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

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

Initiation

Timing ,direction, smoothness - first motor output (ex. Parkinson's pt is frozen and can not move in a timely fashion due to the disease)

Execution

Amplitude, direction, speed, smoothness - continuation of movement (ex. Taking casual steps vs a pt w Parkinson's who has a shuffling gait)

Termination

Timing, stability, accuracy - STOP (ex. Pt has trouble stopping and falls due to this)

International Classification of Function, Disability, and Health (IFC), think about:

Is this something that is progressive (Parkinson's), or something that can be restored (stroke)

Health Screening

- A general system screen done on all patients

- Often referred to as a Wellness Screen

- Early detection and referral

Comprehensive Examination Process

- Identify red flags from your examination

- Identify comorbid conditions

- Understand/interpret medical data

Generate a PT or Movement Systems diagnosis

- A diagnosis that relates to the movement system, not to a pathoanatomical element

Screening Process

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

- TREAT, TREAT AND REFER, OR REFER?

Heath screen: Red flag warranting a med screen

• Warning sign of a serious or potentially serious condition

• Any biomedical factor that MAY require investigation or referral (ex. HR jumping, A fib)

• Includes medical conditions as well as signs of those conditions

Health screen: 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?

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

Yellow

Frontal pole, temporal pole, occipital lobe

Decision making, planning and organizing, problem solving, movement (M1)

what does the frontal lobe control?

Parietal lobe

Sensation, perception, integrating environment (how we are going to move in space)

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, gollobus pallcus, caudate, subthalamic nucleus

components of the Basal Ganglia

circle of willis

• Connects posterior and anterior circulation

• helps with redundancy and circulation (if something happens with one side of the brain, circulation can happen around it)

What is Neurophysiology?

The study of the nervous system and the mechanisms by which it functions - uses EEG, EMG, MEPs, behavioral presentation, etc.

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 neurons

Bipolar neurons

Pseudo-unipolar neurons

Unipolar neurons

Oligodentricytes (drops myelin on axon)

in CNS, what cells produce myelin (increase diameter and speed)?

Schwann cells

in the 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 glia

Astrocytes

- Only in the 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

- Only in the CNS (schwann cells are responsible for myelin in the PNS)

- Responsible for axonal myelination

Microglia

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

- 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

(Needs more excitation before a signal)

Temporal summation

• A single pre-synaptic neuron fires multiple times quickly

• The multiple pre-synaptic firing brings the post-synaptic neuron to threshold

• An action potential is generated

(Annoying sibling that pokes at you for a while and then after you're fed up you finally send the signal)

What is the simplest neural connection?

Reflex (sensory stimulus directly triggers an immediate motor response)

Behavior (CNS processing, integrated neural networks)

What is a complex neural connection?

Upper vs Lower motor neurons

Upper: originated and terminates in CNS (brain and spinal cord)

Lower: originated in CNS, termination on muscle

Central vs Peripheral

Central: brains an spinal cord

Peripheral nerves

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?

CNS injuries

Traumatic brain injury, stroke, cerebral palsy,

Bell's palsy

PNS injuries

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Spinal cord injury: mechanism of injury

Trauma: Falls, Compression, Sports Injuries, MVA

- Ischemia

Spinal cord injury: level of injury

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

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What causes tamarin brain injuries?

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?

TMI can result in:

- Cranial nerve injury (II, III, VI, VII, VIII 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

TMI - Most common modes of injury:

- Falls (nearly ½ of all hospitalizations)

- Firearm-related suicide (most common cause of TBI-related deaths)

- Motor vehicle crashes

- Assaults

TMI - primary damage

- Contusions: a bruise or bleeding on the brain

- Lacerations - blood within or that supply cranial nerves, dura mater

- Diffuse axonal injuries/shearing (very common)

- Hematomas

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

What are the 2 types of strokes?

Ischemic and Hemorrhagic

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 has 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?

(Ex. Cutting off dead area of a leave to prevent further degeneration)

Apoptosis

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

We are born with more neurons than we need (redundancy)

NS uses 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

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

True.

- Exercise can increase synthesis 3-fold

- Partially responsible for exercise-induced neurogenesis

- Aerobic exercise associated with increased BDNF

- Intensity of exercise positively correlated with

BDNF levels

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

BDNF promotes:

Neuroplasticity can be driven by:

- Behavior and environmental changes

- Emotions, thinking, bodily injury

True

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

How does plasticity occur?

- As a result of:

• Experience

• Injury

• The environment

• Learning/behavior

- Physiological mechanisms:

• Axonal sprouting/pruning

• Synaptogenesis

• Excitation/inhibition

What is modified with plasticity?

Modified axons and dendrites (how they communicate and how they are representing on the cortex)

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?

What is apoptosis?

Programmed cell death

What is BDNF's role in neurogenesis?

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

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

functions of the neuromuscular system

msculoskeletal system

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

Integumentary system

Assessment of skin integrity, perfusion

Cardiovascular/pulmonary system

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

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

Hemorrhagic brain injury, stroke, brain bleed. We want to know: when did this happen, how did you land? Refer! Bc of the confusion and slurred speech

What tasks can NOT 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 (for safe, effective, and efficient patient care)

• Supervision of all documentation - (doesn't mean you have to write it all)

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

Hypothalamus

Homeostasis