lecture 5: managment of spasticity Flashcards
what is mm tone
resistance to stretch in resting
MM tone exists on a continuum so what does these mean
- flaccidicty
-hypotonia
-hypertonia
-spasticity
-rigidity
- flaccidicty: complete lack of resistance
-hypotonia : abnormally low resistance
-hypertonia: abnormally high resistance to passive stretch
-spasticity : velocity dependent
-rigidity: velocity independent
what is spasticity
velocity dependent resistance to passive stertch
does spasticity affect people with UMN or LMN lesions
UMN
which condition is spasticity incidence the highest
CP
what is a chronic loss of PROM of a joint because of structural changes in non bony tissues
contractures
____ and ___ significantly contribute to contractures, but are not
the sole cause.
Spasticity and paralysis
what are 4 ways that spasticity may be helpful
- assist patients w postural control and mobility
- maintaining mm mass and bone mineralization
- reduce dependent edema
- prevent DVT
what are teh 5 clinical assessment measure of spasticity
- Placing (NDT - see lab notes)
- Modified Ashworth Scale
- Tardieu Scale
- Penn Spasm Scale
- Patient Reported Impact of Spasticity Measure (PRISM
if a patient has a Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder
(less than half) of the ROM what grade is it on the modified asworht scale
1+
if a patient has a Considerable increase in muscle tone, passive movement is difficult what grade would that be on the modified ashworth scale
3
if the patient has no increase in tone what is the grade on the modified ashworth scale
0
what is the velocity of stretch for the tardieu scale to measure spasticity and what is V1-V3 used for
v1: as slow as possible (passive)
v2: speed of limb fallling w gravity
v3: as fast as possible
V1 used for PROM
V2 & 3 for spasticity
what is the angle of mm reaction for the tardieu scale
measured from 0° position
R1= PROM will catch point
R2: full PROM
for the QUality of mm reaction of the tardieu scale what would a patient be graded if there was a clear catch at precise angle , followed by a release ?
grade 2
for the QUality of mm reaction of the tardieu scale what would a patient be graded if there was a fatigable clonus at precise angle
3
what is the patient reported impact of spasticity measured ?
self report measure of impact of spasticity on numerous things
what are the 7 medical management of spasticity
- botulinum toxin A
- baclofen (oral or intrathecal pump)
- nerve or motor point block
- spinal or cerebral electrical stimulation
- peripheral neurotomy
- rhizotomy
-tendon release w/without transfer
what is the only strain of Neuroparalytic toxin produced by clostridium botulinum bacteria avaiable for clinical use
type A
what are the brand names of botulinum toxin A
botox, dysport , xeomin
how does botox work for spasticity
blocks acetylcholine relseae at the NM junction , autonomic ganglia and posthganglionic parasympathetic and sympathetic nerve endings
for botox does slow twitch fibers recover then fast twitch ? or slower ?
faster
how do you use BOTOX and how do u dose it
inject directly into the MM BELLY
dose based up body weight , size of the mm , client activity levels , and levels of spasticity
• Can be injected for selective muscle
paralysis
• No dysesthesia
• Less muscle irritation
• Minimal pain (done in MD office)
• Graded degree of weakening
• Frequently used during growth
spurts
these are advantages for what
botox
• Costs
• Limits in amount of drug that can
be administered at one time
• Not permanent, and can develop
decreased response, because of
antibody production
• Re-injected no more frequently
than once per 3 months
• Muscle can be overstretched
• Side effects: can produce fever,
swelling, hives.
what is this disadvantages to
botox
what are contraindications of BOTOX
- NM trasnmission disease
-inflammation at projected injection site - preganancy
- children under 2 years of age
what oral medication can be used for systemic effect for generalized spasticity
baclofen , tizanidine, dantrolene, clonidine, diazepam
topical anesthesia is applied to entire extremity except what surfaces
extensor surfaces over lower leg and forearm
what can be given oral bs intrathecal and is effective in reducing spasticity
baclofen
what is the mechanism of action of baclofen
not fully understood
inhibits reflexes at the spinal cord level
possibly inhibits excitatory NT relsease (looks like inhibitory NT GABA)
- Does not reach the systemic circulation or brain in appreciable amounts
• Fewer systemic side effects as stays in area of the cord rather than circulating in the
bloodstream
• Provides a mechanism for patients who otherwise would not tolerate oral baclofen
• Can be used for the management of spinal (SCI, MS) and supraspinal (CP,
CVA, TBI) spasticity
• Can positively affect pain in these populations
• Improvements in voluntary muscle control
what does this relate to
INTRATHECAl BACLOFEN PUMP ( I T B )
what are contraindications for intrathecal baclofen pump
-* Allergy or hypersensitivity to baclofen
* Active infection
what are teh adverse effects of intrathecal baclofen pump
-risk of pump malfunction or tip displacement
- overdose if pump malfunctions causes sedation , respiratory depression , decreased cardiac function
- rapid cessation causing withdrawal syndrome
-risk of disinhibition
what is the implantation of the intrathecal baclofen pump
• Catheter is inserted into subarachnoid space at L3-4 with catheter tip extending to T12-L1.
• Pump is implanted in abdomen
what are the short and long term effects of nerve or motor point blocks
short term is similar to local anesthetic , directly proportional to thickness of fibers
long term casues protein denaturation
what is a advantage difference between botox and nerves or motor point blocks for spasticity
botox does not cause dysesthesias when nerve block does
botox casues less mm irritation as compared to nerves block
nerve block last longer then botox
spinal cord stimulation=
dorsal column stimulation
what is the advantage of spinal stimulation
better tone management of UEs then baclofen pump
what is the cerebral electrical stimulation
- sensory stimulation of sensory nuclei of thalamus for pain control
- cerebellar stimulation for movement disorders
what is a rhizotomy
certain % of sensory nerve root lets are cut
where is a rhizotomy usually performed and what does it require
performed in lower thoracic or lumbar regions and requires laminectomy or laminotomy
are there more advantages or disadvantages for a rhizotomy
disadvantages
what tendons are most commonly released for a tendon release
hamstrings and heel cord (achilles)
does a tendon release a change the mechanism for how mm adn tendon lost original length
NOOOO
what is SPLATT
split anterior tibialis tendon transfer
lateral aspect attached to cuboid ,
frequently after heel cord lengthening
for the tendon release with transfer the ___ ___ tendon transfer from ___ surface of ___ cuneiform to dorsum of ____
Peroneus longus tendon transfer from plantar surface of medial cuneiform
to dorsum of navicular
• Passive stretch
• Electrical stimulation
• EMG biofeedback
• Temperature
• Casting and splinting
• Medications
what kind of treatments are these for reduction of spasticity
non invasive
what is the physcial therapy management of spasticity
-objective assessment
-stretching and range of motion exercises
-strength training
from stretching and range of motion exercises for PT management of spasticity how long wold u have to stretch
long time 20-30 years
what is functional/ neuromuscular electrical stimulation
- antagonist stimulation to increase reciprocal inhibition of spastic mm and increase strength of antagonist
what are contraindications to TES ( 4 )
• Primary muscle disorder
• Degenerative disease
• Behavioral disorders
• Medical complications (strict)
Arrhythmia
Pacemaker
Pregnancy
• Growth complications
Obesity
Fixed contractures
what do u use therapeutic electrical stimulation for
general spasticity that interferes with function
when do u use Therapeutic electrical stimulation (TES)
• Used at night during peak secretion of growth hormone to prevent disuse
atrophy
what electrical stimulation is used to treat pain associated with spasticity to break spasticity pain cycle
TENS
what do u use EMG biofeedback to promote
- To promote voluntary relaxation, keeping readings below threshold
- To promote voluntary active efforts, in combination with
FES/NMES when threshold reached
what nonremoveable cast is more successful wehn contracture present < 6 months adn when patient is able to use extremity
serial cast
are cast and AFOs static or dynamic
static
what splint is very good with painful/hypersensetive patients , holds limb in inhibited posture ,and applies deep pressure stimulation acts on proprioceptors
air filled pressure splint
what is used for general relaxation , hot or cold ?
hot
what is used to numb skin receptors (hot or cold)
collie
