Spasticity due to brain injury
Increased muscle tension

Brain damage or MS can disrupt the electrical currents between the brain and muscles. The brain cannot provide the correct muscle tension. There is then increasing muscle tension in one or more muscles. The muscles cannot work together. The increased irritability in the muscles can lead to stiffness or tight muscles or mild or severe spasticity, while the muscles are actually not strong. The muscles are continuously in a shortened position.
The muscles can contract alternately or even permanently.

 

Spasticity may be accompanied by muscle weakness, incomplete paralysis (paresis) or paralysis on the left or right side (hemiplegia).
Spasticity complicates the movement function of one or more limbs or on one side of the body.

 

Muscles in which it occurs

Spasticity can occur in the muscles or muscle groups of arms, elbows, wrist, shoulders, hands, thumbs, legs, hip, knee, foot and toes.
Spasticity in the arm and hand is most common and results in an inability to open the hand, move the wrist or extend the arm.
If you can no longer move your muscles smoothly or move in a controlled manner, this can cause many practical problems in daily life, in addition to a real risk of falling if you cannot keep your balance properly. If you can no longer open your hand, you can hardly use that hand, or with great difficulty.

 

Spasticity in the legs, hip and foot means that a person cannot bend or straighten the joints. Standing, walking and maintaining balance is then very difficult or impossible. A pointed foot is common with spasticity.

 

Definitions

1. Spasticity is a disturbed control of motor skills (movement) and sensation (feeling) due to upper motor neuron syndrome that manifests itself as a variable or permanent involuntary muscle activation. (European SPASM working group definition)
   
2. Spasticity is a combination of altered skeletal muscle performance with paralysis and increased tendon reflex activity and hypertonia.
3. Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes with enhanced tendon twitches, resulting from hyperexcitability of the stretch reflex.

 

 

Motor neurons

Normally, muscle tension is required to move and function.
During most movements, the impulse that goes from the brain to the muscles runs via the upper motor neurons to the lower motor neurons and then to the muscles.
Spasticity is damage in the part of the brain that controls movement. It is injury to the upper motor neuron.

Spasticity can occur with many types of brain injury and disrupts:

• the pyramidal tract (axons that run from the cerebral cortex via the medulla oblongata to the spinal cord to control skeletal muscles)
  
• the corticospinal tract (from the cerebral cortex to the spinal cord) involved in voluntary movement

 

Cramps, muscle contractions and enhanced reflexes

Alternating contractions may occur, but the spasticity can also manifest itself in permanent cramps. Although the muscles may look tight and strong, they are actually unusable and weak.

Increased excitability of the muscles causes great reflex activity, which then leads to overactivity in the muscles that have to work against gravity. This creates a hemiplegic (half-sided paralysis / spastic) posture.

 

Two forms of spasticity

• Static spasticity: increased muscle tension that occurs independently of muscle activity and in any position; continuously present
  
• Dynamic spasticity: muscle stiffness only occurs in specific situations; present intermittently

 

Fixed patterns

Spasticity often occurs in fixed patterns:

• Shoulder turned in, elbow bent,
  pronounced forearm, with the palm turned backwards, bent wrist and clenched fist, often with a deformity of the thumb in the palm, the patient cannot open the palm
• Flexed wrist: severe spastic wrist flexion can sometimes lead to dislocation of the wrist (wrist subluxation) and carpal tunnel syndrome
• Deformity of the forearm due to the square pronation muscle (pronator quadratus) and/or two-headed muscle (pronator teres) that ensures inward rotation of the hand
• Clenched fist often with deformity of the thumb in the palm
• Bent Elbow: Often a person bumps his or her fist to the throat due to severe elbow flexor spasticity
• Feet turned inward
• Big toe sticking up caused by an overactive tendon of the muscle that moves the big toe upwards (extensor hallucis longus)
• Pointed foot due to toes that are bent too much inward
• Stiff knee, persistent stretching of the knee (knee extension)
• Bent knee, deformity often due to tight hamstrings
• Legs turned outward (abduction)
• Upper legs, thighs that are too close together (addiction) caused by spastic muscles that pull the thighs and knees inward towards the body (adductors). This results in a base that is too narrow for the feet to stand on

 

Possible consequences

• pain, muscle pain and joint pain (read our specific page on pain due to spasticity)
  
• sleep problems
  
• fatigue; Moving stiff muscles takes a lot of energy
  
• bone and joint deformity
  
• muscle shortening and contractures (fused joints, permanent contraction of tendons and muscles)
  
• position deviation
  
• scoliosis (crooked growth of the back)
  
• muscle stiffness, tight muscles, restriction of movement, feeling of heaviness
  
• dislocated joint
  
• atrophy of the muscles / muscle mass decrease
  
• strengthened reflexes
  
• annoying reflexes such as tapping the ground with the foot
  
• involuntary movements
  • with spasms (short/or persistent involuntary, often even painful contractions of muscles)
    
  • with clonus (a series of rapid involuntary contractions of muscles)
    
• ataxia
  
• abnormal posture
  
• reduced strength
  
• loss of dexterity of the hands and fingers, difficulty standing, walking and keeping balance
  
• movement restriction
  
• inability to speak or laugh or with difficulty, facial cramps
  
• difficulty in ADL functions
  
• problems with hygiene, infections
  
• wounds and ulcers under the spastic areas
  
• pressure ulcers
  
• pressure points, for example due to poorly fitting orthoses
  
• urinary tract infections
  
• kidney stones
  
• constipation - difficulty passing stool or obstruction of the intestines

 

Compensation

Sometimes someone who has a paresis (incomplete paralysis or muscle weakness) can compensate for some of the muscle weakness by standing or walking with the help of the spasticity.

 

In which injuries and how often does it occur?

Figures are from the USA

• Stroke (CVA): About 38% of people with a stroke suffer from spasticity. 
• Traumatic Brain Injury: About 50% of people with traumatic brain injury may develop spasticity. It should be noted that lesions in the midbrain areas and the pons gives a higher number.
• Multiple Sclerosis: Figures range from 37% to 78% of people with multiple sclerosis developing spasticity.
• Cerebral palsy: More than 90% of people with CP have spasticity.
• Oxygen deficiency: No figures known. 
• Metabolic diseases, such as adrenoleukodystrophy (Schilder-Addison disease), phenylketonuria: No figures known.
• Brain tumors: No figures known.
• Neurodegenerative disorders: No figures available.

 

Treatment

Some medications or therapies can keep spasticity under control, but there are also people for whom the side effects are too great or the treatment does not work well. Spasticity cannot yet be cured.

The following treatments are currently available.

• Medication by mouth: baclofen, tizanidine, diazepam, and dantrolene sodium, alone or in combination
  
• Medication via the spinal fluid: intrathecal baclofen drug pump (ITB) via a thin tube in the back.
  
• Orthopedic surgery: the position of a bone can be corrected (osteotomy) and tendon attachments can be moved.
  
• Neurosurgery: selective dorsal rhizotomy in which roots of the sensory nerves in the back are cut.
  
• Injection therapy: such as nerve blocks with phenol:
  anesthesia nerve blocks with procaine and lidocaine and botulinum toxin (Botox) injections.
  
• Rehabilitation technique: casting, splinting, positioning, electrical stimulation etc.
  
• Physiotherapy for strengthening muscles and for stretching and relaxing the muscles. Exercises to keep the joints mobile.
  
• Occupational therapy for help with daily activities, also in the field of aids such as orthoses that provide support in the body position.

 

Other movement disorders

There are other movement disorders caused by damage to the basal ganglia (basal nuclei) or the cerebellum or the midbrain which cause the substantia nigra nerve cells to die.
Damage to the Red Cores can also cause movement problems such as an intention tremor. There are other movement disorders caused by damage to the basal ganglia (basal nuclei) or the cerebellum or midbrain when the substantia nigra nerve cells die.
Damage to the Red Cores can also cause movement problems such as an intention tremor.