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SPASTICITY MANAGEMENT CLINIC AT MHRI
Spasticity occurs in many neurological illnesses that affect the central nervous system, including stroke, brain or spinal cord injury, cerebral palsy and multiple sclerosis. Spasticity is treatable !!! using a multimodal form of treatment – thus a clinic. Our clinic specializes in assessing and treating patients with spasticity that interferes with functional ability. Our objective in these patients is to o improve gait, o hygiene, o ability to perform activities of daily living, o ease of care, and o to decrease pain and frequency of spasm. ←
What is spasticity?
“Spasticity” • Disorder of muscle tone due to injury of CNS • upper motor neuron syndrome
• Velocity dependant increase in tonic stretch reflexes ← ← Due to injury to the controlling upper motor neurons (found in the brain and spinal cord), excessive muscle contractions (spasticity) and exaggerated reflexes occur along with weakness. • MS: inflammatory plaques • Stroke: ischemia • Trauma: spinal or brain • ALS: degenerative disease of motor neurons • CP: congenital injury ← ← Pathophysiology: • Loss of inhibitory input to gamma and alpha motor neurons (4,5) • Loss of local inhibitory interneurons (6) • Neuronal reorganization – novel connections (7,8,9) • Rheological changes – muscle stiffness (part that may explain therapy’s benefits in spasticity) (10) ← ← DELAY: Typically, symptoms of spasticity may not occur for weeks to months after an injury to the brain or spinal cord. ← ← Problems caused by spasticity: • Exertional fatigue • Incoordination of motor control • Decreased dexterity of fine motor movements (5)
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Muscle spasms – can be painful and variable, aggravated by fatigue and exertion. Spasms may lock a joint in extension making it impossible to perform motor actions (e.g., sitting in wheel chair) and may propel patients to floor. Imbalance and falls Contractures of tendons and ligaments – if left untreated, spasticity can lead to capsular fibrosis around joints and secondary atrophy of muscles. o hip flexors o knee flexors – along with hip, makes positioning difficult o leg adductors) - difficult catheterization Osteoporosis due to loss of movement
Factors that worsen spasticity: • Pain from any source • Infection or fever (esp. UTIs) • Constipation / fecal impaction • Stress and anxiety • Depression • Fatigue
4 ways spasticity negatively affects patients: (1) SOCIAL FUNCTIONING • Cycle of worsening due to pain and depression • Less independence • Decreased ability to sit or stand
• Impaired sexual function • Bowel and bladder spasticity ← (2) EMPLOYMENT (3) HYGIENE • Unable to perform urinary catheterization • Skin infections • Bathing difficulties (4) SECONDARY MEDICAL CONDITIONS • Musculoskeletal conditions – arthritis, bursitis, tendonitis, low back pain (16) • Osteoporosis – much higher risk in poorly ambulatory MS patients. • Fall risk • Deep vein thrombosis • Skin breakdown – esp. with difficult positioning. Benefits of Spasticity: • Extensor spasm may aid in transfers • May allow ambulation in an otherwise weak leg • Improved edema • Improved respiratory function ← How are patients assessed at our clinic ? ← Careful baseline assessments by a physical and occupational therapist are important in reaching our treatment objectives with each patient.
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History • Body part affected • Impairs function or causes pain? • Fatigue? • Depression? • Sleep disturbance? • Infection? • Weakness? Exam: • Modified Ashworth Scale – degree of muscle stiffness or spasticity; good inter-rater reliability, monitors treatment success • Penn Spasm Scale - # of spasms patient reports experiencing. • Degree of contracturs • Amount of coexistent weakness • Gait assessment Modified Ashworth Scale 0 – normal tone 1 – slight increase in tone 2 – More increase in tone but affected part moves easily in flexion 3 – Considerable increase in tone – passive movements difficult
4 – Affected part rigid in flexion or extension Penn Spasm Scale 0 – No spasms 1 – No spontaneous spasms except with vigerous motor stimulation 2 – Occassional spontaneous spasms and easily induced spasms 3 – More than 1 but less than 10 spontaneous spasms per hour 4 – More than 10 spontaneous spasms per hour \ ← Spasticity can vary depending on body positioning, so a consistent order of muscle evaluation is important. • Active movement may produce a different pattern of activation as opposed to passive movement (e.g., walking may produce different tone than sitting) • Some patients only complain of spasticity with ambulation (11,12,13,14) ← ← Treating certain spastic muscle may also worsen function as the increased tone allows for support during gait. ← ← After the baseline assessment, the patient and team, including a neurologist, will decide on a course of treatment if indicated. ← ← Our objective in these patients is to • improve gait, • hygiene, • ability to perform activities of daily living,
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ease of care, and to decrease pain and frequency of spasm.
TREATMENT. • Ongoing PT/OT management and evaluations are needed to ensure treatments are successful. • Nonpharmacologic o Spasms and stiffness responds to a program of stretching, weight bearing, aerobic exercise. o Therapists aid in starting program – patients supported to continue on their own. o Electrical stimulation to prevent atrophy o Assessment of bracing and splinting o Early contractures may respond to serial bracing. • Oral Pharmacologic: o Based on origin spasticity, side effects, compliance o Baclofen, Tizanadine, Valium, Dantrolene, Clonodine. • Injected o Botulinum toxin – effective in distal muscles, injected every 3 months, very few side effects. o Phenol nerve blocks – good for large proximal spastic muscles (e.g., musculocutanous nerve). • Intrathecal o Baclofen pump – after failure of above, much higher doses can be used with less side effects. Test requires a patient improve at least one level on Ashworth scale for pump placement. • Surgical treatment: o Selective dorsal rhizotomy
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o Tendon lengtheng and release of contractures.
Who are the members of clinic? • The patient: input from the patient and education is vital to success. • Neurologists with neuromuscular fellowship training • Physical therapist • Occupational therapist
← ← At Memorial Hospital of RI, we also have ready access to neurosurgery, orthopedic surgeons, and anesthesiologists trained in pain management, as well as orthodics specialists and wheel chair management specialists ← ← Which patients should be referred to the clinic? ← ← Patients with abnormal tone that interferes with functioning (such as gait, ADLs, comfort, or care giving) will likely benefit from the clinic. ← ← Common neurological illness that require spasticity management include stroke, multiple sclerosis, cerebral palsy, brain and spinal trauma, and ALS. ← ← Other conditions with abnormal tone that may benefit from the clinic includes parkinsonism, tremor, or dystonia. ← ← Common examples of functionally impairing spacticity are shown below: ←