Spasticity After Stroke

Heather Walker, M.D.

Assistant Professor
Department of Physical Medicine & Rehabilitation
UNC-Chapel Hill
 What is a physiatrist???
NOT a physical therapist

NOT a psychiatrist

Education:
Four years medical school
Four years residency
+/- Fellowship Training

Take care of patients with disabilities

Stroke, traumatic brain injury, spinal cord injury, amputations,
burns, pediatrics, etc.
Goal is to improve function and quality of life
 Physiatrists and Stroke
Medical management during acute
inpatient rehabilitation and as an
outpatient
Blood pressure
Bowel and bladder dysfunction
Skin
Language impairments
Cognitive and attentional impairments

SPASTICITY
 What is spasticity??
a motor disorder characterized by a
velocity-dependent increase in tonic
stretch reflexes (muscle tone) with
exaggerated tendon jerks, resulting from
hyperexcitability of the stretch reflex

????????????????????????
Spasticity can be defined as increased
tightness in affected muscles
 What is spasticity??
Increased tightness in muscles
Chest wall Difficulty raising arm to the
side, putting on clothing
Elbow flexors Difficulty straightening arm
to reach for items or dressing
Wrist flexors
Finger flexors Difficulty opening hand
voluntarily or passively (releasing items, hand
hygiene)
 What is spasticity??
Increased tightness in muscles
Hamstrings Difficulty straightening leg
Quadriceps Stiff-knee gait
Calf muscles Difficulty clearing toes when
walking (tripping), foot turns in when walking
Inner thighs Legs cross over each other
when walking, difficulty pulling legs apart for
hygiene
Upper Extremity Spasticity
Lower Extremity Spasticity
 Spasticity Complications

Positioning
Hygiene
ADLs
Sitting or Standing Balance
Contractures
 Treatment Goals
Improvements in position
Mobility
Pain
Contracture prevention
Ease of care are possible
Spasticity Management Steps
Therapeutic modalities
Oral Medications
Nerve blocks & Chemical neurolysis
(Botox injections)
Orthopedic procedures
Intrathecal Medications
 Prior to Intervention
Assess baseline status
Determine specific goals
Patient and family education
PT and OT role after intervention
 Therapeutic Exercise
Stretching and range of motion
Myofascial and joint mobilization
Active assistive, active and
resistive exercise
Endurance training
 Oral Medications
Zanaflex
Adverse effects: drowsiness, dizziness, dry mouth, orthostatic
hypotension

Baclofen
Adverse effects: weakness, sedation, hypotonia, ataxia,
confusion, fatigue, nausea, dizziness, lower seizure threshold
Sudden withdrawal may cause seizures, hallucinations, rebound
spasticity

Dantrium
Adverse effects: weakness (including ventilatory muscles),
drowsiness, lethargy, nausea, diarrhea, Liver toxicity
 Botulinum Toxin Type A (BOTOX):
History of Development
FDA approval of
BOTOX
Dr. Schantz
begins
investigation
C. botulinum
identified
1989
1978
1944
1920s
Dr. Scott initiates
1895 first therapeutic
testing in humans
Botulinum toxin
type A first
isolated
 BOTOX (Botulinum Toxin Type A):
A Focal Therapeutic

Injected directly into overactive

muscles
Reduces contractions, relaxes muscles
Advantages of local injection
Targeted to specific muscles that
are causing the symptoms
When used at recommended doses,
avoids systemic, overt distant
clinical effects
NOT FDA APPROVED FOR
SPASTICITY
 Muscle identification
Three main methods
Exam and anatomic atlas
EMG assistance and guidance
Electronic stimulation
 Side Effects

Localized
Hematoma and bruising are seen
regardless of the site injected
Local weakness, created by diffusion of
Botox and is site specific
Death???
 Intrathecal Baclofen
Small doses of baclofen delivered directly
to the spinal canal
Fewer side effects, better relief of
spasticity
Usually more effective for spasticity in the
lower extremities
Requires committed patient and family,
pump must be refilled every 3 months.
Intrathecal Baclofen
 Surgical Procedures
Tendon lengthening
Neurosurgical procedures

Last resort!
 Take Home Points.
Spasticity is common after stroke, and is
manifested as muscle tightness in the affected
arm and/or leg.

Several different treatment options are available,

including therapies, oral medications and
injections.

If you suffer from spasticity you should be seen

by a physiatrist who specializes in spasticity
management.