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HATEM SAMIR M. SHEHATA, M.D PROFESSOR OF NEUROLOGY
CAIRO UNIVERSITY
SPASTICITY MANAGEMENT. REHABILITATION ART
FIRST ANNOUNCEMENT
Movement Disorders And Spasticity
Workshop
TOPICS Dystonias. Diagnosis and Management. Prof M. Eltamawy
Hemifacial Spasms. Prof Amr Hassan
Tremor. What Is New ?. Prof Hanan Amer
Spasticity Assessment. The Art Of Neurorehabilitation. Prof Hatem S. Shehata
Hands-on: Ultrasound-Guided BTX-A Injection. Didactic Approach. All faculty members (moderators: Dr. Hatem S. Shehata, Dr. Sandra Ahmad)
Faculty:
Prof. M Eltamawy
Prof. Hanan Amer
Prof Hatem Shehata
Prof. Nevin Shalaby
Prof. Amr Hassan
Prof. Sandra Ahmad
Dr. Shaimaa Al-Jaafary
Dr. Wael Ezzat
Dr. Haidy Shebawy
7 December, 2016VENUE: LRC-Kasr
Alaini
HATEM SAMIR MOHAMMED, M.D
OBJECTIVES
• Rehabilitation Process • Spasticity – Definition – Pathophysiology – Impact • Assessment of spasticity and ADL • Spasticity management options • Outcome measures – BTX injection sheet • Clinical cases – video
2
HATEM SAMIR MOHAMMED, M.D
OBJECTIVES
• Rehabilitation Process • Spasticity – Definition – Pathophysiology – Impact • Assessment of spasticity and ADL • Spasticity management options • Outcome measures – BTX injection sheet • Clinical cases – video
3
HATEM SAMIR MOHAMMED, M.D 4
GOALS 1. Optimizing social participation (considering persons’ wishes) 2. Minimizing distress of both patients and caregivers 3. Help patients to maximize behavioral repertoire
SPASTICITY. “HABILITATION/REHABILITATION”
• Rehabilitation is a long-term (may be life-long), problem-solving process of recovery from an injury to obtain ‘optimum function’ despite of residual disability
• It is the process by which physical, sensory, and mental capacities are RESTORED or DEVELOPED in disabled patients
Change/abnormalities (molecular/cellular) - - organ (e.g., (cord malacia, hemorrhage, infarction, TBIDisease Pathology
(Change/abnormalities of whole body set (functional loss S. & S.((functional loss Impairment
How impairment restricts the social tasks (roles). It is the expression of the gap between a person's capabilities and(the demands of the environment (environment interaction
Social Roles((participation
Activity((disability
TERMINOLOGIES SHOULD BE CHANGED
5
REHABILITATION MODEL (ICF-WHO)
HATEM SAMIR MOHAMMED, M.D
REAL CASE SCENARIO . . .• 56 male patient, married (3 daughters), Banker ,
HTN, non diabetic • 1 month ago right sided hemiplegia and dysphasia • Assessment now: hemiparesis (G2 D, 3 P), mild
dysphasia • Pathology: ICH • Impairment: weakness +/- spasticity,
communication disorders • Disability: toilet, dressing, hygiene, chocking,
decision making etc… • Handicap: work / family / carer
6
What is the concern of hisprimary physician ?
HATEM SAMIR MOHAMMED, M.D
HATEM SAMIR MOHAMMED, M.D
NEUROLOGICAL REHABILITATION
• Acute onset disability, with a phase of improvement followed by relative stability: CVS, traumatic insults, infections, etc..
• Fluctuating and/or unpredictable disability, often with some progression: M.S
• Progressive, relatively predictable disability: MND
• Stable diseases present from childhood: C.P
– Categories of Neurological Conditions
7
HATEM SAMIR MOHAMMED, M.D
• A comprehensive service with a multidisciplinary team who should be involved in an integrated program
• This team includes ‘a list of related specialties‘: Neurologist/Neurosurgeons/ Orthopedics/PMR/Therapists/ Occupational and Speech therapy/ Psychologists/Support workers
• Target: increase patients activities and reduce burden of the patient and carers
8
STRATEGIES FOR NEURO-REHABILITATION
HATEM SAMIR MOHAMMED, M.D
Assessment (to collect data) Identify problem Genesis of problem Prognostic factors Expectations (patients / others)
Goals Setting (PLANNING) Short term actions Middle term directions Long term goals
Interventons Deliver treatment (alter natural Hx.) Health education and support Collect further data
Evaluations Compare Goals vs. Set Identify resolvable problems remain
9
REHABILITATION PROCESS
More Actions Needed
No Actions Needed
HATEM SAMIR MOHAMMED, M.D
OBJECTIVES
• Rehabilitation Process • Spasticity – Definition – Pathophysiology – Impact • Assessment of spasticity and ADL • Spasticity management options • Outcome measures – BTX injection sheet • Clinical cases – video
10
HATEM SAMIR MOHAMMED, M.D 26/01/2016
SPASTICITY . . . DEFINITION
• One of the most specific impairment that results in muscle over activity resultingfrom UMNL (++ tonic SR)
• It is one of positive UMNL signsthat involves a long-term monitoring
11
Mild weakness, loss of ‘precision grip’ which involves opposition
HATEM SAMIR MOHAMMED, M.D
• Spasticity is distinct from other motor disturbances: • Sensori-motor disorder • Velocity-dependent increase in tonic stretch reflex activity • Length-dependent (clasp knife) • State-dependent (variables) • Usually seen in the anti-gravity muscles like the arm flexors and the leg
extensors • Associated with high tone spasms and soft tissues changes
12
Pandyan et al., Disabil and Rehab, 2005
SPASTICITY . . . DEFINITION
HATEM SAMIR MOHAMMED, M.D
(1) Disability: weakness / dexterity
(2) Mask actions of antagonists
(3) Seating and postural problems
(4) Pains, stiffness and spasms (discomfort–contractures–deformities)
(5) Hygiene and self care problems
(6) Mood changes and loss of self-esteem (disfigurement–sexuality problems)
(7) Fatigue – Sleep disruption
Disability
Complicatio
ns
13
SPASTICITY . . . CONSEQUENCES
HATEM SAMIR MOHAMMED, M.D
Loss of cortical drive after cerebral or above lesion spinal insults
Loss of descending inhibitory spinal circuits (Dorsal RST)
Increase muscle SR by intact Medial reticulospinal and vestibulospinal tracts
Spastic hypertonia, spasms, and clonus
Greenwood, 1998
INCREASE MUSCLE STRETCH REFLEX
14
SPASTICITY . . . PATHOPHYSIOLOGY
HATEM SAMIR MOHAMMED, M.D
• As a result neural pathways show changes in their level of excitability:
• Altered α-motoneuron excitability
• Altered Ia and Ib inhibition
• Some studies also report changes in the γ-motoneuron excitability (not commonly accepted)
Voerman and Hermens, Disabil and Rehab, 2005
Spasticity (Pathophysiology)
15
HATEM SAMIR MOHAMMED, M.D
NEURAL AND NON-NEURAL COMPONENTS OF SPASTIC LIMB DYSFUNCTION
• These two mechanisms are responsible for the clinically observed resistance to passive movement associated with spasticity
• Muscle hyperactivity (muscle contraction and shortening)
• Bio mechanical changes (soft tissues; tendons, ligaments, joints): thixotropy, intra-articular adhesions
(Gracies, 2005)
16
HATEM SAMIR MOHAMMED, M.D
PRO / CONS POSSIBLE BENEFITS OF SPASTICITY
• A common argument
• > 38% of stroke survivors affected by spasticity
☞ May help patients to walk, stand or transfer (e.g., stand pivot transfers)
☞ May assist in maintaining muscle bulk (inherently prevents atrophy)
☞ May assist in preventing DVTs
☞ May assist in preventing pressure ulcer formation over bony prominences
• No positive overall benefit to spasticity in an individual at any stage of life
17
HATEM SAMIR MOHAMMED, M.D
OBJECTIVES
• Rehabilitation Process • Spasticity – Definition – Pathophysiology – Impact • Assessment of spasticity and ADL • Spasticity management options • Outcome measures – BTX injection sheet • Clinical cases – video
18
HATEM SAMIR MOHAMMED, M.D
ASSESSMENT TOOLS
• Clinical Assessment: subjectivity - inter-rater variability
• Neurophysiological
Voerman et al., 2005
Neurophysiological response to electric stimulation •(H / M reflex)
Evoked potentials •(motor and sensory evoked potentials)
19
HATEM SAMIR MOHAMMED, M.D 20
Muscle Tone
ADL Barthel index, Others QoL tests
Sensory
Gait assessment
Other tools
MAS, Tardeau scale, Bilateral adductor tone
VAS: for pain and dyasthesia Cramps (Spasms)– Spasms Frequency Scale
Gait analysis laboratory Timed-TMWT
Goal Attainment Scale ‘the most difficult’ ROM ‘the easiest – don’t forget’
Assessment Axes
HATEM SAMIR MOHAMMED, M.D
Q: WHICH TOOL WILL YOU USE ??A: THAT HELPS TO ASSESS THE TARGETED OUT COME
Impairment related measures Spasticity Range of movement
Functional measures Reduction of pain Ease of applying splint/orthosis Ease of maintaining hygiene Ease of dressing Improved seating position Improved gait pattern Improved gait efficiency
MAS / Tardeu scale / dynamic EMG Goniometry
Suggested outcome measure Visual analogue scale/Spasm Frequency Scale Timing of tasks/number of helpers/carer rating scale Timing of tasks/number of helpers/carer rating scale Timing of tasks/number of helpers/carer rating scale Photographic record/measurement i.e. pelvis level Video analysis/10 meter walk test Video analysis/patient rating/energy cost assessment
21
HATEM SAMIR MOHAMMED, M.D
CLINICAL SCALES
It measures Stiffness not Spasticity – No Speed of Movement is Specified
Modified Ashworth Scale
22
HATEM SAMIR MOHAMMED, M.D
Measurements take place at 3 velocities
Responses are recorded at each velocity as X/Y, with X indicating the 0 to 5 rating, and Y indicating the degree of angle at which the muscle reaction occurs.
Patient position: supine, with head in midlineTardieu Scale
23
HOW TO CALCULATE‘Tardieu Scale’
24HATEM SAMIR MOHAMMED, M.D
HATEM SAMIR MOHAMMED, M.D
(1, 2) Bowels and Bladder: 0: incontinent, 1: occasional, 2: continent
(3) Grooming: 0: needs help, 1: independent
(4) Toilet use: 0: dependent, 1: need help, 2: independent
(5) Feeding: 0: unable, 1: need help, 2: independent
(6) Transfer: 0: unable, 1: major help, 2: minor help, 3: independent
(7) Mobility: 0: immobile, 1: wheelchair, 2: walk with help, 3: independent
(8) Dressing: 0: dependent, 1: need help, 2: independent
(9) Stair: 0: unable, 1: need help, 2: independent
(10) Bathing: 0 : dependent, 1: independent
Barthel index, ADL
25
Clinical Scales (Cont’d)
HATEM SAMIR MOHAMMED, M.D
VAS: a subjective pain measure, ranged from 0 (no pain) to 10 (unbearable pain). The patients mark the point that represents their perception of the current status
Horizontal line 100 mm in length
Visual Analogue Scale (VAS)
No spasms0
One spasm or less a day1
One to five spasms a day2
Five to nine spasms a day3
Ten or more a day4
Spasm Frequency Scale
How many spasms occurred in the affected muscles or extremities during the last 24 hours ?
26
Clinical Scales (Cont’d)
HATEM SAMIR MOHAMMED, M.D
TIMED 10-METER WALKING TEST (TMWT)
• Patient walks with/without assistance 10 meters (32.8 feet) and the time is measured for the intermediate 6 meters (19.7 feet)
• Start timing when the toes of the leading foot crosses the 2-meter mark
• Stop timing when the toes of the leading foot crosses the 8-meter mark
• It can be performed at preferred walking speed or fastest speed possible (preferred vs. fast)
• Collect 3 trials and calculate the average of the three trials
Acceleration Deceleration
27
HATEM SAMIR MOHAMMED, M.D
• 3 components:
• Kinematics: analysis of body positions, angles, velocities, accelerations of body segments and joints during motion)
• Kinetics: analysis of forces
• EMG
28
Gait Analysis
Assessment Tools (Cont’d)
HATEM SAMIR MOHAMMED, M.D
STANCE-PHASE KINEMATICS
29
Heel-strike ----------------------> Mid-stance --------------------------> Toe-off Contact - - - - - Loading - - - - - Midstance - - - - - - Terminal stance - - - - - - Preswing
Pelvic Angle
Knee Angle
Muscle Activity
60% of gait cycle
HATEM SAMIR MOHAMMED, M.D
PATHOMECHANICS OF HEMIPLEGIC GAIT
• Reduced knee flexion in swing phase (stiff-legged gait)
• Equinus (excessive ankle plantar flexion) which leads to: increase energy required to initiate swing period of gait cycle
• Gait asymmetry, short step length, speed reduction and longer gait cycle
• Mass limb movement pattern: on the paretic side requiring compensatory pelvic adjustment in non-paretic side
• Defective “body image”
30
HATEM SAMIR MOHAMMED, M.D
OBJECTIVES
• Rehabilitation Process • Spasticity – Definition – Pathophysiology – Impact • Assessment of spasticity and ADL • Spasticity management options • Outcome measures – BTX injection sheet • Clinical cases – video
31
HATEM SAMIR MOHAMMED, M.D
GOALS OF THERAPY
• Increase functionality (improve QoL): ROM, ambulation
• Postural benefits: modify body image
• Ease pain – Decrease spasms
• Prevent or decrease contractures
• Facilitate Rehab/Orthosis
• Hygiene
INDIVIDUALIZE /
AVOID GESTALT
32
HATEM SAMIR MOHAMMED, M.D
SPASTICITY MANAGEMENT OPTIONS
Physical therapy
Regular exercises Physiotherapy
Surgery
Severe spasticity
Medical therapy
Generalized Oral agents
Regional Intra-thecal baclofen
Focal BTX-A injection
Phenol blockade
Consider each in combination with others
33
HATEM SAMIR MOHAMMED, M.D
PHARMACOLOGIC MANAGEMENT
• Systemic
• Baclofen (30-90 mg/d), diazepam (5-15 mg/d), dantrolene sodium (100-400 mg/d), clonidine (0.3-0.9 mg/d), tizanidine (< 36 mg/d), carbamates (methocarbamol 3–6 g, carisoprodol), endocannabinoids (Sativex)
• Limitations: non-selective; large dosages often required which may result in intolerable side effects (sedation, weakness, GIT disturbances and hepatotoxicity)
34
HATEM SAMIR MOHAMMED, M.D 35
ECB. ‘Retrograde’ inhibition of nerve impulse transmission1. Action potential at the presynaptic
2. Neurotransmitter (NT) release
3. Glutamate and GABA
4. Binding to GABA-R and iGlu-R
5. Inhibitory …………… Excitatory
6. Activated Glu
7. Increase Calcium
8. ECBs bind to pre-synaptic cannabinoid receptors (CB1-R)
9. Net result is inhibition of further Ca
influx, and so inhibition of NT release
stimulates
endocannabinoid
(ECB) synthesis
HATEM SAMIR MOHAMMED, M.D
• Local treatment options. • Motor point and nerve blocks: aqueous phenol (Neurolysis by coagulate
proteins)
Limitations: tissue necrosis, pain and dysesthesia; variable duration of effect; often irreversible
• Local injections of BTX-A
36
Pharmacologic Management (Cont’d)
Indications: generalized moderately severe spasticity (not adequately treated with oral medications and BTX).
The spasticity reduction in LL (+/-) UL depends on the catheter position in the spinal fluid.
Low catheters (T 10-12): improve mainly the legs. Higher catheters (T 1-2): arm spasticity is targeted.
■ Regional treatment options. Intra-thecal Baclofen (ITB)
37
Pharmacologic Management (Cont’d)
HATEM SAMIR MOHAMMED, M.D
Test dose: 50 ug baclofen injection in spinal fluid. Then evaluate for 4-8 hours (response)
Pump is inserted under abdominal muscles
A catheter is inserted through a needle intrathecally and is threaded upward
Catheter is tunneled under the skin to the abdomen and is connected to the pump
The pump filled with baclofen is programmed by a computer to continuously release a specified dose
38
Pharmacologic Management (Cont’d)
HATEM SAMIR MOHAMMED, M.D
HATEM SAMIR MOHAMMED, M.D
SURGICAL MANAGEMENT
• Selective dorsal rhizotomy
• Selective Neurotomy: partial section of motor nerve branches
• Orthopedic surgery as tendon release (depending on age of patient)
Limitations: invasive; irreversible; parathesia; effectiveness varies
39
Selective Dorsal Rhizotomy (SDR)
1. Exposing LL nerve roots through a midline lumbar incision.
2. Sensory roots are divided into 3 – 5 rootles, that are electrically stimulated to identify and cut nerves with abnormal responses.
Commonly in young patients with LL spasticity (with relative good strength and good back extensors power) or (to improve hygiene).
Prerequisites: No contractures.
Complications rate: 5 – 10% PT should start after a month (1-2 times/wk) if the goal is to improve ROM; and (4-5/wk) if the goal is to improve strength
40HATEM SAMIR MOHAMMED, M.D
HATEM SAMIR MOHAMMED, M.D
Orthopedic Surgery
• Indications: (1) ease care, (2) improve function, (3) cosmetics
• Both bony and soft tissue surgeries
• The major soft tissue procedure involves lengthening the muscle-tendon unit (tenotomy) – and (tendon transfer)
• Other surgeries include: • Capsulotomy
• Fascial arthroplasty
• Removal of excessive callus formation
41
HATEM SAMIR MOHAMMED, M.D
OVERVIEW OF REHABILITATION INTERVENTION
• Early start – better outcome.
• Positioning ‘bed, wheelchair, splinting, casting, AFO)
• Joints stretching and PROM to prevent contractures or shortening • Full stretch for 2 hours / 24 hours (Medical Disability Society, 1988)
• Re-educate ‘Relearning’ and facilitate balance/equilibrium
• Gait training
• In advanced spasticity, (Biomechanical hypertonia) resistant disability ▪ Not velocity-dependent and poor response to antispastic agents.
▪ The only treatment: stretching, positioning, splinting and casting
42
HATEM SAMIR MOHAMMED, M.D
DOES REHABILITATION WORK ??? ROLE OF NEURONAL PLASTICITY
• Late recovery (neuronal plasticity) is proposed to underlie cortical map reorganization following neurological insults
• The undamaged regions of the brain can progressively adopt the function of the lesioned area by neuronal sprouting and synaptogensis leading to change in cortical representations (maps)
This can be enhanced by enriched environment, structured physiotherapy and TMS
43
HATEM SAMIR MOHAMMED, M.D
OBJECTIVES
• Rehabilitation Process • Spasticity – Definition – Pathophysiology – Impact • Assessment of spasticity and ADL • Spasticity management options • Outcome measures – BTX injection sheet • Clinical cases – video
44
HATEM SAMIR MOHAMMED, M.D
NOW . . . I DECIDED TO INJECT BTXWHY ?? HOW ??
• Selection criteria for injection (identify the problem precisely): (1) Preserved functionality (type of spasticity) , (2) Others
• Understanding and expectations of treatment by patient and caregiver
• Dosage and site of injection
45
HATEM SAMIR MOHAMMED, M.D
PREPARATORY STEPS
• Before injection: Checklist • Complete examination
• Goal determined: a contract with patient
• Take into account patients on anti-coagulants
• Muscles to inject
• Muscle localization
• Techniques of injection
• Evaluation after 2-4-6 weeks
46
HATEM SAMIR MOHAMMED, M.D
PROBLEM DISTRIBUTION GOAL SETTING
RegionalMultifocal (generalized with focal problems)Focal
47
HATEM SAMIR MOHAMMED, M.D
COMMON CLINICAL PATTERNS – UPPER LIMB
Adducted/internally rotated shoulder
Flexed wrist Pronated forearm
Clenched fist Flexed elbow Thumb in palm
Courtesy WE MOVE, 2006
48
HATEM SAMIR MOHAMMED, M.D 49
IRO/retrovIRO/ADDIRO/ADDIRO/ADDIRO/ADDSHOULDER
ExtensionFlexionFlexionFlexionFlexionELBOW
Pronated Pronated Neutral SupinatedSupinatedFOREARM
Flexion Flexion Neutral ExtensionFlexionWRIST
28% 8% 86% 27% 6%
HATEM SAMIR MOHAMMED, M.D
COMMON CLINICAL PATTERNS – LOWER LIMB
Equinovarus
Striatal toe
Stiff knee Flexed knee Adducted thighs
50
Courtesy WE MOVE, 2006
HATEM SAMIR MOHAMMED, M.D
WHICH MUSCLES TO TREAT ?• Elbow flexion:
• Biceps brachii, brachialis, brachioradialis, pronator teres • Spastic hand:
• FCR, FCU, FDS, FDP, FPL, interosseii, opponens • Stiff knee gait:
• Rectus femoris, hamstrings
• Equinovarus: • Triceps sure, tibialis posterior
• Toe flexion: • Flexor digitorum longus and brevis, FHL
• Muscle treated frequently depends on patient condition and practitioner personal experience,
51
HATEM SAMIR MOHAMMED, M.D
WHAT IS THE BEST DILUTION ?• 1 or 2, or 5 ml / 100 U BOTOX ®
• High volume dilution and end-plate targeting achieve greater muscle blockade
• Low volume for small muscles - - - Large volume for large muscles
52
HATEM SAMIR MOHAMMED, M.D
WHAT IS THE BEST INJECTION TECHNIQUE AND SITE?
• The best technique is the one you feel confident with • Blind technique:
• Poor accuracy / not to recommend • Risk to inject ‘between’ muscles • Unrelated to injector experience • In one study assessed 121 practitioners injected cadaver muscles, 43%
succeeded and 57% failed
• EMG if large and superficial • ES if small and deep • U/S-guided: if deep or failed to be stimulated
53
HATEM SAMIR MOHAMMED, M.D
BTX INJECTION SHEET . . . . • Signed consent: information – patient and caregivers • Agent used: . . . . . Dilution: (. . . units / ml saline) • Muscle identification: palpation / EMG / Others • Muscle injected Units: ………………… …….. • Appointment date for splinting (type, method of applications, review appointment) • Appointment date for further review (2-4-6 wks):
• Response to injection ? • Has functional goal been achieved ? • Is further injection needed at current time ?
54
HATEM SAMIR MOHAMMED, M.D
INJECTION RECORD
55
HATEM SAMIR MOHAMMED, M.D
DIAGNOSTIC NERVE BLOCK WITH ANAESTHETICS
• Lidocaine injection (1 ml) at the level of motor nerve branches innervating spastic muscles
• Immediate and transient spasticity reduction
• Determine the respective responsibility of spasticity, contracture and weakness
• Evaluation of function without spasticity
56
HATEM SAMIR MOHAMMED, M.D 57
ULTRASOUND - GUIDED INJECTION “UL”
HATEM SAMIR MOHAMMED, M.D
OBJECTIVES
• Rehabilitation Process • Spasticity – Definition – Pathophysiology – Impact • Assessment of spasticity and ADL • Spasticity management options • Outcome measures – BTX injection sheet • Clinical cases – video
58
HATEM SAMIR MOHAMMED, M.D 28/01/2016 59
Target muscle:Extensor Hallucis Longus
DEMO (1) STRIATAL TOE (HITCH-HIKER’S BIG TOE)
HATEM SAMIR MOHAMMED, M.D 28/01/2016 60
Tibialis Posterior
DEMO (2) INJECTION SITE OF TIBIALIS POST.
HATEM SAMIR MOHAMMED, M.D 28/01/2016 61
20 years oldpost-encephalitic Left spastic hemiplegia (2yrs)
Assessment of LL1. Big toe clawing(talipes cavus)2. Spastic Talipus Equinus Target Muscles:1. Triceps surae2. Flexor hallucis longus 3. Quadratus plantae
DEMO (3) (A) CASE SCENARIO
HATEM SAMIR MOHAMMED, M.D 28/01/2016 62
DEMO (3) (B) CASE SCENARIO
Assessment of UL
Fixed elbow flexion deformity (with calcification)
HATEM SAMIR MOHAMMED, M.D 28/01/2016 63
DEMO (3) (C) CASE SCENARIO
Eight days after injection
HATEM SAMIR MOHAMMED, M.D 28/01/2016 64
DEMO (4) UL (ONLY 5 DAYS)
HATEM SAMIR MOHAMMED, M.D 28/01/2016 65
DEMO (4) UL (ONLY 5 DAYS)
HATEM SAMIR MOHAMMED, M.D
DEMONSTRATION
28/01/2016 66
Pronator teres FDP
HATEM SAMIR MOHAMMED, M.D
DEMO
28/01/2016 67
FDS
CASE VIDEOS Disability: (1) weak back extensors(2) flexed posture (overacting leftiliopsoas) – left loin pain(3) overacting adductors(4) co-contraction (hamstrings/quadriceps F)(5) left talipus eq varus (6) disabling spontaneous clonus Plan: (1) BoNT injection: Iliopsoas (left): 50. Quadriceps (rectus femoris – vastus medialis): 25 X 2 (small doses to minimize clonus). Hamstrings: 50 X 2. Adductors (bilateral), left gracilis: 50 X 2. Left Gastromedialis & lateralis: 30. Left tibialis posterior: 50 (2) Stretching of injected muscles (3) Strengthening of back extensors (4) Then gait and balance ex
A.S, 36-yr, SPMS. Diagnosed 10 yr ago Wheel-chair: 18 mo On CPM (9 mo)This patient was subjected to 3 injection sessions4 mo apart
18 Sep 2011
68
3 WEEKS AFTER 1ST INJECTION
(DECREASED HAMSTRINGS OVERACTIVITY– KNEE EXTENDED)
STILL BACK EXTENSORS (WEAK)LEFT LOIN PAIN DISAPPEARED
8 weeks after 2nd injection
(Back extensors can support walking)
69
20 Mar 2012
16 Oct 2011
THANK YOU
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