Spasticity Comprehensive Test Prep Actual Questions And Correct Answers.

UML vs LML - correct answer UML • Weakness • mild atrophy • inc DTR's • Pathological reflexes: snout reflex, Babinski, Hoffman reflex • spasticity LML • Weakness • severe atrophy • dec DTR's Babinski reflex - correct answer - apply stimulus to lateral aspect of foot and across metatarsal heads - normally, response is absent, great toe and small toes flex - positive Babinski response - great toe will extend and small toes will fan out - positive Babinski is seen in young kids, but goes away later Hoffman reflex - correct answer - flicking of terminal joint of middle finger - postive Hoffman - flexion and adduction of the thumb, other fingers may also flex - normally, should see no change in the fingers or thumb - essentially, the Babinski for the upper extremity spasticity - correct answer • A motor disorder characterized by a velocity dependent increase in resistance to muscle stretch (hypertonia) and an increase in tendon reflexes (hyperreflexia) • both hypertonia and hyperreflexia must be present for classic definition of spasticity • there are times when you may see just hyperreflexia and not hypertonia • spasticity can be a problem, interfere with voluntary movement (if they have it) • SCI = no voluntary movement in LE, use extensor spasms/spasticity to transfer hypotonia - correct answer • flaccidity • muscle tone is assessed by resistance to stretch, but this is difficult when assessing hypotonia • in a normal person, no resistance to PROM, so how can we determine hypotonia? • often seen with kids - floppy baby, not enough muscle tone for baby to pick up its head - facial expression, jaw is dropped, muscles look like they are not functioning properly - shoulder and scapula: winging of scapula, slouched over hypertonia - correct answer - spasticity - rigidity - easily assessed by resistance to stretch muscle spindle - correct answer • all normal muscles have muscle spindles, some have more than others • muscle spindles are sensory organs that can tell how stretched the muscle is and how quickly its being stretched; because of the way they sit in the muscle, they are also stretched with muscle • muscle spindles are part of proprioception • within muscle spindle, there are bag fibers and chain fibers - bag fibers have dilated center portion; largely responsible for the ability to pick up the velocity/rate of stretch - chain fibers are straight; used to determine how far muscle is stretched, muscle length sensory and motor neurons and muscle spindles - correct answer • two sensory fibers that come off - Ia fiber is large diameter fiber that enters dorsal area of spinal cord and picks up rate of stretch - II fibers are smaller diameter and enter the same way and pick up how far muscle is stretched • muscle spindles also have motor fibers coming from ventral portion of spinal cord, these are gamma motor neuron fibers - these fibers innervate the end portion of muscle spindle fiber, where there are some contractile elements - contraction of fibers within the muscle spindle on either end makes the fibers more taught/stiff • gamma motor neurons are active when alpha motor neurons are active causing muscle is shortening, this keep spindles sensitive to muscle stretch/length (alpha-gamma coactivation) DTR pathway - correct answer • 1a fiber - comes from spindle, enters spinal cord, cell body in dorsal root ganglion like other sensory neurons - enters and impacts the alpha motor neuron sitting in ventral horn, monosynaptic connection - alpha motor neuron goes to muscle that the fiber came from (agonist m.) - powerful synapse (possibly most powerful synapse in body in causing EPSP, can get EPSP from just one synapse) that causes a contraction, basis of DTR • DTR = stretching muscle, sending impulse to spinal cord through 1a fibers and monosynaptic connection leads to alpha motor neuron - also inhibits antagonist to movement, because 1a fiber also synapses on and excites interneuron in spinal cord that is inhibitory (releases inhibitory neurotransmitter) to antagonist muscle • also some pathways from interneuron that will go across the spinal cord and activate the other side as well descending input - correct answer • pathways coming down from brainstem and cortex have influence on interneurons and motor neurons - they can change how this reflex behaves, based on descending input • some of the corticospinal pathways (and other supraspinal pathways) have presynaptic inhibition on 1a monosynaptic pathway - this dampens the reflex normally • when you have a stroke, you eliminate input of some of these pathways, so there is no presynaptic inhibition - this reflex arc is now more pronounced, may be part of the basis for spasticity after UMN injury - correct answer • α motor neuron in overactive - become overactive because of removal of presynaptic inhibition and also because of interneuronal reorganization that occurs in the spinal cord after injury • over-activity develops over time - for stroke, 2-3 days afterwards you can see increased reflexes because removal of pathways is sudden - with SCI, you may not see spasticity until weeks or months later as reorganization occurs DTR's - correct answer • Biceps (C5,6 - primarily C5) • Triceps (C6,7,8 - primarily C7) • Brachioradialis (C5,6 - primarily C6) • Pectorals (C5,T1 - primarily T1) • Hams (L5,S1 - primarily L5) • Quads (L2,3,4 - primarily L3) • Achilles (S1,2 - primarily S1) grading DTRs - correct answer 4 Very brisk 3 Brisk but normal 2 Normal 1 Minimal 0 absent - may be just a number or a number with a "+", the "+" doesn't mean anything different - spasticity => increased reflex - DTRs can help us locate lesion site, look at where reflexes are normal and where they are hyper-responsive - with CVA, whole side will have increased reflexes, not just extremity supplied by that portion of brain spasticity vs rigidity - correct answer • both have resistanct ot sretch • spacticity - velocity dependent resistance to stretch: the quicker you stretch it, the more resistance you feel (because you have activated the muscle spindles more with quick stretch) - tends to be on only one side of the joint • rigidity - not velocity dependent - on both sides of the joint Ashworth scale - correct answer • this scale is pretty subjective, but helpful for us to document that intervention is decreasing tone/spasticity 0 =No increase in muscle tone 1 =Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved into flexion or extension 1+ =slight resistance f/b min resist <1/2 of ROM 2 =More marked increase in muscle tone through most of the range of motion, but affected part(s) easily moved 3 =Considerable increase in muscle tone, passive movement difficult 4 =Affected part(s) rigid in flexion or extension other spasticity scales - correct answer • Tardieu - original scale is very complicated (ROM at 3 different velocities) - modified Tardieu: stretch out muscle as quickly as you can and document the angle at which you first feel resistance is the number you record (document increase/decrease in tone by change in angle) • Spasm Scales (Penn, Snow) - for spasm (which is involuntary), categorize number of spasms per hour or per day • Spinal cord Assessment Tool for Spastic reflexes (SCATS) - looks at clonus (oscillating motion with increased reflexes) and spasms - very complex measure medications for spasticity - correct answer • Baclofen - most commonly used medication for treating spasticity - problem is that it is oral and systemic, basically weakness all muscles, not just the spastic muscles - we may work with patient after dr. increases dose, to determine if pt is able to function well at this level • Zanaflex - muscle relaxant, helps with spasticity • Dantrolene Sodium - systemic, weakness all muscles • Gabapentin (neurontin) - anti-seizure drug, off-lab