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Neuro Flashcards

1
Q

What causes parkinsons

A

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

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2
Q

Assessment for parkinsons

A

Gait
Balance
Tone

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3
Q

How to assess sensation

A

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

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4
Q

How to assess balance

A

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

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5
Q

How to assess tone

A

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

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6
Q

What is spasticity and stretch reflex

A

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

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7
Q

How to record tone

A

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

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8
Q

How to record sensation

A

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

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9
Q

What is the vestibular ocular reflex

A

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

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10
Q

What makes up the vestibular system

A

Peripheral - otoliths (saccule and utricle) &vestibular nerve
Central - vestibular nuclei in brain stem and cerebellum - integrate the info from peripheral

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11
Q

What is balance

A

Ability to maintain line of gravity within base of support with minimal postural sway

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12
Q

Components of balance

A

Visual - somatosensory
Proprioception - where joints are in space
Vestibular - equilibrium

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13
Q

How do vision vestibular and proprioception affect balance

A

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

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14
Q

Pathophysiology of MS

A

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.

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15
Q

Why may MS have sensation impairment

A

If plaques have formed in ascending pathways of spinal cord or in sensory cortex of brain will have altered sensation such as paraesthesia

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16
Q

Assessment for vestibular

A

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

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17
Q

Outcome measures for balance

A

Berg balance scale

Tinetti

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18
Q

Managing spasticity/ hypertonia

A

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

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19
Q

What are triggers of spasticity

A 
Tight clothes 
Changes in temperature 
Constipation
Anxiety
Dehydration
Infection
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20
Q

What does each descending tract do

A

Corticospinal - voluntary movment skilled movement dexterity tone
Reticulospjnal - tone, posture
Vestibulospjnal - balance - innervates limbs to change position
Rubrospinal- head movements, activates flexor muscles

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21
Q

What does each ascending tract do

A

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

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22
Q

Parkinsonian gait

A 
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
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23
Q

MS gait

A

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

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24
Q

Treatment for parkinsons gait

A

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

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25
Q

Rx for vestibular

A

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

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26
Q

Possible reasons for spasticity to occur

A

Interruption of messages from brain to muscle
Interruption of descending inhibitory tracts from brain or SC
increase excitability of neurones

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27
Q

Prognosis if one sided vestibular problem

A

Good as other side can compensate

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28
Q

Positive signs in Vestibular Ax

A 
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
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29
Q

Definition of muscle tone

A

Resting activity of muscles keeping them primed for activity and reflexes
Resistance to passive movement

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30
Q

Why test balance

A 
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
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31
Q

Stretching

A 
Do fingers 
Then wrist 
Supination pronation 
Flexion and extension of elbow 
Rolling ball or towel on table
Exercise shoulder to decrease risk of subluxation
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32
Q

SCI balance

A

Try supported, unsupported, vision, vestibular, dynamic(weight shifting)
If can stand do this 30 mins a day to reduce loss of bone density

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33
Q

Assessment MS

A

Tone
Sensation
Gait

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34
Q

TBI Ax

A

Sensation
Tone
Balance

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35
Q

Stroke Ax

A

Sensation
tone (1/3 stroke pt have inc tone)
Balance

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36
Q

What other factors could affect balance

A 
Sensory
Cerebellum damaged 
Tone changes
Weakness
Vision
Lack of concentration
37
Q

SCI Ax

A

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

38
Q

What is tbi

A

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

39
Q

Spinal cord injury

A

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

40
Q

Position of stroke patient

A

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

41
Q

Self management

A

Give exercises to do when on medication
Advise support groups
Accept help from friends and family
Set goals for yourself every day

42
Q

Vestibular disorders

A

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

43
Q

Stroke

A

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

44
Q

Secondary problems

A

Contractures due to decreased muscle length and disuse
Pressure sores
Decreased ROM due to contractures
Weakness due to disuse can result in subluxed shoulder

45
Q

How often should change position

A

2-3 hours to prevent contractures pressure sores and increase stimuli to the brain

46
Q

Other ms symptoms

A 
Vision 
Balance 
Fatigue 
Bladder and bowel 
Stiffness 
Tremor 
Speech
Swallowing
Memory
Emotions
Sexual function
47
Q

Parkinson’s symptoms

A 
Tremor
Bradykinesia
Rigidity
Balance
Bowel and bladder problems
Dizziness
Depression
48
Q

Possible causes of PD

A

Genetic link

Exposure to pesticides

49
Q

What is cogwheel rigidity

A

When have rigidity through range but tremor makes it jerky

50
Q

Treating PD medically

A

L dopa - taken orally. Crosses blood brain barrier and is converted to dopamine in the brain. Often given with carbodopa to recuse sickness

51
Q

Asia scale what does it test and grading

A

Mytomes
Dermatomes - light touch and pin prick
Graded A-E, a is complete injury e- normal function

52
Q

Spasticity medication

A

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

53
Q

Complete vs Incomplete injury

A

Complete is no motor or sensory function below lesion

Incomplete may retain some

54
Q

Retraining functional tasks

A

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

55
Q

Why move spastic muscles

A

To maintain length of muscles
Maintain ROM
prevent contractures
Keep them from becoming weak and immobile therefore contracting (trompetto et al 2014)

56
Q

Problems with baclofen

A

Global weakness

Drowsiness which will affect function

57
Q

Gait cycle

A 
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
58
Q

Improving gait

A

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

59
Q

Why do visual cues work

A

They allow us to activate a different pathway to overcome the block at the substantia niagra

60
Q

How to improve freezing

A

Auditory cues such as a rhythm when walking

61
Q

Where to do senaation testing

A

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

62
Q

What is proprioception

A

How long and tense the muscles are

63
Q

Improving limb after stroke

A

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

64
Q

Why is tizanidine better than baclofen

A

Doesn’t cause global weakness and works with ms that has occurred in brain and spinal cord whereas baclofen just works at spinal cord

65
Q

Trompetto et al 2014 pathophysiology of spasticity

A

Important to mobilise muscles otherwise they will contract and this can contribute to hypertonia

66
Q

How does the stretch reflex work

A

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

67
Q

Treating ataxia

A

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

68
Q

Treating low tone

A 
Weight bearing
Balance
Strengthening 
Rom
Functional tasks
69
Q

Retraining functional task

A

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

70
Q

If patient has neglect

A

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

71
Q

Things to look for in gait

A

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

72
Q

Increasing sit to stand and walking in those with NM disorders

A

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

73
Q

Why is there an increase in tone

A

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

74
Q

Flow chart for UMN lesion

A

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

75
Q

Types of MS

A

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

76
Q

Test for increase ROF

A 
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
77
Q

What does the vestibular give info on

A

Spatial orientation
Postural control
Ocular motor system

78
Q

Speech intro

A

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..

79
Q

Why an increase in tone in stroke or TBI

A

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

80
Q

Why an increase in tone in parkinsons

A

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

81
Q

Problems with voluntary movement

A

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

82
Q

What RST is involved in inhibiting tone

A

Lateral

83
Q

exercises stroke

A

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

84
Q

What to look for in normal gait

A

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

85
Q

What to look for in normal gait

A

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

86
Q

Cerebellar ataxia treatment

A

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

87
Q

Managing flaccidity and low tone

A

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

88
Q

Sensory rehab what do u do

A

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

89
Q

What to look for in gait

A

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

Neuro Rehab (1 decks)

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