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Spasticity After Stroke
Heather Walker, M.D.
Assistant Professor
Department of Physical Medicine & Rehabilitation
UNC-Chapel Hill
What is a physiatrist???

NOT a physical therapist
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NOT a psychiatrist

Education:

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
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Four years medical school
Four years residency
+/- Fellowship Training
Take care of patients with disabilities

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Stroke, traumatic brain injury, spinal cord injury, amputations,
burns, pediatrics, etc.
Goal is to improve function and quality of life
Physiatrists and Stroke

Medical management during acute
inpatient rehabilitation and as an
outpatient
Blood pressure
 Bowel and bladder dysfunction
 Skin
 Language impairments
 Cognitive and attentional impairments

 SPASTICITY
What is spasticity??
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“a motor disorder characterized by a
velocity-dependent increase in tonic
stretch reflexes (muscle tone) with
exaggerated tendon jerks, resulting from
hyperexcitability of the stretch reflex…”
????????????????????????
Spasticity can be defined as increased
tightness in affected muscles
What is spasticity??

Increased tightness in muscles
Chest wall  Difficulty raising arm to the
side, putting on clothing
 Elbow flexors  Difficulty straightening arm
to reach for items or dressing
 Wrist flexors
 Finger flexors  Difficulty opening hand
voluntarily or passively (releasing items, hand
hygiene)

What is spasticity??
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Increased tightness in muscles
Hamstrings  Difficulty straightening leg
 Quadriceps  Stiff-knee gait
 Calf muscles  Difficulty clearing toes when
walking (tripping), foot turns in when walking
 Inner thighs  Legs cross over each other
when walking, difficulty pulling legs apart for
hygiene

Upper Extremity Spasticity
Lower Extremity Spasticity
Spasticity Complications
Positioning
 Hygiene
 ADLs
 Sitting or Standing Balance
 Contractures

Treatment Goals
Improvements in position
 Mobility
 Pain
 Contracture prevention
 Ease of care are possible

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
Therapeutic Exercise
 Stretching
and range of motion
 Myofascial and joint mobilization
 Active assistive, active and
resistive exercise
 Endurance training
Oral Medications

Zanaflex

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Baclofen
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Adverse effects: drowsiness, dizziness, dry mouth, orthostatic
hypotension
Adverse effects: weakness, sedation, hypotonia, ataxia,
confusion, fatigue, nausea, dizziness, lower seizure threshold
Sudden withdrawal may cause seizures, hallucinations, rebound
spasticity
Dantrium

Adverse effects: weakness (including ventilatory muscles),
drowsiness, lethargy, nausea, diarrhea, Liver toxicity
Botulinum Toxin Type A (BOTOX®):
History of Development
FDA approval of
BOTOX®
Dr. Schantz
begins
investigation
C. botulinum
identified
1989
1978
1944
1920s
1895
Botulinum toxin
type A first
isolated
Dr. Scott initiates
first therapeutic
testing in humans
BOTOX® (Botulinum Toxin Type A):
A Focal Therapeutic
•
•
•
−
Injected directly into overactive
muscles
Reduces contractions, relaxes muscles
Advantages of local injection
− Targeted to specific muscles that
are causing the symptoms
− When used at recommended doses,
avoids systemic, overt distant
clinical effects
NOT FDA APPROVED FOR
SPASTICITY
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 seen
regardless of the site injected
 Local weakness, created by diffusion of
Botox and is site specific
 Death???

Intrathecal Baclofen
Small doses of baclofen delivered directly
to the spinal canal
 Fewer side effects, better relief of
spasticity
 Usually more effective for spasticity in the
lower extremities
 Requires committed patient and family,
pump must be refilled every 3 months.

Intrathecal Baclofen
Surgical Procedures
Tendon lengthening
 Neurosurgical procedures
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Last resort!
Take Home Points….

Spasticity is common after stroke, and is
manifested as muscle tightness in the affected
arm and/or leg.
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Several different treatment options are available,
including therapies, oral medications and
injections.
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If you suffer from spasticity you should be seen
by a physiatrist who specializes in spasticity
management.