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MECHANISMS OF SPASTICITY _ ITS TREATMENT

VIEWS: 19 PAGES: 62

									THE MANAGEMENT OF SPASTICITY
Dr Anthony B Ward Stoke on Trent, UK.

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.

Upper Motor Neurone Syndrome
Spastic Dystonia Spastic Paresis
Symptoms Positive Negative

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

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

Management Strategy
Prevention of Provocative Factors Team Decision Making Physical Treatment Options Medical

Generalised Spasticity

Focal Spasticity

Regional Spasticity

Oral Agents

Botulinum Toxin Phenol Blockade

Intra-Thecal Baclofen

Oral Agents
Baclofen, Dantrolene, Tizanidine Benzodiazepines

Oral Agents
40% Side-effects
Narrow margin for tolerance, therapeutic effect and side-effects

Phenol Nerve Blockade
Effective  Cheap product  Time Consuming  Cost vs Value
 Very

Phenol
 Painful
 Complications

– Tissue Necrosis – Dysaethesia

Surgery
Posterior Rhizotomy Cordotomy Tendon Release

Surgery
Painful Irreversible Variable Results

Limitations of Surgery
Invasive Irreversible Paraesthesiae Bowel/bladder changes Variable effectiveness

Intra-thecal Baclofen
Effective Costly but Valuable Small Numbers Paraplegia ?Hemiplegia

Botulinum Toxin Type A
Focal Spasticity

Alone or in Combination with Other Treatments

Primary Efficacy Measure: Mean Change from Baseline in Ashworth Wrist Tone
Rigid tone
4 3.5 3 2.5 2 1.5 1 0.5

* *
Day 0 Week 1 Week 4 BOTOX

* * *

Normal tone

0 Week 6 Placebo Week 8 Week 12

* P 0.001

Mean Change from Baseline in Physician Global Assessment (-4 to +4 scale)
Max improved
4 3.5 3 2.5 2 1.5 1 0.5 0 Week 1 Week 4 Week 6 BOTOX Week 8 Placebo Week 12

*

*

*

*

*

No change

* P 0.001

Botulinum Toxin: Cumulative Publications
2500

2000

1500

1000

500

0 Pre 81 83 85 87 89 91 93 95 97 99

Year

Many More Now!

Botulinum Toxin Serotypes



 

Type A B C D E F G

 



Cellular Substrate SNAP-25 VAMP/Synaptobrevin Syntaxin 1A, Syntaxin 1B VAMP/Synaptobrevin Cellubrevin SNAP-25 As For D VAMP/Synaptobrevin

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

Botulinum Toxin Type A Mechanism of Action INTERNALISATION

Botulinum Toxin Type A Mechanism of Action

BINDING

BTX is internalised via receptor mediated endocytosis

x x

xx

x

x x

xx

x

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

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

Electromyography
Muscle Location Activity ?Use for Measurement

R BOTOX

vs

R Dysport

Conversion Ratio approx. 1:4 when converting between brands of toxin. 1 BotoxR unit = 3-5 DysportR units

Possible Adverse Effects
Site Specific - Eg. Weakness Pain - Muscles & Bones “Flu-Like” Syndrome

NON-RESPONSE
Dose Assessment Localisation No Effect EDB, Frontalis Tests Neutralising Antibodies Technical

Copies From: Radius Healthcare, Suite 2, Cobb House,

Oyster Lane, Byfleet, Surrey, KT14 7DU.
enquiries@radiushealthcare.co.uk

Post Injection Physical Treatment
Organise Before Injection Stretching & Strengthening Casting/Splinting Pain Relief Other Interventions

Patient Assessment

Treatment Plan

 



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

Assessment

  

What’s Wrong? Muscle Action & Function Pick Measures to Reflect Outcomes Decide Treatment Goals at Initial Assessment

Treatment with BTX-A
When? How Soon? Spasticity v Contracture
Only Treat Harmful Effects of Spasticity

Aims of Treatment
Improve Function Mobility, Dexterity  Symptom Relief Ease Pain


Decrease Spasms, Allow Orthotic Wearing


Cosmesis

Improve Body Image

Aims of Treatment


Decrease Carer Burden

Care & Hygiene

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

Treatments

Conditions  Chronic Spasticity

 Acute

Equally Effective in Early or Late Rehabilitation
Depends on Treatment Goals

Functional Return

Maintenance of Ability

Chronic Spasticity
 Not

Underlying Condition

BTX –A Treatment
Equally Effective in Early or Late Rehabilitation
Depends on Treatment Goals, Not Underlying Condition

Spasticity
INCREASED MUSCLE TONE

MUSCLE SHORTENING

CONTRACTURE

Assessment
 G.A.

 Sedation

– Benzodiazepine
 Nerve

Block

Post Injection Physical Treatment
Period of Delay? Duration? Intensity?

Post-Injection Care
Intensive Treatment for Minimum of 4 weeks
Home Exercises

Outcomes & Cost-Effectiveness

Treatment Outcomes
Technical - BTX, Muscle Selection, Injection Technique - ITB, Nerve Blockade - Treatment Goals, - Outcome Measures

Patient

Outcome Measures
Modality Impairment Activity Participation Measure
Ashworth Scale, Range of Motion Power, Pain Dexterity, NHPT Walking Speed, Stride Length Handicap Scales, eg. LHS, SF12/36

Satisfaction

Patient Satisfaction (VAS/Lickert)

Patient Benefits

Pattern
Shoulder Adduction & Internal Rotation Elbow Flexion Forearm Pronation Flexed Wrist Clenched Hand Thumb in Palm

Benefits
Sitting Posture, Dressing Balance, Gait Symmetry Reach, Dexterity Dexterity Palm Hygiene Grip

Pattern
Hip Adductor Spasticity

Benefits
Reduce Scissor Gait, Improve Hygiene, Easier Sexual Intercourse Gait Pattern & Speed Improve Sitting Posture Reduce Pain Improve Sitting Posture Standing, Heel Strike, Orthotic Wear, Shoe Comfort

Hip & Knee Flexors

Knee Extensor Spasms Plantar Flexed Inverted Foot

Case Histories
•Tom 55 years, Stroke, Dense Left Hemiplegia, Sensory Loss & Neglect, Spastic Dystonia. Aim of Treatment: Walking Video

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.
Transfers & Indoor Walking

Aim:

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

Patient & Service Benefits

Results - Tom
Patient
   

Service
 



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


 

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

Results - Barbara
Patient
   

Service
 



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


 

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

Outcomes - MG
Patient
     

Service


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


 

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

Patient Satisfaction
Less Consultations  Less Medication (e.g. Analgesics)  Decreased Carer Burden  Improved Quality of Life


Valid Measurement Activity!

Results of Spasticity Studies
Improvement in Impairment Little Functional Change Decrease Care Needs Decrease Pain & Muscle Spasm

Effectiveness
Technical Results  Meeting Patient Needs
  }
}

Guidelines to Clinical Practice Cost-Effectiveness

?Treatment Value

–

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.

Value
Degree of Improvement to Justify Treatment  Reproducibility of Results


Conclusions
•New Way of Managing Spasticity •Value of BTX Promising (Functional Change not yet Evident)

•Appropriate Measures Will Demonstrate Value


								
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