Neuro

- a motor disorder that is characterised by a velocity dependent increase in tonic stretch reflexes (mm tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex, as one component of the upper motor neuron syndrome

• - spasticity: co contraction or dystonia (neuro disorder with mm contractures causing rot and not proper mm contraction)
• - rigidity
• - hyperreflexia
• - primitive reflexes
• - clonus

• - lack of strength
• - lack of motor control
• - lack of coordination
• - these signs are more of a problem than the +ve signs

• - tone- compliance of tissue, spasticity can contribute
• - hypertonia- low tone- not used much, flaccid
• - clonus- fast stretch and hold on stress, contraction/ relax to maintain stretch
• - rigidity: cogwheel - when resistance gives way, leadpipe- constant resistance to stretch throughout movt
• - claspknife phenomenon- like shutting pocket knife
• - contracture- shortening of saccromeres

• The resistance to passive stretch is:
• - bidrirectional- spasticity- resistance both flex and ext
• - relatively independent to the speed of the movement
• - does not result from hyperactive stretch reflexes

• - no relationship between spasiticty and contracture development
• - hypertonia associated wiht contracture but not hyperreflexia
• - the stiffness associated with contracture can contribute to hypertonia and can be confused with spasticity
• - no correlation between contracture and spasiticty

increased mm tension and the ability to stretch

• - spasticity (if you get rid of this you cant increase the pt function) and activity are not correlated
• - spasiticty doesnt make an independent contribution to activity limitations after stroke
• - dereasing spasiticity doent improve acitivty

• - imbalance between excitatory and inhibitory impulses to the alpha motor neurons- due to lack of descending inhibitory input to the alpha motor neuron- cause hyper excitable reflexes from a lesion
• - descening pathways also influences renshaw cells (neurons located in ventral horn) which suppress repeated firing of alpha motor neurons- lesion decreases activity of renshaw cells alpha neurons = reduce their inhibitory activity- this results in rapid, repeated firing of alpha motor neurons from repetitve stretch reflexes triggered by vountary or passive stretch of mm
• - descending pathways also inhibit golgitendon organ (GTO)- proprioceptors at junction of mm tendon, mm belly- protect mm from source- lesion results in lack of inhibition of GTO = excitation of stretch reflex

- in spasticity there may be a secondary myopathy 

• - random things happen in spasticity
• - fibre size- loss of variability
• - the mm is shorter but the sacromeres are longer
• - the contrature tissue around the cell makes it 10 x stiffer than non spastic cells
• - fibre type distribution
• - more connective tissue around fibres make less compliance

• - interferes with functional recovery: may affect mobility, functional independence
• - impaired hygiene (axilla, palm) and sexual function
• - may cause pain jts forced in wrong position
• - impaired sleep- rol over and have a spastic response
• - icreased carer burden
• - all goals for treatment

• - esp for spinal cord injuries
• - an aid to standing and walking via extensor spasms
• - increased strength in isometric and eccentric volntary contractions, facilitated by hyperactive stretch reflexes
• - maintenance of mm mass- not so much instroke but significant in spinal cord injusires
• - can also prevent pressure area sores
• - maintained bone mineralisation/ density
• - improved venous return
• - reduced DVT risk
• - reduced dependent oedema in paralysed limbs

- when spasticity produces disability or activity limitations (personal/ social)

• - static and dynamic mm tone: ashworth, tardieu, tendon jerks
• - mm strengthand selective motor control
• - function

• - prevention of spasticity- takes a while to develop- positioning, seating, PROM- AROM and stretching? handling techniques?
• - find nociceptive stimulus- spasticity triggered by pain eg bowel, bladder, skin
• - relieve pain and symptoms
• - improve function (ADLS, seating, mobility)
• 

• - non invasive, non permanent
• - effective management for some pts

• -difficult to achieve a steady state
• - following a schedule may be diffcult
• - sid effects: drowsiness, hypotonia, and weakness my limit effectiveness

• - peripheral nerve block- into nerve -can cause perm damage
• - motor point blocks- pt mm where it is responsive- botox
• - numerous agents used
• - duration of effects varies
• - numerous complications

• - type A serotype (BTX-A)
• - botox- A
• - dysport

• - focal spasticity- cant inject every mm
• - a specific functional gaol for treatment
• - intense therapy program

• - blocks neuromuscular transmission by inhibiting release of arch trom the presynaptic terminals, resulting in a reversible denervation atrophy
• - chemicals denervation develops over a few days and last 3-4 months
• - collateral sprouting from the adjacent axons limits the duration of clinical effects

• - diffuses easily through mm membranes therefore doesnt require precise location of motor points
• - simple injection technique
• - no CNS side effects
• - no sensory disturbance
• - weakness resolves
• - safe
• - well tolerated

• - lasts 3/12 months
• - injection pain
• - limited maximum dose
• - cost
• - EMG gudieance- locate hard mm. Other is a clearing affect after a pt doesnt matter how much u give

• - excessive weakness decrease function
• - adjacent mm weakness
• - transient fatigue, nausea and H/A 
• - local pain and haematoma
• - flu like illness
• - clinical resistance
• - contraindications- neuro mm junction problems, antibiotcis, pregas, temp, breast feeding

• - baclofen is delivered directly to the spinal cord resulting in effectively a chemical rhizotomy
• - benefit is less cognitive SEs
• - indications are for: serve spasticity, ineffectiveness of oral agents, positive response to test dose via LP
• the one where the machine is in the body

• - cost 30 grand
• - respiratory depression ( drug overdose)
• - drowsiness/ increased weakness
• - seizures 
• - nausea and vomiting
• - infection
• - skin nevrosis
• - pump/ battery/ catheter problmes

• Neurosurgery
• ortho surgery

• ad- perm- one time procedure, evidence for efficacy in reducing spasticity and improving function in children with spastic diplegia
• dis- perm- may need spasticity, potential adverse effects

• - stretch
• - strengthen
• - fatigue
• - EMG biofeedback
• - weight bearing
• - hydrotherapy
• - PNF
• - bobath
• casting
• - orthosics
• - positioning
• - massage
• - edu
• - prevent nociceptive stim
• - ice/vib/ten.heat