Neuro Week 5 - Tone & Strength

___ and ___________ is an important aspect of motor function

ROM; flexibility

Limitation restricts normal action of muscles/joints and an alter the _____________ alignment of body segments and posture

Biomechanical

____________ movement patterns are dysfunctional and lead to additional stresses and increased energy expenditure

Compensatory

Abnormalities that change the COM and BOS increase demands on what system

Postural control system

What is important to distinguish between limited movements at the joint

Whether it is a joint restriction vs decreased flexibility vs increased muscle tone

What is tone

The resistance of muscle to passive elongation or stretch

What is tone influenced by (3)

Physical inertia

Intrinsic stiffness of the muscle and connective tissue

Tonic stretch reflex

Classifications of abnormal muscle tone (3)

Hypotonic

Hypertonicity

Dystonia

Hypotonic

Decreased or absent tone (flaccidity)

2 types of hypertonicity

Spasticity and rigidity

Dystonia is a type of

Hypertonicity

Dystonia

Prolonged involuntary movement/posturing

Brainstem lesion effect on tone: Cortical motor center loss

Increased spastic tone

Brainstem lesion effect on tone: Supraspinal motor center loss (vestibular, reticular, pontine nuclei)

Severe spasticity (often extensor distribution)

Subcortical white matter (corona radiate and internal capsule) lesion effect on tone

Increased spastic tone

Primary motor cortex lesion effect on tone

Spastic tone

Basal ganglia lesion effect on tone

Rigidity

Cerebellum lesion effect on tone

Hypotonia

Anterior horn cell/spinal nerve/peripheral nerve lesion effect on tone

Hypotonia

Is hypotonia considered a positive or negative neuro sign

Negative

Hypotonia

Less than normal resistance during passive elongation

Flaccidity

Absent muscular tone

LMN syndrome s/s

Hypotonia

Areflexia/hyporeflexive

Paresis

Fasciculations

Atrophy

Cerebral and spinal shock

UMN lesions that initially present with LMN signs

Head and neck safety considerations for hypotonia

Swallowing difficulties

Excessive flexion and extension

Shoulder girdle safety considerations for hypotonia

Joint/ligamentous laxity

Careful handling to protect joint

Subluxation

ROM limitations secondary to lack of voluntary mvmt

Pain

Trunk safety considerations for hypotonia

Balance and equilibrium reactions absent to decreased

Poor breathing

Poor postural control

Hip and knee safety considerations for hypotonia

Instability with transfers and gait

Joint laxity leading to pain

Hip subluxation or dislocation

Ankle/foot safety considerations for hypotonia

Instability during transfers and gait

Joint laxity leading to pain and/or contractures

Overall safety considerations for hypotonia

Sensation compromised - inability to move a limb from noxious stimuli

Risk for falls

Skin breakdown

Contractures

Is there a precise and quantifiable measure for hypotonia

No

Typical tests for hypotonia (3)

PROM

Observation

Palpation

PROM findings for hypotonia

Abnormal lack of resistance

Heaviness of the limb

Ability to move too freely with increased ROM > normal

Observation findings for hypotonia

"Lifeless"

Muscle wasting

Atrophy

Joint deformity

Palpation findings for hypotonia

Poor muscular definition

Muscles feel flabby, soft

Spasticity

Velocity dependent increase in muscle tone with increased resistance to stretch

Occurs only on one side of the joint

S/S of UMN syndrome

Spasticity

Hyperreflexia

Babinski

Paresis

How many beats is considered clonus

Greater than 10 beats

What muscles are usually affected with spasticity in the LE and UE

LE - extensors

UE - flexors

Rigidity

Stiffness and resistance to movement that is independent of velocity of movements

Occurs in both the agonist and antagonist

Damage to what structure leads to rigidity

Basal ganglia

Leadpipe rigidity

constant rigidity

Cogwheel rigidity

A form of rigidity where resistance to movement has a phasic quality to it

Often seen with Parkinson's disease

Clinical picture for CNS injury (UMN)

Hypertonicity develops which leads to increased tone, DTRs, and possibly clonus

Decorticate rigidity

UEs in flexion

LEs in extension

Decerebrate rigidity

UEs and LEs in full extension

Does decorticate or decerebrate have worse prognosis

Decerebrate

PT tx for patients who are in decorticate or decerebrate posturing (2)

Preventing contractures and skin breakdown

Dystonic posture

Sustained abnormal posture due to co-contraction of muscles

Dystonia is often caused by a lesion in which area

Basal ganglia

Dystonia is inherited or associated with

neurodegenerative disorders or metabolic disorders

Is dystonia treated with only PT

No

Often treated with PT and some medical intervention

Examination of tone elements (3)

1. Initial observation of resting posture

2. Passive motion testing (MAS, paranoia, clonus)

3. Action motion testing

Paratonia

Resistance to motion that is not conscious nd not spasticity

0 on MAS

No increase in muscle tone

1 on MAS

Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the ROM when the affected part(s) is moved in flexion or extension

1+ on MAS

Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remained (less than half) of the ROM

2 on MAS

More marked increased in muscle tone through most of the ROM, but affected part(s) easily moved

3 on MAS

Considerable increase in muscle tone, passive movement difficult

4 on MAS

Affected part(s) rigid in flexion or extension

*NOT rigidity

In what setting is the modified Tardieu scale used in

Performed more in the research setting

Potential consequences and effects on function for hypertonicity (7)

Joint contractures

Skin breakdown

Gait abnormalities

Postural abnormalities

Skeletal deformities (esp. peds)

Difficulty with ADLs

Secondary loss of strength (tight but weak)

PT intervention for hypotonicity

Positioning and handling

ROM

WB

Facilitation techniques

Shoulder taping

NMES/FES

Incorporating function

Position and handling techniques for hypotonia

Splinting and bracing

Use of GIVMOHR sling

Facilitation techniques for hypotonicity

Quick stretch/tapping

Approximation (encourage WB)

Icing

NMES/FES decreases the risk for

Shoulder subluxation

PT interventions for hypertonicity

Deep pressure

Joint traction

Rhythmic rotation (PNF)

Sustained prolonged stretch

Thermal modalities

Biofeedback

Vibration

E-stim

Acupuncture

Sustained/prolonged stretch for hypertonicity can be accomplished using what techniques

Splints or serial casting

Other interventions for hypertonicity

Aquatic therapy (>90°F)

Quadruped

Rolling

WB activities

Tone-reducing orthotics

Incorporating function

Management of tone by the medical team

Pharmacological intervention for hypertonicity

Surgical intervention

Pharmacological management of hypertonicity

Baclofen - oral or intrathecal

Diazepam, calcium channel blockers, Zanaflex, and cannabis

Botox

Oral Baclofen can have what adverse effect

Sedation and fatigue

Surgical interventions for tone

Tendon lengthening (common in CP)

Deep brain stimulation

_______ __________ coupled with __ intervention often yields the best results

Medical management; PT

Elements of motor performance

Muscle strength/force generation

Power

Endurance

Length or muscle extensibility

Muscle atrophy

Loss of muscle bulk

What are the 2 types of muscle atrophy

Disuse and neurogenic

Does disuse or neurogenic atrophy occur faster and what is the timeframe for both

Neurogenic occurs faster

Disuse: weeks to months

Neurogenic: 2-3 weeks

Muscle performance

Capacity of muscle)s) to generate force

Muscle strength

The force exerted by muscle(s) to overcome a resistance

Isometric/isokinetic/isotonic

Muscle power

Work produced per unit of time OR the product of strength and speed

Characteristics of power

Length tension characteristics

Viscoelasticity

Velocity

Metabolic adequacy (fuel storage and delivery)

Neuromuscular factors

Weakness

Inability to generate sufficient levels of force

Paresis

Partial weakness

Plegia

Absence of strength

Manual muscle testing

Pt must demonstrate isolated joint motion

Prefer functional testing of muscles

May have to use antigravity as cannot isolate against gravity but may be able to without

Handheld dynamometry has been validated in what populations

CVA and CP

May also be useful for patients with other neuro dx

Abnormal UE flexion synergy

Scapula: retraction and elevation

Shoulder: Abduction and ER

Elbow: Flexion*

Forearm: supination

Wrist: flexion

Finger/thumb: flexion and adduction

Abnormal UE extension synergy

Scapula: protraction and depression

Shoulder: adduction* and IR

Elbow: extension

Forearm: pronation*

Wrist: flexion or extension

Fingers/thumb: flexion and adduction

Abnormal LE flexion synergy

Pelvis: elevation and retraction

Hip: flexion*, abd, ER

Knee: flexion

Ankle: dorsiflexion and inversion

Toe: dorsiflexion

Abnormal LE extension synergy

Hip: extension, adduction*, IR

Knee: extension*

Ankle: plantar flexion* and inversion

Toes: plantarflexion

For the UE, what is the most common abnormal synergy

Flexion

For the LE, what is the most common abnormal synergy

Extension

What do you do for patients in synergy

Testing muscle

Strength dependent on isolated movement

Describe the % of ROM

Muscle fatigue

A decline is muscles performance resulting from prolonged or sustained use of the target muscle group

Muscle endurance

The muscle's ability to sustain forces or generate forces repeatedly overtime

importnat to stermine functional capacity

Fatigue

Overwhelming sense of exhaustion and decreased capacity for physical work (or mental work) at the usual level

What fatigue scale can be used as an outcome measure

Fatigue severity scale

When should functional strength testing be used

When MMT isn't appropriate

Estimation of strength made from observation of active movements during performance of functional activities

What are some adult motor assessment tools (9)

Fugl-Meyer assessment

Motricity Index

Mayo-Portland Adaptability Inventory

Wolf Motor Function Test

Arm Motor Ability Test

Canadian Neurological Scale

Modified Motor Assessment Scale

Muscular Impairment Rating Scale

Mayo Test