Neurology Physio OSCE

What are some Treatment Exercises to address/improve: Decreased pelvic control in stance phase

• Weight shift exercise

• Abductor strength exercise

• Side walking exercise

• 1-foot disc lateral sliders

• Stepping up onto cones

What are some Treatment Exercises to address/improve: No trunk rotation or arm swing

• Single step hand-to-target

• ^ same as above, but touch further across body

• reach and grab task

• marching on spot with exaggerated arm swing

• hold patients hand and passively swing their arm

• opposite arm to leg touches (good strength patient only)

What are some Treatment Exercises to address/improve: Impaired sequencing and activation

• marching/walking on spot

• mirroring

• queuing

• tactile tapping of muscle to activate it

• opposite arm to leg touches (good strength patient only)

What are some Treatment Exercises to address/improve: Decreased knee control in mid stance

• manual assistance

• walking over obstacles

• weight transfers

What are some Treatment Exercises to address/improve: Foot drop during swing phase

• step over obstacles

• weight transfers anteroposterior

• address strength/length deficits

• Dorsiflexion ROM

What are some Treatment Exercises to address/improve: No heel strike or roll over to push off

• heel strike exaggeration

• wedge-block to step onto

• heel taps

What are some Treatment Exercises to address/improve: Decreased step length

• step to target on ground

• single leg forward step rocking

• step goal within distance (decrease step goal within distance as patient improves)

• work on step propulsion -> increase power

What are some Treatment Exercises to address/improve: Decreased walking speed

• walking with metronome/ beat to match

• must achieve a certain distance in a certain time

• pace setting with therapist

Cranial Nerve Assessment

Coordination Tests - Upper and Lower Limb + Grading

Upper Limb: (Ataxia)

• Finger chase - finger to finger

• Finger to nose - their nose, my index finger

• Forearm supination/pronation - alternating opposite movements on thighs

• Hand tapping - w/ forearm supported, tap own hand

Lower Limb:

• Heel-shin slide - run opposite heel down shin from knee to ankle, repeat looking for ataxia

• Leg cycling - in supine

• Heel or toe tapping (alternating to make harder)

Grading:

0- no tremor or dysmetria

1- tremor with amplitude <2cm, dysmetria <5cm

2- tremor with amplitude <5cm, dysmetria <15cm

3- tremor with amplitude >5cm, dysmetria >15cm

4- Unable to perform 5 pointing movements/task

Tardieu Scale for Reflex/Spasticity

Testing the movements and reflexes in joints

• move elbow flexors slowly (PROM) and then quickly (V3)

• move ankle dorsiflexors slowly (PROM) and then quickly (V3)

Key points to notice

• Quality of muscle reaction at V1and V3

• Spasticity is present if there is a “catch” at V3

• Clonus present (Quality 4 or 5)

• Hyperreflexia or Hyporeflexia

V1: As slow as possible (measure PROM)

V2: Speed of limb segment falling under gravity (measure spasticity)

V3: As fast as possible (measure spasticity)

Deep tendon reflexes (usually associated)

• Biceps tendon/elbow flexion (C5, C6)

• Triceps tendon/elbow extension (C6, C7)

• Quadriceps tendon/ leg extension (L3, L4)

• Achilles tendon/plantar flexion (S1, S2)

CTSIB Balance Test

*All stances are arms crossed on shoulders and feet together

1. Eyes open, hold for 30 seconds

2. Eyes shut, hold for 30 seconds

3. Eyes open, rotate head R/L

4. Eyes open, stand on foam mat, hold for 30 seconds

5. Eyes shut, stand on foam mat, hold for 30 seconds

6. Eyes open, rotate head R/L, on a foam mat, hold for 30 seconds

Left hemisphere controls:

• Motor function of R side of body

• receives sensory info from R side of body

• language, interpretation and expression

• science, math, logic, reasoning

Right hemisphere controls:

• motor function of L side of body

• receives sensory info from L side of body

• Interpretation of perception

• Abstract and creation

• Art, music, imagination, intuition and insight

What is Neuroplasticity?

The brain’s ability to change and adapt in response to experience, learning, or injury by forming new neural connections

• how we adapt to changing conditions

• connections that are not active will gradually have their influence weakened.

• Influences: pre/post-injury factors, rehab, lesion characteristics

Upper Motor Neuron Lesions

• Paralysis

• fine-motor-skill impairment

• Increased tone (inability for a muscle to relax)

• Altered reflexes → Hyper-reflexia/Babinski

• Altered soft tissue length

• Altered sensation

Lower Motor Neuron Lesions

• Paralysis

• Muscle wasting

• Fasciculations

• decreased tone

• hypo-reflexia

• altered sensation

Motor Areas in Somatosensory

• Located in frontal lobe of both hemispheres

• controls the contralateral side of body

• Arranged topographically (motor homunculus)

Sensory Areas in Somatosensory

• located in parietal, temporal and occipital lobes of both hemispheres

• receive and process information from sensory receptors

• arranged topographically (somatosensory homunculus)

Spinothalamic Tract

• Ascending central pathway for pain, temperature, tickle, crude/touch and pressure

• Anterolateral system

• Enters via dorsal root ganglia, through ipsilateral dorsal horn, to contralateral thalamus

• ^crosses immediately for pain

• ^crosses near brainstem for touch

Spinocerebellar Tract

• Ascending central pathway for unconscious proprioception, postural control, balance, coordination

• Enters via dorsal root ganglia, up through spinal cord to cerebellum, to ventral posterolateral thalamus

Corticospinal Tract

• Descending motor central pathway concerned with control of voluntary, fine motor and skilled movements of distal limbs

• Pyramidal tract

• Starts at primary motor cortex, through pons & pyramids and cross at the pyramidal decussation in the lower medulla, finish at anterior horn where LMNs project to skeletal muscles

• Issues related? Muscle weakness, spasticity, clonus, hyperreflexia

Rubrospinal Tract

• Descending motor pathway controlling motor control, flexor muscle tone in upper limbs, inhibts extensor muscles

• Starts at red nucleus, thorugh to brainstem/spinal cord for the ventral horn and LMN to create movement

• Non-pyramidal route

Tectospinal Tract

• Descending motor pathway that coordinates head and neck movements in response to auditory and visual stimuli

• Starts at superior colliculus, through midbrain, down spinal cord to ventral horn

Vestibulospinal Tract

• Descending motor pathway that works with the reticulospinal tract to modulate muscle tone, and coordinate head and eye movements

• 2 tracts - Lateral and medial

• related to vestibular systems role in balance

Reticulospinal Tract

• Descending motor pathway that influences posture, locomotion, muscle tone, gait and balance by controlling activity of both alpha and gamma motor neurons

• ^ specialises in trunk and proximal limb movements

Corticobulbar Tract

• control of voluntary movement of head and neck muscles, facial expression, chewing/swallowing/speech

• descending motor pathway

• part of pyramidal system

Dorsal Column Medial Lemniscus Tract

• Ascending central pathway carrying conscious, proprioception and discriminative/fine touch

• Enters via Dorsal root ganglia, decussation at lower Medulla, to contralateral Thalamus

• Example Lesions: Multiple sclerosis (decreased proprioception UL → decreased dexterity)

Motor, Sensory and Motor/Sensory Nerves - Which ones are which?

Some Say Marry Money But My Brother Says Big Brains Matter Most

Motor: 3, 4, 6, 11, 12

Sensory: 1, 2, 8

Mixed: 5, 7, 9, 10

Nociceptive vs Neuropathic Pain

Nociceptive pain – caused by activation of nociceptors by a noxious stimulus that is damaging to healthy tissues

Neuropathic pain – caused by a lesion/disease of the somatosensory nervous system.

Dermatome Assessment

C2- 3cm behind ear

C3- supraclavicular fossa

C4- AC joint

C5- anterolateral albow

C6- dorsal thumb

C7- dorsal middle finger

C8- dorsal little finger

T1- anteromedial elbow

T2- axilla

T3- 3rd intercostal space

T4- level of nipples

T5- xiphoid→ sternum upper

T6- xiphoid → sternum lower

T7- quarter way to umbilicus

T8- half-way to umbilicus

T9- three-quarter way to umbilicus

T10- umbilicus

T11- between umbilicus and inguinal ligament

T12- inguinal ligament

L1- proximal thigh

L2- anteromedial thigh

L3- medial femoral condyle

L4- medial malleolus

L5- dorsal 3rd metacarpal

S1- lateral calcaneus

S2- popliteal fossa

S3- ischial tuberosity

S4/5- next to asshole