Spasticity Management 1 5 2007
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Spasticity Management 1 5 2007 Presentation Transcript

  • 1. Spasticity Management Jackie Kawiecki, MD, MHA Courage Center Medical Director January 5, 2007
  • 2. Objectives: Management of Spasticity- Management of Hypertonicity
    • Why
    • When
    • How
    • Reminder: All hypertonicity is not spasticity and treatment is different
  • 3. Definition of Spasticity
    • Velocity dependent resistance to movement
      • Exaggerated velocity dependent stretch reflex
    • Increased deep tendon reflexes (DTR)
    • Abnormal increase in tone
  • 4. Pathophysiology of Spasticity
    • Increased tone (resistance to quick stretch) and hyperactive DTR’s (clonus)
      • Result from central nervous injuries which impair the normal spinal and supraspinal inhibition of segmental spinal reflexes
  • 5. Other Types of Hypertonicity
    • Dystonia
      • Varying tone; increased w/ intent to move; increased w/ heightened emotional state; persistence of primitive reflexes
    • Rigidity
      • Resistance to movement that is NOT velocity dependent
    • Athetosis-Dyskinesia
      • Movement d/o; unable to organize and execute movement; difficulty maintaining posture; persistence of primitive reflexes
      • Wrying distal movements- more in upper extremities (often) than lower extremities
  • 6. Clinical Signs & Symptoms Associated w/ Spasticity
    • Symptoms
      • Pain
      • Difficulty moving
      • Interrupts sleep
      • Interferes with ADL’s and mobility
      • Fatigue
      • Inability to keep orthotics closed or on
      • Impairs hygiene
      • Poor posture
      • Fractures
    • Signs
      • Contractures
      • Poor Posture
      • Gait abnormality
      • Lack of coordination
      • Friction sores
      • Foot deformities
        • Equinovarus most common
      • In children in particular:
        • Hip subluxation/dislocation
        • Femoral anteversion/tibial torsion
  • 7. Measurement Tools
    • Ashworth scale:
      • 5 point scale: 1-5
    • Modified Ashworth scale:
      • 6 pt scale: 0-4 including 1+
    • Spasm frequency
    • Reflex scale
    • Pain scale
  • 8. Modified Ashworth Scale (MAS)
    • 0/4 = Normal tone
    • 1/4 = Slight catch at terminal range
    • 1+/4 = More effort required to range but not difficult; but less than half of ROM of joint involved
    • 2/4 = More effort required to range; more than half of ROM of joint involved
    • 3/4 = Difficult to range
    • 4/4= Rigidity; unable to take through established normal range of joint
  • 9. MAS Reminders:
    • Always take the first measurement for each associated muscle group being tested
      • Continued range in an attempt to get an “avg” will reduce tone in the muscle group being tested
    • Tone is variable
      • Two different examiners may get very different results based on day; time of day
    • Contractures vs. increased tone
      • Document scale score within available range
    • Document utilizing x/4 for MAS and x/5 for Ashworth Scale to assure conveying information correctly in medical record
    • Static (at rest) versus dynamic tone: selective motor control (ability to isolate movement)important to assess
  • 10. Spasm Frequency
    • Can be rated by patient and observer
    • Less frequently used
    • 0/4= No spasm
    • 1/4 = Mild spasm induced only with stimulation
    • 2/4= Spasms occurs less than once per hour
    • 3/4 = More than one per hour
    • 4/4= More than 10 per hour
  • 11. Reflex Scale
    • Total reflex score is calculated by summing score from knee and ankles and divide by 4
    • 0/6= No response
    • 1/6= Hyporeflexia
    • 2/6= Normal response
    • 3/6= Mild hyperreflexia
    • 4/6= Up to 4 beats of clonus
    • 5/6= Unsustained clonus; >4 beats
    • 6/6= Sustained clonus
  • 12. Why treat tone abnormalities
    • Tone interferes with function
    • Pain associated from tone
    • Tone interferes with cares
    • Deformities/Contractures are developing/recurring
  • 13. Tone and Function
    • If patient has ability to initiate movement, then increased tone can interfere with the ability to use that movement
      • Volitional control is ‘masked’ by tone
    • If patient is weak, they may use the tone to assist in augmenting volitional strength
  • 14. When to treat spasticity
    • Influenced by the severity of spasticity
    • Influenced by goals
      • Functional
      • Ease of care
      • Positioning
      • Pain/Comfort
      • Recurrent deformity/contractures
  • 15. Consideration for tone management
    • Risks/benefits
    • Follow-up needed
    • Other impairments
    • Rule out other possible contributing factors then consider treatment of spasticity
      • Any noxious stimulus can drive up spasticity, therefore rule out (most common issues)
        • Bladder related: UTI, renal stones, bladder stones
        • Bowel related: bowel distension, anal fissure
        • Skin related: pressure ulcers, skin tears, ingrown toenail, cellulitis, tight leg bag, tight clothing
        • DVT, heterotopic ossification (HO), occult fractures
  • 16. Interventions for Abnormal Tone
    • Therapy based:
      • PT, OT: including ROM, E-stim, FES
      • Splinting- static/dynamic; casting, including serial casting; positioning techniques; modalities: cold/heat/vibration
    • Oral medications (systemic management)
    • Injected medications (focal management)
      • Botulinum Toxin:
        • Type A (Botox); Type B (Myobloc)
      • Phenol
    • Surgery
      • Implantation of pump for delivery of intrathecal baclofen
      • Orthopedic surgery
      • Selective Dorsal Rhizotomy
  • 17. Oral Medications
    • Benzodiazepams:
      • Most commonly Diazepam (Valium): Spasticity
    • Lioresal (Baclofen): Spasticity/Dystonia
    • Dantrolene sodium (Dantrium): Spasticity
    • Tizanidine (Zanaflex): Spasticity
    • Gabapentin (Neurontin): Spasticity
    • Carbidopa/L-Dopa: Dystonia
    • Trazodone: Dystonia
    • Bromocriptime (Dystonia)
  • 18. Benzodiazepams
    • Mechanism of action:
      • Enhance GABA inhibitory neurons (GABA a receptors)
    • Advantages:
      • First spasticity med available therefore still used by older patients, especially SCI
      • Good if sleep disturbance by spasticity
      • Good if anxiety component
      • Inexpensive
    • Disadvantages:
      • Excessive sedation and cognitive impairments
      • Potentially addictive; physical tolerance; difficulty weaning off- long taper needed to avoid withdrawl
      • Has street value
  • 19. Lioresal (Baclofen)
    • Mechanism of action:
      • Modified form of GABA which works pre-synaptically to decrease release of excitatory transmitter
    • Advantages
      • More selective than valium therefore a first line drug of choice for spasticity
      • Inexpensive
    • Disadvantages
      • Sedation, weakness, fatigue
      • Acute withdrawl associated w/ sz, hallucinations
  • 20. Dantrolene sodium (Dantrium)
    • Mechanism of action:
      • Peripherally acting (at level of muscle) by directly suppressing release of calcium ions from muscle sarcoplasmic reticulum thereby decreasing contractility and force
    • Advantages:
      • More selective
      • Less hypotension
      • Effective for spasticity and pain
    • Disadvantages
      • Affects all skeletal muscle
      • Weakness
      • Nausea
      • Less sedating (in theory)
      • Potential liver toxicity (2-3%)
  • 21. Tizanidine (Zanaflex)
    • Mechanism of action:
      • Centrally acting Alpha 2- noradrenergic agonist acting primarily to decrease polysynaptic reflex activity
    • Similar to clonidine within same family
    • Advantages:
      • More selective
      • Less hypotension
      • Less weakness
      • Effective for spasticity & pain; as well as spasticity & sleep impairment
    • Disadvantages
      • Expensive
      • Sedation
      • Increased liver enzymes (up to 5%); therefore LFTs need to be followed
  • 22. Gabapentin (Neurontin)
    • Action:
      • GABA ‘b’ agonist
      • Has both pre- and post-synaptic actions
      • Inhibits calcium influx to presynaptic 1a terminal thereby decreasing release of excitatory neurotransmitters
    • Advantages
      • Great for combination pain and spasticity
    • Disadvantages
      • Expensive
      • Sedation, weakness, fatigue
  • 23. Botulinum toxin
      • Appropriate for focal spasticity
      • More effective in smaller muscles
      • Possible antibody formation- rec. not injecting any sooner than 3 months between injections
      • Prior authorization process needed: all spasticity ‘off-label’ use
      • Typical max dose per session: 400-500 units
      • If initial injections and Botox naïve: start lower
      • Have seen upwards of 1000 units per session- rare practitioner
      • Peak effect: 7-10 days post-injections
  • 24. Phenol
    • Appropriate for focal spasticity management
    • Chemical destruction of selective motor endings
    • May cause pain/dysesthesias in mixed motor/sensory nerves (up to 15% chance)
    • Needs compounding pharmacy
      • Typical 3-5% mixture
      • If specialty trained and comfortable- up to 7%
    • Typical max use per session= 20 cc
    • Cheap compared to Botox
    • Can re-inject often if needed for optimal effect
    • No need for prior authorization
    • Need more technical skill to do than Botox
    • More time consuming
    • Immediate effect
  • 25. Intrathecal Baclofen Pump
    • Indications:
      • Spasticity that interferes with function; painful; or interferes with cares
      • Failure to respond or tolerate other more conservative approaches
      • Able to geographically access care
      • Reasonable expectations
      • Responds to test ITB dose with decrease in MAS or spasm frequency; reduction of pain
      • Informed consent
      • Extensive prior authorization process
  • 26. Intrathecal Baclofen Pump
    • Post-op management
    • Maintenance
    • Problem Solving