Measuring spasticity

[gcoe]

Hi oc1dean
Thanks for the very useful Movement Disorder University URL. This site gives a great run-down on spasticity and related issues, the various causal theories and pathophysiology, assessment and management.

My understanding is that spasticity after stroke remains a very real problem for a sizeable number of people with stroke, particularly in the chronic phase of recovery, and remains difficult to find effective management that really helps people.

The conclusion that spasticity may not be such a central problem in people with stroke grew for three reasons:

1. When one starts to investigate spasticity it is a real Pandora’s box – and what people with upper motor neurone syndrome present with is highly complex, varies from patient to patient and some of the aspects are not at all well understood. Spasticity was often used as a blanket term to cover a number of observed phenomena: velocity dependent increase response to stretch, hyperactive reflexes, abnormal reflexes, motor control problems such as delayed contraction on voluntary effort, inability to switch off a muscle on voluntary command, excessive co-contraction across a joint, abnormal synergistic action across a number of joints (most commonly flexor synergy in the arm and extensor synergy in the leg), associated reactions, contracture and so on. Part of the problem was seen as bad science – using this global term to define all these divergent phenomena. So what researchers have done is to more closely define spasticity and many now limit the discussion to abnormal velocity-dependent resistance to stretch due to abnormal neural activity. When compared with the most common impairments seen (namely weakness) velocity-dependent resistance to stretch wasn’t found to contribute that much to the disruption to purposeful movement. In contrast weakness, which had been under-estimated was found to be a very major factor. Contracture – often misdiagnosed as spasticity – where there is a shortening of the musculotendinous unit and often changes in the joint as well, is another major factor on disability.

2. Some of the earlier methods of physiotherapy devised for treating stroke had a whole emphasis on reducing spasticity, based on the premise that spasticity and abnormal reflexes were the primary interference with the recovery of normal movement, and that by reducing spasticity normal movement could then be facilitated. Time has shown that these methods were unrealistic (therapists couldn’t really reduce spasticity), the rationale for these methods simplistic and these methods weren’t particularly efficient at promoting normal movement. Since then there has been much more interest in how to promote skilled movement.

3. The emphasis on has been on acute and subacute rehab and I think in these stages spasticity and related phenomena may be less obvious a problem then what appears in later months and years post stroke.

In short there are potentially lots of disabling motor components to stroke. The emphasis in the last few years has been more on developing effective strategies for improving skilled movement. However I don’t think that clinicians and many researchers have completely abandoned investigating the management of the problems related to spasticity. For example the use of Botox combined with aggressive physical therapy for spasticity, often where contracture coexists, has some evidence of effectiveness. And there are lots of conditions other than stroke, where spasticity remains a major hurdle and needs to be better understood. So I don’t think that spasticity has disappeared off the research map and there will be continued interest in it and related problems – particularly as more time and money is spent on living longer with these problems.

What is your experience of the physical therapy you have received? Do you feel spasticity has been ignored?

[oc1dean]

Thanks for the detailed explanation of spasticity, I couldn't find anyone who knew about it. My first PMR doctor knew nothing about spasticity, he wanted to snip the tendons for curled toes rather than knowing about toe crests and metatarsal bumps. none of the therapists knew about spasticity either, but at least I found out that exercise does not increase spasticity. I had to find out about Brunnstroms six stages of recovery myself. I consider myself mildly spastic, but it is an oxymoron that I am not paralyzed enough to easily recover using neuroplasticity.

[gcoe]

You must have found that a discouraging and disappointing experience in your health system. Even though rehab professionals may have differing opinions about the relative importance of spasticity, what is is and how it can be treated, I would have expected a PMR and PT to know something about spasticity and to be acquainted with the area.

It doesn't surprise me that your professionals may not have known much about Signe Brunnstrom’s stages of recovery or her therapeutic methods. At the time (1970's onward) there was a fierce debate about the role of spasticity and how to treat it. Her nemesis, Berta Bobath had a contrary view about spasticity and abnormal reflexes. Basically Bobath believed we should suppress abnormal activity at all costs as it would interfere with recovery while Brunnstrom considered such activity an important step in the recovery of function and that we should use such activity to strengthen the patient. In my part of the world the Bobath Method (in your country often referred to as NDT) dominated the teaching and practice. Because of this "war of views" we weren't exposed to Brunnstrom's ideas which on reflection was a a pity. Of the two Brunnstrom was the greater applied scientist – a real contributor to the observation of normal and abnormal movement at the time. The fact that she emphasised both strengthening and patient lead practice that aimed at skilled movement was ahead of her time. Based on our current knowledge I don’t know if I agree with the staged recovery model however – but that is another story.

Two questions: May I ask what you consider your main problems in terms of what you can’t do now? Would you like me to send you some recent articles on the treatment of spasticity? You may already have them but I have a few new studies stacked away here. If you would like them, however you’ll have to send me an email address – for copyright reasons I can’t post them on public display and the private mail doesn’t have an attachment facility. You can PM me if you want.