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Neuro 2 > Cerebellar Disorders > Flashcards

Cerebellar Disorders Flashcards

1
Q

Role of the cerebellum

A
  1. Multiple roles in motor learning and skill acquisition
  2. Modifying movements based on learning
  3. Motor learning and skill acquisition
  4. Gaze stability, postural responses
  5. Learning
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2
Q

Primary actions of Cerebellum

A
  1. Coordination of voluntary movement — refines control of multiple joints working together and coordinates timing and force production
  2. Maintenance of balance and posture — involving postural adjustment and comparison of intention with afferent information — cerebellum then alters signals to motor effects to modify body positions
  3. Cognitive function — attention and rhythm of language
  4. Motor learning — trial and error in learning and procedural learning like adaptation, fine tuning based on intention and feedback
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3
Q

Cerebellum acts as a _________

A

Comparator
- cerebellum predicts movement as movement occurs
- Compensates for errors in movement by comparing intention of movement with performance
- all this drives adaptation and learning.

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4
Q

Cerebellum’s role in gaze stability

A
  • Cerebellum has a role for motions that are in motion, at variable speeds, and variable directions
  • Direct projections from vestibular nuclei to cerebellum allow us to compare head movements to the clarity of visual image, to adjust and modify VOR as necessary.
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5
Q

What are we looking for when observing voluntary movement

A
  1. Accuracy
  2. Velocity
  3. Range
  4. Direction
  5. Rhythm
  6. Speed
  7. Safety
    analyzing the accuracy of movement. If the patient has good strength and good sensory input what’s left? Cerebellum. Really need all three (cerebellum, strength, sensory input) to have accurate movements
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6
Q

Postural control

A
  • Compare out movements to movements of the environment and modify responses to intention
  • Direct projections from sensory system allows this to happen automatically and based on previous experience.
  • SHORT, MEDIUM, LONG latency responses
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7
Q

Short vs. Medium vs. Long latency responses

A

Short — things we do without even thinking about it. No cog load here at all
Medium — more of a stepping reaction or rescue reaction because there is starting to be some cog load here plus some executive function
Long — even more cog and executive function here

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8
Q

Inputs to the cerebellum

A
  1. Information into cerebellum from cortex regarding intended movements
  2. Information from brainstem and SC from sensory receptors regarding actual movement
  3. Cerebellum = great comparator
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9
Q

Anatomical input to cerebellum

A

Superior peduncle — primary motor efferent effects limb movement

Middle peduncle — sensory afferent including proprioception, auditory visual, and somatosensory info

Inferior peduncle — afferent tracts of proprioception info, efferent affecting axial muscle activity and postural control.

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10
Q

Spinocerebellum functional anatomy

A
  • Outputs primarily focused on axial and limb musculature
  • Produces adaptive motor coordination and error correction.
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11
Q

Injury to Spinocerebellum

A
  1. Hypotonia with weakness/fatigue
  2. Truncal ataxia (hallmark)
  3. Static postural tremor and increased postural sway
  4. Wide BOS with high guard arms
  5. Poor APA
  6. Impaired adaptive motor coordination
  7. Abnormal balance responses
  8. Difficulties with automatic gait
  9. Dyssynergia
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12
Q

Cerebrocerebellum functional anatomy

A
  • planning and timing of movements
  • cognitive functions related to cerebellum which are important in visually guided movements
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13
Q

Injury to cerebrocerebellum

A

usually ipsilateral symptoms
1. Impaired coordination — planning and timing of movements if oss
2. Deficits in motor learning
3. Impaired initiation of movements
4. Impaired speech patterns
5. Multi-segmental movement decomposition (dyssynergia)
6. Dysmetria — over and under shooting, errors in force, direction, and amplitude.
7. Dysdiodochokinesia — impaired RAM
8. Intention tremor.

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14
Q

Injury to Flocculonodular Lobe

A
  • Central vestibular symptoms like poor eye pursuit, VOR, impaired eye-hand coordination
  • Gait and trunk ataxia, poor postural control, wide based gait
  • Complaints of dizziness and imbalance
  • Little change in tone or dyssynergia of extremities.
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15
Q

Anterior Inferior cerebellar artery stroke

A
  • Isolated vestibular syndrome like vertigo, with auditory symptoms like hearing loss.
  • Lateral pontine syndrome
  • Mid-basilar syndrome.
  • Hemi-facial paralysis, Horner syndrome, gait, and ipsilateral limb ataxia.
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16
Q

Superior cerebellar artery stroke

A
  • Acute gait or trunk instability with associated dysarthria, nausea, vomiting
  • Lateral midbrain syndrome
  • Top-Basilar syndrome
  • Ocuolomotor palsy
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17
Q

Posterior Inferior Cerebellar Artery stroke

A
  • Isolated acute vestibular syndrome without auditory symptoms like vertigo.
  • Lateral medullary syndrome
  • Vertebral artery syndrome
  • Leaning ipsilateral to lesion
  • Lateropulsion
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18
Q

Mass effect on cerebellum?

A

Hemorrhagic CVA to cortex or cerebellum can cause mass effect

Risk of herniation of brainstem and cerebellum

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19
Q

Arnold Chiari Malformation

A

Parts of cerebellum or brainstem herniate into spinal column

3 types — 3 is most severe

Symptoms: neck pain, unsteady gait, poor coordination, numbness/tingling, dizziness, swallowing issues, speech and breathing problems

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20
Q

Impairments from chiari malformations

A
  1. Reduced ability to use predictive, fast, automatic movements
  2. Reduced ability to learn from errors in movements or use trial and error learning — may have better learning from small errors.
  3. Impaired motor coordination of voluntary muscle movement — ataxia, intention tremor, dysmetria, poor movement precision and timing, difficult with multi-joint movements
  4. Impaired movement adaption
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21
Q

Motor forces impairments from cerebellum

A
  1. Poor prediction of inertia of extremity — under or over shooting
  2. Poor perception of active forces
  3. Poor prediction of torque interactions
  4. Impaired force scaling
  5. Longer lever arm, more impairment likely observed
  6. Passive proprioception likely to remain intact.
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22
Q

What is Lateropulsion

A

Leaning towards side of lesion
hallmark of PICA STROKE

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23
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.

its leaning because of poor perception of balance not a strength issue

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24
Q

Prognosis for Lateropulsion

A
  1. Grade IV to become Grade III = 25 days
  2. Grade III to become grade II = 19 days
  3. Grade II to become grade I = 32 days.

IT IS OKAY TO PUSH BACK HERE, NEED TO GET THEM IN MIDLINE

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25
Q

Cog impairments from cerebellum injury

A
  1. Executive function
  2. Visual spatial processing
  3. Affective desregulation
  4. Linguistic impairments
26
Q

Ataxia outcome measures

A
  1. ICARS - international co-operative ataxia rating scale = higher score = more impairments
  2. SARA - Scale for Assessment and rating of ataxia = higher score = more impairments
27
Q

What movement analysis phases do they have trouble with

A
  1. Initiation
  2. Execution
  3. Timing

Due to deficits in timing, accuracy, smoothness

28
Q

What is 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
  • Classis signs/symptoms
    — limb movement
    — balance and gait dysfunction
    — oculomotor
    — dysarthria
29
Q

Incoordination issues

A
  • Deficits in motor planning
    1. Increased reaction time/initiation time is slow
    2. Movements are prolonged in duration
    3. Movements show decreased maximal velocity
    4. Movements show an increase in spatial variability — path will vary from trial to trial.
30
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
  • Errors occur in the relative timing of segmental components and multi-joint movements
    — inability to compensate for movement associated interaction torques
    — best to decompose their movements into simpler, more accurate single joint movements.
31
Q

Deficits in countering interaction torques?

A

Present in people with cerebellar disorders
- if they move faster because unable to adjust interaction torques — the abnormal patterns/path of movement and hyper metric and overshooting of the target
- if they move slower and accurately — they tend to decompose the reach into a series of shoulder movements, then elbow movements, then over/under shoot the target
- there is an incoordination between eye, arm, leg, or head.

32
Q

What is dysmetria

A
  • Inaccurate amplitude of movement due to impairment in timing of muscle forces
  • Prolonged duration of initial agonist contraction that accelerates the limbs
  • Delay in onset of subsequent anatagonist muscles to decelerate
  • Results in difficulty controlling the termination of movement, decelerating movement,
  • Rebound phenomenon.
33
Q

What can be cerebellar tremors

A
  • Action tremor — impairment due to alternating contractions of agonist and antagonists
  • Postural tremor — seen while trying to maintain a posture
  • Intention tremor — 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.
34
Q

What are the 6 primary areas of deficits in cerebellar stroke?

A
  1. Poor coordination and grading of muscle power
  2. Reduced postural control, muscle tone, and tremor
  3. Altered timing
  4. Reduced ability to consolidate learning
  5. Reduced ability to adapt to environmental changes
  6. Reduced ability to learn from movement error
35
Q

Why is there poor coordination and grading of muscle power

A

There is impaired cerebellar processing of simultaneously incoming info from cerebral cortex (intended movement) and sensory receptors (actual movement)
- Cerebellum processes to produce movement with appropriate power - injury gives inappropriate coordination and grading.

36
Q

Rehabilitation strategies for poor coordination and grading of muscle power

A
  1. Exercise to improve postural stability — good to do this first.
  2. Reducing degrees of freedom — get them in quadruped.
  3. Provision of external support — AD that has some weight to it.
  4. Target underlying postural instability, minimize compensations
  5. Slow movements down — going fast means larger errors.
  6. Limit complex combinations
37
Q

Why is there reduced postural control, muscle tone, and tremor

A

There is altered regulation of descending motor pathways

38
Q

Rehab strategies for reduced postural control, muscle tone, and tremor

A
  1. Specific strength and balance training
  2. Compensatory strategies to increase stability — get wider BOS and slower movement
  3. Environmental cues to prepare
  4. Assistive devices
  5. Caution about progressing to fast.
39
Q

Why is there altered timing

A

Because impaired functioning of automatic control centers

40
Q

Rehab strategies for altered timing

A
  1. Conscious attention — BIG THING
  2. Use of visual cues
  3. Use of AD
  4. Avoidance of secondary tasks
41
Q

Why is there reduced ability to consolidate learning

A

Because impaired plasticity within deep cerebellar nuclei

42
Q

Rehab strategies for reduced ability to consolidate learning

A
  1. High intensity of practice
  2. Conscious attention to activity
43
Q

Why is there reduced ability to adapt to environmental changes

A
  • Impairment in climbing fibers — purkinje cell system
  • Climbing fivers in inferior olive usually fire when there is an unexpected body movements
  • usually this triggers 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
44
Q

Rehab strategies for reduced ability to adapt to environmental changes

A
  1. Graded exposure to environmental challenges
  2. Set up environment to reduce unexpected movement demands
  3. Sensory cues/prompts
  4. Conscious attention to walking rather than relying on automatic response execution
45
Q

Why is there reduced ability to learn from movement error

A
  1. Impaired plasticity between purkinje cell and parallel fibers
    — simultaneous firing climbing fiber and parallel fiber causes a long term depressing of synapses that control that movement
    — Weakening this pathway and therefore subsequent learning
    — Cerebellar stroke — significantly impacts procedural memory and unconscious recall
    — May mean required to focus on declarative memory, conscious recall.
46
Q

Rehab strategies for the reduced ability to learn from movement error

A
  1. Use stepwise prompts to learn rather than rial and error
  2. Consider patient discussion of task before task is performed
  3. High levels of repetition
  4. Conscious attention to activity rather than relying on automatic execution
  5. Learning in short sequences
  6. High reps
  7. Salient highly engaging activity
47
Q

What are general therapeutic principles

A
  1. Train to control during performance of functional movements — reducing complexity of movement and slowing it down
  2. Safely challenge the patient
  3. Reinforce learning not focus on error learning
  4. Slowly increase complexity — decrease external control and supports, reduce attentional demands to encourage automaticity, and use speed alterations, amplitude, direction, and force changes
48
Q

Gait training with cerebellar injuries

A
  1. Task specific training — emphasis on short sequences of stepping and increasing difficulty gradually.
  2. Emphasis on conscious perception and control of body stability, limb control, and stepping.
  3. Subjects memorized and focused on sensory information
49
Q

Does adding weight to the limbs help

A

Maybe immediate benefit but no long term benefit
— continue to reinforce inaccurate torque and grading issues and postural control once removed.

50
Q

What about use of rhythmic auditory stimulation

A

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

51
Q

Early management with cerebellar injuries

A
  1. Use declarative learning
  2. Sensory cues
  3. Success or failure of task
  4. External supports
  5. Fewer degrees of freedom
  6. High reps
  7. Short sequences of movement
52
Q

What is four point position

A

Positioning patient in quadruped limits degrees of freedom and can produce opportunities to practice movements in simpler, controlled positions.
Promotes trunk control and helps with reaching tasks.

53
Q

What is tall kneeling good for

A

Position patient in tall kneeling, transition from quadruped — can serve as an intermediate position to standing
— promotes trunk control, helps with reaching tasks, helps with hip extension trunk control transitions.

54
Q

What is later management for cerebellar

A
  1. Carefully graded challenges
  2. Increase dual task and task complexity
  3. Increase challenge of movement
  4. Increase speed of movement
55
Q

What is meningitis

A
  1. Inflammation of membranes of brain or SC
  2. Typically caused by an infection — can be bacterial or viral
  3. Symptom include headache, fever, stiff neck, may also include irritability, confusion, light sensitivity, increased HR and RR, lethargy
  4. Kernig’s sign
56
Q

Treatment for meningitis

A
  1. Medical management — antibacterial if bacterial. Symptomatic fluids, pain, corticosteroids, if brain has swelling, seizure medications, antivirals
  2. PT — suport symptomatic therapy, bed positioning, PROM, managing complications of immobility, safety to regain function when appropriate.
57
Q

What is encephalitis

A
  1. Inflammation of the brain, often due to infection
  2. Primary caused by virus or mosquito borne, tick borne, rabies
  3. Secondary — fault immune reaction to infection
  4. Symptoms — may be mild like fever, headaches, achy muscle/joints, fatigue, weakness.
  5. Life threatening — confusion, agitation, hallucinations, muscle weakness, paralysis, loss consciousness
  6. Dx — imaging, blood tests, LP
58
Q

Treatment for encephalitis

A

Mild — bedrest, fluids, anti-inflammatory drugs, antivirals, cortico-steroids
Therapy goals — supportive, then symptomatic
- May cause injury to brain and require assistance for strengthening, balance, coordination, functional mobility once medically stable.

59
Q

What is transverse myelitis

A

Inflammation of one section of the spinal cord
- Etiology — viral, bacterial, fungal, immune system disorder, autoimmune disorder, other myelin disorders
- Symptoms - usually develop over hours to days: sharp shooting back pain or down extremities, abnormal sensation, weakness progressing to paralysis, stiffness to spasticity, fatigue, bowel/bladder
- Usualy affects both sides of body below level of lesion.
- Dx — med history, nerve function test, MRI, LP, blood tests

60
Q

Treatment for Transverse Myelitis

A
  1. Medical — IV, plasma enhance, intravenous immunoglobulin, symptom management
  2. Prognosis — most achieve at least partial recovery, most recovery him first 3 months, but can expand to 2 years.
  3. PT exam and treatment very similar to SCI

Neuro 2 (8 decks)

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