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Spasticity after spinal cord injury

Spasticity affects most people with spinal cord injury, causing spasms, stiffness and limbs that pull into fixed positions. Some tone is useful — it can help with standing and transfers — and some is harmful, causing pain, pressure areas, difficulty with hygiene and care, and broken sleep. Assessment decides which is which, and targeted injections treat the muscles that are costing you most.

After a spinal cord injury, the spinal reflexes below the level of injury lose the regulation that normally comes from the brain. Over the months that follow they become overactive: muscles stiffen, limbs jerk into spasm at a touch or a change of position, and legs or hands are drawn into fixed postures. Spasticity affects the majority of people with spinal cord injury and is one of the most common long-term problems they describe.

How it shows up. In paraplegia the legs are affected — extensor spasms that straighten the legs, flexor spasms that draw the knees up, thighs that pull together, feet that point down and turn in, toes that claw. In tetraplegia the arms and hands are involved as well: elbows that will not straighten, wrists and fingers that curl, a thumb tucked into the palm. The consequences depend on the pattern: pain, difficulty with transfers and positioning in a wheelchair, problems with catheter care and hygiene, pressure areas from postures that cannot be changed, skin breakdown in a closed hand, and sleep broken by spasms.

Spasm as a warning sign. In spinal cord injury, a sudden increase in spasticity is often a message from below the level of injury: a urinary infection, a full bladder or bowel, a pressure sore, an ingrown toenail, a fracture. Before tone is treated, the cause of any change is looked for, because treating the spasm without finding the trigger can hide a problem that needs attention.

Useful tone and harmful tone. Not all spasticity after spinal cord injury should be reduced. Extensor tone in the legs can be what allows a standing transfer; tone maintains muscle bulk and supports circulation; some people use spasms to help empty the bladder or reposition. The assessment weighs what each muscle's overactivity is providing against what it is costing, and treatment is planned muscle by muscle with you and your care team rather than applied to the whole limb.

Treatment. Where the problem is focal — particular muscles producing a particular problem — targeted injections reduce tone in exactly those muscles for a period of months and are repeated as needed. Where tone is widespread, oral anti-spasticity medication may be considered, weighed against drowsiness and other effects. Positioning, stretching, standing programs and splinting maintain range between treatments, and equipment — seating, cushions, orthoses — is reviewed alongside, because a change in tone often changes what equipment is needed. For a small number of people with severe generalised spasticity, referral for consideration of an implanted pump is arranged.

Pain and spasticity together. Neuropathic pain at or below the level of injury, musculoskeletal pain from transfers and wheelchair use, and pain from spasticity itself frequently coexist after spinal cord injury and are easily confused with one another. Dr Martin's training in both pain medicine and rehabilitation medicine means these are assessed together, and treated as one plan. See also pain after spinal cord injury.

Working with your spinal service. Treatment is coordinated with your spinal rehabilitation unit, GP, community physiotherapist and occupational therapist, and carers. Referrals are accepted from any of these. For rural and remote patients, assessment and review can be done by telehealth, with injection visits scheduled in Perth.

Sources: Spinal Cord Injuries Australia; Healthdirect Australia.