02 - Assessment of muscle tone after stroke

Aug 26, 2023

02 - Assessment of muscle tone after stroke

This resource is from the Stroke Training and Awareness Resources (STARs) website - http://www.stroketraining.org

Copyright © Chest Heart \u0026 Stroke Scotland and The University of Edinburgh 2017 CC BY-NC-SA

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
https://creativecommons.org/licenses/…

Content

11.099 -> Morning Allan.

12.099 -> I’m Mark I am your physio.

13.549 -> Hi Mark How are you doing?

15.339 -> I’m very good.

16.339 -> I’m good.

17.339 -> Nice to see you.

18.339 -> I’m here today just to have a look at how you are moving.

20.96 -> OK I’d like to get a sense of your control

25.07 -> of your movement and we are particularly interested today in muscle tone.

28.83 -> That is, if you like the amount of tension or relaxation in your muscles and how the

34.01 -> stroke has affected you in that respect. OK.

37.2 -> Do you have any pain or injuries or anything

39.28 -> I need to know about?

40.81 -> No. Any operations or what not that might affect

43.789 -> the way you move?

45.24 -> Err... I have had tendon...

49.46 -> Transfer I think you said and a release I think?

54.48 -> I had my...

58.28 -> My err, in there, just a release the tendon to stop the tightness.

63.12 -> So you have had some surgery on this wrist and hand.

65.67 -> We will bear that in mind.

67.07 -> OK.

68.07 -> First of all I’d just like to have a wee look at you if that’s OK.

70.49 -> So just you relax.

71.56 -> I’d like just to put my hands on and help you to move if that’s all right?

75.17 -> Of course.

76.17 -> If you want me to stop at any time just let me know.

78.07 -> OK.

79.07 -> I will.

80.07 -> So just observing you at the moment you are looking good there.

81.159 -> I can see and you have shown me that in this arm there is a bit more difficulty

84.87 -> moving than in the left.

86.31 -> You elected to shake hands with your left hand.

89.59 -> So this one has been affected by the stroke to some extent.

93.439 -> Yes I lost part from the stroke in the arm.

96.77 -> OK that’s helpful.

97.77 -> Thank you.

98.77 -> So I’m just going to move around to your left side here.

103.36 -> And the reason I’m moving to the left side is that I just want to feel what the muscles

107.56 -> feel like on the side that the stroke hasn’t affected.

110.53 -> So I’m just thinking about the amount of tension in these muscles.

114.229 -> I’m just feeling how much tone is in them if you like and I can establish that by giving

120.04 -> them a squeeze.

121.149 -> So I can feel these muscles have got some activity there, but not excessive.

124.98 -> It is quite soft and I can move the leg at the hip. OK.

129.68 -> I can lift the leg up.

131.039 -> I can feel you following me when I move this leg.

134.72 -> In fact you have got good control of that leg and you can move it in space.

139.78 -> Now that tells me that on this left side in the leg you can both feel where I am putting it,

146.08 -> but you can also adjust the amount of activity in your muscles as I move it.

150.72 -> OK.

154.22 -> Alright.

156.4 -> And if I come up to your left hand here, again it feels like a very light arm.

161.66 -> You are able to move it yourself,

164.82 -> and I can put it anywhere in space and you have got control of it.

169.74 -> That means that you are adjusting the amount of tension in your muscles according to the

175.08 -> position it is in space against the force of gravity.

179.12 -> So gravity is trying to drop this arm, drop this leg through the bed.

184.9 -> Your muscles are able to counteract that and allow this to move in space nice and smoothly

189.46 -> and freely.

190.46 -> That’s good.

191.46 -> It is also telling me that in this position you are quite relaxed.

195.08 -> OK great.

196.08 -> So I’d just like to come round and just have a wee comparison on this side if I may.

202.7 -> Again, so if I come to this leg here.

206.7 -> It is allowing me to move into medial and lateral rotation at the hip.

212 -> It also feels quite low toned we would say.

215.31 -> There’s no resistance to that movement.

217.17 -> I am just going to come in under the heel here.

220.33 -> Just bend your leg up a little bit.

223.91 -> The difference here is that I’m not feeling this leg following me so much.

227.34 -> So for example if I let this leg go.

229.82 -> This leg is just tending to fall down to the bed.

233.21 -> If I feel the muscles themselves, they are softer than they are on this side.

240.36 -> So the muscles here are more relaxed if you like.

244.14 -> So there’s less tension.

246.3 -> If I look as well there is more bulk in the muscle on your left than there is on the right.

251.67 -> So the stroke has caused this muscle to get a bit smaller as well.

259.88 -> I’ll just check the range of motion here.

262.7 -> I feel you have got a lot of movement into lateral rotation at the hip.

266.71 -> A bit tight into medial rotation OK.

269.44 -> That’s quite common as the leg tends to fall out to the side especially if it’s

274.09 -> got quite low muscle tone.

277.08 -> I just want to compare with the left hip.

281.42 -> Again, just very carefully hold here.

284.84 -> Support you here.

290.34 -> So it's a bit tighter at the left hip.

293.12 -> You feel that?

294.88 -> It’s a bit tighter.

296.57 -> Should that be slacker then?

298.84 -> It shouldn’t be anything.

300.53 -> I think what it is showing that this right hip is very relaxed.

304.6 -> OK, that’s fine.

308.24 -> So if I come up to your arm now.

310.16 -> Bearing in mind what you were able to do with the left.

311.99 -> I’m going to lift this very carefully so we don’t cause any pain.

316.6 -> Again, this one doesn’t quite follow in the same way.

321.66 -> It is tending to feel quite heavy to move.

328.54 -> Tell me if there is any discomfort associated with this.

331.62 -> I will.

333.52 -> OK so that’s good range of movement at the shoulder here.

337.78 -> Now are you able to lift this arm in the air?

342.22 -> OK, that’s excellent.

344.72 -> So what we are seeing here is you are having to generate a lot of activity on the left

348.76 -> side in order to activate the right.

350.86 -> And we can see that we are getting quite a bit of extension activity in the right leg as well.

355.4 -> Excellent, have a wee rest.

357.54 -> So in this position your arm is tending to come into abduction and medial rotation as it flexes.

363.8 -> So the elbow tends to come away from the side as opposed to up in this position.

370.56 -> Before I take the shoulder beyond ninety degrees I just want to check whether we have got a

376 -> bit of mobility at the scapula here.

377.8 -> So if you just relax for me a wee minute.

379.97 -> Just let everything go.

381.1 -> Just see what the shoulder is like here.

383.71 -> Does that feel OK?

385.02 -> Yes.

386.02 -> When I am moving the shoulder here I am thinking of keeping the shoulder blade or the scapula

390.26 -> and the humerus well aligned.

393.31 -> So we are not causing any potential trauma to the gleno-humeral joint, that’s the shoulder joint.

400.54 -> Does that feel OK? Yes.

404.2 -> And then as we come up into flexion.

406.74 -> I just want to make sure that the scapula is following here so I am just feeling the

410.36 -> spine of the scapula.

412.55 -> That’s perfect thank you.

413.92 -> Down to the inferior angle and just make sure the scapula comes up as well.

420.34 -> Any pain there? No.

423.12 -> Excellent.

424.16 -> And relax again.

426.52 -> Have a wee look at your hand.

427.71 -> Have a wee stretch.

428.82 -> Reach up towards the ceiling.

430.37 -> There you go.

431.93 -> So we can get up to ninety degrees combined shoulder flexion with protraction and rotation of the scapula.

437.46 -> Then we can just bring the arm gently back.

442.52 -> So maintaining the alignment of the shoulder girdle as we bring it up into flexion.

448.88 -> Just have a look at your hand again there.

450.63 -> Perfect.

451.63 -> A wee bit of restricted range of motion there, but not too bad.

457.7 -> As we look at the muscles, we can see here that there is increased flexor activity going on.

463.86 -> I am just checking here at pectoralis major and minor.

468.24 -> There is a little bit of increased activity there but you see most of the increased activity

472.82 -> is in biceps and in brachioradialis here at the elbow.

477.7 -> We can see there is a resistance, to passive stretch.

482.389 -> So these flexors are active when it comes to relaxing into extension,

489.3 -> we can see there is a resistance to that.

491.04 -> You can see the muscle activity here...

492.98 -> which is different to this side here where there is more relaxation.

497.7 -> Now this is typical of an upper motor neurone spasticity where we have got a “clasped knife”

504.2 -> phenomenon where it feels tighter in the middle range of the motion then as

509.33 -> we go towards the end of range that releases.

513.7 -> “Clasped knife “phenomenon is what it is called.

518.96 -> There is no rigidity or tremor associated with this.

524 -> This is a classical picture of spasticity.

529.26 -> We can confirm this just by palpating the muscles and we can feel that there is much

534.059 -> more activity in these flexors than really there ought to be in this position.

541.18 -> Because it should be able to relax down just on to the bed.

544.94 -> If I come, and bearing in mind.

547.589 -> You OK there?

548.589 -> Yes. Bearing in mind the surgery as well.

550.17 -> I’ll be careful here.

553.04 -> There a lot of pain that I get in this arm.

556.74 -> OK.

558.14 -> How is the sensation on this side when I am touching you?

561.28 -> A dull, dull feel.

563.6 -> You can feel it is duller than this side? Yes.

566.3 -> Is there any pain or burning or tingling or pins and needles?

570.78 -> No.

571.79 -> Again we can see we have got a restriction in extension at the wrist here.

576.12 -> I can just get beyond neutral.

579.1 -> I don’t want to overcome this because we have obviously got some surgical involvement there.

586.2 -> We also lack a bit of supination.

589.43 -> Totally.

590.43 -> And again that’s the sort of position it would have been in and we have released in to this.

597.88 -> Again we can feel that there’s a little bit of a tension to extending the fingers.

604.14 -> But again, in relation to the surgery, I’m not going to push this too far.

608.4 -> But obviously we would be looking to get the hand into a more extended position.

614.14 -> If I...

615.88 -> Because this is what’s called “velocity dependent”.

619.08 -> You find that if I stretch slowly then the muscle releases quite easily.

625.32 -> If I stretch quickly, we can see that the muscle “catches”.

632.68 -> So we have a “catch” if you like in mid-range here.

635.94 -> And as we keep extending it, so the muscle generates more activity.

641.86 -> So in terms of controlling this muscle tone or releasing it, slow is best.

647.879 -> So a nice slow stretch.

649.8 -> We can lay our hand on the muscle as well which actually causes the muscle to relax

654.179 -> locally in order to then extend.

657.329 -> Then we can extend the wrist and fingers distally as well.

662.44 -> So we can block the wrist with the lateral border of the hand.

667.369 -> Steady the thumb, steady the fingers and just gradually put extension on the wrist.

670.91 -> But I wouldn’t.

673.16 -> Had you not had the surgery we could have worked this a little bit further.

676.36 -> The alternative is to flex at the elbow.

680.319 -> Put the extension on the wrist and fingers and then extend the elbow.

684.42 -> There’s a couple of ways to do it.

687.76 -> So whenever people are working with you Allan, it’s probably a good idea to discuss as

692.05 -> a team the way we manage this.

694.34 -> Ah. OK.

695.26 -> So the long wrist flexors in the forearm.

699.7 -> The flexors in the fingers.

701.28 -> The elbow, the shoulder are all the areas which can tighten up we want to try and control.

709.26 -> Let’s just relax this arm down on to the bed again.

712.72 -> That’s good.

714.319 -> OK.

Source: https://www.youtube.com/watch?v=KnEaBGNjH7w