Spasticity - a cramp by any other name?

Spasticity is one of those problems that seems to come back to haunt people with various types of disability because of spinal cord injury, brain injury, stroke or multiple sclerosis time and time again; so I thought that it would be useful to spend a column or two trying to understand it and then talking about ways in which we can, and do, manage it successfully and even use it to improve quality of life.

So what is this thing called spasticity?

Well some time after the brain or spinal cord is injured, or becomes diseased, we very often start to see the emergence of an increase in the level of resting muscle contraction in the parts of the body affected by the injury. This can even show itself as involuntary re- flex movements during which the (ironically) paralysed body parts seem to move on their own accord and without control.

You may well remember (before you were injured) having pricked yourself - and feeling your hand jerk away even before you were aware of the pain. This is known as a reflex movement and happens without any direct command from the brain. The body, through a so-called “reflex arc” reacts automatically before the brain registers the problem and responds. These re- flexes protect us from harm and damage in an emergency and are responsible for controlling the state of tension in the muscles.

Whilst reflex arcs are able to respond autonomously in the event of an emergency, they are ordinarily controlled by the movement centres in the brain with messages or nerve impulses relayed up and down the spinal cord.

When the brain or spinal cord is injured the balance between the reflex arc and its controlling “computer” is lost and the reflex arc is left without control. This results in the resting tone (medical-speak for the level of tension

or stiffness in the muscles) increasing which result in stiff limbs that are often pulled into awkward and uncomfortable positions. It also results in the jerky, erratic movements that so often make moving in bed, sitting in a chair, transferring and just about everything difficult or impossible.

You may sometimes have heard your doctor or physio talk about an “upper motor neuron lesion”. They were referring to the fact that there is a disruption of the reflex arc’s control system in the nerves, brain and spinal cord above the level of the reflex arc.

This type of injury is also often called “spastic” (meaning that there is spasm present) or hypereflexic (meaning that the reflexes are increased) and is usually seen in people who have had injuries of the brain or strokes, in conditions like multiple sclerosis and often in spinal cord injuries above the level of T12 or L1.

Now that you understand that and if you are living with a disrupted or damaged “upper motor neuron” control system you will appreciate that there is nothing left to control your reflex arc. If you are touched, moved, subjected to pressure or pain or if you are left too long in a particular position, your re- flex arc is activated and without anything to control it spasticity sets in with the attendant stiffness, awkward positions and jerky and erratic movement. Many people say that this is much worse in the mornings after they have been lying flat in bed through the night and slowly improves during the course of the day.

Of course because no two people or their injuries are exactly the same the levels of spasticity, and the problems that result, vary considerably from person to person. You may be lucky enough to have little or no spasticity, but equally you may end up with severe, life disrupting and miserable, constant levels of spasticity.

One thing to understand is that spasticity can be very useful if it is not excessive and disruptive. The muscle activity that is stimulated by reasonable levels of spasticity keeps the muscles working and maintains the bulk of the muscles (prevents muscle wasting), improves and maintains blood circulation, prevents and reduces swelling in the arms and legs and, with practice, can be used to perform certain movements like transfers. So, if spasticity is not severe you could regard it as a friend and it would be a good thing to spend some time with your physio talking about how you can make it work for you.

Unfortunately, when spasticity becomes excessive it can lead to a number of significant problems:

  • Very commonly it can interfere with functional activities and prevent participation in day-to-day life (disrupting transfers and making selfcatheterisation impossible).
  • The excessive friction and chafing caused by the jerky movements can cause pressure ulcer development.
  • The stiff and awkward positions that limbs are pulled into by spasticity can create difficulty in lying and sitting comfortably.
  • If left unchecked over a long period of time, severe spasticity can cause shortening of muscles and tendons and result in permanent contractures (distortion of the normal range of movement around the joints of the effected limb).

One really important thing to understand is that levels of spasticity can increase and decrease under various circumstances. An increase in the level of spasticity can be caused by urinary tract (bladder) infections, constipation, pressure ulcers, and almost any other illness that would ordinarily cause pain, specifically things like pulmonary embolus, pneumonia, appendicitis, gallbladder disease, peptic ulcers and heart disease. Spasticity can also be aggravated by the presence of a broken bone, by ingrown toenails and even piles.

So what is the message this time round? If you do notice a sudden change or increase in the level of your spasticity, you really need to have it checked outby your doctor and/or physio.

Next time around we’ll be looking at ways in which spasticity can be safely and effectively treated.

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