Fw: Understanding Spasticity Fundamentals

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I got this off the Spinal Cord Injury List I am on. I thought some of you

might be interested.

Take Care,

Brande, RHIT

mymocha@...

> Understanding Spasticity Fundamentals

> An essential skill in the care of patients with CNS disorders and injuries

> By Catharine M. Farnan, MS, RN, CRRN, & Saulino, MD, PhD

>

> Spasticity is a complex phenomenon that affects many persons living with

> central nervous system diseases. Key points of this challenging topic

> include advantages and disadvantages of spasticity, various management

> strategies with special emphasis on the intrathecal baclofen therapy and

> nursing interventions for patients living with spasticity.

>

> Background

>

> The word " spasticity " originates from the Greek word for " to tug or to

> draw. " The appearance of spasticity has been described as more difficult

to

> quantify and to characterize than to recognize. Spasticity is one of the

> hallmarks of upper motor neuron disorders (i.e. involving the brain and/or

> spinal cord). It can be an important impairment for the nurse caring for

> patients with these diseases. Simply stated, spasticity is stiffness of

> muscles and occurs when injury to the spinal cord or brain prevents nerve

> signals from reaching areas of the spinal cord that release the

> neurotransmitter gamma aminobutyric acid (GABA).

>

> This substance is believed to assist in allowing muscles to relax. After

an

> injury, this neural system is disrupted and the muscles remain

> uncontrollably tight. Disorders such as stroke, cerebral palsy, multiple

> sclerosis, spinal cord and brain injuries can be associated with

spasticity.

>

> A review of the literature puts forth the definition of spasticity as a

> motor disorder characterized by a velocity-dependent increase in tonic

> stretch reflexes (tone) with exaggerated tendon jerks, resulting from

> hyperexcitability of the stretch reflex. It is fundamental to understand

> that muscle tone is a sensation of resistance as one moves a joint through

> range of motion, with the patient attempting to relax. Muscle tone

involves

> three key points: physical inertia of the limb, elastic-mechanical

> characteristics of muscular and connective tissue, and reflex muscle

> contraction (tonic stretch reflexes). Changes in spastic muscles can lead

to

> stiffness, contracture, fibrosis or muscular atrophy.

>

> Before any intervention is undertaken to modulate hypertonicity, it is

> important to attempt to assess spasticity severity. Three grading scales

are

> commonly used to quantify this syndrome. These grading systems address the

> degree of muscle tone, the frequency of spontaneous spasms and the extent

of

> hyperreflexia. These scales are described in Table 1.

>

> Advantages and Disadvantages

>

> Spasticity can have both desirable and undesirable effects. It can be used

> to assist with mobility, especially by those patients with some voluntary

> motor control. It can be useful in maintaining posture. It can improve

> circulation and may be useful for decreasing the risk of deep vein

> thrombosis. It may decrease the risk of osteoporosis in affected limbs.

> Spasticity can assist in maintaining muscle mass and bulk. It can aid in

> reflexive bowel and bladder function. Conversely, spasticity can also

> interfere with positioning, mobility, and hygiene. In patients with

> voluntary muscle movement, spasticity can interfere with dexterity.

>

> It can limit the range of motion about a joint and result in pain.

Excessive

> hypertonia has been linked to increased metabolic demands. Spontaneous

> spasms can interfere with sleep or duration of wheelchair use. These

spasms

> can lead to skin breakdown because of a shearing effect or due to poor

> healing of surgical wounds due to tension along suture lines. A decision

to

> intervene must consider both the positive and negative aspects of a

> patient's spasticity. Additionally, the practitioner may not desire

complete

> elimination of spasticity, rather titration the hypertonia to maximize the

> risk / benefit ratio. Thus, any antispasticity regimen must be customized

to

> the individual patient.

>

> Spasticity can be modulated by a number of factors. Stretching of the

> involved muscles has been demonstrated to be efficacious in spasticity

> reduction. Continuous or static stretching is preferred over short

duration

> or ballistic stretching. Long duration stretch techniques can be applied

> manually or can utilize adaptive equipment, such as casts or splints.

Other

> therapeutic modalities such as cold application and transcutaneous

> electrical nerve stimulation units can decrease hypertonicity in some

> patients. Co-morbidities of neurological disease can serve as " triggers "

for

> increased spasticity. Any patient with a sudden change in their spasticity

> pattern should be queried for these noxious stimuli. Examples would

include

> urinary tract infections, bladder distention, urolithiasis, bowel

impaction,

> decubitus ulcers, osteomyelitis, etc. These interventions should be

> undertaken prior to initiation of medical treatment.

>

> Nursing interventions for positioning patients with spasticity can be

> significant for many patients. Key points in positioning patients with

> spasticity in bed are aimed at maintaining range of motion and improving

> respiratory and gastrointestinal (an effect of trunk extension) as well as

> the advantages described above.

>

> Specific actions include:

>

>

> Patients with mild to severe spasticity should have their head, torso and

> affected extremities positioned in opposite position to normalize tone.

>

> Patients with spasticity tend to adduct shoulders and hips, which can

result

> in contractures. Ideal positioning includes positioning their extremities

> with the shoulder and hip abducted.

>

> Promote weight-bearing positions.

>

> Combine positioning with maximizing relaxation techniques such as music,

> fans for cooling, fluids, bathing/showering or reducing stimuli such as a

> full bladder, infection, bowel and skin problems.

>

> Coordinate splint, bivalve casts with a positioning schedule and place

> pictorial or photo over bedside for continuity.

>

> For patients with a combination pattern of extension and flexion (which is

> often the scenario of patients with spasticity) aim to position the

patient

> out of these patterns to increase normal movement and tone.

> Treatment Options

>

> If pharmacological treatment of spasticity is warranted, health care

> providers have a number of available agents at their disposal. Table 2

> summarizes the major oral medications that are used for spasticity

> reduction. Individualized treatment regimens are common with some patients

> requiring multiple medications for effective management. Some drugs

require

> laboratory monitoring (specifically, treatment with tizadine and

dantrolene

> mandates monitoring of liver function tests). Monitoring of medication

> levels is unnecessary since the efficacy of these medications is

determined

> by clinical means. It is important to recognize that many patients require

> medication amounts that are above the FDA-advised limits. It is reasonable

> to consider treatment above these limits if the patient is achieving

> inadequate hypertonicity reduction and is not experiencing serious side

> effects.

>

> Occasionally non-oral agents are utilized for spasticity management. This

> would include neurolytic blockage with phenol or Botulinium toxin as well

as

> intrathecal baclofen. The underlying principle of neurolytic blockade is

the

> use of a chemical agent to induce a contained amount of neural destruction

> that results in a decrement in neuromuscular hyperactivity. Phenol can be

> injected into either muscles or nerves. This substance denatures the

protein

> structures within these tissues. Botulinium toxins are injected into the

> involved muscles and migrate to the neuromuscular junction. These toxins

> inhibit the release of acetylcholine into the synaptic cleft. This

blockade

> results in a controlled degree of paralysis within the injected muscle.

> Currently, there are two Botulinium toxins commercially available in the

> United States: type A (Botox®) and type B (Myobloc®).

>

> Intrathecal baclofen therapy is an advanced spasticity management

technique

> that delivers baclofen directly to the central nervous system. This

delivery

> system is indicated when patients are poorly controlled with their current

> regimen or poorly tolerant of other treatments. It is also useful when

> patients require the precise control that the intrathecal delivery system

> affords. Patients must be clinically stable (i.e. greater than one year

> post- central nervous system injury, not in an exacerbation, etc.)

> understand the risks and benefits of therapy and have resources available

to

> return to clinic for refills.

>

> This therapy delivers medication from a small pump directly to the

> cerebrospinal fluid (i.e. the intrathecal space). The pump is about the

size

> of a hockey puck (3.5 x 3.5 inches) and is implanted surgically in the

> abdominal subcutaneous tissue. A catheter is attached to the pump and then

> tunneled along the patient's flank to the vertebral column. The catheter

> then pierces the dura and is left unattached within the intrathecal space.

> The implantation of this pump and catheter system is accomplished via 2 or

3

> incisions (abdominal and lumbar and possibly flank). Patients are usually

> hospitalized for a few days for this procedure. One of the more common

> complications of pump implantation that may require nursing intervention

is

> spinal headache. Classically, spinal headache has an orthostatic component

> that is present when the patient is upright and relieved when the patient

is

> supine. Treatment of spinal headache can include bedrest, overhydration,

> caffeine, abdominal binder placement and in recalcitrant cases epidural

> blood patch.

>

> Immediately following implant, baclofen leaves the pump's reservoir,

travels

> within the catheter and enters the cerebrospinal fluid. Intrathecal

baclofen

> dosing is adjusted by utilizing a radiotelemetry portable computer. In the

> immediate post-implant phase, the patient is maintained on his/her

baseline

> amount of oral antispasticity medication. This protocol is used to prevent

> any withdrawal syndrome. Over the intervening weeks, the oral medications

> are slowly weaned off as the intrathecal baclofen dosage is titrated.

>

> Patients with intrathecal baclofen pumps require chronic maintenance care.

> The pump's reservoir is refilled with additional medication every 1-3

> months, depending on the individual patient's dosage. Reservoir refills

are

> a sterile, office-based procedure. The patient is continually assessed for

> any potential pump malfunction. Any dramatic change in the patient's

> spasticity pattern should prompt an evaluation. Potential problems of this

> therapy include catheter disruption, failure to refill the pump reservoir

> and failure of the pump's power source. In order to avoid this last

> complication, patients should be electively scheduled for battery

> replacement every 4-5 years. Abrupt disruption of intrathecal baclofen can

> be a serious scenario with continuous spasms, tremors, temperature

> elevation, seizure and death having been reported.

>

> Critical to the success of intrathecal baclofen therapy is the nurse's

> in-depth knowledge of spasticity, astute assessment as oral baclofen is

> weaned and intrathecal baclofen is titrated upwards, and mechanics of the

> pump and its potential complications. Post pump implantation, nurses need

to

> closely monitor the patient's respiratory status for depression and

educate

> both family and patient to the side effects of the baclofen. In

> collaboration with the physician and other members of the team, these

> interventions are beneficial.

>

> Conclusion

>

> A fundamental knowledge of spasticity is essential in the quality nursing

> care of many patients who are living with a variety of central nervous

> system disorders and injuries. At times spasticity can be functional for

the

> patients who need it for transfers, but often it may be painful and

> interfere with basics of hygiene and activities of daily living. The

> management of spasticity can be as intricate as the phenomenon itself.

> Nurses can improve painful spasticity by understanding how positioning

> affect tone. Intrathecal baclofen therapy is one advanced method of

> management in the gamut of interventions for people who live with

spasticity

> everyday.

>

> Table 1 - Spasticity assessment systems

> Scale Assessment measure

>

> Ashworth scale

> Degree of muscle tone

>

> 0

>

> 1

>

> 2

>

> 3

>

> 4

> No increase in tone

>

> Slight increase in tone

>

> More marked increase in muscle tone but affected limb easily moved

>

> Considerable increase in muscle tone, passive movement difficult

>

> Affected part is rigid and in flexion or extension

>

> Spasm scale Intensity of spasms

>

> 0

>

> 1

>

> 2

>

> 3

>

> 4

> No spontaneous or elicited spasms

>

> No spontaneous spasms, spasms elicited with vigorous stimulation

>

> Occasional spontaneous and easily inducible spasms

>

> More than 1, but fewer than 10 spontaneous spasms per hour

>

> More than 10 spontaneous spasms per hour

>

> Reflex scale Degree of hyperreflexia

>

> 0

>

> 1

>

> 2

>

> 3

>

> 4

>

> 5

> Absent

>

> Hyporeflexive

>

> Normoreflexive

>

> Mild hyperreflexia

>

> 3-4 beats clonus

>

> Greater than 4 beats of clonus

>

>

>

> (Clonus is a repetitive cyclical contraction between agonist and

antagonist

> muscle groups when a rapid stretch is applied)

>

> Table 2: Oral Pharmacological agents for the treatment of spasticity

> Drug

> Neuro-transmitter affected

> Daily

> Dosage

> Range

> Common side effects

> Comments

>

> Baclofen (Lioresal®)

> GABAB

> 5-200 mg in 3-6 divided doses

> Sedation

> Confusion

> Withdrawal Syndrome

> Intrathecal delivery available

>

> epam (Valium®)

> GABAA

> 2-40 mg in 1-4 divided doses

> Sedation

> Confusion

> Withdrawal Syndrome

> Intravenous delivery available

>

> Clonidine

> (Catapress®)

> a-2 adrenergic

> 0.1-2.4 mg in 2-4 divided doses

> Hypotension

> Sedation

> Transdermal delivery available

>

> Tizadine

> (Zanaflex®)

> a-2 adrenergic

> 2-36 mg in 1-3 divided doses

> Hypotension

> Sedation

> Hepatotoxicity

> Need to check liver function tests every few months

>

> Dantrolene

> (Dantrium®)

> Intracellular calcium

> 25-400 mg in 1-4 divided doses

> Hepatotoxicity

> Nausea

> Need to check liver function tests every few months

>

> Gabapentin

> (Neurontin®)

> Exact mechanism unknown

> 300-3600 mg in 1-4 divided doses

> Leukopenia

> Dizziness

> Ataxia

>

>

>

>

> Resources

>

> Delhaas, E.M., & Brouwers, J.R. (1991). Intrathecal baclofen overdose:

> Report of 7 events in 5 patients and review of the literature.

International

> Journal of Clinical Pharmacology, Therapy, Toxicology, 29(7), 274-280.

>

> Elovic, E. (2001). Principles of pharmaceutical management of spastic

> hypertonia. Physical Medicine and Rehabilitation Clinics of North America,

> 12, 793-816.

>

> Francisco, G.E. (2001). Intrathecal baclofen therapy for stroke-related

> spasticity. Topics in Stroke Rehabilitation, 8, 36-46.

>

> Gracies, J.M. (2001). Pathophysiology of impairment in patients with

> spasticity and use of stretch as a treatment of spastic hypertonia.

Physical

> Medicine and Rehabilitation Clinics of North America, 12, 747-768.

>

> Gracies J.M., et al. (1997a). Traditional pharmacological treatments for

> spasticity. Part I. Local treatments. Muscle Nerve Supplement, 6, S61-S91

>

> Gracies J.M., et al. (1997b). Traditional pharmacological treatments for

> spasticity. Part II. General and regional treatments. Muscle Nerve

> Supplement, 6, S92-S120

>

> Hickey, J. (1997). The Clinical Practice of Neurological and Neurosurgical

> Nursing. 4th Edition. Philadelphia: Lippincott & Wilkins.

>

> Hinderer, S.R., & Dixon, K. (2001). Physiologic and clinic monitoring of

> spastic hypertonia. Physical Medicine and Rehabilitation/Clinics of North

> America, 12, 733-746.

>

> Ivanhoe, C.B., Tilton, A.H., & Francisco, G.E. (2001). Intrathecal

baclofen

> therapy for spasticity hypertonia. Physical Medicine Rehabilitation

Clinics

> of North America, 12, 923-938.

>

> Marquardt, G., & Seifert, V. (2002). Use of intrathecal baclofen for

> treatment of spasticity in amyotrophic lateral sclerosis. Journal of

> Neurology, Neurosurgery, and Psychiatry, 72(2), 275-276.

>

> Meythaler, J.M. (2001). Concept of spastic hypertonia. Physical Medicine

and

> Rehabilitation/Clinics of North America, 12, 725-732.

>

> Meythaler, J.M., et al. (2001). Intrathecal baclofen for spastic

hypertonia

> from stroke. Stroke, 32(9), 2099-2109.

>

> Meythaler, J.M., et al. (1999). Long-term continuously infused intrathecal

> baclofen for spastic-dystonic hypertonia in traumatic brain injury: 1 year

> experience. Archives-Physical Medicine and Rehabilitation, 80(1), 13-19.

>

> Pettibone, K.A. (1988). Management of spasticity in spinal cord injury:

> Nursing concerns. Journal of Neuroscience Nursing, 20, 217-222.

>

> Sampson, F., et al. (2002). Functional benefits and cost/benefit analysis

of

> continuous intrathecal baclofen infusion for the management of severe

> spasticity. Journal of Neurosurgery, 96, 1052-1057.

>

> Savoy, S.M., & Gianino, J.M. (1993). Intrathecal baclofen infusion: An

> innovative approach for controlling spinal spasticity. Rehabilitation

> Nursing, 18, 105-113.

>

> Stempein, L., & Tsai, T. (2002). Intrathecal baclofen pump use for

> spasticity: A clinical survey. American Journal of Physical Medicine and

> Rehabilitation, 79(6), 536-541.

>

> Stretler, T. (1997). Rehabilitation Nursing Procedures Manual. 2nd

Edition.

> New York: McGraw-Hill. 99-103.

>

> Catharine M. Farnan is a clinical nurse specialist in the department of

> nursing at Jefferson University Hospital and Dr. Saulino is

> an assistant professor in the department of rehabilitation medicine at

> Jefferson University, Philadelphia.

>

>

>

>

>

>

> Return to www.advancefornurses.com

>

>

> http://www.advancefornurses.com/pastarticles/sept16_02feature1.html

>

>

>

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