Tone and Neural Plasticity and Ax Flashcards
What are the 10 principles of neuroplasticity?
Use it or lose it
Use it to improve it
Spasticity
Repetition matters
Intensity
Time
Salience - meaningful
Age
Transference - transferable skills
Interference
How do you assess tone?
Observation of the limb
Ask the patient to go floppy and take the limb through range (including pronation and supination) and make sure to do some quick movements
Palpation test of the GHJ for sulcus sign
Will feel catching through range for hypertonia
Heavy limb for hypotonia
Why do you test tone with both slow and quicker movements for PROM
Because spasticity if velocity-dependent
What is hypertonia?
Increased muscle tone
What is hypotonia?
Decreased muscle tone
What would you expect to see with reflex testing with an upper motor neurone lesion? And why?
Brisk or exaggerated reflexes (hyper-reflexia).
Because there is a loss of inhibitory tone of muscles, leading to constant contraction of muscles
What would you expect to see with reflex test for a lower motor neurone lesion?
Normal, reduced, absent (hyporeflexia)
What is the main thing to prevent for someone with abnormal tone (spasticity)
Contractures
What are some interventions to manage abnormal tone?
PROM
Splinting/serial casting
Weight bearing activity
Positioning
Sensory input
Facilitation
Posture and stability training
MDT management - refer for prescription of oral medication e.g diazepam
Education
Task practice
What is a right MCA infarct? What does the MCA supply And how would it present?
When the medial cerebral artery is affected on the right side
MCA supplies the frontal lobe, anterior parietal lobe,
Presents with:
Left sided hemiparesis or hemiplegia
Sensory deficits
Dizziness
Visual deficits etc
What can develop with subacute/chronic cases if tone isn’t addressed?
Non-neural structures can tighten e.g joint capsules and ligaments around the joint itself
What would happen if a person with hypertonia is left unsupported?
Their tone can get worse.
This is because with hypertonia the muscles are over working and continuously contracting involuntarily, if the pt is left to continue to contract to keep themselves supported, this tone can get worse and result in contracture
What do you expect when testing strength in a patient with an upper motor neurone lesion?
Expect weakness globally in that area (e.g all of right arm) and not follow any myotomal pattern.
This is because there is damage to the CNS, specifically the motor cortex in the frontal lobe.
What do you expect for sensation testing with a patient who has an upper motor neurone lesion?
Reduced sensation globally (e.g all the right arm) in a non-dermatomal pattern.
This is because there is damage to the somatosensory cortex in the parietal lobe (not a specific spinal root)
What are postural sets?
The position the treatment is carried out in that will be most beneficial for the exercise
What are examples of postural sets?
Supine, standing, sitting, supported sitting, side-lying, step-standing, prone and perches sitting
What are the key point areas of the body through which movement can be most controlled?
Proximal- shoulder girdle, pelvis, head
Distal- hands and feet
Central- mid-thoracic region
Bobath principles
What is the Modified Ashworth Scale? And what are the different scales?
Allows you to assess tone objectively
0= no increase in muscle tone
1= slight increase in muscle tone (slight catch and release)
2= more marked increase in muscle tone (passive movement difficult)
3= considerable increase in muscle tone (passive movement difficult)
4= affected part(s) rigid
What a person has increased tone the following will occur
Retraction of the scapula
Adduction and medial rotation of the GHJ
Flexion of the elbow
Pronation of the forearm
Flexion and ulnar deviation of the wrist
Flexion of the fingers
Adduction of the thumb
How does hemiplegia and abnormal tone alter the scapulohumeral rhythm?
Increased tone prevents movement of the scapular- moving the arm away from the body may cause trauma to the GHJ via acromial impingement
Hypertonia may lead to shortening of the medial rotators
Moving the arm away from the body may then lead to hypermobility of the scapula to compensate
When a person has decreased tone the following will occur in relation to the scapula:
Scapula rotates medially
Inferior angle of the scapula is closer to the spine than normal. Causing misalignment and abduction of the shoulder joint
- This abduction causes the capsule to become slack and subluxed as the supporting muscles aren’t working effectively.
What happens in practice if the patient continues to have low tone?
- Upper traps may become overactive to compensate
- Muscles may shorten leading to reduced ROM
- Scapula may become immobile or hypermobile
- Low tone in trunk exaggerates abnormal resting position and can worsen with subluxation
- Reach and grasp require coordination of the upper limb and therefore altered scapulohumeral rhythm will impair this.
What happens in practice if the patient continues to have high tone?
- Prevents normal movement of scapula, therefore disrupts scapulohumeral rhythm
- Shortening of medial rotators may lead to overcompensation through scapula
- If scap doesn’t move in sync, supraspinatus could get trapped between humeral head and acromion
If a patient has low tone and you want to start activating trunk muscles, what position would you treat them in and why?
Supported sitting with a therapist supporting through central points.
Because supported sitting in a chair wouldn’t be helpful for rehab and low tone in trunk muscles can cause slumping. This changes the positon of the scapula and you will struggle to do reaching tasks as the pt won’t be able to achieve beneficial ROM to be able to contract trunk muscles for balance
What exercise would you give a patient who has scapula malalignment (e.g winging from internal rotation)
Scapula retraction exercises to target rhomboids and middle fibres of trapezius.
If they have reduced sensation, can place hands on to stimulate sensory input.
What treatment would you give a patient who reduced extension of trunk on right side?
Trunk alignment: pelvic tilt to neutral and anterior to increase thoracic extension.
Use proximal key points (ASIS and PSIS) to help with pelvic tilt facilitation.
What would you ask in your subjective for neuro assessment?
PC
HPC
PMH
DH
SH- normal routine, leisure activities, occupation, how do they manage day-to-day
Any new visual changes
Any new changes to her hearing?
Any changes to swallowing
Are they orientated
Any pain?
What would be in the observation section of the objective assessment?
Pain, distress, oedema, surgical wounds, attachments, gait, any evidence of neglect, muscle wasting
Posture/position- are they leaning to one side
Any evidence of subluxation
Objective assessment for neuro
Observation
Respiratory assessment - check there isnt something serious going on
Palpation of GHJ for any sulcus sign
ROM
Tone (Modified Ashworth Scale)
Strength (Oxford grading scale)
Sensation
Proprioception
Coordination
Dexterity
Vision
Cranial nerves
Reflexes
Transfers/mobility/walking/balance
If they have a sulcus sign on palpation, what should you be careful of going through the rest of the Ax?
be careful not to take the arm past 90degrees, this could make sulcus worse
