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Upper Limb Spasticity

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Iqra Mazhar

Overview

Upper limb spasticity is characterized by tense and overactive muscles in the arms and hands, leading to muscle spasms, limited movement, and muscle stiffness. 
&nbsp;

Upper limb spasticity impacts a person&rsquo;s arm movement. The arm muscles stiffen and flex and, at times, also spasms, i.e., the person cannot control the way their arms twitch or move.

Damage to the spinal cord or the part of the brain that controls voluntary movement, typically by a <a href="https://merisehat.pk/disease/stroke">stroke</a>, illness, or injury, causes spasticity. In a 2020 study, nearly 70% of nursing home residents with a stroke presented with upper limb spasticity<a href="#accordion">[1]</a>. 
&nbsp;

Although the condition itself is not life-threatening, it can nevertheless be uncomfortable and have a significant impact on the patient&rsquo;s life. Day-to-day activities, like getting dressed or taking a shower, become a challenge. 
&nbsp;

There are no specific subtypes of upper limb spasticity. 
&nbsp;

While spasticity affects any group of muscles, upper limb patterns are often stereotypical postural patterns as it affects the biceps, brachioradialis, and brachialis, commonly known as the flexors. 
&nbsp;

There are five typical forms of upper limb spasticity concerning the location of the shoulder, elbow, forearm, and wrist joints:<a href="#accordion">[11]</a> 
&nbsp;

<ol>
	<li>Adducted Shoulder &ndash; The arm is drawn to the body and turned inwards</li>
	<li>Flexed Wrist &ndash; The wrist is bent&nbsp;</li>
	<li>Flexed Elbow &ndash; The hand and the wrist are turned toward the shoulder</li>
	<li>Pronated Forearm &ndash; The forearm is rotated inward</li>
	<li>Clenched Or Thumb-In Fist&nbsp;&ndash;&nbsp;The fingers are either clasped tightly into the palm (fist) or only the thumb is pulled toward the palm and unable to function</li>
</ol>

Flexion of the fingers, wrist, and elbow are the most common patterns of spasticity in the upper limb. 
&nbsp;

Signs and Symptoms

Symptoms of upper limb spasticity may not even appear for weeks, months, or years after the patient has had a brain injury or stroke. Symptoms include<a href="#accordion">[12]</a>:

<ul>
	<li>Stiff arm muscles</li>
	<li>Stiff joints&nbsp;</li>
	<li>Involuntary twitches or jerky movements</li>
	<li>Exaggerated reflexes</li>
	<li>Difficulty moving or using the arms</li>
	<li>Tensed muscles of fingers, wrists, or elbows</li>
	<li>Unusual arm positions</li>
	<li>Rotated shoulders</li>
	<li>Abnormal positioning of wrists or elbows</li>
	<li>Hands clenched into fists</li>
	<li>Pain or difficulty while moving or straightening the arm, elbows, wrists, or fingers</li>
	<li>Muscle contraction that limits the range of motion 
	&nbsp;</li>
</ul>

The individual finds it extremely difficult to move their muscles, especially without treatment. The muscles feel as if they&rsquo;re frozen in that position and they&rsquo;re unable to function normally. Prolonged spasticity can also cause pressure sores. 
&nbsp;

NOTE: Inform your doctor immediately if you experience spasms, muscle tightness, or stiff limbs after a stroke or brain injury. 
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Causes

Nerves help transfer electrical signs from the brain and spinal cord to the muscles, allowing movement of different parts of the body. Any damage to the brain or spinal cord disrupts these signals, causing the muscles to twitch, stiffen, and flex<a href="#accordion">[12]</a>. 
&nbsp;

The following are the common causes of upper limb spasticity<a href="#accordion">[5][12]</a>. 
&nbsp;

<h5>Stroke</h5>

A stroke is a brain injury. Unlike the bilateral dysfunction present in traumatic brain injury patients, stroke patients present with unilateral dysfunction. Depending on the region affected, symptoms may include hemiplegia (inability to move the upper and/or lower limb on one side of the body) and visual disturbances. 
&nbsp;

Nearly 25-43% of stroke survivors develop post-stroke spasticity in the first year after their stroke<a href="#accordion">[5]</a>. This timing varies, though; for some, spasticity occurs soon after a stroke, while it may take more than a year for others. It&rsquo;s common if the stroke is hemorrhagic and the patient is a young adult.

A stroke is the most common cause of upper limb spasticity. 
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<h5><a href="https://merisehat.pk/disease/cerebral-palsy">Cerebral Palsy (CP)</a></h5>

CP is the most common motor disability in childhood and also the most common cause of the spastic disorder. It is a group of disorders that affects a person&rsquo;s ability to move. Damage to the motor control center can occur during pregnancy, childbirth, or after birth up to the age of 3 because of reasons like infections, accidents during pregnancy, arterial malformation, and drug abuse by pregnant mothers. Nearly 75-85% of children with CP have stiff muscles as a result of which they have awkward movements<a href="#accordion">[4]</a>. However, symptoms of spasticity may not appear during childhood and will become evident as they grow older. 
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<h5>Brain Or Spinal Trauma</h5>

Spasticity can be brought on by traumatic injury to the brain or spinal cord due to vehicle accidents, falls, sports injuries, and violence. It particularly affects young adults. The individual suffers from muscle tightness in different regions of the body. The condition improves gradually with time as the injury heals. However, until then, the disruptions cause an imbalance in the inhibitory and excitatory signals sent to the muscles. 
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<h5><a href="https://merisehat.pk/disease/multiple-sclerosis">Multiple Sclerosis (MS)</a></h5>

MS is an autoimmune disease of the central nervous system, which is made up of the brain, spinal cord, and optic nerves. It may lead to bladder dysfunction, sexual impairment, contractures and postural deformities, and coordination difficulties. 
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<h5>Other</h5>

Spasticity may also be caused by:

<ul>
	<li>Amyotrophic lateral sclerosis</li>
	<li>Adrenoleukodystrophy</li>
	<li>Krabbe disease</li>
	<li>Hereditary spastic paraplegias</li>
	<li>Phenylketonuria</li>
	<li><a href="https://merisehat.pk/disease/parkinsons-disease">Parkinson&rsquo;s disease</a></li>
	<li>Tumor 
	&nbsp;</li>
</ul>

There are no specific screening tests for upper limb spasticity. However, in stroke patients, doctors may conduct various tests to assess the degree of tone, pain assessment, and dexterity in the upper limb. 
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Diagnosis

Before diagnosing ULS, it&rsquo;s important to identify what it&rsquo;s not: 
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<ul>
	<li>Spasticity Vs&nbsp;Hypertonicity: Hypertonia is resistance to passive movement and can occur with or without spasticity. It&rsquo;s also not velocity dependent. On the other hand, spasticity is a type of hypertonia in which the spasms increase with movement; the faster the movement, the stronger the resistance. 
	&nbsp;</li>
	<li>Spasticity Vs Spasms: An occasional muscle spasm does not mean muscle spasticity. A spasm is a sudden, involuntary contraction or tightening of a muscle, which is normal and can happen to any individual. It may be painful for some but given that the individual is otherwise healthy and so it&rsquo;s believed to be caused by dehydration, frequent high-intensity exercises, muscle fatigue, and sitting for a long time. On the other hand, spasticity is caused by an underlying neurological condition and does not affect everyone. 
	&nbsp;</li>
</ul>

<h5>Ashworth Scale</h5>

This is the most commonly used assessment tool to measure spasticity in a clinical setting. It was first introduced in 1964 but was later modified in 1987 for better reliability scores while measuring upper extremities.&nbsp; The scale is as follows<a href="#accordion">[6]</a>: 
&nbsp;

<ul>
	<li>0:&nbsp; No increase in muscle tone.</li>
	<li>1: Slight increase in muscle tone, with a catch and release or minimal resistance at the end of the range of motion when an affected part(s) is flexed or extended.</li>
	<li>1+: Slight increase in muscle tone, manifested as a catch, followed by minimal resistance through the remainder (less than half) of the range of motion.</li>
	<li>2: A marked increase in muscle tone throughout most of the range of motion, but affected part(s) are still easily moved.</li>
	<li>3: Considerable increase in muscle tone, difficult passive movement.</li>
	<li>4: Affected part(s) rigid while being flexed or extended. 
	&nbsp;</li>
</ul>

Note: Despite its popularity, it&rsquo;s been criticized for its inability to differentiate between various factors that cause spasticity. Other methods that have been proposed and used include<a href="#accordion">[6][7]</a>:

<ul>
	<li>Modified Tardieu Scale</li>
	<li>Visual Analog Scale (VAS)</li>
	<li>Wartenberg Pendulum Test</li>
	<li>Penn Spasm Frequency Scale</li>
	<li>Spinal Cord Assessment Tool For Spasticity</li>
	<li>Clinical Gait Analysis 
	&nbsp;</li>
</ul>

The aforementioned scales all have their limitations as well.

Typically, the most common sign on an exam is resistance to a passive change in a joint angle. It is most commonly noted in the flexor muscles of the upper extremities. During the physical examination, the patient&rsquo;s muscle movement is tested. The doctor will flex the joints to assess the range of motion and assess the patient&rsquo;s control. 
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However, diagnosing the condition is also difficult because of the varying degrees of spasticity. After the physical examination and neurological testing (using electromyography), a doctor may order further tests, including imaging studies of the head, neck, and spine, preferably through MRI or radiography, to get further information regarding the source of spasticity as well as the extent of damage caused. 
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Treatment

The primary aim of treatment is to improve the quality of life for patients with upper limb spasticity. Therefore, a major, long-term objective of spasticity management would be to improve function. While any approach must be tailored to meet the individual needs of the patient, doctors should ensure that it&rsquo;s a multi-modal approach, a combination of medical intervention and additional therapies, for instance, to: 
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<ol>
	<li>Enhance mobility and dexterity</li>
	<li>Alleviate symptoms</li>
	<li>Reduce discomfort from postural consequences, tendon soreness, and muscle shortening</li>
	<li>Reduce spasms</li>
	<li>Improve postural-body perception</li>
	<li>Reduce the amount of care required for clothing, positioning, and cleanliness</li>
	<li>Improve service responses to prevent/delay surgery, avoid unneeded treatments, and enable other types of therapy 
	&nbsp;</li>
</ol>

<h5>Considerations In The Management Of Upper Limb Spasticity</h5>

<ul>
	<li>The effectiveness of different treatment modalities may be influenced by the site of the brain lesion.</li>
	<li>The duration, intensity, and pattern of motor involvement should be considered to manage spasticity.</li>
	<li>Patient characteristics that need to be taken into account include their age, intelligence, treatment objective, available resources, support network, and related neurological problems they have. 
	&nbsp;</li>
</ul>

<h5>Who Is Suitable For Surgery?</h5>

When assessing patients for treatment, neurologic deficits also need to be taken into account. For instance, visual acuity must be high enough to direct positioning.

Patients with insufficient sensibility and vision should not be considered for functional surgery, although they may still be candidates for other procedures meant to enhance comfort and/or hygiene.

Additionally, many CP, TBI, or SCI patients will also experience mobility and lower extremity limitations, which are frequently treated before upper extremity surgery. 
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<h5>Non-Surgical Treatments</h5>

When planning an intervention, the team of doctors must consider triggers of spasticity in the patient. These include:

<ul>
	<li>Skin Issues (e.g., ingrown toenails, pressure ulcers)</li>
	<li>Pain And Discomfort (due to restrictive clothing, catheter straps)</li>
	<li>Fatigue</li>
	<li>Bladder Or Bowel Issues (e.g., full bladder, <a href="https://merisehat.pk/disease/constipation">constipation</a>)</li>
	<li>Infections (e.g., pneumonia, UTI)</li>
	<li>Menstruation</li>
	<li><a href="https://merisehat.pk/disease/stress">Stress</a></li>
	<li>Seating Or Positioning Issues</li>
	<li>Other Medical Issues (e.g., kidney stones) 
	&nbsp;</li>
</ul>

There are several options available to treat upper limb spasticity:

<ul>
	<li>Physical Therapy</li>
</ul>

A physical therapist may focus on stretching and strengthening exercises to enhance the patient&rsquo;s range of motion. 
&nbsp;

<ul>
	<li>Occupational And Speech Therapy</li>
</ul>

Occupational therapy exercises focus on small groups of muscles to improve both strength and coordination so that the individual can perform daily tasks easily.

Sometimes, individuals with spasticity also require speech therapy to improve their quality of life. 
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<ul>
	<li>Casting Or Bracing</li>
</ul>

Braces or splints are used to prevent involuntary spasms as well as to reduce the tightening of the muscles. 
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<ul>
	<li>Botox Injections</li>
</ul>

Botox injections help relax muscles and relieve spasms. Depending on the pattern of spasticity, Botox is carefully injected into the affected sites. The issue with Botox is that a single administration can last for 12-16 weeks, but it&rsquo;s no longer effective once new nerve endings form. Also, Botox can only be administered in limited amounts. 
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<ul>
	<li>Oral Medications</li>
</ul>

The only reason why doctors prescribe oral medication to treat upper limb spasticity is if the patient&rsquo;s symptoms have started to interfere with their daily sleep or functioning. These are used along with other therapies, like occupational or physical therapy. Medicines like baclofen, diazepam, tizanidine, phenol, dantrolene sodium, gabapentin, and clonazepam are especially helpful to relax their muscles<a href="#accordion">[9][10]</a>.

When conventional medications don&#39;t work, nerve block injections, which are shots of chemicals that numb the nerves that make muscles quiver, may cease spasms. 
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<h5>Surgical Treatment For UPLS</h5>

<ol>
	<li>Intrathecal Baclofen (ITB) Pump</li>
</ol>

A pump is surgically placed inside the patient&rsquo;s abdomen. It releases a steady dose of baclofen into the spinal fluid. Compared to taking baclofen orally, this procedure enables a considerable decrease in spasticity and discomfort with fewer side effects. However, ITB pump therapy should only be reserved for severe cases of spasticity. 
&nbsp;

<ol start="2">
	<li>Selective Dorsal Rhizotomy (SDR)</li>
</ol>

An imbalance in electrical signals to antagonist muscles can result in spasticity. SDR restores this balance by severing selective nerve roots. This procedure is used only in extreme cases of leg spasticity. Most of the patients who are recommended for SDR have cerebral palsy. 
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Inability to move, poor hygiene and self-care, low self-esteem and body image, and pressure ulcers are some of the complications of spasticity. Moreover, it can cause urinary tract infections, frozen joints (contractures), bone fractures, chronic constipation, fever, or other systemic illnesses. 
&nbsp;

Upper limb spasticity, in particular, that occurs after an upper motor neuron lesion can become a long-term disability in adults. This leads to pain, functional loss, and overall reduced quality of life<a href="#accordion">[8]</a>. 
&nbsp;

The following increase the risk of upper limb spasticity:

<ul>
	<li>Stroke</li>
	<li>Brain or spinal cord injuries</li>
	<li>Diseases of the nervous system, e.g., cerebral palsy, multiple sclerosis</li>
	<li>Metabolic diseases 
	&nbsp;</li>
</ul>

This condition cannot be prevented. However, if it occurs as a complication of an underlying infection then treating that infection can help. 
&nbsp;

Similarly, at-home care can help ease some of the symptoms:

<ul>
	<li>Getting plenty of sleep</li>
	<li>Avoiding extremely cold or hot temperatures</li>
	<li>Stretching exercises (with someone&rsquo;s help if required) both for overall health and for spasticity</li>
	<li>Wearing loose-fitting clothing and avoiding restrictive clothes</li>
	<li>Changing position often or at least every 2 hours to avoid developing pressure sores 
	&nbsp;</li>
</ul>

In a recent study, researchers tested the effectiveness of HU-014 in the management of post-stroke upper limb spasticity<a href="#accordion">[3]</a>. HU-014 is a newly developed botulinum toxin that is currently used for cosmetic procedures.

As part of the study, HU-014 was provided to 13 patients. The primary outcome was safety, which included adverse events, vital signs, a physical examination, laboratory testing, and an assessment of antibody production. The secondary outcomes included changes in the Modified Ashworth Scale (MAS) score for the elbow, wrist, and finger flexor; the Investigator&#39;s Global Assessment (IGA) and the Subject&#39;s Global Assessment (SGA); the Disability Assessment Scale (DAS); the Columbia Suicide Severity Rating Scale (C-SSRS); and the Caregiver Burden Scale (CBS) at weeks 4, 8, and 12 from baseline. 
&nbsp;

In patients with post-stroke upper limb spasticity, muscle spasticity, level of disability, and caregiver burden decreased after HU-014 administration. Both the researcher and the patients expressed general satisfaction with the reduction in symptoms during the trial.

Future research with sizable sample size is required to fully demonstrate HU-014&#39;s efficacy. 
&nbsp;

Key Points

<ul>
	<li>Upper limb spasticity is characterized by a hyperactive stretch reflex and elevated muscular tone.</li>
	<li>Uneven signaling due to damage to the brain or spinal cord causes muscles to involuntarily stiffen, flex, and twitch.</li>
	<li>Stroke, traumatic brain damage, multiple sclerosis, spinal cord injury, and cerebral palsy all lead to upper limb spasticity.</li>
	<li>Spasticity&#39;s underlying pathophysiology may differ, but its clinical symptoms, which include elbow flexion, forearm pronation, wrist flexion, and thumb/digital flexion, are generally predictable.</li>
	<li>The management team must comprehend the root of upper extremity spasticity to create the best treatment strategy. 
	&nbsp;</li>
</ul>

[1] Shiner CT, Vratsistas-Curto A, Bramah V, Faux SG, Watanabe Y. Prevalence of upper-limb spasticity and its impact on care among nursing home residents with prior stroke. Disabil Rehabil. 2020;42(15):2170–7.

[2] Sheean G. The pathophysiology of spasticity. Eur J Neurol. 2002;9:3–9

[3] Lee J, Chun MH. Safety and Efficacy of HU-014 in the Treatment of Post-Stroke Upper Limb Spasticity: A Phase I Pilot Study. Toxins (Basel). 2022;14(11):730.

[4] 11 things to know about cerebral palsy. Centers for Disease Control and Prevention.

[5] Let's talk about spasticity after stroke. American Stroke Association.

[6] Harb A, Kishner S. Modified Ashworth Scale. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

[7] Rivelis Y, Zafar N, Morice K. Spasticity. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

[8] Jarratt Barnham a, a, b, et al. Surgical interventions in adult upper limb spasticity management: A systematic review. Hand Surgery and Rehabilitation.