Transcript aocpmr.org
Spasticity http://photo-dictionary.com/phrase/5533/clasp-knife.html#b http://virtualworlds.wikia.com/wiki/3d_models_list_old • Spasticity • Velocity dependent resistance • Feel at beginning of range of motion then releases • Clasp-knife Spasticity • Rigidity • Increased resistance throughout range of motion • Lead Pipe Rigidity • Cogwheel • Intermittent, regular resistance throughout the range of motion http://www.mhl.soton.ac.uk/public/Main/research/projects/dormant/cogwheel/index.html Reflexes • Grade 0= Absent • Grade 1= Hypoactive • Can elicit with distraction (pull hands apart) • Grade 2= Normal • Grade 3= Hyperactive • Spreading of reflex • Grade 4= Clonus http://www.adinstruments.com/solutions/experiments/labchart_experiments/full.php?exp_id=239§ion_id=24&group_id=5&name_id=308&template=education Upper Motor Neuron Injury • Result of injury to CNS • Brain, Spinal Cord • Stroke, Cerebral Palsy, Spina Bifida, Multiple Sclerosis, Spinal Cord Injury • Loss of inhibition of local reflexes from descending spinal tracts (pyramidal tract) • Spastic Paralysis • Hyperreflexia, Spasticity, Positive Babinski, Disuse Atrophy • Dominance of Rubrospinal tract • Flexion of upper extremities • Extension of lower extremities http://monensberkshire.blogspot.com/2010/06/pyramidal-tract.html Lower Motor Neuron Injury • Injury to alpha motor neuron • Anterior Horn (Polio Myelitis, SMA) • Peripheral Nerve (Trauma, GBS) • Flaccid Paralysis • Hypotonia, Absent Reflexes, Fasciculations, Severe Atrophy http://medical-dictionary.thefreedictionary.com/lower+motoneuron Secondary Effects http://www.nlm.nih.gov/medlineplus/ency/presentations/100056_1.htm http://medical- • Contractures • Ankles (Clubfoot deformity), Knees, Hips, Elbows, Wrists • Worsen with growth • Hip Dislocation • Surgical correction • Scoliosis • Seating problems, cardiopulmonary compromise • Bracing, Surgery Spasticity • Results in pain, decreased mobility, contractures, spasms, interferes with sleep and ADLs • Therapy • Repeated, gradual, sustained stretching • Serial casting • Orthoses • Orthopedic surgery • Muscle and tendon lengthening • Lengthened muscles loses grade of strength • Repeat interventions as grow • Medications • Generalized spasticity • Prevent mass extensor spasm • Less used in high function due to side effects Oral • Limited efficacy • Side effects are dose limiting • Slow dose elevation 1.Baclofen 2.Tinazidine • Centrally acting alpha-2 agonist 3.Diazepam or Clonazepam • Benzo, GABA-A agonist • Can use with Baclofen or Tinazidine • Useful for nighttime spasm 4.Dantrolene • Peripherally acting • Inhibits Ca2+ release from SER • Produces more weakness than any other med • Hepatotoxicity: monitor LFTs 5.Other • Clonidine, Gabapentin, Cannabinoids, Cyproheptadine • Intrathecal • Baclofen • Centrally acting • Poor at crossing BBB • Decreased systemic side effects • Increased complications • Spinal fluid leaks • Hemorrhage • Infection • Catheter Dislodgement • Pump Failure • Injections • Chemodennervation: • Avoids systemic side effects • Muscle weakness and injection site reactions • 1. Botulinum-A Toxin • 2. Phenol • 3. Alcohol Dystonia • Dystonia Defined: • Sustained painful muscle contraction • Results from defect at level of basal ganglia (extrapyramidal) • Common causes: • Inherited/ Metabolic Disorders • CO Poisoning • Encephalitis • Focal Brain Disease • Medication Induced • D2 Blockers • Antipsychotics, Metoclopramide http://www.ninds.nih.gov/news_and_events/news_articles/cerebellum_in_dystonia.htm Treatment • Anitcholinergics are most effective • Baclofen, carbamazepine, clonazepam • Focal dystonias- Botulinum toxin References • O’Young, B., Young, M., Stiens, S. (2008). Physical Medicine and Rehabilitation Secrets. Philadelphia, PA: Mosby Publisher. • Lexicomp. Baclofen: Drug information. In: UpToDate, UpToDate, Waltham, MA, 2012. • Lexicomp. Botulinum toxin type A (onabotulinumtoxinA, Botox®): Drug information. In: UpToDate, UpToDate, Waltham, MA, 2012.