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Tone Management Flashcards

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1
Q

what is ms tone and why is it adaptive

A

resting tension in ms
resistance to elongation/stretch when relaxed

state of partial ms contraction at rest that supports posture and provides baseline tension for volitional contractions

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2
Q

what are anatomical structures that contribute to the complex control of a ms fiber (5)

A

cortex
brainstem
cerebellum
spinal stretch reflexes
ms spindles

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3
Q

clinical reasoning: do you always want to dec ms tone if person has hypertonicity?

A

not necessarily

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4
Q

clinical reasoning: do you always want to inc ms tone if person has hypotonicity?

A

yes

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5
Q

what are 4 pathologies can result in hypotonicity and how

A

LMNL:
- impacts ant horn of SC, ventral nerve root, spinal nerves, or peripheral nerves

UMNL:
- damage to corticospinal tract -> have hypotonicity in acute/shock phases & even long term s/p stroke

chromosomal abnormalities (ie downs)
cerebellar lesions

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6
Q

what is hypotonicity and how does it present

A

dec resistance to passive elongation
limbs/trunk feel heavy/floppy
- ms are soft/squishy to palpation

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7
Q

what is hypotonicity associated with (2)

A

dec stretch reflex
dec DTRs

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8
Q

why do you commonly see secondary weakness in hypotonicity

A

those w normal strength w low tone require more energy for more tension to be generated in extrafusal ms fibers to make up for that low baseline tension
- takes more energy to move and endurance may be a problem

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9
Q

what are secondary complications that result from hypotonicity (2)

A

atrophy, weakness
joint misalignment, subluxation

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10
Q

what is a common manifestation that you can observe in people who have low tone

A

poor postural alignment
- forward flexed trunk
- forward head
- post pelvic tilt
- W-sitting in children

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11
Q

what is the goal when treating hypotonicity

A

improve motor response and mvmt patterns for inc safety and independence w functional activities

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12
Q

what are 5 strategies to inc ms response w sensory input

A

approximation
ms tapping, quick swipe
light, graded resistance
wt bearing positions
moveable/pliable surfaces

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13
Q

how does approximation inc ms response

A

inc proprioceptive input from joint receptors
-> help facilitate co-contraction in wt bearing position -> help w extensor response primarily (some flexor, but mostly extensor)

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14
Q

how does ms tapping inc ms response

A

activate ms spindle
-> if activate briskly can inc motor response

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15
Q

how does light, graded resistance inc ms response

A

tracking resistance -> facilitatory to encourage smoother mvmt

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16
Q

how does wt bearing inc ms response

A

stability, postures, co-contraction, proprioceptive input
- get approximation -> facilitate co-contraction and inc extensor response

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17
Q

how does moveable/pliable surfaces inc ms response

A

if hypotonicity -> activates reticular system and facilitates a ms response

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18
Q

what is the focus of treating someone w hypotonicity

A

focus on strengthening ms and proper postural alignment

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19
Q

what is a consideration of when to implement strategies to inc ms response in hypotonic pts

A

preparatory techniques that are not a treatment in and of itself
-> prepping to optimize motor system and prepare for work

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20
Q

if preparatory techniques don’t work, what is the next approach to use and examples of that

A

compensatory approach
- ex: external support via bracing, orthotics, splints for stability, improved function and joint protection

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21
Q

what is hypertonicity

A

inc resistance to passive stretch
-> difficult to move limb and elongate ms

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22
Q

what are 2 conditions that you see hypertonicity in

A

UMNLs
basal ganglia disorders
- ie Parkinsons

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23
Q

what is hypertonicity associated with

A

inc stretch reflex and hyper-reflexia DTRs

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24
Q

how does hypertonicity impact ms

A

preserves ms bulk (dont see much atrophy)
-> still can have underlying weakness

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25
what are examples of hypertonicity (3)
rigidity spasticity clonus
26
when do you want to minimize hypertonicity
if it interferes w function, causes pain, positioning problems, hygiene issues (maladaptive)
27
when do you NOT want to minimize hypertonicity
if supports posture and improves balance, mobility (adaptive) -> may rely on passive tension to help w posture and transfers
28
what is spasticity
velocity dependent inc resistance of ms or ms groups to passive stretch d/t loss of suppression of spinal stretch reflex
29
what is the cause of spasticity
overactive spinal stretch reflex
30
what are 2 functional classifications of spasticity
weak and spastic strong and spastic
31
how is spasticity measured (3)
clinical exam MAS tardieu
32
what is a common sx to be associated w hypertonicity and why
pain - esp w adaptive shortening of ms
33
what are 3 activities to assess as part of a comprehensive clinical exam
balance functional mobility ADLs
34
what are 5 modalities that can treat hypertonicity and what does the literature say ab their use
US cryotherapy vibration estim (TENS, FES) neutral warmth literature doesn't strongly support any of them - some anecdotal success through trial and error
35
how could estim be helpful in treating hypertonicity
could apply to spastic ms to fatigue and tire out could apply to antagonists to get a stronger contraction and overcome the tone in spastic ms to allow for mobility/motion
36
what are 3 manual techniques to temporarily modify hypertonicity and what as sheri baby found to be the most successful
deep pressure ** prolonged stretch (slow speed) RRo
37
how does deep pressure temporarily modify hypertonicity
deep (but not painful) pressure on ms spindle or tendon (GTO) to induce reflexive relaxation - after few seconds ms relaxes, can then start to open limb up slowly
38
why is it important that deep pressure to temp modify hypertonicity not be painful? what is a strategy to avoid this?
if painful stim will trigger guarding and inc ms contraction use widely distributed pressure
39
what are examples of using a prolonged stretch to temporarily modify hypertonicity
splints & air sleeves for longer term management serial casting
40
how does RRo help to modify hypertonicity
rotating along long axis of limb - can do for trunk in hooklying or SL - rotation can be inhibitor to nervous system and relax ms
41
what are 2 examples of noninvasive neuromodulation (NINM) for spasticity management, what are outcomes, & when/where is this seen
repetitive transcranial magnetic stim (rTMS) transcranial direct current stim (tDCS) more effective when combined w other interventions, safe and low risk more on a research level, not seen in practice yet - not FDA approved, not widely clinically available
42
what does the evidence say about serial casting
no/little evidence on permanently altering ms tone or improving function - evidence to improve PROM
43
who is most appropriate for serial casting
if complex spasticity and want to aggressively manage tone and prevent contractures
44
what is the process of serial casting
prolonged stretch over 3-5 days -> then remove and apply new cast in further elongated position and continue until desired effect achieved
45
what are 3 types of medical management options for hypertonicity
meds - oral - intrathecal (baclofen) injections surgical interventions *rTMS and tDCS still in trials
46
what is PT's role in the team's selection of a medical management option
we have insight on how tone is affecting pt function and how the intervention is or isn't working - we can advise on what may be the best option for the pt
47
what are 5 types of oral meds for managing hypertonicity
tizanidine (zanaflex) dantrolene gabapentin diazepam baclofen
48
what are advantages and disadvantages of oral meds
advantages: - easy to admin & make changes quickly - non-invasive - acts globally to target multiple ms groups disadvantages: - large doses may be needed - systemic side effects - compliance - acts globally (if focal spasticity, may cause relaxation of ms throughout body and can lead to weakness and fatigue)
49
tizanidine (zanaflex): purpose, MOA, dosage, adverse effects
reduce spasms acts on alpha-2 adrenergic system at spinal and supraspinal levels to dec spinal stretch reflex starting dose 1-4mg at bedtime - avoid side effects max dosage = 36mg common adverse effects: - fatigue, dizziness, drowsiness - weakness, anxiety, nausea, HAs
50
dantrolene: purpose, MOA, adverse effects
spasticity, dec ms contraction affects release of calcium from sarcoplasmic reticulum of skeletal ms - acts peripherally at level of ms fiber adverse effects: - drowsiness, dizziness, fatigue - ms weakness, **abdominal pain
51
gabapentin (neurontin): MOA, adverse effects
binds to calcium channel receptors on neurons interfering w transmission - works at nerve level - interferes w nerve signal transmission usually well tolerated** side effects of fatigue, reduced concentration
52
diazepam (valium): MOA, adverse effects
inc affinity of neurotransmitter GABA to its receptor in brainstem and SC (works centrally) - results in inc in presynaptic inhibition and dec of monosynaptic and polysynaptic reflexes side effects: - drowsiness, dizziness, fatigue - weakness, nausea - memory impairment, constipation
53
oral baclofen: purpose, MOA, adverse effects, dosage, and important pt ed and why
treat spasticity interacts w GABA neurotransmitter and works w/i CNS pre and post-synaptically to inhibit spinal reflexes - enters CSF and crosses BBB causing side effects Side Effects: - fatigue, weakness - hypotonia, somnolence, n/v - HA, dizziness, paresthesias, withdrawal starting dose 5-10mg 2-3x/day -> inc slowly to 80mg/day education of importance of compliance and dosing schedule - can cause serious side effects if quickly withdraw
54
what pts are appropriate for a intrathecal baclofen pump trial (6)
person w global spasticity, spasms, and/or clonus progressive/chronic dz primarily LE involvement varying functional needs potentially failed focal management on high dose of oral baclofen - ie need >80mg of baclofen
55
what is intrathecal baclofen
surgically implanted pump to deliver baclofen into spinal thecal subarachnoid space
56
advantages and disadvantages of an intrathecal baclofen pump
advantages - lower med doses bc delivered directly into CSF -> dec SE - ability to tailor delivery times to needs - systemic effect - ability to do trial before implantation disadvantages - surgical implant (invasive) - compliance is important (regular f/u, interrogate it, make sure working properly) - doesn't effect UE as well as trunk and LE
57
what happens on trial day for a ITB pump
battery of tests admin med which peaks 3-4hrs post - we will retest at 1.5hr increments after injection
58
what are some tests and assessments we may perform during a trial of ITB pump (7)
ROM spasticity - MAS strength functional assessment - mobility & transfers - postural control & alignment PSFS pain caregiver burden
59
what are indications of a successful ITB pump trial (5)
reduction of spasticity per MAS, PSFS no adverse reactions inc ROM, function, positioning dec in pain, spasms dec caregiver burden & inc (I)
60
botox injection: indication, MOA, duration of effectiveness and why, SE, and outcomes
focal spasticity inhibits acetylcholine release at NMJ -> causes weakness of ms injected & temporary paralysis wears off in 3mo secondary to nerve sprouting and re-innervation - can't do multiple injections in same spot bc of this effect no systemic side effects dec spasticity by 1-2pts on MAS - improves ROM - improves mobility
61
phenol injection: indication, MOA, duration, and effects
focal lesions injected directly into nerves -> damages both motor and sensory nerves via chemical neurolysis lasts 9-12mo effects: ms paralysis, immediate response to injection
62
phenol vs botox
phenol works directly at nerve - causes more paralysis - prevents any contraction at all - no delay botox works at NMJ - may still have some underlying contraction - may have slight delay
63
what are surgical interventions
selective dorsal rhizotomy msk surgeries - tenotomy - myotomy - tendon lengthening or transfer
64
what is a selective dorsal rhizotomy and what does this do? SE?
surgical procedure to cut a portion of dorsal nerve roots in lumbosacral spinal cord -> dec sensory input or afferent arc of stretch reflex at segmental spinal level and dec excitability SE: sensory loss, weakness
65
what population is there good evidence for dec in spasticity after a selective dorsal rhizotomy
children w CP - spastic diplegia
66
what is the purpose of a tenotomy or myotomy as a surgical intervention
prevent contraction to dec hypertonicity
67
what populations do you tend to see MSK surgeries in
more adults than peds
68
why would they do a tendon or ms transfer after a tenotomy or myotomy
try to preserve function that may be lost in surgery
69
when do we intervene for hypotonicity
almost always - almost always marked as mal-adaptive

Neuro Rehab 2 (48 decks)

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