3. Post-stroke Spasticity
ā¢ 67,289 episodes of stroke were
admitted to public hospitals in the
period 2005-20151: >6000/year
ā¢ Largest cause of long-term
physical disability2
ā¢ Prevalence of spasticity : 33-50% 3
ā¢ Lower functional ability at 12
months
3
1. Singapore Stroke Registry Annual Report 2015
2. Singapore National Stroke Association
3. Kong et al: Occurrence and Temporal Evolution of Upper Limb
Spasticity in Stroke Patients Admitted to a Rehabilitation Unit. Arch Phys
Med Rehabil 2012 Jan;93(1):143-8
4. Pathophysiology
Li S and Francisco GE (2015) New insights into the
pathophysiology of post-stroke spasticity. Front. Hum.
Neurosci. 9:192
A motor disorder characterized by a
Velocity-dependent,
Increase in tonic stretch reflexes
With exaggerated tendon jerks
Resulting from hyperexcitability of
the stretch reflex
8. Design and Development Model
Design
Identify the problem
Recruit expert panel
Design solutions
Develop
Prototype
Gather consensus
Review and redesign
Validate
Pilot
Review
Roll out
8
9. Spasticity care pathway
Referral sources: Post inpatient discharge, Outpatient Stroke-Hand clinic
General spasticity Regional and focal spasticity
Oral agents
Therapist: Exercises and Splints Determine Contracture Versus Spasticity
SpasticityContracture
ā Lengthening
procedures
ā FDS to FDP transfer
ā Osteotomy
ā Arthrodesis
Patient has volitional
control?
No
ā Observe
ā Prevent
contracture
Botox injectionYes
Improvement
seen
ā Hyperselective
neurectomy
ā Tendon transfer
No improvement
ā Observe
ā Repeat Botox
ā Contracture
release
10. Aims:
Improve function, reduce pain, improve posture/ care
Treatment objectives
a. Reduce tone
b. Improve range of motion
b. Improve joint position
c. Select cases for neurectomy
Improve Function
1. Reduce spasm
frequency
2. Pain relief
3. Improve gait,
ADLs, hygiene,
ease of care
For the patient and
caregiver
1. Improve
appearance
2. Improve self-
confidence
3. Improve
independence
11. Referral Criteria
Spasticity in upper / lower limb from
ā¢ Cerebrovascular accidents
ā¢ Brain / Spinal cord injury
ā¢ Traumatic
ā¢ Atraumatic
ā¢ Neurodegenerative disorders
ā¢ Multiple sclerosis
ā¢ Amyotrophic lateral sclerosis
Medically stable to undergo an elective
procedure in an outpatient setting
12. Patient selection
Inclusion criteria
ā¢ Hemiplegia or monoplegia
ā¢ Has good prognosis for recovery
ā¢ Functionally good ( some volition/Botox
trial/House)
Exclusion criteria
ā¢ Bedbound patients (except for hygiene and
nursing purposes)
15. Non-surgical
1. Tone reduction
modalities
a. Medications: muscle relaxants
such as baclofen,
benzodiazepines
b. Injections: Botox
2. Physical Therapy
a. Stretching
b. Adaptive strategies and devices
c. Incorporation of spastic limb in
ADLs
d. Post-op: immobilization,
mobilization, incorporation
3. Orthoses
Surgical
1. Tendon/ muscle
procedures
a. Muscle/tendon lengthening
i. Fractional lengthening
ii. Z lengthening
iii. Muscle slide
b. Tendon transfers
2. Joint/Bone procedures
a. Arthrodesis
b. Osteotomy
3. Nerve procedures
a. Neurectomy
4. Amputations
16.
17. - Reduce spasticity in target muscles
Technique:
ā¢ Follows motor ramus until entry point into
target muscle
Improves
ā¢ Selectivity
ā¢ Widespread partial denervation
ā¢ Durability of results
18. ā¢ Systematic review: 7 studies, 174
patients
ā¢ Percentage of fascicles ablated
between 30-80%
ā¢ Length of neurectomy: 5-10mm
ā¢ Remove end branches vs fascicular
selective neurectomy proximally
ā¢ All had improvement in spasticity
ā¢ Recurrence rate: 0-16.1%
19. 17 Stroke
6 received Botox
3
underwent
HSN
1 underwent
tendon
lengthening
22 patients
3 Focal dystonia2 CP
ā¢ 12 Male, 5 Female
ā¢ Mean age 62.9 years
ā¢ Reviewed average 9months
post-stroke
2 received Botox
1
underwent
HSN
1 received Botox
1
underwent
HSN
28. Right LL:
ā¢ FDL, FHL spasm
ā¢ Severe spasm on certain days
ā¢ Causes clawing of toes and pain
ā¢ Coping with gait fairly well with orthosis
ā¢ FHL and FDL spasticity when he walks
37. Welcome to Singapore for the 2023 APFSSH & APFSHT meeting!
www.apfssh2023.org
Proposed dates:
17-20 May 2023 (Wed to Saturday) OR
24-27 May 2023 (Wed to Saturday)
Editor's Notes
Result of hyperexcitability of the stretch reflex
Secondary to damage to the neurons of the corticospinal tracts,
Loss of inhibitory supraspinal influences
Characterised by
Velocity-dependent increase in tonic stretch reflexes (āmuscle toneā)
With exaggerated deep tendon reflexes
Complex problem
Need for an integrated care pathway for these patients
Post Stroke Spasticity Pathway developed using expert panel
Requires MDT approach for optimum treatment
MDTs are seen to be effective in Asian contexts of chronic stroke management, like that of Japanās Stroke Rehabilitation Unit (SRU) in Bobath Memorial Hospital, Osaka. And in Korean contexts as well. No surgeons involved
Evidenceā rehab paper
Volition, house ,
6 patients received Botox injection
3 patients underwent hyperselective neurectomy in upper limb
1 patient with contractures underwent tendon lengthening procedure
Nerve stimulation
Hand function based on house classn; no improvement
Multidisciplinary team approach ensures seamless process for stroke patients with problems of upper limb spasticity
Highly selective neurectomy useful technique to relieve spasticity while preserving function
Need for authentic and patient experienced outcome measures
Effect for neurectomies
Cognitive load in spasticity