Managing Spasticity

Treatments

The goal of spasticity treatment is to improve some aspect of a person's life. This will differ from one person to another and over time.

The healthcare team (physicians, physiotherapists, nurses etc) work with the patient and carer to define goals for the spasticity treatment. The decision to treat spasticity should include full consideration of all aspects of the underlying condition. This can best be done through careful evaluation by the clinical team in consultation with the individual and their carers.

When spasticity does require treatment, a range of effective therapies that can be used alone or in combination are available.

Self Help

Dealing with Spasms

Spasms can sometimes be relieved by pushing your weight through the affected limb. Eg if it occurs in the leg, pressing your hand down on your knee or standing up can beak the cycle of spasm. Otherwise it is best not to fight a spasm as you will probably cause yourself further pain.

Preventing Spasms

Spasticity can be brought on by rapid movement, or by sensory stimulation. An important aspect of spasticity treatment is minimising the types of stimuli that can trigger it: pain, pressure sores, urinary tract infection, ingrown toenails, restrictive clothing, and constipation, for example. Spasms that occur at night could be the result of poor sleeping positions - seeking advice from your physiotherapist on correctly positioning yourself in bed. Appropriate positioning in wheelchairs will also help avoid pressure areas developing.


Medicines

Oral medications are often used to treat spasticity. Side effects can occur and should be monitored, reducing the dose or changing medication may help with these. There are four major oral medicines used to reduce spasticity:

• Benzodiazepines - Diazepam (Valium®) and Clonazepam (Rivotril®)
• Baclofen - (Lioresal®)
• Dantrolene Sodium - (Dantrium®)
• Tizanidine - (Zanaflex®)

Benzodiazepines

Benzodiazepines reduce spasticity through their action on the central nervous system.

Benzodiazepines can be addictive and cause withdrawal symptoms if stopped suddenly. Alcohol needs to be avoided as well as other central nervous system depressants.

Baclofen

Baclofen also works through the central nervous system to reduce spasticity.

Suddenly stopping baclofen may cause seizures, hallucinations, and rebound spasticity. Baclofen should not be taken with alcohol or other central nervous system depressants. Also see Intrathecal Baclofen.

Dantrolene sodium

Dantrolene sodium acts directly on the muscle interfering with the way the muscle contracts.

In addition, there is a potential for liver poisoning. Prior to starting treatment with Dantrolene, a liver function test is performed and compared. Dantrolene and Tizanidine are usually not prescribed together because of the increased risk to the liver.

Tizanidine

Tizanidine acts on the function of the central nervous system.

Its also requires regular monitoring of liver function, since a small proportion of patients experience some liver damage as a result of treatment with Tizanidine.

Physiotherapy

Physiotherapy is the treatment of disorders of movement and function caused by problems in the muscles, bones or nervous system. Physiotherapists assess and treat these disorders by natural methods such as exercise, manipulation, heat or use of electrical and ultrasonic devices. They also advise carers on how to lift properly, carry out exercises at home and how to position the person they care for. Treatment is designed to:

• Reduce excessive muscle tone
• Maintain or improve range of movement and mobility
  
• Increase strength and co-ordination
• Improve comfort.

Treatment is individualised to meet the needs of the person with spasticity.

Treatments may include:

Stretching

Stretching helps to maintain the full range of motion of a joint, keeping it mobile. This helps prevent contractures. To be effective, the prescribed stretching routine must be done on a regular basis, usually once or twice a day.

Strengthening

Spasticity often leads to loss of strength in both the spastic muscles and surrounding ones. Strengthening exercises are aimed at restoring strength to affected muscles, so that when tone is reduced through other treatments, maximum use of the limb is achieved.

Occupational Therapy

An Occupational Therapist assesses and treats people with physical disabilities to enable them to function as effectively as possible in daily life. An occupational therapist may work within the community or at the hospital. They will identify factors leading to the loss of a skill and help with acquisition of new skills or in re-establishing skills that have been lost due to illness or trauma.

Orthoses and Casts

Orthoses, or braces, allow a spastic limb to be held in a more normal position. A cast is a temporary brace. Through using a series of casts a contractured limb can be gradually stretched and returned to a more normal position.

Lycra Dynamic Splinting

Lycra dynamic splints are made-to-measure and consist of sections of lycra stitched together using certain tensions to provide support for limbs sometimes boning is included to assist construction. The splint gives support to the wearer whilst allowing flexibility. It is not a rigid splint it moves with the wearer.

Other Interventions

Intrathecal Baclofen

Intrathecal baclofen (ITB) delivers baclofen directly to the fluid surrounding the spinal cord from an implanted pump. Because the drug is administered right to its site of action, much less baclofen is needed than if it were taken by mouth. This reduces the side effects that baclofen can cause such as drowsiness and fatigue. At the same time, more of the drug actually reaches the nerve cells where it is needed most.

ITB is used to treat spasticity resistant to other treatments and is most effective against spasticity of the lower limbs. To determine whether ITB is likely to produce a beneficial response, a test dose of baclofen can be injected into the spinal fluid. This will give some indication of whether an implantation is likely to be successful. But functional gains are only likely to be seen once the continuous dose of ITB through implantation takes place, since those benefits develop over weeks or months of treatment.

The battery-powered pump used for ITB is about the size of a hockey puck, and is surgically implanted in the abdomen. The baclofen is contained within a store inside the pump. A small tube then carries the baclofen to the spine. The operation to implant the pump is performed under general anaesthesia, and takes about one hour. There is likely to be some tenderness or soreness for several days after the operation, which can usually be controlled with over-the-counter painkillers.

After implantation, the pump can be reprogrammed to adjust the dose, using external controls. The pump also contains an alarm that beeps softly when the baclofen is running low or the batteries need replacing. The baclofen is refilled by injection when needed, usually every 1-3 months. When the batteries run low, pump is removed and replaced, this usually occurs every 4-5 years.

Improvement in spasticity is usually seen within several days of the operation, but significant improvements in function require longer to occur, and will be increased with physical therapy and other forms of rehabilitation.

If infection occurs, the pump may need to be removed temporarily. Other complications include pump failure or breakage. Side effects are usually less than those receiving oral doses of baclofen and these can be managed by adjusting the dose.

Botulinum Toxin Type A (BTX-A)

Botulinum Toxin type A (BTX-A) comes from a bacteria and is injected directly into muscles in small quantities. It is a highly effective treatment for spasticity and other conditions where there is increased muscle activity. Clinical trials have demonstrated that BTX-A is a safe and effective treatment for spasticity in properly selected patients with cerebral palsy, multiple sclerosis, stroke, spinal cord injury, or traumatic brain injury. BTX-A is produced and distributed under two different names and formulations: BOTOX® and Dysport®. As the drug does not travel more than a few centimetres from the injection site, it does not affect distant muscles and can be used to provide selective reduction in muscle overactivity.

A solution of BTX-A is injected into several areas of the spastic muscle near the nerve terminals. BTX-A works inside the nerve terminals to block release of the chemical that stimulates muscle contraction. Some nerve terminals remain unaffected by BTX-A, so that the injected muscle can still contract, but does so with less force. The target muscle is found simply by feel in larger, more accessible muscles, or by electromyography (EMG) to locate the right area in small or deep muscle groups. Small muscles may be injected in only 1-2 areas, while larger muscles may require injection in 3-4 areas. For those that are uncomfortable with needles a local anaesthetic cream or general anaesthetic can be used.

One important benefit of BTX-A is that the dose can be adjusted to provide the precise degree of weakness needed to overcome spasticity, while retaining some strength for normal function. Benefits depend on the patient, the location and degree of their spasticity. Many patients also report a reduction in pain following treatment.

BTX-A is not used to treat widespread, severe spasticity, since the amount of drug required would exceed safe doses and may eventually lead to antibody formation, resistance to the drug, and eventual loss of response. The effects of BTX-A fade after 3-6 months. Re-injection is possible if it is agreed that continuing treatment is likely to be beneficial.

Phenol and Alcohol

Phenol and alcohol are used to interrupt the functioning of nerves that supply spastic muscles. In this way, the signals to those muscles are reduced allowing the muscle to relax.

Unlike BTX-A, phenol and alcohol do not provoke a reaction by the immune system. Since the level and frequency of dosing is not limited by this concern, larger muscles may be treated more effectively. This is often the treatment of choice for severe spasticity in the largest muscles, such as those of the thigh but there are a number of disadvantages in using phenol and alcohol.

The purpose of these agents is to damage the nerve or muscle near the injection site. Damage to nearby sensory nerves may cause temporary or permanent pain, requiring additional medication to control it and damage to other structures may cause tissue breakdown. In addition, the patient may need to have surgery to identify the target nerve and the subsequent injection may be painful.

Surgery

Surgical Treatments

Surgery can play an important role in the treatment of chronic long term spasticity. It is not suitable for patients with recently acquired spasticity as changes in their muscle tone will fluctuate during this time of recovery.

For those with chronic spasticity a number of surgical options may be considered. The benefits and side effects of each procedure need to be assessed along with the likely post operative functional gains for each individual patient. Surgery is permanent and is only likely to be considered once other methods of treating spasticity have proven ineffective in managing the condition.

Neurosurgery and/or orthopaedic surgery may be used to treat spasticity.

• Neurosurgery aims to reduce spasticity by destroying nerve cells in the spinal cord that contribute to overactivity.
• Orthopaedic surgery aims to correct the effects of spasticity through procedures peformed on either muscles, tendons or bones to compensate for the effects of the spasticity
  

Neurosurgery

The main neuro-surgical procedure for spasticity is done on the spinal cord. This procedure is called selective dorsal rhizotomy (SDR) or selective posterior rhizotomy. "Rhizotomy" means cutting the sensory nerve roots that transmit nerve impulses to and from the spinal cord. "Selective" indicates that only selected nerve roots are cut.

Sensory nerves are targeted because of the role they play in generating spasticity. When brain or spinal cord damage occurs the sensory signals to contract/ flex and stretch/extend the muscle become unbalanced. Excess sensory signalling of the sensory nerves to contract can lead to spasticity. SDR attempts to counteract this imbalance by cutting back these extra sensory signals.

SDR is used to treat severe spasticity of the lower limbs that causes problems with mobility or positioning. SDR is used when less invasive treatments are unable to control spasticity adequately.

SDR is performed under general anaesthesia, the procedure lasting about 4 hours. The base of the spinal cord is exposed and nerve roots are stimulated electrically. Those that create abnormal responses are cut. Around 25-50% of all tested roots are cut away.

A week's recovery in the hospital is usually required beginning with strict bed rest, a catheter, and intravenous drip for fluid and pain medication. Gentle physical therapy should be begun after 1-2 days leading up to more vigorous activity. A 3-4 week recovery at home will normally be required before returning to normal activities.

In the weeks following surgery pain, fatigue and changes in sleep and bladder or bowel function may occur. Long-term complications can include low back pain, spine curvature and hip displacement. Although these may be reduced by appropriate physical therapy.
The extent of functional improvement after SDR varies from patient to patient. Factors include the pre-operative function, underlying strength and balance, undertaking regular physical therapy and the patient's motivation during the rehabilitation process.

Orthopaedic Surgery

Orthopaedic surgery targets the muscle, tendon or bone in a spastic limb. The goals of surgery may include reducing spasticity, increasing range of movement, improving access for hygiene or reducing pain.

Contractured Release

In this procedure, the tendon of a contractured muscle is cut either partially or completely. The joint is then positioned at a more normal angle, and a cast is applied. Re-growth of the tendon in this new position occurs over several weeks. A series of casts may be used to gradually extend the joint as it mends. Following cast removal, physical therapy is used to strengthen the muscles and improve range of movement.

Tendon Transfer

A tendon transfer moves the attachment point of a spastic muscle. When the tendon is transferred to a different place, the muscle can no longer pull the joint into an abnormal position. In some situations, the transfer allows improved function. In others, the joint retains passive but not active function. Ankle balancing procedures are among the most effective uses of this type of surgery.

Osteotomy

Involves a small portion of the bone being cut away. The bone is then repositioned in a way that allows a more natural position to be adopted as the bone heals. It is most likely to be used where the spasticity is unlikely to respond to less invasive treatments.

Arthrodesis

Arthrodesis is a fusing together of bones that normally move separately. This fusion limits the ability of a spastic muscle to pull the joint into an abnormal position. Arthrodesis are use most often to correct spasticity in the bones in the ankle and foot.

What is the right treatment for me?

Always follow the guidance of the medical team you are under. Ask about any aspects of your treatment you are unclear about and seek advice immediately if symptoms change or worsen. You may wish to print out these pages and discuss the treatment options listed here with your physician.