Greg Vigna, MD, JD: Spinal Cord Injury Spasticity Requires Treatment

03/27/2013 // Concord, CA, USA // LifeCare123 // Greg Vigna, M.D., J.D. // (press release)

Medical Perspective:

Symptoms of spasticity are common in the spinal cord injured population with ’65–78% having symptoms of spasticity.’ Spasticity is defined as a velocity dependent increase in tone. This means the faster a patient moves an extremity, the stiffer the extremity will become, thereby interfering with voluntary movement. Symptoms of spasticity begin after the resolution of spinal shock in both complete and incomplete cervical and thoracic spinal cord injured patients and would not occur in injuries involving the caudal equina. Symptoms of spasticity include spasms which are involuntary muscle contractions, increased reflexes, and joint deformities because of muscle imbalance by spastic muscles.

Spasticity often negatively impacts a spinal cord injured patient’s life by interfering with daily activities such as sitting, transfers, walking, and sleep. Severe spasticity is more extreme; it can cause a spinal cord injured patient to fall out of a wheel chair and it may be a contributing factor to the formation of pressure ulcers and joint contractors. It also may interfere with bathing and grooming and the care provided by others is more difficult and intensive. Pain is a common complaint directly related to spasticity. Not all spasticity is detrimental. Spasticity is believed to decrease the risk of blood clots and may improve stability with walking and transfers of a spinal cord injured. Therefore, careful consideration by physicians is necessary because treating beneficial spasticity may in fact interfere with function while exposing the patient to potential risk of treatments.

Treatment options for spinal cord injury spasticity include physical therapy, medications, injections, and surgery. Every patient should be prescribed physical therapy and receive range of motion maintenance of effected joints. This is best accomplished by applying ice to spastic muscles followed by prolonged stretching of the muscle. Medications include baclofen, valium, and zanaflex. Baclofen is very effective in spinal spasticity and generally should be started on low doses divided two times a day and increased over time by total dose and frequency to monitor for the desired therapeutic benefit and potential side effects. Baclofen lowers the seizure level, may cause sedation, may become toxic in situations of renal failure, and should be weaned off if the decision is to discontinue the drug. Valium is very effective in spinal spasticity and generally very well tolerated. Valium causes sedation and is effective at night for spasticity that interferes with sleep. Valium has abuse potential and should be monitored, and should be weaned if the decision is to discontinue. Zanaflex is effective in spinal spasticity. Liver function tests should be monitored as well as the potential for low blood pressure. These drugs can be used together.

Patients may also benefit from injection therapy for spasticity that affect one or two muscle groups disproportionate to other muscles. Botulism Toxin (Botox) is safe and effective for treatment of focal (isolated) spasticity that interferes with function or causes pain. The negatives to injection therapy are the pain, high cost, a need to repeat every three months, and potential for antibodies that will neutralize the drug’s effectiveness. It is this author’s opinion that Botox is very beneficial in the child patient because of their small muscle size and is very effective if used for the purpose of decreasing contractures when coordinated with physical therapy and serial casting.

The most popular surgical option for spasticity is implantation of a baclofen pump. This option delivers the medication directly into the fluid around the spinal cord providing excellent control of spasticity while decreasing sedative effects. This should be reserved for patients who have failed to achieve a therapeutic benefit from other less invasive treatments discussed above. Complications include infection, failure of the device (rare), and catheter related problems. Patients must follow up for medication refills every three months and must understand issues and symptoms regarding withdrawal from the drug in cases of noncompliance and failure of the delivery system for the drug. Cost and need for pump reimplantation are additional concerns.

It is my opinion based on my training and experience of taking care of patients with intractable spasticity that patients with difficult to manage spasticity should be managed at a center of excellence by a physician with the experience, training, and access to all of the treatment options available for spasticity. Nothing is worse than seeing a patient implanted with a baclofen pump with unrealistic expectations of increased function, or worse, a patient who receives a pump only to find that her or his function is in fact made worse. Careful consideration related to the severity of spasticity, patient compliance, goals of treatment, and discussion of risk versus benefits must be discussed with the patient.

Life Care Planning Perspective:

A life care planner considering the life-long treatments required in spinal cord injury related spasticity, understands that spasticity often worsens as the patient ages. A life care plan may include the following: routine evaluations by physician, routine medications, routine evaluations by a physical and occupational therapist, routine replacement of braces which may be required spasticity management, daily physical therapy or range of motion provided by a care giver, specialty beds to prevent pressure ulcers in problematic spasticity, and routine blood test to monitor medications. Costs associated with the plan should also be considered, including the costs related to Botox, and costs related to intrathecal baclofen pumps. All reasonable and medically necessary care must be considered. If spasticity is not being treated adequately and the patient’s quality of life is being compromised, a life care planner should recommend a referral to a center of excellence for spasticity.

Personal Injury Attorney Perspective:

Spasticity is another common complication associated with a spinal injury, and requires an attorney to be well versed in the plethora of associated complications. An attorney will need to provide the jury with all anticipated future medical costs for the spinal injury that the negligence (carelessness) or wrongful act a defendant proximately caused (substantial factor). Spasticity treatments would be one of the included costs for past and future economic (medical costs) and noneconomic (pain and suffering) damages over the projected lifetime of the client. This may be a substantial amount. Retention of qualified experts in neurology, physiatry, and neurosurgery would be critical; failure to include this will deny a client a fair outcome. An underfunded settlement may preclude adequate treatment for spasticity causing potentially preventable complications such as pressure ulcers and joint contractures.

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