Part3rehab

Spastic Hypertonia following
TBI I n f o r m
Traumatic Brain Injury
January, 2003
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 Spastic Hypertonia
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
Spastic Hypertonia
Treatment
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
Treatment Options
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 Rehabilitation
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? Medications
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 Benzodiazepines [Diazepam (Valium®),
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? Baclofen (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 Dantrolene sodium (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 Intrathecal
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 Surgical
(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.
Conclusion
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 3. Osteotomy 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.
4. Arthrodesis 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 Evaluating Treatment
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 Editor: Linda Lindsey, MEd
Email: tbi@uab.edu

Source: http://www.karrn.org/pdf/spastichypertonia.pdf