Spasticity

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The terms spasticity or spasticity derived from the Greek word σπασμός ( spasmos , " spasm "; Latinized spasm , dt plural spasms.), And describe an increased typically inherent tension of the skeletal muscles , the more harm to the brain or spinal cord is due .

Neurological basics

In the brain and spinal cord of vertebrates are cells with their long processes (the axon pull) to the muscle to him (stimulate) to innervate. These efferent (executive) nerve tracts are called motor neurons, a distinction being made between the first or upper motor neuron and the second or lower motor neuron. The former (whose cell body, the pyramidal cells, are located in the brain) transmits the control signals for voluntary movements via its axons (which form the pyramidal tract ) to the lower motor neuron, which acts as the actual impulse generator for the muscles. (The origin of movement is explained in detail in the article Motorcortex .) Motor neurons of the spinal cord also receive information via extrapyramidal pathways , with a predominantly inhibitory effect. This is to prevent excessive muscle reaction. The involuntary reflexes are also controlled through these pathways. Various information from the brain converges in the muscle-controlling motor neurons of the spinal cord, the sum of which determines the extent to which a muscle contracts. The extent of the contraction is constantly fine-tuned, in the case of the skeletal muscles between agonists and antagonists of a movement. The basic tension of a muscle that is not voluntarily innervated is also controlled by the descending extrapyramidal motor pathways.

The neurological examination reveals a spastic increase in muscle tension as a "speed-dependent stretch resistance of the not voluntarily innervated skeletal muscle", which means that the spastic hypertension is more pronounced the faster a muscle is passively stretched (in contrast to speed-independent rigidity ).

causes

The cause of spastic paralysis is damage to the areas responsible for movement in the central nervous system (CNS), i.e. the brain and spinal cord, especially the pyramidal tract of the first motor neuron. A lesion of the extrapyramidal motor system is always involved , because this unconscious part of the nervous system constantly sends calming impulses to the muscle in order to regulate tone and self-reflexes . If these are missing, cramping occurs. (If, on the other hand, there is isolated damage to the second motor neuron - that is, without a lesion of the extrapyramidal system - this results in flaccid paralysis .)

By far the most common cause of spasticity is hypoxic damage to motor brain regions caused by a cerebral infarction . Accidents with traumatic brain injuries or spinal cord injuries can also damage the extrapyramidal tracts. Other triggers for spasms are diseases such as spastic spinal paralysis , multiple sclerosis or amyotrophic lateral sclerosis (in about 20% of those affected).

An early childhood brain damage can also cause spastic paralysis. There are different causes for this, whereby in most cases a lack of oxygen during the birth is the cause. This can occur when the oxygen supply via the umbilical cord is interrupted but independent breathing cannot yet start (i.e. the head is still in the birth canal) or cardiovascular arrest occurs. Rarer causes are cerebral hemorrhage at this point in time (this risk is significantly higher for premature babies in particular) as well as prenatal complications that can lead to a lesion of motor pathways: viral infectious diseases of the mother, various types of poisoning or undersupply of the fetus come into question. If one of these causes is present, one speaks of infantile cerebral palsy (ICP).

In addition, a lack of oxygen can damage the affected brain areas at a later point in time. This can happen in children resuscitated after drowning, for example. Spasticity can also occur as a result of inflammation in the central nervous system, such as meningitis , myelitis, or encephalitis . The decisive factor is damage on the way from the first generation of a movement impulse to the last nerve cell that supplies “its” muscle fiber ( motor unit ). The affected muscle initially becomes flaccid and powerless due to the spinal shock, and the muscles' own reflexes ( areflexia ) are also absent . Over the course of weeks to months, the excessive tension then develops. Characteristic for the affected person is no longer the weakness (flaccid paralysis), but the lack of control and coordination, because the superordinate fine control by the pyramidal system and the calming by the extrapyramidal system are missing.

The pathogenetic factors that trigger the spasticity at the neuronal level are z. Sometimes still hypothetical. In this context, the reorganization through the formation of new synaptic contacts (the so-called collateral sprouting ) and through the conversion of inhibitory to excitatory synapses as well as a developing receptor hypersensitivity is discussed. These neurophysiological processes are summarized under the term plasticity of the CNS .

Symptoms

Classification according to ICD-10
G80.0 Spastic tetraplegic cerebral palsy
G80.1 Spastic diplegic cerebral palsy
G81.1 Spastic hemiparesis and hemiplegia
G82.1 Spastic paraparesis and paraplegia
G82.4 Spastic tetraparesis and tetraplegia
G11.4 Hereditary spastic paraplegia
R26.1 Paretic gait
ICD-10 online (WHO version 2019)

Spasticity is not a disease, but always a symptom of damage to or disease of the CNS. Spastic paralyzes show up in very different variations and intensities, ranging from minimal, hardly impairing movement restrictions to the most severe physical disabilities. Each patient has his own spastic pattern. One such example is the Wernicke-Mann posture. Depending on the localization of the paralysis, one differentiates:

  • Monospasticity = spastic paralysis of one extremity
  • Paraspastic = spastic paralysis of both legs
  • Hemispastic = spastic paralysis of the extremities of one half of the body
  • Tetraspasticity / spastic tetraparesis = all four extremities are spastically paralyzed; In addition, the neck and trunk muscles can also be affected.

Since the speaking and swallowing muscles can also be affected, impairments are also possible in this area. These include speech disorders such as slow and / or indistinct articulation ( dysarthria ), or difficulty swallowing ( dysphagia ). If the paralysis also includes the eye muscles, the movements of both eyes are not correctly coordinated, so that double vision ("squint") occurs. In addition to increased muscle tone and resistance to stretching, in most cases "other symptoms such as muscle paresis and slowing of the movement, increased muscle reflexes and pathological external reflexes" occur. This means that mobility is considerably restricted and active movements can only be carried out with difficulty and with little differentiation. The coordination of movements may not be flawless, for example the coordination between eyes and hand (targeted grasping) or symmetrical movements. Athetotic , that is, slow screwed movements, or choreatic , that are random, sudden sudden involuntary movements, occur less often .

In the presence of a congenital spastic disability, early childhood reflexes are retained, which are suppressed in healthy people within the first year of life. One such example is the Palmarreflex (a grasp reflex), in which touching the palm of the hand triggers an immediate closing of the hand. Another pathological reflex that is indicative of damage to the pyramidal trajectory ( pyramidal tract sign ) is the Babinski reflex . If corticospinal motor systems are impaired at a later point in time, these early childhood reflexes are reactivated by the failure of higher-level structures.

Spasticity, on the other hand, does not necessarily go hand in hand with intellectual disabilities. Sometimes those affected seem restricted in their learning and cognitive abilities, which is not due to an intelligence deficit, but rather to the motor-related slower reaction (for example, answer to a question). However, there are also cases with a simultaneous slight intellectual impairment up to severe intellectual disability; here, the lack of oxygen or the infection caused brain damage in other areas as well.

The cramping of the muscles is subject to daily fluctuations. In addition, it can be intensified spontaneously by various stimuli from the internal and external environment. This includes the stretching of the muscles themselves, signals from the bowels, for example bladder filling, environmental conditions such as heat, moisture, touch or psychological influences, for example great joy, fear , anger or depression . It may pain should occur, which can be very strong especially in acute spasm as well as passive stretching of spastic muscles.

diagnosis

In a skeletal muscle with an intact nerve supply, a slight residual tension (the physiological muscle tone) remains with willful relaxation. The examiner can feel this when he moves the joints in the body of the person to be examined without the person being examined actively - the examiner bends and extends an arm or a leg, for example. If he notices that he needs more strength than usual and the stiffness he is working against becomes even greater at the end of each direction of movement and the faster he tries to carry out the movement, this is known as spasticity. During this attempt at flexion one can often observe the so-called pocket knife phenomenon: the increased resistance as an expression of the spastic increase in tone suddenly decreases and the affected muscle can now be stretched further. In connection with spastic increases in tone, pathological reflexes and pyramidal trajectory signs often occur.

Consequential damage

A long-term consequence of the movement disorder is muscle shortening, which in turn further restricts mobility and causes poor posture and misalignment in joints ( contractures ). Joint deformities are particularly common in the ankle and hip (hip dislocation). This can promote inflammatory-degenerative joint damage such as arthritis and osteoarthritis . A scoliosis (lateral curvature of the spine) occurs mainly when a part of the body is more affected by the injury than the other. With very pronounced scoliosis, functional disorders of the lungs are possible. Circulatory disorders and pressure sores ( decubitus ) are particularly at risk for less mobile patients . In addition, the risk of osteoporosis is increased. If a faulty eye coordination cannot (or cannot) be treated adequately, the eye that is “unused” (hidden) when squinting loses visual acuity and can go blind due to the degeneration of the optic nerve. Psychological consequences can be a lack of self-confidence, depression and changes in personality - often as a result of exclusion and social isolation.

therapy

Since spastic paralysis cannot be cured, the aim of the various therapy options is to reduce the existing symptoms, improve mobility and counteract consequential damage such as joint inflammation and deformation. Basically, the therapy should be multidisciplinary. Because of the wide range of variations in the clinical picture, an individual therapy plan must be put together for each patient.

Exercise therapy

Physiotherapy (physiotherapy) is of paramount importance . The therapist tries to minimize spasms, to move joints passively in order to maintain their mobility, but also to strengthen healthy muscle groups and to trigger physiological movement patterns through targeted exercises. Physiotherapy can also be supported by training on a movement trainer or movement therapy device in minimizing spasms. Also, hydrotherapy and swimming can be helpful. If speech and swallowing disorders are present, a speech therapist should also be consulted for treatment. The aim of occupational therapy is to give the person affected assistance in coping with everyday tasks.

Therapeutic riding is another treatment option. A suitable horse with a balanced temperament, which should not be too big (helpers walking next to the horse must be able to hold the patient), should not have too wide a back (because of the spasticity), is absolutely necessary Paralyzed often limited ability to spread the legs) and should have rhythmic gaits, especially when walking (not a 'passer-by'!), As the therapy is mainly carried out in this gait. The effect of hippotherapy is based on the warmth of the horse's back (it is ridden without a saddle, but with a belt with handles and possibly a blanket), which has a relaxing effect on the overly tense muscles, as well as on the steady rhythm of the horse's movements. The step movement of the horse that is transmitted to the patient corresponds almost to the movement sequence when walking and helps to pave the way for a physiological movement pattern. In addition, there are careful stretching exercises and training of the sense of balance. The prerequisite for therapeutic riding is that the patient is not afraid of the horse, as this would lead to additional cramping. The health insurance companies usually do not cover the costs of riding therapy because the medical benefit has not been (sufficiently) proven. Those affected, however, often report (subjective) relief from their symptoms.

Medical therapy

Oral medication

Drug therapy consists primarily in the oral administration of drugs that have an antispastic effect. This is done either by lowering the muscle tone or by blocking the neuromuscular transmission of stimuli to the motor endplate . This relaxes the affected muscles, but also all other muscles in the body, and reduces painful spasms. If the dose is too high , breathing may stop because of the respiratory depression . The sedative effect of the preparations is also not always desirable. Depending on the cause of the spasticity and its severity, the administration of antispastic drugs does not always make sense, since undesirable effects can be greater than the benefits (= functional improvement of the affected muscles).

Botulinum toxin therapy

In addition to oral drug treatment, supplementary therapy with intramuscular injections of botulinum toxins is possible if the focus is on the spasticity of certain muscles. This substance is injected into the affected muscle and acts on the synapses there by preventing the release of the neurotransmitter acetylcholine. The result is a - reversible - flaccid paralysis of the skeletal muscle.

Intrathecal administration of baclofen

For some severe forms of spasticity, conservative treatment with physical therapy and oral medication may be possible. It may not be sufficient and, due to the large number of muscles involved, botulinum toxin administration may not make sense. In such cases there is the option of so-called intrathecal baclofen therapy, in which a drug with a spasmolytic effect is continuously delivered into the spinal canal via an implanted pump . This procedure is very time-consuming, costly and associated with possible complications (e.g. surgical risk).

Operative therapies

In addition to these conventional therapies, there are various surgical techniques that are intended to prevent or correct deformations, as well as those whose aim is the "greatest possible restoration of muscle balance" in order to reduce spastic movement patterns. Some examples are tendon extensions, muscle dislocations, and bone rearrangements. Mostly these measures are used with children of preschool age; orthopedic-surgical corrections are less common in adults and often do not achieve great success. In the most severe spastic paralysis in connection with severe pain and inability to move - especially in the lower extremities - there is the possibility of severing the nerves supplying the affected muscles. With this method, the spastic paralysis becomes a flaccid plegia. Sensitivity disorders of the extremity in question are common side effects of such an intervention, which incidentally often only temporarily improves the spasticity and is therefore rarely carried out nowadays, especially since more effective drug therapies are now available.

Tools

Depending on the severity of the disability, the need for aids is very variable. Often you need: walking aids, orthotics, orthopedic shoes, corsets or even wheelchairs with easy-to-use controls or individually adapted seat shells.

Effects

The effects of spasticity vary significantly depending on their severity, i.e. which parts of the body are affected and how severely. In addition, the cause - and thus any other symptoms of the disease - as well as the age at the occurrence of the damage influence the degree of impairment.

Family, living

Caring for a severely disabled child requires a lot of mental and physical strength from the family and brings some limitations with it. In addition to medical treatment, advice and support, for example from physiotherapists, occupational therapists, associations for the disabled, rehabilitation centers and other auxiliary facilities, make an important contribution to ensuring that the child is supported as much as possible and can grow up in a safe environment.

Of course, the occurrence of spasticity in old age also poses numerous challenges for those affected and their family members. The need for a wheelchair-accessible apartment and facilities for the disabled depends on the degree of impairment.

Everyday life, integration

Limited mobility often makes it difficult to cope with everyday life independently. Depending on the severity, even basic activities such as B. Dressing and undressing, eating and drinking or using the toilet cannot be carried out without assistance. This loss of independence can have negative effects on the self-esteem of those affected.

Participation in social life can be impaired, for example, by being dependent on a wheelchair or other mobility problems (e.g. fear of falling), but also by visual and speech disorders and thus lead to social isolation and loneliness. Sometimes those affected withdraw (even further) from society because they do not feel accepted.

School occupation

Many children with ICP can attend a regular school, although in many cases there are bureaucratic hurdles involved in starting school. To be mentioned here are u. a. Financing problems for the care of a personal assistant, but possibly also the uncertainties of teachers about having a physically handicapped child in the class, because this aspect is often neglected in teacher training. Admission to a regular class can promote the child's integration, but it can also lead to conflicts if the same is demanded of him as is demanded of children without restrictions (and so, for example, the time required to write is increased).

If spastic paralysis occurs at a later point in time, it may It is possible that a learned profession can no longer be pursued (e.g. because of a restriction or loss of mobility or fine motor skills).

Aid organizations

Others

The term spastic and its short forms Spast or Spasti are sometimes used as a swear word in the sense of cretin , i.e. H. "Fool, limited, incompetent person", used.

literature

Individual evidence

  1. ↑ a b Guideline Spasticity - Physiotherapy and drug therapy for spastic syndromes of the German Society for Neurology . In: AWMF online (status 10/2005).
  2. ↑ Spastic, the. Duden , 2017, accessed February 6, 2017 .
  3. ↑ Spasti, the. Duden , 2017, accessed February 6, 2017 .
  4. ^ Etymological dictionary according to Pfeifer , online at DWDS , accessed on February 6, 2017.