Tuesday, August 27, 2019

The bad news is, you may be flaccid. The good news: You may not be.

Flaccid. The word is used to describe a lot of stuff from music to political rhetoric. And it's never good. "Dude your band is totally flaccid!" said no one ever. And when it comes to body parts, its a bad thing. It can be used to describe many body parts that are not doing their job, from ear drums to muscles. 

If, after stroke, a muscle is described as flaccid, it has no movement, and no "tone." Tone means that on some--even nominal--level the muscle is working. 

If a survivor is flaccid on the "bad" side, there is no movement, no tone, no reflexes, no nothing. And if someone moves the survivor's limb it feels like moving an unattached door hinge: There's no resistance. But having a floppy arm is not the only problem. 

Subluxed right shoulder

Because muscles do more than just move things, there can be orthopedic problems. One of them is shoulder subluxation (dislocation). The muscles that hold the shoulder in its shallow joint are called the SITS muscles. When these muscles are flaccid the arm literally falls away from the joint. There are also pain syndromes associated with limb flaccidity. An example is called shoulder-hand syndrome.

Stroke survivors are often flaccid on the "bad" side immediately after their stroke. The good news is that, as the brain comes back online, flaccidity usually goes away. Usually.

But let's step back for a second. Clinicians often misdiagnose someone as flaccid. They might move the limb around a little bit and think, yeah, its flaccid. How might they prove its flaccid? They'd have to "add velocity." That is, they'd have to move the limb rapidly. But how much velocity? How rapidly? Well, to quote myself, Because spasticity is “velocity dependent” (the faster the limb is moved, the more spasticity is encountered), the test is done moving the limb at the “speed of gravity.” This is defined as the same speed a non-spastic limb would naturally drop. In other words, fast. This test is called the modified Ashworth. And its almost never done in someone who is "low tone" after their stroke.

So before the clinician claims you're flaccid, with the concomitant bad prognosis, make sure they do the Ashworth in any muscle they're claiming is flaccid.

If it remains flaccid the first week after stroke, the final outcome is usually poor.

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