Neurology 2

What is Neurological Rehabilitation?

A process helping individuals with disability achieve optimal function and health.

6 Key Characteristic in Neurorehabilitaion

• Motor learning

• Outcome based & Inclusive

• Collaborative care

• Culturally responsive practice

• Tailored treatment

• Critical Evaluation

What does neurological rehab require?

Knowledge, skills, education, advice, and active partnership with patient/family.

Requires active partnership between the patient, their family and health and social care professionals.

Why is participation highly valued?

Because changes at impairment/activity level only matter if they improve participation

What are the three major historical approaches to Neurorehabilitation?

1. Motor Learning

2. Orthopedic

3. Neuro-facilitation

What is collaborative care?

Team‑based, interdisciplinary partnership improving outcomes

• Improved survival rates

• Earlier discharge home

• Improved independence

• Improved learning and development

What is patient-centered care?

Shared decision‑making based on patient values and goals

What are common neurological impairments?

• Weakness (← most common after a stroke, followed by spasticity)

• Fatigue

• Tone disorders

• Coordination issues

• Visuospatial & vestibular disorders

• Sensation issues

What are 5 common functional challenges?

• Mobility

• Self-care

• Communication

• Community participation

• Domestic life (e.g. meal prep)

5 Key Aspects of Any Neurological Physiotherapy Treatment Plan

1. Functional movement re-education

2. Strength & Motor control

3. Flexibility

4. Exercise

5. Impairment-specific interventions

What determines discharge?

Medical stability → safe home function → rehab potential → ability to support rehab at home

Common causes of an Acquired Brain Injury (ABI)

• Stroke (leading cause)

• Trauma

• Infection

• Poisoning

• Hypoxia

• Degenerative neurological diseases

What defines a Cerebrovascular Accident (stroke/CVA)?

What defines a Transient Ischemic Attack (TIA)?

What are the two major stroke types?

Ischaemic (~80%)

• Thrombotic, Embolic, Systemic hypo-perfusion

Haemorrhagic (~20%)

• Subarachnoid, Intracerebral

3 Modifiable & 3 Non-modifiable risk factors for a stroke

Modifiable

• Obesity

• Inactivity

• Smoking

Non-modifiable

• Increasing age

• Family history

• Male gender

What are the key steps in acute stroke care?

FAST recognition, reperfusion, stroke unit care, early rehab, care plan

F - Face droop

A - Arm weakness

S - Speech slurred

T - Time is critical 000

What is the time window for thrombolysis/reperfusion in an acute ischemic stroke (clot breakdown) + what is it?

Within 4.5 hours of symptom onset

• Administration of a clot-busting medication (a thrombolytic agent) through a vein

• It works by dissolving the blood clot that is blocking cerebral blood flow

When should rehab needs be assessed?

Within 24-48 hours of admission

What are the 3 priorities in acute neuro assessment?

1. Cardiorespiratory → Manage potentially life-threatening complications first

2. Functional → Early mobilisation = gold standard = maximises rehab potential and reduces complications

3. Impairments → Supports determination of diagnosis and prognosis

Minimum requirements to attempt standing?

Medically stable, cooperative, pain managed, DVT clear, ≥3/5 LL strength

3 Common Acute Measurement Tools

1. Coordination

2. Muscle strength

3. Balance

What are the aims of acute physiotherapy? POPD

1. Provide respiratory care

2. Optimise musculoskeletal integrity

3. Promote restoration of motor function

4. Discharge planning

What are the 5 steps of motor learning‑based rehab?

Establish baseline → Prepare task → Instruction → Determine practice strategy → Perform repetitive practice

4 Steps of starting Functional Rehab?

1. Develop ocular control

2. Develop postural control

3. Develop coordination

4. Retrain UL and LL function

What mechanisms cause ischemic stroke?

• Large artery atherosclerosis (~50%)

• Small vessel disease (~20–25%)

• Cardioembolism (~20%)

• Other (5–10%): dissection, vasculitis, pro‑thrombotic disorders

Why does stroke mechanism matter for physiotherapy?

It influences lesion size, location, stroke syndrome, prognosis, and expected motor/sensory/cognitive deficit

2 Types of a Hemorrhagic Stroke

Intracerebral - Bleeding within the brain tissue itself

• Caused by: Trauma + chronic HTN

Subarachnoid - Bleeding between the brain and arachnoid space

• Caused by: Aneurysm rupture or vascular malfunctions

Other causes - anticoagulation, drugs, bleeding disorders

What happens when blood flow to the brain is disrupted in a large vessel?

• Internal carotid Posterior: monocular blindness

• Vertebrobasilar system:

  • contralateral motor/sensory deficits

  • 4D’s

  • vertigo

  • nausea/vomiting

  • limb ataxia

  • coma

Examples of what happens when blood flow to the brain is disrupted in a medium vessel?

ACA: “motor“

• gait apraxia (forgetting how to walk)

• rigidity

MCA:

• Homonymous hemianopia (loss of half visual field in both eyes)

• Neglect

PCA: “visual“

• Alexia (cant read)

• hallucinations

What happens when blood flow to the brain is disrupted in a small vessel?

• pure motor hemiparalysis

• pure sensory deficit

• hemiparesis ataxia

• Dysarthria + clumsy hand syndrome

4 types of Stroke Classifications

Total Anterior Circulation Syndrome (high mortality) (low likelihood of indep. walking)

• contralateral hemiplegia, homonymous hemianopia, cerebral dysfunction

Partial Anterior Circulation Syndrome (high chance recovery) (much higher likelihood of independence)

• Any two of hemiplegia/sensory loss, hemianopia or higher cortical dysfunction

Lacunar Syndrome (less disability)

• Pure motor, pure sensory, sensorimotor, or ataxic hemiparesis.

• No cortical signs or visual field loss.

Posterior Circulation Syndrome (good recovery)

• Brainstem/cerebellar signs, CN palsies, bilateral deficits, eye movement disorders, isolated hemianopia

Primary vs secondary injury in intraceberbal haemorrage?

• Primary: haematoma + mass effect

• Secondary: blood toxicity, oxidative stress, inflammation → peri‑haematoma oedema

Key predictors of good recovery?

• Mild initial severity

• Presence of cortical signs

• Early sitting balance

• Early voluntary movement

• Intact cognition

When should mobilization begin? + recommended therapy dose?

• Avoid intensive mobilization in first 24 hours

  • Brain vulnerability, fatigue, not advantageous

• Mobilize by 48 hours if medically stable

  • support neuroplasticity

Dose → 2 hours active task practice (in a time frame of 3 scheduled hours) but still encourage practicing outside of scheduled therapy time!

What must be screened before rehab?

UL sensory-specific training, visual acuity, visual fields & eye movement disorders

What improves ADL performance?

Individualized goals, tailored strategies, assistive technology, VR adjunct

What should physios do with cognitive/communication issues?

Recognize → adapt → refer (SP, OT, neuropsych)

Other complications physios must recognise?

Nutrition, hydration, oral hygiene, mood, behaviour, fatigue, sleep disorders

Ischemic cascade: What is the “Ischemic core” and the “penumbra?”

Ischemic core → Brain tissue destined to die

Penumbra → Salvageable brain tissue area (viable for a few hours (around 3–6 hours)

• Why is this clinically important?
  This is the tissue that can be saved with rapid treatment

Deciding on a Discharge Location: Clinical Decision Flow

• The earlier stroke rehabilitation is commenced, the better the patient’s outcome

When does a stroke (e.g. TACS) become an infarct (e.g. TACI)??

when brain imaging confirms there is actual tissue death (infarction) in that vascular territory

What is Hemiparesis vs Hemiplegia?

Hemiparesis: weakness on one side of the body, Hemiplegia: paralysis on one side of the body

What are the 3 stages of Stroke Recovery?

1. Acute → First 24hours, medical stability is the priority

• Stabilize, Prevent & Mobilize

1. Subacute → 1 week-6 months, intensive rehab to promote neurological recovery

2. Chronic → +6months, focus shifts to long-term management & adaptation

What are the 4 key physio focus areas in stroke rehab?

1. Gait training

2. Task-specific training

3. Balance

4. Strength

What is a TBI (Traumatic Brain Injury)?

• It’s a type of Acquired Brain Injury

• Caused by external mechanical force (e.g. blunt impact)

• Results in permanent or temporary impairments

• Affect 15–45-year-olds mainly (due to risk taking behaviours/sports)

• “Concussion”

TBI Mechanisms of Injury (3)

1. Primary → Mechanical forces acting on brain (e.g. deceleration)

2. Secondary → The physiological aftermath (e.g hypoxia)

3. Associated → lead to associated peripheral injuries

3 Key features (each) of a Primary TBI and Secondary TBI

Primary → Immediate, axonal injuries, hemorrhages

Secondary → Delayed, reduced blood flow, disrupted autoregulation

What domains are commonly affected after TBI?

Physical, cognitive, behavioral, sensory, perceptual, lifestyle

What are 5 common health issues after TBI?

• Seizures

• Dizziness

• Pain

• Post-concussion syndrome (PCS)

• Mental health disorders

Coma vs post-traumatic amnesia (PTA) vs Vegetative state in a TBI patient

Coma: No eye opening, no response to pain, no sleep‑wake cycles, unresponsive

PTA: period from accident until person is oriented to surroundings (less than 5 minutes to more than 28 days)

Vegetative → wakeful, reduced responsiveness with no evident cerebral function, brainstem usually intact

What makes up the Glascow Coma Scale?

1. Eye opening response (1-4 score)

2. Best verbal response (1-5 score)

3. Best motor response (1-6 score)

^ Higher the total, better the patient

Physio aims of Acute Medical Management

• Stabilize patient

• Prevent further neurological damage

• Cease bleeding

• Monitor ICP + conscious state

2 common autonomic, sensory and motor changes after TBI?

Autonomic → sweating and dilated pupils

Sensory → visual field loss and dizziness

Motor → dysphagia and poor balance

2 common cognitive, behavioral + participation changes after a TBI?

Cognitive → impaired memory and language difficulties

Behavioral → depression and irritability

Participation → social roles and driving

Recovery timeline for a TBI?

Mild TBI → days to months; 1-20% still symptomatic after 3 months

Moderate TBI → rapid in first 3-6 months, slower over years (due to neuroplastic factors)

• Recovery is non-linear and highly variable

• Severity indicators:

  • Duration of coma

  • Length of PTA

  • Initial GCS score

• Severe TBI often results in:

  • Long-term disability

  • Cognitive/behavioural changes > physical deficits

TBI vs CVA patient presentation

• TBI often multi-system trauma

• Higher prevalence of impairments

• Coexisting musculoskeletal injures more common

• Fatigue, headaches, sleep disturbances more common

Decorticate positioning vs Decerebrate positioning (TBI)

Decorticate → PF, leg extension, arms tucked into chest

Decerebrate → PF, leg extension, arm extension, wrist flexion

Key PT assessment priorities in TBI?

Arousal, safety, posture, movement, tone, sensation, vestibular function, functional tasks, cognition/perception

What is the key message from the evidence about TBI management?

More therapy, earlier therapy, task‑specific practice!

• Improves cardiovascular fitness, general health

• Reduce depression

Somatosensory Impairments: Apraxia vs Visual Perceptual Impairments vs Neglect

Apraxia → prevents a person from performing purposeful movements or gestures despite having the physical ability and desire to do so

Visual Perceptual Impairments → inability to interpret and understand visual information

Neglect (unilateral) → Failure to attend to stimuli on the side opposite the lesion.

Somatosensory Impairments: Proprioception vs Tactile Functions

Proprioception → body’s ability to sense its position, movement, and force without relying solely on vision, sense of force, and timing of contraction

Tactile Function → sensory functions that involve localization and discrimination of stimuli.

Dysphasia vs Dysarthria vs Dysphonia vs Dyspraxia

Dysphasia → disturbances of language (Wernicke’s & Broca’s)

Dysarthria → disturbance of articulation

Dysphonia → disturbance in vocalization

Dyspraxia → impaired planning & sequencing of muscles required for speech

What is a spinal cord injury (SCI)?

Acute traumatic or non-traumatic damage to the spinal cord causing motor, sensory, and/or autonomic dysfunction

Difference between tetraplegia and paraplegia?

• Tetraplegia/quadriplegia: C1–T1 → affects arms, trunk, legs

• Paraplegia: Below T1 → affects trunk, legs

Complete vs incomplete SCI?

• Complete: No motor/sensory function below S4–S5, no neurological recovery

• Incomplete: Some function preserved below injury, preservation of motor and/or sensory function in S4-S5

2 Traumatic vs 2 non-traumatic SCI causes? F Rt T D

• Traumatic: Falls + road trauma

• Non-traumatic: Tumours + degeneration,

Most common injury levels in SCI patients?

• Traumatic SCI: Cervical

• Non-Traumatic SCI: Thoracic

Primary vs Secondary injury in SCI

Primary → Immediate damage (compression, laceration, concussion)

Secondary → Inflammatory cascade → ischemia, apoptosis, myelin damage

What is spinal shock in SCI?

Flaccid paralysis lasting ~2–6 weeks

What is Anterior Cord syndrome in incomplete SCI?

• Damage towards the front of spinal cord (affects corticospinal tract)

• Trauma MOI: Flexion, dislocation or disc protrusion

• Loss of motor + pain/temp, preserved proprioception

What is Central Cord syndrome in incomplete cervical SCI?

• Damage is in the centre of the cervical spinal cord

• Arms worse than legs weakness, some recovery possible

• Trauma MOI: Hyperextension

What is Brown-Sequard syndrome in incomplete SCI?

• Damage is towards one side of the spinal cord

  • Same side: motor + proprioception loss

  • Opposite side: pain/temp loss

What is Conus Medullaris syndrome in incomplete SCI?

• Trauma affects the spinal cord at L1-L2

• Bowel/bladder dysfunction + saddle sensory loss

What is the most important impairment in SCI?

Muscle weakness (key determinant in motor function)

Why is respiration impaired in SCI? + complications

Paralysis of diaphragm/intercostals/abdominals

• Pneumonia, atelectasis, respiratory failure

When does Autonomic Dysreflexia occur in SCI patients?

+ 4 key symptoms

+3 common causes

+3 managements

• Lesions at or above T6

• overreaction of the autonomic nervous system causing sudden severe high blood pressure.

  • Symptoms: Hypertension, headache, sweating, bradycardia

  • Causes: Bladder (UTI), bowel (constipation), skin (pressure sores)

  • Management: Sit upright, monitor BP, remove cause CALL FOR HELP!

What is spasticity?

Velocity-dependent increase in muscle tone (UMN lesion)

3 examples of musculoskeletal impairments in SCI patients? O C Ho

• Osteoporosis (due to reduced WB)

• Contractures (due to soft tissue muscle imbalance)

• Heterotopic ossification (bone in soft tissue)

Functional Outcomes by Spinal Level: C1-C3, C4, C5, C6, C7-C8, T1-T12, L2-S5

C1–C3 outcomes → Ventilator dependent, fully dependent

C4 → ventilator dependent, small shoulder control

C5 function → Can eat/groom but not transfer, have biceps/deltoids

C6 function → Wrist extension (tenodesis grasp)

C7–C8 function → Independent transfers + ADLs

T1–T12 function → Independent, possible limited walking with aids

L2-S5 function → Full independence in any environment; rapid come back.

Main goals in acute SCI? Ss Pc Mmf Em

• Stabilize spine

• Prevent complications

• Maintain muscle function

• Early mobilization

When is surgery indicated in an SCI patient?

Spinal instability or displacement

What does ASIA assess? (International Standards for Neurological Classification for Spinal Cord Injury (ISNCSCI)) + AIS A/B-D/E

Motor + sensory function to classify SCI severity

AIS A → Complete injury

AIS B → Sensory preserved, motor loss

AIS C → More than half key muscles have less than G3

AIS D → More than half key muscles have more than G3

AIS E → Normal function

International Standards for Neurological Classification for Spinal Cord Injury (ISNCSCI): same as ASIA

Supine

Myo/derma

ASIA
Anal

Comp/inco

1. Assessment in supine for acutely unstable injured person

2. Evaluation of 10 key myotomes and 28 dermatomes (light touch and pinprick)

3. Denotes level of SCI and the degree of impairment: level (C2-S4/5) represents the highest (most cephalad) myotome and dermatome in which normal function is preserved. Neurological Level Injury (NLI)

4. AIS: ASIA Impairment Scale (A, B, C, D, E): describes how much function is maintained below the level of injury: A no function to S4 and S5; E: normal function

5. S4-5: motor function ax by voluntary anal contraction (VAC); sensory ability to feel deep anal pressure (DAP)

6. AIS: determine complete or incomplete SCI.

ISNCSCI or ASIA steps in classification

Sen

Mot

Neuro Lev

Com/Inco

Grade

1. Determine sensory levels for R and L sides

2. Determine motor levels for R and L sides

3. Determine neurological level of injury (NLI): most cephalad of sensory and motor levels (step 1 and 2). Normal fx rostrally (3+)

4. Determine complete or incomplete: Voluntary anal contraction (VAC) and deep anal pressure (DAP)

5. Determine ASIA Impairment scale (AIS) grade: (A-B-C-D-E)

When does most recovery occur in SCI patients?

• First 8 months

Key components of physio assessment in SCI patients? S S S F R/CV

• Strength

• Sensation

• Spasticity

• Function (SCIM, FIM)

• Respiratory + CV fitness

Pressure Injury Prevention with braces: How often reposition in bed?

Every 2 hours

• Sitting → every 30 minutes

Sitting and Standing Objectives in the Acute phase of SCI

Sitting → appropriate cushion, consider compression socks, monitor vitals

Standing → orthostatic hypertension, balance training, stretching

What are the 5 Principles of Management in SCI patients?

1. Assessing impairments, activity limitations and participation restrictions (e.g. strength, pain, mobility, QOL)

2. Setting goals with respect to activity limitations and participation restrictions (e.g. activity limitations, participation, impairments)

3. Identifying key impairments that are limiting achievement of goals (keep in mind some impairments are non-responsive to interventions)

4. Identifying and administering physiotherapy treatments (e.g. bed mobility, gait, contractures, UL function)

5. Measuring the outcome of treatments.

Recommended exercise for SCI?

• 60–80% HR

• 2–3x/week

• 20–60 min

SCI patients provided with a hard or electronic copy of their individualised exercise programs

Nociceptive vs neurogenic pain?

Nociceptive pain arises from actual or potential tissue damage, while neurogenic pain results from damage or dysfunction of the nervous system itself (stabbing/burning)

When to assess respiratory function in an SCI patient?

Assessed by a physiotherapist within 24 hours of admission to hospital

What is Multiple Sclerosis?

A chronic autoimmune demyelinating disease of the central nervous system (brain and spinal cord).

Autoimmune inflammatory demyelination → disrupted nerve conduction; axons initially preserved but may degenerate in chronic plaques.

• More common in females 20-25 years

• Autoimmune disease

6 examples of Common Multiple Sclerosis symptoms? W F S S P E

• Fatigue (most disabling - heat dependent) (common)

• Weakness

• Spasticity

• Sensory loss

• Pain

• Emotional disorders

What is the main Diagnostic Criteria for Multiple Sclerosis?

McDonald Criteria, which require evidence of:

1. Dissemination in space (DIS)

• Lesions in different CNS regions

• “Two separate attacks”

• Demonstrated via MRI (90% positive)

2. Dissemination in time (DIT)

• Evidence that lesions occurred at different points in time

• “Two separate lesions”

What are the 4 subtypes of Multiple Sclerosis (MS)

CIS RRMS SPMS PPMS

1. Clinically Isolated Syndrome (CIS)

2. Relapsing Remitting MS (RRMS) → most common

3. Secondary Progressive MS (SPMS) → develops 10-15 yrs after diagnosis

4. Primary-Progressive MS (PPMS) → steady progression

What are 3 Sensory and 3 motor impairments in Multiple Sclerosis

P L D

W S A

Sensory:

• Proprioception loss

• Lhermitte’s sign (cervical flex. causes shock sensation in upper limbs)

• Dyasthesisa (burning sensation)

Motor:

• Weakness

• Spasticity

• Ataxia

Others: Facial weakness, vertigo, oculomotor abnormalities

What is the most disabling MS symptom?

Fatigue

• Worsens with heat

• Occurs in 75-95% of patients

3 Restorative & 3 Compensatory Approaches to Physio Assessment and Management of MS

A T A

Q P F

Restorative:

• Optimize performance of ADLs

• Target weakness, spasticity, pain

• Avoid heat

Compensatory/Participation:

• Improve QOL

• Ensure interventions are patient-specific

• Manage fatigue

• Aerobic exercise 10–30 min, 2–3×/week

• Resistance training 2–3×/week

• Balance training

• Cooling + intermittent exercise for heat intolerance

• BWSTT improves gait parameters