neuro muscle tone

what is hypertonia ?

excessive resistance to active or passive stretch

what are the 2 types of spasticity ?

clasp-knife and clonus

what is spasticity?

velocity dependent resistance to movement due to neuromuscular over activity with resistance to movement increasing as the speed and amplitude increases

what is clasp-knife?

initial catch followed by release

what is clonus ?

cyclical spasmodic alteration of muscle contraction & relaxation with sustained passive stretch

what is rigidity?

severe hypertonia, both agonist & antagonist are hyperactive

NOT speed dependent

what are the two types of rigidity?

lead pipe and cogwheel

what is lead pipe rigidity?

constant resistance to motion throughout the entire ROM

what is cogwheel rigidity?

resistance that stops and starts as the limb is moved through its ROM (jerky, ratchet)

what is hypotonia ?

decreased resistance to active and passive stretch, LMN is not functioning

can also be due to disuse of muscle over time

paralysis

impaired ability to generate muscle tone, problem within the muscle/motor neuron leading to muscle or SCI

can have increased tone after initial shock

what is flaccidity?

absence of muscle tone, also problem with muscle/motor neuron leading to muscle or SCI

more severe than paralysis

what is a sustained clonus?

clonus greater than 10 beats

MAS 0

no increase in muscle tone

MAS 1

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

MAS 1+

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

MAS 2

more marked increase in muscle tone throughout most of the ROM, but affected part(s) easily moved

MAS 3

considerable increase in muscle tone, passive movement is difficult

MAS 4

affected part(s) rigid in flexion or extension

what is the Brunnstrom Approach?

associated with stroke recovery, loss of top down control resulted in emergence of movement patterns (synergies) which are encouraged

Brunnstorm stage 1

no volitional movement (flaccidity)

Brunnstorm stage 2

appearance of basic limb synergies, movement in associated reactions (spasticity appears)

Brunnstorm stage 3

voluntary movement begin in synergies (increased spasticity)

Brunnstorm stage 4

movement patterns are not dictated solely by limb synergies, voluntary movement outside of synergies (spasticity decreases)

Brunnstorm stage 5

independence from limb synergy patterns, more complex movement (spasticity further decreases)

Brunnstorm stage 6

isolated joint movements are performed with coordination (spasticity disappears)

Brunnstorm stage 7

normal motor function is restored

what are limb synergies in regards to Brunnstorm?

group of muscles that produce a predictable pattern movement in flexion or extension patterns

what are associated reactions in regards to Brunnstorm?

involuntary and automatic movement of a body part as a result of an intentional active or resistive movement in another body part

what is homolateral synkinesis in regards to Brunnstorm?

flexion pattern of the involved UE facilitates flexion of the involved LE

what is Raimiste’s phenomenon in regards to Brunnstorm?

involved LE will abduct/adduct with applied resistance to the uninvolved LE in the same direction

what is Souque’s phenomenon in regards to Brunnstorm?

raising the involved UE above 100 degrees with elbow extension will result in extension/abduction of the fingers

what is the goal of neuro-development treatment (NDT) ?

patient learns to control movement through activities that promote normal movement patterns that integrate function

what is therapeutic handling?

primary intervention strategy, used to facilitate/inhibit movement interfering with normal movement patterns using key points of control

what are the different ways to manage hypertonicity?

prolonged icing, prolonged stretch, inhibitory pressure, neutral warmth, rhythmic rotation, weight bearing, modalities, serial casting

prolonged icing

reduced neurotransmission & spasticity, muscle spindles cooled to decrease excessive stretch reflex

effects can last 1-2 hrs

prolonged stretching

inhibition of hyperactive muscle responders, active/passive stretching for prolonged time

can also be done with splinting/casting

inhibitory pressure

firm/mod inhibitory pressure on tendons

manually and/or through devices such as splints or positioning (WB)

neural warmth

stimulates thermoreceptors and activates parasympathetic response

10-20 mins

rhythmic rotation

slow, repeated rotation of a limb at a point where limitation is noticed

gently moved into range and repeated

modalities

electrical stimulation such as NMES or TENS

used on antagonist muscle for reciprocal inhibition

serial casting

when others fail, maintained pressure, low load prolonged stretch

recast every 5-7 days as ROM progresses

upper flexion synergy

scapular retraction, elevation

shoulder flexion, abduction, ER

elbow flexion

forearm supination

wrist & finger flexion

lower flexion synergy

hip flexion, abduction, ER

knee flexion

ankle DF, inversion

toe DF

upper extension synergy

scapular protraction

shoulder extension, adduction, IR

elbow extension

forearm pronation

wrist and finger flexion

lower extension synergy

hip extension, adduction, IR

knee extension

ankle PF, inversion

toe PF

decorticate

elbows, wrist, and fingers flexed, legs extended & IR

decerebrate

elbows extended, legs extended, and IR

more indicative of severe damage

critical elements of managing synergies

movement opposite to pattern, reciprocal inhibition, begin distal to proximal for tone inhibition, static hold on intermediate joints opposite to pattern

things to manage hypotonicty

quick stretch

tapping

resistance w/o overload

approximation

weight bearing

positioning

strengthening w/o overload

quick stretch for hypotonicity

stimulation of muscle spindle which results in reflex facilitation of the muscle to prevent overstretching as a protective mechanism

approximation/weight bearing

facilitates postural extensors needed to stabilize the body

improved proprioception/joint awareness

tapping for hypotonicity

light tapping over a tendon or muscle belly to facilitate a voluntary contraction