7.  Treatment options for Spasticity

For some people with spasticity, treatment isn't necessary or even desirable. However there are several types of treatment available and evaluation by a medical professional is crucial to determine the best path. The most important activity is regular stretching exercises as prescribed by a physical therapist. Begun early enough, regular stretching or a range of motion exercises may help prevent permanent shortening of your muscles.

Muscle relaxing drugs, taken orally or delivered into the spinal fluid, are the next line of treatment. And local injections of drugs that weaken or paralyse overactive muscle (chemodenervation agents) may be effective against more isolated spasticity.

When severe spasticity cannot be treated with drugs or injections, serial castings or orthopaedic surgery may help your tendons to stretch. Finally, surgical destruction of some overactive nerves in the spine may offer relief.

The goal of any spasticity treatment is always to improve some aspect of your life. For one person, the goal may be to prevent contracture in the legs; for another it may be to improve seating in a wheelchair; and for a third it may be to allow access to the groin area for hygiene. Equally, reducing spasticity may not offer any real benefit. For example, if you have limited control of your leg muscles, the rigidity caused by spasticity might actually help you to stand. Reducing this spasticity would make caregiving harder, rather than easier.

So the decision to treat spasticity should always include full consideration of all aspects of your condition, and set clear goals for the treatment. This must be done through though careful evaluation by the clinical team in consultation with you and your caregivers.

When treatment is recommended, a wide range of therapies are now available singly or in combination.

The main options for the treatment and management of Spasticity are:

  1. Oral medications
  2. Intrathecal medications
  3. Chemodenervation
  4. Surgical treatments
  5. Physiotherapy

Oral medications

Oral medications have a long history in spasticity management - and they're usually the first type of medication prescribed for spasticity. Oral medication is indicated when stiffness, spasms, or clonus interferes with daily functioning or sleep. Effective spasticity management may require the use of two or more drugs, or a combination of oral medications with another type of treatment.

Your doctor will be able to discuss the individual benefits and side effects of the many drugs now available.

Intrathecal medications

Since 1992, intrathecal therapy (ITB) has been successfully used in the treatment of spasticity caused by stroke, cerebral palsy, multiple sclerosis, and acquired brain and spinal cord injuries.

ITB therapy is delivered directly into the intrathecal space using a three-part system - a surgically placed, programmable pump with a reservoir or storage area for the drug; a flexible silicone tube or catheter; and a programming device. Because the drug is administered directly to its site of action, much less is needed than if it were taken orally. The reduced volumes result in fewer side effects, such as drowsiness and sedation. ITB therapy is usually combined with physical therapy and other forms of rehabilitation.

Candidates for ITB therapy usually suffer from severe spasticity that has not responded to more conservative drug treatments, or cannot tolerate the side effects of these drugs at therapeutic doses. To help determine whether ITB therapy might produce a helpful response, you'll need to undergo an ITB therapy screening test. This involves the administration of the drug in a test dose, via a lumbar puncture into the intrathecal space. Peak effect of the drug usually occurs within four hours, and you must be closely monitored in a fully equipped and staffed setting, due to the risk of possible side effects. If you respond positively to this test dose, you can be considered for ongoing ITB therapy.

Once you've been deemed suitable for ITB therapy, a surgeon will perform the operation to place the battery-powered pump and catheter. The entire hospital stay is usually four to seven days. In this time, the pump is programmed to deliver the best possible drug dose to reduce muscle tone and provide relief from the spasticity. Some tenderness or soreness treatable with pain medication is common after the operation. The implanted pump can also cause a slight bulge in the abdominal wall, but many patients stop noticing this after a few weeks. A decrease in the tone of spastic muscles is usually noticeable within several days of the operation, but evidence of significant improvements in function often take longer.

The metered drug dose can be adjusted whenever necessary by reprogramming the pump in your doctor's office. The pump also contains a programmable alarm that beeps softly when the reservoir or the batteries are low. The reservoir can be refilled by injection as needed, usually every one to six months, while the entire pump is replaced when the batteries run low after about seven years.

The side effects of ITB therapy are similar to those for drugs given orally but, as mentioned, are typically milder because of the lower doses of medicine required. About 5 percent of ITB therapy patients develop infections that require the temporary removal of their pump.

Equipment-related risks include pump failure, catheter kinking or breakage, and movement (dislodgement) of the catheter so that the drug no longer reaches the intrathecal space. Mechanical defects or failure to refill the pump reservoir can lead to sudden interruption of drug treatment. In rare cases, this can cause a life-threatening withdrawal syndrome. Your family must be educated about the signs of drug withdrawal, and they'll need a plan for managing such an emergency.

Although it rarely happens, it is possible for a person receiving ITB therapy to receive an overdose of their medication. This may cause drowsiness, lightheadedness, slowed or difficult breathing, seizures, loss of consciousness, and coma. In the event of an overdose, it is very important for the patient or caregiver to immediately contact the patient's physician.

Chemodenervation

Chemodenervation involves the local injection of drugs to weaken or paralyse overactive muscles, and can form part of an overall management program for isolated spasticity.

While oral medications and ITB therapy may provide a general reduction in muscle tone, chemodenervation can offer graded relief in selected muscles. It may be beneficial for hand, arm, or neck problems, for example, when a patient is using ITB therapy for overall muscle relaxation or to treat leg spasticity.

Chemodenervation agents and antispastic agents do not have drug interactions. That means using localised chemodenervation in conjunction with ITB therapy may help to further reduce spasticity.

The effects of chemodenervation are usually greatest for two to six weeks after treatment and typically fade completely after three to six months. In most situations, the drugs will not be injected into the same muscle within three months of the previous injection, in order to limit the possibility of antibody formation. Chemodenervation cannot be used to treat widespread severe spasticity, as the dosage levels required would probably lead to drug resistance and an eventual loss of response.

There are several significant disadvantages to the use of chemodenervation, including damage to nearby sensory nerves. This can lead to temporary or permanent pain, which may need to be controlled with medication. Surgery may also be required to expose the target nerve and, in some instances, muscle near the injection site can be damaged along with the target nerves.

Surgical treatments

Operations involving the nervous system (neurosurgery) and the bones, tendons, and muscles (orthopaedic surgery) are both used to treat spasticity and, in properly selected patients, can play a very important role in the treatment of chronic spasticity.

Patients with a recent brain or spinal cord injury will experience changes in their muscle tone during their recovery period. Treating children with spasticity is particularly challenging, as their spasticity may change as they grow and develop. In some cases, surgery may simply be needed to permit more normal bone and muscle growth.

Usually, a combination of neurosurgical and orthopaedic operations may be undertaken. While each surgical approach has certain strengths and weaknesses, none can completely eliminate spasticity or its effects. As with any other spasticity treatment, surgical intervention must be incorporated into an overall spasticity management plan. And following any surgery with an ongoing physical therapy program is essential to maximizing the potential benefits of the operation.

Orthopedic procedures targeting muscles, tendons and bones are the most frequently performed operations for spasticity. Muscles may be denervated, while tendons and muscles may be released, lengthened, or transferred. The goal may be to reduce spasticity, increase motion, improve access for hygiene, improve the ability to tolerate braces, or reduce pain. A spastic limb may also cause a separate orthopaedic problem, such as carpal tunnel syndrome, spontaneous fracture (breaking of the bone) or dislocation of the hip or knee.

Selective dorsal rhizotomy (SDR) is the most common neurosurgery for the treatment of spasticity. In this procedure, the neurosurgeon will cut the roots (rhizotomy) of nerve fibres lying just outside the back bone, to prevent sensory messages being sent from your muscles to the spinal cord. Selective indicates that only certain nerve roots are cut, and Dorsal means that the target nerve roots are those at the back of the spinal cord (the upper surface when you're lying on your stomach).

Physiotherapy

Physiotherapy for spasticity refers to a range of physical treatments, as opposed to drugs or surgery. It is the most common form of treatment for spasticity in children. The treatment will be designed to meet your specific needs and will reduce muscle tone, maintain or improve range of motion and mobility, increase strength and coordination, and improve care and comfort. Often, the success of physiotherapy is based on your motivation as much as your physiotherapist's skills.

There are five basic methods of physiotherapy for the treatment of spasticity:

Conventional rehabilitation
Stretching forms the basis of conventional rehabilitation for treating spasticity. Stretching helps to maintain the range of motion in your joint and helps prevent contracture. To be effective, the prescribed stretching routine must be done regularly, usually once or twice a day.

Facilitation
This includes neurodevelopmental therapy (also known as Bobath approach) aimed at reducing inappropriate reflexes and training your muscles to achieve normal balanced reactions. Proprioceptive neuromuscular facilitation seeks to retrain spastic muscles for normal motion. Sensory integration involves continually repeating tasks, often with the therapist directing the limb while you remain passive, so that your brain is "retrained" in the proper movements.

Biofeedback techniques
These techniques involve monitoring muscle activity via a device that records when a spastic muscle relaxes or contracts.

Electrical stimulation
Electrical stimulation is sometimes used to re-educate muscles, usually with the goal of resetting the balance between your flexor and extensor muscles. The effects usually last for about 10 minutes when the stimulation is first applied, but after several months the effects may become longer lasting.

Orthoses
Also known as casts, braces, or splints, orthoses include any device that is used to support, align, prevent, or correct deformities or improve the function of movable parts of the body. When used to treat spasticity, orthoses may reduce muscle tone, increase or maintain motion, and prevent skin damage such as the breakdown that would occurs in your palm if your fist is continually clenched.

If you are suffering from spasticity, discuss treatment options
with your doctor, and ask for a referral to a movement disorder specialist near you.

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