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An integrated team approach is required to successfully manage spasticity.

Byline: Mubarak Ali

Pain and disability is a major issues being faced by healthcare providers in our daily practice which needs a team approach. Precious lives are being lost due to stroke in Pakistan, high blood pressure is increasing in our population and posing a big threat to poor people of our country. We need to address this immediately on war footing for which creating mass awareness is very important because it is a preventable disease. This was stated by Prof. Mohammad Wasay, President Pakistan Society of Neurology in his inaugural address at Spasticity Summit organized by Novartis Pharma Pakistan in collaboration with Pakistan Society of Neurology at a local hotel here on august 22, 2015. it was very well attended by Neurosurgeons and Neuro Physicians besides experts from rehabilitation Medicine from various parts of the country.

Prof. Wasay further said that rehabilitation is a major task for Pakistan Society of Neurology which has decided to establish rehabilitation institutes in Sindh province. Bone and Pain Franchise of Novartis Pharma Pakistan has played an important role in creating awareness to manage pain and has also arranged telecast of nine TV programmes on different channels to discuss pain and disability related to neurological diseases which are the major cause of disability. This meeting will help our physicians to handle the patients with pain more effectively, Prof. Wasay added Dr. Farooq Rathore, assistant Professor, Department of rehabilitation Medicine, cMh Lahore Medical c ollege talked about assessment and management of post stroke spasticity.

He stated that about four hundred people are dying every day in Pakistan due to stroke. We need to know its cause but there is lack of quality research in Pakistan. complications of untreated Spasticity, he stated, includes wrist drop, muscle wasting and contractures, increase risk of falls, fatigue, pressure ulcers, pain, diminished self-image and increased cost of treatment besides poor quality of life. Talking about current scenario in Pakistan, Dr. Faooq said that the eye cannot see what the mind doesn't know. Wrong descriptions, lack of formal assessment and documentation, lack of coordination and communication among team members are the major issues. There are twenty assessment scales available while choosing an assessment scale one should keep in mind that it is easy to administer with no steep learning curve and addresses the patient's complaints and issues and should be Practical.

Talking about goals of spasticity treatment Dr. Farooq rathore said that we have to respect each other's domain and work as a team. The simple thing matter a lot and early is better. an integrated team approach is required to successfully manage spasticity. No single treatment is effective and combination of interventions is needed. Management strategies include removal of noxious stimuli, proper positioning. rehabilitation nur s e c an pla y a n i m po rta nt role but they are not available in Pakistan. Poor posture and positioning is also very important besides regular physical therapy. aFO in stroke patients is very effective and also available in major cities of Pakistan. Oral medications, for spasticity includes Tizanidine (Maximum 36 mg), Lioresal (Max 100-120mg, Benzodiazepines (Diazepam, clonazepam), others are (Eperisone, cyclobenzaprine) injections Local anesthetics, Ethanol and Phenol Blocks and Botulinum Toxin, Ethanol and phenol denaturation of proteins.

Phenol is used where people cannot afford Butoc. Post stroke spasticity is a component of the UMN syndrome. it is a common squeal of stroke and its management can be better in MDT set ups. Original research conducted locally and management guidelines should be given priority, he concluded.

Dr. Raja Farhat Shoaib remarked that joint efforts as a team are required to manage spasticity. Dr. Maimoona Siddiqui said that multidisciplinary approach is required for spasticity management. We see increase of young patients which needs our special attention and post stroke centers should be established. Dr. Arif Harekar said that post stroke spasticity is very important, we need to work on this, and need more studies and more disciplines to come together and work as a team. Dr. Mewat Shah said that ultimate improvement would be if development of sub specialties should come under one roof. Low back pain and its management at primary care level Dr. Nadir ali syed along with Dr. Naqeebullah achakzai chaired this session.

Dr Muhammad Adnan Aslam, consultant Neurologist from Fatima Jinnah Medical University Sir Ganga ram hospital Lahore talked about Low Back Pain Prevalence. Low back pain, he stated, is the pain and muscle tension, or st iffness localized below the costal margin and above the inferior gluteal folds with or without sciatica. It is defined as chronic when it persists for 12 weeks or more. Low back pain is a very common problem, prevalent, clinically complex, and exacts a huge cost on the patient, his or her family, and society at large. it is the most frequent cause of disability for people younger than 45 years of age and most common painful condition reported by patients after headache. Of the total number of back pain patients, only 1% to 2% of patients require surgery.

5% to 10% eventually develop chronic low back pain, approximately 1% becomes disabled and up to 75% of low back pain patients have one or more relapses at some point in the future.

The risk of low back pain Dr. adnan said increases as a patient gets older, but once one reaches the age of about 65 the risk stops increasing. Back pain is the most frequent cause of the limitation of activity in people younger than 45 years of age. Some studies have shown that males are at greater risk for low back pain, while other studies suggest that females are more likely to develop this type of pain. a family history of back pain shows to increase one's risk. Prolonged standing, prolonged sitting, lifting heavy objects and working with vibrating tools could all be contributing factors to back problems. alcohol and illicit drug use have been shown to increase one's risk for low back pain. Physical fitness and conditioning may help to prevent back injuries. Poor Posture and alignment, or improper alignment may predispose individuals to developing back pain over time as this can cause undue stress on certain areas of the back.

Sports such as skiing, snowboarding, sledding, tobogganing, gymnastics, wrestling and contact sports such as football and rugby increase the risk ,whether direct injury to the low back, or through injury to other body parts that cause abnormal stress on the low back. Take home message he pointed out is to stay ahead of game , cut the fat, sit smart, stand smart as well , only eat good stuff, Kick the habits and don't smoke. Expensive diagnostic testing cannot always identify cause of back pain, Dr. adnan further added. Dr. Ahmed Asif talking about diagnosis of backache said that in children it is due to use of mobile and computers by school going children. Physical examination, besides X-rays and Mri scan are most commonly used for backache investigations. Dr. Wasim akhtar stated that one should be more careful if the patient is more than fifty years of age, have pain duration of one month and bed rest with no relief.

Dr. Ahsan Numan associate Professor and head Department of Neurology SiMS and Services hospital Lahore discussed the art and Science of LBP management. Education of patient and family to ensure active participation in the pain management plan is very important. We must be flexible in our approach. Templates or algorithmic approaches or guidelines need to be tempered by individual patient factors, Physician reflective experience. Basic Principles in managing Pain includes investigation wisely and effectively, do not delay the treatment, treat immediately and have a good understanding of the pharmacology of analgesics and adjuvant medications. Give medications orally whenever possible and regularly according to its duration of effects and always prescribe a breakthrough dose.

Continuing Dr. ahsan Numan pointed out that Pharmacological options available includes analgesic medications acetaminophen, aspirin, (Opioids)codeine, Oxycodone, hydrochodone, Morphine, non-steroidal anti inflammatory drugs besides ibuprofen, ketoprofen, naproxen sodium, cox-2 inhibitors and muscle relaxants, tizanidine. hot or cold Packs have never been proven to quickly resolve low back injury, but may help ease pain and reduce inflammation especially with cold packs. Bed rest should be limited. individuals should begin strengthening exercises and resume normal daily activities as soon as possible while avoiding movements that aggravate pain. Some studies show that individuals who continue their activities without bed rest respond well. Some studies show that bed rest can lead to secondary complications like depression. Strengthening exercises beyond general daily activities are not advised for acute low back pain (LBP).

Evidence support short and long term benefits of yoga to ease chronic LBP. Spinal manipulation and spinal mobilization must be performed by professionally trained person.

Dr. ahsan further stated that for keeping back healthy, always stretch before exercise or other strenuous Physical activity, do not stoop when standing or sitting, ensure that work surfaces are at comfortable height, sit at chair with good lumbar support, wear comfortable and low heeled shoes, do not try to lift objects that are too heavy, maintain proper diet. Pain is the blessing in disguise, be a clinician with semiological approach, he concluded. Surgical Management of Low Back Pain was discussed by Dr. Ehsan Bari, assistant Professor, of Neurosurgery, aga Khan University hospital, Karachi. Low back pain, he stated is extremely prevalent (69-90%). it is the second most common reason to seek medical attention, only 1% of the patients would have nerve root symptoms. Men and women are equally affected and most common between 30-50 years. about 80-90% of patients will get better with or without treatment within one month.

Surgical options are available which includes minimally invasive, icrodiscectomy, foraminotomy, endoscopic discectomy, Vertebroplasty, Kyphoplasty, laminectomy, Pedicle screw fixation besides vertebral interbody fusion. Back surgery help in increased activity, better physical fitness, improved mood , less need for pain medicines with fewer drug side effects and also ability to go back to work and help in increase in productivity at work. There are also risks of back surgery like infection, dural tear, motor deficit, recurrent pathology and implants issues. conservative management should be tried in all cases for 6 weeks except for in special circumstances. Surgical management is a reasonable option if conservative management fails, he added.

Spasticity Summit

Dr. Akhtar Sherin, associate Professor, Khyber Medical University institute of Medical Sciences, Kohat discussed the guidelines for low back pain patient. The bark of low back pain is usually much worse than its bite. Patient education and counselling must be given preference. currently, practitioners often think of education at last, after medications, manual therapy, and surgery. Practitioners must implement strategies, to educate patients, employers, insurance systems, policy makers and community as a whole. There is no evidence that advice to stay active is harmful for either acute low back pain or sciatica. Light activity, avoiding heavy lifting, bending or twisting, regular exercise and physical activity helps to keep your back fit and healthy.

Walking, swimming and yoga are popular, but it is important to do an enjoyable activity that one can benefit from without making pain worse. There is strong evidence against the use of bed rest in acute low back pain cases without neurologic symptoms. One or two days of bed rest if necessary, but avoid excessive bed rest because this will not help in recovery.

Taking pain killers Dr. akhtar Sherin said will allow the patient to remain active but don't wait until the pain gets too much. One should always check for everyday things that may be aggravating back like stress, repetitive and uncomfortable postures at work, at home or while driving, or long periods of sitting. Only a very small number of people with back pain actually require and undergo surgery. But if the patient still has severe pain after an intensive treatment programme, they may be referred to a specialist for an opinion on whether they can benefit from surgery called spinal fusion. in this situation it is essential to have an Mri scan. There are other treatments for low back pain, but because there is not enough evidence that they are effective they are not currently recommended for use in the NhS in UK for this type of back pain. Massage and Physical therapy might be beneficial.

More quality research is needed for different types of massage and role of rehabilitation in lower back pain should not be underestimated, he concluded.

During the discussion it was pointed out that local guidelines for the management of spasticity are needed. healthcare providers do not have time to have proper history of the patients for which t rained nurses can play an important role. a comprehensive questioner should be prepared by Pakistan Society of Neurology in this regard. Prof. Tariq said that there is a cold war going on between Neurologists and Neurosurgeons that creates lot of problems. We should have guidelines, when to go for surgery, he added. Dr. Naq eebu llah said that acute pain leads to spasticity, we must develop local guidelines according to our needs. Dr. Mansoor said that diagnostic dilemma is the major problem, until a disease is not diagnosed, it will not be managed. Dr. Farooq Rathore suggested that radiologist must be part of these guidelines because there input is very important. Dr. Nadir Syed said that 90% low back pain will usually go in four to six weeks without any treatment.

Spasticity Management in Cerebral Palsy

This session was chaired by Dr. Mansoor Nasir along with Dr. Muhammad Tariq and Dr. aziz Sonawalla. Spasticity Management in cerebral Palsy (cP) was discussed in detail by Prof. Rashid Jooma, from aga Khan University, Karachi. cerebral Palsy, he pointed out is a group of disorders relating to motor development from a remote insult to the developing brain and resulting in physical handicaps of motor control and posture. Spasticity is an inappropriate involuntary muscle activity associated with upper motor neuron paresis and impaired motor control and balance. cP is the most common of all childhood disabilities affecting 0.6 7 out of 1000 live births Worldwide increasing to 40-100 per 1000 live births in premature babies. a household survey in Sindh Province of Pakistan found cP affecting 1.12 out of 1000 children under the age of 5 years.

Spasticity in CP is not a specific symptom but manifestation of a cNS disorder recognized by hyperactive stretch reflexes, increased resistance to passive movement, post uring of extremities and stereotypical movement synergies.

continuing Prof. Jooma said that alleviation of spasticity may not always be desirable. Some patients may experience a decline in function with spasticity reduction. reasons to treat spasticity include reducing pain and muscle spasms, facilitating brace use, improving posture, minimizing contractures and deformity, facilitating mobility and dexterity and improving patient ease of care as well as hygiene/self-care. Traditional step ladder approach to management of Spasticity includes orthopedic procedures, neurosurgical procedures, Botulinum injections, oral medications, rehabilitation therapy and removal of noxious stimuli. a combination of various types of treatment is usually required to attain the specific goals of treatment for a particular patient. Most children with spasticity require rehabilitation by physiotherapy to improve or maintain the range of motion in their spastic limbs. Occupational and physical therapy are a fundamental part of spasticity management, he added.

Bracing devices are used to prevent and correct deformity by keeping body part in a certain position. Talking about medical treatment of spasticity Prof. Jooma stated that Baclofen is the most commonly used oral medication in children with generalized spasticity. Spasticity results from an inadequate release of gammaamino butyric acid (GaBa), an inhibitory neurotransmitter in the central nervous system. Benzodiazepine like Diazepam, clonazepam, and clobazam, are also useful for generalized spasticity. They increase presynaptic neuronal inhibition through GaBa pathways. ataxia, drowsiness and tolerance are the most serious side effects. Dantrolene exerts its action directly at the muscular level by inhibiting calcium release from sarcoplasmic reticulum and thereby uncoupling excitation and contraction.

Muscle weakness, hepatotoxicity, and fatigue are the main side effects, making it a less favorable option. Tizanidine is an alpha-2 adrenergic agonist that hyperpolarizes moto neurons and decreases the release of excitatory amino acids and its side effects include nausea, vomiting, hypotension, sedation, and hepatotoxicity. Spasticity can be focal, or unequally distributed in the extremities. in such instances, botulinum toxin injections can be used before any surgical considerations. Surgical Treatment of spasticity Prof. Jooma stated includes intrathecal baclofen pump, Selective neurectomy, selective dorsal rhizotomy, orthopedic procedures.

Intrathecal baclofen is indicated for children with spasticity that are refractory or intolerant to oral medications. complications are related to the medication or mechanical pump failure. Overdose is typically caused by programming errors and it leads to somnolence, hypotonia, and respiratory depression. Selective Dorsal rhizotomy is a neurosurgical procedure that cuts sensory rootlets of Li to L5 that are contributing to lower limb spasticity by EMG determination. The ideal candidate for this procedure is the cooperative, motivated child with spastic diplegic cP who demonstrates good strength, balance, and range of motion in the lower limbs. ideal age is 4-7 years. The procedure reduces lower limb spasticity with sustained strength, improved gait pattern and decreased use of walking aids, Prof. rashid Jooma concluded. Dr. Nasir Mansoor said that we need to keep in mind that cP patients have weakness, balance and posture problems.

These three things are most important in cP management of spasticity. hip migration if not taken care will land up in great problem. Dr. aziz Sonawalla said that every surgical procedure has particular goal which must be kept in mind. Prof. Muhammad Tariq pointed out that role of physiotherapist and rehabilitation is very critical and main thing to overcome after surgery is the weakness which is always a worry.

Dr. Salman Sharif from Liaquat National hospital Karachi talking about neurosurgical treatment of Spasticity said that several therapeutic and oral medicines are available besides botulinum Toxin injection. interathecal Baclofen Pump was first used in 1960. ITB therapy can be effective because the interathecal dosing can be titrated to balance. it has built in programme and dose can be increased accordingly. it is an effective treatment option for Spasticity but is not recommended for less than four years of age.

Dr. Aneela Darbar was of the view that we lack rehabilitation centers. Every Baclofen pump used patient has to go for rehabilitation. it has major side effects and dose adjustment is also a problem and sometime over dose end up patient in a coma. Prof. Aziz Sonawalla stated that pump is expensive. We have less number of neurologists and expertise is also lacking. There are multiple options available to treat spasticity and major concern should be quality of life of the patient and when there is no way of improvement than one should go for surgical procedure.

How to control muscle movements in Spasticity and Multiple Sclerosis was the topic of presentation by Dr. Muhammad Shahid Mustafa, from Neurocare Department of aga Khan University hospital Karachi. Spasticity, he said, affects lower extremities more than upper extremities. individualized treatment is required based on intensity, frequency and Patient specific concern for side effects. Tizanidine alpha2 receptor agonist is used and typical starting dose is 2 mg at bed time and increased to 12 mg per day in three divided doses. One can go up to 24 mg per day. (or at times 36 mg). it is a drug of choice for patients with weakness and stiffness. it also has side effects like sedation, orthostatic hypotension, Bradycardia and Syncope. Baclofen, Dantrolene, Diazepam Gabapentin and Tolperisone are other medications. intrathecal Baclofen Pump is extremely effective for lower extremity spasticity.

However, it can improve upper extremity spasticity if higher dose is used and in patients who are nonambulatory with severe spasticity it can ease positioning and reduce painful spasms. Botox is helpful for focal spasticity but impractical for diffuse muscle involvement. Tremor can be most disabling and most challenging. Up to 75% of patients experience tremor at some point during their disease, he added. Dr. M. Shahzad Shamim from aga Khan University, hospital, Karachi talking about spasticity after Spinal cord injury (Sci) said that it increase the tonic stretch reflex with exaggerated tendon jerks, clonus, and spasms, resulting from the hyper-excitability of the stretch reflex Involuntary and sustained muscle contractions. 80% patients with Sci will have spasticity which develops gradually over several months.

Management plan should be to maintain a balance between useful and detrimental effects of spasticity on patients quality of life. Multidisciplinary approach is essential and eventual goal is improvement in QOL, aDL and for the patient to be re-introduced to society in a meaningful way. Spasticity after Sci is common and disabling. Pathophysiology is poorly understood. Several management options are available which require multi-dimensional, multi-specialty approach is warranted and there is immense requirement and potential for research, he added. Dr. Ufaq Zara, Medical advisor at Novartis Pharma talked about Pharmacovigilance Quality as a differentiator. Four types of drugs, she stated, are available in Pakistan which includes original molecules, Generics, Substandard drugs and counterfeit drugs. Thalidomide she stated was approved as a sedative in Europe in the late 1950's.The FDa never approved the drug.

By 1961 thalidomide was shown to be very harmful to the fetus, interfering with the normal development of arms and legs. This resulted in children born without limbs. Every drug has some side effects but there is no adverse Drug reactions reporting system in Pakistan. Over two million serious aDrs and about 100,000 deaths are reported in United States every year. We have a poison basket in our home in the shape of medicine which is being misused. Frequency of side effects, Dr. Ufaq Zara said is increasing because of better public awareness, awareness of medical community, better reporting system, regulatory compliance, rapid and early entry of new research products, better acute care in hospitals, besides empowerment of Pharmacists. in Pakistan no data of aDr is available because we do not know our denomination due to various reasons.

All serious events, all non-serious events and labeled events must be reported, she added. aDr reported to Novartis are forwarded within 24 hours to central PVO where data from across the world is being forwarded, notification to health authorities for information and necessary action besides update of prescribing information to increase knowledge of scientific (medical) community which will ensure Patients' safety. Earlier Mr. Mansoor Ali Jafari, Business Franchise Bone and Pain of Novartis in his welcome address thanked Pakistan Society of Neurology which provided its platform to organize Spasticity summit which will help our healthcare providers to manage Spasticity patients in a better way. Novartis, he said, has a long history to provide quality care products and it is a World leader in research and Development of products to protect and improve health and well-being.

Caring and curing is the philosophy of Novartis, he added. The company has core businesses in pharmaceuticals, generics, eye care and animal health. With headquarters in Basel, Switzerland, Novartis is present in over 140 countries worldwide to help save lives and improve the quality of life. Mr. Asif Qureshi, Group Product Manager at Novartis presented the vote of thanks and said that this full day event was a great learning experience for the participants. he thanked the participants for their active participation and his team for organizing the meeting. Participants appreciated the efforts of Mr. Sameer Abdul Ghani, Brand Manager Bone and Pain Franchise Novartis Pharma Pakistan and his team for arranging this informative activity. This academic activity was accretid for 2.5 hours by Dow University of health Sciences, Karachi.
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Author:Ali, Mubarak
Publication:Pulse International
Date:Sep 30, 2015
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