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Treatment of Spasticity in the Adult Patient

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Treatment of Spasticity in the Adult Patient IC 30: Treatment of Spasticity in the Adult Patient Moderator(s): Lindley B. Wall, MD Faculty: Lindley B. Wall, MD, Allan E. Peljovich, MD, MPH, Ida K. Fox, MD, Michelle G. Carlson, MD, Michael S. Bednar, MD Session Handouts Friday, September 06, 2019 74TH ANNUAL MEETING OF THE ASSH SEPTEMBER 5 – 7, 2019 LAS VEGAS, NV 822 West Washington Blvd Chicago, IL 60607 Phone: (312) 880-1900 Web: www.assh.org Email: [email protected] All property rights in the material presented, including common-law copyright, are expressly reserved to the speaker or the ASSH. No statement or presentation made is to be regarded as dedicated to the public domain. Spasticity and Tetraplegia in the Adult Patient Lindley B. Wall-Stivers, MD, MSc Objectives • Develop a sense for the demographics and prevalence of spasticity and tetraplegia • Understand the presentation of patients with these conditions • Learn to evaluate spasticity and tetraplegia in the upper limb General • Allot more than 10 minutes • See the patient more than once • Understand the desires of the patient o What they want different, what they need for function o Specific tasks • Confirm reality – can not make them normal • Enlist the assistance of a therapist Physical Examination • Document in and out – stepwise o Strength testing • Assess tightness and ROM o (Shoulder) o Elbow o Forearm o Wrist o Digits o Thumb Tetraplegia • Level of injury – C2-4, C5, C6, C7 o Stabilization of injury • Muscle strength o Important for tendon transfers • Joint ROM o Need free passive motion • Goal: improve function, self-care • Social Support, emotional stability Stroke/Brain Injury • Severity of injury o Usually no improvement in involved extremity • Assess Joint ROM o Contractures • Muscle – volitional control, spasticity • Goal: Reduce pain, improve hygiene, improve aesthetics Cerebral Palsy • Assess control over extremity o Athetosis • Joint ROM o Passive and Active ROM • Muscle contracture • Muscle spasticity • Goal: function, hygiene care, improve aesthetics References 1. Gohritz A, Friden J. Tetraplegia management update. J Hand Surg Am 2015;40(12):2489-2500. 2. Tafti MA, SC Cramer, R Gupta. Orthopaedic management of the upper extremity of stroke patients. J Am Acad Orthop Surg 2008;16:462-470. 3. Leafblad ND, Van Heest AE. Management of the spastic wrist and hand in cerebral palsy. J Hand Surg Am 2015;40(5):1035-1040. 4. Bunata R, Icenogle K. Cerebral palsy of the elbow and forearm. J Hand Surg Am 2014;39(7):1425-1432. IC 30: Treatment of Spasticity in the Adult Patient The Treatment of Tetraplegia & Spasticity in the Adult Patient ASSH – Las Vegas September 6, 2019 Allan Peljovich, MD, MPH Shepherd Center; Hand & Upper Extremity Center of Georgia; Atlanta Medical Center Orthopedic Residency Program I. Principles of management a. Level of injury Disability i. Complete dependency C4 ii. Nearly independent C7 b. Hand & upper extremity function important principle of SCI care c. Classification systems i. ASIA/ISCoS ii. International Classification for Surgery of the Hand in Tetraplegia (ICT) 1. Precise and specific to tendon transfer based reconstruction iii. What the systems miss? 1. Spasticity 2. Peripheral innervation/denervation d. Challenges to functional restoration i. Paralysis is extensive ii. Does everyone qualify? 1. No…estimated 50-60% iii. Timing of reconstruction e. Solutions to the challenges of reconstruction i. Distill hand & upper extremity function into its most critical and basic elements ii. Reconstructive techniques 1. Non-operative 2. Surgical a. Tendon transfer based b. Nerve transfer based c. Hybrid tendon/nerve transfer d. Functional electrical stimulation i. External vs internal iii. Timing of surgery 1. Neurological stability II. Logistics a. Physical examination i. Skin ii. Musculoskeletal 1. Range of motion a. Is it functional range? i. Assessing for contractures 2. Examining wrist tenodesis effect closely iii. Neurological 1. Sensory 2. Motor 3. Any signs of spasticity? a. Prevalence 65% i. Cervical injuries > Thoracic/Lumbar injuries 1. Higher rate of incomplete injuries, i.e., central cord syndrome b. Nature of spasticity in SCI i. Significance 1. Requires pharmacologic therapy 35% 2. Interferes with function 25% 3. Triggers include system insult, i.e., infections, pressure sores, pain, full bladder, injury a. Sudden onset or increase should trigger a search for the underlying cause 4. Natural progression of untreated spastic muscles a. Spastic contracture myostatic contracture articular contracture b. Tremendous value in early treatment to maintain muscle length and joint mobility 5. Co-contraction spasticity a. Incomplete injuries b. Particularly difficult to treat c. Presentation i. Shoulder adduction/internal rotation ii. Elbow flexion/forearm supination 1. Elbow flexion contractures limit ability to self-care a. Abilities affected with contractures > 50 degrees when triceps is present, and > 25 degrees when triceps is weak iii. Intrinsic (affects grasp and release) 1. Intrinsic minus MCP extension (extrinsic extensor) spasticity 2. Intrinsic plus MCP hyperflexion spasticity iv. Random isolated muscle 1. FPL 2. EDC 3. Sometimes functionally advantageous, especially if it can be reliably and reproducibly triggered III. Surgical Reconstruction i. Preoperative planning 1. Securing resources 2. Coordinate and plan post-operative therapy ii. Formulating a plan of care 1. Understanding the individual’s needs and goals 2. Determine their current physical status a. ICT level 3. Reconcile 1 & 2 4. Reconstructive priorities a. Elbow extension b. Forearm position c. Wrist extension d. Lateral pinch and release e. Palmar grasp and release f. Digital intrinsics iii. Particulars of tendon transfer-based surgeries 1. Achieving elbow extension a. Biceps to triceps tendon transfer b. Posterior deltoid to triceps transfer 2. Achieving wrist extension a. ICT 1 and wrist extension < BMRC 3/5 i. Brachioradialis (Br) to extensor carpi radialis brevis (ECRB) 3. Achieving lateral pinch a. Author’s prioritized pinch pattern for ICT < 3 unless the patient has preference or need for grasp over pinch b. Flexor pollicis longus (FPL) activation for strength i. Tenodesis when ICT 1 ii. BR most commonly used ICT 2 iii. Pronator teres (PT) utilized if BR is alternately used for digital extension or thumb opposition c. Thumb is positioned to meet the lateral index i. In-situ – only if already positions well ii. Trapeziometacarpal (TMC) arthrodesis 1. Stability adds strength to pinch iii. Opposition-adductorplasty 1. Flexor digitorum sublimis (FDS) ring opponensplasty powered by BR 2. ICT 4 3. Better dexterity 4. Typically performed on the dominant thumb in bilateral reconstructions; otherwise TMC arthrodesis is performed. d. Interphalangeal joint is stabilized for strength & effectiveness i. Split FPL to extensor pollicis longus (EPL) tenodesis 1. Author’s preference ii. ELK (extensor pollicis longus-loop-knot) tenodesis 1. Recently described iii. Arthrodesis discouraged as it creates an inflexible digit e. Forearm/wrist level EPL tenodesis if wrist flexion fails to produce sufficient ‘release’ 4. Achieving palmar grasp a. ICT 3 (results better if ICT 4/5) b. Traditionally a 2-stage procedure i. Lateral pinch incorporated ii. Divided into extensor and flexor phases 1. Surgeries separated by 6-12 weeks 2. Can start with either ‘phase’ a. All stabilizing procedures completed during extension phase, i.e., thumb & intrinsics c. Flexor digitorum profundus (FDP) activated for grasp i. Extensor carpi radialis longus (ECRL) typical donor muscle ii. ‘Reverse cascade’ positioning d. Extensor digitorum communis (EDC) activation for ‘release’ i. Forearm-based tenodesis ii. Br as donor 1. PT used for FPL e. Digital intrinsics reconstructed to preserve MCP flexion & avoid less efficient intrinsic minus hand i. Zancolli lasso if digital tenodesis intact ii. ‘House’ tendon graft tenodesis if there is PIP lag with MCP flexion 5. Single-stage pinch and grasp procedure recently described a. ‘Alphabet’ procedure b. Takes advantage of newer, stronger tendon coaptation techniques that allow early activation of transfers. i. Negates the original need to perform these as 2-stage operations ii. Wrist extension 1. ECU is tenodesed to proximally to ulna to centralize otherwise radially deviating wrist extension iii. Lateral pinch 1. Br – FPL 2. TMC arthrodesis 3. Split FPL – EPL 4. EPL tenodesis iv. Palmar grasp (intrinsic function replaces EDC activation for release) 1. House intrinsic tenodesis for index – small 2. ECRL – FDP iv. What about nerve transfers? 1. Role is unclear, but much promise a. Limited data b. No comparative studies c. Unanswered concerns i. Some transfers ‘seem’ to sacrifice potentially critical muscles, i.e., Brachialis nerve branch 1. Biceps is not the primary elbow flexor 2. Precludes use of elbow extension using biceps transfer (strongest elbow extension) ii. Some described nerve transfers inconsistent with vetted concepts – modifications forthcoming? 1. Tip pinch (AIN activation) instead of lateral pinch 2. Utilizing ECRB for donor nerve creates less desirable radial deviation-wrist extension 3. Brachialis donor sacrifices the strongest elbow flexor and could have implications for manual wheelchair use iii. Reliability unclear, and depends upon the specific donor nerve 1. Tendon transfer rupture rates are < 10% a. And, can be salvaged 2. Donor and recipient muscle may be permanently denervated by the time a failure is recognized 2. Nerve transfer advantages a. Greatest advantage
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