Spasticity management must have clear focus for best outcomes
Individualized evaluation and treatment techniques save money
Case managers play a vital role in coordinating spasticity management to ensure that dollars are well-spent. Keeping treatment focused on specific functional goals not only helps the spasticity management team select the best treatment options, it also helps the case manager obtain reimbursement from health plans.
"Case managers should have a clear justification for the treatment, and collaborate with the payer source to establish the purpose of the spasticity evaluation and receive authorization before any treatment is administered," says LuRae Ahrendt, RN, CRRN, CCM, a rehabilitation nurse consultant with Ahrendt Rehabilitation in Norcross, GA. "Spasticity management can be very beneficial. It can also be very expensive. You must help the payer source understand the value of proper spasticity management and its impact on the plan of care. That understanding helps the case manager ensure that the payer will cover the costs of treatment."
Case managers who have a clear functional goal in mind for their patients also help the spasticity team develop the best treatment plan, adds Alan M. Harben, MD, assistant professor of physical medicine and rehabilitation with The Emory Clinic in Atlanta. "It helps the spasticity team if the case manager comes in with specific functional goals in mind for the patient," notes Harben. "The case manager should have a clear understanding of the concerns and goals for the patient before approaching the spasticity team. Otherwise, the treatment will not be clearly focused and may not be cost-effective," he cautions.
Some specific red flags should lead case managers to seek a spasticity consultation, note Harben and Ahrendt. They include the following:
• Has spasticity triggered changes in the patient's overall function?
• Has spasticity triggered changes in the patient's range of motion?
• Has spasticity triggered changes in muscle tone or contracture?
• Has spasticity led to difficulties in activities of daily living or self-care and hygiene? (For example, are transfers becoming more difficult, or is it becoming uncomfortable for the patient to sit in the wheelchair?)
• Has spasticity made bowel or bladder management more difficult?
"Another area for case managers to watch for are skin problems," notes Ahrendt. "Spasticity can cause constant rubbing, which sometimes leads to skin breakdown."
Case managers must not only keep an eye on functional goals, but they must be familiar with which patient populations may develop spasticity problems, stress Harben and Ahrendt. "Early spasticity management can be the key that helps patients achieve the highest possible level of function. Patients who have not had aggressive rehabilitation can be spoiled for future rehabilitation by developing contractures of such severity that they cannot be corrected," cautions Harben. (For discussion of patient populations that may develop spasticity problems, see p. 27.)
Three lines of attack
There are several levels of spasticity management. "A good spasticity clinic will always use a team approach to thoroughly evaluate the patient and select the appropriate treatment for the patient's level of spasticity," notes Harben. (For further discussion of how to select a spasticity clinic, see p. 28.) "The clinic should also offer a wide range of treatment modalities. I believe in starting with less invasive treatments and moving upward to ensure you fully understand the range of the spasticity problem and avoid any unnecessary treatments," he explains.
Levels of treatment for spasticity management from least invasive to most invasive include the following, notes Harben:
• Therapy, including range of motion and splinting and casting.
"Therapy with the proper use of splints and casts can help stretch muscle tissues to prevent contracture and lower muscle tone," says Harben. "It is often enough for patients with mild spasticity to a specific muscle group."
"Medications work best for general spasticity throughout the whole body," says Harben. "Medications cannot completely control spasticity, but do effectively diminish tone in 50% of patients. In addition, these medications can have significant side effects. Patients on spasticity medications must be monitored carefully. They should also be periodically weaned or taken off medication to assess their progress," he adds.
The most common spasticity medications are dantrolene, baclofen, and diazepam. Of the three, dantrolene is the least sedating, but also can cause severe liver toxicity, says Harben. "If a patient is placed on dantrolene, liver function tests should be drawn weekly for the first month and then once a month thereafter. We try to avoid long-term use of this medication because the need to draw blood adds to the expense and it is not completely effective," he notes.
Both baclofen and diazepam are best-suited to spinal cord patients because they are sedating. "This lack of arousal makes these two drugs less effective after stroke or brain injury and better-suited for use in spinal cord patients," explains Harben.
• Nerve blocks.
If patients are unresponsive to therapy or medications, the next treatment to consider is nerve blocks. "Nerve blocks can be both a therapeutic and a diagnostic tool," says Harben. "The nerve blocking agent is injected directly into the affected muscle group. This relaxes the spasticity on a temporary basis and allows therapists to test range of motion without the presence of spasticity," he explains. "Range of motion may improve by 30 or 40 degrees and a corresponding decrease in muscle tone allows therapists to cast specific joints. Blocks can also help the therapist set higher functional goals by making it easier to assess the underlying muscle tone in the absence of spasticity."
Casts applied in this manner are usually left in place for three to seven days, at which time therapists remove the cast and reassess muscle tone, says Harben, adding that the cast can be converted to a splint or a night splint. "If there has been no improvement in range of motion, or not enough improvement, the block can be repeated. If the muscle tone remains high, but the effect of the block is good, the team may recommend moving to a longer-lasting block."
The most common blocking agents are anesthetic blocks, phenol/ethanol blocks, and botulinum toxin, or Botox blocks. Botox is a particularly effective treatment for pediatric patients with spasticity caused by cerebral palsy, brain injury, or other problems, notes Barbara Weissman, MD, medical director of Egleston Children's Rehabilitation Center in Atlanta. "Botox is for children with spasticity in specific muscle groups, usually the legs and arms. It is not appropriate for general spasticity," notes Weissman.
Botox temporary solution only
However, case managers must determine that pediatric patients and their families understand that Botox injections are not a permanent treatment, cautions Weissman. "The body can develop an antibody response to Botox. The amount of time between injections varies, but is usually about three months. Botox injections are usually only a viable option for a year or two, but it can be an important tool to help find other treatment options," she notes.
"Throughout the treatment phase, Botox results in better function for the patient. Botox treatment buys time for the child to grow and gain strength, and may possibly help eliminate the need for surgery later, if physical therapy, casting, or a combination of treatment approaches are employed in conjunction with Botox injection."
• Intrathecal baclofen pumps.
Intrathecal baclofen pumps are implanted directly to the area of the spasticity mechanism, notes Harben. "The advantage of the pumps is that they don't cause sedation like oral medications for spasticity," he says. "The pump is an excellent option for spinal cord patients, but should not be considered until at least 18 months post-injury," he cautions. "The pump must be implanted by a neurologist. Pumps are expensive and invasive and, although they provide excellent results in appropriate patients, the treatment team should first determine whether spasticity is a long-term problem, or a temporary one."
Select rhizotomy candidates with care
Another invasive modality that works for a select group of patients is rhizotomy, a surgery in which nerve roots are cut, notes Weissman. "Rhizotomy can provide spasticity relief, but you must be extremely cautious about which patients you select for the procedure," cautions Weissman. "Some patients [have] underlying [weakness] and they actually use their spasticity to get around. If you take their spasticity away, you can leave them a noodle," she notes. "Before considering the procedure, you must get a good assessment of strength from a physical examination and have a physical therapist that the patient is working with regularly for at least six months. It's possible that physical therapy can help alleviate much of the spasticity and an expensive surgery can be avoided," she adds.