spas ti city assessment and management

8/3/2019 Spas Ti City Assessment and Management

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SpasticitySpasticity

Velocity dependent

increase in muscle

tone do to passive

stretch, characterizedby increased

resistance to passive

motion, involuntary

muscle contractions,and hyper-reflexia.


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Epidemiology of SpasticityEpidemiology of Spasticity

Incidence: Spinal Cord Injury (10,000/ year), Closed Head Injury(1.5 million/ year), Stroke (1/1000/yr), Cerebral Palsy (2/1000 livebirths).

Influenced by: Incomplete > Complete, Tetraplegia > Paraplegia,Men>Women, Legs>Arms, Extension>Flexion.

Pathophysiology: Unknown


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Pathophysiology of SpasticityPathophysiology of Spasticity

Unknown

1) Denervation hypersensitivity ofAlpha Motor Neuron

2) Collateral sprouting resulting infurther loss of inhibitory input.

3) Hyper-excitable Gamma Motorneurons will increase thesensitivity of theneuromuscular spindle.

4) Interneuron activity andexcitability.

Net result is an imbalance ofexcitatory and inhibitoryimpulses resulting in adisinhibition of the alpha motorneuron.


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Spasticity AssessmentSpasticity Assessment

Modified Ashworth Scale:

0 = no increase in muscle tone

1 = slight increase in muscle tone (catch or min resistance

at end range)1 + = slight increase in muscle resistance throughout therange.

2 = moderate increase in muscle tone throughout ROM,PROM is easy

3 = marked increase in muscle tone throughout ROM,PROM is difficult

4 = marked increase in muscle tone, affected part is rigid


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Spasm Frequency Scale: How many

spasms in the last 24 hours in the affected

extremity?0 = no spasms

1 = 1 / day

2 = 1-5/ day3 = 5-9 / day

4 = >10/day


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Adductor Tone Rating:

0 = no increase in muscle tone

1 = increased tone, hips easily abducted 45

degrees by one person2 = hips abducted 45 degrees by on person with

mild effort

3 = hips abducted 45 degrees by one person with

moderate effort4 = two people are required to abduct the hips 45

degrees


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Tardieu: An ordinal rating of tone which measuresthe angle which the catch is first felt (thethreshold angle).

Oswestry: Ordinal which rates stage anddistribution of tone that is addressed by ageneralized grade of either useful or non-usefulmovement.

:


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Direct and Indirect ConsequencesDirect and Indirect Consequences

of Spasticityof Spasticity

Increased Tone

Decreased Range of Motion

Involuntary Movements

Increased Autonomic Reflexes

Exaggerated Reflexes

Muscle Weakness

Muscle Fatigue

Muscle Control

Balance Problems

Increased Caloric Needs

Abnormal Bone Stress

Mobility Dysfunction

ADL Dysfunction

Contracture

Autonomic Storm

Pain

Abnormal Bone Growth

Weight Loss

Tibial Torsion, Leg Length Inequality,Femoral Anteversion, Scoliosis

Sleep Dysfunction

Patient Care (hygiene, transportation)

Bowel and Bladder Dysfunction

Respiratory Dysfunction

Skin Breakdown Communication, Speech, and

Swallowing Dysfunction

Impaired Social, Psychological, andVocational Development


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Advantages of SpasticityAdvantages of Spasticity::

Maintenance of MuscleTone

Maintenance of MuscleBulk (protection of boneysurfaces to prevent skinbreak down)

Tone Effect on Mobility

Tone effect on ADL's Improved Circulation

(orthostatic hypotension)

Prevention of DVT


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Goals of Spasticity Treatment:Goals of Spasticity Treatment:

Improve Function,

Independence,

and Quality of Life

Decrease Cost ofCare


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Mechanism for SpasticityMechanism for Spasticity

Management:Management:

Identify SpasticPatient

Evaluate Caregiver

Follow-through Select Functional

Goals

Identify Treatment

Options Document and

Videotape Results


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Spasticity Management:Spasticity Management:

Remove Noxious Stimuli

Rehabilitation Therapy

Oral Medications Neurolysis

Orthopedic Options

Neurosurgical Procedures


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Remove Noxious StimuliRemove Noxious Stimuli

Identify the

trigger

Prevent

nociceptive

Input to spinal

cord


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Rehabilitation TherapyRehabilitation Therapy

Stretching

Positioning

Seating

Cryotherapy

Biofeedback

Inhibitive Casting

Pool TherapyOrthotics

Electrical Stimulation


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Oral MedicationsOral Medications

Baclofen and Valium

(GABAB/A mimetic),

Dantrolene (inhibits Ca+

release from SR),

Zanaflex and Clonidine

(Alpha-2 Adrenergic

Agonist),

Neurontin (CNS

membrane stabilizer),


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NeurolysisNeurolysis

Botox Injections

Phenol Injections


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Orthopedic OptionsOrthopedic Options

Tenotomy

Myotomy

Osteotomy

Fusion

Tendon Transplant

Tendon Lengthening


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Neurosurgical ProceduresNeurosurgical Procedures

Neurectomy

Myelotomy

Rhizotomy

Selective DorsalRhizotomy

Chordotomy

Implantable duralelectric stimulator

Intrathecal BaclofenPump


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Intrathecal BaclofenIntrathecal Baclofen

Baclofen is a GABA agonist that binds to B receptor to

inhibit ca++ influx into presynaptic terminals

to inhibit the release of excitatory neuotransmitters.

Baclofen is lipophilic and doesn't cross the BBB. Intrathecal Baclofen can be used for the long

term control of severe spasticity without

significant central side effects at a dose less

than 100 times the oral dose.

ITB delivery has been used since 1980 for pain

and 1992 for spasticity.


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