Exam 1 Lecture 2 Pathophysiology of Tone part 2: Tone to end Flashcards Preview

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Flashcards in Exam 1 Lecture 2 Pathophysiology of Tone part 2: Tone to end Deck (43)
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What is tone?

•Muscle tone is the resting level of tension in a muscle in response to passive stretch

  • –Allows a muscle to make an optimal response to voluntary/reflexive commands
  • –Reflects balance of excitatory and inhibitory influences


How does damage to the CNS effect tone?

•Damage to central nervous system often results in an alteration in regulation of muscle tone



What is it


Other symptoms

PT managment


–Decrease in resistance to passive limb manipulation


  • •Infants have a floppy quality or “rag doll” appearance
    • –Arms and legs hang by sides
    • –Little or no head control
  • •Other symptoms include
    • –Difficulty with mobility, posture, breathing and speech, lethargy, ligament and joint laxity, and poor reflexes
  • •PT Management
    • –Developmental positions, strengthening, sensory stimulation, positioning and bracing, weight bearing


Hypotonia vs muscle weakness


Hypotonia is Not the same as muscle weakness

  • –True muscle tone is the ability of a muscle to respond to a stretch  
    • •Low tone results in a slow ability to initiate a muscle contraction and an inability to maintain the contraction
  • –True muscle weakness is characterized by the force exerted by a muscle is less than expected


Hypotonia: causs


•Many causes though the underlying cause is often difficult to determine

  • –Trauma, environmental factors, or by genetic, muscle, or central nervous system disorders
    • •Down syndrome, muscular dystrophy, cerebral palsy etc


Hypotonia: development as an adult

Development as an adult may be associated with

  • –Cerebellar degeneration (such as multiple sclerosis, Friedreich’s ataxia, or multiple system atrophy)
    • •Neurons that control muscle coordination and balance,  deteriorate and die


Is hypotonia or hypertonia more common?


Hypertonia is more common




More common than hypotonia
–Increase in resistance to passive limb manipulation
–Damage to UMN and or descending pathways making afferent pathways more responsive
–Can be spastic (spacticity) or rigid (rigidity)


Pathological spread of reflexes


  • Sign of hyperactivity
  • Contraction of muscles that have different actions while eliciting a reflex
  • Contraction of thigh adductors while testing patellar reflex


What is spacticity?


Velocity dependent increase in resistance to a passive stretch

  • –Classified as a symptom of UMN syndromes
  • Can include
    • –Spastic paresis—spasticity combined with muscle weakness, often in someone with an incomplete SCI
    • –Spastic paralysis—absence of voluntary muscle control in someone with spasticity
  • Can result in secondary impairments in muscles and other tissues
    • Stiffness, contracture of muscle, tendon, joint
      • Spastic muscles seem to undergo intrinsic structural changes which explains why more tension is usually developed with spasticity over time when stretched relative to non spastic muscles


What is spastic paresis?

Spastic paresis—spasticity combined with muscle weakness, often in someone with an incomplete SCI


What is spastic paralysis?

Spastic paralysis—absence of voluntary muscle control in someone with spasticity


What are two things that clinicians recognize the same spasticity in?

–Clinicians also recognize that the same spasticity is triggered by the light touch or hair tug or a hitting a bump in a wheelchair

(I'm not sure what "also" is referring to here)



hyperactive stretch reflex


Characteristics of spasticity following cerebral lesions




–Damage to corticobulbar fibers
–Decrease excitation of descending inhibitory pathways
–Extensors of LE & flexors of UE
–Easier to pharmacologically control


Characteristics of spasticity following spinal cord lesions


–Damage to all descending activity
–Flexor & extensor involvement
–More resistant to pharmacologic control


Must use different techniques than what we would use if it was a brain injury (for example, to break clonus)


Synergy Patterns of Extremities: Flexion


–Upper extremity

  • •Scapular retraction/elevation or hyperextension, shoulder abduction, external rotation, elbow flexion, forearm supination, wrist and finger flexion
  • Looks like primitive reflex

–Lower extremity

  • •Hip flexion, abduction, and external rotation, knee flexion, ankle dorsiflexion, inversion, and toe dorsiflexion


Synergy Patterns of Extremities: Extension


–Upper extremity

  • •Scapular protraction, shoulder adduction, internal rotation, elbow extension, forearm pronation, wrist and finger flexion

–Lower extremity

  • •Hip extension, adduction, and internal rotation, knee extension, ankle plantarflexion, inversion, and toe plantarflexion


what are Synergy Patterns of Extremities?


A consistant pattern of spacticity that can be documented in one term (usually indicate UE, LE, or both)

Sometimes good

Sometimes bad


Negative outcomes of Spacticity: (7)

  1. –Interference with mobility, transfers, ROM, and ADLs
  2. –May lead to heterotopic ossification- bone forms where should have a muscle
  3. –May cause pain and discomfort, possibly to the point of sleep disturbance
  4. –May lead to contractures or dislocations
  5. –Increase risk of skin breakdown
  6. –Bowel and bladder dysfunction
  7. –Decreased pulmonary function


Positive outcomes of Spacticity: (6)


  1. –Maintain muscle tone
  2. –Help support circulatory functions
  3. –Assist with mobility, transfers and ADLs
  4. –Reduced osteopenia
  5. –Prevent formation/decrease risk of DVT
  6. –Sudden increase in spasticity can alert patient to other medical problems such as bladder infections, skin breakdown, or fever


Things about Ashworth and Modified Ashworth Tests (11)

  1. –Clinical gold standard tests for spasticity
  2. –Evaluate muscle tone and stretch reflexes elicited by movement
  3. –Assess all joints in available ROM in same position for all joints
  4. –Perform movement opposite to muscle being tested
  5. –Compare both sides
  6. –Spasticity should be assessed during one quick movement and should not be repeated as this may loosen the muscle
  7. –Always use the highest measure
  8. –Do not perform long passive stretch or perform movement gently
  9. –Measure passive ROM as part of assessment
  10. –Additional grade was added (1+) for the Modified Ashworth to enhance sensitivity and accommodate hemiplegic patients who typically graded at the lower end of the scale
  11. –Does not address frequency or severity of spasms or influence on daily activities


Contensts of the Ashworth Scale

Ashworth Scale

•0 -No increase in muscle tone
•1 -Slight increase in muscle tone, with the limb “catching” when it is flexed or extended
•2 –More marked increase in tone, but limb easily flexed
•3 –Considerable increase in tone; passive movement difficult
•4 –Limb rigid in flexion and extension


Contents of Modified Ashworth Scale

Modified Ashworth Scale

•0 -No increase in muscle tone
•1 -Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected limb) is moved in flexion or extension
•1+ -Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM
•2 -More marked increase in muscle tone through most of the ROM, but affected limb) easily moved
•3 -Considerable increase in muscle tone, passive movement difficult
•4 -Affected limb) rigid in flexion or extension


•Wartenberg Pendulum Test

For Spacticity: Can use test to help determine if interventions ore working well or not.

–Assesses responsiveness of knee extensor muscles to rapid, gravity assisted stretch

  • •Person is supine on table with knee and lower leg hanging over the edge
  • •Examiner grasps the heel of one foot, extends the knee, releases the heel and allows the lower leg to swing
  • •Joint angle during first swing of highest degree of knee flexion is measured


Modified Terdieu Scale


  • •Tests for spasticity; commonly used in pediatrics
  • •R1 is first catch
    • –Resistance to maximal velocity stretch
  • •R2 is end of PROM
    • –Amount of muscle contracture/available length
  • •What is ideal? The closer together they are the less spasticity there is - closer to end range
  • •What is functional? The R1

Different than ashworth because it is for pediactrics

We want resistance to be as close to end range as possible (because we can just teach them to use the range before it catches)

Things before R1 is the functional range.


Spinal Cord Assessment Tool for Spastic Reflexes (SCATS)

Spinal Cord Assessment Tool for Spastic Reflexes (SCATS)

  • Tests ankle clonus and flexor/extensor spasms in the lower extremities
  • Ankle Clonus—rapid, passive dorsiflexion
    • •0—no reaction;
    • •1—mild, <3sec;
    • •2—moderate 3-10 sec;
    • •3—severe >10 sec
  • Flexor Spasm—pinprick of 1 sec to medial arch of foot
    • •0—no reaction;
    • •1—mild, <10 deg gr toe ext OR <10 deg hip/knee flexion;
    • •2—moderate 10-30 deg hip/knee flexion;
    • •3—severe, >30 deg knee/hip flexion
  • Extensor Spasm—passive extension of knee and hip simultaneously
    • •0—no reaction;
    • •1—mild, <3sec;
    • •2—moderate 3-10 sec;
    • •3—severe >10 sec
  • All tested supine


Spacticity: Medications for treatment


  • –GABA agonist (gamma-Aminobutyric acid receptor)
  • –Oral, Intrathecal Pumps


  • –increase in GABA receptor affinity
  • –Limited use because of sedation
    • •Xanax, Paxal, Temazepam (Restoril)

•Dantrolene sodium (Dantrium®)

  • –Acts at muscle relaxant
  • –Generalized weakness

•Gabapentin (Neurontin®)

  • –Use limited by sedation•

Botulinum toxin type A

  • –One of the most effective in spasticity of cerebral or spinal origin


Intrathecal Baclofen pump


Can insert pump directly into the spinal cord.

Can create a direct entry for bacteria into the spinal cord.

Want the tube running in to intrathecal? Area

Important to know where the pump is if the patient has it so we don’t disrupt it


Spacticity: PT Managment


–Education regarding noxious stimuli, positioning, skin etc
–ROM and stretching and exercise program- maintain muscle length
–Motor control, weightbearing
–Standing frame- can get prolonged stretches
–Splinting/serial casting depending on joint and severity

–Muscle lengthening - agonist
–Muscle strengthening – antagonist
•Loss of strength for weeks to months
–Gait training
–Motor learning - constraint induced forced use