Spasticity Management 1 5 2007


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Spasticity Management 1 5 2007

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