Evidence based treatment HB- Spasticity (Stroke) Flashcards
Define spacticity
a disorder of sensorimotor control resulting from an upper motor neuron lesion characterised by a velocity-dependent increase in tonic stretch reflexes with exaggerated tendon jerks, resulting from hyper excitability of the stretch reflex, as one component of the upper motor neurone syndrome
What is spacsticity a result of
combination of neural and non-neural aspects.
Neural aspects: abnormal / exaggerated stretch reflex, increased excitability of muscle spindles and abnormal processing of sensory inputs from muscle spindles in the spinal cord.
Non-neural aspects: changes in the biomechanical properties of the muscles due to immobilisation and disuse= decreasing the muscle length and increasing the intrinsic muscle stiffness
Management and aim of spasticity
involves a specialist multi-disciplinary team
Patient and carer education and physical management.
The aim should be to agree a goal based treatment plan and improve function and / or limiting the secondary musculoskeletal impairments
Management interventions
stretching, casting, splinting, tilt-tabling, strengthen training and functional retraining.
Medicines that target the pathophysiology of the processes that lead to spasticity can be used such as baclofen, dantrolene, diazepam and boNT-A. Often the medicines are used in combination with the physical therapy.
Physiotherapy interventions
24 hour postural management is an essential consideration to ensure appropriate support of the whole body.
Various supports, wedges, t-rolls, specialist seating to provide support and encourage activity.
Maintanece of soft tissue length
should be a key goal and consideration of stretching and how these stretches can fit into 24 hour postural management.
Consider periods of standing / weight bearing with support if required
Splinting and casting
used to provided sustain stretch to help combat contracture development. Stretches should be held for periods of time to ensure that changes occur to the soft tissue components. Passive and active movements can be used to help sustain the soft tissue
modulation of tone
these patterns of movement try to influence the pathophysiological aspects of tone – trying to influence the supraspinal controls and improve the sensory feedback / feedforward into the system.
Re-education of movement and strengthening of the muscles
strengthen muscles that have spasticity. Muscles that have high tone can also be weak as they are often held in either lengthened or shortened positions.
Pharmacological treatment
Oral medications
Botulinum Toxin
Intrathecal therapies
Types of Oral medications
baclofen, tizanidine, dantolene, diazepam, gabapentin
baclofen
effects influences at spinal cord level to inhibit monosynaptic and polysynaptic reflexes
tizanidine
acts to reduce stretch reflexes and co-contraction
dantolene
works directly on the skeletal muscles to reduce muscle fibre excitation
diazepam and gabapentin
reduce spasticity through modulation of GABA ergic transmission
Botulinum Toxin
focal treatment that can target specific muscle groups and inhibits the release of the acetylcholine at the presynaptic terminal to prevent the nerve impulses being transmitted to the muscle. This is often used to provide a temporary 3 month window of denervation and reduction of spasticity to allow the antagonists to be strengthened with the aim of improving function and activity of both muscle groups one the BoTox has worn off.
Intrathecal therapies
small catheter is passed into the subarachnoid space and therefore the drug is administered direct to the spinal cord. This allows for a lower dose is able to have a more targeted response. Intrathecal baclofen is used if the oral dose is too high and therefore additional side effects are showing.
Intrathecal phenol
used with very severe painful spasticity as this is neuro destructive and not reversible.
Upper limb rehabilitation
Common to have difficultes after a stroke
affects 30-75%
Somatosensor deficits in the UL
impaired tactile sensation, impaired stereognosis, and proprioception. Other impairments can include poor coordination, weakness, spasticity, pain and contractures.
Interventions for the UL
focus on both impairment and activities involved in function.
Look at compensatory strategies and / or restorative approaches should be applied.
restoration and rehabilitation use neuroplasticity concepts.
Neuroplasticity
Neuroplasticity is the inherent capacity for cortical reorganisation or development of new functional connections in response to learning and experience. Cortical representation is enhanced by rehabilitative training.
early intense rehabilitation
facilitate task-specific repetitions as this a positive impact on both physical recovery and quality of life measures. High –grade evidence indicates that the rehabilitation environment should be structured to enable maximal practice within the first 6 months post-stroke. The key elements are intensity, specificity and repetition. The practice dose can be maximised with task-specific circuit lass or video self-modeling.
Repetitive, task-specific training
Evidence shows it increses UL rehabilitation and function
Task-specific training
involves repetitive part and whole task practice that are meaningful to an individual patient.
Part practice
involves undertaking the tasks through segmentation.
The movement sequence is broken down into segment parts and practiced in isolation and separately before then ‘chaining’ these segments together to practice either a few segments together or the whole task.
With the overall aim of mastering the task.
five key elements for successful implementation of task-specific training
- Tasks that are relevant to the patient and context
- Random and changing tasks
- Repetitive tasks with massed practice
- Part and whole practice
- Reinforced with positive and timely feedback
greater number of reps the better
Bimanual Training
considers that bilateral simultaneous movement will activate the ‘normal’ movement commands from the contralesional hemisphere to the symmetrically organised upper limb motor homunculus in the ipsilesional hemisphere.
Aims of Bimanual Training
to transfer the learned motor programme from the practiced limb to the hemiparetic limb.
used with chronic stroke patients= positive effect.
May offer a more functional training opportunity in comparison to unilateral limb use.
Bilateral movements
often functional important aspect of rehabilitation.
E.g doing the same things on both sides
Constraint-induced movement therapy
acquired learned non-use of the affected limb exacerbates the impairment, loss of function and cortical representation.
Therefore by constraining the non-affected limb and ‘forcing’ use of the affected limb combined with mass practice leads to a reduction in impairment and an increase in function
Constraint-induced movement therapy effective in which patients
sufficient finger flexion and wrist extension to perform limited tasks. There are strict inclusion criteria and protocols used which means that not all patients are suitable, with the majority of evidence within the chronic stroke population.
Affect Constraint-induced movement therapy
can be limited by adherence, fatigue and compliance.
Despite limitations= possible incorporate some of these principles via modified CIMT into acute therapy= increase the level of practice and lessen the effects of learnt non-use.
Neuromuscular electrical stimulation
involves a low-dose electrical current to the peripheral motor nerves to improve motor performance and cortical excitability
Use of Neuromuscular electrical stimulation
promote functional tasks – Functional Electrical Stimulation FES) with or without activation from the patient.
Current evidence= patient is able to produce the voluntary contraction= more effective than passive stimulation. N
Effective to reduce post-stroke spasticity and hemiplegic shoulder pain.
Mirror theraphy
a form of visual imagery where the mirror ensures that the brain receives the correct visual stimulation by observing the unaffected upper limb carrying out the movement sets.
Set up of mirror theraphy and explanation
placing the mirror in the mid saggital plane the reflection of the non paretic side appears as the affected side.
The premotor cortex is important for neuroplasticity and is responsive to visual feedback.
Strong evidence that when this is combined with other therapy it can help to improve motor function.
Mental practice
developed from sports psychology
shown to enhance an athletes performance when used as an adjunct.
involves rehearsing a specific task or series of tasks mentally.
The stored motor plans for executing the movement can used and reinforced during this activity.
Used as a treatment adjunct to all UL therapy and as a pre-cursor to CIMT.
Robotics
Restorative approach
efficient approach to deliver an increased dose of therapy and provide practice and repetition
i
what does robotics improve
improve function and activities of daily living
where are improvemtns made whn using robotics
predominately the improvements are at the shoulder and elbow with limited success at the hand
Patient satisfication
Patient satisfaction and adherence is good possible due to the high quality gaming approach which increases engagement and motivation
usefulness of robotics
useful adjunct to more conventional therapy as a means of achieving higher dose therapy.
Virtual reality and gaming strategies
provide a computer-based, interactive, multisensory simulation environment that occurs in real time. It is goal directed, reward based which can be used to aid task-specificity and patient motivation
Principle of Virtual reality and gaming strategies
increasing activation of the neural areas by increasing the motor activity as well as the imagery within the task= engages the bilateral motor cortices
increses theraphy does
Virtual reality and gaming strategies pateint choice
patient choice is important as not all patients find this method acceptable and it is not possible to access the technology in all rehabilitation settings.
Non-invasive brains stimulation
Repetitive Transcranial magnetic stimulation and transcranial direct-current stimulation is hypothesised to achieve a greater balance of excitability between the ipsilateral and contralateral lesional motor corticies with the aim of enhancing neuroplasticity secondary to motor practice.
Telerehabilitation
used to improve access to assessment and therapy. There have been a few studies that have reviewed telehealth approaches to improving upper limb function using customised computer based training programmes. Currently the information regarding effectiveness is incomplete.
Secondary Upper Limb Complications
prevent and limit the effects of secondary complications which may affect the upper limb. These include spasticity, contractures, subluxation, hemiplegic shoulder pain and distal oedema. These complications can contribute to pain, depression and a poorer ability to participate in rehabilitation.
combination treatments
Botulinum toxin A combined with targeted therapy has been demonstrated to reduce upper limb spasticity.
subluxation
subluxation is linked with hemiplegic shoulder pain. However if a subluxation is present care should be taken with handling and positioning and protecting the shoulder via education and supportive devices.
Sensory Re-education
affect people with CNS lesions, these can vary from just one type of sensation e.g. light touch to impairments of all sensory abilities. Sensory inputs are important in maintaining normal cortical representation on both the sensory and the motor cortices. Research has demonstrated that fine motor control is affected by sensory impairment. Patients with somatosensory loss often have poor functional outcomes.
What does Sensory Re-education use
learning dependent neural plasticity principles that are designed to facilitate the training effects to greater improvement of sensory capacity.
Focus of the training= assist the individual to decode the altered neural impulses created by the affected hand / limb.
Sensory Re-education aim
Aims to use to the existing sensory nerves receptors and somatosensory spinal tracts by using repeated targeted discrimination tasks. The tasks progress from easy to more challenging within the discrimination, consideration to the removal of the visual stimuli, using anticipation and feedback.
Techniques within a sensory re-education programme
consider texture discrimination, limb position sense, tactile object recognition (stereognosis), mirror therapy for light touch, temperature and pain, thermal stimulation and intermittent pneumatic compression.
These tasks require an active cognitive engagement to attention to the task and the use imagery skills; which can potentially limit the individual’s ability to participate within the treatment.
