Spasticity:Characterization and

Treatment Considerations

Insert Presenter’s Name

1

Definition of Spasticity

1 Lance JW. Symposium synopsis. In Feldman RG, Young RR, Koella WP (eds) Spasticity: Disordered Motor Control. Year Book Medical Pubs, Chicago, 1980: pp. 485-94

Velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neuron syndrome.1

Upper Motor Neuron Syndrome

A group of symptoms that may be caused by damage or injuryto motor neuron pathways or brain regions that control movement2,3

2 Katz RT, Rymer WZ. Spastic hypertonia: mechanisms and measurement. Arch Phys Med Rehabil 1989; 70:144-553 O'Brien CF, Seeberger LC, Smith DB. Spasticity after stroke. Epidemiology and optimal treatment. Drugs Aging 1996; 9:332-404 Young RR ,Wiegner AW. Spasticity.ClinOrthop Relat Res 1987; 50-62

Positive SymptomsPositive Symptoms44 Negative SymptomsNegative Symptoms44

Characterization Muscle overactivity Muscle underactivity

Examples Spasticity, clonus, flexor/extensor spasm, hyper-reflexia, dystonia, and rigidity

Decreased dexterity, weakness, paralysis, fatigability, and slowness of movement

Classification of Spasticity

5 Esquenazi A. Falls and fractures in older post-stroke patients with spasticity: consequences and drug treatment considerations. Clin Geriatr 2004; 12:27-35

6 Gracies JM, Nance P, Elovic E, McGuire J, Simpson DM. Traditional pharmacological treatments for spasticity.Part II: General and regional treatments.Muscle Nerve Suppl 1997; 6:S92-120

Classification of Spasticity Accordingto Distribution of Affected Body Regions5,6

Distribution Definition

Isolated, local motor disturbance affecting a single body part

Focal

Motor disturbance involving a large region of the body

Regional

Motor disturbance involving widespread bodily regions

Generalized

Signs and Symptoms of Spasticity

• Patients with spasticity may experience a range of sensations in the affected limbs7

– Mild muscle stiffness

– Painful muscle contracturesand spasms

• In a recent survey, most patients rated stiffness and limited range of motion as having the most substantial negative impact on their quality of life8

7 O'Brien CF. Treatment of spasticity with botulinum toxin. Clin J Pain 2002; 18:S182-908 WE MOVE. Profile of Patients with Spasticity, 2008. Available at:

http://www.wemove.org/reports/spasticity_2008.pdf. Accessed March 26, 2009

Percentage of 810 patients with spasticity who identified each aspect of their condition as having the most significant impact on quality of life.8

Abnormalposture, pain,

or inabilityto sleep34.5%

Stiffness/limited range

of motion42.0%

Limitationsin activities

of daily living23.5%

Common Limb Deformities in Upper Limb Spasticity

The flexed elbow is bentinto flexion and this posturemay dramatically worsenwith ambulation, causingmore-severe angle flexion.

In the adducted/internally rotated shoulder, the arm is held closely against the side, elbow bent, with the forearm applied across the front of the chest.

Flexion of the wrist iscaused by hypertonicityof the wrist flexor muscles that seem to easily overpower their antagonists of wristextension, so that this is the most common attitude.

Common Limb Deformities in Upper Limb Spasticity

In those with clenchedfist, the fingers are tightlyflexed into the palm. Thiscan lead to poor palmarhygiene and pain with finger manipulation.

Pronation of the forearm seems to be morecommonly encounteredthan supination aftercentral nervous systeminjury.

In those with thumb-in-palm deformity, the thumb is held fixed within the palm with its distal aspect flexed. The thumb is limited in its use as a result of the abnormal posture.

Major Causes of Spasticity in Adults

• Stroke

• Multiple sclerosis

• Spinal cord injury

• Traumatic brain injury

• Adult cerebral palsy

Affects 795,000 Americans annually9

Upper and lower limb

Upper limb only

Lower limb only

% with spasticity10

9 Centers for Disease Control and Prevention. Stroke facts and statistics. Available at: http://www.cdc.gov/stroke/stroke_facts.htm. Accessed April 7, 2009

10 Lundstrom E, Terent A, Borg J. Prevalence of disabling spasticity 1 year after first-ever stroke. Eur J Neurol 2008; 15:533-9

10%

7%

1%

Methods of Spasticity Assessment11

• Physiologic measures such as overall excitability of a motor neuron pool or the shortening of muscle cells that are under spastic control.

• Passive activity measures such as Ashworth scale and passive range of motion.

• Voluntary activity measure such as the Fugl-Meyer test and the Nine Hole Peg Test.

• Functional measures such as the Functional Independence Measure and the Disability Assessment Scale (DAS) and measures of pain.

• Quality of life measures that assess patient satisfaction and perceived importance of spasticity treatment.

11 Elovic EP, Simone LK, Zafonte R. Outcome assessment for spasticity management in the patient with traumatic brain injury: the state of the art. J Head Trauma Rehabil 2004; 19:155-77

Methods of Spasticity Assessment: Examples

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Ashworth Scale12

Grade Description

No increase in muscle tone0

Slight increase in tone – a catch and release at the end of the range of motion

1

More marked increase in tone through most of range

2

Considerable increase in tone, passive movement difficult

3

Affected parts rigid in flexion orextension

4

12 Ashworth B. Preliminary trial of carisoprodol in multiple sclerosis. Practitioner 1964; 192:540-213 Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987; 67:206-714 Brashear A, Zafonte R,Corcoran M, et al. Inter- and intrarater reliability of the Ashworth Scale and the Disability Assessment

Scale in patients with upper-limb poststroke spasticity. Arch Phys Med Rehabil 2002; 83:1349-54

The modified Ashworth scale incorporates a 1+ (Slight increase in tone – catch, followed by minimal resistance in remainder of range) to differentiate the catch that is felt in some patients when limbs are passively moved.13

Disability Assessment Scale14

Domain Description

Extent of palm maceration, ulceration, and/or infection; palm cleanliness; ease of cleaning and nail trimming; effect of hygiene related disability in patient’s life

Hygiene

Ability to put on clothing; effect ofdressing-related disability due toupper-limb spasticity on patient’s life

Dressing

Psychological and/or socialinterference that the limb’s posturehas in the patient’s life

Limb Posture

Intensity of pain; discomfort andinterference of upper limb pain inpatient’s life

Pain

Scores:0 = no functional disability1 = mild2 = moderate3 = severe

Problems That May Be Associated With Spasticity15-18

• Pain

• Contracture

• Fatigue

• Functional limitations (hygiene, dressing, transfers)

• Increased risk of falls

• Pressure sores

• Skin maceration

• Poor orthotic fit

• Diminished self image due to abnormal limb posture

15 Mayer NH, Esquenazi A, Childers MK. Common patterns of clinical motor dysfunction.Muscle Nerve Suppl 1997; 6:S21-3516 Adams MM, Ginis KA, Hicks AL. The spinal cord injury spasticity evaluation tool: development and evaluation. Arch Phys Med Rehabil 2007; 88:1185-9217 Wissel J, Ward AB, Erztgaard P, et al. European consensus table on the use of botulinum toxin type A in adult spasticity. J Rehabil Med 2009; 41:13-2518 Bhakta BB. Management of spasticity in stroke. Br Med Bull 2000; 56:476-85

Factors to Consider in Spasticity Treatment19

• Chronicity of spasticity

• Severity of spasticity

• Distribution of spasticity

• Locus of central injury or damage

• Patient co-morbidities

• Availability of care and support

Decision to Treat Spasticity

19 Gormley ME, Jr., O'Brien CF, Yablon SA. A clinical overview of treatment decisions in the management of spasticity. Muscle Nerve Suppl 1997; 6:S14-20

Treatment Goals

19 Gormley ME, Jr., O'Brien CF, Yablon SA. A clinical overview of treatment decisions in the management of spasticity. Muscle Nerve Suppl 1997; 6:S14-20

20 Barnes MP. Spasticity: a rehabilitation challenge in the elderly. Gerontology 2001; 47:295-9

The inclusion of patients and caregivers in the discussion of goalsis critical because patient and physician goals do not always coincide.

Major Classes of Treatment Goals with Examples of Each 19, 20

• Improve activities of daily living (e.g., dressing, hygiene)• Reduce pain• Enhance ease of care• Improve limb position (cosmesis)• Improve gait

Functional Objectives

• Increase range of motion• Reduce tone• Reduce spasm

Technical Objectives

• Prevent contracture• Prevent skin maceration• Prevent skin ulcers

Preventive Objectives

Spasticity Management Team21

• Physicians

• Rehabilitation nurses

• Allied healthcare professionals (physical therapists, occupational therapists, speech therapists)

• Family and other caregivers

• Coordinator/administrator

• Other (wheelchair clinic, gait lab, orthotics clinic, counseling, social worker)

21 Adams MM, Hicks AL. Spasticity after spinal cord injury. Spinal Cord 2005; 43:577-86

Summary

• Spasticity is a distressing, debilitating consequence of upper motor neuron lesions

– May result from stroke, trauma to the brain or spinal cord,multiple sclerosis, cerebral palsy, or other conditions

– May be focal, regional, or general in distribution

• Common clinical patterns of spasticity are identifiable across etiologies, and are generally caused by marked overactivity of the flexor muscles

• Left untreated, spasticity may result in permanent contracture of muscle and soft tissue, leading to increasing disability, pain, and deformity

Summary

• Thorough assessment of the patient’s condition is essential in determining whether to treat spasticity, for developing a treatment plan, and for gauging treatment progress

• Prior to treatment of spasticity, goals should be identified in consultation with the patient and caregiver or family

• When spasticity is treated, it is best approached as a multidisciplinary endeavor

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© 2010 Allergan, Inc. Irvine, CA 92612APC90SB10 April 2010