L13: Management and prevention of adaptive changes Flashcards
What are 6 adaptive features in UMN syndrome?
- Musculoskeletal adaptations (bio-mechanical and physiological)
- Hypertonia - increased resistance to passive movement
- Decline in endurance and physical fitness
- Learned non-use
- Poor neuroplasticity adaptation
- Can be beneficial or harmful (more or less functional)
- Extension of central dysfunction
What are 3 causes of poor movement recovery post UMN syndrome?
- Previously thought to be due to Positive features e.g. Spasticity
- Negative features e.g. weakness
- Adaptive features e.g. muscle shortening
What are 3 processes that occur with immobility and disuse?
What are 3 adaptive features here?
- Elbow
- Wrist
- Fingers
What is an adaptive feature here?
Shorter, flexed forward, internally rotated and scapula retracted (reinforce subluxed presentation)
SHOULDER
What are 8 musculoskeletal changes in UMN syndrome? What does this result in?
- Muscle and connective tissue stiffness
- Shortening and lengthening of muscles
- Change in the length tension curves
- Loss of joint range of motion.
- Loss or addition of sarcomeres
- Muscle atrophy / wasting
- Changes in muscle fibre type
- Changes in excitation contraction coupling
ALTERED JOINT BIOMECHANICS
What is the measurement between hypertonia and spasticity?
- Quantify overall resistance to passive stretch (Ashworth and Tardieu scales)
- Quantify EMG activity in response to stretch
What does the Ashworth scale measure?
grades resistance to passive movement during a passive muscle stretch. Does not discriminate spasticity vs hypertonia
What does the Tardieu measure?
assesses muscle reaction at different velocities
What are 4 research findings about hypertonia?
- Contracture produced an increase in muscle
- stiffness
- Contracture contributed to stiffness at slow speed, spasticity only at fast speed
- Hypertonia was associated with contracture but not with reflex-hyperexcitability in stroke patients 1 year post stroke
- Early moderate spasticity correlates with later development of contracture
What is the prevalence of shoulder pain post stroke? Why?
- Prevalence up to 85% of patients post stroke
- Consequence of a combination of adaptive and other features, as well as other factors.
Wat are 11 causes of shoulder pain post stroke?
- Hypertonia esp subscapularis and pectoralis muscles
- Weakness or poor shoulder/scapula control
- Glenohumeral subluxation
- Sustained hemiplegic posture
- Immobilisation -> loss of Sh ER and Abd
- Caused by lack of ER (more correlated than subluxation –> unless pulled)
- Frozen or contracted shoulder changes in muscle, capsule / ligament length, adhesive capsulitis
- Shoulder-hand Syndrome (Reflex Sympathetic Dystrophy)
- Pre-existing injury or degenerative disease e.g. arthritis
- Poor manual handling
What is glenohumeral subluxation?
- A palpable gap between the acromion & humeral head.
- Change in the mechanical integrity of the GHJ
- Stretching of capsule and associate muscle
- can occur
How does a glenohumeral subluxation occur post stroke? Is there any way to prevent this?
- Can occur in unsupported arms as early as 2 weeks post-stroke and is irreversible after 8 weeks
- No evidence that it can be reduced prevention is therefore paramoun
What are 5 features of learned non-use?
- Unsuccessful attempts to use impaired arm and leg
- Learn to use unimpaired arm for functional tasks
- Learn to weight bear predominantly on unimpaired leg
- Learned non-use
- Residual capacity in affected hand and leg may be lost
- Reduction in cortical representation occurs
What is an adaptation of motor performance?
When the task is attempted, the movement patterns observed reflect the ‘best’ attempts for their current system
What is an adaptation of motor performance caused by?
Repetitive movements, associated reactions, weakness, etc…
What are 2 secondary complications post stroke?
- Fall rates are as high as 50% in communitydwelling stroke survivors
- Cardiovascular deconditioning occurs as a result of the immobility imposed early after stroke
What are 3 features to anticipate and prevent strokes?
- Get active from Day 1 (Within 48 hrs not 24 hrs)
- Get people as active as possible as soon as possible
- Implement strategies to prevent 20 changes
What are 3 things to do to prevent shoulder pain post stroke?
- Get active
- Support
- Flexibility
What are 4 features to improve motor control (shoulder/scapular functional retraining) when preventing shoulder pain (get active)?
- Apply intramuscular stimulation in acute to subacute phase post stroke
- Facilitating motor activity
- Facilitated practice
- Goal directed, task oriented retraining
What can be done to improve flexibility when preventing shoulder pain?
Stretches
What can be done to improve support when preventing shoulder pain?
What can be done to prevent non-use?
Involve the arm
What can be done to prevent adaptive changes?
Flexibility habits
What are 5 features of prolonged static positioning when preventing adaptive changes post stroke?
- Static prolonged stretches use when:
- functional practice not possible
- poor positions has caused changes
- limitation in ability to participate actively e.g. reduced cognition, behavioural issues
- If patient is unable to free self from positioning, nearby assistance required should pain arises
- Some evidence demonstrates no benefits
- NSF 2010 - Stroke survivors at risk of or have developed contractures and undergoing comprehensive rehab … routine use of splints / prolonged positioning of muscles in lengthened position NOT recommended.
- Work actively is preferred
What are 3 situations (when) is prolonged static stretches when preventing adaptive changes post stroke?
- functional practice not possible
- poor positions has caused changes
- limitation in ability to participate actively e.g. reduced cognition, behavioural issues
What should be limited/ no effective of prolonged static positioning when preventing adaptive changes?
Resting splints: Limited evidence to show usefulness.
What are 2 features of serial casting for prolonged static positioning when preventing adaptive changes post stroke?
- “the process of successively applying and removing corrective casts to increase extensibility in the soft tissues surrounding the casted joint’
- prevent loss of and/or to restore joint range or muscle extensibility in the presence of spasticity, associated reactions etc…
What are 7 features of seating when preventing adaptive changes post stroke?
- Maximise function
- Reduce sustained postures
- Prevent pressure sores
- Maintain soft tissue length
- Reduce discomfort and noxious stimuli
- Reduce influence / development of spastic patterns
- Promote socialisation
Meta-analysis noted benefits of fitness training to improve _____, ____ and _____. Only small
evidence for fitness training to improve _____ capacity
maximal workload; gait speed; walking distance aerobic
What are 4 education features for stroke survivor, family, hospital and support staff?
- mobility level (to optimise activity)
- handling precautions E.g. for the upper limb
- level of functional independence
- ward program
