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Neuromuscular Phys > Lecture 4 Spasticity > Flashcards

Lecture 4 Spasticity Flashcards

1
Q

What is the main difference between spasticity and rigidity

A

Spasticity is velocity dependent

rigidity is all time

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2
Q

Spasticity Incidence by diagnosis

A

CP- 90%

MS: 47-70%

TBI: 51%

SCI: 34%

Stroke: 20%

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3
Q

How do you rate a normal DTR?

A

0- No Response

1- Sluggish or diminished

2- Normal

3- Brisk

4- hyperreflexive or intermittent/transient clonus

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4
Q

The modified ashworth scale measures what?

A

Spasticity

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5
Q

Grading of ashworth scale

A

1- No Increase in tone

2- slight increase in tone, giving a catch when moving into flexion or extension

3- Marked increase in tone but affects parts easily flexed

4- Considerable increase in tone; passive movement difficult

5- Affected part(s) rigid in flexion or extension

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6
Q

What kind of scale is the modified ashworth scale

A

ordinal

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7
Q

Modified Ashworth Scale ratings

A

0- No increase in tone

1- Slight increase with a catch and release. Or by minimal resistance at the end of ROM when joint is moved into flexion or extension

1+ - Slight Increase in muscle tone manifested by a catch, followed by minimal resistance through remainder of the ROM (less than half)

2- More marked increase in muscle tone through most of the ROM, but affected part is easily moved

3- Considerable increase in muscle tone, passive movement is difficult

4- Affected part(s) in rigid in flexion or extension

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7
Q

Considerable increase in muscle tone, passive movement is difficult

What modified ashworth scale rating is this?

A

3

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8
Q

What modified ashworth scale rating is this: Slight increase with a catch and release. Or by minimal resistance at the end of ROM when joint is moved into flexion or extension

A

1

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9
Q

What does the tardieu scale measure?

A

Spasticity

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10
Q

What is V1, V2, and V3 in the Tardieu Scale

A

V1- moving the limb as slow as possible

V2- Speed of limb falling with gravity

V3- moving the limb as fast as possible

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11
Q

Out of V1, V2, and V3 in the tardieu scale, which are used for spasticity

A

V2 and V3

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12
Q

How is the tardieu scale graded?

A

By quality of the muscle reaction through each of the speeds:

0: no resistance through full PROM

1: slight resistance through full PROM with no clear catch

2: clear catch at a precise angle followed by release

3: Fatiguable clonus (Under 10 seconds) at precise angle

4: Unfatiguable clonus at precise angle

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13
Q

How would you grade this on the Tardieu scale: clear catch at a precise angle followed by release

A

2

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14
Q

How would you grade this on the tardieu scale: Unfatiguable clonus at precise angle

A

4

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15
Q

What is R1 and R2 on the Tardieu scale?

A

R1- PROM till catch point

R2- full PROM (till the hard endpoint whether that is their normal end feel or to their contracture)

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16
Q

Penn Spasm Scale

A

0- No Spasm

1- No Spontaneous spasm (excep with vigorous motor stimulation)

2- Occasional spontaneous spasms and easily induced spasm

3- More than 1 but less than 10 spontaneous spasms per hour

4- More than 10 spontaneous spasms per hour

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17
Q

What is baclofen for and what are the 2 ways it’s administered

A

For spasticity

Oral and Intrathecal

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18
Q

How does Botox work?

What kind of muscle fibers recover faster after Botox?

A

Blocks acetylcholine release

Slow twitch fibers recover before fast twitch

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19
Q

Botox injection effects seen when? Peak effects?

How is dose based

A

Effects seen 24-72 hours, peak effects 4-5 days, lasts 8-12 weeks

If casting is indicated, start 2-4 days after injection

Dose based upon body weight, size of muscle, client activity and levels of spasticity

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20
Q

What are the advantages of Botox

A

Selective to muscles you want to paralyze

No dysesthesia and less muscle irritation

Minimal pain

Graded degree of weakening

Frequently used during growth spurts

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21
Q

Disadvantages of Botox

A

Costs

Limit in amount that can be administered at once

Not permanent, can develop tolerance

Reinjection cannot be more frequent than once every 3 months

Muscles can be overstretched

Side effects: fever, hives, swelling

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22
Q

Botox contraindications

A

Neuromuscular transmission disease

Inflammation at projected injection site

Pregnancy

Children under 2 years old

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23
Q

How soon do you preform the Botox post-injection assessment

A

2 weeks

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24
Q

The ideal Botox client has _____ spasticity

A

Localized

No contractures

25
Q

How does baclofen work?

A

Not fully understood

Inhibits reflexes at spinal level

Looks like inhibitory neurotransmitter GABA

26
Q

What kind of baclofen can cross the blood brain barrier or enter systemic circulation

A

Oral

27
Q

What kind of baclofen has fewer side effects

A

Intrathecal

28
Q

What has a higher dose, intrathecal baclofen or oral baclofen

A

Oral

Intrathecal is 1/100 the dose of oral

29
Q

What ashworth scale scores indicate that someone could use a baclofen pump (selection criteria)

A

Severe spasticity (ashworth of 3 or more)

30
Q

Intrathecal baclofen pump selection criteria

A

Ashworth score of 3+

Not dependent on spasticity for function

Movement disorder not main problem

Less invasive modalities not acceptable

Goals identified, therapy available, family capable

Over 1 year since injury

Over 4 years old

31
Q

Intrathecal baclofen contraindications

A

Allergy or hypersensitivity to baclofen

Active infection

32
Q

What specific impairments can a baclofen pump help with

A

Sleep problems

Pain due to spasm

Impaired voluntary movement

Loss of function due to spasticity

Contracture prevention or impede progression or current contractures

Bowel and bladder function

33
Q

How do we know the baclofen pump is working for the patient?

A

Look for decrease of 1 point in ashworth scale

If no respond 24 hours later give 75mcg

If no response 24 hours after that give 100mcg

34
Q

Where is the cather inserted for a baclofen pump?

A

Subarachnoid space at L3/L4
Catheter tip goes up to T12/L1

35
Q

Where is the baclofen pump implanted?

A

In patients abdomen

36
Q

What are the advantages of a baclofen pump

A

Completely reversible

Can fine-tune dosage

Does not cross blood brain barrier (less side effects)

37
Q

What are the disadvantages of a baclofen pump?

A

Need specialized center to implant it

Potential malfunction

Battery life 3-5 years, whole pump has to be replaced

Difficult to help UE without overdoing it for the LE

Infection

CSF leaks

Can see the pump through the skin in thin patients

Refilll every 3 months

Patient can develop tolerance

38
Q

What is a nerve/motor point block

A

Phenol or alcohol injection similar to local anesthetic

39
Q

What are the advantages of motor point blocks

A

Last 6 months

Decrease tone may allow functional mobility in opposing muscles

40
Q

Disadvantages of nerve/motor point block

A

Can cause long term axonal damage

Dysethesias

Muscle irritation

Phenol is a potential carcinogen

41
Q

Spinal cord stimulators affect which part of the spinal cord?

A

Dorsal column

42
Q

Cerebral electrical stimulation to control pain is applied to what part of the brain

A

Sensory nuclei of thalamus

Note: or cerebellum for control of movement disorders

43
Q

What is the advantage of spinal stimulation

A

Better for tone management of the UE than a baclofen pump

44
Q

What are the disadvantages of spinal/cerebral stimulation

A

Infection

Dislodging of electrodes

Less effective than baclofen pump for management of LE spasticity

45
Q

A neurotomy needs to preserve how much of the motor fibers

A

20%

46
Q

What are the advantage of a neurotomy

A

Permanent changes

47
Q

What are the disadvantages of a neurotomy

A

Excess lesions will cause permanent motor function decrease

Insufficient lesioning will cause ineffective results

Can have longstanding pain problems

48
Q

What is a rhizotomy?

What other surgeries must be performed at the same time

A

Certain % of sensory nerve rootlets are cut, usually in lower thoracic and lumbar

Requires laminectomy or laminotomy

49
Q

What are the advantages of a Rhizotomy

A

Permanent changes at the segmental level

50
Q

What are the disadvantages of a rhizotomy

A

Infection

Bleeding

CSF leak

Hyperesthesia

Motor nerve issues permanent

Can adversely affect B&B

Few places will preform this

Long inpatient hospitalization

Sensory loss (temporary)

Can cause over-weakness

51
Q

What is a tendon release?

A

Tendon lengthening procedure

Procedure does not change the original mechanism for how the tendon and muscle originally lost length

Hamstring and Achilles most common

52
Q

What are the advantages of a tendon release

A

Well funded procedure, done for many years

Assists in preventing secondary deformities

53
Q

What are the disadvantages of tendon lengthening

A

Risk of overlengthening

Procedure might not last through growth spurt

Heel cord has to be casted 4-6 weeks WBAT

hamstring must have long leg cast with full knee extension present

54
Q

Non-invasive treatments for spasticity

A

-Passive Stretch

Electrical stim

EMG biofeedback

Temperature

Casting and splinting

Medications

55
Q

How long should patient’s with spasticity stretch?

A

20-30 mins

56
Q

In functional neuromuscular stim, what muscle do we stimulate to combat spasticity and how does it work?

A

Stimulate antagonist to increase reciprocal inhibition of spastic muscle

note: you cannot stimulate agonist to over-fatigue spastic muscle

57
Q

Contraindications to Therapeutic electrical stimulation

A

Primary muscle disorder

Degenerative disease

behavior disorder

medical complications: arrythmia, pace maker, pregnancy

Growth complications: Obesity, Fixed contractures

58
Q

What is therapeutic electrical stimulation

A

subthreshold stimulation to sensory nn

uses specialized TENs unit that can only be issued by TES certified therapist

59
Q

How is TENs used to treat spasticity

A

inhibits pain which can help break the spasticity-pain cycle

60
Q

Serial casting (nonremovable) is most successful when a contracture has been present less than ___________ months and when patient is able to use the extremity

A

6 months

Neuromuscular Phys (26 decks)

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