Spasticity of the hand after hemorrhagic stroke. Muscle spasticity and its treatment

Muscle spasticity after a stroke is an increase muscle tone which significantly reduces the quality of life.

Muscle contraction as an impulse to stretch occurs against the background of mono- or hemiparesis (unilateral and bilateral paralysis, respectively).

The reason for such processes is the damage to the cells of the motor pathways of the brain. The following areas are subject to post-stroke spasticity:

• hands;
• legs;
• shoulders;
• hip.

During a long stay in lying position symptoms gradually increase.

A positive trend is observed in the restoration of motor functions, which is achieved by various methods.

Spasticity after a stroke: drug treatment
The success of therapy directly depends on the time elapsed since the onset of the disease.

The sooner treatment is started, the better the prognosis for recovery. The best result can be achieved when the recovery begins in the first months after the stroke, but no later than a year later.

To immobilize a muscle group by blocking neural transmission, botulinum toxin injections (Dysport, Xeomin, Botox) are practiced. The effect lasts an average of six months, after which it may be necessary to re-administer botulinum drugs.

• Baclofen.
• Mydocal;
• Sirdalud.

Baclofen for stroke from spasticity

The baclofen pump is used intrarectally. It acts at the spinal level due to a decrease in the production of a number of amino acids (aspartate, glutamate).

In addition to relieving spasticity, a centrally acting muscle relaxant helps to achieve significant success in reducing dystonic disorders, as well as minimizing pain.

Side effects:

• stool disorders (diarrhea, constipation);
• drowsiness;
• lowering blood pressure.

The regimen involves a systematic increase in dosage from 15 to 60 mg per day.

Spasticity after a stroke: treatment with folk remedies

Popular methods:

1. Exposure to heat on a spasmodic place (applying warm compresses, bags of salt or cereals).
2. Bandaging of upper and/or lower extremities.
3. Light massage (in the form of stroking and rubbing).
4. Taking warm baths (not hot!).
5. Kinesio taping.
6. Taking herbs.

Teas and tinctures are made from the following components:

• calendula;
• flowers or fruits of horse chestnut;
• raspberries;
• rowan bark;
• Melissa;
• oats;
• blackthorn.

Spasticity of the hand after a stroke is eliminated by creating the effect of a bath.

The limb is placed in a bag with birch leaves, which is fixed and left overnight. Similarly, they work with spasticity in the legs, provided that the dimensions of the container correspond to the length of the limb to the waist.

Treatment of spasticity after a stroke with acupuncture
Acupuncture is a popular method of treatment in post-Soviet countries, but clinical studies conducted abroad do not confirm the effectiveness of this technique.
Exercises for spasticity after a stroke

This is the most effective method deal with such an unfortunate outcome. Loads should not be too exhausting, since excessive intensity only worsens the patient's condition (the tone increases).

Exercise examples:

1. Classes with an expander (compression / unclenching of a special rubber ring).
2. Patients are taught to stand and walk again - stilts and other auxiliary items are used for this.
3. Classes on orthopedic devices.
4. Physical activity (self-execution, with an assistant).

Types of gymnastics:

• alternately bending the legs while lying on the bed, when the ankles are pulled to the buttocks (performed 10 times) - outside help may be required;
• gradual stretching of atrophied areas with vibrational movements.

Parfenov V.A.
Moscow Medical Academy. THEM. Sechenov

Relevance of the problem

In Russia, 300-400 thousand strokes are registered annually, which leads to the presence of more than one million patients who have had a stroke. More than half of them still have movement disorders, which significantly reduce the quality of life and often develop permanent disability (1).

Movement disorders after a stroke are most often manifested by hemiparesis or monoparesis of the limb with an increase in muscle tone by the type of spasticity (1,2,9). In stroke patients, spasticity usually increases in the paretic limbs over several weeks and months; relatively rarely (most often when motor functions are restored), a spontaneous decrease in spasticity is observed. In many cases, in patients with stroke, spasticity worsens motor functions, promotes the development of contracture and deformity of the limb, makes it difficult to care for the immobilized patient, and is sometimes accompanied by painful muscle spasms (2,5,6,9,14).

Restoration of lost motor functions is maximally within two to three months from the moment of a stroke, in the future, the rate of recovery decreases significantly. One year after the development of a stroke, it is unlikely that the degree of paresis will decrease, but it is possible to improve motor functions and reduce disability by training balance and walking, using special devices for movement and reducing spasticity in paretic limbs (1,2,6,9,14)

The main goal of the treatment of post-stroke spasticity is to improve the functionality of paretic limbs, walking, self-care of patients. Unfortunately, in a significant proportion of cases, the treatment options for spasticity are limited to only reducing the pain and discomfort associated with high muscle tone, facilitating the care of a paralyzed patient, or eliminating the existing cosmetic defect caused by spasticity (2,6,14).

One of the most important issues, which has to be decided in the management of a patient with post-stroke spasticity, is reduced to the following: does spasticity worsen or not the functional capabilities of the patient? In general, the functionality of the limb in a patient with post-stroke paresis of the limb is worse in the presence of severe spasticity than in its mild degree. At the same time, in some patients with a pronounced degree of paresis, spasticity in the muscles of the leg can facilitate standing and walking, and its decrease can lead to a deterioration in motor function and even to falls (2,6,14).

Before starting to treat post-stroke spasticity, it is necessary to determine the treatment options for a particular patient (improvement of motor functions, reduction of painful spasms, simplification of patient care, etc.) and discuss them with the patient and (or) his relatives. The possibilities of treatment are largely determined by the time since the onset of the disease and the degree of paresis, the presence of cognitive disorders (2,6,14). The shorter the time since the development of a stroke that caused spastic paresis, the more likely improvement from the treatment of spasticity, because it can lead to a significant improvement in motor functions, preventing the formation of contractures and increasing the effectiveness of rehabilitation during the period of maximum plasticity of the central nervous system. In the long term of the disease, a significant improvement in motor functions is less likely, but care of the patient can be greatly facilitated and the discomfort caused by spasticity can be relieved. The lower the degree of paresis in a limb, the more likely it is that treatment of spasticity will improve motor function (14).

Physiotherapy

Therapeutic gymnastics is the most effective way to manage a patient with post-stroke spastic hemiparesis, it is aimed at training movements in paretic limbs and preventing contractures (2,14).

As methods of physiotherapy, position treatment, teaching patients to stand, sit, walk (with the help of additional means and independently), bandage a limb, use orthopedic devices, thermal effects on spastic muscles, as well as electrical stimulation certain muscle groups, such as the extensors of the fingers of the hand or the anterior tibial muscle (4).

Patients with severe spasticity in the flexors of the upper extremities should not be recommended intensive exercises that can significantly increase muscle tone, for example, squeezing a rubber ring or ball, using an expander to develop flexion movements in elbow joint.

Massage of the muscles of paretic extremities with a high muscle tone is possible only in the form of light stroking, on the contrary, in the antagonist muscles, rubbing and shallow kneading at a faster pace can be used.

Acupuncture is relatively often used in our country in the complex therapy of patients with post-stroke spastic hemiparesis, however, controlled studies conducted abroad do not show a significant effectiveness of this treatment method (10).

Muscle relaxants

Baclofen and tizanidine are predominantly used as oral medications for the treatment of post-stroke spasticity in clinical practice (5-7). Oral antispastic agents, by reducing muscle tone, can improve motor function, facilitate care for an immobilized patient, relieve painful muscle spasms, enhance the effect physiotherapy exercises and consequently prevent the development of contractures. With a mild degree of spasticity, the use of muscle relaxants can lead to significant positive effect however, severe spasticity may require large doses of muscle relaxants, which often cause unwanted side effects (2.5–7.14). Treatment with muscle relaxants begins with a minimum dose, then it is slowly increased to achieve the effect. Antispastic agents are usually not combined.

Baclofen (Baclosan) has an antispastic effect mainly at the spinal level.

The drug is an analogue of gamma-aminobutyric acid (GABA); it binds to presynaptic GABA receptors, leading to a decrease in the release of excitatory amino acids (glutamate, aspartate) and suppression of mono- and polysynaptic activity at the spinal level, which causes a decrease in spasticity.

For its long history, it remains the drug of choice in the treatment of spasticity of spinal and cerebral origin.

Baclofen also has a central analgesic and anti-anxiety effect. It is well absorbed from the gastrointestinal tract, the maximum concentration in the blood is reached 2-3 hours after ingestion. Baclofen (baclosan) is used for spinal (spinal injury, multiple sclerosis) and cerebral spasticity; it is effective for painful muscle spasms of various origins. Baclofen (Baclosan) The initial dose is 5-15 mg per day (in one or three doses), then the dose is increased by 5 mg every day until the desired effect is obtained, the drug is taken with food. The maximum dose of baclofen (baclosan) for adults is 60-75 mg per day. Side effects are manifested by drowsiness, dizziness at the beginning of treatment, although they are clearly dose-dependent and may subside in the future. Sometimes there is nausea, constipation, diarrhea, arterial hypotension.

Baclofen can be used intrathecally with a special pump for spasticity caused by various neurological diseases, including the consequences of stroke (8,11,13). The use of a baclofen pump in combination with therapeutic exercises, physiotherapy can improve the speed and quality of walking in patients with post-stroke spasticity who are able to move independently (8). The available 15-year clinical experience of intrathecal baclofen use in stroke patients indicates the high efficiency of this method in reducing not only the degree of spasticity, but also pain syndromes and dystonic disorders (13). A positive effect of the baclofen pump on the quality of life of stroke patients has been noted (11). Tizanidine is a centrally acting muscle relaxant, alpha-2 adrenergic receptor agonist. The drug reduces spasticity due to the suppression of polysynaptic reflexes at the level of the spinal cord, which may be caused by inhibition of the release of excitatory amino acids and the activation of glycine, which reduces the excitability of spinal cord interneurons. The drug also has a moderate central analgesic effect, is effective for cerebral and spinal spasticity, as well as for painful muscle spasms. The initial dose of the drug is 2-6 mg per day in one or three doses, the average therapeutic dose is 12-24 mg per day, the maximum dose is 36 mg per day. As side effects severe drowsiness, dry mouth, dizziness and a slight decrease in blood pressure may be noted.

Botulinum toxin

In stroke patients with local spasticity in paretic muscles, botulinum toxin type A or botulinum toxin (Botox, Dysport) can be used. The use of botulinum toxin is indicated if a stroke patient has a muscle with increased tone without contracture, as well as pain, muscle spasms, decreased range of motion and impaired motor function associated with spasticity of this muscle (2-4,12,14) . The action of botulinum toxin when administered intramuscularly is caused by blocking neuromuscular transmission due to the suppression of the release of the neurotransmitter acetylcholine into the synaptic cleft.

The clinical effect after injection of botulinum toxin is observed after a few days and persists for 2-6 months, after which a second injection may be required. The best results are noted when using botulinum toxin in the early stages (up to a year) from the moment of illness and mild paresis of the limb. The use of botulinum toxin can be especially effective in cases where there is an equinovarus deformity of the foot caused by spasticity of the posterior leg muscles, or a high tone of the wrist and finger flexors, which impairs the motor function of the paretic hand (14). Dysport has been shown to be effective in the treatment of post-stroke arm spasticity in controlled studies (3).

As side effects from the use of botulinum toxin, there may be skin changes and pain at the injection site. They usually regress on their own within a few days after injection. Significant weakness of the muscle into which botulinum toxin is injected is possible, as well as weakness in the muscles located close to the injection site, local autonomic dysfunction. However, muscle weakness is usually compensated by the activity of agonists and does not lead to a decrease in motor function. Repeated injections of botulinum toxin in some patients give a less significant effect, which is associated with the formation of antibodies to botulinum toxin and blocking its action. The limitation of the widespread use of botulinum toxin in clinical practice is largely due to its high cost.

Surgical treatments

Surgery to reduce spasticity is possible at four levels - on the brain, spinal cord, peripheral nerves and muscles (2,14). They are rarely used in patients with post-stroke spasticity. These methods are more commonly used for cerebral palsy and spinal spasticity caused by spinal trauma.

Brain surgery includes electrocoagulation of the globus pallidus, ventrolateral nucleus of the thalamus or cerebellum and implantation of a stimulator on the surface of the cerebellum. These operations are rarely used and have a certain risk of complications.

A longitudinal cone incision (longitudinal myelotomy) may be performed on the spinal cord to break the reflex arc between the anterior and posterior horns of the spinal cord. The operation is used for spasticity of the lower extremities, it is technically complex and associated with a high risk of complications, therefore it is rarely used. Cervical posterior rhizotomy can reduce spasticity not only in the upper extremities, but also in the lower ones, but is rarely performed due to the risk of complications. Selective posterior rhizotomy represents the most common intervention among operations on the spinal cord and its roots, it is usually used for spasticity in the lower extremities at the level from the second lumbar to the second sacral root.

Dissection of the peripheral nerves can eliminate spasticity, but this operation is often complicated by the development of pain, dysesthesia and often requires additional orthopedic surgery, so it is rarely used.

A significant part of surgical operations in patients with spasticity of various origins is performed on the muscles or their tendons. Lengthening the tendon of the muscle or moving the muscle reduces the activity of the intrafusal muscle fibers, thereby reducing spasticity. The effect of the operation is difficult to predict, sometimes several operations are required. With the development of contracture, surgical intervention on the muscles or their tendons is often the only method of treatment for spasticity.

Conclusion

The treatment of post-stroke spasticity is an actual problem of modern neurology. The leading role in the treatment of post-stroke spasticity has physiotherapy, which should begin from the first days of the development of a stroke and be aimed at training lost movements, independent standing and walking, as well as preventing the development of contractures in paretic limbs.

In cases where a patient with post-stroke paresis of the limb has local spasticity, causing a deterioration in motor functions, local administration of botulinum toxin preparations can be used.

As medicinal antispastic agents used orally, are recommended Baclofen (Baclosan) and tizanidine, which can reduce increased tone, facilitate physiotherapy, as well as caring for a paralyzed patient. One of the promising methods for the treatment of post-stroke spasticity is the intrathecal administration of baclofen using a special pump, the effectiveness of which has been actively studied in recent years.

LITERATURE
1. Damulin I.V., Parfenov V.A., Skoromets A.A., Yakhno N.N. Circulatory disorders in the brain and spinal cord. In: Diseases of the nervous system. Guide for doctors. Ed. N.N. Yakhno. M.: Medicine, 2005, T.1., S. 232-303.
2. Parfenov V.A. Spasticity In the book: The use of Botox (botulinum toxin type A) in clinical practice: a guide for doctors / Ed. O.R. Orlova, N.N. Yakhno. - M.: Catalogue, 2001 - S. 91-122.
3. Bakheit A.M., Thilmann A.F., Ward A.B. et al. A randomized, double-blind, placebo-controlled, dose-ranging study to compare the efficacy and safety of three doses of botulinum toxin type A (Dysport) with placebo in upper limb spasticity after stroke // Stroke. - 2000. - Vol. 31. - P. 2402-2406.
4. Bayram S., Sivrioglu K., Karli N. Et al. Low-dose botulinum toxin with short-term electrical stimulation in poststroke spastic drop foot: a preliminary study // Am J Phys Med Rehabil. - 2006. - Vol. 85. – P. 75-81.
5. Chou R., Peterson K., Helfand M. Comparative efficacy and safety of skeletal muscle relaxants for spasticity and musculoskeletal conditions: a systematic review. // J Pain Symptom Manage. - 2004. - Vol. 28. – P.140–175.
6. Gallichio J.E. Pharmacologic management of spasticity following stroke. // Phys Ther 2004. - Vol. 84. – P. 973–981.
7. Gelber D. A., Good D. C., Dromerick A. et al. Open-Label Dose-Titration Safety and Efficacy Study of Tizanidine Hydrochloride in the Treatment of Spasticity Associated With Chronic Stroke // Stroke. - 2001. - Vol.32. - P. 1841-1846.
8. Francisco G.F., Boake C. Improvement in walking speed in poststroke spastic hemiplegia after intrathecal baclofen therapy: a preliminary study // Arch Phys Med Rehabil. - 2003. - Vol. 84. - P. 1194-1199.
9. Formisano R., Pantano P., Buzzi M.G. et al. Late motor recovery is influenced by muscle tone changes after stroke // Arch Phys Med Rehabil. - 2005. - Vol. 86. – P.308-311.
10. Fink M., Rollnik J.D., Bijak M. Et al. Needle acupuncture in chronic poststroke leg spasticity // Arch Phys Med Rehabil. - 2004. - Vol. 85. – P.667-672.
11. Ivanhoe C.B., Francisco G.E., McGuire J.R. et al. Intrathecal baclofen management of poststroke spastic hypertonia: implications for function and quality of life // Arch Phys Med Rehabil. - 2006. - Vol. 87. - P. 1509-1515.
12. Ozcakir S., Sivrioglu K. Botulinum toxin in poststroke spasticity // Clin Med Res. - 2007. - Vol. 5. - P.132-138.
13. Taira T., Hori T. Intrathecal baclofen in the treatment of post-stroke central pain, dystonia, and persistent vegetative state // Acta Neurochir Suppl. - 2007. - Vol.97. - P. 227-229.
14. Ward A.B. A summary of spasticity management – ​​a treatment algorithm // Eur. J. Neurol. - 2002. - Vol. 9. - Suppl.1. – P. 48-52.

For citation: Shirokov E.A. Stroke and muscle hypertonicity // BC. 2011. No. 15. S. 963

Acute cerebrovascular accident (ACV) is one of the most pressing problems of modern medicine. The number of stroke patients in the Russian Federation is increasing and currently exceeds 1 million people. The most significant consequences of cerebral vascular accidents are associated with movement disorders. Paresis and paralysis, impaired coordination of movements require complex rehabilitation measures aimed at restoring self-service skills and social adaptation. The restoration of lost motor functions is quite active during the first months after a brain stroke, and then the recovery rate decreases. As a rule, already the first weeks of the recovery period are characterized by a noticeable decrease in the degree of paresis, an increase in strength and range of motion. However, during this period, many patients have another problem - impaired muscle tone. Spasticity increases (C), which significantly limits the results of rehabilitation and often becomes an obstacle to the restoration of motor activity. The tone rises different muscles to varying degrees. This leads to the fact that the hand acquires a stable position with flexion in the elbow joint and wrist joint. The leg with central paralysis, an important feature of which is hypertonicity, on the contrary, most often turns out to be unbent. Spasticity leads not only to the formation of stable pathological postures, but also contributes to pathological changes in the joints. As a rule, patients suffer from arthrosis and ankylosis, pain in the joints is no less than from paresis.

The development of C in case of damage to the structures of the central nervous system is associated with a decrease in inhibitory effects on spinal motor neurons. A decrease in inhibitory effects on spinal structures is explained by a combined lesion of the pyramidal and extrapyramidal pathways of the brain, while an important role in the development of spasticity is assigned to damage to the cortico-reticulo-spinal tract. Under conditions of weakening of corticospinal stimuli, as a rule, dysfunction of the extrapyramidal system can also be observed. One of the leading mechanisms of C formation should be considered the disinhibition of the tonic stretch reflex. The secondary changes in muscles, tendons and joints that occur during muscle hypertension increase movement disorders, and therefore resistance to passive movement depends not only on muscle tone disorders, but also on muscle changes, in which signs of atrophy can often be found. An isolated lesion of the pyramidal tract, as a rule, does not cause hypertonicity, but only leads to paresis. However, stroke usually causes damage not only to the pyramidal tract, but also to other structures, such as the cortico-reticulo-spinal tract, which leads to inevitable violations of muscle tone. If post-stroke paresis persists for a long time (several months or more), then structural changes in the segmental apparatus of the spinal cord may occur (shortening of the dendrites of motor neurons and collateral sprouting of afferent fibers that make up the posterior roots), which contribute to a stable restructuring of the motor stereotype. This is facilitated by secondary changes in muscles, tendons and joints, which increase the resistance that occurs in the muscle when it is stretched. Knowledge of the pathogenesis of tonic disorders associated with stroke is necessary to understand the mechanisms of action of drugs, most of which have a so-called central mechanism of action.
It is possible to detect the first signs of growing muscular-tonic disorders already in the first hours after a stroke. Often they are characterized by a decrease in muscle tone. However, after a few days, spasticity becomes noticeable and increases along with the restoration of movement. The functional state of the muscles, muscle tone are assessed during a standard neurological examination of the patient, in the process of monitoring active movements, with passive changes in the position of body parts in space. Spasticity is characterized by an increase in muscle tone, which prevents the expansion of range of motion. Each time when performing the simplest movements, the patient has to overcome the resistance of tense muscles, which aggravates the picture of paresis or paralysis. A characteristic clinical sign of C is its change during the study - the tone increases with passive stretching of the muscle, and the increase in muscle resistance directly depends on the speed of passive movement. A frequent sign that reveals dystonia is uneven muscle tone during flexion and extension of the limb - the "jackknife" phenomenon. The degree of violations of muscle tone can vary significantly during the day, under the influence of external and internal factors (weather, emotional state of the patient, ambient temperature). Patients who have had a stroke are characterized by a change in tone depending on the position of the limb, physical activity, its nature and intensity. Hypertonicity can delay recovery after a stroke, because with severe muscular dystonia, the patient's daily activity is limited to the bed: with any attempt to move to a vertical position, persistent muscle tension prevents movement and forces the patient to return to a horizontal position again. There are other complications of the post-stroke period - limited mobility in the joints, arthrosis-arthritis and associated pain syndromes. Muscular dystonia has a significant impact on the statics of the spine, which in some cases becomes an independent problem (lumbalgia, thoracalgia, vertebrogenic radiculopathy). One of the most important questions that must be addressed in the management of a patient with post-stroke spasticity is the following: does high muscle tone impair the patient's functional capabilities or not? In general, the functionality of the limb in patients with post-stroke paresis of the limb is worse in the presence of severe spasticity than in its mild degree. At the same time, in some patients with a pronounced degree of paresis, spasticity in the leg muscles can facilitate standing and walking, and its decrease can lead to a deterioration in motor function and even falls. Before starting the correction of hypertonicity, it is necessary to determine the possibilities of treatment in this particular case (improvement of motor functions, reduction of painful spasms, facilitation of patient care, etc.) and discuss them with the patient and (or) his relatives. The possibilities of treatment are largely determined by the time since the onset of the disease and the degree of paresis, the presence of cognitive disorders. The shorter the time since the stroke that caused spastic paresis, the more likely improvement is. With a long duration of the disease, a significant improvement in motor functions is less likely, but care for the patient and discomfort caused by C can be greatly facilitated. The lower the degree of paresis in the limb, the more likely it is that treatment will improve motor functions. For clinical assessment of muscle tone and control of the effectiveness of treatment for practical purposes, a modified Ashworth scale is used (Table 1).
The principles of correction of spasticity in the post-stroke period are based on the following provisions:
- pathologically increased muscle tone should be reduced in all cases to prevent irreversible changes in muscles and joints and accelerate the rehabilitation process;
- treatment should be started as early as possible, when the first signs of C appear;
- the duration of treatment is determined by the restoration of the patient's motor activity.
Drug therapy of muscular dystonia in stroke patients is based on the use of muscle relaxants. Before the appointment of muscle relaxants, it is necessary to establish how much an increase in muscle tone makes it difficult to move. In some cases (especially in the early recovery period), hypertonicity helps the patient to maintain support on the paretic limb - then the appointment of muscle relaxants can be delayed. However, this feature, as a rule, requires attention for a short period of time - during the first attempts of the patient to restore walking skills. In the future, a decrease in muscle tone plays a more important role in complex rehabilitation programs, since it allows you to expand the range of motion.
Most often, tolperisone is used to treat spastic syndromes. In its own way chemical structure the drug is close to lidocaine. The action of the drug is based on the blockade of polysynaptic spinal reflexes. In addition, the drug has a central anticholinergic effect, has antispasmodic and moderate vasodilating activity. Tolperisone reduces increased muscle tone and muscle rigidity in spastic paresis, improves voluntary active movements, normalizes peripheral circulation, has a membrane-stabilizing, local anesthetic effect. Its use in adequate doses leads to increased local blood circulation. The main contraindication to the use is myasthenia gravis and intolerance to lidocaine. Usually the beginning of treatment falls on the 2-3rd week of a stroke - the period of activation of the patient. When the first signs of spasticity appear, 50-100 mg of the drug is prescribed per day, which in most cases facilitates movement. In later periods of the disease, with the formation of persistent spastic paresis, higher doses of muscle relaxants are also required. In severe cases of increasing spasticity, intramuscular administration of the drug is used at a dose of 100 mg 2 times a day. Tablets of 50 and 150 mg allow you to act in a wide range of therapeutic doses to achieve the desired effect. The vasodilating effect of tolperisone may be useful in severe atherosclerotic changes in the vessels of the lower extremities. The drug is well combined with non-steroidal anti-inflammatory drugs. It is important to note that the drug does not cause general muscle weakness. Tolperisone does not have a sedative effect.
To correct spasticity of various origins, other agents are also used: tizanidine, baclofen, dantrolene and benzodiazepines. The basis for the use of these antispastic drugs (or muscle relaxants) are the results of double-blind, placebo-controlled, randomized trials that have shown the safety and efficacy of these drugs. An analysis of studies comparing the use of various antispastic agents in a variety of neurological diseases accompanied by spasticity showed that tizanidine, baclofen and diazepam are approximately equally able to reduce spasticity.
In stroke patients with local spasticity in paretic muscles, botulinum toxin type A or botulinum toxin can be used. The action of botulinum toxin when administered intramuscularly is caused by blocking the neuromuscular transmission. The clinical effect after injection of botulinum toxin is observed after a few days and persists for 2-6 months, after which a second injection may be required. The best results are observed when using botulinum toxin in the early stages (up to a year) from the moment of illness and with a mild degree of limb paresis. The use of botulinum toxin can be especially effective in cases where there is foot deformity caused by spasticity of the posterior leg muscles, or high muscle tone of the wrist and finger flexors, which impairs the motor function of the paretic hand. Repeated injections of botulinum toxin in some patients give a less significant effect, which is associated with the formation of antibodies to botulinum toxin and blocking its action. The limitation of the widespread use of botulinum toxin in clinical practice is largely due to the high cost of the drug.
Treatment with muscle relaxants begins with a minimum dose, then it is slowly increased to achieve the effect. Antispastic agents are usually not combined.
Surgical benefits for post-stroke spasticity are also possible. Surgery to reduce spasticity is possible at four levels - on the brain, spinal cord, peripheral nerves and muscles. Brain surgery includes electrocoagulation of the globus pallidus, ventrolateral nucleus of the thalamus or cerebellum and implantation of a stimulator on the surface of the cerebellum. A longitudinal cone incision (longitudinal myelotomy) may be performed on the spinal cord to break the reflex arc between the anterior and posterior horns of the spinal cord. The operation is used for spasticity of the lower extremities, it is technically complex, associated with a high risk of complications, and therefore is rarely used. A significant part of surgical operations in patients with spasticity of various origins is performed on the muscles or their tendons. With the development of contracture, surgical intervention on the muscles or their tendons is often the only method of treatment for spasticity.
So, drug correction of muscle dystonia is carried out mainly with muscle relaxants, but in necessary cases, representatives of other drug groups acting on different levels of the pathological process can be used to reduce muscle tone. In each case, the treatment regimen and doses of drugs are determined individually.
It should be noted that the correction of muscle-tonic disorders is achieved by complex treatment, which includes properly organized and systematic physical therapy, massage, reflexology. Several types of exercise are usually recommended for stroke patients. The so-called general tonic and breathing exercises(contributing to the improvement of the general condition of the body), exercises to improve coordination and balance, to restore the strength of paralyzed muscles, as well as techniques to reduce muscle tone. Along with therapeutic exercises laying or treatment with a position is also used, in which the patient is laid in bed in a special way so as to create the best conditions for restoring the functions of his arm and leg.

Literature
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12. Ward A.B. A summary of spasticity management - a treatment algorithm // Eur. J. Neurol. 2002; 9(1): 48-52.

Muscle spasticity - what is it?

Muscle spasticity is a syndrome that develops when the areas of the upper motor neurons are affected, with an increase in tonic reflexes as a result of stretching, combined with an increase in tendon reflexes. The concept of muscle tone means a certain level of tension of muscle groups and resistance that occurs during extensor or flexion movements of a limb segment. The normal state is considered to be a feeling of some slight elasticity during palpation of the muscles, as well as some muscle tension during unhurried movements. A certain increase in the tone of muscle groups is accompanied by strong resistance during passive movements.

An increase in muscle tone can greatly affect the process of regeneration of previously impaired functions. High level muscle spasticity does not allow the realization of preserved functions, as well as the full recovery of impaired ones. At the same time, the growth of muscle tone is a compensatory factor in the development of paralysis. This determines the urgent need immediately after the start of treatment to clearly determine how necessary and useful it is to lower the muscle tone of the reduced arm or leg.

Symptoms of spasticity

The main symptom of spasticity is involuntary muscle contraction. This process is accompanied by a headache and a general feeling of weakness throughout the body. Not always pain can be attributed to the symptoms of spasticity. Very often, the cause of this condition is too sudden movements, which cause spasmodic contractions of the muscles of the arms or legs. In addition, pain may occur as a result of a change in the position of the patient's body, in particular at the moment when attempts are made to seat him.

The arms or legs, as a result of spastic contractions, cease to obey, become too weak, or acquire additional rigidity. At the same time, a sick person with spastic muscle contractions can feel both weakness and some resistance from the cramped muscles. These factors are a consequence of the conduction of muscles and nerves. In the case of taking medications, there is a certain relief of tense muscles, but the feeling of weakness remains.

Other symptoms of spasticity include involuntary contractions of individual muscle groups, as well as a feeling of general fatigue and loss of a sense of dexterity in the muscles. Numerous patient testimonies characterize spasticity as excessive muscle tension, weakness in the legs, and resistance to movement of the legs and arms.

Spasticity after a stroke

Stroke is an extremely important medical and social problem, since it is one of the causes of many cases of disability, usually related to human movement disorders. In the vast majority of all cases, the acute period of a stroke is characterized by the detection of hemiparesis, in about two-thirds of all cases, the presence of residual effects after a stroke is noted. In the bulk of cases, stroke occurs in people of retirement age, and women are 20% less susceptible to it than men.

Immediately after the onset of a stroke, there is a decrease in muscle tone in the limbs, but after three days it is restored, eventually coming to the average. Depending on the severity of the stroke, the duration of the course of the painful condition and the degree of muscle spasticity may vary. The basis of spasticity after a stroke is a violation of the activity of the human cerebral cortex responsible for the motor activity of the limbs.

Spasticity with cerebral palsy

The spastic form of cerebral palsy is a very common phenomenon. At the same time, the individual muscles of the child's body are in an increased tone, which occurs due to failures in the full functioning of the muscles of the arms and legs. The state of extreme tension is very characteristic of muscles with cerebral palsy and this is the reason for a strong slowdown in their growth. At the same time, there is a much faster growth of bones than muscles, which causes a significant difference in the length of muscles compared to bones and tendons. In this case, there is a decrease in the size of the affected limb and the joints of this limb become less mobile.

In order to prevent all this from happening, immediately after the child is diagnosed with cerebral palsy, classes should be held with him. You can start with regular classes using physical therapy exercises, the results of which will determine the methods of dealing with spasticity. Such an approach will help achieve the desired results.

Spasticity in multiple sclerosis

Spasticity is a symptom that is most directly related to multiple sclerosis. However, when describing the symptoms of their condition, patients do not always correctly interpret it. Often they understand a spasm as a sharp wave of surging pain, while a spasm is involuntary contraction muscle groups. To avoid confusion, the meaning of these terms should be understood.

Spasticity in people suffering from multiple sclerosis often manifests itself in the form of unexpected contractions of certain muscles. These contractions may occur spontaneously or may be the body's response to external stimuli. The degree of manifestation of such symptoms is very diverse, from a mild form to severe spasms that last for a long time. In this case, the patient will need to move to wheelchair. With multiple sclerosis, spasticity may change over time. In this case, the muscles of the arms and legs are mainly involved, much less often the muscles of the back or other parts of the body.

There are some cases in which spasmodic muscle contractions can even be beneficial. This refers to conditions in which the sick person is too weak in the legs and the spasm helps him to take a stable position. In this case, when the spasticity is removed, the person's legs give way and he will not be able to stand on his own.

Spasticity treatment

Treatment methods for spasticity can be different, some of them can be distinguished:

• physiotherapy is used to stretch muscle groups and maintain joint mobility, while reducing the risk of damage to them. With low muscle mobility, physiotherapy can be used as a means of gradual and smooth stretching. In some cases, it may be appropriate to perform minor surgery to increase the length of the ligament by making an incision in the leg;
• drug therapy is used in cases where it is necessary to take medications to relieve increased tension in the muscles of the legs. The mechanism of action may be different, some drugs affect the spinal cord, others on the receptors of the brain;
• botulinum toxin is a tool that provides the proper effect of the application, if necessary, relaxation of the spastic muscle on a short time. Ethanol or phenol can be considered an alternative, although these drugs are suitable for short-term innervation of large and strong muscles, while causing pain in certain nerves.

Spastic exercise

Spasticity manifests itself as a violation of motor activity, manifested in partial or complete immobility, increased muscle tone, as well as involuntary movements. There are certain exercises that can reduce spasticity, restore motor activity and eliminate synkinesis in paralyzed limbs.

Performing exercises requires a certain synchronicity, and both affected limbs participate in them, move in the same direction at different or the same speed. You can do the exercises yourself, you can use someone else's help. Execution implies a medium and slow pace, the number of repetitions is limited to four. You can rest by placing your arm or leg in a position in which the muscles relax most effectively.

Massage for spasticity

With spasticity, the following massage methods can be used. The hands are connected on the chest, while the legs are pulled up to the abdomen, the body bends slightly at the same time, and in this position, free light swaying can be carried out, providing a decrease in muscle tone later certain time. The time during which a decrease in muscle tone occurs should be used in order to conduct a qualitative stimulation of the restoration of certain motor functions that were impaired as a result of muscle spasm. With an increase in muscle tone, it is recommended to repeat the described method of conducting a massage. This technique is most effective when applied to children aged from one month to seven years.

You can apply a form of massage, which is the normalization of muscle tone using a ball. To do this, lie on the ball with your chest and stomach, then make a series of movements in different planes, then change the position of the body and lie down on the ball with your back, subsequently repeating the entire set of movements listed above. Depending on the muscle tone at the time of the exercise, the duration of the exercise should also be determined. On average, in total, this method of massage takes no more than fifteen minutes a day.

Folk remedies

With spasticity of the lower extremities, the following traditional medicine is recommended for use. According to the shape of the legs and torso lumbar the spine needs to sew bags, which are subsequently stuffed with birch leaves plucked from a tree. Immediately before going to bed, the patient should be placed with their feet in these bags, and kept in them for some time, while it is necessary to ensure that the leaves fit the human body as tightly as possible in a dense layer from all sides. This is necessary to create the right temperature environment in the bags so that the person sweats well. At the same time, the feet sweat as profusely as it could happen when using a steam bath. In this position, it is recommended to stay all night. In some cases, it may be recommended to replace the leaves around midnight if they are very wet. After passing through several such sessions, spastic manifestations in the lower extremities will cease to bother.

Spasticity in children

Spasticity in children is the most acceptable variant of hypertonicity, which disappears after several stroking movements, in any case, its sharp decrease can be noted. No time should be wasted when such a symptom is found in a child, one should actively move the adducted limb as quickly as possible or perform a series of passive movements. Spasticity in children can be the result of various injuries or diseases. Most often, spastic muscle contractions haunt disabled children suffering from cerebral palsy; its manifestations are also possible in multiple sclerosis, craniocerebral injuries and traumatic injuries of various parts of the spine. In all these cases, it is much more difficult to eliminate spasticity.

Spasticity in children is inherently an involuntary contraction of individual muscle groups. Symptoms can manifest themselves completely involuntarily, since in this situation there is no control over the energy expended by the muscles of the legs. The commands given by the brain are perceived by the muscles in a completely wrong way, which causes their spontaneous contractions.

Removing spasticity after a stroke proved extremely difficult. The point is the contradiction. We stubbornly restored strength and endurance. Did it with special exercises with a high load and a bunch of repetitions. For the treatment of spasticity, this is a hindrance and harm. When removing spasticity, a relaxing massage and light movements in the exercises are needed. In order to continue recovery after a stroke, it is necessary to conduct mutually exclusive classes. A bad puzzle. But we came up with a simple solution. Make two groups of exercises. First: to restore strength and endurance. The second is to treat spasticity, restore balance and coordination. The decision turned out to be very correct. True, we didn’t reach it right away and for some time did exercises to relieve spasticity along with exercises for strength and endurance. It was noticed early on that active exercise spasticity intensifies.

It became harder to exercise. Increased fatigue. There were pains in the muscles and joints. This made us understand that we are doing something wrong. The mistake was corrected by dividing classes on different days. Started with lifting exercises

Exercise 1.

We perform sitting, right hand.

We relax the left hand and hold it without movement in a comfortable position.

At first, she also tensed up. It needs to be controlled and relaxed.

20 reps x 3 sets.

Exercise 2.

We perform sitting, with the left hand.

We relax the right hand and hold it without movement in a comfortable position.

Alternate touching of the tip thumb with the tips of the remaining fingers.

We touch the tip of the thumb in order: index, middle, ring and little fingers.

Without a pause, we continue touching in the opposite direction.

We touch the tip of the thumb in the reverse order: ring, middle and index.

20 reps x 3 sets.

We make movements slowly, smoothly and accurately. We do not strain the hand, the touch of the fingers is barely perceptible.

Exercise 3

We perform sitting, left and right hand simultaneously. Synchronously.

Alternately touching the tips of the thumbs on both hands, with the tips of the remaining fingers.

We touch the tip of the thumb in order: index, middle, ring and little fingers.

Without a pause, we continue touching in the opposite direction.

We touch the tip of the thumb in the reverse order: ring, middle and index.

20 reps x 3 sets.

We make movements slowly, smoothly and accurately. We do not strain our hands, the touch of the fingers is barely perceptible.

The exercises seem easy. Despite this, they must be done with concentration and attention. The type option to combine with watching TV is no longer available. Any distraction interferes with proper exercise. Mistakes will be fixed in the brain. Will have to relearn. Correcting a fixed, erroneous skill is a thankless task. Waste of energy and precious time. Checked on me))).

In addition to relieving spasticity, coordination of finger movements is wonderfully practiced.

The hardest part was doing the exercise with both hands at the same time. Slightly less complicated with the left hand.

First, speed is not important, but accuracy. It is necessary for the brain to remember the correct movements. No mistakes. As you master the exercise, gradually increase the speed. The main quality, accuracy and the correct order of touches. If during the exercises there was excess tension in the hand, shake the brush two or three times to relax, after relieving the tension we continue. Movement should be light. This is the essence of the exercises.

Removing spasticity is an important task. She interferes greatly Everyday life, takes away strength and constrains movement. This makes it difficult to restore lost skills and stamina. To fully carry out recovery after a stroke, it is necessary to cure spasticity. We do this in parallel with other tasks. This is our