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About Spasticity

Spasticity is defined as an involuntary, velocity-dependent, increased resistance to stretch. This definition means that the amount of resistance to stretching is at least partly determined by the speed with which a spastic muscle is stretched. One factor that is thought to be related to spasticity is the stretch reflex. This reflex is important in coordinating normal movements in which muscles are contracted and relaxed and in keeping the muscle from stretching too far.

Although the end result of spasticity is problems with the muscles, spasticity is actually caused by an injury to a part of the central nervous system (the brain or spinal cord) that controls voluntary movements. The damage causes a change in the balance of signals between the nervous system and the muscles. This imbalance leads to increased activity (excitability) in the muscles.

Overview of Spasticity

The most common causes of spasticity are lack of oxygen to the brain before, during, or after birth (cerebral palsy); physical trauma (brain or spinal cord injury); blockage of or bleeding from a blood vessel in the brain (stroke), and multiple sclerosis (MS). When the damage that causes the eventual spasticity first occurs, the muscles are usually flaccid before they become spastic. Spasticity may not be present all the time—it may be related to a trigger, or stimulus, such as pain, pressure sores, a urinary tract infection, ingrown toenails, tight clothing, or constipation.

Spasticity may be painful, especially if it pulls joints into abnormal positions and or prevents a normal movement of the joints. In some patients, spasticity may cause slight muscle stiffness; in others, there is permanent shortening of the muscle. When the muscle is permanently shortened, the joint becomes misshapen. This is called a contracture and is one of the most significant consequences of spasticity. Another closely related problem with muscles in many people who have spasticity is clonus, or rapid, repeated muscle spasms.

While spasticity may affect any muscle group, there are some common patterns. When spasticity affects one or both arms, flexed (bent) elbow, flexed wrist, and clenched fist may result. These can all affect the person’s ability to dress, eat, or write or may interfere with balance, thereby causing difficulties with walking. Spasticity of the legs can cause flexed hip, adducted (or scissoring) thigh, stiff knee, flexed knee, equinovarus foot, and hyperextended great toe (which is also called the hitchhiker’s toe). Spasticity of one or both legs may interfere with the ability to walk, position in bed, sit, transfer, or stand. In this way, spasticity can make daily care more difficult. Spasticity may be limited to one area (localized), several nearby areas (regional), or many muscles or muscle groups of the body (generalized). When spasticity is generalized daily care may be challenging and lack of comfort becomes an important consideration for treatment approaches.

Epidemiology

Overall, spasticity affects about 500,000 people in the United States and more than 12 million people throughout the world.

Spasticity in Multiple Sclerosis

The number of people with MS varies with geographic location (more people living in northern climates have MS), race (MS is more common in Caucasians), socioeconomic status (rates of MS are higher in those with a higher socioeconomic status), and sex (MS is twice as common in women as in men). Of those people with MS, more than 85% have at least mild spasticity, with more than 30% being forced to at least frequently modify their activities because of the spasticity.

Spasticity in Cerebral Palsy

Although it is not clear how many children have cerebral palsy, cerebral palsy is estimated to affect two to four out of every 1,000 children in the world who are between 3 and 10 years old. About 50% of cerebral palsy is related to a specific event in which levels of oxygen to the brain of the child were not adequate.

Spasticity in Stroke

Every year, 700,000 Americans have a stroke. Overall, 14 out of every 1,000 people older than 65 years of age have had a stroke, and the rate increases with advancing age, particularly in women. Stroke afflicts almost 2,000 out of every 1 million people per year worldwide. Almost 40% of people who have a stroke continue to have spasticity one year later.

Spasticity in Traumatic Brain and Spinal Cord Injury

According to the latest statistics from the Centers for Disease Control and Prevention, every year an estimated 1.5 millions Americans experience a traumatic brain injury, and 11,000, a spinal cord injury. Of the 90,000 people who survive the brain injury, approximately 25% are left with spasticity; among the estimated more than 200,000 people currently living with a disability related to a spinal cord injury, more than half are thought to have spasticity.

Measuring Spasticity

The assessment of spasticity can provide information that will help in making a diagnosis of the cause of spasticity, as well as in measuring response to treatment. If a strong increase in spasticity occurs suddenly, potential causes such as a blood clot, urinary tract infection, sprain, pressure sore, or broken bone should be ruled out or treated, if necessary.

When physicians or therapists assess spasticity, they focus on three main areas: the clinical pattern of motor function, the patient’s ability to control her or his muscles, and how muscle stiffness and any contractures worsen the functional problems. Functional problems may include difficulty with bathing, toileting, eating, sleeping, dressing, sitting, transferring (such as from a chair to a bed), walking, or standing. Both the clinical history and a physical examination should evaluate the stretch reflex, passive and active motion, and function. The healthcare professional who is performing the evaluation must also distinguish spasticity from rigidity or dystonia in a muscle. Dystonia, rigidity, and spasticity cause an increased tone in muscles, but spasticity is typically only present during stretching of the muscle, and rigidity is present even when the muscle is at rest.

Because two or more muscles cross most joints, identifying the muscles affected by spasticity requires isolating the muscles. The identification can take place through clinical evaluation, that is, observing movements and palpating (feeling) the muscles, or by laboratory evaluations, such as biomechanical methods or electrophysiologic tests. The results of this testing can help the clinician to form an opinion about what muscles or activity may be working against the intended movement.

What is Normal Muscle Control?

Overview of Muscles

To better understand what happens in muscles that are affected by spasticity, it is helpful to first understand some key facts about muscles and the nerves that control their movements.

• More than 600 muscles, along with the bones, make up the musculoskeletal system.
  • The bones provide the structure or support for the body, and the muscles provide the ability to move.
  • Muscles are connected to bones by tough cords of tissue called tendons.
  • Most muscles reach from one bone to another and usually cross a joint.
  • The muscles cause the bones to move in relationship to each other.

• Most muscles of the musculoskeletal system work in pairs—called agonists and antagonists. During a movement, the muscle responsible for moving the body part contracts or shortens; this muscle is called the agonist. The antagonist muscle acts against or in opposition to the agonist muscle, stretching when the agonist contracts. The antagonist muscle is responsible for moving the body part back to its original position.

A muscle acts as the agonist in one action and as an antagonist in the opposite action. For example, when bending the elbow and raising the hand toward the shoulder, the bicep muscle contracts and is the agonist; the tricep muscle stretches and is the antagonist. When the movement is reversed and the elbow is extended, the tricep muscle contracts (is the agonist) and the bicep muscle lengthens (is the antagonist).

The Spasticity Management Team

The best treatment of spasticity usually includes an active patient or advocate and caregivers working with several healthcare professionals from various medical backgrounds. Members of this team may include one or more of the following people.

Neurologist: A neurologist is a medical doctor trained in disorders of the nervous system. The neurologist may diagnose the neurologic problem; prescribe treatments, including medications and physical and occupational therapy; and refer the patient for surgical evaluation if necessary. The neurologist may also inject the chemodenervation treatments (see the section on treatment that follows).

Physiatrist: A physiatrist is a medical doctor who specializes in physical medicine and rehabilitation. The physiatrist may design the rehabilitation program, working with other team members to maximize the patient’s function and minimize the disabling aspects of the neurologic injury. The physiatrist may also prescribe medications and administer chemodenervation treatments.

Physical therapist: A physical therapist is a healthcare professional who is responsible for the physical aspects of treatment. The physical therapist may perform or direct another person to perform the exercises that are necessary to assist in maintaining the range of motion of limbs affected by spasticity. The physical therapist may also apply and fit braces, splints, or casts that may be prescribed by the physiatrist or other treating physician. In addition, the physical therapist may direct training to improve the patient’s ability to walk or move and may instruct patients and caregivers on how to position affected arms and legs to help reduce spasticity. A physical therapist often works closely with an occupational therapist to design changes in the home and equipment that might be necessary to accommodate the patient’s needs.

Occupational therapist: An occupational therapist is a healthcare professional who specializes in adaptation of the physical environment to meet the patient's needs. The occupational therapist may teach modifications for dressing, feeding, and grooming to the patient and caregiver. This therapist may also offer expertise on adaptive devices such as wheelchairs and bath equipment and may advise on home and workplace modifications to increase accessibility and ease of use. The occupational therapist is usually the medical professional who advises the school on issues such as seating, writing, and use of facilities.

Neurosurgeon: A neurosurgeon is a medical doctor who is specially trained to perform surgical procedures related to the nervous system. For example, when a patient with severe spasticity has a positive response to a screening test for ITB™ Therapy (intrathecal baclofen bolus) and is then recommended to receive continuous intrathecal baclofen, the neurosurgeon may implant the baclofen delivery pump.

Neurosurgeons may also perform an operation to destroy selected sensory nerves at their entry point into the spinal cord (selective dorsal rhizotomy) when other treatments cannot offer adequate spasticity relief. When a patient requires exposure of a target nerve for chemodenervation, the neurosurgeon may be the physician who performs that operation; a neurologist or physiatrist then usually performs the chemodenervation.

Orthopedic surgeon: An orthopedic surgeon is a medical doctor who is specially trained to perform operations related to bones, joints, muscles, and surrounding connective tissue. These types of procedures may help to reduce or correct contractures that lead to abnormal positioning of joints. Orthopedic operations often involve reconstruction or revision of tendons and bones. The orthopedic surgeon may also assist with the fitting of braces and assessing growth and development, as well as implant the baclofen delivery pump and perform chemodenervation.

Treatment Options

In some patients with mild spasticity, the best treatment may be no treatment, with a watch-and-wait strategy. Typically, treatment is reserved for spasticity that causes pain, interferes with activities of daily living or sleep, leads to increasing levels of functional disability, or poses problems for care. Some key questions that should be answered before beginning any treatment for spasticity include:

• Is treatment necessary?
• Do the patient and caregiver have the time and resources necessary to put the treatment into action?
• Will the treatment improve the patient’s or the caregiver’s quality of life?

Treatment Goals

Patient and family expectations regarding the possibilities of treatments and outcomes may be realistic or unrealistic. Inappropriate expectations about the effectiveness of treatment may lead to disappointment regarding relief of symptoms and spasticity-related pain. Therefore, ongoing communication and agreement by the patient, caregivers, and healthcare professionals regarding the goals of treatment are extremely important. The following list includes goals that are commonly developed in the treatment of spasticity.

• Relieve the signs and symptoms of spasticity
• Reduce pain, frequency of spasms, or irritating stimuli
• Improve gait, hygiene, activities of daily living, or ease of care
• Reduce problems with passive function, that is, the functions provided by the caregiver, such as dressing, feeding, transfer, and bathing
• Improve voluntary active motor function, that is, the behaviors and functions that are under the patient’s control, such as reaching for, grasping, moving, and releasing an object

Measurement of Treatment Effectiveness

Obtaining information on the response of spasticity to treatment is often difficult because the degree of spasticity changes throughout the day in an individual, throughout the course of the disease that causes the spasticity, and in response to various stimuli. Therefore, it is important when measuring response to treatment to have the assessment take place at the same time of day, in the same environment, and using the same measuring techniques and devices.

As mentioned in the section on assessment of spasticity, rating scales may be used to evaluate response to therapy. A combination of rating instruments is often necessary because none cover all areas of importance. The choice of evaluation tools is dependent upon expected change. Scales that are often used in the rating of spasticity include:

• The Ashworth scale, a 5-point scale
• The modified Ashworth scale, a 6-point scale
• The spasm frequency scale, a 4-point scale
• The reflex score, a 5-point scale
• A functional scale (i.e. the Fugl-Meyer scale)

Types of Treatment

A combination of various types of treatment is usually required to attain the specific goals of treatment for a particular patient. Most people with spasticity require physical and occupational therapy to improve or maintain the range of motion in their spastic limbs.

Treatment Options:

Physical and Occupational Therapy

Physical therapy for spasticity refers to a range of physical (as opposed to drug or surgical) treatments. These treatments of spastic muscles are designed to reduce muscle tone, maintain or improve range of motion and mobility, increase strength and coordination, and improve care and comfort. The choice of treatments is individualized to meet the needs of the person with spasticity. Physical therapy is the most common form of treatment for spasticity in children. The success of the therapy is often based upon the motivation of the person with spasticity and the caregiver, as well as the physical therapist’s skills.

Occupational and physical therapists often work in tandem to increase the strength, mobility, and dexterity of people with spasticity. Both types of therapists evaluate patients with spasticity using the aforementioned scales and techniques. While physical therapists typically concentrate on improving strength and large-motor skills, including those necessary for transferring and walking, occupational therapists usually focus on maximizing fine-motor skills, including those necessary to complete activities of daily living such as eating, bathing, dressing, and grooming. When full recovery is not possible, the occupational therapist often assists individuals with spasticity and their family members in adapting their environment – whether that be at school, home, or the workplace – to best suit the needs of the individual with spasticity. Occupational therapists develop adaptive interventions, which include both changes to the physical structure, such as designing wheelchair accessibility, as well as the creation of orthotics, assistive devices, or alternative methods of completing tasks. Occupational therapists assist individuals with spasticity and their family members in overcoming psychological, social, and environmental factors that may get in the way of independent functioning.

Treatment Options:

Oral Medications

The use of oral medication to treat spasticity is indicated when stiffness, spasms, or clonus interfere with daily functioning or with sleep. Effective spasticity management may require the use of two or more drugs or a combination of oral medications with another type of treatment such as chemodenervation or intrathecal drug delivery.

Baclofen

Oral baclofen acts on the central nervous system to relax muscles. It also decreases stretch reflexes, the rate of muscle spasms and clonus, pain, and tightness and improves range of motion. Side effects may include sedation, drowsiness, weakness, decreased muscle tone, confusion, fatigue, nausea, dizziness, and more difficulty in controlling seizures in people with epilepsy. Baclofen may also increase the blood pressure-lowering effects of other medications. Suddenly stopping baclofen may cause seizures, hallucinations, and rebound spasticity. Baclofen should not be taken with alcohol or other central nervous system depressants. It may either worsen or improve bladder problems. Its use has been shown to increase bronchospasm and decrease the cough reflex.

Benzodiazepines (Valium^® and Klonopin^® )

Like baclofen, benzodiazepines are a group of drugs that act on the central nervous system to relax muscles, temporarily decreasing spasticity. Diazepam is the most commonly used benzodiazepine in the treatment of spasticity. Because of their sedative effects, benzodiazepines are given most often at night. Additional effects may include low blood pressure, nausea, difficulty thinking clearly, confusion, depression, clumsiness, and trouble with balance, memory impairment, and behavioral problems. Benzodiazepines may be addictive, and, with long-term use, withdrawal symptoms may occur if the drug is stopped too quickly. These drugs should not be taken in combination with alcohol or other central nervous system depressants.

Dantrolene sodium (Dantrium^® )

Unlike baclofen and the benzodiazepines, dantrolene does not act at the level of the central nervous system. Instead, it acts directly on the muscle by blocking the signals that cause muscles to contract. Dantrolene decreases muscle tone, clonus, and spasm and is less likely to cause problems with confusion or clouded thinking than are the benzodiazepines and baclofen taken by mouth. When used over a long period of time, dantrolene may cause a change in the type of muscle fiber so that the muscle fibers become more rapidly fatigued. It may also cause diarrhea, mild sleepiness, weakness, nausea, or liver damage. The use of dantrolene requires regular monitoring of liver function. Dantrolene is first-line therapy for the treatment of severe spasticity due to traumatic brain injury and may be very helpful in the treatment of spasticity due to cerebral palsy.

Imidazolines (Clonidine and Tizanidine)

Clonidine (Catapres^®, which is available as a tablet or a patch worn on the skin) and tizanidine (Zanaflex^®, available as a tablet) are two imidazolines that reduce spasticity through their action on the central nervous system. These drugs typically cause less muscle weakness than do oral baclofen and benzodiazepines. This factor may be valuable when it is important for the patient to retain strength. When compared with dantrolene, tizanidine may be equal or better in controlling spasticity due to MS or strokes; it can also be used in patients with traumatic brain injury. The imidazolines may be combined with baclofen or benzodiazepines, but the combination may worsen the side effects of both. Dantrolene and tizanidine are usually not prescribed together because of the increased risk for liver problems. The most common side effect of the imidazolines is sedation, and these drugs can cause low blood pressure, dry mouth, dizziness, and hallucinations. The use of tizanidine requires regular monitoring of liver function, since a small proportion of patients show some liver damage as a result of taking the drug.

Gabapentin

Gabapentin (Neurontin^®) is a drug that is typically used in the treatment of seizures and is also used in the treatment of spasticity caused by MS and spinal cord injury. Caution is urged when combining gabapentin with alcohol or other central nervous system depressants because an additive effect may occur. This medication has minimal effects on concentration or thinking, but sedation may be a problem. Common side effects include clumsiness or unsteadiness and continuous, uncontrolled, back-and-forth or rolling eye movements. Less-common effects include changes in behavior, double vision, dizziness, loss of strength, and swelling of the hands or feet.

Valium^® is a registered trademark of Roche Products Inc.
Klonopin^® is a registered trademark of Roche Laboratories
Dantrium^® is a registered trademark of Procter & Gamble Pharmaceuticals
Catapres^® is a registered trademark Boehringer Ingelheim
Zanaflex^® is a registered trademark of Elan Pharmaceuticals
Neurontin^® is a registered trademark of Pfizer Inc.

Treatment Options:

Intrathecal Medications

The US Food and Drug Administration approved the use of ITB Therapy^SM (Intrathecal Baclofen Therapy) for the treatment of spasticity of spinal and cerebral origin in 1992 and 1996, respectively. Since that time, it 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 thecal space with a three-part system made up of a surgically placed, programmable pump with a reservoir or storage area for the drug; a clear, flexible silicone tube or catheter; and a programming device. Because the drug is administered directly to its site of action—within the spinal cord—much less baclofen is needed than if the drug were taken by mouth. Because less of the medication is needed, the side effects of ITB Therapy, including drowsiness and sedation, are much milder than when baclofen is taken by mouth. ITB Therapy is usually combined with physical therapy and other forms of rehabilitation.

ITB Therapy is used to treat severe spasticity that is caused by damage to the brain or spinal cord. Candidates for ITB Therapy have severe spasticity that does not respond to conservative treatment with medications or have intolerable side effects at therapeutic doses. Pharmacotherapy should include, but need not be limited to, a trial of oral baclofen.

To determine whether ITB Therapy is expected to produce a helpful response, the patient undergoes an ITB Therapy screening test. The screening test for ITB Therapy requires the administration of a test dose of baclofen (typically with 50 mcg, usually not to exceed 100 mcg) via lumbar puncture into the thecal space. Peak effect of the drug usually occurs within four hours. Patients who respond positively to the test dose can be considered for ongoing ITB Therapy. During screening, patients must be monitored closely in a fully equipped and staffed setting, due to the risk of possible side effects.

Once it has been determined that ITB Therapy is likely to be effective in treating spasticity, a surgeon performs an operation to place a battery-powered pump. The SynchroMed^® II pump, is smaller than the first style of pump that was used for ITB Therapy with a larger storage area (reservoir) that holds the baclofen. Two different pump sizes are available. The larger size allows for greater time between refills. The pump implantation requires two incisions: one in the lower abdomen to make a pocket for the pump under the skin, and another, smaller, incision in the lumbar region to insert the catheter. Exact placement of the pump differs with each patient, but it is generally implanted near the waistline, about one inch below the skin.

The surgeon inserts one end of the catheter into the intrathecal space using a spinal introducer. A myelogram is often used to confirm catheter placement. The catheter is then tunneled under the skin and the other end is connected to the pump. The pump is sewn into place under the skin in the pocket, and the incision is stitched closed. The tip of the catheter rests between the first and second lumbar vertebrae. The procedure typically lasts about 1 to 2 hours.

The entire hospital stay is usually 4 to 7 days, during which time the pump is programmed to deliver the best possible dose of baclofen to reduce muscle tone. There is some tenderness or soreness for several days after the operation, which can usually be controlled with pain medications. The implantable pump may cause a slight bulge in the abdominal wall, but many people report that they stop noticing this after several weeks. A notable decrease in the tone of spastic muscles is usually noticeable within several days of the operation, but significant improvements in function may take longer to be evident.

The dose of baclofen can be adjusted whenever necessary by reprogramming the pump in the doctor’s office. The pump also contains a programmable alarm that beeps softly when the reservoir is low or the batteries need replacing. The reservoir is refilled by injection as needed, usually every 1 to 6 months. When the batteries run low, about every 7 years, the entire pump is replaced.

The side effects of ITB Therapy are similar to those for baclofen given by mouth but, as mentioned previously, are typically milder because of the lower dose of medicine that is required with ITB Therapy. About 5% of people with ITB Therapy develop infections that require temporary removal of the pump. Other equipment-related risks include pump failure, catheter kinking or breakage, or movement of the catheter (dislodgement) so that the baclofen no longer reaches the intrathecal space. Mechanical defects or failure to refill the pump reservoir can lead to sudden interruption of baclofen treatment. In rare cases, this can cause a life-threatening withdrawal syndrome. To prevent this, families must be educated about the signs of baclofen withdrawal, and have a plan to respond to such possible emergencies.

Although it rarely happens, it is possible for the person receiving ITB Therapy to receive too much medication (overdose). A baclofen overdose may cause drowsiness, lightheadedness, slowed or difficulty 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.

Treatment Options:

Chemodenervation

As with any treatment, chemodenervation must be part of an overall spasticity management program with clearly defined treatment goals. Oral medications and ITB Therapy may be used to provide overall reduction in muscle tone, whereas chemodenervation can provide graded relief in selected muscles. The use of chemodenervation, for example, may be beneficial for hand, arm, or neck problems in certain patients using ITB Therapy for overall muscle relaxation or for leg spasticity. Chemodenervation agents and antispastic agents do not have drug-drug interactions. For example, in patients receiving ITB Therapy, the addition of localized chemodenervation may further help to reduce spasticity.

Local Anesthetics

Local anesthetics such as lidocaine and xylocaine can be injected into spastic muscles to produce short-term chemodenervation. This technique is typically only used to evaluate which muscles are contributing to a spastic deformity. Local anesthetics can also be injected to assess the likely benefit that the patient will receive from long-term chemodenervation with the more widely used substances — phenol, alcohol, or botulinum toxin (BTX).

Botulinum toxin

Two forms of botulinum toxin (BTX), type A (BTX-A, BOTOX^® or Dysport^®) and type B (BTX-B, Myobloc^™ or NeuroBloc^®), are commercially available. BTX temporarily weakens spastic muscles, allowing more normal limb positioning and function. To administer BTX, the physician places a small needle into the spastic muscle. Once the physician has confirmed the placement of the needle, the BTX is then injected.

The major side effects of treatment with botulinum toxin are dry mouth, blurred vision, excess weakness, or mild flu-like symptoms. BTX should be used with extreme caution in people with neuromuscular diseases such as myasthenia gravis or amyotrophic lateral sclerosis (also known as Lou Gehrig disease) or in those taking aminoglycoside antibiotics (including gentamicin, kanamycin, neomycin, streptomycin, and tobramycin).

One other important issue in the use of botulinum toxin in the treatment of spasticity is that of antibody formation. Because the immune system identifies BTX as a foreign substance, it produces antibodies that bind to and inactivate BTX, making it useless for spasticity reduction. Once a person forms antibodies to a particular type of BTX (A or B), any injections with that type of BTX are no longer effective. Repeated, high-dose injections are more likely to cause antibody formation than are less frequently repeated, low-dose injections. Therefore, the smallest amount of BTX necessary to achieve therapeutic benefit should be used, and the interval between treatment sessions should be as long as possible. Patients need to understand this important limitation on BTX therapy.

The effects of botulinum toxin are usually greatest for 2 to 6 weeks following treatment and usually fade completely after 3 to 6 months. In most situations, BTX is not injected again into the same muscle any sooner than 3 months after the last injection to decrease the possibility of antibody formation. In general, BTX cannot be used to treat widespread severe spasticity, since the amount of drug required to bring about meaningful functional improvements would likely lead to antibody formation, resistance to BTX, and eventual loss of response.

Phenol and Alcohol

Phenol and alcohol are injected with a fine needle directly onto nerves or into muscles to destroy them. Phenol and alcohol can effectively weaken a spastic muscle, thereby reducing spasticity and allowing improvements in range of motion. These agents are effective in treating spasticity that occurs in large, powerful muscle groups close to the trunk, such as those of the thigh. Alcohol or phenol may be used in combination with BTX, and all may be combined with other antispasticity treatments. The duration of effect is quite variable, from less than 1 month to more than 2 years.

The cost of either phenol or alcohol is much less than that of BTX. When cost is a major concern, phenol or alcohol may be used to treat muscles in which BTX could also be effective. Unlike BTX, phenol and alcohol do not provoke a reaction by the immune system. Because the amount and frequency of the dose is not limited by this issue, larger muscles may be treated more effectively.

There are several significant disadvantages to the use of phenol and alcohol. Phenol and alcohol may produce more troublesome initial side effects than BTX, such as burning and odd sensations called dysesthesias. Damage to nearby sensory nerves may cause temporary or permanent pain, which may require medication to control. Surgery may be required to expose the target nerve. The mechanism of action for both agents is to destroy tissue, and muscle near the injection site is usually damaged along with the target nerves. Exposure to phenol, though not alcohol, theoretically increases the risk of developing leukemia, although no studies have shown an increased incidence of leukemia as a result of spasticity treatment.

BOTOX^® is a registered trademark of Allergan Inc.
Dysport^® is a registered trademark of Ipsen-Biotech Laboratories
Myobloc^™ is a trademark of Solstice Neurosciences, Inc.
NeuroBloc^® is a trademark of Solstice Neurosciences, Inc.

Treatment Options:

Surgical Treatments

Operations involving the nervous system (neurosurgery) and the bones, tendons, and muscles (orthopedic 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 who have a recent injury to the brain or spinal cord will have changes in their muscle tone that come and go during the recovery period. Surgery should not be undertaken during this time. Treating children with spasticity is particularly challenging because their spasticity may change as they grow and develop. At times, an operation may be undertaken to allow more normal bone and muscle growth.

In many cases, a combination of neurosurgical and orthopedic operations may be undertaken. While each surgical approach has certain strengths and weaknesses, none completely eliminate spasticity or its effects. Surgery should not be seen as a last resort when other treatments have failed. Instead, surgery may be considered when a permanent reduction is needed in muscle tone or when muscle force needs to be redirected.

Patients with chronic spasticity should have a thorough evaluation of their current level of function, and realistic expectations for improvement in function should be established before the operation takes place. As with any other spasticity treatment, surgical intervention must be incorporated into an overall spasticity management plan. An ongoing physical therapy program following surgery is important to maximize the benefits available from the operation.

Neurosurgery for Spasticity

The main operation on the nervous system that is used for the treatment of spasticity is called functional or selective dorsal rhizotomy (SDR). In this procedure, the neurosurgeon cuts nerve roots (rhizotomy) —the nerve fibers lying just outside the back bone (spinal column) that send sensory messages from the muscles to the spinal cord. Selective indicates that only certain nerve roots are cut, and dorsal means that the target nerve roots are those that lie at the back of the spinal cord (the upper surface when a person is lying on his or her stomach).

SDR is used to treat severe spasticity of the legs that interferes with movement or positioning. The best candidate for SDR is a person with good strength and balance, spasticity of one or both legs and not of the arms, little or no fixed contractures in the legs, and strong motivation and support.

SDR is performed with the patient under general anesthesia. Recovery usually includes one day in the intensive care unit and another week or so in the hospital after the operation. Limited physical therapy begins after 1 to 2 days, with activity increasing every day. The person who has had an SDR will usually need about 4 weeks to recover at home before returning to work or school.

The most serious complications after SDR include paralysis of the legs, bladder, or bowel; a leak of cerebrospinal fluid; or infection of the incision or of the covering of the brain and spinal cord (meningitis). Long-term complications may include low back pain, curvature of the spine, and hip displacement. It may be possible to reduce the likelihood of developing these long-term complications through appropriate physical therapy. Changes in how the SDR is performed have reduced the rate at which these complications occur.

Orthopedic Operations

Orthopedic procedures are the most frequently performed operations for spasticity. The targets of these operations are muscles, tendons or bones. Muscles may be denervated and tendons and muscles may be released, lengthened, or transferred. The goals of surgery may include reducing spasticity, increasing range of motion, improving access for hygiene, improving the ability to tolerate braces, or reducing pain. Orthopedic problems that may result from a spastic limb include cubital or carpal tunnel syndrome, spontaneous fracture (breaking of the bone), dislocation of the hip or knee, and heterotopic ossification.

The most common orthopedic procedure for the treatment of spasticity is a contracture release. In this procedure, the tendon of a muscle that has a contracture is partially or completely cut. The joint is then positioned at a more normal angle, and a cast is applied. Regrowth of the tendon to a new length occurs over several weeks. Serial casting may be used to gradually extend the joint. Following cast removal, physical therapy is used to strengthen the muscles and improve range of motion.

Spastic muscles in the shoulder, elbow, forearm, hands, and legs may all be treated with tendon or muscle lengthening. Spasticity in the shoulder muscles may cause abduction or adduction and internal rotation of the shoulder. Abduction results in difficulties with balance, which then affects walking and transferring, and adduction causes problems when reaching for an object or with hygiene and personal care. An operation known as a slide procedure may be used to lengthen the supraspinatus muscle in an abducted spastic shoulder. With adducted shoulders, the surgeon can perform a release of all four muscles that typically cause this deformity.

In an operation known as a tendon transfer, the orthopedic surgeon moves a tendon from the spot at which it attaches to the spastic muscle. With the tendon transferred to a different site, the muscle can no longer pull the joint into a deformed 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 interventions.

Osteotomy and arthrodesis involved operations on the bones and are usually accompanied by operations to lengthen or split tendons to allow for fuller correction of the joint deformity. Osteotomy can be used to correct a deformity that is not able to be fixed with other procedures. In an osteotomy, a small wedge is removed from a bone to allow it to be repositioned or reshaped. A cast is applied while the bone heals in a more natural position. Osteotomy procedures are most commonly used to correct hip displacements and foot deformities. Arthrodesis is a fusing together of bones that normally move independently. This fusion limits the ability of a spastic muscle to pull the joint into an abnormal position. Arthrodesis procedures are performed most often on the bones in the ankle and foot. In triple arthrodesis, the three joints of the foot are exposed, the cartilage is removed, and screws are inserted into the bones, fixing the joints into position. With a short walking cast in place for six weeks or until the bones have fully healed, the patient may bear weight immediately after the operation.

Spasticity Center List

The following resources are available for finding a physician who treats spasticity.

Medtronic ITB Therapy^SM (Intrathecal Baclofen Therapy) is a treatment for the management of severe spasticity. Click here to find a physician in your area who offers this treatment.

WE MOVE offers online, searchable databases of clinical centers across the US that treat individuals with movement disorders. Many centers provide a broad range of diagnostic and treatment services, while others specialize in a particular disorder or group of disorders.

• The WE MOVE Treatment Center Database – click here to search for centers that treat children with movement disorders.

• The WE MOVE Movement Disorder Treatment and Rehabilitation Directory – click here to search for physicians who treat adults with movement disorders.