DTR, UMN, LMN, tone, spasticity Flashcards
S/S LMN
Decreased tone Decreased reflex Ipsilateral paresis/paralysis Fasciculations and fibrillation Neurogenic atrophy
S/S UMN
Hyperreflexia
Hypertonicity
Spasticity
Patterned movements and postures
Types of reflexes
Deep tendon
Or
Abnormal (only present under pathological conditions)
Abnormal reflexes indicate
UMN disorder
Absence of abnormal reflexes indicate LMN disorder
DTR- biceps
C5 (C6)
Biceps tendon at cubital fossa
Elbow flexion
DTR- brachioradialis
(C5) C6
Tendon proximal to radial styloid
Elbow flexion
DTR- triceps
(C6) C7
Tendon proximal to olecranon
Elbow extension
DTR- quadriceps
(L2, L3) L4
Patellar tendon
Knee extension
DTR- Achilles
S1 (S2)
Tendocalcaneus proximal to calcaneus
Ankle plantar flexion
Reflex grading - 0
Absent
No visible or palpable response
Reflex grading - 1+
Diminished
Minimal contraction w/ no movement
Reflex grading - 2+
Normal
Mild contraction w/ minor joint movement
Reflex grading - 3+
Brisk
Moderate to strong contraction w/ obvious joint movement
Reflex grading - 4+
Hyperactive
Very brisk, clonus, document # of beats
For disorders where fatigue is an issue, perform reflex testing
5-6 times.
Reflex testing and UMN
Hyperreflexic
Reflex testing and LMN
Hyporeflexic
Other UMN clues
Patterned movement
Signs of stiffness
Inability to isolate movement from one joint to other
Other LMN clues
May appear floppy or weak
Plantar/babinski reflex
- Sharp object to lateral aspect of sole and ball of foot
- norm: toe flexion and adduction
- ab: extension or falling of toes
- S1-S2
Abdominal reflex
- sharp object abdomen along dermatome
- norm:abdominal muscle contraction
- ab: absence of contraction
- T7-T12
Hoffman’s reflex
- hold middle finger flick up
- norm: finger rebounds into flexion
- ab: absence of contraction
- UMN
Jaw reflex
- mouth slightly open, tap chin
- norm: gentle mouth closure
- ab: rapid Ching closure (UMN) or no motion (LMN)
- brisk: Supra nuc lesion
- absent: LMN pathology along CN V
Cremasteric reflex
- stroke inner aspect upper thigh
- norm: testicular elevation on same side
- ab: no motion detected
- L1-L2
Tone
Slow movement w/ assessment of resistance throughout the ROM
Spasticity
High velocity movement w/ assessment of resistance throughout the ROM
Excessive tone
Hypertonicity often presents in patterns where isolated movement of each joint is difficult
-movement often occurs in patterns
UMN ONLY
UMN synergy pattern - shoulder girdle
Flex: elevation and/or retraction
Ext: depression, protraction
UMN synergy pattern - shoulder
Flex: abduction to 90, ER or shoulder ext
Ext: adduction, IR
UMN synergy pattern - elbow
Flex: flexion
Ext: extension
UMN synergy pattern - forearm
Flex: supination
Ext: pronation
UMN synergy pattern - hip
Flex: flexion, abduction, ER
Ext: extension, adduction, IR
UMN synergy pattern - knee
Flex: flexion
Ext: extension
UMN synergy pattern - ankle
Flex: dorsiflexion
Ext: plantarflexion
UMN synergy pattern - foot
Flex: inversion
Ext: inversion
Severe increased tone and MMT
Cannot do standard MMN
So you do selective movement exam
UE synergy pattern
Flexor synergy tends to predominate
LE synergy pattern
Extensor synergy tends to predominate
What gait phase affected by LE synergy?
swing phase
When extensors predominate and have knee ext, ankle PF can’t clear floor
Selective movement
Isolated movement at a joint not obligated to any movement pattern
So do MMT
Selective w/ pattern overlay
Can move selectively at a joint through at least 50% of range before patterned movement occurs and/or moves selective at a joint except under conditions of high challenge (resistance/against gravity)
*do selective movement exam
Deviating from patterned movement
Can initiate selective movement at a joint but then moves into pattern prior to moving through 50% of range
*do selective movement exam
Completely patterned movement
Completely in patterned synergy
Opposite end from selective movement
Selective movement exam
Modified ashworth - 0
No increase in muscle tone
Modified ashworth - 1
Slight increase in muscle tone.
Catch and release or minimal restiance at end of ROM
Modified ashworth - 1+
Slight increase in muscl tone
Catch, followed by minimal restiance through the remainder of ROM
Modified ashworth - 2
More marked increase in muscle tone through most of ROM but affected parts easily moved
Modified ashworth - 3
Considerable increase in muscle tone, passive movement difficult
Modified ashworth - 4
Affected parts rigid
Tone - 4+
Sustained repsonse
Severe hypertonic
Tone - 3+
Exaggerated response
Mild to moderate hypertonia
Tone - 2+
Normal response
Tone - 1+
Decreased response
Hypotonia
Tone - 0
No response
Flaccidity
Romberg grade
Normal length of time pt is able to balance without unsteadiness/sway is 30 seconds
Stop Romberg if
Subject moves their feet on the floor, changes their arm starting position or opens their eyes if applicable
Two conditions for Romberg
Eyes open
Then
Eyes closed
Romberg cues
- Remove shoes and socks
- Stand w/ feet together and arms folded across chest
- Look straight ahead at a target about 3 ft in front of you
- Stand as stable as you can in this position for 30 seconds
Sharpened Romberg cues
- ”Please remove shoes and socks.”
- “Place one foot directly in front of the other so that your heel touches your toe.”
- “Cross you arms in front of your chest and maintain this position of 30 seconds.”
- “Repeat test with your eyes closed.”
Sharpened Romberg grade/score
Normal length of time that patient is able to balance without unsteadiness or sway is 30 seconds
Sharpened Romberg stop if
subject moves their feet on the floor, changes their arm starting position or they open their eyes
Sharpened Romberg conditions
Eyes opened and closed
FIST grades - 4
Independent: Completes the task independently and successfully
FIST grade 3
Verbal cues or increased time: Completes the task independently and successfully; may need verbal / tactile cues or more time
FIST grade 2
Upper extremity support: Unable to complete task without using upper extremities for support or assistance
FIST grade 1
Needs assistance: Unable to complete task successfully without physical assistance
FIST grade 0
Dependent: Requires complete physical assistance to perform task successfully, is unable to complete task successfully with physical assistance, or dependent
Functional reach cues
- “Lift your arm to shoulder height and make a fist.”
- “Keep your feet on the floor and do not touch the wall or the ruler as you reach.”
- “Please reach as far forward as you can without losing your balance.”
- “You will perform the test three times and the average score will be recorded.”
Functional reach grading
- Distance reached is measured in inches according to the 3rd metacarpal
- An average of the last two trials is recorded
- Test is stopped if patient’s feet lift up from the floor or they fall forward and require assistance
Functional reach values - unable to reach
8x more likely to fall
Functional reach values - reach < 6 inches
4x more likely to fall
Functional reach values - reach 6-10 inches
2x more likely to fall
Functional reach values - reach <10 inches
Subject unlikely to fall
Mutidirection reach cues - forward
Lift your arm to shoulder eight and make a first reach foward as far as you can without moving your feet or taking a step
Mutidirection reach cues - backwards
Lift your arm to shoulder height and make a fist. Lean back as far as you can without stepping bac
Mutidirection reach cues - lateral
Lift your arm to shoulder height and make a fist. Lean back as far as you can without stepping bac
Multi directional reach grade/score
Distance reached is measured in inches according to the end of the index finger
Test is stopped if patient’s feet lift up from the floor or they fall forward and require assistance
Multidirectional reach values - forward
8.9 in
Multidirectional reach values - backwards
4.6 in
Multidirectional reach values - right lateral
6.2 in
Multidirectional reach values - left lateral
6.6 in
DGI norms
Max possible score is 24
Scores of 19 or less, related to increase incidence of falls in elderly
-walk a 20 foot path
DGI score 3
Normal - walks 20 ft, no AD, good speed, no evidence of imbalance, normal gait
DGI score 2
Mild impairment
Walks 20 ft, uses AD, slower speed, mild gait deviations
DGI score 1
Moderate impairment
Walks 20 ft, slow speed, ab gait, evidence of imbalance
DGI score 0
Sever impairment
Cannot walk 20 ft w/out assistance, severe gait deviations, imbalances
DGI change in gait speed
Normal walking speed for about 5 ft
Slow after additional 5 ft
DGI change in speed 3
Normal
Able to smoothly change walking speed without loss of balance or gait deviations. Shows a significant difference in walking speeds between normal, fast, and slow speeds
DGI change in speed 2
Mild impairment
Able to change speed but demonstrates mild gait deviations, or no gait deviations. Unable to achieve a significant change in velocity, or uses assistive device(s)
DGI change in gait speed 1
Moderate impairment
Makes only minor adjustments to walking speed, changes speed but has significant gait deviations, or changes speed and loses balance but is able to recover and continue walking
DGI change in gait speed 0
Severe impairment
Cannot change speeds, or loses balance and has to reach for wall or be supported by examiner
DGI w/ head turns - 3
Normal
Performs head turns smoothly with no change in gait
DGI w/ head turns 2
Mild impairment
Performs head turns smoothly with slight change in gait velocity (i.e., minor disruption to smooth gait path or uses walking aid)
DGI w/ head turns 1
Moderate impairment
Performs head turns with moderate change in gait velocity, slows down, staggers but recovers, can continue to walk
DGI w/ head turns 0
Severe impairment
Performs task with severe disruptions of gait (i.e., staggers outside path, loses balance, stops, reaches for wall)
DGI pivot turn 3
Normal
Pivot and turns safely within 3 seconds and stops quickly with no loss of balance
DGI pivot turn 2
Mild impairment
Pivot turns safely in >3 seconds and stops with no loss of balance
DGI pivot turns 1
Mod impairment
Turns slowly, requires verbal cueing, requires several small steps to catch balance following turn and stop
DGI pivot turns 0
Severe impairment
Cannot turn safely, requires assistance to turn and stop
DGI obstacles 3
Normal
Able to walk around/step over cones safely without changing gait speed; no evidence of imbalance
DGI obstacles 2
Mild impairment
Able to step around/over both cones, but must slow down and adjust steps to clear cones
DGI obstacles 1
Mod impairment
Able to clear cones but must significantly slow speed to accomplish task, or requires verbal cueing
DGI obstacles 0
Severe impairment
Unable to clear cones, walks into one or both cones or requires physical assistance
