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Tone Management
- 1. Tone Management Emily Peters,OTS August 2014
- 2. What is MuscleTone? • “Continuous state of mild contraction, or a state or preparedness in the muscle” (Pendleton, 2012, p. 468) • “Muscle tone does not produce active movements, but it keeps the muscles firm, healthy, and ready to respond to stimulation” (Marieb & Hoehn, 2010, p. 296)
- 3. Physiology of MuscleTone • Signals received at neuromuscular junction result in continuous muscle contraction Muscles and muscle tissue, 2013
- 4. Characteristics of NormalTone • High enough to resist gravity, yet low enough to allow movement • Slight, involuntary, resistance to passive movement • Ability to maintain position of limb if placed passively, and then released • Ease of ability to shift between stability ↔ mobility • Ability to use muscles in groups or selectively with normal timing and coordination
- 5. Why is MuscleTone Important? • Across the lifespan, normal muscle tone allows us to engage in meaningful occupations by: • Keeping muscles ready for action • Maintaining posture • Maintaining balance • Laying framework for quick, reflexive movements
- 6. Causes of AbnormalTone • Children • Down Syndrome • Cerebral Palsy • Muscular dystrophy • Adults • CVA • TBI • Brain tumor • SCI • MS • Myasthenia gravis • The onset and course of abnormal tone is dependent upon the cause
- 7. Hypotonia • Abnormally lowtone • Likely to occur in the acute stages of CVA, contralateral to brain lesion • Diminished deep tendon reflexes • Flaccidity: complete absence of deep tendon reflexes
- 8. Hypertonia • Abnormally hightone • Likely to occur following the acute stages of CVA • May occur in synergistic movement patterns: Co-contraction of flexors and extensors • Flexor synergy often seen in UEs • Extensor synergy often seen in LEs • Rigidity: simultaneous high tone of agonist and antagonist • Lead pipe • Cogwheel • Decorticate • Decerebrate
- 9. Decorticate vs. DecerebratePosture • Decorticate - Flexor synergy upper extremities & extensor synergy lower extremities • Decerebrate - Extensor posturing
- 10. Spasticity • Spasticity isa subset of hypertonia • Overactive reflexes • Involuntary movements • Feel a “catch” with passive movement • May lead to contractures if unmanaged • Clonus: Repetitive contractions in antagonist muscles in response to rapid stretch • Can be associated with moderate-severe spasticity • Finger flexors and ankle plantar flexors • Medical management • Botox injections • Baclofen pump
- 11. Managing Tone: General •Aims of early positioning and mobility • Provide support • Inhibit abnormal tone • Promote symmetry • Provide normal sensory input • Relieve pain and provide comfort • Develop and reinforce basic elements of movement • Principles to remember • Normal movement cannot be superimposed on abnormal tone • Proximal stability facilitates distal mobility
- 12. Managing Hypotonia • Checkfor subluxation at glenohumeral joint before ROM • Position patient in supported sit • Facilitate tone • Quick stretches in attempt to elicit clonus • Cold temperatures
- 13. Managing Hypertonia • Deep,slow stretches • Deep pressure on muscle belly • Warm temperatures • Splinting and serial casting to encourage functional position of extremities
- 14. Assessing High Tone:Modified Ashworth Scale Grade Description 0 No increase in muscle tone 1 Slight increase in muscle tone, catch when limb is moved 1+ Slight increase in muscle tone 2 More marked increase in muscle tone through >50% of the ROM, but affected easily moved through passive range 3 Considerable increase in muscle tone, passive movement difficult 4 Affected limb rigid in flexion or extension
- 15. References Bohman, I. M.(2003). Handling skills using in the management of adult hemiplegia (2nd ed.). Albuquerque: Clinician’s View. Marieb, E. N., & Hoehn, K. (2010). Muscles and muscle tissue. Human anatomy and physiology (8th ed) (pp. 275-319). San Francisco: Pearson Education, Inc. Muscles and Muscle tissue (2013). Overview of Muscle Tissue. Retrieved from http://classes.midlandstech.edu/carterp/Courses/bio210/chap09/lecture1.html. Pendleton, H. M. H., & Schultz-Krohn, W. (2012). Evaluation of motor control. Pedretti's occupational therapy: Practice skills for physical dysfunction (7th ed.) (pp. 468-473). St. Louis: Mosby/Elsevier.
Editor's Notes
- #7 -These are just a few of the causes of abnormal tone
- #10 -Decorticate is more common, and often indicates more positive outcomes -Decerebrate is not as common, and often indicates less positive outcomes
- #15 Modified Ashworth Scale – measures deep tendon reflexes; used to quantify the degree of hypertonicity Place the patient in a supine position. If testing a muscle that primarily flexes a joint, place the joint in a maximally flexed position and move to a position of maximal extension over one second (count "one thousand one”) If testing a muscle that primarily extends a joint, place the joint in a maximally extended position and move to a position of maximal flexion over one second (count "one thousand one”) 0 – No increase in tone 1 – slight increase in tone, catch and release or minimal resistance at end of ROM when affected limb is moved into flexion or extension 1+ - slight increase in tone, catch, followed by minimal resistance throughout the remainder (<half of the ROM) 2 – more marked increase in muscle tone through most of ROM, but affected limb easily moved 3 – considerable increase in muscle tone, passive movement difficult 4 – affected part rigid in flexion or extension