Spasticity so-called myotonia is the resistance that occurs when a part of the body is moved passively, or when a muscle contracts, causing muscle stretching and relaxation in the opposite direction to the activity. Normal muscle tone is an activity that is felt with proper resistance during movement, and the process of movement is not impeded and is performed in flexibility. Hypotonia, or flaccidity, is a passive activity in which there is little or no resistance and the limbs lose their inherent flexibility and tension. When the passive support is removed, the limb loses control due to gravity.
Hypertonia, or spasticity, is a condition that produces an excessive sense of resistance during passive activity; this resistance is more extensive and produces a feeling of heaviness in the limb. When external forces are released to support the limb, the limb is controlled by the pull of the spastic muscle groups. Spasticity is a tense reflex activity, caused by a state of disinhibition, which often occurs in a fixed pattern and thus constitutes a specific profile for patients with hemiplegia and is the most important cause of the patient’s motor function. A common spasticity pattern in patients with hemiplegia is characterized by hyperflexia of the upper limbs and hyperactivity of the lower limb extensors, which is graphically represented in a line drawing in an American book.
Specific manifestations.
Head: flexion to the affected side, face turned to the healthy side.
Trunk: flexion to the affected side and rotation to the posterior side.
Upper extremity pelvis: elevation to the affected side and rotation to the posterior side.
Scapular girdle: posteriorly withdrawn and sunken. Lower extremity
Shoulder joint: internal retraction, internal rotation. Hip joint: extension, internal retraction, internal rotation.
Elbow joint: flexion. Knee joint: extension.
Forearm: anterior rotation. Ankle joint: scapular plantarflexion, internal rotation.
Wrist: palmar flexion, ulnar deviation. Toes: flexion, pronation.
Fingers: flexion, pronation.
In fact, spasticity is not a stereotypical irreversible motor characteristic, but develops through interaction with the environment as a result of reinforcement of abnormal activity. As such, it is a response that can be controlled through treatment.
Bobath used the following six points to form the basis of training to control spasticity.
1. Application of antispastic limb position.
2. Weight-bearing on the affected side.
3, trunk rotation.
4.Extension of the upper limb on the affected side.
5.Shoulder extension forward.
It can be designed to be applied with good results no matter what period the patient is in.
The joint reaction was defined by Riddoch and Buzzard in 1921 and Brunnstrom in 1970 as “an abnormal change in the movement of a part of the body or a greater range of motion or postural fixation when a part of the body is moved as a result of random force or reflex stimulation”. The joint response is an abnormal reflex activity on the affected side. Often this motor pattern is enhanced by spasticity. walshe back noted that “the joint response disrupts casual control and is a postural response that is liberated from inhibition.” This response often occurs when the patient yawns, coughs, sneezes, or struggles to complete a movement, maintain balance, and during the fear of an impending fall.
The joint response is elicited when the limb loses motor function and is not altered by volitional control.
Joint reaction has the following adverse effects on hemiplegic patients.
1. The joint reaction aggravates the spasticity of upper and lower limbs in hemiplegic patients, and the limbs are forced in a fixed limb position to complete the functionally required movements. For example, plantar flexion and inversion of the ankle joint and extension of the lower limb when putting on shoes lead to the inability to complete the movement of putting on shoes. Patients who make an effort to do so will further strengthen the extensor spasm.
2.If the upper limb is often in flexion position, it will lead to joint contracture and affect the improvement of upper limb function.
3.The joint reflects to affect the balance response of the upper and lower limbs, causing the balance dysfunction of the whole body.
4, aggravate the twin contracture, affecting the improvement of motor function.
Compensatory action compensation is to counteract the abnormal state of the deficit by another part of the larger activity. Due to the loss or low function of one limb, patients with hemiplegia use the random movement of the healthy side to achieve functional goals thus forming compensatory movements.
The development of compensatory movements has the following effects on the motor function of hemiplegic patients.
1. Asymmetrical movements.
2. Shift of the center of gravity to the healthy side.
3. Decreased ability to shift the center of gravity.
4. Decreased stability.
5. Abnormal sensation of shifting the midline of the body to the healthy side.
6.Balance reflection is inhibited.
7. Further decrease in motor function.
The patient’s compensatory movement from sitting to standing position begins with the shift of the body’s center of gravity to the healthy side, and the original symmetrical movement of the trunk and bilateral lower limbs is destroyed. The stability of movements performed only by the healthy side is reduced. The normal balance response to inhibition, this asymmetrical movement formation, although it can accomplish the purpose of movement from sitting to standing, can lead to the replacement of movements that the patient can master with training, by abnormal movement patterns, thus greatly reducing the patient’s motor function.
The compensatory action of walking is to shift the body weight toward the healthy side, so that the midline of the body is skewed toward the healthy side, and the body weight cannot be adequately shifted toward the affected side even when the affected lower extremity is in the support phase. This results in a significant shortening of the support phase on the affected side and a rapid completion of the swing phase movement on the healthy side of the lower extremity, resulting in poor body stability, abnormal gait, and further impairment of motor function.
Substitution can lead to greater loss of function than the initial injury. Therefore, in the rehabilitation of hemiplegic patients, attention should be paid to the prevention of compensatory movements and training using normal movement patterns to the maximum extent possible.
Upper limb joint band movement Joint band movement is a pathological abnormal movement pattern. When the motor function of upper and lower limbs of hemiplegic patients enters the spastic phase from the flaccid phase, random movements can appear, but the movement pattern at this time is qualitatively different from the normal random movements. The upper limbs are divided into two types, namely upper limb flexor band movements and upper limb extensor band movements. This abnormal movement pattern develops gradually and reaches a peak when it enters the joint-band movement stage. As the movement of the upper extremity is bound by the above two pathological and stereotyped movement patterns, it seriously affects the emergence of applied movements and should be suppressed through training.
Examples of the effects of upper extremity joint band movements on the motor function of patients are as follows.
1. Due to the effect of upper limb flexor joint band movement, shoulder joint flexion is accompanied by abduction and external rotation, so there is difficulty in hand-molded head, resulting in the inability to complete combing hair, washing face, brushing teeth and all other movements that need to be accompanied by internal retraction and internal rotation when the upper limb is raised.
2.As the shoulder joint flexion is accompanied by the elbow joint flexion and front shoulder rotation, so when the upper limb is extended forward, the elbow joint cannot be extended, and the movement of picking up objects in all directions cannot be completed.
3. The flexor band movement of the upper limb causes palmar flexion of the wrist joint and flexion of the fingers, so the function of picking up objects is lost.
4.When the upper limb is extended, the elbow joint cannot be flexed because it is bound by the flexor band movement, so the patient loses all daily life movements that require shoulder extension and elbow flexion, such as putting on pants, bathing, going to the toilet, and touching the back.
Therefore, upper extremity flexor joint band movements and extensor joint band movements are pathological movements, which are abnormal patterns that seriously affect the completion of applied movements in patients, and if they are not effectively suppressed, the appearance of applied movements in the upper extremity is impossible.
Lower extremity joint band movement is divided into two types of lower extremity extensor joint band movement and lower extremity flexor joint band movement, because the lower extremity movement is bound by these two fixed, pathological movement patterns, which seriously affect the patient’s gait and the completion of the lower extremity application movements. Selective movement of multiple movement patterns in random combinations.
Examples of the effects of lower extremity joint band movements on patients’ motor functions are as follows.
1. Due to the influence of lower limb flexor joint band movements, hip flexion is accompanied by abduction and external rotation, so when the patient lifts the leg, the lower limb must be skewed outward, affecting gait.
2. Due to the influence of the lower limb extensor band movement, the knee joint cannot complete the flexion when the hip joint is extended, and the ankle joint appears plantarflexion and inversion, so the patient feels difficulty in stepping and has to tilt the pelvis to the healthy side and draw the affected lower limb in a circle, resulting in an abnormal gait.
3. Since the hip joint extends and the ankle joint appears plantarflexed and inwardly turned when standing, the patient cannot land on the ground with the whole foot, which affects the balance and stability of the body.
Tension labyrinth reflex The tension labyrinth reflex is caused by the change of the patient’s head position in space and is a reflex at the level of the brainstem. A positive reflex is normal until four months after birth, and should be suppressed after four months as the neurological reflexes progress.
The clinical features are: when the patient is in the supine position, the whole body extensor tone is increased, the spine is extended, the head is tilted back, the shoulder joints are retracted, and the limbs are extended; when the patient is in the prone position, the whole body flexor tone is increased, and if the patient is in a severe state of extensor spasm, the increased flexor tone is not obvious, then it is often expressed as a weakened extensor tension program.
Patients with hemiplegia are often affected by the tonic vagal reflex, which is manifested as follows.
1. If a wheelchair is used for a long time, the trunk is flexed and the head has to be lifted and the neck extended when looking around, resulting in increased tension in the extensor muscles of the lower limbs, hip extension, hip sliding forward, knee extension, and foot slipping off the tread, resulting in a semi-recumbent position in which the patient is asymmetrical from side to side.
2.When performing the turning action, due to neck extension, resulting in increased tension of the extensor muscles, one lower limb cannot complete the forward leaning action, making it difficult to complete turning.
3.When standing, the patient’s head extends backward with increased tension of the extensor muscles of the lower limbs, the shoulders and trunk extend backward, and the knee joint is hyperextended and cannot be flexed, plus the ankle joint is plantarflexed and turned inward, resulting in an abnormal movement pattern.
4. When walking, also due to the effect of extensor tone, lower extremity flexion is difficult, and the patient has difficulty taking steps forward.
Symmetrical Tension Neck ReflexThe symmetrical tension neck reflex, a reflex at the level of the brainstem, is elicited by flexion and extension of the neck muscles and joints. When the neck is extended upper extremity extensor tone is increased and lower extremity flexor tone is increased; when the neck is flexed lower extremity extensor tone is increased and upper extremity flexor tone is increased.
In normal development, this reflex should disappear after 6 months of life. In hemiplegic patients, due to the state of neurological disinhibition, this reflex is released, causing the following characteristics of the patient’s posture and movement.
1.When lying in bed in a semi-recumbent position, the head and trunk underneath The pillow is too high, or when riding in a wheelchair with the neck and trunk in a flexed position, the tension of the lower extremity extensors and upper extremity flexors on the affected side is increased.
2.When the patient sits up from the supine position, the movement is difficult to complete because of the increased tension of the extensor muscles of the lower extremity due to the head lifting action.
3.When walking, the patient looks down at the ground, resulting in increased tension in the extensor muscles of the lower extremity, the affected side supports the phase, the knee joint appears hyperextended, the ankle joint is plantar flexed and in contact with the ground, in swing relative, the hip and knee joints cannot be fully flexed. The upper extremity is in flexion, and the joint response is reinforced by the position of the head.
4.When the patient is transferred from bed to wheelchair, due to head raising, the upper limb is stretched to support the bed, resulting in increased flexor tone of the lower limb on the affected side, knee flexion, and the foot cannot land on the ground, making the affected side unable to bear weight.
5. When walking, due to head raising and neck extension, resulting in increased flexor tone of the lower limb, the affected limb cannot bear weight.
Asymmetric Tension Neck Reflex The asymmetric tension neck reflex, a reflex at the level of the brainstem, is elicited by the stretching of the neck muscles and joints. When the head is rotated, the tension of the extensor muscles of the upper and lower extremities is increased on the side facing the face; the tension of the flexor muscles of the upper and lower extremities is increased on the side facing the back of the head.
During normal development, this reflex should disappear after 6 months of life. Patients with hemiplegia are released for the same reasons as the symmetrical tension neck reflex, which has the following effects on their posture and movements.
1. When the patient extends the upper limb, he or she turns the face to the affected side with force. If the face is not turned to the affected side, the elbow joint cannot be extended.
2. In patients with upper limb flexor spasm, the elbow joint is often in a flexed position, but when the face is turned to the affected side, the elbow joint cannot complete the flexion movement. When eating, washing face, combing hair and other daily life actions, the affected upper limb is flexed and the face must be turned to the healthy side, which affects the completion of normal life actions.
3. Patients with hypotonia of the lower limbs often stand with their faces facing the affected side with assistance, so that the extension of the lower limbs is reinforced. This posture can affect the normal balance response and should be suppressed.
Positive support reflex The positive support reflex is when the uncinate of the toe and the skin of its medial bunion and little toe are stimulated, causing the interosseous muscles to extend and stimulating the proprioceptors resulting in increased extensor tone in the lower extremity. Patients with hemiplegia often have a positive response due to standing and pressure on the toes in contact with the ground. The reflex is normal for positive responses to appear in children 3 to 8 months after birth, and should be suppressed after 8 months as the neural reflexes develop. In patients with hemiplegia, if the primitive reflex is inhibited and released, the following effects on motor function occur.
1. The knee joint of the affected limb is hyperextended, and the ankle joint is plantar flexed and inwardly turned, which affects the foot following the ground in the support phase.
2.When the affected limb is in the support phase, the ankle joint is plantarflexed, making it difficult to complete the weight transfer movement.
3.When training the dorsiflexion movement of the ankle joint of the affected limb, try to prevent stimulation of the toes leading to an increase in flexor tension.
The crossed stretch reflex is a reflex at the level of the spinal cord, and a positive response is normal in infants within 2 months of age, and should be suppressed in infants after 2 months of age as the neural reflexes develop. It was reported that when a painful stimulus was applied to one lower limb of the animal, an increase in extensor tone occurred in the other lower limb in order to support weight.
The following clinical manifestations are also seen in patients with hemiplegia as a result of this reflex.
1. When the patient does a bridging movement in bed, if the lower limb on the healthy side is lifted, the lower limb on the affected side will fall down under the influence of cross-extension.
2.Patients use one leg of the lower limb on the healthy side to bear weight, and when they get up from the sitting position, as long as the healthy side of the lower limb is actively extended, the affected lower limb will be flexed, and this reaction will affect the weight bearing of the affected limb.
3. In some patients, the affected lower limb can stand on one leg, and the knee joint can complete the flexion action when weight-bearing, and there is no excessive tension of the extensor muscle; however, when the lower limb on the healthy side steps forward and is in flexion ten, the affected lower limb will have an extensor hyperactivity pattern, causing balance disorders, and when the affected limb enters the swing phase, it will have difficulty in flexion and affect walking.
Grasp reflex The grasp reflex is a tactile, proprioceptive stimulation of the palm of the hand and the palm side of the fingers that causes finger flexion and internal grasping action. This reflex appears at birth in normal infants and disappears with the development of random grasping movements.
1. Whatever objects are placed in the patient’s hands will cause increased flexor tone in the elbow, wrist and fingers.
2. For patients with severe finger flexion spasm, therapists used to design orthoses for them or put objects such as towel rolls in their hands to hold the fingers in the extended position. This method stimulates the grip reflex and often leads to an increase in spasticity.
3.In the past, therapists designed grasping tennis balls or rubber bands with stimuli in order to allow patients to practice hand grasping movements, etc. Such activities often elicit the grasping reflex and affect the hand extension function.
4, During training, in order to use the self-assisted method, the fingers of both hands are crossed, as the fingers of the healthy side reach from the proximal end of the affected palm to the distal end, eliciting the grasping reflex, resulting in finger flexion and inversion, making it difficult to complete the action.
5, some patients, although they have mastered the motor function of random finger extension, often encounter difficulties when they want to release the object in their hands due to the influence of the grasping reflex.
Balance disorder balance response is a response at the brain cortical level, consisting of supine tilt response, knee-handed balance response, sitting balance response, kneeling balance response and stride response. They usually appear at 6 months, 8 months, 12 months, 15 months, and 18 months of age, respectively, and remain with the child throughout life. If the balance function does not appear or is disrupted, it affects the maintenance of sitting, kneeling, kneeling and standing positions. There are more cases of hemiplegic patients with balance disorders due to damage of brain tissue. If it cannot be improved, it will affect the corresponding motor functions.
The specific performance is as follows.
1. In those with normal sitting balance response, when the body’s center of gravity changes, there will be an adjustment of the head and chest to the opposite side of the deviation of the center of gravity, as well as extension and abduction of the upper and lower limbs to maintain the sitting posture.
If the patient’s sitting balance disappears, he or she cannot independently maintain the sitting position.
2.Patients with normal standing balance reaction, when standing, if external force causes the balance to break down, various adjustment reactions of the head, trunk and ankle joints appear at any time. If balance is still not maintained, a step response in the corresponding direction will occur to maintain body balance. However, patients with standing balance disorder cannot stand and walk independently even if their lower limbs function well.
3.Because of the poor balance function, patients have the tool mentality that they may fall at any time, which makes the whole body muscles highly tense and aggravates the spasm of trunk and limbs.
4.A few patients ignore the importance of balance function and lack of protection awareness, leading to trauma, which often results in serious injuries such as fractures due to inadequate adjustment and protective responses.
Therefore, balance function is a crucial link to the rehabilitation of hemiplegic patients and should not be ignored.
There are more ways to classify sensory disorders sensation, which can generally be divided into two categories: somatosensory and visceral sensation, among which somatosensory has a great impact on the motor function of hemiplegic patients. In the rehabilitation center, it is divided into superficial sensation, deep sensation and compound sensation. The proportion of hemiplegic patients with sensory disorders is quite high, which is one of the important factors that seriously affects the level of rehabilitation and is also a part that is often neglected.
Examples of the effects of sensory impairment on hemiplegic patients are as follows.
1. Due to the loss of sensation, the patient lacks motor awareness and cannot correctly judge whether the lower limbs are on the ground or not, which makes the patient lack confidence in the balance and stability of walking and generates a sense of fear.
2. Loss of joint sensation leads to impairment of joint position and motion recognition, and the patient cannot accurately determine the angle of joint flexion and extension or flexion and extension with eyes closed, so it is difficult to control the angle of joint flexion and extension or flexion and extension, resulting in abnormal gait.
3. When holding objects in the hand, the patient is unable to judge the shape and temperature of the object, which also affects the self-care of daily life.
Patients with significant sensory impairment often have a poor prognosis for functional recovery. Therefore, in order to improve the motor function of hemiplegic patients, it is necessary to pay attention to the rehabilitation of sensory disorders.