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

Station 3: Cranial Nerve Assessment

(will test cranial nerves 2, 3, 4, 5, 6, 7 (excluding taste), 8, 11)

Station 4: 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

• Finger strumming- tap each finger in order

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)

• Alternating hip flexion 

• Alternating prone knee flexion 

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

Station 4: 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)

Assess using a reflex hammer

• Biceps tendon/elbow flexion (C5, C6) in supine

• Triceps tendon/elbow extension (C6, C7) in prone with towel propped under pec

• Quadriceps tendon/ leg extension (L3, L4) off edge of bed

• Achilles tendon/plantar flexion (S1, S2) in prone

Cutaneous Reflex

→ Babinski → CNS lesion

Clonus

→ rhythmic oscillation between opposite directions of movement

• more than 10 beats is “infatigueable”

Station 6: 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

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

• (Left side of Homunculus)

• controls the contralateral side of body

• Arranged topographically (motor homunculus)

Sensory Areas in Somatosensory

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

• (Right side of homunculus)

• 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

• ^crosses immediately for pain

• ^crosses near brainstem for touch

Spinocerebellar Tract

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

Corticospinal Tract

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

• Pyramidal tract

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

Rubrospinal Tract

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

Tectospinal Tract

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

Vestibulospinal Tract

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

• 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

Dorsal Column Medial Lemniscus Tract

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

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

Both: 5, 7, 9, 10

Station 1: Dermatome Assessment

C2- 3cm behind ear

C3- supraclavicular fossa

C4- AC joint

C5- anterolateral elbow

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

^ to be done for a spinal cord injury

For a spinal cord injury patient, what sensation testing should be done?

• Follow the dermatome pattern as outlined by the ASIA scale (specific spots on the body) as were trying to determine the level injured

For a brain injury patient, what sensation testing should be done?

• Assess random alternating areas on the upper arm, lower arm, several areas on the hands and multiple spots on the fingers

  • largely driven by the homunculus representation in the cortex—meaning there are more sites to test.

5 Grades for Motor Scoring

0 - No muscle contraction

1 - Palpable or visible contraction

2 - Active movement; full ROM; gravity eliminated

3 - Active movement; full ROM; against gravity

4 - Active movement; full ROM, against gravity; + moderate resistance

5 - Normal active movement; full ROM; against gravity; + full resistance

5+ - Normal active movement; full ROM; against gravity; + sufficient resistance with no pain

NT - Not testable → severe pain, amputation, >50% ROM

Station 6/7: Essential Components of Reaching

1. Shoulder forward flexion

2. Shoulder abduction

3. Elbow flexion

4. Forearm supination/pronation

5. Wrist extension

6. Wrist radial/ulnar deviation

Station 6/7: Essential Components of Grasp & Manipulation

1. Thumb abduction

2. MCP/IP extension

3. Thumb to 4th & 5tg digit

4. Force throughout 2nd digit

5. Force modulation

6. Individuation of fingers

Station 6/7: Essential Components of sit to stand

1. Initial foot placement - ankle DF

2. Forward trunk + trunk extension

3. Anterior translation of knees

4. Hip/Knee/Ankle PF extension

Station 6/7: Essential Components of Side-lying to Sitting

1. Neck and trunk lateral flexion

2. Pushing of abducted arm

3. Extension of elbow/wrist

4. Hip/knee flexion

5. Lower feet to floor

Station 1: What are some examples of upper limb tactile assessments for a patient with a brain injury?

1. Using a cotton tip (light touch)

   • Dorsal Column-Medial Lemniscus pathway

2. Pin prick test (sharp/dull)

   • Spinothalamic pathway

3. Paperclip 1-or-2 sides (two-point discrimination) deep touch

   • Dorsal Column-Medial Lemniscus pathway

4. Hot and Cold test tubes (temperature)

• Spinothatlamic pathway

Important Tips:

• Start with baseline tester on facial cheeks

• Compare both sides

• Test proximal to distal

• Ask patient to close their eyes

Example: Demonstrate a muscle strength test of shoulder extension for a person with a L) brain injury/CNS lesion?

• Motor weakness or spasticity on the right side, but will check left side first as this is unaffected

• Can be done prone or sitting

Muscles Assessed: Lats, teres major, post deltoid

Looking for: Right sided weakness, spasticity,

2 Signs of Dysfunction in each Cranial Nerve

CN 1 - Olfactory

• Loss of smell & distorted smell

CN 2 - Optic

• Vision loss & impaired pupillary light reflex

CN 3 - Oculomotor

• Drooping eyelids & eye deviated

CN 4 - Trochlear

• Vertical diplopia & head tilt away from lesion

CN 5 - Trigeminal

• Facial numbness & weak jaw muscles

CN 6 - Abducens

• Inability to abduct eye & horizontal diplopia

CN 7 - Facial

• Facial weakness & loss of taste

CN 8 - Vestibulocochlear

• Hearing loss & balance disturbance

CN 9 - Glossopharyngeal

• loss of gag reflex & impaired taste

CN 10 - Vagus

• Voice change & uvular deviation away from lesion

CN 11 - Accessory

• Weak shoulder shrug & weak head turn

CN 12 - Hypoglossal

• Tongue deviation towards lesion & atrophy of tongue

Station 1: How to perform Somatosensation testing

Light touch:

• Compare both sides by dabbing a pulled cotton tip

  • Spinal cord → dermatomal

  • Brian injury → comparable random sides

• Start with a baseline on face

Pain/Pinprick: Deep touch

• Use a pin prick for the sharp and dull sides

• Alternate dull & sharp and ask patient to differentiate between sides → dermatomal pattern

• Compare left and right alternatingly at same location

• Start with a baseline on face

Temperature:

• Using a hot and cold test tube

• Compare left and right alternatingly at same location

• Start with a baseline on face

Proprioception:

• Dynamic: Move limb and get patient to identify direction

• Static: Move the unaffected joint and as patient to repeat action on their affected side

• (testing the Spinocerebellar pathway)

2-Point Discrimination: 

• Use paperclip to either touch 1 side or both and ask which one they feel 

• Start with a baseline on face

What would be some abnormal findings?

• Inability to differentiate, oversensitivity, absent/reduced sensation, mislocalizes

Station 2: Myotome testing (UL and LL)

Upper Limb:

• C1 → Head flexion

• C2 → Head extension

• C3 → Lateral flexion

• C4 → Shoulder elevation

• C5 → Shoulder abduction 

• C6 → Elbow flexion + wrist extension

• C7 → Elbow extension + wrist flexion

• C8 → Finger flexion + thumb extension

• T1 → Finger abduction 

Lower Limb: 

• L2 → Hip flexion

• L3 → Knee extension

• L4 - Ankle dorsiflexion 

• L5 → Great toe extension 

• S1 → Ankle plantar flexion + knee flexion 

^ Alternate sides each time 

• Voluntary movement is executed by corticobulbar and corticospinal tracts 

Station 5: How to perform the Hall-Pike test?

• Assessment for Anterior and Posterior Canal BPPV

• Warn patient of possible symptom reproduction, nausea, sickness, and that there is a vomit bag nearby if needed*

1. Instruct patient where you’re going to grip them and what movement is going to be done.

2. Rotate head 45deg to affected side

3. Patient’s gaze fixed to examiners nose or recommended target

4. Lie down patient swiftly, placing head into 30deg extension and off the bed

5. Observe for nystagmus and other symptoms

Interpretation:

Posterior canal → Affected rotational and up beating

Anterior canal → Affected rotational and down beating

For a peripheral nerve injury patient, what sensation testing should be done?

• Follow the peripheral nerve distribution

  • Median, ulnar, radial, axillary, musculocutaneous, brachial

• i.e. altered sensation of the pinky, most likely going to be ulnar nerve

For a CNS lesion injury patient, what sensation testing should be done?

• Test body segments that correlate with the sensory homunculus 

• This helps identify where in the brain (or nervous system) a problem might be occurring.

• If someone has numbness in the hand and face (which are next to each other in the sensory homunculus), it might point to a problem in a specific part of the brain

If a patient has an unknown lesion, what sensation testing should be done?

• Comprehensive circumferential testing of the whole body

Station 2: Grading strength 

• Grade 0 → total paralysis, no contraction 

• Grade 1 → no movement but contraction observed

• Grade 2 → full ROM, gravity eliminated 

• Grade 3 → full ROM, against gravity only

• Grade 4 → holds against moderate resistance

• Grade 5 → holds against maximum resistance 

Station 4: Rigidity vs Spasticity

Rigidity: increased resistance throughout ROM and is present in all muscles.

Spasticity: jerky and clonus movements

Station 2: Muscle Strength Assessment 

• Get patient to complete movement by self first

• Check unaffected side first

Upper Limb:

• Shoulder abduction (GE= supine)

• Elbow flexion (GE= upright along a bed)

• Elbow extension (GE= upright along a bed)

• Wrist extension/flexion (GE= along a bed)

Lower Limb: 

• Hip flexion (GE= side lying)

• Knee extension (GE= side lying)

• Ankle dorsiflexion (GE= side lying)

• Ankle plantar flexion (GE= side lying)

• Knee flexion (GE= side lying)

GE = Gravity Eliminated 

Station 2 Muscle Strength: If the person has a R) brain injury, what side do we test first?

• The R) side because that would mean the left is affected and we always start with the unaffected side first

Station 4: What are some abnormal findings for coordination, reflexes and muscle tone assessments?

• Dysmetria (over or under shooting)

• Tremor

• Can’t perform rapid alternating movements

• Poor coordination

• Absent reflexes

• Babinski sign/Hoffmans sign

• Clonus

• Jerky resistance

Station 5: How to perform the Supine Roll test?

• Assessment for Horizontal Canal BPPV

1. Patient lying supine with 30deg head flexion → on pillow

2. Rotate patients head 90deg to affected side. Observe nystagmus and symptoms, hold for 1 minute.

3. Turn head back to midline. Hold for 1 minute

4. Rotate patients head 90→ to unaffected side. Observe again. Hold for 1 minute

Horizontal Canalithiasis→ geotropic and greater nystagmus intensity 

horizontal Cupulothiasis→ apogeotropic and lesser nystagmus intensity

Station 5: How to perform the Epley Maneuver?

Located in the posterior canal BPPV

1. Head rotated 45deg to affected side and swifty brought down into 30deg extension off the edge of bed. Hold for 1 minute and observe. 

2. Rotated 90deg to other side. Hold for 1 minute and observe. Symptoms should relieve.

3. Roll patient onto unaffected shoulder. Hold for 1 minute. Guide patient back up. 

Station 5: How to perform the 360 BBQ Head roll? 

Located in the horizontal canal

1. In supine with 30deg flexion, head turned 45deg toward affected ear and held for about 1 minute

2. Head rolled slowly back to neutral, pause for 1 minute

3. Continue toward unaffected ear and stop at 45deg. Hold for about 1 minute

4. Roll in same direction until patient is prone resting on elbow, chin tucked towards chest. Hold for 1 minute.

5. Return patient back to supine, and then sitting

Station 5: What are screening tests to be done before conducting vestibular tests?

• VBI screening test

• Cervical AROM screening

• Recent surgery, cardiovascular and vision history ± medications

Station 5: How to perform the Head Impulse Test? 

1. Position patient upright fixating gaze on nose whole time

2. Hold patients head with both hands 

3. Move head slowly side to size for a baseline 

4. Give a small. quick and unpredictable thrust to one side and return to midline. Repeat on other side. 

5. Repeat 2-3 times on each side

• Positive test: unable to maintain fixation

• differentiate peripheral vs central vertigo and VOR

• “Saccade = Side of lesion”

Abnormal finding: Patients eyes move with their head and then make a corrective saccade back to nose

Result	Suggests
Abnormal HIT (with corrective saccade)	Peripheral cause (e.g., vestibular neuritis)
Normal HIT (no corrective saccade, despite vertigo)	Central cause (e.g., stroke)

Station 7: What are some parameters to change to influence grasp parameters?

• Add a visual target (like tape)

• Change object to grasp

• Change distance, size, shape, weight, texture etc

• Alter height or support conditions

Station 8: How to facilitate a person’s gait for a person with Gr2 LL strength? + GR3 and GR4

~ Instruct examiner to use belt to hold patient up and on affected side ~

Stand phase: 1 hand pushing hip forward, 1 hand pushing knee back

Swing phase: 1 hand pulling foot up, 1 hand pushing knee up/through

^ use a wheel-stool to follow patient along

GR3 - Without examiner holding belt but still facilitating

GR4 - Tactile tapping while they walk normally

Introduction

Wash Hands…

“Hi Sarah, my name is Emily Grace, and I am a second year Physio student. Just before we begin, I am just going to need 3 points of ID including your first and last name, date of birth and address….So today we are going to be conducting a few tests in regard to your level of function and some of these will be pretty hands on, is that okay with you? So were going to get started with…”

VBI Screening

• Performed first in sitting and then standing

• Rotated EOR and held for 10 seconds → observing for signs of VBI/CAD

• Bought back to neutral for 10 seconds → repeated in opposite direction