1. Spasticity is a motor disorder characterized by increased muscle tone and exaggerated reflexes caused by hyper-excitability of the stretch reflex due to loss of inhibitory pathways in the spinal cord.
2. The pathophysiology of spasticity involves denervation supersensitivity, axonal sprouting, and loss of descending inhibition resulting in disinhibition of segmental reflexes. Changes in muscle properties also contribute to increased tone.
3. Spasticity is assessed using measures of physiology like reflexes, muscle tone, and stiffness scales; measures of voluntary movement; and functional measures of activities and quality of life.
Neurodynamics, mobilization of nervous system, neural mobilizationSaurab Sharma
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
constraint induced movement therapy.pptxibtesaam huma
Constraint induced movement therapy
Dr. Quazi Ibtesaam Huma (MPT)
Dr. Suvarna Ganvir (Phd, Prof & HOD)
Dept. of Neurophysiotherapy
DVVPF’s College of Physiotherapy
Content
Introduction
History of CIMT
Components of CIMT
Population for CIMT
Advantages of CIMT
Recent advances
Introduction
History of CIMT
CIMT is based on research by Edward Taub ,his hypothesize that the non use was a learning mechanism and calls this behavior “Learned non-use”.
It was observed that patients with hemiparesis did not use their affected extremity .
Overcoming learned non use
Mechanisms of CIMT
Population for CIMT
Stroke
Traumatic Brain Injury
Spinal Cord Injury
Multiple Sclerosis
Cerebral Palsy
Brachial Plexus Injury
Advantages of CIMT
Overall greater improvement in function than traditional treatment.
Highly researched and credible treatment approach.
There are brain activity and observed gray matter reorganization in primary motor, cortices and hippocampus.
Increase social participation
Components Of CIMT
Types of CIMT
Restraining Tools for CIMT
Minimal Requirement of hand function for CIMT
Recent Advances
The EXCITE Trial: Retention of Improved Upper Extremity Function Among Stroke Survivors Receiving CI Movement Therapy.(2008)
The Extremity Constraint Induced Movement Therapy Evaluation (EXCITE) demonstrated that CIMT administered 3-9 months post-stroke, resulted in statistically significant and clinically relevant improvement in upper extremity function during the first year compared to those achieved by participants undergoing usual and customary care.
This study was the first randomized clinical trial to examine retention and improvements for the 24 month period following CIMT therapy in a subacute sample.
Study design - single masked cross-over design, with participants undergoing adaptive randomization to balance ,gender, prestroke dominant side, side of stroke, and level of paretic arm function across sites.
CIMT was delivered up to 6 hours per day, 5 days per week for 2 weeks.
Subsequent evaluations were made after the two week period, and at 4, 8, and 12 months.
Because the control group was crossed over to receive CIMT after one year.
Primary outcome measures – Wolf Motor Function Test
Motor Activity Log
Secondary outcome measure - Stroke Impact Scale (SIS)
were assessed at each of these time intervals, was administered only at baseline, 4, 12, 16 and 24 month evaluations.
Result :There was no observed regression from the treatment effects observed at 12 months after treatment during the next 12 months for the primary outcome measures of WMFT and MAL.
In fact, the additional changes were in the direction of increased therapeutic effect. For the strength components of the WMFT the changes were significant (P < .05) Secondary outcome variables, including the SIS, exhibited a similar pattern.
Conclusion: Mild to moderately impaired patients who are 3-9 months post-stroke demonstrate
Neurodynamics, mobilization of nervous system, neural mobilizationSaurab Sharma
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
constraint induced movement therapy.pptxibtesaam huma
Constraint induced movement therapy
Dr. Quazi Ibtesaam Huma (MPT)
Dr. Suvarna Ganvir (Phd, Prof & HOD)
Dept. of Neurophysiotherapy
DVVPF’s College of Physiotherapy
Content
Introduction
History of CIMT
Components of CIMT
Population for CIMT
Advantages of CIMT
Recent advances
Introduction
History of CIMT
CIMT is based on research by Edward Taub ,his hypothesize that the non use was a learning mechanism and calls this behavior “Learned non-use”.
It was observed that patients with hemiparesis did not use their affected extremity .
Overcoming learned non use
Mechanisms of CIMT
Population for CIMT
Stroke
Traumatic Brain Injury
Spinal Cord Injury
Multiple Sclerosis
Cerebral Palsy
Brachial Plexus Injury
Advantages of CIMT
Overall greater improvement in function than traditional treatment.
Highly researched and credible treatment approach.
There are brain activity and observed gray matter reorganization in primary motor, cortices and hippocampus.
Increase social participation
Components Of CIMT
Types of CIMT
Restraining Tools for CIMT
Minimal Requirement of hand function for CIMT
Recent Advances
The EXCITE Trial: Retention of Improved Upper Extremity Function Among Stroke Survivors Receiving CI Movement Therapy.(2008)
The Extremity Constraint Induced Movement Therapy Evaluation (EXCITE) demonstrated that CIMT administered 3-9 months post-stroke, resulted in statistically significant and clinically relevant improvement in upper extremity function during the first year compared to those achieved by participants undergoing usual and customary care.
This study was the first randomized clinical trial to examine retention and improvements for the 24 month period following CIMT therapy in a subacute sample.
Study design - single masked cross-over design, with participants undergoing adaptive randomization to balance ,gender, prestroke dominant side, side of stroke, and level of paretic arm function across sites.
CIMT was delivered up to 6 hours per day, 5 days per week for 2 weeks.
Subsequent evaluations were made after the two week period, and at 4, 8, and 12 months.
Because the control group was crossed over to receive CIMT after one year.
Primary outcome measures – Wolf Motor Function Test
Motor Activity Log
Secondary outcome measure - Stroke Impact Scale (SIS)
were assessed at each of these time intervals, was administered only at baseline, 4, 12, 16 and 24 month evaluations.
Result :There was no observed regression from the treatment effects observed at 12 months after treatment during the next 12 months for the primary outcome measures of WMFT and MAL.
In fact, the additional changes were in the direction of increased therapeutic effect. For the strength components of the WMFT the changes were significant (P < .05) Secondary outcome variables, including the SIS, exhibited a similar pattern.
Conclusion: Mild to moderately impaired patients who are 3-9 months post-stroke demonstrate
Late response are the most helpful findings in some of the diseases affecting the peripheral nerves, (e.g GBS, Radiculopathies, ). How to assess these responses while performing Nerve Conduction Studies, is the most technical and theoretical consideration.... Here we go with the same things in the stated slides
what is RNS and what the techniques to perform this test in the lab. Its significance in the evaluation and diagnosis of NMJ disorders like MG, LEMBS etc..
Brian Mulligan described novel concept of the simultaneous application of therapist applied accessory mobilizations and patient generated active movements
Important structures associated with neural control of locomotion- CPGs, Peripheral receptors and afferents, Basal ganglia, Cerebellum, Brainstem, Cerebellar Cortex.
NDT, BOBATH TECHNIQUE, BASIC IDEA OF BOBATH, CONCEPT OF BOBATH, NEUROPHYSIOLOGY OF NDT, ICF MODEL, PRINCIPLES OF TREATMENT OF NDT IN STROKE AND CP, AUTOMATIC AND EQUILIBRIUM REACTIONS, KEY POINTS OF CONTROL, FACILITATION, INHIBITION AND HANDLING IN NDT
Late response are the most helpful findings in some of the diseases affecting the peripheral nerves, (e.g GBS, Radiculopathies, ). How to assess these responses while performing Nerve Conduction Studies, is the most technical and theoretical consideration.... Here we go with the same things in the stated slides
what is RNS and what the techniques to perform this test in the lab. Its significance in the evaluation and diagnosis of NMJ disorders like MG, LEMBS etc..
Brian Mulligan described novel concept of the simultaneous application of therapist applied accessory mobilizations and patient generated active movements
Important structures associated with neural control of locomotion- CPGs, Peripheral receptors and afferents, Basal ganglia, Cerebellum, Brainstem, Cerebellar Cortex.
NDT, BOBATH TECHNIQUE, BASIC IDEA OF BOBATH, CONCEPT OF BOBATH, NEUROPHYSIOLOGY OF NDT, ICF MODEL, PRINCIPLES OF TREATMENT OF NDT IN STROKE AND CP, AUTOMATIC AND EQUILIBRIUM REACTIONS, KEY POINTS OF CONTROL, FACILITATION, INHIBITION AND HANDLING IN NDT
Spasticity Management, A rehab art. Hatem S. ShehataHatem Shehata
Workshop in Cairo University - School of Medicine
Objectives:
Rehabilitation Process
Spasticity – Definition – Pathophysiology – Impact
Assessment of spasticity and ADL
Spasticity management options
Outcome measures – BTX injection sheet
Clinical cases – video
In lesions below the mid-pons, a state of flaccidity, termed spinal shock, ensues immediately after injury with loss of all reflexes caudal to the injury.
The resolution of spinal shock occurs gradually , taking weeks to months.
The recovery from spinal shock is poorly understood and likely results from multiple, simultaneous adaptations in spinal processing that allow motor neuron to function independently from supraspinal control.
Existence of spinal shock, followed by a gradual return of reflexes that eventually become hyperactive, suggests that spasticity is not just a result of a simple on/off switch triggered by an alteration in inhibitory and facilitative signals
Spasticity is a common motor control disorder frequently encountered in the
spectrum of the upper motor neuron (UMN) syndrome. It can result in pain,
fatigue, joint restrictions, functional impairments, and skin breakdown that may
negatively affect many domains of life by causing social avoidance and
diminished life satisfaction . Spasticity was originally defined as a velocity dependent increase in tonic stretch reflexes or muscle tone with exaggerated
tendon jerks resulting from increased excitability of the stretch reflex . This
definition has been criticized for being too narrow and inadequately depicting
the clinical sequelae. In 2005, a European Thematic Network to Develop
Standardized Measures of Spasticity (the SPASM consortium) suggested
broadening the definition to reflect a more clinical entity . They defined
spasticity as “disordered sensory-motor control, resulting from an upper motor
neuron lesion, presenting as intermittent or sustained involuntary activation of
muscles.
In this powerpoint, i have mentioned all the information with diagrams and functions in a very easy way. I am always there to solve any of the queries. Thank you.
The ability of the neurons to change their function, chemical profile ( amount and types of neurotransmitters produced) or structure is referred to as neuroplasticity.
The plastic changes in neuron can occur
Physiologically according to activity and skill.
Pathologically due to injury or disease of CNS.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
3. Introduction
Spasticity is a motor disorder that is characterized by a
velocity dependent increase in tonic stretch reflexes
(muscle tone) with exaggerated tendon jerks, resulting
from hyper excitability of the stretch reflex, as one
component of the upper motor neuron syndrome.
American Academy of Neurology (1990)
4. Why spasticity is important????
Because it often causes disability and impairs
functions of our patient.
So based on that we plan treatment.
5. Normal physiology
Function of muscle spindle
1. It is receptor organ for stretch reflex
2. It is play important role in maintaining the muscle
tone.
8. Pathophysiology
Immediately after scl, there are depressed spinal
reflexes during the state of spinal shock, followed
by development of hyperreflexia and spasticity
over the following weeks to month.
9. The pathophysiology of spasticity is not completely
understood; however, it is believed to arise primarily
from loss of the effect of numerous descending
inhibitory pathways. These include reciprocal 1a
interneuronal inhibition, presynaptic inhibition,
renshaw-mediated recurrent inhibition, group II
afferent inhibition, and the Golgi tendon organs.
10. Axonal collateral sprouting and denervation super
sensitivity are change that may also play a role in the
development of spasticity.
T
11. Let see normal physiology along with pathophysiology
12. The Monosynaptic (Stretch) Reflex
Change in muscle length can evoke a stretch reflex.
Two type
Nuclear bag fibers
Nuclear chain fibers
Group la and 2 fibers
13.
14. Reciprocal inhibition
The la fibers also synapse on interneurons that inhibit
antagonist muscle groups, thereby preventing
contraction of antagonist muscle during activation of
agonist muscle groups; this inhibitory pathway is
referred to as reciprocal la inhibition and can be
altered after SCI.
15. Clinically, reciprocal inhibition can be grossly
observed by eliciting monosynaptic muscle stretch
reflexs: when tendon tapped, a stretch is applied to the
target muscle, which is transmitted to the spinal cord
through the la affrent fibers.
16.
17. This reciprocal la inhibition after SCI may result in
simultaneous coactivation of agonist and antagonist
muscle groups, as is often seen in patients with
spasticity.
18. Recurrent inhibition is mediated by Renshaw cells,
which are inhibitory interneurons located in the
ventral horn of spinal cord. Axon collaterals from
alpha motor neurons synapse on and activate the
Renshwa cells,which in turn project inhibitory
impulses back to these motor neurons as well as to la
inhibitory interneurons.
19. Renshaw activity decreases the activity of the motor
neurons that were previously active and also inhibits la
inhibitory internurons. The level of recurrent
inhibition has been explored in patient with UMN
lesions, and these individuals have been noted to
maintain normal recurrent inhibition during
voluntary movement; this may contribute to impaired
motor function in these patients.
20. There is evidence for increased recurrent inhibition in
the SCI population, which increases inhibition to the
la interneurons. This ultimately allows for
cocontraction of agonist and antagonist muscle groups
due to the decreased la interneuron activity.
21. Reduction in presynaptic inhibition of afferent is
another potential contributor to the Pathophysiology
of spasticity in SCI. reciprocal inhibition was
described by Sherrington in 1906, and this process is
responsible for relaxation of an antagonist muscle
during contraction of agonist.
22. in absence of reciprocal inhibition, cocontraction of
agonist and antagonist muscle groups is seen
simultaneously, interfering with intentional voluntary
movement. GABA mediates spinal inhibition both
presynaptically and postsynapticaly. presynaptic
inhibition of Ia afferent occurs when the inhibitory
aminiacid GABA binds to receptors on the la
terminals, which subsequently increases the amount
of input required to activate the alpha motor neurons.
23. The decreased excitatory input to the alpha motor
neurons in turn depresses the monosynaptic stretch
reflex. Postsynaptic activation of GABA-A receptor can
decrease the activity of motor neurons and
interneurons .afterSCI, the decrease in presynaptic
inhibition ultimately result in increased activity of the
alpha motor neuron; this may contribute to the hyper
reflexiya and spasticity seen in these individuals .it is
possible to modulate the presynaptic inhibition in
individuals with SCI with the use of GABA-Eergic
medications including baclofen and diazepam.
24. GOLGI TENDON ORGAN
Sensitive to intramuscular tension and innervated by
1b sensory afferents.
1 or 2 g of tension is sufficient to increase the firing
rate of the spindle afferents.
But tendon organs don't register impulse conduction
until the tension reaches as high as 100 g.
26. If tension is generated beyond capacity there is sudden
relaxation to prevent possible damage to tendon.
. This sudden relaxation of a muscle in the face of
dangerously high tension is called the lengthening
reaction or the "clasp-knife" reflex because of its
similarity to the way a pocketknife suddenly snaps
closed when the blade is moved to a certain critical
position.
27. Nonreciprocal lb inhibition is another mechanism that
may play a role in development of spasticity of
supraspinal origin but does not appear to be involved
in spasticity related to SCI, Golgi tendon organs, which
are contraction –sensitive receptors, have group I
afferents and lb inhibitory interneurons that projects
to the spinal cord and are involved in preventing
antagonist muscles from firing while the agonist is
firing.
28. There is evidence for replacement of lb inhibition with
facilitation in hemiplegic individual with supraspinal
lesions, leading to simultaneous cofiring of agonist
and antagonist muscle groups: however, studies in
individuals with SCI have shown that lb inhibition is
unaltered.
29. Two additional mechanisms that play role in the
development of spasticity after SCI are axonal
sprouting and denervation supersensitivity . Ditunno
et al describe the transmition from spinal shock
immediately after SCI the development of spasticity
and hyperreflexia 1 to12 months later. in their
proposed 4-phase model of spinal shock.
30. There is observation of areflexia or hyporeflexia , as
well as paralysis and muscle flaccidity for initial 0 to 24
hours postinjury. These findings are due to loss of
excitatory input from supraspinal pathways, including
vestibulospinal and reticulospinal pathways, among
others.
31. Loss of descending inhibitory input to spinal
inhibitiory interneurons may cause further
hyporeflexia. In the second phase of spinal shock,
there is return of the H reflex 1 to 3 days after injury,
although muscle stretch reflexs are still absent. This
likely due to denervation supersensitivity, which
causes increased neuronal firing in response to
neurotransmitters and has been reported to occur in
the brain and spinal cord .
32. The denervation supersensitivity may be due to
decreased reuptake of excitatory neurotransmitters,
up-regulation of receptors on the postsynaptic
membrane, or alteration of degragation and synthesis
of receptors.
33. Phase 3 and 4 of Ditunno’s model describe early
hyperreflexia and later development of spasticity in
patient with SCI. the proposed physiologic mechanism
for both phases is axonal regrowth .
34. new synapse are formed by spinal afferents and
interneurons as well as spared supraspinal descending
pathways. Axonal sprouting of spared descending
motor tracts may result in motor recovery, whereas
axonal sprouting of the neurons involved in segmental
reflexes may produce less desirable effects, such as the
development of hyperreflexia and spasticity.
35. Intrinsic changes within muscle may also play role in
the development of increased muscle tone. These
mechanical changes may include loss of sarcomeres,
increased stiffness of muscle fibers, altered muscle
fiber size and distribution of fiber types, and changes
in collagen tissue and tendons.
36. The work of Kamper et al in stroke patients
demosttrated that muscle fiber played some part in
phenomenon of spasticity as decresing the initial
length of tested spastic metacarpophalangeal fibers
reduced muscle stiffness suggesting that the
biomechanical quality of muscle fibers play some part
in the development of spasticity.
37. These changes in spastic muscle may be a result of the
development of subclinical contracture rather than
true reflex hyperexitibility or be an intrinsic property
of the changes in biomechanical property of the
muscle.
38. A strong, painful, or potentially damaging stimulus
delivered to cutaneous or joint receptors can reflexly
cause a sudden bodily withdrawal away from the
stimulus. Stepping on a tack is a good example of this
reflex in action. The person will typically flex
(withdraw) the stimulated foot and leg while
extending the other leg in order to propel the body
away from the tack.. At the same time, inhibitory
interneurons ipsilaterally inhibit extenders of the
stimulated limb while contralaterally inhibiting flexors
of the opposite limb.
39. This is a polysynaptic, bilateral reflex incorporating
both excitatory and inhibitory interneurons. Delivery
of the stimulus to the receptors in a limb increases the
firing rate of pain-carrying group III and IV afferents
into the posterior horn. where they synapse with
interneurons. Excitatory interneurons ipsilaterally
stimulate alpha motor neurons to the flexors in that
limb while contralaterally stimulating extenders in the
opposite limb - thus the term flexor-crossed-extensor
reflex
40. This reflex is often intersegmental. This should not be
surprising when one considers that many muscles are
involved in such movements. In the cat, for example, a
painful stimulus delivered to one hind leg will not only
reflexly withdraw that leg, but will extend to both hind legs
and forelegs on the opposite side as well. This means that
the group III and IV afferents not only stimulated
interneurons at the same segmental level at which they
entered the cord, but activated synapses at higher and
lower cord levels as well. The ascending and descending
collaterals travel in the fasciculus proprius (ground
bundles) of the white matter. The fibers in these tracts
carry intersegmental connections.
42. Assessment
In this we divide it in three category:
Physiological measures
Measures of voluntary activity
Functional measures
43. Measure of physiological activity
Measure utilizing nerve conduction
Tendon reflex
Measure passive activity
Ashworth scale
Tardieu scale
Range of motion
Stiffness and muscle tone
Stretch and stretch reflexes
Pendulum test model
Reflex threshold angle
44. Measures of voluntary activity
Isolated time movement tests
Performance based measures
Padobarography
Detection of movement
Gait
Balance
Body segment analysis
45. Functional mesures
Visual analoge scale and likert scale
Timed ambulation tests
Functional performance mesures
The pediatric evaluation of disability inventory
Qality of life mesures
36 item short from healthy survey
Satsfaction with life scale
Euro QOL
47. TARDIEU SCALE
This scale quantifies muscle spasticity by assessing the
response of the muscle to stretch applied at
specified velocities.
Grading is always performed at the same time of day,
in a constant position of the body for a given limb.
For each muscle group, reaction to stretch is rated at a
specified stretch velocity with 2 parameters x and y.
48. Velocity to stretch (V)
Quality of muscle reaction
(X)
V1 As slow as possible
V2 Speed of the limb segment
falling
V3 As fast as possible (> natural
drop) with no clear catch at a
precise
angle
V1 is used to measure the passive
range of Motion. (PROM).
Only V2 and V3 are used
followed by release to rate
spasticity )
0 No resistance throughout passive
movement
1 Slight resistance throughout,
2 Clear catch at a precise angle,
Motion. (PROM).
3 Fatigable clonus (<10secs)
occurring at a precise angle
4 Unfatigable clonus (>10secs)
occurring at a precise angle
5. Joint Immobile
Angle of muscle reaction (Y)
49. Angle of muscle reaction (Y)
Measure relative to the position of minimal
stretch of the muscle (corresponding at angle)
Spasticity Angle
R1 Angle of catch seen at Velocity V2 or V3
R2 Full range of motion achieved when muscle is at
rest and tested v1 velocity
50. Testing Positions
Upper Limb
To be tested in a sitting position, elbow flexed by 90° at the
recommended joint
positions and velocities.
Shoulder Horizontal Adductors V3
Vertical Adductors V3
Internal Rotators V3
Elbow Flexors V2 Shoulder adducted
Extensors V3 Shoulder abducted
Pronators V3 Shoulder adducted
Supinators V3 Shoulder adducted
Wrist Flexors V3
Extensors V3
Fingers Angle PII of digit III- MCP
Palmar Interossei V3 Wrist resting position
+ FDS
51. Lower Limb
To be tested in supine position, at recommended joint positions
and velocities
Hip Extensors V3 Knee extended
Adductors V3 Knee extended
External Rotators V3 Knee flexed by 90
Internal Rotators V3 Knee flexed by 90
Knee Extensors V2 Hip flexed by 30
Flexors V3 Hip flexed
Ankle Plantarflexors V3 Knee flexed by 30
52. Spasm frequency scale:
Most commonly used Penn Spasm frequency scale
It is modified by Priebe at al
53. Spinal cord assessment tool for
spasticity
Develop by Benz et al measure spasticity in spinal cord
injury.
Flexor spasm and clonus score of it correlate with
PSFS.
Not widely used.
54. Spinal Cord Injury Spasticity Evaluation Total (SCI-
SET)
Patient reported impact of spasticity measure.
55. References:-
Rehabilitation medicine: principles and practice third
addition edited by joel A.DeLisa
Neurological rehabilitation , third addition Darcy ann
Umphred
Spasticity diagnosis and its manegment
Ditunno et al describe the transmition from spinal
shock immediately after SCI the development of
spasticity
Kamper et al in stroke patients demosttrated that
muscle fiber played some part in phenomenon of
spasticity
56. Elovic EP, simone lk ,zaftonte r outcome and
assessment for spasticity in patient with traumatic
brain injury:the state of the art j head truama rehabili
2004.
Lieber rl ,steinman s brash ia et al. structural and
functional changes in spastic skeletal muscle .muscle
nerve 2004 .
RymerWZ powers rk pathophysiology of muscular
hypertoniyain spasticity neurosurg art rev.