This document discusses spasticity after stroke. It defines spasticity as an abnormal muscle tone with increased resistance to passive stretch. There are different types of spasticity including lead pipe, cogwheel, and clasp knife. The pathophysiology involves loss of inhibitory control in the spinal cord. Treatment options include rehabilitation therapy, oral medications, neurolysis, orthopedic procedures, and neurosurgery. Measurement tools include the Ashworth scale and pain scales. The goals of treatment are to improve function and mobility while decreasing pain.
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Spasticity after stroke
1. Spasticity
After Stroke
Adeagbo, Caleb A
B.Physiotherapy (Lagos)
Department of Physiotherapy,
National Hospital,
Abuja
8/20/2012 1
2. Outline
Introduction
Definitions Measurement
Types of Tools
spasticity Treatment
Pathophysiology Conclusion
Other Types of References
Hypertonicity
Advantages of
Spasticity
8/20/2012 2
3. Introduction
Stroke is the leading cause of
morbidity and mortality
(Lundstrom et al, 2008; Urban et
al, 2012).
Spasticity is a common
complication of stroke that lead
to impaired gait characteristics in
the upper and lower extremities
(Karadag-Saygi et al, 2010).
8/20/2012 3
4. Introduction cont
Optimum management of
spasticity is dependent on an
understanding of its underlying
physiology, an awareness of its
natural history, an appreciation of
the impact on the patient and a
comprehensive approach to
minimizing that impact which is
both multidisciplinary and
consistent over time (Thompson
et al, 2012).
8/20/2012 4
5. Definitions
Stroke is an acute/sudden
focal/global disturbance of the
cerebral function with symptoms
lasting for more than 24hours or
sometimes leading to death with
no other cause than vascular
origin.
8/20/2012 5
6. Definitions cont
Spasticity (meaning to draw or tug)
Spasticity is abnormal muscle tone
recognized clinically as resistance
to passive muscle stretch which
increases with velocity of stretch. It
is defined as 'a motor disorder
characterized by velocity dependent
increase in tonic stretch reflexes
with exaggerated tendon jerks,
resulting from hyperexcitability of
the stretch reflex
8/20/2012 6
7. Types of spasticity
LEAD PIPE: presents as a uniform
resistance to movement throughout
the range of movement.
COGWHEEL: presents as an
intermittent on/off resistance
throughout the range of movement,
making the movements jerky.
CLASP KNIFE: presents as increase in
extensors of a joint when its passively
flexed given way suddenly on exertion
of further pressure.
8/20/2012 7
8. Pathophysiology
The pathophysiologic basis of
spasticity is incompletely
understood.
Spasticity is loss of inhibitory
control over the gamma motor
neuron
This inhibitory influence is in turn
controlled by descending and
peripheral inputs.
8/20/2012 8
9. Pathophysiology contd
Lack of descending control over
spinal cord interneuronal circuits
results in a decrease in the
effectiveness of spinal inhibitory
circuits such as those mediating
reciprocal, presynaptic, and
recurrent inhibition.
8/20/2012 9
10. Pathophysiology contd
The changes in muscle tone
probably result from
alterations in the balance of
inputs from reticulospinal and
other descending pathways to the
motor and interneuronal circuits
of the spinal cord
the absence of an intact
corticospinal system.
8/20/2012 10
11. Pathophysiology contd
Loss of descending tonic or
phasic excitatory and inhibitory
inputs to the spinal motor
apparatus,
alterations in the segmental
balance of excitatory and
inhibitory control
denervation supersensitivity
neuronal sprouting
8/20/2012 11
12. Other Types of Hypertonicity
RIGIDITY - Involuntary, bidirectional,
non–velocity-dependent resistance
to movement
CLONUS - Self-sustaining, oscillating
movements secondary to
hypertonicity
DYSTONIA - Involuntary, sustained
contractions resulting in twisting,
abnormal postures
ATHETOID - Involuntary, irregular,
confluent writhing movements
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13. Other Types of
Hypertonicity contd
CHOREA - Involuntary, abrupt,
rapid, irregular, and unsustained
movements
BALLISMS - Involuntary flinging
movements of the limbs or body
TREMOR - Involuntary, rhythmic,
repetitive oscillations that are not
self-sustaining
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14. Advantages of Spasticity
Maintenance of Muscle tone or
Muscle Bulk
Tone Effect on Mobility
Tone effect on ADL's
Improved Circulation
Prevention of DVT
May assist with postural control
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16. Ashworth scale
0 – no increase in tone
1 – slight increase in tone given a
catch
2 – more marked increase in tone
3 – considerable increase in tone
PM difficult
4 – limb rigid in flexion and
extension (Ashworth scale, 1964)
8/20/2012 16
17. Modified Ashworth Scale
0 = no increase in muscle tone
1 = slight increase in muscle tone
(catch or min resistance at end
range)
1 + = slight increase in muscle
resistance throughout the range.
2 = moderate increase in muscle tone
throughout ROM, PROM is easy
3 = marked increase in muscle tone
throughout ROM, PROM is difficult
4 = marked increase in muscle tone,
affected part is rigid (Bohannon &
Smith 1987)
8/20/2012 17
18. Spasm Frequency
Spasm Frequency Scale: How many
spasms in the last 24 hours in the
affected extremity?
0 = no spasms
1 = 1 / day
2 = 1-5/ day
3 = 5-9 / day
4 = >10/day (Penn et al, 1989)
8/20/2012 18
20. Treatment Goals
Improve functional ability,
Quality of Life and Mobility
Decrease pain associated with
spasticity
Prevent or decrease incidence
of contractures
Ease of care are possible
Decrease Cost of Care
Facilitate hygiene
Ease rehabilitation procedures
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22. Remove noxious stimuli
Identify the “triggering” stimulus
Eliminate the factors that
increase sensory input to the
central nervous system
8/20/2012 22
28. Conclusions
While spasticity management can
be difficult, it may also improve
patient’s quality of life
Spasticity is not necessarily the
enemy, but is part of a pattern of
abnormal motor control
The choice of treatment depends
on pattern of involvement
8/20/2012 28
29. References
Akosile CO, Fabunmi AA (2011).
Pathophysiology, Functional Implications and
Management of Spasticity in Stroke – A Review.
AJPARS 3(1):6-12
Ashworth B (1964). Preliminary trial of
crisoprodol in multiple sclerosis. The
practitioners 192:540-2
Bohannon RW, Smith MB (1987). Interrater
reliability of a modified Ashworth scale of muscle
spasticity. PhysTher 67: 206-7.
8/20/2012 29
30. References cont
Karadag-Saygi E, Cubukcu-Aydoseli K, Kablan
N, Ofluoglu D (2010). The role of Kinesiotaping
combined with Botulinum Toxin to reduce
plantar flexors spasticity after stroke. Top Stroke
Rehabil; 17(4):318–322
Lundstromac E, Terentb A, Borgc J (2008).
Prevalence of disabling spasticity 1 year after
first-ever stroke. European Journal of Neurology
15: 533–539
8/20/2012 30
31. References cont
Urban PP, Wolf T, Uebele M, Marx JJ,
Vogt T, Stoeter P, Bauermann T, Weibrich
C, Vucurevic GD, Schneider A, Wissel J
(2010). Occurence and Clinical Predictors
of Spasticity after Ischemic Stroke. Stroke
41:2016-2020
Thompson AJ, Jarrett L, Lockley L,
Marsden J, Stevenson VL (2012). Clinical
management of spasticity. Available @
www.jnnp.bmj.com Retrieved on August
06 2012, Published by group.bmj.com
8/20/2012 31
32. Thank you
Questions
&
contributions
8/20/2012 32