Intro to Neuro Assessment + Motor Exam

why do we care about location or etiology?

UMN vs LMN, prognosis for treatment

2 questions we ask for differential diagnosis

1- where is the lesion in the NS?

2- what is the nature of the disease process?- etiology

central lesion vs peripheral lesion

central -> SC -> UMN

peripheral -> spinal nerve -> radiculopathy

muscle =

periphery

spinal cord lesion =

myelopathy

brainstem, cerebellum, cerebrum lesion =

encephalopathy

nerve root (spinal n) lesion =

radiculopathy

nerve plexus lesion =

plexopathy

vascular etiology

blood clot, stroke

extrinsic etiology

- outside NS pressing on structure

- tumor, herniation, fluid, pregnant

systemic etiology

- whole body

- endocrine system (DM)

intrinsic etiology

- neurological

- ALS, MS, GB, PD

malingering

pts faking their problems

functional neurologic disorders (FND)

testing, imaging, + assessments

• ex: dystonia, chronic concussion

examination includes

- pt Hx

- systems review

- task analysis

- tests + measures (ICF)

evaluation includes

- problem list

- assessment statement- findings based on data

- outside referrals

PT diagnosis + prognosis (plan of care)

- medical/PT dx

- expected improvement

- timing/freq

- interventions

according to the ICF model, which of the following would be a limitation in activity?

A- requiring minA to perform STS

B- unable to attend school

C- gluteus max weakness of 3-/5

D- foot drop during gait

A- functional movements

what is the difference between activity + participation?

activity- basic task tested in clinic

participation- involvement in life situations

what is the difference between capacity + performance?

capacity- ability to perform in pt clinic

performance- activity abilities in the real world

where do we start our assessment?

observation

- general appearance

- movement

- behavior

- mood

- cognition

atrophy in legs: UMN or LMN?

LMN problem

what questions might you ask your patient during history taking?

- PMH

- onset

- PLOF

- functional level

- day to day

- meds/testing

example of pt identifies limitations/impairments?

asymmetries

example of environmental/external factors + personal/internal factors

external- pain w/ stairs

internal- stressors

cardiopulmonary screen

vitals, breathing diff, pitting edema

neuromuscular screen

Balance, FALLS!, numbness, dizziness, sensory changes (visual, auditory)

musculoskeletal screen

Gross AROM and strength

• weakness, pain?

best way to interview is to ask

open-ended questions- get whole story, learn about pt

purpose of interview?

- ID functional deficits/chief complaints

- info from Hx guides selection of tasks, tests

- organizes your examination

- do not rely on referral dx

important aspects in an interview

- obtain info

- establish rapport and trust

- learn pts goals

- open communication

- enhance motivation

what is a systems review?

asking specific questions to tease out the problem based on the systems

questions to ask about neuromuscular screening

balance, falls, numbers, dizziness, sensory changes

endocrine screening

weight loss/gain, blood sugars

what is a key tenant of physical therapy practice and why?

movement analysis- pattern recognition, allows targeted intervention, more consistency

does every patient with a stroke present the same?

NO- location

do patients with LBP present the same?

NO- tightness, disc herniation, tumor

task analysis of 6 core tasks

1- sitting balance- 30 sec, unsupported

2- sit to stand- w/out UE support, 2-3x

3- standing balance- 30 sec, unsupported

4- walk + turn- walk 10 m, no device/brace

5- ascend/descend step- step up leading w/ LLE -> RLE

6- reach, grasp, manipulate- reach 6" away -> pour into other cup

how can you make standing balance easier? harder?

easier- change BOS wider, let them touch a surface

harder- change surface to foam pad, narrow BOS

task variations

- BOS

- surface type/height

- vision

- speed

- response to internal + external perturbations

- cognitive demand

- external support/physical assistance

movement constructs

- sequencing + timing

- smoothness

- verticality

- stability

- alignment

- amplitude

- speed

- symptom provocation

sequencing + timing definition, example

- spatial + temporal organization of diff body segments

- delayed initiation, stepping response

smoothness definition, example

- complete task w/out interruption

- jerkiness of limb, ataxia, foot placement

verticality definition, example

- orientation of body to line of gravity

- lateral trunk lean, head tilt

stability definition, example

- control COM of BOS

- inc sway, LOB, veering w/ walking

alignment definition, example

- relationship of body segments to one another

- FHP, scoliosis, genu valgus, retracted pelvis, flexed trunk

amplitude definition, example

- ROM of body segments

- dec amplitude of arm swing, asym step length

speed definition, example

- velocity of body segment or displacement

- time to complete task

symptom provocation definition, example

- observation of pt report of symptoms evoked by movement

- change in vitals, O2 sats, dizziness, pain, fear

movement analysis guides our choice of

tests + measures

which statement about the STS movement analysis is correct?

a- you perform + time 5 reps of STS

b- Pt is instructed to push off from armrest

c- utilize any chair that is available

d- utilize a regression variation if the pt is unable to perform the STS task

e- all of the above

d

movement analysis is

qualitative

movement analysis framework

subjective -> analysis of task -> progression/regression -> tests + measures -> plan of care

impairments in body structure + function

- DTRs/abnormal reflexes

- tone

- AROM/synergistic movement

- strength/myotomes

- coordination

- quality of movement

cortical signs can only be found

in the specific lesion

frontal lobe contains

- primary motor

- premotor

- supplementary

primary motor

- where movement originates

- ability to move on contralateral side

- motor homunculus

- plegia, paresis, synergies, UMN signs

premotor

- planning movement

- procedural memory

- apraxia

supplementary

- sequencing of complex movements

- mental rehearsal

what do you know about the prefrontal lobe?

- cognition, personality, abstract thinking

- often assoc w/ TBI

what is the name of the motor tract that leaves from the motor cortex?

corticospinal tract

internal capsule

- pathway for corticospinal + corticobulbar tracts, and ascending somatosensory tracts from thalamus

- common area w/ strokes

corticospinal crosses in the...

cortiobulbar involves...

- medulla

- cranial n, facial expressions

MCA deficits vs ACA

MCA- UE > LE

ACA- LE > UE

will you see UMN signs with damage to the BG or cerebellum?

no- UMN signs only on that pathway

subcortical signs occur in the

brainstem, thalamus, cerebellum

motor involvement

face = UE = LE

cortical signs

- higher mental functions

- visual disturbances

- motor involvement

- astereognosis/agraphesthesia

- face/UE > LE or LE > face/UE

what areas make up the brainstem?

pons, medulla, midbrain

(cranial n run thru)

lateral SC motor tracts innervate

extremities

ventromedial (extrapyramidal) pathways

- originate in BS

- balance, posture, trunk

would a lesion in the SC cause UMN or LMN signs?

UMN

gracilis fasciculus vs cuneate fasciculus

gracilis- legs

cuneate- arms

which of these would produce LMN signs?

a- neuropathy

b- myelopathy

c- encephalopathy

a- peripheral n

peripheral NS

- cranial n

- ANS

- spinal n (LMN)

radiculopathy

- nerve root disease

- bulges out + pushes on spinal nerve as it exits SC

polyneuropathy

- sensory loss

- peripheral neuropathy, GBS, CMT

NMJ disease

- no sensory loss

- MG, botulism

characteristics of muscle disease

- symmetric, proximal weakness

- DTRs intact but depressed (weak)

- no pathological reflexes (bc UMN sign)

- no sensory loss, bowel/bladder dysfunction, deficits in coordination

- no cognitive deficits

LMN/UMN- weakness

both

UMN- diffuse

LMN- focal

LMN/UMN- atrophy

LMN

LMN/UMN- fasciculations

LMN

LMN/UMN- MM tone

UMN- inc

LMN/UMN- MM stretch reflexes

UMN- inc

LMN/UMN- clonus

UMN

pathological reflexes (babinski)

UMN

Pt w/ sensory loss to B knees and below + mm weakness in same area, hyporeflexia and no tone noted. Reports burning in B feet. a possible dx could be:

a- muscular dystrophy

b- SCI at T9

c- peripheral neuropathy

d- L5 radiculopathy

e- don't have enough info

c

atrophy

- loss of mm bulk

- LMN sign

- measure w/ figure 8 tape

disuse vs neurogenic atrophy

disuse- mm will improve w/ use

neurogenic atrophy- mm does not get better

endurance testing is common with

MS, ALS, GB, post polio, Duchenne MD

what are myotomes?

PNS-related to spinal nerves

myotome

group of mm that a single spinal nerve innervates

what diagnoses would you use myotome testing for?

SCI, radiculopathy

what is a dermatome?

- same thing w/ sensory system

- skin in relation to myotome

how do we assess muscle performance with individuals with stroke?

if pt has good movement -> can do MMT

do we see weakness in UMN syndrome?

- paresis, plegia

- hemiplegia, paraplegia, tetraplegia

changes in MM performance due to stroke

- altered recruitment pattern

- reduced motor unit firing rates

- presence of co-contraction

- reduction in # motor units

- loss of type II fibers

what is difference between motor control and muscle strength?

motor control- central issue, how brain organizes movement, loss of isolated movement

muscle strength- how strong, in periphery

if a stoke pt does NOT have isolated contraction, this means they have

synergist movement -> do not MMT

motor control

brain organizes + regulates actions including movement + dynamic postural adjustments

motor control following a lesion in the brain (stroke)

- lack of voluntary isolated movement

- abnormal obligatory synergies- combo of MM groups at multiple joints

- abnormal movements to compensate weakness

- nonfunctional