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

Question 1

What is tone?

Answer 1

•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

Question 2

How does damage to the CNS effect tone?

Answer 2

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

Question 3

Hypotonia

What is it

Infants

Other symptoms

PT managment

Answer 3

–Decrease in resistance to passive limb manipulation

–Flaccid

• •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

Question 4

Hypotonia vs muscle weakness

Answer 4

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

Question 5

Hypotonia: causs

Answer 5

•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

Question 6

Hypotonia: development as an adult

Answer 6

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

Question 7

Is hypotonia or hypertonia more common?

Answer 7

Hypertonia is more common

Question 8

Hypertonia

Answer 8

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)

Question 9

Pathological spread of reflexes

Answer 9

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

Question 10

What is spacticity?

Answer 10

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

Question 11

What is spastic paresis?

Answer 11

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

Question 12

What is spastic paralysis?

Answer 12

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

Question 13

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

Answer 13

–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)

Question 14

Clonus

Answer 14

hyperactive stretch reflex

Question 15

Characteristics of spasticity following cerebral lesions

Answer 15

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

Question 16

Characteristics of spasticity following spinal cord lesions

Answer 16

–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)

Question 17

Synergy Patterns of Extremities: Flexion

Answer 17

–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

Question 18

Synergy Patterns of Extremities: Extension

Answer 18

–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

Question 19

what are Synergy Patterns of Extremities?

Answer 19

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

Sometimes good

Sometimes bad

Question 20

Negative outcomes of Spacticity: (7)

Answer 20

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

Question 21

Positive outcomes of Spacticity: (6)

Answer 21

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

Question 22

Things about Ashworth and Modified Ashworth Tests (11)

Answer 22

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

Question 23

Contensts of the Ashworth Scale

Answer 23

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

Question 24

Contents of Modified Ashworth Scale

Answer 24

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

Question 25

•Wartenberg Pendulum Test

Answer 25

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

Question 26

Modified Terdieu Scale

Answer 26

• •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.

Question 27

Spinal Cord Assessment Tool for Spastic Reflexes (SCATS)

Answer 27

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

Question 28

Spacticity: Medications for treatment

Answer 28

•Baclofen

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

•Benzodiazepines

• –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

Question 29

Intrathecal Baclofen pump

Answer 29

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

Question 30

Spacticity: PT Managment

Answer 30

–Education regarding noxious stimuli, positioning, skin etc
–Positioning
–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

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

Question 31

Spacticity: Surgical Techniques

Answer 31

–Dorsal rhizotomy
–Tendon release

Question 32

•Dorsal Rhizotomy

Answer 32

A surgical technique for spacticity

–Some of dorsal roots are cut (to stop reflex arc)
–Nerve roots are stimulated via EMG to determine the nerve roots causing the spasticity
–Also can relieve assoc pain (may be done just for pain or skin irritation - like if clonus is causing rubbing)
–Paralysis of legs, bladder, and skin possible
–Strict eligibility requirements
–Most common in children with CP

Question 33

What is Rigidity?

Answer 33

• Rigidity—an increase in muscle tone that causes resistance to passive movement throughout the whole range of motion, independent of velocity
• Types of Rigidity
• –Lead-pipe
• –Cogwheel
• –Claspknife

Question 34

What disease is rigidity associated with?

Answer 34

Parkinson’s Disease

Question 35

3 Types of Rigidity

Answer 35

•Types of Rigidity

1. –Lead-pipe
2. –Cogwheel
3. –Claspknife

Question 36

Lead Pip Rigidity

Answer 36

• –Seen especially in Parkinson’s disease
• –Constant resistance to movement throughout the range of motion of a joint
• –It is indicative of increased tone in all the sets of muscles around a joint
• –Lead-pipe rigidity, as with other forms of Parkinsonian rigidity, may be more pronounced on one side

Question 37

Cogwheel Rigidity

Answer 37

• –Alternative episodes of resistance and relaxation or ‘catches’ in ROM
• –Teeth of the cog are analogous to the tensed parts of the tremor
• –May be unilateral initially
• –Antipsychotics medications can cause cogwheel rigidity

Question 38

Clasp Knife Rigidity

Answer 38

Clasp Knife

• Describes the phenomenon in a rigid limb after an initial resistance to passive movement of a joint
• There is a sudden reduction in tone and the limb moves quite freely through the rest of the range of the particular movement

Question 39

Comparison between Lead-pipe and Clasp-knife rigidty

Answer 39

•Comparison

• –Lead-pipe rigidity persists throughout the range of movement of a particular joint, as distinct from clasp knife or cogwheel rigidity which varies through the range

Question 40

Decerebate Rigidity (general)

Answer 40

–Sectioning of the neural axis between the midbrain & brainstem in experimental animals or substantial brain damage above the brainstem in humans

–Caused by substantial brain damage in the midbrain
–Produces a profound extensor rigidity in both UE & LE
–Rigid extension of limbs and trunk, internal rotation of upper limbs and plantar flexion, head is extended

From Notes:

You see it in football games when something takes a fall. Brainstem injury.

Maybe look at a picture of it.

Usually means swelling, doesn’t usually lead to paralysis.

Usually a bad sign when pt is in respirator.

Will be on the test: differentiating between Decerebrate and Decorticate rigidity

Question 41

Describe Decerebrate Rigidity

Answer 41

–Caused by substantial brain damage in the midbrain
–Produces a profound extensor rigidity in both UE & LE
–Rigid extension of limbs and trunk, internal rotation of upper limbs and plantar flexion, head is extended

Question 42

Decortate Rigidity (general)

Answer 42

•Decorticate Rigidity

• –Modeled in animals by sectioning the neuroaxis just rostral to the superior colliculi
• –Higher lesion

–Damage to the brain, superior to the midbrain
–increase UE flexor tone & increase LE extensor tone
–Flexed limbs, extended neck and lower limbs and plantar flexion

Question 43

Describe Decortate Rigidity

Answer 43

–Damage to the brain, superior to the midbrain
– increased UE flexor tone & increased LE extensor tone
–Flexed limbs, extended neck and lower limbs and plantar flexion