Stroke is the sudden loss of neurological function caused by an interruption of blood flow to the brain. Motor deficits are characterized by paralysis (hemiplegia), typically on the side of body opposite the side of the lesion. Interruption of blood flow for only a few minutes sets in motion a series of pathological events. (O’Sullivan, 2007).
There are several risk factors that decrease incidence of hemiplegia and those are regular exercise, lifestyle management, stress reduction techniques and diet.
The measurement of spasticity
The measurement of spasticity is part of the neurological examination of patients with disorders of the central nervous system. The Modified Modified Ashworth Scale (MMAS) was developed for the characterization of muscle spasticity. A study done by Naghdi S et al, (2008) determines the interrater reliability of the MMAS in the assessment of wrist flexor muscle spasticity in adult patients after upper motor neuron lesions resulted in hemiplegia. In conclusion, the MMAS has very good interrater reliability for the assessment of wrist flexor muscle spasticity.
Ansari N in 2009 found that neurologically affected subjects may be affected by spasticity but Modified Ashworth Scale (MMAS) is a clinical tool used to measure spasticity and it has given reliable measurements between examiners when used on patients post-stroke with elbow flexor spasticity.
Spasticity is velocity and acceleration dependent, and it is therefore important to execute physiotherapeutic exercises at a relatively low and constant velocity. This can be more accurately managed by a robot than by a person when such exercises are administered continuously for more than 15-20 min. A controlled clinical by Fagekas G (2006) is under way to assess the effectiveness of the REHAROB movement therapy. According to the experiences of the first clinical investigation, the programming interface and the mechanical interface device between the patient and the robots had been improved.
Complications associated with spasticity in upper extremity-
Acute stroke patients with poor upper limb motor functions are more prone to soft-tissue injury of the shoulder during rehabilitation. Study done by Pong (2009) determines the association between the motor functions of the upper extremity and these injuries, which play an important role in hemiplegic shoulder pain and may impede rehabilitation andf to examine the hemiplegic shoulders for soft-tissue injury by musculoskeletal sonography.
Stokes L (2010) mentions that goals related to passive tasks were more often achieved than those reflecting active function. Qualitative analysis of goals nevertheless demonstrated change over a wide area of patient experience. Goal-attainment scaling provided a responsive measure for evaluating focal intervention for upper limb spasticity, identifying outcomes of importance to the individual/carers, not otherwise identifiable using standardized measures.
Current trends in spasticity management
A single case report was done with a female participant who was suffering from stroke since 2 years. According to Denham SP to neutralize spasticity botulinum toxin A (BTA) injections were given in the left upper extremity to neutralize spasticity and also other treatment approaches like occupational therapy, neurodevelopmental and biomechanical and activity based home program were added for her improvements.
According to Hurvitz EA,Conti GE, Brown SH, botulinum toxin reduced tone and increased ROM of the spastic upper extremity, the time course and degree of motor improvement appears to depend on the complexity of the task. So further studies might focus on adjunct therapy, task-specific training, in addition to botulinum toxin treatments to facilitate functional improvement of the spastic upper extremity.
Ozer K, Chesher SP, Scheker LR, saying that statistically significant differences were found in all three measures for only those treated with combined NMES and dynamic bracing. However, this significant effect lasted for only 2 months after discontinuation of the treatment. We conclude that the combined use of NMES and bracing is more effective than either alone but requires continuous application.
MRI scans were taken at rest and after upper arm exercise. Also opposition to passive movement was measured subjectively. Opposition and MRI to passive movement possibly will be useful in the evaluation of spasticity. For the progress and assessment of antispasticity treatments this might be clinically relevant. (Ploutz-Snyder L et. al., 2006)
Transcranial magnetic stimulation matched with maximum effort to make a target movement has shown to improve hand motor function in patients with chronic stroke. Some chronic patients with stroke who were unable to completely extend the affected fingers were examined in the study. (Izumi S et. el, 2008)
Study done by Zhao J (2009) to evaluate the effect of acupuncture treatment on the spastic states of stroke patients found out that control of spasticity is often a significant problem in the management of patients with stroke. These results suggested that acupuncturing surface projection zone of decussation of pyramid was effective in reducing spastically increased muscle tone and motor neuron excitability in stroke and could improve spastic states of stroke patients by providing a safe and economical method for treating stroke patients.
Botulinum toxin (BTX) treatment can relieve focal arm spasticity after stroke, presumably through dynamic changes at multiple levels of the motor system, including the cerebral cortex. However, the neuroanatomical correlate of BTX spasticity relief is not known and should be reflected in changes of cortical activation during motor tasks assessed using repeated functional magnetic resonance imaging (fMRI). This small study suggests that structures outside the classical motor system, such as the posterior cingulate/precuneus region, may be associated with the relief of post stroke arm spasticity.
Evidence based practice of different treatment strategies
A systematic review of the literature including electronic databases, primary reports, abstracts and conference proceedings followed by a literature-based evaluation was done. Till now no single valid and reliable outcome measure available to capture the full range of true function in affected upper limb. Validated tools are particularly required for passive and lower level function. Patient’s level of function and goals will be dependent on clinical evaluation.
Occupational Therapy management of hemiplegic upper extremity
Occupational therapy services were provided to a participant after botulinum toxin injections improvements 2 years. Injections are given to neutralize spasticity in the upper extremity after a stroke and the participant received occupational therapy for 12 weeks, using neurodevelopmental and biomechanical approaches and an activity-based home program. Two years after the injections, the MAS score ranged between 1 and 1+. Initially, the participant demonstrated functional limitations in areas of splint application, dressing, toileting, and bathing. Following BTA injections and occupational therapy, the participant demonstrated increased independence in all deficit areas. For this participant, BTA, combined with functional, activity-based occupational therapy interventions, was associated with neurological change and greater functional use of the spastic limb.
According to authors Sun S; Hsu C; Hwang C; Hsu P, Wang J, Yang C, constraint-induced movement therapy (CIMT) is a promising intervention for retraining upper-extremity function after a stroke. The purpose of this case report is to describe the use of a combination of botulinum toxin type A (BtxA) and a modified CIMT program for a patient with severe spasticity who was unable to use his right upper extremity
After stroke resistive exercise can improve strength. Also it will not increase spasticity. But its effects on muscle co-contraction and activation are not clear. Also on affected and non affected arms when forward reaching task was given and resisted with loads there were motor control deficits. Affected arm gave response higher that of control arm means normal arm of same individual. Although smaller increases in muscle activation and co-contraction levels that varied with load type were observed in the nonparetic arm. Few advance intervention studies are needed to determine whether loads are preferable for poststroke resistive exercise programs.
Psychosocial aspects associated with spasticity management
In USA stroke is a leading cause of long-term disability but it is difficult to understand that what its effects on quality of life are. The findings in this study are dependable with prior research demonstrating the importance of social factors to quality of life following stroke. Examiners in this study found out that measures of stroke-related quality of life should include assessment of social function and social support.
This article outlines a nonsurgical approach that includes neuromuscular electrical stimulation and dynamic bracing for the management of spastic deformity in cerebral palsy. Neuromuscular electrical stimulation is used commonly for lower extremity spasticity. Its clinical application in upper extremity spasticity, together with dynamic bracing, is a new entity providing predictable and quick short-term results with significant improvement in quality of life.