Multiprofessionelles Spastikmanagement mit Botulinum Neurotoxin A

Zusammenfassung

Schädigungen sensomotorischer Netzwerke im Zentralnervensystem können mit Latenz zum einem Upper Motor Neuron-Syndrome (UMNS) führen. Spastizität ist ein Plus-Phänomen des UMNS und als geschwindigkeits-abhängigen Zunahme des Muskeltonus definiert. Das UMNS mit Spastik führt nach Schlaganfall bei mehr als 35% der Patienten zu deutlichen Aktivitätsstörungen durch Mobilitätseinschränkungen, Feinmotorikstörungen und Schmerzen. Schwere Spastizität kann zu Pflegebehinderungen mit Kontrakturen und Druckgeschwüren führen. Ein medizinisches Management sollte neben physikalischen und medikamentösen Ansätzen eine Hilfsmittelversorgung berücksichtigen. Empfohlen wird die Behandlung im multiprofessionellen Team. In diesem Setting können Einschränkungen durch andere neurologische und neuropsychologische Defizite bei UMNS am besten berücksichtigt werden. Mit dem Patienten oder Angehörigen vereinbarte realistischen Behandlungsziele sollen erkenn-bar im Mittelpunkt der Behandlung stehen. Bei regionalen Einschränkungen durch Spastizität ist die lokale Behandlung mittels Botulinum Neurotoxin Typ A (BoNT A) mit und ohne begleitende Redressions- und Physiotherapieverfahren nach Schlaganfall die Methode der Wahl, da die BoNT A der oralen Behandlung sowohl bezüglich der Symptomreduktion, als auch der Nebenwir-kungshäufigkeit signifikant überlegen ist. Kritisch für den Erfolg dieser Behandlung ist die Muskelauswahl, Dosierung und Injektions-genauigkeit sowie die adäquate Begleittherapie. Neben BoNT A ist Phenol perineural injiziert so-wie die selektive Neurotomie ein lokales Be-handlungsverfahren, wobei Phenolinjektionen als Nebenwirkungen bei 10% Parästhesien zeigen. Bei generalisierter Spastik ist intrathekales Baclofen gut wirksam, erfordert aber eine Pum-penimplantation und eine funktionierende Infrastruktur (Nachfüllen, Komplikationsmanagement). Bei spastischen Muskel- und Sehnenver-kürzungen sind orthopädischchirurgische Ver-fahren indiziert.

Summary

Spasticity is defined as a velocity-dependent increase in muscle tone. But spasticity is only one feature of the Upper Motor Neuron Syndrome (UMNS). Beside increased muscle tone also paresis, spasms or secondary structural changes resulting in reduced tissue viscosity may be relevant for related activity restrictions. Therefore it is essential to identify the relevant factors for disability from UMNS and define specific goals before treatment with patient and caregiver. Treatment of spasticity should be considered when spasticity is causing harm. In focal or multifocal motility or activity restrictions or pain from spasticity BoNT A injections are the treatment of choice. In every case BoNT A should be included in an multi-professional treatment approach. Besides BoNT A also phenol blocks or selective neurotomy are local options but with risks of paraesthesias as side effects. Also oral medication is effective but with respect to the side effect benefit ratio of oral antispastic drugs those should be used only in cases with multisegmental or generalised symptoms. In severe segmental or generalised spasticity intrathecal baclofen application is sufficient but require pump implantation and continuing services. If secondary structural changes of connective tissue result in spastic contractures orthopaedic surgery is recommended.

Schlüsselwörter

Schlaganfall - Spastizität - Botulinum Neurotoxin

Keywords

Stroke - spasticity - botulinum neurotoxin

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