Clonus and strokes

Clonus is a standard secondary effect in people after a stroke, which is manifested by uncontrolled and rhythmic muscle contractions (1). That is an abnormal reflex response that happens when a muscle is quickly stretched. Clonus could cause difficulties in movement and performance, starting from impaired arm function resulting from upper limb clonus to gait dysfunction brought on by ankle clonus.

After a stroke, abnormal communication may occur between the motor and sensory areas of the cerebral cortex and other subcortical areas, causing dysregulation of muscle tone control, which results in characteristic clonic spasms (2). Although often confused with tremor, clonus is a separate condition that requires separate treatment.

Despite the devastating impact of clonus on life after a stroke, the brain’s ability to reorganize neural networks, or neuroplasticity, ensures recovery is feasible. This text describes the signs and symptoms of clonus, in addition to effective treatments.

Varieties of Clonus

Clonus can present itself in various parts of the body, reminiscent of the ankle, knee and wrist. Essentially the most common area of ​​clonus is the ankle joint.

The health care provider can observe ankle clonus by quickly bending the patient’s foot toward the shin. If clonus is present, the foot will bounce up and down involuntarily and rapidly. The bouncing may stop suddenly, regularly disappear, or it might proceed until pressure is created on the only of the foot. Although not as common, clonus may occur within the wrist, fingers, or jaw.

Distinguishing Clonus from other conditions

Clonus will be confused with other conditions reminiscent of tremor, myoclonus, and spasticity. These are different diseases that require separate therapeutic interventions. For that reason, it is necessary to know and understand the differences between these terms.

Tremor is the involuntary, shaking or trembling movement of parts of the body, having various types and causes (3). Myoclonus is a transient, involuntary, irregular twitching of a muscle or group of muscles. There are several different types of myoclonus (4), starting from harmless hiccups to more serious cases affecting movement, eating, and speaking (5). Unlike tremor and myoclonus, clonus is an unusual reflex response to muscle stretching, characterised by rhythmic movement and bouncing. All three reactions could also be unwanted side effects of certain central nervous system conditions.

Take a more in-depth look: That is an example of carpal clonus. (6)

Clonus and spasticity – what is the difference?

Although many stroke survivors and their care partners may confuse these two medical terms, clonus and spasticity are completely different concepts and have different effects on the body. Although spasticity and clonus could also be related phenomena related to changes in upper motor neurons and normal regulation of muscle tone and reflexes, not all stroke survivors with spasticity (increased muscle tone) will necessarily have clonus.

Listed here are some features that distinguish spasticity from clonus:

Spasticity:

• Muscle stiffness and resistance to passive movements. Severity levels vary depending on the person and certain triggers within the environment.
• Stretching resistance is bigger at higher speeds when a “fast stretch” is used on a muscle group. This is named “speed-dependent” drag.
• Each opposing muscle groups of a joint could also be affected, but not all the time.
• Learn more about flexor synergy, spasticity and stroke.

Clone:

• It often involves a rapid series of muscle contractions and relaxations.
• Mostly seen within the ankle (ankle clonus), but may occur in other joints.
• Often triggered by a fast stretch of a muscle, reminiscent of a sudden dorsiflexion of the foot.

What can clonus cause?

Clonus is usually related to hyperactivity of the stretch reflex and is often observed in conditions through which there may be damage or dysfunction of upper motor neurons.

Clonus often occurs because of this of harm to the upper motor neuron, which suggests that there was damage to specific nerve cells within the brain and spinal cord that support body movement. Upper motor neuron lesions disrupt the “normal” nerve signals that travel from the brain to the spinal cord and reach the muscles.

In a stroke, blood flow to the brain is interrupted resulting from a blockage from an ischemic stroke or bleeding from a hemorrhagic stroke. Due to this fact, clonus could also be a symptom of disorders within the brain and nervous system.

Other neurological conditions which will cause clonus

Along with stroke, there are several other neurological conditions that could cause clonus.

These include (7):

• Traumatic brain injuries
• A brain tumor
• Brain infections (meningitis or encephalitis)
• Spinal cord damage
• Cerebral palsy
• Multiple sclerosis
• Amyotrophic lateral sclerosis (ALS)

Symptoms of clonus

Every stroke is different. If clonus occurs, your symptoms could also be roughly severe than those of other individuals with clonus.

Some symptoms may include (7):

• Rhythmic shaking stimulated by rapid stretching or change of position
• Increased muscle tension or pain
• Involuntary movements, reminiscent of bending or crossing an arm or leg
• Decreased balance resulting from rhythmic muscle contractions
• Muscle fatigue brought on by muscle spasms over an extended time period
• Sleep disturbances which can result in excessive tiredness through the day
• Muscle and/or joint contractures if the joints and muscles usually are not stretched properly to take care of length

You should definitely monitor your specific symptoms of clonus and report them to your rehabilitation team to assist with diagnosis, treatment, and management.

Clonus diagnosis

There are special tests your doctor may perform to diagnose clonus in a one who has had a stroke. First, your doctor will perform a physical examination and review your medical history to completely understand your symptoms and overall health. During neurological examination, commentary proves to be very effective in diagnosing clonus.

Other tests may include (8):

• Specific blood test
• MRI scan of the brain or spinal cord
• computed tomography
• Nerve conduction tests
• Electromyogram
• Lumbar puncture (lumbar puncture)

Clonus management

In the event you suffer from clonus after a stroke or other neurological condition or injury, it is feasible to administer your symptoms and maintain a great life with a comprehensive treatment plan. The components of your plan will rely on the severity of your clonus.

Some general treatments may include (7):

• Stretching exercises
• Applying a chilly compress
• Applying hot compresses
• Magnesium supplements to assist calm down muscles
• Oral medications: Examples include baclofen, tizanidine, diazepam, gabapentin, etc.
• Local injections: Botulinum toxin injections, commonly known by the brand name Botox, are sometimes used to treat clonus, particularly in cases of clonus related to spasticity.
• Techniques for coping with clonus during each day activities

Occupational therapy and physiotherapy interventions

To make sure best practice within the treatment and management of clonus, occupational and physical therapy needs to be a part of the rehabilitation care plan. During an occupational therapy and/or physical therapy session, your therapist will show you the right way to stretch and strengthen the affected muscles, promoting increased mobility and functionality. Rehabilitation exercises concentrate on mastering specific movements to help neuroplasticity and retrain neural networks. Exercises reminiscent of yoga can also be advisable to enhance muscle tone, lengthening, stress reduction and overall rest of the nervous system.

If mandatory, your therapist may recommend splints and/or braces to supply joint support. A stroke survivor should seek advice from his or her doctor and therapist about whether she or he thinks a brace or splint could be helpful within the stroke recovery process.

If therapy, medications and residential remedies don’t work, your doctor may recommend surgery. Surgery is usually considered the last option since it involves cutting the nerve channels that cause the muscles to maneuver abnormally. Orthopedic surgery to elongate the muscles could also be mandatory if the condition results in everlasting and long-term shortening of the soft tissues that can’t be corrected with conservative treatment.

Life with Clonus

Clonus within the upper and lower limbs can significantly impact a patient’s ability to perform each day tasks. Experiencing clonus could make personal hygiene, dressing, and even eating difficult. A stroke survivor should discuss these concerns with their doctor and care partner, as it will help them higher understand the circumstances of their clonus.

A stroke survivor may experience clonus while recovering from a stroke, which will be frustrating and embarrassing. It will be significant for the survivor to do not forget that it shouldn’t be their fault. Clonus will be uncomfortable or disabling. Nevertheless, discussing it and counseling with a therapist and doctor can assist the survivor learn to deal with clonus and lead a more fulfilling life.

Bibliography

1. “Clonus: Definition, Causes, Treatment and Tests”. Cleveland Clinic, https://my.clevelandclinic.org/health/symptoms/24822-clonus. Accessed: August 9, 2023
2. Kassam, Adam et al. “Treatment of upper limb clonus with intramuscular injections of botulinum toxin A in a stroke patient.” PM&R, Vol. 7, no. May 5, 2015, pp. 542–46. ScienceDirect, https://doi.org/10.1016/j.pmrj.2014.10.011.
3. “Shakes.” Cleveland Clinic, https://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/tremors/. Accessed: October 25, 2023
4. Neurology Exam: Clonus – StrokeSciences. https://strokesciences.com/neuro-exam-clonus/. Accessed: August 9, 2023
5. “Myoclonus.” National Institute of Neurological Disorders and Stroke, https://www.ninds.nih.gov/health-information/disorders/myoclonus. Accessed: October 25, 2023
6. Wrist maple | NEJM. www.youtube.com, https://www.youtube.com/watch?v=aZCGF-nJEKU. Accessed: August 9, 2023
7. “Clonus after stroke: causes, symptoms and treatment”. Flint Rehab, April 6, 2023, https://www.flintrehab.com/clonus-after-stroke/.
8. Bhimani, Rozina and Lisa Anderson. “Clinical understanding of spasticity: implications for practice.” Rehabilitation Research and Practice, Vol. 2014, 2014, pp. 2014 279175. PubMed Central, https://doi.org/10.1155/2014/279175.