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Stroke Part 2: Synergies and Spasticity
26 Plays23 days ago
Not everything is weakness! In the second of a multi-part series on stroke, Dr. Michael Powers highlights the role of abnormal synergies and spasticity on movement and functional difficulties after stroke. Along the way, you'll learn about stereotypical synergy and spasticity patterns, motor recovery expectations, tools to examine synergies and spasticity, and how to consider synergies and spasticity within an evidence-based plan of care for stroke rehabilitation.
Key Takeaways
- Acute stroke response and flaccidity
- Abnormal synergies and impact on movement
- Stages of motor recovery following stroke
- Outcome measures for synergies: STREAM and Fugl-Myer
- Spasticity as part of the upper motor neuron (UMN) syndrome
- Strongest spasticity components for the upper and lower extremity
- Examining spasticity: Modified Ashworth Scale and Tardieu Scale
- Moving Forward: contextualizing synergies and spasticity within best current evidence
References
- O'Sullivan & Schmitz's Physical Rehabilitation, 8th ed.
- Stroke Rehabilitation Assessment of Movement
- Fugl-Meyer Assessment of Motor Recovery after Stroke
- Best Practice Guidelines for the Management of Patients with Post-Stroke Spasticity
- Moving Forward: State of Evidence in Neurologic Physical Therapy
All music courtesy of Free Music Archive and used via attribution 4.0 international license.
- Intro and Outro: Stylin' by JMHBM
- Transitional: Our Reality by Ketsa
Connect
- email: neuropowerhour@drmichaelpowers.com
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Transcript
Introduction to Stroke Examination and Synergies
00:00:09
Speaker
Welcome to the NeuroPowerHour. I'm your host and neurological navigator, Dr. Michael Powers, physical therapist, board certified in neurologic physical therapy and clinical electrophysiology. Let's get started.
00:00:22
Speaker
Today's episode, we're going to continue our investigation into st stroke. And initially, I was going to talk about the approach to the stroke examination. However, before jumping into that, I realized, well,
00:00:32
Speaker
We've previously discussed the vascular syndromes, ACA, MCA, PCA, and there was really a focus on hemiparesis and hemisensory loss, and these are big issues that we're going to be considering within our examination.
00:00:44
Speaker
But I realized I hadn't really laid the foundation or the groundwork about other findings in stroke that are really going to impact movement and function.
Understanding Synergies and Spasticity in Stroke
00:00:52
Speaker
Specifically, i felt it was important for us to talk about synergies and spasticity.
00:00:57
Speaker
And the reason for that is I don't know to what extent this has been mentioned on prior episodes, and I didn't want to move forward into examination of stroke before really highlighting the role of synergies and spasticities on movement, because considering these factors will impact your examination, but I also wanted to put these impairments within context in terms of best current evidence as it relates to treatment. So let's talk about synergies and spasticity.
00:01:26
Speaker
Acutely after stroke, patients will often present with flaccidity, unable to produce voluntary movement due primarily to cerebral shock. This can last days to weeks. Now, it may not happen in all patients depending upon severity of the initial stroke,
00:01:41
Speaker
But our general framework and understanding of the acute response and recovery is that there's a progression from being flaccid initially towards movement that happens within certain synergies and movement that is potentially constrained by the development of spasticity.
00:01:59
Speaker
So that's kind of our starting point after stroke, then transitioning or progressing towards movement out of synergies and with spasticity eventually declining.
Brunstrom's Stages of Stroke Recovery
00:02:09
Speaker
Brunstrom way back in around 1970 initially outlined stages of recovery following stroke, and we're going to highlight some of these here in a bit.
00:02:18
Speaker
Brunstrom initially described six stages, and she did update this to include seven stages. So depending on the reference that you're looking at, you may see some that indicate six stages, some that indicate seven,
00:02:30
Speaker
and I wouldn't get too hung up on whether it's six or seven. The key here is what you're looking at in terms of moving in and out of Synergy and the development, then increase and then hopefully decrease over time of Spasticity. This episode, then, we're going to dive into Synergies and Spasticity But I will make sure that we try and keep a general understanding of how much we should emphasize these impairments, not only in examination, but as we look forward to our treatment discussion a few episodes from now, really putting these impairments into the proper
Muscle Synergies in Stroke Rehabilitation
00:03:03
Speaker
context. So it may seem that I'm talking out of both sides of my mouth here a little bit because I'm going to be saying...
00:03:09
Speaker
We need to examine synergies and spasticity, want to identify them. However, you're also going to hear me say the primary treatment goals should not necessarily be treating synergies or spasticity in isolation.
00:03:24
Speaker
We'll talk a little bit later this episode that the current best evidence is really on tapping into neuroplasticity through high repetition, high intensity of salient tasks, and So even though I'm highlighting Synergy spasticity, keep in mind these are going to hopefully fade into the background in terms of overall treatment approaches. They're on the problem list, but we're not necessarily always emphasizing treatment. We're treating these in combination or as part of our overall treatment plan.
00:04:00
Speaker
Okay, with that kind of background in place, let's talk about synergies. If you recall, or if you listened to episode one, when I talked about theories of motor learning, we talked about dynamic systems theory. And there in dynamic systems theory, we talked about synergies.
00:04:18
Speaker
And these are groups of muscles or muscles working together during movement. When we have purposeful movements, we're directing movement towards functional or skilled tasks. We're not isolating individual muscles and activating them one at a time sequentially throughout to get a movement. That's not efficient. That's not how we move.
00:04:38
Speaker
Instead, we have muscles that work in a coordinated fashion that work as a team to get the movement or the functional task completed. These are synergies. In an intact neurologic system, these synergies develop through practice and repetition, and we incorporate these synergies to help us efficiently complete skilled and purposeful
Abnormal Synergies and Movement Difficulties
00:04:58
Speaker
movements.
00:04:58
Speaker
Now, after stroke, we'll see the development of what are sometimes called abnormal synergies. Typically in neuro world, when you hear synergies without any prefix, Usually people are talking about abnormal synergies, but I did want to make that distinction here. All in this episode, call it abnormal synergy. But most times when you hear synergies, it's in relation to either stroke or brain injury and abnormal synergies. But I'll be calling it abnormal throughout this episode. These abnormal synergies start out as obligatory, meaning, for example, a patient can't perform an isolated movement of an upper extremity or at a lower extremity without producing movements in the rest of the limb. I'll use myself as an example. If I have an abnormal synergy, maybe I'm trying to flex my elbow.
00:05:45
Speaker
I'm trying to isolate that movement after stroke. but I can't, and so as I'm trying to bend my elbow, you may also be seeing that I'm flexing my shoulder, abducting my shoulder, maybe some rotation as well. So all I'm wanting to do is I'm trying to bring trying to bend my elbow, maybe I'm trying to bring some food to my mouth, but as I'm doing that, my shoulder is abducting, flexing, and my shoulder's rotating as well, so I'm not able to move in a smooth and coordinated fashion because I have this obligatory synergy. You'll see these abnormal synergies in the upper and lower extremities, and these will typically be described as flexion or extension synergy components. According to the O'Sullivan textbook, there are some stronger synergy components for the upper and lower extremity, and what we'll find is that these stronger components are tightly linked to spasticity. Now we haven't gotten to spasticity yet, we'll be talking about that in a bit, but I want you to kind of prepare or think, oh okay, these common spasticity or the stronger spasticity components are going to be linked to what we see as these kind of stronger or more dominant abnormal synergy aspects as well.
00:06:54
Speaker
The more common or the strongest upper extremity synergies are going to be elbow flexion, shoulder abduction, forearm pronation, In the lower extremity, the strongest are going to be hip flexion, hip adduction, knee extension, and ankle plantar flexion.
00:07:09
Speaker
This inability, so if we think again, abnormal synergies, obligatory movements, this inability to move out of a synergy pattern really interferes with movement, activities, and participation.
00:07:23
Speaker
And the reason I really wanted to hone in on the importance of synergies is because if you're not aware of them and if you're approaching the examination of someone who's had a stroke with more of an MSK or an ortho mindset and you see someone having difficulty moving, you may think, well, they're weak. Maybe you see someone having difficulty reaching with their arm to grab an item and you think, oh, they can't move because of weakness. I just need to strengthen.
00:07:48
Speaker
And there may be some component there where there's definitely going to be hemiparesis. And we'll see later that, yes, strengthening is probably part of what's needed.
Motor Recovery Stages and Spasticity
00:07:56
Speaker
However, if you're only seeing the movement challenges through the lens of existing as merely from a lack of force production or from weakness, you're really missing the big picture in not understanding that this is a central nervous system lesion, that part of the problem is these abnormal obligatory synergies that are impacting movement.
00:08:18
Speaker
So you really need to have a clear understanding of that as you're thinking about approaching your examination. Let's talk then a little bit about the stages of motor recovery. Brunstrom outlined six stages, later added a seven a seventh stage. So again, I mentioned, depending on the reference, you may see six or seven stages.
00:08:34
Speaker
Here I'm going to use six stages. That's what's used in the O'Sullivan textbook. That's what I typically teach from when I'm teaching neuro classes. And keep in mind, though, six or seven, it's going to be very similar. And any time that I'm learning and or teaching a scale that has five items, six items, seven items, whatever it is, I like to look for the anchors first. So I like to figure out, OK, what's at the top and what's at the bottom?
00:08:58
Speaker
And we can fill in the middle. And I'm going to do that here as I present the stages of motor recovery. So we start at one, which is right after having had a stroke, and we end at six. That's kind of the top end point. So our anchors are going to be stage one is initial stage flaccid.
00:09:18
Speaker
So that's that period of flaccidity, volitional movement. That's stage one. Stage six is going to be normal motor function and disappearance of spasticity. So if we think about it, we've got our anchors stage one, no volitional movement, low muscle tone, flaccid, stage six, back to normal function.
00:09:37
Speaker
As we move through then from stage one to stage two, in stage two, we're starting the recovery process. We're gonna start to see some synergies appear. We're getting some minimal voluntary movement, but here the movement is not, we're not capable of isolating joints. You may see a patient try and move, but they have to move the entire arm, or you see a big groups of movements happening. Other joints are coming in as the movement's trying to occur, so there's an inability to isolate individual joint motion.
00:10:08
Speaker
You're also not going to get full range here typically, so you're not seeing anti-gravity strength. And here, key point, we're also going to see the development of spasticity. And keep in mind, we're going to talk about spasticity here in a bit, but going to see spasticity developing. That would be stage two. Stage three, the patient's going to get some voluntary control of the movement synergies.
00:10:29
Speaker
Full range of all synergy components isn't necessarily developing. And here spasticity is probably going to peak. So here we've got an increase in spasticity, which is contributing to some of the synergies that we're seeing and some of the difficulties moving out of synergy.
00:10:45
Speaker
In many ways, you could almost see, if you looked at the stages, stage one to three, you've kind of climbed that initial mountain of recovery. We're starting to get some voluntary movement, can't move out of synergy, spasticity is increasing.
00:10:58
Speaker
Now once we get to stage four, we're starting to maybe come back down or we get some downhill speed coming in into stage four. In stage four, we're starting to be able to move a little bit out of synergy, first with difficulty and then a little bit easier.
00:11:14
Speaker
and spasticity is starting to decrease. So the synergy, the obligatory synergies are relaxing a little bit. Spasticity is starting to relax a little bit as well.
00:11:24
Speaker
Stage five, if progress continues, again, not everyone makes it all the way through all the stages. Patients have more ability to move out of synergies. They can master more difficult movement combinations. Basic limb synergies lose their dominance, and spasticity really continues to decrease tremendously.
Challenges in Stroke Movement Assessment
00:11:43
Speaker
Stage six would be normal motor control. Keep in mind, not everyone moves through all the stages. Not every person is going to be stepwise here, but I think this gives you a helpful framework as you go about looking at movement, analyzing what's happening.
00:11:56
Speaker
And I think especially this is helpful if you're coming and approaching the examination of someone who's had a stroke with an ortho or an MSK mindset. It gives you an idea of what actually could be happening instead that's causing movement difficulties.
00:12:11
Speaker
I'm probably harping on this because it's extremely common that I've encountered in the students I've worked with when I teach neurological courses that the students get wrapped up in the MSK ortho mindset and think everything is weakness.
00:12:24
Speaker
And you really do need to understand that when you see these synergies, this isn't weakness in terms of a unidirectional plane of motion, or it's not just a lack of force production, it's an inability to coordinate movement and overcome these abnormal synergies.
00:12:39
Speaker
And I can't stress this enough because, again, I've so seen so many students misunderstand some of these movement problems after stroke as existing purely as weakness or force production problems and then prescribing single joint strengthening exercises that are really doing nothing to tap into neuroplasticity, that are doing nothing to address the underlying movement problems. There are two outcome measures that I wanted to mention here that can be helpful in terms of assessing or contributing to our understanding of how someone is moving after stroke as it relates to synergies, and these are going to be the STREAM and the Fugelmeyer assessment.
00:13:16
Speaker
The STREAM is short for Stroke Rehabilitation Assessment of Movement, 30 items performance-based across three domains looking at upper extremity, lower extremity,
00:13:27
Speaker
and basic mobility items. The nice thing about the stream is it's relatively straightforward to administer, it gives you great information, and a quantitative measure of motor function.
00:13:38
Speaker
For movements, what you're essentially doing is looking at the range and quality of movement in the extremities compared to the unaffected side. For the mobility portion, you're looking at range, assistance required, quality of movement, and need for an external aid.
00:13:53
Speaker
This outcome measure is highly recommended by the Academy of Neurologic Physical Therapy Stroke Edge Task Force, and it's highly recommended across all settings and all acuity levels
Movement Assessment Tools: STREAM and Fugelmeyer
00:14:04
Speaker
for stroke. I've linked information about this outcome measure in the show notes, and I highly recommend you take a look at it because this can be a tool, or should be a tool, that's added to your examination toolkit for someone who's had a stroke. The other outcome measure I want to mention is the Fugelmayr Assessment of Motor Recovery After Stroke.
00:14:22
Speaker
This one is fantastic from a psychometric property perspective. The data you get is amazing. But here I'm going to be transparent and honest. Because the measure takes longer to administer, it's a big measure. My personal experience has been i see this utilized more in the research domain than in the clinical domain.
00:14:41
Speaker
I would say there's tremendous clinical utility in administering it, but as you kind of assess cost-benefit of time you have with the patient, I haven't seen many clinicians incorporate this as part of their standard assessment or examination.
00:14:55
Speaker
Again, this is highly recommended by the Stroke Edge Task Force across all settings and all acuity levels for stroke, so you should be familiar with this outcome measure, and I'll link it in the show notes as well. This outcome measures looking across five domains, motor function, sensory function, balance, joint range of motion, and joint pain.
00:15:13
Speaker
And what's really nice about the Fugelmeyer is it's looking at so many different areas, it gives you a very complete neurologic picture. We're looking at reflexes, looking at movement in synergy, movement out of synergy, mixed synergy movements, sensory
Evidence-Based Stroke Recovery Approaches
00:15:27
Speaker
integrity. So it gives us a lot of great information.
00:15:30
Speaker
Again, I've just seen the time constraints sometimes come in and be a bit of a limiting factor in using this clinically. We've talked then about synergies and hopefully you can conceptualize how if a patient is unable to move out of an obligatory synergy, that's going to impact their movement and function.
00:15:46
Speaker
I do, however, want to throw in a caveat. Back in 2021, Sheetz et al. published a position paper called Moving Forward, and that was somewhat of a call to action within neurologic physical therapy. And this call to action, really the take home message from this paper was that the best current evidence does not support traditional approaches which emphasize normalizing movement and stepwise progressions.
00:16:10
Speaker
And I know we're not talking treatment here, we're talking synergies and spasticity and thinking about our examination. But I did want to put this caveat in because as you're assessing synergy, i do want you to be able to identify synergies on the problem list.
00:16:25
Speaker
But once we start moving into treatment planning and thinking about treatment, I don't want us to make the potential mistake of overemphasizing treatment of synergies because what we'll see within central nervous system disorders that to really optimize neuroplasticity, we don't need perfect movement.
00:16:43
Speaker
We want to improve movement quality to a certain extent, perhaps, but we're going to emphasize function over quality of movement because that's where the evidence lives currently. And that's contentious within neurologic physical therapy. I'm being open and transparent here. There's a lot of heated debate, but I'm going to plant my flag on the side of best current evidence, and that's what I'm going to share on this show.
00:17:04
Speaker
And notice I'm saying current because I'm open to things changing. If studies come out, if new research is available that's saying that what we're doing now is incorrect and or needs to be modified, then so be it. But I'm going to continue to strive to present you with the best current evidence on this podcast.
00:17:22
Speaker
If and when I throw in my anecdotal opinions, I'll make sure you you understand that these are my opinions or these are anecdotal and not necessarily evidence-based. But if you're a student or a novice clinician, you may have clinical instructors or mentors or you may see people in the clinic that swear by certain traditional techniques or approaches that they say get good results.
00:17:43
Speaker
And I think there can be a lot of debate about that. We can have nuanced conversations. But again, according to our best current evidence, we should not be going down the path of optimizing perfect movement because then we're missing out on tapping into neuroplasticity. And that's really what we're after in terms of stroke recovery. rehab.
00:18:01
Speaker
So there's a couple key areas from the Sheetz paper that I want to call attention to as it relates to synergies. First is that facilitation of normal movement is not a prerequisite for optimal recovery in a neurologic population. I should say in the adult neurologic population. Now, it doesn't mean I don't want the movement to look smooth and efficient, but what I'm saying is that the way the movement looks does not need to be optimal for the best overall recovery. And we can actually hold patients back if we don't progress function and tasks that are salient to the person.
00:18:34
Speaker
So if we're overemphasizing quality of movement and underemphasizing function and tasks, we are inhibiting neuroplasticity. And again, I bring that up because I just talk
Understanding Spasticity in Upper Motor Neuron Syndrome
00:18:46
Speaker
synergies. And if you're looking at synergies thinking, hey, the movement's not looking normal.
00:18:51
Speaker
Yes, we're going to look at synergies. We're going to assess them. But keep in mind for our treatment planning, we don't need perfect movement if someone's had a stroke. Other thing I want to point out from the Sheetz paper is a stepwise approach is not supported by the evidence.
00:19:06
Speaker
There's occasions where we can do what's called leapfrogging, where we can go from one developmental position or we can go from thinking we need postural control towards actually jumping over that towards mobility.
00:19:19
Speaker
I bring that up because within functional movements, including synergies and abnormal synergies, many times in neuro, we think about getting stability and postural control before mobility. The key phrase is often proximal control before distal mobility. And that's a general okay rule of thumb, but it's not always needed when you branch this out into functional tasks. Sometimes you can leapfrog over things. So there's certain occasions where we don't necessarily need a stepwise approach.
00:19:47
Speaker
And so I wanted to bring up these caveats in there. Please don't hesitate to reach out to me if you have any questions about what I just said. Again, this is pretty contentious or an area of a lot of discussion within neurological physical therapy, but I think it's important to have these discussions.
00:20:09
Speaker
Having talked about synergies, let's now turn towards spasticity. And before I talk about spasticity, I want to put it into the context as existing as part of what's known as the upper motor neuron syndrome. The upper motor neuron originates in the motor cortex and brainstem, travels to synapse onto the lower motor neurons. The analogy I'll use here, and hopefully it'll work, is that the upper motor neuron is kind of the boss. The boss is in the office sending the message to the worker, to the lower motor neuron.
00:20:39
Speaker
Lower motor neuron then is ultimately is going to terminate right at the neuromuscular junction at the muscle and is going to get the movement actually happening. But the signal starts with the upper motor neuron. That's the boss.
00:20:52
Speaker
And so the boss is saying, here's what needs to happen. But in addition to sending out the messages about what needs to happen, the boss also sends out some influence or has influence on keeping things relaxed and calm.
00:21:06
Speaker
Without the boss, without the upper motor neuron, or if there's a disruption to the upper motor neuron, you're going to see things get more excitable. So we get this what's called descending central inhibition or descending inhibition.
00:21:20
Speaker
That's what the upper motor neuron is doing also in the background. So we're keeping things calm and relaxed. When the boss is out of the office, then without that descending inhibition, you're going to see hyperactivity throughout then the nervous system on the way down.
00:21:37
Speaker
One thing I learned early on when I was learning about upper motor neurons is if you have upper motor neuron syndrome, everything goes up. So we're going to have an up in terms of deep tendon reflex, essentially hyperreflexia.
00:21:49
Speaker
Deep tendon reflexes go up. We're going to see up in terms of primitive reflexes or those reflexes that we hopefully integrated early on. But maybe you see a return of the grasp reflexes or reflexes like that. You're also going to see up in terms of Babinski. Babinski, that great toe is going up. So you lose the upper motor neuron or you have upper motor neuron syndrome. You lose that descending inhibition and everything gets more excitable. We will see weakness as well with upper motor neuron syndromes.
00:22:22
Speaker
But it's going to be a little bit different than what we'd see in lower motor neuron because if we've had a stroke, the neuromuscular junction is intact. That random release of acetylcholine across the neuromuscular junction is still happening. So the muscle is essentially still getting fed, but we're having trouble moving because that initial signal coming down from the boss isn't really getting there.
00:22:43
Speaker
So when you look at a muscle in someone who has upper motor neuron disease, you're not going to see profound atrophy, at least not initially, like you would if it was a lower motor neuron condition, like if the nerve was
Defining Spasticity and Its Impact
00:22:54
Speaker
transected. Now over time, obviously with disuse of the muscles, if it's prolonged in upper motor or neuron syndrome, you'll start to see atrophy, but that takes much longer than what you'd see in a lower motor neuron condition.
00:23:06
Speaker
From a tone perspective, we're also going to see increased tone, where we're going to see that spasticity that we're going to highlight here in a bit. And really, spasticity is one of the hallmark findings of upper motor neuron syndrome.
00:23:18
Speaker
Spasticity, the textbook definition, is a velocity-dependent increase in muscle tone. What that means is if you stretch or passively move, let's say you're passively moving a patient's arm into flexion and extension at the elbow, the faster you move, the more resistance you're going to feel. It's velocity dependent.
00:23:36
Speaker
The other thing you'll typically notice too is that the resistance or the spasticity tends to be worse going in one direction. And spasticity is resulting from that disinhibition, that lack of central inhibition we talked about. The BOSS has gone away. There's a lack of descending inhibition of the spinal reflexes with the resulting hyperactive tonic stretch reflex. So essentially, you've got a hyperactive spinal stretch reflex or a failure of reciprocal inhibition.
00:24:03
Speaker
For our purposes, to summarize, if you want to make it simple, boss went away, everyone's stressed out. We're going to see that as hyper excitability, including spasticity.
00:24:14
Speaker
The faster we move it, the more resistance we're going to get because everyone's stressed out. So the faster movements stress everyone out, that makes the resistance worse when we're assessing for spasticity.
00:24:26
Speaker
And then some of the employees are more stressed than others, which is why it feels maybe harder moving the limb in one direction versus the other. Again, that was my boss work analogy. Hopefully that helps out a little bit.
00:24:37
Speaker
But that is spasticity kind of in a ah brief nutshell. In terms of components of spasticity, somewhat similar to synergies, they're stereotypical stronger components.
00:24:49
Speaker
And these stronger components correlate pretty well with the synergies we discussed earlier. In the upper extremity, the strongest spasticity components are going to be scapular retractor, shoulder adductors, depressors, internal rotators, elbow flexors, forearm pronators, wrist and finger flexors.
00:25:07
Speaker
The long list here, but essentially what you're going to see is probably what you can envision in your mind. You're going to see that that scapular retracts, pulls the arm against the body, the shoulder is adducted, depressed, internally rotated, so that arm is probably held close to the body. with the forearm pronated, wrist and fingers flexed. So it's a kind of a stereotypical position that you've probably seen. So that's the strongest spasticity components in the upper extremity. When you layer your on consideration of synergies onto that, you can imagine maybe the person's able to move the upper extremity a bit, but they're really not able to get out of that starting position because of those abnormal synergies and that spasticity, and or they're not able to isolate a joint movement. So they're in that starting position. They try and extend the elbow, but you're going to see them kind of abduct the shoulder a little bit and not really able to extend the wrist or extend the fingers. That's how you kind of see spasticity and abnormal synergies working together to constrain movement.
00:26:06
Speaker
At the lower extremity, the strongest spasticity components are going to be the pelvic retractors, hip adductors, internal rotators, the knee extensors, plantar flexors, supinators, and toe flexors.
00:26:19
Speaker
Again, this might be somewhat familiar to you if you can imagine someone whose leg looks long. They've got difficulty clearing the foot. They can't bend the knee. Maybe they have a little bit of a scissoring gait here because of the adduction.
00:26:30
Speaker
This is something that you see pretty commonly. It's a pretty stereotypical position that you'll see. And again, you've probably seen this. You see someone who maybe has a little bit of a scissoring gait, who has a long leg, essentially from a functional perspective, because you've got knee extension,
00:26:46
Speaker
ankle and plantar flexed, so maybe a challenge really while walking to not catch the toe, really a challenge to clear the leg and swing during walking. Again, we can see then spasticity contributes to abnormal synergies.
00:27:00
Speaker
Eventually, it could lead to posturing and really, I should say, abnormal posturing with potential contracture. So something we're worried about here absolutely would be the integumentary system, possible skin breakdown after contracture.
00:27:14
Speaker
We need to think about, well, if someone is in this position, in a prolonged position because of spasticity, we don't want a contracture. We also don't want them in that position so long that they're going to get skin breakdown. Another key point about spasticity is you may see the spasticity worsening with increased effort and stress.
00:27:32
Speaker
I've seen many patients as they're walking, they start to engage in increased effort. Maybe they start going up and down stairs, or they're really having to concentrate or focus.
Spasticity Examination and Treatment Goals
00:27:40
Speaker
You'll see that involved upper extremity start to abduct.
00:27:43
Speaker
You'll start to see the wrist flex more. You're seeing that increase in spasticity with effort, and that's just something to be aware of. And it makes sense because if we don't have enough descending inhibition, and now we're getting more cortical excitability, we're getting more of that spasticity coming through as well.
00:27:59
Speaker
In terms of our examination of spasticity, the Academy of Neurologic Physical Therapy, Stroke Edge, does recommend that students be exposed to two scales, the Modified Ashworth Scale and the TARDO Spasticity Scale.
00:28:14
Speaker
Keep in mind, though, that the inter-rater reliability on both of these is not excellent. So these are items that I would argue are probably useful for getting some clinical information,
00:28:25
Speaker
Not probably going to be great for research purposes in terms of tracking progress over time. Anecdotally, i think both are most valuable in looking at our anchors. Well, what's at the top and the bottom?
00:28:38
Speaker
Those areas in between can be a little more challenging. The Tardo is probably a little more reliable and it includes velocity components. But here we have that time or that cost-benefit trade-off again because the Tardo takes longer to administer.
00:28:54
Speaker
Clinically, I've seen more people use the modified Ashworth scale in clinical practice. I'll link both of them in the show notes. I'll just mention briefly here the modified Ashworth scale. Our anchors are going to be 0 and 5, so 0 is no increase in tone.
00:29:08
Speaker
5, the limb is completely rigid. and increasing up the scale is going to then be increasing rigidity or difficulty moving it, including at a one, there's going to be a little bit of an increase in tone, a slight catch and release, to then progressing further through with increasing difficulty passively moving the extremity.
00:29:27
Speaker
Now, what about treating spasticity? I'd really like you to consider, and again, this episode is not treatment focused, but I do want to start with, as that phrase goes, start with the end in mind. So I do want us to start considering, well, what would we do treatment-wise or so what about spasticity?
00:29:45
Speaker
I'd encourage you to really think about how is spasticity impacting the patient overall. And I would argue that it's very rare that purely treating spasticity should be our number one treatment goal.
00:29:58
Speaker
I don't think you're going to be setting goals for decreasing spasticity on a modified ashworth scale. I do think you're looking at treating spasticity along the lines of decreasing pain, preventing contractures, improving posture, improving sleep.
00:30:13
Speaker
I think those are very reasonable considerations where managing and or treating spasticity gets rolled into the overall plan of care. A 2024 scoping review found some good evidence for multiple treatment interventions, including stretching exercises, static stretching with positional orthosis, Botox injections, intrathecal baclofen, and there were multiple others, and I'll link that study in the show notes. I would like you to just be aware of all the different treatments that are available. Some of those will be ones that you may be implementing in therapy, and you may have others that you'll come across because your patient is receiving certain medical treatments for spasticity as well. You may be yourself wondering, well, should I then start a stretching program? I've identified my patient does have some spasticity.
00:30:58
Speaker
Should I be doing some static stretching with some positional orthosis? I think here you're really looking at opportunity costs throughout your treatment decisions, not only the time that you're spending on treating spasticity, but any potential trade-offs. Maybe if you're using an orthosis, is there a risk for potential skin breakdown?
00:31:17
Speaker
Is that offset by the potential benefits of avoiding contracture? Those are the types of things that you're continually assessing. Now, a few potentially hot takes on spasticity. Hot take number one, just because someone has spasticity doesn't mean it automatically needs to be treated.
00:31:33
Speaker
And I've been kind of beating that drum here for a while, saying you want to assess for spasticity, but put it on the problem list. It's not the number one driver or the number one thing that you have to treat.
00:31:44
Speaker
Now, if it's limiting function, if it's causing so much pain the person can't sleep, if it's impacting posture and therefore impacting the ability to be safe across functional tasks, then sure, treating spasticity absolutely gets folded into the treatment plan and perhaps emphasized a bit more.
00:31:59
Speaker
But just because someone has spasticity doesn't mean it needs to be treated. And in some cases, you may even find that a patient can use spasticity to their benefit in terms of completing some movements or functional tasks.
00:32:11
Speaker
The other potentially hot take, hot take number two, is that spastic muscle is weak. So even though we may think while the evidence says that stretching can be helpful for spasticity, keep in mind spastic muscle is weak.
00:32:26
Speaker
So we may need to find ways to include functional strengthening or ways to improve force capacity within spastic muscle as well. So don't make the mistake of thinking that spastic muscle is overly strong because it's not. It's actually still weak as well.
00:32:41
Speaker
But I'm going to call back to the Sheetz et al position paper moving forward as it relates to spasticity because there's some key points to make here. We previously talked about this position paper as it relates to synergies, and now I want to bring it forward as it relates to spasticity. A key point when looking at the evidence in neurologic physical therapy is that strength and coordination are the primary impairments that limit function. I'll repeat that. Strength and coordination are the primary impairments that limit function, not spasticity. And not spasticity was ah explicitly included within that.
00:33:14
Speaker
So the original statement is actually strength and coordination and not spasticity are primary impairments that limit function. That's kind of why I included hot take number two, that spastic muscles are weak, because the evidence here is saying that the ability to coordinate movements, the ability to produce force, are what's really needed to improve function. So I'm not saying don't treat spasticity.
00:33:37
Speaker
But the overemphasis on treating spasticity or trying to eliminate spasticity should not be a main treatment goal because it's not a prerequisite towards improving function in patients after stroke. Because what we'll see, that's what's really needed, and I'll be talking about this at length in future episodes, for recovery is tapping into neuroplasticity.
Neuroplasticity in Stroke Rehabilitation
00:33:59
Speaker
And this is heavily influenced by specificity, amount, and intensity of task practice. If we're so focused on treating synergies and spasticity in isolation, we are losing out on neuroplasticity because we're not focusing on the task practice that's needed. We don't need movements to be perfect.
00:34:20
Speaker
We don't need the complete elimination of spasticity. Now, be nice if spasticity wasn't a possible constraint or it wasn't impacting it. However, if we're putting all of our eggs in the basket of treating spasticity, we've just given up or we have not put enough effort into neuroplasticity.
00:34:37
Speaker
We need a ton of high-intensity practice that's relevant and important to the patient for neuroplasticity. With that in mind then, and I feel like I've made this point repeatedly, kind of playing the repeating game here, i would advocate that as you're examining a patient after stroke,
00:34:52
Speaker
You identify spasticity, you assess it. Spasticity goes on the problem list, but let's put it in the background. Functional movement and accessing neuroplasticity should be in the foreground in terms of our treatment planning. To summarize then, what we've outlined here is the importance of assessing abnormal synergies and spasticity. being aware that you're going to see both of these after stroke, so you're not going into your examination of someone who's had a stroke thinking, what is this? I don't even recognize what's happening here. And I realize, again, I've kind of made a case on both sides here.
00:35:26
Speaker
I've said it's important that we assess synergies, we assess spasticity, but we don't over-index them in terms of our treatment planning or our treatment emphasis. Being aware of how synergies and spasticity can impact movement is really going to help you in your treatment planning down the road because going have more tools in your toolkit other than just pure strengthening or even functional strengthening.
00:35:48
Speaker
You're going to have some motor control treatments in your toolkit, some practice schedule considerations that are going to help you to outline better treatment plans for your patient. And again, we're going to talk about treatment more in future episodes, but I'd like you to prepare yourself that the best current evidence suggests neuroplasticity is optimized by high repetitions of intense and salient practice.
00:36:11
Speaker
Therefore, treating spasticity, and I put treating in air quotes, and facilitating normal, and I put normal in air quotes, facilitating normal movement should not be the emphasis of treatment.
Conclusion and Future Discussions
00:36:22
Speaker
We're identifying synergies, identifying spasticity, assessing them both, and putting them in the problem list bucket so we can address them within a comprehensive treatment plan. Thanks for listening to the NeuroPowerHour.
00:36:36
Speaker
I'm your host, Dr. Michael Powers, and I hope to catch you next time to continue learning.