Hemiplegia

[iraj468]

Hi dears,
I am working about motor deficits in adult hemiplegia.
what is your experience about decreasing spasticity in
this patients?




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[perfphysio]

Often spasticity begins as a result of poor trunk stability and the necessity to stand and walk patients to early. The plasticity of the nervous system can reorganise itself to maintain this "Rigidity" which makes treatment more time consuming and can be seen as a step backwards to the patient. I would intially play around with some seating postures and mobilisation of the trunk and see what happens to the upper limb.
For the persistent spasitcity Botox may have a short term place in reducing spasticity while you work on core control without having to take any "backward steps".

[sven]

I think that sustained stretching is a very important treatment for this type of problem. It causes muscle to relax more and therefore stop it's 'overfiring'. And will help to maintain the musclelength. Muscleshortning will cause that the muscle is at the end of it's range earlier whick in term will cause an increase of tone, a negative effect.
I would like to hear what other readers think.

[katrinawilliams]

This topic is quite controversal. It is also highly complex. The latest evidence to arise from randomised controled trials indicate that spasticity in itself is a problem encounterd in neurological patients it has little direct correlation to functional outcome. Individuals can have spactisity of a high degree but goot functional outcome. I guess what I am trying to say is that at this point the main thing you need to concentrate on in gaining strength in the affected area. Weakness is the main clinical sign which is correlated strongly to functional outcome. Individuals with spactisity MAY be prone to develop shorter muscles due to positioning and then it is very important to maintain muscle length but please do not think that a spastic or tight muscle is a strong one. There is much eveidence out there to refute this.

Our departments approach is as follows.
1) Activate the muscle ASAP and train into function
2) Maintain muscle length especially in those muscles prone to shortening due to prolonged positioning from immobility.
3) Utilise appropriate drugs to assist in the decreasing of tone.
4) Functional Electircal stimulation can assist in improving muscle activation
5) EMG or biofeedback may assist in teaching the patient to relax muscle and activate others.

Problems may arise in the long term patient with minimal muscle return mostly associated with prolonged positioning. To this continued splinting, positioning, stretching, drugs/surgery may be of benefit.

There is very little evidence to suggest that seating positions will decresae spasticity. Active work on trunkal control and better body positions to allow for improved biomechanical posion in sitting for reaching or standing tasks would be the main benefit. Also prolonged stretching has been found to do little to reduce spasticity via cortical inputing rather it does maintain the muscle length. Short muscles are more difficult to activate throughout range and the antagonists need greater ability to work agains a SHORT muscle.

I am sorry this a very difficult to fully explain. YOu would benefit from doing a search via Cochrane/PEdro/Medline for greater depth of information.

Hope this is of some help

[NARSTR]

I've been asking around for ten years for an effective method of reducing spasticity. It has become a much less common problem in adult hemipelgia over the last 20 years. It can be controlled temporarily with seating and bed positioning - and early++ WB. Long term management is different and very controversial. I do not support the theory that serial casting should be done for 6 weeks, every week, when the result is non-functional.
Lots of weight-bearing, upper and lower limbs, does help if done immediately prior to transfer practice, etc.
baclofen is good but makes the patient drowsy. If I come across any good references/reviews will post them

[Afolabi]

In my practice, I`ve found that RIPs, limb vibration,ice massage, relaxation techniques and ice brushing provide some relief to spasticity in hemiplegics. Keep working!
Jide

[sabah]

Spasticity can be reduced by Heat or Cold, by deep rhythmic sedative messaage, by prolong stretching, passive movements, by positioning, by active contraction of both antagonists and agonists. having reduced the spasticity the re education of movement is begin as It is only the re education of movement which prevents the spasticity on long term basis.

[Mich]

Increased tone in muscles following hemiplegia is often adopted by the client attempting to achieve a functional goal to compensate for a lack of tone and movement or stabilty in another area. A problem solving approach must therefore be adopted to find out the underlying cause of this hypertonicity. Often by giving the client the stability or movement they are lacking elsewhere (possibly more proximally) they can then use their limb more selectively rather than having to recruit the muscles for stability.
Working for eccentric lengthening of the hypertonic muscles as well as working the antagonists may also assist in reducing the 'spasticity'. Splinting may help to lengthen the muscle but I feel it's important to work out why they are having to recruit the tone in the first place.

[james]

This is a very general question. Do not "chose" an approach. Evidence Based Practice for Physiotherapy in reducing spasticity does not reflect the extremely effective treatments that we can provide. Review the new definitions of the term "spasticity", and recognise the many components that may lead to spasticity- Hypertonus, hyperreflexia, biomechanical shortening, adaptive postural responses(associated reactions), etc.. Decide on what and where the underlying lesion may be, and what plastic adaptions since has taken place since the insult. Many facilitatory techniques can reduce the unwanted "noise" of spasticity, but don't forget to turn the facilitatation toward functional activities based on the patients goals.
Such an interesting topic! Goodluck.

[reeces]

Spasticity is a general term (just like what James was saying), but in this case I think you are referring to hypertonicity, commonly found in hemiplegics and other CNS lesions (head injuries, for instance).
My basic principles for addressing spasticity is:
- maintain ROM (out of the pathological pattern)
- dynamic weightbearing (not STATIC weighbearing)
- retraining of active movements (selectivity) after normalisation of tone
- integration into functional activities (with lots of facilitation and correction if necessary).
This is just a guideline, again, each patient is individualistic (thus, initial & ongoing assessments are essential!) Adapt your treatment/principles according to the assessment (often changes from day to day).

[physiogayle]

Trunk Stabilisation is extremely effective in reducing spasticity. An additional technique new to the world of physiotherapy is cranio-sacral therapy. Temporal Mobilisation improves lateral rotation of the upper and lower limb.