Spasticity. Disclosure. Objectives

Transcription

1 Spasticity Noon, November 5, 2013 Dr. Bill Black Auditorium Glenrose Rehabilitation Hospital VC# REMOTE SITES: PLEASE MUTE YOUR AUDIO AT ALL TIME EXCEPT WHEN ASKING QUESTION/COMMENTING AT Q/A. This event is an accredited group learning activity as defined by the Maintenance of Certification Program of The Royal College of Physicians and Surgeons of Canada. This event is eligible for 1 MAINPRO-M1 credit from the Maintenance of Proficiency Program of College of Family Physicians of Canada. Members of the Colleges planning on claiming the credit are requested to sign the appropriate attendance records at the entrance. Geriatric Grand Rounds November 5, 2013 Mario DiPersio MD FRCP Physical Medicine and Rehabilitation Spasticity Program for Adults Pediatric Tone Management Clinic Glenrose Rehabilitation Hospital, Edmonton Disclosure I have no relationship that could be perceived as placing me in a real or apparent conflict of interest in the context of this presentation. Objectives At the end of this talk, the geriatric health care provider: Will know that regular passive stretching and use of bracing is important in preventing contractures from developing in geriatric patients with spasticity Will know that Botulinum toxin injections are an effective form of treatment for spasticity Will know about possible surgical interventions and intrathecal baclofen pumps Website: November 5,

2 Definition of Spasticity Upper Motor Neuron Syndrome Spasticity is a motor disorder that is 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 syndrome American Academy of Neurology 1990 Positive Signs Increased muscle tone Exaggerated tendon reflexes Stretch reflexes spread to extensors Repetitive stretch reflex discharges clonus Babniski response Mass synergy patterns Negative Signs Decreased dexterity Paresis / weakness Inadequate force generation Slow movements Fatigability Slowness of movement Positive symptoms of upper motor neuron syndrome Spasticity Flexor spasms Increased phasic and tonic stretch reflexes Muscle co-contraction Negative symptoms of upper motor neuron syndrome Weakness Loss of fine motor dexterity Loss of selective motor control Fatigability It should be noted that treatment of spasticity does not improve these negative symptoms Website: November 5,

3 Common diagnoses causing spasticity Pathophysiology of Impairment After a CNS Lesion Damage to Higher Center Stroke Traumatic brain injury Cerebral palsy Multiple sclerosis Spinal cord injury Paralysis Immobilization in Shortened Position Immediate Consequences Spinal Spasticity Released flexor reflex afferents Delayed Consequences Muscle Overactivity Supraspinal Co-contraction Associated reactions Spastic dystonia Contracture Gracies J-M. Phys Med Rehabil Clin N Am. 2001;12: Forces Contributing to Deformity in UMN Syndrome Clinical patterns of spasticity Muscle Overactivity 1,2 (Dynamic Forces) Generated by muscle contraction Contracture 1,3 (Static Forces) Generated by contracture (resistive) properties of soft tissues Elastic, plastic, and viscous properties of skin, muscles, tendons, joint capsules, blood vessels, and nerves Shoulder adducted and internally rotated Elbow flexed Forearm pronated Wrist flexed Clenched fist Thumb in-palm 1. Sheean G. Expert Rev Neurotherapeutics. 2003;3: Gracies J-M. Phys Med Rehabil Clin N Am. 2001;12: Mayer NH. Muscle Nerve. 1997;20(suppl 6):S1-S13. Website: November 5,

4 t Flexed Elbow Clinical patterns of spasticity maceration and breakdown 1 and grasp objects 1 Clenched Fist Flexed Elbow May lead to skin maceration and breakdown 1 Clinical Inability to reach patterns and grasp objectsof spasticity 1 Flexed elbow Biceps, brachialis, brachioradialis ourtesy of Nathaniel H. Mayer, MD, and Alberto Esquenazi, MD., Esquenazi A. Phys Med Rehabil Clin N Am. 2003;14: Finger flexion Flexor digitorum superficialis Flexor digitorum profundus lumbricals Courtesy of Nathaniel H. Mayer, MD, and Alberto Esquenazi, MD. 1. Mayer NH, Esquenazi A. Phys Med Rehabil Clin N Am. 2003;14: Fingers clasped into palm 1 Inability to wash palm 1 Patients may have difficulty dressing 1 Carpal tunnel syndrome and wrist Clinical patterns of spasticity May lead to skin maceration and breakdown 1 subluxation may occur 1,2 Patients may have difficulty dressing Clinical patterns of spasticity 1 Carpal tunnel syndrome and wrist subluxation may occur 1,2 Courtesy of Nathaniel H. Mayer, MD, and Alberto Esquenazi, MD. 1. Mayer NH, Esquenazi A. Phys Med Rehabil Clin N Am. 2003;14: Thumb in palm deformity Flexor pollicis longus Flexor pollicis brevis Wrist flexion urtesy of Nathaniel H. Mayer, MD, and Alberto Esquenazi, MD. Esquenazi A. Phys Med Rehabil Clin N Am. 2003;14: Flexor carpi radialis Flexor carpi ulnaris Website: November 5,

5 der assive d the motion ant ssing 1 Pronated Forearm Activities such as turning the hand palm side up for fingernail trimming, using eating Clinical utensils, washing one s patterns face, of spasticity reaching for a glass, and shaking hands become difficult 1,2 Adducted Clinical Thighs patterns of spasticity Interferes with hygiene, dressing, and sexual intimacy 1,2 Equinovarus Deformity Difficulty or pain wearing shoes 1 May lead to skin breakdown and pain in fifth metatarsal head 1,2 Courtesy of Nathaniel H. Mayer, MD, and Alberto Esquenazi, MD. Forearm pronation Pronator teres Pronator quadratus er NH, Esquenazi A. Phys Med Rehabil Clin N Am. 2003;14: Adducted thighs Adductor longus Adductor magnus Adductor brevis Courtesy of Nathaniel H. Mayer, MD, and Alberto Esquenazi, MD. 1. Mayer NH, Esquenazi A. Phys Med Rehabil Clin N Am. 2003;14: Muscle Rheology Contracture of Clinical hamstrings patterns of spasticity Equinovarus Deformity Clinical patterns of spasticity Difficulty or pain wearing shoes 1 May lead to skin breakdown and pain in fifth metatarsal head 1,2 Courtesy of Nathaniel H. Mayer, MD, and Alberto Esquenazi, MD. Knee flexion Semitendinosis Semimembranosis Biceps femoris Flexed Knee Overactive hamstrings can flex the knees or act posterior to the hip joints, causing the trunk to extend. As a result, seated patients with flexed knee tend to slide forward in their wheelchairs Stif Might fail to is seated an elevated leg Standing an problematic Courtesy of Nathaniel H. Mayer, MD, and Alberto Esquenazi, MD. 1. Mayer NH, Esquenazi A. Phys Med Rehabil Clin N Am. 2003;14: Ankle inversion Tibialis posterior Courtesy of N 1. Mayer NH, Esquenaz 2. Mayer Website: November 5,

6 Asworth Scale 1. Slight increase in muscle tone, manifested by a catch and release 2. More marked increase in muscle tone, through most ROM but limb easily moved 3. Considerable increase in muscle tone, passive movement difficult 4. Limb rigid in flexion or extension Problems resulting from spasticity Limb contractures Pain Skin breakdown Difficulty position for dressing and diaper changes Difficulty sitting in wheelchair Difficulty positioning in bed Difficulty walking Difficulty fitting into braces Management of Spasticity The most important thing that a geriatric health care provider can do is prevent the joint contractures from developing in the first place Geriatric health care providers should assess all their patients for range of motion of the joints and spasticity This is especially important for nonambulatory or bedridden patients Setting Treatment Goals No meaningful plan can be formulated without first determining the treatment goals. Patient/ Caregiver Physician Symptomatic pain, spasms, skin integrity, disfigurement PROM, tone, pain, spasms, skin integrity Passive Function PROM, ease of care and ADL PROM, ease of care and ADL, orthotic fit Active Function AROM, use of limb, facilitate ADL AROM, limb use for ADL mobility effort ADL=Activities of Daily Living ROM=Range Of Motion P=Passive A=Active Website: November 5,

7 Identify factors that aggravate spasticity Management of Spasticity Approach to Managing Spasticity Examples of factors that can increase spasticity: Urinary tract infections Constipation Ingrown toe nails Pressure ulcers Poor fit in a brace or wheelchair Tight clothing Infections (e.g. pneumonia) Neuroleptic agents Fractures/dislocations Heterotropic ossification Renal stones Syrinx in a SCI Poor posture in bed/wheel chair Daily passive range of motion stretching exercises are the most important component of prevention of contractures in spasticity management Unfortunately, manpower restraints in long term care facilities make daily stretching difficult to implement Management of Spasticity Wrist hand orthoses can be made by occupational therapy or orthotics Hand splints keep the fingers and wrist in a neutral position Soft cloth inserts keep the palmar skin from macerating Management of Spasticity Ankle foot orthoses made by orthotics keep the foot and ankle in a neutral position Ankle splints made by OT can be used to position patients who are bedridden Website: November 5,

8 Management of Spasticity Pharmacologic Treatment of Spasticity Wheelchair seating systems can be modified to optimize patient s positioning and to prevent abnormal posturing Baclofen ( Lioresal ) activates pre-synaptic GABA B receptors in the spinal interneurons This facilitates inhibition of the post-synaptic motor neuron firing Supplied as 10 or 20 mg tabs Start low dose 5 mg bid, gradually titrate up to 20 mg qid max dose Need to be concerned about sedation in geriatric patients In stroke patients, spasticity is often focal not generalized Pharmacologic Treatment of Spasticity Pharmacologic Treatment of Spasticity Zanaflex (Tizanidine ) is an agonist of alpha 2 receptor sites in the spinal interneurons It enhances presynaptic inhibition of polysynaptic spinal reflexes Supplied as 2 or 4 mg tabs Start 4 mg od, increase by 2-4 mg increments, max 12 mg tid Better treatment for generalized spasticity, not focal spasticity for geriatric stroke Dantrium ( dantrolene ) reduces calcium flux across the sarcoplasmic reticulum of skeletal muscle This uncouples the motor nerve excitation from skeletal muscle contraction Due to peripheral mechanism of action, there is less worry about sedation in stroke or brain injury patients Supplied as 25, 50, 100 mg tabs Start 25 mg od for 7 days, then 25 mg tid for 7 days, titrate 50 mg tid, 100mg tid maximum 400 mg total per day Again in stroke, often desireable to treat focal spasticity Website: November 5,

9 Pharmacologic Treatment of Spasticity Diazepam ( Valium ) is a agonist of the post-synaptic GABA A receptor which inhibits reflex activity Commonly used in children with cerebral palsy post operatively but not usually used in geriatrics due to concerns about sedation Supplied as 2, 5, 10 mg tabs 2 10 mg tid - qid Spasticity Program for Adults Interdisciplinary spasticity management program 3 physiatrists Nurse co-ordinator Occupational therapists Physical therapists Provides Botulinum toxin injections and intrathecal baclofen pumps Evaluates patients for possible surgical procedures Botulinum Toxin Mechanism of Action: Normal Neuromuscular Contraction Botulinum toxin is a biological product of Clostridium botulinum Botulinum toxin is injected into muscle directly and acts at the site of the nerve terminal It prevents exocytosis of acetylcholine vesicles from the injected nerve terminal Botilinum toxin cleaves SNARE proteins which mediate calcium regulated exocytosis and inactivates them Website: November 5,

10 Botulinum Toxin Mechanism of Action: Effects On The Neuromuscular Junction Forms of Botulinum toxin Botox ( onabotulinumtoxina ) Xeomin ( incobotulinumtoxina ) Dysport ( abobotulinumtoxina) in Europe Myobloc ( rimabotulinumtoxinb ) in USA Botilinum toxin Botulinum toxin Botulinum toxin is stored as a powder in a bottle It needs to be reconstituted with saline at the time of the injection The Botulinum toxin is then injected into the specific muscles causing the patient s deformity Botulinum toxin is good for managing focal spasticity involving a small number of specific muscles Botulinum toxin is useful in geriatric patients for whom sedating oral medications may cause additional disability Website: November 5,

11 Intrathecal Baclofen pumps A portable electromyographic machine and electrical muscle stimulator is used to ensure that the needle is inside muscle tissue Muscle stimulation causes contraction of desired muscle and movement of the joint controlled by that muscle The injection needle is connected to the stimulator Ultrasound guidance is also used to localize muscle and confirm needle placement Baclofen can be administered intrathecally using a implantable pump Able to give doses of baclofen directly to the spinal cord without causing excessive cerebral sedation More commonly used in pediatrics for cerebral palsy and adults with spinal cord injury or multiple sclerosis Useful for generalized spasticity especially involving the lower body Not used commonly used for geriatric stroke patients with focal spasticity Surgery for spasticity Patients may be eligible for surgery to lengthen the shortened muscle/tendon units Commonly used in pediatrics and younger healthy stroke and brain injury patients Not commonly used in geriatric stroke patients with multiple medical comorbidities Patients may be eligible for tendon transfers to redirect the forces from the spastic muscle to cause the forces to hold the joint in a more neutral position This would be more commonly done in pediatric or younger adult patients Tendon transfers less likely to be done in geriatric stroke patients with multiple medical comorbidities Website: November 5,

12 Dorsal rhizotomy Rheologic Changes Are contractures present? YES Algorithm for Management of UMN Syndrome YES Assessment of Clinical Problems and Patient Goals Does the patient exhibit rheologic changes? NO Peripheral Focal or Multi-focal NO Muscle Overactivity Distribution of problem Central Regional or Generalized Selective dorsal rhizotomy involves cutting of selected Orthopedic Surgery dorsal nerve rootlets exiting the spinal cord This reduces sensory input to the spinal cord altering efferent output to the spastic muscles Adverse Effects Commonly used in pediatrics Not used in geriatric stroke patients Periodic reevaluation Post-treatment Interventions Chemodenervation (Botulinum neurotoxin, phenol, diagnostic blockade) (Posture management, physiotherapy, splints) Adapted from Barnes M et al. The Management of Adults With Spasticity Using Botulinum Toxin: A Guide to Clinical Practice. London, England: Royal College of Physicians; Oral or Intrathecal Agents Pre and post Botlinum toxin pictures Pre and post Botulinum toxin pictures Website: November 5,

13 Pre and post Botulinum toxin pictures Pre and post Botulinum toxin pictures The End Are there any question? Website: November 5,