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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. email@example.com 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
"MECHANISMS OF SPASTICITY _ ITS TREATMENT "