Stroke survivors with physical deficits have to fight to get the muscles moving again. They also have to fight to stop some muscles from moving.
Tone and spasticity are why our elbows curl, our fists squeeze tight, and our toes can curl under our feet so we crush our own toes as we walk.
Dr. Wayne Feng is an expert in tone and spasticity after stroke and he joins us this week to explain how we can address these challenges
If you don't see the audio player below, visit Strokecast.com/MSN/ToneBasics to listen to the conversation.
Who is Dr. Wayne Feng?
From Dr. Feng's Duke Profile:
I am the division chief for Stroke and Vascular Neurology in the Department of Neurology at Duke Health. I see stroke patient in the emergency department, inpatient service as well as in the outpatient clinic. I also treated post-stroke limb spasticity, a disabling complication after stroke. In addition to the patient care, I also run a brain modulation and stroke recovery lab at the Duke University campus to study stroke patients in my lab to develop new stroke recovery therapy. On my days off, my boys and I are big on fishing. I enjoy drinking and collecting tea. As a stroke doctor, I do not drink coffee at all (there is a reason for it). If you come to see, I will tell you.
Current Appointments and Affiliations:
- Professor of Neurology, Neurology, Stroke and Vascular Neurology 2019
- Chief of Stroke & Vascular Neurology in the Department of Neurology, Neurology, Stroke and Vascular Neurology 2019
- Professor of Biomedical Engineering, Biomedical Engineering 2022
[youtube https://www.youtube.com/watch?v=SGeOGI2bry4&w=560&h=315]
Tone and Spasticity Overview
Mos of our limbs move because of the interaction between two types of muscles -- extensors and flexors.
The flexors contract to bend a limb. The extensors contract to extend the limb. For example, the biceps are flexors. They pull our forearm up or into an angle. When people want to show off their arm muscle, the flex their arm -- they activate their flexors.
The triceps on the back of the upper arm are extensors. When they activate, they extend the arm -- they pull the arm straight. When flexors contract extensors relax. When extensors contract, flexors relax. That's how we control our limbs.
After stroke, the flexors can activate on their own. And they can be, well, overenthusiastic, in those actions.
That happens because the default behavior of the flexors is to be active and curl up. When we talk about curling up into the fetal position, that's most of our flexors activating.
The reason we can go through life upright and with our limbs straight is that the cortex of the waking brain is constantly suppressing the normal contracting of the flexors.
After stroke impacting the motor cortex of the brain, the corticospinal tract is disconnected. With that disconnect, the brain can no longer suppress the flexors so they do what they do -- they contract and curl and cause all sorts of problems.
Peripheral vs Cortical Problems
Categorizing issues as cortical or peripheral is a fancy way of saying brain or limb.
A stroke is a cortical issue. The problem exists in the brain. That's where the disconnect happens.
A peripheral issue is when something goes wrong in the limb. Shoulder subluxation, for example, is peripheral issue.
Most PT and OT works with the limbs to treat the cortical issues. Tone and spasticity are caused by cortical issues.
The long-term problems caused by tone and spasticity are peripheral issues.
One of those peripheral issues is contracture. When tone and spasticity is severe and long term, the muscles, tendons, ligaments, and other soft tissue can actually shrink in the contracted position. When that happens, getting the extensors back online and suppressing the flexors no longer helps. The limb can become almost permanently bent.
Repairing peripheral issues, like contracture, may require surgery to sever and extend tendons and other tissue.
Preventing and Treating Tone and Spasticity
The first line of defense is in the immediate short-term after stroke. Getting the limbs moving and keeping them moving to drive the neuroplastic change of recovery helps.
Beyond that, and once tone and spasticity set in, regular stretching is critical. A survivor needs to keep stretching those limbs to prevent contracture.
That's why in conference calls and interviews, I'm often stretching my fingers back and my wrist back to counteract the tone and spasticity in my left arm and hand.
Medication can help, too. Baclofen is a popular choice. It's basically a muscle relaxer that helps counteract the excessive action in my flexors. Some people find it can cause drowsiness so it's not the best choice for everyone.
I tend to take my Baclofen before going to bed. If it makes me drowsy then that's great. It also helps reduce the tone I might experience overnight.
For folks with severe tone and spasticity, a surgically implanted Baclofen pump can help. The medicine directly target the key muscles which means the patient needs much less medicine for a much greater impact. Since it is a low dose, it is less likely to induce the fatigue, too.
Other medications to treat tone and spasticity include:
- Tizanidine
- Flexeril
- Gabapentin
Botox, Dysport, and Xeomin are also treatments that can help. These are neurotoxins that a doctor can inject every three to four months. By delivering the toxins to the flexors, it reduces their ability to flex. That gives the extensors a chance to recover and rebuild a normal relationship. Of course, this is a short-term solution. Combined with exercise, it can definitely help.
I'm probably overdue for my next Dysport treatment.
Contralateral C7 Nerve Transfer for Stroke Recovery: New Frontier for Peripheral Nerve Surgery
A promising area for relieving tone and spasticity is C7 nerve transfer. Recent studies are showing promising results.
Neurosurgeons split the a nerve from the unaffected side of the brain that runs through the spine and reconnect half of it to the equivalent nerve on the affected side. The do this in the neck.
Results show a quick reduction in tone and spasticity even in patients 15+ years after stroke. After a year, patients are experiencing improved use of the limb, too.
The number of people in the studies so far is pretty small (36) and more research is needed. It is a promising result, though, and builds on techniques that have been used to treat non-stroke injuries.
It also highlights the tremendous ability of the brain to adapt since now the unaffected side starts to control the affected side of the body.
You can read a review of the technique and studies at the Journal of Clinical Medicine.
Vagus Nerve Stimulation
In 2021, I spoke with Dr. Jesse Dawson, a Professor of Stroke Medicine and Consultant Physician in the Queen Elizabeth University Hospital in Scotland about his research in Vagus Nerve Stimulation. This research is now being commercialized and used to treat patients in the US.
The therapy involves surgically implanting a stimulator in a patient's chest that connects to the Vagus nerve. During PT or other exercises, the device sends an electric signal to the Vagus nerve. Stimulating the nerve while doing therapy has shown positive results in terms of limb use.
It's interesting because it's not treating the Vagus nerve itself, but stimulating this nerve appears to make the other nerves in the brain more receptive to the therapeutic exercises.
You can learn more about this research here: http://Strokecast.com/VNS.
Survey
What do you think of the Strokecast? Let me know what you like and what you would like to be different by completing the survey at http://Strokecast.com/Survey. I would really appreciate it.
If you complete the survey by March 31, 2023, you could win a $25 Amazon gift card, too.
Hack of the Week
Hand grip exercisers are nice tools to encourage stretching and exercise throughout the day.
These things are like a pair of pliers without the tool end. They are spring loaded. You squeeze them to exercise and they try to force your hand open. You can get them in a variety of strength levels. Start with light weight ones and move on to tougher ones as your strength improves.
What I like about them is that closing a fist comes back before opening one. Closing your fist takes work. Opening your fist is often harder, but these gadgets force the hand open. So you get to practice the squeeze and you get a stretch into fingers, too, to address tone and spasticity.
It's also one more way to reduce the odds of developing a contracture.
Here are a couple options:
https://strokecast.com/Hack/HandExerciserTraditional (Traditional design)*
Links
Where do we go from here?
- Check out Dr. Feng's work at Duke University
- Share this episode with someone you know by giving them the link http://Strokecast.com/ToneBasics
- Complete the Strokecast survey at http://Strokecast.com/Survey
- Don't get best…get better
More thoughts on Tone and Spasticity
Tone and spasticity after stroke is super common among stroke survivors with physical deficits. But what is it? And how can survivors manage it and prevent permanent damage? Dr. Wayne Feng from Duke University takes through the basics in this conversation at http://Strokecast.com/ToneBasics
Tone and spasticity after stroke is super common among stroke survivors with physical deficits. But what is it? And how can survivors manage it and prevent permanent damage? Dr. Wayne Feng from Duke University takes through the basics in this conversation at http://Strokecast.com/ToneBasics
Tone and spasticity after stroke is super common among stroke survivors with physical deficits. But what is it? And how can survivors manage it and prevent permanent damage? Dr. Wayne Feng from Duke University takes through the basics in this conversation at http://Strokecast.com/ToneBasics
Tone and spasticity after stroke is super common among stroke survivors with physical deficits. But what is it? And how can survivors manage it and prevent permanent damage? Dr. Wayne Feng from Duke University takes through the basics in this conversation at http://Strokecast.com/ToneBasics
Tone and spasticity after stroke is super common among stroke survivors with physical deficits. But what is it? And how can survivors manage it and prevent permanent damage? Dr. Wayne Feng from Duke University takes through the basics in this conversation at http://Strokecast.com/ToneBasics
![A picture of a brain scan The text over the image read: You know, once you develop a contracture, it's not a brain issue. It’s a peripheral issue, but certainly if you develop a severe specificity very early and you have good insurance and talk to the provider, I recommend getting [therapy] a little bit early. - Dr. Wayne Feng](https://strokecast.com/wp-content/uploads/2023/01/Feng-06.jpg)
Tone and spasticity after stroke is super common among stroke survivors with physical deficits. But what is it? And how can survivors manage it and prevent permanent damage? Dr. Wayne Feng from Duke University takes through the basics in this conversation at http://Strokecast.com/ToneBasics
Tone and spasticity after stroke is super common among stroke survivors with physical deficits. But what is it? And how can survivors manage it and prevent permanent damage? Dr. Wayne Feng from Duke University takes through the basics in this conversation at http://Strokecast.com/ToneBasics
Tone and spasticity after stroke is super common among stroke survivors with physical deficits. But what is it? And how can survivors manage it and prevent permanent damage? Dr. Wayne Feng from Duke University takes through the basics in this conversation at http://Strokecast.com/ToneBasics
Tone and spasticity after stroke is super common among stroke survivors with physical deficits. But what is it? And how can survivors manage it and prevent permanent damage? Dr. Wayne Feng from Duke University takes through the basics in this conversation at http://Strokecast.com/ToneBasics
Tone and spasticity after stroke is super common among stroke survivors with physical deficits. But what is it? And how can survivors manage it and prevent permanent damage? Dr. Wayne Feng from Duke University takes through the basics in this conversation at http://Strokecast.com/ToneBasics
Tone and spasticity after stroke is super common among stroke survivors with physical deficits. But what is it? And how can survivors manage it and prevent permanent damage? Dr. Wayne Feng from Duke University takes through the basics in this conversation at http://Strokecast.com/ToneBasics
Tone and spasticity after stroke is super common among stroke survivors with physical deficits. But what is it? And how can survivors manage it and prevent permanent damage? Dr. Wayne Feng from Duke University takes through the basics in this conversation at http://Strokecast.com/ToneBasics
No comments:
Post a Comment