SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

Spasticity Sagar Naik,

PT
Spasticity is a disorder of the sensorimotor system characterized by a velocity-dependent increase in muscle tone with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex. It is one component of the upper motor neuron syndrome, along with released flexor reflexes, weakness, and loss of dexterity. Spasticity is the hypertonicity in the muscle group. It can be defined as an initial catch or resistance felt by the examiner when rapid passive movements are performed. In an upper motor neuron syndrome, the alpha motor neuron pool becomes hyperexcitable at the segmental level. Spasticity occurs because the inhibition normally provided by the suppresser areas of the brain is not present. Brain lesions disrupt the linkages and upset the balance between suppresser and facilitory areas of the brain. The major consequence of the disruption of the balance is the excess facilitation of gamma motor neurons resulting in hypersensitive muscle spindles. This results in hyperactive phasic stretch reflexes, hyperactive tonic reflexes, and clonus. Spasticity caused by spinal cord lesions is often marked by a slow increase in excitation and over activity of both flexors and extensors with reactions possibly occurring many segments away from the stimulus. Cerebral lesions often cause rapid build-up of excitation with a bias toward involvement of antigravity muscles. Chronic spasticity can lead to changes in the rheologic properties of the involved and neighboring muscles. The abnormal joint positioning, postures, and unequal distribution of muscle activity imposed by spasticity can produce profound and lasting changes in joints and muscles. Stiffness, contracture, atrophy, and fibrosis may interact with pathologic regulatory mechanisms to prevent normal control of limb position and movement.

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SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

D Mechanism:

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Primary afferent Ia fibers surrounding intrafusal fibers of the muscle spindle are excited when a muscle is stretched. The Ia fiber makes a monosynaptic excitatory connection with alpha motor neurons of its muscle of origin, and it similarly connects with alpha motor neurons of synergistic muscles. The Ia fiber also monosynaptically connects with an inhibitory interneuron that projects directly to the alpha motor neurons of antagonist muscles. When a muscle is stretched, excitation of homonymous and synergistic motor neurons, combined with inhibition of antagonists, subserves the mechanism of reciprocal inhibition. There is evidence for impairment of this mechanism in the UMN syndrome.

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SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

D Features:
Spasticity, spinal model: Removal of inhibition on segmental polysynaptic pathways Slow, progressive rise of excitatory state through cumulative excitation Afferent activity from one segment may lead to muscle response many segments away Flexors and extensors may be overexcited Spasticity, cerebral model: Enhanced excitability of monosynaptic pathways Rapid build-up of reflex activity Bias toward over activity in the antigravity muscles and the development of hemiplegic posture The clinical features of released flexor reflex are: Big toe extension (principal component of Babinski's sign) Ankle, knee, and hip flexion - contraction of abdominals

D Clinical Features:

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POSITIVE SYMPTOMS y Spasticity - Increased muscle tone - Exaggerated tendon jerks - Stretch reflex spread to extensors - Repetitive stretch reflex discharges; clonus y Released flexor reflexes - Babinski response - Mass synergy patterns NEGATIVE SYMPTOMS y Loss of finger dexterity y Weakness - Inadequate force generation - Slow movements y Loss of selective control of muscles and limb segments RHEOLOGIC CHANGES IN SPASTIC MUSCLE y Stiffness y Fibrosis y Contracture y Atrophy

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SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

Potentially Spastic Muscles in the Common Patterns of Upper Motor Neuron Dysfunction

The Upper Limbs

y The Adducted/Internally Rotated Shoulder - Pectoralis major - Latissimus dorsi - Teres major - Subscapularis yThe Flexed Elbow - Brachioradialis - Biceps - Brachialis y The Pronated Forearm - Pronator quadratus - Pronator teres y The Flexed Wrist - Flexor carpi radialis and brevis - Extrinsic finger flexors y The Clenched Fist - Various muscle slips of FDP - Various muscle slips of FDS

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y The Equino-varus Foot (with Curled Toes or Claw Toes) - Medial gastrocnemius - Lateral hamstrings - Soleus - Tibialis posterior - Tibialis anterior - Extensor hallucis longus - Long toe flexors - Peroneus longus y Striatal Toe (Hitchhiker's Great Toe) - Extensor hallucis longus y The Stiff (Extended) Knee - Gluteus maximus - Rectus femoris - Vastus lateralis - Vastus medialis - Vastus intermedius - Hamstrings - Gastrocnemius - Iliopsoas (weak)

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The Lower Limbs
y The Flexed Knee - Medial hamstrings - Lateral hamstrings - Quadriceps - Gastrocnemius y Adducted Thighs - Adductor longus - Adductor magnus - Gracilis - Iliopsoas (weak) - Pectineus (weak) y The Flexed Hip - Rectus femoris - Iliopsoas - Pectineus - Adductors longus - Adductor brevis (weak) - Gluteus maximus (weak)

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y The Intrinsic Plus Hand - Dorsal interossei y The Thumb-In-Palm Deformity - Adductor pollicis - Thenar group - Flexor pollicis longus

SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

D Management:

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SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

General Considerations:

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Carefully assess the extent to which muscle overactivity impacts patients' function, hygiene, comfort, and care. Target the patient's most bothersome dysfunction. Be aware of the complications of spasticity such as pressure sores, contractures, pain, poor hygiene and deconditioning. Some degree of spasticity may be beneficial in maintaining postural control and ambulation, so global reduction of tone may be destabilizing. Consider factors that may aggravate spasticity including intercurrent medical illness, certain classes of medications known to increase muscle tone (e.g. neuroleptic agents) and finally emotional stressors. Factors like y Urinary tract infection y Urolithiasis y Stool impaction y Pressure sore y Fracture & Dislocation y Ingrown toe nail y Clothing that is too tight y Heterotopic ossification

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There are two clinical types of spasticity that can develop in response to injury to the central nervous systemphasic and tonic. Phasic spasticity is often the initial manifestation of spasticity and tonic spasticity may occur months to years later. The muscle has a normal lengthening reaction in phasic spasticity but the muscle shows a decreased amount of stretch in tonic spasticity. This decreased amount of muscle stretch can lead to the gradual development of contractures. Thus, spasticity must be aggressively managed in the early stages to prevent permanent deformities and joint contracture.

SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

Medical Management: M Oral Medications:

Benzodiazepines - Diazepam and Clonazepam is centrally acting agents that increase the affinity of GABA to its receptor. The clinical effects of diazepam include improved passive range of motion and reduction in hyperreflexia as well as painful spasms. These agents also cause sedation and improve anxiety. Baclofen is GABA agonist that has presynaptic and postsynaptic effects on monosynaptic and polysynaptic pathways. The primary site of action is the spinal cord where baclofen reduces the release of excitatory neurotransmitters. Dantrolene sodium acts peripherally at the level of the muscle fiber. It affects the release of calcium from the sarcoplasmic reticulum of skeletal muscle and thus reduces muscle contraction. Dantrolene sodium is generally indicated for spasticity of supra spinal origin. Tizanidine has been used for the treatment of spasticity as a central alpha 2 - noradrenergic agonist; tizanidine facilitates short-term vibratory inhibition of the H-reflex, associated with antispasticity effects without muscle weakness.

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M Botulinum Toxin Type A:

BTX-A affects the neuromuscular junction through binding, internalization, and inhibition of acetylcholine release. It must enter the nerve endings to exert its chemodenervating effect. Once inside the cholinergic nerve terminal cell, BTX-A inhibits the docking and fusion of acetylcholine vesicles at the pre-synaptic membrane. Duration of effect is usually 3 to 4 months, but can be longer or shorter.

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SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

Gradually, muscle function returns by the regeneration or sprouting of blocked nerves forming new neuromuscular junctions. BTX-A is dose-dependent and reversible secondary to the regeneration process.

M Intrathecal Baclofen (ITB):

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Intrathecal baclofen therapy (ITB Therapy) consists of long-term delivery of baclofen to the intrathecal space. This treatment can be very effective for patients with severe spasticity, particularly for those patients whose conditions are not sufficiently managed by oral baclofen and other oral medications. Benefits of ITB Therapy typically include reduced tone, spasms, and pain, and increased mobility. In addition, many patients, caregivers, family members and physicians have reported striking improvements in movement and self-care. Other benefits may include improved speech, sleep quality, bladder control, and self-image. The efficacy of ITB Therapy in controlling spasticity typically allows patients to decrease and often discontinue other spasticity medications.

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M Neurosurgery for Spasticity:
< Selective Dorsal Rhizotomy:

Selective dorsal rhizotomy (SDR) or selective posterior rhizotomy in which nerve roots are cut, the fibers lying just outside the vertebral column that transmit nerve impulses to and from the spinal cord. These nerves carry sensory information to the cord from muscle. Excitatory signals from these sensory nerves are counterbalanced by inhibitory signals from the brain, maintaining normal muscle tone.

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SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

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< Myelotomy & Cordotomy:

Thus when brain or spinal cord damage upsets this balance, excess sensory signaling can lead to spasticity. Hence sensory nerves are targeted. Favorable selection criteria for selective dorsal rhizotomy are as follows: y Pure spasticity (limited dystonia/athetosis) y Function limited primarily by spasticity y Adequate truncal balance / righting responses y Not significantly affected by primitive reflexes / movement patterns y Absence of profound underlying weakness y Selective motor control y Some degree of spontaneous forward locomotion y Spastic diplegia y History of prematurity y Minimal joint contracture & spine deformity y Adequate cognitive ability to participate in therapy y No significant motivational / behavioral problems y Age 3 8 years y Supportive & interactive family

Myelotomy is complete disruption of some spinal cord tracts and cordotomy is complete transection of spinal cord. These surgeries are advocated as treatment modalities in most severe cases of spasticity; rarely performed except occasionally in patients with complete spinal cord injury. Side effects of loss of bowel and bladder function, muscle wasting, and loss of erectile function can be seen.

M Orthopedic Surgery for Spasticity:

Orthopedic surgery is the most frequently used surgical procedure for spasticity. The targets of these surgeries are the muscle, tendon, or bone in a spastic limb. The goals of surgery may include

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SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

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y Reducing spasticity y Increasing range of motion y Improving access for hygiene y Improving tolerability of braces y Reducing pain Orthopedic surgery is done in patients who have been refractory to more conservative measures and patients whose recovery after central nervous system insult has plateaued. These surgeries alters musculotendinous unit in way that decreases tension. It is often used when spasticity has progressed to contracture. Different techniques include y Tenotomy involves transection of tendon y Neurectomy involves excision of part of nerve y Tendon transfer involves moving tendon form one insertion site to another y Tendon lengthening involves sectioning tendon with step-like incision and then sewing longest pieces together, again resulting in increased tendon length y Arthrodesis involves locking joint in fixed position y Bony surgeries, such as rotational osteotomy

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SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

Physiotherapy Management:
When treating a patient who shows spasticity it is necessary to carry out three important aims: y Inhibit excessive tone as far as possible y Give the patient a sensation of normal position and normal movement y Facilitate normal movement patterns

< Body Positioning:

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In cases of spasticity 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. 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. Side lying position well supported by pillows is very convenient since it avoids stimulation of the tonic labyrinthine reflex and also, as head and trunk are in alignment, the stimulation of the asymmetrical tonic neck reflexes. It makes a good resting position for the patient with spasticity and also is convenient for the application of rhythmical trunk rotations of both passive and assisted active form which further helps in reduction of tone. Side lying is not always desirable because of respiratory problems in the older patient or because of the need to obtain a greater range of movement. Other attitudes are often very satisfactory such as crook lying or even with the knees as high on the chest as
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SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

possible. These two positions are helpful if there is flexor spasticity.

< 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:

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Triggering Factors:

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.

< Normal Movements Patterns & Avoidance of

Movement of a normal nature does appear in itself to reduce excessive tone and consequently this should be encouraged in the patient. However, care must be taken if conscious volitional movement is demanded. Due to reflex release, some motoneurone pools are already in an excitatory state and any volitional effort is likely to act as a triggering mechanism to those motoneurone pools giving associated muscle contraction in the spastic pattern. Such patients should not be encouraged to make strong volitional effort since this is inclined to facilitate the production of spastic patterning. Other factors such as quick movements, abruptly performed, noisy surroundings, anxiety, excitement,

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SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

over exertion should also be avoided as it may increase spasticity.

< 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 or dampens muscle contraction and tone due largely to peripheral reflex effects. It can be more effective in extensor muscles than flexors due to the added effects of II inhibition. This method does have its dangers since, if stretching is forced against severe spasticity, the hyperexcitable stretch reflex reacts even more strongly and damage to the periosteum of bone may occur where excessive tension has been applied by the tendons of the stretched muscles. Techniques used are y Manual contacts y Inhibitory casting or splinting y Reflex-inhibiting patterns y Mechanical low-load weights

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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 and provides inhibition of muscle tone. Techniques used y Immersion in cold water; ice chips

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SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

y Ice towel wraps y Ice packs y Ice massage y Ice application with exercises

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< Relaxed Passive Movements: < Inhibitory Pressure (Weight-Bearing):

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 y Wrapping body or body parts: ace wraps, towel wraps y Application of snug fitting clothing (gloves, socks, tights) or air splints y Tepid baths

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.

Prolonged pressure to long tendons inhibits the hypertonicity of a muscle. It activates muscle receptors (muscle spindles, golgi tendon organ) and tactile receptors.

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< Neutral Warmth:

SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

< Biofeedback:

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< Functional Electrical Stimulation: < Tone Reducing Orthosis:

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.

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.

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.

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Firm pressure can be applied manually or by body weight. Weight bearing postures are used to provide inhibitory pressure, such as y Quadruped or kneeling postures can be used to promote inhibition of quadriceps and long finger flexors. y Sitting, with hands open, elbow extended, and upper extremity supporting body weight can be used to promote inhibition of long finger flexors.

SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

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: 9 Rocking chair 9 Swiss ball 9 Equilibrium board 9 Hammock Slow rolling movements

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< Proprioceptive Neuromuscular Techniques:

Techniques used 9 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. 9 Rhythmic Rotation Voluntary relaxation combined with slow, passive, rhythmic rotation of the body or body part around a longitudinal axis, followed by passive movement into the antagonist range. 9 Contract Relax Active Contraction Isotonic movement in rotation is 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.

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SPASTICITY & PHYSICAL THERAPY MANAGEMENT

Sagar Naik, PT

< 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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