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Spasticity research - Is it worthwhile?
Spasticity is my subject for ranting on. None of my doctors were able to explain it or how to recover from it.
When I finally got access to a computer and started researching it I came accross this letter
to the editor of Stroke magazine from William M. Landau.
http://stroke.ahajournals.org/cgi/content/full/35/8/1787
Spasticity After Stroke: Why Bother?
(Stroke. 2004;35:1787.)
© 2004 American Heart Association, Inc.
This alone was very depressing
Then I found another research study that came to the same conclusion.
Found an interesting site Movement Disorder Virtual University that has lots of detail on
spasticity. Here is the link http://www.mdvu.org/library/disease/spasticity/spa_mpath.asp
If you follow it down quite a few levels you can find this
--------------------------------------------------------------------------------------
Subject: Incidence and Consequences of Spasticity After Stroke
Date: 2/20/2004
Spasticity affects less than one quarter of stroke victims, according to this study.
Muscle overactivity and its consequences were assessed in 95 patients both immediately after
and three months a first-time stroke. Seventy-seven (81%) were initially hemiparetic, of whom
20 had spasticity. Among these 20 patients, 14 had hyperreflexia. Within these patients, 3 had
clonus, and 3 had muscle stiffness. Modified Ashworth score was grade 1 in 10 patients, grade
1+ in 7, and grade 2 in 3. None had grades of 3 or 4. At three months, 64 patients (67%) were
hemiparetic, and 18 spastic, reflecting 5 whose tone normalized and 3 who became spastic in the
interim. The correlation between muscle tone and a range of motor and activity scores was low
for most measures at both time points, except for active movements initially, and rapid
movement scores and 9-Hole Peg Test scores at three months.
The authors conclude, “spasticity seems to contribute to motor impairments and activity
limitations and may be a severe problem for some patients after stroke,” but, given the
relatively low numbers of patients with spasticity, they note, “Our findings support the
opinion…that the focus on spasticity in stroke rehabilitation is out of step with its clinical importance.
-----------------------------------------------------------------------------------------
Basically since only 25% of stroke survivors have it and most seem to be able to do ADL's,
clinical research seems unlikely. So we are on our own unless we can somehow change that mindset.
Would these researchers have the same comments if they had to recover from spasticity?
Another one from William M. Landau
Landau, W.M., Clinical Neuromythology XIV: There you go again: The steadfast fad of fixing spasticity. Neurology 45:2295-2296, 1995
He even wrote a book about some of it
Clinical Neuromythology and Other Arguments and Essays, Pertinent and Impertinent by William M. Landau
I haven't read the book because I can't find it in a library and I don't want to put any money in his pocket by buying the book.
But there was some hope when I found an article by Peter Levine
For Recovery, Stretch Those Sarcomeres
http://physical-therapy.advanceweb.com/Editorial/Search/AViewer.aspx?
AN=PT_08apr21_ptp48.html&AD=04-21-2008
www.advanceweb.com
By Pete Levine, BA, PTA
Here are some selected paragraphs on this
--------------------------------------------------
Spasticity after brain injury keeps muscle in a shortened position long enough to loose
sarcomeres. Brain injury kills the part of the brain responsible for contraction and relaxation
of particular muscles. This lack of executive control over muscles leads to a feed-forward
"dance" between the spinal cord and muscles.
Here's how it works. Muscles, ever sensitive to the possibility of being overstretched, send a
never-ending barrage of "help!" signals to the spinal cord. The spinal cord responds by sending back "contract!" messages to all the affected muscles. Only some of the affected muscles are shortened.
For instance, the elbow flexors may have the same relative amount of spasticity as the elbow extensors. But in that battle, as in many of the spastic battles after brain injury, the flexors "win." The "winner" loses by being left in a shortened position 24 hours a day, seven
days a week, 365 days a year. The result is a loss in number of sarcomeres and a pathological
shortening of muscles.
It comes as some surprise to most therapists, but there is very little scientific evidence that
stretching muscle reduces spasticity. In the very short-term, there is a small reduction in spasticity. But spasticity is not reduced in any lasting way by stretching, because spasticity
is not caused by muscles. Spasticity is caused by brain injury. Brain injury causes the brain to cede muscular control to spinal reflexes. Increasing the number of sarcomeres will not
reduce spasticity. If it did, every case of spasticity would be eliminated by a regimented stretching program.
Stretching does have an important role to play, however. The basis of all recovery from brain
injury has to do with neuroplastically rewiring the brain. You can rewire the brain until the cows come home, but once contracture has set in, there is no possibility of improving active range of motion. Stretching provides a flexible template on which neuroplastically driven motor recovery can take place.
-----------------------------------------------
I posted a question asking if spasticity research is still being done to
National Institute of Neurological Disorders and Stroke
National Institutes of Health
but have not heard a reply yet.
I am extremely interested in this subject since if I was truly completely paralyzed I could recover much faster using neuroplasticity if I don't have to stop my spasticity first. It truly is an oxymoron that I am not paralyzed enough to 'easily recover'.
If anyone has more/better information please post it here. Or just rant like I needed to do.
Hope this is useful to someone
Dean
When I finally got access to a computer and started researching it I came accross this letter
to the editor of Stroke magazine from William M. Landau.
http://stroke.ahajournals.org/cgi/content/full/35/8/1787
Spasticity After Stroke: Why Bother?
(Stroke. 2004;35:1787.)
© 2004 American Heart Association, Inc.
This alone was very depressing
Then I found another research study that came to the same conclusion.
Found an interesting site Movement Disorder Virtual University that has lots of detail on
spasticity. Here is the link http://www.mdvu.org/library/disease/spasticity/spa_mpath.asp
If you follow it down quite a few levels you can find this
--------------------------------------------------------------------------------------
Subject: Incidence and Consequences of Spasticity After Stroke
Date: 2/20/2004
Spasticity affects less than one quarter of stroke victims, according to this study.
Muscle overactivity and its consequences were assessed in 95 patients both immediately after
and three months a first-time stroke. Seventy-seven (81%) were initially hemiparetic, of whom
20 had spasticity. Among these 20 patients, 14 had hyperreflexia. Within these patients, 3 had
clonus, and 3 had muscle stiffness. Modified Ashworth score was grade 1 in 10 patients, grade
1+ in 7, and grade 2 in 3. None had grades of 3 or 4. At three months, 64 patients (67%) were
hemiparetic, and 18 spastic, reflecting 5 whose tone normalized and 3 who became spastic in the
interim. The correlation between muscle tone and a range of motor and activity scores was low
for most measures at both time points, except for active movements initially, and rapid
movement scores and 9-Hole Peg Test scores at three months.
The authors conclude, “spasticity seems to contribute to motor impairments and activity
limitations and may be a severe problem for some patients after stroke,” but, given the
relatively low numbers of patients with spasticity, they note, “Our findings support the
opinion…that the focus on spasticity in stroke rehabilitation is out of step with its clinical importance.
-----------------------------------------------------------------------------------------
Basically since only 25% of stroke survivors have it and most seem to be able to do ADL's,
clinical research seems unlikely. So we are on our own unless we can somehow change that mindset.
Would these researchers have the same comments if they had to recover from spasticity?
Another one from William M. Landau
Landau, W.M., Clinical Neuromythology XIV: There you go again: The steadfast fad of fixing spasticity. Neurology 45:2295-2296, 1995
He even wrote a book about some of it
Clinical Neuromythology and Other Arguments and Essays, Pertinent and Impertinent by William M. Landau
I haven't read the book because I can't find it in a library and I don't want to put any money in his pocket by buying the book.
But there was some hope when I found an article by Peter Levine
For Recovery, Stretch Those Sarcomeres
http://physical-therapy.advanceweb.com/Editorial/Search/AViewer.aspx?
AN=PT_08apr21_ptp48.html&AD=04-21-2008
www.advanceweb.com
By Pete Levine, BA, PTA
Here are some selected paragraphs on this
--------------------------------------------------
Spasticity after brain injury keeps muscle in a shortened position long enough to loose
sarcomeres. Brain injury kills the part of the brain responsible for contraction and relaxation
of particular muscles. This lack of executive control over muscles leads to a feed-forward
"dance" between the spinal cord and muscles.
Here's how it works. Muscles, ever sensitive to the possibility of being overstretched, send a
never-ending barrage of "help!" signals to the spinal cord. The spinal cord responds by sending back "contract!" messages to all the affected muscles. Only some of the affected muscles are shortened.
For instance, the elbow flexors may have the same relative amount of spasticity as the elbow extensors. But in that battle, as in many of the spastic battles after brain injury, the flexors "win." The "winner" loses by being left in a shortened position 24 hours a day, seven
days a week, 365 days a year. The result is a loss in number of sarcomeres and a pathological
shortening of muscles.
It comes as some surprise to most therapists, but there is very little scientific evidence that
stretching muscle reduces spasticity. In the very short-term, there is a small reduction in spasticity. But spasticity is not reduced in any lasting way by stretching, because spasticity
is not caused by muscles. Spasticity is caused by brain injury. Brain injury causes the brain to cede muscular control to spinal reflexes. Increasing the number of sarcomeres will not
reduce spasticity. If it did, every case of spasticity would be eliminated by a regimented stretching program.
Stretching does have an important role to play, however. The basis of all recovery from brain
injury has to do with neuroplastically rewiring the brain. You can rewire the brain until the cows come home, but once contracture has set in, there is no possibility of improving active range of motion. Stretching provides a flexible template on which neuroplastically driven motor recovery can take place.
-----------------------------------------------
I posted a question asking if spasticity research is still being done to
National Institute of Neurological Disorders and Stroke
National Institutes of Health
but have not heard a reply yet.
I am extremely interested in this subject since if I was truly completely paralyzed I could recover much faster using neuroplasticity if I don't have to stop my spasticity first. It truly is an oxymoron that I am not paralyzed enough to 'easily recover'.
If anyone has more/better information please post it here. Or just rant like I needed to do.
Hope this is useful to someone
Dean
I also checked out the wemove.org site but it does not contain anything specifically useful explaining what can be done to stop spasticity. Baclofen is not a cure and botox or phenol are too strong. They also do not state what is the specific cause of spasticity.
Dean
Dean
http://wemove.org/ is a great website for movement disorders and has a lot of great information on spasticity. There is a lot of research going on regarding spasticity, the company Allergan is doing some (they produce botox) and some others. To find out more, talk to someone at a university library if possible and have them help you look through the medical databases, there is a way that you can look up research that is going on currently. You could also look at the physician's names and facilities listed in the research articles and contact them directly either through googling their institutions or there may be contact info with their article, etc. I hope this was helpful. Kelly, OT
Got a response back from National Institute of Neurological Disorders but they did not answer the question I asked on ;Is spasticity research still taking place? They threw it back to me to do my own research on whether such research is taking place. What a copout.
Thank you for your message to the National Institute of Neurological Disorders and Stroke (NINDS). We regret the delay in responding.
We are sorry to learn that you had a stroke and can certainly understand your desire for information about treating spasticity as part of stroke rehabilitation. For citations to research articles, you may wish to search PubMed, which provides free access to a bibliographic database of published biomedical literature from the National Library of Medicine (NLM). You can access PubMed at http://www.pubmed.gov. The search strategy "stroke/rehabilitation AND spasticity" is a possible starting point to find articles. To obtain copies of any articles identified by your search, you may need the assistance of a librarian at the nearest university or medical library. Alternatively, the NLM offers a service called Loansome Doc that allows PubMed users to order a copy of any article they locate in the database directly from the Internet.
The NINDS has online information that provides an overview of stroke and summarizes the Institute's research in this field. You can access this information at the following NINDS web sites: http://www.ninds.nih.gov/disorders/stroke/stroke.htm,
http://www.ninds.nih.gov/disorders/stroke/poststrokerehab.htm, and
http://www.ninds.nih.gov/disorders/stroke/detail_stroke.htm.
Information on spasticity is provided at this NINDS site: http://www.ninds.nih.gov/disorders/spasticity/spasticity.htm. Treatment is discussed at http://www.ninds.nih.gov/disorders/spasticity/spasticity.htm#Is_there_any_treatment.
In addition, you may wish to visit the MedlinePlus web site offered by the NLM. The site is designed to assist people in identifying resources that will help them with their health concerns or questions. Materials on stroke and rehabilitation, respectively, are available at the following sites: http://www.nlm.nih.gov/medlineplus/stroke.html and http://www.nlm.nih.gov/medlineplus/rehabilitation.html. Information on neuromuscular disorders can be found at http://www.nlm.nih.gov/medlineplus/neuromusculardisorders.html.
You might consider searching the National Institutes of Health online clinical trials database, which has information about federally and privately funded clinical research studies on a wide range of diseases and conditions. You can access this database at http://clinicaltrials.gov/ to learn about the location of research studies in need of participants, as well as their purpose and criteria for patient participation. New studies are being added to the database every day.
Another source of information about clinical trials on stroke is the Stroke Trials Directory, which is a joint effort of the Internet Stroke Center at Washington University School of Medicine, the NINDS, and the American Stroke Association. You can access the Internet Stroke Center site and the directory of clinical trials at http://www.strokecenter.org/trials/index.aspx. Resources for patients and families are provided at this site: http://www.strokecenter.org/pat.
The NINDS online information on stroke lists voluntary health agencies that offer services to those coping with the aftereffects of stroke. You can access this list at http://www.ninds.nih.gov/disorders/stroke/poststrokerehab.htm#organizations. Organizations concerned with spasticity are listed at http://www.ninds.nih.gov/disorders/spasticity/spasticity.htm#Organizations.
Finally, another possible resource is the National Rehabilitation Information Center (NARIC), which has an extensive collection of materials on rehabilitation and provides publications, referrals, and other information on disability-related topics in response to public inquiries. NARIC's home page is: http://www.naric.com/. This site provides an introduction to their materials about stroke: http://www.naric.com/public/topic.cfm?id=20.
We hope this information is helpful.
Thank you for your message to the National Institute of Neurological Disorders and Stroke (NINDS). We regret the delay in responding.
We are sorry to learn that you had a stroke and can certainly understand your desire for information about treating spasticity as part of stroke rehabilitation. For citations to research articles, you may wish to search PubMed, which provides free access to a bibliographic database of published biomedical literature from the National Library of Medicine (NLM). You can access PubMed at http://www.pubmed.gov. The search strategy "stroke/rehabilitation AND spasticity" is a possible starting point to find articles. To obtain copies of any articles identified by your search, you may need the assistance of a librarian at the nearest university or medical library. Alternatively, the NLM offers a service called Loansome Doc that allows PubMed users to order a copy of any article they locate in the database directly from the Internet.
The NINDS has online information that provides an overview of stroke and summarizes the Institute's research in this field. You can access this information at the following NINDS web sites: http://www.ninds.nih.gov/disorders/stroke/stroke.htm,
http://www.ninds.nih.gov/disorders/stroke/poststrokerehab.htm, and
http://www.ninds.nih.gov/disorders/stroke/detail_stroke.htm.
Information on spasticity is provided at this NINDS site: http://www.ninds.nih.gov/disorders/spasticity/spasticity.htm. Treatment is discussed at http://www.ninds.nih.gov/disorders/spasticity/spasticity.htm#Is_there_any_treatment.
In addition, you may wish to visit the MedlinePlus web site offered by the NLM. The site is designed to assist people in identifying resources that will help them with their health concerns or questions. Materials on stroke and rehabilitation, respectively, are available at the following sites: http://www.nlm.nih.gov/medlineplus/stroke.html and http://www.nlm.nih.gov/medlineplus/rehabilitation.html. Information on neuromuscular disorders can be found at http://www.nlm.nih.gov/medlineplus/neuromusculardisorders.html.
You might consider searching the National Institutes of Health online clinical trials database, which has information about federally and privately funded clinical research studies on a wide range of diseases and conditions. You can access this database at http://clinicaltrials.gov/ to learn about the location of research studies in need of participants, as well as their purpose and criteria for patient participation. New studies are being added to the database every day.
Another source of information about clinical trials on stroke is the Stroke Trials Directory, which is a joint effort of the Internet Stroke Center at Washington University School of Medicine, the NINDS, and the American Stroke Association. You can access the Internet Stroke Center site and the directory of clinical trials at http://www.strokecenter.org/trials/index.aspx. Resources for patients and families are provided at this site: http://www.strokecenter.org/pat.
The NINDS online information on stroke lists voluntary health agencies that offer services to those coping with the aftereffects of stroke. You can access this list at http://www.ninds.nih.gov/disorders/stroke/poststrokerehab.htm#organizations. Organizations concerned with spasticity are listed at http://www.ninds.nih.gov/disorders/spasticity/spasticity.htm#Organizations.
Finally, another possible resource is the National Rehabilitation Information Center (NARIC), which has an extensive collection of materials on rehabilitation and provides publications, referrals, and other information on disability-related topics in response to public inquiries. NARIC's home page is: http://www.naric.com/. This site provides an introduction to their materials about stroke: http://www.naric.com/public/topic.cfm?id=20.
We hope this information is helpful.
I'm In the US, minnesota. It is interesting that you are coming at this from a caregivers perspective, I haven't been able to find out if this is true but I was speculating that neuroplasticity was really only possible if the patient was cognitively aware and helping with the therapy. I was never told anything useful about spasticity from any of my doctors. What I have found useful is a splint for my wrist and hand that I wear while sleeping. This is to keep the wrist from switchblading and the fingers from curling. I also wear a wrist spint(from Walgreens) during the day. I tried a blowup air split for my whole arm to keep the elbow straight at night but that was unsuccessful. By going to a gym I have been able to get some movement out of the arm by using the weight machines at the lowest weight level. those that require both arms and then after a few reps just going to the affected arm. My OT says that recovery has been found to be best when the patient works on functional activities like reaching to open a door. This is not what I am doing since I try to isolate a single muscle and work on it at the gym. I probably used 4 different machines in different body positions to try to get triceps extension. It still does not functionally work very well but it is getting better.
Sounds like you brother needs to make sure he keeps working on ROM to keep all his joints and muscles flexible. If he is able you should have him keep a journal of the efforts/changes that occur on a daily basis so he can go back later and see that progress is being made. Progress does occur but with tons of work. This is probably the hardest thing I have ever done in my life. Learning a new sport is just practice, practice. Learning a new language is just lots of practice. This recovery has no well defined path to follow. Each of us has to figure this out ourself.
Dean
Sounds like you brother needs to make sure he keeps working on ROM to keep all his joints and muscles flexible. If he is able you should have him keep a journal of the efforts/changes that occur on a daily basis so he can go back later and see that progress is being made. Progress does occur but with tons of work. This is probably the hardest thing I have ever done in my life. Learning a new sport is just practice, practice. Learning a new language is just lots of practice. This recovery has no well defined path to follow. Each of us has to figure this out ourself.
Dean
Hi Dean;
I'm very interested in your posts and your research. I'm coming at this from the caregiver's perspective and my approach is quite similar to yours. I'm becoming somewhat of an expert in neuroplasticity, am researching trials and experimental treatments. I'm sorry I don't have anything to contribute to your questions, but rather found your post in researching spacitity, and have a couple of questions.
My brother had an ischemic left-side stroke in Aug/08 and has severe impairment of language and right side hemiplegia. He is walking again but his right arm and hand is becoming increasingly spastic. He is still attending out-patient therapy 2x a week and we have a private therapist come in 3x a week to work with him and especially his arm. The therapists tell me that the tone/spasicity is normal at this stage and gets worse, and then tends to relax. Is this your experience/understanding? How has your arm recovered - any improvement? What country are you in?
Thanks for your very insightful and informative posts.
Marlene
I'm very interested in your posts and your research. I'm coming at this from the caregiver's perspective and my approach is quite similar to yours. I'm becoming somewhat of an expert in neuroplasticity, am researching trials and experimental treatments. I'm sorry I don't have anything to contribute to your questions, but rather found your post in researching spacitity, and have a couple of questions.
My brother had an ischemic left-side stroke in Aug/08 and has severe impairment of language and right side hemiplegia. He is walking again but his right arm and hand is becoming increasingly spastic. He is still attending out-patient therapy 2x a week and we have a private therapist come in 3x a week to work with him and especially his arm. The therapists tell me that the tone/spasicity is normal at this stage and gets worse, and then tends to relax. Is this your experience/understanding? How has your arm recovered - any improvement? What country are you in?
Thanks for your very insightful and informative posts.
Marlene
Thanks for the book recommendation,I will see if my library can get it. I have tried both botox and phenol. It worked for my biceps allowing my triceps to start to work even after the drug wore off. My finger flexors were unsuccessful since my finger extensors brain control was dead. I need to use neuroplasticity to move control to another spot, so I really need permanent absence of spasticity in order to get the extensors to work. I did like Peter Levines comment that spasticity is a brain problem, not a muscle problem and that neuroplasticity can be used to solve that too. To me it seems like a huge oxymoron that I am not paralyzed enough to easily recover.
I will get through this. You might find this interesting on passive movement.
I couldn't see the complete study but starting at here,
http://recoverfromstroke.blogspot.com/ and looking at the relax and recover section it will lead you to here,
http://www.ncbi.nlm.nih.gov/pubmed/15003755
The effects of repetitive proprioceptive stimulation on corticomotor representation in intact and hemiplegic individuals.
Basically passive movement can start neuroplasticity, so I am flexing each of my fingers hundreds of times each day and doing ROM exercises with my cane for my shoulder muscles. I have found Peter Levine blog the most interesting and useful of those that deal with stroke, helpful yet humourous on such a serious subject.
Dean
I will get through this. You might find this interesting on passive movement.
I couldn't see the complete study but starting at here,
http://recoverfromstroke.blogspot.com/ and looking at the relax and recover section it will lead you to here,
http://www.ncbi.nlm.nih.gov/pubmed/15003755
The effects of repetitive proprioceptive stimulation on corticomotor representation in intact and hemiplegic individuals.
Basically passive movement can start neuroplasticity, so I am flexing each of my fingers hundreds of times each day and doing ROM exercises with my cane for my shoulder muscles. I have found Peter Levine blog the most interesting and useful of those that deal with stroke, helpful yet humourous on such a serious subject.
Dean
I too am having a battle with spasticity, many muscles affected, but MAJOR problem area is my shoulder :(
I have been seeing a rehabilitation specialist physician with a spasticity speciality. I've had two lots of botox & phenol nerve blocks into a range of muscles. The treatments have been very successful, giving me a window of opportunity to work on the antagonist muscles. By the time the botox has worn off, I have generally been able to use those antagonist muscles enough to keep working on them & the spastic muscles are much less of a problem. So I am a HUGE fan of the treatments :)
I have just been reading an interesting book that you might like to have a look at, "Upper Motor Neurone Syndrome and Spasticity, Clinical Management and Neurophysiology, 2nd Ed." Michael P. Barnes & Garth R. Johnson Eds. Cambridge University Press 2008.
I borrowed it from my local library via an interlibrary loan from a univerity library - does your library offer a similar process.
HTH
Sue
I have been seeing a rehabilitation specialist physician with a spasticity speciality. I've had two lots of botox & phenol nerve blocks into a range of muscles. The treatments have been very successful, giving me a window of opportunity to work on the antagonist muscles. By the time the botox has worn off, I have generally been able to use those antagonist muscles enough to keep working on them & the spastic muscles are much less of a problem. So I am a HUGE fan of the treatments :)
I have just been reading an interesting book that you might like to have a look at, "Upper Motor Neurone Syndrome and Spasticity, Clinical Management and Neurophysiology, 2nd Ed." Michael P. Barnes & Garth R. Johnson Eds. Cambridge University Press 2008.
I borrowed it from my local library via an interlibrary loan from a univerity library - does your library offer a similar process.
HTH
Sue
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