Multi-Modal Approach for Spasticity Treatment
The treatment of adults with spasticity should be provided by a multidisciplinary team employing a shared-care approach. A variety of treatment options is available and clinical experience has shown that a multi-modal approach has many benefits. In most cases, a combination of various types of treatment is required to achieve the specific goals of treatment for a particular patient.
A rehabilitation plan must be tailored to individual patient needs and is likely to involve medical intervention (e.g., botulinum toxin, pain medication), as well as multiple additional therapies, e.g., physical, occupational and psychological approaches. Together, these therapies enable optimal management of functional problems such as impaired mobility, strength, balance, and endurance, amongst other spasticity-related issues.
The primary aim of treatment is to facilitate life for people with spasticity and for their caregivers, thus improving their quality of life. Therefore, improvement in function is a key long-term factor in spasticity management. Consequently, the development of realistic and clinically relevant goals for each individual is the key for a successful treatment. These goals should be defined and followed up in collaboration with other members of the spasticity management team that may include a specialist for physical medicine and rehabilitation, a neurologist, a physiotherapist, an occupational therapist, a neurosurgeon and an orthotist (specialist concerned with the design, manufacture and application of orthoses).
The importance of adapting the treatment to the individuals’ symptoms and especially to their needs throughout the course of treatment is crucial, with expectations revisited and redefined, if necessary, at regular intervals.
Common Goals of Spasticity Treatment
- Relief of symptoms such as:
- Muscle spasm frequency
- Involuntary movements
- Improvement of active functions:
- Eating and/or drinking
- Sexual activity
- Decrease carer burden (passive functional improvement):
- Ease of moving, handling and positioning
- Routine day-to-day care
- Avoiding progression of impairment:
- Prevention of contractures and deformity
- Optimizing posture and seating to improve tissue viability
- Aesthetic and postural appearance to improve the body image and the fit of clothes
- Enhance impact of conventional rehabilitation intervention: optimize effectiveness of therapies, reduce use of systemic medication to treat spasticity
Physical therapy is the mainstay of treatment for spasticity, and is designed to reduce muscle tone, maintain or improve range of motion and mobility, increase strength and coordination, and improve care and comfort.
Occupational therapies address the functional difficulties of living with spasticity, aiming to gain autonomy while recovering or help patients and carers cope with, and find effective solutions to problems with activities of daily living.
Rehabilitation (physical and occupational therapy) and pharmacological spasticity treatments such as injection of botulinum toxin are considered to work synergistically over time.
Botulinum neurotoxin injections can further facilitate rehabilitation efforts and thus improve spasticity even more. Usually, the effect of a single botulinum neurotoxin injection lasts several weeks, with an average of 3 months.
The main approved oral medications include:
- Cannabinoids containing tetrahydrocannabinol (THC) are approved in some countries as a spray, but are only indicated for moderate to severe spasticity in multiple sclerosis patients after failure of other oral drugs
- Dantrolene: approved in some countries but due to the insufficient level of evidence the recommendation level is low
All oral drugs have in common limited efficacy in combination with a high rate of adverse events, mainly fatigue.
Among the oral treatments, only two (baclofen and tizanidine) have proven their efficacy in reducing spasticity on the Ashworth Scale. They may be used in multiple sclerosis and spinal cord injury-related spasticity, especially to reduce clonus.
Intrathecal baclofen is an effective treatment for spasticity. It can notably be recommended for people with spinal cord injury or multiple sclerosis. It is a long-term treatment with continuous, intra-spinal administration via an implanted pump. It is mainly endorsed for individuals whose spasticity of the legs is broadly distributed and sometimes extends to the trunk. This treatment needs a close follow-up to maintain good efficacy and avoid potential severe adverse events. In widely spread spasticity, such as severe bilateral lower limb spasticity, intrathecal baclofen can be used as a first-line therapy.
When not controllable by physical therapy, oral or intrathecal medications and/or botulinum toxin injections, spasticity symptoms can be treated with selective ablative procedures. In most cases, complementary neurosurgical and functional orthopedic approaches are used.
With surgical interventions, muscles can be denervated or tendons and muscles can be released, lengthened, or transferred to relieve the symptoms of spasticity. In order to release contractures, the contracted tendon is partially or completely split surgically and then the joint is repositioned at a more normal angle. A cast stabilizes the joint over a period of several weeks while the tendon regrows. After removing the cast, physical therapy is necessary to strengthen the muscles and improve the patient’s range of motion.
Surgical intervention that is used for the treatment of spasticity is called functional or selective dorsal rhizotomy. In this procedure, the neurosurgeon performs a rhizotomy by cutting the nerve roots, which are the nerve fibers lying just outside the back bone (spinal column) that send sensory messages from the muscles to the spinal cord. ‘Selective’ indicates that only certain nerve roots are cut and ‘dorsal’ refers to the target nerves that are located at the back of the spinal cord (the upper surface when a person is lying on his or her stomach).
Chemodenervation generally means the interruption of neural transmission by the injection of a chemical compound, which may be:
- Short acting: the injection of local anesthetics (e.g., novocaine, lidocaine, bupivacaine) inhibits the signal transmission and is effective only for minutes (novocaine: 20-45 min) or some hours (lidocaine: 1-3 hours; bupivacaine: up to 12 hours). It is usually done in complex cases to better select the muscles to be treated
- Long acting: this can be achieved with substances such as phenol, alcohol or botulinum neurotoxin injected into the affected muscle
- Phenol and alcohol cause an unspecific necrosis in the injected area, which means an uncontrolled destruction of nerve and muscle tissue. The effect lasts between one month and two years. The high rate of adverse events (temporary or permanent pain near the injection site, as well as vascular reactions) make phenol and alcohol only second-line therapeutic options
- Botulinum neurotoxin is a highly specific treatment causing focal and controllable muscle paresis or paralysis
Taken together, the various forms of chemodenervation can be indicated in localized and severe spasticity and to support or even facilitate other treatments such as physical therapy.
Botulinum neurotoxin is recommended as a first-line therapy in national and international guidelines as part of an integrated treatment approach for post-stroke spasticity.
Botulinum neurotoxin creates a ‘window of opportunity’ for improving motor and activity performance and should be followed by physical and/or occupational therapy.
In multifocal spasticity (more than 2 patterns), it is possible that the number of patterns is too high to be fully treated, e.g., because the total dose exceeds the maximal approved dose or on account of adverse events. In these cases, a complementary pharmacological treatment such as oral treatment, surgery, intrathecal baclofen or phenol blockade may be used.
As botulinum neurotoxin is a locally acting treatment, it can specifically weaken overactive muscles that are affected by spasticity, without weakening healthy muscles.
To maximize benefits of botulinum neurotoxin treatment for people with spasticity and to provide long-term efficacy, it has to be injected by an experienced injector who will take care notably of:
- Titration of optimal dose
- Selection of the right muscles to inject
- Ensuring that the botulinum neurotoxin is injected in the selected muscle (usually performed with the support of ultrasound guidance)