SPASTICITY

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY
Injury to brain

Reduced control over LMN

Disordered spinal segment

Excitability, altered presynaptic activity

Decreased presynaptic Ia inhibition

Increase alpha motor activity

Spinal model
Removal

of inhibition on segmental polysynaptic

pathway Slow progressive raise of excitatory state through cumulative excitation Flexor and extensor may be exagerated

Cerebral model
Rapid

build-up of reflex activity Over activity in any one group (more in anti-gravity muscle group)

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

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 the natural drop of the limb segment under gravity

TARDIEU SCALE
Scoring:
0 No resistance throughout the course of the passive movement 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 when maintaining 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

MADICAL TREATMENT
Oral medicine
at spinal level Pantrolele sodium: at the level of muscle fiber Botulinium toxin: at NMJ
Baclofen:

Intra-thecal therapy:
Baclofen

Surgical treatment
Neuro-surgery Orthopedic

surgery

NEURO-SURGERY
Selective dorsal rhizotomy
Nerve

root are cut (fibers lying out side vertebral column) 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 transection of spinal cord

Cordotomy
Complete

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

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

BODY POSITIONING
it is important to facilitate the patients ability to inhibit the undesirable activity of the released reflex mechanisms The position adopted by the patient is important since the head and neck position can elicit strong postural reflex mechanisms Avoiding these head and neck positions can facilitate the inhibition of the more likely reflexes and if positions have to be adopted, then help in preventing the rest of the body from going into the reflex pattern thus elicited may be required by the patient.

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

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

PRESSURE OVER UNDERSURFACE OF FOOT

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 with plantar flexion of the foot, which is undesirable in case of spasticity If pressure is applied under the heel of the foot then a more useful contraction of muscle is likely to occur giving a suitable supporting pattern

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

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 and provides inhibition of muscle tone

COLD APPLICATION
Cryotherapy Cutaneous stimulation Reduces the activity of alpha motor neuron (or) Reduces the muscle spindle discharge Reduce spasticity

COLD APPLICATION
Cryotherapy Decreases the temperature Decreases the conduction velocity Decreases the spasticity

COLD APPLICATION
Immersion in cold water; ice chips
Ice

towel wraps Ice packs Ice massage Ice application with exercises

NEURAL WARMTH
Retention of body heat stimulates thermoreceptors, autonomic nervous system mainly parasympathetics, which produces generalized inhibition of tone, calming effect, 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

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 a reduction in spasticity may occur

DEEP RHYTHMICAL MASSAGE (TENDON ROLLING)

Deep rhythmical massage with pressure over the muscle insertions can be given to reduce spasticity

INHIBITORY PRESSURE (WEIGHT-BEARING)

Prolonged pressure to long tendons inhibits the hypertonicity of a muscle It activates muscle receptors (muscle spindles, golgi tendon organ) and tactile receptors Firm pressure can be applied manually or by body weight Weight bearing postures are used to provide inhibitory pressure, 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 long finger flexors

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

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

ORTHOSIS
These are plastic AFOs in which foot plate and broad upright are designed to modify reflex hypertonicity 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, thus assisting individual to walk with better foot and knee control

SLOW MAINTAINED VESTIBULAR STIMULATION

Low-intensity vestibular stimulation such as slow rocking produces generalized inhibition of tone It facilitates primarily otolith organs (tonic receptors); less effects on semicircular canals (phasic receptors) Slow, repetitive rocking movements; assisted rocking in a weight-bearing position, for example, rocking with equipments:

Rocking chair Swiss ball Equilibrium board Hammock(suspension)

Slow rolling movements

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 using tracking 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)

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

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