1. Spasticity After Stroke
Heather Walker, M.D.
Assistant Professor
Department of Physical Medicine & Rehabilitation
UNC-Chapel Hill

2. 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

3. 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

4. What is spasticity??
“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…”
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5. Spasticity can be defined as increased tightness in affected muscles

6. 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)

7. What is spasticity?? 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

8. Upper Extremity Spasticity

9. Lower Extremity Spasticity

10. Spasticity Complications
Positioning
Hygiene
ADLs
Sitting or Standing Balance
Contractures

11. Treatment Goals Improvements in position Mobility Pain
Contracture prevention
Ease of care are possible

12. Spasticity Management Steps
Therapeutic modalities
Oral Medications
Nerve blocks & Chemical neurolysis (Botox injections)
Orthopedic procedures
Intrathecal Medications

13. Prior to Intervention Assess baseline status Determine specific goals
Patient and family education
PT and OT role after intervention
Detailed PT and OT evaluations provide specific information about the patient’s baseline status, so that changes can be documented as treatment progresses. This detailed information provides the framework for developing the therapy program. Comparison of pre- and post-intervention status can also be useful to justify payment for treatment from third party providers.
Therapists can also provide helpful input on whether a patient might benefit from a specific type of intervention, working in conjunction with neurologists, physiatrists, orthopedists, and others involved in the patient’s care.
Establishing realistic goals is crucial in determining which treatment or combination of treatments will be beneficial to a patient. Both short and long term goals must be established before a therapy treatment program begins.
It is important to educate not only the patient but all family members and other caregivers who may be involved in the patient’s care. Providing the practical details of the planned surgical or medical intervention helps to educate them, allay fears of the unknown, and encourages them to work with the treatment team to develop reasonable goals and expectations.
Patients and families often want and need to know the details, such as how long surgery will take, and what can be expected afterwards in terms of pain, swelling, and decreased mobility. Providing explicit information regarding the need for increased help with self-care activities, and how long that help will be needed, allows everyone to be better prepared.
The PT/OT program needs to be coordinated with all other medical professionals involved in the patient’s care. This takes extra time and effort on everyone’s part, but definitely pays off in the long run.

14. Therapeutic Exercise Stretching and range of motion
Myofascial and joint mobilization
Active assistive, active and resistive exercise
Endurance training
Stretching and ROM exercises are implemented for the purpose of decreasing contractures and increasing the dynamic range available for functional activities. Myofascial and joint mobilization should be added to the patient’s exercise program as indicated.
Active assistive, active and resistive exercises improve strength and increase motor control. The patient who has undergone intervention to reduce spasticity often will demonstrate significant weakness in the previously spastic muscle(s); with less interference from spasticity and synergies, he can work more effectively on strengthening the involved muscles.
The patient with severe spasticity may demonstrate involuntary co-contraction of muscles around a joint, impairing voluntary movement. However, voluntary co-contraction is an important component of volitional movement. It is used for proximal stabilization, allowing free distal purposeful movement. Co-contraction is also needed for “turn-around”, the transition from one movement to another.
The program should include exercises that will increase the patient’s endurance as well. Improved endurance and more efficient movement will result in decreased energy expenditure.

15. Oral Medications Zanaflex Baclofen Dantrium
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, rebound spasticity
Dantrium
Adverse effects: weakness (including ventilatory muscles), drowsiness, lethargy, nausea, diarrhea, Liver toxicity

16. Botulinum Toxin Type A (BOTOX®): History of Development
FDA approval of BOTOX®
Dr. Schantz begins investigation
C. botulinum identified
1989
1978
1944
In slightly more than 100 years, our knowledge of botulinum toxin type A has expanded from the identification of the bacterium Clostridium botulinum to the commercialization of botulinum toxin type A, as BOTOX®.
C. botulinum was first identified in the late 1890s. In the 1920s a crude form of botulinum toxin type A was isolated by Dr. Herman Sommer and his colleagues at the University of California. Other scientists conducted further purification studies over the next 20 years. In 1944, Dr. Edward Schantz began his investigations with botulinum toxin type A (Schantz, Johnson, 1997).
In the late 1960s, Dr. Alan Scott sought a substance that could be used to weaken eye muscles as an alternative to surgery for patients with strabismus. Dr. Schantz provided him with several substances to test, one of which was botulinum toxin type A 900 kD complex (Schantz, 1994).
In the 1960s and 1970s, Drs. Schantz and Scott continued their research with botulinum toxin type A, including testing the compound in nonhuman animals.
In 1978, Dr. Scott initiated the first tests of botulinum toxin type A in humans for the treatment of strabismus.
In 1989, BOTOX® was approved by the FDA (at that time the product was called Oculinum).
1920s
Dr. Scott initiates first therapeutic testing in humans
1895
Botulinum toxin type A first isolated

17. 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
BOTOX® is a focal therapeutic that is injected directly into muscles. It acts on peripheral cholinergic neurons to inhibit acetylcholine release, which reduces contractions and relaxes muscles.
Local injection of BOTOX® is associated with several advantages. First, treatment can be targeted to the specific muscles that are causing the symptoms. Second, when used at recommended doses, BOTOX® is not expected to result in systemic, overt distant clinical effects.
The beneficial effects of each injection last approximately 3 months, at which time patients may return for reinjection.
Injections can be repeated as long as the patient continues to respond and doesn’t experience an allergic reaction.

18. Muscle identification
Three main methods
Exam and anatomic atlas
EMG assistance and guidance
Electronic stimulation

20. 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???

21. 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.

22. Intrathecal Baclofen

23. Surgical Procedures Tendon lengthening Neurosurgical procedures
Last resort!

24. Take Home Points….
Spasticity is common after stroke, and is manifested as muscle tightness in the affected arm and/or leg.
Several different treatment options are available, including therapies, oral medications and injections.
If you suffer from spasticity you should be seen by a physiatrist who specializes in spasticity management.

25. QUESTIONS???