8/21/2019 PRESSURE INTERVENTION BY SPYGMOMANOMETER ON THE POST-STROKE HEMIPLEGIC PATIENT

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Official Publication of Orofacial Chronicle , India

www.jhnps.weebly.com

ORIGINAL RESEARCH

PRESSURE INTERVENTION BY SPYGMOMANOMETER ON

THE POST-STROKE HEMIPLEGIC PATIENT

Mohamed.Sheeba Kauser1 MPT, Akheel M.D2  MDS

1-MPT (Neurology), ITS Paramedical College, Muradnagar, U.P.,India

2- Oral & Maxillofacial Surgeon, Chennai T.N, India

ABSTRACT:

Background: We aim to investigate whether the direct application of pressure by

sphygmomanometer has any effect on spasticity levels in post stroke hemiplegic

 patient.

Materials and Methods:  We studied on a patient who sustained first ever

ischemic stroke. “After relaxing in a supine posture for 10 min, subject received

the interventions for 10 min with rest intervals. The Modified Ashworth Scale

scores were recorded before and immediately after each intervention.

Results: The patient showed no significant changes in Modified Ashworth Scale

scores but there was a significant decrease in spasticity level. The patient had an

immediate reduction in the tone till the time therapy is given, but after the pressure

is removed, there was again increase in the tone of the muscles of upper limb. 

Conclusion:  The direct application of pressure by sphygmomanometer had nochange in the levels of spasticity in post stroke hemiplegic patient.

KEY WORDS:  Modified Ashworth Scale; spasticity; sphygmomanometer,

 pressure.

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Cite this article: Mohamed Sheeba k., Akheel M.D: Pressure intervention by

spygmomanometer on the post-stroke hemiplegic patient: Journal of head & neck

physicians and surgeons Vol 2 Issue 1 2014: Pg 33-41

INTRODUCTION:

Interruption of the blood supply to the brain, usually caused because a rupture of

 blood vessel or blockage of blood vessel by a clot which is called as a stroke. Any

 blaockage stops the supply of nutrients and oxygen, causing diffuse damage to the

 brain tissues.1

It is a major public-health burden worldwide for increase in

mortality rate.2

Any damage to the pyramidal tracts and its accompanying Para-

 pyramidal (corticoreticulospinal) fibers gives rise to the upper motor neuron

(UMN) syndrome.3 Spasticity has generally been assessed clinically through

 physical/clinical examinations using techniques such as the Modified Ashworth

Scale (MAS)5, Tardieu scale

6, Pendular test

7 etc. The effects of different treatments

of muscle spasticity such as stretching8, weight bearing

9,  joint positioning

10,

electrical stimulation11

, oral medications12

, shock wave therapy13

, ultrasound

therapy14

, cryotherapy15

, vibration16

have been examined.

Pneumatic pressure technique has been used in treatment of various neurological,

orthopedic and medical conditions. MC Knight and Schomberg

18

  tried pneumatic pressure using air splints in the treatment of rheumatoid arthritis and observed that

air pressure resulted in reduction of pain, swelling and stiffness of hands and

increase in the range of motion of the affected joints. Spasticity is a common

 problem among stroke patients requiring rehabilitation. Pneumatic pressure applied

through air splints were found to be useful in reducing the excitability of spinal

motor neurons after the stroke19

. Similarly Robichaud and Agostinucci observed

that circumferential pressure applied with air splints decreased alpha motor neuron

excitability among patients with spinal cord injury20

.But this effect lasted only as

long as the pressure was applied.

Therefore in this study we introduced pneumatic pressure in treatment protocol

rather as splint in conservative management by using sphygmomanometer.

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There are studies showing that application of pressure by the application of

sphygmomanometer helps in spasticity. Hence aim of this study is to know

whether pressure has any effect on reducing tone and extensibility of limb.

CASE REPORT:A 45 year old patient with post stroke hemiplegic patient is reported on the basis

of inclusion and exclusion criteria and was assigned by direct application of

 pressure stimuli .Inclusion criteria were as follows: Post stroke Middle Cerebral

Artery lesion patient, onset of stroke > 4 weeks, patient age: 30  –   60 years,

increased muscle tone of the affected upper limb biceps brachii muscles (MAS

score ≥1),Receiving no stimulant or relaxant medications (including anti- spasticity

and anti- convulsion medications, and pharmacological injections), no peripheral

nerve injury, no history of any other neurological problem like head injury, is ableto follow and obey commands.

Exclusion criteria were Folstein MMSE score below 23, severe aphasia, dementia,

any hearing/ visual problems. Stroke diagnosis was based on computed

tomography (CT) or magnetic resonance imaging (MRI), as well as neurological

functions. The study was conducted without altering the existing medication

regimes of the patients. MAS score, was recorded before (pre) and immediately

after (post) interventions.

Procedure:   After relaxing for 30 min in the supine posture, patient received the

interventions for 10 min. He received pressure through using sphygmomanometer,

the B.P cuff was tied on the biceps brachii muscle belly and pressure was applied

relatively to the patient diastolic pressure and systolic pressure which are checked

 before the starting of the treatment protocol. There by the approximation of the

value of pressure applied is 80MMHG aiming for the extension of elbow and

supination of wrist. The pressure is given with regular interval gaps of 1 minute

with completion of process of one set having 10 repetitions along with hold time of

5 minutes21. This process is carried for 10 sets in one session of treatment. On the

day of treatment two sessions of treatment was given on the alternative days.0n the

other day the patient was treated without pressure therapy intervening the tradition

therapy of spasticity. Spasticity was assessed by using Modified Ashworths Scale

 before and after the intervention.

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MEASUREMENT OF MUSCLE TONE:

The extent of spasticity was measured using the Modified Ashworth Scale (MAS)

for the biceps brachii and wrist flexor muscles. The MAS is an age old established

and reliable instrument, which makes use of a 6-point scale to score the averageresistance to passive movement for each joint. To facilitate analysis of data, the

MAS scores (0, 1, 1+, 2, 3 and 4) were assigned numerical values designated as

“computed MAS scores” (0, 1, 2, 3, 4 and 5, respectively). Changes in MAS scores

were calculated by the subtraction method.

The procedures in the present study were in accordance with the ethical standards.

Patients were given information saying that participation was voluntary and that

they could choose not to participate at any time without having to give a reason

DATA ANALYSIS: 

A pre- test, post- test experimental control group design was used for the study.

Data was tabulated on master chart. Statistical analysis was performed using SPSS

16.0 version software. Man Whittney – U test was used for between group analysis

of Age and MAS pre and post. Independent T test was use for within analysis of

 pre and post. Mean difference between the pre and post was calculated and further

analysed to find out whether the intervention is significant or not. Significance

level was set at P<0.05. 

RESULTS:

Statistically differences were observed within pre and post reading of MAS.

Pre and post analysis for MAS was done by Man Whitney-Utest.

Statistically non significant differences was observed between post and post

readings.

MAS IN BOTH 

0 1 2 3 4 

With pressure Without pressure 

MAS SCORES 

PRE POST 

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Figure 2: showing statastical analysis of MAS with and without intervention.

DISCUSSION:

We compared the efficacy of pressure application using blood pressure cuff with

that of conventional physiotherapy in reducing the spasticity of post stroke

hemiparitic patients using randomized controlled methods. Changes in spasticity

were assessed with MAS scores. Our result shows no significant improvement in

the MAS scores between DAPS group and control group but within group analysis,

the DAPS group improved significantly after pressure application. Whereas no

change was there in control group.

We used modified Ashworths scale to assess spasticity (M.A.S: Bohannon and

Smith 1987, Wade 1992, Engsberg et al.1996). Spasticity was reduced after theintervention in the DAPS group but not in control group. One reason of spasticity

reduction may be associated with tonic pressure reflex. DAPS treatment is

intended to apply multiple pressure stimuli simultaneously to the fully stretched

spastic muscles of upper limb. The stimuli initially produce intense contraction

(known as TPR) of the spastic muscles. After a continuous application of pressure

stimuli on the muscles, the spasticity levels got reduced which can be justified by

the previous study done by A.B Tally,K.P.S Nair,T.Murali17

.

Spasticity level reduction can be due to activation of golgi tendon organs whichcauses autogenic inhibition which is justified in previous studies done by

Johnstone et al 1983, Poole and Whitney et al 1990 in which they explained that

thermal and pressure application reduce stimulation of thermal and tactile receptors

which show a rapid adaptation to stimuli22, 23.This

  then decrease excitability of

intermediate neurons and motor neurons and increase sensorial input. It is claimed

TREATMENT ANALYSIS OF

MAS IN THE PATIENT 

0 2 

4 

Without pressure With pressure 

MASSCORES 

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that autogenic inhibition is ensured by the activation of Golgi tendon organs.

Which resulted in increase stability facilitates motor development and improves

normal motion patterns.

Decrease of spasticity is also because the impulses are given directly oncuteaneous receptors which directly influence motor neurone excitability in the

spinal medulla or indirectly by reticular formation. Neutral heat and pressure

applications decrease the excitability of thermal receptors and tactile receptors

which slow a rapid adaptation to the stimuli. Therefore they decrease the

excitability levels of both interneuron and motor neurons which is justified in

 previous studies done by Johnstone et al 1983 and Barnard et al 198424

.

Reduction of spasticity can be increase in temperature. Skin temperature can be

elevated by friction between the blood pressure cuff and skin22

. This can causerelaxation of muscular and other soft tissues but also to a decrease in gamma

afferent fiber activity that would lead to a decrease in impulses from the muscle

spindles with a consequent inhibition of impulses to the alpha fibres6.

There was no change in the spasticity level as measured by the Modified

Ashworths Scale as only conventional physiotherapy was given to the groups

wherein stretching and techniques based on Bo bath approach was given. Several

limitations of this study should be acknowledged. First, it included only a small

number of participants, therefore future studies with a larger number of

 participants are needed to confirm our results. Samples included were only post

stroke hemiplegic patients, therefore results cannot be generalized to person

outside the sample population. Secondly, only assessments for spasticity motor

function, activity limitation were made in this study, thus future studies should

evaluate changes in quality of life to explain the contribution to stroke

rehabilitation.

FUTURE RESEARCH:

  Larger number of sample size should be included to confirm our results and

generalize the results to population outside our sample population.

  Quality of life, activity limitations and motor functions should also be

assessed for the patients.

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CONCLUSION: 

The present study provide good evidence of anti spastic effect of direct application

of pressure stimulus in post stroke hemiplegic patients

REFERENCES:

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11. Kubota S et al. Stimulus Point Distribution in Deep or Superficial Peroneal Nerve for

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12.  N. Smania, et al. Rehabilitation procedures in the management of spasticity. Eur J PhysRehabil Med 2010, 46:423-38

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14. Ansari NN, Naghdi S, Bagheri H, Ghassabi H.  Therapeutic ultrasound in the treatment ofankle plantar flexor spasticity in a unilateral stroke population: a randomized, single-blind, placebo-controlled trial. Electromyogr Clin Neurophysiol. 2007 May-Jun;47(3):137-43.

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Acknowledgements:  The author wishes to thank the Almighty, Guides and all

those who have helped in this work.

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Conflict Of Interest: The present study does not have any conflicts of interest and

Author has no issues if JHNPS shares data and materials of present study. The

author adheres to all the policies of JHNPS.

Source of Funding: The present study did not receive any grant for practicaladministration and no personal payment of salary has been given to anyone

 participating in the present study.

Correspondence Addresses :

Corresponding Author:

Mohamed Sheeba Kauser

Post graduate Resident

I .T.S Paramedical College, Muradnagar, Ghaziabad, Uttar PradeshEmail:  sheebaishaq.doc@gmail.com