Evidence based treatment HB- Spasticity (Stroke)

Question 1

Define spacticity

Answer 1

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

Question 2

What is spacsticity a result of

Answer 2

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

Question 3

Management and aim of spasticity

Answer 3

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

Question 4

Management interventions

Answer 4

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.

Question 5

Physiotherapy interventions

Answer 5

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.

Question 6

Maintanece of soft tissue length

Answer 6

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

Question 7

Splinting and casting

Answer 7

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

Question 8

modulation of tone

Answer 8

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.

Question 9

Re-education of movement and strengthening of the muscles

Answer 9

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.

Question 10

Pharmacological treatment

Answer 10

Oral medications
Botulinum Toxin
Intrathecal therapies

Question 11

Types of Oral medications

Answer 11

baclofen, tizanidine, dantolene, diazepam, gabapentin

Question 12

baclofen

Answer 12

effects influences at spinal cord level to inhibit monosynaptic and polysynaptic reflexes

Question 13

tizanidine

Answer 13

acts to reduce stretch reflexes and co-contraction

Question 14

dantolene

Answer 14

works directly on the skeletal muscles to reduce muscle fibre excitation

Question 15

diazepam and gabapentin

Answer 15

reduce spasticity through modulation of GABA ergic transmission

Question 16

Botulinum Toxin

Answer 16

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.

Question 17

Intrathecal therapies

Answer 17

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.

Question 18

Intrathecal phenol

Answer 18

used with very severe painful spasticity as this is neuro destructive and not reversible.

Question 19

Upper limb rehabilitation

Answer 19

Common to have difficultes after a stroke

affects 30-75%

Question 20

Somatosensor deficits in the UL

Answer 20

impaired tactile sensation, impaired stereognosis, and proprioception. Other impairments can include poor coordination, weakness, spasticity, pain and contractures.

Question 21

Interventions for the UL

Answer 21

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.

Question 22

Neuroplasticity

Answer 22

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.

Question 23

early intense rehabilitation

Answer 23

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.

Question 24

Repetitive, task-specific training

Answer 24

Evidence shows it increses UL rehabilitation and function

Question 25

Task-specific training

Answer 25

involves repetitive part and whole task practice that are meaningful to an individual patient.

Question 26

Part practice

Answer 26

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.

Question 27

five key elements for successful implementation of task-specific training

Answer 27

• 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

Question 28

Bimanual Training

Answer 28

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.

Question 29

Aims of Bimanual Training

Answer 29

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.

Question 30

Bilateral movements

Answer 30

often functional important aspect of rehabilitation.

E.g doing the same things on both sides

Question 31

Constraint-induced movement therapy

Answer 31

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

Question 32

Constraint-induced movement therapy effective in which patients

Answer 32

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.

Question 33

Affect Constraint-induced movement therapy

Answer 33

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.

Question 34

Neuromuscular electrical stimulation

Answer 34

involves a low-dose electrical current to the peripheral motor nerves to improve motor performance and cortical excitability

Question 35

Use of Neuromuscular electrical stimulation

Answer 35

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.

Question 36

Mirror theraphy

Answer 36

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.

Question 37

Set up of mirror theraphy and explanation

Answer 37

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.

Question 38

Mental practice

Answer 38

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.

Question 39

Robotics

Answer 39

Restorative approach

efficient approach to deliver an increased dose of therapy and provide practice and repetition

i

Question 40

what does robotics improve

Answer 40

improve function and activities of daily living

Question 41

where are improvemtns made whn using robotics

Answer 41

predominately the improvements are at the shoulder and elbow with limited success at the hand

Question 42

Patient satisfication

Answer 42

Patient satisfaction and adherence is good possible due to the high quality gaming approach which increases engagement and motivation

Question 43

usefulness of robotics

Answer 43

useful adjunct to more conventional therapy as a means of achieving higher dose therapy.

Question 44

Virtual reality and gaming strategies

Answer 44

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

Question 45

Principle of Virtual reality and gaming strategies

Answer 45

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

Question 46

Virtual reality and gaming strategies pateint choice

Answer 46

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.

Question 47

Non-invasive brains stimulation

Answer 47

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.

Question 48

Telerehabilitation

Answer 48

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.

Question 49

Secondary Upper Limb Complications

Answer 49

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.

Question 50

combination treatments

Answer 50

Botulinum toxin A combined with targeted therapy has been demonstrated to reduce upper limb spasticity.

Question 51

subluxation

Answer 51

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.

Question 52

Sensory Re-education

Answer 52

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.

Question 53

What does Sensory Re-education use

Answer 53

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.

Question 54

Sensory Re-education aim

Answer 54

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.

Question 55

Techniques within a sensory re-education programme

Answer 55

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.