Treating Spasticity - Oral Medications and Surgery

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Biology 202
1999 Final Web Reports
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Treating Spasticity - Oral Medications and Surgery

Andrea Byrd

Spasticity a disorder of muscle function that causes muscle tightness or spasm. It is the involuntary movement (jerking) of muscles, which occurs when there is damage to the central nervous system. This damage may result from a traumatic brain, injury stroke, tumor, cerebral palsy or multiple sclerosis (1). Symptoms may include hypertonicity (increased muscle tone), clonus (a series of rapid muscle contractions), exaggerated deep tendon reflexes, muscle spasms, scissoring (involuntary crossing of the legs), and fixed joints (2). Spasticity may be as mild as the feeling of stiffness or tightness of muscles, or it may be so severe as to produce painful uncontrollable spasms of the extremities, usually of the legs. It may also produce feelings of pain or tightness in and around joints and can also cause low back pain (3).

Some people find that spasticity is so severe or frequent that it disrupts their life. Health care professional suggest a number of things to calm or stop spasticity: range-of- motion exercises, stress management, prescription drugs, physical therapy regimens, and or surgery. Each offers some help, but treatments like medication and surgery bring complications. The patient is forced to decide if decreasing spasticity is worth the side effects from drugs or loss of some movement and feeling from surgery. Many people who have spasticity take few, if any, medications to control their spasticity (4).

While spasticity cannot be cured, some of the problems associated with spasticity can be cared for in a number of ways. At this present time, there are several medications and surgical methods that are used to help treat spasticity. In most cases, treatments consist of combinations of different medications, implantation devices, and surgery. The investigation of this paper deals with a comparison of the oral medications being used by patients and the numerous surgical procedures available to treat spasticity. The use of oral medications for treatment of spasticity may be very effective. Benzodiazepines, baclofen, dantrolene sodium, and tizanidine are the most widely used agents for reduction of spasticity. The challenge is to establish a treatment plan that will strike a vital balance between improved function, patient satisfaction, and possible side effects. At high dosages, oral medications can cause unwanted side effects that include sedation, as well as changes in mood and cognition (5).

Benzodiazepines such as diazepam are the oldest and most frequently used oral agents for spasticity related to spinal cord injury, cerebral palsy, and cerebral vascular accident. The clinical effects of diazem include improved passive range of motion and reduction in hyperreflexia as well as painful spasms. These agents also cause sedation and improve anxiety (5).

Baclofen has been widely used for spasticity since 1967. Most studies indicate that it improves clonus, spasm frequency and joint range of motion resulting in improved functional status for the patient. Side effects are predominantly from central depressant properties including sedation, ataxia, weakness and fatigue. Tolerance to the medication may develop. Baclofen must be slowly weaned to prevent withdrawal effects such as seizures, hallucinations and increased spasticity. When this medication is used in combination with tizanidine or benzodiazepines the patient should be monitored for unwanted depressant effects(5).

Patients with cerebral palsy and traumatic brain injury respond best with dantrolene sodium. It is less likely that the other agents to cause drowsiness, confusion and other central effects because of its mechanism of action. Dantrolene sodium has been shown to decrease muscle tone, clonus and muscle spasm. The action of this agent is not selective for spastic muscles and it may cause generalized weakness, including weakness of the respiratory muscles. The side effects include drowsiness, dizziness, weakness, fatigue and diarrhea (5).

Tizanidine is used for the treatment of spasticity caused by multiple sclerosis and spinal cord injury. It differs from other antispasticity agents, enabling the avoidance of certain drug dependence, intolerance and interactions. Objective measures of muscle strength demonstrate no adverse effects from tizanidine. Patients report less muscle weakness from tizanidine than baclofen or diazepam. When combined with baclofen, tizanidine presents the opportunity to maximize side effects by reducing the dosage of both drugs. If tizanidine is prescribed in conjunction with baclofen or benzodiazepines, the patient will experience possible additive effects, including sedation (6).

One treatment method that has consistently produced positive results for spasticity patients is the injection of Botulinum toxin, or BOTOX. BOTOX is injected directly into the spastic muscle with the person receiving a dose according to body weight. A small needle is used to administer the BOTOX and there is only minor discomfort associated with the brief treatment. BOTOX can be given without anesthesia and few complications have been reported from it other than the fact it can cause localized weakness, which is actually its desired response. Range of motion exercises and other spasticity-reducing techniques can be used immediately following injection. This form of treatment generally lasts about 12 weeks, then another dose can be administered. If enough tissue lengthening has occurred through stretching and splinting, a permanent effect of increased range of motion can be realized(7).

Surgery can play a very important role in the treatment of chronic spasticity. Patients with acute injury to the central nervous system will have changes in their muscle tone which fluctuate during the recovery period, and surgery should not be undertaken during this time of change. Patients with chronic spasticity should have a thorough evaluation of their current level of function. Realistic expectations for improvement in function should be established before surgical intervention takes places. While each surgical approach has certain strengths and weaknesses, none of them completely eliminate spasticity (9).. Intrathecal baclofen therapy (ITB Therapy) consists of long-term delivery of baclofen to the intrathecal space. This treatment can be effective for patients with severe spasticity, particularly for those patients whose conditions are not sufficiently managed by oral baclofen and other oral medications. Sedation, somnolence, ataxia and respiratory and cardiovascular depression are the drug's CNS depressant properties. Benefits of ITB Therapy typically include reduced tone, spasms, and pain, and increased mobility. The use of ITB Therapy as a treatment for spasticity requires a four-phase approach: patient selection, screening, implantation, and dose adjustment and maintenance. Candidates for ITB Therapy have disabling spasticity unresponsive to conservative pharmacotherapy or intolerable side effects at therapeutic doses. Pharmacotherapy should include, but need not be limited to, a trial of oral baclofen. The screening process for ITB Therapy requires the administration of an intrathecal test dose of baclofen via lumbar puncture. During screening, patients must be monitored closely in a fully equipped and staffed setting, due to the rare risk of life-threatening side effects. The pump implantation requires two incisions: one in the lower abdomen to make a subcutaneous pocket for the pump, and another, smaller, incision in the lumbar region for catheter insertion. Exact placement of the pump differs with each patient, but it is generally implanted near the waistline, about one inch below the skin. The dose delivered by the pump is adjusted using the programmer and telemetry wand. This system is non-invasive and affords flexibility in individualizing doses. The initial total daily dose of intrathecal baclofen after implantation may be up to double the screening dose that resulted in a beneficial response. As with any surgical procedure, the implantation of the pump exposes a patient to a risk of infection and general anesthesia. There is also the risk of spinal fluid leakage. Side effects such as drowsiness, nausea, headache, muscle weakness and light-headedness can stem from the pump delivering an inappropriate dosage of baclofen. These side effects are resolved by assessing the pump and adjusting the dose. Physicians generally start patients on low doses of baclofen with to avoid possible side effects(8).

Musculoskeletal surgery, the most frequently used surgical procedure for spasticity, is performed on the muscle or tendon itself. Tendon lengthening or transfer is often effective in reducing the tension on the muscle, thereby reducing tightness, spasticity and pain. Ankle balancing procedures are among the most effective interventions. Also, surgery aimed at reducing hip and knee flexor tone, as well as wrist and finger flexor tone, can be very successful (9).

Spinal cord surgery (selective posterior rhizotomy) requires dissection and stimulation of nerve rootlets in the lower spine. When there is an abnormal electrical response or activity of the muscle, the nerve rootlet is cut. Although there may be possible benefits of reduction in muscle tone and improved patient functioning, further study of this procedure is needed to clarify its appropriateness and effectiveness in treating spasticity. This procedure may be temporary when used in patients with spasticity from spinal cord injury (9). Osteotomy is a surgical procedure performed on the thigh bone to correct its alignment. Devices are inserted to hold the newly aligned bone in its proper position. Several months later, the devices are easily removed, enabling the patient to return to regular activities (9). Whether treating patients pharmacologically or surgically for spaticity conditions, medical professionals are trying to re-establish or alter the balance of muscle contractions to enhance function. Options for treatment include oral medications and drugs which can be delivered directly into the cerebral spinal fluid at a slow, accurate rate by implanted infusion pumps. Botulinum toxin can be used to relax focal spasticity in the ankle or hand of patients. Surgery can be performed to section nerves and relieve spasticity in very severe cases. The issue is that none of these treatments are perfect, however there are hopes for new drugs that will improve such treatments. These facts make medical care important for maximizing the care of spasticity patients and for development of research centers that can measure the effectiveness of existing treatments and evaluate new treatments.

WWW Sources

1) Spasticity

2)Spasticity, NINDS

3)The Neurosurgery Clinic

4)Second Thoughts

5) Traditional Oral Medications for Spasticity Management

6)Spasticity: Tizanidine/Zanaflex

7) Spasticity Management for People with Cerebral Palsy

8) Intrathecal Baclofen

9) Spasticity: Surgical Treatments

 

 

Continuing conversation
(to contribute your own observations/thoughts, post a comment below)

07/24/2005, from a Reader on the Web

I am experiencing some spaticity in relation to ms issues. Your information pertaining to baclofen was a big help. Mike

 

Additional comments made prior to 2007
I have a rare, inherited neurological disease, Hereditary Spastic Paraparesis/Paraplegia. I just had knee replacement and the knee spasticity in the operated leg has increased tremendously. We are now very worried about contracture and my walking ,which was never great, is severely impaired. It seems as though the surgeryf for knee replacement has accelerated the problems with spasticity. The unoperated leg seems wonderful now in comparison. Any info regarding the increase of spasticity with surgery would be very much appreciated ... Susan, 11 November 2007

Comments

shambhu gupta's picture

movement disorder of my child

My child is 13 years old. He has having some problem in walking. He cannot walk smoothly. His left leg is very weak. While running he falls. His academic performance is very poor. The walking problem was detected since 2011. He was suffered from Chicken pox in the year 2009. He has also urine problem he can not stop urine for a long time and as a result urine leaks in little quantity. Kindly guide us for effective treatment.

vanessa latter's picture

any hope

can any one help, my son who now is 29 is now going through a very depressive stage. when he was 10 he had surgery to remove the left half of the brain with all the complications that brought we got through them, the biggest challange we face is the spasticity in his right arm after trying baclofen and botox and the exercises nothing has worked, please is there any one or thing that can help.

Rachael's picture

Baclofen pump

Hi Luz

I have not had the baclofen pump implanted yet but I'm going to do so soon I have an appointment this Wednesday with another doctor for a second opinion. I will definitely keep you posted as to when I have the procedure done hopefully by spring time. I am scared also I am so sick of being poked and prodded, But is it is it is a decision that I have made , my spasticity is really bad on my left side sometimes the pain is excruciating and I can't even bend my leg and the spasms are unbearable. My husband is a pharmaceutical rep and has studied a lot on the baclofen pump which is supplied by Medtronic you should read about it go on to Medtronic.com. The pump supplies medication directly to the spine, And works a lot different than the oral baclofen and oral Zanaflex do. I have gone in for trial studies and have and have had a lumbar puncture with baclofen medication put into my spine, and it definitely does work. It does not help with this with the heaviness but it does help for you to bend your sisters legs more easily I know how difficult it is to bend them sometimes my husband cannot even bend mine but it won't make it easier for her to bend them herself she'll be able to manually bend them with her arms but not be able to flex them easier on her own. I hope this helps please email me with any other questions. I will keep you updated!

rami abuhamad's picture

spasticity

my 6 year old son has quadriplegic cerebral palsy due to prematurity and hypoxic ischemic encephalopathy,for the last 4 years he had been receiving botox injections every 6 months for his all four limbs,he had developed contractures all over.
his doctor says that there is no benefit from botox now that he had developed contractures and that now he will have to go for surgery.
what is your advice for me regarding continuing botox or doing surgery ?
thanks in advance.

chris grace's picture

MS

i have ppms since 1999, now I am in the weel chair, experiencing muscles weekness in both legs, in right arm and weakness of the spine muscles, anyone can help with advise ?. since traditional medications are normaly for atack/ remission type, not for primary progress multiple sclerose.
good luck for everyone.
chris

Serendip Visitor's picture

Depuy

My father suffered a diabetic stroke last year and half of his body muscles were affected. His right hand and feet have movement issues. he is still undergoing physical therapy to stimulate the muscles. We usually prevent him from falling for he might damaged his hipbones and will further require depuy pinnacle hip replacement surgery. I am happy to have read your blog. it somehow gave me a lot of information.

Cindy Shelton's picture

Stroke at 20

I had a stroke in April 2011 at the age of 20. My neurologist has tried nearly everything short of surgery for my left foot spasticity. He says he is not willing to suggest surgery yet. I'm curious about other treatment options since Baclofen & Zanaflex never helped, they just made me sleepy & being a student at college, I need to remain alert for classes. Botox has also failed to work at all, but this is the only treatment that they are continuing. Surgery would have to wait at least until summer so I can recover for the fall school semester. So far the spasticity hasn't completely made it impossible for me to walk, but I cannot walk normally. I walk on my curled toes in as normal a walk as I can stand.

ILIANA GONZALEZ's picture

GUILLIAN BARRE/CIPD

THANK YOU FOR POSTING THIS ARTICLE, I'BEEN DIAGNOSE SINCE AUGUST 2010 WITH GBS, NOW CHRONIC CIPD.
MY FINGERS ARE CLOSED IN BOTH HANDS, MY PAIN MANAGEMENT DOCTOR JUST INFORMED ME ABOUT THE BOTOX INJECTIONS,I AM WAITING TO HEAR IF MY INSURANCE WILL PAY FOR IT. I AM ANXIOUS, SCARED AND EXITED ,I CANNOT WAIT TO SEE MY HANDS OPENING AGAIN, TO DO ALL THE LITTLE THINGS WE TAKE FOR GRANTED,
LIKE CLEANING YOURSELF AFTER USING THE TOILET,HOLD A FORK,COMB MY HAIR. TYPE ON COMPUTER WITH YOUR FINGERS INTEAD OF MY KNUCKLES, GET DRESS, SO MANY OTHER THINGS.
THANK GOD MY HUSBAND IS BEING THERE FOR ME.
IS THERE ANYONE OUT THERE WITH GBS UNABLE TO WALK AND UNABLE TO USE THE HANDS THAT HAS HAD EXPERIENCE WITH THE BOTOX? PLEASE IF YOU CAN SHARE YOUR STORY WITH ME, MAY BE WE CAN HELP EACH OTHER. GOD BLESS EVERYONE OUT THERE THAT IS SUFFERING.
ILI

Michelle Kinas's picture

Spasticity

Thank you for posting this helpful information. Ten years ago I had a craniotomy for epilepsy which gave me a weakened left leg and dropped foot. Due to an increase in spasticity and shortening of my calf muscle my leg was beginning to turn inwards. To prevent deformity a split tendon transfer was performed about three weeks ago. I have an ex-fix on my leg, which will be on for another month. The pain has subsided for the most part, but I have an increase in spasticity. Or it may be that I am just more aware of it since it hurts with this contraption on.

It seems to decrease when I am not thinking about it. It increases when I am tired and is the worst just before bed. Once asleep, it rarely awakens me...except when it is time to get up. It can be quite painful in the morning, especially with this ex-fix!

I will surely ask my doctor about all this, but wondered if anyone else has experienced similar issues. After a split tendon transfer, and after all the healing and PT, will spasticity still occur? I have tried both baclofen and botox in the past and it seemed to improve movement, but didn't completely get rid of spasticity.

I also have issues with hyper-sensitivity; just lightly touching my left big toe will send my foot into spasms. No more pedicures! Controlling the temperature in my foot is also very difficult. If I am hot, my foot just burns up (and turns red) and if I am a little cold, it turns into an ice cube (and turns blue). And it rarely just feels normal.

Anyone else have split tendon transfer?

Ray's picture

Spasticity

Hi,
My wife had a stroke last year in May. since than we have been thru therpy/excercise etc.she has been taking oral medication for spasticity Baclofen and Dentrolene for spsticity. the spsticity was getting worst so the doctor had given her Botox injection in hand and leg. she has been given Botox about three times in a one year. the biggest problem is her spsticity keeps comming back and they can not do the Botox injection less than 3 months. the spsticity is so bad that she is not able to function or do the regular walk due the muscle tightness and the pain.the doctor is now recommending the Baclofen pump. I was encoraged with above one article but the other person in the article had no luck with Baclofen. I can not decide if I should make her go thru the Baclofen pump surgery?
due to the spasticity and tightness she is getting disturbed in sleep and not able to do her therapy like she did before.some times she looses hopes. I will greatly appriciate if some one can suggest any help or ideas what to might work?

thanks,

Ray

rachael's picture

spasticity

Hi Ray
How is your wife doing? I as well have severe elasticity & just had a consult from my nerologist for a baclofen pump.
I have MS' and have been on every oral med with no luck! So I have decided to have the pump pu I. They do perform a trial dose before it is inserted to make sure you resins to it. I noticed it has been over a year since you wrote this email. Did your wife ever have this done? I will keep you updated on my progress. Good luck. I know how tough it is yo see a loved one go through such discomfort. My husband deals with it too, and has a rough time. I am only 40, but we weed blessed with the birth of our son 6 years ago.
Rachael

Luz's picture

baclofen pump

Hi. Accordinhg to this posting you were going to have the Baclofen pump implanted. Did you do it? If so, would you mind please telling me your experience with it from the patient side, daily living, complications, anything you can share? My sister has MS with very severe spasticity and were are desperate trying to find something that can help but are a bit scared with the pumo option. Thanks a lot for anything you can share.

Denise Roberts's picture

hypertonicity

My 23 year old son was in a near drowning accident when he was 4 1/2 years old. He has had increasing tone since his accident. We have tried oral baclofen, zanaflex and finally the bacolfen pump. None of these treatments have been successful. We are currently taking him off the pump and have seen no increase in tone which was my suspicion for quite some time. Are there any other medications that may help my son?

U's picture

Please update us on the

Please update us on the treatments available to get rid of this disease. I am aware that there is no cure for chronic spasticity..but are there any recent medical developments that anyone is aware of. If yes, kindly share the same as it would be of great help.

Also, please someone let me know some effective steps to minimise this condition of spasticity. (for eg. do exercise help?)

Your comments are valuable and will be of gr8 help to me.

Waitin for responses. Thanks, U

Nora's picture

spasticity

I have been a stroke patient since 2005. I religiously do my physical and occupational therapies for 4 years. My condition has improved and i was able to go back to work. But my problem is the severe spasticity of my left hand. I have been treated 3 times with BOTOX but still after 2-3 months the spasticity comes back. It's very frustrating. I temporary stopped going to my rehab . Mostly what Im doing at home is stretching of my left hand and arm.

Any other hand activity which I can do at home that can lessen or removed the spasticity that I have.

Nora

suzanne's picture

Baclofen pump

My husband has been a quadriplegic since Sept 06 due to a motorcycle accident. He has been through rehab and has PT at home daily and has some return in his legs & arms (not expected by the rehab specialists!!). He went through a severe infection last year and was given resistive antibiotics and was quite ill for 3 weeks. In that 3 weeks, his arms/hands contracted severely. We have worked & worked on his arms to no avail. He has been taking more than the recommended dosage of baclofen for the past 2 years with little relief in the spasms and the pain. He takes 10,383 pills a year! After months of research, telephone calls and referrals, we finally found a doctor who inplants baclofen pumps. He just finished the trial period of injections. The first 2 were very disappointing and discouraging, no effect at all. The last dosage was like a miracle. His arms relaxed, I was able to open his hands with no struggle at all. His fingers opened out completely! We still weren't able to bring his arms out in a supranation position. So while we wait for the pre-cert on the baclofen pump, the doctor is now going to inject Botox in his biceps and forearms this Monday.
For the first time in 2 years, I feel like I don't have to (privately) pretend that he's going to get better!! I am so encouraged now that he will be able to do things for himself again (things we take for granted every day) scratch your nose, brush your teeth, feed yourself. Maybe he won't walk again without help, but he can push himself to a standing position right now and do knee bends, so you just never know what can happen if you just believe it can.

bronstein's picture

on baclofen

Suzanne,

I just happened to check in to look for a movie we made in one of the institutes at Bryn Mawr over the summer and found your post.  I am a T-3 para who teaches fulltime and I have been using baclofen orally for over 20 years.  It's the only thing that has kept me mobile -- well, that and some exercise.  I am glad it is working for you, finally.  From comments in the last paragraph, I take it that your husband is "incomplete."  That's a good thing, of course, and it might also offer more hope for the regaining of some function.  All the reading I do suggests that as various levels of "cures" are found, it will be the incomplete injuries that will benefit first.  Good luck and keep hoping and searching.

Dusty M's picture

Spasticity

My son Dustin, is 31 years old. He has had ungone surgey for a non malignant menginoma last augst, it was follwed 30 days later by gamma knife to treat the small remaing fragments still in plcae after surgery.

Dustin had his first surgery 8 yrs ago and lost motor movment in his right leg.
He did however therapy through it to a point of about 85% MOBILITY. 3 yrs later he underwent six weeks of radiation for the same tumor. Following radiation he began having a few sezuires.

This last surgery 10 moths ago leeft him in a wheel chair for 7 months or so. he has been walking with a cane for some 3 months now, but he is very wobly and unstable. He has to swing his left foot out to take a step . His muscle tone is preventing him from moving his leg in a normal fashion. He has good insurance and we have are persoanlly fanancial secure.

Dustin is the president of a manufacturing corporation and does work daily.
Although his lack of mobility , is wering on him, his therapy this time seems to be at a stand still. He is losing hope for advancement.

Can you or any one anywhere, help him, in any way.

Dusty M

Missy's picture

spasticity

My husband, Rob, is a 40 year old with Glioblastoma Multiforme. He was diagnosed in July, 2008, has had 2 craniotomies with partial resection (10/08, 8/09), standard chemo with radiation 5x/wk x 6 weeks after his first surgery with maintenance chemo for 6 months thereafter.
This was unsuccessful, which led to the second surgery. Since his 2nd surgery in August '09, he has had 2 experimental trials with no success in containing the tumor, and he lost a lot of motor function in his left leg, as his tumor is in the right parietal lobe. He is currently on Avastin every 2 wks via IV and a standard chemo (BCNU) via IV every 6 wks.
After the second surgery, he has not been able to return to work due to his instability ambulating. He uses a straight cane but really needs a walker to be safe and to conserve energy, however, he doesn't want to use it because of his age and how it looks. He has the same gait pattern, swinging his left foot out to clear it to take a step. His extensor tone is preventing him from flexing the left hip and knee in a "normal" fashion and seems to be progressively getting worse. He complains of the tone waking him up at night and now it is causing his wrist and hand to extend, mostly while sleeping.
This lack of mobility is also really wearing on him, he is very frustrated, and wants answers of what can be done.
His neuro-oncologist just put him on Baclofen which we're hoping helps relax the muscles enough to work on strengthening the flexors to assist in his mobility.
Any luck on your end finding answers to something that can help? Our 6, 8, and 10 year old sons would appreciate some help for their dad!
Missy

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