Flaccid or spastic; what strategy works best?

Here's a recently email question I got....

Hi there,

I recently read your article about spasticity located here. 

The article seems to focus on therapies and treatments for patients who still have some motor control over muscles -- i.e. the brain is still in the loop.  Would the same treatments apply to a patient with little or no muscle control over muscles. i.e. muscles remain mostly flaccid post stroke.  Or is there little in the way of physical therapy that can be applied in this situation?

Specific patient is currently being treated with ativan and tizanidine, with the resulting effect that their ability to remain active is significantly deteriorated due to drowsiness.

Thanks,
(Name withheld)

Muscles hate to be overstretched, so if the brain is not online (as is often true after stroke) the muscles rely on the spinal cord to take over the job of protecting the muscles from being overstretched. But the spinal cord is a dumb brain. It can only tell muscles to tighten. The bottom line is: once the spinal cord takes over you end up with tight spastic muscles.

There is emerging research that suggests that if you can reestablish brain control over spastic muscles, the spinal cord will get it out of the way, and spasticity will decline.

So, as you can see the question, above, is a bit confusing because the writer asks, "Will the same treatments apply… in muscles that remained mostly flaccid post stroke?"

When the muscle is flaccid, there is no brain control over the muscle. If that's the case early in recovery (the first few weeks) you may find that the survivor becomes spastic or regains voluntary movement through the arc of recovery. But if the survivor is flaccid for more than a few weeks, the only thing that may have potential is electrical stimulation.  

(Note: because tizanidine -trade name Zanaflex- in particular is used specifically for spasticity, the person you are talking about is spastic. In that case they would have voluntary control into flexion - i.e. if you passively stretch the fingers to "open" the hand, they can squeeze your hand. If this is true, then I'd follow this strategy. It is a common misconception that everyone who is spastic has no control over their muscles. If they can squeeze, have them squeeze over and over and over and over... Tough to do when "their ability to remain active is significantly deteriorated due to drowsiness.")

If you want to see all this blog's entries on spasticity click here.

Recovery is done in three phases.

Recovery from stroke is done in three phases.

ACUTE    SUBACUTE    CHRONIC

1. The acute phase (~day 1 to day 7 [note all time periods are highly variable]). This is usually done in the hospital. In terms of recovery your main responsibility is to keep yourself healthy. Therapists will typically focus on helping you do what you can do. This is a time for convalescence.

2. The subacute phase (~day 7 to 3 months). This is usually done with some help from therapists. You will experience the most recovery during this phase. This is the time that rehabilitation should "put the pedal to the metal." This is where the hard work begins. During the subacute phase the brain is "primed" to recover. Make the most of this phase because it is a window of opportunity to reach the highest level of recovery.Squander it and squander the highest level of potential recovery.

3. The chronic phase (~3 months to the end of life). Typically the survivor has very little contact with rehabilitation professionals during the chronic phase. This is the time to implement a "do-it-yourself" plan for recovery. Recovery comes at fits and starts and is much more difficult than during the subacute phase. Still, important gains can be made during this phase. Up to very recently it was thought that no recovery could be made during the chronic phase. We now know, however, because of the brain's amazing ability to rewire itself, essential progress can be made during the chronic phase.

A blog entry about football-induced brain injury.

There is a problem when it comes to the issue of football and brain injury....

The people that know about football know nothing about the brain, and the people who know about the brain know nothing about football.

I know a little bit about both. Here's my 2¢:

I played football all through high school from freshman to senior. During my sophomore year, I never left the field. Kickoff, kickoff return, punt, punt return, every play on offense, every play on defense. I played pretty much every position on the field from nose tackle to linebacker and defensive back to quarterback to receiver.

Are you interested in having your kids play football? Are you wondering if the years you played may have left a residual affect on your brain? Here are a few things that you should know:
 

Other sports have head injuries. A lot of the popular press points this out. They say "Well, you hit your head in soccer when you head the ball." "When you play hockey you can get checked, that can cause a head injury." Of course they're both true. You could potentially have a head injury in almost any sport. Absolutely. No question. You could hit your head a few times a game.

What most folks don't realize is that in football you hit your head on almost every play. You are either blocking someone, trying to run over someone or falling. When you fall in football it is not a controlled fall. There's a variety of forces -usually other peoples bodies-- that impact the trajectory of your fall. All control is gone. Also, a lot of the time your hands are full, usually with somebody else's jersey.

As you fall your head hits the ground. It may hit many other things on the way to the ground, but it will almost always hit at the ground. When your head hits the ground the skull stops, but the brain keeps going. In fact, during any hit to the head in football, the brain keeps going...

And because the brain keeps going players cannot be protected by any kind of helmet. This is because, once again, the head will stop, the skull will stop, but because the brain is in fluid (cerebrospinal fluid) the brain will keep going. And you might think, who cares? So it keeps going but the skull is really smooth and so it hits a smooth area and it kind of sloshes around a little bit. So what? The impact wouldn't be significant enough to damage the brain. This is where a pretty intimate knowledge about the anatomy of the skull is important. People think of the skull they think of a really smooth surface. In fact, only the top half of the skull is smooth.

The bottom half is so convoluted and has pieces that are so sharp, that if you pressed your hand into it with a few pounds of force, you would  open the skin. So as the brain continues to move forward it is scraped against these many sharp edges that stick up into the bottom of the brain. And because there is a head hit in every play (okay not every play, you may be a decoy and not have to hit anybody. But for most positions almost play the head will get hit. I played QB for a year. I took the worst hits that year) the brain will be scraping every time. There is no good data on what this does to the brain. Everybody is focused on concussions, but because this ("scraping)" is done over and over and over to the brain, it may actually be more damaging in the long term.

So how many hits do high school player take to the head?

A high school football player may take anywhere from 200 to 1,800 hits to the head during the course of a single season. 

So if you think your precious game is above the organ that most makes us human, you can pretty much kiss my...... 

Spasticity After Stroke III: Options for Treatment

      What else works? BOTOX® (botulinum toxin type A) can be injected directly into the spastic muscles to provide months of spasticity relief. Intrathecal baclofen (ITB) therapy delivers spasticity medication to the intrathecal space (fluid flows around the spinal cord) corresponding to the spinal level of the spastic muscles. Oral medication, dorsal root rhizotomy, orthopedic surgeries and other treatments do reduce spasticity. And if you think that these medical interventions have nothing to do with therapists, think again. Physiatrists and neurologists believe that spasticity that limits function is one of the triggers for appointments for these experts in spasticity reduction. Who better than therapists to gently guide patients to these doctors for spasticity treatment?    
        A word of caution here: Once directed to a doctor who specializes in spasticity interventions, patients sometimes forget what to say and end up saying something vague like, "I want to move better." Prior to sending patients with spasticity to these doctors, tell them in clear and concise terms exactly what muscles you want the doctor to work on. If the patient has trouble with dorsiflexion because of spastic triceps surae, having the doctor BOTOX® the finger flexors is not going to help.
       The Holy Grail for spasticity reduction is a melding of doctor-prescribed medical interventions and therapist-delivered neuroplastic treatment options. The proper mix of these interventions is emerging as research goes forward. Guiding patients back to neurology and physiatry and accepting neuroplasticity as the substrate for authentic spasticity reduction are good first steps.

Spasticity I: The "Magic" "Cure" for Spasticity Reduction?

Share

       

Why do I have spasticity? What can I do to get rid of spasticity? When will it go away?"

        People who have any number of pathologies can suffer from spasticity. Spinal cord injury, multiple sclerosis, amyotrophic lateral sclerosis (Lou Gehrig's disease) and other pathologies have spasticity as a sequela. This column will discuss spasticity as it relates to acquired brain injury which includes traumatic brain injury, cerebral palsy and stroke.

     Most clinicians provide patients with overly simplified, incomplete and often inaccurate information about what spasticity is, its etiology and its cure. Therapists generally believe that patients don't want detailed explanations. But patients need to understand their spasticity. Why? Having patients understand their spasticity is essential because spasticity will only reduce if executive control over the spastic muscles, by the brain, 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.