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Official Publication of Orofacial Chronicle , India

www.jhnps.weebly.com

ORIGINAL RESEARCH
PRESSURE INTERVENTION BY SPYGMOMANOMETER ON
THE POST-STROKE HEMIPLEGIC PATIENT
Mohamed.Sheeba Kauser
1
MPT, Akheel M.D
2
MDS


1-MPT (Neurology), ITS Paramedical College, Muradnagar, U.P.,India
2- Oral & Maxillofacial Surgeon, Chennai T.N, India

ABSTRACT:

Background: We aim to investigate whether the direct application of pressure by
sphygmomanometer has any effect on spasticity levels in post stroke hemiplegic
patient.
Materials and Methods: We studied on a patient who sustained first ever
ischemic stroke. After relaxing in a supine posture for 10 min, subject received
the interventions for 10 min with rest intervals. The Modified Ashworth Scale
scores were recorded before and immediately after each intervention.
Results: The patient showed no significant changes in Modified Ashworth Scale
scores but there was a significant decrease in spasticity level. The patient had an
immediate reduction in the tone till the time therapy is given, but after the pressure
is removed, there was again increase in the tone of the muscles of upper limb.
Conclusion: The direct application of pressure by sphygmomanometer had no
change in the levels of spasticity in post stroke hemiplegic patient.
KEY WORDS: Modified Ashworth Scale; spasticity; sphygmomanometer,
pressure.


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Cite this article: Mohamed Sheeba k., Akheel M.D:

Pressure intervention by
spygmomanometer on the post-stroke hemiplegic patient: Journal of head & neck
physicians and surgeons Vol 2 Issue 1 2014: Pg 33-41

INTRODUCTION:

Interruption of the blood supply to the brain, usually caused because a rupture of
blood vessel or blockage of blood vessel by a clot which is called as a stroke. Any
blaockage stops the supply of nutrients and oxygen, causing diffuse damage to the
brain tissues.
1
It is a major public-health burden worldwide for increase in
mortality rate.
2
Any damage to the pyramidal tracts and its accompanying Para-
pyramidal (corticoreticulospinal) fibers gives rise to the upper motor neuron
(UMN) syndrome.
3
Spasticity has generally been assessed clinically through
physical/clinical examinations using techniques such as the Modified Ashworth
Scale (MAS)
5
, Tardieu scale
6
, Pendular test
7
etc. The effects of different treatments
of muscle spasticity such as stretching
8
, weight bearing
9
,

joint positioning
10
,
electrical stimulation
11
, oral medications
12
, shock wave therapy
13
, ultrasound
therapy
14
, cryotherapy
15
, vibration
16
have been examined.
Pneumatic pressure technique has been used in treatment of various neurological,
orthopedic and medical conditions. MC Knight and Schomberg
18
tried pneumatic
pressure using air splints in the treatment of rheumatoid arthritis and observed that
air pressure resulted in reduction of pain, swelling and stiffness of hands and
increase in the range of motion of the affected joints. Spasticity is a common
problem among stroke patients requiring rehabilitation. Pneumatic pressure applied
through air splints were found to be useful in reducing the excitability of spinal
motor neurons after the stroke
19
. Similarly Robichaud and Agostinucci observed
that circumferential pressure applied with air splints decreased alpha motor neuron
excitability among patients with spinal cord injury
20
.But this effect lasted only as
long as the pressure was applied.
Therefore in this study we introduced pneumatic pressure in treatment protocol
rather as splint in conservative management by using sphygmomanometer.

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There are studies showing that application of pressure by the application of
sphygmomanometer helps in spasticity. Hence aim of this study is to know
whether pressure has any effect on reducing tone and extensibility of limb.
CASE REPORT:
A 45 year old patient with post stroke hemiplegic patient is reported on the basis
of inclusion and exclusion criteria and was assigned by direct application of
pressure stimuli .Inclusion criteria were as follows: Post stroke Middle Cerebral
Artery lesion patient, onset of stroke > 4 weeks, patient age: 30 60 years,
increased muscle tone of the affected upper limb biceps brachii muscles (MAS
score 1),Receiving no stimulant or relaxant medications (including anti- spasticity
and anti- convulsion medications, and pharmacological injections), no peripheral
nerve injury, no history of any other neurological problem like head injury, is able
to follow and obey commands.
Exclusion criteria were Folstein MMSE score below 23, severe aphasia, dementia,
any hearing/ visual problems. Stroke diagnosis was based on computed
tomography (CT) or magnetic resonance imaging (MRI), as well as neurological
functions. The study was conducted without altering the existing medication
regimes of the patients. MAS score, was recorded before (pre) and immediately
after (post) interventions.
Procedure: After relaxing for 30 min in the supine posture, patient received the
interventions for 10 min. He received pressure through using sphygmomanometer,
the B.P cuff was tied on the biceps brachii muscle belly and pressure was applied
relatively to the patient diastolic pressure and systolic pressure which are checked
before the starting of the treatment protocol. There by the approximation of the
value of pressure applied is 80MMHG aiming for the extension of elbow and
supination of wrist. The pressure is given with regular interval gaps of 1 minute
with completion of process of one set having 10 repetitions along with hold time of
5 minutes
21
. This process is carried for 10 sets in one session of treatment. On the
day of treatment two sessions of treatment was given on the alternative days.0n the
other day the patient was treated without pressure therapy intervening the tradition
therapy of spasticity. Spasticity was assessed by using Modified Ashworths Scale
before and after the intervention.

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MEASUREMENT OF MUSCLE TONE:
The extent of spasticity was measured using the Modified Ashworth Scale (MAS)
for the biceps brachii and wrist flexor muscles. The MAS is an age old established
and reliable instrument, which makes use of a 6-point scale to score the average
resistance to passive movement for each joint. To facilitate analysis of data, the
MAS scores (0, 1, 1+, 2, 3 and 4) were assigned numerical values designated as
computed MAS scores (0, 1, 2, 3, 4 and 5, respectively). Changes in MAS scores
were calculated by the subtraction method.
The procedures in the present study were in accordance with the ethical standards.
Patients were given information saying that participation was voluntary and that
they could choose not to participate at any time without having to give a reason
DATA ANALYSIS:
A pre- test, post- test experimental control group design was used for the study.
Data was tabulated on master chart. Statistical analysis was performed using SPSS
16.0 version software. Man Whittney U test was used for between group analysis
of Age and MAS pre and post. Independent T test was use for within analysis of
pre and post. Mean difference between the pre and post was calculated and further
analysed to find out whether the intervention is significant or not. Significance
level was set at P<0.05.
RESULTS:
Statistically differences were observed within pre and post reading of MAS.
Pre and post analysis for MAS was done by Man Whitney-Utest.

Statistically non significant differences was observed between post and post
readings.
MAS IN BOTH
0
1
2
3
4
With pressure Without pressure

MAS SCORES
PRE
POST

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Figure 2: showing statastical analysis of MAS with and without intervention.
DISCUSSION:

We compared the efficacy of pressure application using blood pressure cuff with
that of conventional physiotherapy in reducing the spasticity of post stroke
hemiparitic patients using randomized controlled methods. Changes in spasticity
were assessed with MAS scores. Our result shows no significant improvement in
the MAS scores between DAPS group and control group but within group analysis,
the DAPS group improved significantly after pressure application. Whereas no
change was there in control group.
We used modified Ashworths scale to assess spasticity (M.A.S: Bohannon and
Smith 1987, Wade 1992, Engsberg et al.1996). Spasticity was reduced after the
intervention in the DAPS group but not in control group. One reason of spasticity
reduction may be associated with tonic pressure reflex. DAPS treatment is
intended to apply multiple pressure stimuli simultaneously to the fully stretched
spastic muscles of upper limb. The stimuli initially produce intense contraction
(known as TPR) of the spastic muscles. After a continuous application of pressure
stimuli on the muscles, the spasticity levels got reduced which can be justified by
the previous study done by A.B Tally,K.P.S Nair,T.Murali
17
.
Spasticity level reduction can be due to activation of golgi tendon organs which
causes autogenic inhibition which is justified in previous studies done by
Johnstone et al 1983, Poole and Whitney et al 1990 in which they explained that
thermal and pressure application reduce stimulation of thermal and tactile receptors
which show a rapid adaptation to stimuli
22, 23.This
then decrease excitability of
intermediate neurons and motor neurons and increase sensorial input. It is claimed

TREATMENT ANALYSIS OF
MAS IN THE PATIENT
0
2
4
Without pressure

With pressure

MAS
SCORES


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that autogenic inhibition is ensured by the activation of Golgi tendon organs.
Which resulted in increase stability facilitates motor development and improves
normal motion patterns.
Decrease of spasticity is also because the impulses are given directly on
cuteaneous receptors which directly influence motor neurone excitability in the
spinal medulla or indirectly by reticular formation. Neutral heat and pressure
applications decrease the excitability of thermal receptors and tactile receptors
which slow a rapid adaptation to the stimuli. Therefore they decrease the
excitability levels of both interneuron and motor neurons which is justified in
previous studies done by Johnstone et al 1983 and Barnard et al 1984
24
.
Reduction of spasticity can be increase in temperature. Skin temperature can be
elevated by friction between the blood pressure cuff and skin
22
. This can cause
relaxation of muscular and other soft tissues but also to a decrease in gamma
afferent fiber activity that would lead to a decrease in impulses from the muscle
spindles with a consequent inhibition of impulses to the alpha fibres
6
.
There was no change in the spasticity level as measured by the Modified
Ashworths Scale as only conventional physiotherapy was given to the groups
wherein stretching and techniques based on Bo bath approach was given. Several
limitations of this study should be acknowledged. First, it included only a small
number of participants, therefore future studies with a larger number of
participants are needed to confirm our results. Samples included were only post
stroke hemiplegic patients, therefore results cannot be generalized to person
outside the sample population. Secondly, only assessments for spasticity motor
function, activity limitation were made in this study, thus future studies should
evaluate changes in quality of life to explain the contribution to stroke
rehabilitation.
FUTURE RESEARCH:
Larger number of sample size should be included to confirm our results and
generalize the results to population outside our sample population.
Quality of life, activity limitations and motor functions should also be
assessed for the patients.

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CONCLUSION:
The present study provide good evidence of anti spastic effect of direct application
of pressure stimulus in post stroke hemiplegic patients
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Acknowledgements: The author wishes to thank the Almighty, Guides and all
those who have helped in this work.

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Conflict Of Interest: The present study does not have any conflicts of interest and
Author has no issues if JHNPS shares data and materials of present study. The
author adheres to all the policies of JHNPS.
Source of Funding: The present study did not receive any grant for practical
administration and no personal payment of salary has been given to anyone
participating in the present study.

Correspondence Addresses :
Corresponding Author:
Mohamed Sheeba Kauser
Post graduate Resident
I .T.S Paramedical College, Muradnagar, Ghaziabad, Uttar Pradesh
Email: sheebaishaq.doc@gmail.com