Neuro Flashcards
What causes parkinsons
Apoptosis of dopamine producing neurons leads to depletion in dopmanine. Dopamine is a neurotransmitter made in substantia niagra and helps basal ganglia to control and regulate movment. It is also sent to the thalamus and therefore a depletion in it leads to inhibition of movement from thalamus leading to bradykinesia
Assessment for parkinsons
Gait
Balance
Tone
How to assess sensation
Light touch - going to touch you with cotton wool I want you to tell me if you feel it and if it feels the same in both sides
Do in sporadic pattern unless using ASIA scale for SCI
Now I’m going to touch you on your left and right and I want you to say where I touched you
- left right
Do both at same time for stroke as may have sensory in attention
Can also do proprioception by doing joint position sense on fingers and toes to rest fasiculus cuneatus and gracilis
And do mirroring
How to assess balance
Sitting first to determine sitting balance and safety
Eyes open normal base of support with back unsupported - have AO2
Then close eyes to remove visual aspect
Then turn head in sitting
Can do reaching in sitting
Then in standing do:
Normal BOS eyes open/ shut to remove visual aspect of balance
Narrow BOS eyes open and shut (Romberg) if sway with eyes shut has removed vision and proprioception so shows problem with proprioception.
Head turning to test vestibular
How to assess tone
Patient in side lying or supine for LL flexion and extension of knee and ankle
UL sitting
Do 3 times slowly and then do quickly as this will elicit stretch reflex and identify spasticity
What is spasticity and stretch reflex
Spasticity is a velocity dependent change in muscle tone due to exaggerated spinal reflexes e.g. Stretch reflex
This is when the muscle is stretched the body panics and counteracts this stretch by contracting the muscle
How to record tone
Modified ashworth scale
1-catch and release with easy movement through rest of rom
2- catch and release with slight inc In tone for remainder
3-constant resistance through rom
4-rigid in flexion/extension
How to record sensation
Shade body chart for where there is impaired sensation
Record on Nottingham sensory scale (0- absent 1- identifies touch but not 3/3 2- identifies touch all 3 times)
Or for SCI record on Asia impairment scale
What is the vestibular ocular reflex
It’s a reflex that excites muscles on the opposite eye to the direction the head is moving to maintain gaze/focus on a stimulus
What makes up the vestibular system
Peripheral - otoliths (saccule and utricle) &vestibular nerve
Central - vestibular nuclei in brain stem and cerebellum - integrate the info from peripheral
What is balance
Ability to maintain line of gravity within base of support with minimal postural sway
Components of balance
Visual - somatosensory
Proprioception - where joints are in space
Vestibular - equilibrium
How do vision vestibular and proprioception affect balance
Information from all 3 are sent to cerebellum which coordinates movements and posture, this then sends signals to make VOR kick in to control eye movements and signals to muscles to make postural adjustments
Pathophysiology of MS
Nerves are covered in myelin to allow quick and effective conduction of messages. In ms this myelin is attacked by the immune system and is damaged. This reduces the ability of the nerves to send messages and signals. When the myelin is damaged it can cause scarring and cause plaques to form which disrupts nerve communication even more. The axons can become damaged leading to long term disruption.
Why may MS have sensation impairment
If plaques have formed in ascending pathways of spinal cord or in sensory cortex of brain will have altered sensation such as paraesthesia
Assessment for vestibular
VOR - head thrust to see if eyes focus on nose while head is moved
Smooth pursuit - see if can smoothly follow moving target
Saccades - flick between two moving targets
Balance - vision, proprioception and vestibular
Sensation -light touch on lower limbs, touch either side, joint position sense. Do this because will influence balance
Outcome measures for balance
Berg balance scale
Tinetti
Managing spasticity/ hypertonia
Educate patient on triggers
Stretching - maintain muscle length prevent contractures
Range of motion exercises
Weight bearing early on to reduce decrease in bone density and osteoporosis
Strengthen weaker muscles
Promote exercise to reduce fatigue
What are triggers of spasticity
Tight clothes Changes in temperature Constipation Anxiety Dehydration Infection
What does each descending tract do
Corticospinal - voluntary movment skilled movement dexterity tone
Reticulospjnal - tone, posture
Vestibulospjnal - balance - innervates limbs to change position
Rubrospinal- head movements, activates flexor muscles
What does each ascending tract do
Spinothalamic - pain touch temperature vibration
Spinocerebellar - proprioception tells brain how tight the muscle is UNCONSCIOUS
Fasiculus cuneatus - crude touch proprioception vibration above T6
Fasiculus gracilis - same as above but below
Fasiculus synapse in medulla -> thalamus -> sensory cortex
CONSCIOUS
Parkinsonian gait
Flexed posture Reduced knee extension Bradykinesia Akinesia (freezing) Trouble initiating and turning Festinating Reduced trunk rotation and arm swing Look at ground No heel strike Small step length and clearance
MS gait
Possible ataxia - uncoordinated large BOS, wide bos due to bad balance (if messages between brain and ear affected?)
spasticity - may lead to scissoring gait
Weakness leading to toe drag and therefore vaulting hip hitching circumduction to clear floor
Fatigue may lead to increase weakness of muscles
Bad eyesight look at floor & if sensory ataxia will look at floor for position of limbs
Treatment for parkinsons gait
Draw lines on floor to increase step length
Promote heel strike to make you more steady so less likely to fall
Work on posture
Give objects to walk around e.g. Obstacle course
Shifting weight before initiating movement and say ‘ready steady step’
Practising big arm swings
Sit to stands to increase LL strength
Lifting knees up to encourage inc clearance
10 week exercise programme
Trunk exercises for flexibility Morris et al 2010 found this improved balance and gait
Rx for vestibular
Rehabituate VOR - hold card in front while moving head side to side and maintain focus on it. Do in sitting then standing.
Then walk and turn head side to side and can do VOR while walking
Practise smooth pursuit follow thumb with eyes sitting standing walking
Do C spine exercises flex ext lateral rotation
Balance exercises on wobble board eyes open shut turning head
So until vertigo kicks in
Possible reasons for spasticity to occur
Interruption of messages from brain to muscle
Interruption of descending inhibitory tracts from brain or SC
increase excitability of neurones
Prognosis if one sided vestibular problem
Good as other side can compensate
Positive signs in Vestibular Ax
Nausea Dizziness Unable to maintain gaze in VOR using catch up saccades in smooth pursuit rather than smooth eye movement Overshoot or undershoot in saccades
Definition of muscle tone
Resting activity of muscles keeping them primed for activity and reflexes
Resistance to passive movement
Why test balance
If increased risk of falls (PD, stroke, tbi) Vision problems may affect balance If tremor may affect balance Inc tone or weakness Spasticity Decreased sensation
Stretching
Do fingers Then wrist Supination pronation Flexion and extension of elbow Rolling ball or towel on table Exercise shoulder to decrease risk of subluxation
SCI balance
Try supported, unsupported, vision, vestibular, dynamic(weight shifting)
If can stand do this 30 mins a day to reduce loss of bone density
Assessment MS
Tone
Sensation
Gait
TBI Ax
Sensation
Tone
Balance
Stroke Ax
Sensation
tone (1/3 stroke pt have inc tone)
Balance
What other factors could affect balance
Sensory Cerebellum damaged Tone changes Weakness Vision Lack of concentration
SCI Ax
Tone- less inhibition from descending pathways because the inhibitory reticulospinal tract has been damaged Knut leaving the excitatory reticulospinal tract
Sensation - because if a unilateral lesion will affect the DCML pathway and the spinothalamic tracts
Balance - decreased sensation, weakness, tone will affect balance
What is tbi
Can be open - penetration of skull
Or closed - bang to the head tearing cellular structures
May be worse at first due to inflammation and oedema and this can cause long term damage as can move other structures and close blood vessels
Spinal cord injury
Laceration or damage to spinal cord due to inflammation, arthritis, accident, fracture etc
This means messages from brain down spinal cord may not get past the lesion to the muscles causing impaired movement and sensation
Position of stroke patient
Supine - head in midline supported by towels or pillow
weak am on pillow to support
Pillow under knees to prevent DVT contractures
In side lying strong side: Put pillow between legs Rest weak arm on pillow Make sure pt is well rolled over Pillow under feet for Dorisiflexion to avoid foot drop
Side lying weak side:
Weak arm away from body so not crushing it
Shoulder aligned so not pulling behind body
Pillow between legs
Sitting:
Feet flat on floor, body in midline and head, arm supported
Self management
Give exercises to do when on medication
Advise support groups
Accept help from friends and family
Set goals for yourself every day
Vestibular disorders
BPPV
Labrythitis
if crystals are knocked they move the hairs in SCC making head think it’s moving when it’s not
SCC detect horizontal movement and otoliths detect linear
Stroke
Can be ischemic due to thrombus/embolus
Or haemorrhaging which is a bleed in the brain. The brain can’t function in this environment and the intracranial pressure can increase higher than arterial pressure leading to collapse of vessels and ischemic
Secondary problems
Contractures due to decreased muscle length and disuse
Pressure sores
Decreased ROM due to contractures
Weakness due to disuse can result in subluxed shoulder
How often should change position
2-3 hours to prevent contractures pressure sores and increase stimuli to the brain
Other ms symptoms
Vision Balance Fatigue Bladder and bowel Stiffness Tremor Speech Swallowing Memory Emotions Sexual function
Parkinson’s symptoms
Tremor Bradykinesia Rigidity Balance Bowel and bladder problems Dizziness Depression
Possible causes of PD
Genetic link
Exposure to pesticides
What is cogwheel rigidity
When have rigidity through range but tremor makes it jerky
Treating PD medically
L dopa - taken orally. Crosses blood brain barrier and is converted to dopamine in the brain. Often given with carbodopa to recuse sickness
Asia scale what does it test and grading
Mytomes
Dermatomes - light touch and pin prick
Graded A-E, a is complete injury e- normal function
Spasticity medication
Baclofen blocks GABA 2 receptors
So neurotransmitter can’t bind (Ach) so messages aren’t conducted to muscle to contract and therefore they relax
Botox works in the same way
Tizanidine blocks alpha2 receptors
Complete vs Incomplete injury
Complete is no motor or sensory function below lesion
Incomplete may retain some
Retraining functional tasks
Do it passively to show movement
Then active assisted to feel the movement done by patient
Get pt to do actively to inc input from corticospinal tract
Practise components separately and then put them together
Why move spastic muscles
To maintain length of muscles
Maintain ROM
prevent contractures
Keep them from becoming weak and immobile therefore contracting (trompetto et al 2014)
Problems with baclofen
Global weakness
Drowsiness which will affect function
Gait cycle
Initial contact - heel strike? Loading response - equal weight bearing? Mid stance Terminal stance - is there big step length Pre swing - knee flexion? Vaulting? Mid swing Terminal swing
Improving gait
Assist in knee flexion
Weight shifting side to side to promote weight bearing on weaker leg (in sitting and standing)
Sit to stands to increase LL strength
Feel bottom of foot to promote sensation
Practise heel striking movement
Stand and step facilitating knee flexion and ankle dorsiflexion
Mention use of orthotics AFOs
Why do visual cues work
They allow us to activate a different pathway to overcome the block at the substantia niagra
How to improve freezing
Auditory cues such as a rhythm when walking
Where to do senaation testing
Upper limbs as lower limbs to test the tracts e.g. Spinothalamic, fasiculus..
Do on bottom of foot (s1/l5) as this will affect balance
What is proprioception
How long and tense the muscles are
Improving limb after stroke
PROM not into pain or over head to avoid subluxation or impingement
Try and weight bear through arm
Sit at table push ball or towel. If this is too hard just get them to stabilise ball
If have neglect can do mirroring to increase awareness
This helps as repetition will increase plasticity - new pathways will form to re learn
Why is tizanidine better than baclofen
Doesn’t cause global weakness and works with ms that has occurred in brain and spinal cord whereas baclofen just works at spinal cord
Trompetto et al 2014 pathophysiology of spasticity
Important to mobilise muscles otherwise they will contract and this can contribute to hypertonia
How does the stretch reflex work
When muscle is stretched the muscle spindle is activated and sensory fibres send input to motor fibres which send impulse to make the muscle contract
This is exaggerated in umnl patients either the muscle spindle gets over exited or too many motor neurone are activated
Treating ataxia
Balance - regain sitting balance first by sitting supported, unsupported, shifting weight
Practise weight bearing on lower limbs to gain strength
Visual cues to coordinate their foot movement and before moving to the target use eyes to look at target
Educate on exercise
Treating low tone
Weight bearing Balance Strengthening Rom Functional tasks
Retraining functional task
Do bilateral exercises such as lifting large object, unscrewing container lids, catching throwing ball
Reach and grasp to a cup or to put socks on
Dexterity exercises like writing
Balance - reaching to touch Physio hand
Increase sensation by using it to stabilise an object
If patient has neglect
Approach from unaffected side
Use their neglected arm and passively move it while saying what you are doing so you combine touch and auditory senses
Get them to look over to the hand and use their good hand to move it
Things to look for in gait
A- is it ataxic or antalgic (short stance phase to avoid weight bearing)
B- base of support is it large or small
C- foot clearance is it high or are they compensating by vaulting or hip hitching
D- deviation are they walking straight
E- knee, is it flexed
G- good step length
Increasing sit to stand and walking in those with NM disorders
Move the weak side first when transferring as can use strong side to move the weak side
Practising sit to stands and mini squats can hold on at first to improve LL strength, can then move to no hands
Work on core stability such as bridging
Hip hitching - stand on one leg and lift other hip up, LL strengthening
Trunk flexibility - sideways lean on plinth or lean forward pushing something on table (3-5 times)
MORRIS ET AL 2010 SHOWED TRUNK FLEXIBILITY INC GAIT AND BALANCE
Why is there an increase in tone
Tone is usually modulated by descending tracts that both excite and inhibit tone. If there is damage to the inhibitory tract then there is constant firing from the excitatory one leading to increased firing from anterior horn cells and therefore an increase in muscle activity
Flow chart for UMN lesion
An UMNL can lead to muscle over activity (spasticity, dystonia) or muscle weakness - in which disuse leads to contractures.
These both lead to hypertonia and reduced ROM, thereby affecting posture and function
Types of MS
Relapsing remitting - 80%. Have relapses and never fully recover so after every relapse the symptoms worsen
Primary progressive - gradually worsens over time without relapse
Secondary progressive - starts as RR and then gradually worsens
Benign- no symptoms between relapses
Test for increase ROF
TUAG Sit in chair with hands on arm chair Stand up from chair walk 3m turn around walk back sit down Time how long and look at gait If longer than 12s = ROF
What does the vestibular give info on
Spatial orientation
Postural control
Ocular motor system
Speech intro
Hi I’m Louise a second year physiotherapy student, I understand you have MS is that correct?
Ok well today I would like to do 3 assessments which will involve me placing my hands on you and moving you around is that ok?
Ok so the first assessment we are going to do is
Testing for tone - so this will involve me running your arms and legs through a few movements is that ok? Ok so if you Can lie back on the plinth for me, are you comfortable?
PROM does that feel ok? Let me know if you’re in any pain or uncomfortable at any time
Ok so this patient has no increase in tone however I would expect some increase in tone due to (in parkinsons - lack of motor activity of inhibitory pathway?) (ms- damage along the inhibitory reticulospinal pathway) (SCI- damage to inhibitory pathway of RTS or Dec inhibitory signals passing lesion) etc..
Why an increase in tone in stroke or TBI
Death of cells due to lack of blood supply will damage the axons and tracts as they all need blood to work
In tbi the injury can affect the inhibitory pathways and axons and therefore less inhibitory signals get sent to the muscle
Afer injury there is less cortical control over reflexes leading to spasticity
Why an increase in tone in parkinsons
Dopamine is produced in substantia niagra and sent to basal ganglia to help initiate movement and control it. Lack of dopamine leads to loss of input/output from basal ganglia. The extraprymaidal tracts eg reticulospinal arise from the basal ganglia and are therefore affected
Problems with voluntary movement
Due to corticospinal tract damaged e.g. In stroke or tbi if somatosensory cortex or parietal lobe is damaged will affect corticospinal tract as this arises from here
What RST is involved in inhibiting tone
Lateral
exercises stroke
Bridging sit on feet help push through legs
Move objects from one side of table to another
Internal and external rotation and flexion and extension of shoulder but support humerus
Flexion and extension of fingers and wrist
Squeeze Physio hand
Apply resistance to flexion and extension by holding the hand and pushing in opposite direction
Push towel forward back and side to side on table and round in circle x10
Shrug shoulders
What to look for in normal gait
Initial contact is it heel strike or not &is o they have some hip flexion
Loading response
Are they weight bearing is knee and hip in flexion
Mid stance are they in extension
Terminal stance - can they plantarflex
Is single support and double support equal time
What is step length like
Do they have arm swing
What’s posture like
What to look for in normal gait
Initial contact is it heel strike or not &is o they have some hip flexion
Loading response
Are they weight bearing is knee and hip in flexion
Mid stance are they in extension
Terminal stance - can they plantarflex
Is single support and double support equal time
What is step length like
Do they have arm swing
What’s posture like
Cerebellar ataxia treatment
Bridging
Legs flexed to 60 and bend side to side
Sit to stands
Picking up and moving objects side to side
Picking things up and putting behind head and back down
Rapid alternating movements
Passing object from one side over head to other side
Follow pattern with foot
Tandem walking, normal walking and having to start and stop to a command (use visual cues)
Side stepping
Nudging in balance
Catching and throwing all
Bouncing ball alternating left and right hands
Managing flaccidity and low tone
Range of motion of shoulder to 90
Elvow flexion and extension
Supination pronation
Wrist flexion extension
Finger flexion and extension
Finger abduction adduction
Thumb adduction abduction
Get patient to do it as well to inc muscle activity
Roll arm on a ball supported by other hand
Roll towel forwards backwards side to side round
Sensory rehab what do u do
Touch hand in different points and get pt to point where
Get pt to hold different objects with eyes closed and try and describe the objects and then look st them and then re close eyes and focus on them when you know what they are
Do it 2-3 times a day for 10 minutes
Get pt to hold over your hand while drawing shapes or alphabet
What to look for in gait
Is there a short stance phase or ok
Is the trunk straight or anterior or posterior to the hips
are they leaning to one side
do they have arm swing
Do they have good hip extension and knee extension
Is there good ankle plantatflexion
