Neuro Differential Diagnosis & Interventions

Upper Motor Neuron (UMN) vs. LMN Tone

UMN lesions cause increased velocity-dependent spasticity; LMN lesions cause decreased tone (hypotonia).

Basal Ganglia vs. Cerebellar Muscle Tone

Basal ganglia lesions produce non-velocity-dependent rigidity; cerebellar lesions present with normal or decreased tone.

diagnoses of UMN

stroke, sci, tbi, cerebral palsy, MS, ALS

diagnoses of LMN

GBS, PNI, radiculp, polio, ALS

diagnoses of basal ganglia

parkinson

diagnoses of cerebellum

stroke, tumor

Parkinson's Disease (PD) Pathology

Progressive neurological disorder caused by dopamine depletion in the substantia nigra.

Parkinson's Disease Cardinal Signs (TRAP)

Tremor (resting), Rigidity (cogwheel/lead-pipe), Akinesia/Bradykinesia, and Postural instability.

what are some other S/S of parkinsons

Early symptoms:

• Loss of smell

• Constipation

• Sleep disorders

Motor: Hypophonia, mask-like face, micrographia

Cardio: Orthostatic hypotension, fatigue, weakness

Respiratory: Restrictive lung disease due to decreased chest expansion

Cognition/Behavior: Difficulty with dual tasking, depression, dementia

what does cogwheel vs lead pipe ridigity

lead pipe: smooth consistent

cogwheel: jerky, ratchet

Gait Characteristics in Parkinson's Disease

Festinating/shuffling gait (postural), decreased step length/width, reduced trunk rotation, and freezing of gait (sudden inability to move).happens from cognitive overload, and en bloc turning (robot like, body moves together)

strategy to help for freezing of gait

what about festinating gait?

distraction. like drop a tissue or look at the door

give them a heel under toes like a wedge to put more wgt on heels to help with posture and lean back more

Hoehn and Yahr classification of disability

I Minimal or absent; unilateral if present.

II Minimal bilateral or midline involvement.

Balance not impaired.

III Impaired righting reflexes. BALANCE IMPAIRED

Unsteadiness when turning or rising from chair.

Some activities are restricted, but patient can live independently and continue some forms of employment.

IV All symptoms present and severe. Standing and walking possible only with assistance.

V Confined to bed or wheelchair.

intervention for parkinson

Caregiver education

• Gait training

̶ Metronomes, music, visual cues, one step

commands when freezing/frozen

• Posture:

̶ Rotation exercises and crossing midline

̶ Prone lying

• Hypokinesia:

̶ BIG movements

̶ Stretching/ROM/chest mobility

• Balance training

• Tai chi, yoga, cycling, dance therapy

What are the key facts about Levodopa/Carbidopa in Parkinson disease?

✅ Gold standard medication for Parkinson disease

Levodopa crosses the blood-brain barrier and is converted to dopamine.

Carbidopa prevents levodopa breakdown in the periphery, allowing more levodopa to reach the brain and reducing side effects.

🧠 Memory Trick: "Carbidopa = Car Pool." 🚗

Carbidopa escorts (car-pools) levodopa safely to the brain

What is the "on/off phenomenon" with Levodopa/Carbidopa?

On Phase:

Medication is working

Dyskinesia (excessive involuntary movements) may occur

Off Phase:

Medication wears off

Dystonia (muscle stiffness/cramping) and worsening Parkinson symptoms occur

🧠 Memory Trick: "ON = Overmoving; OFF = Frozen."

ON → Dyskinesia = too much movement

OFF → Dystonia = stiff/frozen

What are the PT considerations for a patient taking Levodopa/Carbidopa?

🕐 Schedule PT about 1 hour after the medication dose (during the "on" phase).

🥩 A high-protein diet decreases levodopa effectiveness because amino acids compete for absorption and transport into the brain.

🧠 Memory Trick: "1 Hour = Power 🚶"

Treat when the medication is working best.

"Protein Prevents Parkinson Pills." 🥩❌💊

Dyskinesia vs dystonia

Involuntary, repetitive, smooth,

muscle movements

• e.g., snake-like twisting of arm

• Affects large muscle groups

(arms, head, trunk, legs)

• Not usually painful

• ON phase

DYSTONIA

• Prolonged, involuntary muscle

contractions; muscle spasm

• e.g., toe curling

• Affects a specific muscle or group

of muscles

• Causes pain

(sometimes debilitating)

• OFF phase

Multiple Sclerosis (MS) Pathology

Autoimmune disease marked by progressive demyelination of central nervous system (CNS) neurons.

UMN LESION

s/s of MS

Motor: Spasticity (UMN lesion)

• Sensory: Numbness and paresthesia

• Gait: Scissoring, extensor spasticity in LE, ataxia, uneven steps

• Bladder: Spastic, flaccid

• Speech and Swallowing: Dysphagia (difficulty swallowing), dysphonia (difficulty

with voice production)

• Cognition: Diminished attention, concentration

• FATIGUE

• Optic Neuritis, Trigeminal Neuralgia

• Cerebellum: Nystagmus, coordination, balance, ataxia, intention tremor

• Emotion: Pseudobulbar affect (inappropriate laughing or crying)

what are unique s/s of MS to distinguish between which UMN lesion it is?

LUCC

1. Lhermitte's Sign (neck flexion cuz electric sensation down spine)

to remember think MESSY HAIR. when you flip your neck forward (so neck flexion) your hair will be messy

2. Uhthoff's Phenomenon (heat intolerance) temporay (24 hrs) pseudo exacerbation

to rememeber think "U turn Heat OFF"

3. Charcot's Triad (scanning speech, intention tremor, and nystagmus) SIN

4. Cranial Nerve- II (inflammation of optic nerve so optic neuritis and pupillary light reflex so in MS with light pupils will dilate (marcus gunn pupil)

diff type of MS

• Relapse-Remitting RR: Short duration

attacks with full or partial recovery, may or

may not leave lasting symptoms/deficits

̶Most common form (about 80%)

• Primary Progressive: Steady increase in

disability without attacks/exacerbations

• Secondary Progressive: Initially RR, then

symptoms increase without periods of

remission

• Progressive Relapsing: Steady increase in

disability with superimposed attacks

what was changed in 2013 for MS types

they dont use the term progressive relapsing anymore instead is called clinically isolated syndrome (• First episode of inflammatory demyelination in the CNS

• Could become MS if additional activity occurs

• TWO types:

1. Not active - No additional MRI activity

2. Active - With additional MRI activity >>> Relapse- remitting)

Physical Therapy Exercise Guidelines for MS

Exercise 3-5 days/week at low intensity in cool environments; schedule sessions in the morning to avoid fatigue. for 30 min and can do cycle, walk, swim

Amyotrophic Lateral Sclerosis (ALS) Key Feature

Degeneration of both upper and lower motor neurons without sensory involvement.

A-ALS LEAVES SENSATION

common s/s of ALS

UMN & LMN presentation without sensory loss

̶Muscle atrophy, fasciculations (LMN)

̶Spasticity, hyperreflexia (UMN)

̶Dysphagia, dysarthria (Bulbar)

• ONLY motor neurons will be affected

• Cognition: Dementia, attention deficits

• Emotion: Pseudobulbar affect- emotional lability

• Muscles: Cervical spine extensors weakness is

common

• Respiratory muscle weakness ----> DEATH!

diff between ALS vs MS

ALS- motor only, yes likes neck flexion, 9/10/12 CN

MS- affects sensory, CN2 and no neck flexion!

ALS interventions

Medical Management

• No effective treatment for disease

PT Management

• Focus on functional activities/ADLs and energy conservation initially and end

stages

• Recommend soft foam collar for neck if weakness is present

• Maintain respiratory function, breathing exercises

• Avoid over fatiguing

̶Take frequent breaks during activities, energy conservation techniques

• ROM, positioning if needed

Guillain-Barré Syndrome (GBS) Pathology

Acute autoimmune inflammatory demyelinating polyradiculoneuropathy affecting peripheral and cranial nerves post-infection.

LMN LESION- periphral nerve is affected

S/s of GBS

Motor loss/paralysis:

̶DISTAL TO PROXIMAL

̶Rapid and progressive

• Sensory loss:

̶Glove and stocking

̶Burning, tingling, numbness

• Decreased reflexes/Areflexia

• Respiratory and cranial involvement:

VII, IX, X, XI, XII

• Fatigue

GBS-glove stocking appearance and bilateral

Guillain-Barré Syndrome Clinical Progression

Symmetrical, rapid motor weakness progressing in a distal-to-proximal ascending pattern with areflexia.

Initial Interventions for Guillain-Barré Syndrome

Maintain respiratory care, prevent joint contractures, and use low-to-moderate intensity exercises to prevent overuse.

6-12 mths can recover