Spasticity After StrokeSpasticity After Stroke

Heather Walker, M.D.Heather Walker, M.D.Assistant ProfessorAssistant Professor

Department of Physical Medicine & RehabilitationDepartment of Physical Medicine & RehabilitationUNC-Chapel HillUNC-Chapel Hill

What is a physiatrist???What is a physiatrist??? NOT a physical therapistNOT a physical therapist

NOT a NOT a psychiatristpsychiatrist

Education:Education: Four years medical schoolFour years medical school Four years residencyFour years residency +/- Fellowship Training+/- Fellowship Training

Take care of patients with disabilitiesTake care of patients with disabilities Stroke, traumatic brain injury, spinal cord injury, amputations, Stroke, traumatic brain injury, spinal cord injury, amputations,

burns, pediatrics, etc.burns, pediatrics, etc. Goal is to improve function and quality of lifeGoal is to improve function and quality of life

Physiatrists and StrokePhysiatrists and Stroke

Medical management during acute Medical management during acute inpatient rehabilitation and as an inpatient rehabilitation and as an outpatientoutpatientBlood pressureBlood pressureBowel and bladder dysfunctionBowel and bladder dysfunctionSkinSkinLanguage impairmentsLanguage impairmentsCognitive and attentional impairmentsCognitive and attentional impairmentsSPASTICITYSPASTICITY

What is spasticity??What is spasticity??

““a motor disorder characterized by a a motor disorder characterized by a velocity-dependent increase in tonic velocity-dependent increase in tonic stretch reflexes (muscle tone) with stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex…”hyperexcitability of the stretch reflex…”

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Spasticity can be defined as increased tightness in affected muscles

What is spasticity??What is spasticity??

Increased tightness in musclesIncreased tightness in musclesChest wallChest wall Difficulty raising arm to the Difficulty raising arm to the

side, putting on clothingside, putting on clothingElbow flexorsElbow flexors Difficulty straightening arm Difficulty straightening arm

to reach for items or dressingto reach for items or dressingWrist flexorsWrist flexorsFinger flexorsFinger flexors Difficulty opening hand Difficulty opening hand

voluntarily or passively (releasing items, hand voluntarily or passively (releasing items, hand hygiene)hygiene)

What is spasticity??What is spasticity??

Increased tightness in musclesIncreased tightness in musclesHamstringsHamstrings Difficulty straightening leg Difficulty straightening legQuadricepsQuadriceps Stiff-knee gait Stiff-knee gaitCalf musclesCalf muscles Difficulty clearing toes when Difficulty clearing toes when

walking (tripping), foot turns in when walkingwalking (tripping), foot turns in when walking Inner thighsInner thighs Legs cross over each other Legs cross over each other

when walking, difficulty pulling legs apart for when walking, difficulty pulling legs apart for hygienehygiene

Upper Extremity SpasticityUpper Extremity Spasticity

Lower Extremity SpasticityLower Extremity Spasticity

Spasticity ComplicationsSpasticity Complications

Positioning Positioning HygieneHygieneADLsADLsSitting or Standing BalanceSitting or Standing BalanceContracturesContractures

Treatment GoalsTreatment Goals

Improvements in position Improvements in position MobilityMobilityPainPainContracture preventionContracture preventionEase of care are possibleEase of care are possible

Spasticity Management StepsSpasticity Management Steps

Therapeutic modalitiesTherapeutic modalitiesOral MedicationsOral MedicationsNerve blocks & Chemical neurolysis Nerve blocks & Chemical neurolysis

(Botox injections)(Botox injections)Orthopedic proceduresOrthopedic procedures Intrathecal Medications Intrathecal Medications

Prior to InterventionPrior to Intervention

Assess baseline statusAssess baseline statusDetermine specific goalsDetermine specific goalsPatient and family educationPatient and family educationPT and OT role after interventionPT and OT role after intervention

Therapeutic ExerciseTherapeutic Exercise

Stretching and range of motionStretching and range of motionMyofascial and joint mobilizationMyofascial and joint mobilizationActive assistive, active and Active assistive, active and

resistive exerciseresistive exerciseEndurance trainingEndurance training

Oral MedicationsOral Medications ZanaflexZanaflex

Adverse effects: Adverse effects: drowsinessdrowsiness, dizziness, dry mouth, orthostatic , dizziness, dry mouth, orthostatic hypotensionhypotension

BaclofenBaclofen Adverse effects: weakness, Adverse effects: weakness, sedationsedation, hypotonia, ataxia, , hypotonia, ataxia,

confusion, fatigue, nausea, dizziness, lower seizure thresholdconfusion, fatigue, nausea, dizziness, lower seizure threshold Sudden withdrawal may cause seizures, hallucinations, rebound Sudden withdrawal may cause seizures, hallucinations, rebound

spasticityspasticity

DantriumDantrium Adverse effects: weakness (including ventilatory muscles), Adverse effects: weakness (including ventilatory muscles),

drowsinessdrowsiness, lethargy, nausea, diarrhea, Liver toxicity, lethargy, nausea, diarrhea, Liver toxicity

Botulinum Toxin Type A (BOTOXBotulinum Toxin Type A (BOTOX®®)): :

History of DevelopmentHistory of Development

1944

1920s

1895

Botulinum toxin type A first isolated

Dr. Schantz begins investigation

C. botulinum

identified

Dr. Scott initiates first therapeutic testing in humans

19781989

FDA approval of BOTOX®

BOTOXBOTOX®® (Botulinum Toxin Type A): (Botulinum Toxin Type A): A Focal TherapeuticA Focal Therapeutic

• Injected directly into overactive Injected directly into overactive muscles muscles

• Reduces contractions, relaxes musclesReduces contractions, relaxes muscles• Advantages of local injectionAdvantages of local injection

− Targeted to specific muscles that Targeted to specific muscles that are causing the symptomsare causing the symptoms

− When used at recommended doses, When used at recommended doses, avoids systemic, overt distant avoids systemic, overt distant clinical effects clinical effects

− NOT FDA APPROVED FOR NOT FDA APPROVED FOR SPASTICITYSPASTICITY

Muscle identificationMuscle identification

Three main methodsThree main methodsExam and anatomic atlasExam and anatomic atlasEMG assistance and guidanceEMG assistance and guidanceElectronic stimulationElectronic stimulation

Side EffectsSide Effects

LocalizedLocalizedHematoma and bruising are seen Hematoma and bruising are seen

regardless of the site injected regardless of the site injected Local weakness, created by diffusion of Local weakness, created by diffusion of

Botox and is site specificBotox and is site specificDeath???Death???

Intrathecal BaclofenIntrathecal Baclofen

Small doses of baclofen delivered directly Small doses of baclofen delivered directly to the spinal canalto the spinal canal

Fewer side effects, better relief of Fewer side effects, better relief of spasticityspasticity

Usually more effective for spasticity in the Usually more effective for spasticity in the lower extremitieslower extremities

Requires committed patient and family, Requires committed patient and family, pump must be refilled every 3 months.pump must be refilled every 3 months.

Intrathecal BaclofenIntrathecal Baclofen

Surgical ProceduresSurgical Procedures

Tendon lengtheningTendon lengtheningNeurosurgical proceduresNeurosurgical procedures

Last resort!Last resort!

Take Home Points….Take Home Points…. Spasticity is common after stroke, and is Spasticity is common after stroke, and is

manifested as muscle tightness in the affected manifested as muscle tightness in the affected arm and/or leg.arm and/or leg.

Several different treatment options are available, Several different treatment options are available, including therapies, oral medications and including therapies, oral medications and injections.injections.

If you suffer from spasticity you should be seen If you suffer from spasticity you should be seen by a physiatrist who specializes in spasticity by a physiatrist who specializes in spasticity management.management.