8- Clinical Intro to Neurological PT

Initial conditions, Preparation, Initiation, Execution, Termination

The motor control framework includes:

Initial conditions

which step in motor control framework?

Posture, ability to interact with environment, environmental context

Preparation

which step in motor control framework?

Stimulus identification, response selection, response programming (Is the pt processing the information and able to pick a response and perform it?)

Timing, direction, smoothness

what’s in this step of motor control framework?

Initiation: start of movement

Execution- continuation of movement

which step in motor control framework?

Amplitude, direction, speed, smoothness

Termination- stop

which step in motor control framework?

Timing, stability, accuracy

general system screen done on all patients

What is a Health Screening/Wellness Screen?

Comprehensive Examination Process

identify red flags from examination, Identify comorbid conditions, Understand/interpret data

Generate a PT or Movement Systems diagnosis

diagnosis that relates to the movement system, not to a patho-anatomical element

Screening Process

- identify possible problems that require consultation with, or referral to, another provider

- TREAT, TREAT AND REFER, OR REFER

Red flag warranting a med screen

Warning sign of a serious condition, Any biomedical factor that requires investigation or referral, includes medical conditions

Yellow flag warranting a med screen

• Psychosocial features/aspects (pt is seen in same clothing = elderly neglect)

• Catastrophizing, anxiety, finding painful experiences unbearable, etc.

• Becoming preoccupied with health

• Expectation of passive treatment (e.g., pills, modalities, etc.)

• Kinesiophobia: Fear of movement and of re-injury

red

A patients has slurred speech and heart rate is jumping is an example of a ____ flag?

Yellow

An elderly patient is seen wearing the same clothing everyday. This is a _____ flag.

Frontal pole, temporal pole, occipital lobe

Decision making, planning and organizing, problem solving, movement

what does the frontal lobe control?

Sensation, perception, integrating environment

Parietal lobe controls what?

Balance and coordination

what does the cerebellum control?

Broadmans area 17

Trouble with vision

Sensory and motor, body representation of the cortex in M1 And S1

What is the homunculus?

Midbrain, pons, medulla

What are the components of the brainstem?

putamen, substantia nigra, globus pallidus, caudate, subthalamic nucleus

components of the Basal Ganglia

circle of willis

• Connects posterior and anterior circulation

• helps with redundancy and circulation

Neurophysiology

Study of the nervous system and the mechanisms by which it functions - uses EEG, EMG, MEPs, behavioral presentation

Why neurophysiology is important for PT

- Hypothesis formation for predicting patient status: Body structure and function; Activities

- Initial and re-evaluation testing

- Intervention selection

- Referral need or patient status change

- Understanding how neural injury can impact

movement/function

- Understanding how we impact healing/movement

Weakness in R leg of pt, recover? Compensatory?

Recover: add weight bearing - forceful use for strengthening

Compensatory: tumor of pt was removed=give walker

multipolar, bipolar, pseudo-unipolar, unipolar

Types of neurons

Multipolar neuron

• Have one axon and multiple dendrites

• most common neuron in brain and spinal cord

• ex: alpha motor neuron

Bipolar neuron

• Have two processes, one axon and one dendrite

• usually has a sensory function

• ex: neurons in eye that receive light then transmit signals to the brain

Pseudo-unipolar neurons

• neuron where the single process branches into two, one extending to the periphery and the other to the spinal cord

• primary neurons responsible for coordinating the movement of the arms and legs using input from the brain

• usually has a sensory function

Unipolar neurons

• Have one process that branches into an axon and a dendrite

• rare in vertebrates

Oligodendrocytes (drops myelin on axon)

in CNS, what cells produce myelin?

Schwann cells

in PNS, what cells produce myelin?

Neuroglia

• Supporting cells of CNS

• Outnumber neurons 5-10-fold

• Do not have axons or dendrites

• Do not participate directly in synaptic interactions and signaling

• Help maintain an appropriate environment for neural

function

• Participate in the Blood Brain Barrier

Astrocytes, oligodendrocytes, microglia

Types of neuroglia

Astrocytes

- Cell only in CNS

- Modulate rate of nerve signal propagation

- Help with neurovascular coupling

- Provide a scaffold for some aspects of neural development

- Aid or prevent recovery from neuronal injury

Oligodendrocytes

- Cell only in CNS

- Responsible for axonal myelination

Microglia

- Primarily scavenger cells, remove debris from injury or normal cellular turnover

- in CNS

Synaptic communication

1:1 nerve connection is rare in the CNS (usually multipolar)

Spatial and temporal summation

What are the 2 ways post-synaptic neuron can be excited?

Spatial summation

• Multiple signals arrive simultaneously

• The signals are superimposed

• The result: the post-synaptic neuron is triggered

Single pre-synaptic neuron fires, multiple pre-synaptic firing brings the post-synaptic neuron to threshold, action potential is generated

What happens during temporal summation?

Reflex (sensory stimulus directly triggers an immediate motor response)

What is the simplest neural connection?

Behavior (CNS processing, integrated neural networks)

What is a complex neural connection?

Upper: CNS (brain and spinal cord)

Lower: CNS, muscle

Upper vs Lower motor neurons originate and terminate where?

Central: brain and spinal cord

Peripheral nerves

Central vs Peripheral

Pyramidal: Neurons originating from cortical pyramidal cells forming the corticospinal tract

Extrapyramidal: motor neurons that form other descending (motor) tracts

pyramidal vs extrapyramidal

Sensory: Ascending

Motor: Descending

is sensory ascending or descending? is motor ascending or descending?

Traumatic brain injury, stroke, cerebral palsy

CNS injuries

falls, carpal tunnel syndrome, sports injuries

PNS injuries

trauma, ischemia

Mechanisms of spinal cord injury

Neurological level: lowest level where motor and sensory function is normal on both sides

Spinal cord injury: level of injury

traumatic brain injury

A blow or jolt to the head or penetrating head injury that disrupts brain function

- Closed head injuries, coup contra-coup injuries (assoc. with contusions)

- Severe acceleration and deceleration (shaken baby syndrome)

- Blast injuries

- Penetrating object

falls

What is the leading cause of traumatic brain injury?

traumatic brain injury
II, III, VI, VII, VIII

_____________ can result in:

- Cranial nerve injury (______________ most often injured)

- Abnormal muscle tone and reflexes

- Hypersensitivity to light, dizziness/vertigo, apraxia

Those at greater risk of dying or experiencing long-term health problems

- Racial and ethnic minorities

- Service members and Veterans

- People experiencing homelessness

- People in correctional and detention facilities

- Survivors of intimate partner violence

- People living in rural areas

Falls, Firearm-related suicide, Motor vehicle crashes, Assaults

Most common modes of traumatic brain injury:

Contusions, Lacerations, Diffuse axonal injuries/shearing, Hematomas

primary damage of traumatic brain injury

TMI - secondary damage

- Increased intracranial pressure (ICP) - skull

- Cerebral hypoxia - caused by ICP

- Seizures (from pressure or swelling)

TMI - release of blood and hemoglobin breakdown

Toxic vs. neuroprotective properties

• Heme, red blood cells: toxic to neurons & glia

Stroke

The sudden loss of neurological function causes by an interruption of blood flow to the brain

Ischemic and Hemorrhagic

What are the 2 types of strokes?

Ischemic stroke

Most common accounting for approx. 80% of stroke (ex. Like drinking a milkshake and something blocks the straw so nothing somes up

Hemorrhagic stroke

Rupture of a blood vessel (Vessels have exploded/ pushes out into surrounding tissue: more fatal of the 2 strokes)

Hemiplegic

Paralysis on one side of the body

Weakness on one side of the body

Hemiparesis

True

Stroke: cell death primarily via apoptosis or necrosis. T/F?

Apoptosis

Cutting off dead area of a leave to prevent further degeneration is an example of what?

Stroke injury

• Concurrent vascular & neuronal loss of homeostasis: Temporary or leading to cell death

• Vessel ischemia: Vessel obstruction, Vessel permeability changes occur, Endothelial release of leukocytes

• Ischemia contributes to inflammatory response of neurons & glia: Macrophages (microglia), Cytokines

True, with assistance from Schwann cells; very limited in CNS

The PNS does a better job at neural recovery/ repair/ regeneration and has a much greater capacity. T/F?

Why is repair/regeneration very limited in the CNS?

Lack of ability for mature CNS neurons to regenerate is

"unusual" (Occurs quite naturally during development)

• Possibly due to the brain's ability to remodel its basic wiring

• Once changes have occurred it's beneficial to stabilize them

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CNS inflammatory response

• Up-regulation of perivascular macrophages

• Microglia activation (cytokine, interleukin release)

• Cumulative effect is blood brain barrier modification (fluid level changes)

• Impairs neurogenesis

Thus, one emphasis is on prevention/treatment of inflammatory response: anti-inflammatory corticosteroids

redundancy, compensation, and regeneration

What factors influence nervous system recovery?

Brain-Derived Neurotrophic Factor (BDNF)

A neurotrophic that helps to stimulate and control neurogenesis, support survival of existing neurons

true

Physical exercise is shown to increase BDNF. T/F?

neuronal survival, sprouting of new connections, increases dendritic spine formation

BDNF promotes:

Behavior and environmental changes & emotions, thinking, bodily injury

Neuroplasticity can be driven by:

True

Neuroplasticity is often used in context of stroke rehab/recovery. T/F?

Experience, Injury, environment, Learning/behavior

Axonal sprouting/pruning, Synaptogenesis, Excitation/inhibition

How does plasticity occur?

axons and dendrites

What is modified with plasticity?

For a spinal cord injury, what is a neurological level?

The lowest level of the spinal cord where there is normal spinal;........... watch video

Increase inflammation, hematoma

How can a TBI lead to intracranial pressure increases?

Compression or blockage from a clot

What is an ischemic stroke?

vessel ruptured

What is a hemorrhagic stroke?

Programmed cell death

What is apoptosis?

BDNF supports and facilitated neurons in how they are grown and communicating

What is BDNF's role in neurogenesis?

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neuromuscular

what system is this?

Assessment of tone, quality of movement, coordination, sensation, proprioception, kinetics awareness

musculoskeletal system

which system is this?

Assessment of gross symmetry, ROM, strength, posture, height and weight

Integumentary system

Assessment of skin integrity, perfusion

Cardiovascular/pulmonary system

what system?

Assessment of HR, RR, BP, pulses, and edema

Hemorrhagic brain injury, stroke, brain bleed

Refer bc of confusion and slurred speech

JD presents with confusion, R sided weakness, and slurred speech following a fall from a height at work. What are some differential diagnosis?

What tasks can’t be delegated to others

• Interpretation of physician referrals

• Initial examination, evaluation, dx, and prognosis

• Development/modification of plan-of-care

• Re-examination and discharge exam/planning

• Any time the PT determines that expertise of a PT is required

• Supervision of all documentation

Summary

-Foundational knowledge is required for later clinical

decisions

-Systems background will help you to identify red flags

as well as complete your PT differential diagnosis for PT

specific interventions

-With doctoral level training, knowledge of systems that

contribute to the "Movement system" is essential

Motor and Sensory Homunculi

The homunculi's can change for an amputated pt. Sensation will span out to others and fill in for other parts

health condition, participation, activities, body functions and structures, personal factors, environmental factors

what are the 6 components of the ICF model?