Neuro WK 1: Basics

What is an examination? Use of a standard to quantify an observation

What is an evaluation? Process of determining the MEANING of measurements

What is Neuro Rehab? Problem solving and educational process aimed at REDUCING the participation restriction

Goals of Neuro Rehab: Help pt establish realistic goals and understand/manage condition, capitalize on strengths, prevent/minimize/eliminate impairments, minimize/eliminate enviornmental barriers, improve QoL, assist family/CG

Neuro eval components: review medical hx, sys review, subjective info (pt, family, CG), mottor assessment, sensory assessment, spatial/visual assessment, respiratory assessment, cognitive/communication assessment, ADL, functional assessment

Core outcome measures: berg balance, functional gait, activities specific balance confidence, 10 meter walk, 6 min walk, 5x STS

Disorders of speech: Apashia, Dysarthria, Dysphonia

Cardiopulm Screen (normative values): HR= 60-90, BP=120/80, RR= 12-20

UMN signs: weakness, spasticity, increased reflexes, clonus, Babinski, muscle bulk preserved

LMN sign: weakness, hypotonia, decreased reflexes, fasiculations, early atrophy

UMN syndrome: + signs= spasticity, stereotyped mvmt synergies, spasms, Babinski + clonus exaggerated DTR’s

UMN syndromes: - signs= paresis/paralysis, loss of dexterity, fatigue

Spasticity: velocity-dependent increase in resistance to passive stretch

Spasticity UE: SH ADD and IR, elbow flexors, wrist & finger flexors, forearm pronators

Spasiticy LE: hip ext, IR, ADD, knee extensors, ankle PF

Spasticity influenced by: effort, stress, body position, meds, enviornment, arousal, alertness, time, joint ROM, injuries, age, and chronicity of disease

Penn Spasm Scale Frequency: 0= no spasm, 1= mild via stim, 2= infrequent full 1/hr, 3= more than 1/hr, 4= more than 10/hr

Penn Spasm Scale Severity: 1= mild, 2= mod, 3= severe

Rigidity: increased resistance to passive stretch that is IND of velocity; uniform in both directions

Measure Rigidity: 0= none, 1= slight/detectable, 2= mild-mod, 3= marked full ROM easy, 4= marked full ROM difficult

Hypotonia: flaccidity- resistance to passive mvmt diminished/floppy

Decorticate: UE flex & LE ext

DEcErEbrateE: UE & LE ext

Opisthotonus: strong sustained contraction of neck and trunk extensors

Reflexes Biceps= C5-6

Reflex Brachioradialis= C5-6 (2” prox radial styloid)

Reflex Triceps= C6-7-8 (above olecranon)

Reflex Patellar= L2-3-4

Reflex ADD= L2-3-4 (groove btw qua & ham)

Reflex Achilles= L5, S1-2 (slight DF)

Abdominal reflex= superficial neuro reflex stimulated by stroking the abdomen around the umbilicus

Reactions: automatic overflow response, in response to effort; obligatory and not controlled

Primitive Reflexes: ATNR, STNR, Tonic Labrynthine

Paresis= weakness, partial loss of vol contraction

Parlysis= total loss of vol contraction

Common paralysis: hemiplegia, paraplegia, tetraplegia, and monoplegia

CANNOT accurately assess MMT grade: do not have isolated muscle contractions, demonstarte synergistic mvmt, sig abnormal muscle tone, connot follow instructions

Abnormal synergies: obligatory, highly stereotypical mass patterns- lack isolated jt motions

Fractionation: the ability to move a single jt w/o simultaneously producing unnecessary mvmt in other jts

Atrophy: loss of muscle bulk

Disuse atrophy: loss of muscle bulk d/t lack of use

Neurogenic atrophy: loss of muscle bulk d/t damage to NS

LMN: atrophy early

UMN: atrophy later

Muscle spasm: invol muscle contraction

Cramps: severe, painful spasm

Fasiculations: quick twitches of muscle fibers of a single motor unit that is VISIBLE on the surface

Fibrillations: (LMN lesion) breif contraction of a single muscle fiber NOT VISIBLE on the surface

Dyskinesia= invol, erratic, writhing mvmt of face, arms, legs, or trunk

Bradykinesia= slowness of mvmt and speed (progressive hesitation/halts) as mvmt continues

Akinesia= absence of mvmt

Hyperkinesia= a state of excessive restlessness

Arousal= physiological reainess has varying lvls

Attention= awareness of enviornment/distractability

Orientation= awareness of time, person, place

Cognition= process of knowing (awareness & judgement)

Memory= long & short term

Stereogenosis= tactile object recognition

Tactile localization= where object is

Barognosis= recognition of weight

Two-pt discrimination: sense difference in contact points

Graphesthesia= traced figure identification

What do they require that basic testing does not? Vision, changes w/ age, ability to compensate, impact of function, body image

Somatognosis: difficulties in reference points to the outside world; contralateral side, distinguishing their extremity from therapists extremitiy

Anosognosia: pt does not recognize their impairments or functional limitations

Tasks itself: how it was accomplished, level of assist, range of assist, cues, AD- needed or not needed, safety, impulsivity, other concerns

Independent= pt perfroms 100% no AD

Supervision= 100% but S for safety or setup

Contact guard= 100% but hands on for safety

Min assist= pt perfroms >75%

Mod assist= pt perfroms 50-74%

Max assist= pt perfroms 25-49%

Dependent= pt perfroms <25% or second person needed

Goals: impairments ALWAYS have to measurable AND linked to a functional activity

Example Goal 1: Pt will demonstrate improved right hip flexion AROM from 60 degrees to 90 degrees in order to sit in w/c for 2 hours with no pain.

Example goal 2: Pt will demonstrate improved R hip ext strength to 3+/5 in order to go from sit to stand with min A x1.

CN I: olfactory- smell

CN II: optic- vision, snellen eye chart & visual fields

CN III: oculomotor- eye lid up, eye up, in and down, constrict pupil and accommodates lens

CN IV: trochlear- intorsion of eye (eye down and ADD), eye pursuit

CN V: trigeminal- somatosensation of face, cornea, ant tongue, muscle of mastication; facial sensation, jaw muscle strength

CN VI: abducens- ABD eye, eye pursuit

CN VII: facial- facial expressions, tears, salivary excretion, taste ant tongue

CN VIII: vestibulocochlear- equilibrium and hearing; assess balance, eye head coordination and nystagmus and auditory acuity

CN IX: glossopharngeal- salvitory secretion, tatse post tongue, gag reflex

CN X: vagus- swallowing, phonation, cardiac depressor, GI fx, bronchoconstriction

CN XI: spinal- SCM and upper trap motor fx

CN XII: hypoglossal- tongue mvmt (deviation weak side= atrophy and fasiculations in LMN)

UMN motor cortex or connections btw brain and SC: exaggerated reflexes, decreased motor selection, spasticity, mvmt synergies, early flaccidity, and weakness

UMN basal ganglia: invol or decreased mvmt, decreased mvmt pattern flexibility

UMN cerebellum: loss of coordination

Basal ganglia lesions- Parkinson/Parkinsonism S&S: resting tremor, rigidity, akinesia, and impairment of postural reflexes

Parkinson Hallmark signs: rigidity (neck), akenesia/bradykinesia (UE), facial masking, speech defecits (low, rapid, dysarthria), resting tremor

Parkinsonism/Atypical parkinson/parkinson-plus: does not respond to dopaminergic meds, bradykinesia w/ degradation of repetitive mvmt, not just basal ganglia

Dx Parkinson Plus: Multiple sys atrophy, corticobasal degeneration, drug-related, infectious, toxic, structural

Vascular parkinsonism (arteriosclerotic pseudoparkinsonism): LE emphasia w/ gait and cognitive impairments

Chorea: invol, rapid, irregular, and jerky mvmt involving many jts

Chorea causes & symptoms: dysregulation of basal ganglia motor circuit; excess dopamine (thalamo-cortical output increased)

Hemiballismus: type of chorea that’s violent, flinging of UE/LE (subthalamic lesion- stroke or tumor)

Causes of Chorea: huntington disease, pregnancy, benign hereditary chorea, infection/immune related (sydenham’s chorea), systemic lupus erythematosus, focal vascular lesion BG, drugs (levodopa, neuropletics, and oral contraception), metabolic disorders (hyperthyroidism, hypo/hyper-parathyroidism and hypo/hyper-glycemia)

Challeneges Chorea: increase anxiety and vol mvmt, subsides during sleep, abnormal mvmt, athtosis (writhing mvmt)

Treatment Chorea: depends on etiology, meds (neuroleptic, dopamine depleters, and benzodiazepines)

Huntington Disease: hereditary, neurodegenerative, gene on 4th chromosome

S&S HD: chorea, dystonia, falls

Etiology HD: polyglutamine protein expansion, tangled and fragmented, neuron damage (atrophy: 1st corpus striatum- caudate and putamen, then whole BG)

Juvenile HD: rare, symptoms begin <20yr old

Early stage HD: able to ambulate unassisted, impairments- mild incoordination, minor confusion, mild depression/personality changes, chorea

Middle stage HD: need AD to ambulate, no longer able to drive, work, IADL, basic ADL difficult, difficulty w/ speech and swallowing, chorea mvmt more prominent (skilled vol mvmt difficult, cognitive changes worsen)

Late stage HD: non-verbal/completely unintelligible, in W/C or bed, transfers difficult, chorea severe, increase rigidity and contractures, cognitive symptoms increase

Medical treatment HD: tetrabenazine, haloperidol, fluphenazine, seizure meds, depression meds

HD rehab: PT, OT, PT, psych & social worker, homecare/long term/hospice

PT early: pt ed, general strength, ROM, aerobic training

PT middle: balance, AD, home safety set up

PT late: family/CG ed, safety and comfort measures, positioning, massage, PROM, QoL measures

Athetosis= continuous stream slow, flowing, writhing invol mvmt

Dysmetria= unable to control range of mvmt (hypo or hyper)

Dysarthria= dyscoordination of muscles of speech

Nystagmus= eyes beat rapidly in one direction, then come back to midline

Dysdiadochokinesia= impaired ability to perfrom rapid alt mvmt, mvmt are irregular w/ rapid loss of range and rhythm as speed increases

Ataxia potential causes: TBI, abnormal nutrition, mitochonrial disease, autoimmune syndromes, friedrich ataxia

Ataxia characteristics: dyscoordination UE/LE, wide BoS, irregular speech/swallowing

Progressive ataxia: spinal cord, peripheral nerve, cerebellum degenrate

Progressive ataxia S&S: UE mvmt uncoordination, speech slurred, congenital clubfoot/scoliosis, changes w/ vibration/position sense, decrease mental fx, slight tremor, heart problems

Spinocerebellar ataxia: progressive atrophy of cerebellum; symptoms vary

Spinocerebellar ataxia challeneges: sensation, muscle weakness/stiffness, RLS, tremors, dystonia (twitching of face & tongue, eye bulging), loss of coordination & balance, speech & eye mvmt

Spinocerebellar ataxia: mixed involvement general dystonia, dystonic posturing

Dystonic posturing= sustained abnormal postures caused by co-contraction of muscles that may last several min/hr/days

Spinocerebellar ataxia: involves BG, cerebellum, and sensorimotor cortex

Spinocerebellar ataxia: initiated/worsened by vol action and associated w/ overflow muscle activation

Spinocerebellar child: progress to general dystonia

Spinocerebellar ataxia adult: remains focal

Spastic dystonia: post stroke or ABI

Progressive supranuclear palsy: neuron degneration in many parts of the brain- BG & brainstem

PSP: vertical gaze paralysis (hallmark), surprised/frightened expression, rigidity & bradykinesia, speaking/swallowing, insomina, emotional dysregulation

PSP early stage: sig impulsivity

PSP late stage: depression and dementia, sig mvmt disabilities

Multiple sys atrophy (shy-drager syndrome): rare and progressive deterioration of cerebellar, BG, and brainstem

MSA: unknown cause- severe autonomic instability

MSA Parkinsonian type S&S: rigid muscles, bradykinesia, tremors, impaired posture & balance

MSA Cerebellar S&S: imparied mvmt/coord, unstead gait & LOB, slurred/slow/low volume speech (dysarthria), visual disturbances/blurred or double vision, dysphagia, orthostatic hypotension, high BP supine, irregular HR, dcreased sweating, sleeping disorders

PT MSA: maintain mobility, reduce contractured, and decrease muscle spasms and abnormal posture

Tremor & essential tremor: unintentional, rhythmic oscillation of body part in a fixed plane, contractions of agonist & antagonist muscles in sagittal pattern, resting tremor in body part not activated and completely supported against gravity

Action tremor: occurs w/ vol muscle contraction

Essential tremor: postural & action tremor, begin early, increase severity over time, exacerbated by stress, exercise, fatigue, caffine, meds, improves w/ relaxation and alcohol

Myoclonus: high speed contractions muscle/group of muscles

Myoclonus causes: liver/kidney failure, TBI, metabolic disorders (high/low blood sugar, low Ca, Mg, or Na), alzheimers, creutzfeldt-jakob disease, seizure disorders

Rigidity bed mobility: dec trunk rotation for rolling and supine-sit, limits balance reactions

Bradykinesia bed mobility: inc time to complete leads to fatigue and CG burnout

Chorea & athetosis bed mobility: unsafe limb placement, typically core is strong

Spasticity & spastic dystonia bed mobility: can lead to inability to use limbs for push-off, weakness, inability to position limbs safely, and trunk extensor tone unsafe

Rigidity transfers: dec trunk flexion, difficult sit-stand, poor balance reactions, safety concerns

Bradykinesia transfers: inc time needed for taks leads to inc work of mvmt and fatigue

Chorea & athetosis transfers: unsafe limb placement

Spasticity & spastic dystonia transfers: inability to use limbs for push-off, poor foot placement, weakness, knee collapse sit-stand

Coordination deficits transfers: worse in stand, unsafe foot placement and arm reaching, poor balance reactions

Dorsal columns= proprioception, vibration, and tactile discrimination

Lateral spinothalamic tract= pain & temperature

Anterior Spinothalamic tract= crude touch

Mobility= ROM and the ability to intiate mvmt and move from one position to another

Mobility PNF: RI & RC

Stability= the ability to maintain postural stability and orientation w/ CoM over BoS and the body at rest

Stability PNF: SR & RS

Controlled mobility/Dynamic postural control= the ability to maintain postural stability while parts of body are in motion

Contolled mobility PNF: DR & RR

PNF progression: inc ROM> move CoG over fixed BoS> perform mvmt on stable then unstable surface> alt sensory conditions

Skill= the ability to consistently perform coordinated mvmt sequences for the purpose of attaining an action goal

Skill tech: creeping, crawiling, knee-walking, walking

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