Transcript Therapeutic Strategies to Prevent Tissue Shortening and

Therapeutic Strategies to Prevent
Tissue Shortening and
Cardiopulmonary Deconditioning
Ms. Mary Grace M. Jordan, PTRP
PT 154: Therapeutic Exercise III
December 10, 2009
Learning objectives…
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Discuss the effects on motor function
of length-associated changes
occurring in muscles as a result of
immobility following neurological
impairments.
Discuss strategies to avoid muscle
shortening and joint stiffness in
conscious and unconscious patients.
Learning objectives…
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Discuss underlying cardiorespiratory
complications following neurological
impairments.
Discuss common problems,
therapeutic interventions and their
effects on pulmonary, cardiovascular,
and neurological status.
Keeping the Musculoskeletal
System Flexible
Adaptation to immobility
Effects to function
Strategies for prevention
Anticipating…
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Secondary
musculoskeletal
complications are
common sequelae
of neurological
impairments.
In order to avoid,
the therapist must
anticipate!
What happened?
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Immobilization → sarcomere loss →
muscle adapts to new length
Immobilization → relative increase in
muscle connective tissue (collagen) →
lose extensibility → stiffness
Normal motor function will not be
possible in the presence of muscle
contractures.
Adaptation to Immobility
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Muscle immobilized in a
shortened position →
lose 40% of sarcomeres
Muscle immobilized in a
lengthened position →
produce 25% more
sarcomeres
Effects of Adaptation to
Function
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Both passive and active muscle properties
are affected
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Passive: alteration of length and stiffness →
muscles become short and stiff → loss of
joint ROM → difficulty performance of tasks
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Active: alteration of peak active tension
generation → difficulty performance of tasks
Factors contributing to
changes in muscle length
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Decreased muscle activity and joint movement
leads to adaptive anatomical, mechanical and
functional changes in the neuromuscular
system
Changes to muscle resulting from weakness
and disuse include altered muscle fibre type
and length. atrophy and altered metabolism.
Functional sequelae are increased stiffness and
weakness, decreased endurance and fitness
Factors contributing to
changes in muscle length
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Increased muscle stiffness is a major
contributor to resistance to passive
movement and a major cause of
disability
Adaptive motor patterns reflect muscle
weakness, imbalance, stiffness and
length
Factors contributing to
changes in muscle length
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Patient unable to move due to neurological
insult or degenerative neurological disease.
Environmental factors
Patient was ineffectively immobilized as a
result of paralysis.
Activities are done by staff/caregivers.
Training that takes no account of
biomechanical factors
Spasticity
Strategies for Preserving
Muscle Length and
Connective Tissue Flexibility
ROM exercises
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Active
Active-assisted
Passive
Performed through the
patient’s full available
range
Movements should be
slow and rhythmic
within the patient’s
tolerance.
Passive range of motion
Exercises
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To prevent development of
contractures in unconscious
patients
May be detrimental when
carried out too vigorously.
PROMEs performed in the
presence of spasticity may
activate the hyperactive
stretch reflex.
Continuous Passive Range of
Motion
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Machine
Preset range of motion
Vigorous movements at
the end of range can be
avoided
Hyperactive stretch reflex
avoided
Availability
PNF
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Rhythmic initiation
ROM exercises
administered in
diagonal patterns
Throughout a limb,
combining motions
at more than one
joint.
Stretching Techniques
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Application of manual or
mechanical force to
elongate structures that
have adaptively
shortened and are
hypomobile.
Static stretching
Facilitated stretching
Changes in Body Positions
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Provides an
opportunity to change
individual joint
positions…altering
muscle length
temporarily.
Bed mobility exercises
Transition exercises
STS exercises
Prescription…
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Prolonged passive stretching (15-30 min)
via positioning during the day if a limb
cannot be actively moved, to prevent
predictable muscle shortening and stiffness.
Muscles: plantarflexors, shoulder adductors,
internal rotators, elbow flexors, forearm
pronators, thumb adductors, long finger
flexors.
Prescription…
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Perform short (20 s) stretch to a stiff
muscle(s), done manually by patient or
therapist, just prior to and during
exercise, can have the effect of
preconditioning the muscle(s) through
stress relaxation and decreasing stiffness
.
(Vattanasilp et al. 2000)
Prescription…
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Prolonged stretch to contracted soft tissues
using serial casting, combined with exercise
and training carried out while casting is in
place, with follow-up exercise and training to
prevent or correct length changes. (Moseley 1997)
Negative effect: promotion of learned non-use
Splint worn at night may be useful for those
who do not regain active use of the hand.
Keeping the brain and the
body oxygenated
Cardiopulmonary deconditioning
Therapeutic interventions
Premise…
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Cardiovascular limitations lower exercise
tolerance to work capacity.
Sedentary life-style leads to a further
decline in muscle strength and
cardiovascular fitness.
Complaints of fatigue attributed to
disease process are equally likely to be
due to the demonstrably low levels of
aerobic fitness and endurance.
Patients with stroke…
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Have less energy, and experience increased
social isolation and emotional distress when
compared with individuals of a similar age
Reduced functional capacity after stroke is
therefore likely to be due to reduction in the
number of motor units recruitable during
dynamic exercise, reduced oxidative capacity
of weak muscles and low endurance,
compounded in some individuals by the
presence of co-morbid coronary artery disease
and physical inactivity.
Patients with stroke…
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are physically deconditioned because
aerobic exercise is not routinely
prescribed for stroke patients, either early
in rehabilitation or after discharge
Therapists have restricted any activities
involving intensive effort, in part because
of a belief that effort increases spasticity,
in part because many patients are elderly.
However, according to
available evidence…
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Effort applied in exercise does not
increase spasticity or muscle stiffness.
Elderly individuals are capable of
increasing their cardiovascular fitness,
and improving lifestyle and selfefficacy, with moderately vigorous
exercise
Aerobic exercise…
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has the potential to minimize
secondary effects on muscle fiber
transformation by enhancing motor
unit recruitment and favoring
development of high oxidative fibers
(Potempa et al. 1996).
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may increase endurance capacity and
minimize symptoms of cardiovascular
disease
(Hamm and Leon 1994).
Control of breathing
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Brain as the main
center of control of
breathing
Brain depends on
the lungs for its
supply of oxygen
and elimination of
carbon dioxide
Factors affecting lung function
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Direct damage to
the respiratory
centers
Associated factors
affecting lung
function
Pre-existing factors
Prolonged rest
Common respiratory problems
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Impaired mucociliary clearance
Hypoventilation
V/Q mismatching
hyperventilation
Impaired mucociliary
clearance
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ACBT
AD
Postural drainage
Coughing
techniques
Manual techniques
Suction
Tracheal tickle
Hypoventilation
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Breathing
exercises
Incentive
spirometry
Chest mobility
exercises
Hyperventilation
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Relaxation
techniques
Brown bag
Breathing exercise
V/Q mismatching
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Sitting and
standing
Breathing
exercises
Fitness for Deconditioning
Prevention
Regaining upright posture
Progressive increase in activity
Fitness classes
Physical conditioning
programs
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Recent studies have shown the
benefits of physical conditioning
programmes following stroke,
including improvements in both
aerobic capacity and functional
abilities (Potempa et al. 1995, 1996, Macko et al. 1997,
Teixeira-Salmela et al. 1999).
Aerobic training…
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Supervised aerobic training programs have
been shown to improve V02max, with the
improvement significantly related to
improvements in motor function (Potempa et al.
1995).
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The evidence so far suggests that aerobic
exercise on a bicycle ergometer, treadmill
walking or with graded walking significantly
improves physical fitness when individuals
are tested on the training exercise.
Aerobic training…
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may improve endurance and functional
ability and have the following
physiological benefits:
• increased work capacity
• decreased resting and sub-maximal heart rates and blood
pressure
• weight loss
• improved lipoprotein profile
• decreased platelet aggregation
• delay in onset of angina.
Prescription…
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Initially patients train at a workload
equivalent of 40-60% of V02max
progressing up to 30 min, 3
times/week.
When 30 min is reached, intensity is
progressively increased to the highest
workload tolerable without symptoms.
10 min warm-up and cool-down
Fitness Programs
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Aerobic exercises
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Warm up : 5 -10 minutes
Exercise proper : 20 - 40 minutes
Cool down: 5 – 10 minutes
Strengthening exercises
Flexibility exercises
Calisthenics
Pediatrics
Fitness class for pedia
Play…Play…Play!
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Blowing bubbles
Incentive
spirometry
Wind musical
instruments
Pin-wheel
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Fitness classes
Aerobic exercises
Strengthening
exercises
Flexibility exercises
AGMS
Be imaginative and creative!
Other Evidence?
Static vs Cyclic stretching
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Ankle joint stiffness decreases after both
prolonged static and cyclic stretches
However, neither technique appears to be
better at reducing stiffness in people with
stroke.
Torque relaxation is greater after static
stretching than after cyclic stretching, and
walking speed does not appear to be
influenced by the stretching treatments.
(Bressel & McNair, 2002)
Reference:
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Ada, L & Canning, C. (1990). Anticipating and
avoiding muscle shortening. In Ada, L & Canning,
C. (eds), Physiotherapy: Foundations for practice.
Key issues in neurological physiotherapy. London:
Butterworth-Heinemann Ltd.
Ada, L & Canning, C. (1990). Care of the
unconscious head-injured patients. In Ada, L &
Canning, C. (eds), Physiotherapy: Foundations for
practice. Key issues in neurological physiotherapy.
London: Butterworth-Heinemann Ltd.
Thank you and Good day!