Espasticidad ESPASTICIDAD sus causas y tratamientos m dicos
ESPASTICIDAD sus causas y tratamientos m dicos
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ESPASTICIDAD sus causas y tratamientos m dicos

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Espasticidad. Es un trastorno del tono muscular secundario a una lesi
ESPASTICIDAD sus causas y tratamientos m dicos

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1. ESPASTICIDAD sus causas y tratamientos m?dicos

2. Espasticidad Es un trastorno del tono muscular secundario a una lesi?n del SNC Se caracteriza por un aumento de la resistencia para la movilizaci?n de una extremidad que est? en reposo Es uno de los s?ntomas m?s comunes en el s?ndrome de neurona motora superior Spasticity is a complex disorder which causes significant disability in affected patients. There have been numerous definitions of spasticity, which have varied between investigators and publications. A widely accepted definition of spasticity is a velocity dependent disorder of muscle tone resulting from a central nervous system insult, characterized by increased resistance of a limb to externally imposed motion. In its broader context, one may include spasticity as part of the upper motor neuron syndrome, which includes positive symptoms -- such as increased tone and dystonia -- and negative symptoms -- such as weakness, loss of dexterity, and fatiguability.Spasticity is a complex disorder which causes significant disability in affected patients. There have been numerous definitions of spasticity, which have varied between investigators and publications. A widely accepted definition of spasticity is a velocity dependent disorder of muscle tone resulting from a central nervous system insult, characterized by increased resistance of a limb to externally imposed motion. In its broader context, one may include spasticity as part of the upper motor neuron syndrome, which includes positive symptoms -- such as increased tone and dystonia -- and negative symptoms -- such as weakness, loss of dexterity, and fatiguability.

3. Espasticidad Es debida a una disfunci?n del reflejo de estiramiento muscular La alteraci?n puede localizarse en diversos niveles de las v?as que controlan este reflejo de estiramiento. At its simplest, spasticity may be defined as a disorder of the tonic stretch reflex function which may be mediated by disturbances at several sites in the stretch reflex pathway. Thus, this pathophysiologic and clinical syndrome may result as the final common output from lesions at several sites in the neuraxis. At its simplest, spasticity may be defined as a disorder of the tonic stretch reflex function which may be mediated by disturbances at several sites in the stretch reflex pathway. Thus, this pathophysiologic and clinical syndrome may result as the final common output from lesions at several sites in the neuraxis.

4. Espasticidad Cuando se presenta da?o en el control de los m?sculos desde el sistema nervioso central, las rutas de retroalimentaci?n del m?sculo desde la m?dula espinal producen s?ntomas tales como reflejos tendinosos profundos exagerados (el reflejo rotuliano), tijereteo (cruce de piernas), movimientos espasm?dicos repetitivos, posturas inusuales y posici?n de hombros, brazos, mu?eca y dedos de las manos en ?ngulos anormales. While the pathophysiology of spasticity is not completely understood in spite of considerable experimental and human investigation, the increase in tone is generally thought to reflect the loss of descending inhibitory influences resulting in increased excitability of gamma and alpha neurons. This will be discussed later in the presentation. In addition to the increase in tone, there are frequently other associated features in the spastic syndrome such as hyperreflexia, muscle spasms, and clonus.While the pathophysiology of spasticity is not completely understood in spite of considerable experimental and human investigation, the increase in tone is generally thought to reflect the loss of descending inhibitory influences resulting in increased excitability of gamma and alpha neurons. This will be discussed later in the presentation. In addition to the increase in tone, there are frequently other associated features in the spastic syndrome such as hyperreflexia, muscle spasms, and clonus.

5. Espasticidad Las consecuencias de esta enfermedad son la inmovilizaci?n del paciente, fuertes dolores, dificultad o imposibilidad de higiene personal, luxaciones de miembros, inhabilitaci?n laboral, entre otras. While the pathophysiology of spasticity is not completely understood in spite of considerable experimental and human investigation, the increase in tone is generally thought to reflect the loss of descending inhibitory influences resulting in increased excitability of gamma and alpha neurons. This will be discussed later in the presentation. In addition to the increase in tone, there are frequently other associated features in the spastic syndrome such as hyperreflexia, muscle spasms, and clonus.While the pathophysiology of spasticity is not completely understood in spite of considerable experimental and human investigation, the increase in tone is generally thought to reflect the loss of descending inhibitory influences resulting in increased excitability of gamma and alpha neurons. This will be discussed later in the presentation. In addition to the increase in tone, there are frequently other associated features in the spastic syndrome such as hyperreflexia, muscle spasms, and clonus.

7. Espasticidad: Etiolog?a (diagn?stico) Par?lisis cerebral Traumatismo craneoencef?lico Ictus (accidente cerebrovascular) Esclerosis m?ltiple Lesiones de la m?dula espinal Anoxia Enfermedades neurodegenerativas: ELA, PEF, etc. Spasticity may result from either diffuse or localized pathology of the cerebral cortex, brain stem, or spinal cord. There are many possible causes of such injuries including cerebral palsy, traumatic brain injury, stroke, multiple sclerosis, spinal cord trauma or disease, and anoxic insults. In addition, there are degenerative and inherited diseases that may affect the pyramidal tracts resulting in spasticity.Spasticity may result from either diffuse or localized pathology of the cerebral cortex, brain stem, or spinal cord. There are many possible causes of such injuries including cerebral palsy, traumatic brain injury, stroke, multiple sclerosis, spinal cord trauma or disease, and anoxic insults. In addition, there are degenerative and inherited diseases that may affect the pyramidal tracts resulting in spasticity.

8. Espasticidad: Etiolog?a (localizaci?n) Lesi?n cerebral Difusa: encefalopat?as anoxica, t?xica, o metab?lica Localizada: ictus, TCE, tumor, absceso, quiste, malformaci?n arteriovenosa, hemorragia Enfermedades neurodegenerativas Lesi?n de la m?dula espinal Lesi?n de las v?as descendentes por trauma, enfermedades inflammatorias o desmielinizantes, degenerativas, compresi?n medular The neurological localization of the lesion causing spasticity may result in different clinical manifestations. Thus, it is important to consider whether the spasticity results from cerebral pathology, whether diffuse or localized, or as a result of spinal cord injury from the numerous causes discussed earlier.The neurological localization of the lesion causing spasticity may result in different clinical manifestations. Thus, it is important to consider whether the spasticity results from cerebral pathology, whether diffuse or localized, or as a result of spinal cord injury from the numerous causes discussed earlier.

9. Sd. de neurona motora superior S?ntomas y signos ?positivos?: Espasticidad Hiperreflexia Liberaci?n de reflejos flexores Diston?a S?ntomas y signos ?negativos?: Debilidad P?rdida de destreza Fatigabilidad

10. Hallazgos cl?nicos de la Espasticiadad Los miembros afectos tienen un aumento de la resistencia que ofrecen cuando se trata de estirarlos. Esta resistencia es grande al inicio del movimiento, para vencerse bruscamente despu?s (fen?meno de la navaja de muelle) Esta resistencia aumenta cuando se incrementa la amplitud del movimiento y la velocidad angular con la que se realiza A classical clinical sign of spasticity is the so-called ?clasp-knife? phenomenon, in which the affected limbs show increased resistance to passive stretch, which is severe initially, and then ?gives? as the movement continues. The intensity of this sign varies with the amplitude and angular velocity of the joint movement.A classical clinical sign of spasticity is the so-called ?clasp-knife? phenomenon, in which the affected limbs show increased resistance to passive stretch, which is severe initially, and then ?gives? as the movement continues. The intensity of this sign varies with the amplitude and angular velocity of the joint movement.

11. Espasticidad: Hallazgos asociados Se acompa?a de otras manifestaciones de lesi?n de las v?as descendentes: reflejos cut?neos anormales, particularmente la presencia del reflejo cut?neoplantar (Babinski) Marcha esp?stica. Marcha en ?tijera? Espasmos musculares, dolor, contracturas While spasticity is often viewed narrowly as an alteration in the monosynaptic reflex pathway, resulting in increased tendon jerks, there are also other associated features present on examination. These include abnormal reflexes such as the Babinski response in the foot and the Hoffman reflex in the hands, as well as the ?clasp-knife? phenomenon discussed previously.While spasticity is often viewed narrowly as an alteration in the monosynaptic reflex pathway, resulting in increased tendon jerks, there are also other associated features present on examination. These include abnormal reflexes such as the Babinski response in the foot and the Hoffman reflex in the hands, as well as the ?clasp-knife? phenomenon discussed previously.

12. Patrones cl?nicos

13. ESCALAS ESPASTICIDAD Ashworth modificada Tono muscular del adductor Frecuencia espasmos Grado de dolor Actividades de la vida diaria

14. Escala de Ashworth modificada 0=No increase in muscle tone 1=Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end range of motion when the part is moved in flexion or extension/abduction or adduction, etc. 1+=Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM 2=More marked increase in muscle tone through most of the ROM, but the affected part is easily moved 3=Considerable increase in muscle tone, passive movement is difficult 4=Affected part is rigid in flexion or extension (abduction or adduction, etc.)

15. Adductor Tone Rating 0=No increase in tone 1=Increased tone, hips easily abducted to 45? by one person 2=Hips abducted to 45? by one person with mild effort 3=Hips abducted to 45? by one person with moderate effort 4=Two people required to abduct the hips to 45?

16. Escala Frecuencia de Espasmos 0. Sin espasmos 1. Uno o menos al d?a 2. De uno a cinco al d?a 3. De cinco a nueve al d?a 4. Diez o m?s espasmos al d?a

17. Escala del Medical Research Council para cuantificar la fuerza muscular. 0. Ausencia de contracci?n muscular. 1. Indicio de contracci?n, sin movimiento articular. 2. Movimiento activo a favor de la gravedad. 3. Movimiento activo en contra de la gravedad. 4. Movimiento activo contra resistencia. 5. Fuerza normal.

18. In addition to the classically defined features of alteration in tone and reflexes, there are other accompanying elements of spasticity, which together may be termed the ?upper motor neuron syndrome?. Patients are often disabled more severely by these associated features than by the abnormal tone. Spasticity results in limited functional capacity and increased inactivity. The sequelae of this inactivity may include decubiti, cardiovascular problems, thrombophlebitis, respiratory infections, fixed contractures, osteoporosis, bladder and bowel problems, and social isolation. Ultimately, these consequences of inactivity may lead to further decrease in strength and function.In addition to the classically defined features of alteration in tone and reflexes, there are other accompanying elements of spasticity, which together may be termed the ?upper motor neuron syndrome?. Patients are often disabled more severely by these associated features than by the abnormal tone. Spasticity results in limited functional capacity and increased inactivity. The sequelae of this inactivity may include decubiti, cardiovascular problems, thrombophlebitis, respiratory infections, fixed contractures, osteoporosis, bladder and bowel problems, and social isolation. Ultimately, these consequences of inactivity may lead to further decrease in strength and function.

19. Consecuencias de la espasticidad motilidad aseo cuidado personal patrones de sue?o est?tica autoestima humor sexualidad In addition to the physical sequelae of inactivity, the patient?s ?quality of life? is also negatively impacted. While ?quality of life? may be difficult to quantify, particularly in controlled research studies, it may include the negative impact of spasticity upon the patient's mobility, hygiene, self-care, sleeping patterns, cosmesis, self esteem, mood, and sexual function. Treatment for spasticity is directed not at spasticity per se, but at the functional complications of spasticity.In addition to the physical sequelae of inactivity, the patient?s ?quality of life? is also negatively impacted. While ?quality of life? may be difficult to quantify, particularly in controlled research studies, it may include the negative impact of spasticity upon the patient's mobility, hygiene, self-care, sleeping patterns, cosmesis, self esteem, mood, and sexual function. Treatment for spasticity is directed not at spasticity per se, but at the functional complications of spasticity.

20. Espasticidad: Tratamiento Para desarrollar un plan de tratamiento considerar: ?La espasticidad impide la funcionalidad o la autonom?a? ?Es dolorosa? ?Qu? tratamientos se han empleado y con qu? resultados? Y adem?s considerar: gravedad del problema alcance del problema: local vs. regional vs. generalizado coste - beneficio y riesgo-beneficio limitaciones y efectos adversos del tratamiento salud general del paciente objetivos terap?uticos When developing a treatment program, consider: Is the spasticity preventing function or independence? Is the spasticity painful? What treatment options have already been employed and what were the results? Then, consider these other factors: severity of the problem scope of the problem: local vs. regional vs. generalized cost - benefit and risk - benefit ratio limitations and side effects of treatment overall health of patient therapeutic goals When developing a treatment program, consider: Is the spasticity preventing function or independence? Is the spasticity painful? What treatment options have already been employed and what were the results? Then, consider these other factors: severity of the problem scope of the problem: local vs. regional vs. generalized cost - benefit and risk - benefit ratio limitations and side effects of treatment overall health of patient therapeutic goals

21. Objetivos del tratamiento de la espasticidad Mitigar el dolor Prevenir o reducir las contracturas Mejorar la deambulation Facilitar las Actividades de la Vida Diaria Facilitar la rehabilitaci?n Facilitar la labor del cuidador Mejorar la seguridad El manejo terap?utico debe dirigirse a los objetivos del paciente y del cuidador, tratando de minimizar los efectos adversos Every patient is an individual and selection of treatment options must be based on individual needs. Specific goals for management must be identified. Common goals include: decrease pain prevent or decrease contractures improve ambulation facilitate ADL?s facilitate rehabilitation participation save caregiver's time and improve ease of care increase safety Appropriate management choices are based upon the therapeutic objectives. Physical and occupational therapists can play a key role in identifying these objectives. Treatments with the fewest side effects are usually given priority. Both the patient's and the caregiver's goals must be considered.Every patient is an individual and selection of treatment options must be based on individual needs. Specific goals for management must be identified. Common goals include: decrease pain prevent or decrease contractures improve ambulation facilitate ADL?s facilitate rehabilitation participation save caregiver's time and improve ease of care increase safety Appropriate management choices are based upon the therapeutic objectives. Physical and occupational therapists can play a key role in identifying these objectives. Treatments with the fewest side effects are usually given priority. Both the patient's and the caregiver's goals must be considered.

22. TRATAMIENTO: OBJETIVOS Aumentar: grado de motilidad articular aseo movilidad postura marcha Disminuir: espasmos musculares dolor

23. OPCIONES DE TRATAMIENTO Fisioterapia Terapia ocupacional Medico Baclof?n intratecal Cirug?a ortop?dica Procedimientos Neuroquir?rgicos

24. TRATAMIENTO M?DICO Benzodiacepinas (Valium, Rivotril) Baclofen (Lioresal) Tizanidina (Sirdalud) Dantrolene Clonidina, ciproheptadina, cannabinoides

25. BENZODIACEPINAS Diacepam (Valium), Clonacepam (Rivotril) Mecanismo de acci?n: Aumentan la afinidad del GABA a su receptor. Se une a nivel del tronco encef?lico y de la m?dula espinal Mejoran: el grado movilizaci?n articular disminuyen la hiperreflexia disminuyen los espasmos musculares dolorosos mejoran la ansiedad

26. BENZODIACEPINAS Indicaciones: ictus, par?lisis cerebral, TCE y medulares. Dosis: (Diacepam) inicio 4mg/d?a hasta m?ximo 60 mg/d?a. Efectos 2?s: sedaci?n, debilidad, hipotensi?n, alteraci?n de memoria Otros efectos: tolerancia, dependencia, s?ndrome de abstinencia.

27. BACLOFEN (Lioresal?) Agonista GABA con efectos pre y postsin?pticos a nivel medular Aumenta grado movilizaci?n, disminuye el tono y los espasmos musculares Espasticidad por lesi?n cerebral o medular Dosis: inicio 15 mg/d?a, m?ximo 100 mg/d?a. Efectos secundarios: sedaci?n, ataxia, debilidad, astenia Potencia antihipertensivos Retirada lenta (crisis, alucinaciones)

28. TIZANIDINA (Sirdalud?) Agonista central alfa-2-noradren?rgico. Disminuye clonus y espasmos. Combinaci?n con baclofen. Da?o medular, TCE, ictus, EM. Dosis: Inicio 2 mg/d?a hasta m?ximo 36 mg/d?a. Efectos 2?s: sequedad de boca, somnolencia, astenia, mareo, alucinaciones, control enzimas hep?ticas.

29. DANTROLENE (Dantrium?) Bloquea la liberaci?n Ca++ en el ret?culo sarcopl?smico, reduce contracci?n muscular. Disminuye hiperreflexia, espasmos y aumenta grado movilizaci?n. Espasticidad supraespinal (PCI, TCE) Dosis: Inicio 25 mg/d?a, m?ximo 400 mg. Efectos 2?s: debilidad muscular, fatiga, diarrea, mareo, control enzimas hep?ticas.

30. OTROS Gabapentina Clonidina: alfa2 agonista. Ciproheptadina: antagonista receptores histamina y serotonina. Cannabinoides.

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