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Spasticity Treatments After Stroke-Part 3 of 3

Intramuscular Injection Spasticity Treatments

Intramuscular injections are given to patients who have spasticity or dystonia that is more severe in one or more areas and that is not satisfactorily treated by oral medications. The most common intramuscular medication is botulinum toxin; the most commonly used form of botulinum toxin is Botox. Recently, another form of botulinum toxin has become available, Myobloc; it is used mainly for children who do not respond to Botox injections. The medication can be injected directly into a spastic or dystonic muscle to decrease the tightness in those muscles. These medications weaken only the injected muscle and rarely cause any kind of central nervous system side effects.

Whenever intramuscular medications are used, they are usually injected in several different areas of the affected muscles. It is not unusual to inject 4-6 muscles at one time. Because of the multiple injections that are required, some type anesthetic is usually used, either a topical anesthetic to numb the skin over the muscles to be injected, or children can be given an anesthetic gas to sedate them for the 5 minutes or so needed for the injections.

Botox - Botox is a purified protein from the botulinum toxin. It comes frozen and is dissolved in saline then injected into the muscle through small needles. The amount to be given is determined by how tight the individual muscles are and by the weight of the child. Doses of 10-15 units/kilogram of body weight are commonly used and some experts use higher doses than that. The effects begin about 2-3 days after the botox is injected, hit a peak about 3 weeks later, and usually wear off in about 3 months. Injections are often repeated for 2-4 years. Botox has minimal side effects. Rarely, children may become unusually floppy for a few days or weeks after high doses of Botox.

Myobloc - Myobloc is a purified protein from a different form of botulinum toxin. It has been available for the past two years and there is less information on its use than for Botox. Myobloc comes already is a liquid form and is refrigerated until it is used. Doses of Myobloc are approximately 50 units of Myobloc to 1 unit of Botox. It can be given into any affected muscles and appears to have similar effectiveness and safety to Botox. The costs of the two medications are similar.

Alcohol and Phenol - These two medications were used fairly often before Botox and Myobloc were available but are used infrequently now. They are injected into spastic muscles near nerves and temporarily injure the muscle or nerve. Their effects last somewhat longer, 6-12 months. They may cause unpleasant sensations (feeling) in areas around the injected nerves.

Follow-up: After injections, physical therapists often perform serial casting and initiate therapy to increase range of motion. It is important for your therapist to follow-up with the team with regard to the effectiveness of the injections. Injections may be repeated several times, although effectiveness sometimes decreases after multiple injections.

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"Spasticity is stiff or rigid muscles. It may also be called unusual "tightness" or increased muscle tone. Reflexes (for example, a knee-jerk reflex) are stronger or exaggerated. The condition can interfere with walking, movement, or speech. -National Library of Medicine"

Spasticity Is Common After Stroke

In 2010 the FDA approved Botox to treat spasticity in flexor muscles of the elbow, wrist and fingers.

“Muscles affected by spasticity have increased stiffness and tightness, which may lead to pain, difficulties with hygiene and other activities of daily living, and may affect how a patient looks,” said Russell Katz, M.D., director of the Division of Neurology Products in the FDA’s Center for Drug Evaluation and Research. “In clinical trials, treatment with Botox was found to be beneficial to patients with upper limb spasticity.”

Botox works by temporarily blocking the connections between nerves and muscles, resulting in a temporary paralysis of the spastic muscle.

Botox has a Boxed Warning that says the effects of the botulinum toxin may spread from the area of injection to other areas of the body, causing symptoms similar to those of botulism. Those symptoms include swallowing and breathing difficulties that can be life-threatening.
The most common adverse reactions reported by patients with upper limb spasticity were nausea, fatigue, bronchitis, muscle weakness, and pain in the arms.

Botox has not been shown to be safe and effective treatment for other upper limb muscles, spasticity in the legs, or for treatment of fixed contracture – a condition that affects range of motion. Treatment with Botox is not intended to substitute for physical therapy or other rehabilitative care.

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