Motion Restriction & Muscle tone abnormalities Flashcards
AROM may be restricted by:
- Muscle weakness
- abnormal muscle tone
- pain originating from the musculotendinous unit or other local structures
- inability or unwillingness of pt to follow directions
- as the result of restrictions in PROM
PROM
movement of a joint produced by external forces without voluntary muscle contraction by the pt
PROM may be restricted due to:
- shortening of soft tissues
- edema
- adhesion
- mechanical block
- Spinal disc herniation
- adverse neural tension
Normal PROM > AROM when:
- When limited by distension or approximation of soft tissues
ex. GH flexion firm end feel - check rein: post band of coracohumeral lig, post jt capsule, post delt, teres minor/major, infraspinatus
ex. external rotation with firm end feel - check reign: ant jt capsule, 3 bands of GH lig, coracohumeral lig, subscapularis, teres major, clavicular fibers of pec major
Normal PROM > AROM examples
Ex. GH flexion firm end feel
- check rein: post band of coracohumeral lig, post jt capsule, post delt, teres minor/major, infraspinatus
Ex. external rotation with firm end feel
- check reign: ant jt capsule, 3 bands of GH lig, coracohumeral lig, subscapularis, teres major, clavicular fibers of pec major
Ex. Wrist ulnar deviation with firm end feel
- check reign: radial collateral ligament, radial portion of jt capsule, tension in EPB and APL
Normal AROM=PROM when:
limited by approximation of bone
Normal AROM=PROM examples
Ex. wrist radial deviation with hard end feel
- contact between radial styloid and schapoid bone
-may be firm if limited by ulnar collateral lig., ulnocarpal lig., ulnar portion of jt capsule, tension in ECU, FCU
EX. Wrist pronation with hard end feel
- Contact between ulna and radius
- may be firm if limited by dorsal radioulnar lig, interosseous membrane, supinator
Physiological motion
motion of one segment of the body relative to another segment
accessory motion
motion that occurs between the joint surfaces during normal physiological motion
Capsular pattern of restriction
specific combo of motion loss caused by shortening of the joint capsule sourrounding a joint
- usually restricted in multiple directions
Noncapsular pattern of restriction
Combination of motion loss that does not follow a capsular pattern
noncapsular pattern of restriction caused by:
- ligamentous adhesion
- internal derangement
- extraarticular lesion
- muscle/tendon adhesion
- hematomas
- cysts
- inflamed bursa
Ligamentous adhesion
Limit motion in direction that stretches adhered ligament
-ex. adhesion of wrist ulnar collateral lig will limit wrist radial deviation
Internal derangement
disruption of internal join anatomy ie loose body
- ex. torn labrum will limit ROM in direction that compresses labrum
Extraarticular lesions
May limit motion in either direction of compression of structure or tension to injured structure
- Ex. subdeltoid bursitis limited ROM in direction of compression of bursa
- Ex. EPB and APL tendonitis limit motion in direction of tension to tendons
Contractile tissue
composed of the musculotendinous junction , the tendon, and the tendon’s interface with bone
-injury and dysfunction can cause restriction in AROM
Noncontractile tissue
All tissues that are not components of musculotendinous unit, includes; skin, fascia, scar tissue, ligament, bursa, capsule, articular cartilage, bone, IV disc, nerve, and dura mater
- injury or dysfunction can result in restriction in PROM and may also contribute to restrictions in AROM
Response of myofascial tissue to immobilization
Loss of ground substance
- glycosaminoglycans (GAGs) and water
-loss of interfiber lubriciation
- loss of interfiber distance
- results in new cross links that adhere adjacent collagen fibers
**half life of collagen is 300-500 days half life of ground substance is 1.7-7 days
- constantly being turned over so immobilization causes
problems
Nontraumatized Connective Tissue
Results in fibrosis
Traumatized
Results in scar tissue formation and contracture
Contracute
- Shortening of soft tissues
- May be caused by:
- immobilization
- imbalance of muscle power
- the result of a truama
Contracture: immobilization
Anomalous cross links develop between collagen fibers
- fibers remain in contact for long time periods and adhere at their point of interception
- cross links may prohibit normal collagen alignment when motion attempted
-increases stress required to stretch tissue
Fluid is lost from fibrous CT
-impairs normal fiber gliding
-fibrils have closer contact
Risk of contracture increases when immobilized tissue is injured because:
Scar tissue formation during proliferation stage of healing
- poor fiber alignment
- high degree of crosslinks between fibers
Intraarticular edema
Joint effusion: excessive fluid in joint capsule
- joint capsule distended limiting ability to fold and distend
- may limit both AROM & PROM
Extraarticular edema
Accumulation of fluid outside a joint
- may limit AROM and PROM due to soft tissue approximation sooner than normal
Adhesion
Abnormal jointing of parts to each other
- during healing scar tissue can adhere to surrounding tissue
- fibrofatty tissue inside joints can adhere to joint surfaces as scar tissue develops
- immobilization: synovial memebrane may adhere to articular cartilage
- can effect both quality and quantity of motion
Mechanical block
- bone or fragments of articular cartilage
- tears in intraarticular menisci or discs
- DJD or malunion of healing fx
- loose bodies
Spinal disc herniation
- Can result in direct mechanical block
- indirect blockage due to inflammation of spinal nerve roots
Adverse neural tension
- limited ROM of peripheral nerve
- can be the result of intraneural or extraneural adhesions
Extraneural adhesions can develop where:
- Nerve passes through tunnels
- nerves branch
- nerve is relatively fixed
Intraneural adhesions develop:
Within connective tissue layers
- mesoneurium
- epineurium
- perineurium
- endoneurium
Fascicular arrangement and composition of nerve
- Fascicular arrangement within nerve allows it to glide
- Fascicular composition of nerve protects it from compressive forces
Intraneural restriction responds to:
Tensor movements
Extraneural restriction responds to:
Slider movements
Testing precautions
- active infection/inflammation in/ around joint
- pt taking pain meds who may not be able to respond appropriately
- osteoporosis or condition of bone fragility
- hypermobile joints
- painful conditions if techniques make symptoms worse
- hemophilia
- hematoma
- boney ankylosis
- myositis occificans
- immediately after soft tissue lesion
Creep stretching
lengthening of tissue over time after the application of a constant load
Stress relaxation stretching
when a tissue is stretched to a specific length the force needed to maintain the length decreases over time
Stretching- hysteresis
- when force and length are measured as forced is applied and removed from a tissue the load deformation curve does not follow the same path
- energy gained during lengthening (W=fxd) is not recovered 100% during shortening, some energy given off as heat
to avoid injury total length change should not exceed:
2% to 6%
Transverse friction massage (TFM)
- STM
- mechanically teases apart adhesions
Strain- counter strain (SCS)
- STM
- de-activates muscle spindle thus muscle tension
Myofascial release: functional release (FRT)
- STM
- apply direct pressure to muscle to deactiveate muscle spindle
- uses functional movement pattern (FMP)
Myofascial realease: fixed technique (MFR)
- STM
- apply low load static stress to muscle/fascia unit to activate GTO to release muscle tension
Augmentented STM
- STM
- uses a tool to identify restrictions and reduce tone
- stimulates ruffini endings to decrease sympathetic activity
Spray and stretch
- STM
- deactivates muscle spindle and thus muscle tension
Passive stretching
Low load, prolonged force
- dense CT: >5mins
- muscle/tendon- 30/60sec
PNF stetching
- inhibit contraction of muscle to be stretched while you facilitate contraction of the antagonist
- contract relax
- contract relax, antagonist contraction
Motion
- can inhibit contracture formation
- disrupt adhesions between gross structures
- limit intermolecular cross links
- stretches tissues
- promotes lubrication of tissue
CPM- if AROM is contraindicated
Accelerate healing, improve orientation of collagen fibers, inhibit edema formation
Surgery indications for motion restrictions
- Mechanical block
- increase tendon length reduced due to hypertonicity
- Dupuytren’s contracture
Role of phys agents: increase soft tissue extensibility
- Thermotherapy: increase tissue temp to decrease viscoelasticity of tissue allowing plastic deformation to occur
- stretching window after application 3-4 mins
Role of phys agents: control edema and adhesion formation
- Cryotherapy: limits secondary injury
- E stim: control edema via muscle pumping
- controlling edema formation during acute inflammatory stage limits immobilization
- controling severity and duration of inflammation limits proliferation stage and adhesion formation
Role of phys agents: control pain during stretching
Thermotherapy, cryotherapy, electrical currents
- control pain
- allow longer stretching
- allow motion to begin sooner
Role of phys agents: facilitate motion
Electrical stimulation - motor nerves-AC current - muscle directly- DC current water - provides bouyancy to allow motion against gravity
Muscle tone
- Muscle tension at rest
- readiness to move or hold a position
- priming or tuning of a muscle
- the degree of activation before a movement
- def: passive resistance to the stretch of muscle
Active muscle tone
Resistance generated through the activation of muscle fibers by their neural connections
Passive muscle tone
biomechanical tension generated in the muscle and its CT at the length at which it is being tested
Ex muscle tone
Quads in runner at starting blocks
- active: neural input prepares the muscle by helping take up the slack
- passive: quads are being stretched over bent knee
- to assess tone muscle must be voluntarily quiet
Flaccidity
total lack of tone or no resistance to passive stretch
hypotonicity
decreased resistance to stretch
hypertonicity
increased resistance to stretch
- spastic: velocity dependent (quick stretch)
- rigid: resistance to stretch not dependent on velocity of stretch
Clonus
multiple rhythmic oscillations or beats in the resistance of a muscle responding to a quick stretch
muscle spasm
involuntary contraction of a muscle usually associated with a painful state
Dyskinesia
abnormal movement that is involuntary and has no purpose
Measuring muscle tone: quantitative
- hand held dynomometer
- EMG: electrical activity generated when a muscle is stretched passively
- pendulum test: usues electrogoniometer or isokinetic dynamometer
Measuring muscle tone: Qualitative
- 5 point ordinal scale
- 0- no tone
- 1+- hypotonia
- 2+ normal tone
- 3+ mod hypertonia
- 4+ severe hypertonia
- clinician passively moves muscle at varying speeds
Muscle is composed of
- Contractile elements
- cellular elements
- Connective tissue
- Tendons
- Calcium released from storage in SR allow actin and myosin to bind together
- ATP provides energy source for muscle contraction
Length tension relationship
- length too long
- length too short
Friction
between CT covering muscle fibers
- effected by viscosity of tissue and fluids in which they reside
Elasticity
Results in varying responses to stretch
Muscle tone can be generated by ____ elements alone
Passive
Muscle activation
requires both active and passive elements
Physical agents can change muscle tone and activation by
- Altering accessibility of ATP through improved circulation
- Changing elasticity of tissues
- Changing viscosity thereby friction of tissues
Alpha motor neuron
- Cell body in anterior gray matter or anterior horn of spinal cord
- transmits signals from CNS to muscle
- Travels through ventral root
- will innervate between 6 (eye muscles) and 2000 (calf) muscle fibers
- one axon and its branches and all the muscle fibers it innervates compromise one motor unit
Peripheral nervous system
- Alpha motor neurons
- gamma motor neurons
- some autonomic system neurons
- all sensory neurons
- sensory neurons can stimulate alpha motor neurons in the spinal cord directly so they can respond rapidly to activation (reflex)
Muscle spindle
- sense organ in muscle lying parallel to muscle fibers
- muscle stretch produces muscle spindle stretch
- receptors at equatorial region of spindle sense stretch and activate type 1a sensory neurons that synapse on alpha motor neuron in spinal cord
Techniques to use spindle activation to effect tone
- Tapping
- quick stretch
- high-frequency vibration
antagonist muscle
- Type 1a sensory neurons also transmit signals to alpha motor neuron of antagonist muscle
- provides inhibitory input (reciprocal inhibition)
- muscle spindles register lengthening of muscle only if they are taught
- because muscle fibers change length as muscle contracts, spindle must be reset
Gamma motor neurons
- innervate muscle spindles at their end regions
- when stimulated cause spindle to tighten equatorial region
- this sensitizes muscle spindle length
- Alpha and gamma stimulation at the same time during voluntary movement is called alpha-gamma coactivation
- gamma activation can occur alone
- prepares the muscle spindle to sense expected changes in length
Golgi tendon organs
- sensory organ located at muscle tendon junction
- function in series with muscle fibers
- sense muscle stretch
- protective mechanism for muscle
- sensitive to activation of as few as one or two motor units that are in series with spindle
- transmit signals via type 1b sensory neurons to alpha motor neuron pool
- inhibitory to agonist (autogenic inhibition) and excitatory to antagonist muscle
- prolonged stretch used to inhibit abnormally high tone
cutaneous receptors
- temp, pressure, touch, pain, texture
- cutaneous reflex responses are complex but act to activate or inhibit a muscle
- any phys agent that touches the skin can stimulate a cutaneous reflex response
Central nervous system input
- cerebellum
- basal ganglia
- motor cortex
- limbic system
Low tone
loss of normal alpha motor neuron input to normal muscle
high tone
- may result from peripheral stimulation due to pain, cold, or stress (muscle guarding)
- generally the result of loss of inhibitory control centers in the CNS
Consequences of abnormally low muscle tone
Difficulty developing adequate force for normal posture and movement
- motor dysfunctions
- secondary problems resulting from lack of movement
- pressure sores
- cardiorespiratory endurance problems
Consequences of abnormally low muscle tone: poor posture
Ligaments must perform work of muscles (static stabilizers) - eventual stretching of ligaments - slackening of joints -pain Appearance changes (cosmetically) - slumped posture - drooping facial muscles Pain
Treatment for low muscle tone
- hydrotherapy
- quick ice
- estim
- biofeedback
- light touch
- tapping
- resistive exercises
- ROM exercises
- functional training
- orthotics
Consequences of abnormally high muscle tone
- discomfort or pain from muscle spasm
- contractures
- abnormal posture
- skin breakdown
- increased effort by caregivers
- development of specific movement patterns that may inhibit development of movement alternatives
- may or may not inhibit function
Treatment for high muscle tone associated with pain, cold, or stress
Remove source - eliminate pain -warm pt - alleviate stress relaxation techniques emg biofeedback neutral warmth heat hydrotherapy cold towels stimulation of antagonists - resisted exercises - electrical stimulation
Treatment for high muscle tone associated with spinal cord injury
- selective ROM exercises
- prolonged stretching
- positioning
- orthotics
- meds
- surgery
- heat
- prolonged ice
Treatment for high muscle tone associated with cerebral lesions
- Prolonged ice
- inhibitory pressure
- prolonged stretch
- inhibitory casting
- positioning
- reeducation of voluntary movements
- STM to contralateral muscle
- general relaxation techniques
- soft lighting/music
- slow rocking
- neutral warmth
- slow stroking
- hydrotherapy
- rotation of the trunk
- maintained touch
Treatment of high muscle tone associated with rigidity
- Positioning
- ROM exercises
- orthotics
- serial casting following head injury
- heat
- meds
- general relaxation techniques
- STM to contralateral muscle
