Spasticity: Characterization and Treatment Considerations

Spasticity:Characterization and Treatment ConsiderationsInsert Presenter’s NameDefinition of SpasticityVelocity-dependent increase in tonic stretch reflexes (muscle…

Spasticity:Characterization and Treatment ConsiderationsInsert Presenter’s NameDefinition of SpasticityVelocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neuron syndrome.11 Lance JW. Symposium synopsis. In Feldman RG, Young RR, Koella WP (eds) Spasticity: Disordered Motor Control. Year Book Medical Pubs, Chicago, 1980: pp. 485-94Upper Motor Neuron SyndromeA group of symptoms that may be caused by damage or injuryto motor neuron pathways or brain regions that control movement2,32 Katz RT, Rymer WZ. Spastic hypertonia: mechanisms and measurement. Arch Phys Med Rehabil 1989; 70:144-553 O'Brien CF, Seeberger LC, Smith DB. Spasticity after stroke. Epidemiology and optimal treatment. Drugs Aging 1996; 9:332-404 Young RR ,Wiegner AW. Spasticity.ClinOrthop Relat Res 1987; 50-62Classification of SpasticityClassification of Spasticity Accordingto Distribution of Affected Body Regions5,6DistributionDefinitionFocalIsolated, local motor disturbance affecting a single body partRegionalMotor disturbance involving a large region of the bodyGeneralizedMotor disturbance involving widespread bodily regions5 Esquenazi A. Falls and fractures in older post-stroke patients with spasticity: consequences and drug treatment considerations. Clin Geriatr 2004; 12:27-356 Gracies JM, Nance P, Elovic E, McGuire J, Simpson DM. Traditional pharmacological treatments for spasticity.Part II: General and regional treatments.Muscle Nerve Suppl 1997; 6:S92-120Signs and Symptoms of Spasticity

Patients with spasticity may experience a range of sensations in the affected limbs7

Mild muscle stiffness

Painful muscle contracturesand spasms

In a recent survey, most patients rated stiffness and limited range of motion as having the most substantial negative impact on their quality of life8

Abnormalposture, pain,or inabilityto sleep34.5%Stiffness/limited rangeof motion42.0%Limitationsin activitiesof daily living23.5%Percentage of 810 patients with spasticity who identified each aspect of their condition as having the most significant impact on quality of life.87 O'Brien CF. Treatment of spasticity with botulinum toxin. Clin J Pain 2002; 18:S182-908 WE MOVE. Profile of Patients with Spasticity, 2008. Available at: http://www.wemove.org/reports/spasticity_2008.pdf. Accessed March 26, 2009Common Limb Deformities in Upper Limb SpasticityIn the adducted/internally rotated shoulder, the arm is held closely against the side, elbow bent, with the forearm applied across the front of the chest.Flexion of the wrist iscaused by hypertonicityof the wrist flexor muscles that seem to easily overpower their antagonists of wristextension, so that this is the most common attitude.The flexed elbow is bentinto flexion and this posturemay dramatically worsenwith ambulation, causingmore-severe angle flexion.Common Limb Deformities in Upper Limb SpasticityPronation of the forearm seems to be morecommonly encounteredthan supination aftercentral nervous systeminjury.In those with thumb-in-palm deformity, the thumb is held fixed within the palm with its distal aspect flexed. The thumb is limited in its use as a result of the abnormal posture.In those with clenchedfist, the fingers are tightlyflexed into the palm. Thiscan lead to poor palmarhygiene and pain with finger manipulation.Major Causes of Spasticity in Adults

Stroke

Multiple sclerosis

Spinal cord injury

Traumatic brain injury

Adult cerebral palsy

Affects 795,000 Americans annually9% with spasticity1010%Upper and lower limb7%Upper limb only1%Lower limb only9 Centers for Disease Control and Prevention. Stroke facts and statistics. Available at: http://www.cdc.gov/stroke/stroke_facts.htm. Accessed April 7, 200910 Lundstrom E, Terent A, Borg J. Prevalence of disabling spasticity 1 year after first-ever stroke. Eur J Neurol 2008; 15:533-9Methods of Spasticity Assessment11

Physiologic measures such as overall excitability of a motor neuron pool or the shortening of muscle cells that are under spastic control.

Passive activity measures such as Ashworth scale and passive range of motion.

Voluntary activity measure such as the Fugl-Meyer test and the Nine Hole Peg Test.

Functional measures such as the Functional Independence Measure and the Disability Assessment Scale (DAS) and measures of pain.

Quality of life measures that assess patient satisfaction and perceived importance of spasticity treatment.

11 Elovic EP, Simone LK, Zafonte R. Outcome assessment for spasticity management in the patient with traumatic brain injury: the state of the art. J Head Trauma Rehabil 2004; 19:155-77Methods of Spasticity Assessment: ExamplesAshworth Scale12Disability Assessment Scale14DescriptionDomainGradeDescription0No increase in muscle toneHygieneExtent of palm maceration, ulceration, and/or infection; palm cleanliness; ease of cleaning and nail trimming; effect of hygiene related disability in patient’s life1Slight increase in tone – a catch and release at the end of the range of motionDressingAbility to put on clothing; effect ofdressing-related disability due toupper-limb spasticity on patient’s life2More marked increase in tone through most of range3Considerable increase in tone, passive movement difficultLimb PosturePsychological and/or socialinterference that the limb’s posturehas in the patient’s life4Affected parts rigid in flexion orextensionPainIntensity of pain; discomfort andinterference of upper limb pain inpatient’s lifeThe modified Ashworth scale incorporates a 1+ (Slight increase in tone – catch, followed by minimal resistance in remainder of range) to differentiate the catch that is felt in some patients when limbs are passively moved.13Scores:0 = no functional disability1 = mild2 = moderate3 = severe12 Ashworth B. Preliminary trial of carisoprodol in multiple sclerosis. Practitioner 1964; 192:540-213 Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987; 67:206-714 Brashear A, Zafonte R,Corcoran M, et al. Inter- and intrarater reliability of the Ashworth Scale and the Disability Assessment Scale in patients with upper-limb poststroke spasticity. Arch Phys Med Rehabil 2002; 83:1349-54Problems That May Be Associated With Spasticity15-18

Pain

Contracture

Fatigue

Functional limitations (hygiene, dressing, transfers)

Increased risk of falls

Pressure sores

Skin maceration

Poor orthotic fit

Diminished self image due to abnormal limb posture

15 Mayer NH, Esquenazi A, Childers MK. Common patterns of clinical motor dysfunction.Muscle Nerve Suppl 1997; 6:S21-3516 Adams MM, Ginis KA, Hicks AL. The spinal cord injury spasticity evaluation tool: development and evaluation. Arch Phys Med Rehabil 2007; 88:1185-9217 Wissel J, Ward AB, Erztgaard P, et al. European consensus table on the use of botulinum toxin type A in adult spasticity. J Rehabil Med 2009; 41:13-2518 Bhakta BB. Management of spasticity in stroke. Br Med Bull 2000; 56:476-85Decision to Treat SpasticityFactors to Consider in Spasticity Treatment19

Chronicity of spasticity

Severity of spasticity

Distribution of spasticity

Locus of central injury or damage

Patient co-morbidities

Availability of care and support

19 Gormley ME, Jr., O'Brien CF, Yablon SA. A clinical overview of treatment decisions in the management of spasticity. Muscle Nerve Suppl 1997; 6:S14-20Treatment GoalsThe inclusion of patients and caregivers in the discussion of goalsis critical because patient and physician goals do not always coincide.Major Classes of Treatment Goals with Examples of Each 19, 20Technical Objectives

Increase range of motion

Reduce tone

Reduce spasm

Functional Objectives

Improve activities of daily living (e.g., dressing, hygiene)

Reduce pain

Enhance ease of care

Improve limb position (cosmesis)

Improve gait

Preventive Objectives

Prevent contracture

Prevent skin maceration

Prevent skin ulcers

19 Gormley ME, Jr., O'Brien CF, Yablon SA. A clinical overview of treatment decisions in the management of spasticity. Muscle Nerve Suppl 1997; 6:S14-2020 Barnes MP. Spasticity: a rehabilitation challenge in the elderly. Gerontology 2001; 47:295-9Spasticity Management Team21

Physicians

Rehabilitation nurses

Allied healthcare professionals (physical therapists, occupational therapists, speech therapists)

Family and other caregivers

Coordinator/administrator

Other (wheelchair clinic, gait lab, orthotics clinic, counseling, social worker)

21 Adams MM, Hicks AL. Spasticity after spinal cord injury. Spinal Cord 2005; 43:577-86Summary

Spasticity is a distressing, debilitating consequence of upper motor neuron lesions

May result from stroke, trauma to the brain or spinal cord,multiple sclerosis, cerebral palsy, or other conditions

May be focal, regional, or general in distribution

Common clinical patterns of spasticity are identifiable across etiologies, and are generally caused by marked overactivity of the flexor muscles

Left untreated, spasticity may result in permanent contracture of muscle and soft tissue, leading to increasing disability, pain, and deformity

Summary

Thorough assessment of the patient’s condition is essential in determining whether to treat spasticity, for developing a treatment plan, and for gauging treatment progress

Prior to treatment of spasticity, goals should be identified in consultation with the patient and caregiver or family

When spasticity is treated, it is best approached as a multidisciplinary endeavor

Questions?© 2010 Allergan, Inc. Irvine, CA 92612APC90SB10April 2010