DISORDERS OF THE

TONE
-Hitesh Rohit (3rd year B.P.T.)
INTRODUCTION:-

• Tone:-
• Tone is defined as the resistance of muscle to passive elongation or stretch.
• It represents a state of slight residual contraction in normally innervated,
resting muscle, or steady-state contraction.
• Tone is influenced by a number of factors, including
• (1) physical inertia,
• (2) intrinsic mechanical-elastic stiffness of muscle and connective
tissues,and
• (3) spinal reflex muscle contraction (tonic stretch reflexes).
• Tonal abnormalities are categorized as hypertonia (increased above normal
resting levels),
• hypotonia (decreased below normal resting levels),
• Or dystonia(impaired or disordered tonicity).
HYPERTONIA :-
• 1) spasticity :-
• Spasticity is a motor disorder characterized by a velocity dependent
increase in muscle tone with increased resistance to stretch;
• The larger and quicker the stretch, the stronger the resistance of the
spastic muscle.
• During rapid movement, initial high resistance (spastic catch May be
followed by a sudden inhibition or letting go of the limb (relaxation)
in response to a stretch stimulus,termed “clasp-knife response”.
• Chronic spasticity is associated with contracture, abnormal posturing
and deformity, functional limitations, and disability.

• Spasticity arises from injury to descending motor pathways from the

cortex (pyramidal tracts) or brainstem (medial and lateral
vestibulospinal tracts, dorsal reticulospinal tract) producing
disinhibition of spinal reflexes with hyperactive tonic stretch reflexes
or a failure of reciprocal inhibition.(hyperreflexia)
• The result is hyperexcitability of the alpha motor neuron pool. It
occurs as part of upper motor neuron (UMN) syndrome.

• Increased tonic contraction of muscles is seen at rest, evidenced by

abnormal typical resting postures.When movementsts are attempted,
the result is action-induced normal movement patterns (stereotyped
movement synergies or spastic dystonia).
• Additional signs include associated reactions, defined as involuntary
movements resulting from activity occurring in other parts of the body
(e.g., sneezing, yawning, squeezing the hand).
• Clonus is characterized by cyclical, spasmodic alternation of muscular
contraction and relaxation in response to sustained stretch of a spastic
muscle.
• Clonus is common in the plantarflexors, but may also occur in other
areas of the body such as the jaw or wrist.
• 2) Rigidity:-

• Rigidity is a hypertonic state characterized by constant resistance

throughout ROM that is independent of the velocity of movement
(lead-pipe rigidity).
• It is associated with lesions of the basal ganglia system
(extrapyramidal syndromes) and is seen in Parkinson’s disease.
• Rigidity is the result of excessive supraspinal drive (upper motor
neuron facilitation) acting on alpha motor neurons;
• spinal reflex mechanisms are typically normal.
• Patients demonstrate stiffness, inflexibility, and significant functional
limitation.
• Cogwheel rigidity refers to a hypertonic state with superimposed
ratchet-like jerkiness and is commonly seen in upper extremity
movements (e.g., wrist or elbow flexion and extension) in patients with
Parkinson’s disease.
• It may represent the presence of tremor superimposed on rigidity.
• Tremor, bradykinesia, and loss of postural stability are also associated
motor deficits in patients with Parkinson’s disease.
• 3) Decorticate and Decerebrate Rigidity :-
• Severe brain injury can result in coma with decorticate or decerebrate
rigidity.
• Decorticate rigidity refers to sustained contraction and posturing of
the upper limbs in flexion and the lower limbs in extension.
• The elbows,wrists, and fingers are held in flexion with shoulders
adducted tightly to the sides while the legs are held in extension,
internal rotation, and plantarflexion.
• Decerebrate rigidity (abnormal extensor response) refers to sustained
contraction and posturing of the trunk and limbs in a position of full
extension.
• The elbows are extended with shoulders adducted, forearms pronated,and
wrist and fingers flexed. The legs are held in stiff extension with
plantarflexion.
• Decorticate rigidity is indicative of a corticospinal tract lesion at the level
of diencephalon (above the superior colliculus), whereas decerebrate
rigidity indicates a corticospinal lesion in the brainstem between the
superior colliculus and vestibular nucleus.
• Opisthotonus is characterized by strong and sustained contraction of
the extensor muscles of the neck and trunk, resulting in a rigid,
hyperextended posture.

• Extensor muscles of the proximal limbs may also be involved. These

postures are considered exaggerated and severe forms of spasticity.
• 4)Dystonia :-

• Dystonia is a prolonged involuntary movement disorder characterized

by twisting or writhing repetitive movements and increased muscular
tone.
• Dystonic posturing refers to sustained abnormal postures caused by
cocontraction of muscles that may last for several minutes, for hours,
or permanently.
• Dystonia results from a CNS lesion commonly in the basal ganglia and
can be inherited (primary idiopathic dystonia), associated with
neurodegenerative disorders (Wilson’s disease, Parkinson’s disease on
excessive l-dopa therapy), or metabolic disorders (amino acid or lipid
disorders).
• Dystonia can affect only one part of the body (focal dystonia) as seen
in spasmodic torticollis (wry neck) or isolated writer’s cramp.

• Segmental dystonia affects two or more adjacent areas(e.g., torticollis

and dystonic posturing of the arm)
HYPOTONIA:-
• Hypotonia and flaccidity are the terms used to define decreased or
absent muscular tone.
• Resistance to passive movement is diminished, stretch reflexes are
dampened or absent, and limbs are easily moved (floppy).
• Hyperextensibility of joints is common.
• Lower motor neuron(LMN) syndrome results from lesions that affect
the anterior horn cell and peripheral nerve (e.g., peripheral neuropathy,
cauda equina lesion, radiculopathy).
• It produces symptoms of decreased or absent tone, decreased or
absent reflexes, paresis, muscle fasciculations and fibrillations with
denervation, and neurogenic atrophy.
• Mild decreases in tone along with asthenia (weakness)can also be seen
in cerebellar lesions.
• Acute UMN lesions(e.g., hemiplegia, tetraplegia, paraplegia) can
produce temporary hypotonia, termed spinal shock or cerebral shock
depending on the location of the lesion.
• The duration of CNS depression and hypotonia that occurs with shock
is highly variable, lasting days or weeks.

• It is typically followed by the development of spasticity an classic

UMN signs.
Examination of tone :-
• An examination of tone consists of :-
• (1) initial observation of resting posture and palpation,
• (2) passive motion testing, and
• (3) active motion testing.
• Variability of tone is common. For example, patients with spasticity
can vary in their presentation from morning to afternoon, day to day,
or even hour to hour depending on a number of factors, including
• (1) volitional effort and movement,
• (2) anxiety and pain,
• (3) Position and interaction of tonic reflexes,
• (4) medications,
• (5) general health,
• (6) ambient temperature, and
• (7) state of CNS arousal or alertness

• In addition, urinary bladder status(full or empty), fever and infection,

and metabolic and/or electrolyte imbalance can also influence tone.
• 1)Initial observation:-

• Initial observation of the patient can reveal abnormal posturing of the

limbs or body. Careful inspection should be made regarding the position
of the limbs,trunk, and head.
• With spasticity, posturing in fixed,antigravity positions is common;
• for example, a spastic upper extremity is typically held fixed against
the body with the shoulder adducted, elbow flexed, forearm supinated
with wrist/fingers flexed.
• In the supine position, the lower extremities are typically held in
extension, adduction with plantarflexion, and inversion.
• Limbs that appear floppy and lifeless(e.g., a lower extremity [LE] rolled
out to the side in external rotation) may indicate hypotonicity.
• Palpation of the muscle belly may yield additional information about the
resting state of muscle.
• Hypotonic muscles will feel soft and flabby, whereas hypertonic muscles
will feel taut and harder than normal.
• 2)Passive motion testing :-

• Passive motion testing reveals information about the responsiveness of muscles to

stretch.
• Because these responses should be examined in the absence of voluntary control,
the patient is instructed to relax, letting the therapist support and move the limb.
• During a passive motion test, the therapist should maintain firm and constant
manual contact, moving the limb in all motions.
• When tone is normal, the limb moves easily and the therapist is able to alter
direction and speed without feeling abnormal resistance.
• The limb is responsive and feels light. Hypertonic limbs generally feel
stiff and resistant to movement, whereas flaccid limbs feel heavy and
unresponsive.
• Some older adults may find it difficult to relax; their stiffness should not
be mistaken for hypertonicity.
• Varying the speed of movement is an important determinant of spasticity.
In a spastic limb, resistance may be near normal when the limb is moved
at a slow velocity. Faster movements intensify the resistance to passive
motion.
• It is also important to remember that muscle stiffness with spasticity
will offer the greatest resistance during the first stretch and that with
each successive stretch resistance can be reduced by as much as 20%
to 60%.
• In the patient with rigidity, resistance is constant and not responsive to
increasing the velocity of passive motion.
• Clonus, a phasic stretch response, is examined using a quick stretch
stimulus that is then maintained. For example, ankle clonus is tested
by sudden dorsiflexion of the foot and maintaining the foot in
dorsiflexion.
• The presencee of a clasp-knife response should also be noted.
• All limbs and body segments are examined, with particular attention
given to those identified as problematic in the initial observation.
• Comparisons should be made between upper and lower limbs and
right and left extremities.
• Asymmetrical tonal abnormalities are always indicative of
neurological dysfunction.
• A subjective determination of the degree of tone can be made.
• Therapists need to be familiar with the wide range of normal and abnormal
tonal responses to develop an appropriate frame of reference to grade tone.
• For documentation in the medical record, tone is typically graded on a 0 to 4+
scale:
• 0 No response (flaccidity)
• 1+ Decreased response (hypotonia)
• 2+ Normal response
• 3+ Exaggerated response (mild to moderate hypertonia)
• 4+ Sustained response (severe hypertonia)
Modified Ashworth Scale :-

The Modified Ashworth Scale (MAS) is a clinical scale

used to assess muscle spasticity that is in commonly used
in many rehabilitation facilities and spasticity clinics.
Grade Description
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 ROM when the affected part(s) is moved
in flexion or extension.

1+ Slight increase in muscle tone, manifested by a

catch, followed by minimal resistance throughout
the remainder (less than half) of the ROM.

2 More marked increase in muscle tone through

most of the ROM, but affected part(s) easily moved.

3 Considerable increase in muscle tone, passive

movement difficult.

4 Affected part(s) rigid in flexion or extension.

Special tests :-

In the lower limbs, spasticity can be examined using the pendulum test.
The patient is positioned in supine with Knees flexed over the end of a
table.
The examiner passively extends the knee fully against gravity and then
allows the leg to drop and swing like a pendulum.
A normal and hypotonic limb will swing freely for several oscillations.
• In patients with quadriceps or hamstring spasticity, the leg is resistant
to full extension and when dropped swings for only a few repetitions.
• It quickly returns to the initial dependent starting position.
• Tonic stretch reflexes can be accurately measured using
electromyography (EMG).
• Response to stretch can be documented for various velocities of
stretch and spastic co-contraction can be quantified.
• A myotonometer is a handheld computerized electronic device
developed by Leonard and co-workers that can be used to measure
muscle tone.

• It provides quantitative measurements of force and displacement of

muscle tissue and is able to detect small changes in both extremity and
postural tone
• Documentation:-

• Documentation of tone abnormalities should include a determination

of the specific body segments demonstrating:-
• abnormal tone, the type of abnormality present (e.g., spasticity,
rigidity), whether the changes are symmetrical or asymmetrical,
resting postures and associated signs (e.g., UMN syndrome), and
factors that modify (increase or diminish) tone
• It is important to remember that measurement of tone in one position
does not mean that tone will be the same in other positions or during
functional activities.

• A change in position such as sitting up or standing up can substantially

alter the requirements for postural tone.