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…

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…

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…

Secondary musculoskeletal complications are common sequelae of neurological impairments.

In order to avoid, the therapist must anticipate!

What happened?

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

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

Both passive and active muscle properties are affected

Passive: alteration of length and stiffness → muscles become short and stiff → loss of joint ROM → difficulty performance of tasks

Active: alteration of peak active tension generation → difficulty performance of tasks

Factors contributing to changes in muscle length

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

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

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

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

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

Machine Preset range of motion Vigorous movements at

the end of range can be avoided

Hyperactive stretch reflex avoided

Availability

PNF

Rhythmic initiation ROM exercises

administered in diagonal patterns

Throughout a limb, combining motions at more than one joint.

Stretching Techniques

Application of manual or mechanical force to elongate structures that have adaptively shortened and are hypomobile.

Static stretching Facilitated stretching

Changes in Body Positions

Provides an opportunity to change individual joint positions…altering muscle length temporarily.

Bed mobility exercises Transition exercises STS exercises

Prescription…

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…

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…

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…

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… 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…

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…

Effort applied in exercise does not increase spasticity or muscle stiffness.

Elderly individuals are capable of increasing their cardiovascular fitness, and improving lifestyle and self-efficacy, with moderately vigorous exercise

Aerobic exercise…

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).

may increase endurance capacity and minimize symptoms of cardiovascular disease (Hamm and Leon 1994).

Control of breathing

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

Direct damage to the respiratory centers

Associated factors affecting lung function

Pre-existing factors Prolonged rest

Common respiratory problems

Impaired mucociliary clearance Hypoventilation V/Q mismatching hyperventilation

Impaired mucociliary clearance

ACBT AD Postural drainage Coughing

techniques Manual techniques Suction Tracheal tickle

Hypoventilation

Breathing exercises

Incentive spirometry

Chest mobility exercises

Hyperventilation

Relaxation techniques

Brown bag Breathing exercise

V/Q mismatching

Sitting and standing

Breathing exercises

Fitness for Deconditioning Prevention

Regaining upright posture

Progressive increase in activity

Fitness classes

Physical conditioning programs

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…

Supervised aerobic training programs have been shown to improve V02max, with the improvement significantly related to improvements in motor function (Potempa et al. 1995).

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…

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…

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

Aerobic exercises 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!

Blowing bubbles Incentive

spirometry Wind musical

instruments Pin-wheel

Fitness classes Aerobic exercises Strengthening

exercises Flexibility exercises AGMS

Be imaginative and creative!

Other Evidence?

Static vs Cyclic stretching

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:

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!