Neurologic Impairments: Hypotonia and Hypertonia

Management of Impairments in Neurologic Populations: Hypotonia and Hypertonia

• PT 834: Adult Neuromuscular Diagnosis & Management, Spring 2025

Flaccidity vs. Hypotonia

• Flaccidity involves the complete absence of muscle tone.
• A unique characteristic of flaccidity is the absent resistance to passive movement.
• Common issues with flaccidity: heavy, floppy limbs, abnormal "limp" postures, flabby or soft muscles upon palpation, increased PROM, and increased joint mobility.
• Hypotonia signifies an abnormal decrease in muscle tone.
• Decreased resistance to passive movement is a unique trait of hypotonia.
• Hypotonia characteristics: decreased motor control, poor postural stability, reduced DTRs, decreased muscle force production, and decreased sensation.

Possible Impact on Function

• The severity of hypotonia and the specific presentation impact function.
• Consider impairments, functional limitations, and compensations of a patient with a flaccid upper extremity post-stroke with absent sensation and neglect.

Safety Considerations for Hypotonia

• Swallowing difficulties can lead to choking and aspiration.
• Excessive flexion or extension of the head and neck might be observed.
• Joint and ligament laxity may increase injury risk and the importance of careful handling to prevent joint damage and subluxation.
• Expect range of motion limitations secondary to a lack of voluntary movement and potential for pain.
• Absent or decreased balance and equilibrium, poor breathing, and poor posture control exist.
• Instability during transfers and gait may require addressing joint laxity resulting in pain, hip subluxation, or dislocation.
• Joint laxity in ankles and feet contribute to instability during transfers and gait, may cause pain and/or contractures.
• Compromised sensation may cause an inability to react to noxious stimuli and increases the risk of falls.
• Joint integrity, skin breakdown due to immobility, and contractures from immobility are concerns.

Lifespan Influences: Age-Related Changes

• Natural aging can further compromise function in individuals with hypotonia.
• Muscle activation and recruitment speed may be impacted.
• Soft tissue changes in muscle fibers can decrease the ability to initiate, sustain, and grade movement.
• Recovery for healing time may be prolonged.

Pertinent Examination/Evaluation: Tests and Measures

• Quantifiable measure of hypotonia is lacking.
• Typical tests for the adult with hypotonia include passive range of motion, observation, and palpation.
• Passive ROM reveals an abnormal lack of resistance, heaviness of the limb, and the ability to move too freely with increased ROM > normal.
• Observation can reveal a "lifeless" appearance, muscle wasting/atrophy, and joint deformity.
• Palpation can indicate poor muscular definition and muscles that feel flabby/soft.

Pertinent Examination/Evaluation: Expected Outcomes and Prognostic Factors

• Outcome predictions are challenging.
• Consider the extent and location of the lesion, overall prognosis of the primary condition, the patient's age at onset, and the severity of involvement in other systems.

Intervention: General Approaches

• Compensation focuses on assistive devices, bracing, or equipment and adapting to life without using the impaired limb.
• Recovery focuses on the mobility and/or stability stage of motor control, initiation of muscle activity, and using strategies in alignment with a task-oriented and systems model philosophy.
• Patient and family education is crucial.

Intervention: Adaptive and Supportive Devices

• Wrist/hand splints and shoulder slings for support and stability.
• Table top supports or lateral chair guards to aid trunk stability.
• Compression gloves can help with edema management and sensory input.
• Lower extremity orthoses like ankle foot orthoses (AFO) or knee AFOs (KAFO) for alignment and support.
• Swedish knee cage for knee stability.
• Abdominal binder for core support.
• Gait assistive devices or wheelchair to aid mobility.

Intervention: Therapeutic Techniques

• Positioning and handling considerations should factor in supine and sidelying.
• Range of motion and weight-bearing exercises promote movement and stability.
• Facilitation techniques include quick stretch/tapping, vibration, manual contacts/approximation/resistance, and fast brushing or icing.
• Neuromuscular Electrical Stimulation (NMES) to facilitate muscle activation.
• Strengthening exercises against gravity with manual resistance, weights, or elastic bands can improve muscle strength.
• Shoulder strapping/taping to support joint alignment.

Intervention: Functional Activities

• Functional Electrical Stimulation (FES) can increase either motor return versus neuroprosthesis using Bioness H200 & L300.
• For patients with flaccid limbs, position the limb within function and stabilization of trunk in normal alignment.
• In the presence of limited voluntary control, training Upper extremity placing the hand in weight-bearing during functional activities, Stabilizing jar while opening with other hand, Hand placed appropriately on handle of grocery cart, broom, reaching, grasp, and ambulation with poles.
• In the presence of limited voluntary control, training Lower extremity activities include Foot positioned appropriately during sitting activities, Sit-to-stand, Stepping in different directions, Transitions during function through different positions, Single limb stance, Body weight-supported training over treadmill or overground, and Ambulation over various surfaces and terrains.
• In the presence of limited voluntary control, training Trunk activities incorporation of normal trunk motions to support weight-bearing during sitting or standing tasks, Control of requisite shortening and elongation needed for dressing, and Rotational activities to promote control during rolling, sitting, and gaiti.

Clinical Picture of Hypertonia

• Hypertonicity originates from a lesion of cerebral cortex cells, cerebral corticospinal pathways, corticospinal pathways of the spinal cord.
• Causes include stroke, spinal cord injury (SCI), multiple sclerosis (MS), traumatic brain injury (TBI), and cerebral palsy (CP).
• Impaired motor control is distinct from abnormal tone.
• Hypertonicity in one muscle group can hinder opposing muscle group movement.

Potential Consequences and Effects on Function with Hypertonia

• Hypertonia may cause joint contractures, skin breakdown, gait abnormalities, postural abnormalities, and skeletal deformities.
• Activities of daily living are more difficult due to spasticity affecting opposing muscle groups.
• Secondary loss of strength significantly affects gait/function.

Aims of Targeting Spasticity

• Reducing spasticity, even temporarily, aids the practice more appropriate use of opposing muscle groups in functional activities.
• Functional movement without interference of opposing spasticity help stimulate neural plasticity and optimize motor recovery.
• Interventions should preserve muscle strength and joint for the patient's daily routine.

Preparatory Intervention Specific to Hypertonia

• Reducing hypertonus improves the patient's quality of life and functionality.
• Altering spasticity can enhance function, prevent contractures, increase ROM, prevent deformity, and reduce pain.
• Spasticity treatment is indicated when it interferes with functional activities, causes pain, skin breakdown or contractures.
• Goals should be Preserve muscle strength, joint/integumentary integrity.

Sustained Positioning and Passive ROM

• Provides a prolonged static stretch to spastic muscles and have demonstrate decrease hypertonicity and elongate shortened muscles.
• Longer duration reduction of tone can occur.
• Passive ROM can be applied manually or with specialized equipment.
• Serial casting: Cast is applied in maximal stretch, which supplies a constant stretch to elongate muscles and fatigue.
• Cast typically is changed every 1-2 weeks in a new lengthened position until achieved a desired muscle length.
• Implement an orthotic brace afterward.
• Goal: Position and maintain the joint and associated muscles in a lengthened position in attempt to gain ROM and decrease tone.
• Orthotic devices assist in controlling hypertonicity and also offer orthotic/bracing, passive standers, as well as several adaptive seating devices of which must be custom made to the client intimately.
• Positions reducing spasticity: dissocation of upper and lower extremities in sitting or tall-kneeling, proper weight-bearing through feet, sidelying with flexion of the upper and lower extremity on one side, and extension of the contralateral extremities
• AFOs should NOT be used to improve PF spasticity in acute or chronic stroke.

Equipment

• Ankle foot orthoses and dynamic splints can assist in managing hypertonicity to maintain the foot in a neutral position or slight dorsiflexion to disrupt lower extremity and increase of plantar flexors.
• Seat cushion contour for positioning the pelvis in a posterior tilt decreasing lower extremity extensor tone.
• Supine standing frame for weight bearing and approximation to control joints and decrease spasticity.

Handling and Physical Inhibition

• Use manual facilitation and inhibition to manage hypertonicity such as examples: Neurodevelopmental treatment (NDT), Feldenkrais.
• Gentle, tone-inhibiting positioning and handling techniques help reduce hypertonicity.

Therapeutic Inhibition Techniques

• Inhibition is an intervention method to minimize some abnormal body system function, or prevent abnormal position, posture and movement.
• Therapeutic inhibition produce only TEMPORARY reductions in spasticity and are best combined with a functional task.
• Apply an inhibition technique to a spastic muscle before a mobilization or before a technique to enhance ROM.
• Inhibition useful before interventions to improve voluntary motor control of related muscle groups.
• Deep pressure to increase joint awareness and decrease spasticity using a non-noxious-sustained compressive pressure over the tendon of hypertonic muscle.
• Joint Traction: Increased joint awareness and activation of joint receptors, distraction of distal bone away distally using stabilized proximal point on the extremity, and with caution on hypermobile joints.
• Rhythmic rotation is a slow low-amplitude rhythmic rotary movement of body or head will provide mild repetitive input to the vestibular system and CNS to increase relaxation.
• Sustained stretch can improve a temporary decrease in spasticity to a maximally elongated position for sustained time with reciprocally active muscles.

Thermal Applications for Therapeutic Inhibition Techniques

• Heat can provide a regional muscle relaxation, dampening of muscle tone and excitability, and may reduce muscle tone in a 10 minute application.
• Cold may decrease spasticity by decreasing muscle spindle activation and nerve conduction velocity.
• Check contraindications for those individuals with sensory impairments poor cognition or intolerant diagnoses. Kinesiotape can control joint positioning and reduce excitability of the spastic muscle by perpendicular application on the fibers themselves.
• Electrical stimulation can have a ramp up time while applying NMES on the innervated antagonist muscle or with level sensory while habituating to spinal pathway.
• Avoid electrical stimulation and AFOs to improve plantarflexor spasticity in acute or chronic stroke.

Other Techniques for Therapeutic Inhibition Techniques

• Biofeedback
• Vibration and sonic pulses
• Acupuncture

Techniques for Reducing Rigidity in Parkinson Disease

• Passive stretch and active physical exercise will improve with a treadmill.
• Aquatic exercises in warm water.
• Whole-body vibration.
• Botulinum Toxin A.
• Electrical Stimulation

Interventions: Functional Activities for Aquatic Therapy

• Aquatic pools kept at 84°F and 94°F to provide global relaxation and dampens spastic and rigid tone.
• Water provides Buoyancy and Resistance.
• Resistance to movement serves as an excellent strengthening tool.

Interventions: Functional Activities

• Exercises performed in quadruped.
• Is useful for extensor spasticity.
• Quadruped position is important in floor transitions and functional mobility
• Requires increased motor control core strength and balance to maintain a position in quadruped.
• Rolling the fundamentals of bed mobility.
• Can reduce hypertonicity and increase independence.
• Improves with mobility or complex transisitions
• Weight-bearing for the proper alignment with joint compressions reduces hypertonicity. Postures can use Half kneeling to decreased extremities by improving flexion or extension, trunk and core control or Quadruped, standing or plantigrade.