spinal cord injury 12 - spasticity

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spinal cord injury 12 - spasticity
2013-04-22 09:43:08
spinal cord injury 12 spasticity

spring rosen and karpatkin
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  1. muscle tone def
    resting tension in a muscle evidenced by resistance to enlongation due to joint movement

    balance of excitatory and inhibitory influences on the spinal motor neuron innervating the muscel

    elastic properties of the muscle itself
  2. 3 elements of the neuropath behind spasticity
    • UMN lesion or lesion to descending pathways
    • loss of modulation to spinal reflexes
    • increased responiveness to afferent input
  3. monosynaptic stretch reflex (MSR)
    single synapse between the afferent and efferent limb of the reflex arc -- it's the fastest response in the nervous system
  4. def of spasticity and some nicknames
    • increased responsiveness of the monosynaptic stretch reflex (or a velocity dependant reaction to stretch)
    • aka - DTR, Ia reflex, phasic reflex
  5. spasticity is velocity dependent reaction to stretch but can also be due to these afferent inputs...
    • skin touch
    • pin prick (deformation of tissue give sensory input which leads to motor output)
    • pain
    • hair pull

    stress and fatigue can also stim this
  6. for whom is spasticity more problematic?
    incomplete > complete
  7. why is spasticity more problematic in incomplete than complete SCIs?
    remaining intact supraspinal descending inputs are no longer appropriate for reorganized spinal circuits --> greater motor dyscontrol
  8. sad spiral of spasticity
    as an agonist becomes spastic it resists stretching, so the tendon shortens, further resisting stretch ... so, got to maintain muscle range!
  9. what percent of SCIs report spasticity in frist year? what percent say it's problematic?
    • 60-80%
    • 30-40%, esp in cervical SCIs
  10. when will you see flacid paralysis in SCI?
    • spinal shock
    • damage to peripheral nerves
  11. basic scoring of the Modified Ashworth Scale
    for PROM

    • 0 = no increase in tone
    • 1 = catch and release
    • 1+ = cathc and then minimal resistance
    • 2 = resistance thru range, but movable
    • 3 = considerable resistance in range
    • 4 = can't move, rigid
  12. MAS pros and cons
    • pros: intra and inter-rater reliability
    • cons: only tests passive movement, only tests extremities and not trunk, doesn't account for effects of position or exertion, range is measured so contractures can --> false positives
  13. Tartdieu scale for spasticity
    • (used in research, but he doesn't know people who use it in practice)
    • test movement at 3 speeds: V1 = slower than gravity, V2 = gravity, V3 = faster than gravity
    • rate it 0=5 for resistance, clonus, immovable
  14. pendulum test for spasticity
    pt supine, leg off table, you drop the pt's leg and note where it reverses/bounces up/switces from flexing to extending

    silly test bc it's so unfunctional -- if you treated based on this you'd be treating the impairment, not the fxn
  15. Spinal Cord Assessment Tool for Spastic Reflexes (SCATS)
    looks at reflex respons to stim (pinprick, rapid flexion) -- doesn't look at spasticity in response to functional movement, onloy looks at ankle clonus, flexor reflex, and extensor reflex in the LE
  16. Penn Spasm Frequency scale measures...
    # of muscle spasms / hour
  17. Snow Spasme Frequency scale measures...
    • # spasms / day
    • (problem - this assumes that the # is what's problematic, doesn't record severity, is self reported)
  18. 24hr EEG for spasticity?
    feh - only works if spasms are in cortex, not spinal cord
  19. spasm vs spasticity
    • spasm = twitch
    • spasticity = an increase in resistance to sudden , passive movement and IS velocity dependent. The faster the passive movement the stronger the resistance.
  20. Sahrman & Norton's philosphy on how to treat spasticity
    they say spasticity is more a problem of agonist weakness than antag spasticity (it's a problem of decreased descending drive rather than resistance from the spastic antagonist, that's the primary factor limiting vol mvmnt)

    sooo, treat it by strengthening the muscle opposite to the spastic muscle... may help, may lead to increased spasticity
  21. how does stretching fight spasticity?
    • reduces the H-reflex in the able bodied (that's the measure of excitability of the MSR/monosynaptic stretch reflex)
    • prevents loss of sarcomees
    • prevents buildup of connective tissue
    • maintains ROM
  22. serial casting to treat spasticity?
    • prolonged stretching, w new cast increasing the ROM weekly
    • often paired w chemodenervation
  23. which drug treats spasticity at spinal origin?
    • baclofen - max doese: 80-100 mg
    • side effects: drowsiness, lethargy
  24. which drugs target reducing pain from spasticity?
    tizanidine, clonidine - act at CNS
  25. which drug for spasticity acts at the level of the contractile unit, not the CNS?
    • Dantrolene
    • (but like the others, will have global effects)
  26. chemodenervation
    • injection of phenol or alcohol blocks
    • acts at level of peripheral nerve
    • it dissolves the myelin sheath so the nerve goes flacid and the muscles contoled by that nerve turn off, so you can strengthen the agonist, fight contracture -- kind of a reset button ...may/maynot fix spasticity... neuroplasticity may help
  27. botox's role in battling spasticity?
    • inhibits acetylcholine release at neuromuscular junction
    • works at level of individual (big or small) muscle
    • UE > LE better responses
  28. which spasticity drug works at level of individual muscle?
    • botox -- it inhibits acetylcholine release at NMJ
    • can be used for big or small muscles, but is more effective UE>LE
  29. what to do if spasticity is refractory to oral meds?
    • intrathecal baclofen
    • (it's a neurosurgical procedure allowing for calibration of dosage for specific times. Measured in micrograms, rather than the milligrams of oral baclofen -- replaced 5-7 yrs)