Download An Interdisciplinary Program for the Management of Spasticity

An Interdisciplinary Program for
the Management of Spasticity
Hilary Knecht MSPT
Meghan Montalbano OTR/L
June 29, 2015
Objectives
• Review of Spasticity
– Impairments resulting from spasticity
• Medical Management of Spasticity
• Non-Invasive Management
• Surgical Management
What is Spasticity?
• A muscle control disorder that is characterized by tight or stiff
muscles and an inability to control those muscles
• Caused by an imbalance of signals from the central nervous
system (brain and spinal cord) to the muscles
• It is common in individuals with cerebral palsy, traumatic brain
injury, stroke, multiple sclerosis and spinal cord injury
What are the symptoms of spasticity?
• Increased muscle tone
• Overactive reflexes
• Involuntary movements, which
may include spasms and
clonus
• Decreased functional abilities
and delayed motor
development
• Difficulty with care and
hygiene
• Abnormal Posture
• Contractures
• Bone and joint Deformities
• Pain
SECTION TITLE OR HEADER
Spasticity Facts and Statistics
• 75% of patients with physical disability following severe traumatic
brain injury will develop spasticity requiring specific treatment
• It is not always harmful
• Patients with a combination of weakness and spasticity may rely
on the increased tone to maintain their posture and aid standing
or walking
• Not all individuals with spasticity will require treatment however
spasticity requires assessment over a lifetime as it can change
and progress
5
Interventions for Managing and Treating Skeletal
Muscle Spasticity
• Medical Management Techniques
– Baclofen, Clonidine, Dantrolene sodium, Tinazidine, Botulinum
Toxin A, Phenol Injections, Surgical Tendon Release
• Non-Invasive Management
– Casting, Splinting, Stretching, Strengthening, Transcutaneous
Electric Nerve Stimulation, Bobath treatment, Weight Bearing Gait
Training, Seating
Medical Management Techniques
• Medical Management techniques are consider any techniques which
either involve pharmaceutical management or an invasive procedure.
• These techniques are administered and controlled by a medical
physician
Oral Medications
• Baclofen (GABA b receptor): Most studied in SCI and MS.
– GABA b receptor is what produces baclofen’s range of therapeutic
properties
– Drug is absorbed after oral administration and widely distributed
throughout the body.
– Half life of Baclofen is 2-4 hours and therefore is administered
frequently throughout the day
– Strong side effect profile: sedation, dizziness, weakness
Oral Medications
• Tizanidine (Zanaflex) alpha 2 adrenergic agonist, preventing
release of excitatory neurotransmitters
• Clonidine (transdermal patch) alpha 2 adrenergic agonist,
preventing release of excitatory neurotransmitters
– Side effects: drowsiness, dry mouth, weakness, hypotension,
elevated LFT’s (5%), psychosis
• Dantrolene (blocks release of Ca+ from the sarcoplasmic
reticulum, decreasing ms contraction) peripherally acting
– Side effects: drowsiness, nausea, weakness, paresthesia,
hepatotoxicity (1-2%)
Oral Medications
• Benzodiazepines
– Diazepam acts by facilitating the postsynaptic action of ammaaminobutyric acid
• Side effects include sedation, ataxia, and fatigue
– Clonazepam
• Side effects are weakness, hypertension, ataxia, dyscoordination,
sedation, depression and memory impairment
Motor Point Blocks
• Motor Point
Where the motor nerve enters the muscle
• Motor Point Block
Interruption of neural impulses by anesthesia or destruction
of the nerve at the motor point
Botulinim Toxin (Botox)
• Derived from Clostridium Botulinim. Seven types (A-G)
– Botulinim toxin A: Botox, Dysport
• Cost of Botox: $541. per 100u
• Inhibits release of acetylcholine into the neuromuscular junction (NMJ), decreasing
muscle contraction
• Generally lasts 3-4 months
• Benefit over oral medications: can be used focally to reduce spasticity, not
causing the systemic side effects that oral medications do. WAY MORE
EFFECTIVE
• Administered using EMG-guidance in order to better locate the NMJ and for
needle location. Another method is ultrasound guided.
Phenol Nerve Blocks
• In high concentrations, phenol works to denature proteins,
resulting in neurolysis
• Benefit over Botulinum toxin is that it lasts much longer, and it’s
far cheaper
• Reinervation does occur, but it is incomplete
• Side effects: post-injection dysethesia, and if injected into vessels,
CNS depression, tremors, convulsions
Phenol Nerve Blocks
Advantages
Disadvantages
Duration of effect
Dysaesthesia- sensory nerve
Can be more effective
Technically demanding
Single injection site
Less titratable- all or none
Inexpensive
Infrequently indicated during motor
recovery
Immediate onset (seconds)
Bryn Mawr Rehabilitation
Nerve Block Resource
Bupivicaine
Phenol
Botox
Lasts 1-3 hours
Onset 1-15 minutes
Immediate effects
Takes 2 weeks for full effect
Lasts 4-6 months
Lasts 3-4 months
Do not cast within 24 hours
Avoid aggressive stretching for 24
hours
Temporary- used as assessment tool
Causes nerve lysis
Works at neuromuscular junction
MD must be very accurate because it
is so caustic
MD uses EMG to assist with location
of injection
Baclofen Pump
• This piece of equipment is a programmable pump which holds and stores
a set amount of baclofen. The baclofen is released via a flexible silicone
catheter. The whole device is programmable for rate and dosage.
How does it work?
• GABA b Agonist (inhibitory neurotransmitter)
• Most likely inhibits release of Ca+ into the presynaptic terminal,
impeding release of excitatory neurotransmitters
• With lumbar tip concentration, there is a 4:1 lower extremity:
upper extremity effect
• Therapeutic dose is 1/100 of oral baclofen
Benefits and Risks of Baclofen Pumps
• Benefits
• Risks
– Delivered directly to the site
thereby requiring a lower
dosage
– Infection (5% of people)
– Decreased systemic effects
including sedation and
drowsiness
– Rare cases: rhabdomyolysis,
multiple organ-system failure
and death
– Equipment Failure
Surgical Tendon Release
• Muscles can be de-innervated, and tendons and muscles can be
released, lengthened or transferred
• Surgical releases can be performed at the shoulder, elbow,
forearm, hands and legs
• Types of surgery available
– Tendon transfers
– Contracture release
– Split tendons with osteotomy and arthrodesis
Illustration of Split Anterior Tibialis Tendon Transfer
Non-Invasive Management
• Physical and Occupational Therapy
– Serial Casting
– Splinting
– Range of Motion
– Other Modalities
• Electric Stimulation
• Vibration
• Hot/cold
Goals of Non Invasive Management
• Preventing deformities and the breakdown of skin
• Inhibiting tone
• Maintaining the length of muscle fibers
• Elongating shortened tissues, thereby prolonging proper
positioning
• Optimizing position
• Increasing or maintaining range of motion
• Decreasing pain
Physical and Occupational Therapy
• Breaking compensation habits
• Uncover motor control
• Utilize new function
• Establish sensory level
• Establish visual deficits
• Find motivating tasks
Before you cast or splint
• Establish if there is a baseline contracture
• Establish if there is a flexible end feel
• Confirm patient, staff and family compliance
• Establish other spasticity treatments if needed
Casting
• Serial casting is a technique where there limb is gradually
stretched in order to provide relaxation to the muscle.
• This is thought to increase the range of motion and prevent or
improve a developing contracture.
Splinting
• This intervention provides a prolonged stretch to a muscle and
aims to improve muscle length, correct and prevent contractures
in order to maximize function.
• Dynamic vs. Static splints
Range of Motion
• Principal Goals of Range of Motion and Stretching
– Maintain muscle and soft tissue length across joints
– Facilitate care giving involvement
– Facilitate active control of any residual movements to allow
for active participation in tasks
Other Modalities
•Electrical Stimulation
•Ultrasound
•Vibration
•Hot/cold
Questions
References
• Stein, Joel. Stroke Recovery and Rehabilitation. Demos Medical Publishing. 2009.
• Conroy et al. Hospiral-based stroke rehabilitation in the United States. Top Stroke Rehabil. 2009 Jan-Feb;16(1):34-43.
• Jorgensen et al. Outcome and time course of recovery in stroke. Part II: Time course of recovery. The Copenhagen Stroke Study.
APMR. 1995 May;76(5):406-12.
• Montane E. et al, Oral antispastic drugs in nonprogressive neurological disease: a systematic review.Neurology.2005 Jun 14;64(11).
• Zafonte et al. Antispasticity medications: Uses and limitations of enteral therapy. Am J Phys Med Rehabil 2004;83:S50–S58.
• Simpson et al. Botulinum toxin type A in the treatment of upper extremity spasticity: a randomized, double-blind, placebo-controlled
trial. Neurology. 1996 May;46(5):1306-10.
• Brashear A. et al. Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after a stroke. N Engl J
Med. 2002 Aug 8;347(6):395-400.
• Henzel MK, Munin MC, Niyonkuru C, Skidmore ER, Weber DJ, Zafonte RD. Comparison of surface and ultrasound localization to
identify forearm flexor muscles for botulinum toxin injections. PMR.2010 Jul;2(7):642-6.
• Ivanhoe CB et al. Intrathecal baclofen management of poststroke spastic hypertonia: implications for function and quality of life. Arch
Phys Med Rehabil. 2006 Nov;87(11):1509-15.
• Wanklyn et al. Hemiplegic shoulder pain (HSP): natural history and investigation of associated features.Disabil Rehabil. 1996
Oct;18(10):497-501.
References
• Course provided by: Zachary Bohart, MD Physical Medicine and Rehabilitation,Director, The Comprehensive Spasticity
Management Clinic New England Rehabilitation Hospital Director, The Comprehensive Spasticity Management Clinic Tufts Medical
CenterAssociate Director, The Spasticity Program Braintree Rehabilitation Hospital
• Stein, Joel. Stroke Recovery and Rehabilitation. Demos Medical Publishing. 2009.
• Conroy et al. Hospiral-based stroke rehabilitation in the United States. Top Stroke Rehabil. 2009 Jan-Feb;16(1):34-43.
• Jorgensen et al. Outcome and time course of recovery in stroke. Part II: Time course of recovery. The Copenhagen Stroke Study.
APMR. 1995 May;76(5):406-12.
• Montane E. et al, Oral antispastic drugs in nonprogressive neurological disease: a systematic review.Neurology.2005 Jun 14;64(11).
• Zafonte et al. Antispasticity medications: Uses and limitations of enteral therapy. Am J Phys Med Rehabil 2004;83:S50–S58.
• Simpson et al. Botulinum toxin type A in the treatment of upper extremity spasticity: a randomized, double-blind, placebo-controlled
trial. Neurology. 1996 May;46(5):1306-10.
• Brashear A. et al. Intramuscular injection of botulinum toxin for the treatment of wrist and finger spasticity after a stroke. N Engl J
Med. 2002 Aug 8;347(6):395-400.
• Henzel MK, Munin MC, Niyonkuru C, Skidmore ER, Weber DJ, Zafonte RD. Comparison of surface and ultrasound localization to
identify forearm flexor muscles for botulinum toxin injections. PMR.2010 Jul;2(7):642-6.
• Ivanhoe CB et al. Intrathecal baclofen management of poststroke spastic hypertonia: implications for function and quality of life. Arch
Phys Med Rehabil. 2006 Nov;87(11):1509-15.
References
• Langhorne et al. Medical complications after stroke:a multicenter study. Stroke. 2000 Jun;31(6):1223-9.
• Pong et al. Sonography of the shoulder in hemiplegic patients undergoing rehabilitation after a recent stroke.J
Clin Ultrasound.2009 May;37(4):199-205.
• VanOuwenaller et al.Painful shoulder in hemiplegia. Arch Phys Med Rehabil. 1986 Jan;67(1):23-6.
• Ada L, Foongchomcheay A. Efficacy of electrical stimulation in preventing or reducing subluxation of the
shoulder after stroke: a meta-analysis. Aust J Physiother. 2002;48(4):257-67.
• Yelnik AP et al. Treatment of shoulder pain in spastic hemiplegia by reducing spasticity of the subscapular
muscle: a randomised, double blind, placebo controlled study of botulinum toxin A. J Neurol Neurosurg
Psychiatry. 2007 Aug;78(8):845-8. Epub 2006 Nov 6.
• Najenson T, Yacubovich E, Pikielni SS. Rotator cuff injury in shoulder joints of hemiplegic patients. Scand J
Rehabil Med. 1971;3(3):131-7.
• Hakuno A, Sashika H, Ohkawa T, Itoh R. Arthrographic findings in hemiplegic shoulders.Arch Phys Med
Rehabil. 1984 Nov;65(11):706-1J Nucl Med. 1984 Apr;25(4):423-9.1.
• Chae J, Jedlicka L. Subacromial corticosteroid injection for poststroke shoulder pain:
• Course provided by Collen Kelly Emmett, PT at Braintree Conference in Boston, MA
References
• Post, T. Spasticity and Stroke Update 2010. Special Interest Section Quarterly: Physical
Disabilities. March 2011;34(1)
• Faculty and Disclosures. Spasticity: A Clinical Review: Treatment. Medscape
• Royal College of Physicians, British Society of Rehabilitation Medicine, Chartered Society of
Physiotherapy, Association of Chartered Physiotherapists Interested in Neurology. Spasticity
in adults: management using botulinum toxin. National guidelines. London: RCP, 2009
• Kamath, A., Pandya, N., Namdari, S., et al. Surgical Technique for the Correction of Adult
Spastic Equinovarus Foot. Techniques in Foot and Ankle Surgery. 00(00). 1-8