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Thread: Treating Post-Stroke Spasticity

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    Treating Post-Stroke Spasticity

    Treating Post-Stroke Spasticity


    Cindy Ivanhoe, MD; Baylor College of Medicine, TX






    Related Webcasts
    When Muscles Won't Relax: Understanding Post-Stroke Spasticity
    Treating Post-Stroke Spasticity: What Your Doctor Needs to Know
    State-of-the-Art Treatments for Post-Stroke Spasticity
    Recovering Your Life: Rehabilitation after a Stroke
    Treating Stroke: How to Reduce the Damage

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    The treatment of stroke patients has seen several advances in recent years and among the most significant are two therapies for a post-stroke condition called spasticity. A common physical response to brain injury caused by stroke, spasticity causes muscles in the arms or legs to tighten uncontrollably, causing pain and discomfort. Left untreated, spasticity can have a profound impact on an individual's quality of life.
    Below, Dr. Cindy Ivanhoe of the Baylor College of Medicine, offers an introduction to post-stroke spasticity, and emerging treatment options.

    First, what is spasticity?
    CINDY IVANHOE, MD: Spasticity is a resistance in the muscles to stretch after an injury to the central nervous system. That injury can be the result of a stroke, multiple sclerosis, tumors, and a whole host of different diagnoses.

    And what are the symptoms of this condition? What does it actually do to those who suffer from it?
    When patients have spasticity, they may have a fixed clenching of their hand, or flexion of their fist. They may have trouble getting their arm away from their body so that it's difficult to clean under their arm. They may have abnormal posture. Patients may try to walk, but their feet want to turn inward. You may see patients whose legs will cross each other when you try to transfer them or when you try to clean them. Those are some of the things that you'll see in spasticity.

    What are the long-term effects of this condition?
    The type of recovery patients can have over time will be limited by spasticity if they don't receive appropriate treatment for it. They can have pain associated with their spasticity, or pain associated with attempts to move their joints. And if we don't try to move their joints, they'll have more pain over time. So spasticity really has a major effect, I think often an underestimated effect, on the quality of life of our patients.

    Some spasticity is focal, and some is more generalized. How are they different?
    Focal spasticity affects a smaller part of the body, such as a hand or an extremity. Generalized spasticity affects greater areas of the body.

    What are the traditional treatments for spasticity?
    Many people will start the treatment of spasticity with oral medications, which can relax the affected muscles that are causing the spasticity. The oral medications that are most commonly used for spasticity are diazepam (Valium), dantrolene, oral baclofen and tizanidine, or Zanaflex, which is a relatively new medication.

    But oral medications will very often cause sedation in patients, or lethargy. They may also increase their confusion.

    The medications also will affect their entire body, so if you're trying to target specific muscles, it makes little sense to give medications that affect the whole body.

    Are there any new treatment alternatives for focal spasticity?
    For focal spasticity, I generally use botulinum toxin A, or Botox, because it's a way to target smaller areas with injections rather than treating people with medications that will involve systemic side effects.

    Botox is an off-label therapy for spasticity, which means it is not as yet FDA-approved for the use of spasticity. It's not uncommon for physicians to use medications already approved for other conditions, and the Botox injections have had a positive impact in treating patients with focal spasticity. Botox is one of the first really effective, new treatments that we've had for focal spasticity in decades.

    Botox works by entering nerve endings around the muscle where it is injected, and blocking the release of chemical messages that cause the muscle to contract. Is this correct?
    Yes. It allows us to target specific muscles. And there are no sedating side effects.

    What are its known side effects?
    It has a really low side-effect profile. Patients may have a little bit of bleeding at the site of an injection. They may have a little bit of tenderness during the injection. Some patients have had some flu-like symptoms for a while following an injection, but overall, the side effect profile is quite limited.

    How long does the effect of a Botox injection last?
    On the average, Botox injections last approximately three months.

    And what are the latest treatment options for people living with generalized spasticity?
    The intrathecal baclofen, or ITB therapy, is a relatively new treatment, which has had a dramatic effect on the lives of my patients with generalized spasticity.

    What is ITB therapy?
    It's a pump that's implanted under the skin that is connected to the area around the spinal cord and is able to deliver medication continuously, providing a greater effect on larger muscles. It can also affect smaller muscle groups, as well. You can vary the amount of medication with time of the day, and it has the most dramatic effect on spasticity in the lower extremities and trunk, and to a less predictable degree, the upper extremities.

    What is the medication used in ITB therapy?
    It's called baclofen, and originally, people used oral baclofen to treat spasticity. But because oral baclofen does not penetrate into the brain very easily, it would take high doses of medication to get a small amount into the central nervous system. With the intrathecal baclofen pump, or ITB therapy, we are able to deliver very minute amounts of baclofen directly into the central nervous system.

    What is the benefit of the pump over the oral baclofen?
    Because ITB delivers such a small amount of medication, patients don't have the same sedation,lethargy, and weakness that you see with the oral medication. Additionally, the effects of the medication given intrathecally are much greater than the effects of the medication given orally.

    How is the pump implanted?
    Usually the pump is implanted in the lower abdomen, and then a catheter is tunneled under the skin and threaded up into the intrathecal space around their spinal cord to deliver the medication.

    Who is a good candidate for ITB therapy?
    I have stroke patients who had intrathecal baclofen pumps who are in a vegetative state, who have no true interaction with their environment. I also have stroke patients who have come to me who were walking at the time that I prescribed the baclofen pump, but they wanted to be able to walk better, or were concerned about degenerative changes in their joints as they aged, and those patients are often candidates for ITB therapy as well. So there's a whole spectrum of people who would be appropriate candidates for this therapy.


    Copyright 2002 Healthology, Inc
    http://abcnews.go.com/sections/livin...ity020716.html

  2. #2
    Senior Member Max's Avatar
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    Treating Post-Stroke Spasticity: What Your Doctor Needs to Know

    Treating Post-Stroke Spasticity: What Your Doctor Needs to Know
    Hosted by: Mabel Jong, Freelance journalist

    Participants:
    Alberto Esquenazi, MD - MossRehab, Albert Einstein Medical Center, PA
    Nathaniel H. Mayer, MD - MossRehab, Albert Einstein Medical Center, PA


    Webcast Transcript: Recorded Live: May 2 2002

    MABEL JONG: Hello and welcome to our webcast. I'm Mabel Jong. Spasticity is a complication after stroke or other brain injury where the muscles typically in the arm or leg contract involuntarily, often causing pain and restricting movement. It's a significant issue but one that is often overlooked because of the many other changes in a person's body after a stroke.
    Here to talk about the treatment for spasticity and why it's so important to talk to your doctor about it are Dr. Nathaniel Mayer and Dr. Alberto Esquenazi, both of MossRehab at the Albert Einstein Medical Center in Philadelphia. Gentlemen, thanks so much for being with us.

    Well, first, Dr. Esquenazi, could you describe for me what spasticity is and why it's significant for stroke patients?

    ALBERTO ESQUENAZI, MD: Many patients after they have a stroke develop damage to their brain will develop this term spasticity, which is an increase in the muscle tightness, the muscle stiffness and the muscle activity that occurs when they have a lesion to their brain. And what it does is it basically prevents the patient from being able to function in a normal manner. Their arm or their leg might not be able to move in a normal fluid manner and so would require that they either be aided to dress or to walk or that they may have discomfort, pain or difficulty even washing their hands or feet. And being able to reduce that spasticity will make a big difference in the way they function.

    MABEL JONG: Dr. Esquenazi, what are some of the latest treatment options?

    ALBERTO ESQUENAZI, MD: There are a variety of new treatment options that traditionally spasticity has been treated with pills. And one of the major problems of using oral agents is that they do have side effects. And there are two new modalities of treatment. One is an injectable treatment in which you use Botox or botulinum toxin that is directly injected into a particular muscle and has really no side effects other than affecting the muscle that you want to relieve spasticity from.

    The second new intervention is intrathecal Baclofen. So you take the same medication that you would give by mouth, but this time you insert a very thin catheter, a very thin tube into the spinal cord and through a pump you can deliver medication very precisely just to the spinal cord and reduce the tendency for side effects.

    MABEL JONG: How should one go about talking to their doctor about this condition?

    NATHANIEL H. MAYER, MD: I think that when you go to the physician you have to emphasize what's really bothersome. That is, what is really problematic. You can't take a global view and say, "I can't move and I want to be able to move" because that may not be something that would be entirely possible. But if you tell the physician that your fingernails are digging into the palm, that you can't open your hand to wash, that you can't open your elbow to wash or to put on a sleeve or a coat, then those are very specific complaints that the physician can then say, "Well, if I'm not sure about this, I might be able to refer you to a specialist who does deal with the problem of a foot turning in, or fingernails digging into the palm or that sort of thing."

    MABEL JONG: Now, Dr. Mayer, what are the barriers that exist for patients trying to receive the right treatment for them?

    NATHANIEL H. MAYER, MD: Very often when a patient tries to find out what can benefit them, they're told that "Well, you've had a stroke and we can't reverse the problem in the brain so there really isn't very much more you can do about it except to just live with the problem." And actually a lot can be done if you understand what the stroke has done to muscles. And so physicians who make analysis of muscles and movements often can find many things that can be done for the patient. So this is a great barrier. The barrier with respect to the understanding about the possibilities for rehabilitation.

    MABEL JONG: Now, Dr. Esquenazi, are there patients who are suffering from this unnecessarily?

    ALBERTO ESQUENAZI, MD: Oh, of course. There is no doubt that you can treat this in a way that the patients can feel much more comfortable, that they can have less impose less burden into their families and caretakers. This is something that is treatable, something that can easily be managed when it's done appropriately and where there are specific goals. And it's unfortunate that many patients after a stroke are dealt as individuals that have no further goals. The reality is that there is life after a stroke and there are things that can be done to improve them and make them feel more functional.

    MABEL JONG: Now I had mentioned that this is an issue that is often overlooked among the many other problems that patients are facing after a stroke. Why is that?

    NATHANIEL H. MAYER, MD: People are overwhelmed by the basic problems that they have. When you have a stroke, it often means that you have problems with blood vessels elsewhere in the body. These are life-threatening issues and therefore patients' complaints about their everyday lives may seem to be less significant. And from one perspective, it is less significant but when it's your pain on stretching, when it's your difficulty putting an arm into a sleeve, when it's your difficulty walking, that is a big deal.

    MABEL JONG: If you treat this condition, does it help you overcome some of the other problems associated with stroke?

    ALBERTO ESQUENAZI, MD: Well, I don't know if it helps you overcome some of the problems, but it certainly reduces the possibility of developing side effects or developing other complications. If you are walking on a foot that is turned in, or your nails start digging into your palm, you can develop skin breakdown and with that an infection that then is going to require treatment with antibiotic. And that can have it's own series of side effects. So you're trying to really act in or work in a proactive manner.

    MABEL JONG: And Dr. Mayer, how do you determine what is best for a patient?

    NATHANIEL H. MAYER, MD: A good history tells you 80% and then a physical examination gives you the other 15-20%. But physicians have the basic tools to ask these questions and to make the evaluations and if the general physician, the internist feels that some of these issues are beyond their knowledge, they can refer to a neurologist who specializes in treatments of spasticity or to a physiatrist, somebody who is in the field of physical medicine and rehabilitation.

    MABEL JONG: Dr. Mayer, Dr. Esquenazi, thanks for joining us today.

    ALBERTO ESQUENAZI, MD: Thank you.

    MABEL JONG: And thank you for watching our webcast. I'm Mabel Jong.



    © 2002 Healthology, Inc.
    http://lancasteronline.healthology.c...online&spg=NIP

  3. #3
    Senior Member Max's Avatar
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    Treating Post-Stroke Spasticity

    Treating Post-Stroke Spasticity


    Written by:
    Cindy Ivanhoe, MD - Baylor College of Medicine, TX


    Published on: 2002-07-11

    The treatment of stroke patients has seen several advances in recent years and among the most significant are two therapies for a post-stroke condition called spasticity. A common physical response to brain injury caused by stroke, spasticity causes muscles in the arms or legs to tighten uncontrollably, causing pain and discomfort. Left untreated, spasticity can have a profound impact on an individual's quality of life.
    Below, Dr. Cindy Ivanhoe of the Baylor College of Medicine, offers an introduction to post-stroke spasticity, and emerging treatment options.

    First, what is spasticity?
    CINDY IVANHOE, MD: Spasticity is a resistance in the muscles to stretch after an injury to the central nervous system. That injury can be the result of a stroke, multiple sclerosis, tumors, and a whole host of different diagnoses.

    And what are the symptoms of this condition? What does it actually do to those who suffer from it?
    When patients have spasticity, they may have a fixed clenching of their hand, or flexion of their fist. They may have trouble getting their arm away from their body so that it's difficult to clean under their arm. They may have abnormal posture. Patients may try to walk, but their feet want to turn inward. You may see patients whose legs will cross each other when you try to transfer them or when you try to clean them. Those are some of the things that you'll see in spasticity.

    What are the long-term effects of this condition?
    The type of recovery patients can have over time will be limited by spasticity if they don't receive appropriate treatment for it. They can have pain associated with their spasticity, or pain associated with attempts to move their joints. And if we don't try to move their joints, they'll have more pain over time. So spasticity really has a major effect, I think often an underestimated effect, on the quality of life of our patients.

    Some spasticity is focal, and some is more generalized. How are they different?
    Focal spasticity affects a smaller part of the body, such as a hand or an extremity. Generalized spasticity affects greater areas of the body.

    What are the traditional treatments for spasticity?
    Many people will start the treatment of spasticity with oral medications, which can relax the affected muscles that are causing the spasticity. The oral medications that are most commonly used for spasticity are diazepam (Valium), dantrolene, oral baclofen and tizanidine, or Zanaflex, which is a relatively new medication.

    But oral medications will very often cause sedation in patients, or lethargy. They may also increase their confusion.

    The medications also will affect their entire body, so if you're trying to target specific muscles, it makes little sense to give medications that affect the whole body.

    Are there any new treatment alternatives for focal spasticity?
    For focal spasticity, I generally use botulinum toxin A, or Botox, because it's a way to target smaller areas with injections rather than treating people with medications that will involve systemic side effects.

    Botox is an off-label therapy for spasticity, which means it is not as yet FDA-approved for the use of spasticity. It's not uncommon for physicians to use medications already approved for other conditions, and the Botox injections have had a positive impact in treating patients with focal spasticity. Botox is one of the first really effective, new treatments that we've had for focal spasticity in decades.

    Botox works by entering nerve endings around the muscle where it is injected, and blocking the release of chemical messages that cause the muscle to contract. Is this correct?
    Yes. It allows us to target specific muscles. And there are no sedating side effects.

    What are its known side effects?
    It has a really low side-effect profile. Patients may have a little bit of bleeding at the site of an injection. They may have a little bit of tenderness during the injection. Some patients have had some flu-like symptoms for a while following an injection, but overall, the side effect profile is quite limited.

    How long does the effect of a Botox injection last?
    On the average, Botox injections last approximately three months.

    And what are the latest treatment options for people living with generalized spasticity?
    The intrathecal baclofen, or ITB therapy, is a relatively new treatment, which has had a dramatic effect on the lives of my patients with generalized spasticity.

    What is ITB therapy?
    It's a pump that's implanted under the skin that is connected to the area around the spinal cord and is able to deliver medication continuously, providing a greater effect on larger muscles. It can also affect smaller muscle groups, as well. You can vary the amount of medication with time of the day, and it has the most dramatic effect on spasticity in the lower extremities and trunk, and to a less predictable degree, the upper extremities.

    What is the medication used in ITB therapy?
    It's called baclofen, and originally, people used oral baclofen to treat spasticity. But because oral baclofen does not penetrate into the brain very easily, it would take high doses of medication to get a small amount into the central nervous system. With the intrathecal baclofen pump, or ITB therapy, we are able to deliver very minute amounts of baclofen directly into the central nervous system.

    What is the benefit of the pump over the oral baclofen?
    Because ITB delivers such a small amount of medication, patients don't have the same sedation,lethargy, and weakness that you see with the oral medication. Additionally, the effects of the medication given intrathecally are much greater than the effects of the medication given orally.

    How is the pump implanted?
    Usually the pump is implanted in the lower abdomen, and then a catheter is tunneled under the skin and threaded up into the intrathecal space around their spinal cord to deliver the medication.

    Who is a good candidate for ITB therapy?
    I have stroke patients who had intrathecal baclofen pumps who are in a vegetative state, who have no true interaction with their environment. I also have stroke patients who have come to me who were walking at the time that I prescribed the baclofen pump, but they wanted to be able to walk better, or were concerned about degenerative changes in their joints as they aged, and those patients are often candidates for ITB therapy as well. So there's a whole spectrum of people who would be appropriate candidates for this therapy.



    © 2002 Healthology, Inc.

    http://lancasteronline.healthology.c...ancasteronline

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