Dangers of limb spasticity.
Research studies have shown that the incidence of limb spasticity status after stroke is 39%, and the incidence of spasticity status in patients with severe traumatic brain injury is 75%. Severe limb spasticity after brain injury is the main factor leading to the decrease in the individual’s ability to live independently in daily life and the increase in the degree of disability, and is an important element in the treatment and rehabilitation of brain injury in clinical practice, as well as an important factor in the increasing medical consumption and the increasing investment in medical resources.
After brain injury, the limbs are gradually overtaken by the soft state to the rigid state, that is, the muscle tone gradually increases into the spastic state, and once the pathological pattern of spasticity is generated, most of them will gradually aggravate and generalize. Spasticity can involve skeletal muscles throughout the body, and this severe discoordination can lead to a wide range of systemic dysfunctions, including cognition, speech, swallowing, and bowel function, in addition to limb movement disorders, and form a vicious cycle.
Evaluation of spasticity.
Evaluation of spasticity is done by a multidisciplinary treatment team involving multiple aspects and levels of assessment. Participants in the evaluation typically include neurorehabilitation physicians, neurosurgeons, nurses/specialized nursing staff, physical therapists, occupational therapists, physical therapists, orthotic fabricators, and also the patient and their family or caregivers. The evaluation includes the site of brain injury (focal, multifocal, diffuse, correlation between spasticity and brain injury lesions), stability of the intracranial environment (presence of hydrocephalus, intracranial fluid, cranial defects, other encephalopathies), extent of spasticity involvement, severity of spasticity, stability of spasticity, spasticity complications (muscle atrophy, tendon contracture, skeletal deformities), injurious stimuli, and other factors. A comprehensive assessment of the patient’s and his or her family’s or caregiver’s wishes and expectations, as well as an assessment of available medical expenses and available rehabilitation medical resources are also included.
Goals of treatment for spasticity.
Relieve symptoms: relieve pain, improve sleep, and reduce the frequency of muscle spasms and involuntary movements, such as joint reactions.
Improve active function: improve transfer and mobility, such as the ability to transfer from chair to bed and back again, speed, stability, efficiency and posture of movement, and duration of continuous walking or walking with assistance; upper arm and hand dexterity for holding and retrieving; self-care, such as the ability to wash and dress; and the ability to eat.
Improving passive function: reducing the burden of care, including reducing the difficulty of mobility, care and adjustment of position, and the difficulty of routine daily care (e.g., perineal hygiene, dressing).
Avoidance of damage aggravation: prevention of contractures and deformities, facilitation of the use of orthoses and splints, optimization of posture and sitting, and improvement of the vitality of body tissues.
Improving appearance and posture: improving body image and making clothes fit as well as possible.
Improving the effectiveness of conventional rehabilitation measures: optimizing the effectiveness of treatment and reducing systemic medications used to treat spasticity.
Spasticity treatment program.
Patients need treatment only when they have functional problems or care problems due to limb spasticity. Suitable individualized rehabilitation goals and treatment plans are developed after systematic evaluation. At present, the main clinical prevention and control of spasticity include exercise therapy, physiotherapy, biofeedback therapy, oral antispasticity drugs, intrathecal continuous injection of antispasticity drugs, botulinum toxin injection, and selective cut of posterior spinal nerve roots.
Oral antispasticity drugs are mainly neurotransmitter inhibitors, which inhibit and alter many higher neurological functions, such as cognition, alertness, mood, etc., while relieving muscle tone, and have limited efficacy, are easily resistant to drugs, and are not suitable for long-term application.
Movement therapy (PT, OT) is the most commonly used method, and the therapist adopts various theories of motor control to conduct training with bare hands, which requires high skills and experience of the therapist, and has a long course of treatment with no lasting effect.
Physical therapy is the use of electricity, light, sound, magnetism, temperature and other physical factors for treatment, the effect is limited, mostly as an auxiliary means.
The above methods are mostly suitable for the treatment of mild and moderate spasticity states.
Intrathecal injections are effective, but their clinical application is limited by the limitations of the treatment site, complications associated with foreign body placement, and the high cost of materials and postoperative maintenance.
Botulinum toxin injection and posterior spinal nerve root selective excision are currently the appropriate methods to treat severe spasticity of the limb.