spas ti city after stroke
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Spasticity After Stroke
Heather Walker, M.D.Assistant Professor
Department of Physical Medicine & RehabilitationUNC-Chapel Hill
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What is a physiatrist???
NOT a physical therapist
NOT a psychiatrist
Education: Four years medical school Four years residency +/- Fellowship Training
Take care of patients with disabilities Stroke, traumatic brain injury, spinal cord injury, amputations,
burns, pediatrics, etc. Goal is to improve function and quality of life
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Physiatrists and Stroke
Medical management during acuteinpatient rehabilitation and as anoutpatient
Blood pressure Bowel and bladder dysfunction
Skin
Language impairments Cognitive and attentional impairments
SPASTICITY
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What is spasticity??
a motor disorder characterized by a
velocity-dependent increase in tonicstretch reflexes (muscle tone) with
exaggerated tendon jerks, resulting fromhyperexcitability of the stretch reflex
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Spasticity can be defined as increasedtightness in affected muscles
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What is spasticity??
Increased tightness in muscles
Chest wall Difficulty raising arm to theside, putting on clothing
Elbow flexors Difficulty straightening armto reach for items or dressing
Wrist flexors
Finger flexors Difficulty opening handvoluntarily or passively (releasing items, handhygiene)
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What is spasticity??
Increased tightness in muscles
Hamstrings Difficulty straightening leg
Quadriceps Stiff-knee gait
Calf muscles Difficulty clearing toes whenwalking (tripping), foot turns in when walking
Inner thighs Legs cross over each other
when walking, difficulty pulling legs apart forhygiene
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Upper Extremity Spasticity
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Lower Extremity Spasticity
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Spasticity Complications
Positioning
Hygiene
ADLs Sitting or Standing Balance
Contractures
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Treatment Goals
Improvements in position Mobility
Pain
Contracture prevention
Ease of care are possible
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Spasticity Management Steps
Therapeutic modalities
Oral Medications
Nerve blocks & Chemical neurolysis(Botox injections)
Orthopedic procedures
Intrathecal Medications
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Prior to Intervention
Assess baseline status
Determine specific goals
Patient and family education
PT and OT role after intervention
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Therapeutic Exercise
Stretching and range of motion
Myofascial and joint mobilization
Active assistive, active andresistive exercise
Endurance training
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Oral Medications
Zanaflex Adverse effects: drowsiness, dizziness, dry mouth, orthostatic
hypotension
Baclofen Adverse effects: weakness, sedation, hypotonia, ataxia,
confusion, fatigue, nausea, dizziness, lower seizure threshold
Sudden withdrawal may cause seizures, hallucinations, reboundspasticity
Dantrium Adverse effects: weakness (including ventilatory muscles),
drowsiness, lethargy, nausea, diarrhea, Liver toxicity
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Botulinum Toxin Type A (BOTOX):
History of Development
1944
1920s1895
Botulinum toxin
type A first
isolated
Dr. Schantz
begins
investigation
C. botulinumidentified
Dr. Scott initiatesfirst therapeutic
testing in humans
1978
1989
FDA approval of
BOTOX
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BOTOX(Botulinum Toxin Type A):A Focal Therapeutic
Injected directly into overactivemuscles
Reduces contractions, relaxes muscles
Advantages of local injection
Targeted to specific muscles thatare causing the symptoms
When used at recommended doses,avoids systemic, overt distantclinical effects
NOT FDA APPROVED FOR
SPASTICITY
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Muscle identification
Three main methods
Exam and anatomic atlas
EMG assistance and guidance
Electronic stimulation
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Side Effects
Localized
Hematoma and bruising are seenregardless of the site injected
Local weakness, created by diffusion ofBotox and is site specific
Death???
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Intrathecal Baclofen
Small doses of baclofen delivered directlyto the spinal canal
Fewer side effects, better relief ofspasticity
Usually more effective for spasticity in thelower extremities
Requires committed patient and family,pump must be refilled every 3 months.
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Intrathecal Baclofen
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Surgical Procedures
Tendon lengthening
Neurosurgical procedures
Last resort!
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Take Home Points.
Spasticity is common after stroke, and ismanifested as muscle tightness in the affectedarm and/or leg.
Several different treatment options are available,including therapies, oral medications andinjections.
If you suffer from spasticity you should be seenby a physiatrist who specializes in spasticitymanagement.
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