· arm and/or leg. zseveral different treatment options are available, including therapies, oral...
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SpasticitySpasticity After StrokeAfter Stroke
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What is What is spasticityspasticity????
““a motor disorder characterized by a a motor disorder characterized by a velocityvelocity--dependent increase in tonic dependent increase in tonic stretch reflexes (muscle tone) with stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from exaggerated tendon jerks, resulting from hyperexcitabilityhyperexcitability of the stretch reflexof the stretch reflex…”…”
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Spasticity can be defined as increased tightness in affected muscles
What is What is spasticityspasticity????
Increased tightness in musclesIncreased tightness in musclesChest wallChest wall Difficulty raising arm to the Difficulty raising arm to the side, putting on clothingside, putting on clothingElbow flexorsElbow flexors Difficulty straightening arm Difficulty straightening arm to reach for items or dressingto reach for items or dressingWrist flexorsWrist flexorsFinger flexorsFinger flexors Difficulty opening hand Difficulty opening hand voluntarily or passively (releasing items, hand voluntarily or passively (releasing items, hand hygiene)hygiene)
What is What is spasticityspasticity????
Increased tightness in musclesIncreased tightness in musclesHamstringsHamstrings Difficulty straightening legDifficulty straightening legQuadricepsQuadriceps StiffStiff--knee gaitknee gaitCalf musclesCalf muscles Difficulty clearing toes when Difficulty clearing toes when walking (tripping), foot turns in when walkingwalking (tripping), foot turns in when walkingInner thighsInner thighs Legs cross over each other Legs cross over each other when walking, difficulty pulling legs apart for when walking, difficulty pulling legs apart for hygienehygiene
Upper Extremity Upper Extremity SpasticitySpasticity
Lower Extremity Lower Extremity SpasticitySpasticity
SpasticitySpasticity ComplicationsComplications
Positioning Positioning HygieneHygieneADLsADLsSitting or Standing BalanceSitting or Standing BalanceContracturesContractures
Treatment GoalsTreatment Goals
Improvements in position Improvements in position MobilityMobilityPainPainContracture preventionContracture preventionEase of care are possibleEase of care are possible
SpasticitySpasticity Management StepsManagement Steps
Therapeutic modalitiesTherapeutic modalitiesOral MedicationsOral MedicationsNerve blocks & Chemical Nerve blocks & Chemical neurolysisneurolysis((BotoxBotox injections)injections)Orthopedic proceduresOrthopedic proceduresIntrathecalIntrathecal Medications Medications
Prior to InterventionPrior to Intervention
Assess baseline statusAssess baseline statusDetermine specific goalsDetermine specific goalsPatient and family educationPatient and family educationPT and OT role after interventionPT and OT role after intervention
Therapeutic ExerciseTherapeutic Exercise
Stretching and range of motionStretching and range of motionMyofascialMyofascial and joint mobilizationand joint mobilizationActive assistive, active and Active assistive, active and resistive exerciseresistive exerciseEndurance trainingEndurance training
Oral MedicationsOral MedicationsZanaflexZanaflex
Adverse effects: Adverse effects: drowsinessdrowsiness, dizziness, dry mouth, orthostatic , dizziness, dry mouth, orthostatic hypotensionhypotension
BaclofenBaclofenAdverse effects: weakness, Adverse effects: weakness, sedationsedation, , hypotoniahypotonia, ataxia, , ataxia, confusion, fatigue, nausea, dizziness, lower seizure thresholdconfusion, fatigue, nausea, dizziness, lower seizure thresholdSudden withdrawal may cause seizures, hallucinations, rebound Sudden withdrawal may cause seizures, hallucinations, rebound spasticityspasticity
DantriumDantriumAdverse effects: weakness (including Adverse effects: weakness (including ventilatoryventilatory muscles), muscles), drowsinessdrowsiness, lethargy, nausea, diarrhea, Liver toxicity, lethargy, nausea, diarrhea, Liver toxicity
BotulinumBotulinum Toxin Type A (BOTOXToxin Type A (BOTOX®®)): : History of DevelopmentHistory of Development
19441920s
1895
Botulinum toxin type A first isolated
Dr. Schantzbegins investigation
C. botulinumidentified
Dr. Scott initiates first therapeutic testing in humans
19781989
FDA approval of BOTOX®
BOTOXBOTOX®® ((BotulinumBotulinum Toxin Type A): Toxin Type A): A Focal TherapeuticA Focal Therapeutic
•• Injected directly into overactive Injected directly into overactive muscles muscles
•• Reduces contractions, relaxes musclesReduces contractions, relaxes muscles•• Advantages of local injectionAdvantages of local injection
−− Targeted to specific muscles that Targeted to specific muscles that are causing the symptomsare causing the symptoms
−− When used at recommended doses, When used at recommended doses, avoids systemic, overt distant avoids systemic, overt distant clinical effects clinical effects
−− NOT FDA APPROVED FOR NOT FDA APPROVED FOR SPASTICITYSPASTICITY
Muscle identificationMuscle identification
Three main methodsThree main methodsExam and anatomic atlasExam and anatomic atlasEMG assistance and guidanceEMG assistance and guidanceElectronic stimulationElectronic stimulation
Side EffectsSide Effects
LocalizedLocalizedHematomaHematoma and bruising are seen and bruising are seen regardless of the site injected regardless of the site injected Local weakness, created by diffusion of Local weakness, created by diffusion of BotoxBotox and is site specificand is site specificDeath???Death???
IntrathecalIntrathecal BaclofenBaclofen
Small doses of Small doses of baclofenbaclofen delivered directly delivered directly to the spinal canalto the spinal canalFewer side effects, better relief of Fewer side effects, better relief of spasticityspasticityUsually more effective for Usually more effective for spasticityspasticity in the in the lower extremitieslower extremitiesRequires committed patient and family, Requires committed patient and family, pump must be refilled every 3 months.pump must be refilled every 3 months.
IntrathecalIntrathecal BaclofenBaclofen
Surgical ProceduresSurgical Procedures
Tendon lengtheningTendon lengtheningNeurosurgical proceduresNeurosurgical procedures
Last resort!Last resort!
Take Home PointsTake Home Points……..SpasticitySpasticity is common after stroke, and is is common after stroke, and is manifested as muscle tightness in the affected manifested as muscle tightness in the affected arm and/or leg.arm and/or leg.
Several different treatment options are available, Several different treatment options are available, including therapies, oral medications and including therapies, oral medications and injections.injections.
If you suffer from If you suffer from spasticityspasticity you should be seen you should be seen by a physiatrist who specializes in by a physiatrist who specializes in spasticityspasticitymanagement.management.