Neuro Flashcards
What are the three types of impairments?
Direct/1’- direct result of pathology e.g. lesion
Indirect/2’- complication of direct impairments e.g. oedema
Composite- multiple underlying causes, both primary and secondary
What are the eight direct impairments?
Weakness
Sensation
Proprioception
Coordination
Tone
Perception
Vision
Vestibular function
What are the three stages of motor skill learning?
Cognitive- understanding and learning, frequent errors
Associative- refining practice, minor errors
Autonomous- less conscious attention, smooth/efficient
What is the difference between open and closed skill?
Open- unpredictable environment, performer has to react e.g. soccer
Closed- predictable e.g. golf
What is the difference between discrete, continuous and serial skills?
Discrete- distinct start and end e.g. kicking football
Continuous- no obvious beginning or end e.g. running
Serial- discrete skills linked by a movement sequence e.g. dribbling basketball
What does V1, V3, R1 and R2 mean?
V1- as slow as possible
V3- as fast as possible
R2- end range
R1- range measured at catch or point of clonus
What are some risk factors for stroke?
Age, hypertension, smoking, low physical activity and obesity
What is an ischaemic stroke?
Infarction is cerebral, spinal or retinal cell death attributable to ischaemia causing neurological dysfunction. May result from thrombosis, embolism
What is a subarachnoid stroke?
Haemorrhagic stroke with rapid onset due to bleeding in subarachnoid space
What are intracerebral and intraventricular strokes?
Non-traumatic bleeding into brain or ventricles, increasing ICP
What are some impairments following stroke?
Decreased AMC
Loss of proprioception
Loss of sensation
Neglect
Pushing Syndrome, altered perception of vertical
Language, Cognition, Memory
Pain
What impairments arise with anterior, middle and posterior cerebral strokes?
Ant- lower limb sensation/motor
Middle- upper limb sensation/motor
Post- hemianaesthesia, hemiparesis
How is ischaemic stroke from thrombosis treated?
Intravenous rt-PA to cause thrombolysis
What are gait kinematics?
Amount and type of movement seen at various joints during gait
What are the 3 key muscles of gait?
Ankle PF for push off
Hip extensor in early stance
Hip flexor in late stance
What is drop foot gait?
Increase hip and knee flexion to allow clearance of the foot due to drop foot
What are the immediate effects of trauma?
Cerebral haemorrhage and diffuse axonal injury (shearing of axons)
What are the 2’ implications of trauma?
Cerebral oedema, increased ICP, infection, cardioresp compromise
What is CPP?
Central perfusion pressure= MAP- ICP
After trauma the autonomic system can drop BP, risking no perfusion of the brain
What is PTA?
Post traumatic amnesia, inability to store new information and impaired learning, correlated with GCS, distractable and agitated
How is PTA severity classified?
<5min- very mild
>4 weeks- extremely severe
How is PTA managed?
Minimal stimulation, keep routine, integrate familiar people/environment
What is a heterotopic ossification?
Palpable bony mass that often occurs after CNS injury
What are the complications of heterotopic ossification?
Appear 4-12 weeks post surgery with sudden reduced ROM. oedema, fever
How is the STS phases classified?
Flexion Momentum- initiation of movement
Momentum Transfer- buttocks off to max DF
Extension- after max DF, to end hip E
Stabilization-
OR
Pre-extension- feet backwards, upper body forward, knee F and DF
Extension- extend pelvis, spine, head
What factors affect STS performance in the elderly?
Strength
Tactile sensitivity
Proprioception
Reaction Time
Sway
Pain
What are some deviations of sit to stand in stroke?
Hemiplegic leg positioned backwards in PE phase
Trunk not brought far enough forward
Pause between phases
Slow
Hands for balance
What are some deviations in stand to sit in stroke?
Reduced F at ankle, knee, hip
What are some alterations to make progress and regress treatment for STS?
Change height
Active UL
Scales under feet for symmetry
Change foot position
What are the consequences of falls?
Injury
Fear of falling restricts activities
What are some intrinsic RF’s for falls
Age
Falls history
Cognitive impairment
Sensory loss
Postural hypotension
What is proactive and reactive postural control?
PPC- response in anticipation of a destabilizing force (prior experience)
RPC- feedback to correct response reaction due to external force
How do postural control strategies manifest?
Ankle- small disturbance of COG
Hip- larger disturbance of COG
Step- final defence
What are some extrinsic RFs for falls?
Gait aids
Bed height
Footwear
Clutter
What are some ways to assess falls risk?
Functional reach test
Step test
Four square step test
TUG
Pastor’s- ensures patient can perform postural response
Clinical Test of Sensory Integration of Balance (CTSIB)- multiple criteria, changes vision and surface
What is the 6-pack program for hospital fall intervention?
Falls alert sign
Low-low bed
Walking aid in reach
Bed chair alarm
Toilet regime
Bathroom supervision
What is a functional neurological disorder?
Motor and sensory symptoms related to functional rather than structural disorder, software rather than hardware problem
What is Hoover’s sign as what disorder does it indicate?
FND, asked to lift one leg, the other leg will extend
What is the pathophysiology of MS?
Dysregulation of immune system, CNS infiltrated by T and B cells, inflammation -> demyelination -> axon damage -> degeneration
Develop plaques, decreased nerve conduction, atrophy of axons from 2’ damage
What is the aetiology of MS?
Epstein-Barr virus, necessary but not sufficient
Genetic susceptibility
RF’s- childhood obesity, smoking, concussion
How is MS diagnosed?
MRI
Lumbar puncture to assess CSF
Neurological exam- McDonald criteria disseminated in time, disseminated in space, oligoclonal bands in CSF
What is radiologically isolated syndrome vs clinically isolated syndrome?
RIS- lesions found when imaged for other reasons, may be asymptomatic
CIS- 1st episode of lesion, diagnosed with MS
What is relapsing remitting MS?
Lasting >24 hours without other cause, interspersed by periods of stability
What is 2’ progressive MS?
Progression independent of relapse activity
What is primary progressive MS?
Slow disability progression
What are some symptoms of MS?
Depends on lesion location
- Weakness
- Ataxia
- Tremor
- Speech, swallowing
- Numbness
- Bowel, bladder
- Thinking, memory
Pain, fatigue, vestibular dysfunction
How is MS managed and how does it change recovery?
- Anti-inflammatories and immunosuppressants
- Exercise, slows disability and encourages neurogenesis and neuroplasticity
What are some considerations for exercise in MS?
- Low intensity may be better tolerated
- Strength less adhered than aerobic
- Bladder dysfunction
- Resp. m. weakness (Borg)
- Sensitivity to cold, painful in winter, vests to keep cool in summer
What is the function of the vestibulocerebellum?
Eye movement, visual fixaiton and adapts postural muscles
What is the function of the spinocerebellum?
Somatosensory information, compares ongoing movement with intended movement
Dysfunction can cause hypotonia, reduced balance, ataxic gait
What is the function of the cerebrocerebellum?
Motor planning, coordinating and planning voluntary movements
Dysfunction incoordinated arm movements
How is ataxia treated?
Exercise, incl. hydrotherapy
Balance
Gait aids
Treadmill training
What are the recommendations for physical activity?
150 min of moderate or 75 min of vigorous intensity exercise/week
Break up prolonged sitting
How can circuit class therapy improve stroke patients in rehab?
Improve walking ability, speed and endurance
Balance confidence
Monitor falls risk
What are common observations in stroke pts?
Forward trunk F
Poor AMC, speed, smoothness and trajectory
Less accurate and excessive grasp
Poor anticipatory modulation of grip
What are typical adaptive patterns in stroke?
When reaching, flex trunk instead of shoulder
(Sh elevation, abd, IR, LF of spine, elbow F, wrist pronation)
Excessive opening of hand to grasp
What are some general outcome measures for stroke?
Fugel Meyer Assessment- criteria rated 0-66 test motor Fx, sensory, balance, ROM
ARAT- box with 19 items
Wolf Motor Function Test (WMFT)- rating Fx ability 1-5, e.g. arm to table, extend elbow, grip
Motor Assessment Scale- for UL, e.g. pick up jelly bean and put it in a cup
What are some outcome measures for dexterity in stroke?
Purdue Peg Test- time unimanual and bimanual fine dexterity
Box and block test- timed gross unimanual dexterity
What are some outcome measures for sensation in stroke?
Wrist position sense test for proprioception
Functional Tactile Object Recognition
How do you assess shoulder pain in stroke?
Ritchie Articular Index, 0-3 when in ER
What are some considerations in treatment of UL in stroke?
Subluxation prevention
Initiate voluntary muscle, FES can help stimulate
Prevent loss of muscle length with positioning
Resistance Training
Functional Training
Constraint of non-affected limb
Mirror therapy
What is neglect?
Failure to respond to anything on opposite side of brain lesion
Give an example of the difference between personal, peripersonal and extrapersonal neglect?
P- failure to groom contralesional side or don’t use contralesional limb
PP- failure to eat food on contralesional side or don’t read words at start or end of sentence
EP= failure to observe objects on contralesional side
How can neglect can be divided into 3 categories, what are they?
Sensory- visual, auditory etc.
Motor- akinesia, bradykinesia
Other domains- representational (e.g. drawing half a house), mental images
How can neglect be assessed?
Extrapersonal- describe 10 objects in room
Peripersonal- bisecting line test, circling all the stars
Personal- Comb and Razor test
How can neglect be treated?
Encourage recognition of affected side
Mirror therapy
Up against wall to limit stimuli on good side
What is pusher syndrome?
Active pushing of body across towards affected side due to skewed perceived midline
What are some Fx problems with pusher syndrome?
Difficult indep. sitting and standing
Falls risk
Impaired reactive balance
What is the aetiology of pusher syndrome?
Unknown but associated with lesions in posterolateral thalamus
How is pusher syndrome assessed?
4 point pusher score 0-3, no pushing to severe
Scale of Contraversive Pushing, measure posture, extension and resistance in sitting and standing
Burke Lateropulsion scale, examines rolling, sitting, standing, transfers, walking
How is pusher syndrome treated?
Keep vertical with feedback (visual, wall)
Reach beyond BOS
What is apraxia?
Cognitive perceptual disorder with an inability to perform movement in response to verbal command,
What are the two types of apraxia?
Ideomotor- problem in producing movement despite understanding motor programme
Ideational- recognize objects but cannot explain how to use them e.g. use object incorrectly
What is the aetiology of apraxia?
Left hemisphere lesions
How is apraxia treated?
Errorless training-elimination of incorrect or inappropriate responses
What are some examples of behavioural interventions?
- Operant conditioning, positive reinforcement
- Focus on lifestyle change to prevent behaviours
What is parkinsons disease?
Chronic neurodegenerative disease characterized by rigidity, hypokinesia and resting tremor, with a loss of dopamine producing cells
How is PD commonly presented early on?
Resting tremor early clinical sign
Starts unilateral before progresses to bilateral
What are some RFs for PD?
Age, history, head injury, exposure e.g. pesticides
What is the role of the basal ganglia?
Automatic execution of motor programs
Simultaneous and complex movement
Planning and organizing movement
What is the pathophysiology of PD?
Gradual loss of dopaminergic neurotransmitters in the substantia nigra, causing an imbalance in neurotransmitters
What are the symptoms of PD?
- Tremor
- Rigidity
- All kinesia (Hypo, Brady, A, Dys)
- Postural Instability
What is the difference between the kinesias of PD?
A- freezing
Hypo- reduced movement
Brady- slow movement
Dys- aberrant movements
When does resting tremor change?
Stops with initiation of movement
Increases with emotion, stress, fatigue
How is rigidity different from spasticity?
No clonus
Not velocity dependent
How does levadopa dose affect falls risk?
Increased risk with increased dose
What is characteristic of a PD pt gait?
Overall lack of movement
Reduced step length
Normal or increased cadence
Freezing especially at initiation
How is PD most commonly pharmacologically treated?
Dopamine Replacement Therapy, Levadopa agents
What are some outcome measures for PD?
TUG
10MWT
6MWT
Dynamic Gait Test
Berg Balance Test
Functional Reach
MiniBESTest
How is PD often assessed?
- Unified PD Rating Scale- impairments and activity lim
- Hoen & Yahr Scale- staging scale, 1-5
- Modified Parkinsons Activity Scale (M-PAS)- 18 activities incl. balance, gait, transfers
How can falls self-efficacy be measured?
Falls Efficacy Scale
Activities specific Balance Confidence Scale
What are some treatments for PD?
- Resistance Training
- Core Training
- Education on falls, PA
- Motor Skill Learning
- Gait Training, cuing with floor markers, large arcs, clock turn
What is the utricle and saccule?
Part of peripheral vestibular apparatus
U: detects horizontal movements
S: detects vertical movements
What is the vestibuloocular reflex?
VOR, semicircular canals detect movement, sent to medial and lateral rectus muscles to stabilize on target
What is VOR gain?
Ratio of eye movement to head movement
Velocity of eyes should be exactly opposite to velocity of head
What happens when VOR gain is less than 1 (eyes slower than head)?
Patient complains of blurring
What is the vestibulospinal reflex?
Protective extension of the limbs in response to head position changes
What is the vestibulocolic reflex?
Acts on neck musculature to stabilize the head
What are some secondary symptoms of vestibular dysfunction?
Fatigue
Concentration issues
Anxiety, depression, frustration
Reduced confidence
What are the key questions of a vestibular subjective?
- Characteristics of sensation
- Onset
- Duration of attacks
- Associated symptoms
- Exacerbating factors e.g. movement, diet
What does nystagmus direction suggest about problem area?
Eyes beat to more neurally active side, left ear problem, right beating
What is abnormal saccadic movement?
Cannot move eyes quickly from one point to another or accurately
What are contraindications for Dix-Hallpike?
- Neck surgery/trauma
- RA
- Myelopathy/radiculopathy
How is BPPV diagnosed?
Positive Dix-Hallpike, upbeat torsional nystagmus and vertigo
What is vestibular neuritis and its presentation?
- Inflammation of vestibular nerve
- Acute onset lasting hours to days
- Hearing loss
- Spontaneous horizontal nystagmus
- Positive HIT, negative Dix-Hallpike
How do you perform a skew deviation test?
Cover eye and have pt focus on nose
Uncover eye, see how eye realigns
What HINTS results suggest central problem (e.g. stroke)
- Direction changing nystagmus
- Abnormal skew
- Normal HIT
How is Vestibular Neuritis treated?
Bed rest 24-48 h
Corticosteroids
Vestibular rehab
What is Menieres Disease and how does it present?
Backed up fluid leads to swelling and pressure
- Episodic vertigo
- Hearing loss and tinnitus
How is Meniere’s treated?
Diuretics and low salt intake to reduce fluid retention
Vestibular rehab
What is acoustic neuroma and how does it present?
Benign tumour on vestibular nerve
- Unilateral hearing loss
- Tinnitus
- Disequilibrium
How is acoustic neuroma treated?
- Surgery
- Vestibular rehab postsurge
What is vestibular migraine and how does it present?
Migraine causing vertigo symptoms
- Episodic vertigo
- Photophobia
What does vestibular rehab entail?
Gaze stability, habituation and balance and gait training to:
- Enhance gaze stability
- Enhance postural and gait stability
- Improve ADLs, fitness and feelings of dizziness
What is the difference between gaze stability and habituation exercises?
GS: retrain VOR
H: Controlled exposure to provocative movement
How does the sensory and motor tracts ascend/descend?
Dorsal Light Touch- ascend ipsilaterally
Spinothalamic Pain/Temp- ascend contralaterally
Lateral corticospinal Motor- descend ipsilaterally
How does central cord syndrome present?
- Incomplete injury
- Compression, hypoxia and haemorrhage of central cord
- UL > LL
- Commonly hyperextension injury in fall
How does Brown Sequard syndrome present?
- Hemisection of cord
- Ipsi motor/light touch
- Contra pain and temp
- Penetrating injury
How does anterior cord syndrome present?
- Often flexion injury
- Altered motor, pain/temp, intact light touch
How does cauda equina syndrome present?
- Below L1
- Flaccid paralysis
What are the benefits and limitations of the ISNCSCI (ASIA)?
+ Predict outcomes, helps develop individualized rehab
- Exhaust pts, sensory is ordinal rather than quantitative
How is ASIA scale measured?
A= complete, no sensory or motor in S4-5
B= Sensory incomplete, incomplete with sensory but not motor below neurological level
C= Motor incomplete, incomplete with motor function preserved below neurological level
D= Motor Incomplete, half of muscle function below neurological level being >3
E= Normal
What is the zone of partial preservation?
ZPP- Only in complete injuries (S4-5), dermatomes and myotomes caudal to levels that remain partially innervated
What is the difference between neurogenic and spinal shock?
NS- disruption to sympathetic activity and unopposed vagal tone (vasodilation, hypotension, bradycardia)
SS- temporary loss of reflexes, strength and sensation below lesion level
What are some hospital considerations for SCI?
- Respiratory muscle weakness (IMT, ventilation, abdominal binders)
- Secretion clearance (manual assisted cough)
- Supine to prevent paradoxical breathing
- Pressure care
- Bladder/bowel control
- Pain management
How does autonomic dysreflexia present?
- Sudden hypertension
- Headache
- Bradycardia
- Flushing
- SOB
- Blurred vision
What does the literature say about interventions in paraplegic pts?
- Weak for strength
- Strong for cycling, sports and combined arm cranking/leg cycling for fitness
- Strong for functional training
What is the pathophysiology of GBS and its presentation?
- Inflammatory demyelination and antibody mediated axonal damage
- Ascending weakness, paraesthesia, pain
What is drug therapy for GBS?
Plasmaphoresis- Blood removed and plasma substituted
IVIg
How do you manage GBS?
- Prevent cardioresp (NIV, ACT)
- Maintain muscle length
- Strength training, aerobic exercise
What is the pathophysiology of MND?
Progressive degeneration of motor neurons
What are the three phenotypes of MND?
ALS- Upper and lower, dysarthria, dysphagia, fatigue, asymmetrical weakness
Flail- only LMN signs, hyporeflexia, fasiculations (vibrate), weakness, atrophy
PLS- UMN, weakness, spasticity, hyperreflexia
How is MND diagnosed?
UMN, LMN signs
Neurological tests to differentially diagnose
How is MND managed?
- Drugs for symptom management, cramps, pain, spasticity
- Some evidence that exercise improves ALS function, prevents secondary impairments
