THE MANAGEMENT OF SPASTICITY

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THE MANAGEMENT OF SPASTICITY

• Dr Anthony B Ward
• Stoke on Trent, UK.

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Spasticity

• Velocity dependent increase in muscle tone with
  exagerated tendon jerks resulting in
  hyper-excitability of the stretch reflex in
  association with other features of the Upper
  Motor Neurone Syndrome.

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Upper Motor Neurone Syndrome

• Spastic Dystonia
• Spastic Paresis
• Symptoms
• Positive Negative

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Features of Spasticity

• Positive Symptoms
• Muscle Tone
• Tendon Jerks
• Repetitive Stretch Reflexes - Clonus
• Extensor St. Reflexes
• Released Flexor Reflexes - Babinski, Mass synergy
  pattern

• Negative Symptoms
• Paresis
• Fine Control
• Dexterity
• Fatiguability
• Early Hypotonia

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Physical Management

• Essential
• All Pharmacological Interventions Adjunctive to
  Physical Management
• Before, During, After.

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Oral Agents

• Baclofen, Dantrolene, Tizanidine
• Benzodiazepines

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Oral Agents
40 Side-effects Narrow margin for tolerance,
therapeutic effect and side-effects
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Phenol Nerve Blockade

• Very Effective
• Cheap product
• Time Consuming
• Cost vs Value

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Phenol

• Painful
• Complications
• Tissue Necrosis
• Dysaethesia

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Surgery

• Posterior Rhizotomy
• Cordotomy
• Tendon Release

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Surgery

• Painful
• Irreversible
• Variable Results

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Limitations of Surgery

• Invasive
• Irreversible
• Paraesthesiae
• Bowel/bladder changes
• Variable effectiveness

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Intra-thecal Baclofen

• Effective
• Costly but Valuable
• Small Numbers
• Paraplegia
• ?Hemiplegia

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Botulinum Toxin Type A

• Focal Spasticity
• Alone or in Combination
• with Other Treatments

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Primary Efficacy Measure Mean Change from
Baseline in Ashworth Wrist Tone
Rigid tone





Normal tone
P ?0.001
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Mean Change from Baseline in Physician Global
Assessment (-4 to 4 scale)
Max improved





No change
P ?0.001
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Many More Now!
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Botulinum Toxin Serotypes

• Type Cellular Substrate
• A SNAP-25
• B VAMP/Synaptobrevin
• C Syntaxin 1A, Syntaxin 1B
• D VAMP/Synaptobrevin
• Cellubrevin
• E SNAP-25
• F As For D
• G VAMP/Synaptobrevin

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SAFETY

• 1 Unit LD50 in Mice.
• LD50 in Monkeys 39U/Kg.
• Equiv. to LD50 of 3000U in Humans.
• Dose Range in Clinical Use 60-400U.

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BOTULINUM TOXIN

• DOSAGE
• Dose in Children 4 Units/Kg/Muscle
• Adults - Maximum of 50U at One Site
• Maximum of 400U at one Session
• Three Monthly Intervals

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Clinical Effect

• Onset of Action 12 hours
• Onset of Clinical Effect 24-72 hours
• Observe at 1-4 weeks
• Average duration 3-4 months

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Electromyography

• Muscle Location
• Activity
• ?Use for Measurement

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BOTOXR vs DysportR

• Conversion Ratio approx. 14 when converting
  between brands of toxin.
• 1 BotoxR unit 3-5 DysportR units

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Possible Adverse Effects

• Site Specific - Eg. Weakness
• Pain - Muscles Bones
• Flu-Like Syndrome

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NON-RESPONSE

• Technical Dose
• Assessment
• Localisation
• No Effect EDB, Frontalis Tests
• Neutralising Antibodies

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Copies From Radius Healthcare, Suite 2, Cobb
House, Oyster Lane, Byfleet, Surrey, KT14
7DU. enquiries_at_radiushealthcare.co.uk
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Post Injection Physical Treatment

• Organise Before Injection
• Stretching Strengthening
• Casting/Splinting
• Pain Relief
• Other Interventions

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• Patient Assessment

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Treatment Plan

• What Does Patient Want?
• How is Function Impaired?
• Treatment Options

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Assessment

• Whats Wrong?
• Muscle Action Function
• Pick Measures to Reflect Outcomes
• Decide Treatment Goals at Initial Assessment

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Treatment with BTX-A

• When?
• How Soon?
• Spasticity v Contracture
• Only Treat Harmful Effects of Spasticity

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Aims of Treatment

• Improve Function Mobility, Dexterity
• Symptom Relief Ease Pain Decrease Spasms,
• Allow Orthotic Wearing
• Cosmesis Improve Body Image

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Aims of Treatment

• Decrease Carer Care Hygiene
• Burden Positioning, Dressing
• Time Number to Care1
• Optimise Service Unnecessary Treatments
• Responses Facilitate Therapy
• Prevent/Delay Surgery
• 1Northwick Park Care Dependency Score,
  Turner-Stokes L, Nyein K, Halliwell D. 1999

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Treatments

• Acute Conditions
• Chronic Spasticity

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Equally Effective in Early or Late Rehabilitation
Depends on Treatment Goals

Maintenance of Ability
Functional Return
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Chronic Spasticity

• Not Underlying Condition

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BTX A Treatment

• Equally Effective in Early or Late Rehabilitation
• Depends on Treatment Goals,
• Not Underlying Condition

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Spasticity
INCREASED MUSCLE TONE
MUSCLE SHORTENING
CONTRACTURE
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Assessment

• G.A.
• Sedation
• Benzodiazepine
• Nerve Block

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Post Injection Physical Treatment

• Period of Delay?
• Duration?
• Intensity?

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Post-Injection Care

• Intensive Treatment for
• Minimum of 4 weeks
• Home Exercises

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Outcomes Cost-Effectiveness

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Treatment Outcomes
Technical - BTX, Muscle Selection,
Injection Technique - ITB, Nerve Blockade
Patient - Treatment Goals, - Outcome Measures
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Outcome Measures
Modality Measure
Impairment Ashworth Scale, Range of Motion Power, Pain
Activity Dexterity, NHPT Walking Speed, Stride Length
Participation Handicap Scales, eg. LHS, SF12/36
Satisfaction Patient Satisfaction (VAS/Lickert)
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Patient Benefits
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Pattern
Benefits
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Pattern
Benefits
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Case Histories

• Tom 55 years, Stroke, Dense Left Hemiplegia,
  Sensory Loss Neglect, Spastic
  Dystonia. Aim of Treatment Walking

Video
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Case Histories

• B.F. 52 years, 20 year history of
  M.S. Paraparesis. Increasing instability
  standing walking. Cannot get heel to
  ground. Difficulty in hip extension and
  truncal rotation. Can achieve plantar-grade.
• Aim Transfers Indoor Walking

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Case Histories

• MG 57 years, MS for 20 years, Bilateral
  Adductor Spasticity, Cared for by
  Husband Aim of Treatment Ease Care,
  Transfers, Reduce Pain.

Video
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Patient Service Benefits
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Results - Tom

• Patient
• Walking
• No Carer Required
• Wife Returned to Work
• Financial Social Benefits
• Patient Self-Esteem

• Service
• Treatment Activity
• Reduced Care Costs
• No Care Required
• Less Benefit Payments
• Higher Initial Costs

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Results - Barbara

• Patient
• Walking
• No Carer Required
• Husband Returned to Work
• Financial Social Benefits
• Patient Self-Esteem

• Service
• Treatment Activity
• Reduced Care Costs
• No Care Required
• Less Benefit Payments
• Higher Initial Costs

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Outcomes - MG

• Patient
• Less Analgesia
• Better Posture
• Simpler Seating
• Better Sleep
• Husband Sole Carer
• No Falls

• Service
• Night Time Care Not Required
• Catheter Changes
• Cheaper WCH Seating
• Attends Day Centre

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Patient Satisfaction

• Less Consultations
• Less Medication (e.g. Analgesics)
• Decreased Carer Burden
• Improved Quality of Life
• Valid Measurement Activity!

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Results of Spasticity Studies

• Improvement in Impairment
• Little Functional Change
• Decrease Care Needs
• Decrease Pain Muscle Spasm

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Effectiveness

• Technical Results
• Meeting Patient Needs
• ?Treatment Value

• Guidelines to
• Clinical Practice
• Cost-Effectiveness

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Cost-Effectiveness Studies
Stroke Patients in Germany Wallesch C-W, Meas E,
Leconte P. Eur J Neurology. 1997
Early Spasticity Treatment in Patients Following
Severe Brain Injury In Study, Verplancke D et al.
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Value

• Degree of Improvement to Justify Treatment
• Reproducibility of Results

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Conclusions

• New Way of Managing Spasticity

• Value of BTX Promising
• (Functional Change not yet Evident)

• Appropriate Measures Will Demonstrate Value