary Therapies In Medicine, 34170-185. doi:10.1016/j.ctim.2017.08.010
(2)Katozian, L., Tahan, N., MohseniBandpei, M. A., & JamBarsang, S. (2015). Spasticity following Stroke: A Systematic Review and Meta-analysis. Journal Of Mazandaran University Of Medical Sciences (JMUMS), 25(123), 232-247.
(3)Agence française de sécurité sanitaire des produits de santé (2011), Recommandations de bonnes pratiques : traitement médicamenteux de la spasticité, https://ansm.sante.fr/var/ansm_site/storage/original/application/9771c86bf98d7af854c30b202846ab35.pdf
(4)Baker, J. A., & Pereira, G. (2016). The efficacy of Botulinum Toxin A for limb spasticity on improving activity restriction and quality of life: A systematic review and meta-analysis using the GRADE approach. Clinical Rehabilitation, 30(6), 549-558. doi:10.1177/0269215515593609
(5)Wu, T., Li, J. H., Song, H. X., & Dong, Y. (2016). Effectiveness of Botulinum Toxin for Lower Limbs Spasticity after Stroke: A Systematic Review and Meta-Analysis. Topics In Stroke Rehabilitation, 23(3), 217-223. doi:10.1080/10749357.2016.1139294
(6)Sung Min, L., Junghee, Y., Euiju, L., Hyun Jung, K., Seungwon, S., Gajin, H., & Hyeong Sik, A. (2015). Acupuncture for Spasticity after Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Evidence-Based Complementary & Alternative Medicine (Ecam), 1-12. doi:10.1155/2015/870398
(7)Cai, Y., Zhang, C. S., Liu, S., Wen, Z., Zhang, A. L., Guo, X., & … Xue, C. C. (2017). Electroacupuncture for Poststroke Spasticity: A Systematic Review and Meta-Analysis. Archives Of Physical Medicine And Rehabilitation, doi:10.1016/j.apmr.2017.03.023 ¨
(8)Stein, C., Fritsch, C. G., Robinson, C., Sbruzzi, G., Méa Plentz, R. D., & Plentz, R. M. (2015). Effects of Electrical Stimulation in Spastic Muscles After Stroke: Systematic Review and Meta-Analysis of Randomized Controlled Trials. Stroke (00392499), 46(8), 2197-2205. doi:10.1161/STROKEAHA.115.009633
(9)Duquette, S. A., Guiliano, A. M., & Starmer, D. J. (2015). Whole body vibration and cerebral palsy: a systematic review. Journal Of The Canadian Chiropractic Association, 59(3), 245-252.
(10) Sadeghi, M., & Sawatzky, B. (2014). Effects of Vibration on Spasticity in Individuals with Spinal Cord Injury. American Journal Of Physical Medicine & Rehabilitation, 93(11), 995-1007. doi:10.1097/PHM.0000000000000098
(11)Gobbo, M., Gaffurini, P., Vacchi, L., Lazzarini, S., Villafane, J., Orizio, C., & … Bissolotti, L. (2017). Hand Passive Mobilization Performed with Robotic Assistance: Acute Effects on Upper Limb Perfusion and Spasticity in Stroke Survivors. Biomed Research International, 1-6. doi:10.1155/2017/2796815
(12)Stampacchia, G., Rustici, A., Bigazzi, S., Gerini, A., Tombini, T., & Mazzoleni, S. (2016). Walking with a powered robotic exoskeleton: Subjective experience, spasticity and pain in spinal cord injured persons. Neurorehabilitation, 39(2), 277-283. doi:10.3233/NRE-161358
(13)Kakebeeke, T., Lechner, H., & Knapp, P. (2005). The effect of passive cycling movements on spasticity after spinal cord injury: preliminary results. Spinal Cord, 43(8), 483-488.
(14)Siebers, A., Öberg, U., & Skargren, E. (2010). The effect of modified constraint-induced movement therapy on spasticity and motor function of the affected arm in patients with chronic stroke. Physiotherapy Canada, 62(4), 388-396.
(15)Hugos, C.L. Bourdette, D. Chen, Y. Chen, Z. Cameron, M. (2017) A group-delivered self-management program reduces spasticity in people with multiple sclerosis: A randomized, controlled pilot trial, Mult Scler J Exp Transl Clin. 2017 Mar 23;3(1):2055217317699993
(16)Pan, S. Kairy, D. Corriveau, H. Tousignant, M. (2017) Adapting Tai Chi for Upper Limb Rehabilitation Post Stroke: A Feasibility Study. Medicines (Basel). 2017 Sep 30;4(4). pii: E72. doi: 10.3390/medicines4040072.
(17)Rogers, K.A. MacDonald, M. (2015) Therapeutic Yoga: Symptom Management for Multiple Sclerosis. J Altern Complement Med. 21(11):655-9. doi: 10.1089/acm.2015.0015. Epub 2015 Aug 13.