South
Shore Neurologic Associates Spasticity Management Program
- Extensive
Experience in the management of the difficult spasticity problems
that are not responsive to standard therapy and medications.
- Extensive
Experience in the use of both BOTOX® and Intrathecal Baclofen
Therapy for treatment of focal, regional and generalized spasticity.
The
therapeutic ladder for the management of spasticity typically
begins with stretching programs
- if this
does not adequately control the spasticity, introduce...
- Oral Pharmacotherapy:
- if inadequate
response to maximal therapy or adverse effects at a subtherapeutic
dose, introduce...
- Injections
of botulinum toxin if...
- spasticity
is limited to a "functional unit", e.g.: thigh adductors,
plantar flexors, neck extensors
- Intrathecal
baclofen if...
- spasticity
is "multisegmental", e.g.: both legs diffusely spastic,
spine, widespread; may be used in combination with botulinum
toxin
The medical treatment
of established spasticity is principally of symptomatic nature,
since spasticity is generally a consequence of irreversible central
nervous system damage.
Spasticity is not
heterogeneous.
The benefits of treatments are most commonly seen on the positive
signs of the upper motor syndrome.
The upper motor neuron
syndrome (UMN) includes the positive symptoms of spasticity and
released flexor reflexes, and the negative symptoms of loss of
dexterity, fatigue and weakness. The negative symptoms are often
more important to the function of the patient than the positive
ones.
Improvement in spasticity does not always correlate with functional
improvement.
Spasticity should
be treated only if it is interfering with some level of functioning,
positioning, care or comfort.
Appropriate and Effective
treatment, however, does not always follow the traditional ladder
approach. Treatment decisions may not follow a steady progression
from conservative to more aggressive approaches.
SPASTICITY:
TRADITIONAL AND NEWER
MANAGEMENT OPTIONS UTILIZED
- REHABILITATION
- Neuromuscular techniques:
facilitatory/inhibitory
- Modalities: heat (to relax
spastic muscles), cold (ice for inhibition and pain relief),
electric stimulation (employed to facilitate opposing muscles),
ultrasound - methods most effective during treatment session
with little carryover
- Orthotics: resting splints,
dynamic bracing, serial casting - commonly used to maintain available
range and flexibility, to provide an inhibitory influence to
spastic muscles, and to progressively lengthen and inhibit spastic
muscles through prolonged stretching; require considerable time
for measuring, castings, fabrication and fitting; patient compliance
for doning and adhering to wearing schedules is difficult
- LIMITATIONS: minimaly effective,
particularly in moderate to severe spasticity; orthotics can
be time consuming and expensive to fabricate and modify
- PHARMACOLOGIC:
systemic
& regional
- Systemic: baclofen, diazepam,
dantrolene sodium, clonidine, tizanidine
- LIMITATIONS: non-selective;
large dosages often required which may result in intolerable
side effects
- Regional and Local: motor
point and nerve blocks - phenol and alcohol; effective in limiting
systemic effects of oral pharmacotherapeutics - used to target
specific muscle groups; duration of effect and effectiveness
vary widely from patient to patient; blocks usually have temporary
effect, lasting months - may result in permanent damage, regionally
targeted but results are not always precise; diagnostic nerve
or motor point block and EMG are useful to distinguish between
the contributions of spasticity and stiffness to the clinical
problem.
- LIMITATIONS: painful; time-consuming;
dysesthesis; variable duration of effect
- SURGICAL
- Neurosurgical
Options:
- Rhizotomy - posterior:
neurodestructive
- Cordotomy: very destructive,
rarely done except in extreme cases
- Orthopedic Options:
- Tendon release: (depending
upon age of patient) does not really treat spasticity, disconnects,
can be effective in helping to reduce the frequency or magnitude
of the spasticity problem or for painful joint deformity or cosmesis
- LIMITATIONS: invasive;
irreversible; bowel/bladder changes; paresthesis; effectiveness
varies - can be unpredictable; may have to be repeated - may
not be able to be repeated
- INTRATHECAL
BACLOFEN
- BOTOX®
No
appropriate treatment decisions can be made without considering
the goals of the therapy
