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SPASTICITYSPASTICITY POSTPOSTSTROKESTROKE
Sepideh Pooyania MD. FRCPCSepideh Pooyania MD. FRCPC
April 13, 2010April 13, 2010
ObjectivesObjectivesSpasticitySpasticityPost strokePost stroke
Case presentationCase presentation
DefinitionDefinition
PathophysiologyPathophysiology
Clinical presentationClinical presentation
EvaluationEvaluation
Management: NonManagement: Non--pharmacological,pharmacological,Pharmacological, SurgicalPharmacological, Surgical
Back to the caseBack to the case
Case 1Case 1 Mrs. A is a 67Mrs. A is a 67--yearyear--old woman who had a strokeold woman who had a stroke
18 months ago that resulted in spastic left18 months ago that resulted in spastic left
hemiplegiahemiplegia. She has no useful function in her left. She has no useful function in her left
upper extremity but is able to walk with a caneupper extremity but is able to walk with a cane
and ankle brace.and ankle brace.Over the last 6 months she has noticed aOver the last 6 months she has noticed a
gradually increasing tightness in her left leg, andgradually increasing tightness in her left leg, and
on several occasions she has tripped over theon several occasions she has tripped over the
left toes, which has resulted in minor falls. Herleft toes, which has resulted in minor falls. Her
husband is concerned that she may have ahusband is concerned that she may have a
serious fall, leading to bone injury.serious fall, leading to bone injury.
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STROKESTROKE
Within our aging population, stroke is anWithin our aging population, stroke is an
increasingly common and often disablingincreasingly common and often disablingcondition.condition.
It is the leading cause of adult neurologicdisability in Canada, with over 300,000 people(1% of the population) living with its effects.
Incidence doubles every 10 years after theage of 55
40% of stroke patients have moderate tosevere impairment.
Stroke survival has increased.Stroke survival has increased.
Stroke mortality fell an average of 7%Stroke mortality fell an average of 7%
(from 1990 to 1997)(from 1990 to 1997) and fell an average of 5.4% per year inand fell an average of 5.4% per year in
1998 to 20021998 to 2002
Yang Q,Yang Q, BottoBotto LD, Erickson JD,LD, Erickson JD, et alet al.. Improvement in strokeImprovement in strokemortality in Canada and the United States, 1990 to 2002.mortality in Canada and the United States, 1990 to 2002. CirculationCirculation2006 Mar 14;113(10):13352006 Mar 14;113(10):1335--4343..
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Stroke Related SpasticityStroke Related Spasticity
is a Large & Growingis a Large & Growing
ProblemProblem
The prevalence of spasticity amongThe prevalence of spasticity among
initially hospitalized stroke patients wasinitially hospitalized stroke patients was
%19 at 3 months and %38 at one year.%19 at 3 months and %38 at one year.
Watkins et al,Watkins et al, PrevelancePrevelance of spasticity post stroke, Clinical Rehab 2002, 16:of spasticity post stroke, Clinical Rehab 2002, 16:
515515--522522
SommerfeldSommerfeld et al,et al, SpasticitySpasticity after stroke. Its occurrence and associationafter stroke. Its occurrence and association
with motor impairment and activity.with motor impairment and activity.
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SpasticitySpasticity was associated with worse function.was associated with worse function.
To obtain an accurate picture of prevalence ofTo obtain an accurate picture of prevalence of
spasticityspasticity post stroke, one must assess armspost stroke, one must assess arms
and legs.and legs.
Watkins et al,Watkins et al, PrevelancePrevelance ofof spasticityspasticity post stroke, Clinical Rehabpost stroke, Clinical Rehab
2002, 16: 5152002, 16: 515--522522
SommerfeldSommerfeld et al,et al, SpasticitySpasticity after stroke. Its occurrence andafter stroke. Its occurrence and
association with motor impairment and activity.association with motor impairment and activity.
SpasticitySpasticity
A motor disorder characterized by aA motor disorder characterized by a velocityvelocity--dependentdependentincrease in the tonic stretchincrease in the tonic stretchreflexes (muscle tone) with exaggeratedreflexes (muscle tone) with exaggeratedphasicphasic stretch reflexes (tendon jerks, clonus)stretch reflexes (tendon jerks, clonus)resulting fromresulting from hyperexcitabilityhyperexcitability of the stretchof the stretchreflex and is one of the component of thereflex and is one of the component of theupper motor neuron syndrome.upper motor neuron syndrome.
Lance JW. Symposium synopsis. In: Feldman RG et al, eds. Spasticity: Disordered Motor Control.Chicago, Ill: Year Book Medical Publishers; 1980:487-489.
Copyright2003 Canadian Medical Association or its licensors
Satkunam, L. E. CMAJ 2003;169:1173-1179
Fig. 1: The stretch reflex arc
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HyperexcitabilityHyperexcitability of the stretch reflex canof the stretch reflex can
occur as a result of :occur as a result of :1) Alpha Motor neuron being1) Alpha Motor neuron being hyperexcitablehyperexcitable at the level ofat the level of
spinal cord segment.spinal cord segment.
2) Excessive afferent input from muscle spindle.2) Excessive afferent input from muscle spindle.
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Clinical presentations ?Clinical presentations ?
Clinical presentationsClinical presentations Signs and symptomsSigns and symptoms
StiffnessStiffness
ClonusClonus
PainPain
Flexor and extensor spasmsFlexor and extensor spasms DisfigurementDisfigurement
Impaired active functionImpaired active function Reach, graspReach, grasp
Gait, transfersGait, transfers
Impaired passive functionImpaired passive function Personal carePersonal care
PositioningPositioning
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Evaluation ofEvaluation ofSpasticitySpasticity
EvaluationEvaluation
Some of the factors to consider:Some of the factors to consider:
ChronicityChronicity: It may influence the goals and: It may influence the goals andtype of treatment to be administrated.type of treatment to be administrated.ChronicChronic sapsticitysapsticity may be more resistantmay be more resistantto treatment, specially if contractures haveto treatment, specially if contractures havedeveloped.developed.
SeveritySeverity: Mild: Mild SpasticitySpasticity may need lessmay need lessaggressive conservative measures.aggressive conservative measures.
Scope ofScope of SpasticitySpasticityMild
SpasticityChronic
SpasticitySevere
Spasticity
Courtesy of Nathaniel H. Mayer, MD, and Alberto Esquenazi, MD.
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DistributionDistribution: Focal versus global.: Focal versus global.
DistributionDistribution
Focal
Courtesy of Nathaniel H. Mayer, MD, and Alberto Esquenazi, MD.
Multifocal Regional
Spinal versus CerebralSpinal versus Cerebral::
OralOral antispasticityantispasticity meds tend to respondmeds tend to respond
better with spinalbetter with spinal spasticityspasticity..
CoCo--morbiditiesmorbidities: Poor motor control,: Poor motor control,
cognitive deficits may influence thecognitive deficits may influence the
decision to treat.decision to treat.
Availability of care and ongoingAvailability of care and ongoing
support.support.
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Clinical Scales for ratingClinical Scales for rating SpasticitySpasticity
Ashworth ScaleAshworth Scale Ordinal scale for measuring muscle tone; range 0 to 4Ordinal scale for measuring muscle tone; range 0 to 4
Modified Ashworth ScaleModified Ashworth Scale Defines the lower end of the scale by adding theDefines the lower end of the scale by adding the 1+1+ gradegrade
Tardieu ScaleTardieu Scale Interval scale for measuring stretch response reactions atInterval scale for measuring stretch response reactions at
specific velocitiesspecific velocities
Other ScalesOther Scales Spasm Frequency ScoreSpasm Frequency Score
Ordinal scale for measuring spasm frequency; ratesOrdinal scale for measuring spasm frequency; ratesfrequency of leg spasms/dayfrequency of leg spasms/day
Degree of Adductor Muscle ToneDegree of Adductor Muscle Tone Ordinal scale for measuring muscle tone in a specific muscleOrdinal scale for measuring muscle tone in a specific muscle
group;group; egeg, hip adductors for patients being treated for, hip adductors for patients being treated forreduction in the adducted leg positionreduction in the adducted leg position
The clinical assessment of spasticityThe clinical assessment of spasticity
incorporates descriptive scales ofincorporates descriptive scales of
resistance to passive movement, but theresistance to passive movement, but the
use of ause of a neurophysiologicalneurophysiological measure ofmeasure of
muscle activity levels has been advocated.muscle activity levels has been advocated.
Quantitative measures of spasticityQuantitative measures of spasticity
in postin post--stroke patientsstroke patients
Mechanical stretches of the wrist flexor musclesMechanical stretches of the wrist flexor muscles
of 53 postof 53 post--stroke patients were imposed bystroke patients were imposed by
means of a torque motor at constant speed.means of a torque motor at constant speed.
Patients were clinically studied using thePatients were clinically studied using theAshworth scale for spasticity and the MedicalAshworth scale for spasticity and the Medical
Research Council score for residual muscleResearch Council score for residual muscle
strength.strength.
PisanoPisano F, Quantitative measures of spasticity in postF, Quantitative measures of spasticity in post--strokestroke
patients.patients. ClinicClinic NeurophysiolNeurophysiol.. 2000 Jun;111(6):10152000 Jun;111(6):1015--22.22.
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TheThe neurophysiologicalneurophysiological measures weremeasures were
Hoffmann reflex latency,Hoffmann reflex latency, Hmax/MmaxHmax/Mmaxratio, stretch reflex threshold speedratio, stretch reflex threshold speed
(SRTS), stretch reflex (SR) latency and(SRTS), stretch reflex (SR) latency and
area, passive and total stiffness indices.area, passive and total stiffness indices.
PisanoPisano F, Quantitative measures ofF, Quantitative measures of spasticityspasticity in postin post--strokestroke
patients.patients. ClinicClinic NeurophysiolNeurophysiol.. 2000 Jun;111(6):10152000 Jun;111(6):1015--22.22.
This EMGThis EMG--biomechanical technique allows anbiomechanical technique allows an
objective evaluation of changes in muscle toneobjective evaluation of changes in muscle tone
in postin post--stroke patients, providing easilystroke patients, providing easily
measurable, quantitative indices of musclemeasurable, quantitative indices of muscle
stiffness.stiffness.
PisanoPisano F, Quantitative measures ofF, Quantitative measures of spasticityspasticity in postin post--strokestroke
patients.patients. ClinicClinic NeurophysiolNeurophysiol.. 2000 Jun;111(6):10152000 Jun;111(6):1015--22.22.
The linear distribution of these measures isThe linear distribution of these measures is
particularly indicated for monitoring changesparticularly indicated for monitoring changes
induced by treatment. The apparatus seemsinduced by treatment. The apparatus seems
suitable to characterize neural stiffness, whilesuitable to characterize neural stiffness, whiledifficulties were found in isolating the passivedifficulties were found in isolating the passive
components, because of the occurrence of toniccomponents, because of the occurrence of tonic
EMG activity in most spastic patients.EMG activity in most spastic patients.
PisanoPisano F, Quantitative measures ofF, Quantitative measures of spasticityspasticity in postin post--strokestroke
patients.patients. ClinicClinic NeurophysiolNeurophysiol.. 2000 Jun;111(6):10152000 Jun;111(6):1015--22.22.
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Quantitative measurement ofQuantitative measurement of
post stroke spasticitypost stroke spasticity
Raw EMG data were notch filtered ( 50 HZ) andRaw EMG data were notch filtered ( 50 HZ) andthen smoothed with root mean square methods (then smoothed with root mean square methods (50 millisecond window width). For the analysis of50 millisecond window width). For the analysis ofspasticityspasticity, the average integrated EMG activity (, the average integrated EMG activity (referred to angular displacement) was calculatedreferred to angular displacement) was calculatedduring both lowduring both low--velocity and highvelocity and high--velocityvelocitypassive stretches by use ofpassive stretches by use of MathcadMathcad..
Cousins et al Quantitative Measurement ofCousins et al Quantitative Measurement of PoststrokePoststroke Spasticity andSpasticity andResponse to Treatment WithResponse to Treatment With BotulinumBotulinum Toxin: A 2Toxin: A 2--Patient Case Report.Patient Case Report.Physical therapy Volume 8, Number 7, June 2009.Physical therapy Volume 8, Number 7, June 2009.
TheThe neurophysiologicalneurophysiological measure was able tomeasure was able to
identify when muscle activity levels had beenidentify when muscle activity levels had been
reduced, but a reduction in muscle activity levelsreduced, but a reduction in muscle activity levels
did not always correspond with a reduction indid not always correspond with a reduction in
Modified Ashworth Scale scores.Modified Ashworth Scale scores.
Cousins et al Quantitative Measurement ofCousins et al Quantitative Measurement of PoststrokePoststroke SpasticitySpasticity and Responseand Response
to Treatment Withto Treatment With BotulinumBotulinum Toxin: A 2Toxin: A 2--Patient Case Report. PhysicalPatient Case Report. Physical
therapy Volume 8, Number 7, June 2009.therapy Volume 8, Number 7, June 2009.
Management ofManagement of
SpasticitySpasticity
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Copyright2003 Canadian Medical Association or its licensors
Satkunam, L. E. CMAJ 2003;169:1173-1179
Elimination of noxious stimulationElimination of noxious stimulation
Urinary tract infectionsUrinary tract infections ConstipationConstipation Ingrown toe nailsIngrown toe nails Pressure ulcersPressure ulcers Poor fit in a brace or wheelchairPoor fit in a brace or wheelchair Tight clothingTight clothing Infections (e.g. pneumonia)Infections (e.g. pneumonia) Neuroleptic agentsNeuroleptic agents Fractures/dislocationsFractures/dislocations Heterotropic ossificationHeterotropic ossification Renal stonesRenal stones
SyrinxSyrinx in a SCIin a SCI Poor posture in bed/wheel chairPoor posture in bed/wheel chair
Copyright2003 Canadian Medical Association or its licensors
Satkunam, L. E. CMAJ 2003;169:1173-1179
Fig. 3: Treatment planning for patients with spasticity
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In post strokeIn post stroke spasticityspasticity, general, generalpharmacological treatments are limited bypharmacological treatments are limited byadverse events and lack of evidence ofadverse events and lack of evidence of
functional benefit.functional benefit.
The place of chemicalThe place of chemical neurolysisneurolysis with use ofwith use ofalcohol or phenol should be evaluated withalcohol or phenol should be evaluated withsurgicalsurgical neurotomyneurotomy andand botulinumbotulinum toxin therapy.toxin therapy.
YelnikYelnik , Pharmacology and upper limb post stroke, Pharmacology and upper limb post stroke spasticityspasticity ..
AnnalesAnnales dede readaptationareadaptationa et de medicine physique 47(2004)et de medicine physique 47(2004)
Drug treatments forDrug treatments for spasticityspasticity
A.P.A.P. YelnikYelnik et al,et al, Ann PhysAnn Phys RehabilRehabil Med.Med. 2009 Nov 32009 Nov 3
Drug treatments forDrug treatments for spasticityspasticity
A.P.A.P. YelnikYelnik et al,et al, Ann PhysAnn Phys RehabilRehabil Med.Med. 2009 Nov 32009 Nov 3
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NonNon--pharmacologicalpharmacological
The role of Physical andThe role of Physical and
occupational therapyoccupational therapy The choice of treatment is individualized to meet theThe choice of treatment is individualized to meet the
needs of the person withneeds of the person with spasticityspasticity..
StretchingStretching::It helps to maintain the full range of motion of the joint.It helps to maintain the full range of motion of the joint.
Prevents contractures.Prevents contractures.
To be effective, should be done regularly, usually once orTo be effective, should be done regularly, usually once or twice atwice aday.day.
StrengtheningStrengthening::
To restore the proper level of strength to affected muscles, soTo restore the proper level of strength to affected muscles, so as theas thetone is decreased through other treatments, the affected limb catone is decreased through other treatments, the affected limb ca n ben beused to its fullest potential.used to its fullest potential.
OrthosesOrthoses and castsand casts::
To allow the spastic limb to be maintained in aTo allow the spastic limb to be maintained in amore normal position and reduce contracture.more normal position and reduce contracture.
A cast is a temporary brace. Serial castingA cast is a temporary brace. Serial castinggradually stretches out a contracted limbgradually stretches out a contracted limb..
PositioningPositioning::
Improves comfort and reducesImproves comfort and reduces spasticityspasticity..
ColdCold ::It affects the firing rate of muscle spindle.It affects the firing rate of muscle spindle.
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Electrical stimulation:Electrical stimulation:
Used to stimulate a weak muscle to oppose the activityUsed to stimulate a weak muscle to oppose the activityof a stronger spastic ones.of a stronger spastic ones.
Biofeedback:Biofeedback:Using biofeedback the person withUsing biofeedback the person with spasticityspasticity may be ablemay be able
to train himself to reduce muscle tone consciously.to train himself to reduce muscle tone consciously.
Pharmacotherapy inPharmacotherapy in SpasticitySpasticity
AntispasticAntispastic agentsagents
Muscle weakness,Muscle weakness,
rarerare hapatotoxicityhapatotoxicity
dizzinessdizziness
100 mg100 mg
QIDQID
25 mg25 mg
/day/day
reduces calciumreduces calcium
flux across theflux across the
sarcoplasmicsarcoplasmic
reticulum of skeletalreticulum of skeletal
musclemuscle
DantroleneDantrolene
SodiumSodium
Dizziness,Dizziness,
DrowsinessDrowsiness
Liver dysfunctionLiver dysfunction
36 mg36 mg
/ day/ day
22--4 mg4 mg
QhsQhs
Central alpha 2Central alpha 2
agonist,agonist,
imadazolineimadazoline
receptor inhibitorreceptor inhibitor
TizanidineTizanidine
Sedation,Sedation,
CognitiveCognitive
dysfunctiondysfunction
50 mg50 mg
/ day/ day
5 mg5 mg
QhsQhs
GABA A receptorGABA A receptor
blockerblocker
BenzodiazepinsBenzodiazepins
Sedation, seizures,Sedation, seizures,
confusion, fatigue,confusion, fatigue,
ataxia,hallucinationsataxia,hallucinations
80mg80mg
/day/day
5mg5mg
TIDTID
GABA B agonistGABA B agonist
Pre and PostPre and Post
synapticsynaptic
BaclofenBaclofen
Side effectsSide effectsMax.Max.
dosedose
StartingStarting
dosedoseMechanismMechanism
of actionof action
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othersothers
GabapentinGabapentinis emerging as a useful alternativeis emerging as a useful alternative
inin spasticityspasticity management. Patients may requiremanagement. Patients may requirehigher doses of this drug (2700higher doses of this drug (27003200 mg/d).3200 mg/d).
It reducesIt reduces spasticityspasticity in MS without the sidein MS without the side
effects of worsening concentration and fatigue.effects of worsening concentration and fatigue.
Cutter et al,Cutter et al, GabapentinGabapentin effect oneffect on spaspticityspaspticity in Multiple sclerosis .in Multiple sclerosis .
Arch Phys MedArch Phys Med RehabilRehabil ,2000 Feb; 81(2) 164,2000 Feb; 81(2) 164--99
FampridineFampridine--SRSR(sustained(sustained--release 4release 4--aminopyridine) is a potassiumaminopyridine) is a potassium--channelchannelblocker. Some studies has shown it helpfulblocker. Some studies has shown it helpfulin managingin managing spasticityspasticity in patients within patients withspinal cord injuries.spinal cord injuries.
Potter PJ, et al. Randomized doublePotter PJ, et al. Randomized double--blind crossover trial ofblind crossover trial of fampridinefampridine--SR (sustainedSR (sustainedrelease 4release 4--aminopyridine) in patients with incomplete spinal cord injury.aminopyridine) in patients with incomplete spinal cord injury. JJ
NeurotraumaNeurotrauma1998;15(10):8371998;15(10):837--4949
CannabinoidsCannabinoids
DeltaDelta--99--tetrahydrocannabinol, the activetetrahydrocannabinol, the active
ingredient in cannabis, has also beeningredient in cannabis, has also been
shown to be useful inshown to be useful in spasticityspasticity; however,; however,
evidence of its efficacy compared withevidence of its efficacy compared withother medications requires evaluation.other medications requires evaluation.
PetroPetro DJ. Treatment of humanDJ. Treatment of human spasticityspasticity with delta 9with delta 9--tetrahydrocannabinol.tetrahydrocannabinol.JJ
ClinClinPharmacolPharmacol1981;21(81981;21(8--9 Suppl):413S9 Suppl):413S--416S416S..
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Chronic infusion of medications into theChronic infusion of medications into the
intrathecalintrathecal spacespace
InjectableInjectable pharmacologic therapypharmacologic therapy
IntratechalIntratechal BaclofenBaclofen::administration results in a 100administration results in a 100--fold increase in potencyfold increase in potencycompared with the oral treatment.compared with the oral treatment.
Although this form ofAlthough this form of antispasticityantispasticity therapy is highlytherapy is highlyeffective, its use is limited by the invasive nature of theeffective, its use is limited by the invasive nature of the
treatment and the cost of the implantable devices.treatment and the cost of the implantable devices.
IntrathecalIntrathecal morphine (morphine (InfumorphInfumorph) and) and midazolammidazolam(Versed) :(Versed) :effectiveeffective antispasticityantispasticity as well as analgesic treatmentas well as analgesic treatment
tolerance,tolerance, pruritispruritis, nausea, hypotension, urinary, nausea, hypotension, urinaryretention, and respiratory depression can occur with anretention, and respiratory depression can occur with an
intrathecalintrathecal morphine bolus dose as low as 0.4 mgmorphine bolus dose as low as 0.4 mg
Initially, ITB was considered only in conditionsInitially, ITB was considered only in conditionscharacterized by severe multicharacterized by severe multi--limb spasticlimb spastichypertoniahypertonia in nonin non--ambulatory individuals. Lately,ambulatory individuals. Lately,ITB is used in persons with stroke who canITB is used in persons with stroke who canambulate, with the intent of further improvingambulate, with the intent of further improvingwalking ability. Early clinical experience andwalking ability. Early clinical experience and
evidence suggest that when used in theevidence suggest that when used in theappropriate patient, ITB is efficient and safe inappropriate patient, ITB is efficient and safe inmanaging postmanaging post--strokestroke hypertoniahypertonia in individualsin individualsof various functional levels.of various functional levels.
Francisco GFrancisco GEE.. IntrathecalIntrathecal baclofenbaclofen in the management of postin the management of post--strokestroke hypertoniahypertonia: current applications and future directions: current applications and future directionsstrokestroke RehabilRehabil 2006.2006.
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Clinical issues unique to strokeClinical issues unique to stroke
patients in relation to ITBpatients in relation to ITB 1) Anticoagulation1) Anticoagulation
2) Screening: Should be performed based on2) Screening: Should be performed based onfunction difference ( gait change) or evaluationfunction difference ( gait change) or evaluationby caregiver for hygiene and other passiveby caregiver for hygiene and other passivefunctions rather than Ashworth scale.functions rather than Ashworth scale.
3) Seizure:3) Seizure: SzSz are known to occur during ITBare known to occur during ITBscreening and after pump implantation. This riskscreening and after pump implantation. This riskshould be discussed with the patient.should be discussed with the patient.
Francisco GFrancisco GEE.. IntrathecalIntrathecal baclofenbaclofen in the management of postin the management of post--strokestroke hypertoniahypertonia: current applications and future directions.: current applications and future directions.strokestroke RehabilRehabil 20062006
4) Bowel and bladder: Some studies have4) Bowel and bladder: Some studies haveshown changes in GI motility following ITBshown changes in GI motility following ITBimplantation.implantation. PremorbidPremorbid bowel or bladderbowel or bladderdysfunction may be aggravated by ITB.dysfunction may be aggravated by ITB.
5) MRI scans: may be an issue in5) MRI scans: may be an issue in SynchoMedSynchoMed IIIIpump model .pump model .
Francisco GFrancisco GEE.. IntrathecalIntrathecal baclofenbaclofen in the management of postin the management of post--strokestroke hypertoniahypertonia: current applications and future directions.: current applications and future directions.strokestroke RehabilRehabil 20062006
Guidelines for ITB in Post strokeGuidelines for ITB in Post stroke
SpasticitySpasticity
1) Preferred candidates are the patients who did1) Preferred candidates are the patients who didnot respond adequately to the other treatment ornot respond adequately to the other treatment ordid not tolerate adverse effects of otherdid not tolerate adverse effects of othertherapies and are motivated to participate intherapies and are motivated to participate inlong term ITB management.long term ITB management.
2) The optimal dose can be defined as the dose2) The optimal dose can be defined as the dosethat helps achieve the treatment goals.that helps achieve the treatment goals.
Francisco GFrancisco GEE.. IntrathecalIntrathecal baclofenbaclofen in the management of postin the management of post--strokestroke hypertoniahypertonia: current applications and future directions.: current applications and future directions.strokestroke RehabilRehabil 20062006
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Local Anesthetics andLocal Anesthetics and
ChemodenervatingChemodenervating AgentsAgents Local anestheticsLocal anesthetics
LidocaineLidocaine BupivacaineBupivacaine
EtidocaineEtidocaine
ShortShort--durationduration
diagnostic blockdiagnostic block(2 to 8 hours)(2 to 8 hours)
NeurolysisNeurolysis
PhenolPhenol
AlcoholAlcohol
NeuromuscularNeuromuscularjunction blockadejunction blockade
BotulinumBotulinum NeurotoxinNeurotoxinType AType A
BotulinumBotulinum NeurotoxinNeurotoxinType BType B
LongLong--duration effectduration effect(3 to 6 months)(3 to 6 months)
GraciesJ-M et al.Muscle Nerve. 1997;20(suppl 6):S61-S91.Goodman LS et al. Goodman & Gilmans The Pharmacological Basis of Therapeutics. 9th ed.
New York, NY: McGraw-Hill; 1996;331-347.
ReinjectionReinjection more difficultmore difficultyesyesRepeated use,Repeated use,
long term safetylong term safety
recordrecord
22--8 months, 36 months in some8 months, 36 months in some
referencesreferences33--6 months6 monthsDuration of benefitDuration of benefit
NeededNeededNot neededNot neededMotor pointMotor point
injection techniqueinjection technique
Volume dependentVolume dependentNeedle onlyNeedle onlyPain duringPain during
injectioninjection
NonselectiveNonselective neurolysisneurolysisReversible muscleReversible muscle
relaxationrelaxation
Effects on tissuesEffects on tissues
nonoyesyesAdjustable dilution toAdjustable dilution tomaximize diffusionmaximize diffusion
Potential edema , necrosisPotential edema , necrosisNo irritationNo irritationLocal toxicityLocal toxicity
Immediate anesthetic effect,Immediate anesthetic effect,
NeurolysisNeurolysis at 48at 48--72 hours72 hours11--5 days, peak at days5 days, peak at days
2121--2828OnsetOnset
Depends on number of motor branchesDepends on number of motor branchesDose dependentDose dependentTitration effectTitration effect
PhenolPhenolBoNTBoNT--AA
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BotulinumBotulinum toxin type A injections havetoxin type A injections have
been used to block the final commonbeen used to block the final commonpathway at the neuromuscular junction.pathway at the neuromuscular junction.
It affects the neuromuscular junction throughIt affects the neuromuscular junction throughbinding, internalization and inhibition of ACHbinding, internalization and inhibition of ACHrelease.release.
SimpsonSimpson DMetDMet al.al. BotulinumBotulinum toxin type A in the treatment of upper extremitytoxin type A in the treatment of upper extremityspasticityspasticity: a randomized, double: a randomized, double--blind, placeboblind, placebo--controlled trial.controlled trial. NeurologyNeurology1996;46(5):13061996;46(5):1306--10.10.
Simpson DM. Clinical trials ofSimpson DM. Clinical trials of botulinumbotulinum toxin in the treatment oftoxin in the treatment of spasticityspasticity..Muscle NerveMuscle NerveSupplSuppl1997;6:S1691997;6:S169--7575
Some studies showed central effects ofSome studies showed central effects of
botulinumbotulinum toxin in human.toxin in human.
These effects may include decreasedThese effects may include decreased RenshawRenshaw
inhibition and increased preinhibition and increased pre--synaptic inhibitionsynaptic inhibition
exerted on theexerted on the motoneuronsmotoneurons supplying thesupplying the
injected muscle and reduction of their overallinjected muscle and reduction of their overall
excitability.excitability.
GracisGracis et al, The role ofet al, The role of botulinumbotulinum toxin injection in the management oftoxin injection in the management of
musclemuscle overactivityoveractivity of the lower limb.of the lower limb. DisabDisab and Rehab ,Dec 2007,and Rehab ,Dec 2007,
After about 3 months theAfter about 3 months the presynapticpresynaptic
terminal sprouts and reterminal sprouts and re--establishes itsestablishes its
communication with the muscle fibercommunication with the muscle fiber
(muscle tone returns). Thus,(muscle tone returns). Thus, botulinumbotulinumtoxin type A takes effect about 1 weektoxin type A takes effect about 1 week
after injection and lasts about 3 months,after injection and lasts about 3 months,
after which muscle tone returns toafter which muscle tone returns to
baseline levelsbaseline levels
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Side effects are minimal.Side effects are minimal.
Injection related: Local discomfort, Bruising,Injection related: Local discomfort, Bruising,infection.infection.
Skin reactionSkin reaction
Hypersensitivity to BTXHypersensitivity to BTX--A, rarely reportedA, rarely reportedanaphylaxis,anaphylaxis, urticariaurticaria, soft tissue edema, and, soft tissue edema, anddyspneadyspnea..
EMG changesEMG changes
Diminished type II fiber size in muscles distal toDiminished type II fiber size in muscles distal toinjection siteinjection site
Isolated reports of :Isolated reports of :
precipitated gall bladder attack( likely due toprecipitated gall bladder attack( likely due toautonomic effect of toxin)autonomic effect of toxin)
urinary incontinenceurinary incontinence
necrotizingnecrotizing fascitisfascitis
botulism like syndromebotulism like syndrome
brachialbrachial plexopathyplexopathy
hospitalization and death ( under investigationhospitalization and death ( under investigationby FDA and health Canada)by FDA and health Canada)
Mild long term effects: Change in fiber sizeMild long term effects: Change in fiber size
and EMG abnormalitiesand EMG abnormalities
Caution to use in persons with motorCaution to use in persons with motor
neuropathies, ALS, neuromuscularneuropathies, ALS, neuromuscular
junction disorders.junction disorders.
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BotuliniumBotulinium toxin in the spastic lowertoxin in the spastic lower
extremity has been shown to reduceextremity has been shown to reducespasticity but not necessarily function.spasticity but not necessarily function.
Teasell et al, 2008, SREBR( 11Teasell et al, 2008, SREBR( 11 thth edition)edition)
There is strong evidence that treatment withThere is strong evidence that treatment with
botulinumbotulinum toxin either alone or in combinationtoxin either alone or in combination
with therapy significantly decreases spasticity inwith therapy significantly decreases spasticity in
the upper extremity.the upper extremity.
In stroke survivors. However it is not clear if theIn stroke survivors. However it is not clear if the
improvement is sustained, nor is there strongimprovement is sustained, nor is there strong
evidence that they are associated with improvedevidence that they are associated with improved
function and quality of life.function and quality of life.
Teasell et al, 2008, SREBR( 11Teasell et al, 2008, SREBR( 11 thth edition)edition)
Some of the common indications for use ofSome of the common indications for use of
botulinumbotulinum toxin in spastic UEtoxin in spastic UE
Impairs ability toImpairs ability to
orient handorient handPr. quadratesPr. quadrates
PrPr teresteres
PronatedPronated ForearmForearm
Dressing difficultyDressing difficulty
Skin breakdownSkin breakdown
BrachioradialisBrachioradialis
BicepsBiceps
BrachialisBrachialis
Flexed elbowFlexed elbow
RestrictedRestricted
reaching targetsreaching targets
Frozen shoulderFrozen shoulderDressing problemDressing problem
PecPec MajorMajor
LatsLats.. DorsiDorsi
TeresTeres MajorMajorSubscapularisSubscapularis
Adducted/Adducted/
internally rotatedinternally rotated
ShoulderShoulder
Functional impactFunctional impactMuscles involvedMuscles involved
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Thumb unable toThumb unable to
function duringfunction during
key graspkey grasp
AddAdd PollicisPollicis
Flex Poll LongFlex Poll Long
ThenarThenar groupgroup
Thumb inThumb in
palmpalm
deformitydeformity
Unable to washUnable to wash
palm,palm,
Skin macerationSkin maceration
FDPFDP
FDSFDS
ClenchedClenched
FistFist
Difficulty inDifficulty in
dressing,dressing,
CTS may occurCTS may occur
FCR,FCUFCR,FCUFlexed WristFlexed Wrist
Some of the common indications for use ofSome of the common indications for use of
botulinumbotulinum toxin in spastic LEtoxin in spastic LE
Limited limbLimited limb
advancementadvancement
Short step lengthShort step length
HamstringsHamstrings
GastrocnemiusGastrocnemius
Flexed kneeFlexed knee
IliopsoasIliopsoas
HamstringsHamstrings
Flexed hipFlexed hip
Scissoring,Scissoring,
Difficulty inDifficulty in
hygiene,cathhygiene,cath,,
dressing, mobilitydressing, mobility
Add Long/Add Long/Brv/magBrv/mag
GracillicGracillic
PectineusPectineus
Add thighsAdd thighs
Functional impactFunctional impactMuscle involvedMuscle involved
Long or short toeLong or short toe
flexorsflexorsToe clawing orToe clawing or
curlingcurling
Inability to wearInability to wear
shoe, painshoe, painEHLEHLStriated toeStriated toe
Forefoot contact inForefoot contact instance gait,stance gait,
Weight on lat footWeight on lat foot
GastrocGastroc//SoleusSoleusTibTib Post, EHL,Post, EHL,
PerPer LngLng, Long toe flex, Long toe flex
EquinovarusEquinovarusfootfoot
Toe drag,Toe drag,
Trip and fallTrip and fall
GluGlu Max.Max.
QuadricepsQuadriceps
IlipsoasIlipsoas
Extended kneeExtended knee
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Efficacy and Safety ofEfficacy and Safety of BotulinumBotulinum
Neurotoxin NT 201 inNeurotoxin NT 201 in PoststrokePoststroke UpperUpper
LimbLimb SpasticitySpasticity
KanovskKanovsk et al,et al, ClinClin NeuropharmacolNeuropharmacol.. 20092009
SepSep--Oct;32(5):259Oct;32(5):259--6565
Methods: One 148 patients with anMethods: One 148 patients with anAshworth Scale score of 2 or higher forAshworth Scale score of 2 or higher forwrist and finger flexors and at leastwrist and finger flexors and at leastmoderate disability in their principalmoderate disability in their principaltherapeutic target of the Disabilitytherapeutic target of the DisabilityAssessment Scale were treated either withAssessment Scale were treated either withNT 201 (median, 320 U) or placebo andNT 201 (median, 320 U) or placebo andfollowed up for up to 20 weeks.followed up for up to 20 weeks.
..
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Results: A significantly higher proportion ofResults: A significantly higher proportion of
patients treated with NT 201 werepatients treated with NT 201 wereresponders (improvement of >=1 point inresponders (improvement of >=1 point in
the Ashworth Scale score), as observed inthe Ashworth Scale score), as observed in
comparison to placebo 4 weeks aftercomparison to placebo 4 weeks after
treatment in wrist flexors (odds ratio, 3.97;treatment in wrist flexors (odds ratio, 3.97;
95% confidence interval, 1.995% confidence interval, 1.9--8.3; P
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Muscle Nerve.Muscle Nerve. 2009 Sep;40(3):3742009 Sep;40(3):374--80.80.
Assay of diffusion of differentAssay of diffusion of differentbotulinumbotulinum neurotoxin type aneurotoxin type a
formulations injected in the mouse leg.formulations injected in the mouse leg.
CarliCarli LL,, MontecuccoMontecucco CC,, RossettoRossetto OO
They assessed the extent of diffusion ofThey assessed the extent of diffusion of
three commercial preparations ofthree commercial preparations of BoNTBoNT/A:/A:
BotoxBotox ((AllerganAllergan),), DysportDysport ((IpsenIpsen), and), and
XeominXeomin ((MerzMerz Pharmaceuticals) using aPharmaceuticals) using a
sensitive test based on neural cellsensitive test based on neural cell
adhesion molecule (Nadhesion molecule (N--CAM) expression inCAM) expression in
muscle.muscle.
This allows fine monitoring of theThis allows fine monitoring of the
functional diffusion of this toxin. Thefunctional diffusion of this toxin. The
results indicate that there is no significantresults indicate that there is no significant
difference betweendifference between BotoxBotox,, DysportDysport, and, andXeominXeomin with respect to diffusion intowith respect to diffusion into
adjacent muscles in the mouse leg.adjacent muscles in the mouse leg.
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SURGICAL INTERVENTIONSSURGICAL INTERVENTIONS
Common goals of surgery are usually toCommon goals of surgery are usually to
increase mobility,increase mobility,
decrease the use of external aids,decrease the use of external aids,
correct or prevent deformity,correct or prevent deformity,
and ultimately maximize function.and ultimately maximize function.
Musculoskeletal compensatory techniquesMusculoskeletal compensatory techniques
used by the orthopedic surgeons includeused by the orthopedic surgeons include
tendon lengthening, muscletendon lengthening, muscle--tendontendon
transfer (e.g. the split anteriortransfer (e.g. the split anterior tibialtibial
transfer), contracture release,transfer), contracture release,
capsulotomycapsulotomy,, osteotomyosteotomy, resection, resection
arthroplastyarthroplasty,, arthrodesisarthrodesis,, epiphyseodesisepiphyseodesis,,
ankle fusion, and spine fusionankle fusion, and spine fusion
TheThe neuroablativeneuroablative techniques used by thetechniques used by the
neurosurgeons involve the interruption ofneurosurgeons involve the interruption of
the spinal reflex arc bythe spinal reflex arc by neurectomyneurectomy,,
neurotomyneurotomy,, rhizotomyrhizotomy, dorsal root entry, dorsal root entryzone lesion, andzone lesion, and myelotomymyelotomy..
Other procedures includeOther procedures include cordotomycordotomy,,
cordectomycordectomy, implantation of stimulators, or, implantation of stimulators, or
drug infusion devicesdrug infusion devices
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CASE 1CASE 1
Mrs. A is experiencing a gradual increaseMrs. A is experiencing a gradual increase
in spasticity, confined to her left lowerin spasticity, confined to her left lowerextremity. The patient's main functionalextremity. The patient's main functional
problem is increased plantar flexion, whichproblem is increased plantar flexion, which
is causing her toes to drag and resulting inis causing her toes to drag and resulting in
falls. Oral medication therapy is not thefalls. Oral medication therapy is not the
first choice, as it tends to be less effectivefirst choice, as it tends to be less effective
in treating cerebral causes of spasticity.in treating cerebral causes of spasticity.
Mrs. A is a good candidate for focalMrs. A is a good candidate for focal
treatment of spasticity withtreatment of spasticity with botulinumbotulinum toxintoxin
type A injections into her plantar flexors. Iftype A injections into her plantar flexors. If
she responds well to the first set ofshe responds well to the first set of
injections, she will require repeat injectionsinjections, she will require repeat injections
every 3every 34 months to maintain safe4 months to maintain safe
ambulation. Referral to a physiatrist for theambulation. Referral to a physiatrist for the
injections would be most appropriate.injections would be most appropriate.
THANK YOUTHANK YOU