Plastic Beats Spastic
“Why do I have spasticity? What can I do to get rid of spasticity? When will it go away?”
Most clinicians provide patients with overly simplified information about spasticity, its cause and its treatment. Therapists generally believe that patients don’t want detailed explanations. But patients need to understand their spasticity. Why? Because: spasticity can only reduce if executive (brain) control over the spastic muscles is restored. And executive control over muscles will only happen with repeated firing of the muscle in question. And repeated firing will only happen if the patient wants it to happen.
So how can you explain spasticity in a way that is easy to understand and scientifically valid?
Here is the story of spasticity. Spasticity happens because of a set of circumstances caught in an endless closed loop. The players in this story are the:
Muscles
Spinal cord
Brain
Spastic muscles
The "normal" (non-brain-damaged) cycle is:
Muscleà spinal cordà brainà spinal cordà back to muscle.
The cycle after brain-damaged that produces spasticity is:
There is an injury to the brain. The brain no longer controls certain muscles.
Because the brain is no longer in command, muscle control can be completely lost. The muscles under little control are at risk of tearing. And muscles hate tearing.
Muscles send a “Help, I’m being overstretched!” signal to the spinal cord.
The spinal cord sends the message to the brain. The brain would normally send down a mix of “tighten” and “relax” signals to stabilize the muscle. But the brain is not responding. So the spinal cord does.
The spinal cord says, “Muscles, do that thing you do!” Muscles only do one thing: Flex (contract, tighten). So flex it does. This process is spasticity. (A reverberation of the monosynaptic stretch reflex, if you want to get technical).
These messages go on and on, during most waking hours. Some stroke survivors continue to be spastic even into the first few stages of sleep.
The shortened muscle perceives everything as an overstretch and the alarm signals to the spinal cord proliferate. The process repeats itself in an endless cycle.
Without the proper interventions the muscle can shorten permanently. Other soft tissue can shorten as well including blood vessels and nerves. This permanent shortening is called contracture.
Most therapeutic interventions therapists typically use are, at best, nominally effective against the symptoms of spasticity. Few address the underlying issues causing spasticity. Consider stretching. Stretching reduces spasticity, right? But research of the effectiveness of stretching is equivocal, at best. Cold modalities temporarily reduce spasticity. Heat actually increases spasticity. There is strong evidence wearing a splint is ineffective in reduction of spasticity and contracture formation. The variety of handling techniques that therapists use? No demonstrated effect.
Is there any light at the end of the tunnel? Yes, and it has to do with the plastic (moldable and remoldable) human brain. Repetitive practice, if done properly, has the ability to rewire the brain to restore voluntary control over muscles. As executive (brain) muscular control emerges, spasticity dissipates. Why does reestablishing brain control reduce spasticity? Remember, spasticity is a protection mechanism. It keeps muscles that could be torn relatively immobilized. But the reason that they were at risk of being torn in the first place was that there was no brain control. If you reestablish brain control, you take any need for the spinal cord out of the equation. If you eliminate the spinal cord (except as a relay for information) you eliminate spasticity. Brain controlled muscles is what you want. Repetitive practice is how you get there.
There's clinical research suggests that repetitive practice paradigms reduce spasticity. But it means using the movement that you have, no matter how little, how frustrating, or how little real-world activities can actually be done. Muscles completely paralyzed by spasticity is known as spastic paralysis. Most stroke survivors are not completely paralyzed by spasticity. Muscle that is not completely paralyzed by spasticity can move, at least a little. Movement by those muscles may be just a few degrees of active range of motion within a joint. For instance you may be able to flex your elbow just a little bit, and extend your elbow just a little bit. Maybe only a few degrees. The idea is to use this movement to constantly push just beyond your current limit. A combination of flexion and extension just beyond your present capability is the essence of effective repetitive practice for the reduction of spasticity.
There are variety of tools that can be used to help spasticity help you get rid of spasticity. The primary problem is that repetitive practice is inherently boring. (Imagine flexing and extending your elbow for a few hours a day!) Tools that can help you go beyond your existing abilities are the ones that really help. The goal is to head towards repetitive practice paradigms that are functional (have real-world impact). Once they have a real world impact they become a lot less boring. A good example of that a therapy that requires a lot of repetitive practice is constraint induced therapy (CIT). CIT involves using the upper extremity over and over again. Again, it's all about repetitive practice. But as most stroke survivors know, CIT requires some grasp and release at the hand. Obviously, this is a very high-level stroke survivor. So what do you do in the meantime? There are a number of treatment options that can help jump start grasp release the hand (beyond the scope of this article). But in the meantime you still need to be a get the hand to where it needs to go. And that involves the shoulder, the elbow and the forearm. A general philosophy in the therapies that muscle control starts proximal (close to the body) and moves distal (away from the body). So working on joints that are close to the body may actually spur hand movement. And even if they don't, more movement at the shoulder and elbow can mean a lot to stroke survivor suffering from weakness on the one side of the body. It can mean easier dressing, less pain and discomfort at those joints, more ability to move from place to place (mobility) and... a reduction of spasticity within the muscles that move the shoulder and elbow.
The bottom line is: Take the tools spasticity provides and use those tools to usher it out the door.
Peter G. Levine is the director of SynapsTogether, the author of Stronger After Stroke and The Stroke Recovery Blog, a research consultant for the Neuromotor Recovery and Rehabilitation Laboratory and a seminar instructor teaching plasticity-driving stroke recovery strategies. Contact: StrongerAfterStroke@yahoo.com.