A double blind, cross-over trial of Valium in the treatment of spasticity

Management of spasticity revisited

Spasticity is common after stroke and other neurological conditions and causes considerable limitations of movement, activities of daily living and participation. Interaction with other components of the upper motor neurone syndrome (UMNS) and the heterogeneity of patients' presentations together with limited tools for outcome measurement have hampered the production of randomised controlled trial data for management strategies. Specialist multi-disciplinary goal-centered management programmes are the mainstay of treatment. Pharmacological therapies have limited effect, and physical and positional management are crucial. Targeted intramuscular botulinum toxin injection is now the most popular pharmacological treatment. Intrathecal therapies also play a lesser role. A team approach and holistic assessment are essential to beneficial outcomes.

Rehabilitation in practice: Spasticity management

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is 'The trainee consistently demonstrates a knowledge of the pathophysiology of various specific impairments including spasticity'. Spasticity is an extremely common feature of chronic neurological conditions and, if badly managed, it can result in pain, contractures and pressure sores, all of which can impact on function. It is therefore essential that a multidisciplinary management strategy is in place to help the individual manage their particular situation through education with timely access to interventions including instigation of a physical management programme and medication such as baclofen, tizanidine, dantrolene, benzodiazepines and gabapentin. Further treatment options for focal spasticity are botulinum toxin and phenol nerve blocks or intrathecal baclofen or phenol for predominant lower limb spasticity. Ongoing assessment with the use of appropriate outcome measures can both guide choice of treatment and monitor efficacy.

Improvements in healthcare and cost benefits associated with botulinum toxin treatment of spasticity and muscle overactivity

Spasticity is a widespread, disabling form of muscle overactivity affecting patients with central nervous system damage resulting in upper motor neurone syndrome. There is a range of effective therapies for the treatment of spasticity (e.g. physical, anaesthetic, chemodenervation and neurolytic injections, systemic medication and surgery), but all therapies must be based on an individualized, multidisciplinary programme targeted to achieve patient goals. Appropriate therapy should be based on the extent and severity of spasticity, but spasticity and its consequences, regardless of presentation or cause, are commonly treated with systemic agents. This may be ill-advised as systemic treatment is associated with many undesirable effects. In particular, elderly patients with post-stroke spasticity are at risk from the central adverse effects of systemic medication (e.g. sedation and gait disturbance), which make them more susceptible to falling, with an associated increased risk of fracture. The rising costs of fracture care and its sequelae are fast becoming an international problem contributing to high healthcare expenditure. Botulinum toxin type-A (BoNT-A) treatment is highly effective for some of the more common forms of spasticity and muscle overactivity, and has a favourable profile when compared with systemic agents and other focal treatments. Therefore, the clinical benefits of BoNT-A treatment outweigh the apparent high costs of this intervention, showing it to be a cost-effective treatment.

Walking with modafinil and its use in diplegic cerebral palsy: retrospective review

A retrospective review of pediatric patients with spastic cerebral palsy was undertaken at Texas Tech University Health Sciences Center covering a period from January 1, 2000, until December 31, 2003. One hundred twenty pediatric patients were identified in the Texas Tech University Health Sciences Center child neurology clinic with spastic cerebral palsy. Fifty-nine patients of this group received modafinil treatment for cerebral palsy. Twenty-nine of the 59 patients were noted to have an improving gait on modafinil. Six of these modafinil-treated patients improved from no ambulation or only assisted ambulation to unassisted ambulation. This varied from taking a few steps without holding on to walking down the hall without assistance. Two patients with spastic diplegia secondary to prematurity have had a dramatic improvement in gait during the first 6 months after starting modafinil. Two other patients with spastic diplegia not included in this group of six patients taught themselves to stand up and walk while in water unassisted. During this same time period, only three non-modafinil-treated patients with mild cerebral palsy were noted with gait improvements, but not to the dramatic extent of the modafinil-treated group. A nonambulatory 5-year-old child, who presented for a requested wheelchair prescription because the mother had given up all hope of her child ever walking, is now taking independent steps unassisted after starting modafinil. Modafinil, a central nervous system stimulant, appears to improve tone and ambulation in spastic diplegic cerebral palsy.

Acute Care Management of Post-TBI Spasticity

The management of persons with traumatic brain injury (TBI) who have acute spasticity remains a challenge. A correct stratification is essential to clinical care and determination of efficacy from proposed interventions. The secondary severe sequelae of spasticity after TBI can result in profound functional impairment. These concerns are often best addressed early in the patient's course. Limited research in the area of the acute care treatment of severe spasticity is available. The authors employ a review of the available data as well as recount their own clinical experience in the acute care management of severe spasticity to assist in developing an order for the plethora of potential treatments available to clinicians and researchers. We propose to use a case example to emphasize key clinic points in the management of spasticity in the acute care setting.

The medical management of spasticity

When spasticity produces a clinical disability by interfering with posture, motor capacity, nursing or daily living activities, medical treatment is recommended. It is mainly indicated when the muscle overactivity is diffusely distributed and should be implemented early, to prevent permanent musculoskeletal deformities or contractures. A pharmacological approach relies on the use of drugs which modulate neurotransmitters acting at the cortico-spinal level (GABA, glycine, glutamate, noradrenaline, serotonin). The aim of this treatment is to decrease spinal reflex excitability by reducing the release of excitatory neurotransmitters, or by potentiating the activity of inhibitory inputs. Evaluation of the efficacy of these drugs is determined by the therapeutic objectives which may be biomechanical, or functional. Diazepam increases presynaptic inhibition by stimulating GABA(A) receptors in the brainstem and spinal cord. In double-blind studies of patients with spinal cord lesions, antispastic efficacy has been shown, but side-effects are common. Baclofen stimulates GABA(B) receptors inducing a suppression of excitatory neurotransmitter release. Antispastic efficacy is sufficiently documented, but no definite effects on ambulation or activities of daily living have been proved. Tizanidine has an alpha2-agonist activity (at spinal and supraspinal level) and decreases the presynaptic activity of excitatory interneurones. The main clinical effects are a reduction in tonic stretch, polysynaptic reflexes, and co-contraction, with fewer side-effects but no definite functional change. The efficacy of several other antispastic drugs is documented in a few controlled studies, but the majority of information arises from open trials or anecdotal observations.

Pain and spasticity after spinal cord injury: mechanisms and treatment

STUDY DESIGN

A comprehensive survey of literature on the proposed mechanisms and treatment of pain and spasticity after spinal cord injury (SCI) was completed.

OBJECTIVES

To define the current understanding of these entities and to review various treatment options.

SUMMARY OF BACKGROUND DATA

The neurophysiologic basis of spasticity after SCI is well established. The mechanism of neuropathic pain after SCI remains conjectural, although considerable new data, much of it from animal models, now add to our understanding of this condition.

METHODS

A comprehensive search and review of the published literature was undertaken.

RESULTS

Treatment options for spasticity are effective and include oral medication (baclofen, tizanidine), intrathecal baclofen, and rarely, surgical rhizotomy or myelotomy. Selected patients with post-SCI pain can respond to surgical myelotomy (DREZ lesions) or intrathecal agents (e.g., morphine + clonidine), but the majority continue to suffer.

CONCLUSIONS

Medical and surgical treatments for spasticity are established and highly successful. Management of post-SCI pain remains a clinical challenge, as there is no uniformly successful medical or surgical treatment.

Pharmacological interventions for spasticity following spinal cord injury

BACKGROUND

Spasticity is a major health problem for patients with a spinal cord injury (SCI) that limits patients' mobility and affects independence in activities of daily living and work. Spasticity may also cause pain, loss of range of motion, contractures, sleep disorders and impair ambulation in patients with an incomplete lesion. The effectiveness of available drugs is still uncertain and they may cause adverse effects. Assessing what works in this area is complicated by the lack of valid and reliable measurement tools. The aim of this systematic review is to critically appraise and summarise existing information of the effectiveness of available treatments and to identify areas where further research is needed.

OBJECTIVES

To assess the effectiveness and safety of Baclofen, Dantrolene, Tizanidine and any other drugs for the treatment of long term spasticity in SCI patients as well as the effectiveness and safety of different routes of administration of Baclofen.

SEARCH STRATEGY

We searched the Injuries Group specialised register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE and CINHALH up to 1998. Drug companies and experts active in the area were also contacted.

SELECTION CRITERIA

All parallel and crossover RCTs including spinal cord injury patients complaining of "severe spasticity". Studies where less than 50% of patients had a spinal cord injury were excluded.

DATA COLLECTION AND ANALYSIS

Methodological quality of studies (allocation concealment, blinding, patients characteristics, inclusion and exclusion criteria; interventions; outcomes; lost to follow up) was independently assessed by two investigators. The heterogeneity among studies did not allow quantitative combination of results.

MAIN RESULTS

Nine out of 53 studies met the inclusion criteria. Study design was: 8 cross over, 1 parallel-group trial. Two studies (14 SCI patients), showed a significant effect of intrathecal baclofen in reducing spasticity (Ashworth Score and ADL performances), compared to placebo, without any side effect. The study comparing tizanidine to placebo (118 SCI patients) showed a significant effect of tizanidine in improving Ashworth Score but not in ADL performances. Tizanidine group reported significant rates of adverse effects (drowsiness, xerostomia). For the other drugs (Gabapentine, Clonidine, Diazepam, Amytal and oral Baclofen ) the results do not provide evidence for a clinical significant effectiveness.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to assist clinicians in a rational approach to antispastic treatment for SCI. Further research is urgently needed to improve the scientific basis of patient care.

Comparison of dantrolene sodium and diazepam in the treatment of spasticity

The effects of dantrolene sodium and diazepam were compared in a double crossover study of 42 patients with spasticity due to stable multiple sclerosis. Both drugs reduced the findings of spasticity, clonus, and hyperreflexia, and the complaints of muscle stiffness and cramping. Each drug had different side effects which suggest indications and contraindications for its use in spastic patients.