soft tissue changes and damages due to stroke
TRANSCRIPT
Soft Tissue Changes and
Damages Due to Stroke
Definition of Soft Tissues
How stroke lead to soft tissue changes
Features of stroke
Other factors leading to further soft tissue changes
Clinical Implications
PT interventions
Contents…
What are Soft Tissues?
• Soft tissue refers to tissues that connect, support, or surround other structures and organs of the body.
• Soft tissue includes muscles, tendons, ligaments, fascia, nerves, fibrous tissues, fat, blood vessels, and synovial membranes.
How stroke lead to soft tissue changes..
stroke
ischemia and anoxia of brain tissue
irreversible neural damage.
decreased recruitment of the motor units
results in muscle atrophy
during the recovery, spasticity occurs
How stroke lead to soft tissue changes..
chronically shortened muscle may develop physical changes
further contribute to muscle stiffness.
Process of recovery following stroke-induced hemiplegia1. Flaccidity (immediately after the onset)
- No "voluntary" movements on the affected side can be initiated
2. Spasticity appears - Basic synergy patterns appear- Minimal voluntary movements may be present
3. Patient gains voluntary control over synergies
- Increase in spasticity
4. Some movement patterns out of synergy are mastered (synergy patterns still predominate)
- Decrease in spasticity
Brunnstrom (1966, 1970) and Sawner(1992)
5. If progress continues, more complex movement combinations are learned as the basic synergies lose their dominance over motor acts
- Further decrease in spasticity
6. Disappearance of spasticity - Individual joint movements become possible
and coordination approaches normal
7. Normal function is restored
Positive features
•exaggeration of normal phenomena
•spasticity
Negative features
•decrease in strength
•slowness of movement
•loss of dexterity and coordination
Features of Stroke
Other factors leading to further
soft tissue changes
1. Immobilization in a
Shortened Positiona) Effects on Muscles
Anatomical Changes
up to 40% decrease in the number of sarcomeres. (J. C. Tabary et al, 1972, William & Goldspink 1978) [illustration]
Reduced extensibility (J.C Tabary at al, 1972)
Effects are specific to fiber type. (Gossman et al, 1982) [illustration]
•The absolute and relative numbers of type II fibers increases.
•Accompanied by phagocytosis of type I fibers.
Normal
ShortenedAdaptation
[back]
Biochemical Changes
More pronounced shortened muscles than in lengthened muscles.
Changes in the shortened muscles favor catabolism.
Followed by loss of weight. There is evidence that changes may be specific to muscle fiber types. (Sohar I et al, 1977)
Physiological Changes
1) Passive tension curve shifts to the left. (Tabary et al, 1972)
2) Active tension also decreases. (Gossman et al, 1982)
Passive Tension
b) Effects on Tendons
•Decreased size and amount of collagen fibers Reduces total load tolerance
•Compliance increases due to increased elastic fibers.
•Collagen fibers become thinner and less organized, and cross-links are reduced
•The tendon is less susceptible to immobilization-induced changes.
[CM tipton et al, 1986]
c) Effects on Ligaments
Ligament responds to immobilization at a slower rate
The total collagen mass decreases
strength and stiffness decrease
ligament also shortens
d) Effects on Articular Cartilage
•Decreased loading and motion => degeneration of the articular surface.
• Increased water content, decreased proteoglycans and alters proteoglycan organization.
• Precede softening and fragmentation of chondral surfaces.
•Decreases in cartilage stiffness and thickness make the cartilage more vulnerable to injury.
•Loss of matrix proteoglycan places an increased load on the remaining tissues
•Bony proliferation -> osteophytes formation.
2. Disuse
Accomodation by the use of proximal joints or via unaffected side.
Decreased Loading leads to adaptive shortening of muscles.
Learned Disuse
Secondary soft tissue changes, bring about pain and weakness.
Vicious Cycle
Damages
• Muscle Atrophy
• Decreased ROM
• Decreased Dexterity
• Hygiene
• Balance
PT Interventions
Improving Dexterity
• Constrained Induced Movement Therapy
(Wolf et al 06)
• Correcting PostureThere is a positive relationship between good posture and manual dexterity. (Buffington et al 06)
We can do by giving audio feedback and also use mirrors for visual feedback.
• Task Related Exercises
A study of task related exercise with afferent stimulation, it was shown that even the control group also benefited from the task related exercise.
(McDonnell et al 07)
Tasks like wrist extension against resistance, manipulation of putty and placing objects in boxes.
Improving Range of Motion
1) Positioning• Maintain at-risk muscles ( internalrotators and adductors of the shoulder andlong finger and thumb flexors, plantar
flexors,hip and knee flexors) and soft tissue in alengthen position• To prevent muscle shortening and
increased stiffness.• At least 30 mins a day of positioning the
affected shoulder in ext rotation for stroke patients to reduce contractures. ( Ada L et al, 2004)
2) Serial Casting• Increased joint mobility, reduce
hypertonia and muscle contracture of the limbs increased ROM
• aims to gradually move the limb into a more functional position.
3) PNF Techniques• To enhance both active and passive
range of motion• A combination of passive stretching
and isometrics contractions• Encourage flexibility and
coordination throughout the limb's entire range of motion
Improving Strength1)Task-oriented progressive resistance
strength training• Aim to improve functional performance as well
as to increase muscle strength• Ray – Yau Wang et al (2006) shows significant
improvement of the muscle strength for strong side and paretic side muscle groups.
• Weiss et al suggest that improved rate of task oriented progressive resistance strength training = traditional progressive resistance strength training
• Carl and Shepherd have indicated that transfer is unlikely to occur unless subjects are also practising the task to be learned.
Improving Range of Motion
2) Weight bearing exercises• Allows increased in joint stability and
co-contraction of muscles surrounding the joint.
• Emphasized eccentric control of the muscles
• Aids in muscular recruitment which stimulates functional activities.
• Stroke patients attain significant improvements in knee flexor strength doing weight bearing exercises. ( Dong Koog Noh et al, 2008)
Other factors that may affect the outcome of treatment
• Severity of stroke • Co existing medical problems • Type of stroke• Compliance of pt: post stroke fatigue• Age and pro morbid status of pt
References• Canning et al: Loss of strength contributes more to physical
disability after stroke than loss of dexterity. Clinical Rehabilitation (2004), 18, pp. 300-8
• Wolf et al: Effect of Constraint-Induced Movement Therapy on Upper Extremity Function 3 to 9 Months After Stroke. Journal of the American Medical Association (2006), 296, pp. 2095-2104.
• Buffington et al: Body Position Affects Manual Dexterity. Anesth Analg (2006), 102, pp. 1879-1883
• McDonnell et al : Influence of Combined Afferent Stimulation and Task-Specific Training Following Stroke: A Pilot Randomized Controlled Trial. Neurorehabil Neural Repair (2007), 21, pp. 435–443
• Tabary JC, Tabary C, Tardieu C, et al: Physiological and structural changes in the cat's soleus muscle due to immobilization at different lengths by plaster casts. J. Physiol (1972), 224, pp. 231-244
• Therapeutic exercise: Moving towards function. Carrie M Hall, Lorie Thein Brody. Chap 7.
• Tipton CM et alExperimental studies on the influences of physical activity on ligaments, tendons and joints: a brief review Acta Med Scand Suppl 1986;711: 157-168
• Williams and Goldspink: chnages in sarcomere length and physiological properties ini immobilied muscle J Anat 1978, 127,3 pp. 458-468
Sharman et al : Proprioceptive Neuromuscular Facilitation StretchingMechanisms and Clinical Implications. Sports Med2006 36(11) pp.929-939
Ray-Yau Wang et al : Task –oriented progressive resistance strength training improves muscle strength and functional performance in individuals with stroke. Clinical Rehabilitation 2006;20;pp.860-870
Miller et al: Strength training in spastic hemiparesis: should it be avoided? Neurorehabilitation 9 (1997) pp.17-28
Ada L et al: Thirty minutes of positioning reduces the development of shoulder external rotation contracture after stroke: a randomized controlled trial. Archives Of Physical Medicine And Rehabilitation 2005 Feb; Vol.86(2), pp230/234
Gelber et al : Therapeutics in the management of Spasticity. Neurorehabilitation and Neural Repair, Vol.13, No.1 ,1999
Mortenson et al: The Use of Casts in the Management of Joint Mobility and Hypertonia Following Brain Injury in Adults: A Systematic Review. Physical Threrapy, Vol. 83, No.7,July 2003
Sharman et al : Proprioceptive Neuromuscular Facilitation Stretching Mechanisms and Clinical Implications. Sports Med2006 36(11) pp.929-939Ray-Yau Wang et al : Task –oriented progressive resistance strength training improves muscle strength and functional performance in individuals with stroke. Clinical Rehabilitation 2006;20;pp.860-870Miller et al: Strength training in spastic hemiparesis: should it be avoided? Neurorehabilitation 9 (1997) pp.17-28Ada L et al: Thirty minutes of positioning reduces the development of shoulder external rotation contracture after stroke: a randomized controlled trial. Archives Of Physical Medicine And Rehabilitation 2005 Feb; Vol.86(2), pp230/234Gelber et al : Therapeutics in the management of Spasticity. Neurorehabilitation and Neural Repair, Vol.13, No.1 ,1999Mortenson et al: The Use of Casts in the Management of Joint Mobility and Hypertonia Following Brain Injury in Adults: A Systematic Review. Physical Threrapy, Vol. 83, No.7,July 2003