Therapeutic Strategies to Prevent Tissue Shortening and Cardiopulmonary Deconditioning

1. Therapeutic Strategies to Prevent Tissue Shortening and Cardiopulmonary Deconditioning Ms. Mary Grace M. Jordan, PTRP PT 154: Therapeutic Exercise III December 10, 2009

2. 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.

3. Learning objectives… • Discuss underlying cardiorespiratory complications following neurological impairments. • Discuss common problems, therapeutic interventions and their effects on pulmonary, cardiovascular, and neurological status.

4. Keeping the Musculoskeletal System Flexible Adaptation to immobility Effects to function Strategies for prevention

5. Anticipating… • Secondary musculoskeletal complications are common sequelae of neurological impairments. • In order to avoid, the therapist must anticipate!

6. 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.

7. Adaptation to Immobility • Muscle immobilized in a shortened position → lose 40% of sarcomeres • Muscle immobilized in a lengthened position → produce 25% more sarcomeres

8. 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

9. 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

10. 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

11. 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

12. Strategies for Preserving Muscle Length and Connective Tissue Flexibility

13. 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.

14. 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.

15. 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

16. PNF • Rhythmic initiation • ROM exercises administered in diagonal patterns • Throughout a limb, combining motions at more than one joint.

17. Stretching Techniques • Application of manual or mechanical force to elongate structures that have adaptively shortened and are hypomobile. • Static stretching • Facilitated stretching

18. Changes in Body Positions • Provides an opportunity to change individual joint positions…altering muscle length temporarily. • Bed mobility exercises • Transition exercises • STS exercises

19. 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.

20. 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)

21. 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.

22. Keeping the brain and the body oxygenated Cardiopulmonary deconditioning Therapeutic interventions

23. 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.

24. 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.

25. 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.

26. 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

27. 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).

28. 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

29. Factors affecting lung function • Direct damage to the respiratory centers • Associated factors affecting lung function • Pre-existing factors • Prolonged rest

30. Common respiratory problems • Impaired mucociliary clearance • Hypoventilation • V/Q mismatching • hyperventilation

31. Impaired mucociliary clearance • ACBT • AD • Postural drainage • Coughing techniques • Manual techniques • Suction • Tracheal tickle

32. Hypoventilation • Breathing exercises • Incentive spirometry • Chest mobility exercises

33. Hyperventilation • Relaxation techniques • Brown bag • Breathing exercise

34. V/Q mismatching • Sitting and standing • Breathing exercises

35. Fitness for Deconditioning Prevention Regaining upright posture Progressive increase in activity

36. Fitness classes

37. 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).

38. 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.

39. 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.

40. 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

41. Fitness Programs • Aerobic exercises • Warm up : 5 -10 minutes • Exercise proper : 20 - 40 minutes • Cool down: 5 – 10 minutes • Strengthening exercises • Flexibility exercises • Calisthenics

42. Pediatrics

43. Fitness class for pedia

44. Blowing bubbles Incentive spirometry Wind musical instruments Pin-wheel Fitness classes Aerobic exercises Strengthening exercises Flexibility exercises AGMS Play…Play…Play! Be imaginative and creative!

45. Other Evidence?

46. 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)

47. 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.

48. Thank you and Good day!