Spasticity

Overview

Spasticity is a condition in which muscles stiffen or tighten, preventing normal fluid movement. The muscles remain contracted and resist being stretched, thus affecting movement, speech and gait.

Causes

Spasticity is generally caused by damage or disruption to the area of the brain and spinal cord that are responsible for controlling muscle and stretch reflexes. These disruptions can be due to an imbalance in the inhibitory and excitatory signals sent to the muscles, causing them to lock in place. Spasticity can be harmful to growing children as it can affect muscles and joints. People with brain injury, spinal cord injury, cerebral palsy or multiple sclerosis can have varying degrees of spasticity.

Symptoms

Symptoms of spasticity can vary from being mild stiffness or tightening of muscles to painful and uncontrollable spasms. Pain or tightness in joints is also common in spasticity.

• Muscle stiffness, causing movements to be less precise and making certain tasks difficult to perform
• Muscle spasms, causing uncontrollable and often painful muscle contractions
• Involuntary crossing of the legs
• Muscle and joint deformities
• Muscle fatigue
• Inhibition of longitudinal muscle growth
• Inhibition of protein synthesis in muscle cells

Complications

• Urinary tract infections (UTI)
• Chronic constipation
• Fever or other systemic illnesses
• Pressure sores
• Frozen joints

When & How to Seek Medical Care

It is important to seek medical care when spasticity is experienced for the first time with no known cause, the spasticity is worsening and becoming more frequent, pain is experienced due to stiff joints and muscles or the condition is preventing performance of everyday tasks. Prolonged and untreated spasticity can lead to frozen joints and/or pressure sores on the skin, which are very painful. Begin by contacting your primary care doctor, who may refer you for further testing or physical therapy.

TESTING + DIAGNOSIS

Due to the varying degrees of spasticity, diagnosis may not be so simple. A physical examination with neurological testing will be done to test for spasticity and the severity of it. Imaging such as magnetic resonance imaging (MRI) can provide more information on the source of spasticity and the extent of the damage that has caused it.

Treatment

Fortunately, there are several treatment options for spasticity and patients usually undergo more than one treatment at a time. The following treatments have been shown to effectively alleviate symptoms and improve quality of daily life.

Non-Surgical Treatments

• Physical therapy: stretching and strengthening exercises focusing on large muscle groups to improve range of motion and mobility.
• Occupational therapy: exercises that focus on small muscle groups to improve strength and coordination allowing for improved performance of daily tasks. Speech therapy can also be done by patients whose spasticity has affected their speech.
• Casting or bracing: prevents involuntary spasms and reduces tightening of the muscles.
• Oral Medications: oral medications are used in combination with other therapies or medications, such as physical or occupational therapy. Oral medications are only used if symptoms interfere with daily functioning or sleep. Common medications include:
• Baclofen
• Benzodiazepines
• Dantrolene sodium
• Imidazolines
• Gabapentin
• Botulinum Toxin (Botox) Injections: Botox injections can be used to paralyze the spastic muscle preventing it from contracting. In small amounts, Botox is injected into carefully selected sites determined based on the pattern of spasticity. Botox injections can last up to 12-16 weeks, but, due to the plasticity of the nervous system, new nerve endings will form and the muscle will no longer be inhibited by the Botox. Additionally, while Botox can be very helpful, there is a limited number of injections that can be administered.

Surgery

• Intrathecal Baclofen (ITB) Pump: A pump can be surgically placed in a patient’s abdomen and will release a steady dose of baclofen directly to the spinal fluid. This allows for a significant reduction in spasticity and pain with fewer side effects compared to taking baclofen orally. ITB pump therapy should only be considered in extreme cases of spasticity and has been found to be most effective in treating spasticity in the lower and upper extremities.
• Selective Dorsal Rhizotomy (SDR): Spasticity can be caused by an imbalance in electrical signals to antagonist muscles. SDR rebalances the electrical signals sent to the spinal cord by cutting selective nerve roots. This is only done in severe spasticity of the legs. With proper and precise indication of the problematic nerve roots, cutting these roots will decrease muscle stiffness, while maintaining other functions. SDR is most commonly used in patients with cerebral palsy.

Follow-up

Patients are recommended to follow up with their primary care or specialty doctor regularly to ensure proper treatment of the condition. Typically, for surgeries such as baclofen pump placement, patients are followed by their neurosurgeon who sees them three months, six months and 12 months post operatively and additionally for medicine dosing appointments and any device-related appointments. Patients who take oral medications or who do physical and/or occupational therapy should follow-up with their doctors as instructed and needed.

Resources

Currently Recruiting:

• Evaluation of a Spasticity Management Program for People With Multiple Sclerosis
• Muscle Selection for Botulinum Toxin A Injection in Poststroke Elbow Flexor Spasticity
• Compare Two Guidance Techniques for Botulinum Toxin Injections for the Treatment of Limb Spasticity and Focal Dystonia
• Comparison of Electrophysiologic and Ultrasound Guidance for Onabotulinum Toxin A Injections in Focal Upper Extremity Dystonia and Spasticity

Recently Published:

• Morota, N. (2020). What we have gained and what have remained controversial in the field of rhizotomy for spasticity since 2007. Childs Nervous System. doi: 10.1007/s00381-019-04487-4 This article includes the thoughts of a pediatric neurosurgeon reflecting on his personal experiences with rhizotomy to shed light on what should be changed and what should be kept the same when performing rhizotomy, primarily in children.
• Schiess, M. C., Eldabe, S., Konrad, P., Molus, L., Spencer, R., Stromberg, K., … Plunkett, R. (2020). Intrathecal Baclofen for Severe Spasticity: Longitudinal Data From the Product Surveillance Registry. Neuromodulation: Technology at the Neural Interface. doi: 10.1111/ner.13097M.C This longitudinal, prospective study looked at patient outcomes, both adult and children, to determine the effectiveness and practicality of ithrathecal baclofen pump therapy for severe spasticity. The study found that, even 10 years after pump placement, 87.2% of adult and 76.3% of pediatric patients continued with ITB therapy.
• Berntsson, S. G., Gauffin, H., Melberg, A., Holtz, A., & Landtblom, A. M. (2019). Inherited Ataxia and Intrathecal Baclofen for the Treatment of Spasticity and Painful Spasms. Stereotactic and Functional Neurosurgery, 97(1), 18–23. doi: 10.1159/000497165SG This study aimed to look at the effectiveness of the intrathecal pump therapy for patients with inherited ataxia who also suffer from spasticity. The study found that intrathecal pump therapy provides pain relief for patients who have ataxia and spasticity.
• Mahmood, A., Veluswamy, S. K., Hombali, A., Mullick, A., N, M., & Solomon, J. M. (2019). Effect of Transcutaneous Electrical Nerve Stimulation on Spasticity in Adults With Stroke: A Systematic Review and Meta-analysis. Archives of Physical Medicine and Rehabilitation, 100(4), 751–768. doi: 10.1016/j.apmr.2018.10.016A This review searched the medical literature to determine whether transcutaneous electrical nerve stimulation (TENS) is an effective treatment for spasticity. The review found supporting literatue to conclude that TENS alongside physical therapy is a more effective treatment than just TENS alone, or just physical therapy alone, for lower limb spasticity.

More Resources:

• Laurel’s Cerebral Palsy Story
• Frank’s MS Story
• Kay’s Post-Stroke Story
• Michele’s Post-Spinal Cord Injury Story