Day 3 - Spasticity & Neuro Rehab Flashcards
Treatment of Central Pain Post Stroke 🔑
First Line
- Amitriptyline (75mg/d)
- Gabapentin (Neurontin) 900mg/d
Others
- Pregabalin (Lyrica) 150mg/d
- Naloxone (8mg)
- I.V. Lidocaine → short-term (45 min) pain relief only
- Morphine infusion (9-30mg)
Pathophysiology of Thalamic/Central Pain States Post Stroke (CPSP)
Damage to spino-thalamic pathway → impaired temperature (hot, cold) and pain (pinprick)
→ hyperalgesia +/or allodynia
Risk factors for Post-Stroke Fatigue (PSF)
- Depression
- Chronic pain
- Sleep disorders
Treatment of Post-Stroke Fatigue (PSF)
- Modafinil 200mg/d
- Cognitive Therapy/Graded Activity Training
List 2 screening tools for depression 🔑
- Patient Health Questionnaire (PHQ)-9
- Hospital Anxiety and Depression Scale (HADS)
List 4 Risk Factors for Depression post stroke
- Female sex (especially those with severe depression)
- Previous history of depression
- Stroke severity, functional limitations or need for assistance with activities of daily living
- Cognitive impairment
- Social factors (living alone, divorced or living in a nursing home)
List 2 Pharmacological & 2 Non-Pharmacological Management for Depression Post-Stroke
Non-Pharmacological Management
- Exercise
- Cognitive-Behavioural Therapy (CBT)
Pharmacological
- TCA → Amitriptyline 10-25mg
- SSRI → Escitalopram (Cipralex) 5mg Fluoxetine (Prozac) 10mg
- CNS Stiumlant → Methylphenidate (Ritalin) 5mg
Explain brain lobes and their clinical relation.
Frontal lobe
- Laterally separated from the temporal lobes by the Sylvian fissure.
- Primary motor cortex → voluntary movement → Weakness
- Problem solving, thinking and planning → Apraxia
- Behavior & personality
Parietal lobe
- Primary somatosensory cortex → Perception → Neglect
Temporal
- Primary auditory cortex → Language → Aphasia
- Memory, Object and face recognition
Occipital
- Primary visual cortex → Vision and orientation
List 5 descending tracts.
- Corticospinal
- Vestibulospinal
- Rubrospial
- Olivospinal
- Reticulospinal
Mini-Mental State Examination (MMSE) ORAL.C.
Orientation
- D/M/Y, Season and Time
- Location From country to Ward
Registration
- 3 Objects
Attentions
- 100 minus 7 five times
Language
- Name 2 object
- Give 3 order command
- Read command
- Write sentence
Copy
- Pentagon
Main challenges in bladder for stroke patient.
- Incontinence → areflexia
- Aphasia → communication
- Impaired mobility → WC
- Neurogenic Bladder → neurodynamic study
- Repeated UTI
Cuccurollo
How do you manage bladder dysfunction in stroke patient?
Failure to store
Antimuscarinic agents
- MOA: Prevent acetylcholine release from parasympathetic nerves by binding to receptors on the detrusor muscle, thus assisting in bladder storage.
- Drugs: Solifenacin (Vesicare) or Oxybutynin (Ditropan)
- Side effects: dry mouth, blurry vision, and constipation
Failure to pass
Adrenergic antagonists
MOA: Inhibit smooth muscle activity in the prostate and at the bladder neck
Side effects: Postural hypotension, abnormal ejaculation, and nasal congestion
Spastic Bladder (Hyperactive)
Baclofen, tizanidine, diazepam, and dantrolene sodium
Botulinum toxin type A
Underactive Bladder
Intermittent catheterization (IC)
List 2 investigation you would like to do before treating bladder dysfunction?
- Urodynamics evaluation
- Post void residuals (PVRs)
List 2 pharmacological and 2 nonpharmacological treatments for stress incontinence.
Pharmacological
- Adrenergic agonists
- Oxybutynin (Ditropan)
NonPharmacological
- Take fiber to avoid constipation
- Avoid jumping or running
- Pelvic floor muscle exercises
Stroke patient with diarrhea, how do you manage?
- Treat underlying causes (e.g., bowel infection, diarrhea)
- Timed toileting schedule
- Training in toilet transfer
- Communication skills
Stroke patient with constipation, how do you manage?
- Adequate fluid intake/hydration
- Diet modification (e.g., increase dietary fiber),
- Bowel management (stool softeners, stool stimulants, suppositories 3-2-1 program)
Decreased sexual activity post-stroke attributed to:
- Inability to discuss sexuality with spouse
- Unwillingness to participate in sexual activity
- Reduced body image and self-esteem
- Positioning problems due to disability and spasticity or muscle weakness
Treatment of sexual dysfunction post-stroke
- Emotional support
- Psychotherapy
- Medical consultation (urology)
- PDE5 inhibitor
- Treat underlying spasticity/weakness/contracture
Define Spasticity & Modified Ashworth Scale
A motor disorder characterized by an abnormal, velocity-dependent increase in the tonic stretch reflexes (muscle tone) with exaggerated phasic stretch reflexes (tendon jerks, clonus) resulting from hyperexcitability of the stretch reflex. It is a component of the UMNS.
Modified Ashworth Scale:
0 No increase in tone
1 Slight increase in muscle tone, manifested by a catch and release or minimal resistance at the end of the ROM when the affected part(s) is moved in flexion and extension
1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM
2 More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved
3 Considerable increase in muscle tone, passive movement difficult
4 Affected part(s) rigid in flexion or extension
List 5 management options for spasticity.
Prevention first (non-pharmacological)
- Remove factors or noxious stimuli that may increase spasticity (UTI, etc).
- Exercises: positioning, stretching/ROM.
- Bracing: splinting (static vs dynamic), Serial casting.
- Modalities: cold, electrical stim, FES
Treating second (pharmacological)
- oral medications → Baclofen
- focal treatments → BotoX
- intrathecal baclofen.
- surgical options (selective dorsal rhizotomy)..
Ref: http://www.abiebr.com/set/case-study-2/27-spasticity-post-abi
What is the mechanism of botulinum toxin? 1 Mark
Inhibition of acetylcholine release at the neuromuscular junction
What is the mechanism of botulinum toxin? 1 Mark
Inhibition of acetylcholine release at the neuromuscular junction
Postural abnormalities in upper limb and where to inject.
Postural abnormalities in wrist and where to inject.
Postural abnormalities in hip & knee and where to inject.
Postural abnormalities in ankle and where to inject.
How much Botox will you inject per muscle and per session? What is the effectiveness timeline of Botox?
- Usual dosage of onabotulinumtoxinA (Botox) is 25 to 200 units per muscle
- Initial safe dose for first treatment is likely 400 units total or 6 units per kg for an adult.
- Reinjections should occur after 3 months
“3 days for initial effect, 3 weeks for peak effect, and 3 months duration.”
Cuccurollo
List 4 side effects of Botox.
- Pain/soreness
- Nerve trauma
- Hematoma/bruising/local erythema or swelling
- Flu-like syndrome with headache, nausea, fatigue, general malaise
- Dysphagia may occur from cervical injection (short-lived)
- Unwanted weakness in injected or adjacent muscles (localized)
List 6 side effects of baclofen.
- Brain : Depression - Confusion - Headache - Hallucinations
- Cerebellum : Coordination disorder - Tremor - Ataxia - Nystagmus
- Basal Ganglia : Dystonia
- Brainstem : Blurred vision - Slurred speech - Tinnitus - Diplopia - Dysarthria
- Cardiorespiratory : Hypotension - Dyspnea - Palpitation - Chest pain - Syncope.
- Gastrointestinal : Nausea - Constipation
- Genitourinary: Urinary retention - Inability to ejaculate
List 4 signs of abrupt drug withdrawal of baclofen
- Increased spasticity.
- Agitation
- Confusion
- Hallucinations
- Seizures
- Psychosis
- Dyskinesia
List 10 surgical operations for treatment of spasticity.
Tendon: Release, Transfer, Lengthening
Muscle: Myotomy
Nerve: Peripheral neurectomy → Cordectomy → Dorsal Rhizotomy → Myelotomy
Devices: ITB Pump, Deep brain stimulator
List 4 positive effect of spasticity.
- Hemp in ambulation, standing, or transfers (e.g., stand pivot transfers)
- Maintaining muscle bulk due to muscular contraction
- Preventing deep vein thrombosis (DVT) by providing improved venous flow secondary to muscle contractions
- Preventing osteoporosis
- Can serve as a “diagnostic tool” (spasticity can be a sign of exposure to a noxious stimuli : infection, bowel impaction, urinary retention, etc.)
Cuccurollo
List 4 negative effect of spasticity.
- Interferes with function
- Can cause extreme discomfort/pain
- Interferes with hygiene and nursing care
- Contractures and disfigurement
- Increased risk for development of decubitus ulcers
- Bone fractures
- Joint subluxation/dislocation
- Increased risk of heterotopic ossification (HO)
- Acquired peripheral/entrapment neuropathy
Cuccurollo
List 4 triggers of spasticity.
List 4 reasons for poor outcome of Botox.
- Inactive medication
- Incorrect dose
- Incorrect diagnosis
- Incorrect muscle selection
- Unrealistic goals
- Disease condition
