1. Ten Minutes About: Post Stroke Spasticity
Katherine Bosman-Clark BSN, RN
MSN 621
Alverno College

2. Case Study
Mr. Johnson is a 75 year old male who suffered a stroke 4 months ago. Following his hospital stay he spent one month in an hospital-based inpatient rehabilitation program (rehab). He progressed well and was able to go home with a few adaptations made to his living space. He goes to a clinic several times a week for outpatient physical and occupational therapy. In the past few weeks he has noticed frequent jerking movements in his left arm. They are painful, involuntary and he finds them embarrassing.

3. What You’ll Get From This Tutorial
A look at the causes of one of the most common post-stroke side effects – spasticity
An understanding of the pathophysiology of spasticity
An overview of the most common treatments for spasticity

4. What is Spasticity?
Spasticity is caused by ineffective transmission of nerve impulses. It is usually caused by a disturbance in an upper motor neuron and results in “intermittent or sustained involuntary contraction of muscles” (2). This condition has a significant impact on activities of daily living because of reduced range of motion, painful spasms, and muscle contractures (4).

5. Check Your Knowledge
What symptoms does Mr. Johnson have that indicate spasticity?
Involuntary jerking in his arm.
Right!
Increased somnolence.
This may occur after stroke, but is not related to spasticity. Try again!
Continued need for therapy.
Most patients need therapy post stroke, regardless of spasticity. Try again!

6. What Causes Spasticity?
Spasticity is caused by incomplete transmission of impulses from alpha motor neurons of the brain (5, 8). Alpha motor neurons are responsible for innervating skeletal muscles with their cell bodies in the brain or spinal cord and axons ending in the skeletal muscles (2).
A figure would be really useful!

7. Explanation of the Motor Neuron Pathway
Image provided by Brad Walker and The Stretching Institute. Copyright © All rights reserved. Brad is a leading stretching and sports injury consultant with more than 20 years experience in the health and fitness industry. View more articles here....


8. Gamma-Aminobutyric Acid (GABA)
GABA is the primary inhibitor of impulses crossing synapses in the central nervous system (CNS) (6). When GABA binds to its receptors, channels open allowing chloride ions into the cell and potassium ions out of the cell. (6). In spasticity receptors do not bind GABA effectively and consequently nerve impulses are not inhibited, leading to over contraction of the muscle.

9. What are Consequences of Spasticity?
Contractures result when muscles are shortened for an extended period of time (8).
Spasticity exacerbates functional limitations associated with stroke (2).
In general, spasticity causes a decrease in a person’s functional independence.

10. Check Your Knowledge How can spasticity negatively impact a patient?
It doesn’t.
Spasticity is a painful and inhibits patient’s ability to preform ADLs. Try again!
Contributes to risk for anther stroke.
Spasticity does not increase stroke risk. Try again!
Can decrease quality of life.
Right!

11. What to Keep In Mind When Treating a Patient for Spasticity
Pharmacologic measures exist as effective treatments for spasticity (3)
Physical, occupational, and speech therapy all play important roles in treatment (2)
The patient and caregivers are also important for setting goals of treatment (2)

12. Commonly Used Oral Medications
Drug
Mechanism of Action
Side Effects
Baclofen (Lioresal)
Structural analog of GABA (inhibitory transmitter of CNS) (2)
Drowsiness, sedation, muscle weakness (2)
Tizanidine (Zanaflex)
Alpha-2 adrenergic agonist, binds to spinal receptors to block release of excitatory neurotransmitters (2)
Drowsiness, dry mouth, weakness, hypotension, elevated liver function tests (2)
Diazepam (Valium)
Increases effects of GABA at CNS synapses (3)
Fatigue, drowsiness, reduction in motor coordination (3)
Dantrolene Sodium (Dantrium)
Acts on skeletal muscles by reducing strength of contraction (3)
Decrease in gross motor function (3)

13. Check Your Knowledge
What is a common side effect of oral agents used to treat spasticity?
Drowsiness.
Right!
There are no negative side effects.
All medications have side effects. Try again!
Dysuria.
Post-stroke spasticity does not impact the bladder. Try again!

14. Goals and Tools used in Therapy Treatment
Increase stretch in shortened muscles and tendons
Decrease over-activity of muscles
Improve muscle strength
Increase muscle control
Tools (2)
Stretching programs tailored to the patient’s needs
Braces and/or serial casting
Electrical stimulation

15. Check Your Knowledge
What is the goal of therapy treatments for spasticity?
To encourage use of medication
Try again.
Improve the patient’s quality of life
Right!
To provide work for PTs and OTs
Try again.

16. Summary
Spasticity post-stroke has the potential to greatly impact a patient’s quality of life
Although the causes of spasticity are not well understood, there are treatment options
Both pharmacologic and non-pharmacologic measures may be helpful in treating spasticity

17. Literature Cited
1) Alpha Motor Neuron. (September 12, 2011). Retrieved April 4, 2012 from Wikipedia: 2) Francisco, G.E., & McGuire, J.R. (2009). Physiology and management of spasticity after stroke. In J. Stein, R.L. Harvey, R.F. Macko, C.L. Winstein, & R.D. Zorowitz (Eds.), Stroke Recovery and Rehabilitation ( ). New York, NY: DemosMedical. 3) Gallichio, J. (2004). Pharmacologic management of spasticity following stroke. Physical Therapy, 84(10), ) Kumar, R. T., Pandyan, A. D., Sharma, A. K. (2006). Biomechanical measurement of post-stroke spasticity. Age and Ageing, 35, ) National Institute of Neurologic Disorders and Stroke, National Institutes of Health. (2011, October 4). NINDS Spasticity Information Page. Retrieved April 4, 2012 from 6) Porth, C. M. & Matfin, G. (2009). Pathophysiology Concepts of Altered Health States (8th ed.) (pp ). New York, NY: Lippincott, Williams &Wilkins. 7) Satkunam, L. E. (2003). Rehabilitation medicine: 3. Management of adult spasticity. Canadian Medical Association Journal, 169(11), ) Vanek, Z.F., Berman, S.A. (2010). Spasticity. Retrieved April 4, 2012 from Walker, B. (2012). Understanding the Stretch Reflex, picture. Retrieved April 24, 2012 from