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03 Spass


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03 Spass

  1. 1. Spasticity Management The Role of Physical and Occupational Therapy Part 3 of 6
  2. 2. Prior to Intervention <ul><li>Assess baseline status </li></ul><ul><li>Select appropriate patients </li></ul><ul><li>Determine goals of treatment </li></ul><ul><li>Educate patient and family </li></ul><ul><li>Coordinate with team members </li></ul>
  3. 3. After the Intervention <ul><li>Provide active PT/OT treatment and ongoing evaluation </li></ul><ul><li>Follow-up on home program </li></ul><ul><li>Continue to educate patient and family </li></ul><ul><li>Assess treatment outcomes </li></ul>
  4. 4. Framework for Assessment <ul><li>NCMRR framework </li></ul><ul><ul><li>Developed by National Advisory Board of the National Center for Medical Rehabilitation Research at NIH </li></ul></ul><ul><ul><li>Adopted by the American Physical Therapy Association </li></ul></ul><ul><ul><li>Addresses five dimensions of the disabling process </li></ul></ul>
  5. 5. Five Dimensions of the Disabling Process <ul><li>Pathophysiology: molecular or cellular </li></ul><ul><li>Impairment: organ/system </li></ul><ul><li>Functional limitations: whole body or segmental </li></ul><ul><li>Disability: dysfunction in daily roles </li></ul><ul><li>Societal limitations: potential is limited due to societal barriers </li></ul>
  6. 6. PT/OT Assessment and Goal Setting
  7. 7. Impairment Dimension <ul><li>Range of motion (ROM) </li></ul><ul><ul><li>passive and active </li></ul></ul><ul><ul><li>contractures and/or dynamic limitations </li></ul></ul>
  8. 8. Impairments, cont’d <ul><li>Muscle tone - patient may use spasticity for support in functional activities </li></ul><ul><li>Synergies, selective control </li></ul><ul><li>Strength - reduction in spasticity can unmask weakness </li></ul>
  9. 9. Impairments, cont’d <ul><li>Balance </li></ul><ul><li>Endurance, energy costs </li></ul><ul><li>Positioning </li></ul><ul><ul><li>bed </li></ul></ul><ul><ul><li>sitting (chair,wheelchair,car) </li></ul></ul><ul><ul><li>classroom </li></ul></ul><ul><ul><li>home </li></ul></ul>
  10. 10. Impairments, cont’d <ul><li>Presence of abnormal developmental reflexes </li></ul><ul><li>Delayed or incomplete integration of normal reflexes </li></ul><ul><li>Absence of age-appropriate equilibrium and righting reactions </li></ul>
  11. 11. Functional Limitations Dimension <ul><li>Head control </li></ul><ul><li>Hand to mouth, grasp/release </li></ul><ul><li>Self-care: age appropriate skills in grooming, bathing, dressing, feeding </li></ul><ul><li>Bed mobility </li></ul>
  12. 12. Functional Limitations, cont’d <ul><li>Sitting </li></ul><ul><li>Transfers: home, school, work, community </li></ul><ul><li>Ambulation </li></ul>
  13. 13. Disability Dimension <ul><li>Mobility: work, school, community </li></ul><ul><li>Communication </li></ul><ul><li>Sports, recreation and play </li></ul>
  14. 14. Physical and Occupational Therapy: Treatment Options
  15. 15. Therapeutic Exercise <ul><li>Stretching and range of motion </li></ul><ul><li>Myofascial and joint mobilization </li></ul><ul><li>Active assistive, active and resistive exercise </li></ul><ul><li>Facilitate useful co-contraction </li></ul><ul><li>Endurance training </li></ul>
  16. 16. Functional Training <ul><li>Self care activities </li></ul><ul><li>Bed mobility </li></ul><ul><li>Coming to sit; balance and mobility </li></ul><ul><li>Transfer training </li></ul>
  17. 17. Functional Training, cont’d <ul><li>Wheelchair mobility </li></ul><ul><li>Gait training </li></ul><ul><li>Advanced ambulation skills </li></ul><ul><li>Skills for recreation, sports </li></ul><ul><li>Communication skills </li></ul>
  18. 18. Modalities <ul><li>Must be individualized and not always indicated: </li></ul><ul><li>Heat, cold, biofeedback </li></ul><ul><li>Electrical stimulation (NMES, FES, TES) </li></ul><ul><ul><li>Efficacy not well documented </li></ul></ul><ul><ul><li>Utilized to: </li></ul></ul><ul><ul><ul><li>Stimulate a weak agonist </li></ul></ul></ul><ul><ul><ul><li>Reduce spasticity in antagonist </li></ul></ul></ul>
  19. 19. Bracing <ul><li>AFOs most common lower extremity brace </li></ul><ul><li>With spasticity, may need to change bracing </li></ul><ul><li>Consider skin tolerance and wearing time </li></ul>
  20. 20. Positioning Splints <ul><li>Upper and lower extremity </li></ul><ul><li>Passive or dynamic </li></ul><ul><li>Dynamic brace + ES </li></ul>
  21. 21. Serial Casting <ul><li>Adjunct to pharmacological intervention, chemodenervation </li></ul><ul><li>Can aid in gaining ROM </li></ul><ul><li>Short-leg casts with dorsiflexion cut-out </li></ul>
  22. 22. Equipment <ul><li>The therapist’s role includes: </li></ul><ul><li>Evaluation of need </li></ul><ul><li>Preparation of funding justification </li></ul><ul><li>Instruction of patient and family in use and maintenance </li></ul>
  23. 23. Seating Systems <ul><li>Enhance mobility, cognitive, and communication skills </li></ul><ul><li>Provide interaction with environment </li></ul><ul><li>Maximize upper extremity and respiratory function </li></ul><ul><li>Minimize deformity and skin problems </li></ul>
  24. 24. ADL and Mobility Equipment <ul><li>Examples of ADL and mobility equipment include: </li></ul><ul><li>Modified eating utensils </li></ul><ul><li>Bathtub lifts and bathing aids </li></ul><ul><li>Orthoses and walkers </li></ul><ul><li>Wheelchairs </li></ul>
  25. 25. Safety Issues <ul><li>Abrupt changes in tone require attention to safety issues </li></ul><ul><li>Re-evaluate equipment, bracing and splinting </li></ul><ul><li>Assess and re-teach transfers </li></ul>