Lecture 4 Spasticity Flashcards
What is the main difference between spasticity and rigidity
Spasticity is velocity dependent
rigidity is all time
Spasticity Incidence by diagnosis
CP- 90%
MS: 47-70%
TBI: 51%
SCI: 34%
Stroke: 20%
How do you rate a normal DTR?
0- No Response
1- Sluggish or diminished
2- Normal
3- Brisk
4- hyperreflexive or intermittent/transient clonus
The modified ashworth scale measures what?
Spasticity
Grading of ashworth scale
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
What kind of scale is the modified ashworth scale
ordinal
Modified Ashworth Scale ratings
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
Considerable increase in muscle tone, passive movement is difficult
What modified ashworth scale rating is this?
3
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
1
What does the tardieu scale measure?
Spasticity
What is V1, V2, and V3 in the Tardieu Scale
V1- moving the limb as slow as possible
V2- Speed of limb falling with gravity
V3- moving the limb as fast as possible
Out of V1, V2, and V3 in the tardieu scale, which are used for spasticity
V2 and V3
How is the tardieu scale graded?
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
How would you grade this on the Tardieu scale: clear catch at a precise angle followed by release
2
How would you grade this on the tardieu scale: Unfatiguable clonus at precise angle
4
What is R1 and R2 on the Tardieu scale?
R1- PROM till catch point
R2- full PROM (till the hard endpoint whether that is their normal end feel or to their contracture)
Penn Spasm Scale
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
What is baclofen for and what are the 2 ways it’s administered
For spasticity
Oral and Intrathecal
How does Botox work?
What kind of muscle fibers recover faster after Botox?
Blocks acetylcholine release
Slow twitch fibers recover before fast twitch
Botox injection effects seen when? Peak effects?
How is dose based
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
What are the advantages of Botox
Selective to muscles you want to paralyze
No dysesthesia and less muscle irritation
Minimal pain
Graded degree of weakening
Frequently used during growth spurts
Disadvantages of Botox
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
Botox contraindications
Neuromuscular transmission disease
Inflammation at projected injection site
Pregnancy
Children under 2 years old
How soon do you preform the Botox post-injection assessment
2 weeks
The ideal Botox client has _____ spasticity
Localized
No contractures
How does baclofen work?
Not fully understood
Inhibits reflexes at spinal level
Looks like inhibitory neurotransmitter GABA
What kind of baclofen can cross the blood brain barrier or enter systemic circulation
Oral
What kind of baclofen has fewer side effects
Intrathecal
What has a higher dose, intrathecal baclofen or oral baclofen
Oral
Intrathecal is 1/100 the dose of oral
What ashworth scale scores indicate that someone could use a baclofen pump (selection criteria)
Severe spasticity (ashworth of 3 or more)
Intrathecal baclofen pump selection criteria
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
Intrathecal baclofen contraindications
Allergy or hypersensitivity to baclofen
Active infection
What specific impairments can a baclofen pump help with
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
How do we know the baclofen pump is working for the patient?
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
Where is the cather inserted for a baclofen pump?
Subarachnoid space at L3/L4
Catheter tip goes up to T12/L1
Where is the baclofen pump implanted?
In patients abdomen
What are the advantages of a baclofen pump
Completely reversible
Can fine-tune dosage
Does not cross blood brain barrier (less side effects)
What are the disadvantages of a baclofen pump?
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
What is a nerve/motor point block
Phenol or alcohol injection similar to local anesthetic
What are the advantages of motor point blocks
Last 6 months
Decrease tone may allow functional mobility in opposing muscles
Disadvantages of nerve/motor point block
Can cause long term axonal damage
Dysethesias
Muscle irritation
Phenol is a potential carcinogen
Spinal cord stimulators affect which part of the spinal cord?
Dorsal column
Cerebral electrical stimulation to control pain is applied to what part of the brain
Sensory nuclei of thalamus
Note: or cerebellum for control of movement disorders
What is the advantage of spinal stimulation
Better for tone management of the UE than a baclofen pump
What are the disadvantages of spinal/cerebral stimulation
Infection
Dislodging of electrodes
Less effective than baclofen pump for management of LE spasticity
A neurotomy needs to preserve how much of the motor fibers
20%
What are the advantage of a neurotomy
Permanent changes
What are the disadvantages of a neurotomy
Excess lesions will cause permanent motor function decrease
Insufficient lesioning will cause ineffective results
Can have longstanding pain problems
What is a rhizotomy?
What other surgeries must be performed at the same time
Certain % of sensory nerve rootlets are cut, usually in lower thoracic and lumbar
Requires laminectomy or laminotomy
What are the advantages of a Rhizotomy
Permanent changes at the segmental level
What are the disadvantages of a rhizotomy
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
What is a tendon release?
Tendon lengthening procedure
Procedure does not change the original mechanism for how the tendon and muscle originally lost length
Hamstring and Achilles most common
What are the advantages of a tendon release
Well funded procedure, done for many years
Assists in preventing secondary deformities
What are the disadvantages of tendon lengthening
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
Non-invasive treatments for spasticity
-Passive Stretch
Electrical stim
EMG biofeedback
Temperature
Casting and splinting
Medications
How long should patient’s with spasticity stretch?
20-30 mins
In functional neuromuscular stim, what muscle do we stimulate to combat spasticity and how does it work?
Stimulate antagonist to increase reciprocal inhibition of spastic muscle
note: you cannot stimulate agonist to over-fatigue spastic muscle
Contraindications to Therapeutic electrical stimulation
Primary muscle disorder
Degenerative disease
behavior disorder
medical complications: arrythmia, pace maker, pregnancy
Growth complications: Obesity, Fixed contractures
What is therapeutic electrical stimulation
subthreshold stimulation to sensory nn
uses specialized TENs unit that can only be issued by TES certified therapist
How is TENs used to treat spasticity
inhibits pain which can help break the spasticity-pain cycle
Serial casting (nonremovable) is most successful when a contracture has been present less than ___________ months and when patient is able to use the extremity
6 months
