Neuro 2- Motor function etc Pages 135- 139 Flashcards
Two ways to examine for muscle bulk, firmness
- Determine whether there is atrophy
a. Is atrophy due to denervation, disuse, or primary
atrophy?
b. Is persistent fasiculations present? suggests
neurogenic injury.
c. Examine by inspection, palpation and girth
measurement - Check muscle firmness, tenderness and reactivity
Ways to examine for muscle tone
A. Use PROM to assess muscle stretch reflexes and
responsiveness to passive elongation
B. Check for flaccidity (absent, tone), Hypotonia
(decreased tone)
C. Assess Spasticity (spastic hypertonia)
D. Assess Rigidity
E. Check for Decerebrate Rigidity/ posturing
F. Check for Decorticate Rigidity/ posturing
G. Check for Opisthotonos
H. Use AROM, active movement control to assess tone
in automatic postural adjustments
I. Evaluate and document
What is the difference between Flaccidity and Hypotonia?
Absent tone vs decreased tone
When would PTs observe Flaccidity and Hypotonia?
- In segmental/ LMN lesions; nerve roots and
peripheral N injury - Initially after suprasegmental/ UMN lesions (i.e brief period of spinal shock in spinal cord injuries, cerebral shock in stroke). There is decreased or no resistance to PROM.
Details about Spasticity Aka Spastic hypertonia
- Seen in suprasegmental/ UMN lesions.
2. There is inc. resistance to PROM; determine whether inc in speed inc resistance (spasticity is velocity dependent)
5 signs of spastic hypertonia
- Clasp-knife response
- Clonus
- Hyperactive cutaneous reflexes, positive babinski sign
- Hypereflexia
- Some degree of weakness is usually present
What is Clasp-knife response?
Marked resistance to PROM suddenly gives way
What is Clonus?
Maintained stretch stimulus produces a cyclical, spasmodic contraction; commonly in plantar flexors, also seen in wrist flexors and jaw
What is Hyperactive cutaneous reflexes, positive Babinski sign
DF of great toe with fanning of other toes in response to stroking up the lateral side of the sole of the foot; indicative of corticospinal (pyramidal) tract disruption
What is Hyperreflexia?
Increased deep tendon reflexes
What is the Modified Ashworth Scale used for?
How many grades does it involve?
Identify the stages
- Scale used for grading spasticity.
- Six grades
0- No increase in muscle tone
1- Slight inc in muscle tone, minimal resistance at end
of ROM
1+- Slight inc in muscle tone, minimal resistance
through less than half of ROM
2- More marked inc in muscle tone, through most of
ROM, affected part easily moved
3- Considerable inc in muscle tone, passive movement
difficult
4- Affected part rigid in flexion and Extension
What is Rigidity?
Increase in resistance to PROM that is independent of velocity of movement.
Details about Rigidity
What type of brain disorder is it evident in?
What type of disease is it associated with?
- Seen in Basal ganglia / Nigrostriatal disorders
- Can be Leadpipe or Cogwheel
- Associated with Parkinson’s disease
What is Rigidity associated with Basal ganglia / Nigrostriatal disorders?
Increased resistance to passive movement in agonist and antagonist muscle
What is Leadpipe Rigidity?
Uniformed rigidity throughout the range
What is Cogwheel Rigidity?
Rigidity interrupted by a series of jerks
What is rigidity associated with Parkinson’s disease?
Resting tremor, bradykinesia; strength and reflexes are not affected.
What is Decerebrate Rigidity/ Posturing?
A. Seen in comatose patients with brainstem lesions between the superior colliculus and the vestibular nucleus.
B. Results in increased tone and sustained posturing of all limbs; trunk/neck in rigid extensions
What is Decorticate Rigidity/ Posturing?
A. Seen in comatose patients with lesions above the superior colliculus
B. Results in increased tone and sustained posturing of upper limbs in flexion and lower limbs in extension
What is Opisthotonos?
- Prolonged, severe spasm of muscles, causing the head, back, and heels to arch backwards; arms and hands are held rigidly flexed
- Seen in severe meningitis, tetanus, epilepsy, and strychnine poisoning.
What are the characteristics of UMN Lesions?
- Location of lesion- CNS
- Structures involved- Cortex, Brainstem, Corticospinal
tracts, Spinal Cord - Disorders- Stroke, TBI SCI
- Tone- Inc hypertonia, Velocity dependent.
- Reflexes
- Inc: hyperreflexia, clonus
- Exaggerated cutaneous & autonomic reflexes: +
Babinski response
- Involuntary movements- Muscle spasms: flexor or
extensor. - Strength
- Stroke: weakness or paralysis on one side of the
body - Corticospinal lesions: contralateral if above
decussation in medulla, ipsilateral if below - Spinal cord lesions: BLE loss below level of lesion
- Stroke: weakness or paralysis on one side of the
- Muscle bulk- Variable, disuse atrophy
- Voluntary movements- Impaired or absent:
dyssynergic patterns, obligatory synergies
What are the characteristics of LMN Lesions?
- Location of lesion- PNS
- Structures involved
-SC: Ant horn cell, spinal roots, peripheral nerves
-CN: cranial nerves - Disorders- Polio, GBS, PNI, Peripheral neuropathy,
radiculopathy - Tone- Decreased or absent; hypotonia, flaccidity, Not
velocity dependent - Reflexes- Dec or absent: hyporeflexia, cutaneous
reflexes decreased or absent - Involuntary Movements- With denervation: fasiculitis
- Strength- Limited distribution: segmental or focal
pattern, Root innervated pattern - Muscle bulk- Neurogenic atrophy: rapid, focal,
severe wasting - Voluntary movements- weak or absent if nerve is
interrupted.
Typical patterns of spasticity in UMN syndrome- Upper Limbs: Action and Muscles affected
- Scapula
- Shoulder
- Elbow
- Forearm
- Wrist
- Hand
- Scapula
- Action: Retraction & downward rotation
- Muscles Affected: Rhomboids - Shoulder
- Action: Adduction & IR, depression
- Muscles affected: Pec major, lats, teres major,
subscapularis - Elbow
- Action: Flexion
- Muscles affected: Biceps, Brachalis, Brachioradialis - Forearm
- Action: Pronation
- Muscles affected: pronator teres, Pronator quadratus - Wrist
- Action: Flexion, Adduction
- Muscles affected: Flexor carpi Radialis - Hand
- Action: Finger flexion, Clenched fist thumb adducted
in hand
- Muscles affected: Dig. profundus/sublimis, Add
policis brevis, Flexor pollicis brevis
Typical patterns of spasticity in UMN syndrome- Lower Limbs: Action and muscles affected (1-4 of 7)
- Pelvis
- Hip
- Knee
- Foot & Ankle
- Pelvis
- Action: Retraction (hip hiking)
- Muscles affected: Quadratus Lumborum - hip
- Action & Muscles Affected: Adduction/scissoring
(Add. Longus/ brevis), IR (Add. Magnus, Gracilis),
Extension (Gluteus max) - Knee
-Action: Extension
- Muscles Affected: Quadraceps - Foot & Ankle
- Action & Muscles Affected: PF (gastrocsoleus),
Inversion (Tibialis posterior), Equinovarus, Toes claw,
MP ext. PIP flex, DIP ext (long toe flexors), Toes curl
(Ext. hallacus longus), PIP, DIP Flexion (peroneus
longus)
Typical patterns of spasticity in UMN syndrome- Lower Limbs continued: Action and muscles affected (5-7)
- Hip & knee (prolonged sitting posture)
- Trunk
- COG forward (prolonged sitting posture)
- Hip and knee
- Action & Muscles affected:: Flexion (Iliopsoas). Sacral
sitting (Rectus femoris, Pectineus, Hamstrings) - Trunk
- Actions- Lateral flexion with concavity rotation
(Rotators internal & external obliques) - COG forward (prolonged sitting posture)
-Action: Excessive forward head flexion (rectus
abdominis, external obilques), Foreward head (psoas
minor)
What should PTs include in their examination and documentation of patients with muscle tone problems? (4)
- Determine which body part and joints have
abnormal tone - Determine whether asymmetries exist, UE
vs. LE, axial (trunk) vs. appendicular (limbs),
distal vs. proximal. - Describe the character of the resistance e.g
velocity dependant vs. uniform, clasp-knife,
leadpipe, cogwheel. - Describe the effects of tone on active
movement.
What is deep tendon reflex?
How is it performed?
Normally occurring reflexes in response to stretch of muscle
Tap directly on tendon: stretch stimulus produces contraction of agonist muscle with corresponding quick movement
What is superficial cutaneous reflex?
Normally occurring reflexes in response to noxious stimulus (light scratch) applied to skin.
Reflex scoring scale (Capute) for primitive/spinal and tonic/brainstem reflexes
0- absent
1.+ tone change, no visible movement of extremities
2+ visible movement of extremities
3+ Exaggerated, full movement of extremities
4+ Obligatory and sustained movement, lasting for >
30 seconds
Name some commonly tested reflexes and their corresponding nerves (8)
- Jaw reflex
- Trigeminal (CN V)
- Biceps- (C5- C6)
- Triceps (C7-C8)
- Brachioradialis (C5-C6)
- Hamstring (L5-S3)
- Quadraceps (knee jerk patellar) (L2-L4)
- Achelles (ankle jerk) (S1-S2)
How to score Deep Tendon reflexes?
0- Absent reflex 1+ decreased response 2+ Normal response 3+ Exaggerated response 4+ Hyperactive
DTRs may be abnormal in CNS lesions (hyperreflexia, hyporeflexia) or PNS lesions (hyporeflexia)
What are the 4 superficial cutaneous reflexes? CAPP
- Plantar reflex (S1-S2, tibialis N)
- Positive babinski response
- Abdominal Reflexes (T-L1)
- Cremasteric reflexes (L1-L2)
How is the plantar reflex (S1-S2, Tibialis N) performed?
Stroke the lateral sole of the foot from calcaneous to base of 5th metatarsal and medially across metatarsal heads. This produces PF of the toes
How to perform Babinski Reflex test?
Stroke the lateral sole of the foot from calcaneous to base of the 5th metatarsal and medially across metatarsal heads. This produces DF of great toe and fanning (abduction) of the 4 lesser toes
How to perform Abdominal reflex (T6-L1)?
Lateral to medial scratching of skin (towards umbelicus) in each of the 4 quadrants produces deviation of the umbilicus towards the stimulus.
How to perform Cremasteric reflex (L1-L2)?
Stroke the skin of the proximal and medial thigh. This produces elevation of the testicles (neurologically intact individuals).
This is absent in people with SCI and corticospinal lesions
What are the 3 Primitive/Spinal reflexes?
- Flexor withdrawal
- Crossed extension reflex
- Traction Grasp
How to perform Flexor Withdrawal reflex test?
Apply noxious stimulus (pin prick) to sole of foot. This produces toe extension, DF of the foot and flexion of the entire LE
How to perform crossed extension reflex?
Apply noxious stimulus to sole of the foot. This produces flexion of the stimulated leg, then extension with adduction of opposite leg.
How to perform traction grasp?
A stretch stimulus from grasping the forearm and pulling produces total flexion response of the UE.
apply maintained pressure to the palm of the hand (palmar grasp) or ball of foot (plantar grasp). This produces maintained flexion of fingers or toes.
What are the 4Tonic/ Brainstem Reflexes?
- Asymmetrical Tonic neck ATNR
- Symmetrical Tonic Neck STNR
- Positive Supporting
- Associated Reactions
Persons in which primitive /spinal reflexes are present (2)
Present developmentally in normal infants and in
some patients with TBI
Persons in which Tonic/ Brainstem reflexes are present
Present developmentally in normal infants and in
some patients with TBI
What is Asymmetrical Tonic reflex ATNR?
Rotation of the head to one side produces flexion of the skull limbs and extension of the jaw limbs
What is Symmetrical Tonic reflex STNR?
Flexion of the head produces flexion of the UE with extension of the LE
What is Positive supporting?
Contact to the ball of the foot in the standing position produces rigid extension (co-contraction) of the LEs
What is Associated reactions?
Strong voluntary movements in one body segment produces involuntary movements in another resting extremity.
10 areas to address when examining Motor Function
Examine:.
- Muscle bulk and firmness
- Muscle tone
- Reflexes
- Muscle performance
- For fatigue
- Voluntary movement control
- Presence of Involuntary movements
- Coordination
- Balance
- Gait and locomotion
How can PTs use AROM and active movement control to assess tonee in automatic postural adjustments?
- Check for stiffness in limbs and trunk in maintaining posture against gravity
- Examine for abnormal movements: are movements restricted, are they performed with great effort, are there limitations in voluntary movements?
What is fatigue?
The failure to generate the required or expected force during sustained or repeated contractions.
Some facts about fatigue
- Fatigue is protective: guards against over work and injury
- fatigue is task dependent
What are some sources of fatigue? (3)
- CNS/ central fatigue: seen in MS, ALS, chronic fatigue syndrome
- Neural/ myoneural junction: seen in MS, Postpolio syndrome, GBS and Myesthenia Gravis.
- Muscle contractile failure: metabolic changes at the level of the muscle e.g. depleted ca stores, seen in muscular systrophy.
Things to Determine/Document when examining for fatigue
- Source of fatigue
- Frequency and severity of fatigue episodes
- Threshold for fatigue: level of exercise that
cannot be sustained indefinitely (abrupt
onset, dependent on intensity and duration) - Factors that influence fatigue: health status,
environmental temperature, stress - Level of functional performance:
independence, Mod I, level of assistance, AD - Episodes of exhaustion: limit of endurance
beyond which no further performance is
possible - Overwork weakness or injury: prolonged
decrease in absolute strength and endurance
due to excess activity of partially denervated
muscle. common in postpolio syndrome &
Duchenne’s muscular dystrophy.
What are some tests and measures for fatigue? (2)
- Modified fatigue Impact Scale (MFIS):
subjective scale with 3 subscales, assessing
the impact of fatigue on physical, cognitive,
and psychosocial function. - Isokinetic Dynamometry, Electromyography
(EMG): can observe decrements in force
production.
What should a PT Determine/Document when examining for voluntary movement control?
- Quality (synergistic organization) of muscle
activation patterns - Are movements appropriate and timely in
response to stimulus and command? - Able o vary easily type of contraction pattern
i.e. isometric, concentric, eccentric) - Are movements symmetrical?
- Adequate control of multiple body segments,
postural stabilization. - Assess for presence of abnormal synergy
patterns: muscle synergistic patterns that are
highly stereotyped and obligatory; commonly
seen in UMN dysfunction e.g. CVA, TBI
3 categories of disorders to look at when examining for the presence of involuntary movements
- Extraparymidal disorders, basal ganglia
dysfunction - Cerebellar Disorders
- Cortical disorders
What 5 things may be observed during voluntary movement with extraparymidal disorders?
- Tics
- Chorea
- Athetosis
- Tremor
- Myoclonus
What are Tics?
Spasmodic contractions of specific muscles, commonly involving face, head, neck, or shoulder muscle
What is Chorea?
Relatively quick twitches or “dancing” movements
What is Athetosis?
Slow, irregular, twisting, sinuous movements, occurring especially in UE
What is Tremor?
Continuous quivering movements; rhythmic, oscillatory movement observed at rest (resting tremor)
What is Myoclonus?
Single quick jerk
What may be observed during voluntary movement with Cerebellar Disorders?
Intention tremor occurring when voluntary movement is attempted
What may be observed during voluntary movement with Cortical Disorders?
Epileptic seizures, tonic/clonic convulsive movements
What does a PT have to Determine/Document when examining for presence of involuntary movements?
1. Are movements extraneous and
spontaneous, apparently unintended?
2. Part of body involved, orientation in space.
3. Frequency, amplitude, pattern
4. Effect of triggering stimuli or changes in
environment
5. Methods: patient's self report,
observation/functional assessment,
videotaped analysis.Two areas to look at when examining for patient coordination
- Gross motor coordination- Body posture,
balance, and extremity movements involving
large muscles. - Fine motor coordination- extremity
movement concerned with use of small
muscle groups
Gross muscle coordination- Upper Extremity Tests
- Unilateral- finger to nose
- Rapid alternating movements (RAM)
- Supination/pronation
- Bilateral symmetrical movements (clapping,
RAM) - Bilateral asymmetrical movements- alternate
touch knee/shoulder) - Bilateral unrelated movements- Knee pat/
elbow extension
Gross motor coordination- Lower Extremity Tests
- Unilateral- heel to shin, foot tapping
- Bilateral symmetrical- foot tapping, alternate
knee flexion/extension - Bilateral asymmetrical- alternate knee
flexion/extension - Bilateral unrelated movements- knee
flexion/extension and hip
adduction/abduction.
Gross motor coordination- Postural/trunk test
Whole body movements
Fine Motor Coordination Tests
- Thumb/finger opposition (unilateral, bilateral)
- manual/finger dexterity: grasp and release
- Standardized tests and measures: Jebsen-
Taylor Hand Function Test, Minnesota Rate of
Manipulation Test, Purdue Pegboard.
What should a PT include in the Evaluation and Documentation of patient coordination?
- Speed/rate control: does inc in performance
speed affect quality of motor performance? - Control: are movements precise? Are
continuous and appropriate motor
adjustments made if speed and direction are
changed? Can movement and distance be
judged following a moving target? Does
occluding vision alter performance? - Steadiness: Is there consistency over time?
Can a position be maintained without
swaying?, tremors, or extra movements?
Does patient fatigue rapidly? - Response orientation: Does correct
movement occur in response to a specific
stimulus? - Reaction time: does movement occur in a
reasonable amount of time?
6.
What is Dyssynergia?
Impaired ability to associate muscles together for complex movement
What is Dysmetria?
Impaired ability to judge distance or ROM
What is dysdiadochokinesia?
Impaired ability to perform rapid alternating movements
How to score patient coordination?
0- unable 1- Severe Impairment 2- Moderate Impairment 3- Minimal Impairment 4- Normal Performance
What is balance?
The control of relative positions of body parts by skeletal muscles, with respect to gravity and to each other.
What are the sensory elements of balance? (6)
- Visual System
- Somatosensory
- Vestibular
- Sensory Organization Test (SOT)
- Clinical Test for Sensory Interaction in
Balance (CTSIB) - Modified Clinical Test of Sensory Interaction
on Balance (mCTSIB)
What does the visual system in the Sensory elements of balance examine? (3)
- Visual acuity
- Depth Perception
- Visual Field Defects
What does the Somatosensory system in the Sensory elements of balance examine? (3)
- Proprioception
- Cutaneous Sensation ( touch, pressure)
- LE & Trunk, especially feet and ankles
What does the Vestibular system in the Sensory elements of balance examine?
- Observe balance with changes in head positions
Details about Sensory Organization test (SOT)
1. Equipment
- 6 sensory conditions
Equipment: Computerized moving platform; Stop watch
6 sensory Conditions:
1. Eyes open, stable surface
2. Eyes closed, stable surface
3. Visual conflict- sway referenced vision using
moving surround screen or dome using
force-platform surround screen, stable
support
4. Eyes open, moving surface, using moving
platform
5. Eyes closed, moving surface
6. visual conflict, moving surface
How to evaluate and document the Sensory Organization Test (SOT) test?
- Record time standing position is maintained
(30 sec), record changes in the amount and
direction of postural sway, 1 minimal- 4 fall - Patients dependent on vision become
unstable in conditions 2,3,5,6 - patents dependent on surface
/somatosensory inputs become unstable in
conditions 4,5,6 - Patients with vestibular loss become unstable
in conditions 5 and 6 - Patients with sensory selection problems
become unstable in conditions 3,4,5 and 6.
What is the Clinical Test for Sensory Interaction in Balance (CTSIB)?
Uses medium intensity foam to substitute for a moving platform and a modified visual dome to substitute for a moving visual surround. Test 6 condition, similar to SOT.
What is the Modified Clinical Test for Sensory Interaction in Balance (mCTSIB)?
Tests 4 conditions EOSS, ECSS, EOFS, ECFS
FS= foam surface
