The term spasticity refers to certain muscles becoming overactive, causing muscle stiffness, stiffness, or spasms. Injury results from damage to the brain or spinal cord that may have been caused by conditions such as cerebral palsy, stroke, or multiple sclerosis. Spasticity can affect most of the body (common spasticity) or only a small area (focal spasticity), such as an ankle, a hand, and wrist. A stiff and tense state of the muscles results in significant limitation of daily activities such as walking, moving, and speaking. The effects of spasticity range from mild stiffness to painful, uncontrollable spasms. Which part of the body is affected and the severity of these bodily effects depend on the area of ​​the brain or spinal cord that is damaged and the extent of the damage.

What Causes Spasticity?

Spasticity occurs when muscles receive false nerve signals that cause them to contract (shorten or flex) instead of remaining relaxed (not flexed). Failure to control signals properly is caused by damage to the brain or spinal cord.

The Effect of Spasticity on Daily Life

In fact, even if the muscle tone is low, it is a state of tension that is constantly present in our muscles, even at rest, and when it is at a normal level, it is responsible for maintaining our normal posture. In the case of spasticity, muscle tone increases abnormally. This leads to increased resistance to passive movement.

In daily life, spasticity can cause physical symptoms such as pain, stiffness in the joints, pressure sores, as well as difficulty in moving, decreased hygiene, care and quality of life. As a result, it prevents patients from performing even simple daily activities such as dressing and eating, causing them to live dependent on others. It can also trigger infections or psychological problems such as anxiety, depression and low self-esteem.
Studies have also shown that spasticity is one of the conditions that cause the most important impact on the lives of people who have had a stroke.

Who Is It Seen?

Spasticity occurs when the pathways that prevent muscles from contracting are affected by damage to the brain or spinal cord. Spasticity can be divided into two as spasticity originating from the brain and spinal cord.
The most common diseases in which spasticity is seen;
• Stroke
• Spinal cord diseases
• Cerebral palsy
• Traumatic brain injury
• Multiple sclerosis

Factors Triggering Spasticity

Spasticity can only occur as a result of triggering factors. It can occur when it comes to sudden and rapid movements as well as emotional stimulation. In this type of spasticity, it is recommended to minimize these stimuli and to be careful in this regard.
The factors listed below are the factors that trigger spasticity and increase its severity. For this reason, it is especially recommended that spasticity patients and their relatives pay attention to these conditions.

Urinary tract infection
Infection in any part of the body
ingrown nail
Constipation
pressure sores
menstrual bleeding
Hemorrhoids
anal fissure
gum problems
gallbladder problems
Fracture-dislocation
atherosclerosis
Extremely cold or hot

SPASTICITY SYMPTOMS

Symptoms of spasticity vary according to the area affected by the damage. Spasticity can be seen in the whole body or only in the hands, arms or legs. For this reason, the area where spasticity is seen plays an effective role in the variability of the symptoms.

abnormally bent limbs
Crossed arms and legs
repetitive movements
Posture disorders and abnormal posture
speech problems
joint stiffness
muscle spasms
painful muscle spasms
crippling muscle spasms

CLINICAL EVALUATION OF SPASTICITY

Spasticity is very difficult to measure and is usually largely observational. Approaches to the assessment of spastic hypertonia have focused on subjective measurements such as clinical scalar and more objective measurements such as electromyophic biomechanical analysis, gait analysis, electrophysiological reflex studies. Quantitative evaluation of spasticity is affected by a number of complex situations. These;

• Change in performance due to training effect
• emotional state
• Systemic factorors
• Subtle differences in test administered on different days

There is no test defined as “best” for the evaluation of spasticity. Different approaches are used for evaluation purposes.

Tendon Reflexes: As deep tendon reflexes become hyperactive, their threshold is decreased and their amplitude is increased.

Tendon Impacting or Rapid Stretching: It often causes clonus in the spastic muscle. Clonus is usually seen with severe spasticity and occurs as a series of rhythmic contractions of the muscle against the rapidly applied stretch.

Pathological Reflexes: Spontaneous flexor spasm should be observed and it should be checked whether there is a flexor response and Babinski response to the stimulus made with a sharp object along the plantar surface of the foot.

Scales: Various clinical rating scales have been developed to define spasticity. It includes scales such as Ashworth Scale (AS) Modified Ashworth Scale (MAS) Spasm Frequency Scale Clonus Score, Spasm Severity, Fugl Meyer Scale.

SPASTICITY TREATMENT

The main point in the treatment of spasticity is to decide whether to treat spasticity and to form the treatment team if treatment is to be given.
Spasticity treatment should be applied as a separate program for each patient, as the treatment needs of the patients will be at different levels. In other words, the needs, functionality and complaints of the patient in his daily life are very important.

The functions that patients and their relatives have difficulty with in their daily lives related to spasticity should be learned and the treatment for this function should be chosen as the target.
The patient should be evaluated by a physical therapy and rehabilitation doctor, treatment goals should be determined for the patient, and the patient and their relatives should be informed about the point to be reached with the treatment.
Conditions that increase the patient’s spasticity should be identified and treated.
Treatment is generally divided into three as physical therapy, drug therapy and surgical therapy.

Physiotherapy Practices

Physical therapy applications should be applied at every step of the treatment. Its effects are short-lived and temporary. The main step of treatment is stretching exercises and joint range of motion exercises. Muscle length shortens due to inactivity. Exercises are done to reduce muscle stiffness, lengthen the muscle, and reduce pain.
It should be done twice a day by the patient himself or by his caregiver.
Hot or cold application before stretching increases its effectiveness.
Relief takes several hours.

• Strengthening Exercises; It works the muscle against a certain resistance. It has been reported to increase the functional status of patients.
• However, these exercises are not applied in patients who have had recent surgery, have severe osteoporosis, have blood diseases, have new joint injuries and have severely limited range of motion.
• Ice Treatment; It is beneficial to apply at least 20 minutes before exercise. Its effect lasts up to 2 hours. Caution should be exercised when cooling the upper extremity in patients with coronary heart disease. It should not be applied in cold allergy.
• Hot Therapy; It reduces muscle contraction and raises the pain threshold. Methods such as hot bags, paraffin can be used.
• PNF; Inhibition can be achieved using the muscle-relax method among spastic muscle pnf techniques.
• Vibration: With the vibration applied from the motor point of the antagonist muscle, the antagonist muscle spindle is stimulated and the antagonist muscle contracts, the spastic muscle relaxes.
• Electrical Stimulation; Studies have reported that it reduces muscle contraction.
• Spastic muscle tetanic faradic stimulation
• EMG Biofeedback; Inhibition is achieved by the behavioral conditioning method.
• TENS; It is applied to the dermatome of the spastic muscle. It relaxes the spastic muscle by suppressing the signals carried by the type II fibers from the muscle spindle.
• Posture and Positioning; Wheelchair users should have back support and spring or very soft seating surfaces should not be chosen.
• With standing upright positioning, there may be contractions in the legs.
• Orthosis; It prevents the restriction of the joints and also reduces the contraction by providing stretching to the muscle.

Drug Treatment

Oral muscle relaxants are available. The most commonly used ones are tizanidine, baclofen, cyproheptatin and diazepam.

These drugs;
• To be taken regularly under the control of a doctor,
• Follow-up with blood analysis at intervals determined by the doctor
• It is important that it is not suddenly left uncontrolled.

The most common side effects of these drugs are;
• stupor
• dizziness
• increase liver enzymes
• baclofen lowers the seizure threshold.

Botulinum Toxin Application
For botulinum toxin injection treatment, patients are selected according to age, prevalence, severity, and duration of spasticity. For an effective treatment, the expectation of the patient and their relatives should be learned and realistic expectations and treatment goals should be explained by the doctor.
The doses to be administered are selected according to the age of the patient, the size of the muscle and the degree of spasticity.

Surgical Treatment

Orthopedic Approach in Treatment
It can be considered as a last option in patients who do not respond to drug therapy.

What Can Treatment Offer?

Because spasticity affects each individual in different ways, it falls to the individuals involved, with the help of their doctors, nurses, and therapists, to decide what they want from the treatment they receive. Everyone needs to agree on treatment goals that will improve patients’ quality of life and allow them to do as much as they can. It is important to be realistic about what is possible, given the severity of the spasticity. For example, treatment goals might be:

Better balance, smooth movement and sitting
less fatigue
Ability to dress, eat and clean better
Preventing muscle and joint problems
Fewer bedsores Reducing contractures and the problems they cause
Increasing comfort and reducing pain (This may allow a better fit of a girdle or splint)

EXERCISE

Spasticity occurs due to muscle stiffness, stiffness, and the presence of contracture, as mentioned earlier. For these situations, range of motion exercises, stretching exercises and strengthening exercises are recommended. While performing these movements, the muscle should not be forced too much, that is, the maximum should not be exceeded. It is recommended to do it in certain numbers, times and in sets.