Medically Speaking - Understanding Spasticity
Spasticity is a condition that is commonly seen in patients that have suffered a neurological event. This includes patients living with a spinal cord injury, traumatic brain injury, cerebral palsy, stroke and many other neurological disorders affecting the central nervous system. Spasticity involves muscular over-activity which is involuntary, due to abnormal or impaired control from the brain to the muscle, causing failure of muscle relaxation. Spasticity can present as either generalised (i.e. affecting all muscles below the level of injury) or focal – affecting only a small group of muscles. It is important to realise that the fact that spasticity exists is not an indication for treatment. The management of spasticity is complex and will involve members of the multi-disciplinary team. This team approach will ensure that all factors are taken into account when spasticity is treated. Spasticity can often be beneficial and intervention using medications at the wrong time, can result in the loss of these beneficial factors. Initially, spasticity is not normally treated with medications.
Medication i is only prescribed when the problem becomes moderately severe and impacts on aspects of life such as safety, which results in the potential complications. Overwhelming or poorly controlled spasticity can be the cause for many complications.
Long term complications and clinical problems associated with spasticity include:
- Contractures. This is the shortening of the tendon resulting in the inability to put a joint through its normal range of motion. Severe contractures can complicate the care of patients by making dressing, placement in a wheelchair, hygiene, and general care difficult.
- Seating. Extremely spastic patients have difficulty with seating and specialised supports (such as trunk supports) may be necessary.
- Gait. Severe spasticity can impact on the ability to walk. Spasm may make gait pattern unsafe and predispose patients to injury or confine potentially mobile patients to wheelchairs.
- Upper limb dexterity. Spastic upper limbs limit functional use of that limb making tasks such as grooming, eating, computer use and driving difficult or impossible.
- Pain. Severe spasm can precipitate pain.
- Pressure sores. By ongoing friction, spasticity can cause pressure sores to develop.
Successful treatment of spasticity depends on a thorough understanding of the condition by the attending practitioners and a comprehensive knowledge of all the modalities of treatment that are available. In addition, education of the patient and an explanation of realistic goals is an essential part of good management.
The most important factor for the treatment team is to exclude a secondary cause. There are many potential secondary causes for spasticity, which include bladder problems, bowel problems, pressure sores, pain, depression/anxiety, or even minor ailments such as ingrown toe nails. Once any possible secondary cause has been excluded, one can then look at therapeutic treatment options. A wide range of therapeutic treatment options are utilised. These range from neuromuscular techniques, such as positioning/seating, stretching, weight bearing, strengthening/facilitation of antagonistic muscles and other physiotherapeutic interventions, such as TENS, hydrotherapy and serial casting, to mention a few.
If spasticity remains problematic, then one must consider medications. These will be prescribed by your doctor if indicated and can successfully manage severe spasticity. Treatment options depend on whether the spasticity is focalised, in which case Botox injection can work very well, or generalised spasticity, when oral medication is normally prescribed. Surgical options, such as the implantation of a device to deliver medication directly into the space around the spinal cord, are reserved for when treatment fails on oral medication.
Spasticity is common and should be managed by an experienced team. Treatment is not always required and spasticity can be beneficial. However, severe and poorly managed spasticity can cause many complications. Secondary factors which make spasm worse must first be excluded. Medications are reserved as a last line of treatment.