Spasticity. Pain and Spasticity Management in SCI Nov 23 rd, /19/17

Transcription

1 Pain and Spasticity Management in SCI Nov 23 rd, 2017 Phichamon Khanittanuphong, MD Rehabilitation Division Department of Orthopaedic Surgery and Physical Medicine Faculty of Medicine, Prince of Songkla University Spasticity 1

2 Outlines Definition of spasticity Benefit and disadvantage of spasticity Management Non- pharmacol ogic treatment Pharmacologic treatment 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, as one component of the upper motor neuron disease American Academy of Neurology (1990) 2

3 Modified Ashworth Scale (MAS) 1 Slight increase in muscle tone 1+ Slight increase in muscle tone, less than half of the ROM 2 More marked increase in muscle tone through most of the ROM 3 Passive movement is difficult 4 Affected part is rigid contracture Benefits of Spasticity Aid to standing and walking via extensor spasms Maintained muscle mass Maintain bone mineralization Reduced dependent edema Reduced deep vein thrombosis risk (DVT) Disadvantage of Spasticity Pain Impaired sleep Risk of contracture Impaired perineal hygiene and sexual function Skin shear on bed or chair, risk of pressure ulcer 3

4 Disadvantage of spasticity Impaired standing balance Impaired gait and increased risk of falling Slow voluntary movements Interference with driving Management Multidisciplinary Team Physician Nurse Physical Therapist Occupational Therapist Patient & Caregiver Prosthetist 4

5 Has spasticity disadvantage to a patient? Yes No Non- pharmacologic intervention Remove/treatment any triggers Proper positioning Stretching exercise Cryotherapy Electrical stimulation Splinting, casting and orthoses Regularly spastic assessment How pattern of spastic involvement? Focal spasticity Chemodenervation Botulinum toxin injection ± Surgery if contracture occurs Generalised spasticity Oral antispastic drug Intrathecal baclofen ± Surgery if contracture occurs Non- pharmacologic Intervention Proper positioning ROM and Stretching exercise Cryotherapy Electrical stimulation Splinting, casting and orthoses Proper positioning 5

6 Cryotherapy Range of Motion and Stretching Exercise 6

7 Electrical Stimulation Splinting, Casting and Orthoses Pharmacologic Intervention Oral medication Chemodenervation Intrathecal medication 7

8 Oral Medication Central acting Baclofen Tizanidine Benzodiazepines Peripheral acting Dantrolene sodium Baclofen Analog of GABA - > GABA B receptor Side effect Hallucination, confusion, sedation, hypotonia, ataxia Sudden withdrawal of the drug: seizure, hallucination, rebound spasticity Dose 5 mg po, b.i.d. or t.i.d. Maximum dose of 80 mg/day Tizanidine Alpha 2 adrenergic agonist, presynaptic inhibition Side effect Dry mouth, somnolence, weakness, dizziness, headache, and insomnia, liver function abnormality Dose : Start 4 mg in the evening Average 24 mg/day (tid) Maximum dose 36 mg/day 8

9 Diazepam Facilitating postsynaptic effect of GABA A Side effect Sedation, memory impairment, dizziness, muscle weakness, and reduced motor coordination Sudden withdrawal symptoms: seizure Dose 2 mg po bid titrated up to 60 mg or more/day Chemodenervation Local anesthesia ( e.g. lidocaine ) 2-10% Phenol % Ethyl alcohol Botulinum toxin Techniques Nerve block Motor point block Tibial nerve block 9

10 Intrathecal Baclofen Take Home Message Spasticity is a velocity- dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks. Management depends on whether it interferes patient s function or usual care. Non- pharmacological treatment is essentially applied for all patient. Local or generalized spasticity should be established for selection of medications. SCI- related Pain 10

11 Outlines Type and definition of SCI- related pain Nociceptive pain Neuropathic pain Approximately 80% of people with SCI report chronic pain One third report chronic, severe pain that interferes with activity and affects quality of life International Spinal Cord Injury Pain Classification (ISCIP) Adapted by permission from Macmillan Publishers Ltd Spinal Cord 2012 Jun;50(6):

12 SCI- related Pain Nociceptive pain Pain arising from activation of peripheral nerve endings or sensory receptors that are capable of transducing and encoding noxious stimuli Neuropathic pain Pain that arises as a direct consequence of a lesion or disease affecting the somatosensory system Musculoskeletal pain Visceral pain Other pain At level SCI pain Below level SCI pain Other pain History Date & mechanism of injury Associated injury Vertebral surgery Pain characteristics Psychological assessment Functional, occupational, and recreational history Evaluation Physical examination Neurological testing Focal examination of pain area Inspection, palpation, active and passive ROM, and provocative maneuvers Observation of wheelchair propulsion, posture, and gait Appropriate comfort and fit of assistive devices (cane, walker, crutch) and orthotic devices 12

13 Red Flags (I) Syste m Red flag indicator Red flag condition Musculoskeletal History of recent trauma Visible deformity Changes in range of motion New- onset localized swelling and warmth Fracture or dislocation Heterotopic ossification Regional pathology CVS/ Respiratory Chest pain Shortness of breath Fevers, chills or sweats Autonomic symptoms Differences in calf measurements Abdominal aortic aneurysm/ dissection Myocardial infarction Pneumonia Pulmonary embolism DVT Spinal Cord (2016) 54, S7 S13 Red Flags (II) Syste m Red flag indicator Red flag condition Genitourinary Changes in urine appearance or smell, pain over kidneys New incontinence, leakage History of renal or bladder calculi and scrotal or Testicular sw elling UTI or pyelonephritis Renal or bladder calculi Urinary retention Testicular torsion and epididymitis Gastrointestinal Changes in bowel habit Signs of acute abdomen Stool impaction/ constipation Appendicitis, cholecystitis Dermatologic Redness, ulceration Pressure ulcer Ingrown nail Spinal Cord (2016) 54, S7 S13 Yellow Flags Depressive symptoms Altered appetite Poor motivation to complete daily activities or work Decreased participation in valued activities Pre- existing pain problems with evidence of poor adjustment Avoidance of activities associated with pain Extensive periods of rest or bed rest Catastrophic thinking Significant anxiety and panic symptoms Use and dependence on alcohol or illicit substances Increasing opioid dependence or misuse Spinal Cord (2016) 54, S7 S13 13

14 Nociceptive Pain Musculoskeletal Pain RICE + NSAIDs Mobilization for ROM Strengthening exercise Functional restoration Need address biomechanical abnormalities that can be As s ociated with mobility aids or wheelchair Visceral Pain GI system GU system 14

15 Autonomic Dysreflexia Headache Pain Neuropathic Pain At Level and Below Level SCI pain N.B. Fi n n eru p / P AIN ( ) S7 1 S7 6 15

16 Compressive Neuropathy Carpal tunnel syndrome Screening Recommendations Any member of the health- care team can, and should, screen for the presence of pain. Screened for pain using a simple yes/no question admission to rehabilitation regularly during inpatient rehabilitation after discharge at each follow- up Screening Recommendations Assessment to determine the type of pain, its intensity and interference should be conducted. Address patient concerns, expectations and needs. 16

17 Treatment for Neuropathic pain Pharmacologic treatment Gabapentinoid: pregabalin, gabapentin, TCA: amitriptyline Opioids: tramadol SNRI: velafexine, duloxetine Epidural steroid injection Non- pharmacol ogi c treatment Desensitization technique Massage Exercise Psychologic intervention Surgery Take Home Message Type of pain need to be clarified for proper management. Shoulder pain is common musculoskeletal pain in SCI patients. Bowel and bladder system should be firstly examined when abdominal pain occurs. Headache pain in above T6 level paraplegia frequently results from autonomic dysreflexia. Both medication and non- pharmacological management are important for improving neuropathic pain. 17