Spas Ti City

8/3/2019 Spas Ti City

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SPASTICITY


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PATHOPHYSIOLOGY


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PATHOPHYSIOLOGY

Injury to brain

Reduced controlover LMN

Excitability,altered pre-

synaptic activity

Decreased pre-synaptic Iainhibition

Disorderedspinal segment

Increase alphamotor activity


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Spinal model

Removal of inhibition on segmental polysynapticpathway

Slow progressive raise of excitatory state throughcumulative excitation

Flexor and extensor may be exagerated

Cerebral model

Rapid build-up of reflex activityOver activity in any one group (more in anti-gravity

muscle group)


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ADVANTAGES AND DIS-ADVANTAGES

Advantages Maintain muscle mass

Decrease severity of osteoporosis

Reduced risk of DVT

Reduce dependent edema

Dis-advantages Contracture

Abnormal posturing

Deformity Functional limitation

Gait problem

pain


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ASSESSMENT

Modified ashworth scale

Tardieu Scale

Velocities:V1: As slow as possible, slower than the natural drop

of the limb segment under gravity

V2: Speed of limb segment falling under gravity

V3: As fast as possible, faster than the rate of thenatural drop of the limb segment under gravity


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TARDIEU SCALE

Scoring:

0 No resistance throughout the course of the passivemovement

1 Slight resistance throughout the course of passive

movement, no clear catch at a precise angle 2 Clear catch at a precise angle, interrupting the passive

movement, followed by release

3 Fatigable clonus with less than 10 seconds whenmaintaining the pressure and appearing at the precise

angle 4 Unfatigable clonus with more than 10 seconds when

maintaining the pressure and appearing at a precise angle

5 Joint is immovable


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MADICAL TREATMENT

Oral medicine

Baclofen: at spinal level

Pantrolele sodium: at the level of muscle fiber

Botulinium toxin: at NMJ

Intra-thecal therapy:

Baclofen

Surgical treatment Neuro-surgery

Orthopedic surgery


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NEURO-SURGERY

Selective dorsal rhizotomy

Nerve root are cut (fibers lying out side vertebralcolumn)

These carry sensory information to the cord from muscle Excessive sensory signal can lead to marked increase in

spasticity

Myelotomy

Complete disruption of some spinal tract Cordotomy

Complete transection of spinal cord


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ORTHOPEDIC SURGERY

Spasticity progressed to contracture

Tenotomy: transection of tendon

Neurectomy: excision of nerve Tendon transfer: involving moving insertion of the

tendon

Tendon lengthening

arthrodesis


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AIMS

When treating a patient who shows spasticity it is

necessary to carry out three important aims

Inhibit excessive tone as far as possible

Give the patient a sensation of normal position and

normal movement

Facilitate normal movement patterns


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BODY POSITIONING

it is important to facilitate the patients ability to inhibitthe undesirable activity of the released reflexmechanisms

The position adopted by the patient is importantsince the head and neck position can elicit strongpostural reflex mechanisms

Avoiding these head and neck positions can facilitatethe inhibition of the more likely reflexes andif positions have to be adopted, then help in preventingthe rest of the body from going into thereflex pattern thus elicited may be required by thepatient.


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BODY POSITIONING

As patient develops control in the suppression of the

effect of the reflex activities then he can be

gradually introduced to use of positions which make

suppression of reflex activity more difficult


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ROTATORY MOVEMENTS

Trunk rotation produces lower limb to extend,

abduct and externally rotate

Limb rotations are also very effective in helping to

give a more normal control of muscle tone to the

patient


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PRESSURE OVER UNDERSURFACE OFFOOT

If the pressure is applied to the ball of the foot it

may well stimulate an extensor reflex in which a

pathological pattern of extension, adduction, and

medial rotation of hip is produced together withplantar flexion of the foot, which is undesirable in

case of spasticity

If pressure is applied under the heel of the footthen a more useful contraction of muscle is likely to

occur giving a suitable supporting pattern


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SLOW SUSTAINED STRETCHING

Stretching forms the basis of spasticity treatment.

Stretching helps to maintain the full range of motion

of a joint, and helps prevent contracture, or

permanent muscle shortening

It activates muscle spindles (Ia & II endings), golgi

tendon organs (Ib endings) which are sensitive to

length changes It inhibits muscle contraction and tone due largely to

peripheral reflex effects


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PROLONGED COLD APPLICATION

Application of cold packs to spastic muscles (usually

for 10 minutes or longer) may improve muscle tone

While the effect doesn't last long, it may be used to

improve function for a short period of time, or to

ease pain

It activates thermoreceptors

It decreases neural, muscle spindle firing andprovides inhibition of muscle tone


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COLD APPLICATION

Cryotherapy

Cutaneous stimulation

Reduces the activity of alpha motor neuron

(or)

Reduces the muscle spindle discharge

Reduce spasticity


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COLD APPLICATION

Cryotherapy

Decreases the temperature

Decreases the conduction velocity

Decreases the spasticity


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COLD APPLICATION

Immersion in cold water; ice chips

Ice towel wraps

Ice packs

Ice massage

Ice application with exercises


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NEURAL WARMTH

Retention of body heat stimulates thermoreceptors,autonomic nervous system mainly parasympathetics,which produces generalized inhibition of tone, calmingeffect, relaxation and decreases pain

It should be applied for about 10 to 20 minutes Overheating should be avoided as it might increase

arousal or tone

Techniques used

Wrapping body or body parts:towel wraps Application of snug fitting clothing (gloves, socks, tights) or

air splints

Water baths


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RELAXED PASSIVE MOVEMENTS

Rhythmical, slowly performed passive movements

through normal patterns may also be helpful and in

the more moderate cases patients may

subconsciously join in and by his own activity areduction in spasticity may occur


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DEEP RHYTHMICAL MASSAGE (TENDON ROLLING)

Deep rhythmical massage with pressure over the

muscle insertions can be given to reduce spasticity


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INHIBITORY PRESSURE (WEIGHT-BEARING)

Prolonged pressure to long tendons inhibits the hypertonicityof a muscle

It activates muscle receptors (muscle spindles, golgi tendonorgan) and tactile receptors

Firm pressure can be applied manually or by body weight

Weight bearing postures are used to provide inhibitorypressure, such as

Quadruped or kneeling postures can be used

to promote inhibition of quadriceps and long finger flexors. Sitting, with hands open, elbow extended, and upper extremity

supporting body weight can be used to promote inhibition of longfinger flexors


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BIOFEEDBACK

Biofeedback is the use of an electrical monitor that

creates a signalusually a soundas a spastic

muscle relaxes

In this way, the person with spasticity may be able

to train himself to reduce muscle tone consciously


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FUNCTIONAL ELECTRICAL STIMULATION

Electrical stimulation may be used to stimulate a weak

muscle to oppose the activity of a stronger, spastic one

It improves standing, walking, and exercise training as

well as decreases upper extremity contractures

Appears to improve motor activity in agonistic muscles

and reduce tone in antagonistic muscles

Therapeutic effect may last for less than 1 hour after

stimulation has been stopped, probably because of

neurotransmitter modulation within reflex arc


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ORTHOSIS

These are plastic AFOs in which foot plate andbroad upright are designed to modify reflexhypertonicity by applying constant pressure to the

plantarflexors and invertors They control the tendency of the foot to assume an

equino-varus posture

Foot plate may be modified which maintains the

toes in an extended or hyperextended position, thusassisting individual to walk with better foot andknee control


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SLOW MAINTAINED VESTIBULAR STIMULATION

Low-intensity vestibular stimulation such as slow rockingproduces generalized inhibition of tone

It facilitates primarily otolith organs (tonic receptors); lesseffects on semicircular canals (phasic receptors)

Slow, repetitive rocking movements; assisted rocking in aweight-bearing position, for example, rocking withequipments: Rocking chair

Swiss ball

Equilibrium board Hammock(suspension)

Slow rolling movements


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PROPRIOCEPTIVE NEUROMUSCULAR TECHNIQUES

Techniques used

Rhythmic Initiation Voluntary relaxation followed by

passive movements through increments in range, followed by

active movements progressing to resisted movements usingtracking resistance to isotonic contractions.

Hold relax -

Contract Relax Active Contraction performed followed by

isometric hold of the range limiting muscles in the antagonist

pattern against slowly increasing resistance followed by

voluntary relaxation and active movement into the new

range of the agonist pattern(isotonic contraction)


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MANIPULATING KEY POINTS

For reducing spasticity, manipulating the thumb will

reduce the spasticity. All the movements should be

carried out with thumb in abduction

Another technique to reduce the spasticity is

manipulating the pelvis which is the central key

point. In sitting, place one hand over the lower back

and other near the xiphoid process. Now move the

patient in the figure of 8 pattern forwards and

backwards


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AVOIDANCE OF TRIGGERING FACTORS

Avoid strong violating efforts

Observation of urinary catheter for any block or

full urinary bag that dilate urinary bladder

Avoid noisy surrounding

Avoid quick movement

Anxiety, excitement

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