Interventions for Abnormalities in tone and spasticity (week 7)

what is the tone continuum from least to most

flaccid, hypotonic, normal, hypertonic

how does UMNL effect tone

increased spasticity

how does LMNL effect tone

decreased spasticity

what are the 3 categories of hypertonia

spasticity, rigidity, dystonia

what are the two types of rigidity

cogwheel and lead pipe

why do we care about one

impacts motor control, posture control, restricts ADLs, contractures, effects hygiene, skin breakdown, painful alignment

what is flaccidity

abnormal presence of muscle tone where there is absent resistance to passive movement. Often lack of active movements and severe weakness.

what is hypotonia

abnormal decrease in muscle tone where there is decreased resistance to passive movement, often combined with weakness but active movement is possible.

hypotonia is often attributed with

peripheral nerve lesion, genetics such as down syndrome, ALS, CIPD, or shock immediately following UMN lesion

what are some characterisitcs to hypotonia

heavy floppy limbs, limp posture, soft to palpation, hyper mobility, decreased motor control and force, decreased postural stability, decreased sensation.

what are some safety considerations for hypotonia

difficulties swallowing, painful shoulders, poor breathing, painful hips and knees, painful ankles, overall fall risk

recovery approaches to hypotonia

early and intensive training, utilize strategies to initiate muscle activity (rood and weight bearing), technology

compensation approaches to hypotonia

assistive devices, bracing, equipment, completing tasks with the same limb, patient and family education

what can help hypotonia at the joint

adaptive and supportive braces, table top suport, arm trough, slings, bed positioning

when completing functional activities with flaccidity what should you focus on

positioning limb within a functional range and stabilizing the trunk in normal alignment

what are some facilitation techniques for hypotonia

quick stretch / tapping, vibration, manual contacts and or approximation, use of resistance and overflow, flat brushing or icing

what are some strengthening techniques for hypotonia

gravity and body weight, isometric and eccentric, manual resistance

what is good education to provide patients with hypotonia

bed and wheelchair positioning, management of flaccid limb during transitions, proper ROM and stretching, equipment, skin checks, safety system

what are some good home activities for hypotonia

bed positioning and rolling, stretching, sit to stands, transfer, bed positioning and rolling

what are some examples of hypertonicity

spasticity, spasms, spastic co-contractions, babinski, clonus, exaggerated DTRs, mass movements, stereotypes movement synergies, assocaited reactions

what is spasticity

velocity dependent hypertonicity that varies with movemnt direction. Tone increased above threshold speed. Returns towards a fixed position / angle. Typically if one muscle is spastic, its antagonist will not be.

what is rigidity

increased tone throughout the available range that does not depend on imposed speed. Co-contraction of agonists and antagonists. Immediate resistance to reversal of movement. Limb does not return toward a fixed posture / extreme joint angle.

what is dystonia

variable tone, typically seen in posture

where are brain lesions commonly with spasticity

brainstem (cortical motor center and supraspinal motor center), subcortical white matter, primary motor cortex

where are brain lesions with rigidity

basal ganglia, commonly seen with parkinsons

where are brain lesions with hypotonia

cerebellum

how does hypertonia impact function

joint contractures, skin breakdown, gait abnormalities, postural abnormalities, skeletal deformities, difficulty completing ADLS, secondary loss of strength

what are hypertonicity interventions

inhibition, strengthening, managing secondary complications, medical management, surgical management

what are some inhibitory techniques for hypertonicity

sustained positioning / stretching / PROM, broad contact / slow contact, deep tendon pressure, joint traction, rythmic rotation / dissociation

what are some techniques for sustained positioning and ROM

serial casting, dissociation of UE/LE, trunk pelvis dissociation, weight bearing, prone

what is the goal of deep pressure

to increase joint awareness and decrease spasticity

how do you apply deep pressure

non-noxious sustained compressive pressure along the longitudinal axis of a tendon

what is the MOA for deep pressure

activation of GTO induced elongation to the muscle which thereby reduces tone

goal of joint traction

increased joint awareness along with increased activation of joint receptors

what are contraindications of joint traction

extremely hypomobile or hypermobile joints, hypotonicity.

what is the process of rhythmic rotation

slow, low amplitude rhythmic rotary movements of the body / head which may provide mild receptive input to the vestibular system and CNS.

what is the goal of rhythmic rotation

increased state of relaxation provides some generalized dampening of both spastic and rigid muscle groups.

what is the MOA for rhytmic rotation

total body inhibition achieved through decreased output form the vestibulospinal reflex

heat for hypertonicity

dampens muscle tone and excitability. 10 minutes of application may be sustained for 30 minutes.

cold for hypertonicity

decreases muscle spindle activation and or nerve conduction velocity which decreases muscle tone.

contraindication for cold for hypertonicity

individuals with sensory impairments, poor cognition, or intolerant diagnoses.

why is aquatic therapy good for hypertonicity

warm temperatures, buoyancy provides a greater degree of safety and decreases load forces, resistance to movement in any direction is beneficial.

hypertonicity patient education

optimal positioning, therapy techniques into daily routines, varying positions, prolonged stretching and bracing

what are some ways to medically manage hypertonicity

chemo-denervation agents, CNS depressants, surgical procedures

how does botox work

it is injected intramuscularly into spastic muscle and is effective for roughly 3 months.

side effects of botox

localized pain, anticoagulants, weakness

PT considerations for patients with botox

collaboration with rehab team / PM&R, rehab is required for any long term changes

oral baclofen

more of a global agent for spasticity that is taken orally 6-8 hours apart

side effects of oral baclofen

feeling sleepy, tired, or weak, dizziness, n/v, headaches, dry mouth since it is a CNS suppressant.

why is it good to manage oral baclofen

since it is a CNS suppressant, it can decrease neuroplasticity

intrathecal baclofen pump

a pump surgically implanted under the fascia of the lower abdomen that delivers baclofen through catheter into the CSF surrounding the spinal cord

indications for intrathecal baclofen pump

severe spasticity, impeding function or care, contractures, not well controlled with oral agents

what is selective dorsal rhizotomy

a procedure performed to damped some of the sensory input associated with spastic hypertonicity. problematic ascending dorsal nerves are cut to inhibit control.

deep brain stimulation

used for parkinsons patients or congenital dystonia and involved electrical stimulation to the thalamus

what is the goal of surgeries for secondary orthopedic issues

restore ROM, decrease contractures, preserve MSK function

what are examples of secondary orthopedic surgeries

tendon lengthening procedures, tendon transfer, osteotomies and arthrodesis