Case Diagnosis: Spinal cord injury with severe spasticity
Case Description or Program Description: A 57 yo male status post motor vehicle crash sustained R C5, L C3 ASIA C tetraplegia. He developed spasticity, which progressed despite titration of Baclofen to 100 mg a day. Dantrium was added, but was discontinued due to elevation of ALT. Diazepam was added, with improvement but sedation limited its use. Clonidine, initially oral then transdermal, provided improvement in his spasticity with no sedation, no bradycardia nor hypotension. A 30 year old woman sustained a traumatic spinal cord injury, T7 ASIA B, continued to make neurologic gains. She also developed severe spasticity interfereing with her function. Baclofen titrated to 95 mg a day was not helpful enough, dantolene was added, titrated to 250 mg a day, diazepam 2 mg twice a day. However, higher doses of baclofen, clonidine and dantrolene were limited by sedation. Clonidine 0.1 mg daily, titrated to three times a day, with the Baclofen, diazepam, and dantrium, was effective, labs remained normal, with no adverse effects. Education was also provided to both patients regarding intrathecal Baclofen.
Setting: Long Term Acute Care Hospital
Assessment/Results: Clonidine, used in addition to other spasticity medications, was very effective and well tolerated.
Discussion (relevance): Spasticity after spinal cord injury can be debilitating, impacting mobility, self care, and can lead to complications such as joint contracture. The initial treatment starts with an assessment for any conditions or noxious stimulation which may be exacerbating spasticity, for example wounds or infection. If spasticity interferes with one's function or quality of life, treatment with medications is appropriate. Baclofen, diazepam, dantrolene,, tizanidine, botulinum toxin and intrathecal Baclofen pump are some treatment options.. Clonidine stimulates alpha 2 adrenoreceptors in the central nervous system, activating and inhibitory neuron which decreases sympathetic outflow. The mechanism of action of each of these medications, as well as a summary of the available research, will be presented.
Conclusions: Clonidine, in combination with other spasticity medications, can be effective and well tolerated in people with severe spasticity and traumatic spinal cord injury
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