Spasticity

definition

Spasticity is a type of paralysis. In contrast to flaccid paralysis, in which the affected limbs hang down from the body, muscle tension is greatly increased in spastic paralysis.

In the case of spasticity, the muscles are in a kind of constant excitation, which is due to the disorder that caused them. This lies in the area of ​​the central nervous system, i.e. in the brain or in the spinal cord.

What is harmed by spasticity?

If the nerve tracts in the brain or in the spinal cord that control the movements are damaged, two pathological mechanisms result.

On the one hand, the so-called pyramidal path, which in healthy people is the connection between the brain (more precisely: Motor cortex) and produces the nerves that supply muscles. Since the nerve, which mediates between the pyramidal tract and the muscle, no longer receives stimuli from the brain, its excitability increases, which then leads, for example, to increased reflexes - a diagnostic characteristic of spasticity.

On the other hand, the extrapyramidal system, which opposes the pyramidal path, is influenced. The extrapyramidal system usually has an inhibitory effect on muscle arousal. If this function is no longer available, it leads to overexcitability with increasing muscle tension up to the cramp-like muscle state of spasticity.

In this sense, spasticity is not a disease in itself, but a symptom of nervous damage. The causes of spasticity are varied, but they can always be traced back to damage to the movement-mediating nerve tracts in the brain or spinal cord.

Causes of Spasticity

The most common spasticity occurs as part of a stroke (cerebral infarction). An area of ​​the brain is no longer adequately supplied with blood due to a vascular occlusion or bleeding, which causes an oxygen deficiency. Without oxygen, the sensitive nerve cells (neurons) quickly break down and die. This can result in movement disorders such as spastic paralysis, although this often only occurs as the disease progresses.

The already mentioned lack of oxygen, which can lead to the massive destruction of nerve cells and to various deficits as well as spasticity, may also come about in other ways than a stroke. An example of this is brain damage in early childhood. Children who are exposed to an excessive lack of oxygen during pregnancy or during childbirth suffer temporary, but also permanent damage such as spastic paralysis.

Changes in the structures of the brain and spinal cord caused by accidents can also interrupt the movement-controlling nerve tracts and trigger spasticity.
The most common accident-related injury is traumatic brain injury, which is particularly common after traffic accidents.

Another possibility is in underlying chronic diseases. Multiple sclerosis (MS) or amyotrophic lateral sclerosis (ALS), for example, are classic triggers of spasticity, even if the diseases themselves are by far not as common as a stroke.

Inflammatory diseases of the nervous system (meningitis, encephalitis or myelitis) rarely cause damage.

Spasticity of the lungs and bronchi

A spasticity of the lung or the Bronchi has only one thing in common with spasticity in the actual sense or with spastic paralysis - the spasmodic process. With a so-called Bronchospasm there is increased muscle tension in the respiratory muscles. This narrows the airways, the Breathing resistance increases: the patient can no longer breathe out properly.

The cause of a bronchospasm can often be found on the bottom of one chronic lung disease. A special group of these diseases - obstructive pulmonary diseases - classically cause one Narrowing of the airways. examples for this are bronchial asthma and COPD (the most common smoking disease). Also one acute inflammatory disease the respiratory system, like one bronchitis, may cause bronchospasm. However, this often happens when the patient is already taking a chronic lung disease suffers.

If no disease is the cause of the spasticity of the respiratory muscles, there may be one poisoning with chemical vapors or with smoke.

The treatment an acute bronchospasm is usually associated with Inhalation sprays carried out. A distinction is made between short-acting Medication for acute respiratory distress and long-acting Remedies for existing chronic lung disease.

Spasticity in the bowel

A spasticity in the intestine leads to a malfunction of the intestine. Only a section of the intestine or, in very rare cases, the entire intestine can be affected. The spastic cramping of the intestinal wall alternates between persistent constipation and diarrhea. This is due to the disturbance of the so-called peristalsis. This is the movement of the bowel to allow food to pass through the bowel. Spasticity in the intestine is often accompanied by severe abdominal pain and suddenly sharp cramps.
Spasticity in the intestine can also occur in the context of multiple sclerosis, in which there is a disruption in the transmission of nerves. Antispasmodic drugs are available to treat spasticity in the intestine. The best-known representative of this group of drugs is Buscopan (also Spasman, butylscopalamin written out in full). In addition, pain relievers such as ibuprofen or diclofenac are used to treat the pain.

Spasticity in multiple sclerosis

Multiple sclerosis (MS) is a chronic, inflammatory disease of the central nervous system, i.e. the spinal cord and the brain.

The disease occurs most frequently between the ages of 20 and 30 and its symptoms are characterized by deficits in the cerebellum, spastic paralysis, sensory disorders and other deficits. Since MS is a disease in which the course is often relapsing, the symptoms can vary in severity. The severity of the symptoms can vary between different patients as well as in one patient at different times.

Spasticity occurs in about 30% of all patients at the beginning of the disease and in over 80% during the course of multiple sclerosis. Spasticity, which is caused by inflammation of the nervous system, is variable in its severity. Only the hands can be spastically paralyzed, while the arm can be moved completely normally. The spasticity can also be more extensive, affecting whole limbs or half of the body (e.g. left arm and left leg). In some cases, cross-sectional symptoms can also be observed. For example, both legs are paralyzed, as can be the case after an accident involving the spine.

The exact cause of MS has not yet been clarified, but the mechanism that leads to spasticity must be the same as in other causal diseases. The pyramidal tracts and the extrapyramidal system (see “definition”) are damaged by the inflammation, which leads to over-activation of the muscle-controlling nerve cords.

Read on in the next article under: Spasticity in multiple sclerosis

Spasticity after a stroke

A stroke, also known as a cerebral infarction or apoplexy, describes the massive and sudden undersupply of an area of ​​the brain with blood, which is caused by the occlusion of the supplying vessel or by bleeding.

After a stroke, movement restrictions often occur, which in most cases affect the arms or hands, but less often the lower limbs as well. These limitations are based on damage to the brain, more precisely the areas that control movements.

While the acute symptoms of paralysis are rather flaccid, there are several development possibilities in the further course. The deficits can completely heal, the flaccid paralysis can persist or turn into a spastic paralysis over weeks to months. Since the damage is in the brain, the direct control center of motor skills (movement) is affected.

After the nervous system has overcome the shock of the undersupply, there is gradually an increase in muscle tension, which can turn into a spastic paralysis of a permanent nature.

Read on in the next article under: Spasticity after a stroke

Spasticity in babies

In babies, insufficient oxygen supply can damage the brain, which can lead to spasticity. This oxygen deficiency can already occur during pregnancy, but also at birth or later.
During pregnancy, for example, there is the possibility that the umbilical cord is kinked and thus the supply of the fetus is interrupted. During childbirth, complications can arise such that the child remains in the birth canal for a long time without a functioning oxygen supply, or the umbilical cord is wrapped around the baby's neck.
Swimming accidents are a common cause of birth-independent oxygen deficiency, in which the child's life can be saved, but not all areas of the brain. This damage, known as infantile central palsy, is caused by the death of nerve cells (neurons) in the brain.

Neurons are very sensitive cells and cannot survive long without a functioning supply of oxygen. They are particularly susceptible in infancy. Since the brain is still developing, the failure of a group of nerve cells can cause worse consequential damage than in adults.

The resulting spasticity can be adjusted satisfactorily with good therapy and sometimes enable a life without a wheelchair. Various medications and novel surgical techniques are used. The prognosis of such spasticity caused by early childhood brain damage is strongly dependent on the degree of damage.

Are you more interested in this topic? Read our next article below: Spasticity in babies

How do spastic twitches occur?

A spastic twitch is caused by an incorrect regulation of the activation of muscles by the nerve cells. This is always based on damage to various nerve tracts in the back. The one important pathway is the so-called pyramidal pathway, which sends commands to activate the muscles from the brain via the spinal cord to the respective muscles. The other important tracks are so-called extrapyramidal tracks. These primarily transmit signals to the muscles, which have a calming effect in order to prevent excessive activation of the muscles.

If these tracts are now damaged, the muscle lacks the command to reduce its tension. Accordingly, the tension in the muscle is increased. Now the information or impulses that cause the muscle to perform uncontrolled jerks also predominate. This leads to a twitch, which manifests itself spasticly, i.e. convulsively, due to the lack of control over the nerve tracts.

Diagnosis of spasticity

If spasticity is suspected, the diagnosis is mainly limited to the physical examination. The tests mainly relate to the patient's mobility and muscle tension (also called muscle tone). The examiner tests the tone by asking the patient to relax his limbs completely. The doctor then moves the joints passively, paying attention to the resistance that is opposed to the movement. While the passive movement should be quite simple in a healthy person, the same movement is more difficult in a patient suffering from spasticity. The joint feels stiff in its mobility and the doctor has to use real strength to perform a passive movement to be able to.

If the spasticity is pronounced, even a layperson can see at a glance the cramped limbs, which are overstretched or pressed against the body. This so-called increase in tone (or hypertonicity of the muscles) is also reflected in increased reflexes. Since the extrapyramidal system with its inhibitory character is ineffective, there is a more violent muscle response to reflex triggering than in healthy people. Primitive reflexes, so-called pyramidal trajectories, can also be triggered, which are normally suppressed by the extrapyramidal system. These primitive or early childhood reflexes can normally only be triggered in babies up to a certain age. Examples are the grasping reflex - when the palm of the hand is touched, the patient's hand closes like an infant - and the Babinski reflex, a classic sign of a disorder of the movement system. In the Babinski reflex, brushing the sole of the foot from the heel to the toes triggers a lift of the big toe.

Symptoms of spasticity

The intensity of the symptoms in the presence of spasticity can vary from patient to patient. Depending on the degree of damage, more or fewer muscles are affected. The clinical picture ranges between barely noticeable restrictions of movement and complete physical disability. A subdivision can be made by the localization of the spastic paralysis.

The following forms can usually be observed:

• Monospasticity: one limb is affected by the spasticity;
• Paraspasticity: both limbs on one level of the body, e.g. both legs, are spastically paralyzed;
• Hemispasticity: one half of the body is subject to spasticity;
• Tetraspasticity: all limbs are paralyzed, and the muscles of the chest and neck can also be affected.

In addition to limiting the mobility of the limbs, other muscle-controlled processes can also be influenced. These include, for example, speech disorders (dysarthria) and swallowing disorders (dysphagia). The patient can no longer express himself verbally because the function of the muscles used to produce speech is restricted. Such participation means enormous suffering for those affected. The eye muscles can also be paralyzed. Since the movement of the two eyes is no longer coordinated, double vision occurs. Other symptoms are the pyramidal trajectory signs used for diagnosis, as well as the increased muscle reflexes.

In addition to the physical impairments, the patient can develop psychiatric symptoms. Since spasticity is a symptom of a serious illness, it can lead to anxiety, aggression and depression. Occasionally, the spastic paralysis causes pain due to the extreme muscle tension, which should be treated to relieve the distress.

Do spastic patients have pain?

The excessive uncontrolled activation of the muscles often leads to strong tension and cramps. These can occur in different parts of the body and are often associated with severe pain. If the skeletal muscles, i.e. the muscles that are required for body movements, are affected, the joints can be impaired. Because of the spasticity, these are often brought into painful positions that cannot be easily resolved by those affected.

What is a spastic cough?

A spastic cough is a cramping of the airways, especially the bronchi, which leads to recurring spastic contraction of the lungs. This causes the affected person to cough badly. Particularly noticeable are the audible wheezing and rattling breathing. Most of the time, the spastic cough is caused by an infection that leads to pneumonia.
But breathing in a foreign body, i.e. aspiration, can also lead to spastic cramps in the airways. In the treatment of the latter cause, the removal of the foreign body from the lungs is the first priority. In the event of an infection, it must be treated quickly, depending on the causative agent. In addition, antitussive agents should be taken.

What is spastic cerebral palsy?

Spastic cerebral palsy is a form of paresis (muscle paralysis or relaxation) that is caused by damage to the brain (= "cerebral"). The brain damage is often found in the newborn as a result of malformations, a complication during childbirth, an infection during pregnancy or a brain hemorrhage. The result is a multitude of disorders of the muscles in the arms and legs, which are often associated with severe muscle weakness.
There are excessively pronounced reflexes and an unsteady stance and gait for those affected. In the long term, this leads to a curvature of many joints and the associated severe pain. Scoliosis can also result from spastic cerebral palsy. Furthermore, spastic cerebral palsy can be accompanied by other symptoms. These include a reduction in intelligence and abnormal behavior, such as uncontrolled sadness or anger. Physiotherapy, various joint operations and, for example, Botox are available therapeutically.

Read more on the topic: Spastic cerebral palsy

What is a tetraspastic?

Tetraspasticity is a spasticity that is present in both arms and both legs, i.e. all four extremities. The cause lies in damage to the so-called pyramidal path. This is a strand of nerves that carries information and commands about movements from the brain through the spinal cord to the muscles. If the pyramidal path is damaged, the forwarding of the commands for the execution of a movement is accordingly disturbed. Since all extremities are affected in a tetraspasticity, the location of the damage is above the point where the nerves for the arm muscles originate.

Possible damage is at the level of the spinal cord in the neck area or at the level of the brain stem (an area of ​​the brain that connects above the spinal cord and through which the pyramidal tract runs). The damage to the pyramidal tract leads to an increase in the so-called muscle reflexes, i.e. the reflexes that are triggered, for example, on the biceps muscle and also become visible in the biceps muscle through a twitch. In addition, there is an increased counter-tension in the muscles when trying to move them passively, i.e. without the help of the person concerned.

Read more on the topic: Tetraspastic

Therapy of spasticity

During therapy or when releasing a spasticity, it should be clear from the beginning that no absolute cure can be expected. The various measures can only reduce the discomfort, which, however, usually triggers enormous relief for the patient.

Mobility can be improved by various physiotherapy techniques and other movement concepts (bobath, water therapy, therapeutic riding) and pain in muscles or joints can be alleviated. The use of medication can also be considered for support.

There is no recipe for success in the treatment of spastic paralysis, but an interplay of different disciplines is desirable. Each patient should receive his or her individually compiled treatment program, since spasticity is an extremely changeable and, above all, different clinical picture.

Exercises

Most of the exercises that are intended to improve movement in existing spastic paralysis or to relieve the spasticity come from physiotherapy (physiotherapy). In physiotherapy, for example, affected limbs are passively moved by the therapist in order to maintain their mobility.

Exercises that the patient performs are mainly related to building strength - not only are the spastic muscles trained, but also the healthy muscle groups. Through the holistic muscle building, movements against the spastic muscle tension are possible.

Water therapy is an important aid here. Many movements can be performed in the water without a lot of muscle power. Swimming also strengthens the back, arm and leg muscles.

Another exercise in the broadest sense is therapeutic riding. The patient suffering from spasticity rides a horse, which should have special characteristics (not too big; not too much temperament). The muscle-relaxing warmth of the horse and the natural movement when riding, which is similar to the movement when walking, can (re) learn the movement patterns, train the sense of balance and use the muscles.

More on this: What possibilities are there to solve a spasticity?

Bobath concept

The Bobath concept is a Rehabilitation concept (Restoration of abilities as before the illness) in patients with central paralysis (in the brain or spinal cord). It is assumed that the nervous system has the ability to To transfer the functions of damaged brain areas to healthy areas and thus to regain physical functions.

In the context of the Bobath concept, the spasticity affected limbs or half of the body are particularly encouraged and included in the daily routine. The brain should thus be confronted with the stimuli that are generated by the paralyzed parts of the body. Both the sensitivity and the movement are trained daily and woven into every movement sequence so that the sick limbs constantly with required become. For example, a patient with half-sided paralysis should not lie in bed, but rather sit in a natural position at the table if it is adapted to the situation.

Overall, the Bobath concept is designed to reduce spasticity, the Sense of the position of the affected limbs (Proprioception) too increase, Relieve pain and to restore quality of life to the patient with daily routines as normal as possible. Since the concept is extremely complex, especially at the beginning, it requires a narrow one collaboration of the patient, care provider and relatives.

Medication

Drug therapy for spastic paralysis is complicated.

There are several spasmolytic Medicines (which relieve the spasticity), which have a Decrease in muscle tone work, but they affect all muscles in the body.
As a result, the holistic muscles of the patient. It can also be severe if overdosed Side effects such as respiratory failure, which negatively affects the side-effect-benefit ratio.

Another possibility is to use Botulinum toxin, the botox known from cosmetic surgery. Botox is a Neurotoxinwhich is used here in a highly diluted form. The nerve gets over a injection shut down, which prevents the transmission of stimuli and makes the spastic, cramped muscle groups slack.

In the so-called intrathecal baclofen therapy the drug baclofen is steadily fed into the via a drug pump Spinal canal injected (into the nerve water). Baclofen is a muscle relaxant medicine (Muscle relaxant) and in this dosage form the strongest form drug treatment. It is only used in severe cases of spastic paralysis, for example in the context of MS (multiple sclerosis).

Botox®

Botox® is one of many therapy options to treat spasticity. Different amounts can be injected intramuscularly, i.e. directly into the muscles, with a syringe. The botulinum toxin (Botox® is the abbreviated form of this) A is used in spasticity. It inhibits the release of acetylcholine. It is a neurotransmitter, a substance that mediates the transmission of information between nerve cells. If this is missing, the spasticity is reduced.

Read more on the topic: Botox®

Does magnesium help?

Magnesium can be effective for mild forms of spasticity. Magnesium is the antagonist of the electrolyte calcium, which is required for a muscle to contract. Accordingly, magnesium relaxes a muscle. A simple tablet of magnesium, which is dissolved in water, often helps with mild cramps that occur in the calves, for example after exercise.
This balances the electrolyte balance in the body and brings the balance between magnesium and calcium into harmony. It should be noted, however, that magnesium only helps with spasticity and cannot heal it.

Can spasticity be curable?

Unfortunately, spasticity is usually not completely curable. However, with early detection of the disease and adequate therapy, the symptoms can be significantly reduced. For example, it is important to continuously carry out exercise therapy, i.e. physical or occupational therapy, in order to prevent the progression of muscle twitches and cramps and thus reduce spasticity.