Tone A Total Breakthrough
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Every day we work with clients who present with neurological tone which creates a continual challenge for every day activities, positioning, hygiene and feeding. Being able to intervene within the first 3 days post CVA, or any Brain/Spinal Cord Traumatic event, we are able to work with the sometimes destructive forces of tone to maintain muscle tissue length allowing the fullest return to function possible. This presentation will look at why standard orthotic devices do not meet the needs of these clients and how they can often induce episodes of prolonged tone. We will explore why “Flex” technology does work to relax tone, and also go over the “process” of dealing with neurological tone over time to reduce, stop, and reverse the damage that can be caused from shortened tissue. A neurological client’s road to rehabilitation is a long term one, often taking months and even years, in some cases they will need us in one form or another for the rest of their lives. Being able to manage and reduce tonal episodes and keep muscle fibres lengthened allowing freedom of movement and range of motion over this period is vital for our clients quality of life. It is very exciting that with early intervention with the appropriate devices we can enable our clients to grasp life and live it to their fullest.
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Tone A Total Breakthrough
- 1. Tone a Total Breakthrough Presented by : Amanda Hebben Restorative Bracing www.dmedirect.com.au
- 2. Kenneth A. Mook, M.D. , PH.D Physiatrist, Frazier Rehab Hospital Louisville, Kentucky , USA “I have found that a static, rigid splint is not effective in controlling spasticity because it provides a persistence of a spastic event by not allowing the muscle to shorten. A splint that has static properties with some dynamic “give” during a spastic event allows the muscle to shorten, thereby the spastic event regresses, and yet the splint maintains the proper positioning of the joint. “ www.dmedirect.com.au
- 3. Neurological Tone Neurological Tone can be constant or intermittent. It can be in the form of Spasticity. It can be severe to mild and it can change over time. www.dmedirect.com.au
- 4. Challenges Neurological Tone creates a continual challenge for everyday activities, positioning, hygiene and feeding. www.dmedirect.com.au
- 5. Immobility Costs The more immobile a person becomes, whether one joint or multiple joints, the more unnecessary pain and suffering they go through. There are also increased costs to the Health System.
- 7. Psychosocial Decreased interaction with others Lack of environmental stimuli Decreased self esteem / feelings of helplessness Biochemical changes in the body May show negative changes in personality and attitude
- 8. Early Intervention If we are able to intervene within the first 3 days post CVA or any brain, spinal cord traumatic event, we are more likely to maintain muscle tissue length. www.dmedirect.com.au
- 9. Three Types of Contractures Shortened Adaptive Tissue Neurological Tone Neurological Tone with Adaptive Tissue Shortening www.dmedirect.com.au
- 10. Shortened Adaptive Tissue Adaptive tissue shortening typically results in the person not being mobile enough and stretching muscles and connective tissue enough and often enough to maintain the length of the fibers. www.dmedirect.com.au
- 11. Neurological Tone Neurological Tone can be constant or intermittent. It can be in the form of Spasticity. It can be severe to mild and it can change over time. www.dmedirect.com.au
- 12. Neurological Tone with Adaptive Tissue Shortening When you reach the maximum joint extension after working through the neurological tone, at the end of this increase, you may again feel resistance – kind of gummy and sticky – that prevents full extension. www.dmedirect.com.au
- 13. What Doesn’t Work Rigid Orthopedic splints and braces DO NOT WORK on clients with Neurological Tone www.dmedirect.com.au
- 14. Orthopedic Splints An Orthopedic splint is a medical device for the immobilization of limbs They are designed to facilitate function and healing by limiting motion in particular planes or eliminate movement altogether. www.dmedirect.com.au
- 15. What Does Work A Splint that is actually designed to “Flex” We want the limb to move when it has these “tonal episodes”. When contractions start the splint/brace needs to move with them. www.dmedirect.com.au
- 16. Benefits of Restorative Bracing Continually working through neurological tone to reach muscle inhibition will prevent shortening of tissue which causes life changing deformities. www.dmedirect.com.au
- 17. What is “Restorative” bracing? Bracing MUST be flexible Bracing MUST be adjustable both at initial fitting and also over time as required Bracing MUST have memory to allow it to flex back to it’s start position www.dmedirect.com.au
- 18. Low Load Passive Stretching The splint creates resistance like a spring motion or an exercise. The splint needs to constantly pull the limb back to the set point which is usually slightly stretched from their most open position. As they get accustomed to that position, we readjust the splint a little more slowly bringing them closer to full ROM www.dmedirect.com.au
- 19. The Process Fit splint to the user Set is so user is in a sub maximal stretch only If it hurts you are going too far too fast This first stage starts to realign the muscle fibres to be ready to re- lengthen It will take a minimum of 6 weeks of Low Load Passive stretching to get to this point Within 15 minutes of fitting (may be sooner) you will see a visible “relaxation” or muscle inhibition REVIEW 6 to 8 weeks time www.dmedirect.com.au
- 20. Slowly Does it Begin wear schedule at 30 minutes per day Always check skin after removal of the device Gradually increase wear to no more than 6 hours per day www.dmedirect.com.au
- 24. Alexis – Cerebral Palsy www.dmedirect.com.au
- 25. 18 Year Old with CP (before Botox) www.dmedirect.com.au
- 26. Initial Fitting set at Neutral (before Botox) www.dmedirect.com.au
- 28. After Botox, splint remolded www.dmedirect.com.au
- 31. Long Term Care Client www.dmedirect.com.au
- 32. Long Term Care Client www.dmedirect.com.au
- 34. SUMMARY Never overstretch Must have Flex with Memory in splinting Prolonged low load passive stretch over time to RELENGTHEN shortened tissue If Restorative measures hurt we are doing something wrong Look at the entire patient not just one joint www.dmedirect.com.au
- 35. DON’T STOP. MOST RESTORATIVE CLIENT’S WILL NEED TONE REDUCTION FOR THE REST OF THEIR LIVES. IF WE STAY ON TOP OF IT, WE CAN PREVENT MOST IF NOT ALL DEFORMITY. www.dmedirect.com.au
Editor's Notes
- Physical medicine & rehabilitation specialists, or physiatrists, are doctors who specialize in helping patients rehabilitate from injuries or complications of disease.
- Neurological tone results in patients who have diagnoses like Cerebral Palsy, Parkinson’s disease, after a stroke/Traumatic Brain Injury or other injuries to the brain, Whiplash resulting in Torticollis (Wry Neck), Multiple Sclerosis, Spinal Cord Injury, Spine bifida, and end stage Alzheimer’s disease
- Simple activities of daily living such as walking, eating, dressing, and bathing can become time-consuming and difficult.
- When neurological tone or spasticity limits activity for long periods, it can cause additional medical problems such as; Pneumonia, chest doesn't rise and fall as much as it did so less air is exchanged and mucus builds up often getting infected or lungs and chest may be sore and parts of the diaphragm may not work efficiently... mucus builds up, infection sets in pneumonia results. Pressure sores are a common result of the additional pressure placed on parts of the body resting in unconventional positions with an inability to move and relieve pressure
- Immobility also causes the heart to beat more quickly, and the volume of blood pumped is lower. The volume of blood generally in the body is lower, and there is less oxygen uptake by the body. This results in poorer aerobic fitness and fatigue sets in more easily. The blood also becomes thicker and stickier, which increases the risk of a blood clot forming, especially in the legs and the lungs. Fluid tends to build up in the lungs because the muscles aren’t working to remove excess fluid from the body. Coughing is not as effective due to weakened abdominal and chest muscles, causing mucus to collect in the lungs. Breathing also becomes shallower, which leads to poorer oxygen-carbon dioxide exchange in the lungs. Constipation is common, due to several factors including decreased mobility, decreased fluid intake, decreased movement of the digestive tract and incomplete emptying of the bowels. The bladder is harder to empty and tends to retain fluid, which can lead to infection. There is also greater excretion of urinary calcium, which raises the risk for bladder and kidney stones. Disorientation and confusion when you are unable to view the world in a normal orientation due to skeletal positioning Increased risk for various mental health and cognitive issues, including anxiety, depression, irritability, apathy, sleep disturbances and confusion. Hygiene is difficult to manage and some area can get particularly smelly – contracted hands for example, person is aware of this and the knowledge can lower their self esteem. Pressure sores are a common result of the additional pressure placed on parts of the body andthe blood supply to the skin covering these parts becomes insufficient. Appetite is often suppressed and malnutrition and dehydration may occur if proper attention is not paid to diet.
- Increased risk for various mental health and cognitive issues, including anxiety, depression, irritability, apathy, sleep disturbances and confusion.
- This maintenance of muscle tissue will allow the fullest return to function possible.
- The term “contracture” refers to lost range of motion. That is when a joint or multiple joints or body parts are unable to reach full extension
- If our bodies are mostly water, then not replacing that water each day will allow the body’s tissues to become dehydrated, or dry out. Moisture and nutrition get to connective tissue due to movement. If movement is not maintained, these tissues dry out and the body reabsorbs the connective tissue. These are tissues that are meant to cushion and protect bones from running against each other. Without this protection and padding, not only pain occurs, but also wearing down of bones. To relengthen this shortened tissue, it requires low load passive stretch over long periods of time. This is gentle stretching – it has to be stretched, but not beyond resistance
- Neurological tone results in patients who have diagnoses like Cerebral Palsy, Parkinson’s disease, after a stroke/Traumatic Brain Injury or other injuries to the brain, Whiplash resulting in Torticollis (Wry Neck), Multiple Sclerosis, Spinal Cord Injury, Spine bifida, and end stage Alzheimer’s disease
- The gummy resistance is telling you where their shortened tissue begins. DO NOT OVERSTRETCH! Shortened tissue takes longer to resolve than tone.
- Unlike Clients with Orthopedic conditions who have thick collagen fibres and adhesions which must be broken through to regain full ROM, clients with Neurological tone do not have adhesions and too aggressive stretching can cause needless pain and actually braing harm by tearing tissue and exacerbating any neurological tone that is present or might be developing.
- Orthopedic is rehab – it is quick and involves surgery and perhaps painful therapy to get someone back on their feet after surgery or an injury. Splints are rigid and meant to hold a body part in a certain plane to facilitate healing and function.
- Orthopedic is rehab – it is quick and involves surgery and perhaps painful therapy to get someone back on their feet after surgery or an injury. Splints are rigid and meant to hold a body part in a certain plane to facilitate healing and function.
- It is thought that there might be potential to reduce the severity of the tone over time by continually working through tone to continually reach muscle inhibition -- Relaxation
- RMI’s uses a copyrighted Fishing Pole Analogy to explain how our products work with the Central Nervous System. When you cast a line into the water and hook a fish the fish will pull away… it resists and fights. As it pulls away, the pole is flexible and allows it to pull, but with tension. The fish pulls and the pole lets it. The fish pulls and the pole lets it... This goes on and on until the fish fatigues and relaxes. This gives you a perfect mental picture of how the appropriate technology of splints and braces allows the patient’s joints and body parts to relax by working WITH the Central Nervous System. If we use orthopedic rigid types of splints on patients with this tone, we run the real risk of not only causing them pain, but of actually INCREASING their lost range. If we use stretching measures that are too aggressive, we run the risk of not only causing them pain, but of actually INCREASING their lost range. gently stretch by taking the limb just to resistance and holding it there. When you do this you can actually feel the tone – just like the fish that has been hooked – as it pulls and you hold resistance and it pulls as you hold resistance until it begins to relax and you typically see even a slight increase in range. You may see a dramatic increase. Splints and braces that are appropriate for working with neurological tone patients must be flexible, be able to be adjusted in some fashion to meet different degrees of lost range and changed as that range improves, and they must have memory to again have flex when adjusted.
- The goal with neurological tone is to allow the patient to pull through the episode of tone with mild resistance, then tug the joint back to the preset degree of extension (or in the case of Extensor Tone – we need to tug the joint back toward Flexion). This process repeated for approximately 15-20 minutes will typically allow your patient to reach “Muscle Inhibition” – or a Relaxation
- Every 6 to 8 weeks reassess any gains in ROM and re-fit splint to New sub maximal stretch point and review in another 6-8 weeks and repeat
- It may look like nothing is happening but Low Load Passive Stretching is tiring – like a gym workout for you and I. If you do not regularly exercise then there is no way you would do 200 crunches and not expect to feel sore the next day, the sensible approach would be 20 crunches today and tomorrow, increase to 22 the next few days and so on , build up gradually .... The same goes for wearing a restorative splint easy does it – this is going to be a long process it may take a year or even years don’t rush things
- This is Vance. Vance has Cerebral Palsy from an accident during birth and is flaccid without muscle control in his upper body, but has mild tone in his lower body. We had already corrected his 30 degree bilateral knee contractures before these pictures were taken. Because Vance was unable to hold himself up, it made it very difficult for him to see his environment to learn or even to watch his favorite program on TV Besides his inability to view his environment, his therapist complained that he was lying down to be fed through his feeding tube, which is normal for an infant, but as we grow older our bodies need to be upright as we eat to aid in digestion.
- Vance was fit with a TLSO with an opening made so there is no pressure on the area around his feeding tube and also so he can be fed while sitting up. Mom has sent some pictures of Vance sitting tall on a horse’s back in his device. He outgrew his first one and is now wearing his second. Support the spine for functional activities such as feeding, sitting, standing, walking and play
- Alexis has Cerebral Palsy. Look at the first picture. Her shoulders are rotated forward which restricts full lung expansion and brings her head and neck forward. Her elbows are beginning to hyperextend. Her wrists are in flexion and Ulnar Drift (drifting toward the little finger side – toward the ulnar bone of the forearm). Simply by fitting her wrist/hand/fingers with the Restorative Hands, it relieved the tone in her elbows. If we need to we can always fit her with elbow splints for Extensor Tone, but I am hopeful family and teachers can maintain her elbows in flexion enough to continually reduce the firing of extensor tone (opposite of flexion) to prevent hyperextension deformity. There is still some work to do with windswept hips and her feet position but overall this is a much improved picture and she certainly looks happier and more relaxed.
- This young man has a diagnosis of Cerebral Palsy. As well as the severe position of the wrist there was also a collapse of the Thenar Eminence – when the thumb collapses into the palm of the hand – is different from thumb adduction – it is from the MP joint at the base of the thumb, where joins the wrist and is very common in any neuro patient.
- This 18 year old was in hospital after hip surgery, had a wound on his buttocks, was constipated and in a general bad mood. Since he lived close to our home, I told him I would mold at neutral and remold with a stretch when he got back home and felt better. For this reason I put very little stretch on his wrist since I knew the physician was to do Botox injections in just a few days and the splints would be remolded after that. You can see how the splint begins to bring him into alignment and you want good placement of the thumb.
- After receiving his Botox, it changed the pattern of his hand and resulted in a bit of extensor tone in his fingers. When you have treatments that effect tone, there will still be conditions like muscle memory and shortened tissue that will have an effect on the results. You can see the bony changes in his wrist area.
- Here you see his splints remolded after the Botox. He is in good alignment with Ulnar Drift Finger Separators that bring his fingers to normal. In the top picture you see the Ulnar Drift wrist pad that will gently push his wrist from medial to lateral correcting the drift deformity.
- Client was diagnosed with CP at 9 years old. He had been fitted with rigid splints at age 11 but family said they made him worse and did not allow him to wear splints again. His rib cage was twisted and curved to the right which is common in clients with knee contractures. The right hand is more severe than the left as it also rotated backwards. His right knee is barely visible and his right foot is under his body. As the knees contract and “stick up” in the air when the client is on their back, gravity takes over and the knees fall to one side or the other. It doesn’t take long for tissues to shorten to their length in this position.
- All joints were fitted with splints with Flex properties and you can see not only the extremities but entire torso has straightened out and started to come into alignment, this should continue to progress over time.
- Client presented with a fixed foetal position and was due to have a feeding tube surgically inserted as staff were unable to feed her enough food in this position to sustain life.
- 30 minutes after fitting the TLSO with the cervical extension client was leaning back in the wheelchair and singing. Staff noticed over time that it would typically take about 15 minutes for the client to relax into the TLSO post fitting, they also noticed that her head started to come up of it’s own accord once TLSO was fitted so they were able to dispense with this and just use the TLSO.
- Two weeks after suffering a series of mini strokes the client’s index fingers developed tone, so severe they appear to have been amputated. She responded very well to the Restorative hand splints that gently brought her fingers back into alignment. A neighbour assisted her with donning these one at a time and she has been able to stay at home rather than moving into nursing home care.