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Cindy Ivanhoe, MD, Brain Injury Professional magazine Page 1 of 3
Few approaches to the care of the person with brain injury have changed as much in the last 15-20 years as the approach to spasticity management. There is an increasing interest in treating "spasticity" and the upper motor neuron syndrome (UMNS), though the potential benefits are often overlooked by a host of neurorehabilitation professionals. How often have our patients been told that they should be satisfied that they are alive; that they should just accept that they are “good enough” and have "plateaued." For some, this may be enough. For many, it is not and need not be. Intervening in the management of hypertonicity offers new hope and potential.
The treatment plan begins with the goals of treatment. Goals are influenced by the vision of what might be possible, function, options for therapy, finances, stage of recovery, dedication, and other clinical considerations. Goals may be passive or active. "Passive goals" refer to treating to facilitate care, such as hygiene, splinting, positioning, etc. in patients that are more dependent. Passive goals may be determined early after injury or be an ongoing consideration. Whether early or late, there is a degree to which passive goals can be considered pre-functional. For example, setting a goal of decreasing excessive tone or maintaining /increasing range, can be a precursor to eventually developing active movement. A goal of improved wheelchair positioning may not only prevent skin breakdown and contractures, it can translate to improved weight bearing for transfers and bone integrity, improved standing programs and possibly affect gait. Decreasing adductor tone in the lower limbs can make the difference between requiring 2-3 caregivers vs. one.
"Active goals," implies that there is a gain of more active function. Goals like improved transfers, increased FIM scores, improved gait, are often touted as a goal for interventions. However, medical professionals must keep in mind that we tend to underestimate the value of relatively "small" gains that can have significant meaning for our patients. Injecting toxin into the upper extremity may allow easier access to an augmentative communication device, followed by therapy that taps into previously unrecognized movement and motor control. Intrathecal baclofen (ITB) therapy allowing improved wheelchair positioning or transfers, but may also be a factor that allows improve¬ment in upper extremity function. It is a question of how we orchestrate the best possible outcomes for patients by integrating the variety of clinical and therapeutic interventions.
Advantages of spasticity that are often described include maintenance of muscle bulk, support of the circulatory system, decrease of potential edema from immobility, prevention of deep venous thromboses, assistance in transfers and gait. In some cases, however and to variable degrees, decreasing spasticity can afford one the opportunity to develop more motor function. Significantly, interventions for spasticity management can be fine tuned from one cycle to the next. If someone has the perception of being too "weak" after receiving neurotoxin injections, the dose can be adjusted at the next injection session based on their response. If someone reports being too loose after an ITB pump dose adjustment, the dose can be titrated accordingly. Sometimes a patient may get worse before getting better, or use assorted descriptions to describe changes in their movement quality or pattern.
Oral medications are often prescribed but have not been shown to improve function. There is a difference between having one’s "tone" decreased and being able to transfer in and out of a vehicle and being relaxed and sedated in class. Medications that limit cognition or affect behavior often have limited usefulness and fly in the face of the general philosophy of treating brain injury. We aim for increased alertness, cognition, balance and movement. The risk-benefit ratio of oral medications for the UMN syndrome may not be of great value in the end. Oral medications generally prescribed include oral baclofen, dantrolene, diazepam and tizanidine. They may be prescribed in various combinations, with neurotoxins, pumps, etc. to decrease tone, but have not been shown to improve function. Nerve blocks and motor point blocks are a dying art that allow a cost effective decrease in focal hypertonicity. Agents used include temporary anesthetics for diagnostic purposes and alcohol or phenol for longer effects. Each of these interventions come with their own set of risks and benefits.
Not every spastic muscle needs an intervention. Spasticity that is helpful to some degree, rather than detrimental, may be observed over time. Ankle clonus, which is another positive sign of the UMNS, may be present on exam but may not manifest during gait. Alternatively, it may be contributing to a loss of ankle range of motion, poor orthotic fit or be set off as someone walks longer distances, interfering with endurance and balance. Spasticity may also be interfering with the development of more function. It causes biomechanical influences across multiple joints, with implications for the ongoing evolution of movement, range and comfort.
There is a time and place for the prescription of associated therapies in conjunction with the medical interventions. This should be discussed and addressed when problem solving through the plan of care. When someone is first assessed for neurotoxin injections, there might be discussion about what types of therapy have been tried before, what would be funded and for how long, where in the chain of therapy goals, that therapy is being directed. Has your patient had and performed a home exercise program (HEP) and is it still valid? No one gets therapy for life, even if there are goals. Goals at some point, do move to a more self directed, than medical setting. It should not be overlooked that we all change and so can our patients’ needs and potential. Timing for future interventions must be monitored. Spasticity can change over the course of a lifetime, for better or for worse. The time for interventions is not just at the initial onset of injury.
From Brain Injury Professional, the official publication of the North American Brain Injury Society, Vol. 8, Issue 2. Copyright 2011. Reprinted with permission of NABIS and HDI Publishers. For more information or to subscribe, visit: www.nabis.org.
Brain Injury Professional is the largest professional circulation publication on the subject of brain injury and is the official publication of the North American Brain Injury Society. Brain Injury Professional is published jointly by NABIS and HDI Publishers. Members of NABIS receive a subscription to BIP as a benefit of NABIS membership. Click here to learn more about membership in NABIS.
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