1. Spasticity Treatment Options
Andrea P. Toomer, M.D.
Physical Medicine and Rehabilitation
Culicchia Neurological Clinic

2. Objectives Review the prevalence of spasticity
Discuss the functional implications of spasticity
Review oral, intramuscular and intrathecal treatments for spasticity
Discuss the interdisciplinary approach necessary to improve function in a patient with spasticity

3. Spasticity
VELOCITY DEPENDENT INCREASE IN RESISTANCE TO PASSIVE MOVEMENT FOLLOWING DAMAGE TO THE UPPER MOTOR NEURON SYSTEM
Spasticity of cerebral origin results from lack of descending inhibitory input from subcortical nuclei in brain
Spasticity of spinal origin results from interruption of descending tracts that inhibit or modulate alpha and gamma motor neurons

4. Distribution of Spasticity
Focal
Isolated local motor disturbance affecting a single body part
Regional
Motor disturbance involving a large region of the body
Generalized
Motor disturbance involving widespread regions of the body

5. Prevalence of Spasticity
Brain injury
20% of brain injury survivors experience severe spasticity
Cerebral palsy (CP)
45% of individuals with cerebral palsy have severe spasticity
Stroke
58% experience spasticity according to a survey of stroke survivors or primary caregivers of a stroke survivor (N = 504)

6. Prevalence of Spasticity
Multiple sclerosis (MS)
34% of MS patients experience severe spasticity
Spinal cord injury (SCI)
Between 53% and 78% of SCI patients report spasticity
Approximately 41% of these individuals list spasticity as one of the major medical obstacles to community and workplace re-integration

7. Spasticity is under treated
National Stroke Association survey of 504 stroke survivors (or caregivers)
Up to 58% of stroke survivors develop spasticity1
Of the 292 patients in the study with spasticity:
51% (149 patients) were receiving treatment
49% (143 patients) were untreated

8. Treatment Goals Prevention of contracture Improved seating position
Improved hygiene
Improved mobility
Improved ADL function
Decrease pain
Prevent pressure wounds
Improve quality of life

9. Pharmacologic Treatment

10. Baclofen
Binds to GABA receptors in the spinal cord, suppressing release of excitatory neurotransmitters
Side effects
Sedation
Weakness
GI symptoms
Confusion
Tremor
Insomnia

11. Benzodiazepines
Acts on GABA receptors to facilitate post-synaptic GABA effects to inhibit muscle contraction
Side effects
Sedation
Memory impairment
Abuse potential

12. Dantrium
Acts on muscle tissue to block calcium release from sarcoplasmic reticulum thereby inhibiting muscle contraction
Side effects
Hepatotoxicity
Frequent monitoring of LFTs required
Not centrally acting- does not cause sedation

13. Tizanidine Central α-2 agonist
Decreases release of excitatory amino acids, inhibiting spinal neurons
Side effects
Hypotension
Sedation

14. Chemodenervation
Localized therapy

15. Chemodenervation Phenol
Causes demyelination of the nerve
Immediate onset of relaxation
Effects last up to 36 months (average 6 months)
Complications
Difficulty with administration
Dysesthesias
If injected intravascular can cause convulsions, CNS depression, cardiovascular collapse

16. Chemodenervation Botulinum Toxin
Acts at the neuromuscular junction
Blocks release of acetylcholine from the presynaptic neuron
Injected with audio EMG guidance
Maximum effect in 7-10 days, lasts 3 months
Complications
Focal weakness
Distal spread of toxin

17. Intrathecal Therapy
Global therapy

18. Intrathecal Baclofen
Binds to GABA receptors in the spinal cord, suppressing release of excitatory neurotransmitters
Implanted pump delivers baclofen to the intrathecal (subarachnoid) space
Effective at substantially lower doses than are required orally
Significantly less sedation seen as compared to oral dosing

19. Intrathecal Baclofen Screening Test
Trial dose of baclofen is given intrathecally
PT/OT exam prior to administration
PT/OT exams after administration
Quantify effects of ITB
If trial is positive patient proceeds to implantation

20. Intrathecal Baclofen Pump Implantation
Implanted by a neurosurgeon
Same day surgery
Treatment is initiated at the time of implant
Patient wears an abdominal binder for about a month to prevent edema at the pump site
Begin PT and OT after the post op visit

21. Intrathecal Baclofen Dosing is adjusted slowly Continuous or bolus
dosing options

22. Commitment to ITB therapy
Frequent PT/OT sessions
Daily HEP
Daily use of static and/or dynamic bracing
Frequent doctor visits for dose titration
Visits 2-4 times a year for pump refills
Pump replacement every 7 years

23. Summary
Spasticity occurs as result of damage to the central nervous system
Spasticity can be present with TBI, SCI, CVA, MS, CP
Spasticity can develop gradually and can change over time
Spasticity can limit function, causing difficulty in performing ADLs and mobility skills
Medical complications of spasticity include contracture and skin breakdown
Treating spasticity as a part of an interdisciplinary rehab program can lead to improved function and improved quality of life

24. Treatment Goals Prevention of contracture Improved seating position
Improved hygiene
Improved mobility
Improved ADL function
Decrease pain
Prevent pressure wounds
Improve quality of life

25. Interdisciplinary Treatment
Medical treatments will decrease the muscle tone
PT/OT is necessary to improve function
PT/OT feedback helps us to make determinations in dosing titration

26. Patient Presentations

27. Questions ?

28. Thank You Andrea P. Toomer, M.D. Culicchia Neurological Clinic
(504)
(504) fax