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Treating Post-Stroke Spasticity

The treatment of stroke patients has seen several advances in recent years and among the most significant are two therapies for a post-stroke condition called spasticity. A common physical response to brain injury caused by stroke, spasticity causes muscles in the arms or legs to tighten uncontrollably, causing pain and discomfort. Left untreated, spasticity can have a profound impact on an individual's quality of life.

First, what is spasticity?
Spasticity is a resistance in the muscles to stretch after an injury to the central nervous system. That injury can be the result of a stroke, multiple sclerosis, tumors, and a whole host of different diagnoses.

And what are the symptoms of this condition? What does it actually do to those who suffer from it?

When patients have spasticity, they may have a fixed clenching of their hand, or flexion of their fist. They may have trouble getting their arm away from their body so that it's difficult to clean under their arm. They may have abnormal posture. Patients may try to walk, but their feet want to turn inward. You may see patients whose legs will cross each other when you try to transfer them or when you try to clean them. Those are some of the things that you'll see in spasticity.

What are the long-term effects of this condition?

The type of recovery patients can have over time will be limited by spasticity if they don't receive appropriate treatment for it. They can have pain associated with their spasticity, or pain associated with attempts to move their joints. And if we don't try to move their joints, they'll have more pain over time. So spasticity really has a major effect, I think often an underestimated effect, on the quality of life of our patients.

Some spasticity is focal, and some is more generalized. How are they different?
Focal spasticity affects a smaller part of the body, such as a hand or an extremity. Generalized spasticity affects greater areas of the body.

What are the traditional treatments for spasticity?

Many people will start the treatment of spasticity with oral medications, which can relax the affected muscles that are causing the spasticity. The oral medications that are most commonly used for spasticity are diazepam (Valium), dantrolene, oral baclofen and tizanidine, or Zanaflex, which is a relatively new medication.

But oral medications will very often cause sedation in patients, or lethargy. They may also increase their confusion.

The medications also will affect their entire body, so if you're trying to target specific muscles, it makes little sense to give medications that affect the whole body.

Are there any new treatment alternatives for focal spasticity?

For focal spasticity, I generally use botulinum toxin A, or Botox, because it's a way to target smaller areas with injections rather than treating people with medications that will involve systemic side effects.

Botox is an off-label therapy for spasticity, which means it is not as yet FDA-approved for the use of spasticity. It's not uncommon for physicians to use medications already approved for other conditions, and the Botox injections have had a positive impact in treating patients with focal spasticity. Botox is one of the first really effective, new treatments that we've had for focal spasticity in decades.

Botox works by entering nerve endings around the muscle where it is injected, and blocking the release of chemical messages that cause the muscle to contract. Is this correct?
Yes. It allows us to target specific muscles. And there are no sedating side effects.

What are its known side effects?

It has a really low side-effect profile. Patients may have a little bit of bleeding at the site of an injection. They may have a little bit of tenderness during the injection. Some patients have had some flu-like symptoms for a while following an injection, but overall, the side effect profile is quite limited.

How long does the effect of a Botox injection last?

On the average, Botox injections last approximately three months.

And what are the latest treatment options for people living with generalized spasticity?

The intrathecal baclofen, or ITB therapy, is a relatively new treatment, which has had a dramatic effect on the lives of my patients with generalized spasticity.

What is ITB therapy?

It's a pump that's implanted under the skin that is connected to the area around the spinal cord and is able to deliver medication continuously, providing a greater effect on larger muscles. It can also affect smaller muscle groups, as well. You can vary the amount of medication with time of the day, and it has the most dramatic effect on spasticity in the lower extremities and trunk, and to a less predictable degree, the upper extremities.

What is the medication used in ITB therapy?

It's called baclofen, and originally, people used oral baclofen to treat spasticity. But because oral baclofen does not penetrate into the brain very easily, it would take high doses of medication to get a small amount into the central nervous system. With the intrathecal baclofen pump, or ITB therapy, we are able to deliver very minute amounts of baclofen directly into the central nervous system.

What is the benefit of the pump over the oral baclofen?

Because ITB delivers such a small amount of medication, patients don't have the same sedation,lethargy, and weakness that you see with the oral medication. Additionally, the effects of the medication given intrathecally are much greater than the effects of the medication given orally.

How is the pump implanted?

Usually the pump is implanted in the lower abdomen, and then a catheter is tunneled under the skin and threaded up into the intrathecal space around their spinal cord to deliver the medication.

Who is a good candidate for ITB therapy?

I have stroke patients who had intrathecal baclofen pumps who are in a vegetative state, who have no true interaction with their environment. I also have stroke patients who have come to me who were walking at the time that I prescribed the baclofen pump, but they wanted to be able to walk better, or were concerned about degenerative changes in their joints as they aged, and those patients are often candidates for ITB therapy as well. So there's a whole spectrum of people who would be appropriate candidates for this therapy.

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