Seizures & Muscle Overactivity: UMN Syndrome EXAM 3

- electrical or chemical stimuli

- medical or neurologic pathology, especially brain injury

- reaction to physiologic stress, sleep deprivation, fever, alcohol (or sedative) withdrawal

What are potential underlying causes that can lead to seizures

Idiopathic: most common (60% of all with epilepsy)

What is the etiology of epilepsy

- Prenatal/perinatal brain injury

- Congenital/genetic brain abnormalities

- TBI

- CVA

- CNS infection

- CNS neoplasm

- Medical conditions altering metabolic balance such as electrolyte imbalance, hypoglycemia, disorders of the adrenal glands, thyroid, or parathyroid)

Since epilepsy has a largely idiopathic etiology, what are secondary conditions that are associated with epilepsy

Partial/Focal Seizure

localized, such as in frontal, temporal, parietal, or occipital areas; often 1-2 minutes

- May be aware or unaware of surroundings

- Muscle movement, jerking, or loss of tone in one body area

- Unusual sensations (visual, auditory, somatosensory)

- Sleep disturbance

- Unusual head or eye movements

- Uncontrollable verbal outbursts

- Emotional disturbances

- Confusion

What are clinical signs/presentation of Partial/Focal Seizures

Generalized Seizures

may include cortical or subcortical structures, symmetric or asymmetric; often 1-3 minutes, medical emergency if >5 minutes or if multiple occur w/o pt regaining consciousness (status epilepticus)

if the seizure lasts >5 minutes

if multiple occur w/o person regaining consciousness (status epilepticus)

When might a Generalized Seizure become a medical emergency

- Unresponsiveness/LOC

- Muscle stiffness or jerking

- Loss of bladder/bowel control

- Slowed or stopped breathing

- Sudden collapse

- Vocalizations (crying, grunting)

what are the signs/symptoms of Generalized Seizures

- Age/time since injury at onset

- EEG patterns

- Response to medications

- Clinical signs

- History

What types of history information do we need to know in order to characterize seizures so that we can best treat them

- Stress/emotional triggers

- Medication

- Skipping meals

- Lights/visual stimuli

- Illness/fever

- Sleep deprivation

- Heat and humidity

- Withdrawal from sedative substances (alcohol)

What are some commonly identified triggers for patients with seizures

anti-epileptic drugs

What is the primary treatment method for seizures

- Patient history

- Knowledge of triggers

- Observation of physical manifestations

- Protection from injury

- Emergency medical attention if needed after seizure

- Comorbid condition

In order for PTs to work with patients who suffer from seizures, what do we need to know about the patient

Spasticity

A motor disorder characterized by a velocity dependent increase in tonic stretch reflexes and increased tendon jerks resulting from disinhibition of the stretch reflex, as one component of an upper motor neuron lesion

Spasticity

A velocity dependent increase of muscle tone with exaggerated tendon jerks resulting in hyper-excitability of the stretch reflex in association with other features of upper motor syndrome

- Hyperreflexia

- Clonus

- Spasticity

- Spasms

- Co-contractions

- Associated reactions

What are positive signs that an UMN lesion has occurred

Spasticity

velocity- and muscle length–dependent increase in resistance to externally imposed muscle stretch.

- abnormal synergies

- inappropriate muscle activation

- anomalous muscle coactivation

What other related motor impairments coexist with spasticity and share similar pathophysiological origins.

damage to nerve pathways within the brain or spinal cord that control muscle movement

What is the primary cause of Spasticity

- SCI

- Multiple sclerosis

- Cerebral palsy

- Stroke

- Brain or head trauma

- Amyotrophic lateral sclerosis

- Certain metabolic diseases

What are medical conditions that can present with or lead to the development of Spasticity

UE’s

LE’s

Spasticity commonly affects flexor groups in ___ and extensors in ____

- shoulder adductors and IR’s

- elbow, wrist, and finger flexors

- forearm pronators

- clenched fist with "thumb in palm" deformity

What muscle groups in the UE are commonly affected by Spasticity

- hip adductors

- knee flexors

- ankle PF/invertors

- hyperextension of great toe

What muscle groups in the LE are commonly affected by Spasticity

- Ulcers

- UTI or ANY infection

- Ingrown nails

- Poor posture or fit in equipment

- Constipation

- Stress

- DVT

Spasticity could be increased by any unpleasant stimulus/physiological disruption such as:

Use modified Ashworth scale

When encountering a spasticity or synergies…..how can we differentiate between the 2?

contractures

What adaptive shortening-based condition can develop as a result of spasticity

Assess post vitals (BP, HR, RR), hold on additional therapy that day and notify patients referring physician

A PT is working with a patient with a known comorbidity of epilepsy. During the session the patient experiences a seizure, lasting 2 minutes. How should the therapist proceed?

- Loss of consciousness

- Loss of bowel/bladder continence

- Vocalizations (crying, grunting)

- Slowed or stopped breathing

What are common symptoms of generalized seizures

- Modified Ashworth Scale

- Modified Tardieu Scale

- Isokinetic resistance to passive movement (Biodex, etc.)

- Functional outcome measures

- Response to medications

- ROM/presence of contractures

- EMG activation/electrophysiologic parameters at rest or in functional activity

What are tools to assess spasticity

No increase in muscle tone

What does a score of 0 on the modified Ashworth scale indicate

score of 1

Modified Ashworth Scale

• Slight increase in muscle tone manifested by a catch and release or by minimal resistance at the end range of motion

score of 1+

Modified Ashworth Scale

• slight increase in muscle tone manifested by a catch followed by minimal resistance throughout the remainder of the ROM

score of 2

Modified Ashworth Scale

• more marked increase in muscle tone through most of the ROM but affected part is easily moved

score of 3

Modified Ashworth Scale

• considerable increase in muscle tone, passive movement is difficult

score of 4

Modified Ashworth Scale

• affected part is rigid in flexion or extension

- Relieve pain/discomfort

- Improve posture

- Reduction of burden of care

- Improvement in hygiene (palm, axilla, groin)

- Improvement in body image, self-esteem

- Prevent complication (such as pressure ulcer or moisture-related skin breakdown)

- Facilitate functional positions and movements

What are the goals of treatment for spasticity

- Pharmacologic

- Oral medications; sedation or systemic weakness as side effects

- Localized injections (botox)

- Intrathecal baclofen pump directly into CSF

- Surgical (Rhizotomy, Tendon lengthening and soft tissue release)

- PT (conservative) management

What does the medical management of spasticity entail/include

- Baclofen

- Benzodiazepines

- Gabapentin (Neurontin) and pregabalin (Lyrica)

- Tizanidine

- Dantrolene

- Cannabinoids

What are oral medications used for spasticity management

Suppresses the release of excitatory neurotransmitters (ex. glutamate)

How does Baclofen for the management of spasticity work

Baclofen

the widely used oral anti-spasticity drug for spasticity

Baclofen

Sudden stopping of this spasticity med can provoke rebound spasticity

Benzodiazepines

Useful to treat spasticity that interferes with sleep

Gabapentin (Neurontin) and pregabalin (Lyrica)

use these 2 meds for patients that have spasticity associated with pain

Tizanidine

this spasticity med inhibits excitatory spinal interneurons, and you must monitor liver enzymes

anxiety

tremor

hypertension

tachycardia

What can happen if a patient with spasticity who was taking Tizanidine suddenly stops taking it

Dantrolene

Med for spasticity

- Blocks calcium release from sarcoplasmic reticulum (less sedative)

- Side effect: hepatotoxicity

- Must monitor liver enzymes

Cannabinoids

Med for spasticity

- Receptors in dorsal spinal cord, BG, hippocampus, cerebellum

- Side effects: sedation, psychotropic

Botox

What type of local injection is used for the medical management of spasticity

due to localized effects rather than systemic effects

Why might physicians prefer to use a local Botox injection as opposed to an oral medication

Cryoneurolysis

- US/e-stim guided probe generates an ice ball due to freezing temps from -60 °C to -88 °C

- Ice ball forms from interstitial fluid near peripheral nerve, leading to axonotmesis.

- Afferent nerve cryoneurolysis already an established pain management technique

- May represent a compromise between botox injections and surgeries

Chemical neurolysis for the treatment of spasticity

- Destruction of peripheral nerves via intraneural injection of phenol of alcohol

- Temporarily effective in treating spasticity in large, powerful muscle groups close to the trunk (e.g. hip adductors) as LAST RESORT

- Side effects: skin sloughing, wound infection, necrosis of muscle near the injection site, pain

Intrathecal baclofen pumps for spasticity management

- Stores and delivers programmable doses through a catheter into the spinal subarachnoid space

- Small dose achieves a high concentration within the spinal cord

- Good muscle relaxation without systemic side effects

- Significant limb spasticity despite treatment with oral anti-spasticity drugs

- Requires trial and regular follow up appointments to monitor

infection, skin erosions, CSF leak, seroma formation, pump failure, battery failure, catheter block, non-compliance

What are complications that can occur from an Intrathecal baclofen pump

- high fever

- confusion

- rebound spasticity

- muscle rigidity

What are symptoms of acute withdrawal from an Intrathecal baclofen pump

Selective dorsal rhizotomy for the Surgical management of spasticity

- Surgical section of dorsal nerve roots of the lumbosacral spine

- Temporarily reduces the sensory input into spinal neurons, reducing excitability

- Used to treat spasticity associated with CP (Kheder and Nair 2012)

- SPLATT

- Achilles tendon/hamstring tendon lengthening

What are 2 surgical alteration procedures for the surgical management of spasticity in the foot/ankle

- Stretching

- Splinting

- Casting

- Standing/weight-bearing

- Strengthening

- Functional training

- Other biophysical agents

What does physical therapy management of spasticity include

- Can be performed manually or with the use of devices

- Often requires family/caregiver involvement

- Limited evidence of long-term decrease in tone, conflicting evidence for short-term effectiveness

- No evidence that it is harmful

What are key points about the use of stretching for the management of spasticity

- Worn at rest, often overnight and when limb is not being functionally used during day 

- Provides more prolonged stretch to decrease tone and prevent/remediate adaptive shortening

- May hold limb in static position or provide some dynamic (spring) assist to increase stretch

- Low to moderate evidence for improvement in function

What are key points about the use of splinting for the management of spasticity

- Low to mid-levels of evidence suggest it can change long-standing spasticity and increase ROM (as opposed to no evidence for other interventions)

- Appropriate adjunct following Botox to elbow or plantar flexors

What are key points about the recomended use of serial casting for the management of spasticity

- Provide prolonged muscle stretch

- Immobilize limb in a predetermined position

- Improve muscle length, increase joint ROM, reduce contractures

What are the goals of using serial casting for the treatment of spasticity

- more than 1 clinician required (limb must be held in end range while cast applied)

- Initial cast left on 2-3 days

- After initial cast removed and skin checked, another cast immediately applied, may be left on up to 5 days

- With successive casts, may gain up to 5 degrees of PROM with each cast

What are the key points about the application and clinician procedure of serial casting in the treatment of spasticity

- Medical instability

- Wounds/poor skin integrity

- Heterotopic ossification

- Fluctuating edema

- Fracture

- Bilateral application with HTN

- Peripheral vascular disease/diabetes

- Decreased sensation

- Autonomic disorders

What are precautions/contraindications to the use of serial casting/splinting for the management of spasticity

- Tilt table or standing frame

- Evidence to support improved ankle ROM in patients with MS after 30 minutes in standing frame (Baker 2007)

- Evidence to support decreased spasticity via MAS in patients with SCI (Manella 2013)

- Reduced motoneuron excitability as measured by the H reflex after 30 min on tilt table in adults with stroke (Tsai et al 2001)

What are key points about the use of standing/weight bearing activities for the physical therapy management of the patient with spasticity

- Constraint induced therapy

- Body weight supported treadmill training

what are methods of functional training for the management of spasticity

- Cryotherapy

- Muscle vibration

- Electrical stimulation

What are some common biophysical agents used in PT for the management of spasticity

Low level evidence for spasticity reduction lasting up to 24hrs

What is the evidence on the use of muscle vibration for the management of spasticity

- Limited evidence for short term improvement

- Moderate level evidence for ES as an adjunct to Botox

- Moderate level evidence for NMES combined with other modalities in improving spasticity & joint ROM

What are key points about the use of E-stim for the management of spasticity

- High frequency = neuronal excitation

- Low frequency = neuronal inhibition

- Recent moderate quality evidence supporting benefit for spasticity reduction (UE may be greater than LE)

What are key points about the use of Transcranial Magnetic Stimulation (TMS) for the management of spasticity

extensor

flexor

Spasticity commonly affects ____ groups in the UE and ____ groups in the LE