Rayessa, SpR Stroke Western General and RIE Edinburgh Spasticity Rayessa, SpR Stroke Western General and RIE Edinburgh

Definition Velocity dependent Increased tone Exaggerated reflexes Supraspinal disinhibition of tonic and phasic stretch reflexes

In stroke 1/5-1/3 of hospitalised stroke patients More common in those with hemiparesis and severe strokes More common in arm than leg Contributes to disability in a minority of patients

Features Accompanied by muscle weakness and clumsiness Sometimes flexor or extensor spasms Immediate effect on tone is variable Tone usually greater in antigravity muscles

Effects Restricts active movement Imbalance in tone  shortening of muscles  permanent deformity  contractures Associated reactions: involuntary movements of affected side in response to stimuli( e.g. use of normal limb, upright posture)----significance? Honaga et al, Am J Phys Med Rehabil, Aug 2007

Morbidity Pain, deformity, disability If severe: pressure ulcers at points of contact

How to assess tone Ask patients to relax! ---NOT! Move the limb through its ROM at the joint at different speeds Remember tone influenced by patient’s position, fatigue, pain and drugs CHANGES all the time: poor inter-observer reliability

Scales Modified Ashworth scale: good for arm and knee, poor for ankle Quantitative neurophysiology and electrogoniometry: not widely available. Measure function or achievement of specific goal

Prevention and treatment Modulate changes in muscle tone to patient’s advantage Increase tone in legs and decrease it in arms

1}Exacerbating factors Treat/address: Pain Skin irritation Severe constipation Pressure ulcers Anxiety Any other unpleasant stimuli

2}Positioning and seating Poor positioning: supine extensor spasms Regular positioning helps Optimum position: no evidence Positioning charts : guides Nurses’ and therapists’ experience Balanced, symmetrical, stable: comfortable, able to reach the table

3}Passive movements and PT Passive stretch and maintain ROM Carers should be taught right techniques: careful about shoulders “overuse of sound side”:Use of unaffected side increases tone in affected limb “facilitation and inhibition” techniques: not evaluated in RCTs

Splinting and casting Necessary to prevent and treat contractures Improves ROM ?duration ?methods Badly fitted splints: pain, pressure effects, tendon damage

DRUGS Not well controlled, painful muscle spasms. Baclofen, dantrolene, diazepam,tizanidine Poor evidence base Start low, go slow

Local and regional treatment Botulinum toxin into muscles Short term safety good: repeated injections may be needed, expensive long term

Very troublesome Local injections with ethanol, phenol: beware SEs Intrathecal injections of baclofen Anterior or posterior rhizotomy DREZotomy Tendon lengthening and tendon transfers