Lecture 8: Spasticity - Assessment and Management

Question 1

Define spasticity
- what is the most common leg and upper limb posture

Answer 1

A neurological condition causing large increases in muscle tone when a muscle is stretched. spastic muscles resist stretch and remain abnoramally contracted for long periods

Equinovarus feet: most common pathologic leg posture; can prevent even limited ambulation

Upper limbs: adduction and internal rotation of the shoulder and flexion of the elbow, wrist and fingers

Question 2

What disorders can lead to spasticity?

Answer 2

Disorders leading to spasticity include: stroke, spinal cord injuries, cerebral palsy, multiple sclerosis, TBI

Question 3

What can trigger spasticity

Answer 3

Spasticity can be brought on by a rapid muscle stretch (e.g., clasp-knife reflex) or by other sensory stimulation (draft of cool air)

Question 4

Describe morphological changes to spastic muscles?

Answer 4

Spastic muscles become stiffer, shorter.

Reduction in # of sarcomeres as well.

Question 5

What causes spasticity?

Answer 5

There is decreased inhibition from the brainstem. This can affect spinal reflexes as antagonists will not be inhibited.

At the same time, there is increased muscle spindle input, caused by collateral sprouting of peripheral afferents. This increases the gain.

Motor neurons become hyperexcitable. As excitatory signals from the sensory nerves and inhibitory signals from the brain are unbalanced, normal muscular tone cannot be maintained.

Question 6

Differentiate between dynamic and fixed contractures

Answer 6

Dynamic contracture
- increased stiffness upon stretching a muscle
- can usually be reduced with drug treatment
- if left untreated, can be replaced by fixed contracture

Fixed contracture
- a permanent shortening and hardening of muscles and tendons
- cellular changes (loss of sarcomeres, fibrous scar tissue formation, shortened tendon) leave spastic muscles rigid
- can lead to permanent joint deformity and rigidity
- often painful
- can only be treated with surgery

Question 7

Why does clonus occur?

Answer 7

The inhibition of antagonists is impaired in patients with upper motorneuron syndrome. As such, antagonist muscles are allowed to contract and the joint will oscilliate between opposing movements (flexion/extension

Question 8

What is clonus/tremour frequency?

Answer 8

8-13Hz

Question 9

What are the effects of spasticity on the following:
- activities of daily living
- hygiene
- mobility
- comfort

Answer 9

• Activities of daily living: Inability to independently control muscles can affect activities of daily living such as dressing, eating, grooming.
• Hygiene: Stiff, contractured or spastic muscles can prevent access to areas such as the palm, armpit or groin, interfering with hygiene. Odor and skin breakdown may occur. Bowel/bladder care are more difficult.
• Mobility: Spasticity in leg muscles interferes with mobility, seating and transfers, such as from bed to wheelchair or from sitting to standing.
• Comfort: Spasticity may make it difficult to sit comfortably or to change positions to prevent joint pain and pressure sores.

Question 10

How is spasticity assessed?

Answer 10

Assessment includes identifying which muscles are overactive and determining the effect of spasticity on all aspects of patient function including mobility, employment and activities of daily living.

Question 11

Describe some of the upper limb postures that can be observed in a patient exhibiting spasticity

Answer 11

adducted/internally rotated shoulder

pronated forearm (pronator quadratus and/or pronator teres)

clenched fist (flexor digitorum sublimis)

flexed elbow

flexed wrist - can result in wrist subluxation and carpal tunnel syndrome

thumb in palm deformity
(flexor pollicis longus; adductor pollicis, thenar muscles)

Question 12

Describe some of the lower limb postures that can be observed in a patient exhibiting spasticity

Answer 12

equinovarus

stiff knee: persistent knee extension

striatal toe: overactive extensor hallucis longus

flexed knee (taut hamstring tendons)

adducted thigh: spastic adductors produce a narrow base of support at feet (scissoring thighs)

Question 13

How to determine which muscle is affected by spasticity

Answer 13

Dynamic EMG studies and temporary diagnostic motor point blocks may be used to determine involvement of specific muscles

Involuntary background activity = spasticity

If you stretch muscle and observe inappropriately large EMG response = spasticity

Question 14

In the flexed elbow, _____ is spastic more often than ____ and ___

Answer 14

brachioradialis

biceps

brachialis

Question 15

What can the flexed wrist position result in?

Answer 15

carpal tunnel symptoms may occur secondary to compression of the median nerve

Question 16

Even after good proximal recovery in the upper limb, loss of ___________ often endures

Answer 16

finger and thumb dexterity

Question 17

Definitions of spasms

Answer 17

• Spasm is a jumping or twitching of a muscle or limb without control;
• A spasm can be a “shooting” of the body part into a position without control;
• A rapid series of “spasms” without significant pausing is defined as one spasm.

Question 18

list the spasticity examination rating scales

Answer 18

• spasm frequency scale
• modified ashworth scale
• adductor tone rating
• global pain scale

Question 19

Spasm Frequency Scale

Answer 19

Tracks how many spasms a patient had in affected muscles or extremity in the last 24 hours

0 = no spasms

4 = 10 or more spasms per day

Question 20

Modified Ashworth Scale

Answer 20

5 point scale that describes changes in tone in muscle

0 = no increase in muscle tone

1 = Slight increase in muscle tone, manifested by a catch and release or by minimal
resistance at the end range of motion when the part is moved in flexion or
extension/abduction or adduction, etc.

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 the affected part is easily moved

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

4 = Affected part is rigid in flexion or extension (abduction or adduction, etc.

4 = affected part is rigid in flexion or extension (abduction/adduction, etc.)

Question 21

Adductor Tone Rating

Answer 21

0 = no increase in tone
1 = increased tone
4 = 2 people required to abduct hips to 45deg

Question 22

Global Pain Scale

Answer 22

Rate the total amount of pain the patient has had in the last 24 hours

No pain: 0

Maximum pain: 100

Question 23

Positive signs

Answer 23

addition or distortion of normal function

in upper motor neuron syndrome, caused by loss of supraspinal inhibiiton –> RST and VST upregulation

example: spasticity and released flexor reflexes

Question 24

Negative signs

Answer 24

absence of normal function

example: loss of dexterity, muscle weakness (paresis)

in UMN syndrome, caused by damage of motor cortex and CST pathways

Question 25

What are some positive signs of upper motoneuron syndrome

Answer 25

Spasticity
Increased muscle tone
Exaggerated tendon jerks
Stretch reflex spread to extensors
Repetitive stretch reflex (clonus)
Released flexor reflexes (more easily triggered; even light stimuli may cause it)
Babinski response (lifting of big toe in response to stimulation of sole of foot)
Mass synergy patterns
Clasp knife phenomenon
Babinski sign
Exaggerated cutaneous withdrawal (flexor, pain)
Reflexes
Autonomic hyperreflexia
Dystonia
Contractures may limit voluntary movement and cause discomfort

Question 26

What are some negative signs of upper motoneuron syndrome

Answer 26

Loss of finger dexterity
Weakness
Inadequate force generation
Slow movements
Loss of selective control of muscles and limb segments
Paresis
Lack of dexterity
Fatiguability

Question 27

What are 4 negative rheologic changes that can occur?

Answer 27

Affects plasticity and visco-elasticity of muscle

Stiffness (due to being active all the time, sarcomeres shorten - extensors in legs )

Contracture

Atrophy (not active - flexors in legs; sensors in arm)

Fibrosis (will fix muscles to a certain length and rigidity; generally at an end range of motion)

Question 28

How to determine if posture is caused by spasticity or rheologic changes?

Answer 28

Diagnostic nerve block or motor point block and EMG can distinguish the contributions of spasticity and stiffness to the clinical problem.

Question 29

Differentiate between spasticity of cerebral or spinal origin

Answer 29

cerebral origin
- enhanced excitability of monosynaptic spinal reflex pathways
- rapid build up of reflex activity
- overactivity of antigravity muscles and development of hemiplegic posture

spinal origin
- removal of inhibition on segmental polysynaptic pathways
- slow progressive rise of excitatory state
- flexors and extensors may be overexcited

Question 30

Describe clinical features of the released flexor withdrawal reflex

Answer 30

• ankle, knee, and hip flexion
• contraction of abdominals
• big toe extension (principal component of Babinski’s sign)
• flexor spasms

Demonstrates that selective control of muscle groups may be replaced by mass synergies (obligatory patterns of movement)

Question 31

List the typical spasticity management team and their role

Answer 31

• neurologist: diagnosis, prescribe treatments, refer for surgical evaluation as needed. administer chemodenervation
• physiatrist: designs rehabilitation program, prescribes medication, administer chemodenervation treatment
• physical therapist: facilitates therapeutic exercise
• occupational therapist: adapts physical environment to meet patient needs; teaches parents and caregiver techniques to assist with ADLs. provide expertise on adaptive devices
• neurosurgeon: implant intrathecal baclofen; selective dorsal rhizotomy, can support chemodenervation by exposing target nerve
• orthopedic surgeon: reduce deformities caused by contractures. target tendons and bones. assist with brace fitting and assessing growth development

Question 32

List the activities of daily living and instrumental activities of daily living

Answer 32

DEATH SHAFT

ADL:
Dressing
Eating
Ambulation (walking and transferring)
Toilet
Hygiene

SHAFT:
Shopping
Housekeeping
Accounting (money management)
Food preparation
telephone / transportation

Question 33

What are some of the goals of physical therapy for those with spasticity?

Answer 33

• Reduce muscle tone (with respect to spasticity)
• Maintain/improve ROM and mobility
• Increase strength and coordination
• Improve comfort

An important aspect of spasticity treatment is to minimize the types of stimuli that can trigger it, for example: pain, pressure sores, urinary tract infection, ingrown toenails, restrictive clothing and constipation.

Question 34

What are some possible PT treatments

Answer 34

1. Stretching to maintain full ROM and prevent contractures/permanent shortening
2. Strengthening spastic muscles and the ones nearby
3. Casts and braces – Serial casting can gradually stretch contractured limb
4. Cold packs applied for 10+ minutes can improve muscle tone and/or pain (short term only)
5. Electrical Stimulation – stimulate antagonist of spastic muscles. Results in strengthening and
   transient spasticity reduction
6. Biofeedback - electrical monitor makes a sound when spastic muscle relaxes. Person trains to reduce muscle tone consciously (effectiveness controversial)

Question 35

List the oral medication types that can reduce spasticity?

Answer 35

1. Baclofen
2. Benzodiazepines
3. Dantrolene Sodium
4. Tizanidine

Question 36

Benzodiazepines
- List the two major types
- function
- what are some benefits
- when is it taken
- side effects
- why are these prescribed carefully?
- what should these not be taken in combination with?

Answer 36

Diazepam (valium) and Clonazepam (klonopin and rivotril)

• reduce spasticity by acting on CNS
• improves passive ROM, less muscle overactivity, general relaxation
• taken at night
• drowsiness, loss of strength, unsteadiness, low blood pressure, GI symptoms, memory impairment, confusion, behavioral problems
• addictive
• do not take in combination with other CNS depressants or alcohol

Question 37

Baclofen
- function
- benefits
- side effects
- withdrawal effects
- what should it not be taken in combination with

Answer 37

• reduce spasticity by acting on CNS
• decreased stretch reflex, improved PROM, decreased muscle spasms, pain, and tightness
• drowsiness, sedation, weakness, decreased muscle tone, confusion, fatigue, nausea, dizziness
• hallucinations, seizures, rebound spasticity
• alcohol or other CNS depressants

Question 38

Dantrolene sodium
- how does it differ from other spasticity management drugs?
- benefits
- side effects
- what test(s) should be performed if a person is taking dantrolene sodium?
- what should it not be taken with?

Answer 38

• acts on muscle directly to reduce contractile activation. disables force generating mechanism.
• improved PROM, decreased muscle tone, reduced muscle spasms, tightness, pain
• generalized weakness (does not select for spastic muscles), including weakness of respiratory muscles, drowsiness, dizziness, fatigue, diarrhea, photosensitivity, liver toxicity
• liver function test before and regularly while taking it
• tizanidine

Question 39

Tizanidine
- function
- what sets it apart from baclofen and benzodiazepines?
- side effect
- what test(s) should be performed if a person is taking tizanidine?
- what should it not be taken with?

Answer 39

• reduce spasticity by acting on CNS
• less likely to reduce muscle strength
• sedation, low blood pressure, dry mouth, dizziness, hallucination,
• liver function
• dantrolene sodium

Question 40

intrathecal baclofen
- what is it
- benefits
- uses

Answer 40

• implanted pump delivers baclofen directly to intrathecal space (surrounds spinal cord
• reduces amount of baclofen needed to take orally; reduces side effects including drowsiness and sedation; more drug is brought to nerve cells that needed
• severe spasticity of spinal cord or brain origin; like cerebral palsy; or when oral drugs don’t provide sufficient enough tone reduction

Question 41

How to determine whether intrathecal baclofen is likely to produce a beneficial response? What should be cautioned with testing?

Answer 41

test dose injected into spinal fluid; test several doses to see how much is needed

cannot predict functional gains from continuous ITB since those take weeks or months to develop

Question 42

What would you tell parents to expect surrounding intrathecal baclofen treatment?

Answer 42

Test doses are required

Surgery is done under general anesthesia and requires about 2 hours. Often catheter is implanted into the lumbar interlaminar spaces

Hospital stay is around 4-7 days

Some tenderness or soreness for several days post op is expected and can be controlled with pain medication

A small bulge in the abdominal wall can be expected

The pump may beep when reservoir is low or the batteries require replacement. Please return for refills every 1-3 months and battery replacement every 4-5 years.

Tone reduction is apparent within several days post op.

Physical therapy must be done in conjunction with the treatment for maximal benefits.

Question 43

What are some possible complications related to intrathecal baclofen?

Answer 43

infection

pump failure

tube kinking

breakage

accidental overdose leading to respiratory weakness, diminished consciousness, death

Question 44

Chemodenervation
- what is it
- what 3 chemicals are widely used for chemodenervation

Answer 44

• use of chemicals to interrupt the flow of nerve impulses to spastic muscles.
• alcohol/phenol; botulinum toxin (BOTOX); lidocaine

Question 45

What is lidocaine used for?

Answer 45

Short term chemodenervation when injected

This may be done to
determine which muscles are contributing most to a spastic deformity, or to assess the likely benefit from
long-term chemodenervation.

Question 46

Botulinum toxin
- how does it prevent spasticity
- benefits
- best used for?
- draw backs

Answer 46

• inject into spastic muscle near nerve terminals; blocks acetylcholine release of some nerve terminals. Overall, reduces force production of target muscle
• adjust dose to provide precise degree of weakness to overcome spasticity while preserving strength of normal function; does not affect muscles for respiration since it is highly targeted; overdose very unlikely; can combine with oral medication and intrathecal baclofen and phenol or alcohol
• Effective for smaller, distal muscles;
• Flu-like symptoms sometimes after injections. Weakness (if given too much), Very expensive. temporary benefits that fade completely after 3-6 months. Must space out treatment as long as possible to decrease possibility of antibody formation

Question 47

Phenol and alcohol
- mechanism of action
- advantages
- disadvantages
- Duration of effectiveness

Answer 47

• destroy nerves that supply spastic muscles; cuts off signals allowing muscle to relax

advantages
- do not provoke reaction by immune system, thus dosage and frequency of dosage is not limited. good for treating large muscles
- inexpensive
- improve ROM

disadvantages
- injection is painful
- surgery may be required to expose target nerve
- damages muscle near injection site alongside the target nerves

Duration of effectiveness
- variable: less than 1 month to more than 2 years