Spasticity Management

Jackie Kawiecki, MD, MHA

Courage Center Medical Director

January 5, 2007

Objectives: Management of Spasticity- Management of Hypertonicity

• Why • When• How

• Reminder: All hypertonicity is not spasticity and treatment is different

Definition of Spasticity

• Velocity dependent resistance to movement– Exaggerated velocity dependent stretch reflex

• Increased deep tendon reflexes (DTR)

• Abnormal increase in tone

Pathophysiology of Spasticity

• Increased tone (resistance to quick stretch) and hyperactive DTR’s (clonus)– Result from central nervous injuries which

impair the normal spinal and supraspinal inhibition of segmental spinal reflexes

Other Types of Hypertonicity

• Dystonia– Varying tone; increased w/ intent to move; increased w/

heightened emotional state; persistence of primitive reflexes

• Rigidity– Resistance to movement that is NOT velocity dependent

• Athetosis-Dyskinesia– Movement d/o; unable to organize and execute movement;

difficulty maintaining posture; persistence of primitive reflexes

– Wrying distal movements- more in upper extremities (often) than lower extremities

Clinical Signs & Symptoms Associated w/ Spasticity

• Symptoms– Pain

– Difficulty moving

– Interrupts sleep

– Interferes with ADL’s and mobility

– Fatigue

– Inability to keep orthotics closed or on

– Impairs hygiene

– Poor posture

– Fractures

• Signs– Contractures– Poor Posture– Gait abnormality– Lack of coordination– Friction sores– Foot deformities

• Equinovarus most common

– In children in particular:• Hip subluxation/dislocation• Femoral anteversion/tibial

torsion

Measurement Tools

• Ashworth scale: – 5 point scale: 1-5

• Modified Ashworth scale: – 6 pt scale: 0-4 including 1+

• Spasm frequency

• Reflex scale

• Pain scale

Modified Ashworth Scale (MAS)

• 0/4 = Normal tone• 1/4 = Slight catch at terminal range• 1+/4 = More effort required to range but not

difficult; but less than half of ROM of joint involved

• 2/4 = More effort required to range; more than half of ROM of joint involved

• 3/4 = Difficult to range• 4/4= Rigidity; unable to take through established

normal range of joint

MAS Reminders:• Always take the first measurement for each associated

muscle group being tested– Continued range in an attempt to get an “avg” will reduce tone

in the muscle group being tested

• Tone is variable– Two different examiners may get very different results based on

day; time of day

• Contractures vs. increased tone– Document scale score within available range

• Document utilizing x/4 for MAS and x/5 for Ashworth Scale to assure conveying information correctly in medical record

• Static (at rest) versus dynamic tone: selective motor control (ability to isolate movement)important to assess

Spasm Frequency

• Can be rated by patient and observer

• Less frequently used

• 0/4= No spasm

• 1/4 = Mild spasm induced only with stimulation

• 2/4= Spasms occurs less than once per hour

• 3/4 = More than one per hour

• 4/4= More than 10 per hour

Reflex Scale

• Total reflex score is calculated by summing score from knee and ankles and divide by 4

• 0/6= No response• 1/6= Hyporeflexia• 2/6= Normal response• 3/6= Mild hyperreflexia• 4/6= Up to 4 beats of clonus• 5/6= Unsustained clonus; >4 beats• 6/6= Sustained clonus

Why treat tone abnormalities

• Tone interferes with function

• Pain associated from tone

• Tone interferes with cares

• Deformities/Contractures are developing/recurring

Tone and Function

• If patient has ability to initiate movement, then increased tone can interfere with the ability to use that movement – Volitional control is ‘masked’ by tone

• If patient is weak, they may use the tone to assist in augmenting volitional strength

When to treat spasticity

• Influenced by the severity of spasticity

• Influenced by goals– Functional– Ease of care– Positioning– Pain/Comfort– Recurrent deformity/contractures

Consideration for tone management

• Risks/benefits• Follow-up needed• Other impairments• Rule out other possible contributing factors then

consider treatment of spasticity– Any noxious stimulus can drive up spasticity,

therefore rule out (most common issues)• Bladder related: UTI, renal stones, bladder stones• Bowel related: bowel distension, anal fissure• Skin related: pressure ulcers, skin tears, ingrown toenail,

cellulitis, tight leg bag, tight clothing• DVT, heterotopic ossification (HO), occult fractures

Interventions for Abnormal Tone

• Therapy based: – PT, OT: including ROM,

E-stim, FES

– Splinting- static/dynamic; casting, including serial casting; positioning techniques; modalities: cold/heat/vibration

• Oral medications (systemic management)

• Injected medications (focal management)– Botulinum Toxin:

• Type A (Botox); Type B (Myobloc)

– Phenol

• Surgery– Implantation of pump for

delivery of intrathecal baclofen

– Orthopedic surgery– Selective Dorsal

Rhizotomy

Oral Medications

• Benzodiazepams:– Most commonly Diazepam (Valium): Spasticity

• Lioresal (Baclofen): Spasticity/Dystonia• Dantrolene sodium (Dantrium): Spasticity• Tizanidine (Zanaflex): Spasticity• Gabapentin (Neurontin): Spasticity• Carbidopa/L-Dopa: Dystonia• Trazodone: Dystonia• Bromocriptime (Dystonia)

Benzodiazepams

• Mechanism of action: – Enhance GABA inhibitory neurons (GABA a receptors)

• Advantages:– First spasticity med available therefore still used by older

patients, especially SCI– Good if sleep disturbance by spasticity– Good if anxiety component– Inexpensive

• Disadvantages:– Excessive sedation and cognitive impairments– Potentially addictive; physical tolerance; difficulty weaning

off- long taper needed to avoid withdrawl– Has street value

Lioresal (Baclofen)

• Mechanism of action:– Modified form of GABA which works pre-

synaptically to decrease release of excitatory transmitter

• Advantages– More selective than valium therefore a first line

drug of choice for spasticity– Inexpensive

• Disadvantages– Sedation, weakness, fatigue– Acute withdrawl associated w/ sz, hallucinations

Dantrolene sodium (Dantrium)

• Mechanism of action: – Peripherally acting (at level

of muscle) by directly suppressing release of calcium ions from muscle sarcoplasmic reticulum thereby decreasing contractility and force

• Advantages:– More selective– Less hypotension– Effective for spasticity and

pain

• Disadvantages– Affects all skeletal

muscle

– Weakness

– Nausea

– Less sedating (in theory)

– Potential liver toxicity (2-3%)

Tizanidine (Zanaflex)

• Mechanism of action:– Centrally acting Alpha 2-

noradrenergic agonist acting primarily to decrease polysynaptic reflex activity

• Similar to clonidine within same family

• Advantages:– More selective– Less hypotension– Less weakness– Effective for spasticity &

pain; as well as spasticity & sleep impairment

• Disadvantages– Expensive

– Sedation

– Increased liver enzymes (up to 5%); therefore LFTs need to be followed

Gabapentin (Neurontin)• Action:

– GABA ‘b’ agonist– Has both pre- and post-synaptic actions– Inhibits calcium influx to presynaptic 1a terminal

thereby decreasing release of excitatory neurotransmitters

• Advantages– Great for combination pain and spasticity

• Disadvantages– Expensive– Sedation, weakness, fatigue

Botulinum toxin– Appropriate for focal spasticity– More effective in smaller muscles– Possible antibody formation- rec. not injecting

any sooner than 3 months between injections– Prior authorization process needed: all

spasticity ‘off-label’ use– Typical max dose per session: 400-500 units– If initial injections and Botox naïve: start lower– Have seen upwards of 1000 units per session-

rare practitioner – Peak effect: 7-10 days post-injections

Phenol

• Appropriate for focal spasticity management

• Chemical destruction of selective motor endings

• May cause pain/dysesthesias in mixed motor/sensory nerves (up to 15% chance)

• Needs compounding pharmacy– Typical 3-5% mixture

– If specialty trained and comfortable- up to 7%

• Typical max use per session= 20 cc

• Cheap compared to Botox

• Can re-inject often if needed for optimal effect

• No need for prior authorization

• Need more technical skill to do than Botox

• More time consuming

• Immediate effect

Intrathecal Baclofen Pump

• Indications:– Spasticity that interferes with function; painful; or

interferes with cares– Failure to respond or tolerate other more conservative

approaches– Able to geographically access care– Reasonable expectations– Responds to test ITB dose with decrease in MAS or

spasm frequency; reduction of pain– Informed consent– Extensive prior authorization process

Intrathecal Baclofen Pump

• Post-op management

• Maintenance

• Problem Solving