MANAGING SPASTICITY IN CEREBRAL PALSY

– A Physiotherapist’s perspective

A.S.Jebaraj Fletcher

Definition: Cerebral Palsy

Defined as a persistent but not unchanging disorder of posture and movement, caused by damage to the developing nervous system, before or during birth or in the early months of infancy(World commission for Cerebral Palsy,1988)

Definition: Spasticity

Defined as a velocity dependent increase in resistance to passive stretch of a muscle, with exaggerated tendon reflexes

(Lance,1990; Parziale et al., 1993)

SPASTICITY IN CP Altered muscle tone is one of the earliest signs of

cerebral palsy (Binder H. Eng.GD 1989)

The nature of the movement disorder in spastic cp is a combination of hyper tonus, impaired postural control and equilibrium reactions, persistent primitive reflexes, upper extremity flexor and lower extremity extensor synergies and associated weakness (Winters et al1987)

Cont..

Spasticity may coexist with other movement disorders such as athetosis, chorea, or dystonia

These neurologic abnormalities may lead to muscle shortening, joint capsule tightness and osseous deformities (Vinken PJ & Bruyn)

Types of Spastic CP

PATHOPHYSIOLOGY OF SPASTICITY

1) EXAGGERATED SEGMENTAL REFLEXES Exact mechanism is uncertain The pathological basis of spasticity is the

abnormal enhancement of spinal stretch reflexes

They could be enhanced by increased muscle spindle activity or increased excitability of central synapses involved in the reflex arc.

2) EXAGGERATED SUPRA SEGMENTAL REFLEXES

Lesions at level of brain stem and above, then supra segmental reflexes through the spinal cord and brain stem became hyperactive (e.g., tonic neck and vestibular reflexes)

3) ABNORMAL VOLUNTARY CONTROL

Imbalance in antagonist – agonist voluntary Control

4) RELEASE REFLEX PHENOMENON

Hyperactive Excitatory neuronal firing

5) DECORTICATE & DECEREBRATE RIGIDITY

Decorticate: Upper limb flexed and lower limb Extended

Lesions above superior colliculus lead to decorticate rigidity

Decerebrate: Full Extension Upper and lower limbs

Lesions below superior colliculus may lead to de cerebrate rigidity

Direct and Indirect Consequences of Spasticity: Increased Tone Decreased Range of Motion Involuntary Movements Increased Autonomic Reflexes Exaggerated Reflexes Muscle Weakness Balance Problems

Cont…

Abnormal Bone Stress Contracture Pain Sleep Dysfunction Patient Care (hygiene, transportation) Bowel and Bladder Dysfunction Respiratory Dysfunction

Cont…

Communication, Speech, and Swallowing Dysfunction

Impaired Social, Psychological, and Vocational Development

CLINICAL EVALUATION OF SPASTICITY

Modified Ashworth scale

0 = No increase in muscle tone1 = Slight increase in muscle tone (catch or min resistance at end

range)1+ = Slight increase in muscle resistance throughout the range.2 = Moderate increase in muscle tone throughout ROM, PROM is

easy3 = Marked increase in muscle tone throughout ROM, PROM is

difficult4 = Marked increase in muscle tone, affected part is rigid

Oswestry Scale

It is based on clinical observation and is graded from 0 to 5( No, Mild, Moderate,Severe, Very Severe and solely severe)

Spasm Frequency Scale

How many spasms in the last 24 hours in the affected extremity?

0 = no spasms 1 = 1 / day 2 = 1-5/ day 3 = 5-9 / day 4 = >10/day

Adductor Tone Rating

0 = no increase in muscle tone1 = increased tone, hips easily abducted 45

degrees by one person2 = hips abducted 45 degrees by on person

with mild effort3 = hips abducted 45 degrees by one person

with moderate effort4 = two people are required to abduct the hips

45 degrees

Tardieu scale

A scale depending upon the responses of each muscle to both high and low speed After ranging a joint slowly and then quickly, the spasticity is assigned one of the following scores

Cont.. Tardieu scale

0 No resistance throughout the course of the passive movement.

1 Slight resistance throughout the course of the passive movement with no clear catch at a precise angle.

2 Clear catch at a precise angle, interrupting the passive movement, followed by a release.

3 Fatiguable clonus, less than 10 seconds when maintaining the pressure, appearing at a precise angle.

4 Unfatiguable clonus, more than 10 seconds when maintaining the pressure, at a precise angle

Gait Analysis

A test based on timed 10 m walks during which step are counted has been shown to be of use ( Collen et al, 1990)

Parameters are Stride length, step length and cadence can be measured

Video recording( Still man, 1991)

Photography

Others..

ROM tests: Helps to find tonal changes and severity of tightness

EMG Studies… Pendular tests Tendon reflex Babinski Sign

MANAGEMENT FOR SPASTICITY

Stepped Care Stepped Care for spasticity begins with conservative

methods that carry fewest side effects and progress to aggressive treatments with the most side effects.

First any remedial sources of nociception should be eliminated. UTI, BOWEL IMPACTION, Pressure sores, fractures, paronychia etc may increase spasticity and hypertonus

Second Patient education should be provided. Education allows patients to minimize adverse effects and to function despite spasticity

MOVEMENT & HANDLING

The use of manual handling techniques is one of the principle means available to the neurological physiotherapist in the physical management of spasticity

MAINTANENCE OF SOFT TISSUE LENGTH

1) ACTIVE & PASSIVE ROM EXERCISES Without the full range of motion, peripheral changes cause

muscle imbalance and this compounds any central motor dysfunction (Ada & Canning, 1990; Carr & Shephard,1995)

This can be achieved by passive stretching of tight structures or any active exercises

Daily ROM & Static muscle stretch prevents contracture & capsule tightness and can reduce stretch reflex hyperactivity and improve motor control (Odeen I. Scand. J. Rehabil. Med, 1981)

2) WEIGHT BEARING EXERCISES Standing is an excellent way of maintaining length in soft tissues

Standing is effective in altering tone via. The vestibular system, which is a major source of excitatory influence to extensor muscles, whist reciprocally inhibiting flexor muscles (Markhern, 1987; Brown, 1994)

It is another form of static stretch and it can reverse early contracture and may reduce stretch reflex excitability (Richards CL et al., Scand. J. Rehab. Med, 1991)

Back slabs or Standing frames may be used to assist Standing (Davies, 1994)

3) POSITIONING Various body or head positions can be used minimize facilitation

that is contributing to hyper tonus and to maximize facilitation to

muscles that have reduced voluntary recruitment (Stejskal L, Am. J. Physic. Med.. 1979)

In Children with Cerebral Palsy, Lumbar extensor muscle activity can be altered by adjusting head position and seat and back

angles of seating systems (Nwabhi OM et al., Dev. Med. Child.

Neurology 1983)

4) MODULATION OF MUSCLE TONE Movement and alteration of the alignment of

particular parts of the body can influence muscle tone in other areas

For Example, the rotational element is extremely important and is emphasized in the approaches like PNF (Voss et al, 1985) & Bobath (1990)

HANDLING TECHNIQUES

According to Mary Lynch,

For Spasticity, Speed: Slow Range: Full Repetition: Yes Voice: Quiet, Minimal Other: Longitudinal traction

SPLINTING

Different types of splinting were described and reviewed by Edwards & Charlton (1996)

Prophylactic Splinting:

It is appropriate for patients who need more than positioning and assisted movements to maintain joint range (Conine et al., 1990)

For example, prophylactic splinting can take the form of Plaster boots for Achilles tendon or plaster cylinders for limb to prevent tightness or contractures

Corrective Splinting/ Serial Casting

Corrective splinting is used to increase ROM in the presence of contracture

For example, Serial Casting for elbow contracture which is helpful in slowly correcting contracted joints

Dynamic Splinting

Dynamic splinting aims to facilitate recovery and assist stability for improved function

For example, In children with CP, AFO’s with tone reducing features have been used to inhibit tonic postures of the foot (Hylton N., 1990)

ELECTRICAL STIMULATION

ES.. Cont.. Vang et al, (1995) found electrical stimulation

resulted in a measurable reduction in spasticity in upper limb

O’Daniel & Krapfl, 1989 reported that the use of ES increases the effectiveness of stretching spastic muscles by reciprocal inhibition

ES at nearly all levels of the nervous system relieves spasticity ( Stefanovska. A, 1991)

ES.. Cont..

Shindo (1987), has reported a reduction of spasticity by clinical evaluation, lasting 8 to 72 hours after each session of FES.

Stefanovska (1988) measured decreased tone and increased voluntary strength in ankle plantarflexors after peroneal nerve stimulation for 1 year

THERMAL TREATMENTS

Cryotherapy:

Ice can be used as an adjunct to other treatment methods or as a means of controlling tone in a specific area

Muscle cooling reduces phasic stretch reflex activity and clonus (Hartviksen. K, 1962; Giebler KB, 1990)

Slow Icing reduces spasticity (Roods Approach) Ice can be used with static stretch to overcome

hyperactive stretch reflexes (Giebler KB, 1990)

Apply warm water soaks to spastic muscles or have child sit or lie in warm water

HYDROTHERAPY

Pool therapy can be used a adjunct management for cerebral palsied Children

It helps in stretching large muscle groups & to help movements in trunk.

BIO FEEDBACK

The effectiveness of EMG biofeedback machines in the treatment of increased muscle tone is yet unproven (Moreland & Thompson, 1994)

Bio feedback using either EMG or Joint position sensors and providing auditory or Visual feedback, has reduced spasticity in patients with preservation of voluntary motor control (Neilson et al., J. Neurol. Neuro Surg. Psychiatry, 1982)

It can provide the patient with useful feedback between therapy sessions

Advance techniques

VESTIBULAR STIMULATION

All static positions and or movement patterns facilitate the vestibular system which in turn has effects over muscle tone (Anne G. Fisher et al..)

Various researches proves vestibular stimulation as a therapeutic modality in managing abnormalities of muscle tone. (Weeks ZR, Am. J. Occupational therapy, 1979)

Vestibular stimulation has more impact on the development of Cerebral Palsied or Mentally retarded Children than a normal, at risk or premature infants (Ottenbacher KJ et al., Clinical Paediatrics, 1983)

In StandingSwinging in Glider

SittingUsing Net Hammock

Sitting/ Prone

Prone/supineIn a Barrel

Supine/SitIn Scooter Board

Bouncing

HIPPOTHERAPY

Hippotherapy is a physical, occupational and speech therapy treatment strategy that utilizes equine movement (The American hippo therapy Association)

Benda W et al 2003, reported improvements in muscle symmetry in Children with CP after equine assisted therapy (The Journal of Complimentary Medicines, 2003)

Casady R et al reports positive outcome in 10 CP Children after having hippotherapy

Suit therapy

Suit therapy is often used as part of a comprehensive program of intensive physiotherapy of 5–7 hours a day for four weeks (UCP, 1999).

This therapy is based on a suit originally designed by the Russians for use by cosmonauts in space to minimize the effects of weightlessness. The idea is to move body parts against a resistance, thus improving muscle strength.

Through placement of the elastic cords, selected muscle groups can be exercised as the patient moves limbs; thus, suit therapy is a form of controlled exercise against a resistance. It is also claimed that the suit improves coordination.

The suit consists of a cap, a vest, shorts, knee pads, and shoes. An attached series of elastic cords provides compression to the body’s joints and resistance to muscles when movement occurs.

“..much study is a weariness of the

flesh.” Ecclesiastes 12:12

(Bible)

THANK YOU