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Spasticity After Stroke


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Spasticity After Stroke

  1. 1. Spasticity After Stroke Heather Walker, M.D. Assistant Professor Department of Physical Medicine & Rehabilitation UNC-Chapel Hill
  2. 2. What is a physiatrist??? <ul><li>NOT a physical therapist </li></ul><ul><li>NOT a psychiatrist </li></ul><ul><li>Education: </li></ul><ul><ul><li>Four years medical school </li></ul></ul><ul><ul><li>Four years residency </li></ul></ul><ul><ul><li>+/- Fellowship Training </li></ul></ul><ul><li>Take care of patients with disabilities </li></ul><ul><ul><li>Stroke, traumatic brain injury, spinal cord injury, amputations, burns, pediatrics, etc. </li></ul></ul><ul><ul><li>Goal is to improve function and quality of life </li></ul></ul>
  3. 3. Physiatrists and Stroke <ul><li>Medical management during acute inpatient rehabilitation and as an outpatient </li></ul><ul><ul><li>Blood pressure </li></ul></ul><ul><ul><li>Bowel and bladder dysfunction </li></ul></ul><ul><ul><li>Skin </li></ul></ul><ul><ul><li>Language impairments </li></ul></ul><ul><ul><li>Cognitive and attentional impairments </li></ul></ul><ul><ul><li>SPASTICITY </li></ul></ul>
  4. 4. What is spasticity?? <ul><li>“ a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex…” </li></ul><ul><ul><ul><ul><li>???????????????????????? </li></ul></ul></ul></ul>
  5. 5. Spasticity can be defined as increased tightness in affected muscles
  6. 6. What is spasticity?? <ul><li>Increased tightness in muscles </li></ul><ul><ul><li>Chest wall  Difficulty raising arm to the side, putting on clothing </li></ul></ul><ul><ul><li>Elbow flexors  Difficulty straightening arm to reach for items or dressing </li></ul></ul><ul><ul><li>Wrist flexors </li></ul></ul><ul><ul><li>Finger flexors  Difficulty opening hand voluntarily or passively (releasing items, hand hygiene) </li></ul></ul>
  7. 7. What is spasticity?? <ul><li>Increased tightness in muscles </li></ul><ul><ul><li>Hamstrings  Difficulty straightening leg </li></ul></ul><ul><ul><li>Quadriceps  Stiff-knee gait </li></ul></ul><ul><ul><li>Calf muscles  Difficulty clearing toes when walking (tripping), foot turns in when walking </li></ul></ul><ul><ul><li>Inner thighs  Legs cross over each other when walking, difficulty pulling legs apart for hygiene </li></ul></ul>
  8. 8. Upper Extremity Spasticity
  9. 9. Lower Extremity Spasticity
  10. 10. Spasticity Complications <ul><li>Positioning </li></ul><ul><li>Hygiene </li></ul><ul><li>ADLs </li></ul><ul><li>Sitting or Standing Balance </li></ul><ul><li>Contractures </li></ul>
  11. 11. Treatment Goals <ul><li>Improvements in position </li></ul><ul><li>Mobility </li></ul><ul><li>Pain </li></ul><ul><li>Contracture prevention </li></ul><ul><li>Ease of care are possible </li></ul>
  12. 12. Spasticity Management Steps <ul><li>Therapeutic modalities </li></ul><ul><li>Oral Medications </li></ul><ul><li>Nerve blocks & Chemical neurolysis (Botox injections) </li></ul><ul><li>Orthopedic procedures </li></ul><ul><li>Intrathecal Medications </li></ul>
  13. 13. Prior to Intervention <ul><li>Assess baseline status </li></ul><ul><li>Determine specific goals </li></ul><ul><li>Patient and family education </li></ul><ul><li>PT and OT role after intervention </li></ul>
  14. 14. Therapeutic Exercise <ul><li>Stretching and range of motion </li></ul><ul><li>Myofascial and joint mobilization </li></ul><ul><li>Active assistive, active and resistive exercise </li></ul><ul><li>Endurance training </li></ul>
  15. 15. Oral Medications <ul><li>Zanaflex </li></ul><ul><ul><li>Adverse effects: drowsiness , dizziness, dry mouth, orthostatic hypotension </li></ul></ul><ul><li>Baclofen </li></ul><ul><ul><li>Adverse effects: weakness, sedation , hypotonia, ataxia, confusion, fatigue, nausea, dizziness, lower seizure threshold </li></ul></ul><ul><ul><li>Sudden withdrawal may cause seizures, hallucinations, rebound spasticity </li></ul></ul><ul><li>Dantrium </li></ul><ul><ul><li>Adverse effects: weakness (including ventilatory muscles), drowsiness , lethargy, nausea, diarrhea, Liver toxicity </li></ul></ul>
  16. 16. Botulinum Toxin Type A (BOTOX ® ) : History of Development 1944 1920s 1895 Botulinum toxin type A first isolated Dr. Schantz begins investigation C. botulinum identified Dr. Scott initiates first therapeutic testing in humans 1978 1989 FDA approval of BOTOX ®
  17. 17. BOTOX ® (Botulinum Toxin Type A): A Focal Therapeutic <ul><li>Injected directly into overactive muscles </li></ul><ul><li>Reduces contractions, relaxes muscles </li></ul><ul><li>Advantages of local injection </li></ul><ul><ul><li>Targeted to specific muscles that are causing the symptoms </li></ul></ul><ul><ul><li>When used at recommended doses, avoids systemic, overt distant clinical effects </li></ul></ul><ul><li>NOT FDA APPROVED FOR SPASTICITY </li></ul>
  18. 18. Muscle identification <ul><li>Three main methods </li></ul><ul><ul><li>Exam and anatomic atlas </li></ul></ul><ul><ul><li>EMG assistance and guidance </li></ul></ul><ul><ul><li>Electronic stimulation </li></ul></ul>
  19. 20. Side Effects <ul><li>Localized </li></ul><ul><li>Hematoma and bruising are seen regardless of the site injected </li></ul><ul><li>Local weakness, created by diffusion of Botox and is site specific </li></ul><ul><li>Death??? </li></ul>
  20. 21. Intrathecal Baclofen <ul><li>Small doses of baclofen delivered directly to the spinal canal </li></ul><ul><li>Fewer side effects, better relief of spasticity </li></ul><ul><li>Usually more effective for spasticity in the lower extremities </li></ul><ul><li>Requires committed patient and family, pump must be refilled every 3 months. </li></ul>
  21. 22. Intrathecal Baclofen
  22. 23. Surgical Procedures <ul><li>Tendon lengthening </li></ul><ul><li>Neurosurgical procedures </li></ul><ul><li>Last resort! </li></ul>
  23. 24. Take Home Points…. <ul><li>Spasticity is common after stroke, and is manifested as muscle tightness in the affected arm and/or leg. </li></ul><ul><li>Several different treatment options are available, including therapies, oral medications and injections. </li></ul><ul><li>If you suffer from spasticity you should be seen by a physiatrist who specializes in spasticity management. </li></ul>
  24. 25. QUESTIONS???