Lecture 1: The Neurologic Examination (class 1 and 2) Flashcards
Relook at sylabus - she has important shit there for quiz/examn shit
With every assessment tool, ask:
What could be the cause of the damage leading to this impairment or functional limitation?
* Where: CNS vs PNS
* Why: ex- degenerative disease (huntingtons/parkinsons - degenerate over time), traumatic injury (gunshot)
* How: ex- lesion in the brain (tumor), blood supply diminished (stroke)
Knowing this info will affect pt prognosis which will alter the treatment given to that pt
* we wouldnt be setting gait goals for someone w/ a complete injury at C5
Link all this to function
* we want to see how function is affected
* “ROM degree so they can reach up into a cabinant
Type of PT settings:
* NOTE: w/ stroke if you do a lot too soon you could make it worse
Acute Care: Short time frame w/ Pt, severity of illness is high
* This is right after the incident
Inpatient rehab: Out of acute care and into this where they stay for several days –> a week or 2.
* Used to be able to stay for a month+
* Go here instead of home because of something saftey wise
* They need 3 hours/day of rehab here - needs to be some combo of PT and OT (this is lots of SCI because they’re so impaired
Skilled Nursing Facility:
* This is less intensive care than inpatient rehab ~1.5 hours
* more there for monitoring medications and not quite as much therapy
Long Term Acute Care Facility:
* For pts that dont have the proper support at home
* typically more serious injuries (think someone whose ventilator dependent that can’t be managed at home)
* could also be something like wound care is needed and it could take weeks - well they arent going to be in inpatient rehab for that but they also arent going to want to go home yet
* Sometimes they don’t go home at all after this
Outpatient:
* Come from home
* Any type of frequency here
Home Health Care:
* Have to be homebound to utilize this
* Someone comes to the house for 1:1 care
Assisted living:
* Some kind of neursing/memory care
* pt has help w/ many tasks throughout the day
How many hours/day does a pt need in inpatient Rehab
3+ hours (some combo of speech + OT + PT)
Whats more intensive, skilled nursing facility or inpatient rehab?
Inpatient rehab
* ~3 hours/day between multiple different diciplins
Neuro Eval:
* Establih the diagnosis of underlying impairments (body structure and function)
* Establish the activity limitations and participation restrictions (ICF model)
* Establishing goals to remediate impairments and formulating expected outcomes that encompass remediation of activity limiations and participation restrictions
Supports:
* Decision making in establishing a prognosis and determining specific, direct interventions
UMN lesions:
* Location
* Tone (velocity independent or dependent)
* Reflexes (clonus?)
* Are there muscle spasms w/ this?
* what happens to strength?
* Is there atrophy or hypertrophy
* What happens to voluntary movements?
In CNS (brainstem/spinal cord)
Kind of injuries that affect: Stroke, TBI, SCI
TONE:
* Increase hypertonia
* Velocity depdent
Reflexes
* Hyperreflexia
* Clonus
* Exaggereated cutaneous and autonomic reflexes +Babinski
Involuntary movements: muscle spasms (flexor/extsor)
Strength:
* Weakness or paralysis
* ipsilatearl (stroke) or bilatearl (SCI)
Atrophy
Voluntary movements are impaired or absent
LMN lesions:
* Location
* 5 things that cause it to happen
* Tone
* Velocity idnependent or dependent
* Reflexes?
* Is weakness bilatearl? whats the distribution like?
* Is there muscle hyeprtorphy or atrophy
* What happens to voluntary movements
Happens when cranial nerbe nuclei / nerves/ spinal roots / spinal nerves / peripheral nerves are impacted
Often happen w/
* Polio
* Gullain-Barre
* Peripherl nerve injury
* Peripheral neuropathy
* radiulopathy
Tone:
* decreased or absent - hypotonia, flaccidity
* velocity independent
Reflexes:
* decreased or absent
* hyporeflexia
Ipsilatearl weakness or paralysis
* Limited distribution: segmental or focal pattern, root innervated pattern
Muscle atrophy / severe wasting
Voluntary movements: Weak or absent if nerve interrupted
Is there clonus w/ UMN’s lesions or LMN lesions?
UMN
Muscle syngery is what
When muscles come together to create a movement
* these are abnormal after neuro injuries
* think trying to reach up to a shelf and hand curling = abnormal synergy
* think this is UMN lesions
CNS disorders
after stroke you will have shock
* note: some people keep hypotonicity and never get that tone back
Think about where the anatomy is and what might present
* basal ganglia in parkinsons - for involuntary movements we might see a tremor
* whereas for stroke we might see a spasm (has to do w/ that clonus / hypertonciity that comes w/ that UMN lesion)
This is a good summary table
DCML is what kind of information
Proprioception
Light Touch
Vibration
Corticospinal tract is what kind of information? - quiz
Motor
* fractionization of movement (ability to move one area of the body independent of another)
* intentional voluntary movement
Spinothalamic tract is what kind of information
Pain
Temp
Crude touch
Usually when someone gets more tone post stroke thats a good thing because now you can put weight on that area and use it
Knowledge check: consistent w/ UMN lesion:
* spasticity, atrophy, hyperflexia
* note a lot of people put hypertrophy and that was wrong
Neuro Eval Subjective:
History: Might be pt or caregiver depennding on if they’re a good historian
* Since were proably in inpatient we might be able to get info from nurse/OT - anyone whose in inpatient working w/ them
First impression of cognition and communcation is very important
Need to account for medication that may be affecting them cognitively
Probs pull in template from outpatient clinic and were going to modify it
* think about a histroy taking template and how it would differ between outpatient and inpatient
Patient Interview - acute care/inpatient
* Chief complaint - as them whats going on (however, they’ve already been questioned by other people at this point so this information will already be better known than in an outpatient setting)
* Prior level of function vs current level of function (what was different before the incident vs now - think falling weekly w/ MS vs before MS diagnosis = wasnt falling at all - need to figure out if its a relapse, medication issue, got to pick those things out and figure out wahts going on
* Medications - super important to see what someones on - a lot of the neuro meds interact and cause side effects
* Social situation/living environment
* Diagnostic tests/medical apointments prior
* Direct medial equipment / assistive devices - do they use these if they’re prescribed them? are they even prescribed them? - often times neuro pts will have tons of devices, however, they dont use them correctly or how/when to use them
* fall hx
* patient goals - goal setting in acute care is typically much easier goals (just moving etc…)
* depression screening (those 2 questions)
* Elder abuse screen
This is not a comprehensive list
Neuro Exam Objective -
Observation/posture - during hx while patient not “being assessed” - can even do this while talking to the nurse - key is that they’re not paying attention
Systems review. **Leads us to what we need to test in more detail. we screen out things –> assess
Functional mobility skills/postural stability
* things like “can they stand” support or unsupported
* can they sit supported or unsupported
* get back to those lower level tasks
Balance/postural control
Standarized tests/outcome measures - directly releates to goal setting
* use these tests to write goals
* “Pt will complete TUG in no greater than 13 seconds with least restrictive assistive device to improve saftey with ambulation”
* use these to srt goals because they are standarized / have cut off goals etc..
Screen vs comprehensive exam - some things need to be in more detail and some don’t
* if my pt is cognitvely intact and completely aware and i ask them about their sensation and they say its fine than she normally doesnt test - she screened it out w/o diving into a test / comprehensive exam
Special Tests: they have these in neuro as well as ortho
* there are special vision tests etc…
How motor control fits in
* we might observe abrent movements (clunky bad movements) and we might describe that
* however, theres no 1 specific test because its in everythign - ability to execute smoothly is in everything - some tests give us information on motor contorl, but no were not saying absent motor control due to this test. We could say “they have fine motor contorl evident by their ability to pick something off the ground” - can be broken down into fine and gross
* NOTE: this is done by the corticospinal tract
Outcome measures for lower extremity strength
* 5 times sit to stand
* 30 second sit to stand
Balance test
* Burg balance test
Gait test
* TUG
* 6 minute walk test
* 2 minute walk test
* Gait speed
write goals from these
How we execute so many tasks skillfully / precisely
* what tract affects this
Motor control
If were unable to execute tasks w/ proper motor skills were lacking motor contorl
ability to take on demands
* cognitive and motor
Corticospinal tract
pt had stroke to L hemisphere, what is their involved side?
R side of the body is the “involved side” - this is the weaker side
* So its named based on the side of the body impaired not the side of the brain
* Corticospinal tract decusates in the medulla so it crosses which is why its contralatearlly involved
Movement analysis/Task analysis = how the pt moves
* just ask the pt to move in some way that you’re interested in
* Nurses have the tendency to help more, we want to pt to actually move
A task analysis would be having them do some task
We would note what the pt can do and where you have to intervene
* don’t give them cueing right away, see how they do on their own
Keep in mind their assistive devices - test them w/ what they usually use
* becomes tricky when they want to ween off a device
* need to use a similar assistive device in both tests
First thing you often want to do w/ neuro pts is see if they’re alert and oreinted
* when you’re doing your eval you want to note what setting your in, what your goal is, and what the pt can tolerate
* always be safe (always look at vitals)
* look at cognitiion throughout
She said shes often not testing MMT and ROM that kind of impairment level stuff - shes doing more functional testing - those functional tests take time and energy which are limited in this setting and you get more out of those fuctional tests to see what the pt can do
Have to be fluid in the order of things in the eval because things come up that could change everything “I need to go to the bathroom now” changes what you’re assessing now
eval timeframe changes based on the setting / tolerance of pt
Screening:
* orthostatic hypotension pt comes in. We do a few screening tests to see if its OH or a vestibular issue.
* we can look at vital signs in multiple different positions to see if its OH - were screening that system - “Ok thats normal now I need to go into my vestibular special tests”
Screening to further assess and determine
purpose of screening
Technique used by healthcare providers to gather a patients medical hx
* A series of questions asled to identify a patients symptoms or signs. Its a subjective account of the patients experience, and can be used to identify conditions that dont have a specific diagnosis.
* Discuss anything new, unusual, unexplained, different
* determine need for referral for medical evaluation
* review medical screen and ROS form with the pt - so reviewing their systems w/ the pt - more converstational
Physical therapists seek ifnormation relevant to major body systems through observation and questioning to help determine whether there are symptoms that suggest the need for referral for additional medical evaluation
Someone notes something on their past medical hx and I want to know more about it. Then im probing more and getting more information
maybe intake just says numbness and tingling. Well I want to know more about that
review of systems
A limited set of tests and measures performed by a therapist to plan the rest of an examination. Its the beginning of the hands on part of the examination
This is the screening to asses
Also called gross screen/exam
* can screen things like:
* Vital signs
* Cognition
* Communication
* Cardiovasular and pulmonary
* Integ
* neurmuscular
* MSK
* overall movement
Systems review
* S for screening
Our systems review is like our screening, while our review of systems is like our observation or converstaions about anything new in medical hx
* can do review of systems if something new happened - think unexplained weight loss
* Systems review typically done on eval day
Comprehensive neurologic examination
autonomic function = vital signs
postural stability = moving
postural contorl = how we control ourselves in situations that are either static or dynamic
Knowledge check: Main goal of systems review
* Screen to lead to furtehr assessment
* S for screen
Screen leads us to what we need to asses further
A&Ox4 means
Person (self)
Place
Time
Situation
OT does a lot w/ cognition as well as speech
* were not nearly as invovled w/ this
What is the norm for the MOCA?
> / 26
its scored out of 30
Expressive aphasia =
Brocka aphasia
They have the words they just can’t get them out
would want to use yes/no questions
aphasia
a language disorder that affects a person’s ability to understand and express language, as well as read and write
Expressive aphsia
Nicki aphasia
They’re talking loads but the words make 0 sense
Non verbal gestures are best here
Goal directed behavior
Executive function
levels of consciousness decreasing
No point in cognitive testing when pt is in a stupor
* someone can be confused and can take this test and we might get useful information
* however this is less our scope for PT
* can do a MOCA to show why the PT might benefit from seeing an OT etc…
Tests for language and speech are going to be in that MOCA
There are specific special tests we can do to get more information
think stereognosis (what you’re holding) test. Its a sensation test, however, you need higher level congitive thinking to figure out what you’re holding in your hand.
Autonomic testing
A drop of more than _ systolic or more than _ diastolic indications orthostatic hypotension
A heart rate increase of _ BPM after moving from supine to standing
what causes OH
20 systolic
10 diastolic
20 BPM
all these indicate OH
NOTE: this could be failure of the sympathetic NS to adequality constrict blood vessels in the lower body
* blood loss
* anemia
* dehydration
NOTE: OH is common in parkinsons, and this is super bad because it can lead to falling
Other autonomic testing
( bladder, bowel and sexual functions - questionniare / hx taking
Which lvl of consciousness would PT exam be least sucessful
* Stupor (the lower the worse) / obtunded / stupor / coma all not great
I think lethargic is where PT exam starts being helpful
Skipped to tone portion of lecture (slide 55) - NOTE: The lab stuff is fair game for the written exam
What is muscle tone?
Resting tension in muscle (resistance to stretch in the muscle)
* remember, tone is normal, however you can have too much or to little of it
Resistance to stretch in the muscle
Tone
* so for most people this tone is enough to support us and keep us upright but that doesnt doesnt really impact a normal ROM. You can have high tone that does stop that full ROM though
Is tone testing done actively or passively?
Passively (which is why its always tested in supine)
NOTE: If it was active then we would be adding in muscle strength, which is not what were testing
When muscle tone is considered normal what is resistance to passive stretch like (think someone taking your arm in full ROM)
Minimal - you’re not going to resist that person much. Normal resting tone doesnt block you from moving that limb/body part in that ROM
A range of normal tone exists among healthy individuals - its not like your spastic if your tight.
Is tone a test of muscle length?
No! you’re working in a patients available ROM.
* if someone has a contracture or is lacking for range, its not like you’re going to push them into that full range. You’re just looking for tone issues in their available ROM
What does flaccidity mean?
* What kind of pts get this?
Complete lack of resistance to passive stretch (no tone) - think floppy - you go to pick up their limb and it just falls down
* This is LMN pts or the shock phase of a SCI (UMN)
What does hypotonia mean
* what kind of pts get these?
abnormally low tone (but some tone still exists unlike flacidity)
* These again are those LMN pts or the shock phase following a SCI
Define spasticity
* What kind of pts get these?
Velocity-dependent hypertonia
* UMN pts
Velocity dependent means that it reacts to speed. When we check it we quickly move that limb to get that reflexive catching of the limb (aka excess tone w/ movement) - the muscle turns on more than it should –> hypertonia
* its abnormally high resistance w/ faster movement.
What does velocity dependent mean.
The speed at which you move the limb will affect the outcome
* think spasticity where if you move it fast that muscle will start catching and you’ll see that increased tone.
Velocity dependent hypertonia = spasticity.
EX: Think someone w/ abnoramlly high tone in plantarflexors. If they quickly move to put feet up on foot rest they’re going from plantar flexion –> DF and could trigger that hypertonicity because its a fast movement (and theyre velocity dependent). Essentially that quickly stretch of those plantar flexors that have high tone could cause that muscle to present like it has high tone.
* this kind of tone can be ignited w/ rolling over too quickly in bed, or even just walking.
What are the 3 kinds of hypertonia?
* What kind of injury causes hypertonicity?
UMN injury causes hypertonicity
1) Spasticity
2) Rigidity
3) Dystonia
Is spasticity velocity dependent or velocity independent?
* damage where causes this (2)
* Is this an UMN or LMN pathology?
It’s velocity dependent (meaning that depending on if theres velocity that muscle will lock up and present w/ increased tone)
It comes from damage to the motor cortex or brainstem
* A stroke can cause damage in these areas which is why this is an UMN pathology
* This hypertonicity is an UMN pathology
Is rigidity velocity dependent or velocity independent?
* damage to what area causes this?
* Is this an UMN or LMN pathology?
Rigidity is velocity independent - meaning it doesnt matter how fast you’re moving you’re always going to have that increased muscle tone
Comes from damage to the basal ganglia
* This hypertonicity is a UMN pathology
* NOTE Stiffness in parkinsons is due to this (dengeration of those basal ganglia)
NOTE: w/ rigidity typically the agonist and antagonist are impacted equally and both have hypertonicity, while in spasticity only one (agonist or antagonist)
* again the agonist and anatagonist are fighting eachother, not letting you get through that movement - which causes that rigidity / hypertonicity throughout that entire movement no matter what speed were going
Describe Dystonia?
* Its damage to what area?
* Is it an UMN or LMN pathology?
Prolonged involuntary twisting or writhing repetitive movements, increased muscular tone.
* damage to the basal ganglia
* This hypertonicity is a UMN pathology
* NOTE: this is more in huntingtons but is due to any damage of the basal ganglia
NOTE: you can have cervical dysontia aka twisting of the neck with the hypertonicity locking those muscles up
I added this picture
remember, the pelvic floor is also muscular and can exhibit high or low tone
* so they might hold urine too much, or can’t hold it at all
* So this isnt all just the limbs
what are the two kinds of hypotonicity
* is this UMN or LMN
1) Hypotonia
2) Flaccidity
This is mostly LMN, however, spinal shock (UMN) can behave like this
What is the purpose of assessing muscle tone?
To determine the resting tension of the muscle in the upper and lower extremeities
NOTE: You’re only testing for spasticity on an individual who is appropriate to test in
* “Someone had a stroke” - well I’m going to use the modified ashworth scale to test for spasticity
* If someone has parkinsons, and they have rigidity, I’m not going to do the modified ashworth because they have regidity not spasticity
* I can still do a muscle tone assessment, which is just passively moving their extremity.
Name the stages of the muscle tone scale (note this is not the modified ashworth scale, but the just passively moving their extremity and finding this amount of tone scale)
NOTE: This is not specific to spasticity but just for muscle tone
On the scale whats considered normal tone?
2+
What does the modified ashworth scale test?
Spasticity
How does rigidity differ from tone?
In rigidity both the agonist and antagonist muscles are involved while in tone you typically just have the agonist or antagonist
Go through the scale for rigidity (which differs from the scale for tone)
its similar but is rigidity vs hypertonicity
Would you do the modified ashworth for someone for low tone?
Nope, this scale is specificly meant for spasticity which is high tone
What are the two kinds of rigidity?
Cogwheel Rigidity
Lead Pipe Rigidity
Remember, in rigidity both the agonist and atagonist muscles are resisting the passive stretch
* and its velocity independent, meaning speed is not a factor
What is Cogwheel rigidity
Tension in a muscle that gives way in little jerks when muscle is passively stretched
* just like one of those old cog wheels
Explain Lead Pipe rigidity
A “smooth” rigidity in flexion and extension that continues through the entire range of a stretched muscle
* Think about trying to bend a led pipe - at no point does it get easier to bend it in its ROM
What are three things we can do for rigidity?
Sustained stretching (not just 4x15)
Heat helps
Avoiding triggers
What is our gold standard test for assesing spasticity?
Modified Ashworth Scale
* Remember, spasticity is velocity dependent (speed does affect it) which is why when implementing these tests 2/3 trials are with that increased velocity to try and trigger that spasticity.
What is a movement analysis?
Watching someone do an action before you’re cueing on how to fix it
* gives us a naked eye look at what activity is before fixing it
* Obviously you would need to be careful w/ fall risk
* Big observation of pt
NOTE: We sometimes don’t fix spasticity because it can be useful
* think someone w/ increased tone in legs following a stroke. Well maybe we can use this tone to help them transfer, opposed to having them buckle.
However, tone can get in the way. Think super tight hand/clinched fist. This would significantly limit function.
NOTE: You can spend a session fixing someones tone. However, the next visit it will come right back.
* Dont is reactionary to everything. Mood, medication, movement.
* Were not fixing that underlying CNS disorder, were teaching them out to live w/ it.
* This is part of why doing HEP is more importnat than neuro than other settings.
Explain the 3 things we do in a modified ashworth test to asses spasticity?
1) One to establish ROM –> move limb slowly over a 4 second period to see that ROM (velocity unimportant here)
2/3) We take that limb very quickly through that full ROM twice. This should take 1 second between movements and we do these 2 trials 1 second apart (so barely any time between tests)
Remember this is all passive, we don’t want the muscle actively helping.
If you’re testing elbow flexion you start in elbow flexion and move into extension
* You’re strethcing the muscle you want to test to see if it has spasticity
When assessing the elbow flexors for tone in the modified ashworth scale what position do you start in?
Start in flexion and move to extension. This is true of every body part
If we want to test hip abductors we start in hip abduction –> adduction
* we start in the shortest postion that muscle can go then lengthen it to see if theres tone problems in that ROM
Testing shoulder extension you start in as much shoulder extension as you can, but your in neutral because their in neutral then move into flexion to test the extension
To test the ankle plantar flexors your start in PF –> DF
What is a 0 on the modified ashworth scale?
No increase in muscle tone (this is normal for this scale, not 2+)
What is 1 on the modified ashworth scale?
Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the ROM when the affected part(s) is moved in flexion or extension (so resistance at the end of the motion)
What is a 1+ on the modified ashworth scale?
NOTE: This is the only + on the scale - very similar to 1 except its an and instead of or
Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM (so not just at the end)
* so it doesnt release to nothing
What is a 2 on the modified ashworth scale?
More marked increase in muscle tone through most of the ROM but affected part(s) easily moved
* entire ROM is harder to move in
* Harder to move but you can still move it
What is a 3 on the modified ashworth scale?
Considerable increase in muscle tone, passive movement difficult
* hard to move through that full ROM
What is a 4 on the modified ashworth scale?
Affected part(s) rigid in flexion or extension
* basically impossible to move through that full ROM
* they’re technically rigid here
You proably wouldnt use this scale for a 4. Theres no point in adding the velocity because they proably have rigidity which means you can use that other scale for rigidity (2+ = normal) to asses them because you don’t need the velocity portion.
You would not write a goal on tone because its so variable and dependent on so many things.
Knowledge check: What is the recommended # of movements in the ashworth scale?
3
1 to establish full ROM (4 seconds)
1 to test velocity (1 second)
1 to test velocity (1 second)
NOTE: sometimes these tests can trigger spasms
NOTE: we would not do this test on someone whos flaccid - that could be a saftey issue
What is clonus?
* how many times
Involuntary beating (>5 beats)
* Spasmodic alteration of antagonistic muscle contractions via quick stretch, can be elecited in tone testing
happens w/ quick stretch (happens with tone testing)
* when you hold them in that stretch it beats (once you stop the stretch it stops)
You get rid of it by stopping the stretched movement
NOTE: When assesing strength in the neuro population you’re going to do more functional tests than MMT.
* think 5 times sit to stand or even just doing a movement analysis as they get out of a chair
* We can direct our goals at these functional tests
* Also **remember if they don’t have full ROM you cannot do a MMT”
Functional strength- think standardized tests/outcome measures or patients ability to perform functional mobility skills
myotomes
Ability to maintain stability/orientation with COM over BOS while static
Static postural control (stability)
Body not in motion
BOS fixed
Example - prone on elbows, quadurped, sitting
Ability to maintain stability/orientation with COM over BOS
* bodies in motion
Dynamic postural control
BOS fixed
Examples - weight shifting, limb movements, reaching
Ability to change from one posture to another
* BOS and/or COM are changing
Examples - rolling, supine to sit, sit to stand, transfers
you’re actully moving body here
Ability to consistently perform coordinatied movement sequences to interact with the environment
Skill
Examples: gasp/manipulation for UE; locomotion, stair climbing for LE
This is combining everything together
W/ abnormal sensation we can have damage to
* Brain, brainstem, spinal cord (Tracts - DCML, ALS)
* Nerve root (correlates w/ dermatome)
* Peripherl nerve
What kind of sensations are exteroceptive?
* define it and name the 3
These are our superficial sensations
* Light touch
* Pain
* Temp
How do we test for pain sensation?
Sharp/dull testing
NOTE: Light touch is part of that ull testing
What kind of sensations are proprioceptive sensations?
* Name the 3
Deep sensations
Kinesthesia
Proprioception
Vibration
What are combined cortical sensations?
* name the 7
These are sensations that need several parts of the brain to come together and form (they’re more complex) - take more than 1 pathway to form
* Stereognosis
* Two point discrimination
* Barognosis
* Graphesthesia
* Tactile localization
* Recognition of texture
* Double simultaneous stimulation
Name the order of sensation testing between deep, superficial, and combined cortical?
Superficial –> Deep –> Combined cortical
NOTE: Superificail is super easy to test
When you’re doing sharp dull testing explaim how you’d do it
* Random or set?
* Predictable or unpredictable?
* Proximal or distal first?
Random, unpredictable manner with variation in timing, distal to proximal
* Don’t go from finger to shoulder and back and forth, but just don’t follow the exact set pattern every single time
The distal to proximal is because your deficits are typically distally lost before proximal
* However, this is variable
NOTE: When doing sensory testing we need to be careful of scar tissue or calloused areas because they’re genereally less sensitive with diminished response to sensory stimuli
With sensory testing should eyes be open or closed?
Trial test performed to instruct the pt what to epect and how to respond to application of the specific stimuli with eyes open
Patients vision occluded during the actual test eyes closed
When sensory testing how many different points do you need to test?
5 points on 1 side (however, if you’ve going back and forth its 10)
this is variable but mak sure you’re documenting how many trials and how many they got correct - so you get a percentage
document as intact or impaired
Before you even start sensory testing what do you need to do
Cognitive screen before sensory testing
* because if they arent cognitively there then they wouldnt be able to accurately relay information back to you
* You can’t really do this testing if pt has a profound cognitive impairment
After this we do our pre test with eyes open
Following that we do the test with the eyes closed
If someone has a C4 lesion where would you take as a reference point for sensory?
Anything above C4, so you’re using the face
so when you’re showing them what you’re doing for the test do the normal side first. If someone has right sided deficits you do it on the left side first to show them what it should feel like, then move to the impaired side
* this would be done in the pre test
Obsrvation of the integumentary system is important to check for people w/ lack of sensation due to pressure ucler
* think testing this in stroke, TBI, etc…
* But really test this for anyone who is no longer mobile / ambulatory and then adding in lack of sensation makes this even worse
Sensory deficits are annoying because we can’t really give exercises that much for it
We can give saftey things like watching the affected extremity to make sure its not bumping into things
does cerebellum lead to ipsilatearl or contralateral deficits?
Ipsialtearl while the rest of the brain is considered contraltarel
what kind of deficits do we see w/ cerebellar damage? (not just the side)
Ipsilatearl motor coordination deficits
* note: this isnt as much sterength and more motor coordination
* Think posture, coordinated movements etc…
For spinal cord injury if they have a C5 injury do they have elbow flexion
Yes, is named for deficits below the level of the lesion. So if they have a C5 injury they keep elbow flexion. however, they loseC6 (wrist extension)
Pain produced by a non-noxious stimulus
Allodynia
* it shouldnt hurt but it does
Complete loss of pain sensitivity
Analgesia
Think getting this if they’re on tons of medication
Touch sensation experienced as pain
Dysesthesia (similar to allodynia but is specific to touch)
Increased sensitivity to pain
Hyperalgesia
Abnormal sensation such as numbness, prickling, or tingling, without apparent cause
Parasthesia
Think numbness after a stroke
Dermatomes come off that spinal nerve and are linked to a spinal segment
Peripheral nerves are many different dermatomes coming together as one.
If the person had a stroke would you do dermatome testing, peripheral nerve testing, or something else?
were focusing on more major tracts, not just particiular nerves. So you don’t need to do either of these, you do more of a gross screen.
What is tactile touch?
Light touch
How would you test tactile touch?
* What do you say to the pt
* What to do if pt is non verbal?
Remember, this is light touch
You use a hairbrush, piece of cotton (ball or swab or tissue (she said she just uses her finger but that probs isnt the best)
The area lightly touched or stroked
The patient is asked to indicate when they recognize that a stimulus has been applied by responding “yes” or “now”
* Note: you would do a trial with eyes open then closed
* I’m guessing we also show them what it feels like on the uninvoled side as well
We should do around 5 per limb (not a hard rule) but the quantiative score is found by dividing the number of correct responses by the number of stimuli applied - you should end up with a percentage
* NOTE: missing one or 2 isnt an indication that theres a pathology, you just might be over a calus or something
Non verbal:
* Hold up one or two fingers (yes/no, hot/cold)
* Nodding
* Pointing to index cards containing printed responses
* Hand gestures
How do we test pain perception?
* which tract are we testing?
Pain perception tested via sharp/dull discrimination
* indicates function of protective sensation
HOW:
* Tools - large headed safety pin, a reshaped paper clip, or single use protected neurlogical pin
* carefully cleaned before testing and disposed of afterward (just in case it breaks the skin)
* Randomly applied perpendicularly to the skin
* Vary area and timing
* Sharp enough to deflect skin but not puncture it
Patients response: Answer either sharp or dull to each test
Im assuming eyes open and closed trial starting w/ the contralateral extremeity
Spinothalamic tract
What does monofilament testing tell us?
* What kind of pt is it good for?
Tells us if the person has normal / protective extension
This would be good for a diabetic w/ peripheral neuropathy, sensory impairments to LE, CNS injuries
* this gives us safety information
We don’t write goals on sensation becuase we don’t directly impact it
* “only time can tell”
When monofillament testing what % indicates normal sensation?
4.17 (1 g of force)
When monofillament testing what # indicates protective sensation?
5.07 (10g of force)
W/ monofillament testing you push until it starts to distort
How to do temperature testing
* which tract is this testing?
This allows us to see if the pt can distinguish between warm and cold stimuli
How:
* Two test tubes with stoppers
* Warm water and the other between 104-113 (becuase you dont want to burn them)
* Randomly palced in contact with skin area
* Also i assume we do contralateral side first and do a trial with eyes open –> closed
Patients response:
* The pt asked to reply hot or cold after each stimulus application
Spinothalamic tract
Pressure testing
* how do you do it
The point is to test the perception of pressure
How:
* Therapists fingertip or double-tipped cotton swab - so pressing in (don’t w/ this were indeenting skin and w/ light touch were not)
* Firm pressure on skin surface firm enough to indent skin and stimulate deep receptors
Patients response
* The patient is asked to indicate when an applied stimulis is recognized by responding yes or now
*
Which test examines the awareness of movement?
Kinesthesia testing
How is kinesthesia testing done?
Involved extremeity or joints moved passively through small ROM
Small increments used as joint receptors fire at specific points throughout the range
Basically the patient has to tell you which way the extremity is moving before you come to the end of that movement and stop (we stop and ask them at the end of that movement in proprioception testing)
Patients response:
* verbalize direction (up, down, in, out) while the extremity is in motion
What is the name for joint position sense and awareness of joints at rest?
Proprioception
How do we test proprioception?
Involved extremity or joints moved through a ROM and held in a static position
* so you’re seeing if the involved side can sense where it is in space
Small increments of range are used
caustion with hand palcements to avoid excessive tactile stimulatoin
Patients response: you pick
* Patient describes position verbally
* Duplicates position with contralatearl exremity (position matching)
* Active duplication of position by patient using same limb
How to test for vibration - didnt go into detail here
How:
* Turning fork that vibrates at 128 hz
* Place base of vibrating tuning fork on bony prominence
* Tines briskly hit against open palm of the examiners opposite hand to initate vobration
* Do not touch tines
* random application of vibrating and non-vibrating stimui
* Always start vibration due to sound, then stop by tines
patients response
* distinguish between vibrating and non vibrating tuning fork
Proprioception is which tract?
DCML
Vibration is which tract
DCML
Where does stereognosis come from (which tract or something different)
* What is it
* how to test
* pts response
Combined cortical sensation - so it comes from lots of different parts of the brain
Its the ability to recognize form of objects by touch
Variety of small, easily obtainable, and culturally familiar objects
Differing size and shape are required (ex - keys, button, ring, coins) - something small enough to fit in hand and be deteced by the hand and be familar to pt
Object placed in hand
Patient manipulates object
Pts response:
* Identifies item verbally or with picture cards
What tract or other place does 2 point discimination come from?
* What is it
* How do you test
* pts response
Combined cortical sensation
Its the ability to percieve two points applied to skin simulatensouly
How:
* Measure of smallest distance between two stimuli
* Applied simultaneously and with equal pressure
* Perceived as two distinct stimuli
Patients reponse:
* Patient is asked to identify the perception of “one” or “two” stimuli
Sensory documentation example
Just know its intact or imapired
A pt is unable to detect 5.07 monofilament, which statement is true
* pt has neither normal nor protective sensation (4.17 is normal and 5.07 is the highest it can be to have protective sensation)
KNOW: If screening CNS reflexes you can do babinski or hoffman for extra information - just make sure pt is correct age
didnt cover
What is a normal relfex rated?
2+
What grades are considered hypo reflexive?
0, 1+
What grades are considered hyper reflexia
3+,4+,5+
characterized by cyclical spasmodifc alternation of muscular contraction and relaxation in response to sustained stretch of a spastic muscle
* most common where
Clonus
Common in the plantar flexors (think calf cramps) but may also occur in other areas of the body such as the jaw or wrist
hyper reflexia = UMN disorder (baring shock)
hypo reflexia = LMN disorder
how many beats = clonus in the adult population?
> 5
pt has hypereflexia which disorder is it likely
* answer was stroke because it was the only UMN disorder listed
Difficulty walking in ICF model falls udner activity
damage to what portion of the brain leads to coordination deficits? (2)
Cerebellum (think uncoordinated movement)
* however, there are other places as well, but the cerebellum is in charge of coordinating movements
however, both gross and fine motor coordination take place in the motor cortex (frontal lobe in the precentral gyrus) - and cerebellum
Diliniate between dysmetria and dysdiadochokinesia
* what do these things test for
* what are the two tests assocaited w/ dysdiadochokinesia
* Which one do we do for dysmetria
* Eyes open or closed?
They test for motor cordination deficits
dysdiadochokinesia = rapid alternating movements
* can look at this in UE by going back and forth between pronation and supination (UE test)
* at the foot we do foot tapping (so tapping back and forth between feet) (LE test)
Dysmetria = difficulty reaching a target (problems judging distance or range of motion)
* We test this by doing finger to nose (UE test)
* Heel to shin (starting at ankle and dragging it up to knee) (LE test)
Eyes open initially, however, close eyes to make it more challenging (or just speed up the motion to make it more challenging)
* however, eyes open doesnt really matter that much in this because thats pure sensory, while were testing to motor system and its coordination (not the visual system) –> so having the eyes open is okay and were still testing what we want to be testing
Coordination tests focus on movement capibilities in the following areas
* Reciprocal motion
* movement composition
* movement accuracy
* Fixation or limb holding
Which coordination test is the abiility to reverse movement between opposing muscle groups?
Reciprocal motion
* this fits more w/ dysdiadochokinesia (rapid alternating movements) - how are the muscles working together and are they doing so effectively
Which coordiantoin test involves movement control achieved by synergistic muscle groups acting together?
Movement composition or synergy
* this fits more w/ dysdiadochokinesia (rapid alternating movements) - how are the muscles working together and are they doing so effectively
Which coordination test is the ability to guage or judge distance and speed of voluntary movement?
Movement accuracy
* NOTE: this is like dysmetria
* Think of it as not being sure how many meters you went
Which coordiantoin test addresses the abiity to hold the position of an individual limb or limb segment?
Fixation or limb holding
* this fits more w/ dysmetria
synergies = muscles working together to create a movement
this is for coorination tasks
so **this is saying that for those coordination tests we should start w/ eyes open on practice trail and then do them closed after that ** - even though she said differently prior
* if they’re really struggling w/ eyes closed do it w/ eyes open
these are the tests, she wants us to know
* heel to shin, foot tapping, pronation supination, finger to nose, and finger opposition - all on lab sheet
for sensation/coordination trial w/ eyes open test w/ eyes closed
Knowledge check: which of these tests, tests the ability to reverse movement between muscle groups
Reciprocal motion
* rapid alternating movement
w/ the cranial nerves we screen to see waht we need to further asses
this is broken down more on lab sheet
we dont test olfactory n
optic n = thats how eye exam chart to test (we didnt do this again in class) - Snellen chart; visual acuity
* visual field testing: pt covers 1 eye and looks straight ahead - you start behind them with a pen “let me see when you see this pin. You’re testing all 4 quadrents, even on side thats covered “say “yes” or “now” when you see pen tip/finger in your field of vision. Lisa did arcs or C’s starting from behind the head and moving in a C shape around it
* So optic is vision field / visual acuity she likes testing vision fields better than snellen chart
oculomotor n
* Were doing eye muscles and reflexes. This combines optic and oculomotor for the reflexes, but were doing eye movements
* Eye movements tested through smooth pursuits or that H test - so were drawing that H that gets all those eye muscles that this nerve innervates. - not moving head following it so see if you can smoothly follow it. Typically doing 2 H’s and you focus on 1 eye for each one. Were also seeing if they lose the finger while doing it. - might lose it because of a distracting a backround (like a room full of students). Need to make sure you’re not going too quick or too far. Stay within a normal visual field is. If you go too far you get that nystagmus at end range thats normal, you dont want to strain them though. Again looking for smoothness, no nystagmus, smooth pruisuit.
* Pupillary/Concsensual reflex: this is shining a light into 1 eye - the eye you’re shining it into should constrict - thats the pupillary reflex. Concensual = shine it into same eye and opposite eye constricts. When testing w/ Lisa she covered the contralatearl eye when testing pupillary reflex to so that we don’t get that light in contralateral and make it constrict because of light in it. Dr. King littearly just shined it in ipsilateral eye looked for constriction. Then shined it in ipsilatearl eye and looked for contralateral constriction (concensual)
* Convergence/Accommodation: When you’re holding something outward and bringing it inward twards nose. The eyes should come together. When you remove that stimulus they should go apart, thats the convergence part (so pull that finger straight down). The accomodation is the ability to focus on that object till ~5cm from nose. You start about 12 inches out and bring tip of pin in towards nose, tell them to continue looking straight at it and you’re going to bring it to the tip of their nose and then bring it down. They need to continue looking straight instead of following pen down towards floor. Looking to see if they’re coming together on the way in. The accomidation part is “tell me when it gets blurry on the way in” - i wannt know when it starts to get blurry.
Trochlear - Test with oculomotor on H test
* VOR?
Trigeminal - Does facial/jaw sensation (3 branches so sensory test 3 places), cormeal reflex/jaw jerk reflex, chewing
* To test for sensation touch both sides of face (eyes closed); forehead, cheek, chin (3 places 3 brnaches) - this is just light touch
* We don’t do corneal / jaw jerk - we can easily test it with that sensation test
Abducens - Test w/ oculomotor and trochlear
* does eye movements
* Vor
Facial n
* Does muscles of facial expression
* Protects hearing
* taste from anterior 2/3 of tongue
* corneal reflex
* tears and salivation
* We test for facial expression - lift eyebrows (look surprised), close eyes, puff out cheeks, smile and show teeth, pucker lips
* Look at pt at rest for symmetry
* Test for taste: close eyes, stick out tongue, do you taste sweet or salty, test both sides of tongue (eyes closed)
look at slides and go back through these
CNS screening tests
* Dynamic visual acuity - would do this w/ vistibular pt. we grab their head and turn it quickly side to side while they’re focused on somethign static (she had a smellen chart) infront of them. Were seeing if they can stay stabilized on whatever is infront of them
* Presence of nystagmus - looking for nystagmus during these tests that would be abnormal
* Smooth pursuits; saccades - we did smooth pursuit w/ H test. Saccades is the ability to look back and forth between two objects smoothly
Saccades
ability to focus on an object, moving your focus on 1 object to another.
CNS dysfunction - things were looking for
Abnormal smooth pursuit
* Not smooth
* Inability to maintain focus
* Lacks smoothness
* Nystagmus
Abnormal saccades - looking from one object to another
* over/under shooting
* must us corrections (over or udner shooting and coming back)
* Nystagmus
Gaze evoked or spontaneous nystagmus
* w/ haze holding, presence of nystagmus, shouldnt really see nystagmus w/ eye movement but you defiently shouldnt see it while person is holding gaze on something
* at rest presence of nystagmus
6 D’s
6 D’s that go along w/ CNS dysfunction
1) Dysarthria - issues speaking (bad articulation)
2) Dysphagia (issues swallowing)
3) Diplopia (double vision)
4) Dysmetria (difficulty reaching targets [misjudge meters]) - think finger to nose
5) Drop attacks
6) Dizziness
if they have this they need more investigation
Dont confuse this w/ trigeminal
* facial expression = facial n
* trigeminal = facial sensation
VOR - quick head movement while stabilizing gaze on something
* looks at eyes ability to maintain gaze when head is moving
* Don’t cover their ears and tell them what you’re doing first
* Make sure they dont have neck problems
* jerking fast quick movement - looking to see if their eyes are staying on your nose
VOR - quick head movement while stabilizing gaze on something
* looks at eyes ability to maintain gaze when head is moving
* Don’t cover their ears and tell them what you’re doing first
* Make sure they dont have neck problems
* jerking fast quick movement - looking to see if their eyes are staying on your nose
its abnormal when eyes dont stay alligned on your nose
If theres a lesion in glossopharyngeal n which way does the uvula deviate?
Deviates toward uanffected side (note: issue w/ hypoglossal deviates towards affected side [the tongue])
Think more autonomic ns (parasympatehtic)
we didnt do glossopharyngeal testing
What two muscles are tested w/ spinal accessory n
SCM
Trap
Tested w/ MMT
Theres a lesion in the hypoglossal n. This nerve is responsible for tongue movements. Does the tongue deviate toward the side of the lesion or away from it
Tongue deviates toward the side of lesion (deviates ipsilaterally)
this is how you document for cranial nerve issues
if the reflex was positive or negative, absent or present, intact or abnormal, Can use specific terminology associated w/ test or outcome measure.
* all of these mean the same thing
Vision screen:
* Observation
* Often w/ cranial nerve creen
* Peripheral fields
* Smooth pursuit (tracking)
* Saccades
knowledge check: R spinal accessory n lesion. How do you assess the MMT of this?
Turning head to left and bringing right ear to right shoulder
This is because R SCM does contraltaerl rotation (turns head opposite direction its on) and ipsilatearl latearl flexion
then for traps lesia just had me raise my shoulder and pushed down
Balance/Postural Control
When testing a pt for balance they can really be in any position (sitting, standing, static, dyanmic) - no one set position
Consideriations: Eyes ca be open.closed, they can be inside or outside BOS, internal (they’re sitting still and reaching - its coming from their body) /external perturbations (this would be PT pushing pt) (bumps or anything that perturbes you), reactive (someone bumpbs into you while walking and you haev to react) /anticipatory (I see something coming at me and anticipate it), obstacles
Standaridized tests/outcome measures to asses balance/postural control, mCTSIB, reactive postural control, BBS, TINNETI, ROMBERG, Sharpened ROMBERG, etc… - we have outcome measures again where were going to hit all this again
Gait - we observe fait from all different angles
* observe from the front, back and side
Watch specifically for the following: (gait)
* Distance between the feet; normally the medial malleoli passes appropizmately 2 inches apart
* DF during heel strike and during late stance
* Steppage gait: excessive raising of the knee
* Lower limb stiffness
* Difficulty inititating or stopping walking
* Speed
* Symmetry
For the person below
* kyphotic (head way infront of shoulders)
* AFO - probs had a stroke
* Functional estem
gait is a large part of what we do in neuro PT as well
* note its really easy to pick out abnoramlities in neuro
Assessment and Plan portion of neuro exam
* We wouldnt say something like “pt has s/s consistent w/ parkinsons”
* say “pt has deficits in these areas”
Assessment:
* Summarizing presentation - bringing forward the biggest findings - don’t list out all the outcome emasures and what their scores - say “pt is below normal values evident by TUG and gait speed”.
* Explain why the pt need skilled care
* What is your assessment of the treatment day “pt demonstrated 5 falls during this test…” what do you want to do
