tbi and spasticity - brain injury association of maryland · tbi and spasticity angie davis, pt,...
TRANSCRIPT
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TBI and SpasticityAngie Davis, PT, MHS, NCS; Dan Gladmon, PT, MPT; Michael A. Dimyan, MD
University of Maryland Rehabilitation and Orthopedics Institute
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Learning Objectives
After completing this session, you will be able to:
• Define spasticity and describe its underlying
pathophysiology
• Analyze both positive and negative effects of spasticity on
function in patients with neurologic disorders
• Describe salient outcomes measures used to assess
spasticity
• Discuss medical interventions utilized in the management
of spasticity
• Identify evidence-based therapeutic interventions
employed in spasticity management, including serial
casting
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Spasticity Defined
Lance 1980
“One component of the upper motor neuron syndrome
which is characterized by a velocity dependent increase in
the tonic stretch reflexes.”
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Spasticity and the ICF Model
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Upper Motor Neuron Syndrome
Positive Signs (excessive
normal resting state)
Negative Signs (less than
normal resting state)
Spasticity Lack of strength
Rigidity Lack of motor control
Hyperreflexia Lack of coordination
Primitive reflexes
Clonus
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Pathophysiology of Spasticityshutterstock.com
• Not fully understood
• Imbalance of inhibitory
and excitatory inputs
resulting in over-activity
of the alpha motor
neuron
• Hyperactive stretch
reflex arc
• Lack of supraspinal
inhibition
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Prevalence of Spasticity
Spasticity could be present in our patients with upper motor
neuron injury or disorder, including patients with:
• Traumatic or acquired brain injury
• CVA
• Multiple sclerosis
• Spinal cord injury
• Cerebral palsy
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Spasticity and Brain Injury
• Approximately 50% of patients with acquired or traumatic
brain injury develop spasticity
• This is more difficult to study in this population due to wide
range of injury from mild TBI/concussion to severe TBI
• Patterns of spasticity development widely variable
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Importance of Spasticity
• Lower levels of functional outcomes
• Decreased health related quality of life
• Higher cost of care – increased economic burden
• Increased burden of care on caregivers
• More likely to require institutionalized care
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What does spasticity look like?
• Stereotypical patterns of presentation
• Patients present individually
• Full stereotypical pattern
• Partial patterns
• Outside of pattern
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Lower Extremity Extensor Pattern
1. Crosswords911.com via Google image search
2. www.pediatric-orthopedics.com via Google image search
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Upper Extremity Flexor Pattern
www.physiofunction_co_uk via Google image search
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Claw Hand Pattern
1. www.enviaaesthetic.org via Google image search
2. Pixgood.com via Google image search
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How does spasticity act in function?
Anna: Patient post TBI
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Effects of Spasticity
There are positive and negative effects of spasticity… we
must find the balance.
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Negative Effects of Spasticity
Contracture Decubitus ulcers
Abnormal posturing Restricted volitional movement
Deformity Restricted motor return
Degenerative joint changes Impaired mobility
Pain Impaired ADLs
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Positive Effects of Spasticity
Substitute for decreased strength Improved circulation
Allows increased mobility Decreased risk of
osteoporosis
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Examination of Spasticity
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Examination
• Initial observation
• Patient report
• Penn Spasm Frequency Scale
• Passive motion testing
• Modified Ashworth Scale (MAS)
• Tardieu Scale
• Assessment of function
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Penn Spasm Frequency Scale
Spasm Frequency Spasm Severity
0 = no spasm 1 = mild
1 = mild spasms induced by
stimulation
2 = moderate
2 = infrequent full spasms occurring
< once per hour
3 = severe
3 = spasms occurring > once per
hour
4 = spasms occurring > 10 times per
hour
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Penn Spasm Frequency Scale
Psychometrics Clinical Pearls
Self report measure Nice tool for describing patient
perspective of spasticity
ICF: body structure and function Especially helpful when MAS scores
low to track spasm
Population studied: chronic SCI Be mindful of subjectivity of the scale
Reliability: test-retest excellent
ICC = 0.91
Recommendations: SCI Edge –
reasonable to use, but limited study in
target group for acute, subacute and
chronic SCI and CVA
Rehabmeasures.org
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Modified Ashworth Scale (MAS)(Bohannon and Smith 1987)
Grade Description
0 No increase in muscle tone
1 Slight increase in muscle tone,
manifested by a catch and release or by
minimal resistance at end of ROM
1+ Slight increase in muscle tone,
manifested by a catch, followed by
minimal resistance throughout the
remainder (< half) of the ROM
2 More marked increase in muscle tone
through most of the ROM, but affected
part easily moved
3 Considerable increase in muscle tone,
passive movement difficult
4 Affected part is rigid in flexion or
extension
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Modified Ashworth Scale (MAS)
Psychometrics Clinical Pearls
ICF: body structure and function Training is required to improve
reliability
Population studied: adults & children
with lesions of the CNS
Technique for testing must be
standardized to improve inter and
intrarater reliability
Reliability: varies by muscle group,
population and acuity of patient, from
poor to excellent, ICC = 0.36-0.83
Annual competencies are recommended
Recommendations: SCI Edge
reasonable to use; StrokEdge
recommended; MS Edge unable to
recommend; TBI Edge recommended
Rehabmeasures.org
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Assessment of Function
Observe and assess the effect of spasticity in the upper and
lower extremity in functional tasks
• Bed mobility
• Transitional movements – transfers with varied demands
• Sitting
• Standing
• Gait
• Wheelchair positioning and mobility
• Vary speeds of task
• Add dual task/distraction
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Management of Spasticity
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Goals of Spasticity Management
• Minimize changes in the viscoelastic properties of
connective tissue and muscle
• Alter neural patterns of spasticity and/or spasms
• Decrease and/or manage pain
• Maintain hygiene and skin integrity
• Promote neuroplasticity
• Improve or maintain function
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Medical Management
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Medical Management
Systemic
Baclofen
Tizanidine
Dantrolene
Cyclobenzaprine
Metaxalone
Carisiprodol
Methocarbamol
Benzodiazepines
Gabapentin
Injected
Botulinum Toxin
Phenol
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Therapeutic Intervention
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Therapeutic Interventions
• Weightbearing
• Active Movement
• Passive Movement and Stretching
• Constraint-induced movement therapy
• Positioning – splinting, serial casting
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Weightbearing
Benefits/Evidence
Promotes antigravity muscle
activation in trunk and lower
extremities
Maintains or improves joint and soft
tissue flexibility
Modulates neural component of
spasticity through prolonged stretch
and altered sensory input
Decreases lower extremity spasms
Positive psychological effect
Images: google.com; bioness.com
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Active Movement:
Progressive Resistive Exercise
Benefits/Evidence
Increased strength and function
without increased tone or pain
Enhances motor learning in paretic
limbs
Reverse disuse weakness in chronic
illness/injury
Strengthen antagonist muscle to
those which are spastic
Strengthen spastic muscles
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Active Movement: Aerobic ExerciseCycling, Running, Walking, Swimming
Benefits/Evidence
Increased muscle strength
Increased endurance
Improved AROM
Enhanced motor learning
Decreased spasticity
Images: google.com
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Active Movement: Functional Task Practice
Benefits/Evidence
Promotes neuroplasticity
Trains functional movement
for learning
Incorporates weightbearing and
exercise with same
noted benefits
Images: google.com
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Active Movement: NMES/FES
Benefits/Evidence
Produces functional movement
May improve motor return, avoiding
abnormal patterns
Repeated movement may reinforce
neuroplasticity
May assist in skill acquisition
Combined with Botulinum
Toxin Injection
Decreased scores on MAS
Increased ROM at the ankle
Improved gait mechanics
Increased gait speed on 10MWT
Decreased cost and burden of care
Decreased secondary effects of
spasticity
Images: Bioness.com
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Active Movement: Treadmill Training
Benefits/Evidence
Decreases spasticity
Allows early training of postural and stepping reactions
Facilitate motor learning of gait cycle, increased motor recovery
Increased gait speed
Increased balance
Increased stepping with step activity monitor
Increased QOL
Increased gait tolerance
Increased muscle activation on EMG
Decreased spasticity ankle plantarflexors
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Active Movement/Passive Movement:
Robotics
Benefits/Evidence (Active)
Provides assisted ROM to joints
Reduces spasticity
Benefits/Evidence (Passive)
Reduces spasticity in the upper extremity
Addresses mechanical factors of spasticity
Increased afferent stimulation to motor cortex
for motor relearning
Images: marylandva.gov; allinahealth.org
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Passive Movement: Stretching
Benefits/Evidence
Maintain or increase joint mobility
Low load, long duration stretch is most effective
Focus on spastic muscles
Image: google.com
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Constraint-Induced Movement Therapy
Benefits/Evidence
When combined with Botulinum toxin injection:
Decreased spasticity on MAS
Increased motor control on Fugl-Meyer, Motor Activity Log and Wolf
Motor Function test
Increased coordination
Application
Started 1 week post injection
CIMT with mitt for 6 hours per day,
5 days per week for 2 weeks per protocol
Image: youtube.com
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Positioning: Casting and Splinting
Benefits/Evidence
Decrease motor neuron excitability (neural component)
Reduce tensile stress of soft tissues (non-neural component)
Increased flexibility
Decreased ankle plantarflexion contracture due to spasticity
Restored biomechanics
Improved gait scores
Improved function
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Serial Casting
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Definitions: Serial Casting
Stoeckmann 2001
“The application and removal of a series of casts, with the
result of progressively increased range of motion with
each casting with the purpose of correction of deformity,
lengthened contractures, and reduced spasticity.”
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Rationale: Serial Casting
• Muscle shortening is reversible
• Prolonged stretch inhibits spasticity
• Controls sensory input to the limb
• Increases patient’s visual and tactile attention to the limb
• Both number and length of sarcomeres are increased
thereby affecting length–tension relationship
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Indications: Serial Casting
• Increased spasticity
• Range of motion loss
• Loss of function in affected limb
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Considerations: Serial Casting
• Contraindications Other Considerations
Open wounds Medical stability
Unhealed fracture/external fixator Functional use
Acute inflammation Pain
Uncontrolled hypertension HO
Recent episode of autonomic dysreflexia Subluxation
• Precautions Timing
Fluctuating edema Bi-valve
Poor skin integrity
Reduced sensation
Cognitive impairment
Agitation
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Evidence: Serial Casting
Best Practice in Serial Casting
• Botulinum toxin injections and casting is better than botulinum toxin
alone for improved ankle ROM
• Timing of casting with botulinum toxin injection: 2-4 weeks
• Goals of ankle serial casting: 10 degrees ankle DF in subtalar neutral
with knee extended for ambulatory patients; 0 degrees for non-
ambulatory patients
• Serial cast change interval: < 5 days best to decrease complication and
discontinuation rates
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Serial Cast Application
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Disclaimer
These videos and discussion is intended as an introduction
to serial casting.
This is a potentially low volume, high risk procedure that
requires further training, practice, observation and
competency.
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Serial Casting Supplies
• Stockinette
• Tongue depressors (2)
• Foam padding
• Cotton roll padding
• Fiberglass
• Bucket
• Lotion (if leaving on only)
• Cast saw
• Cast splitter
• Bandage scissors
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Serial Casting: Supine Positioning
• Patient supine
• Bolster under knees
• Knee flexed
• Support ankle in
dorsiflexion with
subtalar neutral
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Serial Casting: Prone Positioning
• Patient prone
• Knee flexed
• Support ankle in
dorsiflexion with
subtalar neutral
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Apply Stockinette
• Stockinette should
extend to the knee
beyond toes
• Tongue depressors
along 1st an 5th
metatarsals and extend
out beyond toes
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Add Foam Padding
• Proximal end of cast –
2 finger widths below
fibular head
• Distal end of cast - past
toes, around tongue
depressors
• Over medial and lateral
malleoli
• Along tibia
• Over any additional
bony prominences
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Apply Cotton Roll Padding
• Work distal to proximal
• Overlap by half
• Avoid wrinkles
• 2 layers of padding
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Cotton Roll Padding Application
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Completed
Cotton Roll Padding Application
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Fiberglass Application
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Completed Fiberglass Application
• During application:
• Work distal to
proximal
• Overlap by half
• Apply 2 layers of
fiberglass
• Do not pull material
tightly as you wrap
• Ensure 2 fingers can
fit around proximal
end of cast
• Ensure all toes are
visible, but included
within the cast
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Draw Medial Cut Line for Removal
• Ensure cut line is
anterior to the malleolus
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Draw Lateral Cut Line for Removal
• Ensure cut line is
anterior to the malleolus
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Cast Removal
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Completed Medial Cut
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Completed Lateral Cut
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Cast Splitter
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Bi-Valved Short Leg Cast
• Remove all padding
and stockinette
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Bi-Valve Padding Supplies
• Large roll adhesive
padding for top and
bottom halves of cast
• Edging roll for covering
edges of top and
bottom halves of cast
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Completed Bi-Valved Short Leg CastOpen
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Completed Bi-Valved Short Leg CastClosed
• Secure with Ace wraps
or strapping
• Ensure proper fit with
patient
• Instruct in appropriate
wearing schedule
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Any Questions?
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Thank you for your attention.