Choosing the best treatment option for each patient is a function of medical teamwork, with the patient’s symptoms comprehensively evaluated by an assessment team including a doctor specializing in rehabilitation, a neuro-orthopedic specialist, physical and occupational therapists, a nurse and a social worker and, when needed, an orthotist. Patients and their caregivers are the most important members of the team, as they help identify the problems and treatment goals that help determine the interventions. This team approach has had proven success in establishing personal treatment plans that achieve optimal patient outcomes.

Treatment strategies will vary based on several factors. Those factors include the patient’s current ability to perform daily activities, severity and scope of the musculoskeletal problem, therapeutic and functional goals of treatment, possible side effects and a risk/cost benefit analysis.

Treatment Options

Orthoses

Orthoses, also known as casts, braces, or splints, include any device that is used to support, align, prevent, or correct deformities or to improve the function of movable parts of the body. The goals in treating spasticity with orthoses include reducing tone, increasing or maintaining range of motion, and preventing the breakdown of skin. A variety of orthotic devices are available, including recently developed orthoses that provide not only correct positioning, but also deep pressure and warmth to the tissue. Proper limb positioning improves comfort and may improve function.

Medication

Systemic or focal medication, aimed at changing muscle tone or easing tension in the muscle, can be used to treat spasticity. Oral medications such as Diazepam, Clonazepam or Tizanidine may be effective in decreasing tonic stretch reflexes and controlling spasticity, although there is some evidence that oral antispastic drugs provide limited effects of short duration and may lead to unwanted side effects such as drowsiness, dizziness and confusion.

There is abundant evidence that injection with botulinum neurotoxin (BoNT-A), is successful in improving function. BoNT-A, which blocks the release of the chemical acetylcholine that triggers muscle contractions, is among the most recent and successful treatment options for reducing abnormal muscle activity and improving gait or motor patterns. Treatment with BoNT-A is often combined with physical and occupational therapy and/or oral medications, intrathecal baclofen therapy or phenol nerve block. In general, BoNT-A is well tolerated with few reports of serious adverse effects; injections need to be repeated about every three months to achieve maximal effectiveness.

Intrathecal baclofen has been utilized effectively to control spasticity in a number of neurologic disorders including spinal cord injury, brain injury, cerebral palsy, multiple sclerosis and others. This therapy makes use of an implanted pump and catheter system. Three main indicators for intrathecal baclofen therapy are:

• Spasticity that is poorly controlled despite maximal therapy with other modalities
• Spasticity that is poorly controlled because of poor patient tolerance of other modalities
• Spasticity reduction that benefits from the precise control that the intrathecal delivery system affords

In general, patients must be clinically stable, understand the risks and benefits of intrathecal baclofen therapy, have resources available to return to clinic for refills and have demonstrated a positive response to a test dose of intrathecal baclofen.

Other Interventions

• Surgical intervention, including neuro-orthopedic surgery, may also be used to relieve spasticity and improve function. Surgery can be used to lengthen, reposition or release muscles or tendons or to target nerves that transmit motor impulses. Orthopedic rehabilitation, a subspecialty of orthopedic surgery, focuses on the linkages between bones, joints, muscles and the nervous system and involves using a surgical procedure to control or reduce spasticity or hyper tonicity.
• Nerve blocks with phenol require technical skill to administer without involving other sensory nerves or branches, but they can be quite effective in decreasing muscle overactivity.
• Rehabilitation and physical therapy to help the patient re-learn how to use the limb. Stretching and strengthening exercises can improve range of motion and help prevent contracture.