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Spasticity After Stroke

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

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Spasticity After Stroke

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  1. Spasticity After Stroke Heather Walker, M.D. Assistant Professor Department of Physical Medicine & Rehabilitation UNC-Chapel Hill

  2. 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

  3. 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

  4. 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…” ????????????????????????

  5. Spasticity can be defined as increased tightness in affected muscles

  6. 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)

  7. 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

  8. Upper Extremity Spasticity

  9. Lower Extremity Spasticity

  10. Spasticity Complications • Positioning • Hygiene • ADLs • Sitting or Standing Balance • Contractures

  11. Treatment Goals • Improvements in position • Mobility • Pain • Contracture prevention • Ease of care are possible

  12. Spasticity Management Steps • Therapeutic modalities • Oral Medications • Nerve blocks & Chemical neurolysis (Botox injections) • Orthopedic procedures • Intrathecal Medications

  13. Prior to Intervention • Assess baseline status • Determine specific goals • Patient and family education • PT and OT role after intervention

  14. Therapeutic Exercise • Stretching and range of motion • Myofascial and joint mobilization • Active assistive, active and resistive exercise • Endurance training

  15. 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

  16. Botulinum Toxin Type A (BOTOX®): History of Development FDA approval of BOTOX® Dr. Schantz begins investigation C. botulinum identified 1989 1978 1944 1920s Dr. Scott initiates first therapeutic testing in humans 1895 Botulinum toxin type A first isolated

  17. 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

  18. Muscle identification • Three main methods • Exam and anatomic atlas • EMG assistance and guidance • Electronic stimulation

  19. 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???

  20. 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.

  21. Intrathecal Baclofen

  22. Surgical Procedures • Tendon lengthening • Neurosurgical procedures • Last resort!

  23. 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.

  24. QUESTIONS???

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