Download Spasticity

Spasticity:
Introduction and Overview
R. Samuel Mayer, MD
Assistant Professor
Vice Chair of Education
Department of Physical Medicine and Rehabilitation
Johns Hopkins University School of Medicine
Deputy Director, Quality Improvement,
Department of Physical Medicine and Rehabilitation
The Johns Hopkins Hospital
Objectives
• Assess spasticity by history and
physical examination and testing.
• Distinguish between generalized and
localized impairments.
• Discuss treatment options for specific
upper motor neuron syndromes.
Consequences of Spasticity
• May interfere with mobility, exercise, and
joint range of motion
• May interfere with activities of daily living
• May cause pain and sleep disturbance
• Can make patient care more difficult
Possible Advantages of
Spasticity
• Maintains muscle tone
• Helps support circulatory function
• May prevent formation of deep vein
thrombosis
• May assist in activities of daily living
• May assist in maintaining erect posture
• May assist in gait
Pathophysiology
Central Nervous System (CNS) Tracts
--Spinothalamic
--Corticospinal
--Corticothalamic
--Corticocerebellar
Mechanical vs Spastic
Contracture
• Fixed
• Tendon and/or
ligament
• Charcot joint
• Heterotopic
ossification
• Dynamic
• Slow stretch
• Palpable antagonistic
muscle action
• Increased reflexes
Most often, both mechanical and spastic factors
Assessing Muscle Tone
• History
• Physical examination
• Measurement tools
Key Questions in History
• Location?
• Time of day,
aggravating/alleviating
factors? (diary)
• Painful spasms?
• Functional limitations?
• Need for extensor tone
in legs for standing?
Physical Examination
• Standard
musculoskeletal
examination including
range of motion
(measured with a
goniometer)
• Standard neurologic
examination
• Clonus
• Ashworth scale
Modified Ashworth Scale (MAS)
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0 = Normal tone
1 = Slight “catch”
1+ = Significant “catch”
2 = Mild, limb moves easily
3 = Moderate, passive range of
movement difficult
• 4 = Severe, rigid limb
Quantitative Evaluation
• Gait lab with surface
electromyography
(mostly research use)
• Fugl-Meyer test for
upper limb dexterity
Goal Attainment Scales (GAS)
• Select 2 SMART (specific, measurable,
achievable, realistic, time-frame) goals
with patient
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•
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•
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-2 did not achieve by a lot
-1 did not achieve by a little
0 achieved
+1 exceeded by a little
+2 exceeded by a lot
Spectrum of Care for
Management of Spasticity
Prevent
Nociception
Intrathecal
Baclofen
(ITB™)
Therapy
Rehabilitation
Therapy
Oral
Drugs
Patient
Orthopedic
Treatments
Injection
Therapy
Neurosurgeries
Treatment Paradigms
“Old School”
“New School”
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•
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•
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• Generalized vs
localized
• Brain vs spinal
(spinal cord injury
[SCI])
• Acute vs chronic
• Patient-specific
analysis of side
effects
Stepwise approach
Modalities
Medications
Injections
Tendon surgery
Nerve ablation
Generalized Spasticity
Remove Nociceptive
Factors
Stretch/Splint
Positioning
Oral Medication
Intrathecal Medication
Myelotomy
Dorsal Rhizotomy
Modalities
Oral Medications (1)
• Baclofen
• Binds GABA-b receptors
• SCI > brain
• Side effects—weakness, lethargy, rebound
seizures—if stopped abruptly
GABA = gamma-aminobutyric acid.
Oral Medications (2)
• Dantrolene
• Blocks Ca++ channels in muscle
• No CNS effects, but causes significant
weakness
• Hepatic dysfunction rare
CNS = central nervous system.
Oral Medications (3)
• Tizanidine
• Alpha-2 agonist
• Brain = SCI
• Side effects: lethargy, orthostasis, dry mouth
Oral Medications (4)
• Diazepam
• Enhances GABA through benzodiazepine
receptors in brain
• Brain > SCI
• Rapid development of tolerance
• Side effects: drowsiness, delirium, abuse
potential, withdrawal seizures
Children with CP Guidelines
• Level B evidence for diazepam
• Level C evidence for tizanidine
• Level U evidence for baclofen, dantrolene
CP = cerebral palsy.
Delgado MR, et al. Neurology. 2010;74:337-343.
Intrathecal Baclofen
• Generalized spasticity
• Not controlled or side effects
from oral medications
• Delivers @ 1/50 dose
baclofen direct to
cerebrospinal fluid
• Infinitely programmable
• Refill every 3 to 12 months
• Mechanical complications
Efficacy of Intrathecal Baclofen
• CP: statistically significant gains in
Gillette Functional Assessment
Questionnaire1
• Stroke: improved Sickness Impact Profile
at 3 and 12 months2
• Cost/quality-adjusted life-year: $10,550 to
$19,5703
1. Brochard S, et al. Pediatr Neurol. 2009;40:265-270; 2. Ivanhoe CB, et al. Arch Phys Med Rehabil. 2006;87:1509-1515;
3. Sampson FC, et al. J Neurosurg. 2002;96:1052-1057.
Intrathecal Baclofen in Cortical
vs Spinal Spasticity
• No difference in outcomes, dosing, or
adverse events among patients with SCI,
TBI, stroke, or CP
• Important note: MS patients required far
smaller dosing
TBI = traumatic brain injury.
Saval A, Chiodo AE. J Spinal Cord Med. 2010;33:16-21.
Case #1
• 25-year-old man with C7 ASIA A
tetraplegia from transverse myelitis for 5
years; now with worsening spasticity in all
4 limbs and trunk, which is painful and
limiting transfers
ASIA: American Spinal Injury Association.
Question 1
In managing this patient, would you:
A. Inject his biceps, quadriceps, and hamstrings
bilaterally with botulinum toxin
B. Look for nociceptive causes for his increased
tone such as urinary tract infection (UTI) or
pressure sore
C. Instruct him in stretching 10 minutes daily
D. Refer him immediately for an intrathecal
baclofen trial
Answer
B. Look for nociceptive causes for his
increased tone such as UTI or pressure
sore
Localized Spasticity
Prolonged Stretch
Bracing/Splinting
Ultrasound
Smaller Muscles
Shorter Acting
Botulinum Toxin A
Botox, Dysport
Botulinum Toxin B
Myobloc
Larger Muscles
Semipermanent
Phenol
Alcohol
Tendon Surgery
OnabotulinumtoxinA (Botox®), AbobotulinumtoxinA (Dysport®), RimabotulinumtoxinB (Myobloc®).
Phenol and Alcohol
• Causes degeneration of both motor
sensory fibers
• Can do nerve blocks in pure motor
nerves, but avoid mixed or sensory
nerves
• Motor point blocks
• Lasts 4 to 9 months
Phenol vs Alcohol
• 100% effective in gastrocnemius
injections for 6 months
• 90% of patients injected with alcohol had
relief at 9 months, 70% of those with
phenol
Kocabas H et al. Eur J Phys Rehabil Med. 2010;46:5-10,
Botulinum Toxins
• Can be injected using anatomic landmarks or
as motor point block
• 4 formulations in United States:
onabotulinumtoxinA (Botox®) +
abobotulinumtoxinA (Dysport®),
incobotulinumtoxinA (Xeomin®), and
rimabotulinumtoxinB (Myobloc®)
• Lasts 2 to 4 months
• NOT FDA approved for spasticity, except
onabotulinumtoxinA for upper limb only.
FDA = US Food and Drug Administration.
Botulinum Toxin Efficacy
• Stroke: improvement at 6 months in MAS and
GAS, but not Assessment of Quality of Life1
• CP: meta-analysis shows 4 of 6 Class I trials
in lower limb, 4 of 6 Class II trials in upper
limb showed significant functional
improvement2
• Better than tizanidine for upper limb
spasticity3
1. McCrory P, et al. J Rehabil Med. 2009;41:536-544; 2. Lukban MB, et al. J Neuro Transm. 2009;116:319-331; 3.
Simpson DM, et al. J Neurol Neurosurg Psychiatry. 2009;80:380-385.
Botulinum Toxin Dosing
• Toxin dosing among formulations are NOT
equivalent
• Dosing mostly an art, not science, based on size
of the muscle (and patient) and degree of
spasticity
• Dosing table available in Sheean et al1
• Dosing peak effects for various muscle in
Yablon et al2
1. Sheean G, et al. Eur J Neurol. 2010; 17:74-93; 2. Yablon SA, et al. Mov Disord. 2010;26:209-215.
Upper Motor Neuron Syndromes
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Shoulder flexion/internal rotation
Elbow flexion/pronation
Wrist flexion
Finger flexion
Hip flexion
Knee flexion
Knee hyperextension
Equinovarus
Toe flexion/extension
Shoulder
• Internal
rotation/adduction
Case #2
• 70-year-old woman with spastic
hemiparesis with painful right
shoulder, adductor, and internal
rotation contractures
• How would you treat?
Question 2
The MOST appropriate treatment would be:
A. Tizanidine 4 mg by mouth 3 times daily
B. Intrathecal baclofen trial
C. Botulinum toxin injection into
subscapularis and pectoralis major
D. Botulinum toxin injection into deltoids
and infraspinatus
Answer
C.
The subscapularis and pectorals are
the major adductors and internal
rotators of the shoulder. The
spasticity is well localized, and hence
treated best by local injection.
Elbow
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Flexion/pronation
Muscles?
Biceps (2-joint rule)
Brachialis
Brachioradialis
Pronator teres
Hand
• Flexed wrist, MCPs,
PIPs, DIPs
• Muscles?
• FCR, FDS, FDP,
lumbricals
DIP = distal interphalangeal; FCR = flexor carpi radialis; FDP = flexor digitorum profundus; FDS = flexor
digitorum superficialis; MCP = metacarpophalangeal; PIP = proximal interphalangeal.
Hand
• Thumb in palm
• Muscle?
• Flexor pollicis longus
Lower Limb
• Hip flexion/adduction
• Muscles?
• Iliopsoas, rectus
femoris/add mag
• Knee flexion
• Muscles?
• Hamstrings
• Equinovarus
• Muscles?
• Gastrocnemius/soleus
Case #3
• 40-year-old man with spastic diplegic
CP has a scissoring gait with bilateral
equinovarus, hamstring, and hip
flexion/adduction spasticity with
minimal mechanical contracture. He
has not responded to oral
medications.
Question 3
How would you treat this patient?
A. Intrathecal baclofen trial
B. Phenol injections into bilateral
adductors, rectus femoris, medial
hamstrings, and gastrocnemius
C. Botulinum toxin injections into bilateral
adductors, rectus femoris, medial
hamstrings, and gastrocnemius
D. Options A and B are both reasonable.
Answer
D.
Options A and B are reasonable
depending on patient preference and
social and financial issues.
Aggressive splinting or serial casting
is probably needed as well.
Ankle and Foot
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•
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Inversion
Muscle?
TP
Great toe, small toe
flexion
• Muscles?
• FHL, FDL
FD = flexor digitorum longus; FHL = flexor hallucis longus; TP = terminal phalanx.