Lecture 12- Motor Examination Flashcards
What are the 6 parts of the ICF Model?
- Health Condition
- Impaired Body Functions and Structures
- Activity Limitation
- Participation Restrictions
- Environmental Factors
- Personal Factors
What is the organization of examination?
- Pathophysiology
- Impairements
- Sensory/Perceptual
- Cognitive/Behavioral
- Motor
- Functional Limitations
Primary neuromuscular impairements, with time, can often lead to ________ effects.
secondary
What part of the examination do we most often see secondary sequelae?
motor portion
Paresis and spasticity are ________ effects of a stroke.
primary
With time, paresis and spasticity from a stroke can lead to ___________ effects.
secondary
What is the primary things we are looking for in a motor exam?
strength (muscle weakness)
Musculoskeletal contributions to strength reflect:
- Length of _________ arm of the muscle
- ______/_______ relationship of the muscle
- Type of muscle fiber
- ___________ area of muscle
- Fiber arrangement
- movement
- length/tension
- cross-sectional
Neural contributions to strength reflect:
- Number of _________ recruited
- Discharge __________
- Type of motor units recruited
- motor units
- frequency
What is weakness in the context of neuropathology?
- inability to generate force
- inability to recruit or modulate motor neurons
Neurologically induced weakness may result from:
- _______ lesion
- Lesion in ________ pathways
- Disruption of impulses from _______ motor neurons
- Peripheral nerve injury
- Synaptic dysfunction at __________
- Damage to muscle tissue
- cortical
- descending
- alpha
- NMJ
- What is paralysis or plegia?
- What is dense hemiplegia?
- total or profound loss of muscle activity
- nothing in muscles involved (even twitch)
What is paresis?
mild or partial loss of muscle activity
Muscle Weakness by Distribution
- What is monoplegia?
- What is hemiplegia?
- What is paraplegia?
- What is tetraplegia?
- isolated region that has muscle weakness
- one-sided
- spinal cord injuries, half (lower or upper)
- full body (quad)
What are some common observations we will see due to underlying weakness in neurologic pathology?
- Postural abnormalities
- Asymmetrical weight bearing
- Abnormal synergies
Postural abnormalities can present both at rest and with ________.
activity
Asymmetrical weight bearing produces big differences in ______ time of gait.
stance (weak side less time)
What is abnormal synergies?
- result of loss of ability to recruit a limited number of muscles that are supposed to control a movement
- muscle weakness can produce mass pattern of movement
What are the most common synergies we see and where do we see them?
- Flexor synergy - UE
- Extensor synergy - LE
What is flexor synergy characterized by?
- scapular retraction and elevation
- shoulder abduction and ER
- elbow flexion
- supination
- wrists and finger flexion
What is extensor synergy characterized by?
- hip extension, adduction, and IR
- knee extension
- ankle PF and inversion
- toe PF
Can you have extensor synergies in the UE and flexor synergies in the LE?
Yes, just less likely
What is muscle tone?
muscles resistance to passive stretch
Is a certain amount of muscle tone normal?
Yes
Normal tone is high enough to resist the effects of ______ but low enough to allow our muscles to move freely.
gravity
What is hypotonicity?
flaccid muscle (floppy)
What is hypertonicity/spasticity?
rigid (stuck)
Tone is both _______ and non-________ components.
neural
- Neural contributions to muscle tone come from a net balance of ___________ input on motor neurons from corticospinal, rubrospinal, reticulospinal, vestibulospinal tracts.
- Descending info coming from these tracts are _________.
- descending
- inhibitory
Neural contributions to muscle tone also come from the sensitivity of ________ connections.
synaptic
Non-neuronal contributions to muscle tone come from connective tissue plasticity and __________ properties of the muscles, tendons and joints
viscoelastic
What is the difference between spasticity and hypertonia?
- Both are resistant to movement
- Spasticity is velocity dependent while hypertonia is not.
In ________ we will see the same results whether we move the muscle fast or slowly.
hypertonia
Spasticity
- _________ dependent increase in resistance to passive movement
- Sometimes described as _________ phenomenon
- Occurs as a result of damage to _________ tract or other nearby descending paths (ex: corticoreticulospinal)
- Can be associated with ________ (commonly in distal extremities > proximal)
- velocity
- clasp-knife
- pyramidal
- clonus
What is clonus?
- quick stretch causing bouncing of muscle
- more common distal
Clonus is indicative of a _____ injury.
UMN
What 2 main things happen after acute CNS damage?
- paresis
- CNS plastic rearrangements
What is thought to be the main reason we see muscle overactivity?
CNS plastic rearrangements after acute CNS damage
What are the 2 spasticity mechanisms?
- changes in neural contributions
- results in alterations to threshold of stretch reflex
Decrease in descending activity leads to a _________ in inhibitory synaptic input which leads to _______ in tonic excitatory input
- decrease
- increase
What scale is used to assess muscle tone?
Modified Ashworth Scale
What is the scale of the Modified Ashworth Scale?
0-4
0= no increase in muscle tone
4= affected part(s) rigid in flexion or extension
Does the Modified Ashworth Scale look at hypotonicity?
No, 0 means normal
What is another, lesser used scale to assess muscle tone?
Tardieau Scale
Different tests performed for the Tardieau Scale.
V1 (PROM)= slow as possible
V2 (spasticity)= speed of limb falling under gravity
V3 (spasticity)= fast as possible
Which muscle tone scale accounts for clonus?
Tardieau Scale
Hypertonia is _________ independent.
velocity
Hypertonia is predominantly seen in flexors or extensors?
flexors
What are the 2 main presentations of hypertonia?
- Leadpipe
- Cogwheel
What is leadpipe hypertonia?
constant resistance to movement throughout entire ROM
What is cogwheel hypertonia?
alternating episodes of resistance and relaxation
Hypertonia can present as ________ at rest. What are the two types?
Posturing
- decorticate
- decerebrate
Decorticate posturing is a result of lesions ______ the red nucleus while decerebrate posturing is a result of lesions ______ the red nucleus.
- above
- below
How does decorticate posturing present itself?
- UE flexion
- LE extension/IR/PF
How does decerebrate posturing present itself?
-UE and LE extension
We tend to see ________ much more with cortical involvement.
spasticity (pyramidal)
We tend to see _______ much more with basal ganglia involvement.
rigidity (extrapyramidal)
Brainstem involvement above/below the red nucleus can result in what?
above= decorticate posturing below= decerebrate posturing
In regards to chronicity, increases in non-neuronal changes results in increased “__________”
stiffness
What are some common pathologies with hypertonicity?
- CVA, TBI, MS
- Parkinsons Disease (rigidity)
People with hypotonicity have a _____________ in resistance to lengthening.
reduction
How is hypotonicity different from flaccidity?
Flaccidity is a complete loss of muscle tone while hypotonicity isn’t a full loss
Hypotonicity is a disruption of ________ input from stretch reflex resulting in a lack of cerebellar efference influence resulting in decreased input to _______ motor neurons.
- afferent
- gamma
What are some common pathologies with hypotonicity?
- cerebellar lesions, DS, muscular dystrophies, late stage ALS, post-polio
- ACUTE CNS injuries -> hypertonicity/spasticity once subacute/chronic
Functional implications of an INCREASE in muscle tone:
- abnormal posturing
- misalignment
- high risk for injury during prolonged rest (skin breakdown)
- bias with recruitment (increased likelihood of synergistic movement)
- destabilization with changes in position (clonus, increased risk for contractures)
Functional implications of a DECREASE in muscle tone:
- fall into gravity
- high risk for injury during dynamic tasks
What is coordination?
- the ability to use different parts of the body together smoothly and efficiently
- affects quality of movement
What kind of velocity curve should we see with coordination?
bell shaped velocity curve
What are the 3 critical componenets of coordination?
- sequencing
- timing
- grading
What is incoordination?
- movements that are awkward, uneven, inaccurate
- disruption of sequencing, timing, grading
Does incoordination cause a lack in the bell-shape velocity curve? Why or why not?
Yes, loss of coupling between synergistic joints and muscles
What lesions cause incoordination?
- motor cortex, basal ganglia, cerebellar lesions
- also tied to proprioceptive lesions
What are the 3 terms used to describe the grading/scaling of incoordination?
- dysmetria
- hypermetria
- hypometria
What is dysmetria? (C)
-problems judging path to get to a location
What is hypermetria?
-overshooting target they are reaching for
What is hypometria?
-undershooting target they are reaching for
Coordination deficits can cause timing difficulties as well:
- ________ reaction times
- ________ movement times
- Difficulties ___________ movement
- Rebound phenomenon
- Dysdiadochokinesia
- increased
- slowed
- terminating
What is rebound phenomenon?
- difficulty checking/halting movement when resistance is moved
- more common in cerebellar lesions
What is dysdiadochokinesia?
inability to perform rapid alternating movements
Coordination deficits can cause activation and sequencing difficulties as well:
- abnormal _________
- coactivation
- impaired inter-joint ________
- synergies
- coordination
Coactivation may cause contraction of both ________ and _________ during walking.
flexors and extensors
What is impaired inter-joint coordination?
- can only move 1 joint at a time
- may have to elevate shoulders, then flex shoulder, then extend elbow to reach
What are the tests we perform to examine coordination deficits?
- finger to nose
- alternating supination/pronation
- hand or foot tapping
- heel to shin
All tests performed for coordination look at _____ joint movements and we observe the patients performing them.
-multi
What are involuntary movements?
movements we aren’t performing on purpose
-dystonia
-tremors
-athetosis
choreiform
What is dystonia a disorder of?
basal ganglia
Dystonia
- Basal ganglia
- Syndrome dominated by __________ muscle contractions
- Causes twisting, repetitive movements, abnormal postures
- Coactivation ________/_________
- Focal, segmental, hemibody, or generalized/whole
- sustained
- agonist/antagonist
What are tremors?
- Rhythmic, involuntary oscillatory movement of a body part
- Can be intermittent or constant, sporadic or as a sequelae to disease or injury
Where are tremors most often seen?
hands
What is the difference between resting tremor and action tremor?
Resting Tremor
-occurs in body part that is not voluntarily activated, relaxed
Action Tremor
-any tremor that is produced by voluntary contraction of a muscle
What are the 2 most common subcategories of action tremors?
- postural tremor- person maintains a part of body against gravity (put arms up)
- intential tremor- produced with a purposeful movement (reaching across table or up)
Choreiform and Athetosis are both linked to dysfunction of what?
basal ganglia
- What is athetosis?
- Does it affect UE or LE more?
- What is it common in?
- slow, writing and twisting movements
- UE>LE
- common in cerebral palsy
- What is choreiform?
- What can cause this?
- involuntary, rapid, irregular and jerky movements
- seen with Huntington’s Disease; side effects of PD medicine
Spasticity and hypertonia can lead to loss of ____, contractures
ROM
Immobilization of joints can lead to increased _________.
- Increase resistance to stretch, decrease in sarcomeres can lead to ________ in connective tissue.
- Decrease rate of protein synthesis can lead to ________.
-stiffness
- increase
- atrophy
When we have ROM issues, we see a change in ______/________ relationship.
- This leads to further weakness
- alters mechanical advantage
length/tension
Endurance issues can be both _______ and ________.
primary and secondary
Endurance Issues:
- Decrease in central drive to spinal cord motor neurons
- Decrease in activity level/immobility
- Presence of _________
comorbities (Afib, CAD, COPD, DM, etc…)
Can neuromuscular impairements cause musculoskeletal pain?
Yes, should always keep an eye out for it.
Musculoskeletal Pain Main Reasons:
- ___________ movements resulting in overworking of certain muscles
- Muscle __________ causing abnormal loading through joints
- ____ and alignment issues
- Decreased efficiency of movements leading to increased __________ required to complete tasks
- synergistic
- asymmetries
- ROM
- workload
