This document discusses musculoskeletal impairments that can occur secondary to neurological conditions. Physically disabling neurological illnesses can lead to complications like contractures, deformities, and pain that limit function. Hemiplegic shoulder pain is one common complication after stroke and can be prevented through proper handling and positioning of the affected shoulder. Other impairments discussed include reflex sympathetic dystrophy, heterotopic ossification, and fatigue. The management of these secondary complications involves prevention through early mobility and stretching, as well as treatment through physical therapy modalities like electrical stimulation and massage.

1. Musculoskeletal impairments in
neurological conditions
DR-BRIJESH GADHIYA(PT)
MPT(NEURO), CMS & ED
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2. Introduction
• Physically disabling neurological conditions
can result in secondary musculoskeletal
complications that limit patient’s activities
even further.
• These secondary complications can develop at
any stage after the onset of a neurological
illness, and the ability of clinicians to
recognize and treat these complications will
improve patients’ functioning.
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3. Introduction(cont…)
• The impairments caused by neurological
conditions can result in direct degenerative
complications in skeletal and soft tissues.
• Complications may also arise secondarily to
the neurological condition’s treatment.
• As trauma is a common cause of neurological
deficits, patients who have sustained trauma
often present with concomitant
musculoskeletal injuries.
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4. Common musculoskeletal impairment
in neurological condition
• Hemiplegic shoulder pain
• Reflex sympathetic dystrophy
• Contracture and deformity
• Hetrotopic ossification
• Osteoporosis
• fatigue
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5. Hemiplegic shoulder pain
• Hemiplegic shoulder pain is among the four
most common, yet preventable complication
that stroke survivor may experience
• HSP can occur in the 2nd week after stroke
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6. Hemiplegic shoulder pain(cont…)
Definition:
• HSP is a shoulder pain that is present at rest,
during passive or active movement on the
hemiplegic side after stroke with no direct
relation to trauma or injury.(kim et al 2014)
Incidence:
• rates ranging from 38 to 84% of cases.
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7. Causes
• In flaccid stage
– Proprioceptive impairment
– Lack of tone
– Muscle paralysis reduces the support(rotator cuff)
– Shoulder subluxatation
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8. Causes(cont…)
• In spastic stage
– Abnormal muscle tone
– Poor scapular position (depression, retraction and
downward rotation)
– Tightness in ligament, tendons and jt capsule
– Poor handling and positioning
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9. Symptoms
• Pain with or without movement of the
hemiplegic shoulder
• Sharp stabbing pain
• Early on pain can be intermittent and limited
to shoulder and later on constant severe and
more than just shoulder.
• Reduced mobility
• Tenderness
• swelling22/12/2015 9
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10. HSP outcome measures
• VAS
• NPRS
• Faces pain scale
• Ritchie articular index
• Shoulder Q
• Graded chronic pain disability score
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11. Management
• The ideal management of HSP is to prevent it
• It must be begin immediately after stroke.
• Handling and positioning
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12. Handling
• Good handling technique of the hemiplegic
upper extremity day and night is
recommended to prevent HSP because it
prevent trauma to soft tissues.
• Support is provided both proximally and
distally to the UE.
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13. Positioning
• Maintaining the upper limb in the correct
position
• The recommended position for the affected
upper limb is abduction, external rotation
with the shoulder slightly flexed.
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17. Strapping of the shoulder
• To prevent and reduce shoulder subluxtation
• Provide sensory stimulation
• To facilitate or inhibit musculature
surrounding the scapula.
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18. Slings and other devices
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20. Physiotherapy treatment
• Electric neuromuscular stimulation
• Positioning and handling
• Cryotherapy
• Therapeutic exercise
• Mobilization technique
• Gentle stretching
• EMG biofeedback
• Relaxation training
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21. Reflex sympathetic dystrophy
• Also known as chronic regional pain
syndrome(CPRS).
• Prolonged soft tissue injury can result in CPRS.
• This pain typically has a diffuse onset and is
characterized as aching through out the limb.
• The wrist tends to assume flexed position with
intense pain likely during wrist extension
movements.
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22. Mechanism of RSD
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23. Stages
Stage 1
• Acute/ reversible stage
• Lasts 3weeks to 6 months
• Vasomotor changes include discoloration and
alteration in temperature.
• The skin may be hypersensitive to touch,
pressure or temperature variations.
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24. 22/12/2015 24
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25. Stages (cont…)
Stage 2
• ischemic stage
• Lasts 3 to 6 months
• Characterized by subsiding pain and early
dystrophic changes
• Muscle atrophy
• Vasospasm
• hyperhydrosis
• Radiographic evidence of early osteoporosis22/12/2015 25
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26. Stages (cont…)
Stage 3
• Atrophic stage last for months or years
• Progressive atrophy of skin, muscle and bones
• Pericapsular fibrosis and articular changes
become pronounced
• Hand typically becomes contracted in a
clawed position with MP extension and IP
flexion.
• Marked atrophy of thenar and hypothenar
muscles with flattening of the hand22/12/2015 26
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27. Management
• Chances of reversal of signs and symptoms are
high for stage 1 and variable for stage 2, while
stage 3 changes are largely irreversible.
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28. Management (cont..,)
• Relieve pain and control edema
– TENS
– Vibration
– Ice
– Retrograde massage
– Elevation
– Elastic compression
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29. Management (cont..,)
• Increase mobility
– In early stage gentle active exercise
– Tendon glide exercise
– Neural mobilization
– Later on mobilization and stretching
• Improve muscle performance
– distraction(1 to 5 pounds up to 10 min)
– Isometric ex and later resisted ex
– Stress loading
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30. Management (cont..,)
• Improve total body circulation
– Low impact aerobic exercise
• Desensitize the area
– Work with various texture and tap or vibrate over
sensitive area
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31. Contractures and deformity
• Contracture develop secondary to prolonged
shortening of structures across or around
joint, resulting in limitation in motion.
• Contracture initially produce alteration in
muscle tissue but rapidly progress to involve
capsular and pericapsular changes.
• Once the tissue changes have occurred the
process is irreversible.
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32. Contractures and deformity(cont…)
• Faulty positioning, hetrotrophic ossification,
edema, and imbalance in muscle pull
contribute to the specific direction and
location of contracture development.
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33. In traumatic SCI
• Hip: flexion with adduction and IR.
• Shoulder:
– tightness in flexion or extension depending on
early positioning.
– Both patterns associated with adduction and IR.
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34. In stroke
• In UL:
– Elbow flexors
– Wrist and finger flexors
– Forearm pronators
• In LL:
– Planter flexion contracture
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35. In cerebral palsy
• Upper limb:
– Pronation contarcture of forearm
– Flexion deformities of the wrist and fingers
– Thumb in palm deformity
– Swan neck deformity
– Shoulder adduction and internal deformity
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36. In cerebral palsy(cont…)
• Spine:
– Scoliosis
– Kyphoscoliosis
• In hip:
– Adduction deformity
– Flexion and internal rotation deformity
– Dysplastic and subluxated hip
– Pelvic obliquity
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37. In cerebral palsy(cont…)
• In knee:
– Genu recuvatum
– Genu valgum
– Patella alta
– Subluxation or dislocation of patella
– Knee flexion contracture
• In foot:
– Equinus deformity
– Talipus equinovarus
– Halux valgus and claw toes22/12/2015 37
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38. In poliomyelitis
• Iliotibial band contractures
• Results in 9 classical deformities
Lumbar
scoliosis Hip flex
abd
Pelvic
obliquity
ER of
femur
Flex & valgus
of knee
Post & lateral
subluxation
of tibia
ER of tibia
Equinus
foot
shortening
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39. In arthrogryposis multiplex
congenita
• foot: planovalgus and equinovarus
• Knee: flexion contracture and fixed in
extension
• Hip: extension, abduction and ER
• Shoulder: IR
• Elbow and wrist flexed
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40. Management
Prevention
• Early mobilization stressing out of bed upright
postures and weight bearing activities along
with the use of involved extremities.
• Consistent and concurrent program of ROM
exercise
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41. Management
• Use orthotic devices and splints
• Casting
• Massage therapy to relax tense muscles
• Stretching
• Prolonged stretch
• PNF technique
• Strengthening
• Electrical stimulation
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44. Hetrotropic ossification
• Heterotropic ossification is osteogenesis in
soft tissues below the level of lesion.
• The etiology of this abnormal bone growth is
unknown.
• However, multiple theories has been
proposed, including tissue hypoxia secondary
to circulatory stasis, abnormal calcium
metabolism, local pressure and micro trauma
related to overly aggressive ROM exercise.
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45. Hetrotopic ossification(cont…)
• Hetrotopic ossification is always extra-articular
and extracapsular.
• It may develop in tendons, connective tissue
between muscle, aponeurotic tissue or the
peripheral aspects of muscle.
• Typically occurs adjacent to large joints, with
the hips and knees more commonly involved.
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46. Hetrotopic ossification(cont…)
• Other joints that have demonstrated
involvement include the elbows, shoulders
and spine.
• Early symptoms are swelling, decreased ROM,
erthema and local warmth near a joint.
• Elevated serum alkaline phosphate levels
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47. Management
• Diphosphates has been used to inhibit the
formation of calcium phosphate and to
prevent ectopic bone formation.
• Combination of pharmacological therapy with
Regular exercises during the early formation
stages of ectopic development.
• Surgery is used when extreme limitations in
function impede rehabilitation.
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48. Osteoporosis
• A bone disease characterized by a
loss of bone per unit volume.
• Due to changes in calcium metabolism
• Decreased physical activity
• Changes in protein nutrition
• Hormonal and calcium deficiency
• Pt who are immobilized and restricted in
weight bearing demonstrate increase risk of
osteoporosis.22/12/2015 48
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49. Management
• High protein and
calcium reach diet
• Adequate vit D intake
and calcium intake
• Analgesics and anti
inflammatory drugs
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50. Physiotherapy Management
• Weight bearing exercise, such as walking,
jogging, stair climbing
• Resistance training
• Bicycle ergometer
• Whole body vibration as antiosteoporotic
intervention on vibration platform
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51. Fatigue
Definition:
• A subjective lack of physical and/or mental
energy that is perceived by individual or
caregiver to interfere with usual and desired
activities.
(by panel on fatigue of the MS Council for
clinical practice Guidelines)
• Fatigue is daily event, experienced by 75% to
95% of individual with the disease.
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52. Fatigue (cont…)
• Fatigue is the result of central activation
failure (central fatigue) and failure in
excitation-contraction coupling.
• Fatigue comes on abruptly, without warning
and resembles an overwhelming flu-like
exhaustion.
• Severity of disease does not seem to be
related to fatigue severity.
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53. Precipitating factors
• Physical exertion
• Exposure to heat and humidity
• Depression mood and sleep disorders
• Low-self esteem
• Medical condition and secondary complication
of disease
• Side effect of medication
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54. Evaluation
• Assess the frequency, duration and severity of
fatigue.
• Modified fatigue impact scale
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55. Management
• Aerobic exercise training
• Energy effectiveness strategies
– Activity diary (level of fatigue, value of activity,
performance of activity)
• Energy conservation
– Adoption of strategies that reduce overall energy
requirement of the task.
– By modifying the task or environment
– Broken down activity in parts.
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