2. Spastic Paresis
Spasticity
Poor motor control
Dystonia
Rigidity
Spasms
Contractures
Pain
(i) Brain injury medicine: principles & practice, New York, Demos, 2007 pp 469-489 (ii) Neurology
1997;47:1488-1492 (iii) Movt Disord 1997;12:428-431
3. UMN lesion
Muscle
Overactivity
Weakness
Dynamic
• spasm
• Co-
contraction
• Clonus
• Associated
reactions
• Flexor
withdrawal
Static
• Spastici
ty
• Spastic
dystoni
a
Immobilization at
short muscle length
Biomechanical changes –
reduced compliance and
contractures
Hypertonia
Reduced ROM
Abnormal posture
Impaired function
(i) Disability and Rehabilitation 2005;27(1/2):26) (ii) Spasticity: Disordered Motor Control, Miami,FL:Year Book
Medical Publishers, 1980:485-495 (iii) Neurology 1994;44:S12-S20 (iv) J Neurol. 2018 Apr;265(4):856-862
4. Rehabilitation goals for muscle
overactivity
Improvement of functional alignment
Improvement of selective motor control
Improvement of strength
Improvement of functional abilities
Enhancement of community participation
5.
6. Physical assessment of spasticity
Modified Ashworth scale
Modified Tardieu scale
Penn spasm frequency scale
7. Functional assessment
Action research arm test
Wolf motor function test
Modified Frenchay scale
Nine-hole peg test
Box and block test
Jebsen Taylor hand function test
Observational gait analysis
8. Self reported assessment
PRISM-Patient Reported Impact of Spasticity Measure
GAS-Goal Assessment Scale
COPM-Canadian Occupational Performance Measure
Arm AM- Arm Activity Measure
DAS-Disability Assessment
9. Protocols
No definitive protocols but recommendations by various groups
National Institute on Disability & Rehabilitation Research Model System –
lack of controlled clinical trials
Physical interventions
(i) Brain Injury 21;2007:133-160 (ii) J Head Trauma Rehabil 21;2006:379-387 (iii) J Head Trauma
Rehabil 24;206-218 (iv) Mt Sinai J Med 76;2009:182-189
10. Manual stretching
Spasticity and immobilization produces short muscles and contractures
Defined as a process of producing elongation
Common intervention – manual or robotic devices
Effects do not last long
Can prevent contractures
Evidence supports stretching for 10-30minutes to prevent or reverse soft tissue
changes
But not without risks
Heterotopic ossification
Muscle tears – adductor longus
Shoulder capsule tear
Fracture shaft femur
(i) Ann Rehabil Med 2013;37(2): 235-240 (ii) Neuro Rehabilitation 2011;28(1): 21-28
11. Stretching
Static progressive stretch – serial cast
Tone inhibiting splint
Static progressive splinting e.g., JAS (joint activating system)
Positioning devices e.g., tilt table, standing table
Dynamic splinting – incorporates spring system to provide stretch
Kinesio taping
(i)Arch Phys Med Rehabilil 1966;47(6):345-352 (ii) Histochem Cytochem 2003;51(1):19-29 (iii) Phys
Thera 2003;83(7):648-658 (iv) Clin Rehab 2007;21(11):963-976 (v) Head Trauma Rehabil
1990;5(4):23-42 (vi) Phys Thera 1982;62(12):1799-1808
13. Constraint induced movement
therapy
Two primary component
Intensive motor training of more affected limb (up to six hours a day)
Motor restriction of the less affected upper limb
Selective patients
Post intervention i.e., post chemo-neurolysis and chemo-denervation
Good results in our experience
(i) Arch of Phys Med & Rehabil 2005;86:204-209 (ii) Brain Injury 2003;17:675-684 (iii) Stroke
2010;41(10):2309-2315
14. Partial body weight
supported gait
training
(i) Arch Phys Med Rehabil 2008;89(4):684-91 (ii) Neuro Rehabilitation 2019 Dec 18;45(4):519-524 (iii)
J Head Trauma Rehabil 2005;20:402-415 (iv) Am J Phys Med Rehabil 2006;85:68-74
15. Strengthening training
Once avoided and criticized
Functional strengthening & resistance training
Neither effortful activity or high intensity exercises exacerbates spasticity
Substantial evidence to support
Beneficial in multidisciplinary approach to reduce spasticity
(i) Top Stroke Rehabil 2008;15(3):177-199 (ii) Dev Med Child Neurol 2010;52(4):358-363 (iii) J Rehabil
Res Dev 2004;41(3A):293-312
16. Biofeedback
Helps gain or regain control over bodily processes
Several types of feedback
Used for functional situation and not non-purposeful stimulation
Improved functional outcome is the goal
Patient directed goals
(i) J NeuroEngineering Rehabil 2006; 3, 11 (ii) J of Stroke and Cereb Dise 2012;21(3):187-192 (iii) J
NeuroEngineering Rehabil 2018;15, 45
17. Electrical stimulation
Important option for motor control
Incorporates patient’s voluntary motor activation, practice repetitions and
feedback
Focused attention on a specific segment or muscle group
Remediation of spasticity, pain, weakness & impaired motor control
Higher intensity stimulation for reeducation or strengthening – NMES
EMG triggered neuromuscular stimulation may enhance functional motor
recovery
(i) Am J Phys Med Rehabil June 2019;98(6):484-499 (ii) J Hand Surg April 1, 1999:24(2):226-232 (iii)
Neurorehabil Neural Repair 2010;24:263-72 (iv) J Neurol Phy Ther 2010;34:193-201
18.
19. Virtual reality
Computer based virtual reality environment simulate real-world settings
Feedback, intensity and duration can be modified
In a controlled environment
Extremely flexible with infinite repetition, altering type and pattern of
sensory inputs
Improves functional skills
It can be immersive or non-immersive
Simulation practice has shown to improve performance in real world
Useful modality to induce cerebral plasticity and improve motor skills
Limited studies and restrictive cost
(i) Stud Heath Technol Inform. 1997;44:123-145 (ii) J Rehabil Res Dev 2004;41(3A):283-292 (iii)
Stroke 2005;36(6):1166-1171 (iv) Top Stroke Rehabil 2007;14(1):1-12
20. Robotic therapy
(i) J Neurol Sci 1995;130(1):59-68 (ii) Ann Phys Rehabil Med. 2020 Nov;63(6):518-534 (iii) J Environ
Res Public Health. 2020 Sep 9;17(18):6557 (iv) Annu Int Conf IEEE Eng Med Biol Soc. 2019
Notas do Editor
I thank the executive committee of the world federation of neurosurgical societies for inviting me
Following neurotrauma there are various neurological deficits, ranging from mild headaches to vegetative states.
Spastic paresis is one of the common presentation
It remains one of the priority goals of patient and care givers to achieve functional improvement
Today , I would share some of the approaches that we have learned, and we practice for rehabilitation of spastic paresis
Individuals with moderate to severe brain injury can suffer from variety of different motor deficits.
Tremor have been demonstrated in some studies as one of the most frequent movement disorder followed by dystonia
But they are usually present in addition to ataxia, spasticity and paresis.
Spastic paresis is most commonly seen rehab problem post brain injury.
In. today’s presentation, I’ll talk of therapy-based interventions in spastic paresis management
Spasticity as we know of today is not the result of pyramidal pathway’s lesion alone but is usually associated with a lesion or lesions involving both pyramidal and para-pyramidal systems
And in spite of the current focus on its management, the impact of treatment on activity, participation and independence has remained limited.
we are still evolving and understanding spasticity
Lance in 1980 defined it as a velocity dependent increase in tonic stretch reflexes due to hyperexcitability of the stretch reflex
in 1994 one of the group defined it as a motor disorder resulting from abnormal intra-spinal processing of primary afferent input.
In 2005 it was defined as a disordered sensori-motor control, resulting from an upper motor neuron lesion, presenting as intermittent or sustained involuntary activation of muscles.
In 2018 the Interdisciplinary Working Group of Movement disorders redefined its current context with reference to chemo denervation
that spasticity is involuntary muscle hyperactivity in the presence of central paresis, and it can consist of spasticity sensu stictu which describes involuntary hyperactivity triggered by rapid passive movement – clasp knife phenomenon along with dystonia, rigidity, spasm, pain and contracture
The presentation of spastic paresis is highly variable, necessitating individualised goal directed treatment.
There are comparative analysis where one modality has been observed to be better than other.
But experience teaches that optimal spasticity management involves coordinated medical management like pharmacological, surgical and minimally invasive interventions like nerve blocks combined with therapy efforts
For a rehab management we must have goals and they are
Improvement of functional alignment
Improvement of selective motor control
Improvement of strength
Improvement of functional abilities
Enhancement of community participation
To achieve a goal, we have to have a measure
as lord kelvin said , if we can not measure it ,we can not improve it
Here I share some of the measures that we use in our day-to-day practice.
For spasticity assessment we use modified Ashworth scale , modified Tardieu scale and Penn spasm frequency scale
And for all interventions we must measure the functional outcome along with clinical measures
we frequently use
Action research arm test
Wolf motor function test
Modified Frenchay scale
Nine-hole peg test
Box and block test
Jebsen Taylor hand function test
Observational gait analysis
And how much a rehab intervention or admission has made difference
there are certain patient’s self rated scales also
PRISM-Patient Reported Impact of Spasticity Measure
GAS-Goal Assessment Scale
COPM-Canadian Occupational Performance Measure
Arm AM- Arm Activity Measure
DAS-Disability Assessment
And our favourites are in particular DAS and GAS
There are no definitive protocols at place but recommendations by different academic societies and groups
Most of the research are retrospective or longitudinal studies or case reports as opposed to clinical trials
And very few focus on comprehensive motor rehabilitation model
But most clinicians agree that rehabilitation is essential for functional recovery
Spasticity combined with immobilization produces short muscles and contractures
And stretching is common intervention
It is a process of producing elongation of muscles and tissues which can be done manually or with robotic devices
But the changes are not long lasting, but it does prevent contractures
It has its own bag of complications like muscle tear, hematoma, heterotopic ossification and sometimes a fracture
These complications can happen both with manual or robotic interventions
There are different ways to do it
And various studies have demonstrated its relevance and benefit
Serial cast is a stepwise application of cast to immobilize limb in a desired position
It is discontinued after 3-4 applications ; it is what we commonly do
it is labor intensive but an economical choice for our patients
Increase in muscle length reduces reflexive alpha motor neuron excitability and Golgi tendon stimulation
Cast also improves proximal motor control and strength
It also increases number of sarcomeres in series
Other methods to achieve stretching in addition to cast are tone inhibiting splints, static progressive splinting, positioning devices, dynamic splinting and kinesio taping
Constraint Induced Movement Therapy is an intervention for the improvement of upper extremity movement following brain injury
It has two components intense motor training of affected limb and motor restriction of unaffected limb
Intense therapy means at least six hours every day
But not all survivors of neuro-trauma will be able to voluntarily move the limb
Or will have the compliance to follow instructions
it is promising but or a selective group of patients
Post neurotrauma there is a decreased ability to sit, stand or walk
Movement disorder like spasticity and spastic dystonia inhibits the ambulatory capacity as well as quality
Lack of strength and balance prevent a functional gait
Body weight supported treadmill training when compared with conventional gait training has conflicting evidence
Some newer studies have supported its use to initiate ambulation training
our center’s experience says it helps to initiate ambulation and improve weight bearing on individual limbs during single limb support of gait cycle
And when used with tone inhibiting cast in lower limbs it also improves proximal motor control
Strengthening training was once avoided and criticized as an activity that would increase spasticity
Progressive structural Resistance training and functional strengthening has been shown to increase strength, gait speed, functional outcomes and improved quality of life
There is substantial evidence that resistance training increases gait speed and strength with no increase in spasticity
Biofeedback is an intervention that helps patients gain or regain control over bodily processes
There are several types of biofeedback thermal , EEG, EMG
EMG is used more frequently to decrease muscle tension, spasms and can also increase contractions for strengthening purpose
Surface electrodes are used over muscles to produce an auditory or visual signal
And through that feedback one can attempt to increase or decrease the signal by modifying the voluntary effort of muscle contraction
Motor learning strategies are employed while using biofeedback
It is always better to work from patient-directed goals because the patient’s desire to accomplish a specific skill will motivate him to learn
Electrical stimulation is an important treatment option to improve motor control
For motor learning purposes electrical stimulation is used with patient’s voluntary motor activation and it also include practice, repetitions & feedback
Reported outcomes include improved function and remediation of impairment such as spasticity, pain, weakness, and impaired motor control
Active, repetitive movement training mediated by transcutaneous cyclic and EMG-triggered neuromuscular stimulation may enhance functional motor recovery
Computer technology has led to creation of immersive virtual environment
They permit an individual to interact in computer generated environment that simulate real world setting
Specific therapy can be safely provided that may otherwise be too dangerous or complex in actual settings
The technology is extremely flexible , capable of remaining completely consistent over infinite repetitions or altering the type and pattern of sensory inputs and task complexities
Useful modality to improve functional skill
Improvement in quantity and quality of gait has been observed along with improvement in hand functions
fMRI and clinical tests has shown improvement in motor skills
Head on trials are limited but, in our experience, it has been helpful in clinical scenarios where the motor power is fair with poor motor control in upper limb
Rehabilitation robots have been designed to provide intensive and highly repetitive therapies as a mean to improve motor and functional recovery while reducing spasticity
They promote better limb alignment and functionally appropriate motor skills
It specifically address the time and labor constraints of conventional therapy
It has a prohibitive starting cost and lack of robust evidence
For upper limb MANUS and for gait training LOKOMAT are popular models
