Spasticity

Question 1

What are the initial 3 characteristics of spasticity?

Answer 1

1. Primacy of basic excitatory protective reflex responses (stretch, withdraw, jj protective reflexes).
2. Reflex cascade effects (aka reflex spill over, domino reflex). One stimulus can invite a series of reflex responses (spastic reaction; clonus at a joint).
3. Re-emergence of basic motor patterns
   - >Flexion dominance
   - >Babinski’s sign

Question 2

After the initial characteristics of spasticity occur, 2 more additional changes occur that add to the spasticity, identify and briefly explain each. What is the general affect of this?

Answer 2

1. IA neuronal sprouting: IA’s add synapses with their partner alpha’s, meaning that stretch info exponentially increases its influence and therefor on the stretch of the stretch reflex response.
2. Decrease in GABA (inhibitory NT used by interneurons in reflex arc) availability in SC.
   - > Reduced GABA avail. makes the GTO response shorter/weaker

General affect = the natural ‘balancing act’ of tone management between stretch and GTO reflexes is thrown off in favour of stretch reflex.

Question 3

What is the general main goal of mx therapy in regards to spasticity?

Answer 3

To fight contracture

Question 4

When treating spasticity, what is the best positioning to use?

Answer 4

Flexion is usually ‘neutral’ position for spastic joints. Treat as much as possible in sidelying, when treating in other positions, be mindful that extra pillowing may be needed to keep j’s comfortably flexed. The degree of flexion that is neutral for spastic joints varies

Question 5

Treating spasticity: before beginning to manipulate mm tissue, hold the mm, _____________________.

Answer 5

…hold the muscle in a tolerable, shortened position for at least 30 seconds to ‘calm’ its mm spindles.

Question 6

What is the most effective way to use GTO responses in treating spasticity?

Answer 6

It is best to isolate the stretch to the tendon (do not have the mm lying in a stretched position during the technique). Ie without stretching the mm, bow the tendon. You can also apply GTO simultaneously with mx

Make the approach as precise as possible on the mid-tendon or the aponeurotic attachment.

Question 7

Temperature choices in treating spasticity?

Answer 7

S tends to be exacerbated by cold AND hot (withdraw response). Warm is generally the only well tolerated temperature range for hydro applications. Warm can be used to reduce hyperreflexia.

Question 8

Treating spasticity: ROM work, explain the process.

Answer 8

Begin by bringing the jj into comfortable flexion. Hold quietly for at least 30 seconds. Then slowly and evenly extend to a place of resistance or early spastic reaction. Hold for a few seconds. If the resistance lessens, stretch a bit more in the same manner. If not, reduce the stretch until the reaction subsides and hold there. If the reaction is too intense or ‘spreads’, bring the jj back to neutral and let it rest there before trying anything else. Don’t attempt to mx and stretch at the same time, also, never fight the 1A.

Question 9

Spasticity tx: stretching procedure.

Answer 9

As much as possible have the tissues ‘warmed up’ before stretching. Some people prefer to be stretched at the beginning of tx, others at the end, discuss it with your patient (get it over with at the beginning of tx vs. stretching at the end if they need some tone to walk out.

Question 10

Medication and treating spasticity?

Answer 10

In most cases, it is best to mx when the patient has an optimal amount of antispasmodic meds in their system

Question 11

Things that can help in treating spasticity (to do pre-tx)? (2)

Answer 11

1. Use of spasticity reducing technologies: being rolled prone over a large ball (moderate, longitudinal px on abdomen) or put in weight baring machine/machine that supports standing)
2. Where possible, it’s best to arrange so that the patient in the place and position where you will begin the tx, with clothing on or off as needed and some time to rest quietly beforehand.

Question 12

List the 4 main clinical problems that increase spasticity and briefly describe each.

Answer 12

1. Ishcemia: increased tone and decreased mobility reduce circulatory flow. Muscles that are poorly perfused will tend to be more irritable. Poor tissue health and tissue toxicity will add to spasticity.
2. Altered biomechanics and degenerative jj change: whether the person perceives them as painful or not, altered range, abnormal mechanics and degenerative changes will tend to increase reflex reacitivity related to jjs. Compensatory postures and movements may also overstress mms and exacerbate spastic jjs.
3. Contracture: contracture compromises tissue circulation and jj health. It also increases spasticity by reducing the amount of available tolerable movement.
4. Poor tissue healing: spasticity can compromise injury repair. Inflexible/matted scarring and reduced tissue health may add to irritable reactions.

Question 13

Resistance exercise and spasticity?

Answer 13

Research has indicated that resistance exercise can help reduce tone levels in spastic mms.

Question 14

Spasticity and cardiovascular status?

Answer 14

It’s important to check on cardiovascular status in all patients with spasticity, regardless of cause, as spasticity, esp. F/B, can generate stress on the heart ( due to increased TPR and increased tonicity/caloric requirements)

Question 15

Functional contracture?

Answer 15

In some cases, functional contractures are medically induced - ex: hand contractured around wheel chair controls; stability in L-spine for posture)

Question 16

Spasticity and skin quality?

Answer 16

People with spasticity, esp. w/o voluntary movement, can have a number of skin care issues. Be observant of skin quality and indicators of breakdown.

Remember that mx on-site at an early sage of decubitus ulcer (bed sores) is CI-ed.