Treatment of Spasticity

Neurological conditions resulting from lesions of the brain or spinal cord often show clinical signs of upper motor neuron syndrome (UMNS). Spasticity as a symptom of UMNS may occur isolated, but in a majority of cases it is a partial symptom. The treatment of spasticity in the context of neurological rehabilitation is a great challenge. Early diagnosis, adequate therapy initiation, and follow-up documentation are important elements of successful treatment.

What does the term “spasticity” mean?

Spasticity is a motor disorder that is also known as spastic syndrome or UMNS. Spasticity means increased muscle tone. It usually develops after damage to the central nervous system and leads to significant limitations in motor function and quality of life. Thus, spasticity frequently occurs in cerebrovascular events, traumatic brain injury, MS, cerebral paralysis, and spinal cord trauma. Spasticity does not develop immediately after the acute central nervous system lesion, but after a certain time interval of a few weeks to months. Spasticity is a condition in which certain muscles are continuously contracted. This contraction causes stiffness or tightness of the muscles and can interfere with normal movement, speech and gait. Spasticity is usually caused by damage to the portion of the brain or spinal cord that controls voluntary movement.

Symptoms of Spasticity:

• Increased muscle tone 
• Overactive reflexes
• Involuntary movements, which may include spasms (brisk and/or sustained involuntary muscle contraction) and clonus (series of fast involuntary contractions)
• Back Pain
• Decreased functional abilities and delayed motor development
• Difficulty with care and hygiene
• Abnormal posture
• Contractures (permanent contraction of the muscle and tendon due to severe persistent stiffness and spasms)
• Bone and joint deformities

​Management of Spasticity:

The quantitative assessment of spasticity and muscle spasms is of central importance in order to be able to estimate the potential of possible treatment effects. A specialized and goal-oriented management program is the main prerequisite for successful treatment of spasticity. Important elements are involvement of the patient and definition of realistic therapy goals. In addition to conducting an in-depth analysis and physical examination, spasticity-specific factors and conditions should be carefully considered and included early into the therapeutic goal-setting process. The following are to be documented:

• All previous pharmacological and physical therapies of the patient’s spasticity
• Pain, muscle spasms, and tone
• Joint mobility
• Sleeping problems
• Bladder and intestinal complaints
• Independence in everyday life
• Skin condition in the regions of spastic musculature and in cases of joint deformities
• The following conditions should also be measured and documented:
  • Spasticity: Measurements of spasticity are made using the Modified Ashworth Scale (MAS). This detects the speed-dependent resistance of the musculature to passive movement.
  • Paresis: Not infrequently, in addition to the increased muscle tone, pronounced paralysis (paresis) is also present. This must be recorded and documented in a timely manner. This is done using the paresis classification according to the British Medical Research Council. This scale goes from 0° (no contraction visible or perceptible) to 5° (normal strength).
  • Pain: Since spasticity can also be associated with pain, additional documentation of the pain perception by appropriate scales is appropriate.
  • Range of motion: The range of motion of the joints is also documented.
  • Mobility: At the activity level, mobility of the extremities as well as targeted standing and walking ability are recorded.
  • Independence in daily life: Since spasticity can have a decisive influence on daily life, independence in everyday life must also be contemplated.

Treatment options:

There are many strategies and treatments for spasticity to help you recover, return to work and regain function. In order to achieve the best results possible, a mixture of therapies and medications are often used to treat spasticity. Ask a healthcare professional about the best treatment plan for you. Some of the options include:

• Braces. Putting a brace on an affected limb
• Exercises. Range-of-motion exercises
• Stretching. Gentle stretching of tighter muscles
• Movement. Frequent repositioning of body parts
• Medications. Medications are available to treat the effects of spasticity
• ITB Therapy. A programmable, battery-powered medical device that stores and delivers medication to treat some of the symptoms of severe spasticity
• Injections. Injections block the chemicals that make muscles tight
• Surgery. Surgery on the muscles or tendons and joints may block pain and restore movement

For spasticity therapy, there is a graduated plan, depending on localization and spread. Physiotherapy in combination with drug therapy is used.

1. Pharmacological options for the treatment of spasticity

Oral medication

Anticonvulsant drugs are used to reduce painful muscle spasms. However, these influence not only the affected muscles, but all muscles in the body. An individual and gradually titrated dosage is important. The following are used:

Antispasmodics (e.g. baclofen, tizanidine)
Benzodiazepines (e.g. diazepam)
Focal therapies

Focal therapies have the advantage that they can be used for certain muscle groups or localized spastic alterations, without causing systemic side effects. The treatment is carried out with the muscle-relaxing agent botulinum toxin by injection directly into the affected muscles. Thus, the effect remains locally limited. The drug develops its effect after a few days and leads to muscle relaxation. The injection must be repeated at regular intervals.
Neurosurgical
Selective peripheral neurotomy
Intrathecal baclofen therapy
Selective dorsal rhizotomy
Dorsal root entry zone lesioning

Other surgical
Tendon-lengthening procedure
Bony anatomy correction / rotation osteotomies
Intravascular botulinum toxin injections
Intramuscular botulinum toxin injections

Chemoneurolysis with alcohol and phenol

In case of focal injections of ethanol and phenol, the therapy is carried out by destruction of nerve tissue. Today, chemoneurolysis is hardly used anymore.

Intrathecal baclofen

Oral antispasmodic therapy often quickly reaches its tolerance limits due to systemic side effects. In addition, the effect also causes, in a dose-dependent manner, weakening of less strongly affected muscles, drops in blood pressure or increases of pre-existing ataxia (movement disorder). The most common side effect is a severely limiting fatigue, which has a strong impact on everyday life. Rehabilitative measures are hampered thereby. Intrathecal therapy with baclofen (ITB) can be used efficiently here. The drug is administered by catheter, and a very low dose is usually sufficient for efficient reduction in muscle tone. ITB should ideally be supplemented with conventional physiotherapy. ITB is a procedure that is only used for severe spasticity.

2. Surgical therapy procedures

If there are any special medical conditions, a neuro-orthopedic or neuro-surgical operation may also be considered. Since surgery often leads to only temporary alleviation of spasticity, it is rarely performed.

The Spasticity Awareness  is on June 17 - 24, 2018. Please join us in raise the awareness about the condition that affects over 12 million people worldwide.

Tips to live with spasticity

Managing spasticity with assistive devices, aids and home adaptations can help ensure your safety and reduce the risk of spasticity-related falls. Physical and occupational therapists will recommend the appropriate aid(s) as well as safety procedures, maintenance and proper fit. Some modifications in your home to improve safety include:

Ramps
Grab bars
Raised toilet seats
Shower or tub bench
Plastic adhesive strips on the bottom of the bathtub
Braces, canes, walkers and wheelchairs may help you move about freely as you gain strength.
Always follow rehabilitation therapists’ recommendations regarding limitations and safety needs.

The author Dr. Javier Blanco is a medical director at the Rehabilitation Clinic Dussnang, a healthcare facility of VAMED. Dr. Christian Kätterer is a senior physician at REHAB Basel.

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+"Neurorehabilitation in Vienna" - from Prim. Dr. Christoph Stepa