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8/3/2019 Spas Ti City Assessment and Management
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SpasticitySpasticity
Velocity dependent
increase in muscle
tone do to passive
stretch, characterizedby increased
resistance to passive
motion, involuntary
muscle contractions,and hyper-reflexia.
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Epidemiology of SpasticityEpidemiology of Spasticity
Incidence: Spinal Cord Injury (10,000/ year), Closed Head Injury(1.5 million/ year), Stroke (1/1000/yr), Cerebral Palsy (2/1000 livebirths).
Influenced by: Incomplete > Complete, Tetraplegia > Paraplegia,Men>Women, Legs>Arms, Extension>Flexion.
Pathophysiology: Unknown
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Pathophysiology of SpasticityPathophysiology of Spasticity
Unknown
1) Denervation hypersensitivity ofAlpha Motor Neuron
2) Collateral sprouting resulting infurther loss of inhibitory input.
3) Hyper-excitable Gamma Motorneurons will increase thesensitivity of theneuromuscular spindle.
4) Interneuron activity andexcitability.
Net result is an imbalance ofexcitatory and inhibitoryimpulses resulting in adisinhibition of the alpha motorneuron.
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Spasticity AssessmentSpasticity Assessment
Modified Ashworth Scale:
0 = no increase in muscle tone
1 = slight increase in muscle tone (catch or min resistance
at end range)1 + = slight increase in muscle resistance throughout therange.
2 = moderate increase in muscle tone throughout ROM,PROM is easy
3 = marked increase in muscle tone throughout ROM,PROM is difficult
4 = marked increase in muscle tone, affected part is rigid
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Spasticity AssessmentSpasticity Assessment
Spasm Frequency Scale: How many
spasms in the last 24 hours in the affected
extremity?0 = no spasms
1 = 1 / day
2 = 1-5/ day3 = 5-9 / day
4 = >10/day
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Spasticity AssessmentSpasticity Assessment
Adductor Tone Rating:
0 = no increase in muscle tone
1 = increased tone, hips easily abducted 45
degrees by one person2 = hips abducted 45 degrees by on person with
mild effort
3 = hips abducted 45 degrees by one person with
moderate effort4 = two people are required to abduct the hips 45
degrees
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Spasticity AssessmentSpasticity Assessment
Tardieu: An ordinal rating of tone which measuresthe angle which the catch is first felt (thethreshold angle).
Oswestry: Ordinal which rates stage anddistribution of tone that is addressed by ageneralized grade of either useful or non-usefulmovement.
:
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Direct and Indirect ConsequencesDirect and Indirect Consequences
of Spasticityof Spasticity
Increased Tone
Decreased Range of Motion
Involuntary Movements
Increased Autonomic Reflexes
Exaggerated Reflexes
Muscle Weakness
Muscle Fatigue
Muscle Control
Balance Problems
Increased Caloric Needs
Abnormal Bone Stress
Mobility Dysfunction
ADL Dysfunction
Contracture
Autonomic Storm
Pain
Abnormal Bone Growth
Weight Loss
Tibial Torsion, Leg Length Inequality,Femoral Anteversion, Scoliosis
Sleep Dysfunction
Patient Care (hygiene, transportation)
Bowel and Bladder Dysfunction
Respiratory Dysfunction
Skin Breakdown Communication, Speech, and
Swallowing Dysfunction
Impaired Social, Psychological, andVocational Development
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Advantages of SpasticityAdvantages of Spasticity::
Maintenance of MuscleTone
Maintenance of MuscleBulk (protection of boneysurfaces to prevent skinbreak down)
Tone Effect on Mobility
Tone effect on ADL's Improved Circulation
(orthostatic hypotension)
Prevention of DVT
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Goals of Spasticity Treatment:Goals of Spasticity Treatment:
Improve Function,
Independence,
and Quality of Life
Decrease Cost ofCare
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Mechanism for SpasticityMechanism for Spasticity
Management:Management:
Identify SpasticPatient
Evaluate Caregiver
Follow-through Select Functional
Goals
Identify Treatment
Options Document and
Videotape Results
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Spasticity Management:Spasticity Management:
Remove Noxious Stimuli
Rehabilitation Therapy
Oral Medications Neurolysis
Orthopedic Options
Neurosurgical Procedures
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Remove Noxious StimuliRemove Noxious Stimuli
Identify the
trigger
Prevent
nociceptive
Input to spinal
cord
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Rehabilitation TherapyRehabilitation Therapy
Stretching
Positioning
Seating
Cryotherapy
Biofeedback
Inhibitive Casting
Pool TherapyOrthotics
Electrical Stimulation
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Oral MedicationsOral Medications
Baclofen and Valium
(GABAB/A mimetic),
Dantrolene (inhibits Ca+
release from SR),
Zanaflex and Clonidine
(Alpha-2 Adrenergic
Agonist),
Neurontin (CNS
membrane stabilizer),
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NeurolysisNeurolysis
Botox Injections
Phenol Injections
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Orthopedic OptionsOrthopedic Options
Tenotomy
Myotomy
Osteotomy
Fusion
Tendon Transplant
Tendon Lengthening
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Neurosurgical ProceduresNeurosurgical Procedures
Neurectomy
Myelotomy
Rhizotomy
Selective DorsalRhizotomy
Chordotomy
Implantable duralelectric stimulator
Intrathecal BaclofenPump
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Intrathecal BaclofenIntrathecal Baclofen
Baclofen is a GABA agonist that binds to B receptor to
inhibit ca++ influx into presynaptic terminals
to inhibit the release of excitatory neuotransmitters.
Baclofen is lipophilic and doesn't cross the BBB. Intrathecal Baclofen can be used for the long
term control of severe spasticity without
significant central side effects at a dose less
than 100 times the oral dose.
ITB delivery has been used since 1980 for pain
and 1992 for spasticity.
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