Traditional treatments, plus new drugs, help alleviate painful muscle twitching
Tuesday, June 27, 2000
By Patti Murphy
Though she's been riding horses for 23 years, Sue Lehman lately feels a new sense of accomplishment when she takes the reins in her hands.
In May, the Blair County woman briefly trotted her horse without help for the first time since 1995, when she suffered a head injury in a car accident. She lost the use of her right hand, and her ability to walk and talk.
But now Lehman, 31, exercises faithfully, has trained her left hand to do things she used to do with her right hand and can walk short distances with assistance.
"I was limited, but now I feel more free," Lehman typed into a speech synthesizer that "spoke" her words in a recent telephone interview.
As for the horseback riding, Annette Lehman, Sue's mother, and Renee Isenberg, Sue's hired caregiver, gave this account:
When Lehman returned to the saddle seven months after her injury, a host of friends surrounded her as she rode because she had balance difficulties.
By last winter, she could handle a trotting horse (a trot is like a brisk walk) with two people jogging closely at her sides. Lehman still needs help mounting her horse, but can ride more independently. She has a better grip on the reins. Others spot her from a distance so they can help her if the horse suddenly picks up speed.
Lehman credits her progress to a treatment she's been following to alleviate spasticity that caused tremors and stiffness in her limbs.
Up to 1.2 million Americans experience some degree of spasticity from neurological disorders. Spasticity means that muscles are out of control because the brain and spinal cord do not transmit nerve signals that allow muscles to work properly.
Spasticity is comparable to the twitch you feel when the doctor taps your knee with a hammer to test your reflexes. But spasticity lingers and often has a debilitating ripple effect.
"Each twitch triggers another twitch because the muscle is so overactive," said Dr. Thomas Franz, medical director of the head injury program at HealthSouth Harmarville Rehabilitation Hospital in Indiana Township.
There's "kind of a reverberating circuit that actually predisposes a person to more spasticity," said Dr. Michael Munin, medical director of UPMC Health System's relatively new Spasticity Evaluation and Treatment Center.
Spasticity causes permanent muscle contractions, abnormal muscle tone and pain. It may lead to immobility or general weakness that impedes daily activities and interrupts sleep. Muscles may be alternately floppy or rigid.
Spasticity can be useful. A person with weak legs, for example, may find that rigid muscles help to straighten and lock the legs, making it easier to stand or pivot from a wheelchair onto a bed.
Care for spasticity is a distinct component of rehabilitation, combining traditional treatments -- such as braces to stabilize spastic limbs -- with new anti-spasmodic drug therapies. The UPMC center, which opened last fall, provides such care. HealthSouth's spasticity management clinic at the Rehabilitation Hospital of Greater Pittsburgh in Monroeville opened three years ago.
The Harmarville site started a clinic earlier this year.
Physical therapists evaluate patients with strokes, spinal cord injury or disease, head injury, cerebral palsy or multiple sclerosis for frequency of spasms, abnormalities in muscle tone, resistance in joints, range of motion and degree of pain. Treatments are recommended based on the number and location of muscles involved in the spasticity, as well as what a patient hopes to achieve.
"It's so individual," Munin said. "It's not a cookbook approach."
Treatment usually is ongoing and tends to be most successful if the patient exercises, he said.
When Munin, a physiatrist, began treating Lehman two years ago, her main goal was to strengthen her right hand. She also wanted relief for clonus, another name for repetitive muscle contractions, in her right ankle. The clonus caused her foot to shake.
Doctors gave Lehman periodic injections of Botox (a diluted form of the botulism poison) in her right hand at precise points determined by a special device called an electromyogram. The drug paralyzes spastic muscles while strengthening underlying weaker ones. It can take about two weeks for the injections to take effect. Lehman had the shots less frequently as her hand became more flexible. She says she'll schedule another one if her hand becomes tight.
Lehman also takes oral Baclofen, an anti-spasmodic medication, for the clonus. And Munin also prescribed a form of physical therapy done with electric stimulation to get the overactive muscles to work in sync with muscles inhibited by the spasticity in Lehman's hand. Lehman, who lives near Hollidaysburg, gets that at Altoona Hospital.
In a recent e-mail to a nurse practitioner at the center, Lehman listed things she's learned to do for herself in the past few months because of the treatments. For example, she can put lotion on her face with her left hand while holding the jar in her right. Someone had to do it for her before. It's easier now for Lehman to transfer from her wheelchair to a mat on an exercise table. For daily workouts, she rides an exercise bike and uses a pool at the home she and her parents share.
Lehman, who majored in equestrian studies in college, spends a lot of time at the barn on her parents' 20-acre property caring for her two horses. She plans to start a therapeutic riding program.
While Munin noted that Lehman's spasticity is pretty complex, some cases require more invasive measures to optimize relief. Little more than a decade ago, the best option in the most severe cases of spasticity was a rhizotomy, a blanket cutting of nerve roots at the back of the spinal cord. The surgery reduced pain but made muscles limp, said Franz, the Harmarville head injury program medical director.
People now undergo a selective dorsal rhizotomy, a microscopic surgery that targets just the nerves that contribute to spasticity.
An option for those who do not respond well to oral medications is an implanted pump programmed to deliver Baclofen into the spinal fluid at specific times and dosages. The pump, about the size of a hockey puck, goes in the lower back near the abdomen. It must be refilled after one to three months.
Simpler solutions work in some cases.
A person with an isolated problem, such as not being able to bend an elbow after a stroke, may get immediate relief with a phenol injection similar to the Botox procedure, though phenol is less safe for long-term use.
Some people do well with a brace worn at night or with a daily stretching program.
Treatment may not be appropriate for those with mild disabilities.
There has to be "a significant problem interfering with the quality
of life," Munin said.
Patti Murphy is a free-lance writer who writes about disability issues.