Muscle Length (AKA Range of Motion),
Muscle Strength
and Function at any Level
Liz Kelly, PT
Penn State Hershey Children’s Hospital
The Pennsylvania State University College of Medicine
Hershey, Pennsylvania
Stretching or Lengthening Muscles (AKA ROM)
• Length means strength Janet Travell
• 30 seconds is the optimal time to hold a static stretch.
This is as effective as stretching twice or three times
per day. J.B. Feland, et al
• Functional stretching should be combined with
functional strengthening to achieve optimum outcomes.
• To prevent bony deformities, early correction of
muscle imbalance Dias
• If possible give the muscle tissue strength to take
advantage of it’s new length.
Young Children
• Develop body awareness and upper limb function by
incorporating play into exercise.
• Work on postural muscles that will help them develop stability
and balance
• Later, concentrate on developing upper arms, shoulders,
wrists, and fingers that will be needed to accomplish
transfers and to propel a wheelchair.
• ROM, strengthening, and work in a pool all help to develop
and maintain basic movement as well as other functions of
daily life to promote independent living
Michael Horvat, EdD, MAT Professor of Adapted Physical Education
Play with a purpose
• Kids who don’t play can be socially and cognitively
delayed
• Play is what children do; it is how they grow and
learn. The importance of play cannot be over-stated;
it impacts all areas of development.
• Through play kids will learn motor skills, cognitive
skills and develop their social interaction skills
EARLY INFANCY
• At birth, most infants with thoracic lesions do not
have fixed contractures and can be put through full
ROM exercises without discomfort or excessive
pressure.
• To minimize the development of contractures, a few
simple and inexpensive splinting strategies can
prevent the infant’s legs from falling into external
rotation
• Some studies indicate that ROM can be maintained
with as little as 15 minutes of stretch per day.
•
M. Gram, Myelodysplasia
PREVENTION OF CONTRACTURES
• Some contractures and deformities can be prevented
• Contractures can limit the use of bracing or mobility
aides
• Contractures can complicate dressing and transfers
• Poor sitting posture can compromise sitting stability,
the function of internal organs and general mobility
Muscle Length,
Length Measurements, and
Muscle Extensibility
Know your baseline and your goal
Standing Program
• To maintain ROM in lower extremities
• Improve circulation in head, trunk and lower
extremities
• Improve bowel and bladder function
• May promote bone mineral density
• Actual weight born in a stander is quite variable.
• Studies are needed to delineate relevant factors and
identify ways to maximize weight-bearing loads while
in a stander
Diminished Bone Mineral Density
• Either osteopenia or osteoporosis, is a significant
medical problem that must be considered when
treating patients with myelomeningocele. The
measurement of bone mineral density may help
identify those patients at risk for sustaining multiple
pathologic fractures. Single photon absorptiometry to
measure BMD is readily available, inexpensive, and
has been shown to be accurate and reproducible.
Bone Mineral Density (BMD) in Myelomeningocele Lee S. Segal, MD
Orthopedic Warning Signs
• Weight bearing and muscle contractions are essential
to the growth of normal bones. The child with spina
bifida may lack some of this stimulus. The bones are
normally strong but after mobilization is lost or after
prolonged time in bed, the bones lose calcium and
become brittle and are quite prone to fractures.
• Swelling, deformity, local heat or redness, and fever
are warning signals of a fracture.
An Introduction to Spina Bifida by David G. McLone, M.D., Ph.D
Physical Activity in Children
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Improves strength and endurance
Helps build strong bones
Helps control weight
Decreases anxiety and stress
Improves self esteem
Improves BP and cholesterol levels
Prevents disease
Promotes health
Healthy People 2010
Components of an Exercise Program
Flexibility/Muscle Length
Yoga, gymnastics, dance, static stretch, Pilates
Strength/Coordination/Balance
Roller skating, ice skating, gymnastics, Pilates,
ballet/dance, martial arts, ball activities, climbing on
playground equipment, Pilates
Endurance
Dance, swimming, bike riding, walking, stair climbing,
jumping, organized games, running
Description of a Fitness Program at a
PT School
• Ten weeks
• Began with a 6 to 10 minute walk, run/walk to warmup
• Stretched in a large group led by a PT student
• Large group activity
– Relays, balance beam, jump rope, trampoline, hop
scotch, ball skills, hula hoops, step-aerobics, obstacle
courses.
Description of Program
• Older children went to the fitness center in groups of
two or three with a PT student to use the weight
machines
• Younger children stayed in the large group room to
work on similar strengthening activities
• Strengthening focused on the large muscle groups
Promoting Fitness in Children with Disabilities: Strategies for
Success. Lebanon Valley College, Lebanon, Pennsylvania
Participants’ Perceptions
• Improved attitudes toward physical activity
– All participants identified at least one component of the program
that they enjoyed and looked forward to each week.
• Improved self confidence
– One participant stated, “I found out that I’m actually stronger than I
thought I was.”
– Another participant enjoyed “being with kids who are more like me
and need a little help on things.”
Parent Perceptions
• Improved attitudes toward physical activity
– One parent reported her daughter asked to participate in a schools
sports program for the first time
• Improved self-confidence
– Many identified the program as a “non-threatening environment”
– One parent stated her daughter “has seen that she can be
successful at physical activities, as opposed to gym class, where
she feels she can’t keep up with others.”
• Improved social-skills
Prevention: Healthy People
2010
• Goal #1: Increase daily physical activity among children and
adolescents.
• Goal #2: Reduce the amount of time kids spend watching
television, video games, and using the Internet.
• Goal #3: Decrease the consumption of energy-dense, highsugar/high-fat foods like soda, ice cream, junk food, and fast
food.
• Goal #4: Increase the consumption of nutritious foods like fruits,
vegetables, whole grains, and skim milk.
• Goal #5: Create social, monetary, and policy-driven incentives.
STRENGTH
• A manual muscle test (MMT) performed by a
Physical Therapist can determine motor level
• If the child is under the age of 3 your PT can observe
which muscles are strong enough to move a joint
through it’s full ROM, partial ROM or palpate/touch
the muscle to determine activity/innervation
• Early determination of level of lesion can alert the
orthopedist to potential deformities that may need
splinting or balancing with surgery.
• Early determination allows early ROM and positioning
Determine Myelomeningocele Level
• Defined as lowest level of
normal sensation
• Motor function below that
level is absent or impaired
• Higher levels less
functional
• Problems specific to each
level
Romness
Consistent Definition of Level of Lesion
• Should be used in all studies e.g., the lowest
functioning nerve root motor level with a definition
of minimum strength, or the most distal sensory
level.
Evidence-Based Practice in Spina Bifida: Developing a Research
Agenda
Muscle Strength Assessment
• A loss in strength may erode a person’s ability:
To care for themselves
To attend school or work
To enjoy recreation
To participate in community events
THE CHALLENGE
• A manual muscle test (MMT) may not be consistent
or reproducible until the age of 5 or 6 years of age
• Often muscle classification systems are not
consistent (L4 may be L5 depending on who is
testing)
• Many facilities do not offer regular or annual tests
• Can take up to one hour for a complete test
CLASSIFICATION of
FUNCTIONAL MOTOR LEVEL
• A practical classification of spina bifida, based on the
neurological level of the lesion.
• The use of this classification is important when
planning orthopedic surgery, since different
techniques and postoperative care change according
to the functional level.
Functional Motor Levels (Dr.Luciano Dias)
Group I
Thoracic or high lumbar level lesion
No quadriceps function
Limited/household walking until early adolescence with
RGO,HKAFO
95%-99% are wheelchair users as adults, although
exceptions are seen
Thoracic 6 -12
• MUSCLE FUNCTION
• Upper trunk
• LE muscle function is absent
Thoracic 6 - 12
• POSSIBLE ORTHOPEDIC CONCERNS
Kyphoscoliosis
Contractures: hip abduction, hip external rotation, hip
flexion
Knee: Flexion and extension
Clubfeet, heel cords
Fractures
Thoracic 6 -12
• POSSIBLE ORTHOTICS NEEDED
TLSO
Night splint for body, KAF, AF
For mobility:
Para podium, RGO, HKAFO, KAFO
Thoracic T 6 - 12
• POSSIBLE MOBILITY EQUIPMENT
Wheelchair
Walker/crutches:
for exercise or household ambulation
Lumbar 1
POSSIBLE MUSCLE FUNCTION
Hip flexors (weak)
Lumbar 1
• POSSIBLE ORTHOPEDIC CONCERNS
Scoliosis
Hip/knee flexor contractures
Hip dislocation
Heelcord tight, clubfoot, fractures
Overuse of UE’s
Lumbar 1
• POSSIBLE ORTHOSES NEEDED
Abduction splint
Parapodium early
RGO, HKAFO, KAFO later
Lumbar 1
POSSIBLE MOBILITY EQUIPMENT
Wheelchair for community distances
Walker or crutches in the home
L1 – L2 Exceeds criteria for L1 but does not meet
criteria for L2
Lumbar 2
• POSSIBLE MUSCLE FUNCTION
Hip flexors 3/5 strength
Hip adductors 3/5 strength
Lumbar 2
• POSSIBLE ORTHOPEDIC CONCERNS
Scoliosis
Hip/knee flexor contractures
Hip dislocation
Heel cord tight, clubfoot
Fractures
Overuse of UE’s
Lumbar 2
• POSSIBLE ORTHOTIC NEEDS
Hips abduction splint
Parapodium early
RGO, HKAFO, KAFO later
Lumbar 2
• POSSIBLE MOBILITY EQUIPMENT
Wheelchair for community distances
Walker or crutches in the home
Lumbar 3
• POSSIBLE MUSCLE FUNCTION
Knee extensors 3/5 muscle strength
Lumbar 3
POSSIBLE ORTHOPEDIC CONCERNS
Scoliosis
Hip/knee flexor contractures
Hip dislocation
Heel cord tight, clubfoot
Fractures
Overuse of upper extremities
Lumber 3
POSSIBLE MOBILITY EQUIPMENT
Wheelchair for community
Walker or crutches in the home
Lumbar 3 (L3)
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POSSIBLE ORTHOTIC NEEDS
Abduction splint
Parapodium early
RGO, HKAFO, KAFO later
• L3 – L4 Exceeds the criteria for L3, but does not
meet the criteria for L4.
Group II
Low Lumbar level lesion
Quadriceps and medial hamstring function
No gluteus medius/maximus function
Ambulation requires AFO or crutches
79% retain community ambulation as adults
Most use wheelchairs for long-distance mobility
Significant difference in ability to walk between children with
L4 and L3 level lesions (Asher and Olson, 1983)
Medial hamstring function is needed for community ambulation
Lumbar 4 and Lumbar 5
• POSSIBLE MUSCLE FUNCTION
Lumbar 4
Medial knee flexors (hamstrings) 3/5
Ankle invertors/dorsiflexors
Lumbar 5
Hip abductors (weak)
Lateral knee flexors 3/5
Ankle evertors 3/5
Lumbar 4 and Lumbar 5
• POSSIBLE ORTHOPEDIC CONCERNS
Lumbar lordosis
Hip flexor contractures
Hip dislocation
Tight heel cords
Calcaneovalgus
Clubfoot
Fractures
Lumbar 4 and Lumbar 5
• POSSIBLE ORTHOSES NEEDED
Night splint (hip abduction)
HKAFO, KAFO, or AFO (later)
Lumber 4 (L4) and Lumbar 5 (L5)
• POSSIBLE ASSISTIVE DEVICE
Wheelchair, walker, crutches, cane for community
walking
Independent household ambulation
L4 – L5 Exceeds the criteria for L4, but does not meet
the L5 criteria.
Group III Sacral level lesion
High Sacral-no gastrocsoleus strength; walks with and without
support but uses AFO braces; has characteristic gluteus lurch
with excessive pelvic obliquity and rotation during gait
Low sacral-good gastrocnemius/soleus strength and normal
gluteus medius and maximus function;walks without the need
for AFO’s ; gait is close to normal.
Sacral 1 and Sacral 2
• POSSIBLE MUSCLE FUNCTION
S1 Hip Abductors 3/5 strength
S2 Hip extensors 3/5
Plantar flexors 3/5
Toe Flexors 3/5
Sacral 1 and Sacral 2
POSSIBLE ORTHOPEDIC CONCERNS
Watch hips closely
Calcaneovalgus
Calcaneous, tight heel cord
Toe clawing
Heel ulcers
Sacral 1 and Sacral 2
• POSSIBLE ORTHOSES NEEDED
AFO
SMO
Shoe inserts or none
Sacral 1 and Sacral 2
• POSSIBLE ASSISTIVE DEVICES
Community walking: walker
crutches
cane
Long distance alternative: bike
scooter
Independent household ambulation
Sacral 2 -3
• Normal manual muscle test (MMT)
• Bowel and bladder uncertain (too young for training)
Sacral 3 -5
POSSIBLE MUSCLE FUNCTION
All muscle activity normal
POSSIBLE ORTHOPEDIC CONCERNS
None
POSSIBLE ORTHOTICS
None or shoe inserts
POSSIBLE ASSISTIVE DEVICE
None
Good Core Strength
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Joseph H. Pilates (1880-1967)
Devised a core strengthening program (centering)
Focus on proper posture and technique
Overall muscle length and strength
Pelvic control requires the balance of back and
abdominal musculature
• Arms and legs are more efficient when core is strong