Life on Wheels (24 page)

Some people take advantage of spasticity to help them make transfers to and from their wheels or to assist in emptying their bladder. However, spasms can also interfere with transfers, when they are more likely to occur. Spasms can force you constantly out of position in your chair, adding to the challenge of anyone assisting you who must manage your posture throughout the day.

There are three approaches to spasticity, depending on how it affects you: managing it on your own, pharmaceutical, and surgical. Doctors will often not treat spasticity unless it is disrupting the ability to make transfers or the ability to sleep or is a substantial source of pain. Other times, you might be treated by a doctor who considers spasticity something to always prevent.

Some people manage their moderate spasticity on their own, learning how to avoid stimulations that cause spasms and knowing how to respond to calm the response if it occurs. For others, the spasticity is too strong a response and needs more significant measures to manage.

Stress increases spasticity, so relaxation methods are valuable. Simple breathing exercises and self-hypnosis can help moderate spasms. If you sense spasms coming and they are painful for you, you are more likely to become tense and upset, which actually promotes the spasms. Learning how to relax in response to the onset of spasms is a useful skill.

This woman with SCI has found a gentle approach to managing her spasticity:

Certain postures are known to promote or inhibit specific reflex patterns. Lying in the prone position, face down, tends to inhibit flexion, in which the body would close toward the fetal position. Standing also inhibits flexion, which would interfere with walking. Sitting promotes flexion. Lying on your side or face up (supine) tends to inhibit extension in which the arms, legs, and hips open up.

Spasticity promotes contracture—in which muscles are trained into chronically shortened positions. It is important to counteract spastic muscles with stretching and range-of-motion exercises in the opposite direction to prevent the body from becoming restricted in its ability to move and achieve comfortable postures.

Stimulants like coffee and caffeinated tea generate more nervous system activity and so can increase spasms. Relaxing drinks like chamomile tea have a calming effect. Kava kava is an herb that some people have found helps them manage symptoms.

Your general health has an impact on spasticity. Being overweight and eating a poor diet—especially with too much sugar, which is a stimulant— adds stress to your nervous system.

The most well-known drug for managing spasticity is baclofen, known commercially as Lioresal
^®
. Baclofen is similar in chemical structure to GABA, a neurotransmitter deficient in people with spasticity. In some cases, baclofen has also been found to improve bladder control. In rare instances, reversible coma has occurred from toxic levels of baclofen.

Baclofen is available as an oral medication, but, if taken orally, little of the drug actually reaches the spinal fluid where it must do its work. The oral form only lasts in the bloodstream for eight hours.

Baclofen is more commonly used with an intrathecal pump, which supplies a continuous stream of the drug directly to the spinal fluid. With this method of distribution, only 1/100th of the typical oral dose need be taken. The baclofen pump is surgically implanted underneath the skin and needs to be replaced every four to five years. The pump must be refilled every month or two by means of an injection.

The next most common medication is diazepam, which may also be sold as Valium
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. Diazepam is a muscle relaxant and sedative. It is absorbed quickly by the body and stays in the system longer than baclofen when taken orally. Still, diazepam needs to be taken two to three times per day. Diazepam works on the brain, causes drowsiness, and can lead to dependence.

The medication dantrolene—sold as Dantrium
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—weakens the muscles themselves, so is less likely to cause drowsiness or other central nervous system side effects that are common with the use of sedatives. Dantrolene is more preferred for cerebral forms of spasticity. It is considered helpful for spasticity in MS, which is predominately spinal. In a small percentage of users, the drug has caused slight liver damage. There is some concern that it could exacerbate seizures in people with CP.

Several other drugs are also used for spasticity, including tizanidine (Zanaflex
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) and vigabatrin (Sabril
^®
). As with all medications, be sure to ask your doctor specifically how the drugs function in your body, why she recommends it in your case, the effects on libido, and what possible side effects could occur. For example, the medications might affect memory, emotional state, concentration, and energy level.

Drugs can also be injected directly into muscles, selectively impeding the spastic response. Alcohol and phenol have commonly been used for this purpose over the last 20 years, but are painful to people with sensation. Botulinum toxin (Botox
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or Myobloc
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) is a purified form of the toxin that causes botulism or food poisoning. It is safely injected into muscle and is now frequently used, particularly with children with CP. Botulinum toxin injections are also found useful for abnormal facial contractions in MS. Botulinum toxin usually takes two to three days to take effect and can last for as long as two to four months.

The baclofen pump has also supplanted surgical measures, which were once used widely. Aside from the aforementioned cutting of tendons—known as a tenotomy—the most typical surgery was the dorsal rhizotomy, which is still an option in some cases. In a dorsal rhizotomy, the surgeon operates on the nerves in the spinal canal, which branch out to the areas where a person experiences spasms. Under general anesthesia, he will literally test each nerve branch for abnormal responses to stimulation and then cut, burn, or chemically injure those peripheral nerves to interrupt the spastic response.

For people who are functionally impaired by spasticity, experience considerable pain, and have no expectation of recovering use of the muscles fed by those nerves, a dorsal rhizotomy might remain a valid option that could make a great difference in quality of life. It is generally reserved for severe cases.

Tendon transfer is another option a surgeon might consider. This procedure moves the tendon attached to a spastic muscle to another connection where its force can be used. For example, it could use a spastic response to aid in the movement of a hand or elbow or the ability to lift a foot while walking, a common issue for stroke survivors. This operation is very complex and requires a surgeon to identify very specifically what muscles are impaired and which ones have a controllable spastic response in order to determine if a transfer could be of rehabilitative value.

Getting older might itself lessen the effects of spasticity. Nerve conduction slows as we age, and muscle mass and blood flow to the spinal cord become reduced. At the same time, as you age, your body also gets more sensitive and your ability to be patient with spasms or pain might be reduced. If you experience overuse injuries with age, this also might cause spasms to be painful, which in the past could be better endured.

The human body’s stress reaction is referred to as the “fight or flight” response. To help you fight with your arms or run away from danger, the body increases its heart rate and sends blood to the extremities. When you are experiencing stress reaction, blood is taken away from your digestive tract. While you are under stress, you are not absorbing nutrients effectively; they are instead excreted through your bodily wastes. Vitamin C is lost in large amounts to the stress response.

Under stress, there is a tendency to limit your breathing and the amount of fresh oxygen you take into your body. Shallow breathing also involves holding muscles of the trunk, abdomen, and often the shoulders and neck in constant, low-level exertion. For people with pulmonary limitations as a factor of their disability, stress only decreases their respiratory efficiency.

There are a number of unique stresses you might experience as a wheelchair user:

Pushing a wheelchair to overexertion raises your body’s metabolic processes in ways that mimic a continual stress response.

Awkwardness in handling your body while wheeling, transferring, or performing daily tasks such as work or cooking is stressful and fatiguing over the course of a day.

Some daily tasks such as dressing or using the bathroom could be strenuous for you.