dr barth green on spacticy

[Guest guest]

these notes were taken during dr Greens presention at the asap confrence last

summer ..please do rent the tape for more details ...posted by sara patterson

following the confrence .

Notes on Dr. Barth Green's presentation of Spasticity

****these are just my notes, for the complete presentation you will need

to rent the video tape when it becomes available. I can not guarantee

this is free of errors!*****

Spasticity very simply put is the nervous system losing it's balance.

Picture the brain as a big computer center and the spinal cord as a

telephone cable with all the peripheral nerves bringing messages in and

out. We call it modulation which means the uppers and downers all sort

of have pretty good control. What happens for a lot of different reasons

(a lot of different injuries and diseases in the nervous system) is that

the balance between uppers and downers-so to speak- electrically and

chemically, becomes dysfunctional or disordered. when you are injured or

if you are born with a problem or develop a problem one of the things

that happens when you lose certain control is you have a loss of

inhibition- or downers- and you have fascilitation or excitation or

uppers. And this is manifested or presents itself with increased tone

and stiffness of the extremities.

Increased tone, or spasticity, is a common clinic issue that faces people

with Chiari I from brain stem problems and from those with SM from spinal

cord dysfunction. Some of the spasticity problems can be very local.

Some people have spasticity limited to the face, one eye, or one leg.

Even the trunk sometimes can be isolated with spasticity. More common,

of course, it to view spasticity below the level of injury, the level of

involvement.

We look at spasticity as:

Very Minor- it doesn't bother anybody

Moderate degree- which actually can be very helpful. Those of you

that deal with rehabilitation issues and restoration of function know

that some spasticity allows people to stand, it allows them to transfer,

it allows their bowel and bladder to spontaneously empty so it can be

very important.

Very Severe-it can be disabling and dangerous.

In spinal cord injury or in people that have had surgery, most often

spasticity doesn't occur for at least 6 or sometimes as long as 16 weeks

after an injury or after a surgery where someone suffers a spinal cord

shock. This is initially preceeded by a lower motor neuron or flaccid

state, where there is no tone in the muscles and they become spastic over

time.

One of the most common causes of spasticity in someone with a spinal cord

injury or brain stem lession are not spinal cord cysts, scar tissue or

tethering- but the most common causes are really other systemic issues

like bedsores, bladder infections, impactations of the bowel, or a

fracture of the leg that you might not be able to feel because you don't

have sensation in that part of your body. All of these causes are much

more common causes than a spinal cord cyst. So what you end up doing at

the end of a work up is if all these things are negative-if you have

evaluated the patient who has had uncontrolled spasticity and you rule

out all the most common causes then you end up looking to the MRI scan to

see if you can diagnose a spinal cord cyst or a tethered cord. It is

interesting that in cases of paralysis the more incomplete the paralysis

the worst the spasticity.

Again if it's a minimal or moderate amount it may be a good thing because

it keeps the muscles full and strong, it keeps tone, it helps

circulation, it supposedly helps prevent osteoporosis. But the severe

type of spasticity, as many of you know, can result in severe disability.

IT can result in sheering injuries, incubitus ulcers, contractures.

That is why we need to have treatments available for individuals who

suffer the severe form of spasticity that compromises their activities of

daily living and the quality of their life.

This is a group of meds available and I'm going to share with you my

prejudices. I believe Dantron(sp?) is a bad drug because it has a high

liver toxicity profile, so I don't use it. Valuim is very addictive and

depressive which is something people with spasticity don't need so I

don't use Valium.

The most common and least expensive because it's now generic, and the

most commonly used because it gives the least profile of side effects is

Baclofen. But some people are allergic or sensitive to Baclofen and some

can't tolerate it. Every single medication can affect certain

individuals in different ways. Nothing is innocuous, not even water as

some of you know depending what's in it. Its important to say it's not

totally safe, but this seems to be the most commonly used.

A newer generation of drugs- Zanaflex is also very useful and has less

side effects than some of the others. The combination of Periactin and

Canapress(sp?!)came out of studies in Canada. Periactin is just an

antihistamine but in combination these two drugs seem to help people who

don't respond to the usual drugs. The problem with Periactin is it

generates a tremendous appetite. Other meds are available .

There are also many alternatives to meds including:

stretching

iceing someone down

standing

weight bearing

walking

walking in a pool, hydrotherapy

relaxation training

meditation, yoga, bio feedback

Then there is the use of epidural implants for people who don't respond

to these other treatments. Baclofen pump is one you've all heard about.

I don't like to use it very often in my spinal cord injury or with

chronic neurological disorders because it is a foreign body and has a

high infection rate. But it is a reasonable thing for individuals who

have tried all medications and all procedures and are really down to the

end of the line.

****these are just my notes, for the complete presentation you will need

to rent the video tape when it becomes available. I can not guarantee

this is free of errors!*****

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