spas ti city
TRANSCRIPT
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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