Hypotonia and Flaccidity: Part 1

Hypotonia

• Hypotonia involves managing impairments in neurologic function
• Divided into parts
• This section addresses part 1

Flaccidity

• Flaccidity means there is an absence of muscle tone
• There is absent resistance to passive movement

Hypotonia

• Hypotonia means there is an abnormal decrease in muscle tone
• There is decreased resistance to passive movement

Common Characteristics of Hypotonia

• Heavy, floppy limbs
• Abnormal "limp" postures
• Flabby or soft muscles with palpation
• Increased PROM and joint mobility
• Decreased motor control, postural stability, DTRs, muscle force production, and sensation

Possible Impact on Function Due to Hypotonia

• Function depends on the severity of the hypotonia and the patient's presentation
• Consider a patient with a flaccid UE post-stroke who also has absent sensation and neglect

Other Impairments Expected

• Loss of Proprioception & Sensation increases the risk of injury due to a lack of awareness of limb position
• Severe Motor Impairment results in no active movement in the affected UE (0/5 MMT)
• Edema & Joint Instability results in weak musculature and lack of movement leading to swelling and potential joint subluxation, such as inferior GH subluxation
• Neglect & Inattention results in limited spontaneous use of the affected UE, often kept in a dependent position
• Reduced Postural Control causes difficulty maintaining balance in sitting or standing due to asymmetric weight shifting

Functional Activity Limitations with Hypotonia

• Dressing: Difficulty putting on a shirt due to the inability to position or assist with the affected UE
• Feeding: Unable to stabilize a plate or use both hands to manipulate utensils
• Transfers: Difficulty pushing off with both hands when rising from a chair, leading to reliance on the less affected side
• Wheelchair Use: The affected arm may dangle unsupported, increasing the risk of injury
• Safety Concerns: Increased fall risk due to impaired protective responses

Automatic Compensation for Hypotonia

• One-Handed Strategies: Using only the less affected limb, which leads to learned non-use
• Postural Adjustments: Leaning toward the unaffected side to compensate for weak postural control
• Use of External Support: Resting the flaccid arm in a lap tray or sling to prevent injury
• Increased Trunk Involvement: Excessive trunk movement to assist with reaching tasks

Safety Considerations for Hypotonia

• Head/neck: Swallowing difficulties leading to choking and aspiration, and excessive flexion/extension
• Shoulder girdle: Joint/ligamentous laxity, risk of subluxation, range of motion limitations, and pain; careful handling is needed to prevent damage
• Trunk: Absent or decreased balance and equilibrium reactions, poor breathing, and poor posture control
• Hip and knee: Instability during transfers and gait, joint laxity leading to pain, and possible hip subluxation or dislocation
• Ankle/foot: Instability during transfers and gait, and joint laxity leading to pain and/or contractures
• Overall: Compromised sensation leading to inability to react to noxious stimuli, risk for falls, joint integrity issues, skin breakdown due to immobility, and contractures

Lifespan Influences and Age-Related Changes

• Natural aging can further compromise function in individuals with hypotonia
• There is decreased muscle activation and recruitment speed
• Soft tissue changes in muscle fibers
• Decreased ability to initiate, sustain, and grade movement
• Recovery time increases after an insult

Secondary Implications of Long-Term Hypotonia

• Musculoskeletal: Joint instability, contractures, spinal deformities
• Neuromuscular: Muscle atrophy, weakness, decreased endurance
• Functional: Impaired ADLs, mobility, fall risk
• Circulatory/Integumentary: Edema, pressure ulcers
• Respiratory/Swallowing: Breathing issues, dysphagia, aspiration risk
• Cognitive/Behavioral: Learned non-use, compensation, reduced activity engagement

Examination and Evaluation for Hypotonia

• A precise quantifiable measure is lacking
• Typical tests for adults include:
  • Passive Range of Motion (ROM) such as an abnormal lack of resistance or heaviness of the limb
  • Observation for Posture and size/shape of muscles which may appear "lifeless" or show muscle wasting, atrophy, and joint deformity
  • Palpation for poor muscular definition where muscles feel flabby and soft

Expected Outcomes and Prognostic Factors

• Outcome predictions are challenging

Considerations

• Extent and location of the lesion
• Overall prognosis of the underlying condition, such as stroke versus amyotrophic lateral sclerosis
• Age at onset
• Severity of involvement to other systems

Intervention: General Approaches

• Compensation versus Recovery?
• Recovery focuses on strategies for initiating muscle activity, beginning at the mobility or stability stage of motor control, and uses a task-oriented and systems model philosophy
• Compensation involves assistive devices, bracing, or equipment, and learning to adapt without using the impaired limb
• Patient and family education are an important addition

Adaptive and Supportive Devices (Compensation)

• Wrist/hand splints and shoulder slings
• Tabletop supports or lateral chair guards
• Compression gloves
• Lower extremity (LE) orthoses, such as ankle foot orthosis (AFO) or knee AFO (KAFO)
• Swedish knee cage and abdominal binder
• Gait assistive devices or wheelchairs

Therapeutic Techniques

• Positioning and handling considerations such as using bolsters, wedges, or towel rolls in a supine position to achieve midline alignment and support weak areas, encourage shoulder ABD and ER
• ROM, weight-bearing
• Facilitation Techniques involve quick stretch/tapping, vibration, manual contacts, approximation, and resistance, and fast brushing or icing

Other Therapies

• Neuromuscular Electrical Stimulation (NMES)
• Strengthening through gravity, body weight, or manual resistance, using tools like weights and elastic bands
• Shoulder strapping/taping prevents overstretching, promotes postural control, and reduces pain/discomfort

Functional Activities

• Functional Electrical Stimulation (FES) to improve function, movement, and neuromuscular re-education
• Flaccid limb with no voluntary control placed in a functional position and stabilize the trunk in normal alignment
• Limited voluntary control exercises for the upper extremity such as hand weight bearing during functional activities, stabilizing a jar, placing hand on a grocery cart handle, and ambulation with poles
• Exercises for the lower extremity such as foot correctly positioned during sitting, sit-to-stand, stepping, transitions through different positions. Can also be the Balance obstacle course
• Incorporate normal trunk motions to support weight-bearing during sitting or standing tasks
• Control of requisite shortening and elongation needed for reaching, dressing, grooming, and gait
• Rotational activities to promote control during rolling, sitting, and gait

Hypertonia

• Clinical Picture
  • Hypertonicity develops after a CNS injury (upper motor neuron lesion)
  • Increased tone, increased tendon reflexes, and possible clonus occur

Lesion Locations

• Lesions of the cerebral cortex cells cause neurons in the brain's outer layer which are responsible for motor control, sensory processing, and cognition
• Lesions of the cerebral corticospinal pathways cause neural tracts from the cerebral cortex to disrupt voluntary motor commands to the spinal cord Corticospinal pathways of SC: The final segment of the corticospinal tract in the spinal cord that directly synapses with motor neurons to control movement may be related to stroke, spinal cord injury (SCI), multiple sclerosis (MS), traumatic brain injury (TBI), or cerebral palsy (CP)

Key notes

• Impaired motor control is distinct from abnormal tone
• Hypertonicity in a particular muscle group may cause difficulty with active movement of an opposing muscle group

Potential Consequences and Effects on Function

• Joint contractures, skin breakdown, gait abnormalities, postural abnormalities, skeletal deformities
• Difficulty completing activities of daily living (ADLs) as spasticity may interfere with actions of opposing muscle groups
• Secondary loss of strength may affect gait/function more than primary hypotonia

Aims of Interventions Targeting Spasticity

• Techniques decreasing spasticity can provide a window of time to practice more appropriate use of opposing muscle groups
• More appropriate practice and repetition of functional movement can help stimulate neural plasticity and optimize motor recovery
• Interventions to joint and integumentary integrity must be implemented and continued as a permanent part of the patient's daily routine

Preparatory Intervention Specific to Hypertonia

• Reducing hypertonus improves mobility, reduces discomfort, and enhances independence in daily tasks
• Altering spasticity physically or pharmacologically can enhance function, prevent contractures, increase range of motion, prevent deformity, or reduce pain

Spasticity Alteration Results

• Enhances function by improving voluntary movement and motor control
• Prevents contractures by reducing prolonged muscle tightness that leads to joint restrictions
• Increases range of motion by allowing greater flexibility in affected limbs
• Prevents deformity by minimizing abnormal postures and reducing musculoskeletal stress
• Reduces pain by decreasing excessive muscle tone, spasms, and secondary complications like pressure sores

Spasticity

• Treatment is considered when increased tone interferes with functional activities, is painful, or leads to complications like contractures or skin breakdown
• Goals: Preserve muscle strength, joint/integumentary integrity

Sustained Positioning and Passive ROM

• Prolonged static stretch to spastic muscles decreases hypertonicity, and may elongate shortened muscles over time, resulting in a longer duration of tone reduction
• Passive ROM may be applied manually or via specialized equipment
• Serial casting applies casts in progressively greater range over several weeks to provide constant stretch, fatiguing and elongating the muscle and is typically changed every 1 to 2 weeks, with an orthotic brace implemented afterward

Orthotic Devices for Hypertonicity

• Orthotic/bracing, passive standers, and adaptive seating devices can assist in controlling it
• All orthoses must be custom-made to fit the client intimately
• Goal: Position and maintain the joint and associated muscles in a lengthened position to gain ROM and decrease tone

Positions to Reduce Spasticity

• Dissociation of UE and LE in sitting or tall-kneeling
• Proper weight-bearing through the feet
• Side lying with flexion of the upper and lower extremity on one side
• Extension of the contralateral extremities

Equipment for Managing Hypertonicity

• Ankle foot orthosis maintain the foot in a neutral position or in slight dorsiflexion in order to disrupt the LE extension synergy and provide static sustained stretch to plantar flexors
• Dynamic splints allows for some slight movement of an extremity while providing a low load, long duration stretch to a joint
• Seat cushion contour contributes to positioning the pelvis in a posterior tilt to decrease extensor tone
• Supine standing frames provide weight-bearing to a lower extremity, approximating joints

Physical Inhibition

• Manual facilitation and inhibition is used to manage hypertonicity
• Neurodevelopmental Treatment (NDT): Focuses on normalizing muscle tone and promoting functional movement patterns
• Feldenkrais Method: Emphasizes gentle movements to retrain the nervous system Through movement exploration and body awareness
• Gentle, tone-inhibiting positioning and handling techniques help reduce hypertonicity
• Attempting to maximize patient function and achieve therapeutic goals

Therapeutic Inhibition Techniques

• Minimizes some abnormal body system function, such as hypertonicity or hypersensitivity to prevent some abnormal position, posture, or movement
• Goals Regain functional skills
• Techniques tend to produce TEMPORARY reductions in spasticity/hypertonicity that may NOT translate to long lasting improved functional capacity

Technique Application

• Apply technique to a spastic muscle before a mobilization or before a technique to enhance ROM
• Can also be useful before interventions to improve voluntary motor control of related muscle groups

Deep Pressure

• Goal: Increase joint awareness and decrease spasticity.
• Sustained compressive pressure (non-noxious) over the longitudinal axis of the tendon of a hypertonic muscle to elicit increased activation of the Golgi tendon organ (GTO)
• Increased activation of the GTO helps induce an elongation to the muscle, reducing tone

Joint Traction

• Goal: Increase joint awareness and activation of joint receptors
• Placing one hand proximally on the extremity to provide a stabilizing force and gently distracting using a firm grip of your other hand applied distally.
• Traction force may be sustained or applied intermittently.
• Contraindicated: Extremely hypomobile or hypermobile joints

Therapeutic Inhibition Techniques (cont'd)

• Rhythmic Rotation
  • Slow low-amplitude rhythmic rotary movements of the body/head providing mild repetitive input to the vestibular system and CNS
  • State of relaxation for dampening of muscle groups
  • Total-body inhibition achieved through decreased output from the vestibulospinal reflex
  • Diagonal stretching

Sustained Stretch

• Slow prolonged stretch to the spastic muscle for a temporary decrease in spasticity
• Place hypertonic muscle at a maximally elongated position
• Activation of the GTO can decrease tension and contractibility
• Greater effect on extensor muscles
• Combine with or followed by active contraction of the antagonist muscle group to provide reciprocal inhibition

Thermal Applications

• Heat
  • Examples: Warm therapeutic pool, neoprene garments, or air splint to provide regional muscle relaxation
  • Heat dampens muscle tone and excitability with sustained effects up to 30 minutes
• Cold
  • Lengthened icing or immersion of limb for decreased muscle spindle activation and/or nerve conduction velocity and tone
• Contraindications
  • Sensory impairments, poor cognition, or intolerant diagnoses
• Kinesiotape is elastic therapeutic tape designed to mimic the qualities of human skin; It helps to control joint position and reduce excitability of spastic muscle fibers.
• Place Kinesiotape perpendicular to the muscle fibers to dampen the firing

Electrical Stimulation (NMES)

• Applied to the innervated antagonist muscle group; results in immediate but short spasticity duration
• Reciprocal inhibition of spastic muscle group and fatigue of the spastic muscle lowers spasticity temporarily.
• Sensory-level electrical stimulation (no motor response) to temporarily reduce muscle spasticity possibly via sensory habituation of spinal pathway

Other Techniques

• Biofeedback
• Vibration and sonic pulses
• Acupuncture

Techniques Specific for Parkinson's disease

• Passive stretch
• Physical activity/exercise (treadmill walking)
• Aquatic exercise in warm water
• Whole-body vibration
• Botulinum Toxin A
• Electrical stimulation

Functional Activites: Aquatic Therapy

• Therapeutic pools between 84°F and 94°F
• The warmth Provides global relaxation and dampens rigid tone
• Also provides buoyancy and resistance

Pool benefits

• Buoyancy helps create a greater degree of safety and stability when working on ambulatory activities and eliminates the effects of gravity
• Resistance to movement in any direction in the water provides is a benefit of performing gait training and serves to assist strength training
• Exercises performed in quadruped are especially useful for extensor spasticity:
• Quadruped position helps induce flexion into the hips and knees, providing a prolonged stretch
• Important for floor transitions
• Maintenance of the quadruped position increases motor control, core strength, and balance as a dynamic activity

Rolling

• is a Fundamental component of bed mobility
• Rhythmic rotation helps reduce hypertonicity while increasing proficiency + independence
• It is the basis for many complex transitional movements, including car transfers and pivot transfers

Weight-bearing activities

• Joints must be in good alignment
• Weight-bearing, which is joint approximation, compressing the joint surfaces, decreases hypertonicity
• Postural Alignment such as half-kneeling should be used to improve dissociation, one limb in flexion and one in extension, and decrease spasticity in LE's.
• Quadruped, tall-kneeling, supported standing through arms on a table, and weight-bearing through legs on the floor

Ataxia/Incoordination

• Involves management of impairments in neurologic populations part II

Primary Impairments of Ataxia

• Dysmetria: Inability to control movement distance, leading to overshooting or undershooting
• Decomposition of movement: Breaking a multi-joint movement into individual steps caused by poor coordination
• Rebound phenomenon: Inability to stop a movement after resistance is removed
• Dysdiadochokinesia: Impaired ability to perform rapid alternating movements
• Asthenia: Generalized muscle weakness due to cerebellar dysfunction
• Intention tremor: Tremor that worsens as a movement approaches its target. (cerebellum)
• Hypermetria: Overshooting a target due to impaired movement scaling

Related Symptoms of Ataxia

• Titubation: Rhythmic head or trunk tremor, often seen in cerebellar disorders
• Postural tremor: Tremor occurring when maintaining a position against gravity
• Dysarthria: Impaired speech due to poor motor control of speech muscles
• Staccato speech: Speech with irregular pauses and broken rhythm, common in cerebellar dysfunction
• Nystagmus: Involuntary, repetitive eye movements, often indicating vestibular or cerebellar dysfunction

Possible Impact on Function

• Ataxic gait associated with impairment, balance, and affects mobility
• Problems with Functional activities of the UE such as self-care like buttoning a shirt.
• Balance Deficiency is a Result of changes in control of and decreased muscle tone

Deficits

• Dysmetria and Rebound phenomenon
• Problems with Vision such as reading and eye-foot and hand cordination.

Functional Anatomy

Key areas in the brain Spinocerebellum area : responsible for posture and cordination. Cerebrocerebellum area: responsible for Plans and fine-tunes volntary movements The vestibulocerebellum area: responsible for Maintain balance, eye movements, and head coordination.

• Spinal cord (descending BS corticospinal pathways)
• Cerebal cotex (regardin the motor command)
• Vestibular nuclei (vestibular apparatus)

Lifespan Influences

• Natural Aging has effects on individuals by having reduced muscle strenght, reaction time and postural control
• Many conditions cause these diagnosis, like heditary disorders, tumors and vascular disoders

Intervention

• Systemic reviews revealed that therapy has a Gait and Trunk contorl with the right movments. Also by improving one and other , patients can use multiple ways to compensate

Treatment Plans To Consider

• Treat the underlyng pahtology
• know the functional of patient and the health.
• know compensations can go against to the patient
• Video game Technology
• Weighted vest

Precautions During Interventions

• use some type of resistance to perform movement
• aviod the rate of intensity and cardiovascular issues
• know how fast can patient control their own movement
• teach pt how to monitor his fatiuge.

Weakness:

• Is a primary impairment in neurological disorders adversely affecting function
• Importance of strength training in patients with neurological disorders
• Remediate weakness deficits
• Prevent secondary impairments
• Promote optimal health and wellness
• Evidence-based support for effectiveness of strength training across neurological diagnoses
• Each patient should be prescribed a customized exercise program

Weakness Impairments in the Neurological World

Weakness: Introduction

• Is a primary impairment in neurological disorders adversely affecting function
• Importance of strength training in patients with neurological disorders
• Remediate weakness deficits
• Prevent secondary impairments
• Promote optimal health and wellness
• Evidence-based support for effectiveness of strength training across neurological diagnoses Each patient should be prescribed a customized exercise program

Rationale for Strength Training in Persons with Neurological Disorders

• Evidence supports strength training linked to improved functional outcomes
• Shown in patients with TBI, MS, Parkinson disease (PD), cerebral palsy (CP), and neuromuscular diseases
• Benefits of strength training programs:
• Moderate to high intensity programs promote neuroplasticity
• Reverse effects of prolonged inactivity, reduce fall risk, prevent disuse atrophy
• For which diagnoses do you expect full or partial recovery? For which a decline? Goals of training?

Strength Training and Rehabilitation

• Spasticity and Functionality*.
• Promote Flexibility and Movement for Neuro Recovery.*
• Techniques decreasing spasticity * More appropriate practice * Interventions toward joint inegreity and patient Goals: Preserve muscle strength.

Sustained Positioning and Passive ROM

• decreased hypertonicity and may some cases
• \decrese the tone by static strech.*

Exercise Plans

Therapist May Apply:

• Kinesitape
• Thermal Application
• Electrical Stimulation
• BioFeed Back

Use as treatment:

• Rolling
• Weight training
• Quad Ru ped Also Use Adaptive Device depending On Pt and Quality of Life.

Sensory Impairment

• Ability of patient to take in organize sensory -Stimul. -Tactile, Proprioceptive, and Vestibular normal- sensory stimulus has response and is efficient.
• Imparement- Process is Interupted by the pt and sensory is limited.

Types Of Impairment

• Hyposentitivity
  lost of awareness
• *Hypersentitivity**,**definessivness to over sensory

Intervention

• In addition towards sensory all should be address.*

• Therapy

• Sensory diet

• Inpt sensory + tactile vestublar motorresponse