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Medication Management of Spasticity
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If exercise, stretching, and therapies do not control spasticity, certain prescription medications that you can take at home on your own can help. While these medications technically are part of a group of medications called “muscle relaxers”, not all “muscle relaxers” work well for spasticity. We provide expert spasticity assessment to determine whether certain spasticity medications may help a person with spasticity to achieve their functional goals in a highly individualized way. We also balance any choice of medication with consideration of risks, side effects, and potential benefits as well as understanding of the unique medical and personal goals of the individual and their caregiver(s).
Botulinum Toxin Injections
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If spasticity affects a very specific body part, or interferes with function despite medications that can be taken at home, botulinum toxin injections may be recommended to better treat spasticity. Botulinum toxin is a toxin that is purified from the clostridium botulinum bacteria. There are four forms of botulinum toxin that are used to treat spasticity in the USA (Botox®, Xeomin®, Dysport®, and Myobloc®). Botulinum toxin treats spasticity by “turning down the volume” on the nerve signals coming from the new pathways formed after injury that cause the muscles to go into spasm. The physiatrist’s approach to this treatment option depends heavily on a person’s functional goals. Sometimes spasticity in one muscle group can actually help a person with one particular activity, while spasticity in another body area interferes with a particular function. Because botulinum toxin is given through injection into specific muscles and generally stays where it is injected, this treatment can be very specific and targeted to specific functional goals. It also allows a person and their doctor to pick and choose which spasticity to reduce and which spasticity to leave as it is to optimize function.
Intrathecal Baclofen
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Baclofen is a type of muscle relaxer that works at the spinal cord to reduce abnormal signals in the new pathways that cause spasticity. Baclofen can be taken by mouth, but also can be given directly to the spinal cord through a catheter attached to a pump with the medication in it. This is called “intrathecal baclofen”. By giving the baclofen directly to the spinal cord, smaller doses can be used for more potent effects, and there are much fewer side effects. This treatment is most effective for spasticity that impacts the legs and feet.
To find out if this treatment option will be effective in helping a person with spasticity to achieve their goals, a screening trial, essentially a test run, is done by performing a lumbar puncture and injecting a small dose of baclofen directly into the spinal canal. Once the medication is injected, measurements are taken over the course of several hours as the medication effect rises to a peak, and then eventually wears off. During those hours of treatment effect, both the individual and their physiatrist can see if this treatment option is likely to help them achieve the functional goals of spasticity management. If the trial is successful, a referral is made to have the pump surgically placed.
Once the pump is placed, the medication needs to be refilled every 1 to 6 months. The dosing of the medication is adjusted to optimize spasticity control through a specialized device that can tell the pump what to do. This adjustment is done in the office to maximize safety. The pump is powered by a battery, which needs to be replaced periodically with a surgery. If a problem with the pump is suspected, arrangements need to be made to seek medical attention as soon as possible.Phenol Nerve Blocks
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Alcohol neurolysis (often with phenol or ethanol) is another technique that is used to treat spasticity in a particular body area. It works by selectively denervating (burning the nerve) a nerve branch to a particular muscle that is spastic—effectively cutting off the communication of the abnormal new pathway signals to the target muscle. This technique has been used for spasticity as early as the 1950’s, and provides potent reduction in spasticity. Because the nerve is damaged by the alcohol in this technique, there is no option to preserve any normal signals that may be coming to the target muscle through old pathways, and the effect of treatment is potent. The effects occur almost instantly, and can last 9-12 months or more. Physiatrists will consider this treatment option for severe spasticity in a specific body area that has nerves specific to the muscles that can be treated in a body part that the individual has extremely limited ability to specifically control.