aha spasticity and hypertonicity - clinical...

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TheUnrelen.ngMispercep.onsofSpas.cityandHypertonicity:ClinicalApplica.on

BethFisher,PT,PhD,FAPTARyanFrendewey,PT,DPT,NCSJosephRobinson,PT,DPT,NCS

AHA,Inc.Interna.onalConference"PiecingTogetherOurFuture"

Hilton,FortCollins,ColoradoMarch9th-11th,2017

OutlineforToday’sPresenta.on

•  Clinicalmanagement:amovementre-educa.onperspec.veversusaspas.city/toneperspec.ve

Whatistheproblem?

•  Spas.cityandhypertonicityerroneouslylinkedtovoluntarymovementcapability

•  Spas.cityandhypertonicityusedsynonymously•  Theissuesremainintheforefrontofourclinicalconversa.ons

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TheEvidenceThereisnoconvincingevidencethathypertoniaorspas.cityinterferewithvoli.onalmovement

Time To Move Forward

“So,Iignorehypertoniaandspas3cityandmaintainjointmobility...That’sit?”

ClinicalApplica.on:MovementAssessment&Re-educa.on

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Objec.ves

•  U.lizeamorecontemporaryandevidence-basedframeworkformanagingthepa.entwithmovementdysfunc.on

•  Discussmovementdevia.onswithaccuratedescriptorsthathelpguidefurthermovementassessment

“Theilliterateofthetwenty-firstcenturywillnotbethosewhocannotreadandwrite,butthosewhocannotlearn,

unlearnandre-learn.”–AlvinTofflerIftheevidenceconsistentlydemonstratesthatspas.cityandhypertonicityarenotthedirectcauseofmovementdysfunc.on,whydowepersistinassessmentandinterven.on

oftheseimpairmentswithrela.ontomovementdysfunc.on?

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Historical

Assessments

Condi.onsthatPromoteChange

1.  Currentapproachesarenotadequatetosolveclinicalproblemsperceivedbytherapists.

2.  Theore.calassump.onsunderlyingcurrentapproachesdonotfitcurrentknowledge.

Gordon,JG.Assump.onsUnderlyingPhysicalTherapyInterven.on_2ndEd

Gordon,2000

Pa.ent’sGoal

PhysicalExam

Spas.city

Hypertonicity

MovementAnalysis

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Wernicke-MannSyndromeApostureanomalywithpar.alhemiplegiaoftheextremi.escharacterizedbytypicalpostureandgaitdisorders.Thehandandfingerisheldadducedwiththelowerarmedflexed,thelegisstretchedwithplantarflexionofthefoot,sothatitmovesinacurvedway.Itiscausedbylesionsofthecentralnervoussystemresul.ngincontralateralspas9cparalysisofthemusclesofupperandlowerlimbsandface.hhp://www.whonamedit.com/synd.cfm/899.html

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MovementAssessmentGoal

MovementDiscovery

“Don’tDoThat”

ChangeDemand

Devia9onIsola9on

Tac9leCueing

ModifiedTask

ImpairmentMi9ga9on

Physical,environmental,orcogni.veconstraintsthatmaymaskcapability

ImproveROMand/orstrengthtomeetrequirementsofmovementgoal

Manualfacilita.onthatmodifiesperformancebyreducingcompensa.onorimprovingperformance

Anewtaskthatputstheemphasisonakeydevia.onseenintheprimarytask

Quickverbalfeedbacktoseeifthepa.entcanreduceagivencompensa.on

Keydevia.onisisolatedandtakenoutoffunc.onalcontext

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“Puttheringonthepole”

“Keepyourbackagainstthechairnext.me”

“Don’tDoThat”

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Historical:Kneeextensorandplantarflexorspas.cityorhypertonicitylimitsherabilitytostand

Proposed:Decreasedanteriorweightshimtofeetlimitshercapacitytoperformtask.

ChangeDemand

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Historical:Spas.cityorHypertonicityofthekneeextensorsorplantarflexorsdrivesthekneeintoearlyextensionProposed:Posi.onofthegroundreac.onforceanteriortothekneejointpromotesakneeextensionmoment.

Devia9onIsola9on

ChangeDemand

ImpairmentMi9ga9on

PREPOST

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Historical:Elbowflexorhypertonicityand/orspas.citylimitselbowextension

Proposed:Ini.ateswithscapulareleva.onbecausethephysicaldemandofthetaskismaskinghiscapacity

Devia9onIsola9on

SecondaryTask

ChangeDemand

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SecondaryTask

ChangeDemand

Devia9onIsola9on

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ChangeDemand

SecondaryTask

ChangeDemand

Devia9onIsola9on

ImpairmentMi9ga9on

“Don’tDoThat”

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Researchers

Academia

CliniciansPa.ents

Summary

#CSMNeuro#Mispercep.onCSM

“Weneedtoteachourselvestheanaly3calskillsnecessaryformakingasophis3catedbiomechanicalandfunc3onalevalua3onofourpa3ents’movementdisorders.”-JamesGordon,2000

Iftheevidenceconsistentlydemonstratesthatspas.cityand

hypertonicityarenotthedirectcauseofmovementdysfunc.on,whydowe

persistinassessmentandinterven.onoftheseimpairmentswithrela.onto

movementdysfunc.on?

#CSMNeuro#Mispercep.onCSM