Monday, December 9, 2013

Spasticity reduction in dystonia and stroke

So, here's the deal. I'm a member of the FB young stroke survivors group.  If you are not, I'd suggest you join. These folks do not pull punches and most are robustly and actively  engaged in their recovery. (Many have the same posture as Dean of Deans' stroke musings. (Put his blog in your faves. Now.)  The group as a whole reminds me very much of many spinal cord injured people who I've worked with; no BS, been there done that, laid bare.

I'm also a member of the "Neuronauts" group on FB. This group has a pathology that causes a spastic pull on muscles called dystonia. The muscles that are affected can be pretty much anywhere and can jam body parts into themselves and into other body parts. I'm not generally Mr. Empathetic, but the Neuronauts will break your heart. Shocked, sad helpless is the way their stories sometimes make me feel. Stories of living with a complete and painful betrayal of their bodies. Short term excruciating pain and long term injuries often result. 

Dystonia is caused by injury to the basal ganglia (which can be caused by stroke). The basal ganglia is a "gang" of structures deep in the brain. "The basal ganglia... monitors the speed of movement and controls unwanted movements"
Examples of dystonia
    
Spasticity
Spasticity is uncontrolled reflexes. Reflexes exists in all of us all the time. But you usually never see them. They are only "unloaded" when there's an emergency. Like, when you burn yourself and you hand ends up by your ear and you wonder how it got there. Or when you step on a sharp stone walking barefoot and your hip and knee quickly bends. Or when you lose your balance and your arms fly around wildly without your consent in an effort to keep you on your feet. These are all emergency situations. There is simply no time to consult the brain. The reflexive impulse goes from receptors on periphery of the body, to the spinal cord (where reflexes reside) and back. Its about speed because its an emergency.

If there is no emergency the brain dampens the reflexes down. But if there is a brain injury the dampening stops and the reflexes are unloaded. This unloading causes muscles to fire even though there's no emergency. This constant firing of the muscles is spasticity.

There are many treatments for spasticity. Most of them fall into 3 catigories: 

1. Don't work. 
2. Work but are a band-aid (work until you take them away). 
3. Work and are permanent.

Examples of #1 above are splinting and hot packs. Examples of #2 above are drugs and stretching. An example of the 3rd category: Dorsal root rhizotomy.

Dorsal root rhizotomy (DRR)
A Dorsal root rhizotomy (aka selective dorsal rhizotomy, aka DRR) is a delicate surgery where some of the little hair-like "rootlets" that go into the spinal cord are surgically cut. (GRAPHIC: Selective Dorsal Rhizotomy...starts @ 2 min in).

And I don't want to white wash it...it is a surgery. But it is a very small incision and recovery is quick. The reduction of spasticity after DRR is permanent. For the life of me, I don't know why it is not more often used. I've seen sores the size of steaks- life threatening sores- created by spastic limbs crushing the skin.The DRR would elevate this. It also reduces pain in the area. It is done very selectively. The neurosurgen will test ever nerve rootlet to see what it does before cutting. In this way, the amount of spasticity is gradated. If more spasticity is helpful (some people use their "tone" to help them function) it is left.

Does it work for dystonia and the spasticity that results? Yes. (Less medical explanation here). Will insurance pay for it? Sometimes. Does it work for spasticity post stroke? Yes, but it can be tricky in the legs.

3 comments:

Mike said...

One trhing I noticed as well as my therapists was that months after my basal ganglia bleed, I was more spastic than the other patient, and it made any movement difficult, resulting to shortened connective tissues and fascia which made recovery so difficult because of the tightness.However , all is not lost as there are ways to fix lower extremity and upper extremity tight muscles and ligaments.The effort needed is extremely high.

KHiggs said...

Is Dorsal root rhizotomy effective on the arm and hand? Everything I find is showing results for the leg.Also, what are the side effects? This procedure seems very risky. How do you find a doctor that will do this? Mike, what are the other ways you are talking about? What did you find to be effective? I had a clot in my basal ganglia and still struggle with pain and tightness in my left hand, although I have movement and signals in all of my fingers. For the shortened connective tissue and fascia I do "Rolfing" which helped alot.

KHiggs said...

Is Dorsal root rhizotomy effective on the arm and hand? Everything I find is showing results for the leg.Also, what are the side effects? This procedure seems very risky. How do you find a doctor that will do this? Mike, what are the other ways you are talking about? What did you find to be effective? I had a clot in my basal ganglia and still struggle with pain and tightness in my left hand, although I have movement and signals in all of my fingers. For the shortened connective tissue and fascia I do "Rolfing" which helped alot.

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