The Effects Of A Stroke: Tonicity and Spasticity In The Extremities
Written by Jessica Dietz, PT, DPT, NCS
According to the American Heart Association, someone in the United States has a stroke every 40 seconds. The effects of stroke continues to be the leading cause of serious long-term disability in the United States. However, up to 80% of strokes can be prevented by lifestyle changes (especially exercise!) and management of atrial fibrillation, diabetes, high blood pressure and cholesterol.
There are two different types of stroke– ischemic and hemorrhagic.
Ischemic strokes: are the most common type of stroke and also the most preventable. Ischemic strokes occur due to disruption of blood flow to the brain, such as narrowing/blocked arteries or blood clots.
Hemorrhagic strokes: are less common and due to a blood vessel break or bleed in the brain like an aneurysm. For more information about types of strokes, visit the American Stroke Association.
Depending on the location, severity, and several other risk factors, every person with a stroke is different! There are many possible changes someone may experience as an effect of stroke such as:
- Difficulty speaking or swallowing,
- Altered cognition
- Vision changes
- Difficulties with balance
Only about 10% of patients experience a full recovery after having a stroke. That means almost 90% have some type of mild to severe impairment as an effect of a stroke that may continue to require rehabilitation or medical management.
One common as well as frustrating and potentially debilitating effect after a stroke is “TONE and/or SPASTICITY”. Throughout this blog, we will discuss more about tone/spasticity and its management and treatment.
What Is Tone/Spasticity?
Your doctors may have used the terms “tone” or “spasticity” to describe the stiffness in your extremities. Although tone and/or spasticity can be found in the neck and trunk it more commonly occurs in the extremities after a stroke. Often times these two terms are used interchangeable, however, they are different so it is important to know the difference as they are managed differently. To make it even more complicated, sometimes you can have both!
Everyone has some degree of TONE, which is the body’s underlying resting resistance to movement or stretch. Think, if you have low tone (i.e. hypotonicity) your limbs would be very easy to move almost like an overcooked noodle. More commonly, we see too much tone (i.e. hypertonicity) which causes a stiffness and resistance to movement.
SPASTICITY, however, is the body’s resistance to quick movements caused by a quick stretch to the muscle. For example, a quick stretch to your calf muscle when you are sitting can create clonus (which is a type of spasticity) that causes a fast beating motion of your leg. Spasticity is different than just muscle spasms as spasms often occur randomly and without a stretch of the muscle.
Why Does Tone/Spasticity Matter?
Normally with movement or stretch to the muscle, there would be a normal resistance in contrast to that movement or stretch. However, after a stroke there is often a loss of normal inhibition from the brain which can lead to over-excited neurons and nerve tracts. Hypertonicity and spasticity can further lead to postural changes, contractures (i.e. permanent loss of a joint’s range of motion), balance difficulties, and pain.
Here are two examples of condition presentations and how they impact function.
Example #1 – Hypertonicity in arm/hand
One of the most common presentations is hypertonicity in the affected arm and hand. This can cause the arm to remain stiff and difficult to move for getting dressed or performing other daily activities. Hypertonicity in the hand can cause the hand to remain in more of a clenched, fisted position which makes fine motor tasks difficult, such as grabbing a utensil to eat. This is also a common example of how an affected limb can be stiff (due to tone), weak, and potentially painful.
Example #2 – Spasticity in leg
Another presentation can be spasticity in the quadriceps muscle. The quad muscle is one of the most important muscles for standing and walking. If this muscle becomes spastic after a stroke it can lead to hyperextension of the knee or “stiff leg” when trying to take a step or go upstairs. This is a good example of also the phenomenon that spastic muscles are often WEAK muscles and sometimes you can use your spasticity for function. But if you take too much medication that decreases your spasticity you may find it more difficult to stand or walk.
How To Manage Tone/Spasticity?
Often the first treatment for both tone and spasticity include medication. Some common medications include: Baclofen (lioresal), Clonazepam (klonopin), Dantrolene (dantrium), Iazepam (valium), and Tizanidine (Zanaflex).
Other treatments for higher levels of tone/spasticity are botox injections, phenol/alcohol injections, and intrathecal baclofen pump. These medications should be managed and monitored by your doctor for the appropriate dose to minimize side effects of high doses.
Physical therapy and exercise provide conservative and non-medical management of either tone and/or spasticity. Physical therapy can help the most in the following ways:
Optimize the “window of opportunity” that exists with any of the above medications or injections that are used. For example, botox injections are most effective within 3-90 days after the procedure. This means we may have more range of motion, less resistance to movement, or less pain that our therapeutic interventions may be more effective.
Optimize function despite having tone or spasticity. Despite medication and other management, there usually is some level of abnormal tone or spasticity present which means you have to learn how to move and safely function with this new tone/spasticity. There are many “tricks of the trade” and techniques that a physical therapist can recommend to help maintain independence and function.
Skilled observer of function and movement. Often times, physical therapists and doctors work together in order to find the appropriate dosage of medication as well as muscle groups for injections that will allow someone to be the most mobile and independent.
Some other non-medical treatment ideas that can be performed in therapy include vibration, electrical stimulation (e-stim), taping, orthotics or bracing, and other adaptive devices.
The most successful treatment although continues to be specific stretching and strengthening, so see your local physical therapist for specific stretches and strengthening exercises to make it individualized to you!
How To Prevent A Stroke
We could not have a blog about stroke without highlighting the importance of stroke prevention! Once again, 80% of strokes can be prevented. Some of the most important prevention recommendations include some of the following:
- Exercising/moving more
- Eating healthy
- Maintaining a healthy body weight
- Quitting smoking
- Decreasing alcohol consumption
- Having regular doctor visits