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Neuro Eval II > Cerebellar > Flashcards

Cerebellar Flashcards

1
Q

Role of the cerebellum

A
  • Multiple roles in motor learning and skill acquisition
  • Modifying movements based on learning
  • Motor learning and skill acquisition
  • Gaze stability
  • Postural responses
  • Learning
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2
Q

Primary actions of cerebellum

A
  • coordination of voluntary movement
  • maintenance of balance and posture
  • cognitive function
  • motor learning
  • comparator
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3
Q

cerebellar coordination of voluntary movement

A
  • Refines control of multiple joints working together
  • Coordinate timing and force
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4
Q

cerebellar maintenance of balance and posture

A
  • Postural adjustments
  • Comparison of intention with
    afferent information- cerebellum alters signals to motor efferents to modify body position
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5
Q

cerebellar cognitive function

A
  • attention
  • rhythm of language
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6
Q

cerebellar motor learning

A
  • Trial and error in learning
  • Procedural learning- adaptation, fine tuning based on intention and feedback
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7
Q

Cerebellum acting as comparator

A
  • Cerebellum Predicts Movement as Movement Occurs
  • Compensates for errors in movement by comparing
    intention of movement with performance
  • This drives adaptation and learning
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8
Q

Gaze stability

A

Direct Projections from vestibular nuclei to cerebellum allow us to compare head movement to the clarity of visual image, to adjust and modify VOR as necessary

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9
Q

Cerebellum has a role for objects that are….

A

in motion, at variable speeds, and variable directions

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10
Q

Things to watch for when observing voluntary movements

A
  • Accuracy
  • Velocity
  • Range
  • Direction
  • Rhythm
  • Speed
  • Safety
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11
Q

Postural control

A
  • Compare our movements to
    movements of environment and modify responses to intention
  • Direct projections from sensory systems allow this to happen automatically based on previous experiences
  • Short Latency Responses
  • Medium Latency Responses
  • Long Latency Responses
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12
Q

inputs to cerebellum

A
  • Information into cerebellum from cortex regarding intended movements
  • Information from brainstem and spinal cord from sensory receptors regarding actual movement
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13
Q

Anatomical input to superior peduncle

A

primary motor efferent effect limb movement

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14
Q

anatomical input to middle peduncle

A

sensory afferent including proprioception, auditory, visual, and somatosensory information

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15
Q

anatomical input to inferior peduncle

A

afferent tracts of proprioception information, efferents affecting axial muscle activity and postural control

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16
Q

functional anatomy - spinocerebellum

A
  • Output primarily focused on axial and limb musculature
  • Produces adaptive motor coordination- error correction
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17
Q

Injury to spino-cerebellum can produce:

A
  • Hypotonia with weakness/ fatigue
  • Truncal ataxia
  • Static postural tremor and increased postural sway
  • Wide BOS, high guard arm position
  • Poor anticipatory postural control
  • Impaired adaptive motor coordination
  • Abnormal balance responses
  • Difficulties with automatic gait
  • Dyssynergia
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18
Q

Functional anatomy - cerebrocerebellum

A
  • Planning and Timing of Movements
  • Cognitive Functions related to Cerebellum/Important in visually guided movements
  • Ipsilateral symptoms typical
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19
Q

injury to cerebrocerebellum can result in:

A
  • Impaired coordination- planning/timing of movements * Deficits in motor learning
  • Impaired initiation of movement
  • Impaired speech patterns
  • Multi-segmental movement decomposition (dyssynergia)
  • Dysmetria
  • Dysdiodochokinesia
  • Intention Tremor
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20
Q

Functional Anatomy - Flocculonodular Lobe

A
  • Central vestibular symptoms- poor eye pursuit, VOR,
    impaired eye-hand coordination
  • Gait and trunk ataxia, poor postural control, wide based gait
  • Complaints of dizziness/imbalance
  • Little change in tone or dyssynergia of extremities
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21
Q

Possible diseases/ lesions to cerebellum

A
  • Hereditary ataxia, Friedreich’s ataxia
  • Neoplastic or metastatic tumors
  • Infection
  • Vascular stroke
  • Developmental- ataxia, cerebral palsy, Arnold-Chiari syndrome
  • Trauma-TBI
  • Drugs, heavy metals
  • Chronic alcoholism
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22
Q

Cerebellar Stroke - Anterior Inferior Cerebellar Artery (12%)

A
  • Isolated vestibular syndrome- vertigo, with auditory symptoms such as hearing loss
  • Lateral Pontine Syndrome
  • Mid-basilar Syndrome
  • Hemifacial paralysis, Horner
    syndrome, gait and ipsilateral limb ataxia
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23
Q

Cerebellar Stroke - Superior Cerebellar Artery (36%)

A
  • Acute Gait or trunk instability with associated dysarthria, nausea, vomiting
  • Lateral midbrain Syndrome
  • Top-Basilar Syndrome
  • Oculomotor palsy
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24
Q

Cerebellar Stroke - Posterior Inferior Cerebellar Artery (40%)

A
  • Isolated acute vestibular syndrome without auditory symptoms
  • Lateral medullary syndrome
  • Vertebral artery syndrome
  • Leaning ipsilateral to lesion (lateropulsion)
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25
Q

Mass Effect impact on cerebellum

A
  • Hemorrhagic CVA to cortex or cerebellum can cause
    mass effect
  • Risk of herniation of brainstem and Cerebellum
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26
Q

What is Arnold Chiari Malformation?

A
  • Parts of the cerebellum or brainstem herniate
    into spinal column
  • Three types- 1, 2, 3 (3 being most severe)
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27
Q

Symptoms of Arnold Chiari Malformation

A
  • Neck Pain (type 1)
  • Unsteady gait
  • Poor coordination
  • Numbness/tingling
  • Dizziness
  • Swallowing issues
  • Speech and breathing problems
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28
Q

Impairments involved with Arnold Chiari Malformation

A
  • Reduced ability to use predictive, fast, automatic movements
  • Reduced ability to learn from errors in movements or use trial and error learning
  • Impaired motor coordination of voluntary muscle movement
  • Impaired movement adaptation
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29
Q

3 hallmarks of impaired motor coordination

A
  • ataxia
  • intention tremor
  • dysmetria
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30
Q

Cerebellar impairments - motor forces

A
  • Poor prediction of inertia of extremity
  • Poor perception of active forces
  • Poor prediction of torque interactions
  • Impaired force scaling
  • Longer lever arm, more impairment likely observed
  • Passive proprioception likely to remain intact
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31
Q

Lateropulsion

A

leaning to side of lesion

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32
Q

what is the hallmark of a PICA stroke

A

ipsilateral lateropulsion

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33
Q

grading severity of lateropulsion

A
  • 1- Head and body tilt without imbalance
  • 2- head and body tilt, with considerable
    sway/imbalance, no falls
  • 3- head and body tilt, falls with only eyes closed
  • 4- head and body tilt, falls with eyes open
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34
Q

Prognosis for lateropulsion

A
  • Grade IV to become Grade III- 25 days
  • Grade III to become Grade II- 19 days
  • Grade II to become Grade I- 32 days
    ** they will recovery but it delays the process
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35
Q

cognitive impairments

A
  • Executive function
  • Visual Spatial Processing
  • Affective Dysregulation
  • Linguistic Impairments
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36
Q

Motor planning/ motor execution stages

A
  • Initiation
  • Execution
  • Timing
  • Due to deficits in timing, accuracy, smoothness
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37
Q

Cerebellar ataxia

A
  • Due to damage or dysfunction affecting the cerebellum and/or its input/output pathways
  • Cerebellum can’t use error information to update its prediction
  • Hereditary or Acquired
38
Q

Signs/ Symptoms of cerebellar ataxia

A
  • Limb movement
  • Balance and gait dysfunction * Oculomotor
  • Dysarthria
39
Q

Deficits in motor planning

A
  • Increased reaction time/ initiation time- slow to start movements
  • Movements are prolonged in duration
  • Movements show decreased maximal velocity
  • Movements show an increase in spatial variability- path varies from trial to trial
40
Q

What is dyssynergy

A
  • Decomposition of movement * Lack of coordination between agonist, antagonist, and other synergic muscles resulting in an absence of the normally smooth, sequential performance of various components of an action
41
Q

Errors occur in the relative timing of segmental components and multi-joint movements

A
  • Inability to compensate for movement-associated interaction torques
  • Decompose their movements into simpler, more accurate single joint movements
42
Q

deficits in countering interaction torques

A
  • Move faster- unable to adjust interaction torques
  • Abnormal patterns/path of movement
  • Hypermetric and overshooting of target
  • Move slower and accurately- tend to decompose the reach into a series of shoulder movements, then elbow movements, then over/ undershoot target
  • Incoordination between eye, arm, leg or head
43
Q

Dysmetria

A
  • Inaccurate amplitude of
    movement due to impairment in timing of muscle force
  • Prolonged duration of initial
    agonist contraction that accelerate the limb
  • Delay in onset of subsequent
    antagonist muscles to decelerate
  • Results in difficulty
    controlling the termination of movement, decelerating movement
  • Rebound phenomenon
44
Q

Action Tremor

A

impairment due to
alternating contractions of agonists and antagonists

45
Q

Postural tremor

A

seen while trying to maintain a posture

46
Q

intention tremor

A
  • seen while moving, oscillatory movement about a joint.
  • Most marked at end range because of delay in visuomotor processing
    compounding the presence of an already incoordinate movement
47
Q

6 Areas of deficits in cerebellar strokes

A
  • Poor coordination and grading of muscle power
  • reduced postural control, muscle tone and tremor
  • altered timing
  • reduced ability to consolidate learning
  • reduced ability to adapt to environmental changes
  • reduced ability to learn from movement error
48
Q

poor coordination and grading of muscle power

A
  • Impaired cerebellar processing of simultaneously incoming information from cerebral cortex (intended movement) and sensory
    receptors (actual movement)
  • Cerebellum processes to produce movement with appropriate power –> Injury gives inappropriate coordination and grading
49
Q

poor coordination and grading of muscle power - rehabilitation strategies

A
  • Exercises to improve postural stability
  • Reducing degrees of freedom
  • Provision of external support- AD, orthotics
  • Target underlying postural instability, minimize compensations
  • Slow movements down
  • Limit complex combinations
50
Q

Reduced postural control, muscle tone and tremor

A

altered regulation of descending motor pathways

51
Q

Reduced Postural Control, Muscle Tone and Tremor- Rehabilitation Strategies

A
  • Specific strength and balance training
  • Compensatory strategies to increase stability – wider base of support, slower movement
  • Environmental cues to prepare
  • Assistive Devices
  • Caution about progressing to fast
52
Q

Altered timing - mechanisms

A

impaired functioning of automatic control centers

53
Q

altered timing - rehabilitation strategies

A
  • Conscious attention
  • Use of visual cues
  • Use of assistive device
  • Avoidance of secondary tasks
54
Q

reduced ability to consolidate learning - mechanism

A

impaired plasticity within deep cerebellar nuclei

55
Q

Reduced ability to consolidate learning- Rehabilitation Strategies

A
  • High Intensity of Practice
  • Conscious attention to activity
    ** high reps
56
Q

Reduced ability to adapt to environmental changes

A
  • Impairment in climbing fiber- Purkinje cell system
  • Climbing fibers in inferior olive usually fire when there is an unexpected body movement (error signal)
  • Usually this triggers strong Purkinje response and adaptive movement
    is initiated
  • When injured this dysfunction negatively impacts the ability to respond to error signal
  • Normal learning from trial and error will be impaired
57
Q

Reduced ability to adapt to environmental changes- Rehabilitation Strategies

A
  • Graded exposure to environmental challenges
  • Set up environment to reduce unexpected movement demands
  • Sensory cues/prompts
  • Conscious attention to walking rather than relying on automatic response execution
58
Q

Reduced ability to learn from movement error- Mechanism

A
  • Impaired plasticity between Purkinje cell and parallel fibers
  • Cerebellar stroke- significantly impacts procedural memory- unconscious recall
  • May mean required to focus on declarative memory- conscious recall- may mean increased need for practice to not have skill deteriorate
59
Q

Impaired plasticity between Purkinje cell and parallel fibers

A
  • Simultaneous firing of climbing fiber (which can signal error in movement)
    and parallel fiber (signaling intended movement) causes a long-term depressing of synapses that control that movement
  • Weakening this pathway and therefore subsequent learning
60
Q

Reduced ability to learn from movement error- Rehabilitation Strategies

A
  • Use stepwise prompts to learn rather than trial and error (explicit cues)
  • Consider patient discussion of task before task performed * High Levels of repetition
  • Conscious attention to activity (walking for example) rather than relying on automatic execution
  • Learning in short sequences
  • High repetitions
  • Salient highly engaging activity
61
Q

General Therapeutic principles

A
  • Train to control during performance of functional movement
  • Safely challenge the patient
  • Reinforce learning not focus on error learning
  • Consider practice environment
  • Slowly increase complexity
62
Q

training to control during performance of functional movements

A
  • Reduce complexity of movement
  • Slow down movement
63
Q

Slowly increasing complexity

A
  • Decrease external control and supports
  • Reduce attentional demands to encourage automaticity
  • Speed alterations, changes in amplitude, direction, and force
64
Q

Gait training

A
  • Task specific training- Emphasis on short sequences of stepping and increasing difficulty gradually
  • Emphasis on conscious perception and control of body stability, limb control, and stepping
  • Subjects memorized and focused on sensory information
65
Q

should you add weighting?

A
  • may provide immediate benefit but no long term benefit
  • continue to reinforce inaccurate torque and grading issues and postural control once removed
  • just probs dont even do it
66
Q

rhythmic auditory stimulation

A

may have short term effect on improving stride length and velocity and decreased variability

67
Q

early management

A
  • Use Declarative Learning
  • Sensory Cues
  • Success or failure of task
  • External supports
  • Fewer degrees of freedom
  • High repetitions
  • Short sequences of movement
68
Q

Four point position

A

Positioning patient in four point position limits degrees of freedom and can produce opportunities to practice movements in simpler, controlled positions

69
Q

Tall kneeling

A

Positioning patient in tall kneeling position, transition from four point to tall
kneeling, intermediate position prior to standing

70
Q

Later management

A
  • Carefully graded challenges
  • Increase dual task and task complexity
  • Increase challenge of environment
  • Increase speed of movement
71
Q

What is meningitis

A

inflammation of the membranes of the brain or spinal cord

72
Q

what causes meningitis

A

typically an infection
- can be bacterial or viral

73
Q

symptoms of meningitis

A
  • headache, fever, stiff
    neck; may also include irritability, confusion, light sensitivity, increased HR and RR, lethargy
74
Q

Kernig’s Sign

A

resistance to extension of leg while hip is flexed

75
Q

medical management of meningitis

A

Antibacterial if Bacterial, treatment of viral meningitis is symptomatic- fluids, pain, corticosteroids if brain swelling, seizure medications, antivirals

76
Q

PT treatment of meningitis

A

support symptomatic therapy, bed positioning, PROM, managing complications of immobility, safety to regain function when appropriate

77
Q

What is encephalitis

A

inflammation of the brain due to infection

78
Q

primary encephalitis

A

caused by virus (herpes, Epstein Barr) or mosquito borne (West Nile), Tick borne, rabies virus

79
Q

secondary encephalitis

A

faulty immune reaction to infection

80
Q

symptoms of encephalitis

A

may be mild such as fever, headaches, achy muscle/joints,
fatigue, weakness

81
Q

symptoms of when encephalitis becomes life threatening

A

confusion, agitation, hallucinations, muscle weakness, paralysis, loss of consciousness

82
Q

Treatment of mild encephalitis

A

bedrest, fluids, anti-
inflammatory drugs, antivirals,
cortico-steroids

83
Q

Therapy goals for encephalitis

A
  • supportive, then symptomatic
  • May cause injury to the brain and require assistance for
    strengthening, balance,
    coordination, functional mobility- once medically stable
84
Q

What is transverse myelitis

A

inflammation of one section of the spinal cord

85
Q

etiology of transverse myelitis

A

viral, bacterial, fungal, immune system disorder, autoimmune disorder, other myeline disorders (MS)

86
Q

when do symptoms of transverse myelitis develop

A

over hours to days

87
Q

does transverse myelitis affect one or both sides of body below the lesion?

A

both

88
Q

symptoms of transverse myelitis

A

Pain- sharp shooting back pain or down extremities,
abnormal sensation, weakness progressing to paralysis, stiffness to spasticity, fatigue, bowel/bladder

89
Q

Medical Management of Transverse Myelitis

A

IV steroids, Plasma exchange, intravenous immunoglobulin
(IVIG), symptom management

90
Q

Prognosis of medical myelitis

A

most achieve at least partial recovery, most recovery in
first 3 months, but can expand to 2 years

91
Q

PT exam and treatment of medical myelitis

A

similar to spinal cord injury

Neuro Eval II (16 decks)

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