Spaticity s troke hand clinic nov 2019
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Design, Development and piloting a new care pathway for stroke spasticity a multidisciplinary approach
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Spaticity s troke hand clinic nov 2019
- 1. Tong Pei-Yein, Rachel Law, Lim Hai Fon, Ang ML, Tham HL, Jasmyn A, Sim J, Chen ZY, Rajaratnam V
- 2. Stroke-Hand Surgery Service • Outpatient-based • Multidisciplinary team • For the management of post-stroke spasticity, in the upper and lower limbs
- 3. Post-stroke Spasticity • 67,289 episodes of stroke were admitted to public hospitals in the period 2005-20151: >6000/year • Largest cause of long-term physical disability2 • Prevalence of spasticity : 33-50% 3 • Lower functional ability at 12 months 3 1. Singapore Stroke Registry Annual Report 2015 2. Singapore National Stroke Association 3. Kong et al: Occurrence and Temporal Evolution of Upper Limb Spasticity in Stroke Patients Admitted to a Rehabilitation Unit. Arch Phys Med Rehabil 2012 Jan;93(1):143-8
- 4. Pathophysiology Li S and Francisco GE (2015) New insights into the pathophysiology of post-stroke spasticity. Front. Hum. Neurosci. 9:192 A motor disorder characterized by a Velocity-dependent, Increase in tonic stretch reflexes With exaggerated tendon jerks Resulting from hyperexcitability of the stretch reflex
- 5. Problems with spasticity • Pain • Fatigue, inconvenient involuntary motion • Functional limitations • Contractures • Skin maceration • Poor self image
- 7. Multidisciplinary team approach required Need for an integrated care pathway for these patients Neurologist Surgeon Specialty nurse Rehab physician + therapists
- 8. Design and Development Model Design Identify the problem Recruit expert panel Design solutions Develop Prototype Gather consensus Review and redesign Validate Pilot Review Roll out 8
- 9. Spasticity care pathway Referral sources: Post inpatient discharge, Outpatient Stroke-Hand clinic General spasticity Regional and focal spasticity Oral agents Therapist: Exercises and Splints Determine Contracture Versus Spasticity SpasticityContracture ● Lengthening procedures ● FDS to FDP transfer ● Osteotomy ● Arthrodesis Patient has volitional control? No ● Observe ● Prevent contracture Botox injectionYes Improvement seen ● Hyperselective neurectomy ● Tendon transfer No improvement ● Observe ● Repeat Botox ● Contracture release
- 10. Aims: Improve function, reduce pain, improve posture/ care Treatment objectives a. Reduce tone b. Improve range of motion b. Improve joint position c. Select cases for neurectomy Improve Function 1. Reduce spasm frequency 2. Pain relief 3. Improve gait, ADLs, hygiene, ease of care For the patient and caregiver 1. Improve appearance 2. Improve self- confidence 3. Improve independence
- 11. Referral Criteria Spasticity in upper / lower limb from • Cerebrovascular accidents • Brain / Spinal cord injury • Traumatic • Atraumatic • Neurodegenerative disorders • Multiple sclerosis • Amyotrophic lateral sclerosis Medically stable to undergo an elective procedure in an outpatient setting
- 12. Patient selection Inclusion criteria • Hemiplegia or monoplegia • Has good prognosis for recovery • Functionally good ( some volition/Botox trial/House) Exclusion criteria • Bedbound patients (except for hygiene and nursing purposes)
- 13. Evaluation • General examination • Evaluation tools • Assessment scales • Investigations • Botox Trial • Expectations • ?Radiographs • ?Dynamic EMG • ?Nerve blocksGreen’s Operative Hand Surgery 7th Edition
- 14. Botulinum Toxin-Type A To FDS muscle
- 15. Non-surgical 1. Tone reduction modalities a. Medications: muscle relaxants such as baclofen, benzodiazepines b. Injections: Botox 2. Physical Therapy a. Stretching b. Adaptive strategies and devices c. Incorporation of spastic limb in ADLs d. Post-op: immobilization, mobilization, incorporation 3. Orthoses Surgical 1. Tendon/ muscle procedures a. Muscle/tendon lengthening i. Fractional lengthening ii. Z lengthening iii. Muscle slide b. Tendon transfers 2. Joint/Bone procedures a. Arthrodesis b. Osteotomy 3. Nerve procedures a. Neurectomy 4. Amputations
- 17. - Reduce spasticity in target muscles Technique: • Follows motor ramus until entry point into target muscle Improves • Selectivity • Widespread partial denervation • Durability of results
- 18. • Systematic review: 7 studies, 174 patients • Percentage of fascicles ablated between 30-80% • Length of neurectomy: 5-10mm • Remove end branches vs fascicular selective neurectomy proximally • All had improvement in spasticity • Recurrence rate: 0-16.1%
- 19. 17 Stroke 6 received Botox 3 underwent HSN 1 underwent tendon lengthening 22 patients 3 Focal dystonia2 CP • 12 Male, 5 Female • Mean age 62.9 years • Reviewed average 9months post-stroke 2 received Botox 1 underwent HSN 1 received Botox 1 underwent HSN
- 20. Hyperselective Neurectomy (HSN) Upper limb 1. Biceps 1 2. FCU 1 3. FCR 1 4. FDS 4 5. FPL 2 6. PT 2 Lower limb 1. FDL 2 2. FHL 2 3. Gastrocnemius 1
- 22. FCU Neurectomy
- 23. FCR Neurectomy
- 25. FDS Neurectomy Nerve stimulation for identification of FDS fascicles • Interfascicular dissection • Select branches for neurectomy (nerve stimulation) • Neurectomy (1-2cm): 2 out of 3 branches
- 26. FPL
- 28. Right LL: • FDL, FHL spasm • Severe spasm on certain days • Causes clawing of toes and pain • Coping with gait fairly well with orthosis • FHL and FDL spasticity when he walks
- 29. FHL
- 33. Patient Procedure performed Pre- surgery MAS Post-surgery MAS 1 HSN Biceps 3 Biceps 1 2 HSN FDS 3 FPL 2 PT 3 FDL 3 FHL 3 FDS 2 FPL 1 PT 2 FDL 1 FHL 1 3 HSN Tenotomy • Abductor hallucis FDS 3 FPL 3 FHL 3 FDL 3 FDS 2 FPL 1 FHL 1 FDL 1 4 (Lengthening) Z-lengthening Fractional FPL 3 FDS 4 FPL 0 FDS 3 0 0.5 1 1.5 2 2.5 3 3.5 Pre Post Average Modified Ashworth Scale Average MAS 56% improvement in spasticity score
- 34. Patient Procedure performed Hand Function (House) Pre/Post Patient satisfaction (Good/Fair/Poor) 1 HSN biceps 8/8 Good 2 HSN FDS, FPL, PT FDL, FHL 2/2 Poor (UL) Good (LL) 3 HSN FDS, FPL, FHL, FDL Tenotomy • Abductor hallucis 1/1 Fair (UL) Good (LL) 4 (Lengthening) Z-lengthening Fractional 8/8 Poor
- 35. Conclusions • Evolving management strategies • Simpler assessment instruments • Robust patient experience outcome measures • More interactions among stroke MDT • *Counselling • *Education & raise awareness (patients and physicians)
- 37. Welcome to Singapore for the 2023 APFSSH & APFSHT meeting! www.apfssh2023.org Proposed dates: 17-20 May 2023 (Wed to Saturday) OR 24-27 May 2023 (Wed to Saturday)
Editor's Notes
- Result of hyperexcitability of the stretch reflex Secondary to damage to the neurons of the corticospinal tracts, Loss of inhibitory supraspinal influences Characterised by Velocity-dependent increase in tonic stretch reflexes (“muscle tone”) With exaggerated deep tendon reflexes Complex problem Need for an integrated care pathway for these patients Post Stroke Spasticity Pathway developed using expert panel Requires MDT approach for optimum treatment
- MDTs are seen to be effective in Asian contexts of chronic stroke management, like that of Japan’s Stroke Rehabilitation Unit (SRU) in Bobath Memorial Hospital, Osaka. And in Korean contexts as well. No surgeons involved Evidence– rehab paper
- Volition, house , 6 patients received Botox injection 3 patients underwent hyperselective neurectomy in upper limb 1 patient with contractures underwent tendon lengthening procedure
- Nerve stimulation
- Hand function based on house classn; no improvement
- Multidisciplinary team approach ensures seamless process for stroke patients with problems of upper limb spasticity Highly selective neurectomy useful technique to relieve spasticity while preserving function Need for authentic and patient experienced outcome measures Effect for neurectomies Cognitive load in spasticity