So far in this exciting miniseries on spasticity we have looked at what it is and how it can be treated with physical treatment and exercise. In this column I’m going to talk about treatment with oral medications and nerve blocks, while in the next and last column I will look at intrathecal delivery systems and surgical options.Perhaps it is really important to say up front that none of these options should even be considered without a complete assessment by a doctor who knows and understands your condition - whether this is a spinal cord injury, a brain injury, a stroke or some other neurological condition. Each of these treatments has potentially dangerous side-effects and no one should start with any of them lightly.Oral medication.
Starting first with oral medication it is probably fair to say that only 2 really effective drugs are available in South Africa, while a third is frequently (and often inappropriately) used to treat spasticity.
Baclofen or Lioresal, possibly the most commonly used drug is also probably the most effective. It can be prescribed for generalised or widespread spasticity and is most often used three or four times a day in doses of up to 100 mg (while always trying to use as low a dose as possible).
Unfortunately Baclofen has quite a nasty side-effect profile and in some people can cause confusion, depression and tiredness. It can also cause dry mouth, nausea and constipation and should never be stopped suddenly. Many people have also stopped taking it because they felt that it gave them an unpleasant buzz.
Having said that, it can be extremely effective and decrease your spasticity to a point where it is no longer a problem. Like all other medication for spasticity it has to be used on a longterm basis and is not a simple one off cure.
Another drug, that is used less often, is Dantrolene Sodium or Dantrium. This drug can also decrease spasticity effectively, but is often not as powerful as Baclofen. Fortunately it does avoid many of the side-effects that we see with Baclofen, but can result in problems with liver metabolism. As a result people who are taking Dantrium need to have regular blood tests done to ensure that it is not affecting their liver. If these blood tests do show signs of liver problems, the drug is simply withdrawn and the liver recovers. This drug can also be used three or four times a day in doses of up to 100 mg per day.
The third drug that is frequently used is Diazepam (Valium or Pax). While this drug does indeed reduce spasticity levels in many instances, it carries a number of very serious side-effects. It was originally developed as a sedative and anxiety relieving agent and it does just that - it causes severe sedation and drowsiness and can leave you half-awake. Long-term use of this drug also exposes you to a risk of addiction and depression.
Unfortunately this drug is also very inexpensive and is therefore frequently prescribed, especially within the state health sector and on low-budget medical scheme options. My approach is always that it should be avoided andonly ever used as a last option, when all other options have been explored and have either not worked or are unavailable. Even then, I would always try to use it for a short while only. Discuss this with your doctor and be aware that there are significant problems.
Nerve and Muscle Blocks
A second option that can be considered is the use of injections into spastic muscles and the nerves supplying those muscles. The most commonly used drug in this setting is Botox, which is now used frequently and with good effect in reducing spasticity.
One thing that is important to understand is that this type of treatment is best reserved for focal or localised spasticity - that is, spasticity which is concentrated or more severe in one set of muscles or in one limb. This technique is certainly not for everyone and before considering it, you would need to be carefully examined by your physio and by your doctor.
The injections need to be performed by a doctor who has been trained to give them and probably will have to be given several times as the results are not permanent.While Botox, the new kid on the block, is a lot safer than some of the older drugs that were used for nerve and muscle blocks, these injections do sometimes cause unwanted side-effects and do not always work.
Having said that, in the right patient, and given properly, these injections can significantly reduce spasticity. Once again, this is not a magic bullet, but one option to explore with your physio and doctor if your spasticity is more localised than generalised. So, what will you take home from this? It is really important to understand that both the oral and injectable drugs carry a number of unwanted side-effects and are not always completely effective. They need to be used carefully and responsibly.
You need to talk about side-effects and problems with your doctor and physiotherapist and you need to keep exploring options with them, while never forgetting to engage in physical exercise and therapy.
It is easy to be overwhelmed by the discomfort, nagging hassle and indignity of spasticity, while the drugs themselves often add to your problems.
Keep the communication channels open and stick to your guns. Our experience is that if you keep going you will eventually see the results.