Post stroke spasticity is a movement disorder that occurs in approximately 25-43% of people who have had a stroke. This (frustrating) movement problem can be painful, cause soft tissue stiffness, joint contracture, and abnormal limb posture. Along these same lines, it can dramatically impact recovery due to its negative impact on normal movement, speech and gait (walking).
If you have spasticity, I am probably not telling you (yet), anything you don’t already know. But, do you really know what is going on inside your body? First, why does your body seem to move without your consent? And second, why does your arm and your leg feel stiff, heavy, and sometimes painful? Understanding what spasticity is, and how it is impacting your movement, could be the missing link between you and getting to the next level in your recovery.
What is post stroke spasticity?
Spasticity is a movement disorder that is caused by damage to the brain or the spinal cord. It causes involuntary muscle contractions due to hyperexcitability of the stretch reflex.
What happens when there is injury to the brain?
The stretch reflex is a muscle contraction in response to muscle lengthening. Under normal conditions (healthy brain), It is somewhat of a protective mechanism.
An example of the stretch reflex in action is how it works to keep the body upright. If a person standing upright leans to one side, the spine muscles on the opposite side will lengthen, trigger the stretch reflex, immediately shorten (contract) and prevent the person from following over.
Now, this is a good thing, right? Of course, it is. Unless……..it loses connection with the brain. The brain helps to inhibit unnecessary muscle contraction to allow for normal movement. For instance, let’s say you lean to one side to reach for something in a drawer and NOT because someone pushed you. In this case, the brain would step in to inhibit the stretch reflex.
So, now back to spasticity.
When the brain loses connection with the stretch reflex (due to a stroke or a brain injury), the stretch reflex kind of goes “haywire”. In some severe cases of spasticity the stretch reflex NEVER turns off. Meaning that the muscle is in a constant contracted state. Ugh…..
It is important to know that there are varying degrees of this contraction. There are some factors that can make the muscle contract. I call these “spasticity triggers”.
Here are some things that can cause a “spasm” after a stroke:
- Painful stimulus – this can be anything from a bladder infect, UTI, extreme temperatures, abrasive clothing etc.
- Emotional stressors – In some cases extreme emotions including laughing, crying, getting angry..etc. can also “trigger” spasticity.
- Touch – Light touch or even a light breeze that blows over the surface of the skin can trigger a spasm.
- Fast movement – the faster you lengthen a muscle that has spasticity, the stronger it will try and contract
How do you minimize “triggers” after a Stroke?
- Remove anything that might be causing pain – wear soft clothing, identify and address any possible infections, make sure braces and splints are fitting properly.
- Try and remove emotional stressors – Although this might not be easy, try and find ways to manage extreme emotions.
- Dress appropriately – Wear proper clothing if extreme hot or cold causing the muscles to stiffen up.
- Desensitization strategies – If light touch “triggers a spasm” you can try using desensitization strategies.
What happens over time?
Spasticity usually sets in 1-3 weeks following a stroke or a brain injury. However, if left untreated, it will worsen over time. Here are some things that can cause spasticity to worsen over time after a stroke or a brain injury:
- Muscle shortening
- Disuse Atrophy
Types of Post Stroke Spasticity?
In the arm, the most common post stroke spastic pattern is flexion.
- Shoulder flexion
- Shoulder adduction
- Shoulder internal rotation
- Elbow flexion
- Wrist flexion
- Finger flexion
- And thumb adduction
In the leg, it is common to see either a strong flexor pattern or extensor pattern.
Flexor Spasticity in the Leg
- Hip flexion
- Hip external rotation
- Hip abduction
- Knee flexion
- Ankle Dorsiflexion
Extensor Spasticity in the Leg
- Hip extension
- Hip internal rotation
- Hip adduction
- Knee extension
- Ankle plantar flexion
- Ankle inversion
- Toe flexion
- Great toe extension
How do you prevent spasticity from getting worse over time?
The main goals are to prevent the muscle from permanently shortening and prevent (as much as possible) disuse atrophy or neglect.
Conservative Treatment for Post Stroke Spasticity
Remove painful stimulus
Identify and treat infections as soon as possible, see your orthotist on a regular basis to make sure your braces and splints are fitting correctly
This is an absolute non-negotiable. Many want to resort to just using medication to “treat” their spasticity. There is no medication in the world that can replace a daily stretching routine. In the video I go into much more detail about why this is so important and in the Stretching the arm and the leg is essential to prevent spasticity from getting worse over time.
If you have spasticity in the muscles on the back of the lower leg (also called the calf muscle or plantarflexors) the foot will point down involuntarily. Walking on a pointed foot can make spasticity worse. An ankle foot orthosis (AFO) is a type of brace that prevents the foot from pointing downward. Without this type of brace, spasticity WILL worsen over time.
Many people ask me “how to I get my fingers to move?” It is important to know that the arm recovers in stages. Recovery starts with the shoulder and the last component of the arm to recover (in most cases) is the wrist and the hand. That being said, it could be months or even years before you will start to see any improvement in the wrist and hand.
I know, not the most encouraging news.
However, you NEED to take steps to make sure that the muscle in the hand do not shorten to the point where recovery is impossible. As stated above, the most common pattern in the arm is a flexor pattern. With this in mind, a brace should be one that keeps the wrist straight, the hand and fingers extended the thumb abducted.
Work with your local orthotist to get a day time splint and a night time splint to keep the hand open and the wrist extended.
Electrical stimulation can be used in to ways. First, electrical stimulation on a TENS setting can help reduce pain and therefore reduce spasticity. Second, electrical stimulation can be used on a neuromuscular re-education setting to the muscle opposite the spastic muscles. In some cases, contracting the antagonist (muscle opposite the spastic muscle) can decrease spasticity.
Note: Most of the research concludes that electrical stimulation did not show any clinically significant change in post-stroke spasticity.
Acupuncture is another potential option. Clinically, I have seen my own patients have a positive response to acupuncture. I have not at this point done an in depth review of the literature to know if research support this as a conservative treatment option for spasticity.