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Physiotherapist - HI FIVE CHILD DEVELOPMENT CENTRE, Juhu, Mumbai-49 and ASHA CBR PROJECT - LEONARD CHESHIRE DISABILITY CENTRE,Mumbai.

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Sunday, February 14, 2010

SYNERGY AND SPASTICITY IN HEMIPLEGIC CP !!!

Spasticity refers to increased tone in group of muscles and is sign if upper motor neurone lesion.The deep tendon reflexes are exaggerated.Well in case of hemi cp,severe spasticity will make movements impossible , while moderate spasticity will allow some slow movements but they will be performed with too much effort and abnormal coordination but fine movements of the limbs especially involving the distal portion will be difficlut or impossible.
In hemiparesis there are some muscles which are always involved and which finally give rise to a pecular abnormal mass movement pattern and attitude that is charecteristic of many hemiparesis patient.The spasticity invariably affects the antigravity muscle for reasons not clearly understood.It is however presumed that this antigravity muscles are relatively more stretched than progravity muscles in neutral position hence stimulating the stretch reflex giving rise to spasticity.

SYNERGY :Synergy patterns are abnormal ,stereotyped ,primitive ,mass movement pattern associated with spasticity and which can be triggered either reflexly and voluntarily.
Synergy can be either flexor or extensor.They involve the action of certain muscles in combination that gives rise to abnormal pattern not useflu for functional activities.

ABNORMAL SYNERGY IN UPPER AND LOWER LIMBS :
Flexion synergy - For upper limbs :Shoulder girdle retraction and elevation ,shoulder abduction external rotation,supination,felaxion of elbow,wrist and finger flexion
Flexion synergy for lowr limbs :Hip flexion abduction and lateral rotation , knee felxion,dorsiflexion and inversion.
Extension synergy - For upper limbs :Shoulder girdle protraction and depression,shoulder adduction,internal rotation,elbow extension,pronation,wrist and finger flexion.
Extension synergy - For lower limbs :Hip extension,adduction,internal rotation,knee extension,ankle plantar flexion,inversion,and plantar flexion.
Thus is can observed that the following muscles does not take part in either of the synergies :
1)Lat dorsi
2)Teres major
3)Serratus anterioir
4)Wrist and finger extensors
5)Ankle evertors
It is highly essential to understand that synergies are different from the abnormal attitude seen in a hemiparesis patient.The abnormal hemiplegic attitude is due to the combination of strongest component of the flexor and extensor synergy in both upper and lowr limbs.
VOLUNTARY CONTROL TESTING FOR ASSESSING SYNERGY PATTERNS :
GRADE 0 :NO CONTRACTION
GRADE 1:FLICKER OF CONTRACTION PRESENT PRESENT OR INITIATION OF MOVEMENT
GRADE 2:HALF RANGE OF MOTION IN SYNERGY OR ABNORMAL PATTERN
GRADE 3:FULL RANGE OF MOTION IN SYNERGY OR ABNORMAL PATTERN
GRADE 4:INITIAL HALF RANGE IS PERFORMED IN ISOLATION AND THE LATTER HALF IN PATTERN
GRADE 5:FULL RANGE OF MOTION IN ISOLATION BUT GOES INTO PATTERN WHEN RESISTANCE IS OFFERED
GRADE 6:FULL RANGE OF MOTION ISOLATION AGAINST RESISTANCE.

Here i have uploaded the video of hemi cp of 6 years who is trained for the coordination and reach outs for the affected upper limb.Observe carefully the synergy that the child has developed.

Dr.Harish (PT)


video

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In my opinion, all other muscles are involved except ankle evertors, on your lists. isn't it?

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