Spasticity; can it be prevented from

surfacing at all?

By
Rajul vasa
Applied movement scientist
Mumbai [India]
www.brainstrokes.com
 Book description of spasticity.

 Spasticity is described in medical books as a resistance

to passive movement in UMN (upper motor neuron) disorder as
a result of lesion in the CNS (central nervous system)
 Studies indicate that spasticity affects more than half a
million people in the United States alone, and more
than 12 million people worldwide.
 Following stroke, approximately 65% of individuals
develop spasticity.
But, It is very important to consider patient’s
experiences of spasticity in their daily life and
experiences of therapists about spasticity in clinical
practice.
 What does the patient wants to know?

 Medical service providers consider Spasticity as an

inevitable phenomenon once damage is done to the
brain. Whereas ………………
 Stroke subject wants to get rid of it for good and
wonder why they experience such a tightness
despite all medical treatment.
 Book definition does not interest patient. No patient
likes to hear that spasticity is inevitable or to know
that drug can only help reduce spasticity.
 Surgery reduces contracture but does not put an
end to spasticity.
 Distress to Frustration

 Stroke subjects feel helpless when arm comes in their way during
standing up, sitting down, walking and climbing and is not under their
control and does not move according to their desire.
 Stroke subjects get bothered when paretic arm remain closer to the body
on the chest, bent most of the time with difficulty to reach out in open
with the fingers fisting unable to open even while bathing with thumb
remaining in the palm all the time in some people .
 Taking few steps is frustrating with foot turning in Supination and heel
rising within the shoe despite wearing orthotic splints. Frustration mounts
when walking demands constant attention at the foot while placing it
which otherwise they could take for granted when normal.
 Toe clawing, great toe extension, bunion toes, difficulty in bending the
knee are also some of the constant challenges for many with frustration
mounting from constant fear of falling for simple activities like standing
and walking which is also highly fatiguing.
 Dark tunnel

 When all the efforts fail to get rid of the

spasticity like relentless exercising, taking
expensive drugs, living with all side effects
of drugs and being jobless frustrates many
when no clear direction is seen and no clear
answer to the problem is found.

One of the E mail [unedited] letters out of many

sent to me from around the world speaks
volume. [ Name of the patient and place is kept secret]
 E mail letter
Subject: How does one eliminate severe muscle spasticity after
acute thrombo embolic stroke without medication.

“I have tried every muscle relaxant on the market, nothing works. I

have asked to be evaluated for Botox injections and I was told not to
expect any help from Botox. The distinct feeling that I get from health
professionals is to simply accept the condition as permanent and not
hope for any motor function recovery. My stroke also afflicted me with
epilepsy and it is simply to dangerous to perform unsupervised
physical therapy with that neurological condition, I had a mild seizure
on June 13 after nearly 18 months of normality. In any case I have a
very serious drop foot problem where I must drag my lower limb by
raising my hip in a completely unnatural manner. When health
specialists demonstrate such pessimistic attitudes how can a stroke
survivor demonstrate optimism? It is like someone telling me, don’t
worry and be happy you are still alive after all. I am really starting to
believe that in my case no amount of hard work will ever pay
dividends and provide some quality of life improvement. Contd….
 E mail letter (continued)

Post stroke depression is a real bitch and a serious bladder control

issue does not help at all. I don’t believe in miracles and nothing I have
seen in post stroke rehabilitation to date will change my mind on the
possibility of performing meaningful post acute stroke recovery. How
can you succeed where thousands have failed before? If the Vasa
Concept is as effective as you claim, why is it not in use in all reputable
stroke rehab facilities? You seem to promote healing principles that are
more associated with the treatment of the energy centers of the human
body. Building new neuro muscular pathways to healthy parts of the
brain implies teaching the brain skills that have been dormant for
decades or have never been used at all. What is the trigger mechanism
capable of performing such a reorganization of the brain. Triggered
electro-myography was invented with the promise of helping stroke
survivors rebuild new neuro muscular pathways; it has proven nearly
useless with acute stroke survivors. Contd……
 E mail letter (continued)

Victims wishing to use E.M.G. must do so at their own expense since

insurance companies do not recognize it's benefit as a therapeutic
apparatus. Most stroke victims are already affected by loss of revenue
and must incur additional debt burden to seek new rehabilitation
therapies. Since money does not grow on trees, very few have the
possibility of seeking truly beneficial therapies that might help to restore
lost motor control functions. It really comes down to how bad do you
want to obtain medical treatment and how much are you willing to spend
to get rid of the wheelchair permanently. In western society, stroke
rehabilitation is the domain of Physiatrists and they operate within a
very rigid frame of medical teaching in which holistic medicine has no
foundation or merit. We are not in a position to challenge what the
medical field considers to be it's imminent domain. We are the patients
and must often accept medical prognostics at face value. If the
physiatrists were the individuals afflicted by brain attacks, I suspect that
many of them would question traditional teaching and seek help in
uncharted territory. In a society where healthcare is provided by the state.
The state prefers to keep medical expenditure per capita to a minimal. “
Sincerely.
 Chaotic brain is made more chaotic.

 Some patients even try oil massage, pigeon blood

massage, and any alternative medicine in the hope
to get rid of spasticity.
 Acupuncture, acupressure and massage is very
good for a number of orthopedic ailments but in
neurological conditions like stroke it can make the
chaotic brain more chaotic with externally induced
sensory inflow it cannot cope in presence of lesion.
I feel time is up to look at the spasticity with non
traditional view to find its root cause and of course
it’s solution.
 What one must know
 What one needs to know is that spasticity is not a
direct effect of lesion in the brain.
 Immediate direct effect on muscle following stroke
is flaccidity and hypotonia.
 Spasticity is triggered by self-organizing brain with
passage of time for a purpose [Rajul Vasa unpublished
observation].
 Spasticity does recur despite all treatment as long
as purpose for its birth is not taken care of in
therapeutics. [Rajul Vasa unpublished observation]
 One must remove the purpose to rid of the spasticity
permanently. [Rajul Vasa unpublished observation]
 Optimality of self-organized brain.

I believe that spasticity is a product of self-

organizing brain in self defense to prioritize
safety following stroke. [Rajul Vasa unpublished observation]
 Brain maintains one priority for all living organisms on this earth. It is to
prioritize safety of COM (centre of mass) at any cost.
 With paralysis safety of body is at stake as paretic body does not have
power to combat force of gravity and adds on to disequilibrium.
 Spasticity is an optimal attempt of the self-organized brain to offer
increased resistance to move paretic body thereby minimize instability and
disequilibrium arising from flail paretic segments with increased degrees of
freedom that threatens safety of COM. [Rajul Vasa unpublished observation]
 Spasticity also acts as a powerful “BRAKE” [Rajul Vasa unpublished observation]
on the fluid change in posture thereby avoiding disequilibrium and
optimizing and capitalizing on resistance to move, for defense of COM.
Clinically applied definition of spasticity in
Vasa Concept.
Prolonged activity of “spastic” muscles is an
endeavor of self organized stroke CNS to
restrict the increased degrees of freedom of
paretic flail segments with continuous
proactive anticipatory contraction in chain of
muscles [not reflex contraction] to restrict the
boundaries of COM movement in different
Cartesian coordinates in self defense for; safety
of COM is always a priority for all living self
organizing biological system.
 Events that follow with stroke

 Paretic body mass without power in muscles to combat

gravitational force causes disequilibrium and poses threat to the
safety of COM.
 Self-organizing brain with instant plasticity switches control on
COM from paretic body to good body exclusively. For; safety of
COM is always a priority.
 With one side turning flail and paretic, the opposite good side pulls
on paretic side unopposed causing trunk to rotate away from
paretic side. This leads to unloading of paretic lower limb from
sustaining head arm trunk [HAT] mass. [Large postural muscles of both sides of the
trunk act like ONE CIRCULAR RING having common insertion on central axis at the back and Linea alba in the
front]

 With unloading of paretic lower limb, snowball effects on paretic

body [Mouth +Face + Trunk + upper limb + lower limb] , on quality of speech, effects in
distant distributed sensory, motor, perceptual, cognitive and limbic
areas of brain gets triggered……….
 Neural endorsement of mechanical
Unloading of paretic Lower Limb.

 Self-organizing brain exploits unopposed mechanical pull

of good trunk muscles with its simultaneously ongoing
sensory inflow from reoriented and rotated head arm
trunk to neurally endorse mechanical unloading of paretic
lower limb from sustaining passive inertial mass of head
arm and trunk [HAT] in order to reduce the threat to COM
(centre of the mass) and prioritize safety by reorganizing
anticipatory postural circuits to control and restore COM
exclusively with good side of the body and to make it as an
automatic act. [Rajul Vasa unpublished observation]

This makes it almost impossible to reload the paretic limb

unless one takes care of control on COM and restore COM
with paretic limbs automatically [Rajul Vasa unpublished observation]
through therapeutics based on Vasa Concept.
 Bilateral innervation of the trunk

I feel that….
 Self-organizing brain might be exploiting bilateral
innervation of the trunk also to bind anatomically
connected paretic torso with good torso at the
central axis.
 Reorganization of cerebello-cerebellar inter
connectivity might be helping to sustain paretic
trunk against the force of gravity when standing.
 Binding of paretic trunk to good trunk mechanically
with contracture might help to sustain interactive
disequilibriating forces when lower limbs go in
swing phase of the gait cycle while walking.
 Binding of the torso at the central axis

I also feel that …

 Self-organizing brain might be binding the paretic torso to
good torso in order to reduce threat to the safety of COM
from inertial mass of the paretic torso.
 Self-organizing brain might be passively binding paretic
torso to central axis with contracture in deep tissues and in
small inter vertebral muscles to strengthen egocentric
reference for paretic good side.
 Self-organizing brain might be binding the paretic torso
with good torso in order to make the paretic body to follow
the good body, and to allow the good body to lead
uninterruptedly so that exchange of dominance between
two sides comes to an end to prioritize safety of COM
 What does it lead to?

It leads to chain of unseen under currents that gives

birth to abnormal synergic grouping in chain of
muscles with spasticity to sacrifice selective control.
 Paretic limbs unable to sustain force of gravity reinvents
its presence in 3 dimensional space for gravicentric
reference via good side of the body by moving in one
single direction, only towards the central axis thereby
strengthening the egocentric reference of paretic limbs to
central axis [Rajul Vasa unpublished observation] from physiological
inter limb coupling and inter limb sensation.
 Synergic grouping also enable the entire body to work as
one whole [Rajul Vasa unpublished observation] entirely optimally
integrated unit [though integrated differently & abnormally] despite
paresis.
Birth of spasticity from walking with unloaded
lower limb
 In normal people during daily activities like standing up, sitting down,
walking and climbing all 4 limbs remain integrated and tightly coupled
with physiological inter limb sensation and inter limb knowledge.
 For a stroke subject with paretic unloaded lower limb that no longer
control and restore COM also makes simultaneous sensory afferent
inflow to remain consistent and unchanging.
 Consistently unchanging imbalanced afferent inflow between paretic
and non paretic good side might be leading to reorganization of spino-
spinal circuits and supra spinal postural circuits for automatic safety of
COM with good side.
 Paretic upper limb tightly coupled with rest of the limbs comes under
heavy influence of paretic unloaded lower limb that no longer controls
or restores COM making upper limb to go in abnormal looking flexion
adduction posture or bent elbow posture in order to not let the COM
run out of the narrow support surface.
 Physiological inter limb coupling

 Normal physiological inter limb coupling enables

normal people to have swing of the arm when both
lower limbs are alternately responsible for weight
bearing and weight shifting of the inertial mass of the
head arm and trunk [HAT]during walking with both
sides of the body constantly alternating to lead and to
follow one another highly subconsciously automatically
without thinking.
 It is this coupling between the limbs that allow one arm
to reach out in open easily to pick things when the other
limbs are acting as a supporter of the act to complete the
act of reaching and picking. Whereas In a stroke
subject……
 Normal Lady In a stroke subject, upper limb
Hopping on single goes in flexion posture that can
leg
be compared with normal inter
limb coupling in a normal
woman seen in the picture
hopping on one leg that can be
compared with reduced loading
or unloading of the paretic lower
limb while walking making
abnormal looking flexion posture
to be inevitable under the given
circumstances in stroke pts.
 Swinging of arms while walking.

 Flexed abnormal synergic posture of

paretic UL in defense of COM from
unloading of paretic LL of HAT mass
prevents swing of arms that may risk
COM safety on narrow support surface.
 Abnormal Flexion synergy in UL
sacrifices volitional control for safety of
COM.
 In a stroke subject, upper limb
Flexed posture goes in flexion posture difficult to
of upper limb. change even with passive external
force.
Paretic UL treated individually
under direct focus in
multidisciplinary approach by a
specialist may result in; Mental
exclusion of paretic limbs from
being part of one whole during
postural activities of daily living,
this makes stroke as a condition to
become permanent.
  Paretic unloaded LL sustains itself
Right knee
recurvatum against the force of gravity from
collapsing with force from bone on
bone locking with passive recurvatum
of the knee i.e. knee joint locking on
ligamentous over stretching.
 Some patients also develop
exaggerated quadriceps activity in
knee extension that makes lower limb
act as a prop making knee bending
difficult.
 Leg as a prop helps to support the
[HAT] mass briefly when good limb
goes in swing phase of walking with
its consequences on upper limb……
Looking down Walking pattern
 Different Walking pattern emerges in different
and walking. stroke subjects .
 Looking down for safety feeling emerges
without their knowledge.
 Walking speed reduces greatly.
 Step length reduces and number of steps /
minute reduces.
 Balance becomes precarious and may need
external support of hemiwalker / cane / crutch
etc.
 Good body continues to lead the entire body
preventing any exchange of dominance between
two sides changing complete rhythm of cyclical
alternating action of walking.
 Gait training has little effect on restoring safety
feeling or rhythmic cyclical automatic action or
on use of eyes for balance.
 Egocentric and Gravicentric reference.

 Paretic upper limb exaggerates its egocentric

reference for sustaining itself in gravitational field by
coming closer to central axis with flexed adducted
posture.
 This adds onto, no swing of the arm.
 Paretic body finds its gravicentric reference via good
body and gets mechanically towed to be a constant
follower of good side of the body.
 “Normally abnormal, becomes normal”

 “Normally abnormal, becomes normal” for the

stroke CNS with full stop on the exchange of
dominance between two sides of the body making
good side to “lead” always and paretic side to
always “follow” making stroke, a condition forever
with deterioration in general condition with muscle
to continue to get tightened and get wasted though
stroke is not a progressive disorder.
Contemporary management of spasticity

 Forced passive movement.

 Inhibitory exercises. [Though spasticity do reappear after a while].
 Splinting. [Passive sustained stretch from splint falls short to activate the Golgi tendon making
spastic muscle more spastic and contracted under sustained contraction].

 Number of drugs are available in the market but none

promise to get rid of spasticity for good.
 Spastic muscle may go under surgeon’s knife, but it is
not the permanent solution.
 Spasticity management is directed more towards goals in
“passive” function, such as making it easier to get the
arm through a sleeve or to maintain hygiene.
 Permanent solution in Vasa Concept

I feel, manmade efforts become dwarf compared to

powerful purpose of self-organized brain to maintain its
priority unless….
 Therapeutic efforts are directed towards maintaining the
same priority to control and restore COM with paretic
side of the body so that purpose for birth of spasticity is
removed for good.
 Promote paretic body to lead entire body and make good
body to learn to follow the paretic body to allow smooth
exchange of dominance between two sides of the body to
lead and to follow on the need of the moment
automatically without thinking and planning.
Restoration of exchange of dominance between paretic and
good side will not allow spasticity to surface at all.