Treating Spasticity - Oral Medications and Surgery
Andrea ByrdSpasticity 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 Sources1) Spasticity 
2)Spasticity, NINDS 
3)The Neurosurgery Clinic 
4)Second Thoughts 
8) Intrathecal Baclofen 
9) Spasticity: Surgical Treatments 
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