Dr C P Ravikumar

Muscle spasticity may occur after any disease, defect or injury involving the brain or spinal cord, like stroke, multiple sclerosis or cerebral palsy, which make up the body’s central nervous system. With this, the nerves that are attached to the muscles of the body (making up the peripheral nervous system) are not under the control of the brain, which results in the nerves and muscles being activated, involuntarily. This may lead to repetitive contraction of the muscles, without intermittent relaxation, which over time causes stiffness, rigidity and spasticity.
When one tries to move a spastic limb to complete its full range of motion, a resistance to movement is felt. This prevents normal fluid motion of the muscles of the affected region of the body, which may hamper movement, speech and gait. It reduces the individual’s capability to perform routine functions, and the muscle spasm itself may cause pain.

If left untreated, spasticity can lead to a permanent contracted state, which causes deformities in the joints like:
Muscle stiffness leading to bent elbows
• Curled toes
• Clenched fists
• Flexed thumb
• Rigid ankles
• Dropped in or turned in foot
• Muscle imbalance in the limbs.

A diagnosis of muscle spasticity can usually be made after a physical examination to check nerve activity and shortening of muscles due to spasticity as well as checking for joint functions during active and passive movements. Alleviating muscle spasticity can help to decrease the intensity and pain of spasms, as well as increase the range of motions to allow improved functions. This leads to:

1. Better hygiene practices, for washing and bathing
2. Better fitting of braces or splints that the patients may also have to wear
3. Better functional activity (standing, walking, sitting, use of upper limbs and extremities)
4. Better gait and stretching of muscles

Initial interventions for muscle stiffness and spasticity are usually:
1. Physical therapy or occupational therapy after consultation with a clinical neurologist integrating stretching exercises with better alignment for functional activities. Since spasticity can be either focal (affecting an arm or leg), regional (affecting a large area of the body like the torso) or generalized, the treatment plans are tailored for individual patients.
2. In order to deal with muscle groups that are in spasm, a more focused approach with the help of a nerve block, like botulinum can be tried. The nerve blocking agent will stop transmission of impulses through the nerve to the affected muscles, thereby reducing the spasticity of the muscle.
Botulinum toxin (or Botox) is purified from bacteria called clostridium botulinum. It is a neurotoxin and is commonly injected into various sites on the body, depending upon its use. Botox has been used for cosmetic purposes to smoothen wrinkles and age lines on the face, as well as to reduce excessive sweating.

Treatment of Muscle Spasticity with Botox
1. After consultation with a clinical neurologist and physical therapist, a patient’s problem muscle group is identified, making sure that there are no irreversible contractures of the muscles.
2. Physical therapy is generally scheduled after Botox injection, in order to take advantage of the reduced spasticity. In some cases bracing or splinting, may be needed.
3. The clinical neurologist determines:
• The quantity and dosage of Botox to use
• Number of sites to inject
• Muscle groups to be targeted. In rare cases, an electromyograph (EMG) machine may be needed to localize a muscle.
4. The site is prepped for injection. A topical analgesic may be used to decrease the discomfort of the needle pricks. Injections are usually made with s small bored needle.
5. After the procedure, the patient is evaluated for a few hours and then patients can resume normal activity. The Botox should begin to take effect within a few hours.
6. The effects of Botox injections are not very long lasting. They usually improve stiffness and reduce spasticity for a period of 3-5 months post procedure.
7. A patient can undergo the procedure multiple times, as long as they are at least 3 months apart.

Side effects of Botox treatment for muscle spasticity are varied and include:
• Itching, rash, red itchy welts,
• wheezing, asthma symptoms, trouble breathing
• Dizziness or feeling faint.
• dry mouth, trouble swallowing
• discomfort or pain at the injection site
• tiredness, headache,
• double vision, blurred vision, drooping eyelids, dry eyes
• hoarse rough voice or inability to speak (dysphonia)
• unable to say words clearly (dysarthria)
• unable to control passing of urine
There are individuals who are also allergic to botulinum, which may cause swelling of lips, throat and tongue, obstructing airways and should be treated as a medical emergency. Studies have shown that Botox along with strength training and physical therapy have seen improved functional activities of patients suffering from muscle spasticity, although the results will vary on a case to case basis. In view of the adverse reactions that could occur with Botox treatment, it should always be given under the supervision of trained and experienced specialists.

Disclaimer: The above information is for awareness and education purposes only and cannot be used for diagnosis or treatment of any condition. Please consult with a physician for any concerns or questions

References: 1. https://www.botoxspasticity.com/about-spasticity 2. https://www.cincinnatichildrens.org/health/b/botox 3. Schwabe AL. Botulinum Toxin in the Treatment of Pediatric Upper Limb Spasticity. Semin Plast Surg. 2016;30(1):24-28. doi:10.1055/s-0036-1571302
Dr C P Ravikumar

Dr C P Ravikumar

CONSULTANT – PEDIATRIC NEUROLOGY
Aster CMI Hospital, Bangalore