The Role of the SLP

Muscle Tone and the SLP:

Definitions, Neurophysiology,  Oral-Motor Assessment
Assessment, and Interventions  Strength
 Endurance
H th M
Heather M. Clark,
Cl k PhPh.D.,
D CCC
CCC-SLP
SLP  Range of motion
Fellow Professor
 Coordination
Department of Neurology Communication Sciences and Disorders
Mayo Clinic, Rochester MN Appalachian State University, Boone NC
 Oral-Motor Treatment
Nancy Pearl Solomon, Ph.D., CCC-SLP  Targets same areas
Research Speech-Language Pathologist
Walter Reed Army Medical Center, Washington DC
http://ganex.blogspot.com/2009/10/least-stressful-jobs-cnnmoney.html
The views expressed in this presentation are those of the authors and do not necessarily reflect the official
policy or position of the Department of the Army, the Department of Defense, or the US Government.

Outline
Why Not Muscle Tone? Part 1: Foundations
 Presumed to be important for normal and  Literature review
disordered neuromuscular function  Current concepts of muscle tone and the role of
 Abnormal muscle tone is presumed to be the muscle spindle
associated with specific neuropathologies of  Muscle tone impairments associated with
speech and swallowing neuropathology
 Assessment procedures/tools are unavailable
 Applications by other disciplines
 Interventions targeting muscle tone are often
 Assessment of muscle tone for limbs and torso
recommended to improve speech and
swallowing but lack evidence  Therapeutic interventions involving sensory and
motor techniques

Outline
Part 2: SLP Applications Muscle Tone Defined
 Assessment of orofacial muscle tone  Resistance of a resting muscle to passive
 Unique anatomical and physiological features of stretch
orofacial muscles  Influenced by tissue elasticity and resting
 Evidence of tone impairments underlying motor unit activity
dysarthria and dysphagia
 Measurement procedures
 Therapeutic interventions: preliminary results
 Sensory: icing and vibration
 Motor: strengthening exercises http://www.thespiraltree.com/userfiles/images/Spiral%20internal%20images/medpose1.jpg

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Muscle Tone Regulation Stretch Reflex
 Peripheral Reflexes  Receptor: Muscle spindle
 Stretch (muscle spindles)  Stimulus: Change in muscle length
 Descending pathways
 Indirect upper motor neuron pathways
 Basal ganglia control circuit
 Cerebellar control circuit

Prototypical Stretch Reflex

 Rapid lengthening of muscle spindle
causes discharge of Ia afferents
 Afferent: Ia  These synapse directly with α motor
neurons
 Efferent: α
 Collaterals of Ia synapse on inhibitory Ia
 Effects
interneurons that inhibit α motor neurons
 on agonist: Mono (and poly-) synaptic excitation
of the antagonist
 on antagonist: Disynaptic inhibition
 GABA
 Result: contraction

Central Regulation Central Regulation

of the Stretch Reflex of the Stretch Reflex
 Indirect upper motor  Basal Ganglia
neuron pathway Control Circuit
 Descending g neural drive  Inhibitory effect on
th motor
the t thalamus
th l
has an overall inhibitory
effect on reflexes  If damage leads to
reduced thalamic
 Removal of this influence inhibition, then
leads to hyperreflexia cortical excitation
(increased excitability of is abnormally
gamma motor neurons) heightened
Rubchinsky et al., 2003;
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC283608/figure/fig1/

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Central Regulation
of the Stretch Reflex Tone Impairments
 Cerebellar Control  Hypotonia
Circuit  Flaccid: diminished signals in reflex arc
 Thought to affect tonicity,  Cerebellar: increased inhibition from descending
such
h th
thatt damage
d leads
l d to t i di t pathway
indirect th onto
t llower motor
t neuron poolsl
hypotonia
 Hypertonia
 Most relevant in children
 Spastic: released inhibition from descending
 Mechanism not understood
indirect pathway onto gamma motor neurons
 Rigid: increased excitability of α motor neurons

http://sprojects.mmi.mcgill.ca/cns/histo/systems/cerebellum/images/cerebellum_efferents.gif
 Variable Tone

Tone Impairments in
Neurologic Disease Assessment of Muscle Tone
 Developmental  Acquired  Clinical
 Cerebral Palsy  Parkinson Disease: rigid  Passive displacement of relaxed limb
 Hypotonia: ataxic  Stroke  Modified Ashworth Scale (6-point scale)
 Hypertonic: spastic,  Cerebral: spastic
p
hyperkinetic
 Subcortical: spastic or  P iti lilimb
Position b passively
i l and
d release
l
 Down Syndrome flaccid  Observe if position is maintained
flaccid Cerebellar: hypotonia
 
 Muscle palpation
 Moebius Syndrome  MS: spastic, ataxic
 Feel for resistance to tissue deformation
 flaccid  ALS: spastic, flaccid
 Pendulum swing
 Hyperkinesias: dystonia
 Lift limb and release
 Observe free swinging of limb

Management of Tone
Assessment of Muscle Tone Impairments
 Instrumental  Pharmacologic  Surgical
 Torque motor  Muscle relaxants  Spasticity
 Resistance to rotation around a joint  (e.g., Baclofen)  Tendon lengthening
 Electromyography  Muscle paralytics  Rhizotomy
 Muscle activity: agonist-antagonist  (e.g., botulinum toxin)  Rigidity
 Myotonometer  Pallidotomy
 Resistance to deformation  Deep brain stimulation
 Myoton
 Damped oscillation to tissue perturbation

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Behavioral Interventions for Tone
 Intended to affect muscle spindle
 Stretching
 Vibration
 Tapping
 Intended to affect nerve/muscle function
 Icing
 Massage
Vibration
 Stimulates muscle spindle
 Increases tone of stimulated muscle
 Decreases tone of antagonist
g 
 Evidence
 Improves head/neck alignment (Canon et al 1987)
 Improves spasticity (Noma et al 2009)
Icing
 Decreases nerve conduction velocities
 Decreases muscle contraction speed and
extent
 Evidence
 Numerous studies in PMR literature
addressing various muscle groups
 Improved jaw opening in children with spastic
CP (dos Santos & de Oliveira, 2004)
clarkhm@appstate.edu
Passive Stretching
 Fast
 Stimulates stretch reflex
 Increases tone
 Slow
 Inhibits stretch reflex
 Decreases tone
 Evidence
 Moderate to strong evidence that stretching
does not affect spasticity in limb
(Cochrane review)
Tapping
 Stimulates muscle spindle
 Increases tone
Evidence appears to be lacking
SUMMARY
Part 1: Foundations
 Muscle tone is mediated by stretch reflex
 Stretch reflex is affected by
 Muscle spindle function
 Central nervous system regulation
 Therapeutic interventions
 Aim to alter responsiveness of muscle spindle
or other components of the stretch reflex
 Evidence for benefit in general skeletal muscles
varies
2010 ASHA Convention nancy.p.solomon@US.ARMY.MIL
 Muscle Spindle Action in
Part 2: SLP Applications Speech/Swallowing Muscles

 Assessment of orofacial muscle tone  Jaw closing muscles

 Unique anatomical and physiological features of  High density muscle spindles
orofacial muscles  Strong stretch reflex
 Evidence of tone impairments underlying  Face & lips
dysarthria and dysphagia  Low density or lack of muscle spindles
 Measurement procedures  Do not exhibit stretch reflexes
 Therapeutic interventions: preliminary results
 Sensory: icing and vibration
 Motor: strengthening exercises

Muscle Spindle Action in Assessment of

Speech/Swallowing Muscles Orofacial Muscle Tone
 Tongue & palate  Clinical
 Muscle spindle density similar to limbs  Stretch
 Do not exhibit typical stretch reflexes  Palpation
p
(Neilson et al., 1979)
 Instrumental
 Pharynx, larynx  OroSTIFF (only one
 Presence of muscle spindles varies across designed for orofacial use)
muscles
 Myotonometer
 No studies to date have demonstrated stretch
reflexes in the human larynx (Ludlow, 2005) or  Myoton
pharynx http://meded.ucsd.edu/clinicalmed/neuro_exam25.jpg

Clinical Assessment of
Muscle Tone Instrumental Tools
 Resistance to passive stretch or  Measure tissue response to perturbation
displacement  Resistance to passive stretch
 Externally applied stretch, usually across a joint  Resistance to tissue deformation/palpation
p p
 Resistance to deformation
 Palpation of relaxed muscles
 Orofacial tone assessments
 Dworkin & Culatta (1996)
 Beckman (1988)

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 OroSTIFF Myotonometer

 Measures deformation and force

 Calculates tissue compliance

(Chu, Barlow, Myotonometer (Neurogenic

Kieweg, & Lee, Technologies, Missoula, MT)
2010)

http://www.neurogenic.com

Myoton
 Parameters
 Frequency of oscillation
 Damping coefficient (www.myoton.com;
Müomeetria Estonia)
Müomeetria,
 Stiffness

 Veldi et al. (2002)

 Application for sleep apnea
 Assess tone of tongue and velum
http://www.myoton.com/proddoc/Presentation.pdf

Evidence for Tone Impairments in

Dysarthria and Dysphagia Stiffness of tongue and cheeks
Presumed (Darley, Data
 Are measures of tissue stiffness obtainable and
Aronson & Brown, 1969)  Flaccid: hypotonia
(Solomon & Clark, 2010)
repeatable from the tongue and cheeks of
 Flaccid: hypotonia neurologically normal individuals?
 Spastic: No hyperactive
 Spastic:
p spasticity
p y  Do tongue and cheek stiffness differ between
t t h reflexes
stretch fl in
i th
the
 Hypokinetic: rigidity tongue in spastic persons with LMN, UMN and no neurologic
 Ataxic: normal dysarthria (Nielson, et al 1979) lesions?
 Hyperkinetic: mixed  Hypokinetic: Increased lip  Does stiffness of the right and left sides differ in
stiffness (Hunker, Abbs, & persons with unilateral neurologic deficits?
Barlow, 1982; Chu et al., 2010)  Lower with LMN impairment
 Ataxic: none  Higher with UMN impairment
 Hyperkinetic: none
(Solomon & Clark, 2010)

clarkhm@appstate.edu 2010 ASHA Convention nancy.p.solomon@US.ARMY.MIL

Method Results: Stiffness by Group
 Participants
 9 neurologically normal adults
 13 neurologically impaired adults

Summary: Interventions for

Tongue & Cheek Stiffness Orofacial Muscle Tone
 Normal and disordered participants tolerated  Sensory
the Myoton measurement procedures well  Applied by clinician
 Tongue stiffness was generally lower in the  Target
g sensory y endings
g or afferent pathways
p y
LMN group than in the normal group of reflex loops
 Very preliminary  Motor
 Interpret with extreme caution!!
 Performed by patient
 Target efferent pathways or muscle function

Slow Stretch Quick Stretch & Tapping

 Peripheral targets • Peripheral targets
 Inhibits stretch reflex to – Intended to increase tone by
reduce tone and stimulating the stretch reflex
i
increase ROM – Would
W ld expectt greatest
t t effects
ff t
(applicable only for jaw) in jaw-closing musculature

 Central targets • Central targets

 Calming effect – Alerting effect (addresses
(addresses hyporesponsivity)
hyperresponsivity) – Stimulate proprioceptive
pathways (be aware of
interference issue)

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 Massage Vibration

 Peripheral Targets  Peripheral Targets

 Superficial and deep  Elicits tonic/tendon
cutaneous receptors vibratory reflex (TVR)
 I t d d to
Intended t ddecrease  Acts on the muscle spindle
tone and/or muscular  Increases tone of agonist
hyperfunction  Decreases tone of

 Central Targets antagonist via reciprocal

inhibition
 Speed and/or intensity  Would be expected to only
of massage determines influence jaw-closing
whether effects are muscles
calming or alerting

Vibration Cold

 Central Targets  Peripheral Targets

 Purported to have calming or  Decreases tone by
alerting effects, depending on decreasing nerve
the child conduction velocities
 Activate proprioception  May heighten sensitivity
pathways (interference effects)
of cutaneous receptors
 Additional Issues
 Central Targets
 Prolonged vibration may
cause tissue breakdown  Generally has an
 May exacerbate alerting effect
extrapyramidal symptoms

Sensory intervention on orofacial

muscle tone: Preliminary study Method
 Participants
 Submental Tissue
 16 women
 Vibration
 Neurologically normal
 Icing
 Tissue compliance
measures
 Tested on 2 days
 Before and after
 Icing (Clark & Solomon, submitted)
 Vibration

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Submental Compliance Before & Summary:
After Sensory Intervention Submental compliance
16.0
 Submental tissue compliance decreased
14.0
* (stiffness increased) after icing but not
12.0 vibration
10.0
 I
Increased d tissue
ti stiffness
tiff after
ft icing
i i could
ld
8.0 derive from
Pre-Tx
6.0
Post-Tx  Stiffening of non-muscular and muscle tissue
4.0
 Changes in blood flow
2.0
 Increased muscular activity

.0

Vibration Icing

Motor Intervention Didgeridoo playing reduces snoring

 25 adults with OSAS
 No evidence for swallowing or speech
 14 practiced ~25 min, 6
 Limited indirect evidence from obstructive days per week, 4 months
sleep apnea syndrome (OSAS) literature  11 controls
 Guimaraes et al. (2009)
 Improved
 31 adults with obstructive sleep apnea syndrome
 3 month program of oropharyngeal exercises
 Daytime sleepiness
(Epworth scale)
 Improved snoring frequency and intensity, daytime
sleepiness, sleep quality, and overall severity  Partner rating of sleep
disturbance
 Puhan et al. (2005)
 Apnoea-hypopnoea index
(Puhan, Suarez, Lo Cascio,
Zahn, Heitz, & Braendli, 2005)

SUMMARY
Case Study Part 2: SLP Applications
 42 y.o. male  Orofacial muscle tone is rarely assessed by the SLP, and
 Multiple injuries is almost never quantified
 2 mo post blast injury  Certain instruments may become available to determine
 Evaluation orofacial tissue stiffness
 Strength
g ((IOPI))
 Tone (Myoton)  Th
Therapeuticti iinterventions
t ti iintended
t d d tto normalize
li ttone may
 4 mo post be applied to the orofacial muscles, but no evidence exists
 Tongue exercises  Very new and very preliminary evidence indicates that
 40 trials
 4x/day  Tissue compliance can be assessed for the lingual, facial, and
 4 days/wk submental muscles
 5 mo post  Icing may increase submental tissue tone
 Add cheek exercise  Tongue strengthening exercise increases strength but may or may
 6 mo post not increase tone
 Discharge  Much more work needs to be done to address these issues

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 References
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