PTE 763: exam 2

what are the three primary systems that provide sensory input for balance?

1. visual

2. vestibular

3. proprioception

semicircular canals

detect angular/rotational movements

otolith organs

detect linear acceleration and head position

what are the two key reflexes associated with the vestibular system?

1. vestibulo-ocular reflex: stabilizes gaze during head movement

2. vestibulo-spinal reflex: controls postural tone and muscle activation

what is the sensory organization test (SOT)?

a balance assessment that evaluates how well a person uses the visual, vestibular, and somatosensory systems to maintain stability under various sensory conditions

what are the six test conditions of the SOT?

conditions 1-3 on stable surface: eyes open, eyes closed, and visual surrounding is moving

conditions 4-6 on moving surface: eyes open, eyes closed, and visual surrounding is moving

conditions 5 and 6 on the SOT impair/effect the vision and somatosensory systems, causing the body to rely on the ______ system.

vestibular

the SOT can be performed on which patient populations?

• older adults with fall history

• stroke survivors

• patients with Alzhiemer’s, Parkinson’s, TBIs, or vestibular dysfunctions 

what is benign paroxysmal positional vertigo (BPPV)?

an episodic spell of vertigo related to head position lasting for several seconds

what provokes an episode of BPPV?

free-floating otoconia in the semi-circular canals (canalithiasis) or otoconia attached to the cupula (cupulolithiasis) which have become displaced from the macule of the utricle

what other diagnosis is often confused with BPPV?

orthostatic hypotension

BPPV is the most common cause of spells of dizziness in the _____ population.

elderly

what is vestibular neuritis?

a sudden, intense period of vertigo (spinning), dizziness, and imbalance caused by inflammation of the vestibular nerve in the inner ear, often due to a viral infection

what is the time frame difference between acute vs. chronic episodes of vestibular neuritis? 

acute: up to one week

chronic: several weeks to months

what is vestibular labyrinthitis?

a sudden, acute attack of severe vertigo and imbalance, accompanied by hearing loss and tinnitus, caused by inflammation of the inner ear's labyrinth

what is the expected recovery time frame following vestibular labyrinthitis?

few weeks to months

inflammation and irritation of the vestibular nerve and inner ear’s labyrinth can arise following a ____ _________.

viral infection

what is opscillopsia? 

neurological condition characterized by the sensation that objects in the visual field are moving or oscillating, even when they are stationary

what are some examples of underlying conditions that may result in opscillopsia?

• vestibular disorders

• neurological disorders

• eye disorders

• inner ear disorders

• some medications

what is the typical prognosis seen with opscillosia?

it depends! may resolve on its own or may be a chronic condition that requires ongoing management

what’s the difference between balance and postural control?

balance: ability to maintain vertical center of gravity within base of support in a given sensory environment

postural control: optimal alignment and stability

what anatomical points does the plumb line pass through?

ears, shoulders, pelvis, knees, and ankles

describe what allows individuals to be balanced under various conditions like sitting vs standing, walking vs running, stationary vs moving, etc.

the effective interaction of afferent sensation and efferent motor control

what are anticipatory postural adjustments?

adjustments made before or during voluntary movements due to the “postural set” developed by the body to counteract expected forces

• loss of balance doesn’t occur

what are reactive postural responses?

movements in response to unexpected losses of balance driven by either internal or external perturbations

what are fixed-support strategies?

“in-place” movements used when center of mass is controlled over a stable base of support

• ankle and hip strategies

what are change-in-support strategies?

used when fixed-support strategies are not sufficient

• suspensory, stepping, and reaching strategies

describe ankle strategy.

postural sway control from the ankles and feet causing the head and hips to travel in the same direction at the same time

when do ankle strategies occur?

when sway is small, slow, and near midline

what is the muscle activation pattern used for ankle strategies?

distal to proximal (triceps surae → hamstrings → paraspinals)

describe hip strategy.

postural sway control from pelvis and trunk causing the head and hips to travel in opposite directions (quick shift of COM at the hips)

when do hip strategies occur?

when sway is sudden, large, fast, and nearing limits of stability

what is the muscle activation pattern used for hip strategies?

proximal to distal

• musculature used depends on direction (abdominals → quadriceps vs. paraspinals → hamstrings)

describe suspensory strategy.

lowering whole body center of mass closer to base of support

describe stepping strategy.

realigns base of support under center of mass by taking a step (forward, backward, or lateral) triggered by large, fast perturbations

describe reaching/grasping strategy.

upper limb movements to stabilize center of mass and extend base of support as a protective mechanism from falls

balance tests for ______ are appropriate for patients who have difficulty finding midline or holding still in standing/sitting.

stability/static

T or F: balance tests usually adequately cover multidimensional aspects of balance.

F; there are advantages and limitations to all balance tests (example: berg vs. tinetti)

what are the groups of balance tests?

• quiet standing

• active standing

• sensory manipulation

• functional scales

• combined test batteries

what are some examples of quiet standing tests?

• romberg

• sharpened romberg

• single leg stance

• nudge/push

the functional (forward) reach test is classified as a balance test assessing ____ standing.

active

what are some examples of sensory manipulation tests?

• sensory organization test (SOT)

• clinical test for sensory interaction on balance (CTSIB)

list some examples of functional scales tests.

• Berg

• TUG

• Tinetti

• DGI

a patient s/p CVA 1 year ago is in therapy for gait training as he still lacks ankle strategies. what are some training guidelines that could help him?

• sway body slowly in different directions on firm surface

• head and pelvis travel in same direction

• add functional activities

• add perturbations (anticipated and surprise)

a patient s/p right meniscus lesion 6 weeks ago is lacking hip strategies after beginning weight bearing activities. what are some guidelines that could help her?

• touch pelvis/hips on opposite sides causing sway in different directions while on a narrow surface

• rock heel to toe

• add functional activities

• add perturbations (anticipated and surprise)

an elderly patient is receiving therapy to reduce her fear of falls. she needs help improving her stepping strategies. what are some guidelines that could help her?

• practice stepping in all directions

• practice stepping on curbs, stairs, or balance beams

• increase to stepping on/over larger objects

• add perturbations (anticipated and surprise)

what are some ideas to challenge balance during gait training?

• change directions (sidestepping, weaving, etc)

• narrowing base of support

• reduce foot-to-surface contact

• starting, stopping, turning, bending, varying speed, stepping, carrying objects

• altered surfaces

• reduce lighting/visibility

what are the two main functions of the cerebellum?

1. adjustments

2. coordination

why is the cerebellum considered an adaptive feedforward system?

it relies on learned, stored motor patterns to create timely and efficient (sudden) motor programs

what is the overall consequence of cerebellar damage?

the nervous system cannot rely on the stored motor programs and must use slower feedback loops resulting in incoordination

list some incidents that can cause cerebellar damage.

• stroke/toxicity/tumors/trauma

• immune mediated

• congenital and developmental

• infection

• metabolic issues

• degenerative diseases

signs and symptoms usually occur ______ to the cerebellum lesion site.

ipsilaterally

from which arteries does the cerebellum receive blood flow?

superior cerebellar, AICA, and PICA

what are the three divisions of the cerebellum?

1. spinocerebellum

2. cerebrocerebellum

3. vestibulocerebellum 

the spinocerebellum comprises of the…

vermis and intermediate zone

the cerebrocerebellum comprises of the…

lateral zone

the vestibulocerebellum comprises of the…

flocculus and nodulus

spinocerebellum

receives somatosensory info from the spinal cord and influences motor execution, balance, and postural control

cerebrocerebellum

projects info to the cerebral cortex and influences motor planning and coordinated movements of the extremities (especially visually guided movements)

vestibulocerebellum

receives vestibular and visual info and regulates balance and head-eye movements

a patient is performing the neurological exam 8 hours after suffering a stroke. he demonstrates postural control deficits, fails the combined cortical tests (dysmetria and dysdiadochokinesia), measures 1+ in L DTRs, and shows deficits with CN 3,4,6 tests. what issue is manifesting?

cerebellar dysfunction

hypotonia found in patients suffering a cerebellum dysfunction may exhibit a pendular reflex. what is that?

the continued, multi-swinging motion of a limb after a deep tendon reflex

patients suffering a cerebellum dysfunction may exhibit which types of tremors?

• intention: tremor activated by movement

• titubation: postural tremor of head/neck

T or F: following injury to the cerebellum, patients may complain of asthenia-generalized sense of weakness/heaviness and fatigue easily.

T

what other general deficits can patients experience with cerebellum dysfunctions?

• deficits in motor learning and adaption

• ataxic speech

• cognitive and psychiatric impairments

how could a therapist limit degrees of freedom to make the task of walking more manageable?

use assisted devices/braces, external cues, shorten commands, partial → whole movements

describe the gait pattern usually seen in patients with cerebellum dysfunction.

wide base of support, shuffling steps, lack of any flexion or extension movements, shorten step length, lack of balance and coordination

what are effective treatment principles for cerebellum dysfunction?

• be prescriptive/targeted/specific

• progress towards high repetitions

• constrain or limit some degrees of freedom

• simplify the task/ reduce the challenge

• keep in functional and salient

what is multiple sclerosis (MS)?

a chronic, autoimmune disease that mistakenly attacks the myelin sheath, affecting the central nervous system 

• degenerative disease

multiple sclerosis results in…

demyelination and sclerotic plaque formation

describe the etiology of MS.

in genetically susceptible individuals: immune system mistakes portion of myelin protein for virus → targets it for destruction → attacks its own neural tissue → autoimmune response

what is the expectant life longevity in patients with MS?

can have normal life expectancies just may experience prolonged MS signs and symptoms

________ climates see a higher change of MS within their populations.

northern

• possibly due to low vitamin D levels

what are the top signs and symptoms associated with MS?

paresthesia/pain, unsteady gait, vision problems, fatigue, weakness, spasticity, intention tremor, bowel/bladder dysfunction, and cognitive problems

______ is the most debilitating symptom for most individuals with MS.

fatigue

what time of day are most patients with MS most energetic?

morning

explain the physiological reasoning as to why patients with MS cannot tolerate an increase in body temperature.

elevated body temp → Na+ channels close too soon and K+ is released to soon → weaker action potentials of shorter durations → worsening of neurologic symptoms

how is MS diagnosed?

largely based on clinical findings from evidence of CNS lesions following imaging and 2 or more distinct episodes of neurologic disturbance between ages 10-59.

what medicinal treatment is used for acute MS relapses?

first intravenous corticosteroids and then oral corticosteroids

when does natural improvement of acute MS exacerbations occur?

within 4-12 weeks of onset

T or F: exercise is recommended during acute exacerbations of MS.

F; not recommended due to inflammation and corticosteroid side effects

what are some psychosocial challenges to consider for patients with MS?

• benign for some, severely disabling for others

• may have unexpected exacerbations

• symptoms may vary form morning to evening

• planning for the future is difficult

• may have depression, anxiety, and fear

• many symptoms are not “visible”

• may be misunderstood

describe the gait pattern seen in a patient with MS.

decrease: speed, stride length, hip movement, knee flexion, and ankle movement

increase: double stance time

why might a patient with MS experience cognitive dysfunction?

loss of tissue and increase in CSF caused by inflammation and atrophy in grey matter

• processing speed, memory, attention, executive functions, and visuospatial processing are affected the most

what is developmental coordination disorder (DCD)?

a neurodevelopmental condition characterized by poor motor coordination and clumsiness that significantly interferes with daily activities and is not better explained by another neurological or intellectual condition

what are the over-arching diagnostic criteria for DCD?

• motor skills are substantially below expected

• clumsiness, slowness, and inaccuracy of performance of motor skills

• significantly and persistently interfere with and negatively affect ADLs

• deficits are not better explained by other disorders

• onset of symptoms is in the early developmental period

T or F: children can “outgrow” their diagnosis of DCD.

T! via learning and adapting

what pathological factors may lead to DCD?

genetic factors and pathologies of the cerebellum, basal ganglia, parietal lobe, medial orbitofrontal cortex (limbic system), and dorsolateral prefrontal cortex (attention and problem solving region)

a peds therapist visits a school for observation after a teacher reports a “trouble kiddo”. the therapist notices the child shows decrease attention span, visuospatial issues, slower movement time, clumsiness, and irritation. what diagnosis could be possible?

developmental coordination disorder (DCD)

patients with DCD often have slow reaction time and movement time. what’s the difference between these two?

reaction time: the amount of time it takes to respond to a stimulus, starting from the presentation of the stimulus and ending with the occurrence of a response

movement time: the duration of the actual physical movement from its initiation to its completion

what is one musculoskeletal reason patients with DCD are messy?

they experience a prolonged burst of agonist activity and a delayed onset of antagonist activity

what are some activity limitations seen in DCD?

• difficulty identifying important details of a task

• analyzing task to understand its components

• using past experiences to plan a new strategy

• executing a task as planned

• utilizing feedback

why might children with DCD get a bad reputation in school?

they experience participation restrictions like slow performance of ADLs, slow and messy school work, poor performance with PE, and poor peer interactions

list the 5 concurrent conditions sometimes seen with a diagnosis of DCD.

1. attention deficit hyperactivity disorder

2. autism

3. anxiety

4. depression

5. specific language impairment

what other diagnoses must be ruled out in order to achieve a medical diagnosis of DCD?

• cerebral palsy

• muscular dystrophy

• attention deficit disorder

• perceptual or visual impairments

list the outcome measures used with DCD.

• Canadian occupational performance

• goal attainment scale

• perceived efficacy and goal setting program

• children’s assessment of participation and enjoyment (activities of children)

list the standardized assessments used with DCD.

• peabody developmental motor scale

• Bruininks-Oseretsky test (BOT)

• movement assessment battery for children

• school functional assessment

what interventions should a therapist focus on when treating a child with DCD?

core stability training, cardiorespiratory training, and functional movement power training

description of functional movement power training:

identifying weakness and utilizing multiple muscle groups for exercises

• start with strength and then add speed/time to build up power

what are the four task-oriented interventions for DCD?

1. motor skill training

2. neuromotor task training

3. cognitive orientation to daily occupational performance (CO-OP)

4. motor imagery