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MUSCLE TONE AND MANUAL MUSCLE TESTINGPHT 1261C Tests and Measurements
Dr. Kane
DEFINITIONS
Tone Factors affecting tone Postural Tone Hypertonia Hypotonia Dystonia
Spasticity – velocity dependent Clasp knife response UMN syndrome Clonus Babinski Sign
Rigidity Lead pipe Cogwheel
DEFINITIONS - CONTINUED
Hypotonia – flaccidity LMN syndrome Spinal Shock/Cerebral Shock
Dystonia Focal vs. segmental vs. posturing
Decorticate Rigidity Decerebrate Rigidity Opisthotonus
VARIATIONS IN TONE
Volitional Effort and movement Stress and anxiety Position and interaction of tonic reflexes Medications General Health Environmental temperatures State of CNS arousal or alertness Urinary bladder status Fever/infection Metabolic or Electrolyte imbalances
EXAMINATION OF TONE
Initial Observation of resting posture & palpation Common posturing – see Table 8.1 page 235 Palpation – consistency, firmness & turgor
Passive Motion Testing Responsiveness of muscles to stretch Vary speed for spasticity and clonus Grading Scale
0 = no response (flaccidity) 1+ = decreased response (hypotonia) 2+ = Normal response 3+ = exaggerated response (mild to moderate hypertonia) 4+ = sustained response (severe hypertonia)
Active Motion Testing/Special Tests Pendulum test Myotonometer
SPASTIC HYPERTONIA – MODIFIED ASHWORTH SCALE
Gold standard subjective 5 point ordinal scale Interrater & intrarater reliability is good Problems:
Inability to detect small changes Limited to extremity testing only
Grades 0 = no increase in muscle tone 1 = slight increase in muscle tone; catch & release 1+ = slight increase in tome with catch & minimal
resistance through rest of range 2 = marked increase in tone through most of ROM 3 – considerable increase in tone; passive motion
difficult 4 = affected parts rigid in flexion or extension
DEEP TENDON REFLEXES
Table 8.3 page 237 O’Sullivan Grading Scale
0 = no response 1+ = present but depressed, low normal 2+ = Average, normal 3+ = Increased, brisker than average; possibly
but not necessarily normal 4+ = very brisk, hyperactive with clonus;
abnormal Increased with UMN lesions; decreased with
LMN Reinforcement maneuvers
MANUAL MUSCLE TESTING
Palmer Chapter 2 Not applicable for strength testing in patients
who lack voluntary or active control of muscular tension (e.g. CNS disorders)
Not appropriate for spasticity May get inaccurate results due to gravity
and activation of stretch reflex Reliability – ½ grade intertester is acceptable
Follow proper procedures Give clear instructions Demonstrate and explain Improved with dynamometry
MANUAL MUSCLE TESTING - CONTINUED
Validity Palpate muscle Proper stabilization Prevent substitution muscles or patterns Not functional
MMT USES
1. Establish a basis for muscle re-ed and exercise; Develop plan of care Show progress Shows effectiveness of treatment Additional information before muscle transfer
surgery 2. Determines how functional a patient can
be. 3. Determines a pt.'s needs for supportive
apparatus – orthoses, splints, assistive devices
4. Helps determine a diagnosis. 5. Determines pt.'s prognosis
FACTORS THAT CONTRIBUTE TO EFFECTIVENESS OF MUSCLE CONTRACTION
Length of muscle when activated Active insufficiency
Type of contraction Eccentric > Isometric > Concentrically
Muscle Fiber Types Type I slow twitch – fatigue resistant Type II fast twitch – fatigue rapidly Must consider speed of contraction & resistance
applied Type II – require less resistance to reach “normal” grade
Speed of contraction Increased speed = increased tension ECCENTRIC Increased speed = decreased tension CONCENTRIC
ANATOMICAL FACTORS THAT AFFECT MUSCLE CONTRACTION
Number of motor units per muscle Functional excursion Cross sectional Area Line of pull of muscle fibers Number of joints crossed Sensory receptors Attachments to bone & relationship to joint
axis Age of pt. Sex of pt.
EVALUATING SKELETAL MUSCLE STRENGTH
Anatomical, physiological, & biomechanical knowledge of skeletal muscle positions and stabilization
Elimination of substitution motions Skill in palpation & application of resistance Careful direction for each movement that is
easily understood by the patient Adherence to a standard method of grading
muscle strength Experience testing many individuals with
normal muscle strength & varying degrees of weakness
FACTORS TO CONSIDER IN MMT
Weight of limb or distal segment with minimal effect of gravity (GM)
Weight of limb plus the effects of gravity (AG) Weight of limb plus gravity plus manual
resistance
FACTORS AFFECTING GRADING OF MMT
Amount of manual resistance applied (opposite torque exerted by muscle)
Ability of muscle to move through complete ROM
Evidence of presence or absence of muscle contraction by palpation & observation
Gravity and manual resistance GM – muscle contracts parallel to gravitational
force AG – muscle contract against the downward
gravitational force Grades are dependent on: age, sex, body
build, occupation, etc.
FACTORS AFFECTING MMT RESULTS Fatigue Joint ROM limitations
Range grade/strength grade (-20 degrees/4 (good) Pain Subjectivity Positions –AG/GM
Range Palpation Resistance –break or make method
Stabilization Provides support Prevents substitution motions
Substitution Recording measurements
PROCEDURE FOR SPECIFIC MMT
Position in AG position & stabilize – see page 31 Expose body part & drape appropriately Explain the test and demonstrate to patient Determine available ROM
PROM or AROM; test range; possibly goniometry Align body part to direction of muscle fibers Stabilize proximal segment Have patient move distal segment through test
ROM or hold at end range of motion Observe and palpate muscle belly Apply resistance – end range or through range Record grade & date & initial; document in SOAP
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