Chapter 2: Examine Motor Function

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Chapter 2: Examine Motor Function
2015-03-09 23:16:53
Motor Function Exam
NPTE: Chapter 2
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  1. Examine Muscle Bulk and Firmness
    • Atrophy - due to denervation, disuse, or primary atrophy
    • The presence of persistent fasciculations suggests neurogenic injury
    • Examine by inspection, palpation, and girth measurement 
    • Check firmness, tenderness, and reactivity
  2. Examine Muscle Tone
    PROM to assess muscle stretch reflexes and responsiveness to passive elongation
  3. Flaccidity and Hypotonia
    • Flaccidity: absent tone
    • Hypotonia: low/decreased tone 
    • Seen in segmental/LMN lesions - nerve roots and peripheral nerve injury
    • Seen initially after suprasegmental/UMN lesion (i.e. brief period of spinal shock in SC injuries, cerebral shock in stroke) -- there is decreased or no resistance to PROM
  4. Spasticity (Spastic Hypertonia)
    • Seen in suprasegmental/UMN lesions 
    • Increased resistance to PROM - determine whether increasing the sped increases the resistance (spasticity is velocity-dependent)

    • Additional signs of spastic hypertonia
    • Clasp-knife response
    • Clonus
    • Hyperactive cutaneous reflexes
    • Positive Babinski response
    • Hyperreflexia
    • Some degree of muscle weakness
  5. Clasp-Knife Response
    Marked resistance to PROM suddenly gives way
  6. Clonus
    • Maintained stretch stimulus produces a cyclical, spasmodic contraction
    • Common in PF, also seen with wrist flexors and jaw
  7. Hyperactive Cutaneous Reflexes, Positive Babinski Response
    • DF of great toe with fanning of other toes in response to stroking up lateral side of sole of foot
    • Indicative of corticospinal (pyramidal) tract disruption
  8. Hyperreflexia
    Increased DTRs
  9. Modified Ashworth Scale
    6 grades for grading spasticity

    • 0 = No increase in muscle tone
    • 1 = Slight increase in muscle tone, minimal resistance at end of ROM
    • 1+ = Slight increase in muscle tone, minimal resistance through less than 1/2 of ROM
    • 2 = More marked increase in muscle tone, through most of ROM, affected part easily moved
    • 3 = Considerable increase in muscle tone, passive movement difficult
    • 4 = Affected part rigid in flexion or extension
  10. Rigidity
    • Increased resistance to PROM that is independent of velocity of movement 
    • Seen in basal ganglia/nigrostriatal disorders -- increased resistance to passive movement in agonist and antagonist muscle
    • Associated with Parkinson's disease, resting tremor, bradykinesia
    • Strength and reflexes are not affected
  11. Leadpipe Rigidity
    Uniform throughout the range
  12. Cogwheel Rigidity
    Interrupted by a series of jerks
  13. Decerebrate Rigidity/Posturing
    • Seen in comatose patients with brainstem lesions between superior colliculus and the vestibular nucleus
    • Results in increased tone and sustained posturing of all limbs
    • Trunk/neck in rigid extension
  14. Decorticate Rigidity/Posturing
    • Seen in comatose patients with lesions above superior colliculus 
    • Results in increased tone and sustained posturing of upper limbs in flex and the lower limbs in ext
  15. Opisthotonos
    • Prolonged, severe spasm of muscles
    • Causes head, back, and heels to arch backwards
    • Arms and hands held rigidly flexed
    • Seen in severe meningitis, tetanus, epilepsy, and strychnine poisoning
  16. Use AROM, active movement control to assess tone in automatic postural adjustments
    • Check stiffness of limbs and trunk in maintaining posture against gravity
    • Examine for abnormal movements -- are movements restricted, are they performed with great effort, are there limitations in voluntary movements?
  17. Examine Reflexes
    • DTR's: normally occurring reflexes in response to stretch of muscle
    • Superficial cutaneous reflexes: normally occurring reflexes in response to noxious stimulus (light scratch) applied to skin
    • Primitive spinal reflexes
    • Midbrain/cortical reactions
  18. Reflex Scoring Scale
    For primitive/spinal and tonic/brainstem reflexes

    • 0 = no response/absent reflex
    • 1+ = trace or decreased response
    • 2+ = normal response 
    • 3+ = brisk or exaggerated response 
    • 4+ = sustained response
  19. Decreased Strength: Paresis (Weakness) or Paralysis (Loss of Voluntary Motion)
    • CVA: hemiparesis or hemiplegia
    • SC Injury: paraplegia or tetraplegia (quadraplegia) 
    • TBI: any level or degree possible
  20. Clinical Issues With Strength Testing Patients with CNS/UMN Lesions
    • Passive restraint: soft tissue changes restrict ability to move (contractures) 
    • Active restraint: spastic muscles restrict ability to move
    • Abnormal synergistic activity, inappropriate coactivation of muscles 
    • Recruitment problems: abnormal type II fiber recruitment
    • Abnormal reflex activity: restricts ability to move
    • Isokinetic dynamometry
  21. Isokinetic Dynamometry
    • Seen with pts with UMN syndrome (i.e. stroke) Demonstrate decreased torque development with increased problems at higher speeds
    • Decreased limb excursion
    • Extended time to peak torque development
    • Extended time peak torque held
    • Increased time intervals between reciprocal contractions
    • Changes on "supposedly normal" extremities
  22. Clinical Issues with Strength Testing Patients with PNS, LMN Lesions
    • With myopathies: see proximal weakness of extremities 
    • With neuropathies: see distal weakness of extremities 
    • Some conditions produce decremental strength losses (i.e. myasthenia gravis)
  23. Examine for Fatigue
    • Fatigue = failure to generate the required or expected force during sustained or repetitive contractions 
    • Fatigue is protective (guards against overwork and injury) and task-dependent
  24. Sources of Fatigue
    • CNS/central fatigue: seen in MS, ALS, and chronic fatigue syndrome
    • Neural/myoneural junction: seen in MS, post polio syndrome, Guillain-Barre syndrome, myasthenia gravis
    • Muscle contractile failure: metabolic changes at level of muscle (i.e. depleted Ca2+ stores) seen in muscular dystrophy
  25. Fatigue: Determine/Document
    • Source of fatigue
    • Frequency and severity of fatigue episodes
    • Threshold for fatigue (level of exercise that cannot be sustained indefinitely) -- onset is typically gradual, not abrupt 
    • Factors that influence fatigue = health status, environmental temperature, and stress
    • Level of functional performance/amoutn of assistance
    • Episodes of exhaustion: limit of endurance beyond which no further performance is possible
    • Overwork weakness or injury
  26. Overwork Weakness or Injury
    • Prolonged decrease in absolute strength and endurance due to excessive activity of partially denervated muscle
    • Common in postpolio syndrome and Duchenne's muscular dystrophy
  27. Fatigue: Tests and Measures
    • Modified fatigue impact scale (MFIS): subjective scale that includes three subscales assessing the impact of fatigue on physical, cognitive, and psychosocial function
    • Isokinetic dynamometry, electromyography (EMG): can observe decrrements in force production
  28. Examine Voluntary Movement Control
    • Quality (synergistic organization) of muscle activation patterns
    • Are movements appropriate and timely
    • Able to vary easily type of contraction pattern (i.e. concenctric, isometric, eccentric)
    • Are movements symmetrical
    • Adequate control of multple body segments, postural stabilization
    • Assess for presence of abnormal synergy patterns - commonly seen in UMN dysfunction
  29. Involuntary Movements: Extrapyramidal Disorders, Basal Ganglia Dysfunction
    • Tics: spasmodic contractions of specific muscles, commonly involving face, head, neck or shoulder muscles 
    • Chorea: relatively quick twitches or "dancing" movements
    • Athetosis: slow, irregular, twisting movements, occuring especially in the upper extremities
    • Tremor: continuous quivering movements; rhythmic oscillatory movment observed at rest (resting tremor)
    • Myoclonus: single, quick jerk
  30. Involuntary Movements: Cerebellar Disorders
    Intention tremor occuring when voluntary movcement is attempted
  31. Involuntary Movements: Cortical Disorders
    • Epileptic seizures
    • Tonic, clonic convulsive movements
  32. Coordination Exam: Upper Extremity Tests
    • Unilateral finger to nose
    • Rapid alternating movements (RAM)
    • Supination/pronation
    • Bilateral symmetrical movements (clapping, RAM)
    • Bilateral asymmetrical movements (alternate touch knee/shoulder)
    • Bilateral unrelated movements (knee pat/elbow ext)
  33. Coordination Exam: Lower Extremity Tests
    • Unilateral (heel to shin, foot tapping)
    • Bilateral symmetrical (foot tapping, alternate knee flex/ext)
    • Bilateral asymmetrical (alternate knee flex/ext)
    • Bilateral uneralted movements (knee flex/ext and hip add/abd)
  34. Fine Motor Coordination
    • Extremity movements concered with use of small muscle groups
    • Thumb/finger opposition (unilateral/bilateral)
    • Manual/finger dexterity: grasp and release
    • Standardized tests and measures: Jebsen-Taylor Hand Function Test, Minnesota Rate of Manipulation Test, Purdue Pegboard
  35. Dyssynergia
    Impaired ability to associate muscles together for complex movement
  36. Dysmetria
    Impaired ability to judge the distance or range of movement
  37. Dysdiadochokinesia
    Impaired ability to perform RAM
  38. Coordination Exam: Scoring
    • 0 = unable
    • 1 = severe impairment
    • 2 = moderate impairment
    • 3 = minimal impairment
    • 3 = normal performance
  39. Sensory Elements of Balance
    • Visual system (visual acuity, depth perception, visual field defects)
    • Somatosensory (proprioceptions, cutaneous sensation (touch, pressure), LE and trunk (esp feet and ankles))
    • Vestibular (balance changes in head position)
  40. Sensory Organization Test (SOT)
    Computerized moving platform

    • Examine 6 different sensory conditions -- progressing in difficulty
    • 1) Eyes open, stable surface
    • 2) Eyes closed, stable surface
    • 3) Visual conflict (sway referenced vision), stable surface
    • 4) Eyes open, unstable surface/moving platform
    • 5) Eyes closed, unstable surface/moving platform
    • 6) Visual conflict, moving platform
  41. SOT: Evaluation and Documentation
    • Record time standing posture is maintained (30 seconds) - record changes in amount and direction of postural sway 
    • 1 = min sway --> 4 = fall
    • Pts dependent on vision: unstable with 2, 3, 5, and 6
    • Pts dependent on surface/somatorsensory inputs: unstable with 4, 5, and 6
    • Pts with vestibular loss: unstable with 5 and 6
    • Pts with sensory selection problems: unstable with 3, 4, 5, and 6
  42. Clinical Test for Sensory Interaction in Balance (CTSIB)
    • Uses medium-density foam to substitute for moving platform and modified visual dome to substitute for moving visual surround
    • Tests 6 conditions, similar to SOT
  43. Modified Clinical Test of Sensory Interaction on Balance (mCTSIB)
    Tests four conditions:

    • EO/SS
    • EC/SS
    • EO/FS (foam surface)
    • EC/FS
  44. Limits of Stability (LOS)
    • Ability to move COM over the BOS during self-initiated movements
    • Can use force-plate analysis
  45. Center of Alignment
    • Location of COM within center of BOS
    • Center of pressure documented using force plate analysis
  46. Ankle Strategy
    • Ankle muscles (DF and PF) maintain balance by shifting COM forward or back using long axis of motion
    • LE is relatively fixed
  47. Hip Strategy
    Hip and lower trunk muscles maintain balance by shifting COM using hip motions
  48. Steppage Strategy
    Rapid steps taken to realign COM within BOS
  49. Static Balance Exam
    • Sitting: holding a steady position (UE supported/unsupported)
    • Standing: double limb and single limb support
    • Romberg: pt stands with feet in normal stance position, first EO then EC (used to detect posterior column (sensory) ataxia)
    • Sharpened or Tandem Romberg: pt stands in tandem heel-to-toe position (EO then EC - increases sensitivity of Romberg test)
  50. Dynamic Balance Exam
    • Functional movement tasks: standing up and sitting down, walking, turning
    • Navigation through obstacle course 
    • Dual-tasking: walks while talking, walk and carry, walk and compete cognitive task (count backwards by 3s from 100) 
    • BOS challenges: sits on swiss ball, wobble board, dyna disc, foam
  51. Timed Walking Test
    • Pt asked to walk 1st at preferred speed
    • Then at maximal speed over set distance (i.e. 10m or 50 ft)
    • Velocity, cadence (steps/minute), and stride length are calculated
  52. 6 Minute Walk Test (6MWT)
    • Examines ability to walk at self-selected speed for set time interval (also 12MWT or 2MWT)
    • Total distance walked is measured
    • Overall exercise tolerance is determined