The management of pain in spasticity

Pain is a common feature of spasticity and muscle spasms and the reasons for this are discussed in this article. However, the causes of this spasticity have to be determined and for successful management, knowing the underlying mechanisms, which produce spasticity, is necessary. In addition to knowing the range of available treatments, one has to know their particular contribution to the overall management of the patient. The assessment and management of the spastic patient is multi-disciplinary and painful spasticity changes over time. This therefore requires repeated assessments and the direction of the treatment may also change. Pain may be a dominant feature, but is rarely the sole symptom. This article looks at a strategy for the overall management of the patient with the focus on managing pain.     

The pharmacological management of spasticity.

The spectrum of antispasticity therapies is fairly broad. Familiarity with the various therapies will enable a nurse involved in the care of neurological patients to deliver the effective treatment and minimize adverse events. Referral to specialty care centers may be appropriate for selected patients who require more complex interventions for spasticity control.     

The contemporary surgical management of spasticity in children.

Orthopedics and neurosurgery offer multiple surgical modalities for improving the function, care, and well-being of children with spasticity. One surgical approach is not the best for all children with spasticity not adequately controlled with more conservative measures. For that reason, a multidisciplinary evaluation is important to optimize outcome for these children.     

Rehabilitation procedures in the management of spasticity

Spasticity is a major disabling symptom in many patients with spinal and/or cerebral lesions. During functional movements, spasticity manifests itself within the complex condition of the "spastic movement disorder". The pathophysiology of the spastic movement disorder relies on multiple factors including abnormal supraspinal drive, abnormal control of reflex activities, and changes in muscle mechanical properties. The most widely used procedures for management of spasticity are represented by pharmacological treatment aimed at inhibiting reflex hyperexcitability. In the last decades, several non pharmacological procedures for treating spasticity have been put forward, including muscle stretching, muscle reinforcement, physical agents and pain management. These procedures may have both neurophysiological and biomechanical effects on the spastic movement disorder. In the present paper, the literature concerning non-pharmacological procedures in the treatment of spasticity was reviewed and discussed, taking into account the multifaceted pathophysiology of the spastic movement disorder. Although further research in this field is recommended, existing evidence supports the potential role of rehabilitation interventions as a therapeutic tool, which could be integrated with traditional pharmacological procedures in the management of the spastic movement disorder.     

Evaluation and primary management of spasticity

Spasticity is often a lifelong manifestation of central nervous system damage in adults with upper motor neuron lesions. Practitioners who initiate the management of spasticity when damage occurs are more likely to offer the patient a life without permanent joint deformity. Spasticity may be helpful or harmful to the patient, but in either event warrants a careful assessment and management plan based upon current health care concepts. Two general intervention principles and three specific intervention measures, including the use of medication, are discussed.     

Botulinum toxin in the management of spasticity in adults

Botulinum toxin (BTX) is a powerful neurotoxin which blocks cholinergic transmission at the neuromuscular junction. Judiciously applied, it can reduce local muscle overactivity while maintaining the strength in other muscles. To date BTX has not been licensed for use in spasticity in the UK and the literature pertaining to clinical practice is still relatively scant. However, controlled trials have provided evidence of the effectiveness of BTX both in reducing spasticity itself and in achieving functional gain. The guidance given here to clinicians involved in the management of spasticity covers the types of patient suitable for treatment using BTX, the appropriate dosage, and the necessary follow-up procedures and documentation.     

Management of spasticity associated pain with botulinum toxin A

Lesions of the central nervous system often result in an upper motor neuron syndrome including spasticity, paresis with pyramidal signs, and painful spasms. Pharmacological treatment with oral antispasticity drugs is frequently associated with systemic side effects which limit their clinical use. Botulinum Toxin A (BtxA) injected in spastic muscles has been shown to be effective in reducing muscle tone, but only few studies have reported pain relief as additional benefit. Therefore, we investigated the effects of local BtxA injections in 60 patients with acute (< 12 months) and chronic spasticity and pain in a prospective multicenter study. Target muscles for BtxA were selected on the basis of clinical examination. Intramuscular BtxA injections were placed in muscles exhibiting increased muscle tone in combination with pain during passive joint movement. Patients received a mean total dose of 165.7 +/- 108.2 [30-400] units BOTOX((R)) per treatment session in a mean 3.4 +/- 1.5 muscles. Baseline and follow-up (mean 5.9 weeks) measures included a patient self-assessment of pain and function on a five-level scale, a physician's evaluation of function, and a global rating of response to BtxA. Fifty-four of sixty patients experienced improvement in pain without subjective functional improvement. The effects were comparable in acute (n = 17) and chronic (n = 43) spasticity. Physician's assessment of gain in function increased significantly (p < 0.05) only in patients with chronic spasticity. No serious adverse event was observed. Mild reversible side effects (local pain, hematoma, edema, mild weakness) were observed in four patients. In conclusion, we found that intramuscular BtxA injections are a potent, well-tolerated treatment modality to significantly reduce spasticity-related local pain. This problem may be a main indication, especially in patients with poor response or intolerable side effects to oral medication.     

Intrathecal baclofen for spasticity management in Rett syndrome

Intrathecal baclofen infusions have proven to be effective for management of spasticity during the last two decades. Efficacy of intrathecal baclofen for spasticity of spinal origin has been well established and has shown promise in treatment of spasticity that is not spinal in origin. Rett syndrome is a neurodevelopmental disorder primarily affecting girls and women. Manifested in the advanced stages of this syndrome is increased spasticity leading to functional decline. Presented is a case report of a 32-yr-old white woman with Rett syndrome, diagnosed before the age of 2 yr, and significant spasticity that was successfully managed with intrathecal baclofen. After placement of an intrathecal baclofen pump, the dose was increased slowly during 1 yr to 800 microg/day with good clinical response. There was observed a significant decrease in upper and lower limb Ashworth scores, from an average of 3-4 to 2-3, during this 1-yr period. The decrease in spasticity in this patient eventually led to improved range of motion, positioning, skin care, hygiene, and quality of life. Intrathecal baclofen is an effective option in managing severe spasticity from Rett syndrome.     

The art of pain management

Pain assessment is fundamental to the successful management of pain. Effective communication, in particular the use of empathy, underpins assessment. Concepts within the art of nursing can usefully be applied to the understanding of pain.     

The management of procedural pain

The principles of acute pain management can be applied to the control of procedural pain. The nurse should act as the patient's advocate to prevent undue anxiety and suffering. Analgesia should be given before any potentially painful procedure. Non-pharmacological pain management measures should be used alongside, not instead of, analgesia.     

The VN's role in pain management

ABSTRACT:

Preventing pain has become an important goal for the veterinary team, despite the difficulties involved in pain recognition. A multi-dimensional approach to pain assessment, along with the use of a structured method of assessment is considered to be best practice.¹ PRICE, J. and NOLAN, A. (2007) The physiology and pathophysiology of pain. In: SEYMOUR, C. & DUKE-NOVASKOVSKI, T. (Eds.) BSAVA Manual of Canine and Feline Anaesthesia and Analgesia 2nd edition. Gloucester: BSAVA. [Google Scholar] The implementation of a structured system for pain assessment within the veterinary practice will improve pain recognition and treatment, as the physical act of performing the assessment means that the individual's level of pain is considered. Veterinary nurses (VNs) can be involved in the assessment process and often have the most contact with in-patients and clients, so are ideally placed to recognise signs of pain and encourage treatment.     

The role of acupuncture in pain management

This article reviews the theories and applications of acupuncture to musculoskeletal pain management. First, Chinese theories of acupuncture are discussed briefly. Next, current understanding of nociception and central pain modulation is discussed in detail,followed by discussion of the physiologic effect of acupuncture analgesia.Other theories of acupuncture analgesia are presented based on neuromodulation of the central nervous system. Finally,the efficacy of acupuncture for many musculoskeletal pain syndromes,including spine-related pain, soft tissue pain, neuropathic pain, arthritis of the knee, and upper extremity tendinitis, is reviewed.The article concludes with a discussion of methodologic issues related to conducting randomized, placebo-controlled trials of acupuncture and goals for future research in this area of pain management.     

The pharmacologic management of pain in children

We have attempted to dispel many of the myths and misconceptions surrounding the use of narcotic analgesics in the treatment of childhood pain. Our hope is that an improved understanding and application of effective and safe therapies will minimize the suffering of the child with acute or chronic pain.     

The management of pain in wound care

The management of pain in the presence of wounds is often ignored. In this article, the author reviews the physiology of the pain specific to chronic and acute wounds and reminds nurses of the considerations involved.     

The management of pain in long-term care

OBJECTIVE: The purpose of this paper is to present salient principles of pain management in nursing homes and other long-term care settings. METHODS: Review and author opinion. RESULTS: Pain is a common problem in nursing homes and other long-term care facilities. Often unrecognized and under-treated, pain is a major source of suffering and functional impairment. These patients present substantial barriers to pain assessment and management. Multiple concurrent disease processes, cognitive impairment and communication difficulties, and limited access to diagnostic technologies make assessment more difficult. Multiple medications, altered physiology and pharmacology and limited access to a variety of drug and non-drug interventions make treatment strategies more difficult to implement. DISCUSSION: Clinicians who care for patients receiving long-term care services must help establish a treatment plan that is reasonable given the limited resources and skills available in nursing homes and other long-term care facilities. Medication regimens should be simplified as much as possible. Contingency plans for pain management must be anticipated and made available so that delays do not occur during medication changes or dosage adjustments. Long-term care facilities need substantial support from physicians and other pain experts for education to continuously update their skills and knowledge. As the need for health systems for frail elderly persons continues to grow, it is important to provide comfort and effective pain control appropriate for these new settings.     

Use of injectable spasticity management agents in a cancer center

Purpose

This study aims to analyze the utilization and effectiveness of injectable spasticity medications by the physiatry team at a referral-based tertiary cancer center.

Methods

A retrospective review and analysis of patient and injection characteristics were obtained from patients who had received onabotulinum toxin or phenol nerve block injections from December 1, 2007 through January 31, 2012. Out of 3,724 physiatry consultations during this period, 20 (less than 1 %) different cancer patients received a total of 54 total procedures.

Results

The majority of patients (17/20, 85 %) had a positive response to the injection. A positive response to the injection was defined by: (1) if the patient qualified to receive and was given another injection or (2) if there is a record of improvement if they did not receive another injection. A total of ten of 20 (50 %) patients received only one injection. Of these, seven of ten (70 %) reported a positive response to the injected agent. Those with only one injection tended to live farther away and die sooner. Four of 54 (7 %) injection procedures resulted in undesirable reported side effects (two for phenol, two for botulinum toxin). Nine of 54 (17 %) procedures occurred while the patients were on a chemotherapy protocol. All patients were injected at least 1 year out from initial diagnosis.