Characterization and Treatment Considerations

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Spasticity:

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Year Book Medical Pubs. Young RR. 1980: pp. resulting from hyperexcitability of the stretch reflex.Definition of Spasticity Velocity-dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks. Chicago.1 1 Lance JW. Koella WP (eds) Spasticity: Disordered Motor Control. as one component of the upper motor neuron syndrome. 485-94 . Symposium synopsis. In Feldman RG.

clonus. flexor/extensor spasm. fatigability. dystonia.3 Positive Symptoms4 Negative Symptoms4 Characterization Examples Muscle overactivity Spasticity.ClinOrthop Relat Res 1987. 9:332-40 Young RR . paralysis. Drugs Aging 1996. weakness. Arch Phys Med Rehabil 1989. and slowness of movement 2 3 4 Katz RT. Spastic hypertonia: mechanisms and measurement. Seeberger LC. 50-62 . Smith DB. Epidemiology and optimal treatment. 70:144-55 O'Brien CF.Upper Motor Neuron Syndrome A group of symptoms that may be caused by damage or injury to motor neuron pathways or brain regions that control movement2. Spasticity.Wiegner AW. and rigidity Muscle underactivity Decreased dexterity. hyper-reflexia. Spasticity after stroke. Rymer WZ.

12:27-35 Gracies JM. McGuire J. local motor disturbance affecting a single body part Motor disturbance involving a large region of the body Regional Generalized Motor disturbance involving widespread bodily regions 5 6 Esquenazi A. Falls and fractures in older post-stroke patients with spasticity: consequences and drug treatment considerations.Classification of Spasticity Classification of Spasticity According to Distribution of Affected Body Regions5. 6:S92-120 .Muscle Nerve Suppl 1997. Simpson DM.6 Distribution Definition Focal Isolated. Part II: General and regional treatments. Elovic E. Traditional pharmacological treatments for spasticity. Clin Geriatr 2004. Nance P.

wemove. or inability to sleep 34. Available at: http://www. most patients rated stiffness and limited range of motion as having the most substantial negative impact on their quality of life8 Limitations in activities of daily living 23.pdf. Accessed March 26.8 7 8 O'Brien CF. Treatment of spasticity with botulinum toxin. 2008. pain. Clin J Pain 2002. 2009 . Profile of Patients with Spasticity.org/reports/spasticity_2008. 18:S182-90 WE MOVE.0% • In a recent survey.5% Stiffness/ limited range of motion 42.Signs and Symptoms of Spasticity • Patients with spasticity may experience a range of sensations in the affected limbs7 – Mild muscle stiffness – Painful muscle contractures and spasms Abnormal posture.5% Percentage of 810 patients with spasticity who identified each aspect of their condition as having the most significant impact on quality of life.

Common Limb Deformities in Upper Limb Spasticity In the adducted/internally rotated shoulder. the arm is held closely against the side. causing more-severe angle flexion. . The flexed elbow is bent into flexion and this posture may dramatically worsen with ambulation. Flexion of the wrist is caused by hypertonicity of the wrist flexor muscles that seem to easily overpower their antagonists of wrist extension. with the forearm applied across the front of the chest. elbow bent. so that this is the most common attitude.

Common Limb Deformities in Upper Limb Spasticity Pronation of the forearm seems to be more commonly encountered than supination after central nervous system injury. In those with thumbin-palm deformity. . the fingers are tightly flexed into the palm. the thumb is held fixed within the palm with its distal aspect flexed. This can lead to poor palmar hygiene and pain with finger manipulation. In those with clenched fist. The thumb is limited in its use as a result of the abnormal posture.

htm. Eur J Neurol 2008. Stroke facts and statistics. Borg J. Accessed April 7.gov/stroke/stroke_facts. 2009 10 Lundstrom E.Major Causes of Spasticity in Adults • Stroke • Multiple sclerosis Affects 795. Prevalence of disabling spasticity 1 year after first-ever stroke. Terent A.cdc. 15:533-9 .000 Americans annually9 % with spasticity10 10% Upper and lower limb • Spinal cord injury • Traumatic brain injury • Adult cerebral palsy 7% 1% Upper limb only Lower limb only 9 Centers for Disease Control and Prevention. Available at: http://www.

Methods of Spasticity Assessment11 • Physiologic measures such as overall excitability of a motor neuron pool or the shortening of muscle cells that are under spastic control. • Quality of life measures that assess patient satisfaction and perceived importance of spasticity treatment. • Passive activity measures such as Ashworth scale and passive range of motion. Zafonte R. Outcome assessment for spasticity management in the patient with traumatic brain injury: the state of the art. 11 Elovic EP. • Functional measures such as the Functional Independence Measure and the Disability Assessment Scale (DAS) and measures of pain. • Voluntary activity measure such as the Fugl-Meyer test and the Nine Hole Peg Test. J Head Trauma Rehabil 2004. 19:155-77 . Simone LK.

Zafonte R. and/or infection. ease of cleaning and nail trimming. 67:206-7 14 Brashear A. Arch Phys Med Rehabil 2002. ulceration.Methods of Spasticity Assessment: Examples Ashworth Scale12 Grade Description Disability Assessment Scale14 Domain Description 0 1 2 3 4 No increase in muscle tone Slight increase in tone – a catch and release at the end of the range of motion More marked increase in tone through most of range Considerable increase in tone. Phys Ther 1987. Preliminary trial of carisoprodol in multiple sclerosis.Corcoran M. passive movement difficult Affected parts rigid in flexion or extension Hygiene Extent of palm maceration. Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Practitioner 1964. followed by minimal resistance in remainder of range) to differentiate the catch that is felt in some patients when limbs are passively moved. 192:540-2 Bohannon RW. 83:1349-54 10 . discomfort and interference of upper limb pain in patient’s life Scores: 0 = no functional disability 1 = mild 2 = moderate 3 = severe Dressing Limb Posture Pain The modified Ashworth scale incorporates a 1+ (Slight increase in tone – catch. effect of hygiene related disability in patient’s life Ability to put on clothing. palm cleanliness.13 12 13 Ashworth B.and intrarater reliability of the Ashworth Scale and the Disability Assessment Scale in patients with upper-limb poststroke spasticity. effect of dressing-related disability due to upper-limb spasticity on patient’s life Psychological and/or social interference that the limb’s posture has in the patient’s life Intensity of pain. Inter. et al.

Hicks AL.Problems That May Be Associated With Spasticity15-18 • Pain • Increased risk of falls • Contracture • Fatigue • Functional limitations (hygiene. Childers MK. Esquenazi A. Management of spasticity in stroke. Ward AB. Common patterns of clinical motor dysfunction. J Rehabil Med 2009. et al. Arch Phys Med Rehabil 2007. Erztgaard P. 6:S21-35 Adams MM. Br Med Bull 2000. 41:13-25 18 Bhakta BB. European consensus table on the use of botulinum toxin type A in adult spasticity. 56:476-85 . 88:1185-92 17 Wissel J. Ginis KA.Muscle Nerve Suppl 1997. dressing. transfers) • Pressure sores • Skin maceration • Poor orthotic fit • Diminished self image due to abnormal limb posture 15 16 Mayer NH. The spinal cord injury spasticity evaluation tool: development and evaluation.

. Muscle Nerve Suppl 1997.Decision to Treat Spasticity Factors to Consider in Spasticity Treatment19 • Chronicity of spasticity • Severity of spasticity • Distribution of spasticity • Locus of central injury or damage • Patient co-morbidities • Availability of care and support 19 Gormley ME. Yablon SA. Jr. A clinical overview of treatment decisions in the management of spasticity. O'Brien CF. 6:S14-20 .

Major Classes of Treatment Goals with Examples of Each 19. hygiene) • Reduce pain • Enhance ease of care • Improve limb position (cosmesis) • Improve gait Functional Objectives Preventive Objectives • Prevent contracture • Prevent skin maceration • Prevent skin ulcers 19 Gormley ME.Treatment Goals The inclusion of patients and caregivers in the discussion of goals is critical because patient and physician goals do not always coincide. 6:S14-20 20 Barnes MP. 20 Technical Objectives • Increase range of motion • Reduce tone • Reduce spasm • Improve activities of daily living (e. 47:295-9 . Jr. dressing.g. A clinical overview of treatment decisions in the management of spasticity... Spasticity: a rehabilitation challenge in the elderly. Gerontology 2001. Muscle Nerve Suppl 1997. O'Brien CF. Yablon SA.

social worker) 21 Adams MM. Hicks AL. 43:577-86 .Spasticity Management Team21 • Physicians • Rehabilitation nurses • Allied healthcare professionals (physical therapists. orthotics clinic. counseling. occupational therapists. Spinal Cord 2005. Spasticity after spinal cord injury. gait lab. speech therapists) • Family and other caregivers • Coordinator/administrator • Other (wheelchair clinic.

and are generally caused by marked overactivity of the flexor muscles • Left untreated. or other conditions – May be focal. pain. trauma to the brain or spinal cord. cerebral palsy. spasticity may result in permanent contracture of muscle and soft tissue. leading to increasing disability. debilitating consequence of upper motor neuron lesions – May result from stroke. or general in distribution • Common clinical patterns of spasticity are identifiable across etiologies. regional. and deformity .Summary • Spasticity is a distressing. multiple sclerosis.

Summary • Thorough assessment of the patient’s condition is essential in determining whether to treat spasticity. it is best approached as a multidisciplinary endeavor . for developing a treatment plan. goals should be identified in consultation with the patient and caregiver or family • When spasticity is treated. and for gauging treatment progress • Prior to treatment of spasticity.

Inc. CA 92612 APC90SB10 April 2010 17 . Irvine.© 2010 Allergan.

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