**5.5 Spinal braces**

• Spinal braces are usually used in cases with muscle weakness. In the patients with spasticity being the predominant complaint, spinal braces are not frequently used. It is because they are difficult to fit on the patients, are not comfortable, and can induce breathing problems and sores [2]. In these cases, the use of customized seating with individualized truncal and pelvic support can be a more beneficial and comfortable option. The braces can be used in patients with kyphosis and scoliosis if it helps in sitting.

## **6. Pharmacological intervention**

On the decision for the treatment of spasticity, considering goals is a critical point and pharmacological interventions should be considered with nonpharmacological treatment for optimizing the effectiveness of management [2]. Another important point in prescription of drugs is about the patient's situation and the dosage and timing should be considered according to it. For example, painful nocturnal spasms may best be managed with a long-acting agent taken at night-time that has sedative side effects. As a rule for all medication, "start low and go slow" [2]. Although it is time-consuming, this approach will limit any deleterious effects on function or unwanted side effects. For better discussion, pharmacological interventions are categorized according to spasticity pattern including, generalized, segmental, and focal.

been decreased with this regime, the first drug can be cautiously withdrawn to see if monotherapy with the second-line drug alone is sufficient to achieve the goal of treatment. For optimizing the treatment, it is very important the patient has had written information about treatment goals and efficacy and side effects

2400 mg daily, usually in three divided doses

**Drug Starting dose Maximum dose Side effects**

three divided doses

three or four divided doses

three or four divided doses

four divided doses

Drowsiness, weakness, paresthesia,

Drowsiness, weakness, dry mouth,

Drowsiness, somnolence, dizziness

Drowsiness, reduced attention, memory impairment Dependency and withdrawal

nausea, vomiting

postural hypotension Monitor liver function

Anorexia, nausea, vomiting, drowsiness, weakness, dizziness,

syndromes

paraesthesiae Monitor liver function

Baclofen 5–10 mg daily 120 mg daily, usually in

*Rehabilitation Medicine Management of Spasticity DOI: http://dx.doi.org/10.5772/intechopen.93008*

Diazepam 2 mg daily 40–60 mg daily, usually in

Tizanidine 2 mg daily 36 mg daily, usually in

Dantrolene 25 mg daily 400 mg daily, usually in

Gabapentin 300 mg daily (can start at 100 mg daily)

*Drugs in spasticity treatment.*

Evidence-based recommendations for choosing the drug are listed below:

Tizanidine: It reduces sign and symptoms in MS, spinal cord injury and

Dantrolene: It is the only available agent that works out of CNS with direct action on skeletal muscle. So, it can be prescribed for spasticity originating from both spinal and supraspinal lesions. It is effective in management of MS patient and has modest effect in spinal cord injury, stroke, and cerebral palsy [46–48]. It

Diazepam: The efficacy of it in spinal cord injury, cerebral palsy, and MS has been proven. However, its side effects are more than those of other drugs in the

Gabapentin: There is beneficial effect of gabapentin on measures of spasticity in

Clonidine: Its major use has been as an anti-hypertensive agent, but it is efficient

In children's spasticity, baclofen (for long treatment) and diazepam (for rapid

including stroke or traumatic brain injury [43].

does not demonstrate any changes in function.

MS and spinal cord injury [49, 50].

in the spinal cord injury spasticity [43].

onset) are recommended by NICE guideline [27].

Baclofen: It is more effective in patients with either multiple sclerosis (MS) [44] or spinal cord injury and few have concentrated on spasticity of cerebral origin,

stroke; no functional benefit has, however, been demonstrated in MS and spinal

of drugs.

**Table 7.**

cord injury [45].

studies [43].

**101**

### **6.1 Generalized spasticity**

There are several oral treatments for management of generalized spasticity. However, there is more interest for some medications according to the country strategy (e.g., there is more discussion in American papers for Clonidine, but it is currently little used in the UK) [39]. Generally, these drugs are used more for spasticity management: baclofen, diazepam, tizanidine, dantrolene, gabapentin, and clonidine (**Table 7**). They may be used to provide systemic effect for modest spasticity severity. Choosing the drug is dependent on patient problems and goals [2, 39]. For example, if the neuropathic pain is a problematic as well as spasticity, gabapentin should be considered for this patient. Besides, some of the drugs are more recommended in papers for specific diagnosis; for example, gabapentin is also recommended as first- or second-line treatment for spasticity in the UK National Guidelines for Multiple Sclerosis [39].

There is no evidence-based consensus for combination drug regimes for oral treatment. However, they can be used according to associated features [2, 43]. There is no right or wrong way to titrate drugs in combination, and professionals suggest avoiding polypharmacy. If there is intolerance for maximum dose of firstline drug, continue the highest level the individual can tolerate comfortably and added the second-line drug and titrated upward. If the patient's problem has

*Rehabilitation Medicine Management of Spasticity DOI: http://dx.doi.org/10.5772/intechopen.93008*


### **Table 7.**

Contracture prevention [40]:

Performance improvement [42]:

**6. Pharmacological intervention**

**5.5 Spinal braces**

segmental, and focal.

**100**

**6.1 Generalized spasticity**

Guidelines for Multiple Sclerosis [39].

• Enough studies for contracture correction by splints are not available.

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

• Elbow gaiters are recommended to maintain extension and improve function.

• Spinal braces are usually used in cases with muscle weakness. In the patients with spasticity being the predominant complaint, spinal braces are not frequently used. It is because they are difficult to fit on the patients, are not comfortable, and can induce breathing problems and sores [2]. In these cases, the use of customized seating with individualized truncal and pelvic support can be a more beneficial and comfortable option. The braces can be used in

On the decision for the treatment of spasticity, considering goals is a critical

There are several oral treatments for management of generalized spasticity. However, there is more interest for some medications according to the country strategy (e.g., there is more discussion in American papers for Clonidine, but it is currently little used in the UK) [39]. Generally, these drugs are used more for spasticity management: baclofen, diazepam, tizanidine, dantrolene, gabapentin, and clonidine (**Table 7**). They may be used to provide systemic effect for modest spasticity severity. Choosing the drug is dependent on patient problems and goals [2, 39]. For example, if the neuropathic pain is a problematic as well as spasticity, gabapentin should be considered for this patient. Besides, some of the drugs are more recommended in papers for specific diagnosis; for example, gabapentin is also recommended as first- or second-line treatment for spasticity in the UK National

There is no evidence-based consensus for combination drug regimes for oral treatment. However, they can be used according to associated features [2, 43]. There is no right or wrong way to titrate drugs in combination, and professionals suggest avoiding polypharmacy. If there is intolerance for maximum dose of firstline drug, continue the highest level the individual can tolerate comfortably and added the second-line drug and titrated upward. If the patient's problem has

point and pharmacological interventions should be considered with nonpharmacological treatment for optimizing the effectiveness of management [2]. Another important point in prescription of drugs is about the patient's situation and the dosage and timing should be considered according to it. For example, painful nocturnal spasms may best be managed with a long-acting agent taken at night-time that has sedative side effects. As a rule for all medication, "start low and go slow" [2]. Although it is time-consuming, this approach will limit any deleterious effects on function or unwanted side effects. For better discussion, pharmacological interventions are categorized according to spasticity pattern including, generalized,

patients with kyphosis and scoliosis if it helps in sitting.

*Drugs in spasticity treatment.*

been decreased with this regime, the first drug can be cautiously withdrawn to see if monotherapy with the second-line drug alone is sufficient to achieve the goal of treatment. For optimizing the treatment, it is very important the patient has had written information about treatment goals and efficacy and side effects of drugs.

Evidence-based recommendations for choosing the drug are listed below:

Baclofen: It is more effective in patients with either multiple sclerosis (MS) [44] or spinal cord injury and few have concentrated on spasticity of cerebral origin, including stroke or traumatic brain injury [43].

Tizanidine: It reduces sign and symptoms in MS, spinal cord injury and stroke; no functional benefit has, however, been demonstrated in MS and spinal cord injury [45].

Dantrolene: It is the only available agent that works out of CNS with direct action on skeletal muscle. So, it can be prescribed for spasticity originating from both spinal and supraspinal lesions. It is effective in management of MS patient and has modest effect in spinal cord injury, stroke, and cerebral palsy [46–48]. It does not demonstrate any changes in function.

Diazepam: The efficacy of it in spinal cord injury, cerebral palsy, and MS has been proven. However, its side effects are more than those of other drugs in the studies [43].

Gabapentin: There is beneficial effect of gabapentin on measures of spasticity in MS and spinal cord injury [49, 50].

Clonidine: Its major use has been as an anti-hypertensive agent, but it is efficient in the spinal cord injury spasticity [43].

In children's spasticity, baclofen (for long treatment) and diazepam (for rapid onset) are recommended by NICE guideline [27].

### **6.2 For regional or segmental spasticity**

This type of spasticity benefits from interathecal administration. This route of administration delivers the medication directly to where it is needed with less unwanted side effects like drowsiness and impaired cognition. Interathecal baclofen pump has been used since 30 years ago [39]. It is effective for lower limbs and trunk spasticity [51]. To manage changing needs, the dose and timing of drug delivery can be programmed over the 24-hour period. It has the beneficial effect in the autonomic storming in people with brain and spinal cord injury [39]. The risk of infection and the need to attend clinics every 3 months or so to have the pump refilled are its significant disadvantages.

• Causing pain

• Causing pain

cases [27]:

• Disturbing sleep

to support posture

• Has severe muscle weakness

• Is receiving aminoglycoside treatment

The person has any of the following:

• Generalized spasticity

• Fixed muscle contracture

• Marked bone deformity

**7. Setting up a service**

efficient team.

**103**

adapted physical therapy treatment.

• Impeding tolerance of other treatments, such as orthoses

• Causing cosmetic concern to the child and young person

• Causing cosmetic concern to the child and young person

Botulinum toxin is not recommended in the following cases [27]:

• Bleeding disorders for example due to anticoagulant therapy

• Had previous adverse reaction or allergy to the botulinum toxin type A

There are concerns about people likelihood of engaging in post treatment

Setting up a spasticity clinic or service depends on the local conditions and available resources. Setting up a clinic needs a team in which every member has certain tasks. Undoubtedly, the roles and duties will overlap, but it is important to understand the abilities and skills of each professional to evaluate what they can offer for the treatment process [2]. Thus, outlining the key skills and roles of each team member and providing a competency framework can help in making an

Administration of botulinum toxin should be done with caution in the following

be considered in the following cases [27]:

*Rehabilitation Medicine Management of Spasticity DOI: http://dx.doi.org/10.5772/intechopen.93008*

• Impeding gross motor function

• Compromising care and hygiene

Botulinum toxin injection for patients with focal spasticity in lower limb should

• Impeding tolerance of other treatments, such as orthoses and use of equipment

The pump is recommended in children with severe motor function impairment (GMFCS level 3, 4, and 5) and bilateral spasticity affecting upper and lower limbs [27].

An intrathecal baclofen test to assess the therapeutic effect and adverse events is necessary before making the decision for intrathecal pump implantation. For evaluation of response, assessing the patient is necessary within 3–5 hours after sedation and recovery. Before pump implantation, written information is necessary including possible adverse effects, signs and symptoms suggesting the dose is too low or high, complications and follow-up appointments [27].

Implantation of the infusion pump can occur within 3 months of satisfactory response to intrathecal baclofen test [39].

Using intrathecal phenol injections is suggested in some studies too [52]. Compared with the intrathecal phenol, baclofen pump has complication of surgical procedure for implantation of pump, malfunction of pump, needing for dose adjustment and refilling the pump [52]. The advantages of intrathecal phenol include: less individual responsibility, low cost, no requirement of special equipment, and avoiding the regular clinical visits for refills. But the complications of this procedure are bladder and bowel incontinence, limb weakness, and paraesthesia, which are the reasons for intrathecal phenol not being considered for spasticity management routinely [52].

### **6.3 Focal spasticity**

The most famous treatments that are used in this category are phenol neurolysis and botulinum toxin.

Phenol nerve block has been used for the treatment of spasticity since the 1960s and it has advantages in comparison with botulinum toxin including: faster onset of spasticity relief and greater degree of muscle relaxation for much longer and at much less expense [27, 39]. But it has disadvantages including, neurogenic pain or paraesthesia (if applied to a mixed motor/sensory nerve) and careful localization (needing for experienced hand), so some specialist prefer Botulinum toxin. However, it is appropriate for patients with troublesome spasticity and dystonia of hip adductors and calf muscles, especially for non-ambulant patients or "walkers" who are already dependent on an ankle-foot orthosis (AFO) [27, 39].

Botulinum toxin use has shown significant effects on improving the symptoms of patients with focal spasticity or dystonia [27, 39, 43]. The method of use and injection is discussed in detail in chapter x. Here is a brief explanation of its indications and contraindications.

There is more interest in botulinum toxin injection. This procedure for patients with focal spasticity in upper limb should be considered in the following cases [27]:


*Rehabilitation Medicine Management of Spasticity DOI: http://dx.doi.org/10.5772/intechopen.93008*

• Causing pain

**6.2 For regional or segmental spasticity**

refilled are its significant disadvantages.

response to intrathecal baclofen test [39].

lower limbs [27].

**6.3 Focal spasticity**

and botulinum toxin.

tions and contraindications.

**102**

• Impeding fine motor function

• Compromising care and hygiene

This type of spasticity benefits from interathecal administration. This route of administration delivers the medication directly to where it is needed with less unwanted side effects like drowsiness and impaired cognition. Interathecal baclofen pump has been used since 30 years ago [39]. It is effective for lower limbs and trunk spasticity [51]. To manage changing needs, the dose and timing of drug delivery can be programmed over the 24-hour period. It has the beneficial effect in the autonomic storming in people with brain and spinal cord injury [39]. The risk of infection and the need to attend clinics every 3 months or so to have the pump

The pump is recommended in children with severe motor function

*Neurostimulation and Neuromodulation in Contemporary Therapeutic Practice*

necessary before making the decision for intrathecal pump implantation. For evaluation of response, assessing the patient is necessary within 3–5 hours after sedation and recovery. Before pump implantation, written information is necessary including possible adverse effects, signs and symptoms suggesting the dose is too

low or high, complications and follow-up appointments [27].

are already dependent on an ankle-foot orthosis (AFO) [27, 39].

impairment (GMFCS level 3, 4, and 5) and bilateral spasticity affecting upper and

An intrathecal baclofen test to assess the therapeutic effect and adverse events is

Implantation of the infusion pump can occur within 3 months of satisfactory

Using intrathecal phenol injections is suggested in some studies too [52]. Compared with the intrathecal phenol, baclofen pump has complication of surgical procedure for implantation of pump, malfunction of pump, needing for dose adjustment and refilling the pump [52]. The advantages of intrathecal phenol include: less individual responsibility, low cost, no requirement of special equipment, and avoiding the regular clinical visits for refills. But the complications of this procedure are bladder and bowel incontinence, limb weakness, and paraesthesia, which are the reasons for intrathecal phenol not being considered for spasticity management routinely [52].

The most famous treatments that are used in this category are phenol neurolysis

Phenol nerve block has been used for the treatment of spasticity since the 1960s and it has advantages in comparison with botulinum toxin including: faster onset of spasticity relief and greater degree of muscle relaxation for much longer and at much less expense [27, 39]. But it has disadvantages including, neurogenic pain or paraesthesia (if applied to a mixed motor/sensory nerve) and careful localization (needing for experienced hand), so some specialist prefer Botulinum toxin. However, it is appropriate for patients with troublesome spasticity and dystonia of hip adductors and calf muscles, especially for non-ambulant patients or "walkers" who

Botulinum toxin use has shown significant effects on improving the symptoms of patients with focal spasticity or dystonia [27, 39, 43]. The method of use and injection is discussed in detail in chapter x. Here is a brief explanation of its indica-

There is more interest in botulinum toxin injection. This procedure for patients with focal spasticity in upper limb should be considered in the following cases [27]:


Botulinum toxin injection for patients with focal spasticity in lower limb should be considered in the following cases [27]:


Botulinum toxin is not recommended in the following cases [27]:


Administration of botulinum toxin should be done with caution in the following cases [27]:

The person has any of the following:


There are concerns about people likelihood of engaging in post treatment adapted physical therapy treatment.

### **7. Setting up a service**

Setting up a spasticity clinic or service depends on the local conditions and available resources. Setting up a clinic needs a team in which every member has certain tasks. Undoubtedly, the roles and duties will overlap, but it is important to understand the abilities and skills of each professional to evaluate what they can offer for the treatment process [2]. Thus, outlining the key skills and roles of each team member and providing a competency framework can help in making an efficient team.

In general, four professionals have roles in a spasticity clinic team including a physician (a pediatric or adult neurologist or a physical medicine and rehabilitation specialist), nurse, occupational therapist, and physiotherapist [2]. In the following, the tasks of each professional are briefly discussed.

collection, organization, and extraction so that effective and useful proposals will be presented. The development of these services based on this information results in optimizing the services as much as possible and targeted funding for treating these

Spasticity is one of the common symptoms in a wide range of neurological conditions and it needs a multidisciplinary approach for best management. This chapter provided an excellent paradigm to incorporate many of the key elements that are fundamental, including: assessment of the individual with spasticity, provision of education and promoting self-management, physical management of spasticity (physiotherapy or occupational therapy), orthoses, pharmacological

The authors certify that there is no conflict of interest with any financial orga-

Demographic data and checklist for impact of the spasticity on the

Severity rating out of 10

Indicate if pain has been getting worse, better, or remains the

patient's communications and interactions with the environment.

Spasticity Please comment on site and severity of spasticity

Spasms Please comment on which muscles, extensors or flexors, severity, pain, frequency, and duration

Pain Please comment on presence, severity, and management.

Sleep patterns Please comment on disturbances, positions, and quality Bed mobility Please comment on how much, type of mattress used

Clonus Please comment whether spontaneous

same

Bladder Please comment on current management

**Patient's name: Date of birth: Date: Diagnosis:** Current medication Please comment on dose, route, times, and any side effects experienced

patients.

**8. Conclusion**

**Conflict of interest**

**Appendix 1.**

Primary difficulty:

intervention, and setting up a service.

*Rehabilitation Medicine Management of Spasticity DOI: http://dx.doi.org/10.5772/intechopen.93008*

Other medication used in the past for spasticity:

Is it attributed to spasticity: Yes/No

Not needing to be assessed

Not needing to be assessed

Not needing to be assessed

Not needing to be assessed

Not needing to be assessed

**105**

Other difficulties related to spasticity:

nization regarding the material discussed in this chapter.

Why did they stop taking it (ineffective, not tolerated, other reason?)

Physician:


Nurse:


Physiotherapist:


Occupational therapist:


Permanent presences of other specialists in the team are not necessarily needed, but they can be helpful in the treatment process. These specialists include orthopedics, neurosurgeons, speech therapists, orthotists, social workers, continence advisors, and psychologists.

One of the valuable points in setting up such services is their growth and development to provide better services. This goal is achieved through data

collection, organization, and extraction so that effective and useful proposals will be presented. The development of these services based on this information results in optimizing the services as much as possible and targeted funding for treating these patients.
