Overview of Section I
(A) Spasticity is a movement disorder caused by different central nervous system disorders and characterized by involuntary muscle contractile responses and velocity-dependent detrusor reflex hyperactivity, and is a component of the upper motor neuron syndrome.
Clinically spasticity and tonic, clonic and painful spasticity can co-exist and interact with each other and should be appropriately differentiated. Zhang Chong, Department of Neurology, The First Affiliated Hospital of Guangxi University of Traditional Chinese Medicine
Tonic: It is a movement disorder with increased muscle tone, but without Babinski’s sign and hyperactive knee reflex.
Clonic: It refers to a brief, non-persistent contraction of single or multiple muscles, such as facial twitching.
Nociceptive spasm: is a paroxysmal and spontaneous. It is a single or multiple muscle contraction that lasts for a period of time and is painful, as seen in tetanus, etc.
(ii) Spasticity and abnormal movement patterns
Abnormal movement patterns in stroke patients
1. Abnormal movement patterns of the upper limbs.
Typical postures include inward or internally rotated deformity of the shoulder joint, elbow flexion, forearm rotation forward, wrist flexion, fist clenching, and thumb flexion inward.
The spastic muscles are: latissimus dorsi, vastus lateralis, pectoralis major, subscapularis, biceps brachii, rotator anterioris roundus, etc.
2. Abnormal movement patterns of the lower limbs.
Horseshoe clubfoot or valgus, knee hyperextension or flexion, bunion hyperextension, hip hyperextension, femoral adduction deformity.
The spastic muscles are: anterior tibialis, posterior tibialis, medial and lateral gastrocnemius, peroneus longus, etc.
Assessment of spasticity in Section II
Neurological grading
0 Low muscle tone
1 Normal muscle tone
2 slightly high, no restriction of limb movement
3 High muscle tone, restricted movement
4 Muscle stiffness, difficulty or inability to move passively
Modified Ashworth Classification
Grade 0: no elevated muscle tone (normal muscle tone).
Grade 1: Slightly elevated muscle tone, with a feeling of “catching” or sudden release during passive extension and flexion of the limb, or a small resistance at the end of ROM (joint mobility).
Grade 1+: Significantly elevated muscle tone with a “stuck” sensation during passive flexion and extension, and minimal resistance for less than the last 1/2 ROM.
Grade 2: Significantly elevated muscle tone, with resistance in greater than 1/2 ROM, but easy passive movement.
Grade 3: Significantly elevated muscle tone with difficulty in passive movement.
Grade 4: The affected limb is stiff in the flexed or extended position
Section 3: Medical rehabilitation of spasticity
I Decision-making process of clinical rehabilitation treatment
Before proceeding with treatment, the necessity and purpose of treatment should first be clarified. Factors affecting treatment decisions include: stroke site, duration, severity, extent of lesions, cognitive impairment, care and support, and also decubitus ulcers and various pains.
II Comprehensive rehabilitation
(i) Preventive rehabilitation
(1) Provide preventive rehabilitation education to patients, adopt anti-spasticity position and maintain normal joint range of motion to prevent abnormal limb position and contracture of joints caused by spasticity.
(2) Remove triggers that aggravate spasticity, including injurious stimuli, such as: urinary tract infection, bed sores, deep vein thrombosis, pain, fractures, etc. Remove mental stress factors (anxiety, depression ). Prevent excessive exertion, fatigue, etc.
(II) Therapeutic training
(1) Postural control: Postural control is used to regulate the muscle tension of the whole body, it is used to inhibit the increase of muscle tone of certain muscle groups by using various postural reflexes that become activated after the destruction of central nerves. For example, various anti-spasticity postures, but the effect is still difficult to determine.
(2) muscle tension: any activity or posture that causes the spastic muscle to receive continuous tension can cause the corresponding muscle and muscle tone to decrease. For example, the upper limb to take bobath stretch support posture, can reduce the upper limb spastic muscle flexor muscle tone, stretching the Achilles tendon can reduce the gastrocnemius muscle tone. Stretching can take active exercise, passive exercise, specific posture apparatus (rising platform, brace, inclined plate, etc.)
(C) physical therapy
(1)Cold therapy for muscles: applying cold packs of ice or immersing the affected limb in ice water for 25-30 minutes can reduce spasticity for up to 3-4 hours, during which exercise training can be performed.
(2) Heat therapy or ultrasound therapy and hydrotherapy can also reduce myospasm, but the effect of these methods is short-lived.
(iv) Myoelectric biofeedback
Some reports show that EMG biofeedback can reduce spastic muscle activity at rest, reduce joint response, improve gait and reduce motor errors. However, it can only temporarily improve functional ability at the time of application and lacks learning effect.
(E) Peripheral muscle or nerve stimulation
The effect of transcutaneous electrical stimulation ( TENS ) is controversial, many literature reported that it can reduce muscle spasticity and can improve active activity. The effect of a single TENS can last for tens of minutes or even twenty-four hours. There are some studies showing that functional electrical stimulation (FES) can reduce the degree of myospasm in hemiplegic patients, inhibit the spastic simultaneous contraction of antagonistic muscles, and improve motor control.
(vi) Central electrical stimulation
Spinal cord electrical stimulation can change the spinal cord stage mechanism, change presynaptic inhibition, detrusor reflex and inhibit the altered H reflex of spastic state, but it has not been promoted in China due to the small size required by the electrical stimulator, high technical parameters, high surgical precision and high price.
(VII) Surgical treatment
Peripheral neurectomy can be considered as surgical treatment in patients with severe spasticity for which non-surgical treatment is ineffective. Surgical treatment includes alarm stimulator implantation, selective dorsal heel dissection, etc.
More frequently applied in patients with hemiplegia is the treatment of acromegaly, mostly using local drug block or wearing short lower limb brace.
Surgery should be performed 1 to 2 years after the onset of the disease.
(VIII) Others
In the rehabilitation treatment of spasticity also includes the application of Chinese acupuncture and massage, static or dynamic splinting, continuous plaster tube type, brace and orthosis application and other measures.
Three drug treatment
(A) Systemic anti-spasticity drug treatment
1, Baclofen Baclofen (national commercial product for Liolaixu)
(1) Characteristics: Beta receptor agonist of presynaptic inhibition of neurotransmitters, can strengthen presynaptic inhibition, is the most commonly used oral antispasticity drugs, good for mild and moderate spasticity after stroke, poor for severe.
(2) Dose: The initial dose of this drug should not be too large, usually 5 mg, 2-3 times a day, increasing by 5 mg every three days or seven days until the desired effect occurs and then maintained.
2.Tizanidine
(1) Properties: In patients with spasticity, tizanidine can dose-dependently reduce the activity of the detrusor reflex and polysynaptic firing, and also enhance the inhibition of the human H-reflex as well as reduce abnormal co-contraction movements, and these effects can improve the clinical symptoms of patients with spasticity.
(2) Dose: The initial dose is 2~4 mg administered word by word at night and slowly increased, the maximum recommended dose is 36 mg/day, the antispasticity effect is similar or even better than that of baclofen.
3.Myna
(1) Properties: 20 minutes after taking the drug, the activity of afferent nerve fibers into the muscle shuttle is blocked, while the nerve impulses sent by γ motor neurons can be blocked, so as to achieve skeletal muscle relaxation, with the effect of promoting random movements, such as extension and flexion of the extremities, but does not reduce muscle strength.
(2) Dose:Usually the starting amount is 25 mg each time, three times/day, taken orally after meals, and the maximum dose does not exceed 400 mg/day.
4.Cannabis
Cannabis botanicals have a long history of use in the treatment of pain and spasticity, improving sleep and suppressing nausea and vomiting.
There are reports of patients with spasticity due to stroke smoking marijuana can cause muscle relaxation, but long-term large amounts can cause cognitive impairment, addiction.
(B) The use of neurochemical blocking agents
Neurotoxins
Botulinum toxin: It is an exotoxin produced by the botulinum pike in the growth and reproduction, and belongs to the neurotoxin of high molecular protein. According to the different antigens of botulinum toxin, it is divided into seven types A, B, C, D, E, F and G. Type A botulinum toxin is the most studied and is now used to treat certain neuromuscular diseases.