Drugs Affecting Muscle Spasm & Spasticity

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Drugs used to manage muscle spasm & spasticity can be divided into 2 major groups: skeletal muscle relaxants & spasmolytics

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Muscle spasms are treated with a combirnation of physical therapy, centrally acting muscle relaxants , & anti-inflammatory agents

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Spasticity is treated with physical therapy & drugs called spasmolytics

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Spasmolytics are categorized as centrally acting or peripherally acting. These agents act in the brain or in the peripheral muscles.

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Muscle contraction occurs with inflow of calcium ions (Ca2+)

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Muscle contraction stops when Ca2+ is removed from the immediate environment of the myofilaments

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Muscle spasm (acute onset)
sudden, violent involuntary contraction of a muscle or group of muscles. Spasm is usually related to a localized skeletal muscle injury from acute trauma. May also stem from disorders related to a localized skeletal muscle injury or an imbalance in electrolytes

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When a muscle spasm, it freezes in contraction & becomes a hard knotty mass, rather than normally contracting & relaxing in quick succession.

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During spasm, the blood vessels that normally feed the muscles & supply oxygen constrict, further compounding the problem.

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Tonic spasm = unusually prolonged and strong muscular contraction;
Clonic spasm = occur repeatedly, forcibly, & in quick succession, with equally sudden & frequent relaxations

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Spasticity is a condition in which certain muscles are continuously contracted. This contraction causes stiffness or tightness of the muscles & may interfere with gait, movement, or speech. May be associated with spinal cord injury

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The degree of spasticity varies from mild muscle stiffness to severe, painful, & uncontrollable muscle spasms.

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Centrally Acting Muscle Relaxants: They act in the central nervous system. The prototype is cyclobenzaprine (Flexeril), because evidence indicates that it is the most efficacious; Cyclobenzaprine is structurally similar to the tricyclic antidepressants.

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However Diazepam (Valium), a benzodiazepine, is mentioned because it is used in managing both muscle spasms & spasticity

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Pharmacotherapeutics:
Manages muscle spasms associated with acute musculoskeletal disorders

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Pharmacokinetics
Administered: oral Metabolism: liver. Excreted: urine and bile. Onset: 1 hour. Duration: 12-24 hours.

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Pharmacodynamics:
Relieves muscle spasms through a central action

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Contraindications and precautions:
Hyperthyroidism
14 days within use of MAOIs

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Adverse effects:
CNS depression and anticholinergic activity
Arrhythmias, seizures, and MIs

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Drug interactions
Tramadol, guanethidine, MAOIs, histamine-1 blocking agents, and various herbal remedies

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Core Patient Variables
Health status: Assess past medical history and drug allergies
Life span and gender:
Pregnancy category B
Use precaution in administration to elderly
Lifestyle, diet, and habits:
Avoid alcohol and other CNS depressant use

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Nursing Diagnoses & Outcomes: Risk for Injury related to CNS depressant effects and potential cardiovascular effects.
Desired outcome: the patient will remain free from injury throughout therapy.

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Planning & Interventions: Maximizing therapeutic effects:
Take with full glass of water at evenly spaced intervals
Coordinate physical therapies with administration
Minimizing adverse effects:
Assess for excessive sedation
Caution patient orthostatic hypotension

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Teaching Assessment & Evaluation: Patient and family education; Take medication as prescribed; Explain adverse effects; Do not take with other OTC medications;
Ongoing assessment and evaluation: Evaluate patient’s safety; Monitor level of sedation

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Centrally Acting Spasmolytics: Patient and family education; Take medication as prescribed; Explain adverse effects; Do not take with other OTC medications; Ongoing assessment and evaluation:
Evaluate patient’s safety;
Monitor level of sedation

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Baclofen:Core Drug Knowledge
Pharmacotherapeutics:
Relieves some components of spinal spasticity

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Pharmacokinetics:
Administered: oral. Distribution: crosses blood–brain barrier. Metabolism: liver. Excreted: urine and bile. Peaks: 2–3 hours.

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Pharmacodynamics:
Acts specifically at the spinal end of the upper motor neurons at GABAB receptors to cause hyperpolarization

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Contraindications and precautions: Hypersensitivity and spasticity of cerebral origin
Adverse effects: Drowsiness, weakness, dizziness and lightheadedness, headache, nausea and vomiting, hypotension, constipation, lethargy and fatigue, confusion, insomnia, and increased urinary frequency
Drug interactions: CNS depressants or TCAs

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Core Patient Variables: Health status: Assess past medical history and allergies; Perform physical assessment; Life span and gender: Older patients are more susceptible to sedation; Lifestyle, diet, and habits: Caution the patient about the concurrent use of alcohol; Environment:
Assess environment where drug will be given

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Baclofen: Nursing Diagnoses & Outcomes: Risk for Disturbed Sensory Perception related to visual changes, vestibular dysfunction, and somatosensory changes
Desired outcome: the patient will be protected from injury if dizziness, weakness, visual changes, or perceptual changes occur.

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Baclofen Planning & Interventions: Maximizing therapeutic effects:
Take with full glass of water at evenly spaced intervals; If GI distress occurs, coordinate with meals; Minimizing adverse effects: Ensure patient safety; Do not abruptly stop medication

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Teaching, Assessment & Evaluation: Patient and family education: Teach importance of patient safety; Caution the patient about the concurrent use of alcohol; Ongoing assessment and evaluation:
Monitor for hallucinations or psychotic episodes; Assess for improved symptoms of spasticity

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Baclofen therapy does not affect skeletal muscle spasms resulting from CVA or parkinsonism. Because of the mechanism of action of the drug.

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Peripherally Acting Spasmolytics: relax muscles through direct action on the skeletal muscle fibers. They do not interfere with neuromuscular communication. They have no CNS effects. Prototype drug: dantrolene (Dantrium).

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Dantrolene Core Drug Knowledge: Pharmacotherapeutics: Used to treat malignant hyperthermia
Pharmacokinetics: Administered: oral or IV. Metabolism: liver. Excreted: kidneys. Peak: 5 hours. T½: 7.3 hours.
Pharmacodynamics: Reduces the amount of Ca2+ released from the sarcoplasmic reticulum, thereby relaxing the muscle

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Contraindications and precautions: Liver disease
Adverse effects: Muscle weakness, fatal hepatitis, seizures, and pleural effusion with pericarditis; Drug interactions: CNS depressants, clofibrate, estrogens, verapamil, and warfarin.

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Core Patient Variables: Health status: Assess past medical and physical assessment
Life span and gender: Consider the age before administration
Lifestyle, diet, and habits:
Assess for lactose intolerance
Environment:
Can cause photosensitivity

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Nursing Diagnoses & Outcomes: Risk for Injury related to muscular weakness
Desired outcome: the patient will be injury free despite muscular weakness.
Risk for Disturbed Sensory Perception: Kinesthetic related to dizziness, malaise, and fatigue; Desired outcome: the patient will remain free of injury from adverse effects.
Disturbed Body Image related to drug-related dermatologic effects; Desired outcome: any adverse effects will be resolved by the end of therapy.

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Dantrolene is used to treat: Malignant hyperthermia, IV dantrolene is the drug of choice for acute treatment of malignant hyperthermia. Preoperatively, it can be used orally or intravenously to prevent malignant hyperthermia in patients considered at risk.

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Planning & Intervention: Maximizing therapeutic effects:
Administer with food or milk to avoid gastric distress; Do not crush extended release capsule; Minimizing adverse effects: Provide for patient safety; Advise the use of sunscreen; Titrate dose to maximum effectiveness

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Teaching, Assessment & Evaluation: Patient and family education; Explain why the drug is prescribed; Discuss adverse effects of drug;
Ongoing assessment and evaluation: Monitor for improvement in symptoms of spasticity and decrease in resistance to passive movement