What is muscle hypertonicity, what are its causes, symptoms and treatment in adults? Muscle tone in a child: types of disorders and directions for their treatment

Muscle tone - muscle tension during complete relaxation of a person. This contributes to maintaining posture, finding the internal organs in a certain position and taking the body of certain postures.

In the case of an increase (hypertonicity), the muscles are constantly tense. This leads to pain, movement is constrained. Secondary changes occur in muscles and joints. Hypertonicity indicates that the nervous system is damaged.

Causes of the violation

An increase in muscle tone can occur when:

• vascular and heart diseases, as a result of which the central nervous system is damaged;
• congenital pathologies of the central nervous system;
• in which the brain or spinal cord is damaged;
• demyelinating diseases.

Changes that occur with the mental and emotional state do not have a significant effect on increasing muscle tone.

Types and causes of increased tone

With the spastic form of hypertonicity, the nerve centers and motor pathways are affected, it is not distributed to all muscle groups, but selectively. leads to the emergence of speech difficulties, difficulty in movements, pain in the muscles, involuntary crossing of the legs.

The reasons for this condition may be:

With rigid (plastic) hypertonicity, a spasm of all muscles occurs simultaneously. It occurs if the brain or spinal cord is affected, with poisoning with toxins, hypnosis. These factors lead to uncontrolled limb positions.

Features of the clinical picture

Increased muscle tone is easily determined. He is accompanied by:

• the appearance of tension in the body;
• immobility;
• the appearance of discomfort in the process of movement;
• stiffness and muscle spasms;
• spontaneous movements;
• increased tendon reflexes;
• spasmodic muscles relax slowly.

In the process of movement, muscle tone increases, which leads to pain in the back and legs. Physical exercise and stress contribute to the occurrence of temporary cramps and pulling pain in certain muscles. The person feels stiff.

Recurring such conditions can mean the appearance of serious diseases.

If muscle spasticity has passed into a neglected form, then the muscle acquires greater density. Any physical impact causes severe pain.

Features of infantile hypertonicity

Lack of oxygen, vitamins for the fetus during pregnancy, trauma during childbirth and other causes can lead to hypertonicity in the newborn. However, even a normal pregnancy and childbirth cannot guarantee that the child will not have increased muscle tone.

Often the tension disappears when the child reaches one and a half years and is not a serious violation. Only a neurologist can diagnose hypertension.

Reasons for parents to be concerned:

• the child's sleep is disturbed;
• the baby becomes nervous, constantly crying, while there is a trembling of the chin;
• eats poorly, often burps after eating;
• when sleeping, arms and legs convulsively tighten, head thrown back;
• began to hold his head at the age of up to one month (with muscle spasm of the neck and occiput);
• stiffness in movements is observed, when trying to remove the arms and legs from the body, begins to cry;
• if you put the child and at the same time hold him under the armpits, the baby moves with his feet, imitating a gait. A baby with hypertonicity will stand on tiptoe, while a healthy child will lean on the whole foot.

Massage, therapeutic baths, paraffin wrap and caress of parents will help to return the tone to normal. You can use aromatherapy and fitball exercises.

In any case, if dangerous symptoms appear, you should consult a specialist, since hypertonicity indicates a more serious illness.

Diagnostics and methods of therapy

If there are obvious symptoms of increased muscle tone, it is urgent to conduct a diagnosis. This will indicate a specific disease. To do this, experts resort to:

• (MRI);
• (EMG) - study of the bioelectric potential of the muscle with excited muscle fibers;
• a blood test is performed.

The treatment of increased muscle tone is to overcome the disease that caused hypertonicity, as well as the removal of the symptoms of tension themselves.

Comprehensive treatment of muscle hypertonicity is:

In order to prevent it is necessary:

• use of postural hygiene;
• moderate exercise;
• stretching and relaxing muscles;
• drinking large amounts of water;
• preventive use of physiotherapy and massage, exposure of the muscle to cold and heat, avoidance of stress.

Hypertonicity requires a long and complex treatment. Therefore, at the first manifestation of it, it is necessary to immediately seek medical help.

Musculature is one of the important components of the ODA, which is responsible for the motor activity of the body along with the ligamentous apparatus and the nervous system. If there is a violation of its functioning, then this is fraught with various uncomfortable sensations. Therefore, we will further consider how to remove the hypertonicity of the muscles of the back or another area of ​​the body.

- a pathological condition in which there is a persistent and reversible increase in the tone of muscle tissue.

The trigger mechanism for the development of the condition lies either in the defeat of the muscles, or in the violation of the process of transmission of the nerve impulse.

Reference. The phenomenon is considered a symptom of many diseases, and most often occurs against the background of ailments of the nervous system.

The state of muscle tissue in the normal state and during spasm

In neurology, there are several main varieties of this disorder:

• spastic;
• plastic;
• mixed.

spastic view develops when elements of the pyramidal system are damaged (neurons that transmit nerve impulses from the center of the brain to skeletal muscles).

It spreads unevenly, that is, some muscle group may be affected. A good example of this type is observed in stroke with damage to the motor centers of the brain.

plastic look occurs with dysfunction of the extrapyramidal system, represented by brain structures that are involved in the control of movements, maintaining muscle tone, body position in space.

It is characterized by a constant character, due to which a spasm of all muscle groups is observed. A striking example of this type can be observed in the course of Parkinson's disease.

Characteristics of the types of muscle hypertonicity

mixed variety develops with the defeat of both systems (pyramidal and extrapyramidal). It has symptoms of the two previous forms of the pathological phenomenon. It can occur against the background of tumor formations of the brain.

The reasons

Raise muscle tone can develop under the influence of various negative factors and diseases.

Reference. Conventionally, all the causes of a pathological phenomenon can be divided into 2 groups: physiological and pathological.

Physiological factors that may contribute to the development of this disorder include:

1. Prolonged stay in an uncomfortable position.
2. Bruises, various kinds of injuries.
3. Frequent stressful situations.
4. Posture disorder.
5. Overwork.

The phenomenon can act as a protective reaction to pain, for example, tension in the back muscles with damage to the vertebrae, bruise.

As pathological causes are various diseases that are accompanied by an increase in muscle tone:

Stroke is one of the causes of muscle hypertonicity.

1. Stroke.
2. brain and spinal cord.
3. Bruxism is the grinding of the teeth, which is manifested by various symptoms, among them - hypertonicity of the facial muscles, or rather chewing.
4. Vascular pathologies.
5. dystonic syndrome.
6. Spastic form (hypertonicity of the sternocleidomastoid muscle).
7. Infectious diseases of the CNS.
8. Epilepsy.
9. Parkinson's disease.
10. Myopathy.
11. Multiple sclerosis.
12. Head injury.
13. Tetanus.

Since this condition can be a symptom of a serious pathology, therapy requires a thorough diagnosis and an individual approach to the choice of treatment methods.

In adults, hypertonicity of the neck muscles or muscles of another area of ​​the body is manifested by such characteristic symptoms:

• increased tendon reflexes;
• feeling of stiffness;
• muscle spasm;
• slow relaxation of spasmodic muscles;
• uncontrolled physical activity;
• discomfort when moving;
• tension, limited mobility.

Hypertonicity has a characteristic clinical picture

When moving, the muscle tone increases, which leads to the appearance of soreness, temporary convulsions.

Prolonged muscle tension can provoke a violation of the circulatory process and the formation of painful seals.

When contacting the hospital, the patient undergoes a thorough examination, which allows you to identify the causes that provoked an increase in muscle tone, the condition of muscle tissue and the nature of spasm.

Reference. During the examination, laboratory and hardware diagnostic techniques are used.

After a conversation and examination of the patient, the specialist selects the necessary diagnostic methods, which include:

1. General and biochemical blood test- many indicators are examined, the main of which is the level of electrolytes.
2. MRI, CT for examination of the brain and cerebrospinal fluid.
3. EMG(electromyography) - finding out the speed of the nerve impulse.

EMG is one of the main diagnostic methods

Also in some cases, a muscle biopsy may be needed, consultation with specialists from another field of medicine(endocrinologist, psychiatrist, etc.).

The choice of methods for treating increased muscle tone depends on the factor of its occurrence, the severity of the lesion and the patient's well-being. Postural exercises - aimed at preventing contractures and pathological body position.

Methods of conservative treatment

Implementation in such cases is rarely resorted to.

Conclusion

To prevent the development of muscle hypertonicity, you should regularly visit a specialist to monitor the state of the body and the course of the existing disease, moderately load the body, periodically undergo massage courses.

MUSCLE SKELETON.

ABOUT MUSCLE TONE DISORDERS IN INFANTS AND THEIR CORRECTION

The first movements of the crumbs occur due to the muscular-articular feeling, with the help of which the child determines his place in space long before birth. In the first year of life, the muscular-articular feeling gives the child a powerful stimulus for development. It is thanks to him that the baby learns to make conscious movements (raise his head, reach for a toy, roll over, sit down, get up, etc.). And the main characteristic of the muscular skeleton of newborns is tone.

TONE IS DIFFERENT

First of all, you need to figure out what muscle tone is and what is considered the norm. Even in sleep, our muscles do not fully relax and remain tense. This is the minimum tension that is maintained in a state of relaxation and rest, and is called muscle tone. The younger the child, the higher the tone - this is due to the fact that at first the surrounding space is limited by the uterus, and the child does not need to perform targeted actions. In the fetal position (with limbs and chin tightly pressed to the body), the muscles of the fetus are in great tension, otherwise the child simply would not fit in the uterus. After birth (during the first six to eight months), muscle tone gradually weakens. Ideally, the muscle tone of a two-year-old baby should be approximately the same as that of an adult. But almost all modern babies have problems with tone. Bad ecology, complications during pregnancy, stress and a number of other adverse factors provoke a violation of tone in newborns. There are several most common disorders of muscle tone.

Increased tone (hypertonicity).

The child seems tense and pinched. Even in a dream, the baby does not relax: his legs are bent at the knees and pulled up to his stomach, his arms are crossed on his chest, and his fists are clenched (often in the form of a "fig"). With hypertonicity, the child holds his head well from birth due to the strong tone of the occipital muscles (but this is not good).

Decreased tone (hypotension).

With reduced tone, the child is usually lethargic, moves his legs and arms a little, and cannot hold his head for a long time. Sometimes the legs and arms of the child unbend at the knee and elbow joints by more than 180 degrees. If you lay the child on his stomach, then he does not bend his arms under his chest, but spreads them apart. The child looks limp and flattened.

Asymmetry of muscle tone.

With asymmetry on one half of the body, the tone is higher than on the other. In this case, the head and pelvis of the child are turned towards the tense muscles, and the torso is bent in an arc. When the child is laid out on his stomach, he always falls to one side (where the tone is increased). In addition, asymmetry is easily detected by the uneven distribution of the gluteal and femoral folds.

Uneven tone (dystonia).

With dystonia, signs of hyper- and hypotension are combined. In this case, the child has some muscles too relaxed, while others are too tense.

TONE DIAGNOSIS

Usually, immediately after childbirth, the doctor, on the basis of visual diagnostic tests, reveals violations of the tone and motor activity of the newborn. In addition, all babies have the so-called "residual" (posotonic) reflexes, which can also be used to determine violations of muscle tone. In principle, you yourself can check how the child is doing with the tone. Here are some basic tests that allow you to determine deviations in the development of muscle tone and postural reflexes of the newborn.

Breeding the hips.

Lay the child on his back and carefully try to unbend the legs and push them apart. But do not use force and make sure that the child does not get hurt. Normally, you should feel moderate resistance. If the legs of a newborn are fully extended without resistance and easily spread apart in different directions, this is evidence of a reduced tone. If the resistance is too strong and at the same time the child's legs cross, this is a sign of hypertonicity.

Sitting by the hands.

Lay the child on his back on a hard, flat surface (for example, on a changing table), take the wrists and gently pull towards you, as if seating him. Normally, you should feel moderate resistance to extending your arms at the elbows. If the child's arms unbent without resistance, and in the sitting position the stomach is strongly protruded forward, the back is rounded, and the head is tilted back or lowered down - these are signs of reduced tone. If you are unable to take the child’s arms away from the chest and unbend them, this, on the contrary, indicates hypertonicity.

Step reflex and ground reflex.

Take the baby vertically under the armpits, place him on the changing table and lean forward slightly, forcing him to take a step. Normally, the child should stand, leaning on a full foot with straightened toes. And when leaning forward, the child imitates walking and does not cross his legs. This reflex gradually fades away and practically disappears by 1.5 months. If this reflex persists in a child older than 1.5 months, this is evidence of hypertonicity. Also, increased tone is indicated by tucked toes, crossing the legs when walking, or relying only on the forefoot. If, instead of standing, the newborn crouches, takes a step on strongly bent legs, or refuses to walk at all, these are signs of reduced tone.

Symmetric reflex.

Lay the baby on his back, put your hand under the back of his head and gently tilt the baby's head to the chest. He should bend his arms and straighten his legs.

asymmetrical reflex.

Lay the child on his back and slowly, without effort, turn his head to the left shoulder. The child will take the so-called swordsman's position: stretch out his arm forward, straighten his left leg and bend his right leg. Then turn the child's face to the right side, and he should repeat this pose only in the opposite direction: he will stretch his right arm forward, straighten his right leg and bend his left.

tonic reflex.

Put the child on his back on a hard surface - in this position, the extensor tone of the newborn increases, he tries to straighten his limbs and seems to open up. Then turn the child over on his stomach and he will "close", pull the bent arms and legs under him (the flexor tone increases on the stomach).

Normally, symmetrical, asymmetric and tonic reflexes are expressed moderately and gradually disappear by 2-2.5 months. If the newborn does not have these reflexes or is too weakly expressed, this indicates a reduced tone, and if these reflexes persist by three months, this is a sign of hypertonicity.

Moreau and Babinski reflexes.

Watch your child carefully. When overexcited, he should scatter his arms to the sides (Moro reflex), and when irritated (tickling) of the soles, the child reflexively begins to unbend his toes. Normally, the Moro and Babinski reflexes should pass by the end of the 4th month.

If the muscle tone and the reflexes associated with it do not undergo changes corresponding to the age of the baby, this is a very dangerous signal. You should not rely on the notorious "maybe" and expect that problems with muscle tone will go away on their own. Violation of tone and development of reflexes often leads to a delay in motor development. And with a strong deviation from the norm, we are talking about the possible formation of diseases of the nervous system, ranging from convulsions to cerebral palsy (ICP). Fortunately, if a doctor diagnoses a violation of tone at birth (or in the first three months), the threat of developing serious diseases can be prevented with the help of massage, because in the first year of life the nervous system has a huge recovery potential.

HEALING MASSAGE

It is best to start massage when the baby is two months old. But first, it is necessary to show the child to three specialists: a pediatrician, an orthopedist and a neuropathologist, who make a diagnosis and give recommendations. If the child needs medication, it is usually "customized" to the massage. A properly and timely massage course helps to correct many orthopedic disorders (clubfoot, incorrectly turned feet, etc.), normalize muscle tone and eliminate "residual" reflexes. In case of serious deviations from the norm, massage should be done by a professional. But you can slightly adjust the tone at home.

It is better to massage during the day, at least an hour after feeding. You should first ventilate the room and make sure that the temperature is not lower than 22 degrees, the child should not be hot or cold. Hands should be washed with warm water, wiped dry (so that they are warm). It is not necessary to coat the entire body of the child with massage oil or cream, it is enough to apply a small amount of cream to your hands. For massage, you can use a special oil or a regular baby cream. While massaging, gently talk to your baby and watch his reaction. When the first signs of fatigue appear (crying, whimpering, displeased grimaces), you should stop exercising.

During massage, all movements are made from the periphery to the center, starting from the limbs: from the hand to the shoulder, from the foot to the groin. In the first lessons, each exercise is repeated only once. At first, the entire massage complex will take no more than 5 minutes. Gradually increase the number of repetitions and time to 15 - 20 minutes.

To eliminate hypertonicity and residual reflexes, manifested in the excessive activity of the child, a so-called gentle massage is performed - it relaxes and calms.

Start the massage by stroking the arms, legs, back with the back and palmar surfaces of several closed fingers.

You can alternate planar (with the surface of the fingers) and embracing (with the whole brush) stroking.

After stroking, the skin is rubbed in circular motions. Lay the baby on his stomach, and place your palm along the back of the baby. Without taking your hands off your baby's back, gently move his skin up, down, right, and left with stroked movements, as if you were sifting sand through a sieve with your hand.

Then lay the child on his back, take his hand and gently shake it, holding the child by the forearm. Thus, massage both hands and feet several times.

Now you can move on to swinging. Grasp the child by the muscles of the arm (just above the wrist) and gently but quickly shake and shake the arms from side to side. Your movements should be fast and rhythmic, but not abrupt. Do the same with the legs, grabbing the child by the calf muscles. You need to finish the massage in the same way as you started - with a smooth stroke.

With a reduced tone, on the contrary, a stimulating massage is performed, which activates the child.

Stimulating massage includes a large number of "chopping" movements. After traditional stroking with the edge of the palm, lightly walk along the legs, arms and back of the baby. Then lay the baby on his stomach and roll his knuckles over his back, buttocks, legs and arms. Then turn the child on his back and roll the knuckles over his stomach, arms and legs.

In addition to massage, physical therapy helps to normalize muscle tone, for example, exercises on big inflatable ball.

Put the child on the ball with his stomach, legs should be bent (like a frog) and pressed against the surface of the ball. Let dad, for example, hold the child's legs in this position, and you take the baby by the arms and pull him towards you. Then return the baby to its original position. Now take the baby by the shins and pull them towards you until the child's face is at the top of the ball or the legs touch the floor. Gently return the baby to its original position. Then tilt the child forward (away from you) so that he reaches the floor with his palms (just make sure that the baby does not hit his forehead on the floor). Repeat this exercise several times back and forth.

With an asymmetric tone, a relaxing massage should be done with an effort on the side in which the tone is lower.

In addition, the following exercise has a good effect on inflatable ball: put the child on the beach ball with the side in which he arches. Gently rock the ball along the axis of the child's body. Repeat this exercise 10-15 times daily.

Even if the child's muscle tone is normal, this is not a reason to refuse preventive massage.

Preventive massage includes both relaxing and activating movements. Such massage techniques are used as stroking (they begin and end the massage), rubbing, kneading with stronger pressure.

In a circular motion (clockwise), massage the stomach to prevent colic and constipation.

Stroke your baby's soles with your thumb and lightly pat them.

Then with the whole palm, preferably with both hands, stroke the baby's chest from the middle to the sides, and then along the intercostal spaces.

From three months, it is useful to combine massage with gymnastics. The main purpose of preventive massage is to prepare the child for walking. From two months to a year, a healthy child must undergo at least 4 massage courses (15-20 sessions each). When the child begins to walk, the intensity of the massage is reduced to two times a year. It is advisable to take massage courses in spring and autumn in order to improve the condition of the immune system, which is usually weakened at this time of the year.
Natalya Aleshina
Consultant - Pediatric Neurologist
Knyazeva Inna Viktorovna
www.7ya.ru

http://www.mykid.ru/health/42.htm

Muscle hypertonicity in adults Muscle tone refers to the presence of muscle tissue resistance when performing passive movements in the joint. This is how muscle tone is examined. They also compare symmetry in certain areas of the body, for example, on both arms or legs. Muscle tone depends on: elasticity of muscle tissue; state of neuromuscular transmission; peripheral nerve fibers; motor neurons of the spinal cord; centers of regulation of movements in the brain, its basal ganglia, reticular formation, cerebellum and brain stem, the state of the vestibular apparatus. Thus, the causes of muscle tone disorders can be hidden both in the defeat of the muscle tissue itself, and in the presence of pathology of the nervous system at all its levels (from peripheral to central). There are two groups of violations of muscle tone - hypotonicity (reduced) and hypertonicity (increased). It is the latter that will be discussed in this article. What is muscle hypertonicity and how it happens It is important to understand that muscle hypertonicity is not a separate disease, but just a symptom of a large number of ailments and pathological conditions, most of which are neurological problems. In neurology, it is customary to distinguish between two types of muscle hypertonicity: spastic (pyramidal) and plastic (extrapyramidal). The spastic type occurs when the structures of the pyramidal system (a chain of neurons that transmit movement commands for skeletal muscles from the center in the brain) are damaged. In case of damage to the central neuron of this system, spastic hypertonicity occurs. At the same time, passive movements are performed with great difficulty (resistance), but only at the very beginning of the movement. Further, the limb lends itself easily, the so-called "jackknife" symptom. This symptom is especially noticeable if you perform movements very quickly. Since the reason lies in damage to the motor center of the brain, such disorders are very often widespread, that is, not one muscle is affected, but a whole group of them, for example, the extensors of the lower leg, the flexors of the foot on the lower extremities. The most obvious example of spastic hypertonicity is in patients who have had a stroke with damage to the motor centers of the brain. The plastic type of hypertonicity is observed when the extrapyramidal nervous system is damaged (a set of brain structures and nerve pathways that are involved in the regulation and control of movements that do not require activation of attention, for example, maintaining a posture in space, organizing a motor reaction when laughing, crying, etc. ). This type of hypertonicity is also called muscle rigidity, which differs from spasticity in that resistance to passive movement is constantly present, and not only at the beginning of movement. A characteristic feature is that the limb freezes in the position that it is given, the so-called "wax flexibility". In the case of rapid performance of passive movements, the symptom of "gear wheel" is characteristic - a kind of discontinuity in resistance during passive movements. The most obvious example of plastic hypertonicity is in patients with Parkinson's disease. In some cases, when the pyramidal and extrapyramidal systems are damaged, a mixed type of hypertonicity may occur, for example, with brain tumors. In such patients, signs of spastic and plastic hypertonicity are combined. Muscle hypertonicity in adults Increased muscle tone in adults does not always indicate pathology. It can also occur as a physiological process. But it is important to remember that in medicine, hypertonicity is called its persistent increase, and temporary disorders, rather, should be called muscle spasm. Physiological causes Consider the following causes of muscle spasm: Overstrain and overwork of the muscles. In the case when the muscles have to do a lot of work, the energy reserves in them are exhausted and the muscle fiber "freezes" in a state of contraction, since the process of muscle relaxation is not at all passive, but even very energy-consuming. Therefore, until the body replenishes energy reserves, the muscle fiber will remain spasmodic. Example: painful spasm of the calf muscles after a long run. Prolonged stay in an uncomfortable or monotonous position with an increased load on a certain muscle group. The mechanism of spasm development is the same as in the previous case. Most often, such a spasm occurs in the muscles of the neck during prolonged work at the computer, back when working in the garden. As a defensive response to pain. The development of spasticity of certain muscle groups can occur with pain as a protective reaction. For example, protective tension of the muscles of the anterior abdominal wall in diseases of the gastrointestinal tract, spasm of the muscles of the spine with damage to the cervical, thoracic, lumbar vertebrae. Injuries and stressful situations. Pathological causes There are a lot of diseases that occur with muscle hypertonicity syndrome. Consider the most common of them: Acute disorders of cerebral circulation (ischemic and hemorrhagic stroke) - there is hypertonicity of the muscles of the limbs (thigh, foot, shoulder, hand), face, tongue. Tumors of the brain and spinal cord. Traumatic brain injury. Parkinson's disease. Spasmodic form of torticollis (hypertonicity of the sternocleidomastoid muscle). Bruxism (hypertonicity of the masticatory muscles). dystonic syndrome. Epilepsy. Hepatic encephalopathy. Myotonia. Tetanus. CNS infections. Multiple sclerosis. Vascular diseases of the brain and spinal cord. Cerebral palsy. Principles of treatment Treatment of muscular hypertension includes two main areas: Elimination of the underlying disease. Correction of the consequences of pathology in the form of hypertonicity. Unfortunately, it is not always possible to get rid of the root cause of the pathology. In such cases, only complex therapy, which includes the use of medications, massage, therapeutic exercises, psychotherapy, physiotherapy and reflexology, will help alleviate the patient's condition and relieve muscle rigidity. Drug therapy can reduce the tone of spasmodic muscles, reduce pain, improve the function of nerve fibers, and establish microcirculation in the affected tissues. Most often, muscle relaxants and antipsychotics, B vitamins, and metabolic agents are prescribed for this purpose. In some cases, botulinum toxin is used to eliminate the increased tone. With it, you can eliminate rigidity in certain muscles, for example, facial, chin area, etc.

The main drugs used to reduce muscle tone are muscle relaxants. According to the mechanism of action, muscle relaxants of central action (affect the synaptic transmission of excitation in the central nervous system) and peripheral action (inhibit direct excitability of striated muscles) are distinguished. When using muscle relaxants, quite significant side effects can occur, which should be carefully evaluated when choosing a drug.

When choosing antispastic drugs, their ability to inhibit polysynaptic reflexes (reduction of spasticity) is taken into account, while having the least effect on monosynaptic reflexes (muscle strength). The antispastic drug should reduce muscle spasticity with minimal loss of muscle strength.

Drug therapy is based on the use of tablet and injection forms. Antispastic agents used orally, by reducing muscle tone, can improve motor functions, facilitate care for an immobilized patient, relieve painful muscle spasms, enhance the effect of physiotherapy exercises, and prevent the development of contractures. With a mild degree of spasticity, the use of muscle relaxants can lead to a significant positive effect, however, with severe spasticity, large doses of muscle relaxants may be required, the use of which often causes undesirable side effects. Treatment with muscle relaxants begins with a minimum dose, then it is slowly increased to achieve the effect.

The centrally acting muscle relaxants most commonly used in Russia for the treatment of spastic muscle hypertonicity include baclofen, tizanidine, tolperisone, diazepam.

Baclofen (Baclosan, Lioresal) has an antispastic effect mainly at the spinal level. The drug is an analogue of gamma-aminobutyric acid (GABA), which binds to presynaptic GABA receptors, leading to a decrease in the release of excitatory amino acids (glutamate, aspartate) and suppression of mono- and polysynaptic activity at the spinal level, which causes a decrease in spasticity. The drug also exhibits a moderate central analgesic effect. Baclofen is used for spinal and cerebral spastic muscle hypertonicity of various origins. The initial dose is 5-15 mg / day (in one or three doses), then the dose is increased by 5 mg every day until the desired effect is obtained. The drug is taken with food. The maximum dose of baclofen for adults is 60-75 mg/day. Side effects are more often manifested by sedation, drowsiness, decreased concentration, dizziness and often weaken during treatment. Perhaps the occurrence of nausea, constipation and diarrhea, arterial hypertension, increased ataxia, the appearance of paresthesia. Caution is required in the treatment of elderly patients, stroke patients, patients with gastric and duodenal ulcers. Baclofen is contraindicated in epilepsy, a history of seizures.

With severe spasticity, when the usual oral administration of antispastic drugs is not effective, intrathecal administration of baclofen is indicated, which was first proposed in 1984 by R. Penn. To achieve the required concentration of the drug in the cerebrospinal fluid, it is necessary to take quite significant doses of baclofen, which can lead to impaired consciousness, drowsiness, and weakness. In this regard, systems have been developed in which baclofen is delivered directly to the intrathecal space of the spinal cord using an intrathecal baclofen pumping system. At the same time, the clinical effect is achieved with much lower doses of baclofen than when using tablet forms.

This system consists of a reservoir containing baclofen or a similar drug, a pump (pump), with which the drug is dosed into the intrathecal space of the spinal cord through a lumbar catheter, and a power supply unit. From the reservoir, baclofen enters directly into the cerebrospinal fluid, and its dosage is controlled by a special radio telemetry device. The amount of drug entering the cerebrospinal fluid can be changed depending on the clinical picture. Baclofen is added to the reservoir after 2-3 months by percutaneous puncture.

The use of a baclofen pump improves the speed and quality of walking in patients with non-fixed reflex contractures due to high spasticity of synergistic muscles and imbalance of antagonist muscles. The available 15-year clinical experience of using baclofen intrathecally in stroke patients indicates the high efficiency of this method in reducing not only the degree of spasticity, but also pain syndromes and dystonic disorders. A positive effect of the baclofen pump on the quality of life of stroke patients was noted.

Tizanidine (Sirdalud) is a centrally acting muscle relaxant, an alpha-2-adrenergic receptor agonist. The drug reduces spasticity due to the suppression of polysynaptic reflexes at the level of the spinal cord, which may be caused by inhibition of the release of excitatory amino acids L-glutamate and L-aspartate and activation of glycine, which reduces the excitability of spinal cord interneurons. Tizanidine also has a moderate central analgesic effect. The drug is effective for cerebral and spinal spasticity, as well as for painful muscle spasms. The initial dose of the drug is 2-6 mg / day in one or three doses, with individual selection, the dose is increased by 2 mg by 3-4 days. When taken orally, the effect of the drug appears after 30-45 minutes, the maximum effect occurs within 1-2 hours. The average therapeutic dose is 12-24 mg/day, the maximum dose is 36 mg/day. As side effects, drowsiness, dry mouth, dizziness and a decrease in blood pressure may occur, which limits the use of the drug in post-stroke spasticity. The antispastic effect of tizanidine is comparable to the effect of baclofen, but tizanidine, with an adequate dosage selection, is better tolerated, because it does not cause general muscle weakness and does not increase muscle weakness in a paralyzed limb.

Tolperisone (Mydocalm) is an antispastic drug of central action, it depresses the caudal part of the reticular formation and has N-anticholinergic properties. Tolperisone reduces the activity of spinal neurons involved in the formation of spasticity by limiting the flow of sodium through the membrane of nerve cells. The most commonly used dose is 300-450 mg/day in two or three divided doses. A decrease in muscle tone when prescribing tolperisone is sometimes accompanied by a vasodilating effect, which should be taken into account when prescribing to patients with a tendency to arterial hypotension. Also, the drug can cause or increase urinary incontinence in patients.

The main side effect of baclofen, tizanidine and tolperisone is the rapid onset of muscle weakness, and in each case the doctor must find a balance between a decrease in tone and an increase in weakness. The balance curve between a decrease in spastic tone and an increase in muscle weakness in patients with an increase in the dose of Mydocalm, Sirdalud or Baclofen shows that the most rapid increase in weakness occurs when taking Baclofen, and the mildest drug that allows you to effectively select an individual dosage is Mydocalm. In all cases, given the presence of a narrow therapeutic window, the course of treatment begins with a small dose of the drug, gradually increasing it until a distinct antispastic effect is achieved, but not until weakness appears.

Diazepam (Realanium, Relium, Sibazon) is a muscle relaxant because it has the ability to stimulate reduced presynaptic inhibition at the spinal level. It has no direct GABA-ergic properties, increases the concentration of acetylcholine in the brain and inhibits the reuptake of norepinephrine and dopamine in synapses. This leads to an increase in presynaptic inhibition and is manifested by a decrease in stretch resistance, an increase in the range of motion. Diazepam also has the ability to reduce pain caused by muscle spasm. Along with a decrease in muscle tone, lethargy, dizziness, impaired attention and coordination develop due to toxic effects on the central nervous system. This significantly limits the use of diazepam as a muscle relaxant. It is used mainly for the treatment of spasticity of spinal origin, if necessary, a short-term decrease in muscle tone. For the treatment of spasticity, it is prescribed at a dose of 5 mg once or 2 mg 2 times a day. The maximum daily dose may be 60 mg. At high doses, there may be disturbances in consciousness, transient liver dysfunction and blood changes. The duration of treatment is limited due to the possible development of drug dependence.

Clonazepam is a benzodiazepine derivative. Clonazepam has a sedative, central muscle relaxant, anxiolytic effect. The muscle relaxant effect is achieved by enhancing the inhibitory effect of GABA on the transmission of nerve impulses, stimulating benzodiazepine receptors located in the allosteric center of the postsynaptic GABA receptors of the ascending activating reticular formation of the brainstem and intercalary neurons of the lateral horns of the spinal cord, as well as reducing the excitability of the subcortical structures of the brain and inhibition of polysynaptic spinal reflexes.

The rapid onset of drowsiness, dizziness and addiction limits the use of this drug. To reduce the manifestation of possible adverse reactions, it is necessary to reach a therapeutic dose by slow titration over two weeks. For oral administration, adults are recommended an initial dose of not more than 1 mg / day. Maintenance dose - 4-8 mg / day. Perhaps the appointment of small doses in combination with other muscle relaxants. Clonazepam is effective in paroxysmal increases in muscle tone. Contraindicated in acute diseases of the liver, kidneys, myasthenia gravis.

Dipotassium clorazepate (Tranxen) is an analogue of benzodiazepine, is transformed into the main metabolite of diazepam, has a greater activity and duration of antispastic action than diazepam. Its good effect was noted in the treatment in the form of a decrease in phasic stretch reflexes, it has a slight sedative effect. The initial dose is 5 mg 4 times a day, then reduced to 5 mg 2 times a day.

Dantrolene is an imidazoline derivative that acts outside the central nervous system, mainly at the level of muscle fibers. The mechanism of action of dantrolene is blocking the release of calcium from the sarcoplasmic reticulum, which leads to a decrease in the degree of contractility of skeletal muscles, a reduction in muscle tone and phasic reflexes, and an increase in the range of passive movements. An important advantage of dantrolene in relation to other muscle relaxants is its proven effectiveness in relation to spasticity not only of spinal, but also of cerebral origin. The initial dose is 25 mg / day, if tolerated, the dose is increased within 4 weeks to 400 mg / day. Side effects - drowsiness, dizziness, nausea, diarrhea, decreased glomerular filtration rate. A serious danger, especially in elderly patients at a dose of more than 200 mg / day, is a hepatotoxic effect, therefore, during the treatment period, liver function should be regularly monitored. Elimination of dantrolene by 50% is carried out due to hepatic metabolism, in this regard, it is contraindicated in liver diseases. Caution should also be observed in severe heart or lung diseases.

Katapresan - is used mainly for spinal injuries, acts on alpha-2-agonists of the brain, has presynaptic inhibition. Side effects include lowering blood pressure and depression. The initial dose is 0.05 mg 2 times a day, the maximum is 0.1 mg 4 times a day.

Temazepam interacts with benzodiazepine receptors of the allosteric center of postsynaptic GABA receptors located in the limbic system, ascending activating reticular formation, hippocampus, intercalary neurons of the lateral horns of the spinal cord. As a result, channels are opened for the incoming currents of chloride ions and thus the action of the endogenous inhibitory mediator, GABA, is potentiated. The recommended dose is 10 mg 3 times a day. Its combination with baclofen is effective.

The main drugs used to treat spastic muscle hypertonicity are presented in Table.

Thus, the choice of drug is determined by the underlying disease, the severity of muscle spasticity, as well as side effects and features of the action of a particular drug.

For example, tizanidine and baclofen have a greater effect on the tone of the extensor muscles, therefore, in cases of significant hypertonicity of the arm flexor muscles, slight spasticity of the leg muscles, their administration is not indicated, since a slight increase in the tone of the leg extensor muscles compensates for muscle weakness in the leg and stabilize the patient's gait. In this case, the means of choice are methods of physical impact on the muscles of the upper limb.

In the treatment of cerebral spasticity, Sirdalud is most often used, and in spinal spasticity, Sirdalud and Baclofen are used. An important advantage over other muscle relaxants is Mydocalm, which does not have a sedative effect and has a favorable tolerance spectrum, therefore it is the drug of choice for outpatient treatment and for the treatment of elderly patients.

A combination of several drugs is acceptable, which allows you to effectively reduce the tone at lower doses of each of the drugs. The combination of drugs with different points of application, ranging from centers in the brain to muscles, can lead to a summation of the therapeutic effect.

The effectiveness of oral antispastic drugs decreases with their long-term use, often there is a need for an increasing increase in dosages to maintain the initial clinical effect, which is accompanied by an increase in the frequency and severity of adverse reactions.

In a situation where spasticity is local in nature and the systemic effect of oral muscle relaxants is undesirable, local methods of exposure are preferable, one of which is the local administration of botulinum toxin.

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A. A. Korolev,Candidate of Medical Sciences

FSBI All-Russian Center for Emergency and Radiation Medicine named after V.I. A. M. Nikiforov" Ministry of Emergency Situations of Russia, St. Petersburg