NPTE Neuro DD - SCI, CVA, TBI, MS, PD, MG, etc

TRAP for Parkinson's

T- tremors (oscillatory movements)

R- rigidity, stiffness in limbs, neck or trunk

A- akinesia, loss or impairment in power of voluntary mvmnt

P- posture and balance

HuntinGton's disease

is Genetic!

-hereditary disease that is neurodegenerative

-autosomal-dominate illness

Cerebellar Disorders: three cerebellar regions are:

Vestibulocerebellum:

-eye movements = nystagmus

-balance and equilibrium = truncal ataxia

Spinocerebellum:

-gait ataxia

-limb ataxia

Cerebrocerebllum:

- decreased coordination of finger movement

Coordination testing for cerebellar disorders

-Finger to nose

-Heel to shine

(overshoot or undershoot = dysmetria)

Signs of cerebellar damage = VANISHED

V- vertigo

A- ataxia

N- nystagmus

I- intentional tremor

S- slurred speech

H- hypotonia

E- exaggerated broad based gait (ataxia)

D- dysdiadochokinesia (unable to do rapid alternating movements

Multiple Sclerosis

What: autoimmune disease characterized by inflammation, selective demyelination and gliosis; chronic demyelination of central nervous system

Where: mainly in CNS but can affect cortical, subcortical, cerebellum, spinal cord, CN

Who: females 2:1, onset 20-40 yo, case presentation is usually very active pt with declining function, more common in caucasians

Clinical Presentation:

-visual impairments

-sensory and motor impairments

-intention tremor

-neuropathic pain

-fatigue that lasts for DAYS-WEEKS

-emotional disturbance and psychosocial problems due to unpredictable status

-Lhermittes' Sign: flexion of neck= electric shock in extremities

-Uthoff's Phenomenon: heat exposure=exaggerated symps

Dx:

-MRI with 2 lesions separated by TIME and SPACE

-CSF: elevated immunoglobins and presence of oligoclonal IgG bands and protein elevation

-Decreased nerve conduction velocity

PT Tx

-Don't let them overheat

-AM sessions due to increased fatigue with day

MS: Primary Progressive

PPMS

-Steady worsening from the start

-Steady decline W/O attacks

-No remissions (so no relapses)

MS: Relapsing-Remitting

RRMS

-Unpredictable attacks which may or may not leave permanent deficits followed by periods of remission

-May be symptom free for months or years

MS: Progressive-Relapsing

PRMS

-Steady decline since onset with superimposed attacks

MS: Secondary Progressive

SPMS

-Initially RRMS that suddenly begins to have decline without periods of remission

MS and gait

-Weakness: can cause toe drag and lead to vaulting

-Spasticity

-Balance issues: "drunken gait"

-Sensory deficits

-fatigue

Visual symptoms are the first symptom of _______________________

MS

-Optic neuritis

-Marcus Gunn- reduced pupillary constriction

-Nystagmus

-Diplopia: double vision

Myasthenia Gravis

What: Neuromuscular junction disorder caused by autoimmune medicated acetylcholine receptor damage resulting in NM transmission deficits

Who: all genders, races, ages, average age onset 20-50's

Clinical Presentation:

-asymmetrical ptosis

-diplopia

-unstable/waddle gait

-limb/cervical weakness

-facial expression changes

-dysarthria

-dysphagia

-respiratory weakness

-Weakness will improve after resting

Gullain-Barre syndrome (GBS)

B for bilaterally

AKA: Acute demyelinating polyradiculoneuropathy

What: autoimmune disease that attacks own peripheral nerves distal to proximal affecting bilaterally and ascends

LMN disorder

Who: Male>Female, any age group, usually someone that has had recent Respiratory or GI infection/virus

Clinical presentation

-Stocking glove distribution of ascending and bilateral weakness that rapidly occurs for 2-3 weeks but progressing no greater than 4 weeks (nadir)

- can progress to lung function and put pt on vents

-Diminished DTRs

Amyotrophic Lateral Sclerosis (ALS)

What: LMN and UMN disorder that causes ultimately respiratory failure and death within 3-5 years

Clinical Presentation

-Hyporeflexia and hyperreflexia

-Fasciculations

-Pseudo-bulbar affect

-respiratory weakness

-frontotemporal dementia

-cognitive impairments

-behavioral impairments

-Clinical sign- cervical extensor weakness

Level of SCI and Degree of Respiratory Function: C1 or C2

-VC 5-10% of norm

-No cough

-On ventilator

Level of SCI and Degree of Respiratory Function: Injuries below T11

- essentially normal VC and strong cough

Key Muscles for ASIA testing

C5 - elbow flexors

C6 - wrist extensors

C7- elbow extensors

C8 - finger flexors

T1 - finger abd

L2 - hip flexors

L3 - knee extensors

L4 - Ankle DF

L5 - Long toe extensors

S1 - Ankle PF

ASIA A

Complete - no sensory or motor function is preserved in sacral segments (S4-5)

ASIA B

Sensory incomplete

-Sensory but not motor fxn is preserved below NLI and includes sacral segments S4-S5

(so they have to have LT/PP of sacral segments or DAP)

ASIA C

Motor incomplete

-Motor fxn preserved in most caudal sacral segments for VAC

OR

-pt meets criteria for sensory incomplete status (S4-S5 for LT, PP or had DAP

AND pt has some sparing more than three levels below IL motor level on either side for less than half of key muscles below NLI have muscle grade > or = to 3

ASIA D

Motor Incomplete

Motor fx preserved below the neurological level muscle grade > or = to 3 in more than half key muscles

Key Sensory Points

C2 - behind the ear

C3 - supraclavicular fossa (midclavicular line)

C4 - AC joint

C5 - radial side of antecubital fossa

C6 - dorsum hand on proximal phalanx of thumb

C7 - dorsum hand on proximal phalanx of middle finger

C8 - dorsum hand on proximal phalanx of little finger

T1 - ulnar side of antecubital fossa

T2 - apex of axilla

T3 - Midclavicular line @ 3rd ICS

T4 - 4th ICS @ nipple line

T5 - 5th ICS (midway btw T4 and T5)

T6 - 6th ICS @ level of xiphisternum

T7 - 7th ICS (midway btw T6 and T10)

T8 - 8th ICS (midway btw T6 and T10)

T9 - 9th ICS (midway btw T8 and T10)

T10 - 10th ICS @ umbilicus

T11 - 11th ICS (midway btw T10 and T12)

T12 - Midpoint of inguinal ligament

L1 - Midway btw T12 and L2

L2 - Mid-anterior thigh

L3 - Medial femoral condyle

L4 - Medial malleolus

L5 - Dorsum of foot on 3rd MTP

S1 - Lateral heel

S2 - Popliteal fossa

S3 - Ischial tuberosity

S54-S5 - perianal area

Brown-Sequard Syndrome

What: Hemisection of the spinal cord due to GSW or stab

Results:

Ipsilateral deficits

-loss of sensation (LT, proprioception, vibratory sense) (dorsal columns) and paralysis of muscles (corticospinal tract)

Contralateral deficits

-Loss of pain and temperature (spinothalamic tract) but does not start until SEVERAl segments below)

Anterior Cord Syndrome

What: due to hyperflexion injury of C-spine

(The head goes anterior to flex C-spine)

Preservation of proprioception, vibratory and discriminatory sense

Results:

-Loss of motor function (anterior corticospinal tract)

-Loss of pain and temp (spinothalamic tract ant/lateral)

Central Cord Syndrome

What: Caused by hyperextension injuries, congenital or degenerative narrowing of the spine

(whiplash)

Walking quads - most common incomplete SCI syndrome

Results in:

-UE > LE in involvement

-Sensory impaired but < than motor impaired

- Preservation of sacral tracts (sexual and B&B preserved)

Posterior Cord Syndrome

What: rare syndrome when posterior spinal artery is compressed

Results in:

-Loss of proprioception, pain, 2-point discrimination, and stereognosis

Motor is preserved

Conus Medullaris Injury

What: injury at L1-L2 caused by disc herniation, trauma or tumor

Clinical Presentation

-Bilateral and symmetrical loss of sensation in saddle distribution

-symmetrical motor loss

Results in:

-Mixed UMN and LMN signs (areflexic B&B and saddle anesthesia)

Cauda Equina Syndrome

What: Injury below L1-2

Clinical Presentation

-Unilateral and asymmetrical loss of sensation and motor

Results in:

LMN injury and S&S

Spinal Shock

The period of altered reflex activity immediately after a traumatic SCI

Autonomic Dysreflexia

What: Occurs in SCI pt with NLI T6 and above; is LIFE THREATENING

Results in:

-Noxious stimuli triggers sympathetic surge

-Signal cannot pass down due to NLI

-brain decreased HR but elevate BP presists

-elevation of BP (from 90-110 SBP to 250-300 SBP)

Unregulated PSNS control above lesion = bradycardia, nasal congestion and flushing

uncontrolled below lesion = goose bumps, cold and clammy

Steps for treating AD

1. Sit them up!

2. Loosen tight clothing

3. Check BP every 5 min

4. Check bladder then bowel

5. Check body for any other irritating stimuli

6. Apply nitropaste 1 in above injury and wipe off when resolved

What SCI level can breath without ventilator briefly?

C4- glossopharyngeal breathing

What SCI level can use manual w/c on level surfaces?

C5

What SCI level is the first level someone can indep transfer with level surfaces and have the POTENTIAL to be independent?

C6

Transfer using Sideboard

What SCI level can consistently be independent living?

C7

What SCI level is a community ambulator?

T8

What is the first SCI level to drive?

(low effort) C5 or C6 (for sure independent)

What is the first SCI level to stand outside bars with braces/RGO?

C8

Micturition is controlled by :

S2, S3, S4

UMN Bladder

-Spastic or hyperreflexic bladder

-Lesion: Above conus medullaris and sacral segments (T11-T12 and above)

-Bladder will reflexively empty in response to certain level of filling pressure

-Dyssynergia: detrusor is hyperreflexive but sphincter may have increased tone

Tx: Intermittent cath, indwelling cath

LMN Bladder

-Essentially flaccid and no reflex action of detrusor muscle

-Involving T12/L1 and below

-Bladder empties with increased intra-abdominal pressure

(can use Valsalva or Crede's maneuver) to empty

-Have high residual urine volume (can't get it all out)

Tx: Still will intermittent cath to keep volumes below 500-600 mL

2 bladder dysfunction

1. Failure to store: areflexive sphincter and spastic detrusor

2. Failure to empty: areflexive bladder and sphincter that is unable to relax

UMN Bowel

-Reflex/spastic bladder with lesion above S2

-PSNS and internal sphincter connections from S2-4 are intact so reflex defecation when rectum filled with stool

Tx:

-Digital stimulation to manual stretch anal sphincter

-Then add valsalva and/or abdominal massage for evacuation

-Empty daily or every other day

LMN Bowel

-Flaccid/areflexive bowel (lesions below cauda equina)

-Feces can be impacted

Tx:

-manual evacuation and gentle valsalva

-Emptied 1x/day or 2x/day

Lhermittes' Sign

flexion of neck= electric shock in extremities in pt with MS

If the NPTE stem of the questions talks about a female, btw 20-40 yo, who is very active and has sudden unrelenting fatigue, think

MS most likely

MS can have 2 CN involvements with condition, what two nerves?

Optic nerve = vision issues

Trigeminal nerve = eating, shaving and touch to face may trigger painful episode

What is defined as a MS exacerbation?

Neurological symptoms lasting >24 hours (new or recurrent)

-can last days to weeks to months

Pool therapy for MS patients, water temp must be

< 85 degs

Anterior Cerebral Artery CVA

Results in:

-CL motor and sensory loss (LE > UE)

-Sensory loss (LE>UE)

-Memory and behavioral impairments due to frontal lobe involvement

-Urinary incontinence (bladder/genitals on homunculus)

-Problems with imitation, bimanual tasks and apraxia

Middler Cerebral Artery CVA (most common)

Results in:

-CL motor and sensory loss involving UE and Face (UE>LE)

-CL homonymous hemianopsia

-If L CVA = aphasia

-If R CVA = perceptual problems (UL neglect, depth perception, spatial relations agnosia, apraxia)

Posterior Cerebral Artery CVA

Results in:

-CL homonymous hemianopsia

-Memory deficits

-Visual agnosia

-Prosopagnosia (difficulty naming people on sight)

-Central poststroke (thalamic pain)

Agnosia

inability to recognize an object by sight, touch or hearing

Apraxia

inability to carry out learned sequential movements on command

ideational apraxia

an impairment in the ability to carry out a sequence of actions because they do not recognize what to do with the object on command

Absolutely don't have the ability to do the task on command or on their own

ideomotor apraxia

the inability to carry out a simple motor activity in response to a verbal command, even though this same activity is readily performed spontaneously when provided with the object

Has the motor ability to do the task but not on command and only on their own

Form discrimination

unable to discriminate objects of similar shape/form

Figure-ground discrimination

inability to visually distinguish a figure from the background in which it is embedded

(example: buttons on a shirt)

R CVA clinical presentation

-L sided weakness/paralysis

-L neglect, spatial perceptual problems

-Poor judgement, (impulsive)

-Shortened attentions span and short-term memory loss

-Communication problems due to weakness in face

-Cognitive problems

R CVAs are like toddleRs - impulsive and no regard to safety

L CVA clinical presentation

-R sided weakness/paralysis

-Aphasia

-Personality changes - cautious, disorganize behavior

-Difficulty with new information, generalizing or conceptualizing

-Decreased memory

L CVA are like oLd people - slow and cautious people

UE flexion synergy pattern

-Scapular retraction, elevation or hyperextension

-Shoulder ABD/ER

-Elbow flexion

-Forearm supination

-Wrist and finger flexion

LE extension synergy pattern

-Hip ext/ADD/IR

-Knee extension

-Ankle PF, Inv

-Toe extension

What stage of the brunnstrom's stages does spasticity peak?

Stage 3

Supine Positioning for CVA pt in bed

Head/neck: Neutral

Trunk: midline

More affected UE:

-Scapular protraction

-Shoulder forward and slight ABD

-Arm supported on pillow

-Elbow extended

-Hand on pillow w/ neutral wrist, fingers extended and thumb ABD

More affected LE:

-Hip forward

-Knee on small pillow to prevent hyperextension

-Nothing against soles of feet

-Can splint for PF persisting

Side-lying on more affected side positioning for CVA pt in bed

Head/neck: neutral

Trunk: midline

More affected UE:

-Scapular protraction

-Shoulder forward

-Arm in slight ABD and ER

-Elbow extended

-Forearm supinated

-neutral wrist, fingers extended and thumb ABD

More affected LE:

-Hip extended

-Knee flexed and supported by pillows

(Alt: slight hip and knee flexion with pelvic rotation)

Side-lying on LESS affected side positioning for CVA pt in bed

Head/neck: neutral

Trunk: midline; small pillow under ribs to elongate side

More affected UE:

-Scapular protraction

-Shoulder forward

-Arm supported on pillow with

-Elbow extended

-Forearm supinated

-neutral wrist, fingers extended and thumb ABD

More affected LE:

-hip flexion and knee flexion but all on pillow

UE D1 flexion

Shoulder: Flex, ADD and ER

Forearm: supinated

Wrist: radially flexed

(Putting on a seat belt or eating)

UE D1 Extension

Shoulder: Ext, ABD and IR

Forearm: pronated

Wrist: ulnarly extended

(pushing away the bad food)

UE D2 Flexion

Shoulder: Flex, ABD, and ER

Wrist: radially extended

(Draw your sword)

UE D2 Extension

Shoulder: Ext, ADD, and IR

Wrist: ulnarly flexed

(Putting sword back)

Head/neck and trunk chop

Lead arm= Weak arm begins in D1 Flex --> D1 ext

Strong arm = holds from the top of the wrist and moves into D2 ext

Remember: we don't chop our legs

So Chops only happen for weak arm doing D1 flex<>ext

(used as HEP PNF)

Head/neck and trunk lift

Lead arm = weak arm begins in D2 extension --> D2 flex

Strong arm = holds from underneath wrist and moves into

D1 flex

Remember: we would want to lift our sword up until the end of battle

UE Thrust Pattern

Both UEs flexed and ADD, forearms supinated and hands flexed and arms tucked close to side

Pt asked to thrust out and PT resists motion out and back in

LE D1 Flexion

Hip: Flex, ADD, ER

Knee: Ext or flex

Ankle: DF, Inv

Toe: extension

Hacky sack

LE D1 Extension

Hip: extension, ABD, IR

Knee: flex or ext

Ankle: PF, Ev

Toe: flex

LE D2 Flexion

Hip: flex, ABD, IR

Knee: flex

Ankle: DF, Eve

Toe: Flex

(pee on the firehydrant)

LE D2 Extension

Hip: ext, ADD and IR

Knee: flex or ext

Ankle: PF, Inv

Toe: flex

(Image: R leg)

Can kind of think like crossing legs to not pee

GCS measures

Level of consciousness

GCS Scores

- 8 or less, Severe

- 9-12, Moderate

- 13-15, Mild

Decordicate posturing

UE: arms are flexed/adducted with the wrists and fingers are flexed

LE: legs are extended with feet plantar flexed

Decerebrate posturing

-"extensor posturing";

-abduction of arms, elbow and wrist extension and extension and PF of legs

Think decerebrate has a lot of e's for extension of all extremities

Rancho IV

Confused and agitated

-alert and has increased state of activity

-may be aggressive of flight behavior

-absent short-term memory

-unable to really cooperate with treatment

Tx:

-calm area for tx

-be calm and consistent (same time, place, PT)

-know when to stop

Rancho V

Confused, inappropriate, non-agitated

-unable to learn new info

-frequent brief periods

-consistent with simple commands

-inappropriate use of objects

Hoehn and Yahr Scale

I - minimal or absent; UL if present

II - Minimal BL or midline involvement; balance not impaired

III - Impaired righting reflexes, Unsteadiness when turning or rising from chair, Some activities restricted but can live indep

IV - All symptoms present and severe, standing and walking possible with assitance

V - confined to bed or w/c

Horner's Syndrome

What: Stroke of vertebrobasilar artery

Clinical Presentation:

-miosis (pupil constriction)

-ptosis (droppy eyelid)

-Decreased sweating

-Dsyphagia and dysphonia

-Impaired thermal sense over 50% of body

Vertebral Arteries supplies

Cerebellum: Posterior Inferior Cerebellar Artery (PICA)

Medulla: Medullary Artery

Basilar arteries supplies:

Pons: pontine arteries

Internal ear: Labyrinthine arteries

Cerebellum: Anterior Inferior Cerebellar Artery (AICA)

Locked-in syndrome

What: Caused by thrombosis and BL infarction of ventral pons

Presentation:

-acute hemiparesis progressing to tetraplegia and lower bulbar paralysis (CN V-XII)

-Mutism

-Cannot move or speak but alert and oriented

-Vertical eye movement and blinking preserved

Important muscles for each SCI level:

C2-3: part diaphragm, neck extensors, facial muscles

C4: diaphragm, traps (sip and puff)

C5: 3BIRDS - Biceps, Brachioradialis, Brachialis, Infrasp, Rhomboids, Deltoid, Supinator

C6: PET SLIP - P Major, ECR, T minor, SA, LD, Infrasp, Pronator

C7: FEET- FCR, EBP, Extrinsic finger ext and Triceps

C8: wrist flexion and finger flexion, hand instrisics

T1-6: hand intrinsics, full UE use, PHYSIOLOGICAL walking (RGOs)

T8-T12: abdominal muscles, KAFO's

L1-L2: iliopsoas, community ambulation, needs w/c

L3-L4: quadriceps, indep ambulation with (K)AFOs and crutches

Brown POT

Brown Sequard Syndrome = Pain and Temp lost on the Opposite side of the injury

SCI ASIA scale simplified

A- complete loss

B- Incomplete, Sensory (+) but motor (-)

C- Incomplete, Sensory (+) and Motor (+) but LESS than 50% mm have MMT >3/5

D- Incomplete, Sensory (+) and Motor (+) but MORE than 50% mm have MMT >3/5

E- E is ME = Normal

SCI below T10 has

mostly normal respiration

Spastic Bladder (UMN)

-Pt with injury ABOVE S2

Tx

-intermittent catheterization every 3-6 hours (4 hours optimal)

-Suprapubic tapping

Flaccid Bladder (LMN)

-Pt with injury BELOW S2

Tx

-intermittent catheterization every 3-6 hours

-valsalva or crede's maneuver

Key Muscles for C5 SCI = 3BIRDS

3B - biceps, brachioradialis, brachialis

I- Infraspinatus

R- Rhomboids

D- Deltoid

S- Supinators

Key Muscles for C6 SCI = PET SLIP

P- Pec Major

E- ECR

T- Teres minor

S- Serratus Anterior

L- Lat Dorsi

I - Infraspinatus

P- Pronator

Key Muscles for C7 SCI = FEET

F- FCR

E- EPB and EPL

E- Extrinsic finger ext

T- Triceps

SCI C1-C2 respiratory

-Relies on ventilator

-But has some innervation of: Upper Traps, SCM, Neck extensors, Facial muscles

SCI C3-C4 respiratory

-Relies on ventilator

-But has some innervation of diaphragm, scalenes and levator scapulae

C4 can do glossopharyngeal breathing