Introduction
Spasticity was first defined by Jim Lance in 1980. It is a velocity-dependent increase in the stretch reflexes of the muscles, accompanied by increased muscle tone. It is a significant cause of disability in older people; which when not managed appropriately can result in unnecessary complications for the patient and their family. The prevalence of spasticity is estimated to be higher in post-stroke patients or patients with cerebral palsy.
What Is Spasticity?
An abnormal increase in muscle tone or muscle stiffness that may interfere with the self-care and daily activities of the patient such as walking, posture, speech, etc is called spasticity. It is usually caused by an interruption or damage to nerve impulses that control the movement of muscles or muscle reflexes. An imbalance in the signals sent to the muscles can be a reason for these interruptions, which locks the muscles in place. Spasticity in older people can be triggered by various factors such as extreme cold or hot temperatures, high humidity, tight clothes, stress, and fatigue.
How Can Spasticity Be Assessed?
The assessment of spasticity is a matter of consideration to determine the type of treatment. The modified Ashworth scale was proposed to grade muscle spasticity. It is as follows:
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Grade 0 - No increase in muscle tone
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Grade 1 - A slight increase in muscle tone; associated with a catch and minimal resistance at the end of the range of motion when the affected parts are moved.
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Grade 1+ - A slight increase in muscle tone; associated with a catch and minimal resistance through half of the range of motion.
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Grade 2 - A marked increase in muscle tone throughout the range of motion, but affected parts can still be moved.
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Grade 3 - A considerable increase in muscle tone, and difficulty in passive movement.
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Grade 4 - The affected part or parts are rigid in flexion or extension.
What Are the Causes of Spasticity?
Spasticity may be caused due to the following factors:
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Damage to the part of the brain due to ischemia or lack of blood supply and oxygen results in a stroke.
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Presence of a lesion in the brain which may cause cerebral palsy.
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Injury to the head or the spinal cord.
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Neurodegenerative illness (damage to the brain and nervous system over time).
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Diseases such as multiple sclerosis, phenylketonuria, adrenoleukodystrophy, etc.
What Are the Signs and Symptoms of Spasticity?
Some of the signs and symptoms of spasticity include:
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Muscle spasms and inability to stretch the affected muscles.
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Tightness or stiffness of muscles.
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Abnormal and unusual postures.
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Limited range of motion.
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Involuntary jerky movements.
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Hypertonicity of muscles (increased muscle tone).
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Severe pain and discomfort in the affected area affecting normal activities.
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Fixed joints (contractures) may be seen in severe cases, which can lead to reduced movement and bending of the joints.
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Increased muscle contractions.
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Exaggerated deep tendon reflexes.
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Scissoring of legs (crossing of legs).
How Can Spasticity Be Diagnosed?
Diagnosis of spasticity is challenging due to its varying degrees in different people. A physical examination followed by neurological testing is carried out to diagnose spasticity and its severity. A neurological examination is done to determine the upper motor neuron or lower motor neuron injury or the involvement of both. It includes a sensory examination of the cranial nerves for sight, smell, hearing, and touch throughout the body, a motor examination to check for muscle strength, reflexes, ability to push and pull, body balance, etc. Spasticity is graded according to the modified Ashworth scale.
An electromyogram (EMG) and a nerve conduction study are advised to test muscle function by the application of electric impulses to the muscles. A magnetic resonance imaging (MRI scan) can be recommended to determine the exact source of spasticity and the extent of damage that has occurred.
How Can Spasticity Be Managed in Older People?
It is required to seek medical care at the occurrence of spasticity for the first time with an unknown cause, as it is frequent and may worsen with time. Several treatment options are available for patients with spasticity and a combination of therapies may be required to obtain good results. Nonsurgical treatment methods include;
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Physical exercises may help to strengthen the muscles, facilitate stretching, and improve the range of motion.
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Occupational therapy exercises help to improve muscle coordination, improve performance in daily activities.
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Oral medications such as Tizanidine, Dantrolene sodium, Baclofen, Gabapentin, benzodiazepines, and imidazolines may be prescribed along with other therapies to relieve the symptoms or if the symptoms interfere with sleep.
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Botulinum toxin (Botox) injections are administered to paralyze the muscle causing the spasm and preventing contraction. It is injected into the selected sites based on the pattern of spasticity for about 12 to 16 weeks.
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Casting, or bracing can be performed to prevent involuntary muscle spasms and muscle tightening. Thermoplastic splinting or orthotics can also be recommended to influence muscle extensions and increase flexibility. It also reduces stress on the soft tissues and lowers the excitability of the motor neurons.
Surgical treatment may be recommended for tendon release or to sever the nerve-muscle pathway, it is performed only when the other treatment options are ineffective. It includes:
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An intrathecal Baclofen pump can be surgically placed in the abdomen which releases a steady dose of Baclofen directly into the spinal fluid and reduces spasticity and pain. It is recommended only in extreme cases but is found to be very effective in the treatment of spasticity of the upper and lower extremities. A periodic follow-up is required every three months, six months, and one year postoperatively along with medicine dosing and device-related appointments.
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A selective dorsal rhizotomy is the surgical removal of the nerve roots with precise indication to decrease muscle stiffness while maintaining the other functions and correcting the imbalance of the electrical signals that are sent to the spinal cord. It is indicated in patients with spasticity due to cerebral palsy.
What Are the Complications of Spasticity?
Spasticity especially in older patients requires immediate care and treatment, as poor management can lead to long-term complications such as soft tissue contractures (shortening of the muscle), chronic constipation, frequent urinary tract infections (UTI), painful pressure sores (ulcers caused due to constant pressure), and limited function.
Conclusion
An abnormal increase in muscle tone or muscle stiffness that interferes with the self-care and daily activities of the patient is called spasticity. It is associated with muscle stiffness, increased muscle tone, severe pain, limited range of motion, and abnormal posture. It can be managed with oral medications and physical therapy, and in some extreme cases by surgery. As the treatment of spasticity is quite challenging in older people, a multidisciplinary treatment from both the physician and a physiotherapist along with patient cooperation through regular follow up is essential for the successful management of the condition.
