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

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

3. 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

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

5. 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

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

7. 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

8. 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

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

11. 1}Exacerbating factors
Treat/address:
Pain
Skin irritation
Severe constipation
Pressure ulcers
Anxiety
Any other unpleasant stimuli

12. 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

13. 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

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

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

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

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