Traumatic Brain Injuries

Severy injury or trauma to the brain (known as traumatic brain injury-TBI) can ofter cause spasticty can cause deformities such as contratures and interfere with the activies of daily living (ADLs)

In assessing a peron with TBI, the team considers the severity of the injury, the length of time since it occured, 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 funcitoning (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 postioning 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 postion. 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 funtion.

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 benifits 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 treaments. 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 trreatments are tried to determine their effectiveness. Each situation is different and other therapies may be needed to maiximize funtional 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 inprove 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.

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Last updated 11/23/99