UNDERSTANDING SPASTICITY
Can you describe a typical patient treated
for spasticity?
Julio was born with cerebral palsy which declared itself
with knee flexion rigid fixed spastic hypertonic positioning. He walked
with braces until he was 12, at which time he came to America and discarded
his braces for social reasons. He eventually became mobile only thru the
freedom afforded by his wheelchair. Julio was treated with phenol injections
to his hamstrings. Subsequently, a specific individualized prescription
for physical therapy was ordered by Dr. Geller. After much hard work, Julio’s
dreams were realized and today he walks with only a cane.
What is spasticity?
Spasticity is a triad of painful mass muscle spasms,
rigid posturing of limbs, and increased reflexes. Any component of the
triad can occur in varying severity. Spasticity affects many individuals
with brain and spinal cord injuries.
Is spasticity medically dangerous or functionally
disabling?
Rigid posturing can cause skin breakdown or prevent access
for hygiene care. Examples include fingers digging into the palm, shoulder
pulled across the chest wall with no access to clean the axilla, ankle
supination with walking on the outside of the foot, knee flexion with knee
buckling and falling. Spasms which occur during standing can predispose
to falls, fractures, and head trauma. Spasticity often markedly impairs
a person’s ability to perform functional self-care and mobility tasks.
Is spasticity ever medically or functionally
beneficial?
Yes! Rigid posturing of the elbow in mild flexion, for
example, can allow the person to carry bags of groceries. Spasms may maintain
muscle bulk to permit sitting, decreasing the risks of skin breakdown and
infections.
When is spasticity treated?
Because spasticity has potentially beneficial as well
as detrimental medical and functional aspects, a team of specially trained
therapists often collaborate with the physician to evaluate and comprehensively
treat spasticity.
How is spasticity treated?
Therapy interventions constitute the foundation of spasticity
management. Often utilized supplemental treatments include injections,
medications, and surgery. Therapies precede and follow all spasticity treatments
to maximize flexibility, strength, coordination, ambulation and self care
function. Injections are without cognitive side effects, and are commonly
adjuncts to therapies, medications, and surgery.
What injections can be delivered to treat spasticity?
Botox, phenol, alcohol, and local anesthetic can be delivered
via EMG guided injection to spastic muscles.
What are the benefits of injections?
They are enormously safe and can be done quickly in the
office with no risk of anesthesia. They allow titration of spasticity to
remove dangerous intense components and leave sufficient tone for medical
benefit and functional use. Injections supplement management with Zanaflex,
baclofen, and other antispasticity medications to maximize treatment without
compromising cognition.
When is local anesthetic used in the evaluation
of spasticity?
Local anesthetics temporarily reduce spasticity for a
few hours, allowing a spasticity team to discriminate whether reduction
of spasticity improves function and warrants more long lasting treatments.
What is phenol?
Phenol is a medication used to treat spasticity of some
large muscle groups. It is most often delivered to the biceps (elbow flexors),
hamstrings (knee flexors), gastrocnemius (ankle plantarflexors which point
the toe down), and hip adductors (pulls the kneecaps together) to achieve
short or long term antispasticity effect. This improves the safety and
efficiency of walking, ease of donning clothing, and ability to clean the
groin and manage the bladder.
What is Botox?
(Link to Botox page)
When would the physician prefer to inject Botox
instead of phenol to treat spasticity?
The technique of delivery of Botox is free of extensive
searching inside the muscle, allowing the procedure to be quick and almost
pain-free. Maximal botulinum presentation to the muscle endplate is enhanced
with the use of EMG or nerve stimulation equipment. As such, Botox is the
preferred injected medication when delivered to the hand, back, abdomen,
and chest wall (pectoralis major), as well as the forearm muscles and the
lower leg ankle invertors (tibialis posterior).
When would the physician prefer to inject phenol
instead of Botox to treat spasticity?
Botox is more likely to cause antibody formation when
used to treat large muscles. As such, delivery of Botox to the hamstrings,
biceps, gastrocnemius, or hip adductors may predispose to antibody formation
and inability to use Botox at the vast number of areas in which only Botox
works.
Which doctors are trained in the use of EMG
equipment to guarantee the best treatment?
Rehabilitation is the only medical specialty in which
physicians must complete 250 EMG’s to board certify. Further expertise
in EMG can be confirmed by additional certification by the American Board
of Electrodiagnostic Medicine.
Who delivers Botox?
The physician specialty that is most commonly trained
in the use of EMG machines are rehabilitation doctors. Neurologists also
deliver Botox to decrease spasticity.
Which medications can be used to treat spasticity?
Zanaflex, Dantrium, Baclofen, Clonidine, and Valium are
used to treat spasticity. Different drugs have different side effects,
and considerations of liver disease, level of arousal, strength, mood depression,
blood pressure, swallowing problems, and a host of additional factors must
be considered to individualize spasticity treatment.
Are drugs given in isolation?
Physical and occupational therapy constitutes the foundation
of antispasticity management. Injections are commonly co-delivered to decrease
the side effects of higher doses of medications.
What type of surgery may be used to treat spasticity?
Orthopedic procedures most frequently involve tendon
lengthening. The newest, reversible, and exciting neurosurgical intervention
is the Baclofen pump (www.medtronics.com) which delivers lioresal to the
lumbar spinal cord.
Is the Baclofen pump used in isolation?
Because Baclofen pumps deliver antispasticity medication
to the lumbar spinal cord which mediates spasticity in the legs, the upper
extremities are commonly co-treated with Botox
or phenol.
Who will be my doctor?
Aaron S. Geller, M.D. graduated with highest honors from
the University of Pennsylvania School of Medicine. He is triple board certified
by the American Board of Pain Medicine, the American Board of Electrodiagnostic
Medicine / EMG / Peripheral Neurology, and the American Board of Physical
Medicine and Rehabilitation.
How can I schedule an evaluation with Dr. Geller?
Please bring your doctor’s referral.
Dr. Geller’s offices in Nashua NH can be contacted via
phone via e-mail at GellerTreatment@hotmail.com
