Spasticity - Physical and Occupational Therapy Evaluation In Adult Patients with Spasticity

Spasticity

Physical and Occupational Therapy Evaluation In Adult Patients with Spasticity

Physical and Occupational Therapy Evaluation In Adult Patients with Spasticity
Kathleen Albany, PT, MPH
MF Brin, MD, editor
Muscle Nerve 1997; 20 (suppl 6):S221-S231.

Abstract: Physical and occupational therapists play important roles in the evaluation and management of patients receiving botulinum toxin injections for spasticity. Baseline evaluation includes areas beyond the muscles being injected, since local spasticity reduction may lead to more widespread functional changes. Because the evaluation itself influences tone, a consistent order of muscle evaluation is recommended. The range of preinjection assessments includes evaluation of tone, mobility, strength, balance, endurance, assistive devices, and others. After injection, therapeutic interventions have multiple aims, including strengthening and facilitation, increasing range of motion, retraining of ambulation and gait, improving the fit and tolerance of orthoses, and improved functioning in ADLs.

Key Points:

The sudden decrease in muscle tone brought on by BTX enables the therapist to focus on functional goals and implement interventions quickly and effectively

Since a decrease in spasticity in one area can precipitate functional changes in other associated or unanticipated areas, the evaluation must include areas beyond those being injected

With local spasticity suddenly reduced, the patient may present with a different clinical and functional picture and may be a candidate for therapeutic interventions not previously possible

Because the assessment measures themselves may influence tone, it is important to run the testing series in the same order each time

Standardized assessments for motor control that can be tested for validity and reliability have yet to be devised for use in the neurologic patient

A chief complaint of patients is the effort required and the fatigue that results when completing activities in the presence of moderate to severe spasticity

Therapeutic interventions for spasticity may be grouped into six categories: therapeutic exercise, gait training, ADL, modalities, positioning, and patient education

No research has been published to date analyzing the influence of BTX therapy on the effectiveness of physical or occupational therapy treatments

After injection, a priority for therapeutic intervention is strengthening and facilitation of the opposing and neighboring muscle groups

Decreased mobility and abnormal movement patterns may lead to under-stimulated proprioceptors and mechano-receptors

Following spasticity reduction, stimulation can be provided through a variety of techniques

Deviations in ambulation or gait immediately after BTX injections may reflect weakness in the antagonists, which may have been under-utilized in the presence of spastic agonists

Decreased spasticity and improvements in ROM and strength have considerable implications for ADLs such as dressing, bathing, feeding, and grooming

Modality use may continue as needed. It is prudent, however, to avoid modality use over the injection areas for a period of 10 days following injection, with clinical judgment guiding decisions thereafter

Patient compliance, skin tolerance, wearing schedule, and donning abilities for orthoses may be improved following a reduction in spasticity

Together, inhibitory casting and BTX may serve as an effective combination for problematic limb spasticity

Educating the patient is essential for carryover of the therapeutic program

Table 1: A Possible Order for Evaluation of Muscles in the Patient with Spasticity

Assessment in the patient with spasticity is complicated by the effect of the evaluation procedures on muscle tone; the exam influences that which it is measuring. The proper order of evaluation can minimize this influence, and performing the evaluation in the same order each time ensures consistency of effect between successive exams.

Muscle tone is assessed before any functional or other clinical assessments requiring movement or handling of the patient. The upper extremity precedes the lower, right precedes left.

The upper extremity is evaluated in the sitting position. As indicated below, the shoulder rotators, pronators, supinators, wrist flexors/extensors, and finger flexors are assessed with the elbow in 90° of flexion. Other muscle groups are assessed with the elbow extended.

The following order of muscles may be considered:

With elbow extended, evaluate:

Shoulder Flexors
Shoulder Extensors
Shoulder Adductors
Shoulder Abductors

With elbow flexed, evaluate:

Shoulder Internal Rotators
Shoulder External Rotators
Elbow Flexors (shoulder at 0° flexion)
Elbow Extensors
Pronators (elbow flexed 90°)
Supinators
Wrist Flexors
Wrist Extensors
Finger Flexors

The patient is positioned in supine for assessment of all muscle groups of the lower extremity except the knee flexors. The right side is assessed first, followed by the left. The patient is then positioned prone for assessment of the right, then the left, knee flexors.

The following order of muscles may be considered:

Supine

Hip Flexors
Hip Extensors
Hip Adductors
Hip Abductors
Knee Extensors
Ankle Plantarflexors
Ankle Dorsiflexors
Ankle Invertors
Ankle Evertors

Prone

Knee Flexors

The Modified Ashworth Scale assessment is executed first, followed by the Bilateral Adductor Tone measure, if required. Goniometric measurements for active and passive ROM follow muscle tone assessment. All other aspects of evaluation may then be executed.