Week 3: Exam & Tx of Coordination, Sensation, and CNs

What is the definition of coordinated movement according to the Guide to PT Practice?

Coordinated movement involves multiple joints and muscles activated at the appropriate time and with the correct amount of force for smooth, efficient, and accurate movement.

Which brain areas are primarily responsible for smooth and accurate movement?

The cerebellum and basal ganglia.

Can movement occur without sensation?

Yes, movement can occur without sensation, as seen in individuals with peripheral neuropathy.

What role does the motor cortex play in coordination?

The motor cortex integrates sensory information to coordinate voluntary movements and controls simple, single-joint movements.

Somatotopic Organization:

organized in a way that reflects the complexity of movements; more cortical area dedicated to finely controlled body parts (hands, fingers, and face)

motor cortex compromises brodmanns areas

4 and 6

Broadmans area 4

-primary motor cortex

• Directly controls simple, single-joint movements

• Integrates sensory information to coordinate precise, contralateral movements

Broadmanns area 6

-Premotor Area (PMA): Coordinates movements involving multiple joints and anticipates postural adjustments needed for complex tasks.

-Supplementary Motor Area (SMA): Facilitates the initiation and coordination of sequential movements and bilateral tasks, ensuring smooth and efficient motor execution.

What is the primary function of the corticospinal tract?

It transmits signals from the motor cortex to the spinal cord, essential for skilled, fine motor control, especially of distal limbs.

corticospinal tract role in coordination

Crucial for executing precise and coordinated movements

Other Major Descending Pathways

-Corticobulbar Tract: Controls muscles of the face and neck, contributing to coordinated facial expressions and movements

-Tectospinal Tract: Guides head movements during visual tasks, coordinating neck muscle activity

-Reticulospinal Tract: Influences muscle tone and reflexes, essential for posture and gait coordination

-Vestibulospinal Tracts: Contributes to postural control and head movements, facilitating coordinated axial and head-eye movements

- Rubrospinal Tract: Plays a minimal role if any in human motor coordination but merges with the corticospinal tract in the cervical region

What is the function of the cerebellum?

The cerebellum regulates movement, postural control, and muscle tone, acting as an error detector and movement corrector.

cerebellum receives input from the

vestibular, auditory, and visual systems, muscle spindles, GTO's, joint and skin receptors

cerebellum role in motor learning

To compare the motor plan with the sensory feedback of the actual movement to make adjustments and correct movements

What are the three functional divisions of the cerebellum?

Cerebrocerebellum, Spinocerebellum, and Vestibulocerebellum.

Cerebrocerebellum

-Controls same side of the body (right hemisphere of cerebellum controls right side)

-Involved Planning, timing, coordinating, and initiating complex voluntary movements esp. those of distal limbs

-Damage: Dysfunction of Fine motor skills of hands, limb ataxia (dysdiadochokinesia, dysmetria, action tremor)

spinocerebellum

-Regulates tone, posture and execution of movement

-Uses info about limb position and touch/pressure; corrects movements if not going as planned

-Damage/dysfunction: Gait ataxia (wide BOS, staggering, veering), truncal ataxia, orthostatic tremor

-Functional issues: difficulty with reaching and use of LEs

Vestibulocerebellum (Flocculonodular Lobe)

-Receives info from vestibular receptors and transmits info to vestibular nuclei

-Also receives info from visual brain areas

-Maintains equilibrium, balance, and posture and eye movements

What is ataxia?

Ataxia is the loss of coordinated movement, commonly associated with cerebellar dysfunction.

Gait ataxia

walking with wide BOS, high guard position, irregular stepping patterns, impaired swing phase and deviations of forward progression with poor balance

What does the term 'dysdiadochokinesia' refer to?

the inability to perform rapid alternating movements on the same limb.

What is dysmetria?

the inability to judge distance or range of movement.

What is the difference between hypometria and hypermetria?

Hypometria is underestimation of movement distance, while hypermetria is overestimation or overshooting.

What is intention tremor?

Intention tremor occurs during movement and is indicative of cerebellar dysfunction.

postural tremor

back and forth oscillatory movements of the body with standing: cerebellar

resting tremor

a tremor that is apparent when the client is at rest and diminishes with activity

What is nystagmus?

Nystagmus is rhythmic quick oscillatory movements of the eyes, often occurring when the eyes move away from midline to fix on a peripheral object.

What does the rebound phenomenon refer to?

The rebound phenomenon is the loss of the check reflex to halt forceful active movements when resistance is removed.

Dyssynergia:

movement of individual joint sequentially vs movement of limb together

movement decomposition

the breakdown of movements between multiple joints

dexterity

-skillful movement of the fingers during fine motor tasks.

-Issues with dexterity results from damage to the cerebrocerebellar

What is the function of the supplementary motor area (SMA)?

The SMA facilitates the initiation and coordination of sequential movements and bilateral tasks.

What is the role of peripheral feedback in the cerebellum?

Peripheral feedback provides the cerebellum with information about body position, rate, timing, and force of movement.

What is the role of the Basal Ganglia in movement?

-indirectly influences movement by receiving information from the cortex and returning it via the thalamus.

-Involved with Movement selection, movement initiation, & production of automatic movements

-Doesn't receive peripheral inputs

-Motor Learning: involved in procedural learning & habit formation

Issues of movement associated with the BG

-Poverty or slowness of movement: PD

-Involuntary Extraneous movements: HD

-Alterations in posture and/or muscle tone: PD

What are common disorders associated with the Basal Ganglia?

Parkinson's Disease (PD) and Huntington's Chorea (HD).

What is Bradykinesia?

the slowness of movement, often seen in Parkinson's Disease.

Define Akinesia.

the inability to initiate movement, typically observed in later stages of Parkinson's Disease.

What is Dystonia?

sustained involuntary contractions of agonist and antagonist muscles, resulting in abnormal posture.

What type of tremor is commonly associated with Parkinson's Disease?

Resting tremors, specifically a pill-rolling tremor involving the thumb and index finger.

What is Athetosis?

Athetosis is characterized by slow writhing and twisting movements, often seen in distal upper extremities.

What is Chorea?

involuntary rapid irregular jerky movements affecting multiple joints, commonly associated with Huntington's Disease.

What is Hemiballismus?

large amplitude, sudden, and violent movements of the arms or legs on one side of the body, resulting from a lesion of the contralateral subthalamic nucleus.

What is the Dorsal Column/Medial Lemniscal Pathway's role in coordination?

It provides proprioception, kinesthesia, and localized touch, which are crucial for coordinated movement.

Damage to the DCML we may see

-dysmetria, visual dependence for foot placement

-Patients Compensate with vision

What age-related changes affect coordination?

Decreased strength (sarcopenia), slowed reaction time, decreased range of motion, postural changes, and impaired balance.

Purposes of coordination examination: Used to determine

-Synergistic action of muscles

-Safety risk. factor for falls

-Level of skill, efficiency of movement

-Initiation control, termination of movement

-Effect on ADLs

-Timing, sequencing, accuracy of movement

-Effect of therapy or medication on motor functions

What are the five aspects of coordination?

Accuracy, speed, smoothness, reciprocity of movement, and interlimb coordination.

Examination of Coordination steps

-Position patient appropriately

-Explain test/ ask for consent and include what to expect

-Instruct patient in test via demonstration

-Have them perform on less/ noninvolved side first for baseline

-Remember to exclude vision and change speed as appropriate

-Document findings of BOTH sides

what is a PT Observing with a Movement Analysis of coordination

-Is there an observed tremor at rest or with movement?

-Are movements direct, precise, and easily reversed?

-Do movements occur within a reasonable or normal amount of time?

-Does increased speed of performance affect quality of motor activity (speed-accuracy trade-off)?

-Can continuous and appropriate motor adjustments be made if speed and direction are changed?

-Can a position or posture of the body or specific extremity be maintained without swaying, oscillations, or extraneous movements?

-Are placing movements of both UEs and LEs accurate?

-Does occluding vision alter the quality of motor activity?

-Is there greater involvement proximally or distally?

-Is there greater involvement on one side of the body versus the other?

-Does the patient fatigue rapidly?

-Is there a consistency of motor response over time?

What is the Finger-to-Nose test?

The patient brings the tip of their index finger to their nose while the shoulder is abducted to 90° and the elbow extended.

Describe the Finger-to-Therapist's Finger test.

The patient touches the therapist's index finger, which can be moved to test the ability to change distance, direction, and force of movement.

Finger-to-finger

Both shoulders are abducted to 90° with the elbows extended. The patient is asked to bring both hands toward the midline and approximate the index fingers from opposing hands.

alternate nose to finger

The patient alternately touches the tip of their nose and the tip of the therapist's finger with the index finger.

The position of the therapist's finger may be altered during testing to observe the ability to change distance, direction, and force of movement.

finger opposition

he patient touches the tip of the thumb to the tip of each finger in sequence. Speed may be gradually increased.

Mass grasp test

An alternation is made between opening and closing the fist (from finger flexion to full extension). Speed may be

gradually increased.

pronation/supination

With elbows flexed to 90° and held close to the body, the patient alternately turns the palms up and down. This test

also may be performed with shoulders flexed to 90° and elbows extended. Speed may be gradually increased. The

ability to reverse movements between opposing muscle groups can be examined at many joints. Examples include

active alternation between flexion and extension of the knee, ankle, elbow, or fingers.

What does the Rebound test assess?

It assesses the check reflex by observing the contraction of the opposing muscle group after resistance is suddenly released.

What is the purpose of the Tapping test?

To evaluate the ability to rapidly alternate movements, such as tapping the hand on the knee.

Pointing and past pointing

-The patient and therapist are opposite each other, either sitting or standing. Both patient and therapist

bring shoulders to a horizontal position of 90° of flexion with elbows extended. Index fingers are

touching or the patient's finger may rest lightly on the therapist's. The patient is asked to fully flex the

shoulder (fingers will be pointing toward ceiling) and then return to the horizontal position such that

index fingers will again approximate. Both arms should be tested, either separately or simultaneously.

-A normal response consists of an accurate return to the starting position.

-In an abnormal response,

there is typically a "past pointing," or movement beyond the target. Several variations to this test

include movements in other directions such as toward 90° of shoulder abduction or toward 0° of

shoulder flexion (finger will point toward floor). After each movement, the patient is asked to return to the initial horizontal starting position.

Alternate heel-to-knee; heel-to-toe

From a supine position, the patient is asked to touch the knee and big toe alternately with the heel of the

opposite extremity

Toe-to-examiner's finger

From a supine position, the patient is instructed to touch the great toe to the examiner's finger. The position of the finger may be altered during testing to observe the ability to change distance, direction, and force of movement (to stabilize lower back, the opposite hip and knee may be flexed)

heel-on-shin

From a supine position, the heel of one foot is slid up and down the shin of the opposite LE.

Drawing a circle

The patient draws an imaginary circle in the air with either UE or LE (a table or the floor also may be used). This also may be done using a figure-eight pattern. This test may be performed in the supine position for the LE

Fixation or position holding

-UE: The patient holds arms horizontally in front (sitting or standing).

-LE: The patient is asked to hold the knee in an extended position (sitting).

What is the significance of occluding vision during coordination tests?

Occluding vision can help determine if visual input is necessary for quality of motor activity.

What is the impact of aging on dexterity and agility?

Dexterity and agility decrease with age, contributing to a higher risk of falls.

What is the role of proprioception in coordination?

Proprioception is essential for joint position sense and awareness of movement, which are crucial for coordinated actions.

What is the effect of decreased range of motion in older adults?

Decreased range of motion can lead to stiff joints and impaired coordination.

What is the relationship between speed and accuracy in older adults?

Older adults may slow down their movements to improve accuracy, reflecting a speed-accuracy trade-off.

Which tests are suggested for assessing dysdiadochokinesia?

-Finger-to-nose

-Alternate nose-to-finger

-Pronation/supination

-Knee flexion/extension

-Walking, alter speed or direction

Which tests can assess dysmetria?

Pointing and past pointing, drawing a circle, and heel on shin.

What is dyssynergia?

A lack of coordination of muscle movements.

What tests can be used to assess dyssynergia?

Finger-to-nose, alternate heel-to-knee, and toe-to-examiner's finger.

How can hypotonia be assessed?

Through passive movements and deep tendon reflexes.

What tests can assess intention tremor

-Observation during functional activities (tremor will typically increase as target is approached or movement speed is increased)

-Alternate nose-to-finger

-Finger-to-finger

-Finger-to-therapist's finger

-Toe-to-examiner's finger

What tests can assess resting tremor

-Observation of patient at rest; limb or jaw movements

-Observation during functional activities (tremor will diminish significantly or disappear with movement)

Asthenia

lack of strength, of energy and a general feeling of tiredness

What tests can assess asthenia

-Fixation or position holding (upper and lower extremity)

-Application of manual resistance to determine ability to hold

What tests can assess bradykinesia?

Walking while observing arm swing and trunk motions, and timed tests of functional activities.

What are disturbances of posture?

Impairments in the ability to maintain a stable position.

Which test assesses disturbances of gait?

Walking along a straight line, sideways, backward, and altering speed and direction.

Standardized Measures for Coordination

-Scale for the Assessment and Rating of Ataxia SARA

-9-Hole Peg Test

What is the Scale for the Assessment and Rating of Ataxia (SARA)?

A standardized measure designed to assess ataxia symptoms, scoring from 0-40 with higher scores=more ataxia

SARA measures

§ Gait

§ Stance

§ Sitting

§ Speech Disturbance

§ Finger Chase

§ Nose-Finger Test

§ Fast Alternating Hand Movements

§ Heel-Shin Slide

What is the purpose of the 9-Hole Peg Test?

To provide a timed measure of dexterity, particularly for individuals with MS and stroke.

instructions for 9-hole peg test

§ Should be conducted with the dominant arm first.

§ Timing should be performed with a stopwatch and recorded in seconds.

§ The stopwatch is started when the patient touches the first peg.

§ The stopwatch is stopped when the patient places the last peg in the container.

What does the Jebsen-Taylor Hand Function Test assess?

It evaluates hand function through tasks like writing, card turning, and simulated eating.

What does the Minnesota Manual Dexterity Test measure?

It measures dexterity through placing and turning operations using a board with wells and disks.

Perdue Pegboard Test

•Measures fine coordination with the use of small pins, washers, and collars

What is the purpose of the O'Connor Tweezer Test?

To assess eye-hand coordination and fine motor dexterity using tweezers.

Finger Dexterity Test

-used to test finger dexterity

-seated position

-place 3 pins in each hole as fast as possible

Handy Tool Dexterity Test

Utilizes ordinary tools to examine coordinated movement of arm/hand/fingers during a functional task

Roeder Manipulative Aptitude Test

Examines arm/hand/finger coordination as well as eye-hand coordination using washer-nut assemblies and rows of sockets for installing nuts

What should be documented when assessing coordination?

-Are movements direct, precise & easily reversed?

-Performed in a reasonable amount of time?

-Does speed affect performance?

-Can motor adjustments be made?

-Does vision occlusion alter performance?

-Greater involvement distally or proximally?

What are the symptoms of cerebellum dysfunction?

-Ataxia

-Dysmetria

-Dysdiadochokinesia

-Tremor (intention & postural)

-Dexterity

What are the symptoms of basal ganglia dysfunction?

-Akinesia

-Bradykinesia

-Dystonia

-Rigidity

-Tremor (resting)

-Athetosis, choreiform movement, hemiballismus

What is Spinocerebellar Ataxia?

A group of 40 types of inherited degenerative disorders that impact the cerebellum.

What is Friedreich's Ataxia?

An inherited disorder impacting the spinal cord, cerebellum, and peripheral nerves.

What is sporadic ataxia?

A group of non-genetic diseases resulting in ataxia and dysarthria, sometimes a precursor to Multiple Systems Atrophy.