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SCI Forum

 

Spasticity and Spinal Cord Injury

 

Part 1: The Good, The Bad, and The Not-So-Ugly: Medical and Pharmacological Treatments for Spasticity

 

By Rina Reyes, MD, Amy Icarangal, PT, and Geralyn Bertellotti, OT.
Presented on January 13, 2015

Spasticity in spinal cord injury is often viewed as a cause of dysfunction and pain. But there is more to it than that. This SCI Forum presentation explored the positive effects of spasticity (“the good”), the negative effects (“the bad”), the neutral effects (“the not so ugly”), and a variety of interventions for spasticity. A rehabilitation medicine physician, a physical therapist, and an occupational therapist summarized the causes of spasticity and discussed a variety of conventional and non-conventional treatment options. Watch the video or read the report.

Presentation time: 68 minutes. After watching, please complete our two-minute survey!

Click here to watch this video on YouTube, with or without closed captions.

Report

Table of Contents

Medical and pharmaceutical treatments

 

By Rina Reyes, MD, Associate Professor, Rehabilitation Medicine, and Director, UW Medicine Spinal Cord Injury Rehabilitation Program

 

What is spasticity?

Spasticity is the name for involuntary muscle movement or tightening that is caused by central nervous system injuries like SCI or TBI.  Although we don't know the exact mechanism, we do know that the injury to the spinal cord causes a disruption in the very complex nerve circuits of the brain and spine that control reflex motor activity.  When the brain and spinal cord can no longer communicate normally with the rest of the body, the muscles controlled by the injured parts of the spinal cord can become overactive.

Spasticity varies widely from person to person and can include a variety of symptoms, such as:

How common is spasticity in spinal cord injury?

Most people with SCI (65%-78%) have spasticity, and a large percentage of them (28%-43%) report it to be a problem. For some people, spasticity can significantly decrease their quality of life and reduce their ability to be independent. Studies report that close to half (43%-49%) of people with SCI take medications for spasticity, although in my experience it's actually more than half.   

What areas are affected by spasticity in the body? 

Spasticity can affect any muscle below the level of the spinal cord injury lesion. It can appear in the arms or legs, bowel or bladder, trunk or neck, or even in the abdomen.

Spasticity evolves

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Spasticity can have both desirable and undesirable symptoms.  

The key to appropriate management of spasticity is understanding its impact on the individual. This makes it possible to determine what needs to be treated and how aggressively, and what does not need to be treated.

The Good
 How can spasticity be good for you? 

The Bad

The not so bad—those effects that are not too bothersome and you learn to live around them.

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Principles of Spasticity Treatment

Many people have a mixture of good, bad and neutral effects of spasticity. So the principle in treating spasticity is to manage the bad effects, maintain the beneficial effects, and learn to live with the effects that are neither good nor bad. 

Reasons to treat spasticity:

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What your health care provider needs to know:

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How to evaluate spasticity

There is no single test or measure that describes the total picture of a person’s spasticity. Your health provider needs to perform a combination of tests in order to fully understand your spasticity and how it affects you.

Figure 1
PENN SPASM FREQUENCY SCORE (PSFS)

  • No spasms
  • Mild spasms induced by stimulation
  • Infrequent spasms occurring  1x/hour
  • Spasms occurring >1x/hour
  • Spasms occurring > 10X/hour

MODIFIED PSFS

  • Mild
  • Moderate
  • Severe

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Evidence-Based Treatments

Just like the experience of spasticity itself, response to treatment varies widely from person to person, and most people have to go through a period of trial and error.  In most cases treatment involves a combination of approaches: medication and non-medication treatments, multiple medications, or medications and injections. Your provider may need to work with your insurance company to get more than one treatment covered, since some insurers limit or require pre-authorization of certain medications and treatments.

Oral Medications

Baclofen
This is often our first line medication treatment. It works by relaxing and depressing the neural reflex circuit that causes spasticity.  Specifically, Baclofen activates the GABA chemical receptors in your nervous system, which are the chemicals that relax the nervous system.
Baclofen is very good at controlling spasticity but has a number of possible side effects:

Baclofen affects people differently and doses can vary widely. Some people only need ten milligrams two or three times a day while others need more than twice that amount. Some people find the side effects to be intolerable at the amount of Baclofen they need to control their spasticity.

Alpha-2 Adrenergic Agonists
This class of drugs alters the chemical environment in the spasticity neural circuit to enhance the amino acids and proteins that tend to relax the muscles.

Dantrolene 
This drug acts directly and only on the muscle and decreases the strength of muscle contractions. For many decades this was the mainstay of spasticity treatment, along with Diazepam. It can be mildly sedating, and the primarily concern is the risk for liver toxicity, so you should be on the lowest effective dose and follow the liver testing schedule. While it’s not often used as a first-line medication for spasticity, it might be a good adjunct treatment to the other medications. 

Benzodiazepines (for example, Diazepam)

There are multiple uses for this medication, including treating seizure disorders, anxiety or sleep problems. It has a similar mechanism of action to Baclofen but acts on a slightly different receptor.  It seems to be as effective as baclofen but causes greater sleepiness, confusion and fatigue.  There is a risk for developing tolerance to this medication, meaning over time you need more and more to be effective. You can also become physically dependent on it.  For these reasons, it is not a first line treatment and we use the minimal dose possible. It is best used only at night for people whose spasticity keeps them from sleeping, and for emergency, in-hospital use.

 

Medical Marijuana (Cannabis)

Many people with SCI use marijuana to help manage their spasticity. To learn about how it works, what the risks and benefits are, and the legal concerns, refer to the 2014 presentation on Medical Marijuana and Spinal Cord Injury by Dr. Greg Carter at http://sci.washington.edu/marijuana. 

Focal Treatment (Blocks or Injections)

Blocks and injections are a way to treat local, meaning not widespread, spasticity without causing the system-wide side effects like sleepiness or confusion that come with oral drugs. It can also be used to enhance therapeutic benefit of bracing, splinting or even electrical stimulation.  Longer-acting blocks last from 2 – 5 months.

Neurolytic injections with phenol

Phenol is a drug that chemically destroys the peripheral nerve involved in the reflex loop causing spasticity. Nerves in the peripheral nervous system outside the spinal cord are able to regrow themselves, so the effect of phenol is temporary. It is used in nerves that have very little sensory component in order to avoid the possibility of causing pain.   Injecting phenol requires electrical stimulation, time, and precision to find the exact injection site in the muscle.

Neurotoxins, including botulinum toxin

Botulinum toxin is a protein made by a specific kind of bacteria. It is used medically by injecting it into the spastic or overactive muscle to cause temporary paralysis or weakening of that muscle. Because it can be used on any muscle that is accessible by needle it is easier and faster to administer than phenol. It is more expensive, however, and therefore harder to get covered by insurance companies. Injections need to be repeated about every three months and dosing needs to be prescribed with care because over time it can become less effective.

The Bottom Line: Botulinum toxin treatment is only as good as the proper identification and localization of the target muscle. Use to treat focal spasticity problems, possibly in combination with other medications and interventions.

 

Surgery treatments

Intrathecal baclofen
The intrathecal baclofen pump is a surgically implanted system used to control spasticity by infusing baclofen directly into the spinal canal and around the spinal cord. This method was created to solve the problems and side effects of taking oral spasticity medications. This system delivers baclofen directly to where it is needed—into the intrathecal space inside the spinal canal that contains the fluid that bathes the spinal cord. Therefore, people need far less Baclofen than the oral dose, and it can be precisely controlled with fewer side effects of sedation.  The system consists of a teardrop-shaped hockey puck-sized canister surgically implanted under skin in the lower abdomen and attached to a catheter that winds around the body under the skin and into the spinal canal.  It is only appropriate for those people who are accepting of the surgical risks and the maintenance requirements for a pump. This method is described in an SCI Forum presentation available at http://sci.washington.edu/info/forums/reports/intrathecal_baclofen.asp.

Other surgical options
Ablative surgeries that cut nerves in order to interrupt the nerve circuit causing spasticity (selective dorsal rhizotomy, myelotomy, neurectomy) are irreversible and primarily considered only when less invasive methods are not successful.

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What treatments are best for you?

Discuss with your health care provider:

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Physical therapy approaches

Amy Icarangal, PT, Harborview Medical Center

When I’m working with patients on their spasticity, what I want to know from a physical therapy point of view is how their spasticity affects their functioning, breathing, walking, posture and ability to be independent?  My goal as a therapist is to help patients function better. There are several non-medication approaches a PT can help with.  

Stretching

Why it works: Stretching causes a temporary reduction in muscle tone and increases flexibility and range of motion. The effects of stretching can last several hours.

How long and how often: Generally you should hold a stretch for 30 seconds to a minute for one to five repetitions, but this varies a lot and depends on the nature and severity of your spasticity.

Types of stretches

What to stretch

If you tend to flex (bend) when you spasm, you should stretch the front muscles, including biceps, pectorals (chest), abdominals, wrist flexors (inside of lower arms), hands, hip flexors and hamstrings. 

If you tend to go into extension (straighten out), then you need to stretch your shoulder blades, lower back, hands, quadriceps, and calf muscles.  It’s also important to stretch in diagonal and lateral (side-to-side) patterns.

How long to hold a stretch is dependent on when you feel (less spasms) or see that muscle release (less tension in the muscle belly or less “jumping” of the leg).

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Strengthening 

Why it may work

The American College of Sports Medicine (ACSM) provides the following guidelines regarding strengthening exercises for individuals with SCI:

I also recommend that you work out of the patterns that cause your spasms. For example, if your hips and knees tend to flex when you spasm, work on exercises that make your hips and knees extend.  For you to be strong, you need to be strong throughout the entire muscle length or range of motion and have a balance of flexor and extensor muscles. This allows you build long, lean, and strong muscles.

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Weight-bearing and standing

Why it may work:

Whole body vibration

This therapy uses equipment with a platform that vibrates while the person stands on it (with or without a standing frame). This is an emerging treatment, but there have been only a few studies in the SCI population. 7, 8, 9, 10

Why it may work

Dosing used in studies:

At this time, it is unclear how much (frequency) whole body vibration and how long (duration) may be therapeutic. There are also concerns about the risk for fracture.

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Occupational therapy approaches

Geralyn Bertellotti, OT, Harborview Medical Center. 

 

Splinting

Splinting is a treatment option if you have spasticity in any of your extremities, such as your arm, leg, hand, or ankle.

Why it may work

Static splinting uses a splint that doesn't change. Static splints are usually easy to get on and off. The splint should stay on at least two hours, preferably overnight if tolerable. Splinting provides a low amplitude, longer duration stretch.  With any kind of splint you need to check your skin regularly to make sure you don't have any pressure points or irritation anywhere. 
Dynamic splinting is a splint that moves. It provides a low-load, prolonged-duration stretch at the end range of that motion to a group of muscles. It allows stretch to occur while the muscle is relaxed as well as positional change during spasm.
Duration for dynamic splinting usually starts with a 15-minute wearing time to make sure that there are no skin, joint or pain problems, gradually building up to more than two hours.  If a dynamic splint is left on too long, it could create some pain. The tension can be increased a little more every three to five days.    

Thermal modalities

Cold
Why it may work

Cold can be applied from 20 minutes up to 1 hour. Icing too long can result in damage to the skin. The beneficial effects of icing only last about an hour.

Heat
Heat works because it increases blood flow, delivering more oxygen and nutrients to the muscle. Applications can last about 20 minutes. Make sure your skin is protected so you don’t burn yourself.

Electrical stimulation

This is an electrical current to the muscle that activates the nerves and creates a contraction of specific muscles. Electrical stimulation is applied to the muscle opposing the spastic muscle to decrease the excitatory impulse that muscle. For example, biceps and triceps are opposing muscles. Electrical stimulation may help with spasticity by allowing opposing muscle groups to contract /relax or by stimulating a spastic muscle to help reorganize and normalize neuron activity or excitability. One example of this type of treatment is Transcutaneous Electrical Nerve Stimulation (TENS).

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References

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Handouts and PowerPoint Presentations:

Other Resources:

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