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MANAGING SPASTICITY INCEREBRAL PALSY– A Physiotherapist’s perspectiveA.S.Jebaraj Fletcher

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Definition: Cerebral PalsyDefined as a persistent but not unchanging disorderof posture and movement, caused by damage to thedeveloping nervous system, before or during birth orin the early months of infancy(World commission for Cerebral Palsy,1988)

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Definition: Spasticity Defined as a velocity dependent increase inresistance to passive stretch of a muscle,with exaggerated tendon reflexes(Lance,1990; Parziale et al., 1993)

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SPASTICITY IN CP Altered muscle tone is one of the earliest signs ofcerebral palsy (Binder H. Eng.GD 1989) The nature of the movement disorder in spastic cpis a combination of hyper tonus, impaired posturalcontrol and equilibrium reactions, persistentprimitive reflexes, upper extremity flexor and lowerextremity extensor synergies and associatedweakness (Winters et al1987)

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Cont.. Spasticity may coexist with other movementdisorders such as athetosis, chorea, ordystonia These neurologic abnormalities may lead tomuscle shortening, joint capsule tightnessand osseous deformities (Vinken PJ & Bruyn)

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Types of Spastic CP

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PATHOPHYSIOLOGY OFSPASTICITY

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1) EXAGGERATED SEGMENTAL REFLEXES Exact mechanism is uncertain The pathological basis of spasticity is theabnormal enhancement of spinal stretchreflexes They could be enhanced by increasedmuscle spindle activity or increasedexcitability of central synapses involved inthe reflex arc.

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2) EXAGGERATED SUPRA SEGMENTALREFLEXES Lesions at level of brain stem and above,then supra segmental reflexes through thespinal cord and brain stem becamehyperactive (e.g., tonic neck and vestibularreflexes)

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3) ABNORMAL VOLUNTARY CONTROLImbalance in antagonist – agonist voluntaryControl4) RELEASE REFLEX PHENOMENONHyperactive Excitatory neuronal firing

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5) DECORTICATE & DECEREBRATE RIGIDITY Decorticate: Upper limb flexed and lower limbExtended Lesions above superior colliculus lead todecorticate rigidity Decerebrate: Full Extension Upper and lowerlimbs Lesions below superior colliculus may lead tode cerebrate rigidity

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Direct and Indirect Consequences ofSpasticity: Increased Tone Decreased Range of Motion Involuntary Movements Increased Autonomic Reflexes Exaggerated Reflexes Muscle Weakness Balance Problems

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Cont… Abnormal Bone Stress Contracture Pain Sleep Dysfunction Patient Care (hygiene, transportation) Bowel and Bladder Dysfunction Respiratory Dysfunction

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Cont… Communication, Speech, and SwallowingDysfunction Impaired Social, Psychological, andVocational Development

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CLINICAL EVALUATIONOF SPASTICITY

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Modified Ashworth scale0 = No increase in muscle tone1 = Slight increase in muscle tone (catch or min resistance at endrange)1+ = Slight increase in muscle resistance throughout the range.2 = Moderate increase in muscle tone throughout ROM, PROM iseasy3 = Marked increase in muscle tone throughout ROM, PROM isdifficult4 = Marked increase in muscle tone, affected part is rigid

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Oswestry Scale It is based on clinical observation and isgraded from 0 to 5( No, Mild,Moderate,Severe, Very Severe and solelysevere)

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Spasm Frequency ScaleHow many spasms in the last 24 hours in theaffected extremity? 0 = no spasms 1 = 1 / day 2 = 1-5/ day 3 = 5-9 / day 4 = >10/day

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Adductor Tone Rating0 = no increase in muscle tone1 = increased tone, hips easily abducted 45degrees by one person2 = hips abducted 45 degrees by on personwith mild effort3 = hips abducted 45 degrees by one personwith moderate effort4 = two people are required to abduct the hips45 degrees

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Tardieu scale A scale depending upon the responses ofeach muscle to both high and low speed Afterranging a joint slowly and then quickly, thespasticity is assigned one of the followingscores

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Cont.. Tardieu scale0 No resistance throughout the course of the passive movement.1 Slight resistance throughout the course of the passivemovement with no clear catch at a precise angle.2 Clear catch at a precise angle, interrupting the passivemovement, followed by a release.3 Fatiguable clonus, less than 10 seconds when maintaining thepressure, appearing at a precise angle.4 Unfatiguable clonus, more than 10 seconds when maintainingthe pressure, at a precise angle

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Gait Analysis A test based on timed 10 m walks duringwhich step are counted has been shown tobe of use ( Collen et al, 1990) Parameters are Stride length, step length andcadence can be measured Video recording( Still man, 1991) Photography

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Others.. ROM tests: Helps to find tonal changes andseverity of tightness EMG Studies… Pendular tests Tendon reflex Babinski Sign

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MANAGEMENT FORSPASTICITY

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Stepped Care Stepped Care for spasticity begins with conservativemethods that carry fewest side effects and progressto aggressive treatments with the most side effects. First any remedial sources of nociception should beeliminated. UTI, BOWEL IMPACTION, Pressuresores, fractures, paronychia etc may increasespasticity and hypertonus

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 Second Patient education should beprovided. Education allows patients tominimize adverse effects and to functiondespite spasticity

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MOVEMENT & HANDLINGThe use of manual handling techniques isone of the principle means available to theneurological physiotherapist in the physicalmanagement of spasticity

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MAINTANENCE OF SOFT TISSUELENGTH1) ACTIVE & PASSIVE ROM EXERCISES Without the full range of motion, peripheral changes causemuscle imbalance and this compounds any central motordysfunction (Ada & Canning, 1990; Carr & Shephard,1995) This can be achieved by passive stretching of tight structures orany active exercises Daily ROM & Static muscle stretch prevents contracture &capsule tightness and can reduce stretch reflex hyperactivity andimprove motor control (Odeen I. Scand. J. Rehabil. Med, 1981)

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2) WEIGHT BEARING EXERCISES Standing is an excellent way of maintaining length in soft tissues Standing is effective in altering tone via. The vestibular system,which is a major source of excitatory influence to extensormuscles, whist reciprocally inhibiting flexor muscles (Markhern,1987; Brown, 1994) It is another form of static stretch and it can reverse earlycontracture and may reduce stretch reflex excitability (Richards CLet al., Scand. J. Rehab. Med, 1991) Back slabs or Standing frames may be used to assist Standing(Davies, 1994)

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3) POSITIONING Various body or head positions can be used minimize facilitationthat is contributing to hyper tonus and to maximize facilitation tomuscles that have reduced voluntary recruitment (Stejskal L, Am.J. Physic. Med.. 1979) In Children with Cerebral Palsy, Lumbar extensor muscle activitycan be altered by adjusting head position and seat and backangles of seating systems (Nwabhi OM et al., Dev. Med. Child.Neurology 1983)

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4) MODULATION OF MUSCLE TONE Movement and alteration of the alignment ofparticular parts of the body can influencemuscle tone in other areas For Example, the rotational element isextremely important and is emphasized in theapproaches like PNF (Voss et al, 1985) & Bobath(1990)

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HANDLING TECHNIQUESAccording to Mary Lynch,For Spasticity, Speed: Slow Range: Full Repetition: Yes Voice: Quiet, Minimal Other: Longitudinal traction

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SPLINTING

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 Different types of splinting were describedand reviewed by Edwards & Charlton (1996)

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Prophylactic Splinting: It is appropriate for patients who need morethan positioning and assisted movements tomaintain joint range (Conine et al., 1990) For example, prophylactic splinting can take theform of Plaster boots for Achilles tendon orplaster cylinders for limb to prevent tightness orcontractures

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Corrective Splinting/ Serial Casting Corrective splinting is used to increase ROM inthe presence of contracture For example, Serial Casting for elbowcontracture which is helpful in slowly correctingcontracted joints

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Dynamic Splinting Dynamic splinting aims to facilitate recoveryand assist stability for improved function For example, In children with CP, AFO’s withtone reducing features have been used toinhibit tonic postures of the foot (Hylton N.,1990)

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ELECTRICALSTIMULATION

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ES.. Cont.. Vang et al, (1995) found electrical stimulationresulted in a measurable reduction inspasticity in upper limb O’Daniel & Krapfl, 1989 reported that theuse of ES increases the effectiveness ofstretching spastic muscles by reciprocalinhibition ES at nearly all levels of the nervous systemrelieves spasticity ( Stefanovska. A, 1991)

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ES.. Cont.. Shindo (1987), has reported a reduction ofspasticity by clinical evaluation, lasting 8 to72 hours after each session of FES. Stefanovska (1988) measured decreasedtone and increased voluntary strength inankle plantarflexors after peroneal nervestimulation for 1 year

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THERMAL TREATMENTSCryotherapy: Ice can be used as an adjunct to other treatmentmethods or as a means of controlling tone in aspecific area Muscle cooling reduces phasic stretch reflexactivity and clonus (Hartviksen. K, 1962; Giebler KB, 1990) Slow Icing reduces spasticity (Roods Approach) Ice can be used with static stretch to overcomehyperactive stretch reflexes (Giebler KB, 1990)

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Apply warm water soaks to spastic musclesor have child sit or lie in warm water

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HYDROTHERAPY Pool therapy can be used a adjunctmanagement for cerebral palsied Children It helps in stretching large muscle groups & tohelp movements in trunk.

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BIO FEEDBACK The effectiveness of EMG biofeedback machines inthe treatment of increased muscle tone is yetunproven (Moreland & Thompson, 1994) Bio feedback using either EMG or Joint positionsensors and providing auditory or Visual feedback,has reduced spasticity in patients with preservationof voluntary motor control (Neilson et al., J. Neurol. Neuro Surg.Psychiatry, 1982) It can provide the patient with useful feedbackbetween therapy sessions

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Advance techniques

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VESTIBULAR STIMULATION All static positions and or movement patternsfacilitate the vestibular system which in turn haseffects over muscle tone (Anne G. Fisher et al..) Various researches proves vestibular stimulation asa therapeutic modality in managing abnormalities ofmuscle tone. (Weeks ZR, Am. J. Occupational therapy, 1979) Vestibular stimulation has more impact on thedevelopment of Cerebral Palsied or Mentallyretarded Children than a normal, at risk orpremature infants (Ottenbacher KJ et al., Clinical Paediatrics, 1983)

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In StandingSwinging in Glider

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SittingUsing Net Hammock

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Sitting/ Prone

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Prone/supineIn a Barrel

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Supine/SitIn Scooter Board

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Bouncing

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HIPPOTHERAPY Hippotherapy is a physical, occupational andspeech therapy treatment strategy that utilizesequine movement (The American hippo therapy Association) Benda W et al 2003, reported improvements inmuscle symmetry in Children with CP after equineassisted therapy (The Journal of ComplimentaryMedicines, 2003) Casady R et al reports positive outcome in 10 CPChildren after having hippotherapy

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Suit therapy Suit therapy is often used as part of acomprehensive program of intensive physiotherapyof 5–7 hours a day for four weeks (UCP, 1999). This therapy is based on a suit originally designedby the Russians for use by cosmonauts in space tominimize the effects of weightlessness. The idea isto move body parts against a resistance, thusimproving muscle strength.

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 Through placement of the elastic cords, selectedmuscle groups can be exercised as the patientmoves limbs; thus, suit therapy is a form ofcontrolled exercise against a resistance. It is alsoclaimed that the suit improves coordination. The suit consists of a cap, a vest, shorts, knee pads,and shoes. An attached series of elastic cordsprovides compression to the body’s joints andresistance to muscles when movement occurs.

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“..much study is a weariness of theflesh.” Ecclesiastes 12:12(Bible)THANK YOU