Tone, Mobility, Selective Capacity and Force Generation

Question 1

List 3 positive signs of UMN lesions.

Answer 1

1. Hyperreflexia
2. Spasticity
3. Pathological reflexes

Question 2

List 6 negative signs of UMN lesions.

Answer 2

1. Paresis (decreased force generation)
2. Loss of fractionation
3. Abnormal motor unit recruitment
4. Obligatory synergies
5. Decreased coordination and dexterity
6. Spatial and temporal movement abnormalities

Question 3

What occurs with the loss of fractionation?

Answer 3

Patient loses the ability to move single joints or aspects of the extremities in isolation from the others

Question 4

Obligatory synergies result in decreased ______.

Answer 4

Selective Capacity

Question 5

What is resting muscle tone?

Answer 5

Light tension in the muscle when it is at rest

Question 6

Describe the position of the shoulder, elbow, forearm wrist, hips and ankles in decorticate rigidity.

Answer 6

Shoulder adduction
Elbow flexion
Forearm supination
Wrist Flexion
Hip IR
Ankle PF

Question 7

Describe the position of the shoulder, elbow, forearm, wrist, and ankles in decerebrate rigidity.

Answer 7

Shoulder adduction
Elbow extension
Forearm Pronation
Wrist Flexion
Ankle PF

Question 8

List 3 interventions used to treat hypertonia. Why are they effective in treating this condition?

Answer 8

1. Air casting
2. Serial casting
3. Splinting

Provide low load, long duration stretch to high tone muscles

Question 9

What typically occurs immediately after a CVA?

Answer 9

Flaccidity/Hypotonia

Question 10

What is flaccidity/hypotonia?

Answer 10

Complete absence of muscle tone

Question 11

True or False: Flaccidity/hypotonia most commonly affects the LE.

Answer 11

FALSE

Most common in the UE

Question 12

Length of time the period of flaccidity lasts is related to ____.

Answer 12

Prognosis

Longer the flaccidity lasts, the poorer the prognosis

Question 13

What are 2 effects of hypotonia on the musculoskeletal system?

Answer 13

1. Knee laxity (genu recurvatum)

2. Shoulder subluxation (weight of arm pulls humeral head down)

Question 14

List 5 interventions used to treat hypotonia.

Answer 14

1. Neurofacilitation
2. E-stim to improve active movement (takes long time)
3. E-stim of supraspinatus to prevent subluxation
4. Scaled active movement / mirror training
5. Positioning to prevent subluxation

Question 15

What is scaled active movement or mirror training?

Answer 15

Patient begins to convert trace movements into meaningful movements

Affected limb is perceived as moving as the patient observes the non-affected limb moving in the mirror

Question 16

What should be avoided when positioning the arm to prevent subluxation?

Answer 16

Avoid using arm sling to position the UE to prevent formation of contractures

Question 17

What is spasticity?

Answer 17

Velocity dependent response of muscle to passive stretching

Question 18

Spasticity: Resistance ____ as speed and rhythm of movement increases.

Answer 18

INCREASES

Question 19

Spasticity: Resistance to passive movements could be ____ or ____.

Answer 19

unidirectional or bi-directional

Question 20

What is clonus? (2)

Answer 20

1. A series of involuntary, rhythmic, muscular contractions and relaxations.
2. Self re-excitation of hyperactive stretch reflex

Question 21

What are 2 causes of clonus?

Answer 21

1. Increase in motor neuron excitability (decrease descending inhibition)
2. Nerve signal delay (increased nerve conduction time and long reflex pathways)

Question 22

What are 2 causes of spasticity?

Answer 22

1. Decreased supra-spinal pre-synaptic inhibition of alpha motor efferents
2. Stimulation by a hypersensitive fusimotor system

Question 23

What position must the patient be in when performing the Modified Ashworth Scale? How many times is it performed?

Answer 23

1. Supine
2. Performed twice

V1: move through entire ROM slowly
V2: move through entire ROM < 1 sec

Question 24

List and describe all 6 grades on the Modified Ashworth Scale.

Answer 24

0 – no increase in tone / normal tone
1 – slight increase in tone manifested by catch and release or by minimal resistance at End ROM
1+ - slight increase in muscle tone, manifested by catch followed by minimal resistance throughout the reminder (less than ½) of the ROM
2 – marked increase in muscle tone throughout most of the ROM but affected parts easily moved
3 – considerable increase in muscle tone, passive movement difficult
4 – rigidity in flexion or extension

Question 25

What is the inter-rater/intra-rater reliability, validity and convergent validity of the Modified Ashworth Scale?

Answer 25

1. Adequate to good intra-rater reliability 2. Poor to adequate inter-rater reliability 3. Poor criterion validity 4. Adequate convergent validity

Question 26

List 5 things than can influence spasticity.

Answer 26

1. Tonic Labyrinthine changes in different positions 2. Postural exertion / Mental exertion 3. Pain or discomfort (INCREASES SPASTICITY) 4. Infections, decubiti, inflammations (INCREASES SPASTICITY) 5. Handling (INCREASES SPASTICITY)

Question 27

List 6 complications associated with spasticity.

Answer 27

1. Reduced strength and function (intact muscles trying to resist spastic muscles, which weakens them) 2. Inactivity / Immobility 3. Tissue adaptation, contracture/deformity 4. Tissue breakdown, mechanical damage and necrosis 5. Discomfort 6. Impaired posture (respiratory distress/infections)

Question 28

List 4 things that are associated with inactivity/immobility secondary to spasticity.

Answer 28

1. Cardiovascular problems 2. Social isolation 3. Osteoporosis 4. DVTs

Question 29

List 4 effects of spasticity on the musculoskeletal system.

Answer 29

1. Trunk asymmetries 2. Ankles and feet (i.e. equino varus, very severe) 3. Finger deformities (contractures develop) 4. Heterotrophic ossifications: abnormal bone growth in muscle

Question 30

What is a possible advantage of spasticity? Provide 2 examples.

Answer 30

1. May assist with posture control and ADLs Example: Spastic gastrocs stabilize knees Example: Spastic hams stabilize trunk

Question 31

List 6 inhibiting techniques used to treat spasticity.

Answer 31

1. Slow rocking (vestibular input) 2. Counter rotation 3. Deep tendon pressure 4. Prolonged stretching 5. Reflex inhibition position (closed chain, approximation) 6. Positioning

Question 32

List 4 PT interventions used to treat spasticity.

Answer 32

1. Joint mobilization 2. STM 3. Muscle stretching programs 4. Casting

Question 33

List 2 types of casting that can be used to treat spasticity.

Answer 33

1. Inhibitive: restore normal anatomical & biomechanical relationships 2. Serial: long duration, low load stretch

Question 34

List 5 oral medications used to treat spasticity.

Answer 34

``` Baclofen (Lioresal) Diazepam (Valuium) Dantrolene (Dantrium) Tizanidine (Zanaflex) Clonidine (Catapres) ```

Question 35

List 2 injectable medications/ nerve blocks used to treat spasticity.

Answer 35

1. Phenol | 2. Botulinum toxin type A or B (Botox)

Question 36

List 3 surgical interventions used to treat spasticity.

Answer 36

1. Selective Dorsal Rhizotomy (knocks out sensory information from muscle spindle) 2. Intrathecal Baclofen therapy 3. Tendon lengthening (Z-plasty: cut the tendon and reattach it to make it longer)

Question 37

What is intrathecal Baclofen therapy? Highest level it can be placed?

Answer 37

1. Baclofen is delivered directly to the spinal cord via indwelling pump 2. Highest level = T8 so diaphragm remains unaffected allowing the patient to breathe

Question 38

What is the typical presentation of the joints in an UE flexion synergy? (7)

Answer 38

``` Elevation Retraction Abduction **Elbow Flexion** Supination Radial Deviation Wrist and Finger Flexion ```

Question 39

What is the typical presentation of the joints in an LE extension synergy? (7)

Answer 39

``` **Hip Extension** Adduction IR **Knee Extension** **Plantar Flexion** Inversion Toe Flexion ```

Question 40

List 5 interventions used to treat synergies.

Answer 40

1. Grade tasks to avoid synergy – (NDT) 2. AAROM out of synergy (lots of GE (gravity eliminated) work) 3. Strengthen out of synergy 4. Facilitate opposite synergy (Brunnstrom) 5. Loading with isometrics out of synergy

Question 41

List 9 impairments associated with impaired force generation after stroke.

Answer 41

1. Decrease in # of motor units 2. Decrease rate of firing of motor units 3. Abnormal recruitment of motor units 4. Learned non-use 5. Atrophy of muscle 6. Loss of type II/fast twitch fibers (become smaller and do not fire as efficiently) 7. Disordered patterns of agonist-antagonist muscle activity (can be caused by spasticity) 8. Passive restraints due to changes in viscoelastic properties of muscle and connective tissue 9. Increased fatigability (lack sufficient strength needed to sustain level of activity)

Question 42

What were Bobath's vs Guliani's beliefs regarding the use of strength training to treat patients with synergies?

Answer 42

1. Bobath “synergies will increase”: if muscles responsible for synergies were strengthened (don’t strengthen) 2. Guliani “weakness will decrease function and increase synergies”: so argument was to strengthen the synergistic muscles

Question 43

What is the current consensus regarding the use of strength training to treat patients with synergies?

Answer 43

Strengthen regardless of the presence of a synergy

Question 44

How many stages make up Brunnstrom's stages of recovery?

Answer 44

7

Question 45

Define stages I, II, III of Brunstrom's stages of recovery.

Answer 45

Stage I : Flaccidity Stage II Spasticity and Synergies Emerge Stage III: Voluntary control of synergies and spasticity increases

Question 46

Define stage IV of Brunstrom's stages of recovery. (3)

Answer 46

1. Movement in Synergy still dominates 2. Movements out of synergy emerges 3. Spasticity decreases

Question 47

Define stage V of Brunstrom's stages of recovery. (3)

Answer 47

1. Dominance of synergies decreases 2. Isolated Movement Increases 3. Spasticity Decreases

Question 48

Define stage VI of Brunstrom's stages of recovery. (3)

Answer 48

1. No spasticity 2. Isolated movement dominates 3. Coordination emerges

Question 49

Define stage VII of Brunstrom's stages of recovery.

Answer 49

Normal function restored