Ms hipotónico

HandFun Meeting 2013

THERAPEUTIC CONSIDERATIONS ABOUT THE HYPOTONIC UPPER LIMB

TANIA ROMEU CES


Hypotonic Upper Limb• Acute phase

• After this phase, the development of hypertonia in the anti-gravity musculature is expected.▫ Upper motorneuron syndrome

• Prolonged Muscular Flaccidity after stroke negative indicator in the prognosis of the final outcome for stroke patients (Formisano, 2005)


Shoulder subluxation• Frequent complication of motor impairment, soft tissue

damage, joint capsule, rotator cuff injury and in some cases pain. (Dohle 2013, Hesse 2013)

• Increased risk during the acute phase

• Subluxation of the shoulder can cause

▫ Painful shoulder

▫ Reflex Sympathetic Dystrophy (Dohle 2003)

Dohle 2013, Murie-Fdez 2012


Brain Plasticity• Cerebral plasticity: dynamic potential of the

brain to reorganize itself during biological development or following damage (Duffau, 2006)

• Reorganisation of cortical sensorimotor maps after cerebral injuries (Duffau, 2001)

• CNS is malleable and can be modified in response to practice (Duffau, 2006; Daly & Ruff, 2007)


Neuromuscular system

Executive system

Visualsystem

Posturalsystem

Somatosensory

system


Motor Cortex

• Multiple cortical representations for hand and forearm movements in primary motor cortex (Duffau 2001)

• Improvements in arm and hand motor function during recovery post-stroke have been related to reorganisation in primary and secondary sensoriomotor areas (Lindberg et al, 2003)

• Pathways


ParadigmTreatment focused on the compensation

of deficits

Treatment as recovery of functions

(Duffau; 2006; Behrman et al, 2006; Daly & Ruff, 2007)


Facilitation techniques• Fast brushing• Cold stimulation• Quick stretch• Fast tapping• Vibration

Proprioceptive Neuromuscular Facilitation (FNP) (Pop T, 2013)


ORTESIS• Omo Neurexa (Ottobock)▫ Hesse S, 2013

Hesse S, Herrmann C, Bardeleben A, Holzgraefe M, Werner C, Wingendorf I, Kirker SG. A new orthosis for subluxed, flaccid shoulder after stroke facilitates gait symmetry: a preliminary study. J Rehabil Med. 2013;45(7):623-9.

• Soporte de hombro unilateral (Orliman)


Robotics• Anti-gravity robot• Compensatory torso

movements• Visual Feedback• Significantly reduced shoulder

instability

• Increased motor power (the control of scapular protraction and retraction and shoulder flexion and extension)

Dohle CI, Rykman A, Chang A, Volpe BT. Pilot study of a robotic protocol to treat shoulder subluxation in patients with chronic stroke. J Neuroeng Rehabil. 2013; 10: 88.


Electrical stimulation

• Electrical stimulacion and Bobath concept (Fil 2011)

• Prospective randomized controlled trial. N=48

• Supraspinatus muscle, mid and posterior portions of the deltoid muscle.

• It approach proved to be efficient in preventing inferior and anterior shoulder subluxation in the acute stages of stroke.

Fil A, Armutlu K, Atay AO, Kerimoglu U, Elibol B. The effect of electrical stimulation in combination with Bobath techniques in the prevention of shoulder subluxation in acute stroke patients. Clin Rehabil. 2011;25(1):51-9.


Shoulder subluxation• Normalization of muscle tone of the trunk to reduce

the risk of shoulder subluxation (Murie-Fdez 2012)

Hand• Encourage the use of the hand in day to day

activities to increase the postural depth tone of the scapular waist and trunk (Díaz-Arribas 2006)

• Dorsiflexion


• Treatment focused on the task

• Specificity activity

• Bimanual exercise

• Intensive use

• Dual task

• Patterns of movement/ avoid compensations

Intensity vs task specificity (Page, 2003)


Affolter Model• Perception Information

• Reality

Guiding• Elementary • guiding• Nursery


Recovery is a dynamic process that cannot be encapsulated at one timepoint (Langhorne 2001)

Thank you!!

[email protected]@tania_romeu

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