Spasticity After Stroke

Heather Walker, M.D.Assistant Professor

Department of Physical Medicine & RehabilitationUNC-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

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®

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.