Stroke Rehab

1
Stroke Rehab

• Spasticity Management with Focus on Focal
  Treatment
• Dr. Stephen McNeil
• Clinical Neurosciences
• University of Calgary

2
Objectives

• Briefly review spasticity/ UMN syndrome
• Highlight common spasticity patterns
• Outline common spasticity problems
• Summarize botulism M.O.A., uses, pros and cons
• Review the evidence behind use
• Discuss interesting cases

3
Disclosures

• I have received speaker honoraria from
  Allergan in the past and serve on the executive
  committee of the Allergan Academy of Excellence.

4
Spasticity
- more difficult to characterize than
recognize

• Spasticity is a motor disorder characterized by
  velocity-dependent increase in tonic stretch
  reflexes (muscle tone) with exaggerated tendon
  jerks, resulting from hyperexcitability of the
  stretch reflex, as one component of the upper
  motor neuron syndrome
• Muscle tone the sensation of resistance felt as
  one manipulates a joint through ROM

5
Upper Motor Neuron Syndrome
Can be caused by any cerebral or spinal injury/
lesion

• Positive Symptoms
• Increased passive resistance to stretch
• Flexor spasms / patterns of spasticity
• Increased reflexes / Clonus

• Negative Symptoms
• Weakness
• Incoordination
• Fatigue

Spasticity evolves in days/weeks after injury
Gormley ME et al. Muscle Nerve. 199720(suppl
6)S14-S20 Hinderer SR et al. Phys Med Rehabil
Clin N Am. 200112733-746 Vanek ZF. eMedicine.
2002. Available at http//www.emedicine.com/neuro
/topic706.htm.
6
Typical Synergy Patterns

• Upper Extremities
• Thumb-in-palm deformity
• Clenched fist
• Flexed wrist
• Pronated forearm
• Flexed elbow
• Adducted/internally rotated shoulder

• Lower Extremities
• Equinovarus foot
• Striatal toe
• Extended knee
• Flexed knee
• Adducted thighs
• Flexed hip

Mayer NH et al. Muscle Nerve. 199720(suppl
6)S21-S35.
7
Upper ExtremitiesThumb-in-Palm Deformity

• Muscles involved
• Adductor pollicis (AP)
• Flexor pollicis longus (FPL)
• Thenar group
• Functional impact
• Thumb held within palm
• Distal interphalangeal (DIP) joint flexed
• Thumb unable to function during key grasp

Mayer NH et al. Muscle Nerve. 199720(suppl
6)S21-S35.
8
Upper ExtremitiesClenched Fist

• Muscles involved
• Flexor digitorum profundus (FDP)
• Flexor digitorum sublimis (FDS)
• Functional impact
• Fingers clasped in palm
• Unable to wash palm
• Skin maceration, breakdown, and noxious odor

Mayer NH et al. Muscle Nerve. 199720(suppl
6)S21-S35.
9
Upper ExtremitiesFlexed Wrist

• Muscles involved
• Flexor carpi radialis/brevis/ulnaris
• Extrinsic finger flexors
• Functional impact
• Difficulty inserting hands into narrow openings
  (eg, sleeves)
• May have pain on passive range of motion
• Carpal tunnel symptoms may occur

Mayer NH et al. Muscle Nerve. 199720(suppl
6)S21-S35.
10
Upper ExtremitiesPronated Forearm

• Muscles involved
• Pronator quadratus
• Pronator teres
• Functional impact
• Impairs ability to orient hand

Mayer NH et al. Muscle Nerve. 199720(suppl
6)S21-S35.
11
Upper ExtremitiesFlexed Elbow

• Muscles involved
• Brachioradialis
• Biceps
• Brachialis
• Functional impact
• Bent elbow inadvertently hooks onto things
• Difficulty dressing and reaching for things
• Can lead to skin maceration and breakdown

Mayer NH et al. Muscle Nerve. 199720(suppl
6)S21-S35.
12
Upper ExtremitiesAdducted/Internally Rotated
Shoulder

• Muscles involved
• Pectoralis major
• Latissimus dorsi
• Teres major
• Subscapularis
• Functional impact
• Arm adducted tightly forearm lies against middle
  of chest
• Severely restricted ability to reach
  targets/apply force/push objects
• Frozen shoulder
• Dressing problems

Mayer NH et al. Muscle Nerve. 199720(suppl
6)S21-S35.
13
Lower Extremities Equinovarus Foot

• Muscles involved
• Gastrocnemius medial/lateral
• Lateral hamstrings
• Soleus
• Tibialis posterior/anterior
• Extensor hallucis longus
• Long toe flexors
• Peroneus longus
• Functional impact
• Foot and ankle turned in
• During stance, contact occurs at forefoot weight
  is borne primarily on lateral border

Mayer NH et al. Muscle Nerve. 199720(suppl
6)S21-S35.
14
Lower Extremities Striatal Toe (Hitchhikers
Toe)

• Muscles involved
• Extensor hallucis longus
• Functional impact
• Inability to wear a shoe
• When wearing shoe, pain at tip of toe and under
  first metatarsal during stance

Mayer NH et al. Muscle Nerve. 199720(suppl
6)S21-S35.
15
Lower Extremities Extended Knee

• Muscles involved
• Gluteus maximus
• Rectus femoris
• Vastus lateralis/ medialis/intermedius
• Hamstrings
• Gastrocnemius
• Iliopsoas (weak)
• Functional impact
• Knee remains extended throughout gait cycle
• Toe drag in early swing may cause tripping and
  falling

Mayer NH et al. Muscle Nerve. 199720(suppl
6)S21-S35.
16
Lower Extremities Flexed Knee

• Muscles involved
• Hamstrings medial/lateral
• Quadriceps
• Gastrocnemius
• Functional impact
• Knee remains flexed throughout swing and stance
  phases of gait
• Limited limb advancement with resultant short
  step length

Mayer NH et al. Muscle Nerve. 199720(suppl
6)S21-S35.
17
Lower Extremities Adducted Thighs

• Muscles involved
• Adductor longus/brevis/magnus
• Gracilis
• Iliopsoas (weak)
• Pectineus (weak)
• Functional impact
• Scissoring thighs when sitting and walking
• May interfere with hygiene, dressing, and
  mobility

Mayer NH et al. Muscle Nerve. 199720(suppl
6)S21-S35.
18
Effects of Spasticity on Patient

• Impaired mobility
• Increased risk of falls
• Difficulty with seating and transfers
• Skin breakdown secondary to positioning
  difficulties
• Development of contractures
• Orthopedic deformity
• Sleep disturbance

• Sexual dysfunction
• Fatigue from high energy expenditure
• Pain or abnormal sensory feedback
• Interference with activities of daily living
  (ADL) (eg, dressing, bathing, toileting)
• Depression due to lack of functional independence

Mayer NH et al. Muscle Nerve. 199720(suppl
6)S21-S35 Moberg-Wolff EA. eMedicine. 2001.
Available at http//www.emedicine.com/pmr/topic17
7.htm.
19
Effects of Spasticity on Caregiver

• Factors significantly associated with level of
  caregiver strain
• Amount of time spent helping patient
• Severity of patients disability
• Caregivers health
• Healthcare providers need to identify caregivers
  at greatest risk for strain and provide services
  to alleviate that strain

Bugge C et al. Stroke. 1999301517-1523.
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Spasticity Treatment Goals

• Improve mobility
• Decrease pain
• Decrease spasms
• Increase range of motion
• Improve fit of orthoses
• Improve cosmesis
• Decrease caregiver burden

• Improve positioning
• Prevent contractures
• Delay or prevent surgery
• Improve function/ ADLs
• Improve Quality of Life
• Minimize side effects to patient

Gormley ME et al. Muscle Nerve. 199720(suppl
6)S14-S20.
21
Physical Modalities

• Range of Motion (ROM) exercises
• Stretching
• Heat, cold, electrical stimulation
• Casting, splinting, wheelchair seating

22
Pharmacologic Interventions

• Systemic medications
• Baclofen, Tizanidine, Dantrolene sodium,
  Diazepam, Gabapentin

• Intramuscular botulinum toxin, phenol neurolysis

• Intrathecal medications

23
Mechanism of Action of BoNT

• Direct intramuscular injection results in a
  presynaptic blockade of acetylcholine (ACh)
  release

Vanek ZF. eMedicine. 2002. Available at
http//www.emedicine.com/neuro/topic706.htm.
24
Botulinum Toxin Type A Mechanism Current
Hypothesis
1
2
3
4
5
5
Data published dePaiva et al. PNAS 1999, 963200
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Botulism in Spasticity

• Can work on three factors
• Decrease spastic co-contraction
• Decrease spastic dystonia (stretch sensitive
  tonic mm contraction)
• Make stretching and lengthening injected mm
  easier

26
Evidence

• 15 class 1 RCTs for spasticity post stroke
• All showed benefit for reducing tone
• Most showed benefit for global satisfaction of
  caregivers, patient or provider
• 6 showed benefit in function but 4 of these were
  passive function

27
Evidence Problems

• Huge variation in patient groups
• No consistent dose used
• Fixed dose and muscles often
• EMG versus stimulator versus anatomic
• Lack of standardized rating scales
• What is function??
• Often no mvmts, not walking prior

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Where Does BoNT-A Fit Into the Treatment
Algorithm?

• As primary therapy for focal spasticity
• Reduces local muscle overactivity
• Improves effectiveness of PT/OT
• Prolongs benefit of physical/occupational therapy
• As adjunctive treatment for focal or generalized
  spasticity (synergistic effects)
• Splinting
• PT/OT
• Use with ITB or oral meds
• Need CLEAR Tx Goals

Davis EC et al. J Neurol Neurosurg Psychiatry.
200069143-149
Turner-Stokes L et al. Clin Med. 20022128-130
Vanek ZF. eMedicine. 2002. Available at
http//www.emedicine.com/neuro/topic706.htm.
29
Benefits of BoNT

• Minimal side effects unlike oral meds
• Can be combined with all other treatments
• If beneficial can be repeated as needed or to
  other areas
• Any increase in weakness is usually very
  transient and reversible
• Target the individual mm at fault

30
Potential Cons

• Cost
• Diffusion of toxin (other mm, swallow)
• Muscle atrophy
• Doses needed for larger muscles
• Technical considerations in some cities
• Injection side effects

31
Critical Issues Impacting Success With BoNT-A

• Patient selection
• Proper assessment of motor problem
• Realistic goals
• Often requires multidisciplinary assessment
• Dose/concentration/dilution
• Dependent on muscles involved, previous
  responses, and treatment goals
• Muscles/injection technique
• Large, superficial muscles identified by
  palpation
• Smaller/deeper muscles may require EMG or
  electrical stimulation guidance

Vanek ZF. eMedicine. 2002. Available at
http//www.emedicine.com/neuro/topic706.htm.
32
Posttreatment Algorithm
Review outcomes Were objectives met?
Yes
No

• Modify injection procedure/dose
• Reassess adjunctive therapies
• Reevaluate patient selection/goals

• Continuous reevaluation at follow-up to review
• Injection strategy
• Injection timing
• Reassessment of adjunctive therapies

Brin MF et al. Muscle Nerve. 199720(suppl
6)S208-S220.
33
CASE 1

• 35 Y.O. female with lt mca, aca stroke secondary
  to carotid dissection
• 3 days post stroke severe internally rotated and
  flexed rt arm, severe pain with attempts at any
  mvmts by PT
• Tried on Baclofen and Zanaflex (seizures and
  severe sedation)
• Asked by PT to see at day 5 for ??BOTOX

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EXAM

• Marked increased tone with no voluntary mvmts
  pec, elbow flexors
• Very difficult to do any passive range
• Distal arm still quite flaccid
• What should would do??
• Did we change this patients outcome??
• (compare to the St. Elsewhere patient)

35
BoNT Misconceptions

• Statement It should not be done in people with
  weakness, just getting strength back
• Often done in these patients. We are trying to
  eliminate/decrease a spasticity pattern to allow
  them to use the mm more effectively or to
  activate antisynergy mm without having to fight
  as much tone

36
Plasticity - Concept

• Change at the muscle afferent level may bring
  about synaptic plasticity higher up stream at
  spinal, supra-spinal and cortical levels
• This is known to occur in other neurologic models
  ex. Neuropathic pain

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Does this Occur with BOTOX Use??

• Byrnes Brain 1997
• fMRI and TCMS in patients with longstanding
  writers cramp
• Abnormal cortical map of hand
• Disappeared post injection
• Returned to normal state x 3 months post BOTOX
  injections

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Some Further Evidence

• Modugo (MN) 1998 change in 1A afferent
  inhibition level post BOTOX for tremor
• Gilio 2000 (AOfN) increased intracortical
  inhibition of dystonia post BOTOX
• Thickbroom part of Byrnes group. Can reverse
  cortical map with BOTOX treatment

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Clinical Experience

• BOTOX is more effective in breaking tone patterns
  when used early
• BOTOX can help with prevention of common
  complications of acute neurologic events ex.
  Frozen shoulder, achilles contracture
• In patients with well established motor patterns
  functional success is much more difficult
• Needs to be combined with therapy

40
Case 2

• 55 y.o. Rt Handed Female
• Rt MCA stroke 3 months prior
• Excellent motor recovery but significant UE FF
  and WF tone
• Poor functional recovery
• Inpatient OT, PT , splint etc x 3 months
• Still marked finger, wrist flexion. Not using
• What should we do??

41
Case 2

• Patient had her FDS,FDP and FCR injected under
  stimulator guidance
• f/u 6 weeks later
• Hand therapist amazed
• Husband amazed
• I was amazed
• And the Patient continued to neglect that side

42
Clinical Pearl

• When looking at function post stroke cognition,
  mood, sensation, visual spatial, motivation, and
  other motor deficits all come into play

43
Clinical Experience

• Number of patients with significant functional
  improvement without significant change in R.O.M.
• AND
• Patients with significant improvement in R.O.M.
  with no functional change

44
Case 3

• 80 y.o. with dense Rt MCA stroke
• Minimal changes first few months
• Discharged to long term care
• Lift transfers
• Severe lt hemispasticity with problems sleeping,
  sitting in chair
• No functional goals but the patient/caregivers
  have goals

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Initial Assessment
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Post Injection