By Ramon A. Gil, M.D. –
This is May: “Stroke Awareness Month” and you may have already heard that in 2011 Stroke became the 4th, no longer the 3rd, cause of death in this country. This great achievement does not resolve other aspects of this huge public health problem. Stroke remains the number 1 cause of severe long term disability, and it is expected that, unless risks factors such as Obesity, Diabetes and Smoking are drastically reduced in our country, we may be facing a rise in the incidence of Strokes in the very near future. A critical factor leading to disability in stroke survivors is what we want to bring to your attention today. This is the most underdiagnosed and undertreated complication of Stroke. It is called Post Stroke Spasticity.
It is estimated that there are more than 4.5 million stroke survivors in the USA, and nearly 800,000 people suffer a stroke every year. Nearly 80% of stroke victims developed Spasticity and less than half are receiving adequate treatment.
What is Spasticity?
The term Spasticity refers to the stiffness affecting some of the muscles in the affected side of the body, which often leads not only to severe disability with a significant degree of functional impairment, but pain as well as increased burden on the caregiver who often has to struggle as he or she works very hard stretching those stiff joints trying to assist the patient to perform basic activities of daily living such as applying deodorant, getting dressed, or washing the palm of the hand. In one of the CME Courses for Medical Personnel that we organized a few years ago, our dear friend, Dr. Gerard Francisco, Director of the Department of Physical Medicine and Rehabilitation at the University of Texas Medical School in Houston, explained to the audience that a “very simple method to assess the degree of spasticity affecting the upper extremity in a stroke survivor was, rather than clinical scales or complex methods, to simply smell the affected hand, often with a “clenched fist.” Not only hygiene is compromised, but often the nails cut the skin of the palm and could potentially lead to serious infections. Similar problem occurs with maceration of the skin at the elbow or at the axillary region.
Spasticity also affects the gait, the balance, the use of braces or splints. It leads to pain, increases the rate of falls and reduces quality of life. Without adequate medical treatment, stroke survivors often spend months and even years receiving useless or very unproductive “rehabilitation treatments.” We often compared this tragic situation as “trying to rehabilitate a limb with a cast on.”
The treatment of Spasticity involves the use of different medications as well as surgical treatments for some selected patients. The oral agents Baclofen, Tizanidine and Dantrolene are the most commonly used. They work relaxing the muscles, but unfortunately the effective doses are almost always associated with side effects such as drowsiness, confusion, hallucinations and increased risk of falls. These problems very often prevent the use of these agents.
Following a stroke, a group of muscles in the affected limbs will become “overactive” (stronger, spastic, tonically contracted) and the opposite muscles are weakened. In the arm, the flexor muscles are spastic and the extensors are weak. In the leg, one tends to see the opposite (extensor muscles becoming spastic, and flexor muscles are weakened by the stroke). These patterns lead to the typical posture of the stroke survivors, having the arm in a flexion posture (including the wrist) and a clenched fist, and an extended leg with plantar extension. Onabotulinum toxin type A (Botox) is approved for the treatment of upper limb spasticity. Abobotulinum toxin type A (Dysport) is also being used (off label). These agents (BoTN’s) impair the communication between the nerve endings and the muscles, therefore, the muscles don’t contract effectively becoming weaker as the muscle tone is reduced.
Another very important treatment for Spasticity is Intrathecal Baclofen Pump. This device was approved by the FDA in the 1980’s. It delivers a liquid form of Baclofen directly into the spinal canal and it is not only very effective, but it reduces the side effects of the oral preparation to practically “nothing.” The pump is implanted in the abdominal wall and we refill the reservoir at variable intervals depending on the type of pump (20 or 40 cc) and the patient’s dose in 24 hours.
Using a hand held computer, we interrogate and adjust the settings of the pump as needed by the individual patient. Patients with severe spasticity affecting one or both legs (as often seen in Multiple Sclerosis patients or Spinal Cord problems) will benefit significantly from this modality of treatment.
Physical and the Occupational therapists interventions are a critical part of the treatment. Oral agents, BoTN’s and even surgical interventions won’t do as well as they could without the involvement of well trained therapists. Their participation in the treatment enhances tremendously the effect of BoTN’s injections and maximizes the functional status of the patient and improving quality of life.
If you or a loved one suffered a stroke and have some questions in reference to Post Stroke Spasticity, take advantage of our FREE SCREENINGS. For more details or to make an appointment, contact us at 941-743-4987.
Ramon A. Gil, M.D.
Medical Director, Parkinson’s Disease
Parkinson’s Disease Treatment Center of SW Florida