Spasticity Flashcards
Damage to CNS - UMN signs
Negative signs
Negative Signs
- muscle weakness
- loss of motor control/coordination/dexterity
- muscle fatigue
positive signs of muscle over activity
Positive signs of muscle over activity:
Exaggerated spinal reflexes
-Stretch-deep tendon
-Nociceptive-flexor or extensor spasms
-Cutaneous- Babinski
Efferent Drive
Disordered Control-Co-contraction
Involuntary movements
-Spasticity
-Dystonia
-Athetosis
-Ataxia
Describe these 5 abnormal movements
Dystonia:
Chorea:
Athetosis:
Choreoathetosis:
Ataxia
Dystonia: Abnormal posturing, twisting, or repetitive movements
Chorea:Abrupt, quick jerky dance-like movements
Athetosis: Writhing, distal movements
Choreoathetosis:Combination of both chorea and athetosis
Ataxia:Flailing movements, wide-based gait
Not everything that is an abnormal movement pattern is spasticity, and therefore will not respond as well to current treatments for spasticity.
Dystonia is characterized by sustained abnormal posturing, twisting, or repetitive movements. Underlying co-contraction of agonist and antagonist muscles occurs.
Chorea is characterized by abrupt, quick jerky movements of the head, neck, arms, or legs. These movements may resemble a strange dance.
Athetosis is characterized by slow, writhing movements, most often in the distal extremities.
Choreoathetosis, as the name implies, is a combination of chorea and athetosis. It may appear as involuntary, purposeless movements.
Dystonia, chorea, athetosis, and choreoathetosis are related to disturbances in the motor circuit involving the cortex, thalamus, and basal ganglia.
Ataxia refers to awkward, unsteady gait and balance. Patients with ataxia have a wide-based gait. Ataxia is usually associated with damage to the cerebellum or brainstem.
The above is not an exhaustive list. For example, some patients may have tremor. Others may have hemiballismus (violent, large-amplitude, proximal limb movements).
Patients may have more than one of these disorders. They may also have spasticity and one or more movement disorders.
_____ is described as hypertonia (increased muscle tone) resulting from abnormal spinal processing of proprioceptive input.
Increased Tonic stretch reflex
Velocity-dependent
Dynamic/static
Spasticity:
hypertonia (increased muscle tone) resulting from abnormal spinal processing of proprioceptive input.
Increased Tonic stretch reflex
Velocity-dependent
Dynamic/static
Physiology of UMN spinal reflexes
1 Disinhibition of normal stretch reflexes
Phasic from short stretch-DTR or clonus
- Disinhibited of normal nociceptive reflex
Flexor withdrawal reflex-flexor spasm
3 Release of normal primitive cutaneous reflexes
Babinski
Positive supporting reflex-extensor spasm
In a normal person there is little to no muscle contraction in a passively stretched limb even at fast rates
Resistance is primarily due to: 2
In a normal person there is little to no muscle contraction in a passively stretched limb even at fast rates
Resistance is primarily due to biomechanical factors
Elastic tissue properties
Joints, blood vessels, muscles, etc
With spasticity there is a lot of muscle contraction activity with stretch even at slow rates due to
Muscle activity increases with speed of stretch: AKA?
Activity may or may not stop with release of stretch: AKA?
With spasticity there is a lot of muscle contraction activity with stretch even at slow rates due to increase tonic stretch reflex
Muscle activity increases with speed of stretch—velocity dependent
Activity may or may not stop with release of stretch—dynamic/static
Passive sustained stretch of the muscle excites ________ sending impulses back to the spinal cord which responds with an enhanced tonic stretch reflex causing additional muscle contraction
Passive sustained stretch of the muscle excites the muscle spindle Ia afferents sending impulses back to the spinal cord which responds with an enhanced tonic stretch reflex causing additional muscle contraction
** most of tonic reflex is generated by spindle activity
________-continuous muscle contractions without voluntary contraction, obvious spinal tonic or phasic reflex activity, or sensory afferent input
Due to:
EFFERENT DRIVE — Spastic Dystonia-continuous muscle contractions without voluntary contraction, obvious spinal tonic or phasic reflex activity, or sensory afferent input
Due to tonic supraspinal drive to the AHC (anterior horn cell)
(dont confuse with BG disease) has sustained resistance to being moved.
EMG: quiet - contracture. loud - efferent drive
describe a pathological co-contraction
appearance?
Simultaneous contraction of agonist and antagonist due to reduced reciprocal inhibition
Appearance of weakness due to excessive reciprocal inhibition
REALOGIC - change in muscle fibers and skin in joint capsule to long term spasticity can lead to contracture. Check for UMN signs and clonus which are not present in other movement disorders
when disinhibition is either not being generated or blocked below
efferent drive.
tonic stretch is a mis-interpretation of input.
three clinical etiologies for
1. spinal origin UMN disease
2. Cerebral origin
Spinal Origin
Spinal Cord Injury
Spinal Cord Disease
Multiple Sclerosis
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Cerebral Origin
Traumatic Brain Injury
Stroke
Cerebral Palsy
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6 components of evaluating spasticity
ROM
Strength/Selective Motor Control (inability to raise one leg instead of two)
Ashworth and Modified Ashworth Score for tone
Spasm and Reflex Scales
Gait Study
Functional Outcome Measures
describe the ashworth scale
1 - no increase in tone
2. slight increase in tone
3. marked increase in tone but affected parts easily flexed
4. considerable increase in tone; passive movement difficult
5. affected parts rigid in flexion or extension
describe the modified ashworth scale
0 no increase in tone
1 slight increase in tone (catch and release at end of ROM)
1+ slight increase in tone, manifested by a catch, followed by minimal resistance throughout remained (less than half of the ROM)
2 marked increase in tone through most of ROM but affected parts easily moved
3. considerable increase in tone; passive movement difficult
4 affected parts rigid in flexion or extension
Define the spasm scale (spasm frequency)
what used for?
ITB trials
0 no spasms
1 no spontaneous spasms (except vigorous stimulation)
2 occasional spontaneous spasms easily induced
3. >1 but 10 spontaneous spasms/hr
4 considerations for spasticity:
Spasticity waxes and wanes
Dynamic vs static tone
Multiple muscle groups may contribute to joint deformity
Patient perception
An individual’s spasticity may vary depending on the time of day, their stress level, illness, fatigue, and emotional state.
Remember that while an individual’s static evaluation of spasticity may not be significant, a patient may demonstrate dynamic spasticity that severely limits functional capabilities.
Dynamic: Muscle imbalance across a joint while performing a functional task. Interpretation requires awareness of multi-system nature of such tasks.
Static: Passive testing of muscle tone at a single joint level
Thoroughly assess which muscle groups are contributing to joint contractures: e.g., many smaller muscles in the lower extremity are overlooked as contributors to an equinovarus deformity (extensor hallicus longus, toe extensors, and anterior tibialis). Spasticity patterns are not always typical.
Always consider the patient’s perception of his or her spasticity. If the patient doesn’t perceive the spasticity as a problem, then treatment may not be required.
list 7 ways that spasticity may interfere with functioN:
Mobility
Hygiene
Self-care
Exercise
Joint Range of Motion
May cause pain and sleep disturbance
Can make patient care more difficult or increase caregiver time
4 possible advantages of spasticit
Maintains muscle tone
Helps support circulatory function
May prevent formation of deep vein thrombosis
May assist in activities of daily living
9 goals of spasticity management
Reduce spasticity
Improve functional ability and independence
Decrease pain associated with spasticity
Prevent or decrease incidence of contractures
Facilitate hygiene
Improve orthotic fit
Decrease burden of care
Improve positioning
Delay or prevent surgery
describe the old step-ladder approach to management of spasticity
- remove noxious stimuli
- rehab therapy
- oral meds
- neurolysis
- ortho procedures
- neurosurgical procedures
New approach to treatment of spasticity?
Discuss patient issues ad decide what actually needs to be addressed.
Then there is a “spectrum of care” for management including:
Prevent nociception
ITB
oral drugs
injection therapy
neurosurgical treatments
ortho treatment
rehab therapy
How does one prevent nociception?
Eliminate the factors that increase sensory input to the spinal cord
14 things to treat to reduce noxious stimuli
GERD
Ingrown nails
Restrictive clothing
Fatigue
Psychological factors
Change in temperature or humidity
Musculoskeletal Pain
Infection
Stones
Menses
Constipation/impaction
Deep vein thrombosis
Pressure Ulcers
Progression of disease
9 methods of rehab therapy for spasticity
Stretching
Weight bearing
Cryotherapy
Inhibitory casting
Vibration of the antagonist
Pool therapy
EMG biofeedback
Electrical stimulation
Positioning and rotary movements
What is sandifer syndrome?
pediatric medical disorder characteried by GI symptoms and neuro features. s/s include spasmodic torticollis, and dystonia. Can also have severe hypotonia. Onset is usually confined to infancy and early childhood. peak prevalence at 18-36 months.
spasms last for 1-3 minutes and may occur up to 10 times per day. ingestion of food is often associated with symptoms.
advantages (3) and disadvantages (3) of rehab therapy for spasticity
Advantages
Rehabilitation interventions are not invasive.
Active participation of patient and/or family is encouraged, and often critical to success.
Emphasis on functional gains has become increasingly important.
Disadvantages
Casting, orthoses, positioning: may put skin integrity at risk.
Costs of treatments and equipment are sometimes prohibitive.
Intervention often requires motivation & patient participation, especially for functional gains and for motor learning to occur.
