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Managing Spasticity with Oral Medication and Physical Therapy


What is spasticity?   

Spasticity occurs because of damage to the central nervous system, the brain or the spinal cord, leading to an abnormal increase in muscle tightness. Such damage to the brain or spinal cord occurs in neurological conditions like stroke, multiple sclerosis, cerebral palsy, or spinal cord injury, which are conditions where individuals experience spasticity. 

  

Spasticity can affect any muscle in the body, and it can either be localized to a specific region or be more generalized. Symptoms of spasticity can be painful and disabling and interfere with different domains of an individual's quality of life.    

    

The symptoms and severity of spasticity vary broadly, and clinicians consider how these symptoms interfere with an individual's lifestyle to inform an appropriate treatment, should treatment be necessary. For example, does it lead to pain that prevents participation in perceived important life activities? Does the individual want to retrieve the fine motor skills of their hand to feel successful in their workplace or hobby? By exploring these contexts, clinicians can tailor treatments more effectively, addressing not only the physical symptoms but also the personal goals and priorities of the individual.      

 

Pharmaceutical Treatment   

    

Botulinum Toxin (Botox)   

Botox is a naturally occurring toxin that temporarily blocks muscle nerve signals, helping to loosen up muscles experiencing abnormal tightness. Relaxing the muscle using Botox can relieve pain, prevent contractures, and improve range of motion. The benefits of Botox last about two to four months.   

    

Botox injections are typically applied locally, allowing physicians to address specific muscle groups experiencing spasticity. This precision is beneficial in avoiding widespread weakness and maintaining functional mobility in other areas. Therefore, Botox treatment is especially used in upper limb spasticity.   

    

Although it has proven to have good tolerance and efficacy compared to oral agents, administering botox carries some risks. For example, the individual may experience too much weakness in the targeted muscle, impairing functionality. There is a risk of bleeding and infection, as with any injection. Less commonly, there is also a low risk associated with impaired swallowing if applied near the neck or facial muscles, though this is rare.    

    

Oral Medication   

    

Oral agents are easier to administer compared to other interventional treatments and may be well-suited to patients with generalized spasticity (spasticity in multiple areas of the body). For example, spasticity leading to difficulties with walking or uncontrolled limb movement can be debilitating in accomplishing activities of daily living. Medication options may be considered at the physician's and patient's discretion in such cases.   

    

Some side effects of oral medication may include fatigue, cognitive blunting, or drowsiness.   

    

When considering medications, a comprehensive discussion about patient expectations and side effects occurs between physician and patient.    

    

Physical Therapy   


Physical therapy aims to promote optimal movement patterns, minimize or manage contracture formation, and help with pain management. There are various techniques and therapies within physical therapy, and combining them yields the best results, including:    

    

Muscle lengthening: It helps to improve muscle flexibility, reduce spasms, and enhance overall function. Muscle lengthening techniques include stretching, casting, splinting, or seating.   

    

Muscle strength: Therapists also help work on muscle strength, and depending on the context, various tools can also be used. In sports rehab, clinicians may use other techniques like isokinetics to provide additional resistance.    

    

A tool like functional electrical stimulation (FES) can be used to electrically activate muscle groups to restore or improve functional abilities. They can help stimulate muscle contractions, improving strength and range of motion. FES is typically used in conjunction with other therapies for comprehensive management.    

    

Stretching and Orthotics 

  

Over time, spasticity may lead to a contracture, which refers to the permanent shortening or tightening of muscle, tendon, or soft tissue, resulting in a reduced range of motion at a joint. Physicians may recommend a range of motion or stretching exercises to prevent contracture formation.   

    

Orthotics are another means to support or correct musculoskeletal or biomechanical issues, such as minimizing or preventing spasticity or reducing spasticity-related pain. The most used orthotic devices include ankle-foot orthoses and resting hand splints.    

    

Other methods   


In addition to the techniques discussed in the blog, there are many treatment options in the realm of therapy-based interventions, technology-based interventions such as robotics or virtual reality, sensorimotor stimulation, pharmaceuticals, and complementary and alternative medicines.    

    

Treatments differ based on a variety of medical and individual factors. These factors include whether the spasticity is generalized or focal, its predominance in the upper or lower limb, the additional symptoms it may be causing, and, most importantly, the extent to which these symptoms impact an individual's overall quality of life and well-being.    

    

The overall goal of treating and managing spasticity is to relieve spasticity-associated pain and address how it interferes with their activities of daily living. Treatment is multifaceted, can require trial and error, and uses a multidisciplinary approach involving medications, physical therapy, and other types of rehabilitation that can together reduce spastic tone, facilitate the return of motor control and improve patients' overall quality of life.    

 

 



Acknowledgements 

A special thanks to Dr. Jordan Vanderende for providing his expertise on this topic 

 

 

 

References 


Chang, E., Ghosh, N., Yanni, D., Lee, S., Alexandru, D., & Mozaffar, T. (2013). A review of spasticity treatments: Pharmacological and interventional approaches. Critical Reviews in Physical and Rehabilitation Medicine, 25(1–2), 11–22. https://doi.org/10.1615/critrevphysrehabilmed.2013007945 


Saikaley, M., Pauli, G., Iruthayarajah, J., Mirkowski, M., Iliescu, A., Caughlin, S., Fragis, N., Alam, R., Harris, J., Dukelow, S., Chae, J., Knutson, J., Miller, T., & Teasell, R. (2018). Chapter 10 upper extremity motor rehabilitation interventions - EBRSR. Evidence Based Review of Stroke Rehabilitation. http://ebrsr.com/sites/default/files/Ch.%2010%20Upper%20Extremity%20Motor%20Interventions_v20.pdf 


6.2. lower limb spasticity following stroke. Canadian Stroke Best Practices. (2019). https://www.strokebestpractices.ca/recommendations/stroke-rehabilitation/lower-limb-spasticity-following-stroke 

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