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
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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

Therapeutic Exercise
Stretching

and range of motion Myofascial and joint mobilization Active assistive, active and resistive exercise Endurance training

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, rebound spasticity

Dantrium

Adverse effects: weakness (including ventilatory muscles), drowsiness, lethargy, nausea, diarrhea, Liver toxicity

Botulinum Toxin Type A (BOTOX): History of Development

Dr. Schantz begins investigation

FDA approval of BOTOX

C. botulinum identified

1989 1978 1944 1920s

1895
Botulinum toxin type A first isolated

Dr. Scott initiates first therapeutic testing in humans

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

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.