Spasticity Management

What is spasticity?

Spasticity is the medical term for when muscles involuntarily “seize up,” contracting and becoming tense  when they shouldn’t.  It’s as if the patient is flexing the affected muscles – but without meaning to, and without being able to stop.  The result is stiffness, rigidity and muscle pain.

Sometimes, spasticity can be seriously debilitating.  Without treatment, it can disrupt patients’ daily activities, making it very difficult for them to care for themselves.  Spasticity can interfere with even routine activities such as dressing, washing and eating.

However, spasticity can be managed.  With help and proper care, many people with this disorder can become more active and more comfortable.

How does spasticity happen?

Spasticity happens when the affected muscles don’t “hear” messages from the brain telling them to relax.  The condition is caused by nervous system disorders.  These include stroke, traumatic brain injury, spinal cord injury, multiple sclerosis and cerebral palsy.

Spasticity is a very common disability in stroke survivors.  Each year in Canada, about 50,000 people have strokes.  About 10% go to an inpatient rehabilitation program and 15% require long-term care.  It’s estimated that about 300,000 Canadians are living with disabilities – including spasticity- caused by stroke.

What muscles are affected by spasticity?

Spasticity can affect any group of muscles, although certain patterns of muscle involvement are more common than others.  It may be confined to a single group of muscles, or it can affect multiple muscle groups.

In the upper body, spasticity often involves muscle groups in the shoulders, elbow area, forearms, wrists and hands.  This can make it difficult for affected persons to maintain a healthy posture, or to use their arms and hands for routine tasks.

In the lower body, spasticity can affect muscle groups in the thighs, knees and feet.  The result can be difficulty walking or even sitting comfortably.

Many degrees of spasticity exist, from mild, occasional stiffness to permanent shortening of the affected muscles.  In mild cases, the disorder can cause manageable “nuisance” effects.  In more severe cases, however, spasticity can be both disabling and very painful.  In its most serious form, spasticity makes muscles remain permanently flexed or contracted.  This is known as contracture.

Do I need spasticity?

Without proper treatment, spasticity can:

• Disrupt basic activities such as eating or dressing
• Reduce mobility
• Cause discomfort and painful muscle spasms
• Interfere with hygiene by limiting access to underarms, groin, etc.

How do I manage my spasticity?

Usually, the first step in managing spasticity is assessment.  Doctors need to understand exactly what is causing the disorder, as well as the symptoms it’s producing.

Often, the underlying cause of spasticity will be fairly apparent: a stroke, a traumatic brain injury, a spinal cord injury, or a disease like multiple sclerosis or cerebral palsy.

Assessing symptoms and deciding how to treat them may require input from several different types of healthcare professionals. These may include:

• Neurologists – doctors who treat brain and nerve disorders.  Neurologists often “coach” the treatment team.  They diagnose the underlying problem and prescribe treatment, including drugs and therapies.
• Physiatrists – doctors who specialize in rehabilitation.  Physiatrists put together individualized programs of rehabilitation for the patient.  They may also prescribe drugs as needed.
• Physiotherapists – specialists who help patients regain mobility and function through physical therapy.  Physiotherapists help patients do exercises to improve range of motion, mobility and other physical skills.   They also teach patients how to do appropriate exercises on their own.
• Occupational therapists – specialists who help patients return to as normal a life as possible by adjusting their environments and learning appropriate coping techniques.  Occupational therapists advise the patient – and often the caregivers as well – on how to manage day-to-day activities such as eating and washing.  They also give advice on modify in the patient’s work and home environment to improve quality of life.

Will my spasticity go away soon?

Spasticity is a long-term health condition.  Symptoms can change over time.  Also, new treatments and new approaches to therapy do become available from time to time.  For these reasons, it’s important to reassess management plans on a regular basis, to be sure they still offer maximum benefit.

What are the treatment options available to me?

A whole range of therapies are available to treat spasticity and to make it easier for patients to cope.  Often, these treatments are given in combination for best results.  Common treatments used in combination included:

• Botox® (botulinum toxin type A)
• Physiotherapy
• Occupational therapy
• Surgery (in some cases)
• Drug therapy

What is Botox®?

Botox® (botulinum toxin type A) is a purified neurotoxin complex protein produced from the bacterium Clostridium Botulinum.

Botox® is produced in strictly controlled laboratory conditions and given in extremely small therapeutic doses.  Botox® is generally well-tolerated and is an effective treatment for many conditions associated with hyperactive muscle disorders.

Botox® acts as a neuromuscular blocker when injected into the muscle.  It works at the nerve endings and binds with them to block the signal to the muscle.  It effectively filters the brain signal – making the muscle weaker, and reducing the hyperactivity.

Botox®has proven effective in more than 15 years of clinical study and patient treatment.  Botulinum toxin type A is one of seven different seroty pes of botulinum toxins (A,B,C,D,E,F,G).  Each type of toxin has different properties and actions.  In Canada, Botox®(botulinum toxin type A) is approved for use in adult spasticity as well as other uses.  Toxins A,B,E and F are the only ones that have any effect in humans.

How does Botox® work?

The brain sends electrical messages to the muscles to contract, thereby producing movement.  The action of the muscles is controlled by the part of the brain called the basal ganglia, which regulates specific muscles.  The electrical message is transmitted from the nerve ending to the muscle by a chemical called acetylcholine.  Botox® restricts the relay of the chemical signal to the muscle because it is a neuromuscular blocker.  Botox® inhibits the release of acetylcholine so that the muscle does not receive the message to contract and, as a result, the muscle relaxes.

Botox® may inhibit the release of neuropeptide neurotransmitters, which is believed to contribute to the reduction of pain.

Botox® Mechanism of Action

Botox® binds to the nerve ending, Botox® is absorbed and inhibits the release of the chemical transmitter, acetylcholine.

When Botox® blocks the release of acetylcholine, the electrical signal from the brain cannot be transmitted to the muscle, thus interrupting the signal and allowing the muscle to relax.

How is Botox® administered?

Botox® is injected into the muscle in spasms.  Your doctor will determine the muscle(s) in need of treatment.

Does the treatment hurt?

Most patients report minor and temporary discomfort from the injections.  A very fine needle is used to inject the muscle in one or more places.  Botox® has a neutral pH (Neither acid nor alkaline) which helps minimize pain on injection.

When does Botox® start to work?

Usually you will see the effects of Botox® within two weeks after injection.  Some people notice continued improvement for up to six weeks.

How long does the effect last?

Botox® offers sustained relief over the course of long-term treatment.  The relief you will feel from Botox® will normally last for three to four months.  Then you will notice a gradual fading of its effects over several weeks.  At this time you may return to your doctor for reassessment to determine the need for the next injection.

Usually, Botox® treatment is required three to four times a year.  Individual symptoms may vary throughout the course of the condition, and so the degree of relief and duration of effect varies from person to person.

Physiotherapy: A mainstay in treatment for spasticity

Physiotherapy for spasticity very often includes stretching (sometimes called “range of motion”) exercise.  These help prevent the muscles and tendons from shrinking.  They also help keep joints from becoming stiff and “frozen”.  A trained physiotherapist helps the patient move parts of the body affected by spasticity without causing injury or pain.

Occupational therapy: Seizing the day

Sometimes, spasticity interferes with day-to-day living.  In these cases, patients may need to learn new skills to help them get back on top of their daily routines.  Occupational therapy is designed to teach patients whatever skills they need to remain mobile and to take an active role in life.

Occupational therapy might include such things as learning new strategies for getting around, dressing and grooming.  It also includes advice on acquiring and using devices such as wheelchairs and special equipment to assist people with disabilities.

Surgery: In some cases an option

For some people with severe spasticity, surgery may be an option.  Surgery can fall into one of two categories:

• Neurosurgery to inactivate nerves causing the spastic reaction
• Orthopedic surgery to correct joint damage or deformity caused by long-term spasticity

Because even minor surgery does have some risk associated with it, the patients and their healthcare team must weigh the pros and cons very carefully before choosing this option.

Other medications:

A number of medications are available to help spasticity by relaxing muscles.  In Canada, these drugs include:

• Diazepam
• Baclofen
• Tizanadine

These medications help to relax muscle contractions and improve range of motion.  However, like all drugs, they have unwanted side effects.

If you think you would benefit from drug therapy for spasticity, ask your doctor which medication would be best for you.

Getting back into motion

Spasticity is a disabling and painful condition that affects many Canadians.  The good news: with care and proper therapy, many Canadians with spasticity can reduce pain and become more active.