Traumatic
BRAIN INJURIES
by
Cindy B. Ivanhoe, M.D.
Sever injury or
trauma to the brain (known as
traumatic brain injury-TBI) can
often cause spasticity can cause deformities such as
contractures and interfere with the activities of daily living
(ADLs)
In assessing a person
with TBI, the team considers the severity of the injury, the
length of time since it occurred, how recuperation has
progressed, and any changes that might affect functioning.
Injuries are rated mild, moderate, or severe by the team. The
more severe the injury, the longer the time required for
improvement. The type and timing of treatment also affect the
outcome.
Oral medications
To date, nor
oral medication has proved effective for treating spasticity due
to TBI. Levels of cognitive functioning
(memory, attention and concentration)
can be adversely affected by oral medications, sedation is often
induced and spasticity remains undiminished regardless of
dosage. One oral medication, tizadine
(Zanaflex®),
was recently released for the treatment
of certain types of spasticity; however, clinical experience
with Zanaflex in children and adults with TBI is limited.
Casting and stretching
Casting techniques
for positioning and stretching can improve an individual's
movement patterns and skills. For example, a spastic hand can be
casted to facilitate relaxation of the fingers. It is important
to note, however, that casting is not well-tolerated in
individuals with severe spasticity.
Serial casting of
limbs can be essential for individuals with TBI-induced
spasticity. During the serial casting process, a joint is
stretched and then casted in the most useful position. The Cast
is removed within a day or two after further stretch is
achieved. This process is repeated until maximum range of motion
occurs.
Another form of
casting, called inhibitory casting, applies constant pressure
along particular areas of the sole of the foot which can further
decrease tone and improve function.
Injection therapy
Injections alone or with casting can
decrease tone. Unlike oral medications, injections can
specifically target the muscles responsible for the body
position that needs to be corrected. The most commonly injected
medications are phenol and Botulinum toxin
(Botox®)
Phenol is used
when nerve (or motor)
point blocks are performed. Motor point
blocks involve a series of injections of very small amounts of
phenol into target muscles. An electrical instrument gently
stimulates the muscle to identify the best injection sites to
"block" spasticity. The stimulation produces a burning
sensation. The procedure may require an individual to lie still
for as long as 30 minutes.
Injected phenol
destroys a very small number of muscle and decreasing the
accompanying tone. Motor point blocks can be repeated as needed
to achieve relaxation of spasticity. Possible complications
include bleeding, swelling, pain, changes in sensation and the
slight risk of a blood clot in the arm or leg injected. Phenol
injections are usually successful to some degree, and their
benefits may last from two weeks to six months. They are
relatively inexpensive and can be repeated as often as
improvement in spasticity continues.
Botulinum toxin
injections have become a very useful tool in the treatment of
spasticity. These injections take less time to perform and are
often better tolerated by an individual than phenol motor point
blocks. Unlike phenol blocks, Botox injections do not involve
any discomfort other than the needle stick.
(For additional information on this
treatment option, refer to the "Oral and Intramuscular
Medications: article in this special report)
The intrathecal baclofen therapy
(ITB)
pump is one of the most dramatic treatments. The pump is an
excellent option when spasticity involves multiple joints and
muscles and its benefits are primarily in the legs and trunk,
although some relaxation may occur in the upper limbs. The ITB
pump is not usually implanted until one year following traumatic
brain injury. During those those 12 months, less invasive
treatments are tried to determine their effectiveness. Each
situation is different and other therapies may be needed to
maximize functional improvement. Indeed, treatment options
can-and should- be in combination. In addition, the beneficial
effects of physical therapy and- after other
interventions-orthopedic surgery, should not be overlooked.
Treatment of
spasticity in individuals with TBI can improve function,
decrease care needs and unmask underlying movement. The right
combination of treatments can produce an enormous improvement in
an individual's comfort, self-care and quality of life.
Credit for this article goes to Cindy B. Ivanhoe,M.D. and
exceptional Parent Magazine.
