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Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
Recognising features (contracture and spasticity)
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Recognising features (contracture and spasticity)

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  • 1. Recognising features due to neuromuscular impairments – contracture and spasticity Richard Baker Professor of Clinical Gait Analysis 1
  • 2. 2
  • 3. How can you visualise the supplementary data on the graphs? 3
  • 4. What is muscle “contracture”? 4
  • 5. Contracture 5 Joint angle indicates muscle length For biarticular muscles we need to standardise the position of one of the joints Baker (2013). Measuring Walking – a handbook of clinical gait analysis. London: Mac Keith Press
  • 6. Muscle length 6 Baker (2013). Measuring Walking – a handbook of clinical gait analysis. London: Mac Keith Press
  • 7. Contracture 7 “muscle” length muscle belly length distal tendon length origin insertion muscle fibre length Pennation angle (q) muscle volume Physiological cross sectional area = muscle volume Fibre length x cos(q)
  • 8. Contracture 8 origin insertion half fibre length half fibre width/ half muscle belly length half tendon length half pennation angle
  • 9. Fibre length 9 half fibre length Shortland AP, Fry NR, McNee AE, Gough M. (2009) Muscle structure and function. In Gage JR, Schwartz MH, Koop SE, Novacheck TF. The identification and treatment of gait problems in cerebral palsy. London: Mac Keith Press
  • 10. Muscle belly length 10 Shortland AP, Fry NR, McNee AE, Gough M. (2009) Muscle structure and function. In Gage JR, Schwartz MH, Koop SE, Novacheck TF. The identification and treatment of gait problems in cerebral palsy. London: Mac Keith Press half fibre width/ half muscle belly length
  • 11. Tendon length 11 Barber, L., Barrett, R., & Lichtwark, G. (2012). Medial gastrocnemius muscle fascicle active torque-length and Achilles tendon properties in young adults with spastic cerebral palsy. J Biomech, 45(15), 2526-2530. half tendon length Only one study (and balance of circumstantial evidence) suggests that Achilles tendon is long in young adults with cerebral palsy
  • 12. “Contracture” 12 Shortland AP, Fry NR, McNee AE, Gough M. (2009) Muscle structure and function. In Gage JR, Schwartz MH, Koop SE, Novacheck TF. The identification and treatment of gait problems in cerebral palsy. London: Mac Keith Press
  • 13. “Contracture” 13 Smith, L. R., Lee, K. S., Ward, S. R., Chambers, H. G., & Lieber, R. L. (2011). Hamstring contractures in children with spastic cerebral palsy result from a stiffer extracellular matrix and increased in vivo sarcomere length. J Physiol, 589(Pt 10), 2625-2639.
  • 14. Contracture Probably represents: • Shortening of the muscle belly through atrophy or loss of fascicles. • Increased muscles stiffness as a results of hypertrophy of the extracellular matrix. 14
  • 15. Recognising contracture from the graphs 15
  • 16. Hip flexor contracture 16 Modified Thomas test Left 20° Right 20 °
  • 17. Hip abductor contracture 17 Hip abduction (knee and hip 0 °) Left 20° Right 25 °
  • 18. Hamstrings contracture? 18 True popliteal angle Left 50° Right 55 ° Pelvic Tilt60 0 Ant Pst deg Hip Flexion70 -20 Flex Ext deg Knee Flexion75 -15 Flx Ext deg
  • 19. Hamstrings contracture? 19 Baker (2013). Measuring Walking – a handbook of clinical gait analysis. London: Mac Keith Press
  • 20. Hamstrings contracture? 20 True popliteal angle Left 50° Right 55 °
  • 21. Plantarflexor contracture 21 Dorsiflexion (knee 90°) Left -10° Right -5° Dorsiflexion (knee 0°) Left -25° Right -25°
  • 22. Plantarflexor contracture 22 Baker (2013). Measuring Walking – a handbook of clinical gait analysis. London: Mac Keith Press
  • 23. Plantarflexor contracture 23 Dorsiflexion (knee 90°) Left -10° Right -5° Dorsiflexion (knee 0°) Left -25° Right -25°
  • 24. What is “spasticity”? 24
  • 25. Spasticity 25
  • 26. Levine, 1952 A condition of paralysis or muscular weakness associated with hyperreflexia, the symptoms of which include increased resistance to manipulation, exaggeration of the deep reflexes, and clonus. 26 Levine, M. G., Knott, M., & Kabat, H. (1952). Relaxation of spasticity by electrical stimulation of antagonist muscles. Arch Phys Med Rehabil, 33(11), 668-673.
  • 27. Lance, 1980 “spasticity is a motor disorder characterized by a velocity dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks, resulting from hyper-excitability of the stretch reflexes, as one component of the upper motor neuron syndrome.” 27 Lance, J. (1980). Pathophysiology of spasticity and clinical experience with baclofen. In R. Feldman, R. Young & W. Koella (Eds.), Spasticity: disordered motor control (485- 495). Chicago: Year book medical publishers.
  • 28. Pandayan, 2005 “disordered sensori-motor control, resulting from an upper motor neuron lesion, presenting as intermittent or sustained involuntary activation of muscle” 28 Pandyan, A. D., Gregoric, M., Barnes, M. P., Wood, D., Van Wijck, F., Burridge, J., . . . Johnson, G. R. (2005). Spasticity: clinical perceptions, neurological realities and meaningful measurement. [Review]. Disabil Rehabil, 27(1-2), 2-6.
  • 29. Spasticity • Not a property of the muscle. • Property of the nervous system. 29
  • 30. NIH Taskforce on Childhood Motor Disorders • Spasticity • Tone • Selective motor control 30 Sanger, T. D., Delgado, M. R., Gaebler-Spira, D., Hallett, M., & Mink, J. W. (2003). Classification and definition of disorders causing hypertonia in childhood. Pediatrics, 111(1), e89-97.
  • 31. NIH Taskforce on Childhood Motor Disorders Spasticity “resistance to externally imposed movement with increasing speed of stretch and varies with the direction of joint movement” 31 Sanger, T. D., Delgado, M. R., Gaebler-Spira, D., Hallett, M., & Mink, J. W. (2003). Classification and definition of disorders causing hypertonia in childhood. Pediatrics, 111(1), e89-97.
  • 32. NIH Taskforce on Childhood Motor Disorders Tone [resistance to] “passive stretch while the patient is attempting to maintain a relaxed state of muscle activity ” 32 Sanger, T. D., Delgado, M. R., Gaebler-Spira, D., Hallett, M., & Mink, J. W. (2003). Classification and definition of disorders causing hypertonia in childhood. Pediatrics, 111(1), e89-97.
  • 33. NIH Taskforce on Childhood Motor Disorders Spasticity – response to fast stretch Tone – response to slow stretch 33 Sanger, T. D., Delgado, M. R., Gaebler-Spira, D., Hallett, M., & Mink, J. W. (2003). Classification and definition of disorders causing hypertonia in childhood. Pediatrics, 111(1), e89-97.
  • 34. NIH Taskforce on Childhood Motor Disorders Selective motor control “the ability of the body to isolate the activation of muscles in a selected pattern in response to demands of a voluntary posture of movement” 34 Sanger, T. D., Chen, D., Delgado, M. R., Gaebler-Spira, D., Hallett, M., & Mink, J. W. (2006). Definition and classification of negative motor signs in childhood. Pediatrics, 118(5), 2159-2167
  • 35. Measurement 35
  • 36. Tone Modified Ashworth Score (MAS): • originally defined as measure of spasticity. • joint moved through full range of movement over a period of about one second. • too fast to measure tone – too slow to measure spasticity 36 Bohannon, R. W., & Smith, M. B. (1987). Interrater reliability of a modified ashworth scale of muscle spasticity. Physical Therapy, 67(2), 206-207.
  • 37. MAS for tone (MASt?) • Perform stretch slowly so as not to elicit spasticity. • Use same scale as MAS. 37
  • 38. MASt 38
  • 39. Spasticity Tardieu (1954) • Complex • Impractical • In French! 39 Tardieu, G., Shentoub, S., & Delarue, R. (1954). [Research on a technic for measurement of spasticity]. Rev Neurol (Paris), 91(2), 143-144.
  • 40. Modified Tardieu Scale • Assess passive range of movement (and MASt) of gastrocnemius conventionally • Perform the same movement as quickly as possible. • Record the angle at which the joint “catches”. • Difference between this and PROM indicates spasticity. 40 Boyd, R. N., & Graham, H. K. (1999). Objective measurement of clinical findings in the use of botulinum toxin type A for the management of children with cerebral palsy. European Journal of Neurology, 45 (suppl 4), s23-35.
  • 41. MTS Notes • We have defined spasticity as depending on velocity which will only be indirectly indicated by the angle of catch. • Repeatability studies also suggest that the measurement should only be taken as indicative. 41
  • 42. Selective motor control Perform at time of MRC strength tests for individual muscles. 2 muscle can be activated independently to other muscles. 0 muscle can only be activated as part of a patterned movement (often a flexor or extensor synergy) 1 allows for an intermediate grading 42 Ounpuu?
  • 43. Recognising spasticity from the graphs 43
  • 44. 44

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