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MECHANISMS OF SPASTICITY ITS TREATMENT

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MECHANISMS OF SPASTICITY ITS TREATMENT Powered By Docstoc
					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         Negative Symptoms
 Muscle Tone              Paresis
 Tendon Jerks
                           Fine Control
 Repetitive Stretch
                           Dexterity
  Reflexes - Clonus
                           Fatiguability
 Extensor St. Reflexes
 Released Flexor          Early Hypotonia
  Reflexes - Babinski,
  Mass synergy pattern
   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                  Regional
        Spasticity       Focal      Spasticity
                       Spasticity


Oral Agents        Botulinum Toxin         Intra-Thecal
                   Phenol Blockade           Baclofen
        Oral Agents

Baclofen, Dantrolene, Tizanidine
        Benzodiazepines
         Oral Agents
       40% Side-effects

       Narrow margin for
tolerance, therapeutic effect and
           side-effects
Phenol Nerve Blockade

     Very  Effective
     Cheap product
    Time Consuming
      Cost vs Value
      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    4
tone
        3.5
         3
        2.5
         2
        1.5                                                            *
                        *                             *
         1                                *
                                 *
        0.5
Normal 0
 tone         Day 0   Week 1   Week 4   Week 6      Week 8      Week 12

                               BOTOX      Placebo
                                                          * P 0.001
         Mean Change from Baseline in
      Physician Global Assessment (-4 to +4 scale)
  Max        4
improved
            3.5
             3
            2.5
             2      *        *        *
                                              *
            1.5                                            *
             1
            0.5
No change    0
                  Week 1   Week 4   Week 6   Week 8      Week 12

                                    BOTOX      Placebo         * 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   Cellular Substrate
    A     SNAP-25
    B     VAMP/Synaptobrevin
    C     Syntaxin 1A, Syntaxin 1B
    D     VAMP/Synaptobrevin
           Cellubrevin
    E     SNAP-25
    F     As For D
    G     VAMP/Synaptobrevin
             SAFETY

1 Unit = LD50 in Mice.
 LD50 in Monkeys = 39U/Kg.
  Equiv. to LD50 of 3000U in Humans.
 Dose Range in Clinical Use = 60-400U.
                                                      Botulinum Toxin Type A
                                                      Mechanism of Action

                                   INTERNALISATION

          Botulinum Toxin Type A
          Mechanism of Action      BTX is
                                   internalised via
                                   receptor                            x
BINDING                                                           xx
                                   mediated                 x x
                                   endocytosis



                           x
                      xx
                x 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
   BOTOXR       vs   Dysport R




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


Technical     Dose
              Assessment
              Localisation
No Effect     EDB, Frontalis Tests
Neutralising Antibodies
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                  Care & Hygiene
    Burden                          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


 Acute Conditions
 Chronic Spasticity
       Equally Effective in Early or Late
                Rehabilitation
Depends on Treatment Goals




      Functional Return      Maintenance of Ability
        Chronic Spasticity


    Underlying
 Not
 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

Patient       - Treatment Goals,
              - Outcome Measures
                Outcome Measures
Modality          Measure

Impairment        Ashworth Scale, Range of Motion
                  Power, Pain

Activity          Dexterity, NHPT
                  Walking Speed, Stride Length
Participation     Handicap Scales, eg. LHS, SF12/36

Satisfaction      Patient Satisfaction (VAS/Lickert)
Patient Benefits
        Pattern                  Benefits

Shoulder Adduction &    Sitting Posture, Dressing
Internal Rotation       Balance, Gait Symmetry


Elbow Flexion Forearm   Reach, Dexterity
Pronation
Flexed Wrist            Dexterity
Clenched Hand           Palm Hygiene

Thumb in Palm           Grip
         Pattern                      Benefits

Hip Adductor Spasticity   Reduce Scissor Gait,
                          Improve Hygiene,
                          Easier Sexual Intercourse
Hip & Knee Flexors        Gait Pattern & Speed Improve
                          Sitting Posture

Knee Extensor Spasms      Reduce Pain
                          Improve Sitting Posture
Plantar Flexed Inverted   Standing, Heel Strike, Orthotic
Foot                      Wear, Shoe Comfort
          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.

Aim:   Transfers & Indoor Walking
         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                  Treatment Activity
   No Carer Required        Reduced Care Costs
   Wife Returned to         No Care Required
    Work
                             Less Benefit
   Financial & Social        Payments
    Benefits
                             Higher Initial Costs
   Patient Self-Esteem
              Results - Barbara
    Patient                   Service
   Walking                  Treatment Activity
   No Carer Required        Reduced Care Costs
   Husband Returned         No Care Required
    to Work
                             Less Benefit
   Financial & Social        Payments
    Benefits
                             Higher Initial Costs
   Patient Self-Esteem
              Outcomes - MG
    Patient                  Service

   Less Analgesia          Night Time Care Not
   Better Posture           Required
   Simpler Seating          Catheter Changes
   Better Sleep            Cheaper WCH
   Husband Sole Carer       Seating
   No Falls
                            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       }   Guidelines to
 Meeting Patient Needs   }   Clinical Practice

   ?Treatment Value      –   Cost-Effectiveness
    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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