Non-mainstream therapies getting attention
Pharmacologic interventions including oral and injected drugs are a mainstay of spasticity management; however, drug therapies alone are not considered sufficient, and the general consensus supports a broader therapeutic strategy.
The Role of Nonpharmacologic Therapies
“Spasticity management usually requires a multimodal approach, using nonpharmacological and pharmacological treatment strategies,” Patricia Branco Mills, MHSc, MD, FRCPC, physical medicine and rehabilitation specialist at GF Strong Rehabilitation Centre in Vancouver, British Columbia, Canada, told Neurology Advisor. “The goals are generally to improve function, quality of life, and medical/health status through a transdisciplinary, holistic approach,” Dr Mills said.
In a 2017 review of new technologic advances in neurorehabilitative treatments for spasticity, Naro and colleagues2 emphasized that physical therapy and occupational therapy should be included in any rehabilitation program for focal or generalized spasticity, with other therapies added to achieve optimal results. In a review of spasticity management in stroke, Francois Bethoux, MD,3 reported that because of complications associated with drug and surgical treatment that may exacerbate functional performance through weakness and compensatory hypertonia in weakened limbs, treatment should rely on nonpharmacologic approaches used either before or adjunctively to these strategies.3 In addition to PT, he pointed to multiple other modalities, including ultrasound, thermotherapy, neuromuscular electrical stimulation and muscle strengthening exercises applied to an agonist muscle, and robotic devices for stretching and movement training, as important to a treatment plan.3
Noninvasive Neuromodulation Therapies
Noninvasive neuromodulation therapies designed to modify neuroplastic mechanisms for better adaptive muscle responses via the application of electromagnetic stimuli in conjunction with weak currents and or biochemical agents show potential for reducing spasticity across a number of conditions.
Repetitive transcranial magnetic stimulation (rTMS) involving the indirect application of magnetic pulses in a repeating pattern to induce cortical excitability, has demonstrated more consistent magnitude and duration of benefits in studies of spasticity.
Transcranial direct current stimulation (tDCS) is a method of direct application of low-amplitude current to the brain via rubber electrodes (with saline-dampened sponges) adhered to the scalp to induce excitability. The treatment exerts a neuromodulating effect on neuronal firing rates and plasticity with potential to restore normal balance of the polarity of the neurons. A sham-controlled study showed Anodal tsDCS significantly decreases spasticity and might be a complementary strategy for the treatment of spasticity in HSP.
SOURCE: J Spinal Cord Med. 2018 Dec 3:1-8. doi: 10.1080/10790268.2018.1543926. [Epub ahead of print] PMID: 30508408
Spinal direct current stimulation (tsDCS) in hereditary spastic paraplegias (HSP): A sham-controlled crossover study.
1 a Neuropathophysiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy.
2 b Section of Neurophysiopathology, Department of Clinical and Experimental Medicine, Pisa University Medical School, Pisa, Italy.
3 c “Aldo Ravelli” Center for Neurotechnology and Experiental Brain Therapeutics, Department of Health Sciences, University of Milan & ASST Santi Paolo e Carlo, Milan, Italy.
4 d Neurology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy.
5 e Clinical Center for Neurostimulation, Neurotechnology, and Movement Disorders, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy.
Other Noninvasive Therapies
Lacey Bromley, PT, DPT, NCS, MSCS, a physical therapist from Susan Bennett PT and Associates and a consultant in MS therapeutic strategies, explained that several inhibitory techniques can also be employed to reduce spasticity for a short period. “These include prolonged stretching of the spastic muscle (30-60 seconds), prolonged cold of the spastic muscle, biofeedback techniques, and cutaneous electric stimulation on the opposing muscle. However, these strategies will only reduce the tone temporarily.”
“We have had success utilizing [functional electrical stimulation] on the common peroneal nerve, which innervates the anterior tibialis muscle,” she told Neurology Advisor, referring to the task-directed stimulation therapy that, similar to neuromuscular electrical stimulation, delivers small impulses directly to the affected nerves to force muscle contraction that produces functional movement. Both therapies have demonstrated reductions in spasticity in CP, spinal cord injury, and stroke.2
A wide range of nonpharmacologic therapies and devices are under investigation for spasticity. Their benefits, however, rely largely on the hemisphere of application and the underlying mechanisms, which will require further study for better results.4 Dr Mills observed that many modalities that show promise include targeted exercises, casting/splints, and electromagnetic devices. “Given that pharmacological options can have side effects that patients want to avoid or minimize, there should be a high priority on investigating nonpharmacological treatment strategies that can be used on their own or to improve the effects of pharmacological strategies when given in combination,” Dr Mills said.
Nonpharmacologic Approaches to Spasticity Management
Linda Peckel, January 29, 2019
Alternative nonpharmacologic therapies
Nabiximols, a cannabidiol, reduced spasticity symptoms and was tolerable and safe when used in patients with motor neuron disease, according to a phase 2 trial published in Lancet Neurology.
“Although nabiximols has been licensed in many countries for symptomatic control of spasticity in multiple sclerosis and cannabinoids are increasingly recognized as a valuable option for pain management,” concluded the researchers, “before we can confidently recommend the routine use of cannabinoids for symptomatic management of spasticity in patients with motor neuron disease, further studies are warranted to confirm our results.”
Nabiximols Improve Spasticity Symptoms in Motor Neuron Disease
Brandon May, January 29, 2019