Problems w/ Body Structure/Function: Abnormal MM Tone and Motor Control: Exam 1 Flashcards
Muscle Tone
what is it?
Resist. offered by mm’s when passively lengthened
*like a dimmer switch that can be turned up/down
MM tone will be uniform _________ @ all speeds
resistance
Some ex’s of Abnormal MM tone
- HypOtonia/flaccidity
- flaccidity==comp. absence tone
- HypERtonia
- spasticity—-velocity dep.
- rigidity—non-velocity dep.
- Dystonia
- Spasm
Dystonia
Involuntary mm contractions
force body into abnorm/painful postures
MM Spasm
sustained involuntary mm contraction
HypOtonia
what is going on?
- LOSS of normal alpha-gamma coactivation
- slack spindle, no proprio. input
HypOtonia
Pathologies:
- Down’s
- Cb damage
- UE paralyzed after CVA
- UE more common
Hypotonia
what should you examine?
- Passive motion
- Relaxed posture —- whole posture
Hypertonia
Spasticity
-
Velocity-dependent INC in resist. to PROM
- add speed===INC resistance
Hypertonia
Rigidity
-
NON-velocity dependent INC resistance to PROM
- stiff regardless
Spasticity vs. Spastic Paralysis
2 diff. things!!!
Hypertonia
what should you Examine?
- passive mvmt @ varying speeds
- consider abnorm reflexes
- DTR’s
- Clonus
- Babinski
- observe posture @ rest
Rigidity
Decorticate
the FLEXION one
- UE Flexion
- trunk, and LEs in EXT
***LOOK AT THE ARMS THOUGH—-THIS IS THE FLEXION ONE!!!
Rigidity
Decerebrate
the one w/ all the e’s…..EXTENSION ONE!!!
- EXT of trunk and ALL extremities!!!
Rigidity
2 types
- Lead pipe
- SLOW resist. t/o ROM
- Cog Wheel
- catch and release t/o ROM
Measuring Tone
- Min, Mod, Severe
- describe specific mm groups
- WHERE in the ROM resistance is encountered
- Modified Ashworth
NOTE: NO SCALE FOR HYPOTONIA
Modified Ashworth Scale
Explain
- Controlled, but rapid PROM @ ea jt thru ROM
- Starting point:
- limb @ rest w/ pt pos’d comfortably
- Score:
- 0-4/4
Mod. Ashworth
Grade 0
NO inc in mm tone
Mod. Ashworth Scale
Grade 1
SLIGHT INC. in mm tone
manifested by catch and release OR by MINIMAL RESIST. @ end range of motion when part moved
Modified Ashworth
Grade 1+
SLIGHT INC mm tone
manifested by catch, followed by MIN resist. t/o remainder (<50%) of ROM
Mod. Ashworth
Grade 2
MORE marked INC in mm tone thru MOST (>50%) of ROM
BUT affected part is easily moved
Mod. Ashworth
Grade 3
CONSIDERABLE INC’S in mm tone, passive mvmt is difficult
Mod. Ashworth
Grade 4
affected part is rigid in position
Hypertonia causes
Neural Mech’s
- AMNs are more sensitive to input
- depolarized—-closer to firing threshold
- net INC excitatory inputs
- net DEC inhibitory inputs
Hypertonia
NON-Neural Causes
- altered viso-elastic props of connect. tissue from immobilization
- tendons, ligs, jt cap
- contractures
- changes in mm fiber structure
- fibrosis, atrophy
- free Ca+ in motor fibers
3 other ways to measure mm tone
- functional performance
- self-report scale
- reflexes
**H-reflex—-sensitivity of AMN system
Flexibility is the cornerstone to…..
Mobility!!!!!
Treating abnormal tone
- Consider:
- neural and non-neural mech’s
- systems
- Functional relevance
changing tone does NOT necessarily…..
change function!!!
if they are functioning w/ it…..no need to “treat” it
In relationship to function
when would you want to test mm tone?
passively vs. their motor behavior DURING functional activity
Treating Hypertonia
pharmacologically
- Baclofen—-antispasmatic
- valium
- botox
Treating Hypertonia
Sx
nerve cut or block
Treating hypertonicity
prolonged stretch
- serial casting
- air splints
*restores ROM and minimizes reflex
2 other ways to treat hypertonicity
rhythmical rotation (exactly what it sounds like)
Wt. Bearing
Rational for tx hypertonia
Activating the GTOs
Autogenic inhibition
DIRECT PRESS. to tendon of hypertonic mm
effects are temporary
allows for functional task practice
Spastic paralysis is related to…
abnormal synergy patterns
Abnormal synergy is the inability to what?
inability to isolate mm’s or mvmts
Abnormal synergy
group of mm’s working together when they shouldn’t
typical patterns for UE/LE synergy patterns combines what
Flex/Ext
UE Flexor Synergy
see pics
UE Flex synergy
Scapula
retraction
downward rotation
elevation
UE Flexor synergy
Shoulder
ABD
rel. ER
EXT
UE Flex synergy
Elbow
FLEX w/
pro/sup
UE Flex synergy
Wrist
FLEX w/
radial/ulnar deviation
UE Flex synergy
Fingers
Flexion
UE Extensor Synergy
see pics
UE EXT synergy
Scapula
LESS retraction
Downward rot.
Depression
UE EXT synergy
Shoulder
ADD
IR
min. Flex
UE EXT synergy
Elbow
EXT
Pro
UE EXT synergy
Wrist
FLEX
min. Ulnar dev
UE EXT synergy
Fingers
Flexion
LE Flex synergy
see pics
LE FLEX synergy
Pelvis
elevated
retracted
POST tilt
LE FLEX synergy
Hip
flex
ABD
ER
LE FLEX synergy
Knee
Flexion
LE FLEX synergy
Ankle
DF
inversion
LE EXT synergy
see pics
***EXT synergy more common in LE
LE EXT synergy
Pelvis
elevated
retracted
ANT. tilt
LE EXT synergy
Hip
rel. EXT
ADD
IR
LE EXT synergy
Knee
EXT
LE EXT synergy
Ankle
PF
Inversion
Typical Arm Posture w/ Abnorm Synergy
- Shouder ADD.
- EXT pattern
- Elbow FLEX
- FLEX pattern
- Forearm PRO
- EXT pattern
- Wrist FLEX
- FLEX pattern
Typical Leg posture abnorm synergy
- Hip FLEX and ADD.
- Knee EXT
- Ankle PF
Stages of Recovery from Spastic Paralysis
Brunnstrom and Bobath
- Brunnstrom—more detailed
- 7 stages from flaccid thru full recovery
- Bobath
- 3 stages
Brunnstroms Stages 1 and 2 correlate to…
Bobath stage 1:
Initial Flaccid Stage
Brunnstrom’s Stages 3 and 4 correlate to…
Bobath’s stage 2
Stage of Spasticity
Brunnstrom’s stages 5 and 6 correlate to….
Bobath’s stage 3
Stage of Relative Recovery
Stages of Recovery
Brunnstrom and Bobath correlations
see pics
Brunnstrom’s Stage I
Flaccidity of involved limbs
NO reflex or voluntary mvmt
Brunnstrom’s Stage II
- MIN voluntary mvmt or associated rxns
- contraction somewhere else causes contraction where we’re looking
- ex. yawn and it kicks off contraction
- mvmts in partial or whole synergy patterns
- Spasticity BEGINS to develop
Brunnstrom’s Stage III
- Voluntary control of mvmt synergies
- mvmt may NOT be thru full ROM
-
spasticity reaches peak
- Hypertonia @ this point
- may be severe
NOTE: not everyone starts in stage I
Brunnstrom’s Stage IV
- SOME mvmts out of synergy
- spasticity declining, but observable
- Ind. can now
- place hand behind body
- flex arm to horiz. pos.
- pro/sup wrist w/ elbow @ 90deg
- Ind. can now
Brunnstrom’s Stage V
- DECLINING spasticity
- able to perform more diff. mvmts OUT of spasticity
-
indiv. can now:
- arm raise to side (ABD)
- arm raise forward (flex) overhead
- PRO/SUP w/ elbow extended
-
indiv. can now:
Brunnstrom’s Stage VI
- Individual, isolated mvmts
-
indiv can: isolating elbow===huge progress
- hand from lap to chin
- hand from lap to opp knee
-
indiv can: isolating elbow===huge progress
- NEARLY norm.
- NO SPASTICITY
Brunnstrom’s Stage VII
Normal motor function
Brunnstrom’s Method
Neurophys. tx based on the use of reflexes to elicit mvmt; stereotyped whole-limb mvmt patterns are facilitated
***encouraged abnorm mvmts bc “mvmt is mvmt”
Brunnstrom’s Method
Theory
- synergies due to absence of control from above
- Hemiplegia is a reversion back to earlier phylogenic pd
- return of abnorm reflexes====Normal
- seq. of recovery similar to development
- abnorm synergies can be used early in recovery to facilitate mvmt
Associated Rxns
eliciting of involuntary mvmt w/ resisted voluntary mvmt of some other part of body
How can we use Associated Rxns?
- Facilitate tone in hypotonic mm
- Inhibit tone in hypertonic mm
Using Assoc’d Rxns to facilitate/inhibit tone
Sag. plane UE
SAME RELATIONSHIP
- Resist Flex uninvolved —-> get Flex involved
- Resist EXT uninvolved—-> get EXT involved
Using Assoc’d Rxns to facilitate/inhibit tone
Sag Plane LE
Relationship is RECIPROCAL
- Resist FLEX uninvolved—–> get EXT involved
- Resist EXT uninvolved—-> get FLEX involved
Assoc’d Rxns to facilitate/inhibit tone
Frontal Plane UE
Relationship is SAME
Ramiste’s-like phenomenon
- Resist shoulder ABD uninvolved—> get shoulder ABD involved
- Resist ADD uninvolved—-> get ADD involved
Assoc’d Rxns to facilitate/inhibit tone
Frontal Plane LE
Relationship is SAME
Ramiste’s Phenomenon
- Resist hip ABD uninvoled—-> get ABD involved
- resisted ABD—-> opp. side ABD
2 Abnormal reflexes that will Facilitate/Inhibit Tone
- Asymmetrical Tonic Neck Reflex (the bow and arrow baby)
- Symmetrical Tonic Neck Reflex (when baby crawls on all 4 holds neck in EXT)
ATNR
Rotation of the Neck facilitates…..
- EXT of “Chin Side” limbs
- FLEX of “Back of Skull Side” limbs
**Eventually disappears
STNR
EXT. of neck facilitates….
- UE EXT & LE FLEX
STNR
FLEX of the neck facilitates….
- UE FLEX and LE EXT
NDT Theory or…
Neurodevelopment Theory
NDT Theory in a nutshell….
Normalize posture/tone
THEN integrate mvmt
W/ NDT
Abnormal mvmt is the result of what?
failure to integrate primitive reflexes
According to NDT theory….
Normal mvmt CANNOT be superimposed on __________
what must you do?
abnormal posture/tone
*Inhibit abnorm mvmt, THEN facilitate normal mvmt
According to NDT Theory
How is Movement improved? Through what?
Thru inhibition or modification of impairments of spasticity and abnorm reflex patterns
According to NDT….
what is motor output controlled by??
SENSORY INPUT!!!
3 Pos’s of developmental principles:
- cepahlo-caudal
- proximal-distal
- symmetrical-asymmetrical
Developmental principles
Wt. Shift
- Sagittal
- Frontal
- Horizontal
Tx Principles of NDT
Handling
- “key points of control”
- Reflex Inhibiting Patterns (RIPs)
- inhibit abnorm tone/mvmt
-
Facilitation
- encourages norm. mvmt
Tx Principles of NDT
If hypertonia is DEC…. then what can happen?
“Weak” mm’s can contract
NDT Tx Principles
Abnorm postural rxns vs. normal postural rxns
- Abnorm postural rxns should be CHANGED
- Normal postural rxns should be FACILITATED
4 Steps to NDT Tx
- Prep pt to move—- have to get them out of tone
* RIPs
* sensory stimulation to normalize tone
- Prep pt to move—- have to get them out of tone
- MOVE pt—you move them passively
- Pt ACTIVELY MOVES w/ PT’s control
- Pt moves W/OUT ASSIST or control
What are the 2 MAIN problems in NDT?
- Abnormal control of movement
- Abnormal tone of postural mm’s
NDT Summary:
Aim of Tx
- DEC spasticity
- Facilitate normal mvmt
*NOTE: This is only a temporary reduction
NOTE: Permanent DEC in spasticity only achieved when pt able to perform selective mvmts.
