Spasticity after stroke

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  • 1. Spasticity After Stroke Adeagbo, Caleb A B.Physiotherapy (Lagos) Department of Physiotherapy, National Hospital, Abuja8/20/2012 1
  • 2. Outline Introduction Definitions  Measurement Types of Tools spasticity  Treatment Pathophysiology  Conclusion Other Types of  References Hypertonicity Advantages of Spasticity8/20/2012 2
  • 3. Introduction Stroke is the leading cause of morbidity and mortality (Lundstrom et al, 2008; Urban et al, 2012). Spasticity is a common complication of stroke that lead to impaired gait characteristics in the upper and lower extremities (Karadag-Saygi et al, 2010).8/20/2012 3
  • 4. Introduction cont Optimum management of spasticity is dependent on an understanding of its underlying physiology, an awareness of its natural history, an appreciation of the impact on the patient and a comprehensive approach to minimizing that impact which is both multidisciplinary and consistent over time (Thompson et al, 2012).8/20/2012 4
  • 5. Definitions Stroke is an acute/sudden focal/global disturbance of the cerebral function with symptoms lasting for more than 24hours or sometimes leading to death with no other cause than vascular origin.8/20/2012 5
  • 6. Definitions cont Spasticity (meaning to draw or tug) Spasticity is abnormal muscle tone recognized clinically as resistance to passive muscle stretch which increases with velocity of stretch. It is defined as a motor disorder characterized by velocity dependent increase in tonic stretch reflexes with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex 8/20/2012 6
  • 7. Types of spasticity LEAD PIPE: presents as a uniform resistance to movement throughout the range of movement. COGWHEEL: presents as an intermittent on/off resistance throughout the range of movement, making the movements jerky. CLASP KNIFE: presents as increase in extensors of a joint when its passively flexed given way suddenly on exertion of further pressure. 8/20/2012 7
  • 8. Pathophysiology The pathophysiologic basis of spasticity is incompletely understood. Spasticity is loss of inhibitory control over the gamma motor neuron This inhibitory influence is in turn controlled by descending and peripheral inputs.8/20/2012 8
  • 9. Pathophysiology contd Lack of descending control over spinal cord interneuronal circuits results in a decrease in the effectiveness of spinal inhibitory circuits such as those mediating reciprocal, presynaptic, and recurrent inhibition.8/20/2012 9
  • 10. Pathophysiology contd  The changes in muscle tone probably result from  alterations in the balance of inputs from reticulospinal and other descending pathways to the motor and interneuronal circuits of the spinal cord  the absence of an intact corticospinal system.8/20/2012 10
  • 11. Pathophysiology contd Loss of descending tonic or phasic excitatory and inhibitory inputs to the spinal motor apparatus, alterations in the segmental balance of excitatory and inhibitory control denervation supersensitivity neuronal sprouting8/20/2012 11
  • 12. Other Types of Hypertonicity  RIGIDITY - Involuntary, bidirectional, non–velocity-dependent resistance to movement  CLONUS - Self-sustaining, oscillating movements secondary to hypertonicity  DYSTONIA - Involuntary, sustained contractions resulting in twisting, abnormal postures  ATHETOID - Involuntary, irregular, confluent writhing movements 8/20/2012 12
  • 13. Other Types of Hypertonicity contd CHOREA - Involuntary, abrupt, rapid, irregular, and unsustained movements BALLISMS - Involuntary flinging movements of the limbs or body TREMOR - Involuntary, rhythmic, repetitive oscillations that are not self-sustaining8/20/2012 13
  • 14. Advantages of Spasticity Maintenance of Muscle tone or Muscle Bulk Tone Effect on Mobility Tone effect on ADLs Improved Circulation Prevention of DVT May assist with postural control8/20/2012 14
  • 15. Measurement Tools Ashworth scale Modified Ashworth scale: Spasm frequency Reflex scale Pain scale8/20/2012 15
  • 16. Ashworth scale 0 – no increase in tone 1 – slight increase in tone given a catch 2 – more marked increase in tone 3 – considerable increase in tone PM difficult 4 – limb rigid in flexion and extension (Ashworth scale, 1964)8/20/2012 16
  • 17. Modified Ashworth Scale0 = no increase in muscle tone1 = slight increase in muscle tone (catch or min resistance at end range)1 + = slight increase in muscle resistance throughout the range.2 = moderate increase in muscle tone throughout ROM, PROM is easy3 = marked increase in muscle tone throughout ROM, PROM is difficult4 = marked increase in muscle tone, affected part is rigid (Bohannon & Smith 1987)8/20/2012 17
  • 18. Spasm FrequencySpasm Frequency Scale: How many spasms in the last 24 hours in the affected extremity?0 = no spasms1 = 1 / day2 = 1-5/ day3 = 5-9 / day4 = >10/day (Penn et al, 1989)8/20/2012 18
  • 19. Pain scale Numerical rating pain intensity scale: a verbal analogue scale. Scale 0 – 10 (Kremer et al, 1981).8/20/2012 19
  • 20. Treatment Goals  Improve functional ability, Quality of Life and Mobility  Decrease pain associated with spasticity  Prevent or decrease incidence of contractures  Ease of care are possible  Decrease Cost of Care  Facilitate hygiene  Ease rehabilitation procedures8/20/2012 20
  • 21. 8/20/2012 21
  • 22. Remove noxious stimuli Identify the “triggering” stimulus Eliminate the factors that increase sensory input to the central nervous system8/20/2012 22
  • 23. Rehabilitation therapy Positioning  EMG biofeedback Joint mobilization  Electrical Stretching stimulation Strengthening  Orthotics Exercises  Splinting- Modalities: static/dynamic Cryotherapy,  Casting: Hydrotherapy, including serial Thermotherapy casting Soft tissue manipulation8/20/2012 23
  • 24. Oral medications Lioresal: Baclofen Benzodiazepams: Diazepam (Valium) Dantrolene Sodium Tizanidine Gabapentin (Neurontin)8/20/2012 24
  • 25. NeurolysisBotulinum toxin InjectionsPhenol Injections8/20/2012 25
  • 26. Orthopedic approach Tenotomy Tendon lengthening Myotomy Tendon transfers8/20/2012 26
  • 27. Neurosurgical approach Neurectomy Myelotomy/Cordectomy/ Chordotomy Rhizotomy Selective Dorsal Rhizotomy Implantable dural electric stimulator Intrathecal Baclofen Pump8/20/2012 27
  • 28. Conclusions While spasticity management can be difficult, it may also improve patient’s quality of life Spasticity is not necessarily the enemy, but is part of a pattern of abnormal motor control The choice of treatment depends on pattern of involvement8/20/2012 28
  • 29. References Akosile CO, Fabunmi AA (2011). Pathophysiology, Functional Implications and Management of Spasticity in Stroke – A Review. AJPARS 3(1):6-12 Ashworth B (1964). Preliminary trial of crisoprodol in multiple sclerosis. The practitioners 192:540-2 Bohannon RW, Smith MB (1987). Interrater reliability of a modified Ashworth scale of muscle spasticity. PhysTher 67: 206-7.8/20/2012 29
  • 30. References cont Karadag-Saygi E, Cubukcu-Aydoseli K, Kablan N, Ofluoglu D (2010). The role of Kinesiotaping combined with Botulinum Toxin to reduce plantar flexors spasticity after stroke. Top Stroke Rehabil; 17(4):318–322 Lundstromac E, Terentb A, Borgc J (2008). Prevalence of disabling spasticity 1 year after first-ever stroke. European Journal of Neurology 15: 533–5398/20/2012 30
  • 31. References cont  Urban PP, Wolf T, Uebele M, Marx JJ, Vogt T, Stoeter P, Bauermann T, Weibrich C, Vucurevic GD, Schneider A, Wissel J (2010). Occurence and Clinical Predictors of Spasticity after Ischemic Stroke. Stroke 41:2016-2020  Thompson AJ, Jarrett L, Lockley L, Marsden J, Stevenson VL (2012). Clinical management of spasticity. Available @ www.jnnp.bmj.com Retrieved on August 06 2012, Published by group.bmj.com8/20/2012 31
  • 32. Thank you Questions &contributions8/20/2012 32