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Spasticity injections

Spasticity injections reduce tone in specific overactive muscles in the arm, hand, leg or foot after stroke, spinal cord injury, brain injury, multiple sclerosis and similar conditions. Dr Chris Martin is a pain and rehabilitation physician who has performed thousands of spasticity injections, and plans each treatment around a defined goal — comfort, care, positioning or function.

Spasticity is involuntary muscle overactivity that follows injury to the brain or spinal cord. The affected muscles stay tight, resist stretch and pull limbs into fixed postures — a clenched hand, an elbow held bent, a foot that turns in and points down. Spasticity injections place a small amount of medication directly into the overactive muscles to reduce that tone, opening a window in which the limb can be stretched, positioned, cared for and, where possible, retrained.

Who they help. Spasticity injections are used for people with focal spasticity — tone concentrated in particular muscles — after stroke, spinal cord injury and brain injury, in adults with cerebral palsy, in multiple sclerosis, and after other neurological illness or injury. The patterns treated most often are in the upper limb (shoulder, elbow, wrist, hand and thumb) and the lower limb (hip, knee, ankle, foot and toes).

Dr Martin's experience. Spasticity management sits within rehabilitation medicine. Dr Martin holds fellowships in both rehabilitation medicine (FAFRM, RACP) and pain medicine (FFPMANZCA); his Advanced Training in rehabilitation medicine included spasticity management, spinal cord injury and brain injury, and he then completed a selected fellowship in interventional pain procedures. He has performed thousands of spasticity injections and has trained other medical practitioners in the technique. Because spasticity and pain so often occur together, having one physician manage tone, pain and function — rather than separate services managing each — is the model this practice works to.

Assessment comes first. Not all spasticity should be treated. Some people rely on increased tone to stand, transfer or walk, and reducing it in the wrong muscle can take away function rather than restore it. Before any injection, the pattern is examined muscle by muscle: which are overactive, what posture they produce, what that posture is costing you, and whether shortening has already become fixed. Goals are agreed with you and with those who care for you, and they differ from person to person — a hand that can be opened for washing, a foot that clears the ground, a shoulder that can be dressed without pain, spasms that stop waking you at night.

The procedure. Almost all spasticity injections are performed in the rooms, and inhaled pain relief is available for comfort during the injections. Treatment in hospital under sedation is reserved for exceptional cases — where injections cannot be tolerated in the rooms, or where it is not medically suitable — and is decided with you at assessment. The target muscles are located with ultrasound or electrical stimulation, so that the medication reaches the muscle intended and not its neighbours — this matters most in the forearm and lower leg, where many small muscles lie close together. Several muscles are usually treated in one session. The appointment takes 20 to 40 minutes, the injections themselves are brief, and most people return to their usual activities the same day.

What to expect afterwards. The effect is not immediate. Tone begins to soften over the first week, is usually at its fullest by two to four weeks, and then gradually returns over the following months. Treatment is repeated when the benefit wears off, at intervals set by how long the effect lasts for you and by what your goals require. Progress is reviewed against the goals agreed at the outset, and the muscle selection and doses are adjusted at each cycle.

Why the rehabilitation matters. The injection reduces tone; it does not by itself lengthen a shortened muscle or teach a new movement. That work — stretching, splinting, serial casting where needed, and task-specific practice — happens in the weeks after the injection while the window is open, and it is what turns a temporary change into a lasting one. Injection and rehabilitation are planned together here, with your physiotherapist, occupational therapist and care team.

Upper limb patterns. Adducted or internally rotated shoulder, flexed elbow, pronated forearm, flexed wrist, clenched fist and thumb-in-palm. Goals are usually hygiene, dressing, pain relief, positioning, and — where some voluntary movement remains — hand function. See upper limb spasticity.

Lower limb patterns. Equinovarus foot (pointing down and turning in), clawed or extended toes, stiff or flexed knee, and adductor spasticity of the thighs. Goals are usually walking, standing and transfers, footwear and orthotic fit, hygiene, and comfort in bed or a chair. See lower limb spasticity.

Risks. Whilst pain procedures are generally safe and well tolerated, all procedures carry risks. The specific risks relevant to you and your procedure will be discussed with you, and written information provided, before you decide to proceed.

Other approaches. Where spasticity is widespread rather than focal, oral anti-spasticity medication may be considered against its sedative cost. Targeted nerve procedures are an option for some patterns. Serial casting can lengthen muscles that have begun to shorten. Where deformity has become fixed, surgical opinion is arranged. These are combined around your goals rather than used in isolation, and are discussed as part of the overall plan.

Referral and funding. A referral is required from a GP, neurologist, rehabilitation physician, hospital team or residential care doctor. Injections in the rooms are billed privately with a Medicare rebate, and a gap applies. In the exceptional cases where injections are performed in hospital, no-gap arrangements may apply depending on your fund and policy. A fee estimate is supplied on booking, prior to your consultation. For patients in rural and remote Western Australia, initial and review consultations can be by telehealth, with injection visits scheduled in Perth.

Common questions

Are spasticity injections painful?
The injections are brief and most people describe them as a few sharp stings rather than lasting pain. Several muscles are usually treated in one session of 20 to 40 minutes. Inhaled pain relief is available in the rooms for comfort during the injections, and the appointment is planned so that muscles are located precisely and the number of needle passes kept small. For the exceptional cases that cannot be managed in the rooms, treatment under sedation in hospital is arranged.

How long do spasticity injections last?
The effect develops over one to two weeks, is usually at its fullest by two to four weeks, and then wears off gradually over a number of months. Treatment is repeated when the benefit fades, at intervals set by how long it lasts for you and what your goals need.

Can spasticity injections help years after a stroke or injury?
Often, yes. Spasticity does not need to be recent to respond, and reducing tone can improve comfort, care and positioning long after the original injury. What cannot be reversed is contracture — muscle that has already shortened permanently — which is why assessment distinguishes the two before any treatment is planned.

Do I need a referral for spasticity injections?
Yes. A referral from a GP or specialist is required both to be seen and to claim a Medicare rebate. Referrals are accepted from GPs, neurologists, rehabilitation physicians, hospital and rehabilitation services, and residential care doctors, by Healthlink (EDI painmdwa), fax or email.

Which muscles can be injected?
Any accessible muscle contributing to a treatable pattern. In the arm and hand: shoulder, elbow, forearm, wrist, finger and thumb muscles. In the leg and foot: hip adductors, hamstrings, calf muscles, the muscles that turn the foot inward, and the toe flexors. Muscles are located with ultrasound or electrical stimulation so that the treatment reaches the intended target.

Will I still need physiotherapy?
Yes, and it is the part that produces lasting change. The injection reduces tone for a period of months; stretching, splinting and practice within that window are what lengthen the muscle and retrain movement. Injection and rehabilitation are planned together with your physiotherapist and care team.

Can rural and remote patients access spasticity treatment?
Yes. Initial assessment and follow-up reviews can be done by telehealth for patients across Western Australia, with the injection visits themselves scheduled in Perth. Where a patient is already under a regional rehabilitation service, treatment is coordinated with that team.