MUSCLE TONE
M
U
S
C
L
E
T
O
N
E
-Dr. Adarsh Kumar Srivastav (PT)
Assistant Professor
School of Health Sciences
CSJMJU
I
N
T
R
O
D
U
C
T
I
O
N
•
D
e
f
i
n
i
t
i
o
n
:
R
e
s
i
s
t
a
n
c
e
o
f
m
u
s
c
l
e
t
o
p
a
s
s
i
v
e
e
l
o
n
g
a
t
i
o
n
o
r
s
t
r
e
t
c
h
w
h
e
n
a
n
i
n
d
i
v
i
d
u
a
l
a
t
t
e
m
p
t
s
t
o
m
a
i
n
t
a
i
n
m
u
s
c
l
e
r
e
l
a
x
a
t
i
o
n
.
•
F
a
c
t
o
r
s
1.
Physical
Inertia
2.
Intrinsic mechanical
elastic
stiffness
3.
Reflex
muscle
contraction
(
tonic
stretch
reflex)
•
T
O
N
A
L
A
B
N
O
R
M
A
L
I
T
I
E
S
-
Hypotonia
Hypertonia-Spasticity
and
Rigidity
Dystonia
Decerebrate
and
Decorticate
Rigidity
A
B
N
O
R
M
A
L
T
O
N
E
S
P
A
S
T
I
C
I
T
Y
•
Hypertonic
motor
disorder
•
Velocity
dependent
•
Clasp-
knife
response
•
Chronic
spasticity-
abnormal
posture,
deformity,
disability
•
Injury
to
pyramidal
tract-
UMN
lesion
•
Loss
of
inhibitory
control
over
lower
motor
neurons
•
Results
in
disordered
spinal
segmental
reflexes
•
Increased
alpha
motorneurone
excitability
•
S
i
g
n
a
n
d
s
y
m
p
t
o
m
s
-
hyperactive
stretch
reflexes
Involuntary
flexor
and
extensor
spasms
Babinski’s
sign
positive
–Abnormal
plantar
reflex
Exaggerated
deep
tendon
reflexes
Loss
of
precise
autonomic
control
C
l
o
n
u
s
-
c
y
c
l
i
c
,
s
p
a
s
m
o
d
i
c
a
l
t
e
r
a
t
i
o
n
o
f
m
u
s
c
l
e
c
o
n
t
r
a
c
t
i
o
n
r
e
l
a
x
a
t
i
o
n
i
n
r
e
s
p
o
n
s
e
t
o
m
u
s
c
l
e
s
t
r
e
t
c
h
o
f
a
s
p
a
s
t
i
c
m
u
s
c
l
e
.
C
o
m
m
o
n
i
n
p
l
a
n
t
a
r
f
l
e
x
o
r
s
…
R
I
G
I
D
I
T
Y
•
Hypertonic
state
•
I
n
c
r
e
a
s
e
d
u
n
i
f
o
r
m
r
e
s
i
s
t
a
n
c
e
t
h
a
t
p
e
r
s
i
s
t
s
t
h
r
o
u
g
h
o
u
t
t
h
e
w
h
o
l
e
R
O
M
(
l
e
a
d
p
i
p
e
)
•
Cause-
lesion
of
the
basal
ganglia
system
(
Parkinson’s
disease)
•
Stiffness,
inflexibility,
Significant
functional
limitation.
•
Due
to
excessive
supraspinal
drive
(UMN
facilitation)
•
Spinal
reflex
mechanisms
are
normal.
•
C
o
g
w
h
e
e
l
-
H
y
p
e
r
t
o
n
i
c
s
t
a
t
e
w
i
t
h
s
u
p
e
r
i
m
p
o
s
e
d
r
a
c
h
e
t
l
i
k
e
j
e
r
k
i
n
e
s
s
,
c
o
m
m
o
n
l
y
i
n
U
E
m
o
v
e
m
e
n
t
e
.
g
E
l
b
o
w
f
l
e
x
i
o
n
/
e
x
t
e
n
s
i
o
n
)
H
Y
P
O
T
O
N
I
A
•
Flaccidity-
Absent
muscular
tone
•
Resistance
to
passive
movement
is
diminished
•
Stretch
reflexes
are
dampened
or
absent, limbs
are
floppy
•
Occurs
in
Lower
Motor
Neuron
Lesion-
affection
of
ant
horn
cell
and
peripheral
nerves
•
Symptoms-
Decreased
or
absent
reflexes,
paresis
or
paralysis,
muscle
fasciculation
and
fibrillation,
muscle
atrophy.
•
Temporary
states
of
flaccidity
or
hypotonia-
Spinal
Shock/
cerebral
Shock depending
upon
location
of
lesion.
D
Y
S
T
O
N
I
A
•
Hyperkinetic
movement
disorder
characterized
by
disordered
tone
and
involuntary
movements
involving
large
portion
of
the
body.
•
Movements
are
similar
to
athetoid
movements
with
typical
twisting/writhing
motions.
•
Dystonic
Posturing-
sustained
abnormal
postures
due
to
co-contraction
of
muscles.
•
Result
from
a
CNS
lesion
(Basal
Ganglia).
•
Focal
Dystonia-
Affects
only
one
part
of
the
body
e.g spasmodic
torticollis.
•
Segmental
Dystonia-
Affects
two
or
more
adjacent areas
e.g
dystonic
posturing
of arms.
D
E
C
E
R
E
B
R
A
T
E
R
I
G
I
D
I
T
Y
•
A
b
n
o
r
m
a
l
E
x
t
e
n
s
o
r
R
e
s
p
o
n
s
e
-
r
e
f
e
r
s
t
o
s
u
s
t
a
i
n
e
d
c
o
n
t
r
a
c
t
i
o
n
a
n
d
p
o
s
t
u
r
i
n
g
o
f
t
h
e
t
r
u
n
k
a
n
d
l
o
w
e
r
l
i
m
b
s
i
n
a
p
o
s
i
t
i
o
n
o
f
f
u
l
l
e
x
t
e
n
s
i
o
n
.
•
Indicative
of
corticospinal
brainstem
lesion
between
superior
colliculus
and
vestibular
nucleus.
•
Elbows-
extended,
Shoulders-
adducted,
Forearm-
pronated,
wrist
and
fingers-
flexed,
lower
limb-
stiff
extension
and
plantarflexion.
D
E
C
O
R
T
I
C
A
T
E
R
I
G
I
D
I
T
Y
•
A
b
n
o
r
m
a
l
F
l
e
x
o
r
R
e
s
p
o
n
s
e
-
r
e
f
e
r
s
t
o
s
u
s
t
a
i
n
e
d
c
o
n
t
r
a
c
t
i
o
n
a
n
d
p
o
s
t
u
r
i
n
g
o
f
u
p
p
e
r
l
i
m
b
s
i
n
f
l
e
x
i
o
n
a
n
d
l
o
w
e
r
l
i
m
b
s
i
n
e
x
t
e
n
s
i
o
n
.
•
Is
indicative
of
corticospinal
tract
lesion
at
the
level
of
diencephalon
•
Elbows,
wrist
and
fingers-
flexion,
Shoulder-
adducted,
lower
limb-
Extension,
I.R
and
plantarflexed.
E
X
A
M
I
N
A
T
I
O
N
O
F
T
O
N
E
•
Consists
of
Initial
Observation
of
resting
posture
and
palpation
Passive
motion
testing
Active
motion
testing
•
T
o
n
e
i
s
v
a
r
i
a
b
l
e
i
n
n
a
t
u
r
e
.
H
e
n
c
e
d
e
p
e
n
d
s
o
n
f
o
l
l
o
w
i
n
g
f
a
c
t
o
r
s
Volitional
effort
and
movement
Stress
and
anxiety
Position
and
interaction
of
tonic
reflexes
Medications
General
health
Environmental
temperature
State
of
CNS
arousal
and
alertness
Urinary
bladder
status
Fever and
infection
Metabolic
and
or
electrolyte
imbalance
•
I
n
i
t
i
a
l
O
b
s
e
r
v
a
t
i
o
n
a
n
d
p
a
l
p
a
t
i
o
n
Abnormal
posturing
of
limbs
or
body.
With
spasticity-
fixed
posturing
in
synergy
pattern
Flaccidity
–
limbs
appear
floppy
and
lifeless
With
palpation
–
gives
more
information
about
resting
state
of
a
muscle
Consistency
,
firmness
and
tergor
should
be
examined
Hypertonic
muscle
–
feels
taut
and
harder
Hypotonic
muscle
–
feels
soft
and
flabby
TYPICAL
PATTERNS
OF
SPASTICITY
IN
UMN
LESION
TYPICAL
PATTERNS
OF
SPASTICITY
IN
UMN
LESION
•
Passive motion
testing
:
•
Responsivness
of
muscle
to
stretch
•
Patient
is
instructed
to
relax
,
maintain
firm
and
constant
manual
contact
•
Normal
tone-
limb
moves
easily
and
therapist
is
able
to
alter
direction
and
speed
without
feeling
abnormal
resistance.
•
Hypertonic
muscle-
stiff
feeling,
resistant to
movement,
•
Hypotonic
mucscle-
heavy
feeling
and
unresponsive
•
Increasing
the
speed
of
movement
–
increases
the resistance
in
case
of
hypertonic
muscle.
•
Clonus-
maintained
quick
stretch
stimulus
•
Begin
tone
assessment
with
normal side
•
Comparison
between
upper
and lower
limbs
and also
between
right
and
left
side.
GRADING
OF
TONE
•
0-4+
scale
•
0-
No
Response
(flaccidity)
•
1+ Decreased
response
(hypotonia)
•
2+
normal
response
•
3+
Exaggerated
response
(Mild
to
moderate
hypertonia)
•
4+ sustained
response
(Severe hypertonia)
MODIFIED
ASHWORTH
SCALE
•
I
n
c
a
s
e
o
f
S
p
a
s
t
i
c
i
t
y
•
S
u
b
j
e
c
t
i
v
e
,
5
p
o
i
n
t
o
r
d
i
n
a
l
s
c
a
l
e
,
•
0
N
o
i
n
c
r
e
a
s
e
i
n
m
u
s
c
l
e
t
o
o
n
e
•
1
S
l
i
g
h
t
i
n
c
r
e
a
s
e
i
n
m
u
s
c
l
e
t
o
n
e
,
m
a
n
i
f
e
s
t
e
d
b
y
c
a
t
c
h
a
n
d
r
e
l
e
a
s
e
o
r
b
y
m
i
n
i
m
a
l
r
e
s
i
s
t
a
n
c
e
a
t
t
h
e
e
n
d
o
f
t
h
e
R
O
M
w
h
e
n
t
h
e
a
f
f
e
c
t
e
d
p
a
r
t
i
s
m
o
v
e
d
i
n
n
f
l
e
x
i
o
n
o
r
e
x
t
e
n
s
i
o
n
•
1
+
S
l
i
g
h
t
i
n
c
r
e
a
s
e
i
n
m
u
s
c
l
e
t
o
n
e
,
m
e
n
i
f
e
s
t
e
d
b
y
c
a
t
c
h
,
f
o
l
l
o
w
e
d
b
y
m
i
n
i
m
u
m
r
e
s
i
s
t
a
n
c
e
t
h
r
o
u
g
h
o
u
t
t
h
e
r
e
m
a
i
n
d
e
r
(
l
e
s
s
t
h
a
n
h
a
l
f
)
o
f
t
h
e
R
O
M
•
2
m
o
r
e
m
a
r
k
e
d
i
n
c
r
e
a
s
e
i
n
m
u
s
c
l
e
t
o
n
e
t
h
r
o
u
g
h
m
o
s
t
o
f
t
h
e
R
O
M
,
b
u
t
a
l
t
e
r
e
d
p
a
r
t
i
s
e
a
s
i
l
y
m
o
v
e
d
•
3
C
o
n
s
i
d
e
r
a
b
l
e
i
n
c
r
e
a
s
e
i
n
m
u
s
c
l
e
t
o
n
e
,
p
a
s
s
i
v
e
m
o
v
e
m
e
n
t
d
i
f
f
i
c
u
l
t
•
4
A
f
f
e
c
t
e
d
p
a
r
t
r
i
g
i
d
i
n
f
l
e
x
i
o
n
a
n
d
e
x
t
e
n
s
i
o
n
•
Pendulum
test
–
with
the
patient
seated
in
high
sitting
,
patient’s
knee
is extended
fully
and
allowed
to
drop
•
A
Normal
and
hypotonic
limb
–
swings
freely
for
several
oscillations
•
Hypertonic
Limb-
resistant to
the
swinging
motion
and
quickly
return
to
initial
starting
dependent
position
•
A
myotonometer
–
•
handheld
computerised
electronic
device
•
Quantitative
measurements
of
force
and
displacement
of
muscle
tissue
S
U
M
M
A
R
Y
•
Introduction
•
Abnormal
Tone-
Spasticity
Rigidity
Hyp
o
tonia
Dystonia
Decerebrate
Rigidity
Decorticate
Rigidity
•
Examination
of
tone
•
Modified
Ashworth
Scale
R
E
F
E
R
E
N
C
E
•
Physical
Rehabilitation
by
Susan
B
O’Sullivan
–
5
th
Edition
THANK YOU
Muscle tone is crucial for maintaining muscle relaxation and function. Abnormalities such as hypotonia, hypertonia, spasticity, rigidity, dystonia, and others can impact movement and overall health. Learn about the causes, symptoms, and implications of these tone abnormalities.
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Presentation Transcript
MUSCLE TONE -Dr. Adarsh Kumar Srivastav (PT) Assistant Professor School of Health Sciences CSJMJU
INTRODUCTION Definition: Resistance of muscle to passive elongation or stretch when an individual attempts to maintain muscle relaxation. 1. Physical Inertia 2. Intrinsic mechanical elastic stiffness 3. Reflex muscle contraction ( tonic stretch reflex) TONALABNORMALITIES - Hypotonia Hypertonia-Spasticity and Rigidity Dystonia Decerebrate and Decorticate Rigidity Factors
ABNORMAL TONE SPASTICITY Hypertonic motor disorder Velocity dependent Clasp- knife response Chronic spasticity- abnormal posture, deformity, disability Injury to pyramidal tract- UMN lesion Loss of inhibitory control over lower motor neurons Results in disordered spinal segmental reflexes Increased alpha motorneurone excitability
Sign and symptoms- hyperactive stretch reflexes Involuntary flexor and extensor spasms Babinski s sign positive Abnormal plantar reflex Exaggerated deep tendon reflexes Loss of precise autonomic control Clonus- cyclic, spasmodic alteration of muscle contraction relaxation in response to muscle stretch of a spastic muscle. Common in plantar flexors
RIGIDITY Hypertonic state Increased uniform resistance that persists throughout the whole ROM (leadpipe) Cause- lesion of the basal ganglia system ( Parkinson s disease) Stiffness, inflexibility, Significant functional limitation. Due to excessive supraspinal drive (UMN facilitation) Spinal reflex mechanisms are normal. Cogwheel- Hypertonic state with superimposed rachetlike jerkiness, commonly in UE movement e.g Elbow flexion/ extension)
HYPOTONIA Flaccidity-Absent muscular tone Resistance to passive movement is diminished Stretch reflexes are dampened or absent, limbs are floppy Occurs in Lower Motor Neuron Lesion- affection of ant horn cell and peripheral nerves Symptoms- Decreased or absent reflexes, paresis or paralysis, muscle fasciculation and fibrillation, muscle atrophy. Temporary states of flaccidity or hypotonia- Spinal Shock/ cerebral Shock depending upon location of lesion.
DYSTONIA Hyperkinetic movement disorder characterized by disordered tone and involuntary movements involving large portion of the body. Movements are similar to athetoid movements with typical twisting/writhing motions. Dystonic Posturing- sustained abnormal postures due to co-contraction of muscles. Result from a CNS lesion (Basal Ganglia). Focal Dystonia-Affects only one part of the body e.g spasmodic torticollis. Segmental Dystonia- Affects two or more adjacent areas e.g dystonic posturing of arms.
DECEREBRATE RIGIDITY Abnormal Extensor Response - refers to sustained contraction and posturing of the trunk and lower limbs in a position of full extension. Indicative of corticospinal brainstem lesion between superior colliculus and vestibular nucleus. Elbows- extended, Shoulders- adducted, Forearm- pronated, wrist and fingers- flexed, lower limb- stiff extension and plantarflexion.
DECORTICATE RIGIDITY Abnormal Flexor Response -refers to sustained contraction and posturing of upper limbs in flexion and lower limbs in extension. Is indicative of corticospinal tract lesion at the level of diencephalon Elbows, wrist and fingers- flexion, Shoulder- adducted, lower limb- Extension, I.R and plantarflexed.
EXAMINATION OF TONE Consists of Initial Observation of resting posture and palpation Passive motion testing Active motion testing
Tone is variable in nature. Hence depends on following factors Volitional effort and movement Stress and anxiety Position and interaction of tonic reflexes Medications General health Environmental temperature State of CNS arousal and alertness Urinary bladder status Fever and infection Metabolic and or electrolyte imbalance
Initial Observation and palpation Abnormal posturing of limbs or body. With spasticity- fixed posturing in synergy pattern Flaccidity limbs appear floppy and lifeless With palpation gives more information about resting state of a muscle Consistency , firmness and tergor should be examined Hypertonic muscle feels taut and harder Hypotonic muscle feels soft and flabby
TYPICAL PATTERNS OF SPASTICITY IN UMN LESION Upper limb Scapula Shoulder Actions Retraction, Downward rotation Adduction , internal rotation , depression Flexion Pronation Muscles affected Rhomboids Pectoralis major, LD, Teres major, Subscapularis Biceps, Brachialis, Brachioradialis Pronator teres, Pronator Quadratus, Flexor Carpi radialis FDP, FDS, Add Pollicis Brevis, FPB Elbow Forearm Wrist Hand Flexion adduction Finger flexion, clenched fist thumb. Adducted in palm
TYPICAL PATTERNS OF SPASTICITY IN UMN LESION Lower limb Pelvis Hip Action Retraction Adduction , Internal rotation, extension Extension PF, Inversion, Toes claw, Toes curl Muscles affected Quadratus lumborum Add Longus/brevis, Add Magnus Knee Foot and ankle Quadriceps Gastroc soleus , Tibialis Posterior , Long toe flexors Rotators , internal /external obliques Trunk Lateral flexion, rotation
Passive motion testing : Responsivness of muscle to stretch Patient is instructed to relax , maintain firm and constant manual contact Normal tone- limb moves easily and therapist is able to alter direction and speed without feeling abnormal resistance. Hypertonic muscle- stiff feeling, resistant to movement, Hypotonic mucscle- heavy feeling and unresponsive Increasing the speed of movement increases the resistance in case of hypertonic muscle. Clonus- maintained quick stretch stimulus Begin tone assessment with normal side Comparison between upper and lower limbs and also between right and left side.
GRADING OF TONE 0-4+ scale 0- No Response (flaccidity) 1+ Decreased response (hypotonia) 2+ normal response 3+ Exaggerated response (Mild to moderate hypertonia) 4+ sustained response (Severe hypertonia)
MODIFIED ASHWORTH SCALE In case of Spasticity Subjective , 5 point ordinal scale, 0 No increase in muscle toone 1 Slight increase in muscle tone , manifested by catch and release or by minimal resistance at the end of the ROM when the affected part is moved inn flexion or extension 1+ Slight increase in muscle tone , menifested by catch , followed by minimum resistance throughout the remainder (less than half) of the ROM 2 more marked increase in muscle tone through most of the ROM , but altered part is easily moved 3 Considerable increase in muscle tone, passive movement difficult 4 Affected part rigid in flexion and extension
Pendulum test with the patient seated in high sitting , patient s knee is extended fully and allowed to drop ANormal and hypotonic limb swings freely for several oscillations Hypertonic Limb- resistant to the swinging motion and quickly return to initial starting dependent position Amyotonometer handheld computerised electronic device Quantitative measurements of force and displacement of muscle tissue
SUMMARY Introduction Abnormal Tone- Spasticity Rigidity Hypotonia Dystonia Decerebrate Rigidity Decorticate Rigidity Examination of tone ModifiedAshworth Scale
REFERENCE Physical Rehabilitation by Susan B O Sullivan 5thEdition
