Which treatment is beneficial for a client with muscle spasm?
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Any runner at one point or another has had a varying degree of a muscle spasm or a cramp. Spasms are painful and uncontrollable in the moment. Sometimes they can take your breath away. Soft tissue manual therapy is an effective technique to relieve spasms and the soreness caused from them. Show
Spasms DefinedA spasm is an involuntary contraction of a muscle. There are two type of spasms. Clonic and tonic spasms. Clonic spasms are marked by alternating cycles of relaxation and contraction and tonic spasms are sustained periods of contraction. Cramps are strong, painful usually short lived spasms. Causes of SpasmsThere are many reasons people experience muscle spasms; the four most common causes are nutritional deficiencies, ischemia, exercise-associated muscle cramping and splinting. In order to avoid spasms or alleviate them it is important to know exactly what is causing the spasm. Once known, address the causes prior to and after running. Nutritional deficiencies – such as magnesium and calcium can cause people to become prone to cramping, especially in the feet. For common nutritional deficiencies in runners and how to fix them click here. Ischemia – occurs when a muscle is suddenly or gradually deprived of oxygen and can be caused by anything that constricts blood flow. Let’s use a gastrocnemius or calf muscle spasm. A tight gastrocnemius muscle can constrict blood flow to the lower leg causing lower leg muscles to work harder and use more of an anaerobic (no oxygen) environment. An anaerobic environment causes by products and lactic acid fragments to accumulate in gastrocnemius and possibly surrounding muscles. As a reaction, the gastrocnemius becomes even tighter, more overworked, and painful. Because gastrocnemius is not functioning at 100% spasms can occur. Until some sort of intervention is introduced, the spasm/pain cycle continues . Massage in ischemic conditions is extremely effective because massage can release the tight muscles that cause the constriction and restore proper flow of oxygen and nutrients to the muscle. Exercise-Associated Muscle Cramping – occurs towards the end of a strenuous workout. Dehydration, heat, and electrolyte imbalances can all be a cause for this. Exercise-Associated cramps can be alleviated or even prevented with proper hydration, warm up and cool down after vigorous workouts. Splinting – occurs as a protective mechanism after injury to a specific area. Pain is a safe guard so further injury won’t occur. Massage in this situation is not recommended. Once the splinting has resolved, massage is very effective at relieving tight muscles and increasing the circulation of blood and oxygen to the area of injury. Why is Massage so EffectiveWhile a runner is in an active spasm, massage may damage the muscle. Instead, a technique called reciprocal inhibition is used. Using our example from above, if a runner is having a gastrocnemius (gastroc) spasm, the therapist will compress the gastroc while activating the antagonist muscle, in this case tibialis anterior. By activating the antagonist muscle, the therapist shuts off gastroc which, will help relax the spasm. A light stretch on gastrocnemius might be introduced as the spasm is subsiding. Once the spasm has been alleviated, a massage technique is used to flush out the area of cramping. Massage is also recommended a few days after a spasm to help keep muscles loose and increase blood flow to the area. If you experience chronic spasms or cramping let the experts at The FIT Institute help you today. Massage is an excellent tool to use while training for any type of activity. Salvo, Susan G, (2017). Mosby’s Pathology for Massage Therapists (4th ed.). Elsevier Health Sciences. By: Erin B., LMT The FIT Institute is a physical therapy and sports performance facility in North Center. We increase the of an athlete’s career by teaching proper movement patterns that often lead to overuse injuries, we do this by bridging the gap between physical therapy and sports performance. SCI ForumClick here to watchSpasticity Part 2: Real Life Stories A Panel DiscussionSpasticity and Spinal Cord InjuryPart 1: The Good, The Bad, and The Not-So-Ugly: Medical and Pharmacological Treatments for SpasticityBy Rina Reyes, MD, Amy Icarangal, PT, and Geralyn Bertellotti, OT. Presented on January 13, 2015Spasticity in spinal cord injury is often viewed as a cause of dysfunction and pain. But there is more to it than that. This SCI Forum presentation explored the positive effects of spasticity (“the good”), the negative effects (“the bad”), the neutral effects (“the not so ugly”), and a variety of interventions for spasticity. A rehabilitation medicine physician, a physical therapist, and an occupational therapist summarized the causes of spasticity and discussed a variety of conventional and non-conventional treatment options. Watch the video or read the report.
Presentation time: 68 minutes. After watching, please complete our two-minute survey! Click here to watch this video on YouTube, with or without closed captions. Report Table of Contents
Medical and pharmaceutical treatmentsBy Rina Reyes, MD, Associate Professor, Rehabilitation Medicine, and Director, UW Medicine Spinal Cord Injury Rehabilitation ProgramWhat is spasticity?Spasticity is the name for involuntary muscle movement or tightening that is caused by central nervous system injuries like SCI or TBI. Although we don't know the exact mechanism, we do know that the injury to the spinal cord causes a disruption in the very complex nerve circuits of the brain and spine that control reflex motor activity. When the brain and spinal cord can no longer communicate normally with the rest of the body, the muscles controlled by the injured parts of the spinal cord can become overactive. Spasticity varies widely from person to person and can include a variety of symptoms, such as:
How common is spasticity in spinal cord injury?Most people with SCI (65%-78%) have spasticity, and a large percentage of them (28%-43%) report it to be a problem. For some people, spasticity can significantly decrease their quality of life and reduce their ability to be independent. Studies report that close to half (43%-49%) of people with SCI take medications for spasticity, although in my experience it's actually more than half. What areas are affected by spasticity in the body?Spasticity can affect any muscle below the level of the spinal cord injury lesion. It can appear in the arms or legs, bowel or bladder, trunk or neck, or even in the abdomen. Spasticity evolves
[Back to Table of Contents] Spasticity can have both desirable and undesirable symptoms.The key to appropriate management of spasticity is understanding its impact on the individual. This makes it possible to determine what needs to be treated and how aggressively, and what does not need to be treated. The Good
The Bad
The not so bad—those effects that are not too bothersome and you learn to live around them. [Back to Table of Contents] Principles of Spasticity TreatmentMany people have a mixture of good, bad and neutral effects of spasticity. So the principle in treating
spasticity is to manage the bad effects, maintain the beneficial effects, and learn to live with the effects that are neither good nor bad. Reasons to treat spasticity:
[Back to Table of Contents] What your health care provider needs to know:
[Back to Table of Contents] How to evaluate spasticityThere is no single test or measure that describes the total picture of a person’s spasticity. Your health provider needs to perform a combination of tests in order to fully understand your spasticity and how it affects you.
Figure 1
MODIFIED PSFS
[Back to Table of Contents] Evidence-Based TreatmentsJust like the experience of spasticity itself, response to treatment varies widely from person to person, and most people have to go through a period of trial and error. In most cases treatment involves a combination of approaches: medication and non-medication treatments, multiple medications, or medications and injections. Your provider may need to work with your insurance company to get more than one treatment covered, since some insurers limit or require pre-authorization of certain medications and treatments. Oral MedicationsBaclofen
Baclofen affects people differently and doses can vary widely. Some people only need ten milligrams two or three times a day while others need more than twice that amount. Some people find the side effects to be intolerable at the amount of Baclofen they need to control their spasticity. Alpha-2 Adrenergic Agonists
Dantrolene Benzodiazepines (for example, Diazepam)
There are multiple uses for this medication, including treating seizure disorders, anxiety or sleep problems. It has a similar mechanism of action to Baclofen but acts on a slightly different receptor. It seems to be as effective as baclofen but causes greater sleepiness, confusion and fatigue. There is a risk for developing tolerance to this medication, meaning over time you need more and more to be effective. You can also become physically dependent on it. For these reasons, it is not a first line treatment and we use the minimal dose possible. It is best used only at night for people whose spasticity keeps them from sleeping, and for emergency, in-hospital use. Medical Marijuana (Cannabis)Many people with SCI use marijuana to help manage their spasticity. To learn about how it works, what the risks and benefits are, and the legal concerns, refer to the 2014 presentation on Medical Marijuana and Spinal Cord Injury by Dr. Greg Carter at http://sci.washington.edu/marijuana. Focal Treatment (Blocks or Injections)Blocks and injections are a way to treat local, meaning not widespread, spasticity without causing the system-wide side effects like sleepiness or confusion that come with oral drugs. It can also be used to enhance therapeutic benefit of bracing, splinting or even electrical stimulation. Longer-acting blocks last from 2 – 5 months. Neurolytic injections with phenol Phenol is a drug that chemically destroys the peripheral nerve involved in the reflex loop causing spasticity. Nerves in the peripheral nervous system outside the spinal cord are able to regrow themselves, so the effect of phenol is temporary. It is used in nerves that have very little sensory component in order to avoid the possibility of causing pain. Injecting phenol requires electrical stimulation, time, and precision to find the exact injection site in the muscle. Neurotoxins, including botulinum toxin Botulinum toxin is a protein made by a specific kind of bacteria. It is used medically by injecting it into the spastic or overactive muscle to cause temporary paralysis or weakening of that muscle. Because it can be used on any muscle that is accessible by needle it is easier and faster to administer than phenol. It is more expensive, however, and therefore harder to get covered by insurance companies. Injections need to be repeated about every three months and dosing needs to be prescribed with care because over time it can become less effective. The Bottom Line: Botulinum toxin treatment is only as good as the proper identification and localization of the target muscle. Use to treat focal spasticity problems, possibly in combination with other medications and interventions. Surgery treatmentsIntrathecal baclofen Other surgical options [Back to Table of Contents] What treatments are best for you?Discuss with your health care provider:
[Back to Table of Contents] Physical therapy approachesAmy Icarangal, PT, Harborview Medical CenterWhen I’m working with patients on their spasticity, what I want to know from a physical therapy point of view is how their spasticity affects their functioning, breathing, walking, posture and ability to be independent? My goal as a therapist is to
help patients function better. There are several non-medication approaches a PT can help with. StretchingWhy it works: Stretching causes a temporary reduction in muscle tone and increases flexibility and range of motion. The effects of stretching can last several hours. How long and how often: Generally you should hold a stretch for 30 seconds to a minute for one to five repetitions, but this varies a lot and depends on the nature and severity of your spasticity. Types of stretches
What to stretch
If you tend to flex (bend) when you spasm, you should stretch the front muscles, including biceps, pectorals (chest), abdominals, wrist flexors (inside of lower arms), hands, hip flexors and hamstrings. If you tend to go into extension (straighten out), then you need to stretch your shoulder blades, lower back, hands, quadriceps, and calf muscles. It’s also important to stretch in diagonal and lateral (side-to-side) patterns. How long to hold a stretch is dependent on when you feel (less spasms) or see that muscle release (less tension in the muscle belly or less “jumping” of the leg). [Back to Table of Contents] StrengtheningWhy it may work
The American College of Sports Medicine (ACSM) provides the following guidelines regarding strengthening exercises for individuals with SCI:
I also recommend that you work out of the patterns that cause your spasms. For example, if your hips and knees tend to flex when you spasm, work on exercises that make your hips and knees extend. For you to be strong, you need to be strong throughout the entire muscle length or range of motion and have a balance of flexor and extensor muscles. This allows you build long, lean, and strong muscles. [Back to Table of Contents] Weight-bearing and standingWhy it may work:
Whole body vibrationThis therapy uses equipment with a platform that vibrates while the person stands on it (with or without a standing frame). This is an emerging treatment, but there have been only a few studies in the SCI population. 7, 8, 9, 10 Why it may work
Dosing used in studies:
At this time, it is unclear how much (frequency) whole body vibration and how long (duration) may be therapeutic. There are also concerns about the risk for fracture. [Back to Table of Contents] Occupational therapy approachesGeralyn Bertellotti, OT, Harborview Medical Center.SplintingSplinting is a treatment option if you have spasticity in any of your extremities, such as your arm, leg, hand, or ankle. Why it may work
Static splinting uses a splint that
doesn't change. Static splints are usually easy to get on and off. The splint should stay on at least two hours, preferably overnight if tolerable. Splinting provides a low amplitude, longer duration stretch. With any kind of splint you need to check your skin regularly to make sure you don't have any pressure points or irritation anywhere. Thermal modalitiesCold
Cold can be applied from 20 minutes up to 1 hour. Icing too long can result in damage to the skin. The beneficial effects of icing only last about an hour. Heat Electrical stimulationThis is an electrical current to the muscle that activates the nerves and creates a contraction of specific muscles. Electrical stimulation is applied to the muscle opposing the spastic muscle to decrease the excitatory impulse that muscle. For example, biceps and triceps are opposing muscles. Electrical stimulation may help with spasticity by allowing opposing muscle groups to contract /relax or by stimulating a spastic muscle to help reorganize and normalize neuron activity or excitability. One example of this type of treatment is Transcutaneous Electrical Nerve Stimulation (TENS). [Back to Table of Contents] References
[Back to Table of Contents] Handouts and PowerPoint Presentations:
Other Resources:
[Back to Table of Contents] Is physical therapy good for muscle spasms?Treatment for Muscle Spasm Myofascial Pain Syndrome involves addressing the underlying cause of the condition as well as managing the pain produced by the spasms. Manual therapy interventions are found to be very beneficial in treatment of this condition.
What causes a muscle spasm?Overexercising, dehydration, and stress are the most common causes. The spasms happen when the muscle suddenly moves involuntarily. Muscle spasms may feel like a slight twitch or a painful cramp, and they can occur in the muscles in any part of the body.
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