Spasticity in Stroke and Brain Injury Patients

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This presentation summarizes the problem of spastic hand and arm problems in patients who have had strokes or traumatic brain injury. Some surgical considerations are reviewed for specific problems.

This presentation summarizes the problem of spastic hand and arm problems in patients who have had strokes or traumatic brain injury. Some surgical considerations are reviewed for specific problems.

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  • origins of the flexor pollicis brevis, opponens pollicis, and abductor pollicis muscles are detached from their origins while protecting the recurrent branch of the median nerve.














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  • 1. Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 2. STROKE AND BRAIN INJURY SURGICAL CONSIDERATIONS C. NOEL HENLEY, MD OZARK ORTHOPAEDICS - HAND AND ARM SURGERY August 24th, 2010
  • 3. SUMMARY defining the problem phases or periods of recovery surgery as a rehabilitation tool surgery - timing and expectations examples of surgical options for the spastic hand Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 4. STROKE SCOPE OF THE PROBLEM cause of 200,000 deaths per year - U.S. 250,000 survivors each year thrombosis = most common cause arteriosclerosis = most important risk factor Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 5. STROKE IMPAIRMENT cognitive clinically similar to senility/dementia aphasia - cannot understand instructions apraxia - cannot perform a previously learned action Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 6. STROKE IMPAIRMENT sensory loss of touch sensation, vision disturbances; range from mild to severe motor period of flaccid paralysis - followed by increased muscle tone voluntary movement returns in proximal muscle groups and moves distally Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 7. BRAIN INJURY SCOPE OF THE PROBLEM approximately 500k new cases each year in the US 11% of these will die shortly after injury good or moderately good neurologic recovery for 80% of the survivors mostly occurs in patients younger than flickr.com - artfulblogger 45 Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 8. BRAIN INJURY PREDICTORS OF OUTCOME age Glasgow Coma Scale duration of coma brain stem involvement duration of post-traumatic confusion Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 9. BRAIN INJURY ROLE OF THERAPISTS IN SUSPECTING FRACTURES/INJURIES missed fractures missed peripheral nerve injuries early fixation/repair may prevent substantial disability later on Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 10. PERIODS/PHASES OF RECOVERY
  • 11. STROKE/BRAIN INJURY PERIOD OF ACUTE INJURY goal is medical stabilization therapists may be involved early for splinting the hand, wrist or elbow to prevent deformity flickr.com - rafahkid Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 12. STROKE/BRAIN INJURY PERIOD OF PHYSIOLOGIC RECOVERY may last for up to 18 months patient commonly in a rehabilitation facility maximum motor control usually regained by 6 months Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 13. STROKE/BRAIN INJURY PERIOD OF PHYSIOLOGIC RECOVERY dangers of spasticity may prevent adequate joint ROM interferes with joint and limb positioning force required for PROM may be too painful in the face of spasticity peripheral neuropathies may result from pressure or positioning (CTS, CuTS) Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 14. STROKE/BRAIN INJURY PERIOD OF PHYSIOLOGIC RECOVERY temporary control of spasticity and preventing complications is a major focus of treatment in this subacute phase Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 15. STROKE/BRAIN INJURY PERIOD OF FUNCTIONAL ADAPTATION TO RESIDUAL DEFICITS usually neurologically stable after six months definitive decisions on surgery or bracing can be made time of greatest contribution by the reconstructive surgeon and post-op therapy Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 16. STROKE/BRAIN INJURY PERIOD OF FUNCTIONAL ADAPTATION TO RESIDUAL DEFICITS weigh early surgery with risks of waiting on improved motor control more contractures osteopenia nerve compression muscle atrophy immobility/pressure sores Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 17. GENERAL THERAPY MEDICATIONS ORTHOTICS baclofen casting dantrolene dynamic splints NEUROSURGICAL PROCEDURES NERVE BLOCKS intrathecal baclofen neurolytic blocks phenol rhizotomy alcohol Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 18. SURGERY
  • 19. MUSCULOSKELETAL RECONSTRUCTIVE SURGERY AS A REHABILITATION TOOL extremities, musculoskeletal system, and brain musculoskeletal system gives mobility to the brain the brain and mind interact with the world, positioned by the extremities and musculoskeletal system independent mobility and function are foundational to human life and well-being Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 20. MUSCULOSKELETAL RECONSTRUCTIVE SURGERY AS A REHABILITATION TOOL balance of cognitive, behavioral, and physical well-being after brain injury/stroke musculoskeletal limitations can be devastating for patients improvement in physical mobility and function is therapeutic in emotional, cognitive, and behavioral spheres Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 21. MUSCULOSKELETAL RECONSTRUCTIVE SURGERY AS A REHABILITATION TOOL wellness promotion among the physically disabled maximizing function and mobility to avoid complications of chronic incapacity infection pain social isolation physical/emotional dependence these benefits also accrue to the patient’s family in a real sense Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 22. MUSCULOSKELETAL SURGERY TIMING AND EXPECTATIONS should be performed early, before deformities are severe and fixed effects of therapy, injections, and systemic medications may be beneficial, but are temporary surgery is a powerful rehabilitation tool that creates permanent change in muscle tone and force direction Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 23. MUSCULOSKELETAL SURGERY TIMING AND EXPECTATIONS results of surgery are improved when deformities are corrected early maximum muscle strength is preserved less muscle lengthening is needed when deformity is mild scar-producing joint releases are rarely needed ligament flexibility and cartilage integrity is preserved patients may be in better physiologic and nutritional condition early in their rehabilitation process Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 24. MUSCULOSKELETAL SURGERY TIMING AND EXPECTATIONS assessing volitional control is critical pre-operatively amount of improvement correlates with residual motor control, not with severity of deformity extremity function versus patient function/quality of life surgical release of a contracted arm in a hemiplegic patient may allow her to dress independently, though the arm remains “nonfunctional” Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 25. MUSCULOSKELETAL INDICATIONS voluntary use will the patient use the hand in ADLs, even as a functional assistant? Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 26. MUSCULOSKELETAL INDICATIONS cognitive ability patient and family must understand goals follow commands cooperate with postoperative therapy able to incorporate the improved motor function into hand use adequate memory to retain knowledge taught in therapy Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 27. MUSCULOSKELETAL INDICATIONS sensibility pain, light touch, temperature two point discrimination is a good screening test age hand placement test in hemiplegic patients Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 28. MUSCULOSKELETAL PRE-REQUISITES FOR ACTIVE FUNCTION PROCEDURES obey simple commands cooperate with therapy after surgery retain what is taught from session to session assimilate newly learned activities into daily activities Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 29. MUSCULOSKELETAL PRE-REQUISITES FOR ACTIVE FUNCTION PROCEDURES intact pain, light touch, temperature sensation; 2PD <10 mm; kinesthetic awareness (reproduces body positions) +spontaneous extremity use +volitional motor control of affected extremity Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 30. DEFORMITIES
  • 31. DEFORMITIES BIRD’S EYE VIEW shoulder adduction + internal rotation spasticity elbow flexion spasticity wrist and finger flexion spasticity intrinsic spasticity Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 32. DEFORMITIES BIRD’S EYE VIEW shoulder adduction + internal rotation spasticity elbow flexion spasticity wrist and finger flexion spasticity intrinsic spasticity Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 33. DEFORMITIES SPASTIC CLENCHED FIST unmasking of primitive grasp reflex fingernails may dig into the palm good hygiene may be difficult pain with manipulation Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 34. DEFORMITIES SPASTIC CLENCHED FIST FDS/FDP contribute to deformity Intrinsic contracture may be masked by extrinsic spasticity chemodenervation may be useful early surgery fractional lengthening (if volitional motor control is present) superficialis to profundus transfer if not Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 35. DEFORMITIES SPASTIC CLENCHED FIST - SURGERY fractional lengthening division of the palmaris longus incising tendon fibers at the musculotendinous juntion (FDS/P) tendons FPL allows tendons to lengthen with minimal scarring from incision or sutures pronator or wrist flexor lengthening may also be performed Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 36. FRACTIONAL LENGTHENING
  • 37. DEFORMITIES SPASTIC CLENCHED FIST - SURGERY fractional lengthening post-operatively prevent hyperextension of wrist with a volar wrist splint active/active assist finger ROM on first post-op day release passive surgical procedure risk of hyperextension/overpull of extensors Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 38. DEFORMITIES SPASTIC CLENCHED FIST - SURGERY superficialis to profundus tendon transfer advantages over release more pleasing hand position at best: mass action grasp pattern at least: restraint to extension Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 39. DEFORMITIES SPASTIC CLENCHED FIST - SURGERY superficialis to profundus tendon transfer volar approach palmaris transected four FDS tendons sutured together distally then cut four FDP tendons sutured together proximally, then cut with the fingers extended, the distal ends of FDS are sutured to the proximal ends of FDP (FDP tendons motored by the FDS) Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 40. SUPERFICIALIS TO PROFUNDUS TRANSFER
  • 41. DEFORMITIES SPASTIC THUMB-IN-PALM DEFORMITY heterogeneous appearance spastic muscles = FPL, adductor pollicis, thenar muscles (FPB) Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 42. DEFORMITIES SPASTIC THUMB-IN-PALM DEFORMITY - SURGERY FPL fractional lengthening thenar muscle slide thumb IP joint stabilization Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 43. DEFORMITIES SPASTIC THUMB-IN-PALM DEFORMITY - SURGERY Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 44. DEFORMITIES SPASTIC THUMB-IN-PALM DEFORMITY - SURGERY first dorsal interosseous may be contracted and require release first web contracture may require z- plasty of the web space therapy post-op active therapy started after three weeks of immobilization Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 45. DEFORMITIES INTRINSIC SPASTICITY look for swan neck or boutonniere deformities may be painful and disfiguring intrinsic tightness test positive when PIP flexion is decreased (tighter) with the MCPs extended (with the intrinsic tendons on stretch) Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 46. DEFORMITIES INTRINSIC SPASTICITY overpull of extrinsic extensors combined with spastic intrinsic muscles Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 47. DEFORMITIES INTRINSIC SPASTICITY dynamic EMG and diagnostic nerve blocks may be helpful in these patients spasticity versus contracture Ex: spastic intrinsics will relax with ulnar motor nerve denervation; contracted muscle-tendon units will not relax unless cut/released/lengthened Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 48. DEFORMITIES INTRINSIC SPASTICITY - SURGERY intrinsic release done if intrinsic contracture present after extrinsic flexor release/STP transfer complete intraoperatively done at level of MCP joints fingers held in safe position after this release for two weeks with gentle ROM of MCPs after splint removal recurrent intrinsic-plus deformity (safe position) is common, so ulnar motor neurectomy is usually performed at the same time Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 49. INTRINSIC RELEASE, NEURECTOMY
  • 50. DEFORMITIES INTRINSIC SPASTICITY - SURGERY neurectomy - ulnar nerve motor branch to prevent intrinsic spasticity (intrinsic plus hand) now that extrinsic flexors are not spastic, intrinsic spasticity may be unmasked Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 51. CONCLUSION Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 52. CONCLUSION phases of recovery are critical Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 53. CONCLUSION phases of recovery are critical surgery may be more successful early in the course of recovery and rehabilitation Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 54. CONCLUSION phases of recovery are critical surgery may be more successful early in the course of recovery and rehabilitation accurate assessment of pre-operative function is mandatory for success Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 55. CONCLUSION phases of recovery are critical surgery may be more successful early in the course of recovery and rehabilitation accurate assessment of pre-operative function is mandatory for success therapists are intimately involved during all stages! Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 56. ACTION STEPS Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 57. ACTION STEPS Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com
  • 58. ACTION STEPS join my Hand and Arm Therapy Digest e- mail list - drhenley@gmail.com THANKS! Stroke and Brain Injury Spasticity - Surgical Considerations www. noelhenley.com