Boise State University ScholarWorks Psychological Sciences Faculty Publications and Department of Psychological Science Presentations 10-4-2012 Optimal Management for People with Severe Spasticity Jeffrey S. Shilt Saint Alphonsus Health Systems Pennie S. Seibert Boise State University Vivek Kadyan Saint Alphonsus Health Systems This document was originally published by Dovepress in Degenerative Neurological and Neuromuscular Disease. Copyright restrictions may apply. DOI: http://dx.doi.org/10.2147/DNND.S16630 Degenerative Neurological and Neuromuscular Disease Dovepress open access to scientific and medical research Open Access Full Text Article REVIEW Optimal management for people with severe spasticity Jeffrey S Shilt1 Abstract: Spasticity is characterized by velocity-dependent increase in tonic stretch reflexes Pennie S Seibert2 and tendon jerks. Many people affected by spasticity receive late treatment, or no treatment, Vivek Kadyan1 which greatly reduces the potential to regain full motor control and restore function. There is much to consider before determining treatment for people with spasticity. Treatment of pedi- 1Idaho Spasticity Program, Saint Alphonsus Health Systems, Boise, ID, atric patients increases the complexity, because of the substantial difference between adult and 2Department of Psychology, Boise pediatric spasticity. Proper patient evaluation, utilization of scales and measures, and obtaining State University, Boise, ID, USA patient and caregiver history is vital in determining optimal spasticity treatment. Further, taking into consideration the limitations and desires of individuals serve as a guide to best management. We have grouped contributing factors into the IDAHO Criteria to elucidate a multidisciplinary approach, which considers a person’s complete field of experience. This model is applied to goal setting, and recognizes the importance of a spasticity management team, comprising the treatment subject, his/her family, the environment, and a supportive, well-informed medical staff. The criteria take into account the complexity associated with diagnosing and treating spasticity, with the ultimate goal of improved function. Keywords: spasticity treatment modalities, pediatric spasticity management, optimal management for spasticity Introduction Spasticity is clinically described as a motor disorder, characterized by a velocity- dependent increase in tonic stretch reflexes and exaggerated tendon jerks, resulting from hyper-excitability of the stretch reflex, as one component of the upper motor neuron syndrome. Many diseases and injuries affecting the central nervous system (CNS) result in impairment of neuromuscular function, manifested as spasticity. Cerebral palsy (CP), multiple sclerosis (MS), traumatic brain injury (TBI), spinal cord injury (SCI), and cerebrovascular accident (CVA) are commonly encountered condi- tions that result in this neuromuscular dysfunction. In people with spasticity, neural impulses misfire, resulting in symptomatology that can affect both the upper and lower extremities. An estimated 500,000 people in the United States, and twelve million people worldwide, experience spasticity.1 Yet, many of those affected are neglected, or treated late for their spasticity, and relegated to salvage treatment of end effects on the mus- Correspondence: Pennie Seibert culoskeletal system. This approach leaves little hope for regaining full motor control 1055 N Curtis Road, Boise, ID 83706, USA and restoring pre-disease or pre-injury function. Tel +1 208 367 6750 When treating spasticity, it is imperative to understand its functional effects, and Fax +1 208 367 6836 Email [email protected] recognize that spasticity is not always deemed detrimental by the affected person, submit your manuscript | www.dovepress.com Degenerative Neurological and Neuromuscular Disease 2012:2 133–140 133 Dovepress © 2012 Shilt et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article http://dx.doi.org/10.2147/DNND.S16630 which permits unrestricted noncommercial use, provided the original work is properly cited. Shilt et al Dovepress or their caregiver. In its mildest form, spasticity may substitute Though formal motion analysis in a gait lab is ideal, for muscular weakness, aid in the preservation of muscle mass, observational analysis with simple video is inexpensive, less and decrease the prevalence of deep venous thrombosis.2 labor- and time-intensive, and is often equally informative. However, spasticity is damaging in its more severe forms. We highly recommend obtaining video during an initial, Spasticity causes imbalanced muscle forces that act upon bones, thorough baseline physical therapy visit, when possible. joints, and the muscles themselves. This imbalance results in Many picture archiving and communicating systems store bony angular and torsional deformities, subluxation/dislocation these videos alongside radiographic studies, making them of joints, capsular contractions, and muscle shortening. These readily accessible. findings were substantiated by Mercer Rang, who studied During these initial sessions, passive range of motion spastic mice that had developed restricted joint range, restrictive is assessed during different velocities of movement to muscle excursion, and bony degeneration.3 These findings measure contracture and degree of spasticity. The Modified are considered to be the musculoskeletal ramifications of Ashworth Scale (MAS) is the most-utilized scale to measure spasticity. Other skeletal ramifications include pain, casting spasticity. Since its inception, however, the validity and or bracing challenges, skin complications, and challenges reliability of MAS has been challenged. To address issues for fracture management.4 Additionally, spasticity impacts with MAS, the Modified Modified Ashworth Scale (MMAS) children differently than adults. Spasticity during growth was developed. In the revised scale, the ambiguity of the compounds the soft tissue ramifications of increased tone. This 1+ grade has been omitted, and grade 2 has been redefined. is highlighted by excessive muscle shortening and abnormal MMAS ranges from 0–4: 0 = no increase in muscle tone; bone growth, as a result of the imbalanced muscle forces acting 1 = slight increase in muscle tone, manifested by a catch upon growth plates.5,6 and release, or by minimal resistance at the end of the range Many aspects are considered before deciding on treat- of motion when the affected part(s) is moved in flexion or ment options for individuals with spasticity. These aspects extension; 2 = marked increase in muscle tone, manifested not only include present-time quality of life, comfort, and by a catch in the middle range and resistance throughout the function, but also future impairments, which may present remainder of the range of motion, but the affected part(s) is as the result of growth, or expected decline in strength with easily moved; 3 = considerable increase in muscle tone, with age. Assessment of these aspects includes the patient’s and passive movement being difficult; and 4 = affected part(s) the caregiver’s perspectives.7 is rigid in flexion or extension.12 Though MMAS is not cur- rently widely used, studies have supported the reliability of Patient evaluation the scale.13 It allows grades to be more clearly defined, and While it is easily recognized that severe TBI, CVA, and a provides for better clinical practice. variety of neurological disorders can result in spasticity, If appropriate, active motion is assessed for measures the actual diagnosis of spasticity is more complex. The of function, timed functional trials, fatigability and repeat- complexity arises from challenges in distinguishing among ability, and selective motor control. A number of scales abnormal patterns of muscle tone, such as volitional guard- exist, which are used with the appropriate diagnoses and ing, contracture, dystonia, paresis, paratonia, and rigidity.4,8–10 underlying impairment.14 Furthermore, other movement disorders may be present in Though physical examination is a critical component of addition to spasticity. The incidence of these other movement patient evaluation, the patient and caregiver history is also disorders varies, depending upon the underlying etiology. It integral to determining optimal treatment for spasticity. can be very frequent in cerebral palsy, rare following stroke Understanding the limitations that each person experiences (3.7%), and nonexistent following spinal cord injury.11 as a result of the spasticity, as well as understanding their Establishing the presence of accompanying movement respective desire for tone reduction and strengthening, helps abnormalities is important, as many of these are unaffected guide best management. For example, with adults who rely by traditional treatments for spasticity, and may appear more upon stand-pivot transfers, and depend upon their spasticity prominent when spasticity is reduced. Observation of the to achieve this task, and who have either a low desire or an patient during tasks, and in ambulation, can identify these inability to strengthen adequately, intrathecal baclofen may additional movement disorders by their salient features.12 not be the optimal choice to reduce spasticity. On the other Video analysis is extremely helpful in diagnosis, and hand, a very motivated young child, with substantial growth serves as a useful aid in detecting change following treatment. remaining, and a supportive family, may be an excellent 134 submit