Spastisite ve Tedavisi
Özet
Spastisite; inme, serebral palsi, multipl skleroz ve omurilik yaralanmaları gibi üst motor nöron bozuklukları sonrasında gelişen, kas tonusunun hıza bağlı artışı ve abartılı reflekslerle karakterize bir motor bozukluktur. Günlük yaşam aktivitelerini ve fonksiyonelliği olumsuz etkileyen bu durum, her zaman kötü bir semptom olmayıp bazen hastanın hareketine veya ayakta durmasına destek sağlayabilir. Spastisitenin klinik takibinde Ashworth, Modifiye Ashworth ve Modifiye Tardieu gibi skalalar altın standart olarak yaygın şekilde kullanılmaktadır. Tedavi yönetimi fonksiyonelliği en üst düzeye çıkarmayı amaçlar ve mutlaka multidisipliner bir yaklaşım gerektirir. Bu kapsamda kutanöz veya visseral tetikleyicilerin ortadan kaldırılması ilk adımdır. Medikal tedavide baklofen, tizanidin, dantrolen sodyum ve benzodiazepinler gibi sistemik ajanlar tercih edilirken fokal durumlarda Botulinum Toksin enjeksiyonu uygulanır. Fizik tedavi yöntemleri arasında sıcak/soğuk uygulamalar, TENS, terapötik ultrason, ESWT, germe egzersizleri, bantlama ve alçılama yer alır. İntratekal baklofen pompası ve selektif dorsal rizotomi gibi girişimsel yöntemlerin yanı sıra kontraktür gelişen olgularda tenotomi gibi cerrahi gevşetme ameliyatlarına başvurulur. Tedavi rejimleri hastanın benzersiz koşullarına göre esnek ve bireysel olarak planlanmalıdır.
Spasticity is a motor disorder characterized by a velocity-dependent increase in muscle tone and exaggerated tendon reflexes, commonly resulting from upper motor neuron lesions such as stroke, cerebral palsy, multiple sclerosis, and spinal cord injuries. While it impairs activities of daily living, it is not always a detrimental symptom; in certain cases, it can provide the necessary tone to assist with mobility or standing. In clinical practice, scales like the Ashworth, Modified Ashworth, and Modified Tardieu are utilized as standard tools to evaluate spasticity and treatment efficacy. The primary goal of management is to maximize functional capacity through a comprehensive, multidisciplinary approach. Identifying and eliminating cutaneous or visceral triggers represents the baseline of patient care. Pharmacological management includes oral agents such as baclofen, tizanidine, dantrolene sodium, and benzodiazepines for generalized spasticity, whereas Botulinum Toxin injections are preferred for focal symptoms. Physical therapy modalities encompass thermotherapy, cryotherapy, TENS, ultrasound, ESWT, stretching exercises, taping, and serial casting. Interventional procedures like intrathecal baclofen pumps or selective dorsal rhizotomy, along with surgical interventions such as tenotomy for contractures, are indicated for severe cases. Consequently, successful management requires flexible, individualized treatment regimens tailored to each patient's unique conditions.
Referanslar
Thompson AJ, Jarrett L, Lockley L, et al Clinical management of spasticity Journal of Neurology, Neurosurgery & Psychiatry. 2005;76:459-463
Lance JW. (1980) Spasticity: disordered motor control.. In: Feldman RG, Young RR, Koella WP(Eds), Symposium synopsis (p. 485-94) Chicago: Yearbook Medical.
Mayer NH. Clinicophysiologic concepts of spasticity and motor dysfunction in adults with an upper motoneuron lesion. Muscle Nerve Suppl. 1997; 20:1–14.
Zeng H, Chen J, Guo Y, et al Prevalence and Risk Factors for Spasticity After Stroke: A Systematic Review and Meta-Analysis. Front Neurol. 2021 Jan 20;11:616097
Corrado B, Di Luise C, Servodio Iammarrone C. Management of Muscle Spasticity in Children with Cerebral Palsy by Means of Extracorporeal Shockwave Therapy: A Systematic Review of the Literature. Dev Neurorehabil. 2021 Jan;24(1):1-7. doi: 10.1080/17518423.2019.1683908. Epub 2019 Nov 1. PMID: 31674272.
Holtz KA, Lipson R, Noonan VK et al Prevalence and Effect of Problematic Spasticity After Traumatic Spinal Cord Injury. Arch Phys Med Rehabil. 2017 Jun;98(6):1132-1138.
Kheder A, Nair KP. Spasticity: pathophysiology, evaluation and management. Pract Neurol. 2012 Oct;12(5):289-98. doi: 10.1136/practneurol-2011-000155. PMID: 22976059.
Sherrington C. Decerebrate rigidity, and reflex coordination of movements. J Physiol. 1898 22:319–32. doi: 10.1113/jphysiol.1898.sp000697
Mandigo CE, Anderson RC. Management of childhood spasticity: a neurosurgical perspective. Pediatr Ann. 2006;35(5):354–62.)
Berker N, Yalçin S, Root, L. et al editors. The HELP Guide to Cerebral Palsy. 2nd ed. Washington, USA: Global Help; 2010. pp. 30–3.
Ashworth B. Preliminary trial of carisoprodol in multiple sclerosis. Practitioner, 1964, 192: 540-542. PMID: 14143329.
Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther. 1987 Feb;67(2):206-7
Numanoğlu A, Günel MK. Intraobserver reliability of modified Ashworth scale and modified Tardieu scale in the assessment of spasticity in children with cerebral palsy. Acta Orthop Traumatol Turc. 2012;46(3):196-200. doi: 10.3944/aott.2012.2697. PMID: 22659636.
Boyd RN, Graham HK. Objective measurement of clinical findings in the use of botulinum toxin type A for the management of children with cerebral palsy. Eur J Neurol 1999;6:23-35.
Davidoff RA, Sears ED. The effects of lioresal on synaptic activity in the isolated spinal cord. Neurology 1974;24:957-63
Edgar TS. Oral pharmacotherapy of childhood movement disorders. J Child Neurol 2003;18 Suppl 1:S40-9
Penn RD, Kroin JS. Intrathecal baclofen in the long-term management of severe spasticity. Neurosurgery 1989;4:325-32
Kroin JS, Ali A, York M, Penn RD. The distribution of medication along the spinal canal after chronic intrathecal administration. Neurosurgery 1993;33:226-30
Nutt DJ, Malizia AL. New insights into the role of the GABA(A)-benzodiazepine receptor in psychiatric disorder. Br J Psychiatry. 2001 Nov;179:390-6
Seldenrijk A, Vis R, Henstra M et al. Systematic review of the side effects of benzodiazepines. Ned Tijdschr Geneeskd. 2017;161:D1052
Chang E, Ghosh N, Yanni D et al. A Review of Spasticity Treatments: Pharmacological and Interventional Approaches. Crit Rev Phys Rehabil Med. 2013;25(1-2):11-22
Simon O, Yelnik AP. Managing spasticity with drugs. Eur J Phys Rehabil Med. 2010 Sep;46(3):401-10. PMID: 20927006.)
Edward M, Goldstein MD: Spasticity Management: An overview. J Child Neurol 16:16-23, 2001
Nance PW, Young RR. Antispasticity medications. Phys Med Rehabil Clin N Am 1999;10:337-55.).
Krach LE. Pharmacotherapy of spasticity: oral medications and intrathecal baclofen. J Child Neurol 2001;16:31-6
Rabchevsky AG, Kitzman PH. Latest approaches for the treatment of spasticity and autonomic dysreflexia in chronic spinal cord injury. Neurotherapeutics. 2011;8:274–82
Matsumoto S, Kawahira K, Etoh S et al. Short-term effects of thermotherapy for spasticity on tibial nerve F-waves in post-stroke patients. Int J Biometeorol. 2006 Mar;50(4):243-50.
Garcia LC, Alcântara CC, Santos GL et al. Cryotherapy Reduces Muscle Spasticity But Does Not Affect Proprioception in Ischemic Stroke: A Randomized Sham-Controlled Crossover Study. Am J Phys Med Rehabil. 2019 Jan;98(1):51-57.
Gracies JM. Physical modalities other than stretch in spastic hypertonia. Phys Med Rehabil Clin N Am. 2001 Nov;12(4):769-92, vi. PMID: 11723865
Fernández-Tenorio E, Serrano-Muñoz D, Avendaño-Coy J et al. Transcutaneous electrical nerve stimulation for spasticity: A systematic review. Neurologia (Engl Ed). 2019 Sep;34(7):451-460. English, Spanish
Mahmood A, Veluswamy SK, Hombali A et al. Effect of Transcutaneous Electrical Nerve Stimulation on Spasticity in Adults With Stroke: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil. 2019 Apr;100(4):751-768
Ansari NN, Adelmanesh F, Naghdi S et al. The effect of physiotherapeutic ultrasound on muscle spasticity in patients with hemiplegia: a pilot study. Electromyogr Clin Neurophysiol. 2006 Jul-Aug;46(4):247-52. PMID: 16929632.
Radinmehr H, Ansari NN, Naghdi S et al. Comparison of Therapeutic Ultrasound and Radial Shock Wave Therapy in the Treatment of Plantar Flexor Spasticity After Stroke: A Prospective, Single-blind, Randomized Clinical Trial. J Stroke Cerebrovasc Dis. 2019 Jun;28(6):1546-1554. PMID: 30935809.
Elnaggar RK, Abd-Elmonem AM. Effects of Radial Shockwave Therapy and Orthotics Applied with Physical Training on Motor Function of Children with Spastic Diplegia: A Randomized Trial. Phys Occup Ther Pediatr. 2019;39(6):692-707
Mihai EE, Dumitru L, Mihai IV, Berteanu M. Long-Term Efficacy of Extracorporeal Shock Wave Therapy on Lower Limb Post-Stroke Spasticity: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Clin Med. 2020 Dec 29;10(1):86
Bovend'Eerdt TJ, Newman M, Barker K, Dawes H, Minelli C, Wade DT. The effects of stretching in spasticity: a systematic review. Arch Phys Med Rehabil. 2008 Jul;89(7):1395-406.
Smania N, Picelli A, Munari D, Geroin C, Ianes P, Waldner A, Gandolfi M. Rehabilitation procedures in the management of spasticity. Eur J Phys Rehabil Med. 2010 Sep;46(3):423-38. PMID: 20927008.
Santamato A, Micello MF, Panza F et al. Adhesive taping vs. daily manual muscle stretching and splinting after botulinum toxin type A injection for wrist and fingers spastic overactivity in stroke patients: a randomized controlled trial. Clin Rehabil. 2015 Jan;29(1):50-8. doi: 10.1177/0269215514537915. Epub 2014 Jun 10. PMID: 24917588.
Ding XD, Zhang GB, Chen HX, Wang W, Song JH, Fu DG. Color Doppler ultrasound-guided botulinum toxin type A injection combined with an ankle foot brace for treating lower limb spasticity after a stroke. Eur Rev Med Pharmacol Sci. 2015;19(3):406-11. PMID: 25720711.
Newman CJ, Kennedy A, Walsh M et al. A pilot study of delayed versus immediate serial casting after botulinum toxin injection for partially reducible spastic equinus. J Pediatr Orthop. 2007 Dec;27(8):882-5. doi: 10.1097/BPO.0b013e31815b4d7d. PMID: 18209608.
Sätilä H. Over 25 Years of Pediatric Botulinum Toxin Treatments: What Have We Learned from Injection Techniques, Doses, Dilutions, and Recovery of Repeated Injections? Toxins (Basel). 2020 Jul 6;12(7):440. doi: 10.3390/toxins12070440. PMID: 32640636; PMCID: PMC7404978.
Winter G, Beni-Adani L, Ben-Pazi H. Intrathecal Baclofen Therapy-Practical Approach: Clinical Benefits and Complication Management. J Child Neurol. 2018 Oct;33(11):734-741. doi: 10.1177/0883073818785074. Epub 2018 Jul 16. PMID: 30009656.
Enslin, J. M. N., Langerak, N. G., & Fieggen, A. G. (2019). The evolution of selective dorsal rhizotomy for the management of spasticity. Neurotherapeutics, 16(1), 3-8.
Kıter E, Catak A. Serebral palsili hastalarda selektif dorsal rizotomi, Totbid. 2021;20:341-343
