Spas Ti City After Stroke

8/2/2019 Spas Ti City After Stroke

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Spasticity After Stroke

Heather Walker, M.D.Assistant Professor

Department of Physical Medicine & RehabilitationUNC-Chapel Hill


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What is a physiatrist???

NOT a physical therapist

NOT a psychiatrist

Education: Four years medical school Four years residency +/- Fellowship Training

Take care of patients with disabilities Stroke, traumatic brain injury, spinal cord injury, amputations,

burns, pediatrics, etc. Goal is to improve function and quality of life


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Physiatrists and Stroke

Medical management during acuteinpatient rehabilitation and as anoutpatient

Blood pressure Bowel and bladder dysfunction

Skin

Language impairments Cognitive and attentional impairments

SPASTICITY


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What is spasticity??

a motor disorder characterized by a

velocity-dependent increase in tonicstretch reflexes (muscle tone) with

exaggerated tendon jerks, resulting fromhyperexcitability of the stretch reflex

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Spasticity can be defined as increasedtightness in affected muscles


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Increased tightness in muscles

Chest wall Difficulty raising arm to theside, putting on clothing

Elbow flexors Difficulty straightening armto reach for items or dressing

Wrist flexors

Finger flexors Difficulty opening handvoluntarily or passively (releasing items, handhygiene)


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Increased tightness in muscles

Hamstrings Difficulty straightening leg

Quadriceps Stiff-knee gait

Calf muscles Difficulty clearing toes whenwalking (tripping), foot turns in when walking

Inner thighs Legs cross over each other

when walking, difficulty pulling legs apart forhygiene


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Upper Extremity Spasticity


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Lower Extremity Spasticity


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Spasticity Complications

Positioning

Hygiene

ADLs Sitting or Standing Balance

Contractures


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Treatment Goals

Improvements in position Mobility

Pain

Contracture prevention

Ease of care are possible


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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


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Therapeutic Exercise

Stretching and range of motion

Myofascial and joint mobilization

Active assistive, active andresistive exercise

Endurance training


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Oral Medications

Zanaflex Adverse effects: drowsiness, dizziness, dry mouth, orthostatic

hypotension

Baclofen Adverse effects: weakness, sedation, hypotonia, ataxia,

confusion, fatigue, nausea, dizziness, lower seizure threshold

Sudden withdrawal may cause seizures, hallucinations, reboundspasticity

Dantrium Adverse effects: weakness (including ventilatory muscles),

drowsiness, lethargy, nausea, diarrhea, Liver toxicity


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Botulinum Toxin Type A (BOTOX):

History of Development

1944

1920s1895

Botulinum toxin

type A first

isolated

Dr. Schantz

begins

investigation

C. botulinumidentified

Dr. Scott initiatesfirst therapeutic

testing in humans

1978

1989

FDA approval of

BOTOX


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BOTOX(Botulinum Toxin Type A):A Focal Therapeutic

Injected directly into overactivemuscles

Reduces contractions, relaxes muscles

Advantages of local injection

Targeted to specific muscles thatare causing the symptoms

When used at recommended doses,avoids systemic, overt distantclinical effects

NOT FDA APPROVED FOR

SPASTICITY


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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 seenregardless of the site injected

Local weakness, created by diffusion ofBotox and is site specific

Death???


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Intrathecal Baclofen

Small doses of baclofen delivered directlyto the spinal canal

Fewer side effects, better relief ofspasticity

Usually more effective for spasticity in thelower extremities

Requires committed patient and family,pump must be refilled every 3 months.


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Intrathecal Baclofen


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Surgical Procedures

Tendon lengthening

Neurosurgical procedures

Last resort!


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Take Home Points.

Spasticity is common after stroke, and ismanifested as muscle tightness in the affectedarm and/or leg.

Several different treatment options are available,including therapies, oral medications andinjections.

If you suffer from spasticity you should be seenby a physiatrist who specializes in spasticitymanagement.


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Spas Ti City After Stroke

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