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Spastic Hypertonia following
TBI I n f o r m
Traumatic Brain Injury
By: Jay Meythaler, JD, MD
What is Spastic Hypertonia?
your hand send messages through the spinal cord toyour brain, which identifies the sensation. A
Spastic hypertonia (SH) is a term that doctors use to
message is then sent back to your hand, telling it to
provide a more complete description of spasticity
move away from the heat. There is also a message
and various conditions of extreme muscle tension.
that controls the muscle movement, so the arm stops
Spastic hypertonia refers to uncontrollable “jerking”
movement (muscle spasms), stiffening orstraightening out of muscles (rigidities), shock-like
Another example of reflex movement is called
contractions of all or part of a muscle or group of
crossed reflex. For example, if you step on a sharp
muscles (myoclonus), and abnormal tone in the
object you automatically lift your foot. Another
muscles or involuntary sustained muscle contraction
message tells the muscles in the opposite leg to react
so that leg can support all your weight. Movementoften occurs without ever having to think about the
Movement & Reflex Centers
The body moves in response to messages sent by
Understanding Muscle Tone
way of the nerves from the brain to the muscleslocated throughout your body. Reflex centers
Many different mechanical and chemical factors
located in the brain and spinal cord process these
affect how your muscles move. Muscle tone is
messages. For example, when you pick up a cup of
most important. Muscles with too much or too little
water, a message from your brain tells your hand to
tone cannot function at their best. Muscles lacking
move and pick up the cup. As you touch the cup,
tone are flaccid or soft and cannot offer resistance
the nerves in your hand send a message back to the
when stretched. A muscle with high tone is rigid or
brain signaling that you have touched the cup. The
hypertonic. This makes it difficult for a person to
brain sends a message back to certain muscles to
perform normal tasks (walking, picking up objects,
pick up the cup. In addition, the brainstem and
dressing). For example, muscle tone must change
spinal cord modify these unconscious messages to
for you to pick up a cup. The muscles must be able
help you coordinate and refine each movement.
to contract to grasp the cup and then relax at the
These messages help you adjust your grasp and
balance the cup so you do not spill the water.
After a Traumatic Brain Injury
Other movements are in response to sensations suchas temperature, texture, pressure or pain. Movement
Spastic Hypertonia often occurs after a traumatic
may be the result of protective reflexes. For
brain injury (TBI) as a result of damage to the brain
example, when you touch a hot cup you quickly jerk
stem, cerebellum or mid-brain. The damage affects
your hand away from the heat. The nerves from
the reflex centers in the brain, interrupting the flowof messages along various nerve pathways. This
A publication of the UAB TBI Model System,
disruption of signals can cause changes in muscle
providing information on traumatic brain injury for
tone, movement, sensation and reflex. The location
persons with a head injury, their families andrehabilitation service providers.
of the brain injury can affect which areas of the bodyare affected and what the specific motor deficit maybe. For example, the changes in movement mayinvolve only one side of the body.
TBI Inform - January 2003
The reflex centers in the brain are more complex
with normal range of motion or regular daily
than those in the spinal cord. This can make the
activities. For example, stiffened muscles or
treatment of spastic hypertonia in individuals with
contracted muscles may keep individuals from doing
TBI more difficult to treat than in persons with
their own self-care routines such as dressing or
grooming. In some cases it also makes it difficultfor the caregiver to assist with basic tasks.
Shortly after a brain injury, individuals often gothrough a period of increased muscle tone wheretheir body posture becomes very rigid. A common
Possible Advantages of
position is elbows held rigidly at their sides, wrists
and fingers bent and fists clenched. The legs are
usually extended at the hips and knees with ankles
2. Reduces bone loss and decreases the risk
and toes flexed. When the elbows are bent it is
referred to as decorticate posture. If the elbows are
3. Increases metabolic requirements such as
extended it is called decerebrate posture.
promoting blood circulation andimproving breathing.
As the patient recovers, nerve signals that control
4. Helps in performance of daily self-care
motor functions may change. Some signals may not
reach the reflex centers of the brain. In other cases,
the brain may send too many signals, and the
5. Helps in performance of daily functions
muscles cannot respond properly. As motor
such as picking up items, transferring or
movement begins to return, the movement is usually
unconscious and reactive rather than planned and
6. Warns when there is a problem in areas
purposeful. There may be spasms or other large
uncontrolled movements. During the first sixmonths, there will be changes in patterns andmovements as the individual recovers. Muscle tonecan develop and change dramatically over the firstyear following injury.
Possible Disadvantages of
1. Limits range of motion.
2. Causes pain due to stress put on joints
Proper positioning is the primary treatment goal for
an individual with TBI who has abnormal posturing
caused by spastic hypertonia. The individual needs
to be properly positioned when laying and sitting.
and participating in other activities.
Therapists often work on preventing contractures or
4. Interferes with other activities such as
further tightening of the muscles that may develop
positioning of the limbs. 85% of individuals with
TBI who require inpatient rehabilitation develop
contractures from spastic hypertonia. There is also
concern that abnormal posture can lead to pressure
6. Causes rubbing and friction to the skin
sores, a decrease in blood flow to the extremities or
and increases the risk for pressure sores.
Spastic hypertonia in not necessarily a medicalproblem unless the extreme muscle tone interferes
TBI Inform - January 2003
Quality of Life
The goal of all treatment for SH is to improve
The doctor must first determine which nerve
quality of life (QOL). However, many individuals do
pathways are damaged before selecting the type of
not know when treatment is necessary. It may be
treatment. This can vary from patient to patient,
hard to decide if SH is having more of a positive or
negative impact on your QOL. You can ask yourselfthe following questions to help decide whether or
not treatment is right for you or the person you arecaring for.
Daily Range of Motion exercises and regularstretching can promote relaxation of rigid or spasticmuscles. All stretching and exercises should be
Does spastic hypertonia limit your independence
prescribed by a physical therapist. One helpful
by keeping you from doing things for yourself
treatment in reducing SH for some persons is the use
of standing devices or standing frames. These can
Do you need more personal assistance because
counteract the tendency of muscles to flex after
Do you lose sleep because of your spastichypertonia?
Does your spastic hypertonia you at risk forother medical problems such as a pressure sore?
Medications are the most widely used option fortreating SH. Some medications are taken by mouth
If you decide that treatment for spastic hypertonia
(oral) or by feeding tube (enteral feeding). Your
may improve your QOL, you should talk with a
doctor may first prescribe oral medications because
doctor who is familiar with individuals with TBI.
they are usually effective for individuals with TBI.
Some treatment options can be dangerous and evenlife threatening if not properly monitored by a
doctor. Other important factors to consider in
Clonazepam (Klonopin® or Rivotril®)] act on
the central nervous system and result in adecrease of overactive muscles and fewer painful
What is the cause (etiology) of your spastic
spasms. These drugs are sedative/hypnotics andare used mainly for nighttime spasms and sleep
disturbances. Common side effects are dizziness,
Do you have a support network if you need help
drowsiness, impaired memory and attention, and
in taking your medication or applying a splint or
loss of strength. These medications can be
addictive for some individuals, so a sudden stop
Do you need transportation to and from the
in use may cause symptoms of withdrawal. This
is not the first drug of choice in a new head
injury because of cognitive side effects that can
Do you have other current medical problems
such as a lack of balance, numerous infections,high/low blood pressure, or depression?
Lioresal®) is another medication that
works through the central nervous system. It
helps to improve passive range of motion and
reduces muscle spasms, pain and tightness.
Daily functioning and activities of daily living
insurance or will you have to pay for your
individuals reported side effects such as
TBI Inform - January 2003
dizziness, drowsiness, weakness, fatigue, nausea,
more normal position or function of the involved
constipation or incontinence and sexualdysfunction.
The advantage to using these drugs is that they onlywork for several weeks. If you do not like the side
(Dantrium®) is a
effects, you can stop treatment with no permanent
benzodiazepines and baclofen. It acts at the
disadvantage is that the overall effect is temporary
muscle, rather than on the central nervous
and localized muscle weakening will clear up. Each
chemical has advantages and disadvantages, so you
should talk to your doctor about any possible risks
movement, decreases muscle tone and reduces
muscle spasms, tightness and pain. Its use hasbeen limited in individuals with TBI because it
is not selective for spastic muscles. Dantrolenecan cause generalized weakness to all muscles,
Intrathecal medication is a fast growing treatment
including the respiratory muscles. This drug is
option. First, an Intrathecal Pump (IP) is surgically
metabolized in the liver and requires a blood test
implanted into the abdomen. The difference between
to monitor liver enzymes. The most common
the IP and other surgical options is that the IP
side effects are dizziness, drowsiness, diarrhea,
surgery is reversible. Second, the IP has a reservoir
of medicine (usually the same baclofen used as anoral medication). The medicine is pumped through a
Tizanidine (Zanaflex®) is a medication that
small tube directly to the fluid surrounding the
reduces SH by acting on the central nervous
system. It does not reduce the strength ofmuscles as much as other types of oral or
Advantages of the Intrathecal Pump
transdermal medications (skin patch). It is a
Medicine is sent directly to the nerve cells
short acting drug and should be taken during
daily activities when the relief of SH is most
Medicine dosage can be adjusted as needed.
important. Some individuals may experience
Much less medication is needed than if it
side effects such as sedation, dizziness, and low
were taken orally, which reduces side effects,
Reservoir is easily refilled by injection when
There are other oral medications that are currently
being studied to determine their effectiveness on
spastic hypertonia. A medical doctor experienced inworking with individuals with TBI will be able to
Disadvantages of the Intrathecal Pump
Requires surgery to implant the pump.
Motor Point Blocks
Tubing can become disconnected or kinked.
Risks include infection, baclofen overdose,
Chemodenervation is the use of chemicals injected
pump dysfunction, and developing symptoms
directly into the muscle to interrupt the flow of
nerve impulses to the spastic muscles. Some of thesechemicals include Botulinum Toxin Type A
(BOTOX® and Dysport®), Botulinum Toxin B(Myobloc®), and Phenol and Alcohol. They work
Before surgery can be successful, the muscle tone
by reducing muscle contractions and allowing a
must first be controlled or reduced. Otherwise the
TBI Inform - January 2003
contracture is bound to return despite splinting and
life (QOL). Your doctor may know of new treatment
positioning. Individuals who choose surgery as an
option should also understand that most of these
Am I more or less independent in my daily
counterbalance the effects of SH through various
procedures to muscles, tendons or bones. Four
common types of these orthopedic surgeries are:
Do I have more or less pain than I did beforetreatment?
1. Contracture release
either partially or
completely cuts a tendon to release a contracture
You may decide that your current treatment is not
of the tendon or muscle. A contracture is an
improving your QOL. You may want to consider
abnormal joint posture due to persistent muscle
another treatment option, or you may also decide
shortening. When muscles are not stretched
that no treatment is the right option for you.
regularly, the tendons shorten and tighten, whichlimits the muscle’s full range of motion.
2. Tendon transfer
moves the attachment point of
a spastic muscle. This means that the muscle
Spastic Hypertonia is common for individuals with
can no longer pull the joint into a deformed
TBI. However, not all individuals choose treatment.
If you decide that treatment for SH might improve
is removing a small wedge from a
your quality of life, it is up to you and your doctor to
bone to allow it to be repositioned or reshaped.
choose the treatment option that is best for you.
is the fusing together of bones that
About the Author
Jay Meythaler, JD, MD, is a Professor in the UAB
Deparatment of Physical Medicine & Rehabilitation.
Dorsal root rhizotomy is a surgical treatment rarely
Dr. Meythaler is Director of Brain Injury Services at
used for individuals with TBI. The procedure
Spain Rehabilitation Center, UAB Hospital. He serves
interrupts the reflex arcs or sensory inputs to the
as Medical Director of the UAB Traumatic Brain
spinal cord when the nerve roots are cut, burned or
Injury Care System funded by the National Institute on
chemically injured. This is also an irreversible
Disability & Rehabilitation Research (NIDRR) and the
procedure. For example, once a nerve is cut, there is
UAB Injury Control Research Center sponsored by the
no procedure to restore the nerve function.
Center for Disease Control (CDC). His specialty is inneurorecovery following TBI and he is recognized
nationally for his research exploring treatment andrecovery from TBI. Dr Meythaler is the principleinvestigator at UAB TBI Clinical Trials Network,
You should keep in close contact with your doctor
sponsored by the National Institute of Child Health and
and continue to reevaluate your current quality of
This paper is published by the UAB Traumatic Brain Injury Model System, supported by grant #H133A020509 from the NationalInstitute of Disability and Rehabilitation Research, Office of Special Education and Rehabilitative Services, Dept of Education,Washington, DC. Opinions expressed are not necessarily those of the granting agency.
Permission to reprint this newsletter, in part or completely, is granted for educational purposes. Published by the UAB-TBIMS,Birmingham, AL.” 2003 Board of Trustees, University of Alabama.
UAB-TBIMS Project Director
: Thomas Novack, PhD
Dept of Physical Medicine & Rehabilitation
Linda Lindsey, MEd
This book has several contentions. Together they form an argument. 1. There are some situations in medical ethics and bioethics with which existing analytical tools are wholly unable to deal. The notion of human dignity is sometimes the only concept that is any use. 3. The role of dignity in the really hard cases suggests that it might be useful in the easier cases too, if we only knew how to
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