For citation: Damulin I.V. Spasticity after a stroke // BC. 2005. No. 7. P. 501

Stroke remains an extremely important medical and social problem, since it is one of the most common causes of disability, in most cases associated with movement disorders. In 80–90% of patients in the acute period of a stroke, hemiparesis is detected, residual effects of a stroke of varying severity and character are observed in about 2/3 of patients. Almost three quarters of people with stroke are 65 years of age or older, with the incidence of stroke about 20% higher in men than in women.

More than 50% of patients have arterial hypertension, 25% have diabetes mellitus, and almost 25% have a history of stroke. In addition to arterial hypertension and diabetes mellitus, risk factors for stroke are damage to the great vessels of the brain, atrial fibrillation, smoking, hyperlipidemia, and elevated fibrinogen levels. Among the main risk factors for stroke in young people, cerebral embolism, trauma of extracranial vessels, vasculopathy of various origins, impaired blood coagulation, use of oral contraceptive drugs, childbirth, drug addiction (especially cocaine addiction), as well as HIV-related diseases should be noted. infection. It should be noted that cocaine leads to cerebrovascular disorders, affecting blood pressure and vascular tone, causing prolonged vasospasm, increasing thromboxane synthesis and increasing the tendency of platelets to thrombus, while also increasing the risk of cardiogenic embolism. Chronic use of cocaine leads to cerebral atrophy and pathology of the white matter of the cerebral hemispheres. According to the methods of functional neuroimaging, multiple zones of cerebral hypoperfusion are revealed. Disorders of the frontal type are quite typical for this category of patients, manifested, in particular, by an increase in the number of perseverative errors when performing the Wisconsin card sorting test. Vasculitis is the cause of only 3-5% of strokes in people under 50 years of age. The incidence of cerebral vasculitis is 1-2 cases per 1 million population per year (for comparison: systemic vasculitis - 39 cases). The main mechanism leading to defeat nervous system with vasculitis, ischemia is. The occurrence of ischemia during inflammation of the vascular wall is associated with three pathogenetic factors: vascular obstruction, an increase in the tendency to blood coagulation, which is due to the influence of pro-inflammatory cytokines on the endothelial surface and a change in vascular tone. However, more often with vasculitis, the vessels of the visceral organs or the vessels that supply the peripheral nerves with blood are affected. Perhaps this is due to the structural features of the walls of cerebral vessels (in particular, lymphocytic adhesion of the endothelium of cerebral vessels is less than 5%, in other organs - 15–20%) and the presence of a blood-brain barrier.
One of the serious complications of a stroke is spasticity in the affected limbs, which is observed in almost 65% of stroke patients. In patients with spasticity, the risk of falls and, accordingly, trauma increases significantly; contractures, pain syndromes, pressure sores, osteoporosis, pelvic disorders and thrombophlebitis often occur. The immediate cause of death in this category of patients may be cardiovascular, pulmonary or renal complications.
Spasticity is understood as a movement disorder characterized by a speed-dependent increase in tonic stretch reflexes as a result of damage to the upper motor neuron. Clinically, this is manifested by increased muscle resistance, varying in its severity depending on the amplitude and angular velocity of the passive movement produced. A characteristic feature of spasticity is the "folding knife" phenomenon, when during passive flexion of the affected limb, the resistance of the muscle expressed at the beginning of the movement is suddenly replaced by its contraction in the direction of the movement. Spasticity, as a rule, is accompanied by paresis and other symptoms characteristic of the defeat of the upper motor neuron. Among the clinical signs of damage to the upper motor neuron, the so-called. "Positive" and "negative" symptoms, as well as changes in spasmodic contracted muscles (Table 1).
Immediately after the development of a stroke, muscle tone in the paretic limbs is often reduced, but within 2–3 days it increases, ultimately leading to a characteristic posture with increased tone in the adductors and flexors of the arm and the adductors and extensors of the leg. Slight changes in the motor sphere in the form of a slight decrease in muscle strength and revitalization of reflexes can also be noted on the ipsilateral side. An increase in muscle tone in paretic limbs can occur not only after a few days from the onset of the disease, but also after a longer period of time (after weeks or even months).
The severity of clinical manifestations can vary depending on the localization of the focus, the volume of the affected tissue and the duration of the disease. Regulation of muscle tone is carried out under the influence of both central and peripheral impulses on a-motor neurons of the spinal cord. a-motoneurons, which innervate muscle fibers, are located in the anterior horns of the spinal cord. Afferent impulses from receptors in the muscles are transmitted to the structures of the spinal cord through sensory fibers. The sensory fibers end on the a-motor neurons of the anterior horns (monosynaptic pathways), as well as on the intercalary neurons of the posterior horns of the spinal cord, connected, in turn, with motor neurons that innervate the antagonist muscles (polysynaptic pathways). The origin of spasticity is based on the violation of the inhibitory effects of the supraspinal regions on the spinal motor and intercalary neurons. At the same time, at the spinal level, there is an imbalance between the processes of excitation and inhibition, as well as denervation hypersensitivity and neuronal sprouting. The previously expressed hypothesis about the selective hyperactivity of the g-system, as one of the leading pathogenetic mechanisms of spasticity, has not found reliable experimental evidence.
With long-term pyramidal syndrome, changes in the muscles themselves also have a definite effect on the increase in muscle tone (Table 2).
A number of these disorders (altered response to stretching, impaired rapid muscle fiber relaxation, impaired reciprocal inhibition, impaired muscle contractility due to changes in muscle fiber structure, secondary pain and impaired ability of antagonist muscles to provide resistance comparable to the action of spastically altered muscles) can be reduced when using methods of muscle chemodenervation or the administration of botulinum toxin preparations. However, the decrease in muscle strength and the increase in the latency period for muscle activation can increase with such treatment.
Despite the fact that spasticity is considered one of the characteristic signs of damage to the corticospinal pathway, it is based on the defeat of the extrapyramidal motor pathways. Important role reticulospinal and vestibulospinal descending pathways play in the regulation of muscle tone. By itself, an isolated lesion of the pyramidal tract at the level of the cortex, the legs of the brain, the base of the pons or the pyramids of the medulla oblongata is not accompanied by an increase in muscle tone.
In the rehabilitation period after a stroke, movement is first restored in the proximal parts of the limbs, then in the distal ones. Usually, with a stroke of the corresponding localization, weakness in the upper extremities occurs earlier than weakness in the lower extremities, and, as a rule, the restoration of normal motor functions in the hemiparetic arm is worse than in the leg. One explanation for this is that functional recovery in the hand includes not only regression of muscle weakness, but also restoration of the ability to perform fine, coordinated movements. In contrast, functional recovery in the leg, which is manifested by the restoration of walking, can occur even with a slight or moderate increase in muscle strength. In addition, the success of rehabilitation measures in the hand can be significantly limited due to the addition of changes in the shoulder joint and the associated pain.
The prognosis for the restoration of motor functions in the hand is significantly worse if plegia is noted immediately at the onset of the disease, as well as if, after 4 weeks from the onset of the disease, the grasping by the hand is not restored. However, in about 9% of patients with severe paresis in the arm in the acute period of the disease, a satisfactory recovery can subsequently be achieved, and in 70% of patients who show some improvement in motor functions during the first 4 weeks from the onset of the disease, complete or significant restoration of motor functions in the hand. It is believed that if a patient does not have active movements in the limbs during the first 2 weeks after the onset of a stroke, then there will be no complete regression of movement disorders in the future. In the case of independent complete recovery of the lost motor functions, the duration of the recovery period, as a rule, does not exceed 3 months (usually 1.5–2 months after a stroke), however, in some cases, some improvement can last up to 6–12 months and even a longer period of time ...
Spasticity leads to significant functional disorders and impaired quality of life of patients. However, spasticity itself does not always require treatment, and a decrease in increased muscle tone does not always have a positive value for the patient. For example, in some patients with severe paresis, the presence of spasticity in muscles that anatomically and functionally impede the force of gravity ("antigravity" muscles) can facilitate standing and walking. In addition, the presence of increased muscle tone can inhibit the development of muscle atrophy, soft tissue edema and osteoporosis, as well as reduce the risk of deep vein thrombosis of the lower extremities. Indications for the treatment of spasticity are only those cases where, due to increased muscle tone, “functioning, positioning or comfort” is impaired.
The main objectives of treatment are not only to reduce the severity of pathologically increased muscle tone, but also to reduce the severity of pain, prevent the development of contractures, improve the patient's ability to self-care, and facilitate rehabilitation. Therefore, examining a patient with spasticity, the doctor must solve the following tasks:
1. To identify patients who are candidates for a specific method of antispastic therapy.
2. Determine a specific method of therapy, the use of which in terms of restoring motor functions may be most effective in a given patient (muscle relaxants, botulinum toxin injections, local administration of phenol or alcohol, dorsal rhizotomy).
3. Monitor the dynamics of the main motor characteristics (muscle strength, joint mobility, etc.) and the patient's functional activity (walking, self-care ability, activity in everyday life) during therapy.
Thus, the clinical assessment of spasticity should be carried out not only in order to identify the affected muscles (or muscle groups), but also to determine the effect of the existing spasticity on all aspects of the patient's life, including the ability to move, work capacity and activity in Everyday life, which is important for planning therapeutic programs (Table 3). For a more detailed assessment, electromyography can be used, as well as diagnostic local blockade with an anesthetic, which helps in the choice of the subsequent treatment method.
When assessing the increase in muscle tone, one should also take into account the fact that it can vary significantly depending on the patient's posture and his emotional state. An increase in the severity of spasticity can occur under the influence of internal factors (with urinary retention, inflammatory urological diseases, urolithiasis, constipation) and external causes (fractures, improper position of the spastic limb in bed, deep vein thrombosis of the lower extremities).
It should be emphasized that spasticity is clinically realized in various forms and with the participation of different mechanisms, including changes in both presynaptic and postsynaptic inhibition. Therefore, there is no universal, equally effective treatment for all types of spastic syndrome. However, since the pathological enhancement of polysynaptic reflexes and the excitation of spinal motor neurons are the basis for a direct increase in muscle tone, an important direction of drug therapy is the effect on these structures.
For spasticity, the following treatment methods are used: physiotherapy and therapeutic exercises, oral muscle relaxants, injections of botulinum toxin preparations, intrathecal injection of baclofen using a pump, chemodenervation (phenol, alcoholization), as well as operations on tendons, joints and rhizotomy. The first three of them are currently the most widespread.
Physiotherapeutic methods and remedial gymnastics are most effective in the early phase of the onset of spasticity and are aimed at activating natural recovery processes. Previously, it was believed that one of the goals of rehabilitation of patients with stroke is the use of techniques in which the main emphasis was on the use of unaffected limbs in order to make patients more independent in everyday life. At the same time, no significant load was exerted on the affected limbs. It has now been proven that the activation of the affected limbs directly affects the processes of functional cerebral reorganization and thus contributes to a better recovery of the neurological defect. In addition, excessive use of unaffected limbs by patients with hemiplegia can lead to such an undesirable phenomenon as increased tone in hemiparetic limbs. Positional therapy, thermal and cold procedures, phonophoresis, transcutaneous electrical stimulation of nerves, etc. are widely used. These techniques not only reduce increased muscle tone, but also increase the range of motion in the joints, as well as prevent contractures. All this ultimately leads to an increase in the functional activity of patients. Unfortunately, the benefits of these therapies are usually short-lived. In addition, to date, there are no evidence-based controlled studies to study the effectiveness of these techniques.
The use of botulinum toxin preparations is more justified in situations where muscle spasm is predominantly local in nature. The duration of the effect is determined by the dose of the injected drug, the size of the muscle, the activity of the muscle, and a number of other factors, including the simultaneous carrying out of physiotherapeutic procedures. The effect of the drug administration lasts on average for 2–6 months. In some patients, there may be a disappearance of the positive effect after repeated injections of botulinum toxin. The most common reasons for this are the wrong choice of the muscle into which the drug is injected, or inadequate doses of botulinum toxin. However, some patients (less than 10%) may have a true lack of effect. It is believed that this may be based on antibodies blocking botulinum toxin type A, but the results of immunological research methods are controversial. It should be noted that the use of botulinum toxin preparations is largely limited due to their high cost.
In practice, muscle relaxants are most widely used - baclofen, tizanidine (Sirdalud), diazepam, dantrolene, tolperisone. Among the drugs in this group, Sirdalud occupies a special place, which is associated with the mechanism of its action and clinical effect. As a central a2-adrenergic agonist, Sirdalud has a stimulating effect on the monoaminergic nuclei of the brain stem. This leads to inhibition of spinal motoneurons connected by type II afferent fibers with the stem centers, and, accordingly, to a decrease in muscle tone. At the same time, the release of excitatory amino acids from intercalated spinal neurons decreases. Descending adrenergic supraspinal pathways play a significant role in the regulation of muscle tone. Anatomically, these pathways are closely associated with spinal structures, especially with the anterior horns; the results of physiological studies indicate their participation in the regulation of reflex spinal responses. In the spinal cord, most of the a2-receptors are located on interneurons, not on motor neurons. Being a clonidine derivative, Sirdalud has a high affinity for a2– and practically does not act on a1 –adrenergic receptors. Under the action of Sirdalud, the release of aspartate from spinal neurons is inhibited. This drug selectively inhibits through the a2-adrenergic receptors the intercalary neurons of the posterior horns of the spinal cord, which underlies its analgesic effect.
It is suggested that the additional antispastic effect of Sirdalud is due to its influence on the a2-receptors of noradrenergic neurons located in the area of ​​the blue spot and affecting the spinal structures. It was found that the effect of Sirdalud, as well as norepinephrine, on adrenergic receptors does not change with the introduction of a1- and b-adrenergic antagonists or an opiate receptor antagonist naloxone. The experiment did not reveal the effect of Sirdalud on Ranshaw cells. D. Coward, analyzing the results of experimental and clinical studies, emphasizes that the antinociceptive effect of Sirdalud is independent and is not associated with its muscle relaxant effect.
Against the background of the action of Sirdalud, only the tonic component of muscle contraction decreases while the phasic reaction is preserved. This is different from the action of baclofen, which reduces tonic and phasic components, which is accompanied by a decrease in muscle strength.
Thus, the antispastic effect of Sirdalud is associated with several mechanisms of action (presynaptic and postsynaptic inhibition of interneurons, a possible effect on the glutamatergic system). An essential point is that Sirdalud is not contraindicated in patients with epileptic seizures, which makes it possible to prescribe it to patients with post-stroke spastic paresis and convulsive seizures. Experimental data indicate a possible antiepileptic effect of high doses of the drug, the mechanism of which remains unclear. However, Sirdalud is not used as an actual antiepileptic drug.
The antispastic effect of Sirdalud is roughly comparable to that of baclofen and diazepam. However, Sirdalud has, in comparison with these drugs, important advantages - better tolerance and the absence of a significant decrease in muscle strength. The latter circumstance significantly limits the use of baclofen and diazepam, since a decrease in muscle strength can be observed in both paretic and intact limbs. It should be noted that more than 10% of patients who started taking baclofen are forced to later refuse to take it because of the increase in muscle weakness.
Sirdalud is widely used to treat spasticity of various origins. The positive antispastic effect of the drug is dose-dependent, which is confirmed by the parallel determination of the drug level in the blood plasma. The selection of an individually effective dose (from 2 mg to a maximum dose of 36 mg / day) is usually carried out within 2-4 weeks. After oral administration, the effect of the drug appears within 30–45 minutes, the maximum effect occurs within 1–2 hours. Improvement is noted in 60-82% of patients (for comparison: while taking baclofen - in 60-65%, diazepam - in 60-83%), while spasticity decreases on average by 21-37% (while taking placebo - on 4-9%).
It is important to note that the mechanism of action of Sirdalud is significantly different from the mechanisms of action of other drugs used to reduce increased muscle tone. Therefore, Sirdalud is used in situations where the antispastic effect of other antispastic agents is absent (in the so-called "nonresponsive" cases). In addition, given the differences in mechanisms of action, Sirdalud and baclofen can be used in combination to treat spasticity.
Sirdalud is characterized by a gastroprotective effect, the origin of which remains unclear. The data of experimental and clinical studies indicate its ability to protect the gastric mucosa from the action of non-steroidal anti-inflammatory drugs. The mechanism of this effect is associated with adrenergic activity, inhibition of the production of gastric secretions and the ability to prevent changes in glycoproteins caused by the influence of aspirin or indomethacin.
The incidence of such adverse reactions as dizziness, drowsiness, dry mouth, general weakness, correlates with the level of the drug in the blood plasma. Against the background of the appointment of Sirdalud, there may be a slight decrease in blood pressure, which is explained by the structural similarity of this drug with clonidine. On healthy volunteers, it was shown that against the background of a single dose of 6–12 mg of Sirdalud, a decrease in blood pressure averages 10–15%. The literature mentions the ability of Sirdalud to potentiate the effect of antihypertensive drugs.
In isolated cases, a transient increase in the level of hepatic enzymes is possible, which disappears after a dose reduction or discontinuation of the drug, therefore, Sirdalud should be carefully prescribed to patients with hepatic or renal insufficiency. The drug, as a rule, is well tolerated during long courses of therapy.

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Depending on the area of ​​the brain affected by the stroke, some body movements, speech and body functions may change. Individual areas of the brain are endowed with their own functions and control specific parts of the body. The prognosis for a stroke patient depends on the site of the disease and the severity of the brain damage. It is known to be not uncommon for hands that become weak after a stroke. Using drugs and the right exercises to strengthen your muscles can bring control and strength back to your arm muscles, which will bring you back to being a normal person.

Steps

Part 1

restoring strength through exercise

Develop your shoulders. According to the American Heart Association, the reuse of affected body parts such as hands, palms, and fingers is revealing new ways of communication between the brain and the affected area. Movement and physical therapy help stroke patients retrain their brains to use skills fine motor skills... The exercises for developing the shoulders are as follows:

• Flexion of the shoulder. Holding a dumbbell in your hands, maintain a straight elbow and raise your hand above your head and lower it down. Repeat this exercise ten times. Take a dumbbell in your other hand and repeat the same exercise. Do it at least once a day.
• Shoulder abduction. Hold the dumbbell in one hand, keeping it straight. Then move your arm to the side at shoulder height. Return your hand to yourself. Repeat this ten times and then switch to the other hand. Repeat this exercise at least once a day.

1. Also work out your elbows. Here are two exercises you can do to strengthen your elbows, forearms, and hands:

   • Breeding elbows. Lean forward slightly and hold your elbows behind you. Lift the dumbbell behind you, keeping your elbows straight, and then bend them. Repeat this ten times, and then switch hands and repeat on the other side.
   • Flexion of the elbows. Take a dumbbell with one hand. Then, bend your arm at the elbow, and then straighten it. Repeat this ten times. Change sides and repeat, or do both elbows at the same time.

2. Make turns as well. To strengthen your arms, hands, and fingers and strengthen muscles, you can do twists in addition to flexion and extension exercises. Here are two types of pivoting exercises to help strengthen your muscles:

   • Outside reversals... Take an elastic band in your hands. Begin the exercise with your elbows bent 90 degrees to your body. Rotate your arms with your palms to the sides. Repeat this ten times. Do it at least once a day.
   • Internal rotations. Tie one end of the elastic to the doorknob. Then, while supporting your elbow at a 90 degree angle, pull the other end towards your abdomen. Do this exercise at least once a day as well.

3. Strengthen your wrists. Dumbbell wrist exercises are considered weight bearing exercises. This type of physical activity leads to the formation of new bone tissue, and it makes bones stronger. Together with an increase in blood flow with physical activity also increases muscle mass and strength. The following can be done:

   • Take a dumbbell in both hands with the elbows bent 90 degrees. Turn your palms up and down ten times. Do this exercise at least once a day.
   • With palms down, hold a dumbbell in each hand and bend your elbows to 90 degrees. Lift your wrists up and down while keeping your elbows in their original position. Repeat this ten times. As usual, do this at least once a day.

4. Understand the action of these exercises. Exercises such as flexion and abduction of the shoulder, flexion and extension of the elbows, external and internal rotations develop the muscles of the arms, elbows, wrists and shoulders. Working out the damaged part of the body through stretching, pushing, or lifting stimulates muscle growth and increases their effectiveness. Regular exercise increases the number of myofibrils (muscle fibers) in each cell, which accounts for 20 to 30% of muscle growth.

   • Due to the increased blood flow, more oxygen is supplied to the muscle fibers and nutrients leading to increased muscle mass. An increase in muscle mass leads to an increase in muscle strength. When muscles start to work, they develop more mitochondria, small power plants that convert chemical energy into energy for use by cells.

   Part 2

   using a medication approach

   1. Take 40 to 80 mg of baclofen (Lioresal) every day. This drug acts on the central nervous system by preventing nerve impulses in the brain that cause muscles to contract. It relaxes muscles by reducing muscle spasms, tightness, pain, and increasing range of motion. For adults, the required dose of baclofen is 40-80 mg / day for four separate doses.

      • The analogue of the drug baclofen is dantrolene sodium (dantrium). The recommended dose is 25 mg to a maximum of 100 mg three times a day.

   2. Try 8 mg of tizanidine hydrochloride (zanaflex) every 6 or 8 hours. This drug also blocks nerve impulses in the brain that cause muscles to contract. The ideal starting dose is 4 mg every 6 or 8 hours. The maintenance dose is 8 mg every 6 or 8 hours.

      • However, the effectiveness of the drug only lasts for a short period of time, so it is advisable to use it as needed to relieve discomfort and to be able to perform certain actions.

   3. Consider taking benzodiazepines such as Valium and Klonopin. This type of medication acts on the central nervous system, thereby relaxing the muscles and reducing spasticity for a short period of time.

      • The oral dose varies as benzodiazepines come under different names (in other words, there are different medical names for the drug). Consult your doctor for the correct formulation.

   4. Consider getting botulinum toxin (Botox) injections to reduce spasticity. Botox injections attach to nerve endings and block the release of chemical carriers that signal the brain to activate muscle contraction. Essentially, the treatment prevents muscle cramps.

   5. Consider phenol injections as an alternative. Phenol destroys the nerve conduction that causes spasticity. It is used as an injection directly into the affected muscles or into the spine. The dosage may vary depending on the manufacturer.

      • Check with your doctor if this course of treatment is right for you. Phenol injections are not suitable for all stroke patients.

   6. Talk to your doctor about electrical stimulation therapy. This therapy stimulates the affected nerve endings in the brain to force the muscles to contract. This therapy helps restore movement and control of the arms and hands, improves muscle tone, and reduces pain in the patient after a stroke. It also increases blood flow to the brain to speed healing and reduce swelling, improve drug flow to the skin, and reduce muscle spasticity.

      • Again, electrical therapy is not for everyone. Only your healthcare professional knows if this procedure is right for you.

   7. Consult a physical therapist to initiate muscle therapy. There are two types of muscle recovery you might want to consider:

      • Limited-induced movement therapy. This therapy is often performed during the rehabilitation period to increase the brain's ability to heal itself and the affected hands to recover their function. The healthy arm is restrained by the device to allow the injured arm to be used for as much activity as possible.
      • Rehabilitation therapy. Rehabilitation therapy (RT) helps the patient after a stroke to re-learn his daily activities, habitual before the illness. This will speed up your recovery as you learn to live and work with disabilities... Your doctor will help you convert your home to make it safer and easier to move around inside it.

   8. Work with your stroke rehabilitation team to determine which treatment is best for you. The return of power to your hands does not mean that you are using only one medicine or type of treatment. During stroke rehabilitation, you and the rehabilitation team will work together to determine which medications work well and what improves the stiffness in your hands after a stroke.

      • Medication is not a panacea for a stroke; it only relieves the spasticity symptoms that constrict muscles. Muscle spasticity causes pain, disrupts body position and leads to uncontrolled movements. The arms may begin to regain their normal strength and range of motion if the patient's medication relieves the spasticity.

   Part 3

   understanding your condition

   1. Be aware of the type of stroke you have suffered. When blood flow to an area of ​​the brain is obstructed, it leads to the development of a stroke. Brain cells that are not supplied with blood die due to lack of oxygen. In a matter of minutes and without warning, a stroke can occur and affect a person. There are two types of stroke:

      • Ischemic stroke. This is the most common type of stroke. About 87% of stroke patients suffer from this type. It develops from a blood clot in a blood vessel that interrupts the flow of blood to the brain. It can also be caused by an embolism or a blood clot that travels to other parts of the body.
      • Hemorrhagic stroke. Rupture of blood vessels on the surface of the brain that fill the space between the skull and the brain leads to hemorrhagic stroke. A hemorrhagic stroke can also be caused by a ruptured artery in the brain, which causes bleeding into nearby tissues.

   2. Find out what symptoms can be caused by a stroke. Stroke patients may experience weakness on one side of the body and may affect either the arms or legs or both parts of the body. There may also be speech impairments, problems with vision, memory and intelligence, difficulty swallowing, urinary incontinence, and problems with bladder... In severe cases of stroke, paralysis or even death can occur.

      • Hands and palms after a stroke can become especially sensitive. A patient with a stroke may experience an attack of spasticity, uncontrolled squeezing and stiffness of the muscles, which causes difficulty in moving the hand and palm. The injured arm or leg is on the opposite side of the body from the part of the brain affected by the stroke.

Stroke is one of the most pressing problems of modern medicine. A high percentage of mortality and loss of performance, a tendency to form

Stable residual events, frequent damage to patients of working age are the main points that explain the need to develop effective prevention and treatment measures.

Movement disorders are the most common consequence of all that are noted in patients after a stroke. The greatest chances of recovery are observed during the first months. Just during this period, many patients after a stroke develop muscle hypertonicity, which greatly complicates rehabilitation.

Development mechanism

In order to better understand the mechanism of development of muscle hypertonicity, let us consider the main aspects of the regulation of movements.

The earlier classes on prevention of spasticity begin, the better the result.

Muscle contractions are normally regulated at three levels:

• spinal cord;
• stem nuclei of the brain;
• cortex.

Any of these areas can stimulate muscle contraction. Thanks to the close cooperation of these departments, a person can perform the necessary movements, and muscle tone remains normal.

Impulses from motoneurons of the spinal cord provide automatic movements, for example, sharp bending when exposed to a painful stimulus. The overlying sections have a regulatory effect on the motor cells of the spinal cord, and it can be both inhibitory and stimulating.

The stem nuclei are responsible for maintaining posture and balance. The vestibular nucleus increases the tone of the muscles that extend the limbs. The red core, on the contrary, bends the limbs. In this case, the spinal motoneurons of the opposite muscle groups are inhibited. This relationship is called reciprocal.

The cerebral cortex regulates the voluntary movements of a person. To date, scientists have compiled detailed maps of the localization of areas that are responsible for the movement of individual parts of the body.

The motor cortex of the brain has an inhibitory effect on the spinal motoneurons, due to which integral movements are provided, and not individual twitching of the muscles. In a patient after a stroke, damaged areas of the cerebral cortex lose their inhibitory effect on the underlying structures. Outwardly, this is manifested by the development of muscle hypertonicity.

Treatment

Increased skeletal muscle tone is often a major barrier to recovery in stroke patients.

It should be borne in mind that the optimal result can be obtained only with a combination of medication and non-medication methods of treatment.

Non-drug treatment of hypertension includes:

• correct positioning of the patient;
• massotherapy;
• gymnastics;
• physiotherapy procedures.

An integrated approach will help to overcome spasticity and restore motor functions of the limbs

Of the drugs, muscle relaxants and botulinum toxin are actively used.

Patient position

One of the main points in the treatment of muscle hypertonicity in patients after a stroke is giving the paretic limb a physiological position.

An effective way to deal with spasticity

The affected arm should be placed on a chair next to the patient's bed. Due to the increased muscle tone, it will be brought to the trunk. To prevent this phenomenon, a roller is placed in the armpit from soft tissue.

The arm is extended in elbow joint and turn with the palm up. To hold the limb in this position, sandbags or other devices are used. It is advisable to bandage the fingers and hand to the splint.

The leg should be slightly bent at the knee, and the foot should be at right angles to the lower leg.

The duration of the position treatment is about 2 hours. It can be repeated several times during the day. As soon as the attending physician permits, the patient is assisted to sit up and taught to walk.

Massage

Shoots well increased tone muscle massage. It must be carried out from the first days of the disease. From massage techniques it is necessary to choose stroking and light rubbing. They help to reduce muscle tone, improve blood circulation and lymph drainage in the paretic limb. The duration of the first sessions should not exceed 10 minutes. Over time, it is increased to 20 minutes. The duration of the course depends on the individual characteristics of the patient and is determined by the attending physician. As a rule, after 20-30 sessions a break of 10-15 days is required. After that, the course is repeated. The decision to discontinue massage therapy depends on the results achieved.

Physiotherapy

Complex remedial gymnastics consists of active and passive movements. Passive movements consist of flexion and extension of the muscles, which is carried out by the caregiver. If possible, the patient makes passive movements with the help of a healthy limb. Due to the increased tone, the movements can be intermittent and abrupt at the beginning. Over time, the tone decreases, and they become smoother.

Physical exercise very important for the development of muscles and joints

As soon as the patient after a stroke is able to perform active movements, he should engage in therapeutic exercises on his own. In addition to flexion and extension exercises, exercises aimed at stretching the muscles are added. If done correctly, they relieve hypertonicity well and help the patient recover faster.

With increased muscle tone, the patient after a stroke is categorically not recommended exercises with an expander, an elastic band, and the like - they only intensify spastic phenomena and worsen the situation.

Muscle relaxants

Of the medicines for the treatment of hypertonicity in patients after a stroke, muscle relaxants of central action are used, which well relieve muscle tone without affecting their strength. Their mechanism of action is to inhibit pathological impulses that emanate from spinal motoneurons.

Treatment with muscle relaxants begins with minimal doses. If necessary, they are increased to achieve the effect. Expected effects:

• decreased muscle tone;
• improvement of motor functions;
• removal of pain syndrome;
• prevention of the development of contractures;
• increasing the effectiveness of medical gymnastics;
• facilitating patient care.

In our country, the most common muscle relaxants are baclofen, tizanidine, or sirdalud, tolperisone, or midocalm, diazepam.

Also, to restore and relax muscles, doctors prescribe muscle relaxants.

Lack of treatment with muscle relaxants - the possibility of development side effects, of which the most common:

• drowsiness;
• dizziness;
• nausea;
• constipation;
• lowering blood pressure.

Botulinum toxin treatment

The use of botulinum toxin for the treatment of hypertonicity is indicated in patients after stroke with local spasticity.

The main indications for the use of botulinum toxin:

• lack of contractures;
• severe pain syndrome;
• violation of motor functions associated with increased muscle tone.

The mechanism of action is to block the transmission of impulses from the nerve cell to the muscle fiber. The clinical effect develops a few days after the injection and lasts for 2-6 months, depending on the individual characteristics of the patient. Due to the production of antibodies, repeated injections eliminate hypertonicity not so effectively.

This method is not widely used in the fight against hypertonicity in patients after a stroke. This is primarily due to the high cost of the drug.

Finally

Treatment of increased muscle tone in stroke patients is one of the key points, which will not only significantly improve the patient's condition, but also facilitate caring for him.

Physical therapy and massage are the main therapeutic areas, while monotherapy with muscle relaxants will not bring the expected result.

Medicines only enhance the effect of gymnastic procedures. This should be borne in mind by relatives or caregivers caring for the sick.

Until now, we have hardly discussed movement disorders in our loved ones, since there is no direct connection with here, and we did not want to blur the main theme of our site. However, recent discussion of the problems that develop after stroke - and in Russia, stroke remains a very common cause of development - has shown that this topic is important.
I was asked to tell about her without much ado, in simple words... I promised to try.

I read in a serious scientific journal that after a stroke, movement disorders are manifested in one way or another in more than 80% of patients. Due to the death of cells that previously regulated the work of muscles, they weaken (paresis) or turn off completely (paralysis). Disorder of body position and coordination of movements are also possible. This is fraught with falls and - at best - a developing fear of walking independently, and at worst - a fracture. Along with this, "head problems" only increase the risks.

Fortunately, even in old age, the plasticity of the brain allows it to rebuild and gradually restore the lost motor functions. And here the task of doctors (and after overcoming an acute disorder - and of those around them) is to create the necessary conditions for early rehabilitation: the main method is physiotherapy exercises in combination with physical and occupational therapy.

However, in about every third case, in the post-stroke period, the so-called spasticity begins to develop - an increased tone in the muscle, which prevents its stretching and forcibly returns the limb to a certain position, which limits overall mobility. The spasm is rather difficult to physiotherapy and interferes with normal recovery. As it turned out, visitors to our site also encountered such a phenomenon.

Due to the constant tone, which does not decrease even at rest, changes begin to occur in muscles, tendons and joints (fibrosis, atrophy), painful deformities (contractures) and pathological postures develop, which aggravate the problem and seriously complicate the patient's life.

Spasticity does not develop immediately, usually several months after a stroke. However, a specialist can notice the first signals in 2-3 weeks. Initially, flaccid muscles come to a tone, which increases and becomes more pronounced when responding to external stimuli (for example, an attempt to bend or straighten a limb). Six months later, maximum a year, spasticity turns into a problem that noticeably affects the patient's quality of life. It hurts.

In the upper torso, the shoulder, elbow, wrist, and fingers are often affected. In the lower body, spasticity can affect the hip, knee, ankle, or toes. The flexor muscles are usually affected in the arm area, and the extensors on the leg.
Look at the pictures from our newspaper "Memini".

You've probably seen something similar in patients with cerebral palsy.
Needless to say, this problem badly affects a person's ability to dress independently, eat (simply not able to hold a spoon), write with a pen, hygiene suffers, etc.
If spasticity is not treated, then after 3-4 years contractures form - deformities of the joints. Bones are deformed too. Forced painful postures occur.

I will not write about who is to blame. Immediately I turn to the question "What to do?"

The answer is simple: heal.

Treatments for spasticity may include:
prescribing drugs (central and local action),
physiotherapy,
occupational therapy.
(In rare cases, a decision may be made about surgical treatment.)
The basis of therapy is the effect on the muscle, which allows you to reduce its tone. Below we will consider in more detail the role of each of these methods.

PURPOSE OF MEDICINAL PREPARATIONS

Oral (taken by mouth) medications most commonly used to reduce spasticity include:

centrally acting muscle relaxants- baclofen, tizanidine, etc.

anticonvulsants- clonazepam, diazepam.

Both groups of drugs help to ease muscle contraction and improve range of motion. Their reception relieves painful muscle spasms, enhances the effect of physiotherapy exercises and, as a result, prevents the development of contractures. Unfortunately, the peculiarity of these drugs is that they act not only on the spastic muscles, but on the entire body as a whole. For the treatment of spasticity, these drugs are prescribed in high dosages, which leads to the appearance of side effects in the form of general weakness, dizziness, changes in mood and lethargy. This is especially unpleasant if the patient after a stroke and without it begins to develop cognitive impairment.

For this reason, more and more specialists are inclined to replace the above drugs with injections of botulinum toxin type A. In terms of the effect on muscle, botulinum toxin significantly exceeds all existing drugs taken in the form of tablets, and is comparable to surgical intervention. At the same time, denervation of the muscle with the help of a toxin is an extremely simple and safe procedure that can be performed by a doctor who has undergone appropriate training. Botulinum toxin preparations are well tolerated, and the likelihood of drug-drug interactions when using them is minimal. The recommendation of the American Academy of Neurology explicitly states the need to offer patients botulinum neurotoxin as one of the methods to reduce muscle tone and improve passive function in adult patients with spasticity.

In our country, three botulinum toxin preparations are widely used to treat spasticity: Botox (USA), Dysport (England), Xeomin (Germany). The latter is positioned by the manufacturer as a new generation drug, free from complexing proteins. In addition, the Chinese drug Lantox is registered in Russia, but, as far as I know, it is used mainly in cosmetology.

PHYSIOTHERAPY

Physiotherapy has traditionally played an important role in the treatment of spasticity. The main components of the method include rehabilitation exercises, massage, acupuncture, thermal and electrical effects on spastic muscles, and the use of orthopedic devices.

Standard rehabilitation involves daily stretching to help restore strength to affected muscles, maintain range of motion in the joint, and prevent contractures. Regular stretching can ease muscle contraction and reduce stiffness for several hours.

Massage plays an important role in the restoration of motor functions and in the prevention of pathological conditions. It allows you to relieve pain, helps to restore muscle performance, and improves their blood supply. However, only a specialist can be trusted to perform the massage, since spastic and hypotonic muscles need different influences.

In Russia, acupuncture is often used in complex therapy, but controlled studies conducted abroad do not show significant effectiveness of this treatment method.

Electrical stimulation is widely used to restore balance between flexor and extensor muscle tone. The effect usually lasts about 10 minutes when the stimulation is applied for the first time, but after several months of such procedures, the effect may be longer. Alternatively, the spastic muscle can also be stimulated directly to cause fatigue.

In the treatment of spasticity, limb-fixing bandages, bandages, tourniquets, splints, orthoses can be used. They allow you to maintain and align a spastic limb, as well as correct its deformity and improve function. Today in medical engineering, many orthopedic devices have been developed that provide not only immobilization and fixation in correct position but also deep pressure and heat maintenance in tissues. Modern devices include a setting mechanism that controls the desired function: from fixing with a lock to providing the necessary movement with assistance.

ERGOTHERAPY, OR LABOR THERAPY

Occupational therapy is a practice specially selected by a doctor that allows a patient to recover self-care skills after a stroke. Consider this as a special exercise in physical therapy, in which the exercise has a practical meaning: buttoning a button, using a cutlery ... Through occupational therapy - by repeating the same movements on a regular basis - patients recover lost everyday life skills whenever possible. Otherwise, when it is not possible to restore some important actions, occupational therapy allows one to choose adaptations that compensate for the loss of a useful skill, or to form new motor models, alternative to those used before the disease.

In other words, functional therapy is aimed at preserving all the functions of the limb through the restoration of old motor models and / or the creation of new dynamic stereotypes based on a new location of muscles, which allows the normal execution of movements. An important role here is played not only by the patient's diligence, but also by the help of the person caring for him.

SURGICAL INTERVENTION

The two main categories of surgery for spasticity are performed at the level of the nervous system (neurosurgery) or bone, tendon, and muscle (orthopedic surgery). The most significant indication for surgical treatment the development of contracture is advocated. In this case, orthopedic surgery is often the only treatment for spasticity. Through the operation, muscles can be denervated, tendons and muscles can be released from contractures, lengthened or moved, thereby reducing spasticity. Muscles can be denervated by cutting off certain nerves where they exit from the spinal cord (dorsal rhizotomy). This surgery is mainly used to treat severe spasticity of the leg muscles that interferes with the patient's movement.

To summarize briefly, the ideal option is to relax with botulinum toxin (lasts about 3-4 months) and develop. Here are just the prices ...

Although I have read two studies. In one, the authors argued that if you calculate the costs that can be avoided thanks to botulinum therapy (nurse, aids), then in general it turns out even profitable. In another scientific language it is said approximately the following: it is better to spend money and get a result than to drink pills in large doses (by the way, they are also not free in our country), without much success.
True, both studies were carried out abroad.

Earlier this word was unfamiliar to me. Spasticity resembles stiffness in severely frozen hands, when there is a desire to move fingers, but it does not work out. Plus, it also brings them down and crumbles.

When I started recovering from a stroke, this condition was almost throughout my entire body. It is especially strong on the left side. I was almost completely paralyzed, but not big movements still came out to do. They turned out as if in condensed milk. Tight, clumsy and very slow. There was constant tension in the hands, fingers. It did not go away for a minute, even in calm state and did not allow normal movements. Hands involuntarily assumed an unnatural position. The left one was retracted by itself to the side of the body. The right one was bent at the elbow and pulled up to the chest. I was very tired physically and mentally from the fact that I could not relax. Only in the prone position was it easier. But as soon as he sat down, immediately the muscles of the body and limbs tensed as abnormal. Again, I quickly got tired of excessive stress. It turned out to sit for one or two minutes and the strength ended.

Spasticity made it impossible to make fine and precise movements. For example, if I was handed a cup of water, I couldn't take it. Didn't "hit" it, missed. When they put the cup in my hand, I could not hold it and wrap my fingers around it. They didn't shrink. At the same time, the tension in the hand was unreal. All this gimmick was wildly exhausting. To remove spasticity in all limbs at once is not a real task. Painfully, it is large-scale. And we, as always, have broken down a difficult task into simple fragments that have become feasible. We decided to divide the treatment of spasticity into pieces:

SAVING HANDS.

LEGS RESCUE.

It has become easier. In the course of training, I noticed that the decrease in spasticity in the left hand was accompanied by a slight relief in the right and in the legs. The connection is not significant, but noticeable. We did exercises and massages evenly for the left and right limbs. Although the spasticity was much stronger on the left side of the body. Over time, everything became equal. This approach turned out to be correct.

It turned out to remove spasticity with a complex of gymnastics and massages.

EXTREMELY IMPORTANT!

Start with minimal movements.

Do not overload during exercise.

Do the minimum number of repetitions.

Do not do vigorous and strong massage. Only light touches.

Do not add or increase muscle tone.

Learn to relax muscles and release tension in them.

Do not do gymnastics to relieve fatigue spasticity.

Do it only in the morning.

While recovering from a stroke, I'm used to the fact that there are no easy tasks. But removing the spasticity turned out to be an overly difficult job. The point is in the contradiction of the tasks performed. After a stroke, I needed to restore muscle strength throughout my body. That is, a lot of hard work. But at the same time it is necessary to treat spasticity. And for this, loads and endurance training are a hindrance. It turns out the first excludes the second. We solved this puzzle by alternating classes. One day: massage + gymnastics to relieve spasticity + exercises to restore balance and coordination. This does not require a lot of effort, the load is not great. The next day: strength training + endurance. And so in turn.

At the moment, the spasticity was removed. There are leftovers, but they don't get in the way. Freedom and lightness returned to movement. The tension is gone. Pain and muscle fatigue are gone. I began to spend less energy on movement. This made it possible to smoothly increase the load on morning exercises.

What would recovery after a stroke give nice results, you have to comply with such a regime. Gradually, I gain strength and increase stamina. Now I can conduct classes in one day. In the morning I do exercises with strength exercises... In the afternoon, gymnastics and massages to relieve spasticity + exercises for balance and coordination. Half a day, between classes, is enough for rest.

Exercises for relieving spasticity in:

SAVING HANDS.