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

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

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

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…” ????????????????????????

Spasticity can be defined as increased tightness in affected muscles

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)

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

Upper Extremity Spasticity

Lower Extremity Spasticity

Spasticity Complications Positioning Hygiene ADLs Sitting or Standing Balance Contractures

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

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

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.

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.

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

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

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.

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

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???

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.

Intrathecal Baclofen

Surgical Procedures Tendon lengthening Neurosurgical procedures Last resort!

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.

QUESTIONS???