Managing Tone and Spasticity By Mitchell H. Paulin, M.D. Board Certified, Physical Medicine and Rehabilitation Specializing in the Management of Tone and Spasticity Spasticity interferes with life; it affects quality of life and daily activities, including walking, speech, and all types of movement. Spasticity usually occurs as a result of a spinal cord injury or brain injury, either from trauma, stroke or lack of oxygen. It can be caused by metabolic diseases, multiple sclerosis and cerebral palsy and can range from mild to severe stiffness, pain and uncontrollable spasms.
Treating Spasticity
There are four general treatment modalities for spasticity and tone management.
1. Physical modalities that include physical and occupational therapies
2. Medical models that act at different points and peripherally on the central nervous system
3. Intrathecal injections into the central nervous system
4. Peripheral motor nerve blocks that significantly decrease spasticity and muscle tone with the utilization of chemoneurolysis (Phenol Motor Nerve Blocks) or chemodenervation (Botulinum Toxin).
Each treatment modality has limitations, although in some instances combinations of treatments can provide greater relief. For example, alone, physical and occupational therapy involve constant exercise and movement to provide improvement. However, therapy alone can result in limited improvement. Coupled with intrathecal injections or peripheral motor nerve injections where the muscles are released medically, improvements in motion can be further enhanced with physical and occupational therapy.
Benefits of Nerve Blocks
There are five reasons a nerve block injection is used.
1. Improve functional use of the muscle
2. Improve seating and positioning
3. Improve hygiene
4. Relieve pain
5. Improve patient’s self image.
The most significant purpose not mentioned in this list is to improve range of motion; thereby facilitating functionality thus allowing individuals to care of themselves, while achieving the previously mentioned improvements.
Achieving Optimum Results:
The goal of any spasticity and tone management program should be to achieve optimal results; however, it is essential that each patient’s optimal goal coincides with the physician’s expectations – the patient should expect the same results as the treating physician. Using a diagnostic block, a patient can realize expected results for a limited period, thus ensuring a physician’s and patient’s goal coincides. Ideally, a diagnostic block is administered in a hospital setting, where physical and occupational therapists are available to take part in the process and to oversee movement and exercise at the time the block is administered. When administered in the office setting, The patient, caregivers and medical staff all participate in the post block assessment. This team approach enables the patient to achieve optimal results and shows the patient what they can expect to achieve as a long-term result. Working together as a team, outcomes can be very good.
Case Studies:
On any given day, the variety of patients seeking relief from the affects of spasticity can range in age and require a variety or treatment modalities, including the following: -
Katie, a 21-year-old patient suffering from spasticity as the result of a traumatic brain injury. Specifically, the patient seeks to improve function and relief from spasticity in her fingers and toes. Using electromyography (EMG) as guidance, injections can be precise and placed in the location where the most spasticity occurs. In the five years since Katie has received injections, she has achieved outcomes that surpass her original goals. -
Amy, a 48-year-old young stroke survivor with right hand paraparesis. Four months post-injection, this patient continues seeing positive results with a fully functioning hand, including fine motor skills. Improvement continues and as a result no treatment was required at this visit. -
Helen, a 78-year-old stroke survivor with a stiff arm and foot drop. The patient suffers from recurring spasticity affecting range of motion and function. The last treatment on the patient’s calf to alleviate foot drag was one year ago and no further treatment is required at this time. The arm stiffness is treated on an eight-week cycle, using an EMG to guide injections to the location where the greatest spasticity occurs. -
John, 65-year-old with left hemiparesis as a result of a spinal cord injury. Following a diagnostic block, the patient receives an intramuscular phenol injection to reduce reflex contraction and spasticity. Phenol injections react on an entire muscle group with a single injection; thus requiring fewer injections. Patients who receive a phenol injection require regular return visits, usually three times a year.
Currently, the Center for Tone Management that is part of Bryn Mawr Rehab Hospital treats upwards of six patients each day on an inpatient basis. Additionally, upwards of 100 nerve blocks are completed each week on an outpatient basis, similar to the case studies previously mentioned. This is the tip of the iceberg compared to the number of individuals who suffer with spasticity as a result of brain injury, stroke, spinal cord injury, multiple sclerosis, cerebral palsy and other neurological injuries and diseases.
For more information on the Center for Tone Management, contact Dr. Paulin.
