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

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Presentation on theme: "Spasticity After Stroke Heather Walker, M.D. Assistant Professor Department of Physical Medicine & Rehabilitation UNC-Chapel Hill."— Presentation transcript:

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 physical therapist NOT a psychiatrist NOT a psychiatrist Education: Education: Four years medical school Four years medical school Four years residency Four years residency +/- Fellowship Training +/- Fellowship Training Take care of patients with disabilities Take care of patients with disabilities Stroke, traumatic brain injury, spinal cord injury, amputations, burns, pediatrics, etc. Stroke, traumatic brain injury, spinal cord injury, amputations, burns, pediatrics, etc. Goal is to improve function and quality of life Goal is to improve function and quality of life

3 Physiatrists and Stroke Medical management during acute inpatient rehabilitation and as an outpatient Medical management during acute inpatient rehabilitation and as an outpatient Blood pressure Blood pressure Bowel and bladder dysfunction Bowel and bladder dysfunction Skin Skin Language impairments Language impairments Cognitive and attentional impairments Cognitive and attentional impairments SPASTICITY 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…” “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…”????????????????????????

5 Spasticity can be defined as increased tightness in affected muscles

6 What is spasticity?? Increased tightness in muscles Increased tightness in muscles Chest wall  Difficulty raising arm to the side, putting on clothing Chest wall  Difficulty raising arm to the side, putting on clothing Elbow flexors  Difficulty straightening arm to reach for items or dressing Elbow flexors  Difficulty straightening arm to reach for items or dressing Wrist flexors Wrist flexors Finger flexors  Difficulty opening hand voluntarily or passively (releasing items, hand hygiene) Finger flexors  Difficulty opening hand voluntarily or passively (releasing items, hand hygiene)

7 What is spasticity?? Increased tightness in muscles Increased tightness in muscles Hamstrings  Difficulty straightening leg Hamstrings  Difficulty straightening leg Quadriceps  Stiff-knee gait Quadriceps  Stiff-knee gait Calf muscles  Difficulty clearing toes when walking (tripping), foot turns in when walking 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 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 Positioning Hygiene Hygiene ADLs ADLs Sitting or Standing Balance Sitting or Standing Balance Contractures Contractures

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

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

13 Prior to Intervention Assess baseline status Assess baseline status Determine specific goals Determine specific goals Patient and family education Patient and family education PT and OT role after intervention PT and OT role after intervention

14 Therapeutic Exercise Stretching and range of motion Stretching and range of motion Myofascial and joint mobilization Myofascial and joint mobilization Active assistive, active and resistive exercise Active assistive, active and resistive exercise Endurance training Endurance training

15 Oral Medications Zanaflex Zanaflex Adverse effects: drowsiness, dizziness, dry mouth, orthostatic hypotension Adverse effects: drowsiness, dizziness, dry mouth, orthostatic hypotension Baclofen Baclofen Adverse effects: weakness, sedation, hypotonia, ataxia, confusion, fatigue, nausea, dizziness, lower seizure threshold Adverse effects: weakness, sedation, hypotonia, ataxia, confusion, fatigue, nausea, dizziness, lower seizure threshold Sudden withdrawal may cause seizures, hallucinations, rebound spasticity Sudden withdrawal may cause seizures, hallucinations, rebound spasticity Dantrium Dantrium Adverse effects: weakness (including ventilatory muscles), drowsiness, lethargy, nausea, diarrhea, Liver toxicity Adverse effects: weakness (including ventilatory muscles), drowsiness, lethargy, nausea, diarrhea, Liver toxicity

16 Botulinum Toxin Type A (BOTOX ® ): History of Development s 1895 Botulinum toxin type A first isolated Dr. Schantz begins investigation C. botulinum identified Dr. Scott initiates first therapeutic testing in humans FDA approval of BOTOX ®

17 BOTOX ® (Botulinum Toxin Type A): A Focal Therapeutic Injected directly into overactive muscles Injected directly into overactive muscles Reduces contractions, relaxes muscles Reduces contractions, relaxes muscles Advantages of local injection 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

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

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20 Side Effects Localized Localized Hematoma and bruising are seen regardless of the site injected Hematoma and bruising are seen regardless of the site injected Local weakness, created by diffusion of Botox and is site specific Local weakness, created by diffusion of Botox and is site specific Death??? Death???

21 Intrathecal Baclofen Small doses of baclofen delivered directly to the spinal canal Small doses of baclofen delivered directly to the spinal canal Fewer side effects, better relief of spasticity Fewer side effects, better relief of spasticity Usually more effective for spasticity in the lower extremities Usually more effective for spasticity in the lower extremities Requires committed patient and family, pump must be refilled every 3 months. Requires committed patient and family, pump must be refilled every 3 months.

22 Intrathecal Baclofen

23 Surgical Procedures Tendon lengthening Tendon lengthening Neurosurgical procedures Neurosurgical procedures Last resort! Last resort!

24 Take Home Points…. Spasticity is common after stroke, and is manifested as muscle tightness in the affected arm and/or leg. 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. 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. If you suffer from spasticity you should be seen by a physiatrist who specializes in spasticity management.

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