Tone abnormalities

MUSCLE TONE

- underlying tension in muscle that serves as a background for contraction. It has been variously
described as muscle tension or stiffness at rest, readiness to move or hold a position, priming or
tuning of the muscles, or the degree of activation before movement.
- also described as passive resistance in response to stretching of a muscle.
- includes involuntary resistance generated by neurally activated muscle fibers, as well as passive,
biomechanical tension inherent in connective tissue and muscle at the length at which the
muscle is tested.
- must be assessed when there is no active contraction or resistance to muscle stretch

CHALLENGES TO ASSESSING MUSCLE TONE

- HYPOTONICITY = low tone, describes decreased resistance to stretch compared with normal
muscles.
- Flaccidity= is the term used to denote total lack of tone or the absence of resistance to stretch
within the middle range of the muscle’s length.
- Paralysis= describes complete loss of voluntary muscle contraction. Paralysis is a movement
disorder and not a tone disorder, although it may be associated with abnormalities of muscle
tone
- HYPERTONICITY= Hypertonicity, or high tone, describes increased resistance to stretch
compared with normal muscles. Hypertonicity may be rigid or spastic.
- Clonus= is the term used to describe multiple rhythmic oscillations or beats of involuntary
muscle contraction in response to a quick stretch, observed particularly with quick stretching of
ankle plantar flexors or wrist flexors.
- clasp-knife phenomenon= consists of initial resistance followed by sudden release of resistance
in response to stretch of a hypertonic muscle, much like the resistance felt when closing a
pocketknife

MEASURING MUSCLE TONE: Quantitative

- Dynamometer= Greater resistance to high-velocity movement than to low-velocity movement

indicates increased tone.
- Myometer= An alternative hand-held device for measuring muscle tone is the myotonometer.
When held against the skin and perpendicular to a muscle, the myotonometer can apply a force
of 0.25 to 2.0 kg and electronically record tissue displacement per unit force, as well as the
amount of tissue resistance
- Isokinetic Testing Systems= Assessments of resistive torque as measured by an isokinetic
machine moving a body part at various speeds can be used to control for the biomechanical
components of muscle tone and to determine the overall spasticity of muscles crossing the joint
being moved.
- Electromyography (EMG)= is a diagnostic tool frequently used in research for quantifying
muscle tone . EMG is a record of the electrical activity of muscles using surface or fine
wire/needle electrodes
 - Pendulum Test= The test consists of holding an individual’s limb so that when it is dropped,
gravity provides a quick stretch to the spastic muscle. Resistance to that quick stretch will stop
the limb from falling before it reaches the end of its range

MEASURING MUSCLE TONE: Qualitative

- Clinical Tone Scale= Muscle tone is assessed qualitatively more often than quantitatively. The
traditional clinical measure is a 5-point ordinal scale that places normal tone at 2.
- Muscle Stretch Reflex= Another commonly used qualitative method of assessing muscle tone is
to observe the response elicited by tapping on the muscle’s tendon, activating the muscle
stretch reflex.
- Ashworth Scales= The Modified Ashworth Scale is used to describe normal or increased tone,
whereas the commonly used 5-point scale describes low, normal, and high tone
- The Tardieu and Modified Tardieu = scales require examiners to move the body part at slow,
moderate, and fast velocities, recording the joint angle where there is any “catch” in resistance
to movement before releasing, and comparing that angle with the angle where movement stops
and the resistance does not release

NORMAL MUSCLE TONE

- Muscle tone and muscle activation depend on normal composition and functioning of muscles,
the PNS, and the CNS.
- biomechanical and neural factors influence muscular responses, neural stimulation through
alpha motor neurons serves as the most powerful influence on both muscle tone and activation,
especially when the muscle is in the midrange of its length.
- Multiple sources of neural input, both excitatory and inhibitory, are required for normal
functioning of the alpha motor neurons
- the sum of all input determines the amount of muscle tone and activation.

CONSEQUENCES OF ABNORMAL MUSCLE TONE: Decreased Muscle Tone

POSSIBLE CONSEQUENCES OF ABNORMALLY LOW MUSCLE TONE

1. Difficulty developing adequate force output for normal posture and movement
- Motor dysfunction
- Secondary problems resulting from lack of movement (e.g., pressure sores, loss of
cardiorespiratory endurance)
2. Poor posture
- Reliance on ligaments to substitute for muscle holding eventual stretching of ligaments,
compromised joint integrity, pain
- Cosmetically undesirable changes in appearance (e.g. slumping of spine, drooping of facial
muscles)
- Pain

INTERVENTIONS FOR LOW MUSCLE TONE

- Hydrotherapy
- quick ice
 - electrical stimulation
- light touch
- tapping
- executive exercises
- range of motion exercises
- therapeutic exercises
- functional training
- orthotics

Physical agents used to reduce hypotonicity caused by alpha motor neuron damage include
hydrotherapy and quick ice.

Physical agents used for hypotonicity caused by decreased input to the alpha motor neuron include ES,
hydrotherapy, and quick ice

CONSEQUENCES OF ABNORMAL MUSCLE TONE: Increased Muscle Tone

- HIGH MUSCLE TONE

Many pathological conditions result in abnormally high muscle tone. Any of the supraspinal
lesions mentioned in the previous section, as well as Parkinson’s disease, could ultimately result
in hypertonicity, even though they can begin with some form of low muscle tone.

POSSIBLE CONSEQUENCES OF ABNORMALLY HGH MUSCLE TONE

- Discomfort or pain from muscle spasms

- Contracture
- Abnormal posture
- Skin breakdown
- Increased effort by caregivers to assist with bathing, dressing ,transfers
- Development of stereotyped movement patterns that may inhibit development of movement
alternatives
- May inhibit function

INTERVENTIONS FOR HIGH MUSCLE TONE

HIGH MUSCLE TONE ASSOCIAATION INTERVENTION

Pain, cold, or stress Remove the source:
- Eliminate pain
- Warm the patient
- Alleviate stress
Relaxation techniques
EMG biofeedback
Neutral warmth
Heat
Hydrotherapy
Cold towels or cooling garments
Stimulation of antagonists:
 - Resisted exercise
- Electrical stimulation

Spinal cord injury Selective ROM exercises

Prolonged stretch
Positioning
Orthotics
Medication
Surgery
Heat
Prolonged ice

Cerebral lesions Prolonged ice

Inhibitory pressure
Prolonged stretch
Inhibitory casting
Continuous passive motion
Positioning
Reeducation of voluntary movement patterns
Stimulation of antagonists:
- Resisted exercise
- Electrical stimulation
General relaxation techniques:
- Soft lighting or music
- Slow rocking
- Neutral warmth
- Slow stroking
- Maintained touch
- Rotation of the trunk
- Hydrotherapy
Rigidity Positioning
ROM exercises
Orthotics
Serial casting after head injury
Heat
Medication
General relaxation techniques (as listed above

MOTION RESTRICTIONS

RANGE OF MOTION

- The amount of motion that occurs when one segment of the body moves in relation to an
adjacent segment
 - Motion restriction is an impairment that may directlyor indirectly contribute to patient
functional limitation and disability

TYPES OF MOTION

ACTIVE MOTION

- Active motion is the movement produced by contraction of the muscles crossing a joint.
Examination of active ROM can provide information about an individual’s functional abilities.
- restricted by muscle weakness, abnormal muscle tone, pain originating from the
musculotendinous unit or other local structures

PASSIVE MOTION

- movement produced entirely by an external force without voluntary muscle contraction by the
patient
- restricted by soft tissue shortening, edema, adhesion, mechanical block, spinal disc herniation,
or adverse neural tension

PHYSIOLOGICAL AND ACCESSORY MOTION

- Physiological motion is the motion of one segment of the body relative to another segment.
- Accessory motion, also called joint play, is the motion that occurs between joint surfaces during
normal physiological motion

PATTERNS OF MOTION RESTRICTION

CAPSULAR PATTERN OF MOTION RESTRICTIONS

- is the specific combination of motion loss that is caused by shortening of the joint capsule
surrounding a joint
- Capsular patterns generally include restrictions of motion in multiple directions.

NONCAPSULAR PATTERN OF MOTION RESTRICTION

- is motion loss that does not follow the capsular pattern.

- A noncapsular pattern of motion loss may be caused by a ligamentous adhesion, an internal
derangement, or an extraarticular lesion

TISSUES THAT CAN RESTRICT MOTION

CONTRACTILE TISSUES

- composed of the musculotendinous unit, which includes the muscle, the musculotendinous
junction, the tendon, and the interface of the tendon with bone.
- Skeletal muscle is considered to be contractile because it can contract by forming cross-bridges
of myosin proteins with actin proteins within its fibers.
- Tendons and their attachments to bone are considered contractile because contracting muscles
apply tension directly to these structures.
NONCONTRACTILE TISSUES

- All tissues that are not components of the musculotendinous unit are considered noncontractile.
- Noncontractile tissues include skin, fascia, scar tissue, ligament, bursa, capsule, articular
cartilage, bone, intervertebral disc, nerve, and dura mater.

PATHOLOGIES THAT CAN CAUSE MOTION RESTRICTION

CONTRACTURE

- Motion may be restricted if any of the soft tissue structures in an area have become shortened.
- A contracture may be a consequence of external immobilization or lack of use.
- External immobilization usually is produced with a splint or a cast.
- Lack of use is usually the result of weakness, as may occur after poliomyelitis; poor motor
control, as may occur after a stroke; or pain, as may occur after trauma

EDEMA

- This allows the capsule to fold or distend, altering its size and shape as needed for movement
through full ROM.
- Intraarticular edema is excessive fluid formation inside a joint capsule.
- Extraarticular edema generally restricts motion in a noncapsular pattern.
- Accumulation of fluid outside the joint, a condition known as extraarticular edema, may also
restrict active and passive motion by causing soft tissue approximation to occur earlier in the
range

ADHESION

- Adhesion is the abnormal joining of parts to each other.

- Adhesion may occur between different types of tissue and frequently causes restriction of
motion
- Prolonged joint immobilization, even in the absence of local injury, can cause the synovial
membrane surrounding the joint to adhere to the cartilage inside the joint.
- Adhesions can affect both the quality and the quantity of joint motion

MECHANICAL BLOCK

- Motion can be mechanically blocked by bone or fragments of articular cartilage, or by tears in

intraarticular discs or menisci.
- Loose bodies or fragments of articular cartilage, caused by avascular necrosis or trauma, can
alter the mechanics of the joint, causing “locking” in various positions, pain, and other
dysfunction

SPINAL DISC HERNIATION

- result in direct blockage of spinal motion if a portion of the discal material becomes trapped in
a facet joint, or if the disc compresses a spinal nerve root where it passes through the vertebral
foramen.

ADVERSE NEURAL TENSION

 - results from the presence of abnormal responses produced by peripheral nervous system
structures when their ROM and stretch capabilities are tested.

WEAKNESS

- result of contractile tissue changes such as atrophy or injury, poor transmission to or along
motor nerves, or poor synaptic transmission at the neuromuscular junction

OTHER FACTORS

- Motion restrictions may be caused by many other factors, including pain, psychological factors,
and tone.
- Pain may restrict active or passive motion, depending on whether contractile or noncontractile
structures are the source of the pain.
- Psychological factors, such as fear, poor motivation, or poor comprehension, are most likely to
cause restriction of only active ROM.
- Tone abnormalities, including spasticity, hypotonia, and flaccidity, may impair the control of
muscle contractions, thus limiting active ROM.

EXAMINATION AND EVALUATION OF MOTION RESTRICTIONS

QUANTITATIVE MEASURES

- These tools provide objective and moderately reliable measures of ROM and are practical and
convenient for clinical use.
- Radiographs, photographs, electro goniometers, flexometers, and plumb lines may be used to
enhance the accuracy and reliability of ROM measurement

QUALITATIVE MEASURES

- Qualitative assessment techniques, such as soft tissue palpation, accessory motion testing, and
end-feel, provide valuable information about motion restrictions that can help guide treatment.
- Soft tissue palpation may be used to assess the mobility of skin or scar tissue, local tenderness,
the presence of muscle spasm, skin temperature, and the quality of edema.

TEST METHOD AND RATIONALE

ACTIVE RANGE OF MOTION

- Active ROM is tested by asking the subject to move the desired segment to its limit in a given
direction.
- Testing of active ROM yields information about the subject’s ability and willingness to move
functionally and is generally most useful for evaluating the integrity of contractile structures

RESISTED MUSCLE TRAINING

- Resisted muscle testing is performed by having the subject contract his or her muscle against a
resistance strong enough to prevent movement.
- Resisted muscle tests provide information about the ability of a muscle to produce force.
- Cyriax identified four possible responses to resisted muscle testing and proposed interpretations
for each of these response
 FINDING INTERPRETATION
Strong and No apparent pathology of contractile
painless or nervous tissue

Strong and Minor lesion of musculotendinous unit

painful

Weak and Complete rupture of musculotendinous unit

painless

Weak and Partial disruption of musculotendinous unit

painful Inhibition by pain as a result of pathology
such as inflammation, fracture, or neoplasm
Concurrent neurological deficit

PASSIVE RANGE OF MOTION

- Passive ROM is assessed when the tester moves the segment to its limit in a given direction.
- During passive ROM testing, the quantity of available motion is measured, and the quality of
motion and symptoms associated with motion and the end-feel are noted.

PASSIVE ACCESSORY MOTION

- Passive accessory motion is tested using joint mobilization treatment techniques.

- During accessory motion testing, the clinician notes qualitatively whether the motion felt is
greater than, less than, or similar to the normal accessory motion expected for that joint in that
plane in that particular individual, and whether pain is produced with testing.

MUSCLE LENGTH

- tested by passively positioning muscle attachments as far apart as possible to elongate the
muscle in the direction opposite to its action.
- testing of muscle length by this technique will produce valid results only if the pathology of the
noncontractile structures or muscle tone does not limit joint motion.

ADVERSE NEURAL TENSION

- is usually tested by passive placement of neural structures in their position of maximum length.
- Evaluation is based on comparison with the contralateral side, comparison with norms, and
assessment of symptoms produced in the position of maximum length.
- Adverse neural tension tests include passive straight leg raise (PSLR, or Lasègue’s sign), prone
knee bend, passive neck flexion, and upper limb tension tests.

TREATMENT APPROACHES FOR MOTION RESTRICTIONS

 STRETCHING

- When a stretch is applied to connective tissues within the elastic limit, over time these tissues
may demonstrate creep, stress relaxation, and plastic deformation

MOTION

- Motion can inhibit contracture formation by physically disrupting the adhesions between gross
structures and/or by limiting intermolecular cross-linking.
- Active or passive motion stretches tissues, promotes their lubrication, and may alter their
metabolic activity

SURGERY

- Surgery will be necessary if motion is restricted by a mechanical block, particularly if the

mechanical block is bony.

THE ROLE OF PHYSICAL AGENTS IN THE TREATMENT OF MOTION RESTRICTIONS

INCREASE SOFT TISSUE EXTENSIBILITY

- used as components of the treatment of motion restriction because they can increase soft tissue
extensibility, thereby decreasing the force required to increase tissue length and decreasing the
risk of injury during the stretching procedure

CONTROL INFLAMMATION AND ADHESION FORMATION

- Controlling inflammation may help prevent the development of motion restrictions by limiting
edema during the acute inflammatory stage, thereby limiting the degree of immobilization.

CONTROL PAIN DURING STRETCHING

- Pain control may assist in the treatment of motion restrictions because, if pain is decreased,
tissues may be stretched for a longer period, and this may increase tissue length more
effectively.
- If pain is controlled, motion may be initiated sooner after injury, limiting the loss of motion
caused by immobilization

FACILITATE MOTION

- Electrical stimulation of the motor nerves of innervated muscles or direct electrical stimulation
of denervated muscle can make muscles contract.
- These muscle contractions may complement motion produced by normal physiological
contractions or may substitute for such contractions if the patient does not or cannot move
independently