When treating a patient who shows spasticity it is necessary to carry out three important aims:
Inhibit excessive tone as far as possible
Give the patient a sensation of normal position and normal movement
Facilitate normal movement patterns
A) Body Positioning:
In cases of spasticity it is important to facilitate the patient’s ability to inhibit the undesirable activity of the released reflex mechanisms.
The position adopted by the patient is important since the head and neck position can elicit strong postural reflex mechanisms.
Avoiding these head and neck positions can facilitate the inhibition of the more likely reflexes and if positions have to be adopted, then help in preventing the rest of the body from going into the reflex pattern thus elicited may be required by the patient.
As patient develops control in the suppression of the effect of the reflex activities then he can be gradually introduced to use of positions which make suppression of reflex activity more difficult.
Side lying position well supported by pillows is very convenient since it avoids stimulation of the tonic labyrinthine reflex and also, as head and trunk are in alignment, the stimulation of the asymmetrical tonic neck reflexes.
It makes a good resting position for the patient with spasticity and also is convenient for the application of rhythmical trunk rotations of both passive and assisted active form which further helps in reduction of tone.
Side lying is not always desirable because of respiratory problems in the older patient or because of the need to obtain a greater range of movement.
Other attitudes are often very satisfactory such as crook lying or even with the knees as high on the chest as possible. These two positions are helpful if there is flexor spasticity.
B) Rotatory Movements:
Trunk rotation produces lower limb to extend, abduct and externally rotate.
Limb rotations are also very effective in helping to give a more normal control of muscle tone to the patient.
C) Pressure over undersurface of Foot:
If the pressure is applied to the ball of the foot it may well stimulate an extensor reflex in which a pathological pattern of extension, adduction, and medial rotation of hip is produced together with plantar flexion of the foot, which is undesirable in case of spasticity.
If pressure is applied under the heel of the foot then a more useful contraction of muscle is likely to occur giving a suitable supporting pattern.
Normal Movements Patterns & Avoidance of Triggering Factors:
Movement of a normal nature does appear in itself to reduce excessive tone and consequently this should be encouraged in the patient.
However, care must be taken if conscious volitional movement is demanded.
Due to reflex release, some motoneurone pools are already in an excitatory state and any volitional effort is likely to act as a triggering mechanism to those motoneurone pools giving associated muscle contraction in the spastic pattern.
Such patients should not be encouraged to make strong volitional effort since this is inclined to facilitate the production of spastic patterning.
Other factors such as quick movements, abruptly performed, noisy surroundings, anxiety, excitement, over exertion should also be avoided as it may increase spasticity.
D) Slow Sustained Stretching:
Stretching forms the basis of spasticity treatment. Stretching helps to maintain the full range of motion of a joint, and helps prevent contracture, or permanent muscle shortening.
It activates muscle spindles (Ia & II endings), golgi tendon organs (Ib endings) which are sensitive to length changes.
It inhibits or dampens muscle contraction and tone due largely to peripheral reflex effects.
It can be more effective in extensor muscles than flexors due to the added effects of II inhibition.
This method does have its dangers since, if stretching is forced against severe spasticity, the hyperexcitable stretch reflex reacts even more strongly and damage to the periosteum of bone may occur where excessive tension has been applied by the tendons of the stretched muscles.
- Techniques used are
- Manual contacts
- Inhibitory casting or splinting
- Reflex-inhibiting patterns
- Mechanical low-load weights
E) Prolonged Cold Application:
Application of cold packs to spastic muscles (usually for 10 minutes or longer) may improve muscle tone.
While the effect doesn't last long, it may be used to improve function for a short period of time, or to ease pain.
It activates thermoreceptors.
It decreases neural, muscle spindle firing and provides inhibition of muscle tone.
- Immersion in cold water; ice chips
- Ice towel wraps
- Ice packs
- Ice massage
- Ice application with exercises
F) Neutral Warmth:
Retention of body heat stimulates thermoreceptors, autonomic nervous system mainly parasympathetics, which produces generalized inhibition of tone, calming effect, relaxation and decreases pain.
It should be applied for about 10 to 20 minutes.
Overheating should be avoided as it might increase arousal or tone.
- Wrapping body or body parts: ace wraps, towel wraps
- Application of snug fitting clothing (gloves, socks, tights) or air splints
- Tepid baths
G) Relaxed Passive Movements:
Rhythmical, slowly performed passive movements through normal patterns may also be helpful and in the more moderate cases patients may subconsciously join in and by his own activity a reduction in spasticity may occur.
H) Deep Rhythmical Massage (Tendon Rolling):
Deep rhythmical massage with pressure over the muscle insertions can be given to reduce spasticity.
I) Inhibitory Pressure (Weight-Bearing):
Prolonged pressure to long tendons inhibits the hypertonicity of a muscle.
It activates muscle receptors (muscle spindles, golgi tendon organ) and tactile receptors.
Firm pressure can be applied manually or by body weight.
Weight bearing postures are used to provide inhibitory pressure, such as
- Quadruped or kneeling postures can be used to promote inhibition of quadriceps and long finger flexors.
- Sitting, with hands open, elbow extended, and upper extremity supporting body weight can be used to promote inhibition of long finger flexors.
Biofeedback is the use of an electrical monitor that creates a signal—usually a sound—as a spastic muscle relaxes.
In this way, the person with spasticity may be able to train himself to reduce muscle tone consciously.
K) Functional Electrical Stimulation:
Electrical stimulation may be used to stimulate a weak muscle to oppose the activity of a stronger, spastic one.
It improves standing, walking, and exercise training as well as decreases upper extremity contractures.
Appears to improve motor activity in agonistic muscles and reduce tone in antagonistic muscles.
Therapeutic effect may last for less than 1 hour after stimulation has been stopped, probably because of neurotransmitter modulation within reflex arc.
L) Tone Reducing Orthosis:
These are plastic AFO’s in which foot plate and broad upright are designed to modify reflex hypertonicity by applying constant pressure to the plantarflexors and invertors.
They control the tendency of the foot to assume an equino-varus posture.
Foot plate may be modified which maintains the toes in an extended or hyperextended position, thus assisting individual to walk with better foot and knee control.
M) Slow Maintained Vestibular Stimulation:
Low-intensity vestibular stimulation such as slow rocking produces generalized inhibition of tone.
It facilitates primarily otolith organs (tonic receptors); less effects on semicircular canals (phasic receptors).
Slow, repetitive rocking movements; assisted rocking in a weight-bearing position, for example, rocking with equipments:
- Rocking chair
- Swiss ball
- Equilibrium board
Slow rolling movements
N) Proprioceptive Neuromuscular Techniques:
- Rhythmic Initiation – Voluntary relaxation followed by passive movements through increments in range, followed by active movements progressing to resisted movements using tracking resistance to isotonic contractions.
- Rhythmic Rotation – Voluntary relaxation combined with slow, passive, rhythmic rotation of the body or body part around a longitudinal axis, followed by passive movement into the antagonist range.
- Contract Relax Active Contraction – Isotonic movement in rotation is performed followed by isometric hold of the range limiting muscles in the antagonist pattern against slowly increasing resistance followed by voluntary relaxation and active movement into the new range of the agonist pattern.
O) Manipulating Key Points:
For reducing spasticity, manipulating the thumb will reduce the spasticity. All the movements should be carried out with thumb in abduction.
Another technique to reduce the spasticity is manipulating the pelvis which is the central key point. In sitting, place one hand over the lower back and other near the xiphoid process. Now move the patient in the figure of 8 pattern forwards and backwards.