Supplementary ‘diagnostic’ opportunities for assessing muscle tone and muscle length & alternative focal treatment approaches for consideration. Presentation 3rd Feb 2017 It is sometimes quite difficult to distinguish between severe spasticity and contracture formation. To decide on an appropriate anti-spastic treatment and determine realistic expectations, in some cases, this distinction is very important. Diagnostics: What are the benefits of assessing muscle tone and muscle length under ‘GA’ as opposed to conscious? • Establish neural (dynamic element) v non neural (fixed contracture) • May use when cannot differentiate if dynamic aspect (gd 3+ on Ashworth scale) or permanent contracture/physical change from fibrosis. • Is it really that simple…. The use of Anaesthetics is complex … • • • • • ‘Type’ of anaesthetic may impact ‘true outcome’….?? Anaesthetics often a ‘cocktail’ of meds which target different components of muscle shortage. Main aspect - sleep/anaesthetic element - deep sleep is the element for getting ‘floppy’. Tone not dropped fully (individual to person). Up to anaesthetist to ‘juggle’ to get it right to i.e.: get more relaxation. • • • Conscious sedation/light sedation (propofol/midazolam) preferred over ‘full GA’ by medics - less medical risks however also less control of what ‘switching off’ - will give ‘indicator’ re potential spastic/dystonia component and ‘active’ element of resistance. Muscle ‘relaxant’ (Ach receptors agonists and antagonists, i.e.: recuronium)–picture of contracture, spasticity component largely eliminated with deeper GA. Analgesia component -pain inhibition. Challenges to putting someone under anaesthetic • Clinical risk - general health risk/ethics – risk v benefits, is this truly necessary – most clinicians take opportunity if linked to other procedures. • Time • Cost • What is the clinical gain –would this truly give us the answers that we are looking for? Ask self • Does clinical examination tell me enough? • How long have symptoms been present – likelihood of contracture? • How does this link with patient goals? • Risk/Benefits of additional information? • Would outcome of Botox give the conclusion anyway? • Sleep – how is client positioned as REM sleep induces muscle atonia. What about more Regional Anaesthesia to determine: contracture or spasticity ? • Anaesthetic injection near a cluster of nerves to numb/block the area of body/specific nerve distribution: • • Epidural/Spinal Block Diagnostic Peripheral Nerve Block with local Analgesia • The most common drugs include lidocaine, ropivacaine, bupivacaine, and mepivacaine, fentanyl. • • • Nerve blocks with local anaesthetics/analgesic which are reversible and temporary are used as diagnostic tests (Yalcin et al, 2014). Reduced clinical risk. Clinically used by some prior to Botox ie.: they can be used to determine which muscle is contributing to a pathologic posturing, as in the case of inversion of the foot. Also resemble the effects of more permanent motor blocks to determine their potential effects. Question? When might you opt for: • Spinal Block • Diagnostic Peripheral Nerve Block with local Analgesia Spinal Nerve block & Diagnostic Peripheral Nerve Block • • • From focal/botox perspective – ? is it more valuable to go as regional/territorial as possible and observe effects. Blocks can be more accurate on target areas ie.: in what ‘switches off’. Modulation of dose –pain will always go before movement – can ask question how pain contributes to spasm/changes in tone. Diagnostic Nerve Blocks • • • • Tibial nerve block in lower limb equinovarus deformity can be useful to establish if contracture/spasticity. • DTNB probably most useful, in situations where it is uncertain if a more harm than good possible particularly when significant function is based on primitive motor behaviours or spasticity, or when blocks may affect more than one aspect of a function such as ambulation. Eliminates spasticity within few mins and some hrs later allowing Ax of contribution of different muscle groups. Utility – Inexpensive, easy to perform, low risk, can do in any clinic setting, short Ax - numb within 5 min assess in 10, review if mobility improved after. Needle for conduction, anaesthesia coupled with portable electrical stimulator or emg (Deltombe et al 2015) or use in conjunction with ultrasonographaphy (Yalcin et al 2014). BEST PRACTICE when considering equinus foot Selective rather than non selective diagnostic nerve block of branches to identify spastic muscle. (Deltombe et al 2015) Treatment options Dr M Sivan Treatment: Focal Spasticity Management– Is Botox our only option?? • Widespread use of botulinum toxin for focal spasticity has reduced the frequency of phenol procedures, particularly in the upper limb where many situations call for the injection of smaller muscles, which are eminently susceptible to botulinum toxin techniques (Roy C 2012). Possible reasons to consider Phenol: • • • • • • • Sensitivity/Previous reaction to Botox Unsuccessful Rx with Botox Poor tolerance to systemic muscle relaxants Generally longer duration of effect Large muscle groups that would exceed safe dose for Botox - Large dose range can be used Cost reduction - typically, sufficient phenol to treat elbow flexors might cost 5% of the botulinum dose required. In supplement to Botox where total dose required excessive Gaid 2012 Phenol nerve blocks • Treatment of efferent component of reflex arc • Conversion of UMNS to LMNS via “partial denervation of nerve”/ chemical neurolysis • Carbolic Acid (from Benzene) • Soluble in water (<6.7%) • 1-‐2% local anaesthetic • >5% Denatures protein/ tissue necrosis • Injection -Inflammatory reaction –Nerve destruction – Wallerian degeneration –Fibrosis and re-‐innervation sprouting The safer and more common use of phenol infiltration at the peripheral • Max 1 Gm (20 Ml of 5% phenol) nerve level is now more accepted • Duration 6 Months-1 year for brain injury and spinal cord injury patients (Botte et al 1995). Phenol nerve blocks • Painful dysesthesia (due to mixed nerve nature) (0-‐32%)–Higher incidence with tibial nerve, median and ulnar nerve; lower incidence with musculocutaneous and obturator nerve • Motor point blockade - Injecting motor points rather than nerve trunks are that individual muscles can be targeted. The absence of sensory fibres reduces the chance of dysaesthesia following injection. • Muscle atrophy/ fibrosis • DVT if vessel involvement • Swelling (sympathetic involvement) • Reversal of muscle imbalance, weakness in muscle, muscle or ligament sprains can occur after nerve blocks caused by loss of reflexive protection against overstretching the muscle in which spasticity has been relieved, changes in the dynamics of ambulation, or loss of reflexive support for other soft tissues. Phenol Nerve Block Lower Limb can do: • OBTURATOR NERVE BLOCK – ADDUCTORS. • SCIATIC NERVE – HAMSTRINGS • FEMORAL NERVE – QUADRICEPS • TIBIAL NERVE – EQUINOVARUS DUE TO INCREASED TONE OF SOLEUS, TIBIALIS POST AND TIBIALIS ANT. (Gaid 2012) • Wichers 1991 - Partial blocking of the tibial nerve with phenol as a treatment of gait disorders due to pes equinus in central paralysis. • May be valuable in improving walking. • Only done after trial block with anaesthesia. • Functional results linked to levels of activity pre nerve block, sitters and hardly walkers less favourable. Results ascribed to better possibility to actualise future muscle balance improved by block. May be useful early phase. Phenol Nerve Block • Obturator nerve block is used to treat hip joint pain and in the relief of adductor muscle spasm associated with hemi-or paraplegia. • With the introduction of modern nerve stimulators, selective blockade of the obturator nerve has become more reliable and has seen a resurgence of interest in recent times. • Neurolytic blockades with alcohol or phenol, performed with the help of a nerve stimulator and/or radioscopy, result in a costeffective and effective reduction of muscle spasms. • The main drawback is its temporal duration and the need to repeat the blockade when the previous block wears off (New York School of Anaesthesia). Phenol block versus botulinum toxin Phenol nerve block Botulinum toxin injection Immediate action Delay > 5 days Longer duration of action >6 months Shorter duration up to 3months Can be repeated immediately Ideally not repeated within 3 months Targets multiple muscles Localised effect Cheap <£1 Expensive >£100 Possible sensory side effects No sensory side effects Requires more technical skills, can be done at bedside, or in a clinic or office, and general anaesthesia is rarely required. EMG/ USS guided Easier to perform, can be done at bedside, or in a clinic or office, and general anaesthesia is rarely required. Anatomy/EMG/ USS guided Dr M Sivan Permanent Solution? Neurotomy Fouad (2011) • Selective peripheral neurotomy of tibial nerve indicated for Rx spastic foot in well selected cases. Retrospective study 16 pts Grade 3,4 modified Ashworth. • Variable SPN Tibial nerve neurotomy undertaken when spasticity localised to specific muscle or muscle group or few easily accessible peripheral nerves. • SPN - supresses spasticity without excessively impacting motor power - if this is goal at least 1/5motor fibres preserved. • Soleus reported to be exclusively involved in 75% of cases in some studies. • Operative planning essential with detailed assessment of each spastic muscle to determine where to section. • Differentiation between spasticity and contracture essential before deciding options. • SPN considered after perioperative motor blocks /possible trial with botox. • Need post op rehabilitation. Deltombe et al (2015) • Compare diagnostic tibial nerve block with anaesthetics followed by STN in equinovarus. • Test spasticity using ashworth, gait - video and distance, passive df, mrc strength. • Decrease spasticity, improved kinematics at 2 months and 2 yrs. • Both reduce spasticity equally. • Diagnostic nerve block valuable screen before neurotomy. • Deformity mainly caused by triceps surae (soleus/gastroc) and tib posterior. • Partial sectioning of motor nerve branches- spare sensory fibres to avoid neuropathic pain and sensory deficit. • Benefit long lasting. Selective Peripheral Tibial Neurotomy Bollens et al (2011) Kim et al (2010) • • • • • • • • Effects of tibial nerve neurotomy (TNN) as a treatment for adults presenting with spastic equinovarus foot: A systematic review Use controversial, review based on case studies/series no rct. Partial and selective sectioning of motor nerve braches to selective muscles sectioning afferent fibres to sc lead to decrease in myotactic reflex gain. Efferent extensive denervation of corresponding muscle. Collateral sprouting of axons in next month leads to widening of persisting motor units thus recovery of pre op motor strength. Can have positive effect gait based on study findings. Neurotomy old technique rx adduction via obturator. • • • • • • • • • Long term results of microsurgical tibial neurotomy of spastic foot comparison of adult and child Selective neurotomy generally safe and effective long lasting with equinovarus deformity Can recalibrate balance agonist and antagonist when other approaches unsuccessful/ reduces focal spasticity Side effects – possible sensory - normally FDL and occ Tibialis Post Sectioning needs to be sufficient to prevent reoccurrence Cannot replace surgery of contracture, perform before fixed deformity develop Similar outcomes in adults and children Satisfaction higher in children than adults. Pain most often transient. Post op rehab needed. Treatment of spasticity in children • It is not common place for children to be put under anaesthetic as an assessment procedure • For the treatment of localized or segmental spasticity, botulinum toxin is recommended as an effective and generally safe treatment. • For more generalized spasticity, a number of useful oral agents and intrathecal baclofen are available, each with their positive and negative attributes Treatment of focal/segmental spasticity • Two strategies are in current use: perineural injection of phenol or ethyl alcohol and intramuscular injection of botox • Although the use of botox has grown exponentially and has substantially replaced phenol and alcohol, all 3 techniques are used for focal spasticity and addressing specific muscles in generalized spasticity. • Botox provides a specific presynaptic neuromuscular junction blockade but does not injure the nerve or muscle. • Phenol and alcohol are effective by providing neural and, at times, muscle destruction. • The common denominator of these medications is the blockade of the agonist muscles allowing increased stretch and resting length while the antagonist muscles continue activity and strengthen. The goal is a more appropriate balance between the agonists and antagonists with prolonged improvement. Botulinum toxin type A for treating children and young people with spasticity – Nice pathways Consider botulinum toxin treatment in children and young people in whom focal spasticity of the upper limb is : • Impeding fine motor function • compromising care and hygiene • causing pain • impeding tolerance of other treatments, such as orthoses • causing cosmetic concerns to the child or young person. • Consider botulinum toxin treatment where focal spasticity of the lower limb is : • Impeding gross motor function • compromising care and hygiene • causing pain • disturbing sleep • impeding tolerance of other treatments, such as orthoses and use of equipment to support posture • causing cosmetic concerns to the child or young person. Botulinum toxin treatment , including assessment and administration, should be provided by healthcare professionals within the network team who have expertise in child neurology and musculoskeletal anatomy. Administering botulinum toxin : • To avoid distress to the child or young person undergoing treatment with botox think about the need for: • topical or systemic analgesia or anaesthesia • sedation (see the NICE pathway on sedation in children and young people). • Consider ultrasound or electrical muscle stimulation to guide the injection of botulinum toxin type A. • Consider injecting botulinum toxin type A into more than one muscle if this is appropriate to the treatment goal, but ensure that maximum dosages are not exceeded. Treatment of generalized spasticity • For individuals who have generalized spasticity, oral or enteral medications can provide systemic symptom relief. Advantages include the relative ease of use and the lower cost compared with other interventions, but each of these drugs carries with it risks of side effects and a fairly limited base of research on therapeutic efficacy in children. • these agents may be attractive as a convenient initial treatment, as a means to help with sleep, and/or in combination with focal treatments for spasticity in children Intrathecal baclofen • ITB requires surgical implantation and carries with it a moderate risk of complications • Complications may involve overdosing, under dosing with or without withdrawal, catheter malfunction, wound infections, or fluid collections around the pump and occur at varying rates but may be more frequent in younger patients or those with greater spasticity • For best results, spasticity treatment should be part of an integrated therapeutic approach in which patients, caregivers, therapists, physicians, and surgeons have an open and clear communication about the overall rehabilitation process of the patient. Conclusion Diagnosis • Use of ‘GA’ likely for very few. • Regional diagnostic nerve block in some cases may have a place for consideration. Treatment/Management focal spasticity • There may be a place to consider alternative options than Botox in selected cases. • Clear clinical reasoning essential to select cases and support care planning.