New Treatments Open Doors for People with Spasticity

For decades, children affected by spasticity - an abnormal, involuntary tightening of the muscles that makes movement difficult and painful - could look forward to little improvement in their condition.

Spasticity is often caused by cerebral palsy, a childhood stroke, a brain or spinal-cord injury, or "shaken baby" syndrome. As a result, the brain is unable to communicate effectively with the muscles, causing tightening, stiffness, and uncontrollable movements. This problem can make basic functions like walking very difficult.

In the past, treatment of spasticity was limited simple stretching of the affected muscles or orthopedic surgery to avoid hip dislocations. But new medical developments, complemented by a systematic team approach, are brightening the picture for children with spasticity. "We look at moving people along from dependence to functioning at a much higher level," says Elizabeth Moberg-Wolff, MD Medical College of Wisconsin Associate Professor of Physical Medicine and Rehabilitation and a Pediatric Physiatrist at Children's Hospital of Wisconsin.

Dr. Moberg-Wolff has been named program director for Tone Management and Mobility at Children's Hospital of Wisconsin. This comprehensive program is offered through Physical Medicine and Rehabilitation.

A Team Approach
The Tone Management program features a multidisciplinary approach to treating spasticity. "We are very team-oriented," says Dr. Moberg-Wolff. "We can offer physical therapy, splinting, casting and positioning, oral and injectable medications, orthopedics, and neurosurgery. We work as a team to decide on the proper time to use each treatment for our patients."

Dr. Moberg-Wolf is encouraged by the expanding array of tools now available to help children and adults with spasticity. The essential problem to address, she explains, is that "either the brain or spinal cord is sending the wrong message to the muscles," keeping them in a state of constant high tone. "We are aiming at giving the patient more selective motor control, making their bodies responsive to their brains," she says.

Pump a Major Innovation
The medical profession now has new medications and surgical procedures to relax muscle tone and provide the patient with much more freedom of movement. Especially beneficial has been the use of a pump, surgically inserted under the skin, which releases medication around the spinal cord, explains Dr. Moberg-Wolff.

The pump is a circular device somewhat smaller than a hockey puck, which is implanted in the patient's abdomen during a surgery that takes about 60 to 90 minutes. "The pump sends out baclofen through a small tube called a catheter, which bathes the spinal nerves in a soothing fluid and allows the muscles to relax. The medication does not enter the bloodstream or cross into the brain as medicines given by mouth do," she notes.

"The pump catheter can be positioned higher or lower in the spinal canal depending on where the main problem with spasticity is located. It is placed in an upper position if the problems are with arms, speech, and the trunk. The pump is placed lower if the problem is mainly in the legs."

The pump, which has been available for children for about a decade and is undergoing constant refinements, has made a big difference for those with spasticity. "Much less care may be needed and the patients may get their arms loose enough to move voluntarily," she says. "And children who can walk may now walk faster."

The pump is now also being used commonly for children and adults with stroke, spinal cord injury, multiple sclerosis or brain injury-related spasticity.

Botox Relaxes Muscles
Another medication providing relief is Botox, which relaxes muscle fibers. Long before it became famous as an anti-wrinkle treatment, Botox was used to help people with spasticity ease the contractions of their muscles. "It works for about three months before its direct effects wear off," Dr. Moberg-Wolff says. It often buys time until a child is old enough for other interventions.

Orthopedic surgery to alter the position or length of muscles, tendons, and bones is another mainstay of treatment. A neurosurgical procedure known as rhizotomy, in which spinal nerve roots are cut, can also permanently reduce spasticity in affected muscles. This procedure has been in use for about 20 years, but is only used on a very specific set of patients.

The Tone Management program continues to use physical therapy to stretch and loosen the muscles. "The therapy part is really important, because we are working to re-train, strengthen, and stretch the muscles while the medications are working," says the doctor.

Making Repetition Interesting
Getting children to make repetitive motions in therapy poses some challenges. "We're working on innovations to keep and hold the kids' attention and reinforce specific muscle movements. Rather than telling a child to keep unclenching their hand and turning it up, we hope that we can hook them up to a computer screen that produces images when they succeed," says Dr. Moberg-Wolff. "Horseback therapy and swim therapy can also be important for stretching the child's muscles," she adds.

Whatever the primary course of treatment, an entire team of professionals works to oversee each element of care and ensure that the plan for each child is followed. "The fact that we work with the big picture for each child is extremely important," says Dr. Moberg-Wolff. "Our extended team may include a rehab physician, occupational, speech, and physical therapists, people from orthopedics and neurosurgery, a social worker or case manager, and of course the family and child."

"With this many specialties involved, much of our work involves orchestrating all the care and providing good case management," she says.

The Tone Management program is part of Physical Medicine and Rehabilitation at Children's Hospital.

Physical Medication and Rehabilitation is a medical specialty that grew out of the need to treat war veterans who had injuries and disabilities. The specialty has evolved to include those with brain trauma, strokes, spinal cord injuries, brain tumors, and any type of disease that causes an impairment or disability. "This is one of the oldest programs in the country," says Dr. Moberg-Wolff.

"The goal of our Tone Management program is to increase the quality of life for our patients, despite their disabilities. Sometimes we simply improve ease of care, or add to their level of comfort, but in many cases, we create more independence for the children we see."

For more information on the Tone Management and Mobility program, call the program's nurse line at 414-266-6631 or the office at 414-266-3085.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.