فیزیوتراپی در سکته مغزی (2)

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از فراگیر انتظار می رود پس از پایان این جلسه بتواند علایم مثبت و منفی پس از سکته مغزی را برشمارد. انواع ضعف پس از سكته مغزى را توضیح دهد. روش های اندازه گیری قدرت عضلات پس از سکته مغزی را توضیح دهد. توضبح دهد کوکانتراکشن پس از سکته مغزی به چه دلیلی ایجاد می شود و درمان آن چیست؟ نواع اختلال تون پس از سکته مفزی را توضیح دهد. روش های اندازه گیر اختلال تون را توضیح دهد. سه مکانیسمی که در ایجاد هیپرتونیسیتی نقش دارد را شرح دهد. عوامل موثر بر تون عضلات را لیست کند. 

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THE UPPER MOTOR NEURON SYNDROME *Negative features *Positive features «Adaptive features 

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NEGATIVE FEATURES «Muscle weakness * Slowness of muscle activation (walking or stand up) .They find It difficult to generate the force needed to move at high velocity. + Loss of dexterity(skill)& coordination * Hyporeflexia or Areflexia in acute phase or brain shock 

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POSITIVE FEATURES * Reflex hyperexcitability (exaggerated tendon jerk) & clasp-knife phenomena, Babinski & clonus) + Resistance to passive movements (hypertonus) 

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ADAPTIVE FEATURES * Physiological, mechanical, and functional changes in muscle & other soft tissue *Adaptive motor behavior (Altered motor pattern) Car r& Shepherd 1998 Neurological rehabilitation 

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MOTOR IMPAIRMENTS * Muscle weakness or paresis * Unable to generate normal levels of muscular force, tension, or torque to initiate and control movements or to maintain a posture. + Atrophy of involved muscle fiber * Muscles controlling grip strength & the wrist & finger flexor are the most severely affected muscle group . 

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MUSCLE WEAKNESS DUE TO LOSS OF INNERVATION, IMMOBILITY & DISUSE + Loss in the number of motor unit available for recruitment * changes in recruitment ordering * changes in firing rate * impaired motor unit synchronization * changes in motor unit type * size of the muscle 

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ne TO PREVIOUS 8 OPINION *Weakness in agonist muscle is not due to spasticity(reflex hyperactivity) in an antagonist muscle group but is a direct result of reduction in descending motor commands, compounded by disuse & 

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STROKE DOESN’T AFFECT ONLY ONE SIDE OF THE BODY. THE MUSCLES ON THE UNINVOLVED SIDE CAN ALSO EXHIBIT WEAKNESS FOLLOWING THE INJURY. 

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:3 ۱۳2۸۵۸5۵۴6۱۷۶۱ له !57۳ عا ۳۷/5 * MMT (Medical Research council 1976,Wade 1992) *Dynamometry (grip force, hand- held, isokinetic dynamometers) + Lateral Step-up test(Worrell et al 1993) provides an indication of functional lower limb strength. 

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‎AND REDUNDANT 3‏ كك ‎MUSCLE ACTIVITY ‎-Abnormal movement pattern ‎*muscle coconntraction ‎*Associated movements ‎ 

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ADAPTIVE MOVEMENT PATTERN *Sterotyped & primitive pattern ۰۱00۱6211۷6 of spasticity *They will be appear by reflex (associated mvts) or voluntary movements 

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—_— 1 WEAKNESS ARE AFFECTED BY: *Joint alignment and mobility *Changes in muscle &tissue length *Problems of muscle tone & muscle activation 

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MUSCLE WEAKNESS LEADS TO: ‘Inability to perform movement components ,Movement sequences, and functional movements *Development of atypical and compensatory movement patterns. 

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INAPPROPRIATE PATTERN OF ۳۱۱۹۵۱۶ ۵۷۰ ۳ + Patient activates the wrong muscles for the task being performed. + Movement patterns are initiated from the wrong part of the body. + Patient may substitute a strong muscle for a paralyzed muscle. * The patient use these abnormal patterns of muscles activation to stabilize body position ,move trunk & limbs &attempt functional movements. 

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TREATMENT + Normal pattern of muscle activation + Normal sequencing of movement pattern + Appropriate force production during muscle activation * Quieting of inappropriate muscle activity ٠ Normal pattern of coordination 

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CO-CONTRACTION OF 9 MUSCLES * This is not itself an abnormal phenomena in motor control. * Muscle cocontraction & stiffening of a limb can illustrate lack of skill + it is found in attempting a novel task, moving at fast speeds, and in children 

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CO-CONTRACTION OF MUSCLES * Cocotraction may be a manifestation of lack of skill in reorganizing task-specific muscle activation pattern in the presence of inadequate motor unit recruitment and weakness. * Stiffening the lower limb in stance may illustrate difficulty in controlling muscle contraction when bearing weight through the limb (Carr & Shepherd 2003) 

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EXCESSIVE COCONTRACTION * The patient activates correct muscles & additional inappropriate muscles are simultaneously contracting. Once the muscles have been activated ,the patient maybe unable to stop the muscle firing. * Cocontraction of muscles on the involved side leads to hypertonicity , muscle shortening , and to permanent changes in the resting posture of the trunk & extremities. 

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ASSOCIATED MOVEMENTS - Also called synkinesis or overflow * unintentional movements which may accompany volitional movements, resulting from irradiation of neuronal excitation in the cortex or spinal cord during voluntary mvts. * They are seen in normal people under condition of stress + In adult they are associated with lack of skill when performing complex tasks or when generating maximum force levels.(Carr 2003) 

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ASSOCIATED MOVEMENTS * They are seen in stroke patient during stressful activity specially in upper limb + Associated Reaction occur in the presence of pathology (walsh 1923) and indicative of spasticity with increased effort (Bobath 1990 ,Stephenson et al.1998) 

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CHANGES IN TONE * Tonal changes affects on: muscle tone (amount of tension in muscle that was measured by resistance to passive lengthening) * postural tone (body’s readiness to move & its ability to resist the downward pull of gravity) 

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PES OF ABNORMAL TONE HYPOTONICITY *Hypotonicity (lower than normal) + Difficult to distinguish between low tone & weakness *This leads to secondary impairments in alignment & joint stability *It occurs in acute stage or throughout recovery 

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HYPERTONICITY * Increased active stiffness in the affected muscle groups * Positional shortening result in a passive stiffness of the muscle * Structural reorganization of connective tissue (Malouin et al . 1997) 

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= 1 HYPERTONICITY *Hypertonicity may also develop in muscles that are weak or paralyzed but have been maintained in a constant position of shortness because of changes in biomechanical alignment . 

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SPASTICITY * Velocity- dependent resistance to stretch &hyperactive tendon jerks (hyperreflexia) Spasticity & hypertonicity are used almost interchangeably + True spasticity such as occurs with massive brain damage is probably not responsive to therapy but hyper &hypo tonicity do respond to specific handling Ryerson, Levit 1997 

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VARIATION OF MUSCLE TONE IN STROKE + Hypertonicity throughout the involved side + hypertonic extremities with hypotonic trunk muscles + hypertonicity in the arm & lower tone in the trunk & leg + hypotonic upper extremity & hypertonic lower extremity + increased tone in the proximal muscles of extremity & decreased tone in the lower arm or leg & vice versa 

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—_— 1 VARIATION OF MUSCLE TONE IN STROKE * Parietal lobe lesions are associated with hypotonia * Decerebrate rigidity is found in massive closed head injury. 

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ASSESSING TONE DTR Clonus Clasp knife response Modified Ashworth scale Resistance to passive movement Pendular test Drop arm test Observation of posture * Voluntary movements 

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=< ‏جع‎ ‎b ‎THE FOLLOWING FACTORS AFFECTS ~— ON MUSCLE TONE *Body position *performance of certain movement pattern or activities Stressful or emotional situations 

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* Levit ced Qyersoc. Pucriocd Ooveweu Reeducaiod: @ Ovctewporary Ordel Por Stroke Rebabilitaicc ‏,لو‎ (OOP + Cites, @, Circke Rehebitaica, Dew York, Dew ‘ork, COU, Clsevier.