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Rehabilitation in spastic paresis

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Rehabilitation in Spastic
Paresis
Mrinal Joshi
Jaipur, India

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Spastic Paresis
 Spasticity
 Poor motor control
 Dystonia
 Rigidity
 Spasms
 Contractures
 Pain
(i) Brain injury me...

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UMN lesion
Muscle
Overactivity
Weakness
Dynamic
• spasm
• Co-
contraction
• Clonus
• Associated
reactions
• Flexor
withdra...

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Rehabilitation in spastic paresis

  1. 1. Rehabilitation in Spastic Paresis Mrinal Joshi Jaipur, India
  2. 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. 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. 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. 5. Physical assessment of spasticity  Modified Ashworth scale  Modified Tardieu scale  Penn spasm frequency scale
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. Serial Cast Tone Inhibiting Cast Dynamic Splinting Standing Table Dynamic Splinting
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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

Editor's Notes

  • 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

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