Tone and Coordination

Question 1

What are the components of a motor assessment?

Answer 1

ROM: goniometer, ruler, tape or observation

Flexibility: muscle length ROM

Strength: Individual muscles, muscle group, myotomes or function. MMT, dynamometer or functional tests.

Tone and Deep Tendon Reflexes

Coordination: movement control/smoothness

Involuntary movements: tics, tremors, ballistic and choreic (discoordinated) movements

Question 2

What is tone?

Answer 2

Inherent amount of resistance to lengthening of relaxed muscle and associated fascial structures when a joint is moved.

Readiness of the muscle for action or muscles ability:

• Adapt to changes in length
• Maintain constant force under changing circumstances.

Question 3

Why is tone important?

Answer 3

1. Postural Control/Stability: Tone in neck muscles, shoulder girdle and trunk (core).
2. Voluntary movement and movement control.

Question 4

1. What is normal muscle tone?

2. What is the continuum of muscle tone?

Answer 4

Normal= The right amount of tension inside the muscle at rest, needed for the muscle to contract on command and be ready for voluntary movement.

Lower then normal tone:

• No tone
• Flaccidity
• Hypotonia

Normal

Higher then normal tone:

• Hypertonia
• Spasticity
• Rigidity

Question 5

1. What is hypotonia?

2. What is it associated with?

Answer 5

1. Not enough tension in the muscle at rest.
   - May have mushy or floppy feel to it.
   - Lack of graded control of the muscle when used (lack motor coordination)
2. Lower motor neuron conditions (ALS), cerebellar lesions, spinal cord injury, early stages of acquired brain injury (Stroke).

Question 6

1. What is hypertonia?

2. What conditions is it associated with?

Answer 6

1. Too much tension in the muscle at rest.
   - Muscle is tight and tense even when it isn’t doing anything.
   - Voluntary movement can be difficult, stiff.
2. Upper motor neuron conditions, CP, MS, stroke, TBI, Parkinson’s.

Question 7

What is the difference between spasticity and rigidity? What conditions are these symptoms associated with.?

Answer 7

Spasticity: velocity dependent resistance to stretch: amount of stiffness felt related to the speed of the movement. Fast movements elicit more resistance than slow movements.
Typical in: MS, SCI, CP

Rigidity: non-velocity dependent resistance to passive stretch that affects agonists and antagonists (both directions of movement); uniform increase in tone whether joint is passively moved quickly or slowly
Parkinson’s disease

Question 8

What is clasp-knife?
Lead-pipe?
Cogwheel?

Answer 8

CK: Spasticity where there is a sudden release of tone at a particular point in the ROM.

LP: Feels like lead pipe throughout movement

CW: On-off clicking throughout movement.

Question 9

What are the differences between spasticity and rigidity in terms of:
A. Pattern of muscle involvement
B. Nature of tone
C. Clinical significance

Answer 9

A.
Spasticity: UE flexors, LE extensors, distal more then proximal.

Rigidity: Flexors and extensors equally, proximal more than distal.

B. Spasticity: velocity-dependent

Rigidity: Constant throughout ROM and not related to velocity

C. Spasticity: upper motor neuron sign (pyramidal)

Rigidity: Extrapyramidal

Question 10

How is Tone assessed

Answer 10

Tested by moving limb segment through range (passive) and judging or grading the amount of resistance to lengthening movement.
Tonic response=resistance to passive stretch.

Low tone: qualitative, when a muscle has no or little resistance to passive lengthening. May feel soft on palpation.

High Tone/Spasticity: Modified Athworth Scale

Question 11

How is the Modified Ashworth Scale Test Conducted?

Answer 11

Pt in supine.

Test muscle that flexes a joint: place in maximally flexed position and move to a position of maximal extension over 1 second. Vice versa for extension.

Spasticity is velocity dependent so the speed of the passive movement is important!

Question 12

What is the Babiniski reflex?
Hoffman’s reflex?
What are they associated with?

Answer 12

Babiniski: Sensory stimulus on the lateral aspect of the sole of the foot from the heel towards the toes.
Normal: toes flex
Abnormal: Positive or upping of the toes flaring out and up or great toe goes up.

Hoffman’s reflex: Taping or flicking the nail of the terminal phalanx of the middle finger.
Abnormal: positive response is flexion of the terminal phalanx of the thumb.

Associated w/ upper motor neuron conditions.

Question 13

1. What is a Deep Tendon Reflex?

2. How are DTRs tested

Answer 13

1. Muscle phasic response to a quick stretch.

Pt in a relaxed position w/ jt supported. Compare L and R.
Short light blow w/ reflex hammer near muscle tendon (wrist action PT)

Question 14

What are the five reflexes and their spinal nerve roots?

Answer 14

Biceps reflex C5/C6
Brachioradialis reflex C6
Triceps reflex C7/C8
Patellar Reflex L3-L4
Ankle Reflex S1/S2

Question 15

What is the Scale for Deep Tendon Reflex Rating?

Answer 15

0=Absent
1=Diminished
2=Average 
3=Brisk 
4=Hyperactive or clonus

Question 16

What is a pendular reflex?

Answer 16

Associated w/ cerebellar lesions these are reflexes that are not brisk, but actually involve poor agonist-antagonist movement control where the limb loosely swings forwards and backwards several times.

Question 17

1. What is Clonus?
2. How is it assessed?
3. What are the results and how can they be interpreted?

Answer 17

1. Abnormal and involuntary rhythmical series of contractions(oscillations) in response to sudden stretch of the muscle associate w/ upper motor neuron lesions.
2. Test when DTRs are hyperactive.

Muscle in relaxed state; test ankle or wrist.
Ankle: Briskly dorsiflex ankle.
Wrist: Briskly extend wrist.

3. No Clonus: No movement=normal

Clonus=abnormal
Unsustained: Stops by itself (count # beats)
Sustained: Constant doesn’t stop

Question 18

1. What is Clonus?
2. How is it assessed?
3. What are the results and how can they be interpreted?

Answer 18

1. Abnormal and involuntary rhythmical series of contractions(oscillations) in response to sudden stretch of the muscle associate w/ upper motor neuron lesions.
2. Test when DTRs are hyperactive.

Muscle in relaxed state; test ankle or wrist.
Ankle: Briskly dorsiflex ankle.
Wrist: Briskly extend wrist.

3. No Clonus: No movement=normal

Clonus=abnormal
Unsustained: Stops by itself (count # beats)
Sustained: Constant doesn’t stop

Question 19

1. What is the impact of low tone?

2. What is the impact of high tone?

Answer 19

1. Posture, jt stability, movement and coordination.
2. Variable impact: minor stiffness to complete immobility.
   -Can affect functional tasks (ADLs, transfers)
   -High tone muscles that are not regularly stretched or are poorly managed can cause ms shortening and joint contractors, less ROM for movement.

Question 20

What are PT techniques for:

1. Increasing tone
2. Decreasing tone

Answer 20

1. Facilitatory techniques:
   - tapping or brushing over muscle
   - quick ms stretch
   - local icing to muscles (quick ice)
   - High frequency vibration
   - jt approximation or wb
   - Estim-on muscle
2. Inhibitory techniques:
   - Positioning- out of spasticity patterns
   - Prolonged ms stretch
   - Prolonged ice on ms
   - Low frequency vibration
   - Joint traction/distraction
   - Estim on antagonist, TENS

Question 21

1. What is coordination?

2. What is ataxia often associated w/?

Answer 21

1. Smoothness of movement and involves the integration of motor and sensory systems.
   Normal=Smooth and accurate
   Abnormal=Incoordination=ataxia (not just b/c of muscle weakness) lack of motor control…
2. Cerebellar conditions

Question 22

What are the three important movement qualities to observed w/ Coordination?

Answer 22

1. Speed and timing
2. Accuracy and precision
3. Fluidity

Question 23

What are two ways to assess coordination?

Answer 23

1. Rapid alternating movement (RAM)=quick succession of agonist-antagonist movements
   UE: wrist/hand RAM-pronation and supination or tapping
   LE: Foot RAM: tapping
2. Point-to-point movements=evaluate accuracy and precision w/ no over/undershooting and fluidity or smoothness of multi-joint movements.

UE: Finger to nose
LE: Heel to shin

Question 24

What is abnormal
1-RAM

2-Pt-toPt

Answer 24

1-Dysdiadocokinesia
2- dysmetria (over or undershooting)
dysyndergia (jerky multi-joint movement)

Question 25

What are important things to do while assessing coordination?

Answer 25

1. Explain to pt or show movement. 2. Ask pt to perform movements as quickly and accurately as able 3. EO 4. Therapist observe movement for any abnormality in speed/timing, accuracy/position, fluidity 5. Compare both sides 6. Count # times in10 s

Question 26

What is Dyskinesia?

Answer 26

Category of movement disorders characterized by involuntary movements

Question 27

What are examples of dyskinesia? A. What are the types of tremors? B. Dystonia C. Chorea

Answer 27

``` A. Tremors: Rhythmic oscillations of any body part. Action: during voluntary movement Intention: Target related Postural: holding antigravity positions Resting: no movement ``` B. Sustained contractions often w/ repetitive twisting or abnormal posture. C. Irregular purposeless movement of any part of the body: could be ballistic or flailing. Involves lesions to cerebellum or basal ganglia.

Question 28

1. When assessing tone what kind of observation are you recording? 2. When is a more specific test for tone required?

Answer 28

1. Qualitative description of the resistance to passive movement of the LE or UE. Note wether it is: low (hypotonic), no tone, normal, higher or hypertonia. 2. When there is hypertonia use the MAS to quantify tone at each joint for spasticity or rigidity.

Question 29

What assessments do we need to know for PHTH 551: A. Tone B. Coordination C. What are some considerations for coordination testing?

Answer 29

``` A. Passive tone UE and LE MAS DTR Babinski, Hoffman's signs Clonus ``` B. RAM: Pronation/supination, hand tapping, finger tapping, foot tapping. Finter to nose test Heel to shin test C. Observer: Compare sides, speed, accuracy, fluidity of movement. Number of movements in 10 sec. -Give proper instructions, demonstrate as needed. -Tell pt to do the movement as quickly and accurately as possible.

Question 30

How is the MAS done?

Answer 30

- Pt in supine. - If testing a muscle that primary flexes as muscle, place joint in a maximally flexed position and move to a position of maximal extension over one second count. (Vice versa for a muscle that primary extends a joint) - Give a score in response to resistance to passive movement.

Question 31

What is the scoring system for the MAS?

Answer 31

0 No increase in muscle tone 1 Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension 1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM 2 More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved 3 Considerable increase in muscle tone, passive movement difficult 4 Affected part(s) rigid in flexion or extension

Question 32

How do you test the Babinski Reflex? What is a normal and abnormal response??

Answer 32

Procedure: Stroke the lat aspect of the sole of the foot and then come across the ball of the foot medially with a sharp object. Normal response: Plantar flexion of the big toe. Abnormal response: Extension of the large toe which may be accompanied by fanning of the toes and at times flexion of the knee and hip. A positive Babinski's sign is indicative of an upper motor neuron lesion affecting the LE in question.

Question 33

How do you test Hoffman's Sign? What is an abnormal response?

Answer 33

Procedure: Flick or tap the distal phalanx of the middle finger. Abnormal response: Reflex contraction of the thumb and/or index finger. (i.e. flexing towards each other) Cervical spinal cord compression is often associated w/ a positive sign.

Question 34

What can you do if you are having trouble eliciting a DTR?

Answer 34

Jendrassik's Maneuver: Have pt interlock fingers and pull tension on them. Distract the pt. Or Ask pt to clench teeth.

Question 35

What is an abnormal response to DTR?

Answer 35

Absent reflexes Hypo (diminished reflexes) Hyperactive reflexes Reflexes that are not symmetrical

Question 36

How do you test the DTR for: 1. Biceps reflex 2. Brachioradialis reflex 3. Triceps reflex 4. Knee Jerk Reflex 5. Ankle Reflex

Answer 36

Use a reflex hammer. Palpate the muscle tendon and visually observe muscle. 1. C5 and C6 nerve roots: Place thumb on biceps tendon and strike thumb with the reflex hammer and observe the arm movement. Repeat on the other side to compare. 2. C6 nerve roots: Strike brachioradialis tendon directly with a hammer when the pt arm is resting. Strike the tendon roughly 3 in above the wrist. Repeat other arm. 3. C6 and C7 nerve roots, predominantly C7: Strike triceps tendon directly with the hammer while holding the pt arm with your other hand just above the elbow. 4. L3 and L4 nerve roots, mainly L4. Let LE hang freely off the edge of the bench. Strike the quadriceps tendon directly with the reflex hammer. 5. S1 nerve root: Hold the relaxed foot with one hand and strike the achilles tendon with a hammer. Note plantar flexion.

Question 37

What may lead to pendular reflexes?

Answer 37

Cerebellar insults Reflexes that are brisk. Ie for knee jerk reflex if normal it would swing back and forth one time, but if pendular may swing forward and backwards several times.

Question 38

When should you test for clonus? How is clonus tested?

Answer 38

If any of the other reflexes are hyperactive. Ankle: Hold the relaxed lower leg in hand and sharply dorsiflex the foot and hold it dorsiflexed. Fee for oscillations between flexion and extension of the foot indicating clonus. Normal: no movement elicited. Wrist: Quick wrist extension and then hold to elicit clonus response.

Question 39

What sort of observations should you record for coordination tests?

Answer 39

Quality of the movement: fluidity, accuracy. Quantitative measure: number of repetitions performed in a given time frame or the time taken to perform as specific number of repetitions.

Question 40

What is dysmetria? | How do you test it?

Answer 40

Abnormal and inaccurate movement (over or undershooting) Point to Point Movement: 1. Finger to nose test: note full extension of the elbow is required. 2. Heel to shin: running heel from knee to ankle along shin.

Question 41

What is dysdiadochokinesis? | How do you test it?

Answer 41

Abnormal RAM Rapid Alternating Movements 1. Pronation/Supination test: Often performed with the elbow flex 90 degrees 2. Foot tapping: with feet supported on surface. (like the floor) 3. Hand tapping, finger tapping tests (individual or all), finger opposition.