Muscle Tone Management

what are the benefits of spasticity?

may improve function, may improve B&B, foster circulation, prevent mm atrophy, improve respiratory function, prevent osteoporosis, draw attention to noxious stimulus in absence of sensation

what are consequences of spasticity?

may inhibit function, contribute to jt contractures, lead to postural abnormalities/skeletal deformities, painful or contribute to px syndromes, interfere with sleep, lead to skin breakdown

what are the goals for spasticity management?

improve function/independence, prevent or improve MSK status, improve fit and performance of adaptive and AD, decr px, preserve skin integrity, facilitate hygiene

what are the different methods used to treat spasticity?

physical rehab, oral pharm, pharm injection, intrathecal admin of pharm, surgery

inhibitory techniques are done through ___ stimulation

sensory

what are examples of inhibitory techniques for spasticity?

deep pressure, rhythmic rotation, oscillations, ice (prolonged), neutral warmth, positioning

stretching?

move jt into lengthened positions, away from their stereotypical shortened positions

what are the benefits of positioning techniques for spasticity?

WB on affected side or limb (include sidelying on affected side, table top or arm board when sitting), minimize effects of tonic reflexes

what are the benefits of splinting?

prevent loss of (or restore) range of motion

what is splinting used in adjunct with?

pharmacologic or surgical management

what is needed for splinting?

careful fabrication, fitting, monitoring, follow through to ensure participation in wearing schedule

what does splinting have limited use in?

controlling mod to severe spasticity

what is the benefit of serial casting?

restore ROM

what does serial casting need?

careful fabrication, fitting, monitoring, follow through to ensure participation in wearing schedule

what does serial casting have limited use in?

controlling mod to severe spasticity (MAS 4+)

what are the indications for the use of serial LE casts?

- persistent mild to mod hypertonus

- restrictions in active movement secondary to soft tissue tightness

- loss of PROM and failure to restore jt mobility via manual techniques and stretching

- jt mobility restrictions interfere with functional activity and/or use of splints or orthoses

what are contraindications for casting?

long standing contracture, orthopedic limitations, unstable medical condition, poor skin condition, compromised circulation, marked or fluctuating edema, agitation, uncooperative pt or caregiver

what are considerations for the use of serial LE casts?

if the jt restriction is recent (less than 18 mo), rule out fixed orthopedic limitations, impairments in integ and vascular systems (pressure sores, abrasions, edema or infections), ability to understand rationale for casting

what are the guidelines that need to be followed for the use of LE casts?

MSK exam, integ/vascular/sensory/neuromuscular status, precede with stretching & jt mob as needed, progress gradually, first cast change in 3 days to inspect skin

how is the final holding cast done?

rigid cast for up to 14 days or as a resting splint (bivalved cast)

how often are subsequent casts cahnged?

5-10 day intervals

what activities are done inbetween subsequent casts?

mobs, stretching and WB activities

what are the three things that need to be checked post casting?

toes, comfort, alignment

what are things to observe in the toes?

color changes, warmth, sensation, swelling

what are things to observe comfort-wise with casting?

evidence of px or evidence of mm spasm that may reflect excessive stretching

what are things to check for with alignment in a cast?

shaft/floor angle → should be at 90 or less (DF) to prevent genurecurvatum, backward propulsion and excessive anterior proximal cast pressure

global spasticity needs ___ treatment

global

focal spasticity needs ___ treatment

localized

what are global RX options?

oral med, intrathecal baclofen

what are localized RX options?

botox, phenol

benzodiazepines?

reduces spasticity, clonus, flexor spasms, bladder function

what are side effects of benzos?

sedation, memory loss, weakness, ataxia, incoordination, depression

baclofen?

selective effect on GABA-b; inhibits presynaptic calcium activity, inhibiting release of excitatory neurotransmitters → reduces hyperactivity of monosynaptic and polysnaptic reflexes, clonus, and cutaneous reflexes that elicit mm spasms

what are the side effects of baclofen?

sedation, fatigue, weakness, nausea, dizziness, paraesthesias, low seizure threshold

what might happen d/t a rapid withdrawal of baclofen?

hallucinations, seizures, tingling, paraesthesia, skin crawling, hyperthermia, HA, hypotension, autonomic dysreflexia, mental status changes

what are indications for intrathecal baclofen?

severe spasticity interfering with function, other management strategies are not effective, pt is motivated/reliable/cooperative, pt is adult or child > 4

what are contraindications to baclofen?

infection, pregnancy, baclofen allergy

what are the benefits of ITB?

lower doses → large CSF concentration with fewer systemic effects, individualized regultion of infusion rates, effective for UE/trunk/cervical hypertonus

what are risks of ITB?

infection (meningitis or abscess), post op risk of CSF leak

what is used short-term to prevent CSF leakage with ITB?

limited activity or abdominal binder

tizanidine?

inhibitory signals to spinal interneurons → reduction in mm tone and frequency of mm spasms

clonidine?

decr sympathetic outflow, reducing spasticity in pt with brain injury; used in combo with baclofen

dantrolene?

reduces Ca release, interfering with excitation/contraction coupling necessary for skeletal mm contraction

phenol?

therapeutic nerve block; nerve trunk or motor point → kills axon, preserves sheath → block of mixed motor/sensory nerves may cause painful dysaesthesia

what are two meds that are diagnostic blocks?

lidocaine, bupivacaine → fast acting, temporary

how long does it take phenol to start its effects? how long does it last?

effect: 1-24 hours; duration: 3-6 months

what is phenol often used in conjuction with?

casting

botulinum toxin?

blocks presynaptic release of ACh at NMJ (chemical denervation); transient paralysis of target mm

when does botox have its max effect? how long does it last?

2-6 wks; 3-4 months

when does focal paralysis occur with botox?

24-72 hous

what does botox cause in mixed nerves?

paraesthesias

what are the indications for the use of botox?

pre-injection mm imbalance, local hypertonus, hypertonus interfering with function or compromising skin or joint integrity

what are contraindications to botox?

pregnancy, pre-existing motor neuron disease (myasthenia gravis), other drug interactions

what are common applications of botox in UE?

shoulder aDD.IR, elbow flexion/forearm pronation, wrist and fingers

what mm is botox used in for shoulder aDD/IR?

subscap, teres major, lat dorsi, pec major

what mm is botox used in for elbow flexion/forearm pronation?

brachialis, biceps, brachioradialis, pronator teres and quadratus

what mm is botox used in for wrist and fingers function?

flexor carpi radialis and ulnaris, flexor digitorum superf/profundus, flexor pollicis long/brevis, lumbricals

what are common applications of botox in LE?

knee flexion, knee extension, hip aDD, equinovarus, toe flexion

what mm is botox used in for knee flexion?

HS

what mm is botox used in for knee extension?

quads

what mm is botox used in for hip aDD?

adductors

what mm is botox used in for equinovarus?

HS, tibialis anterior, tibialis posterior

what mm is botox used in for toe flexion?

flexor hallucis/digitorum longus

what is the benefit of ultrasound guided injection?

helps ensure injection goes into correct mm and the thickest part of the mm

what is selective dorsal rhizotomy?

30-60% of nerve rootlets at selected spinal nerve levels are sectioned; may result in reductions in mm tone, improvement in ROM, improvement in mtoor performance

what is the typical nerve level for a selective dorsal rhizotomy?

L2-S2

what does selective dorsal rhizotomy require?

intensive post-op therapy, often with specific exercise and functional training protocols

what are limitations of selective dorsal rhizotomy?

excessive nerve root section causes weakness, disruption of posterior spinal column may cause instability (surgical levels are limited)

what are indications for orthopedic surgery?

contractures, skeletal deformity, crouch gait

what are common targets for tendon lengthening/release or transfer procedures?

hip aDD, hamstrings, heel cord

what is a possible result in tendon lengthening/release or transfer procedures?

irreversible weakness

t/f: strength training is contraindicated with spasticity

false