Aquatic Spasticity Inhibition

Julia Meno Fettig, CTRS, CMT, ATRIC

Therapeutic Aquatics, Inc.

julia@aquatictherapyinfo.com

jmeno@wyoming.com

208-709-5326

Definition:

Spasticity is a form of muscle over-activity. A spastic muscle is one in which a muscle resists being stretched out, and the resistance to stretch is greater the faster the muscle is moved.1 Spasticity is a motor disorder characterized by a velocity-dependent increase in tonic stretch reflexes with exaggerated tendon jerks, resulting from hyper-excitability of the stretch reflex.2

Etiologies:

            •          Damage to upper motor neurons

            •          CVA

            •          MS

            •          CP

            •          Anoxia

            •          TBI

            •          SCI

            •          Neurodegenerative disorders

            •          Infection

Pathophysiology:

            •          Not completely understood

            •          Increase in deep tendon reflex

            •          Abnormal descending pathways

            •          Alterations within the reflex arc

            •          Plastic rearrangement of spinal circuitry

Symptoms:

            •          Spastic dystonia

            •          Spastic co-contraction

            •          Extra-segmental co-contraction

            •          Abnormal cutaneous reflexes

            •          Muscle over-activity with yawning, breathing, etc.

            •          Muscle shortening

            •          Motor weakness

Treatments:

            •          Rehabilitation, PT, OT, TR, Speech, Social

            •          Orthoses

            •          Oral medications

            •          Injection therapy

            •          Intrathecal baclofen ITB

            •          Chemodenervation

            •          Neurosurgery

            •          Orthopedic surgery

        Types/Patterns of Spasticity: (See Overhead Diagrams)

            •          Upper Extremities, mild, moderate, severe

            •          Lower Extremities, mild, moderate, severe

Assess for Treatment:

            •          The amount of spasticity in each limb

            •          The impact of changing spasticity on function

            •          The degree of weakness

            •          The impact of weakness on function

Treatment Goals (vary depending on the individual& level of involvement)

            •          Increase ROM

            •          Improve mobility and strength

            •          Decrease Pain

            •          Increase Endurance & Cardio Fitness

            •          Improve Proprioception

            •          Improve Gait & Fall Prevention

            •          Decrease Energy Expenditure

            •          Decrease Spasm Frequency

            •          Improve Self Esteem

Aquatic Factors to Consider for Safety for Individuals with Spasticity

(Reduce all internal and external factors that can exasperate spasticity)

            •          Extreme changes in temperature

            •          Loud noises

            •          Irritants

            •          Tight fitting suit or aqua shoes

            •          Introduction to hydrostatic pressure

            •          Quick movements during transfers

            •          Placement and use of aquatic equipment

            •          Contact with pool floor and walls, benches, jets, stairs, ladders, railings

            •          Velocity of movements

            •          Turbulence

            •          Fatigue

Pre-Aquatic Therapy Assessment

 (Re-evaluate client following set # of aquatic treatments)

            •          Proprioceptive skills- sensory, balance, coordination

            •          Motor skills- functional mobility assessment

            •          ROM & Posture– specific musculoskeltal assessment

            •          Spasmodic Activity- muscle involvement, focal or diffuse, frequency, degree, chronic vs. acute

            •          Reflexes – deep tendon response, primitive, developmental

            •          Cognition- comprehension of activity/environment, decision-making, etc.

            •          Communication skills- must have established communication plan

            •          Pharmacology – medications that could interact adversely with water based activity

            •          Assistive Care and/or Services/Equipment

 Manual Treatments for Spasticity that are utilized in Aquatic Therapy Applications

            •          Soft Tissue Mobilization

            •          Joint Mobilization

            •          Deep Tissue Massage

            •          Fascia's Release

            •          Trigger Point Therapy

            •          Joint Approximation

            •          Joint Distraction

            •          Cardiovascular Training

            •          Compression

            •          Stroking

            •          Vibration

            •          Stretching

            •          Breath Awareness

            •          Positional Cuing

            •          Exercises, active-assist, active, resisted

            •          Strengthening – isometric, isotonic, isokinetic

            •          PNF proprioceptive neuromuscular facilitation patterns

 Spasticity Specific Aquatic Therapy Accommodations

            •          Slow rhythmical movement with rotational components.

            •          Slow sustained stretch, minimize frictional resistance and turbulence.

            •          Stop stretch movement 5 degrees before spasm initiation, gently repeat.

            •          Gradual release of agonist - antagonist using slow reversals and rhythmic

                       initiation PNF patterns.

            •          Passive figure 8 patterns to reduce muscle tone and inhibit co-contractions.

            •          Utilize water assistive and supported activities for active stabilization and functional

                        use activities.

            •          Aquatic equipment selection to: maximize relaxation, for stabilization, or to facilitate

                        a neuromuscular response.

            •          Easy reciprocal active/ assisted open chain movements.

            •          Applications of tactile cuing and movement assistance using: compression, stroking,

                                    tapping, jamming, vibration, turbulence into or from body segment.

  Pool Lab:

            •          Halliwick introduction to inhibitory/facilitatory philosophy- practice altered body positions in water adjustment, disengagement and changing directions through the transverse plane.

            •          Select Myofascial Aquatic techniques used for decreasing muscle tone and increasing pain free ROM. (See Myofascial Aquatics course notes for specific applications and treatment description).

            •          PNF upper and lower extremity patterns utilizing rhythmic initiation and rhythmic stabilization.

            •          Select Bad Ragaz treatment patterns and their specific applications to reduce muscle tone, elongate

                        shortened musculature, and inhibit muscle over-activity during active movements. Demonstration of

                        an isokinetic closed chain exercises to facilitate co-ordination and timing of movement patterns.

            •          Introduction to beginning Ai Chi Postures to engage active participation while practicing internal

                        regulation of spastic triggers.

            •          Conclude with modified Water Exercises and Adapted Aquatics to practice active movement and

                        improve cardiovascular fitness.

Reference Assessment Tools

Aquatic

“Aquatic Therapy Assessment” by Carter, Dolan LeConey, 1994

“Assessment Forms”, Lepore, Gayle, Stevens, “Adapted Aquatics Programming”, Appendix B, 1998

“Diagnostic Aquatics Systems Integration – Pre-Aquatic Therapy Assessment” Vargas, Ph.D., P.T. Aquatic Therapy Interventions and Applications, 2004

Spasticity

Spasticity Examination Rating Scale and Office Data Form, Brin MF, Albany KA 1991

Modified Ashworth Scale

Oswestry Scale

Tardieu Scale

Bibliography

 Chaitow N.D., D.O., Leon.  Soft-Tissue Manipulation, A Practitioners Guide to the Diagnosis and Treatment of Soft Tissue Dysfunction and Reflex Activity. Healing Arts Press. 1988

Meno-Fettig, CTRS, ATRIC. “Bad Ragaz Ring Method, An Introduction - A Visual Instructional Manual” Therapeutic Aquatics, Inc. (2002)

Sova, Ruth, “Aquatics – The Complete Reference Guide for Aquatic Fitness Professionals” Jones & Bartlett

Publishers (1992)

Vargas, Ph.D., P.T.”Aquatic Therapy Interventions and Applications” Idyll Arbor, Inc. (2004)

Case-Smith, EdD, OTR/L, FAOTA “Occupational Therapy for Children,” Forth Edition. Mosby (2001)

Stanborough, Michael. “Direct Release Myofascial Technique, An Illustrated Guide For Practitioners” Churchill Livingstone, 2004

Lepore, Gayle,  and Stevens, “Adapted Aquatics, Programming, A Professional Guide, Human Kinetics (1998)

Enoka, R. "Neuromechanical Basis of Kinesiology" 2 ed.  Human Kinetics (1988)

Campion, M. R.  (1990). Adult Hydrotherapy a Practical Approach. England: Heinemann Medical Books

Ratliffe, M.A., P.T.  (1998). Clinical Pediatric Physical Therapy: A Guide Fot the Physical Therapy Team. Mosby,

Umphred, PhD., P.T.  (1995).    Neurological Rehabilitation (3^rd Ed.).    Mosby, Inc.

Internet Sources:

mdvu.org, Movement Disorder Virtual University, We Move, 2008

Answers.com/spasticity defintion