Spasticity

Question 1

Damage to CNS - UMN signs

Negative signs

Answer 1

Negative Signs

• muscle weakness
• loss of motor control/coordination/dexterity
• muscle fatigue

Question 2

positive signs of muscle over activity

Answer 2

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

Question 3

Describe these 5 abnormal movements
Dystonia: 
Chorea:
Athetosis: 
Choreoathetosis: 
Ataxia

Answer 3

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.

Question 4

_____ is described as hypertonia (increased muscle tone) resulting from abnormal spinal processing of proprioceptive input.
Increased Tonic stretch reflex
Velocity-dependent
Dynamic/static

Answer 4

Spasticity:

hypertonia (increased muscle tone) resulting from abnormal spinal processing of proprioceptive input.

Increased Tonic stretch reflex
Velocity-dependent
Dynamic/static

Question 5

Physiology of UMN spinal reflexes

Answer 5

1 Disinhibition of normal stretch reflexes
Phasic from short stretch-DTR or clonus

2. Disinhibited of normal nociceptive reflex
   Flexor withdrawal reflex-flexor spasm

3 Release of normal primitive cutaneous reflexes
Babinski
Positive supporting reflex-extensor spasm

Question 6

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

Answer 6

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

Question 7

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?

Answer 7

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

Question 8

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

Answer 8

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

Question 9

________-continuous muscle contractions without voluntary contraction, obvious spinal tonic or phasic reflex activity, or sensory afferent input
Due to:

Answer 9

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

Question 10

describe a pathological co-contraction

appearance?

Answer 10

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

Question 11

when disinhibition is either not being generated or blocked below

Answer 11

efferent drive.

tonic stretch is a mis-interpretation of input.

Question 12

three clinical etiologies for

1. spinal origin UMN disease
2. Cerebral origin

Answer 12

Spinal Origin
Spinal Cord Injury
Spinal Cord Disease
Multiple Sclerosis
�

Cerebral Origin
Traumatic Brain Injury
Stroke 
Cerebral Palsy
�

Question 13

6 components of evaluating spasticity

Answer 13

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

Question 14

describe the ashworth scale

Answer 14

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

Question 15

describe the modified ashworth scale

Answer 15

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

Question 16

Define the spasm scale (spasm frequency)

what used for?

Answer 16

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

Question 17

4 considerations for spasticity:

Answer 17

Spasticity waxes and wanes
Dynamic vs static tone
Multiple muscle groups may contribute to joint deformity
Patient perception

Question 18

list 7 ways that spasticity may interfere with functioN:

Answer 18

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

Question 19

4 possible advantages of spasticit

Answer 19

Maintains muscle tone
Helps support circulatory function
May prevent formation of deep vein thrombosis
May assist in activities of daily living

Question 20

9 goals of spasticity management

Answer 20

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

Question 21

describe the old step-ladder approach to management of spasticity

Answer 21

1. remove noxious stimuli
2. rehab therapy
3. oral meds
4. neurolysis
5. ortho procedures
6. neurosurgical procedures

Question 22

New approach to treatment of spasticity?

Answer 22

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

Question 23

How does one prevent nociception?

Answer 23

Eliminate the factors that increase sensory input to the spinal cord

Question 24

14 things to treat to reduce noxious stimuli

Answer 24

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

Question 25

9 methods of rehab therapy for spasticity

Answer 25

``` Stretching Weight bearing Cryotherapy Inhibitory casting Vibration of the antagonist Pool therapy EMG biofeedback Electrical stimulation Positioning and rotary movements ```

Question 26

What is sandifer syndrome?

Answer 26

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.

Question 27

advantages (3) and disadvantages (3) of rehab therapy for spasticity

Answer 27

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.

Question 28

Name the most common 7 most common drugs to treat spasticity

Answer 28

``` Baclofen (Lioresal) - Gaba B Gabapentin (Neurotin) - Cal Ch central acting Tizanidine (Zanaflex) Dantolene Sodium (Dantrium) - CCC Clonidine (Catapres) - central Alpha Clonazepam (Klonopin) Gaba A Diazepam (Valium) GAba A ```

Question 29

What is an unwanted side effect of dantrium

Answer 29

raging cystic acne.

Question 30

Which medication is drug of choice in CP kids for spasticity

Answer 30

baclofen careful, decreases seizure threshold

Question 31

Advantages (2) and disadvantages (3) of oral drugs for spasticity

Answer 31

Advantages Non-invasive, not permanent Effective management for some patients Disadvantages Difficult to achieve a steady state Following a schedule may be difficult Side effects: drowsiness, hypotonia, and weakness may limit effectiveness or interfere with function if spasticity is temp dependent may have summer and winter dose of meds

Question 32

4 most common ortho procedures for spasticity

Answer 32

Tenotomy Tendon lengthening Myotomy Tendon transfers - posterior tib causes inversion, will do ant tib transfer - stroke and TBI. Any surgery will ultimately result in weakness. Do not operate if movement d/o or tone isn't controlled

Question 33

Advantages (1) and disadvantages (3) of ortho surgical procedures for spasticity

Answer 33

Advantages Effects usually last a few years Disadvantages Anesthesia risks Non-weightbearing after bony procedures Risk of weakness, decreased function ---------------------------------------------------- Advantages Effects usually last at least a few years, but often need to be repeated. It is thought that other interventions for spasticity management reduce the need for orthopedic interventions, or the need to repeat orthopedic procedures, but controlled studies have yet to be done. Disadvantages Anesthesia risks Non-weightbearing for several weeks after bony procedures, according to most surgeons' postoperative protocols for patient management. Weakness is a problem after some procedures, and is often compounded by the weightbearing restrictions. Risk of decreased function if the patient has a loss of strength, and with a long period of inactivity during recovery from some procedures. Also changes in biomechanical alignment may interfere with functional abilities if a correction was made to a secondary impairment that enabled function.

Question 34

4 neurosurgical treatments for spasticity

Answer 34

Neurectomy Myelotomy Cordectomy *Selective Dorsal Rhizotomy

Question 35

describe how selective dorsal rhizotomy is performed: often performed on kids between ages _____ Usually involves ____ of intensive therapy post-operatively if improved function is goal complication:

Answer 35

Dorsal sensory nerve roots are severed Each rootlet within root is stimulated Abnormally-responding rootlets are severed ``` Examples of abnormal response to rootlet stimulation: Contraction of inappropriate muscle Clonus Prolonged response Can be done “non-selectively” (without stimulating each rootlet) Can be done to improve function or to improve comfort/care Other possible surgical complications: Transient dysrhythmias Fever Bronchospasm Aspiration pneumonia Urinary retention ``` Often performed on children between ages of 4 and 12 years (adults "re wire" so not as helpful" Usually involves 6-12 months of intensive therapy post-operatively if improved function is goal Complications include possible sensory loss

Question 36

Advantages (2) and disadvantages (3) for selective dorsal rhizotomy

Answer 36

dvantages Permanent – one-time procedure (kids) Evidence for efficacy in reducing spasticity and improving function in children with spastic diplegia Disadvantages Permanent – may need spasticity Potential adverse effects: spinal, sensory Not effective for dystonia

Question 37

groups who would benefit from ITB therapy

Answer 37

``` Used to treat individuals with severe spasticity due to Cerebral palsy Brain injury Stroke Spinal cord injury Multiple sclerosis ``` recall: spine vs cerebral cause: know which you are treating b'c trial, placement of catheter, and changes in doses are different

Question 38

Indications for ITB therapy (3)

Answer 38

1. Patients with spasticity of spinal origin: unresponsive to oral antispasmodics and/or experience unacceptable side effects at effective doses of oral baclofen 2. Patients with spasticity of cerebral origin should be one year post brain injury to be considered for ITB Therapy 3. Patients must demonstrate a positive response to the screening test

Question 39

Synchromed infusion system is made up of:

Answer 39

1. Pump - infuses drug at programmedrate 2. Catheter - delivers drug to theintrathecal (subarachnoid) space of the spinal cord 3. Programmer- allows for precise dosing. easily adjustable dosing

Question 40

How does intrathecal baclofen work?

Answer 40

GABAb receptor agonist | Reduces excitatory input to the alpha motor neuron

Question 41

``` Pharmacokinetics of baclofen: Intrathecal 600mcg/day dose: _____ IT lumbar concentration Lumbar to cervical concentration ratio: Therapeutic dose is: Half life: ``` Oral: 60mg dose: ______ IT lumbar concentration Half life

Answer 41

``` Intrathecal 600 mcg/day dose: 1.24 mcg/mL IT lumbar concentration Lumbar to cervical concentration is 4:1 Therapeutic dose is 1/100 of oral Half-life 4-5 hours ``` Oral 60 mg dose: 0.024 mcg/mL IT lumbar concentration Half-life 3-4 hours

Question 42

Why is nausea less of a side effect profile in IT med form

Answer 42

IT vs oral -- gravity keeps medicine concentrated in the spine as opposed to the brain - less sedating and causal of nausea

Question 43

4 stages of ITB therapy process

Answer 43

Stage 1: Patient Selection Stage 2: Screening Test Stage 3: Implant Stage 4: Maintenance

Question 44

stages of patient selection for ITB therapy - 6

Answer 44

Conduct complete patient history and physical exam Evaluate patient’s spasticity, spasms/clonus, strength Assess orthotic and other equipment needs Assess patient’s independence and functional status Determine oral antispasmodic use Assess potential barriers to long-term compliance including social support structure

Question 45

Inclusion (4) and exclusion (2) criteria of patients for ITB therapy

Answer 45

``` Step A - Include Severe spasticity > 4 years of age and enough body mass to support the system Appropriate, agreed-upon goals Patient/family motivation ``` Step B - Exclude Infection Allergy to baclofen

Question 46

Use ITB therapy cautiously in patients who: 7

Answer 46

``` Use ITB Therapy cautiously in patients who: Need spasticity to sustain upright posture and balance in locomotion Have impaired renal function Are pregnant or breastfeeding Have a history of autonomic dysreflexia Have a psychotic disorder Use CNS depressants and/or alcohol Have a history of uncontrolled seizures ```

Question 47

what are some unwanted effects of screening trial? | 2

Answer 47

Discuss possibility of hypotonia (flaccidity) during screening test Withdraw patient from oral antispasmodics to avoid risk of overdose or uncomfortable side effects (no meds from bedtime on or occasionally after midnight) evaluate tone and spasms prior to trial - use ashworth and spasm scale

Question 48

Describe the screening test flow chart:

Answer 48

1. bolus 50mcg (will get + or - response) 2. if - response after 24h, give 75mcg bolus (will get + or - response) 3. If - response after 24h, give 100mcg bolus (will get + or - response) 4. If - response persists, not a candidate. If dystonic, harder to treat with ITB - will need 100mcg trial at least. May need to perform continuous 3 day trial in hospital.

Question 49

onset of action for intrathecal baclofen based on bolus

Answer 49

Onset ½ - 1 hour after bolus Peak 4 hours after bolus Duration 4 - 8 hours after bolus perform ashworth and spasms scale at beginning and after 4h

Question 50

describe continuous baclofen screening trial

Answer 50

Intrathecal catheter to an external pump Effects first seen at 6 to 8 hours after initiation of continuous infusion Increase dose by 50ug every 8 hours Maximal effect observed in 24 to 48 hours

Question 51

ashworth score changes during ITB screening trial

Answer 51

1-point drop for cerebral origin spasticity | 2-point drop for spinal origin spasticity

Question 52

Why is duration of improvement important during screening trial of spasticity

Answer 52

need to know how long it will last. if ~10-14h, pt is sensitive. if lasts 12h, starting dose is screening dose.

Question 53

titration period of ITB after pump placement: After first 24 period: Increase once every ______ until desired clinical effect is achieved. Adults with spasticity of spinal origin: Adults with spasticity of cerebral origin: Peds:

Answer 53

After First 24-Hour Period Increase dose slowly Increase only once every 24 hours until desired clinical effect achieved Adults with spasticity of spinal origin 10-30% increments Adults with spasticity of cerebral origin 5-15% increments Pediatrics 5-15% increments (must decide spasticity vs dystonia)

Question 54

Goals of titration period of ITB?

Answer 54

To Achieve Greatest therapeutic effect Lowest possible dose Minimal systemic side effects

Question 55

3 benefits of pump programmability

Answer 55

Doses can be tailored to match patient needs Lowest effective dose Doses can be changed noninvasively

Question 56

Common side effects of ITB: 5 Although rare overdose may lead to: 4 ______ and _____ may occur

Answer 56

Common side effects: hypotonia, somnolence, nausea/vomiting, headache, dizziness *** can get headache after dose increase. If does not go away in 3 days, should decrease dose. **** Overdose, although rare, could lead to respiratory depression, loss of consciousness, reversible coma, and in extreme cases, may be life-threatening Catheter and procedural complications may occur

Question 57

advantages (5) and disadvantages (3) of ITB therapy

Answer 57

Advantages Reversible (refill with saline) Non-invasive programmability Potential for fewer side effects than oral drugs Evidence to support efficacy in reducing spasticity May improve function, comfort and care Disadvantages Complications: infection, catheter problems, overdose, baclofen withdrawal Refills – variable interval every month to six months Cost

Question 58

What is the minimal flow rate to maintain patency

Answer 58

0.04mcg

Question 59

IF needing to replace baclofen in catheter in ED, up to ____% of total daily dose can be bolused

Answer 59

25% go into cont gtt screening mode. Recall, should start seeing effects at 1h.

Question 60

Describe injection therapy for spasticity: Diagnostic: Neurolytic

Answer 60

Diagnostic: - lidocaine - bupivacaine neurolytic - ethanol - phenol also BOTOX

Question 61

BOTOX for spasticity | 5 advantages

Answer 61

``` Can be administered without anesthesia No systemic effect diffuses readily into the muscle Facilitates treatment goals Effects are local and dose-dependent Can be used with other therapies including ITB Therapy ```

Question 62

Mechanism of action of botox: | indications: 8

Answer 62

Mechanism of Action Acts pre-synaptic at the nerve terminal too prevent acetylcholine release Available as toxin A or B Clinical Indications Strabismus, blepharospasm, spasticity, dystonia, spasmotic dysphonia, writer’s cramp, tremor, torticollis

Question 63

Recommended dosing of Botox A

Answer 63

12 U/kg up to a max 400 U total dose in a three month period of time 50 U maximum dose per injection site Number of injection sites per muscle depends on muscle size and ease of access

Question 64

Botox efficacy: 1. onset: 2. Peak: 3. Duratio:

Answer 64

1. 24-72h 2. Peak at 2 weeks 3. duration 3-8 months

Question 65

Botox A complications and adverse side effects 4

Answer 65

Flu-like illness with fever for 1-3 days Weakness and temporary loss of function Temporary pain Local irritation and bruising

Question 66

5 positive effects of Botox

Answer 66

Decrease spasticity scores Improve range of motion Improve functional status Decrease spasticity/tone in non-injected limbs Increase muscle length with decrease contracture formation

Question 67

muscles spastic in clenched fist

Answer 67

FDS | FDP

Question 68

muscle for botox in 1. equinovarus (3) 2, varus (2)

Answer 68

Equinovarus gastrocnemius soleus tibialis posterior Varus tibialis anterior EHL