Chapter 26 Spasticity

Question 1

Spasticity is a disorder characterized by a __________ increased resistance to __________ stretch, associated with exaggerated tendon jerks, resulting from hyperexcitability of the __________. Spasticity is part of the __________ syndrome, which includes the positive symptoms of spasticity and uninhibited flexor reflexes in the lower limbs and the negative symptoms of weakness and poor dexterity.

Answer 1

Spasticity is a disorder characterized by a velocity-dependent increased resistance to passive stretch, associated with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex. Spasticity is part of the UMN syndrome, which includes the positive symptoms of spasticity and uninhibited flexor reflexes in the lower limbs and the negative symptoms of weakness and poor dexterity.

Question 2

Indications for treating spasticity include ______, decreased function, ______, skin breakdown, poor cosmesis, and poor positioning.

Answer 2

Indications for treating spasticity include pain, decreased function, poor hygiene, skin breakdown, poor cosmesis, and poor positioning.

Question 3

Potential factors that may be exacerbating spasticity (e.g., ______, ______, bowel impaction, ingrown toenails, and ______) should be addressed.

Answer 3

Potential factors that may be exacerbating spasticity (e.g., pressure ulcers, UTIs, bowel impaction, ingrown toenails, and SSRIs) should be addressed.

Question 4

Care should be taken before treating any spasticity that may be utilized functionally (e.g., __________).

Answer 4

Care should be taken before treating any spasticity that may be utilized functionally (e.g., hypertonia in the lower limbs assisting transfers or gait).

Question 5

A _______ program should be the cornerstone for most spasticity treatment programs. _______, _______, or bracing can help preserve ROM by “resetting the _______.”

Answer 5

A stretching program should be the cornerstone for most spasticity treatment programs. Splints, casting, or bracing can help preserve ROM by “resetting the muscle spindles.”

Question 6

Contractures can be reduced by ________ a joint (i.e., increasing the stretch stepwise for 1 to 2 days at a time), although this technique is not always well-tolerated and may lead to _______.

Answer 6

Contractures can be reduced by serially casting a joint (i.e., increasing the stretch stepwise for 1 to 2 days at a time), although this technique is not always well-tolerated and may lead to skin breakdown.

Question 7

___________ (>15 minutes) may be helpful transiently by reducing the hyperexcitability of the muscle stretch reflex and reducing nerve conduction velocities.

Answer 7

Cryotherapy (>15 minutes) may be helpful transiently by reducing the hyperexcitability of the muscle stretch reflex and reducing nerve conduction velocities.

Question 8

___________ (>15 minutes) can improve function and reduce tone for hours after the _________ (thought to be due to neurotransmitter modulation at the spinal cord level).

Answer 8

Functional electrical stimulation (>15 minutes) can improve function and reduce tone for hours after the stimulation (thought to be due to neurotransmitter modulation at the spinal cord level).

Question 9

Hippotherapy, which involves ________ movements, is found useful in spasticity reduction in ________ limbs.

Answer 9

Hippotherapy, which involves rhythmic movements, is found useful in spasticity reduction in lower limbs.

Question 10

In treating spasticity, Other modalities include application of _______, cold, warmth, vibration, massage, low-power laser, and acupuncture.

Answer 10

Other modalities include application of tendon pressure, cold, warmth, vibration, massage, low-power laser, and acupuncture.

Question 11

Oral Medications – These may be indicated for ________ spasticity.

Answer 11

Oral Medications – These may be indicated for nonfocal spasticity.

Question 12

FDA-approved medications include _______, _______, _______ (clonidine), and tizanidine. Recently, offlabel use of _______ has shown promising results in the treatment of spasticity in a small group of MS patients undergoing a crossover study.

Answer 12

FDA-approved medications include baclofen, diazepam, dantrolene (clonidine), and tizanidine. Recently, offlabel use of gabapentin has shown promising results in the treatment of spasticity in a small group of MS patients undergoing a crossover study.

Question 13

Botulinum Toxin-A (BTX-A) – BTX irreversibly blocks _________ by _________. BTX-A (Botox and Allergan) is FDA-approved for _________, _________, and _________ and most recently for severe glabellar (between the eyebrows) frown lines. It is also widely used for spasticity and myofascial pain with favorable results. Onset of effect is typically _________ hours. Peak effect is at _________ weeks. Clinical efficacy is typically up to _________ months. Recovery is due to _________.

Answer 13

Botulinum Toxin-A (BTX-A) – BTX irreversibly blocks NMJ transmission by inhibiting presynaptic ACh release. BTX-A (Botox and Allergan) is FDA-approved for blepharospasm, strabismus, and cervical dystonia and most recently for severe glabellar (between the eyebrows) frown lines. It is also widely used for spasticity and myofascial pain with favorable results. Onset of effect is typically 24 to 72 hours. Peak effect is at 2 to 6 weeks. Clinical efficacy is typically up to 3 to 4 months. Recovery is due to axonal sprouting.

Question 14

Advantages of BTX-A over phenol include _________ into the injected area (up to 3 to 4 cm), making injections technically easier, and the absence of _________ (since it is selective for the NMJ)

Answer 14

Advantages of BTX-A over phenol include ready diffusion into the injected area (up to 3 to 4 cm), making injections technically easier, and the absence of dysesthesias (since it is selective for the NMJ)

Question 15

BTX-B (Myobloc) – BTX-B was FDA-approved in 2000 for _________. Clinically, it is used for similar indications as BTX-A, although the units are markedly different (initially, 2,500 to 5,000 U of BTX-B divided among the affected muscles). BTX-B may be effective in patients who have _________ due to repeated use.

Answer 15

BTX-B (Myobloc) – BTX-B was FDA-approved in 2000 for cervical dystonia. Clinically, it is used for similar indications as BTX-A, although the units are markedly different (initially, 2,500 to 5,000 U of BTX-B divided among the affected muscles). BTX-B may be effective in patients who have developed resistance to BTX-A due to repeated use.

Question 16

Phenol (carboxylic acid) – Phenol destroys nerves in a dose-dependent manner, with onset within ______ hour and a duration that can last ______ (duration varies widely in the literature).

Answer 16

Phenol (carboxylic acid) – Phenol destroys nerves in a dose-dependent manner, with onset within 1 hour and a duration that can last years (duration varies widely in the literature).

Question 17

There are _______ distinct BTX subtypes. The BTX _______ chain binds to the presynaptic end plate and the receptor–BTX complex is internalized by endocytosis. The _______ chain of BTX-A lyses _______, a protein needed for fusion of ACh vesicles with the presynaptic membrane.

Answer 17

There are seven distinct BTX subtypes. The BTX heavy chain binds to the presynaptic end plate and the receptor–BTX complex is internalized by endocytosis. The light chain of BTX-A lyses SNAP-25, a protein needed for fusion of ACh vesicles with the presynaptic membrane.

Question 18

Phenol injections can be combined with BTX injections during a single session, which may be especially useful when there are ______ concerns (i.e., phenol for ______, ______ muscles and BTX for ______, ______ muscles).

Answer 18

Phenol injections can be combined with BTX injections during a single session, which may be especially useful when there are BTX dosage concerns (i.e., phenol for large, proximal muscles and BTX for smaller, distal muscles).

Question 19

Advantages of Phenol over BTX include _______, _______, and longer duration of effect.

Answer 19

Advantages of Phenol over BTX include low cost, lack of antibody formation, and longer duration of effect.

Question 20

Disadvantages versus BTX include the greater technical skill involved and potential for ________, although the latter can be reduced by limiting injections to relatively accessible motor branches of nerves (e.g., pectoral, musculocutaneous, obturator, inferior gluteal, and branches to hamstrings, gastroc–soleus, and tibialis anterior) and avoiding mixed nerve injections (main tibial or median nerve).

Answer 20

Disadvantages versus BTX include the greater technical skill involved and potential for dysesthesias, although the latter can be reduced by limiting injections to relatively accessible motor branches of nerves (e.g., pectoral, musculocutaneous, obturator, inferior gluteal, and branches to hamstrings, gastroc–soleus, and tibialis anterior) and avoiding mixed nerve injections (main tibial or median nerve).

Question 21

A trial with a ________ prior to phenol neurolysis can be helpful in predicting the potential effects.

Answer 21

A trial with a local anesthetic (e.g., marcaine, 0.25% to 0.5%) prior to phenol neurolysis can be helpful in predicting the potential effects.

Question 22

Intrathecal Baclofen (ITB) – ITB is indicated for severe spasticity (Ashworth grade ______ ) 2° to ______ (FDA-approved in 1992) and severe spasticity of ______ origin (FDA-approved in 1996).

Answer 22

Intrathecal Baclofen (ITB) – ITB is indicated for severe spasticity (Ashworth grade ≥ 3) 2° to SCI (FDA-approved in 1992) and severe spasticity of cerebral origin (FDA-approved in 1996).

Question 23

A trial of _______ or a _______ with external pump is often given before implantation of an internal pump.

Answer 23

A trial of epidural baclofen or a subarachnoid catheter with external pump is often given before implantation of an internal pump.

Question 24

A screening trial of epidural baclofen might be as follows: ______ mg epidural bolus on day 1; if not efficacious, ______ mg on day 2; if prior doses not successful, ______ mg on day 3. A drop in spasticity of ≈ ______ Ashworth grades during the trial may roughly predict efficacy of the implanted pump.

Answer 24

A screening trial of epidural baclofen might be as follows: 50 mg epidural bolus on day 1; if not efficacious, 75 mg on day 2; if prior doses not successful, 100 mg on day 3. A drop in spasticity of ≈2 Ashworth grades during the trial may roughly predict efficacy of the implanted pump.

Question 25

The pump is typically placed in the ______ to be away from the appendix. The pump is typically refilled every ______ weeks depending on the dosage being administered and the size of the pump. The patient must be committed to being compliant with seeing the physician for refills of the medication. The battery lasts about ______ years (the pump must be removed to replace the battery).

Answer 25

The pump is typically placed in the LLQ to be away from the appendix. The pump is typically refilled every 4 to 12 weeks depending on the dosage being administered and the size of the pump. The patient must be committed to being compliant with seeing the physician for refills of the medication. The battery lasts about 5 years (the pump must be removed to replace the battery).

Question 26

Potential problems with the implanted system include infection, catheter kinking or dislodgment, and _______ 2° to CSF leak out of the catheter site.

Answer 26

Potential problems with the implanted system include infection, catheter kinking or dislodgment, and headaches 2° to CSF leak out of the catheter site.

Question 27

The __________ procedure can be an effective treatment for the spastic equinovarus foot. The lateral portion of the __________ is reattached to the __________ and __________ bones. __________ tendon lengthening usually accompanies the SPLATT.

Answer 27

The split anterior tibial tendon transfer (SPLATT) procedure can be an effective treatment for the spastic equinovarus foot. The lateral portion of the split distal anterior tibialis tendon is reattached to the third cuneiform and cuboid bones. Achilles tendon lengthening usually accompanies the SPLATT.

Question 28

Selective dorsal rhizotomy may be of some benefit in _______. The procedure involves _______ and exposure of the _______. The dorsal rootlets are stimulated individually, and rootlets that produce abnormal EMG responses in limb musculature (believed to be contributing to spasticity) are then severed. _______ rootlet lesions are undesirable as denervation atrophy may follow, with resultant skin breakdown. Favorable selection criteria for rhizotomy include spastic CP (without athetosis), age between 3 and 8 years, HO prematurity, good truncal balance, and a supportive family.

Answer 28

Selective dorsal rhizotomy may be of some benefit in CP. The procedure involves laminectomy and exposure of the cauda equina. The dorsal rootlets are stimulated individually, and rootlets that produce abnormal EMG responses in limb musculature (believed to be contributing to spasticity) are then severed. Anterior rootlet lesions are undesirable as denervation atrophy may follow, with resultant skin breakdown. Favorable selection criteria for rhizotomy include spastic CP (without athetosis), age between 3 and 8 years, HO prematurity, good truncal balance, and a supportive family.