Treatment of Spasticity

 A perspective

by Peter Rosenbaum, M.D. and John McLaughlin, M.D.

Spasticity is one of several types of abnormal motor control that can occur. It must be distinguished from other causes of hypertonia (increased resistance of muscle to being stretched) because the treatment may be different. Spasticity results from injury or abnormal development of parts of the brain that control and coordinate body movements. Many people consider Spasticity the cause of problems in people with cerebral palsy. They think it should be treated to help improve an individual's day to day life.

This Exceptional Parent Special Report presents current thinking about the best way to manage Spasticity. The articles are written by experts who work with people with cerebral palsy and other conditions in which Spasticity is a problem.

To understand the meaning of effects to "treat" something and achieve specific results, we will turn to a framework formulated by the World Health Organization in 1980, and recently modified by the National Center for Medical Rehabilitation Research (NCMRR) at the National Institutes of Health. These guidelines outline a conceptual framework for treatment structure and objectives.

The NCMRR framework

The guidelines define pathophysiology as a problem with the basic level of the body's function. In cerebral palsy, for example, insufficient oxygen to the developing brain might be one cause of damage to the cells and nerves in the brain that control muscular actions and may cause Spasticity. The damage to the brain is responsible for the level of pathophysiology. The NCMRR guidelines also address impairment, functional limitation and disability as part of their framework.

Impairments  are the specific limitations in the way the mind and body work. For people who have Cerebral Palsy, impairment shows up in how the brain controls movement. When individuals have impairments which interfere with how well or easily they perform activities in ordinary ways, they have functional limitations. The functional limitations of people with Spasticity might be observerd as awkward walking or as difficulties in performing activities of daily living (ADL's) such as eating, dressing and using the toilet. 

The NCMRR conceptual framework also recognizes that human activities involve interactions with other people and the environment. When people have functional limitations that affect their ability to do things they want to, they are said to have a disability. For a person with Spasticity, disability can mean having problems getting around in the community or participation in everyday activities.

In addition, there are societal limitations  that people may experience when they have disabilities. Here the problems lies in the community or the environment rather than in the person. For example, if children cannot get appropriate treatment or health care insurance will not pay for the Assistive equipment needed to function well, they will experience societal limitations.

When treating Spasticity, the goal can be to improve the way the nerve cells work-responding to the pathophysiology. This is often where drugs can be effective. When surgery lengthens a spastic muscle, it targets the impairment caused by Spasticity. It is essential to determine whether any treatment affects the functional limitations and disabilities experienced by the individual. For example, treating Spasticity in the presence of muscle weakness and contractures may lead to a loss of mobility if a child relies on Spasticity for support. Moreover, if a child has underlying muscle weakness, elimination Spasticity will not improve mobility unless physical therapy for muscle strengthening and gait training is added to the treatment program.

However, if the same child has painful cramps, is irritable and up half the night or does not tolerate being in his wheelchair, then treating the Spasticity has real value.

It is important for individuals who have Spasticity, as well as for their parents and care providers, to weigh all treatment implications. The question must always be asked: How will treatment affect functional limitations and disability? Today, this is especially important because some treatments for Spasticity are expensive and may produce undesirable side effects and outcomes.

Credit for this article goes to Dr. Rosenbaum,MD and Dr. McLaughlin,M.D. Thank you Dr. McLaughlin for sharing this information with CPN.