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Neuro? Logical! Forum for all neuro-things => from neuron to brain...

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Old 28-02-2012, 09:12 AM   #1
rajulvasa
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Default contractures in neurological patients

I read following in Neurorehabilitation group discussion started by Jakob Lorentzen
Research Physiotherapist PhD Copenhagen Area, Denmark

How to treat contractures in neurological patients?

Does anybody have suggestions to how efficient treatment and / or prevention of contractures in joints could be conducted? One often used method is passive stretching, but several published reviews have now stated that stretching have no relevant effect in relation to increase range of motion and decrese muscle tone.
Perhaps somebody out there have experiences with useful techniques or methods.


for the benefit of my somasimple friends i thought of putting my answer in this thread as well.

I feel what we have learnt in the past about contracture is based on assumptions, trial and error which makes contracture to return despite different interventions and our struggle as well as patient struggle continues to remove contracture even in this 21st century.

Modern times have more number of therapists with masters and doctoral education. It is time we grow beyond being a technician like our predecessors and fellow therapists of last century who were trained to be technicians delivering techniques in clinical set ups. We must no longer watch sadly contractures to develop or return despite our huge efforts.

Time to begin to explore the root cause behind the development of increased tone, spasticity and passive tissue contracture to be able to not let the contractures surface at all!

Time is ripe to grow beyond treating symptoms and search for answers what made symptoms like contracture, stiffness and spasticity to erupt in paretic flail weak body and look at lesion as the catalyst and not as primary cause.

In order that contracture do not develop at all, one needs to work with paretic body to restore its capacity to control and restore center of mass [COM] before plasticity of brain hands over the charge to control and restore COM to safety to good non- paretic body in stroke patients, and before adaptability of paretic muscles takes over the scene and before the paretic flail weak body is influenced by self-organizing brain to work defensively to defend and safe guard COM with passive tissue contracture in connective tissue within and around the muscle and general connective tissue that connects entire body together to be able to function as one integrated whole.

When the weak paretic muscles that not only cannot generate enough force to be able to control and restore COM to safety but becomes a threat to the safety of COM because of increased degrees of freedom in multilinked musculo-skeletal system [MSS] from paresis, self-organizing CNS following lesion begins to induce morphological changes in connective tissue, fascia and muscles to ensure contracture not only to generate some internal force against gravity to bring homeostasis in the internal cellular environment where skeletal muscle contributes 40% of total body mass and when paretic muscle cell cannot generate force it can disturb homeostasis of forces that hold colonies of cells together with mechanotranduction to hold almost 60 % of body mass made of extra cellular fluid together with fascia tissue together so that entire body can function as one integrated whole despite paresis. Homeostasis is the internal need of the body for survival of living tissue.

Contracture also contributes towards compressing, restricting, or even freezing degrees of freedom in multilinked body thereby ensure COM safety. Safety of COM is a priority for all living being.

One can prevent birth of contracture by acting at the root level as explained above

Rajul Vasa
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Old 28-02-2012, 07:09 PM   #2
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Thank you Rajul for posting again. I am going to spend some extra time reading your thread again so I can form my questions correctly. I work with a client who has MS and distinct upper motor neuron lesions and her contractures are significant now. I am interested in this post.

Karen
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Old 29-02-2012, 03:50 AM   #3
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Rajul,

I have read through your post and examined your website. I am not sure if you language is intentionally vague but to me it seems that way. That being said I think I understand some of what you are saying.

1) Muscle contracture is centrally driven.

2) That this is a protective response driven by the CNS to preserve center of mass (COM) in the even to of a supraspinal neuro insult.

3) That it is due to self organizing properties of the CNS, the CNS limits degrees of freedom of movement of the paretic limb. It is through mechanical coupling are the paretic and non paretic sides linked together. Due to mobility and stability dominances and decrease in degrees of freedom does the non paretic side serve to move and dominate while the spastic side follows.

4) What I am not sure is how some of your techniques are vastly different than current neurological rehab techniques. I think most PT's that have graduated in the last 20 years in the US understand that neurological driven contractures due to spasticity will not be changed by passive stretching alone.

While I think you are trying to look more intuitively at the human nervous system and its responses to insult. I think you have made some leaps in logic that do not jive with my own internal understanding of the science.

A cortical lesion is going to exert decreased discriminating control over the spinal cord. Thus leading to decreased independent control of effectors (muscles and joints in this case). This loss of independence results in motor groups and joints being linked into fixed synergies of movement. You could call this decrease in synergistic behavior losses of degrees of freedom of movement.

Changes in the CNS causing an imbalance between sensory input, descending involuntary muscle control and corticalspinal tracts results in the manifestation of particular changes in tone and the fixed synergies that develop.

Generally, over time these fixed synergies of movement become further strengthened because motivational centers have become complacent with motor output--despite it being significantly decreased than pre-insult.

For bilateral integration of center of mass and movement--you have two sides with a multitude of flexible ways of solving movement related problems (COM being only one). In a neural insult you have significantly reduced fixed and stereotypical solutions on one side and decrease overall in the number of solutions. Thus resulting in the CNS using the fixed synergy and more variable side together in a synergy to produce movement and stabilize COM.

Therefore it seems to me that diversification and incorporation of new challenging movements that encourage the use of effectors ignored by the CNS in its attempt to solve movement and gravity related problems, is the best way to focus on reducing excessive spasticity. This is a constant process throughout every stage of rehab. Perhaps this is what your VASA method is about.

Fyi, I define a synergy as a group of interdependent variables/effectors that are able to co-vary their performance in order to preserve a coordinated output.

A real life example of a synergy would be say you and a friend decided to do dig a grave (we will not speculate on the reason for this). Say you want to dig a grave 10 feet deep, 10 feet in length and 4 feet in width. This grave must be dug in 2 hours. Given these constraints and because there are two variables (you and your friend) there are an infinite number of combinations which you and your friend can combine your efforts to complete the task. When a synergy works well, the effort of one person (in this case) is calculated and compensated for by the other. In the case of the grave if I take a break, my friend picks up the slack so we get the job done on time and vice versa. You have synergisticaly combined your efforts to preserve the output (goal) of the task. A fixed synergy in the above example would be you and your friend only being able to work at a set rate, regardless if the the other one takes a break. Thus decreasing your ability to compensate/complement the other and complete the task by the set time.

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Old 29-02-2012, 03:26 PM   #4
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I look forward to your questions dear Karen
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Old 29-02-2012, 03:28 PM   #5
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(Just want to say hi, Rajul. Haven't seen you here for a long time. Welcome back.)
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Old 29-02-2012, 03:43 PM   #6
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Quote:
Originally Posted by Milehigh View Post
Rajul,

I have read through your post and examined your website. I am not sure if you language is intentionally vague but to me it seems that way. That being said I think I understand some of what you are saying.

1) Muscle contracture is centrally driven.

2) That this is a protective response driven by the CNS to preserve center of mass (COM) in the even to of a supraspinal neuro insult.

3) That it is due to self organizing properties of the CNS, the CNS limits degrees of freedom of movement of the paretic limb. It is through mechanical coupling are the paretic and non paretic sides linked together. Due to mobility and stability dominances and decrease in degrees of freedom does the non paretic side serve to move and dominate while the spastic side follows.

4) What I am not sure is how some of your techniques are vastly different than current neurological rehab techniquesThank you for recognizing that current neurological rehab techniques are different from my concept and clinical approachI think most PT's that have graduated in the last 20 years in the US understand that neurological driven contractures due to spasticity will not be changed by passive stretching alone.You are absolutely right that PT’s who have graduated in last 20 years in US believe that neurological contractures due to spasticity cannot be changed by passive stretching alone.

While I think you are trying to look more intuitively at the human nervous system and its responses to insult. I think you have made some leaps in logic that do not jive with my own internal understanding of the science. Different minds have different views, thoughts, dreams, beliefs, and this is natural and is characteristic of supreme nature so that inventions are inevitable, monotony is boring.



A cortical lesion is going to exert decreased discriminating control over the spinal cord. Thus leading to decreased independent control of effectors (muscles and joints in this case). This loss of independence results in motor groups and joints being linked into fixed synergies of movement. You could call this decrease in synergistic behavior losses of degrees of freedom of movement. Limited view of neurophysiologists studying motor control, movement and brain in limited laboratory atmosphere without any clinical experiences of patients.

Changes in the CNS causing an imbalance between sensory input, descending involuntary muscle control and corticalspinal tracts results in the manifestation of particular changes in tone and the fixed synergies that develop. Yes, we have learnt this in our basic science studies depending on the research studies of scientists who studied and researched based on benchmark studies of ‘the then pioneers’.

Generally, over time these fixed synergies of movement become further strengthened because motivational centers have become complacent with motor output--despite it being significantly decreased than pre-insult. We all have our own views rightfully.

For bilateral integration of center of mass and movement--you have two sides with a multitude of flexible ways of solving movement related problems (COM being only one). In a neural insult you have significantly reduced fixed and stereotypical solutions on one side and decrease overall in the number of solutions. Thus resulting in the CNS using the fixed synergy and more variable side together in a synergy to produce movement and stabilize COM. CNS always works optimally, nature always works to conserve energy, CNS prioritizes safety at any cost.



Therefore it seems to me that diversification and incorporation of new challenging movements that encourage the use of effectors ignored by the CNS in its attempt to solve movement and gravity related problems, is the best way to focus on reducing excessive spasticity. This is a constant process throughout every stage of rehab. Perhaps this is what your VASA method is about. VASA CONCEPT you may glance thro’ once again. Thank you for your interest.

Fyi, I define a synergy as a group of interdependent variables/effectors that are able to co-vary their performance in order to preserve a coordinated output.

A real life example of a synergy would be say you and a friend decided to do dig a grave (we will not speculate on the reason for this). Say you want to dig a grave 10 feet deep, 10 feet in length and 4 feet in width. This grave must be dug in 2 hours. Given these constraints and because there are two variables (you and your friend) there are an infinite number of combinations which you and your friend can combine your efforts to complete the task. When a synergy works well, the effort of one person (in this case) is calculated and compensated for by the other. In the case of the grave if I take a break, my friend picks up the slack so we get the job done on time and vice versa. You have synergisticaly combined your efforts to preserve the output (goal) of the task. A fixed synergy in the above example would be you and your friend only being able to work at a set rate, regardless if the the other one takes a break. Thus decreasing your ability to compensate/complement the other and complete the task by the set time.
great imagination. thank you ERic.

Eric
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Old 01-03-2012, 05:16 PM   #7
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Quote:
Originally Posted by Diane View Post
(Just want to say hi, Rajul. Haven't seen you here for a long time. Welcome back.)
thank you Diane,

yes long time i was not seen because I was extremely busy with number of crucial projects.

hope to be in contact with you all once again.
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Old 01-03-2012, 07:49 PM   #8
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Hi Rajul,

I work in a pediatric school setting with a population of students with CP (spastic quadriplegia). Contractures are constantly an issue for some of our students and I'm not a big believer in passive stretching to prevent and certainly not to change contractures once they have developed.

What are your thoughts for working with a population like this that has severely limited volitional movement, is non-ambulatory, and fully dependent on others for mobility and care?
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Old 03-03-2012, 08:10 AM   #9
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hi christopher,

i would love to cooperate with you if you wish me to see your CP population.
you can send the video film of these children thro' sendspace.com where you record their daily activity, their dependence and independence in motor actions, contracture and spasticity of limbs trunk on close up video and on photos.

i can suggest thro' www.sendspace.com what i think, why i think and what can be done if you are open to new way of treating these children.

you may also talk to me on my skype id to exchange view more directly with me.
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Old 05-03-2012, 09:27 PM   #10
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Hi Rajul,
Something that might interest you, a blogpost from HumanAntiGravitySuit, Neuroplasticity, neurogenesis baby!
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