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Thursday, March 24, 2016

The use of Botox triggers spasticity. Who benefits, who benefits?

In Germany every two minutes a person suffers from a stroke. It is the third leading cause of death in this country. Thanks to education, technical progress and good medical care, many lives are saved, but the price of survival can be high.

Life after a stroke

Survivors often suffer from physical limitations and have not seldom lost the limited ability to cope with their everyday lives. You may not be able to use your affected arm to wash or dress. Walking is often not possible or only associated with significant risk of falling. Speaking or feeding may also be impaired. In addition to these limitations of everyday activities, there are often serious changes in body functions and body structures. Muscles become stiff and joints immobile, which can ultimately lead to significant pain. It is understandable that in this situation every means is welcome, that it can alleviate these symptoms.

What is “spasticity”??

After a stroke, there are different symptoms, one of many can not be just that of spasticity. Muscle strength and coordination, as well as adjustment processes in the muscle that lead to shortening, take place. Sensory and perceptual disorders are also common. You can not remember exactly where your foot or arm is. Disturbances of the sense of balance and vision can increase the risk of falling considerably. Involuntary accompanying movements, e.g. a stiff arm while walking, helping to maintain balance or enhance sensory feedback to the brain “where” you are in the room. These involuntary movements or body tensions are rarely an expression of over-excitability (hyperreflexia, hypertonicity) of the central nervous system (O’Dwyer 1996). In most cases, they are an expression of meaningful adjustments to ensure the greatest possible stability. For this reason one speaks today of the “spastic paresis (paralysis)” (Dietz 2013).

How does Botox work??

The goal of botoxtherapy is to inhibit muscle reflexes. For this purpose, it must first be objectively determined whether they are actually increased. This can only be measured objectively in the EMG (electromyogram). Even if over-excitability is detected, it is important to analyze whether inhibiting this over-excitability leads to an improvement in day-to-day activities. In a recent study on drug approval, botox therapy has been shown to decrease muscle tone (muscle tension) but not improve walking ability (Kaji et al., 2010)! Somewhat critically one must remark that in this study – which seems very impressive at first because of the high number of test persons (120 persons) – the muscle tone was measured with the Modified Ashworth scale (MAS). This has long been considered by experts to be inappropriate for assessing muscle tone (IGPTNR 2004).

When is Botox indicated?

Spasticity often causes unpleasant contractures for severely affected, immobile and bedridden patients (irreversible muscle shortening with associated joint misalignments). Here, Botox can be useful in conjunction with physiotherapy, occupational therapy, speech therapy, and appropriate adjuncts to help the patient enjoy relaxed body positions and daily body care.

When is Botox not indicated?

Mobile people, on the other hand, can definitely use the increasing muscle tension positively, since their arms or legs are stabilized: the affected person is often enabled to handle some everyday activities independently. Uncomfortable here is the stiffness and any associated pain for which understandably relief is sought.

Why strengthening instead of inhibition to relieve spasticity?

Since paralysis is the biggest problem in the daily lives of stroke patients, it is obvious that the paralyzed muscles have to be strengthened. It has now been proven that active movements regulate muscle tension (Dietz 2013). For people who want to and are able to walk – though cumbersome – activity is important for this reason! Rigid muscles need to be actively stretched, for which the sufferer needs the support of a trained therapist as well as often additionally custom-made aids. In addition, the weak muscles must be specifically strengthened. Since the brain does not know any isolated movements, they must be integrated into “tasks” that are relevant to everyday life, i. are action-oriented. Weak leg muscles are best trained by climbing stairs or getting up and sitting down, weak arm muscles by practicing dressing or washing. This requires the expert support of therapists who are familiar with functional anatomy and biomechanics. This is the only way to avoid secondary damage caused by joint dysphagia. Admittedly, this way is more exhausting than the musculature to inhibit medication and get passively moved. Only the consequence of the latter is increasing weakness, along with increasing stiffness and pain.

Conclusion: The desire to actively participate in life requires activity!

If it is the goal of the person concerned to actively participate in life, he must be given the opportunity to be active. The goal of the therapy must be shared with the person concerned, his relatives, the nursing staff, the treating physicians and therapists.

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Christina Cherry
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