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PHTY3140 > L12: Assessment management of increased tone and abnormal posturing - Use of positioning handling > Flashcards

L12: Assessment management of increased tone and abnormal posturing - Use of positioning handling Flashcards

1
Q

What is tone (hypertonia) versus spasticity?

A

Tone (hypertonia) - generic term (eg. furniture)

Spasticity - more specific (eg. chair as a part of furniture)

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2
Q

What does judging tone look like?

A
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3
Q

What are the negative features of the upper motor neuron syndrome (UMN)?

A

weakness, dexterity, inco-ordination, etc…

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4
Q

What are the positive features of the upper motor neuron syndrome (UMN)?

A

Spasticity, tendon hyperreflexia, clonus, clasp-knife phenomenon, flexor and extensor spasms, Babinski sign, Spastic dystonia, ataxia, etc…

  • Gain in abnormal patterns
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5
Q

What are the 2 causes of UMN syndrome?

A
  1. Acquired brain injuries: Cerebrovascular disease, MS, Spastic Diplegia, Brain damage (fronto-cerebral cortex, brain stem), etc.
  2. Incomplete spinal injuries: spinal cord compression or lesions
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6
Q

What are examples of acquired brain injuries that cause UMN syndrome?

A

Cerebrovascular disease, MS, Spastic Diplegia, Brain

damage (fronto-cerebral cortex, brain stem), etc.

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7
Q

What are examples of incomplete spinal injuries that cause UMN syndrome?

A
  1. Neural and non-neural contributors
  2. 3 primary descending tracts (supra-spinal fibres) that influence spinal reflex excitability
    • Inhibitory or excitatory in action
    • Pyramidal and para-pyramidal (extrapyramidal) dysfunction
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8
Q

What are excitatory tracts?

A
  1. arise in bulbopontine tegmentum (brain stem) and vestibular nucleus
  2. run via the medial reticulospinal and vestibulospinal tracts
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9
Q

What are inhibitory tracts?

A
  1. arise in the ventromedial reticular formation.
  2. run via the dorsal reticulospinal tract
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10
Q

What are the 3 categories of neural positive features?

A
  1. Sp reflexes dysfunction (resting tone)
  2. Efferent drive dysfunction
  3. Disordered movement control
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11
Q

What are 2 features of spinal reflexes dysfunction (resting tone)?

A
  1. Tonic stretch (Spasticity)
  2. Disinhibition
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12
Q

What are 3 features of efferent drive dysfunction (resting tone)?

A
  1. Spastic dystonia
  2. Associated reactions
  3. Effort tone

Active tone (response to gravity)

Resting tone (passive movement)

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13
Q

What is a feature of disordered movement control?

A

Co-contractions / activation

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14
Q

Spinal reflexes dysfunction are _____ dependent. What does that mean?

A
  1. Afferent dependent (muscle stretch, pain, cutaneous)
    2.
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15
Q

What do spinal reflex dysfunction result in?

A

Reduction of the inhibitory pathways to the spinal cord

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16
Q

What occurs because spinal reflex dysfunction?

A

Damage to the UMN further distal from the cerebral cortex results in greater positive feature development.

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17
Q

What are 6 details features of spinal reflex dysfunction?

A
  1. Afferent dependent (muscle stretch, pain, cutaneous)
  2. Reduction of the inhibitory pathways to the spinal cord
  3. Damage to the UMN further distal from the cerebral cortex results in greater positive feature development.
  4. Development/heightening of tonic stretch reflex
  5. Disinhibition of existing normal reflexes
  6. Release of primitive reflexes
    7.
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18
Q

What are the 3 neural components of spasticity?

A
  1. Mediated by 1a afferents excitation
  2. Interneuron and renshaw cell reduced inhibition of antagonist muscles
  3. ?? Neuroanatomical location linking to spasticity: insula, thalamus, basal ganglia, what matter tracts, putamen
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19
Q

What are the 2 non-neural components of spasticity?

A
  1. ↓ sarcomere number, ↑ connective tissue within muscle → readily transmits pulling forces
    • More ready to transit pulling forces –> Increase in afferent transmission –> greater descending response
  2. Infection, pain, etc.
    • (eg. MS –> UTI –> can exaggerate spasticity even more)
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20
Q

What is a tonic stretch reflex?

A

Velocity-dependent increase in tonic stretch reflex, with exaggerated tendon jerks, resulting from hyper-excitability of the neurons involved in stretch reflex, as a component of the upper motor neuron syndrome.

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21
Q

What are the 3 features that intensity is dependent on for spasticity?

A
  1. Speed of movement
  2. Length the muscle at which it is stretched
  3. Overall length of the muscle
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22
Q

Impairment of stretch reflexes _____ (does/does not) cause hypotonia

A

does NOT

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23
Q

Spasticity ____ (is/is not) a contributor to reduced function

A

is not

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24
Q

What are 3 features of flexor spasm in the disinhibition of normal reflexes?

A
  1. Cutaneous stimulus
  2. Polysynaptic activation of muscles
  3. Ankle DF, hip/knee F
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25
Q

What are 3 features of extensor spasm in the disinhibition of normal reflexes?

A
  1. Proprioceptive stimulus - Hip E- Change in hip joint position
  2. Normally for ↑ limb stiffness for stance (When extend leg)
  3. Ankle PF, hip/knee E
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26
Q

What are 3 characteristics of clonus as a disinhibition of normal reflexes?

A
  1. Stretch of muscle produces sustained rhythmic contractions of muscles (5-7Hz)
  2. Propriospinal phasic stretch reflex (deep tendon reflex or tendon jerk)
  3. Exaggeration develops via a hyperactive phasic stretch reflex
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27
Q

What are 2 characteristics of primitive reflexes as a disinhibition of normal reflexes?

A
  1. Babinski, ATNR, STNR, TNR
  2. Reflexes present at birth and suppressed during development
    • Once children are on their feet –> symptoms lessen
28
Q

What is a characteristic of flexor withdrawal as a disinhibition of normal reflexes?

A

nociceptive

  • Similar response to flexor spasm but heightened
29
Q

What are 2 characteristics of the Clasp Knife Phenomenon?

A
  1. A combination of spasticity, modified by flexor reflex afferents.
  2. Stretch a muscle quickly through range → tonic stretch reflex → maintain the stretch slowly → excitability of the tonic stretch reflex reduces to sub-threshold and the resistance melts away eventually

Stretch muscle quickly –>tonic stretch reflex resisting –> stiff –> maintain movement –> release

30
Q

What are 3 characteristics of the Efferent drive dysfunction?

A
  1. Not entirely dependent on peripheral feedback
  2. May be driven by reflex activity higher in the CNS
  3. Spastic dystonia, associated reaction, effort tone
31
Q

What are 3 characteristics of Spastic dystonia in the Efferent drive dysfunction?

A
  1. Continuous muscle contractions that occur in the apparent absence of voluntary contraction
  2. In the absence of sensory feedback from the periphery
  3. Come from tonic supraspinal drive to the alpha motor neurones
  4. Cause remains unclear
32
Q

What are 3 characteristics of associated reaction in the Efferent drive dysfunction?

A
  1. E.g. Elbow increases in overall flexed position with general movement
  2. Not voluntary
  3. Not due to stretch or nociceptive reflex.
  4. Related to the amount of effort being expanded elsewhere
  5. Cause?
  6. May be failure to inhibit spread of motor activity via the propriospinal pathways in the spinal cord
  7. Correlates partially with the amount of spasticity that is present in the limb
  8. NOT SYNKINESIS

Active response in another body part/area when trying to generate a movement in a certain part of the body

33
Q

What are 3 characteristics of Disordered control - Co-contraction?

A
  1. Voluntary muscle movement dysfunction
  2. Much overlap with the negative symptoms
  3. Simultaneous contraction of agonist and antagonist muscle groups
  4. Stems from theory of reciprocal inhibition and control mechanisms
  5. In the UMN syndrome reciprocal inhibition disordered in two ways
  6. Reduced / Excessive reciprocal inhibition
34
Q

What are 4 characteristics of assessment of spasticity?

A
  1. Functional analysis of movement
  2. Identification of missing components
  3. Functional outcome measure appropriate to task or function being assessed
  4. Functional outcome measures do not appear to bear much correlation to measures of spasticity
35
Q

What are 5 characteristics of spasticity impairment testing for assessment?

A
  1. Tardieu scale **(Tardieu 54) can differentiate contracture from spasticity
  2. Ashworth and modified ashworth scale
    • Assesses more hypertonia rather than spasticity
  3. Patient reported impact of spasticity measure (PRISM)
  4. Wartenberg Pendulum Test
  5. Powered oscillation systems
  6. EMG activity assessment in response to stretch
36
Q

What are 6 features of the Tardieu Spasticity test?

A
  1. Supine head midline for lower limb
  2. Sitting for upper limb
  3. Uses 3 different velocities V1, V2, V3
  4. A response is recorded at each velocity as two points X/Y
  5. X being a score of 0-5 rating
  6. Y being the degree of angle where muscle reaction occurs
  • V1= slow as possible
  • V2= at the speed of gravity that limb falls/drops
  • V3= fast as possible
37
Q

What are 6 features of the muscle length assessment for spasticity?

A
  1. Need to differentiate spasticity from muscle length
  2. Perform passive ROM test slowly with consistent pressure
  3. Spasticity will give, contracture will not
  4. End feel different
  5. Consider joint restrictions
  6. Perform in position of minimal reflex influence
38
Q

What are 5 considerations for pharmacological management?

A
  1. Prolonged effects of overactive muscles
  2. Pain, Contracture, Pressure areas
  3. Care loads
  4. QOL
  5. Functional improvements - may be positive or negative

Variable effects throughout the day or any side effects (eg. at night?)

39
Q

What are 5 Pharmacological Management (oral)?

A
  1. Tizanidine (Zanaflex)*
  2. Baclofen (Liserol)*
  3. Diazepam (valium)
  4. Dantrolene (Dantrium)
  5. Cannaboids (TCH)
40
Q

What ae 3 side effects of Pharmacological Management (oral)?

A
  1. Dry mouth
  2. Muscle weakness
  3. Drowsiness
41
Q

What are 2 characteristics of Pharmacological Mx - BTX-A (invasive)?

A
  1. Marketed as BOTOX or Dysport
  2. Injected directly into the muscle: blocks acetylcholine production resulting in decreased muscle spasms
42
Q

What are 4 goals of use in Pharmacological Mx - BTX-A (invasive)?

A
  1. Increase mobility of muscle and ROM
  2. Decrease spasms or reflex muscle activation
  3. Decrease pain associated with contraction or joint position
  4. Improve cosmesis
43
Q

What are 3 situations where Pharmacological Mx - BTX-A (invasive) is ideal?

A
  1. Small number of muscles affected
  2. Patient and family compliance with post-injection Mx (splinting, exercise, stretches etc…)
  3. Better immediate results in patients with minimal muscle contractures

After injections there is a window of opportunity for patients to practice movements that they wouldn’t usually be able to do

44
Q

What are 3 cons/ negatives of Pharmacological Mx - BTX-A (invasive) is ideal?

A
  1. Will need repeated doses
  2. Expensive: Medicare rebate provides 3 free service for
  3. Stroke patients per year
  4. Can cause permanent sensory loss and motor unit death
  5. No clear evidence for improving function
  6. Weakened muscle → decrease function / recovery? E.g.
  7. Ankle PF contributes to 30% of knee E in stance; therefore before Btx consider if spasticity is affecting function
45
Q

What are 6 characteristics of Pharmacological Mx - Baclofen Pump?

A
  1. For patients with severe features: unable to tolerate side-effects or not responsive to other methods
  2. Placed at T10-L1 level: small reservoir
  3. Need to be close to monitoring and replacement service provider
  4. Tested before implant with baclofen bolus injection
  5. Muscle overactivity reduction quickly noted.
  6. Needs intensive therapy for best functional outcomes
46
Q

What are 3 side effects and issues of Pharmacological Mx - Baclofen Pump?

A
  1. Expensive
  2. infection local and cerebral
  3. Careful screening of patients is needed
47
Q

What are 5 goals of Physiotherapy Mx of spasticity/hypertonia?

A
  1. promote optimal movement
  2. minimise contracture and development of deformity
  3. reduce pain
  4. improve quality of life
  5. reduce or manage care load needs
48
Q

What are 7 goals of Physiotherapy Mx?

A
  1. Assess function observational and outcome measures
  2. Differential diagnosis of impairments
  3. Measurement of spasticity/tone
  4. Goal setting with patient
  5. Prevention and management of provocative factors
  6. Implementation of the chosen intervention
  7. Re-assessment and follow up
49
Q

What are 3 characteristics of Physiotherapy Mx- msucle strengthening?

A
  1. Evidence to suggest that strengthening muscles does not make spasticity / tone worse
  2. Assist in overcoming functional deficit from the negative feature of weakness
  3. May assist in overcoming disorder reciprocal inhibition (disordered control – co-contractions) and associated reactions – from effort
50
Q

What are 6 components of Physiotherapy Mx?

A
  1. Functional retraining
  2. CIMT
  3. FES
  4. EMG biofeedback
  5. Handling
  6. Movements
51
Q

What is functional retraining of physiotherapy management?

A

Strength, cortical control, prevention of disuse

52
Q

What is FES of physiotherapy management?

A

Alter associated reactions – reciprocal inhibition strengthening of muscle and its associated influences

53
Q

What is EMG biofeedback of physiotherapy management?

A

Improve disordered control cocontraction; awareness of muscle activation or overactivity for client volitional relaxation

54
Q

What are 3 characteristics of handling of physiotherapy management?

A
  1. Optimise body alignment for effective movement and muscle selection to function – facilitation or key points
  2. May provide extra proprioceptive input to modulate spinal reflexes
  3. Use of key points to modulate spinal reflexes
55
Q

What are 2 characteristics of movements of physiotherapy management?

A
  1. May modulate spinal reflexes or fatigue them from bombardment, providing more normal or expected inputs to the spinal cord for appropriate outputs
  2. May assist the patient in relaxation, maintenance of muscle and joint ROM
56
Q

What are 5 treatment and management options?

A
  1. Mx aggravating factors: pain, infections, pressure sores, distress/anxiety, dizziness
  2. Acupuncture, NMES (moderate as adjunct)
  3. Improve motor function as adjunct or alone (low evidence):
  4. CIMT, Physical activity, etc.
  5. Vibration (low evidence)
  6. Mx of non-neural changes: splinting (very low quality evidence), static positioning (low quality evidence), Serial
  7. Casting (??), passive movements (insufficient evidence), self
  8. stretching
57
Q

What are the 3 key points?

A
  1. Central – trunk → Influence trunk postural tone
  2. Proximal – head, scapular, pelvis
    • Head – link to neck reflexes and righting reactions
    • Scapular – influence tone in upper limb
    • Pelvis – influence tone in lower limb
  3. Distal – thumb, toes
    • Thumb – influences tone in upper limb
    • Lateral three toes – influences tone in foot and
58
Q

What are 4 characteristics of weight bearing for method and rationale in physiotherapy management?

A
  1. Modulates biomechanical properties of joint and muscle ROM/length
  2. Modulates positive features via bombardment or activation of the spinal reflexes (muscle stretch, cutaneous, proprioceptive reflexes) or via feedback to the vestibulo-spinal system
  3. Activates normal muscle activity for standing (a type

of strengthening or functional task training)

  1. Daily standing maintains normal tone, and reduces frequency of muscle spasms and maintains joint and muscle range/length

All can prevent pain a potential facilitating factor in increasing spinal reflexes

59
Q

What are 2 characteristics of therapeutic positioning for physiotherapy management?

A
  1. Moderate postural effects on tone
  2. Provides support for contracted limbs
60
Q

What are 7 characteristics of therapeutic seating for physiotherapy management?

A
  1. Maximize function
  2. Reduce sustained postures
  3. Reduce influence of spastic postures
  4. Prevent pressure sores
  5. Maintain soft tissue length
  6. Reduce discomfort and noxious stimuli
  7. Promote socialisation
61
Q

What are 5 characteristics of serial casting for physiotherapy management?

A
  1. Level I evidence (Mosely 97; Mortenson and Eng 01)
  2. May influence spasticity / tone via
  3. Decreased sensory input, cutaneous reflexes. Short lived influence
  4. Increases sarcomere number
  5. Tonic stretch reflex less irritable
  6. Strong evidence to say DON’T splint
62
Q

What are effectiveness of quick ice for physiotherapy management?

A
  • Thought to activate muscle spindles.
  • Evidence shows the muscle spindles work the same in normals to those with spasticity. Thus no longer considered accurate. No evidence for quick ice to modulate spasticity. May relate to a potential bombardment of peripheral reflexes to the spinal reflexes, altering the output
  • Don’t really use
63
Q

What are 4 past strategies of prolonged icing for physiotherapy management?

A
  1. Thought to decrease nerve conduction and muscle spindle sensitivity; muscle spindle not the issue
  2. May modulate via bombardment
  3. Nerve conduction - evidence that cooling achieves this for reduction in spasticity
  4. Evidence that peripheral full limb cooling reduces tremor in UMN syndromes via reduction in nerve conduction. However benefits only maintained for 24 hours. Thus warrants further investigation.
64
Q

What are 2 past strategies of vestibular stimulation for physiotherapy management?

A
  1. Slow rocking – inhibitory
  2. Fast movements like spinning – excitatory
65
Q

What are the 4 steps in management of spasticity?

A

PHTY3140 (28 decks)

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