Spasticity and Spinal Cord Injury - Datarealm

Spasticity and Spinal Cord InjurySpinal Cord Injury Model Systems Consumer InformationThis publication wasproduced by the SCI ModelSystems in collaborationwith the Model SystemsKnowledge TranslationCenter (http://msktc.washington.edu) withfunding from the NationalInstitute on Disability andRehabilitation Researchin the U.S. Departmentof Education, grant no.H133A060070.What is spasticity?Spasticity is the uncontrolled tightening or contracting of the muscles that iscommon in individuals with spinal cord injuries. About 65%–78% of the SCIpopulation have some amount of spasticity, and it is more common in cervical(neck) than thoracic (chest) and lumbar (lower back) injuries .Symptoms and severity of spasticity vary from person to person and can include:• Sudden, involuntary fl exing (bending) or extending (straightening) of a limb,or jerking of muscle groups such as in the trunk (chest, back, and abdomen),bladder, or rectum.• Hyperactive (overactive) refl exes, such as a muscle spasm when you arelightly touched.• Stiff or tight muscles at rest, so that it is diffi cult to relax or stretch yourmuscles.• Muscle tightness during activity, making it diffi cult for you to control yourmovement.What causes spasticity?The nerves of the spinal cord and brain form a complex communication circuitthat controls our body movements. Information on sensations or processessuch as touch, movement or muscle stretch is sent up the spinal cord to thebrain. In response, the brain interprets the signal and sends the necessarycommands back down the spinal cord to tell your body how to react. Thereaction of the body, such as jerking away from a hot object, is a refl ex andhappens quickly and automatically.After a spinal cord injury, the normal fl ow of signals is disrupted, and the messagedoes not reach the brain. Instead, the signals are sent back to the motorcells in the spinal cord and cause a refl ex muscle spasm. This can result in atwitch, jerk or stiffening of the muscle.Just about any touch, movement or irritation can trigger and sustain spasms.Common triggers are:• Stretching your muscles.• Moving your arm or leg.• Any irritation to the skin, such as rubbing, chafi ng, a rash, in-grown toenails,or anything that would normally be very hot or cold or cause pain.• Pressure sores.• A urinary tract infection or full bladder.Copyright © 2011 Model Systems Knowledge Translation Center (MSKTC).

Spinal Cord Injury Model Systems Consumer Information• Constipation or large hemorrhoids.• Fracture or other injury to the muscles, tendonsor bone below the level of spinal cord injury.• Tight clothing, wraps or binders.Spasticity can be irritating, inconvenient or evenlimit your ability to go through your day.What are the benefits of spasticityin SCI?Spasticity is not always harmful or bothersome anddoes not always need to be treated. Sometimesspasticity can help with functional activities such asstanding or transferring. Spasticity that causes yourfi ngers to bend can help you grip objects. Spasticitycan also be a signal that you have a medicalproblem that you might not know about otherwise,such as a urinary tract infection, fracture, orpressure sore.What problems are caused byspasticity?• Spasticity can be painful.• Spasticity can result in loss of range of motion inyour joints (contractures).• Severe spasms can make it diffi cult for youto drive or transfer safely, or to stay properlyseated in your wheelchair.• Spasticity in your chest muscles may make it difficult to take a deep breath.• Strong spasms in the trunk or legs can cause youto fall out of your wheelchair when you changeposition, transfer, or ride over uneven surfaces.• Repeated muscle spasms at night can cause youto sleep poorly and be tired during the day.• Spasms can cause rubbing that leads to skinbreakdown.• Spasticity can make movement harder to control,so that activities such as feeding yourselfmay be more diffi cult.Managing spasticity after SCIFirst, practice healthy behaviors and good self-carethat will help you avoid problems that can increasespasticity, such as urinary tract infections and skinbreakdown. Check to see if any of the commontriggers listed above may be causing the problem.Physical treatmentsThe following treatments will help to maintain fl exibilityand therefore reduce spasticity and the riskfor permanent joint contracture:• Regular stretching (range-of-motion) exercisestwice daily will help maintain fl exibility and temporarilyreduce muscle tightness.• Weight-bearing or standing with support, suchas using a standing frame or other supportivedevices, will help stretch muscles.• Splints, braces, or progressive casting into thedesired position provides continuous musclestretching that helps to maintain fl exibility and aposition that does not trigger a spasm.• Careful use of hot or cold packs. When used inbody areas that have partial sensation, check skintolerance frequently as it may result in a burn if toohot and frostbite if too cold. Avoid the use of hotpacks over areas without sensation.MedicationsWhen physical measures are not enough to controlspasticity, medications may be needed.• Oral medicationsIf spasticity involves large areas of your body, yourdoctor may prescribe one or more of the followingmedications:• Baclofen• Benzodiazepines (muscle relaxants) such asdiazepam, clonazepam• Dantrolene• TizanidineThe effectiveness of these medications varies witheach person. Because these medications can haveside effects such as fatigue or drowsiness, weakness,nausea, or sometimes low blood pressure, yourprovider needs to monitor you closely.• Nerve or motor point blocksIf only part of your body has spasticity, anestheticmedications, alcohol, phenol or neurotoxins (suchas strains of botulinum toxin) can be injected intothe muscles that have spasticity. The medicationsrarely cause widespread side-effects. The benefi ts ofthe injections are only temporary, however, so injectionsmust be repeated a few times a year. Theseinjections can be used alone or in combination withoral spasticity medications.Spasticity and Spinal Cord InjuryPage 2 of 3

Spinal Cord Injury Model Systems Consumer InformationSurgery• Intrathecal medication therapy (alsocalled a “pump” or “baclofen pump”)Intrathecal drug therapy uses a surgically placed,battery-powered pump and an attached catheterto deliver medication directly into the spinal canal,around the spinal cord (called the “intrathecal”space). The most commonly used intrathecal drugfor spasticity is baclofen. Intrathecal baclofen canbe used in conjunction with the other treatmentslisted above. This treatment is generally not recommendeduntil other treatments have been triedand failed to provide relief or if oral medicationscause unacceptable side effects.Advantages of intrathecal baclofen:• The drug is delivered directly around the spinalcord, so lower doses of medication are needed.• Fewer negative side effects because the drugdoes not enter the bloodstream.• The amount and dosing schedule of drugthroughout the day can be precisely set andadjusted by the health care provider to meeteach individual patient’s needs.• The pump can be stopped or removed, if necessary.Disadvantages of intrathecal baclofen:• You will need surgery to implant the pump andcatheter system. Any surgery has risks, such asinfection.• The pump has a limited battery life and willneed to be replaced about every 5-7 years.• You will need to go to your provider periodicallyfor pump refi lls (done by injecting baclofenthrough the skin into the pump reservoir).Mechanical problems with the device may occurand could result in a baclofen overdose or underdose.For this reason, it is important for you tounderstand the risks, monitor yourself carefully,and get regular follow-up from your provider.• Other SurgeryOther surgical treatments for spasticity are farless commonly performed because they are notreversible. These include cutting a section of thespinal cord (myelotomy) or nerve roots (rhizotomy),or lengthening and transposing a tendon. Yourdoctor will discuss these surgical options with youif necessary.Which treatment is best for me?Discuss your specifi c needs and treatment optionswith your health care provider or team. You mayneed to try different methods, medications, orcombinations of treatments before you feel yourspasticity is under control. Consider the followingquestions and discuss them with your provider:• What are your goals for treatment of yourspasticity?• How important is it that the treatment can bereversed or stopped?• What are the possible short-term and long-termside-effects of each treatment?• Are there other health conditions that wouldinfl uence the treatment choice?• If you are considering intrathecal baclofen: Willyou be able to follow the maintenance requirements?Do you have a good understanding ofthe possible risks and benefi ts?Whatever treatment you choose, you will needto work closely with your treatment provider orteam to get the best possible outcome.What happens to spasticity over time?In general, spasticity appears to become less bothersomeover time. Possibly this happens becausepeople learn to avoid things that trigger spasticity.Changes that naturally go on in the body as youage, such as a slowing down of nerve conduction,may also decrease spasticity. However, an unexplained,sudden or dramatic change in your spasticitylevel may sometimes signal a problem, so letyour health care provider know immediately.SourceOur health information content is based on research evidencewhenever available and represents the consensus ofexpert opinion of the SCI Model System directors.AuthorshipSpasticity and Spinal Cord Injury was developed by Maria R.Reyes, MD and Anthony Chiodo, MD, in collaboration withthe Model Systems Knowledge Translation Center.Portions of this document were adapted from materials developedby the University of Michigan and UAB Model Systems.DisclaimerThis information is not meant to replace the advice froma medical professional. You should consult your health careprovider regarding specifi c medical concerns or treatment.Spasticity and Spinal Cord InjuryPage 3 of 3