SpasticitySpasticity After StrokeAfter Stroke

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What is What is spasticityspasticity????

““a motor disorder characterized by a a motor disorder characterized by a velocityvelocity--dependent increase in tonic dependent increase in tonic stretch reflexes (muscle tone) with stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from exaggerated tendon jerks, resulting from hyperexcitabilityhyperexcitability of the stretch reflexof the stretch reflex…”…”

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Spasticity can be defined as increased tightness in affected muscles

What is What is spasticityspasticity????

Increased tightness in musclesIncreased tightness in musclesChest wallChest wall Difficulty raising arm to the Difficulty raising arm to the side, putting on clothingside, putting on clothingElbow flexorsElbow flexors Difficulty straightening arm Difficulty straightening arm to reach for items or dressingto reach for items or dressingWrist flexorsWrist flexorsFinger flexorsFinger flexors Difficulty opening hand Difficulty opening hand voluntarily or passively (releasing items, hand voluntarily or passively (releasing items, hand hygiene)hygiene)

What is What is spasticityspasticity????

Increased tightness in musclesIncreased tightness in musclesHamstringsHamstrings Difficulty straightening legDifficulty straightening legQuadricepsQuadriceps StiffStiff--knee gaitknee gaitCalf musclesCalf muscles Difficulty clearing toes when Difficulty clearing toes when walking (tripping), foot turns in when walkingwalking (tripping), foot turns in when walkingInner thighsInner thighs Legs cross over each other Legs cross over each other when walking, difficulty pulling legs apart for when walking, difficulty pulling legs apart for hygienehygiene

Upper Extremity Upper Extremity SpasticitySpasticity

Lower Extremity Lower Extremity SpasticitySpasticity

SpasticitySpasticity ComplicationsComplications

Positioning Positioning HygieneHygieneADLsADLsSitting or Standing BalanceSitting or Standing BalanceContracturesContractures

Treatment GoalsTreatment Goals

Improvements in position Improvements in position MobilityMobilityPainPainContracture preventionContracture preventionEase of care are possibleEase of care are possible

SpasticitySpasticity Management StepsManagement Steps

Therapeutic modalitiesTherapeutic modalitiesOral MedicationsOral MedicationsNerve blocks & Chemical Nerve blocks & Chemical neurolysisneurolysis((BotoxBotox injections)injections)Orthopedic proceduresOrthopedic proceduresIntrathecalIntrathecal Medications Medications

Prior to InterventionPrior to Intervention

Assess baseline statusAssess baseline statusDetermine specific goalsDetermine specific goalsPatient and family educationPatient and family educationPT and OT role after interventionPT and OT role after intervention

Therapeutic ExerciseTherapeutic Exercise

Stretching and range of motionStretching and range of motionMyofascialMyofascial and joint mobilizationand joint mobilizationActive assistive, active and Active assistive, active and resistive exerciseresistive exerciseEndurance trainingEndurance training

Oral MedicationsOral MedicationsZanaflexZanaflex

Adverse effects: Adverse effects: drowsinessdrowsiness, dizziness, dry mouth, orthostatic , dizziness, dry mouth, orthostatic hypotensionhypotension

BaclofenBaclofenAdverse effects: weakness, Adverse effects: weakness, sedationsedation, , hypotoniahypotonia, ataxia, , ataxia, confusion, fatigue, nausea, dizziness, lower seizure thresholdconfusion, fatigue, nausea, dizziness, lower seizure thresholdSudden withdrawal may cause seizures, hallucinations, rebound Sudden withdrawal may cause seizures, hallucinations, rebound spasticityspasticity

DantriumDantriumAdverse effects: weakness (including Adverse effects: weakness (including ventilatoryventilatory muscles), muscles), drowsinessdrowsiness, lethargy, nausea, diarrhea, Liver toxicity, lethargy, nausea, diarrhea, Liver toxicity

BotulinumBotulinum Toxin Type A (BOTOXToxin Type A (BOTOX®®)): : History of DevelopmentHistory of Development

19441920s

1895

Botulinum toxin type A first isolated

Dr. Schantzbegins investigation

C. botulinumidentified

Dr. Scott initiates first therapeutic testing in humans

19781989

FDA approval of BOTOX®

BOTOXBOTOX®® ((BotulinumBotulinum Toxin Type A): Toxin Type A): A Focal TherapeuticA Focal Therapeutic

•• Injected directly into overactive Injected directly into overactive muscles muscles

•• Reduces contractions, relaxes musclesReduces contractions, relaxes muscles•• Advantages of local injectionAdvantages of local injection

−− Targeted to specific muscles that Targeted to specific muscles that are causing the symptomsare causing the symptoms

−− When used at recommended doses, When used at recommended doses, avoids systemic, overt distant avoids systemic, overt distant clinical effects clinical effects

−− NOT FDA APPROVED FOR NOT FDA APPROVED FOR SPASTICITYSPASTICITY

Muscle identificationMuscle identification

Three main methodsThree main methodsExam and anatomic atlasExam and anatomic atlasEMG assistance and guidanceEMG assistance and guidanceElectronic stimulationElectronic stimulation

Side EffectsSide Effects

LocalizedLocalizedHematomaHematoma and bruising are seen and bruising are seen regardless of the site injected regardless of the site injected Local weakness, created by diffusion of Local weakness, created by diffusion of BotoxBotox and is site specificand is site specificDeath???Death???

IntrathecalIntrathecal BaclofenBaclofen

Small doses of Small doses of baclofenbaclofen delivered directly delivered directly to the spinal canalto the spinal canalFewer side effects, better relief of Fewer side effects, better relief of spasticityspasticityUsually more effective for Usually more effective for spasticityspasticity in the in the lower extremitieslower extremitiesRequires committed patient and family, Requires committed patient and family, pump must be refilled every 3 months.pump must be refilled every 3 months.

IntrathecalIntrathecal BaclofenBaclofen

Surgical ProceduresSurgical Procedures

Tendon lengtheningTendon lengtheningNeurosurgical proceduresNeurosurgical procedures

Last resort!Last resort!

Take Home PointsTake Home Points……..SpasticitySpasticity is common after stroke, and is is common after stroke, and is manifested as muscle tightness in the affected manifested as muscle tightness in the affected arm and/or leg.arm and/or leg.

Several different treatment options are available, Several different treatment options are available, including therapies, oral medications and including therapies, oral medications and injections.injections.

If you suffer from If you suffer from spasticityspasticity you should be seen you should be seen by a physiatrist who specializes in by a physiatrist who specializes in spasticityspasticitymanagement.management.