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Related theory

Consequences of neurological damage

Disease or damage to the CNS or PNS can lead to temporary or permanent complex physical, cognitive, psychological and psychosocial problems, including the inability to move independently (Box 7.4).

Box 7.4

Neurological symptoms that can affect a person's capacity to move independently

Muscle weakness or paralysis:
- affecting single muscles or joint movements – such as weak ankle muscles
- affecting one limb
- affecting one side of the body – known as hemiparesis (weakness) or hemiplegia (paralysis)
- affecting both legs and trunk, depending on the level of damage – known as paraplegia
- affecting all four limbs and trunk – known as quadriplegia or tetraplegia
Altered muscle tone – spasticity, flaccidity or rigidity
Difficulties with co‐ordination, such as ataxia
Nerve pain
Sensory impairment – numbness, pins and needles, hypersensitivity or proprioceptive loss
Balance impairments
Visual problems
Autonomic dysfunction, such as blood pressure changes
Seizure activity
Changes to bladder or bowel function
Confusion
Altered mood
Perceptual changes – difficulty with the interpretation of sensation into meaning
Cognitive changes – difficulties with concentration, understanding, comprehension, memory, planning, problem solving, safety awareness and memory
Behavioural changes
Speech and language difficulties:
- dysarthria – difficulty forming words due to changes in control of the mouth muscles
- expressive dysphasia – difficulty finding words
- receptive dysphasia – difficulty understanding words

Source: Adapted from Lundy‐Ekman ([66]) with permission of Elsevier.

If a person with a neurological presentation has problems moving, they are deprived of the physical benefits of movement and are at risk of developing secondary complications such as those described in Table 7.4. These changes can occur in as little as one week. They also present a challenge to health professionals assisting these patients’ mobility. Effective management of patients with neurological impairment requires holistic assessment and multidisciplinary management.

Table 7.4 Common postural problems seen in patients with neurological impairment

Presentation	Posture	Complications
Low‐tone patients	Extended neck and protracted chin Protracted and dropped shoulder with glenohumeral subluxation Flexed thoracic spine Flattened lumbar spine Pelvis tilted backwards (posterior pelvic tilt) Feet fall into plantar flexion	Difficult sitting or standing up against gravity May fall or slump forward or to the side when sitting Heavy arm when standing or walking may affect balance Foot‐drop affects walking At risk of shoulder joint subluxation
Spasticity of the upper limb (commonly seen in CP, TBI or stroke)	Adduction and internal rotation of the shoulder Flexion of the elbow and wrist Pronation of the forearm Flexion of the fingers and adduction of the thumb	Difficulty accessing under the arm when washing and dressing Difficulty holding and manipulating objects Joint and muscle pain
Spasticity of the lower limb	Flexor patterns commonly seen in CP, MS or TBI: Hip adduction and flexion Knee flexion Ankle plantar flexion and/or inversion Extensor patterns commonly seen after TBI: Knee extension or flexion Ankle plantarflexion and eversion Great toe extension	Difficulty maintaining hygiene Difficulty dressing Difficulty toileting Difficulty positioning in bed and seating Difficulty standing, transferring and walking

CP, cerebral palsy; MS, multiple sclerosis; TBI, traumatic brain injury.

Source: Adapted from Pandey and Berman ([96]).

Altered muscle tone

A person with neurological damage often suffers from changes in their muscle tone. A decrease in muscle tone is known as low tone or flaccidity, whereas an increase in muscle tone is known as high tone, which may be spasticity or rigidity (Lundy‐Ekman [67]).

Low tone

A patient with low tone will find it hard to move their affected limbs and may even have difficulty sitting up against gravity. They may have little or no activity in the muscles that lift the foot, meaning that they cannot clear their foot when walking. This is known as foot‐drop, and it can cause inefficiencies in walking, or even falls if the patient catches their toes and trips.

Because the integrity of the shoulder joint is reliant on muscle tone, patients with low tone in the arm will often present with a shoulder glenohumeral joint subluxation. In this case the humeral head is pulled downwards and forwards in relation to the glenoid fossa because the weight of the flaccid arm is unopposed by the shoulder joint muscles. This causes a palpable gap between the humeral head and the acromion. A shoulder subluxation (Figure 7.22) and hemiparetic shoulder pain can occur with many neurological conditions, but they are particularly prevalent in the stroke population (Ada et al. [3], Harpreet et al. [41]). This can be very painful if not managed well and will ultimately affect the patient's functional outcomes. The use of an orthopaedic splint or shoulder subluxation brace may provide support and comfort for the patient (Table 7.5).

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Figure 7.22 Shoulder subluxation.

Table 7.5 Shoulder subluxation supports

	An orthopaedic sling can provide enough support to a flaccid arm in the early stages of rehabilitation to prevent complications.
	Specially designed subluxation braces are appropriate for some patients.

High tone

Increased tone is a state of muscle overactivity. This is sometimes referred to as spasticity, although this is just one cause of high tone. Spasticity is caused by overactive stretch reflexes in the muscle. High tone may also be caused by an overactive flexor withdrawal reflex or by rigidity, the latter of which is a type of overactivity seen in Parkinson's disease where a muscle is stiff throughout movement.

Spasticity, the most commonly seen presentation of high tone, can occur in any muscle, but common patterns do exist (see Table 7.4). It can vary relative to the time of day, environmental factors, activity and time since onset. Spasticity is made worse with effort, pain, infection and fatigue, to name a few factors. It causes involuntary muscle movements, pain, stiffness and tightness, and ultimately affects a person's functional ability. Spasticity and its consequences can have a negative effect on a person's quality of life, so optimum management of this troublesome symptom is paramount (Bhimani and Anderson [9], Pandey and Berman [96]).

Certain medications can be used to manage spasticity in appropriate patients. There are a variety of pharmacological options for managing tone, and it is important to be aware of these when treating patients with high tone. The most commonly used are (Chang et al. [19]):

Oral baclofen: this is the first‐line antispasmodic. It is centrally acting and can cause drowsiness, so may not be appropriate for all patients.
Diazepam: a benzodiazepine that has benefits for managing tone overnight, allowing more comfortable sleep. As it tends to act on flexor reflexes, it is better suited to managing spinal spasticity than cerebral spasticity.
Botulinum toxin injection: a locally acting, long‐lasting treatment for focal spasticity.

Posture

Posture and postural control will be affected in patients with neurological impairment. ‘Posture’ describes the biomechanical alignment of the joints and orientation of the body to the environment (Duff et al. [35]), while ‘postural control’ describes the body's ability to balance and move against gravity. If a patient is unable to maintain a good postural alignment or actively change their own posture, it becomes important for those caring for them to ensure good positioning and regular movement to reduce complications such as pain and soft tissue shortening. Therefore, additional considerations should be applied for neurological patients with tonal issues, and these should always be discussed with the physiotherapist (Preston and Edmans [102]).