1. Katherine Bosman-Clark BSN, RN MSN 621 Alverno College

2.  Mr. Johnson is a 75 year old male who suffered a stroke 4 months ago. Following his hospital stay he spent one month in an hospital-based inpatient rehabilitation program (rehab). He progressed well and was able to go home with a few adaptations made to his living space. He goes to a clinic several times a week for outpatient physical and occupational therapy. In the past few weeks he has noticed frequent jerking movements in his left arm. They are painful, involuntary and he finds them embarrassing.

3.  A look at the causes of one of the most common post-stroke side effects – spasticity  An understanding of the pathophysiology of spasticity  An overview of the most common treatments for spasticity

4. Spasticity is caused by ineffective transmission of nerve impulses. It is usually caused by a disturbance in an upper motor neuron and results in “intermittent or sustained involuntary contraction of muscles” (2). This condition has a significant impact on activities of daily living because of reduced range of motion, painful spasms, and muscle contractures (4).

5. What symptoms does Mr. Johnson have that indicate spasticity? Involuntary jerking in his arm. Right! Increased somnolence. This may occur after stroke, but is not related to spasticity. Try again! Continued need for therapy. Most patients need therapy post stroke, regardless of spasticity. Try again!

6. Spasticity is caused by incomplete transmission of impulses from alpha motor neurons of the brain (5, 8). Alpha motor neurons are responsible for innervating skeletal muscles with their cell bodies in the brain or spinal cord and axons ending in the skeletal muscles (2).

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8. GABA is the primary inhibitor of impulses crossing synapses in the central nervous system (CNS) (6). When GABA binds to its receptors, channels open allowing chloride ions into the cell and potassium ions out of the cell. (6). In spasticity receptors do not bind GABA effectively and consequently nerve impulses are not inhibited, leading to over contraction of the muscle.

9.  Contractures result when muscles are shortened for an extended period of time (8).  Spasticity exacerbates functional limitations associated with stroke (2).  In general, spasticity causes a decrease in a person’s functional independence.

10. How can spasticity negatively impact a patient? It doesn’t. Spasticity is a painful and inhibits patient’s ability to preform ADLs. Try again! Contributes to risk for anther stroke. Spasticity does not increase stroke risk. Try again! Can decrease quality of life. Right!

11.  Pharmacologic measures exist as effective treatments for spasticity (3)  Physical, occupational, and speech therapy all play important roles in treatment (2)  The patient and caregivers are also important for setting goals of treatment (2)

12. DrugMechanism of ActionSide Effects Baclofen (Lioresal)Structural analog of GABA (inhibitory transmitter of CNS) (2) Drowsiness, sedation, muscle weakness (2) Tizanidine (Zanaflex)Alpha-2 adrenergic agonist, binds to spinal receptors to block release of excitatory neurotransmitters (2) Drowsiness, dry mouth, weakness, hypotension, elevated liver function tests (2) Diazepam (Valium)Increases effects of GABA at CNS synapses (3) Fatigue, drowsiness, reduction in motor coordination (3) Dantrolene Sodium (Dantrium) Acts on skeletal muscles by reducing strength of contraction (3) Decrease in gross motor function (3)

13. What is a common side effect of oral agents used to treat spasticity? Drowsiness. Right! There are no negative side effects. All medications have side effects. Try again! Dysuria. Post-stroke spasticity does not impact the bladder. Try again!

14. Goals (6) Increase stretch in shortened muscles and tendons Decrease over-activity of muscles Improve muscle strength Increase muscle control Tools (2) Stretching programs tailored to the patient’s needs Braces and/or serial casting Electrical stimulation

15. What is the goal of therapy treatments for spasticity? To encourage use of medication Try again. Improve the patient’s quality of life Right! To provide work for PTs and OTs Try again.

16.  Spasticity post-stroke has the potential to greatly impact a patient’s quality of life  Although the causes of spasticity are not well understood, there are treatment options  Both pharmacologic and non-pharmacologic measures may be helpful in treating spasticity

17. 1) Alpha Motor Neuron. (September 12, 2011). Retrieved April 4, 2012 from Wikipedia: http://en.wikipedia.org/wiki/Alpha_motor_neuron. http://en.wikipedia.org/wiki/Alpha_motor_neuron 2) Francisco, G.E., & McGuire, J.R. (2009). Physiology and management of spasticity after stroke. In J. Stein, R.L. Harvey, R.F. Macko, C.L. Winstein, & R.D. Zorowitz (Eds.), Stroke Recovery and Rehabilitation (413-436). New York, NY: DemosMedical. 3) Gallichio, J. (2004). Pharmacologic management of spasticity following stroke. Physical Therapy, 84 (10), 973-981. 4) Kumar, R. T., Pandyan, A. D., Sharma, A. K. (2006). Biomechanical measurement of post-stroke spasticity. Age and Ageing, 35, 371-375. 5) National Institute of Neurologic Disorders and Stroke, National Institutes of Health. (2011, October 4). NINDS Spasticity Information Page. Retrieved April 4, 2012 from http://www.ninds.nih.gov/disorders/spasticity/spasticity.htm. http://www.ninds.nih.gov/disorders/spasticity/spasticity.htm 6) Porth, C. M. & Matfin, G. (2009). Pathophysiology Concepts of Altered Health States (8 th ed.) (pp.1189-1190). New York, NY: Lippincott, Williams &Wilkins. 7) Satkunam, L. E. (2003). Rehabilitation medicine: 3. Management of adult spasticity. Canadian Medical Association Journal, 169 (11), 1173-1179. 8) Vanek, Z.F., Berman, S.A. (2010). Spasticity. Retrieved April 4, 2012 from http://emedicine.medscape.com/article/1148826-overview. http://emedicine.medscape.com/article/1148826-overview Walker, B. (2012). Understanding the Stretch Reflex, picture. Retrieved April 24, 2012 from http://www.thestretchinghandbook.com/archives/myotatic-stretch- reflex.php.http://www.thestretchinghandbook.com/archives/myotatic-stretch- reflex.php