Spasticity assessment and management Flashcards
what would you include in the subjective assessment regarding patient’s condition?
- impact on patient e.g., pain, sleep, function
- frequency and severity
what factors would you check for and ask about in the subjective assessment?
- any aggravating or easing factors
- check for exacerbating factors
what details do you need to know about medication?
- type
- frequency
- effectiveness
-side effects
what should you look at regarding medical history?
- previous spasticity management
- was this effective?
what are the 6 exacerbating factors?
- pain/ discomfort
- infection e.g., UTI, chest infection
- constipation
- poor postural management
- in growing toenail
- pressure sores
what are the 9 assessments you would complete in an objective assessment?
- posture
- AROM/PROM
- strength
- sensation
- co-ordination
- reflexes
- tone
- balance
- function
what is the main scale used for assessment of spasticity?
- modified Ashworth scale
what is the MAS scores meaning?
0= no increase in muscle tone
1= slight increase in tone, manifested by catch and release at the end of ROM
1+= slight increase in tone, manifested by a catch, followed by minimal resistance throughout the remainder of range
2= marked increase in tone throughout most of range, still easily moved
3= considerable increase in tone, passive movement difficult
4= affects part(s) rigid in flexion/ extension
how do you test spasticity?
- inner to outer range
- assess slowly at first to assess PROM available
- then move limb more quickly to assess spasticity
what is the other scale used to measure spasticity? when it is commonly used?
- modified Tardieu scale
- commonly used in children with spasticity- type cerebral palsy
what does the MTS involve?
- ankle moved into dorsiflexion
- knee moved into extension
what does R1 and R2 represent in the MTS?
R1= angle of muscle response (catch) as joint is moved at the fastest velocity possible
R2= angle of muscle response (end range) at the slowest velocity possible
what does the difference between R1 and R2 indicate? what does a large difference show?
- difference between R1 and R2 indicates the relative contribution of spasticity versus contracture
- large difference shows more spasticity whereas small difference shows contracture
what are the 9 contra- indications and cautions for testing spasticity?
- haemophilia
- osteoporosis
- fracture
- joint instability
- severe pain
- osteomyelitis
- acute joint infection
- DVT
- flaccidity
what are the two things that treating spasticity reduces?
- reduces pain
- reduces carer burden
what are the two factors that treating spasticity improves?
- improves functional activity e.g., gait, transfers, UL function
- improves passive activity e.g., improve ROM for care tasks
what does treating spasticity help to maintain? (3)
- maintains skin hygiene/ integrity
- maintains seating and positioning
- maintains current ROM/ activity status
what does treating spasticity support?
- supports other interventions e.g., physiotherapy/ orthotics with the benefits it brings
how does spasticity relate to the ICF model level of impairment? (3 problems)
- muscle spasms
- abnormal trunk and limb posture
- pain
what is the effect of muscle spasms? (3)
- pain
- difficulty with seating and posture
- fatigue
what is the effect of abnormal trunk and limb posture? (3)
- contractures
- limb deformity
- pressure ulcers/ other tissue viability problems
what is the effect of pain from spasticity? (2)
- distress and low mood
- poor sleep patterns
what are the two problems that arise on the activity level of ICF regarding spasticity?
- loss of active function
- loss of passive function
what effect does active function loss have? (3)
- reduced mobility and dexterity
- difficulty with sexual intercourse
- difficulty with continence
what effect does passive function loss have? (3)
- difficulty with care and hygiene
- increased carer burden
- difficulty with wheelchair seating or bed positioning
how does the participation level of ICF relate to spasticity? (1)
- impact of muscle spasms, loss of active function, etc
what are the 4 ways that lack of participation due to spasticity effect the patient?
- poor self- esteem/ self- image
- reduced social interaction
- impact on family relationships
- impact on work
what are the three factors that treatment should be focused on?
- focused on a goal
- focused on independent functions
- focused on improvement or maintenance
when would you not treat spasticity?
- when extensor activity in lower limbs may be helpful for transfers so reducing spasticity may cause a loss of function for the patient
what should you discuss with the patient before treating spasticity? what should you explain?
- discuss the balance between the benefits and harms of treating spasticity
- explain that some people use their spasticity to maintain their posture and ability to stand, walk or transfer in which muscle relaxants will adversely affect this
what is spasticity useful for and why would you not treat in this case? (2)
- may be useful for function or circulation
what is the medication used to treat focal/ multi- focal spasticity?
- botulinum toxin
is there evidence of botulinum toxin effect?
- evidence that it is safe and effective for treating upper and lower limb spasticity for both active and passive goals
what effect does botulinum toxin have?
- only has a temporary effect
how does botulinum toxin work?
- works by blocking the vesicle- dependent release of acetylcholine and other neurotransmitters from the presynaptic nerve terminal at the neuromuscular junction
what does botulinum toxin result in?
- results in partial and temporary muscle weakness in the treated muscles
what is suggested before BoNT- A is used? (3)
- all aggravating factors have been addressed
- an appropriate physical management programme is in place
- suitable programme of ongoing appropriate management is planned
what should all botulinum toxin injections be accompanied by?
- formals assessment outcome
what review should the therapist do after the injection? when should this be done?
- therapist review in 7-14 days for assessment
- and if necessary orthotics/ splinting
when do the MDT review the patient after the injections?
- MDT review at 4-6 weeks to assess effect and patient status
- also review at 3-4 months to plan future management
what does follow up MDT review after injection vary due to? (3)
- re- injection intervals
- trajectory
- types of goals
what is used to treat regional spasticity?
- nerve blocks
what is an example of a nerve block?
- phenol
what is phenol?
- long- acting, local neurolytic agent which denatures protein causing tissues necrosis
what is the effect of phenol dependent on? (2)
- dependent on volume and concentration
what are the potential side effects of phenol?
- sensory symptoms e.g., pain
what is intrathecal baclofen?
- manages severe spasticity of cerebral or spinal origin
- reduces muscle hyperactivity
do intrathecal baclofen have more side effects than oral medication?
- intrathecal baclofen has less CNS side effects than oral medications e.g., fatigue
what do patients receive before implementation of intrathecal baclofen?
- patients receive a test dose so patient and clinician can evaluate potential effects
how is intrathecal baclofen administered?
- medication delivered directly to intrathecal space via implanted pump
what needs to happen to the pump of intrathecal baclofen regularly?
- needs to be refilled
what are the two many surgery options?
- selective dorsal rhizotomy
- orthopaedic surgery
what does SDR stand for? what is it used for?
- selective dorsal rhizotomy
- used to reduce spasticity in children with cerebral palsy with benefit to impairment and function
what does orthopaedic surgeries involve? (3)
-muscle lengthening
- tendon transfers
- multi- level surgery
what is the response to treatment?
- variable
- takes time to optimise
what do you need to regularly do with the management plan?
- reassess and review chosen measures
- adequate follow up is essential to ensure treatment meets the needs and goals of the individual patient
what should you consider when handling a patient?
- consider patient’s position
- comfort
- support
- surface area
what should the therapist’s hand be when handling patient? how should the therapist be?
- should have warm hands
- therapist should be calm
how do you handle the limb?
- cradle the limb with the whole han
what speed should you complete handling in?
- slow supportive handling to try and reduce spasticity
what should individuals at risk of contracture/ loss of joint range receive? what does it provide?
- receive interventions e.g., splints, casts or positioning
- to provide passive stretch of sufficient duration and intensity where there is stull potential for reversibility
what does postural management/ 24 hour positioning enhance? (4)
- comfort
- respiration
- communication
- visual ability
what does postural management reduce? (3)
- pressure sores
- adaptive muscle shortening
- pain
what are the three factors we need to consider in postural management/ 24 hour positioning?
- positions across the day e.g., for sleep, for eating
- is position for rest or activity?
- 24 hour approach required
when is splinting/ orthotics used?
- for function e.g., AFOs for standing/ walking
- at rest e.g., resting hand splint
when is splinting/ orthotics effective?
- improves effectiveness of chemo denervation (botulinum toxin injections)
what does the COT & ACPIN guidelines cover?
- cover splinting (thermoplastic) and (serial) casting fibreglass casting tape or plaster of paris
what did the COT and ACPIN guidelines suggest about ankle casts?
- ankles casts are used with botulinum toxin (in people with stroke and ABI) to improve ROM when there is clinically significant spasticity
what do ankle splints prevent?
- prevents loss of ROM at the ankle when positioning at PG (for people with stroke)
should splints be used for the upper limb?
- for upper limb, splints should not be used routinely to prevent loss of ROM in the writs/ hand (for people with stroke and ABI), but maybe beneficial in some cases
what does weight bearing help with?
- helps normalise tone
what should weight bearing be considered for?
- considered for both upper and lower limb spasticity
what is a good option for lower limb spasticity?
- standing frames can be a good option for lower limb spasticity as well as providing other benefits
how do you improve activity performance and motor control?
- improve activity performance by task practice training
- repetitive practice
what is functions electrical stimulation used for? (2)
- used to activate muscles
- used for upper limb/ lower limb
what is FES most effective for?
- most effective for people with UMNLs
what is there good evidence for regarding FES?
- good evidence base for effectiveness of addressing dropped foot
what do the National Stroke Guidelines advise about treatment for spasticity?
- people with spasticity in the upper or lower limbs after stroke should not be treated with electrical stimulation
what should people with spasticity in wrist/ fingers be considered for?
- considered for ES after injection to maintain ROM and/ or to provide regular stretching as an adjunct to splinting or when splinting is not tolerated
what are some outcome measures? (7)
- pain scale
- spasm frequency scale
- ArmA (arm activity measure)
- LegA (leg activity measure)
- AARS (associated reaction rating scale)
- SQoL- 6D (spasticity related quality of life tool)
- GAS (goal attainment scaling)
what do objective measures alone fail to identify?
- fail to identify the complexity of spasticity
