Neuro Diff Dx Flashcards
Parkinsons Disease is depletion of _ from the _
Dopamine from the Substantia nigra
Exercise SLOWS the progression!
People w/ PD are TRAPped
CARDINAL SIGNS
T:Tremor– shaking, usually starts 1 side; “pill-rolling”
R: Rigidity– stiffness, of limbs, neck, or trunk (1. cogwheel 2. lead pipe)
A: Akinesia– LOSS or impairment in POWER of voluntary mvmt
P: Posture and Balance– Anteropulsion
Bradykinesia also present==> SLOWNESS of mvmt
Shuffling, short-stepped gait pattern
LOSS OF ARM SWING**
PD Sx’s: Resting Tremor
Often occurs first in ONE hand, resembles pill-rolling
PD Sx’s: Rigidity
Cogwheel (exactly what it sounds like) and Lead Pipe (exactly what it sounds like)
PD Sx’s: Akinesia, BRADYkinesia
Hesitation, SLOW mvmt.
Diff rising from a sitting pos is COMMON sign of disordered control over mvmt
PD Sx’s: Postural INstability
Lean FORWARD or BACKWARD when upright==impaired balance/coord.
PD Sx’s
see pics
This scale stages the SEVERITY of PD:
Hoehn and Yahr Stages
Staged 1 (good)-5 (worst)
Hoehn and Yahr Stages of PD
ALL: Stage 1 (best): Stage 5 (worst)
see pics
Hoehn and Yahr Stages of PD:
ALL
- Stage 1: Develop MILD sxs but able to go about day-day life (BEST)
- Stage 2: Sx’s such as tremors and stiffness worsen, may develop POOR posture or have trouble walking
- Stage 3: Mvmt begins to SLOW DOWN, LOB (uses AD, falls/unbalanced, rollator
- Stage 4: Sxs are severe and cause significant issues w/ day-day living, UNABLE to live alone and will need care
- Stage 5: Walking or standing may be IMPOSSIBLE @ this point, people in Stage 5 often confined to WC or bed (WORST)
PD: Gait related impairments:
2 VERY characteristic ones…
- Festinating gait:progressive INC in speed w/ a shortening of stride–can be anteropulsive (forward festinating)
-
Freezing of Gait (FOG)– sudden, abrupt INability to initiate ANY mvmt. Ex’s: doorways, turns
- USE: music, count steps, cognitive tasks
PD related Gait impairments:
ALL
- Festinating
- Freezing
- Diff turning: incd steps per turn
- Reduced stride length; incd step-step variability
- Reduced speed of walking
- Incd time in DLS
- Insuff hip, knee, and ankle flexion–> shuffling steps
- Insuff heel strike w/ incd FOREFOOT loading
- Reduced trunk rotation: DECd/absent arm swing**
- Diff dual tasking–> simultaneous motor/cog
- Diff w/ attn demands of complex environments
Training ideas for gait related impairments
Visual/auditory cueing
ex. ladder for equal step length, count steps
Medical mgmt PD:
GOLD STANDARD DRUG TX
LEVODOPA/CARBIDOPA (Sinemet)
Medical mgmt PD:
SEs and **what should you remember about this?? **
SEs: Dyskinesias–Dynamic INvoluntary choreoathetotic mvmts occurring @ peak of Levodopa dose–> Initial=facial grimace w/ twitch lips, tongue protrusion–> Severe=involves limbs, trunk, neck
REMEMBER: This is SE of the MEDS (Levodopa) NOT from PD itself!!!!
Practice!
PT working w/ 67yo male. Pt displays rigidity, slowed mvmts, INvoluntary oscillatory mvmts, intsability w/ recent uptick in falls. Based on presentation which neuro dx is likely ?
PD!!!
TRAPped
Huntington’s Disease (HD)
- Neurodegen GENETIC (hereditary) disease– degen of BG, cerebral cortex
- Autosomal-dominant illness– CAG repeats
- Combo of–> mvmt disorders, COG decline, behavioral changes
NOTE: When you hear Parkinsonism
NOT actually PD from DEC in dopamine
Just “PD-like” sx’s
HD Sx’s:
AGE????
35-55
HD- Sx’s
- 35-55yo
- mm coord impairs AND cog decline, psychiatric probs
- **Huntingtons Chorea–> **INvoluntary jerking or writhing mvmts (ex. unable to sit still)
- MM probs–> rigidity or mm contracture (dystonia)–think superimposing involuntary mm’s– piano example w/ fingers
- Slow/abnorm eye mvmts
- Impaired gait, posture and balance
- Diff w/ production of speech or swallowing*
Cerebellar disorders
THINK* in terms of tremor*…
INTENTION tremors
Three specialized regions of Cerebellum for controlling multiple types of mvmt
- Vestibulocerebellum
- Spinocerebellum
- Cerebrocerebellum
Vestibulocerebellum
Input, Output, Deficits as result
Input–> Vestibular
Output–> eye mvmts; vestib nuclei; balance/equilib
Deficits–> Nystagmus, TRUNCAL ataxia
Spinocerebellum
Input, Output, Deficits as result
Input–> Somatosensory, visual/auditory/vestib
Output–> medial upper motor neurons; lateral upper motor neurons
Deficits–> Ataxic gait, Limb ataxia (dysmetria)
Cerebrocerebellum
Input, Output, Deficits as result
Input–> Cerebral cortex
Output–> Motor and premotor cortex
Deficits–> DEC coord of fine finger mvmt
Practice!
Pt w/ NORMAL sensation and reflexes presents w/ DEC mm tone and asthenia (weakness). Which other s/s are MOST likely present?
Truncal Ataxia
CB disorders–> HypOtonia, lack energy, weakness (asthenia)
Cerebellar Disorder–> Coordination Testing
see pics and note Dx tests
- finger to nose, heel to shin
Finger to nose test– >
Cerebellar ataxia
*can also see dysmetria (over/under shooting)
S/S Cerebellar Disorder
Mnemonic to remember?
VANISHED
V: Vertigo
A: Ataxia
N: Nystagmus
I: Intention tremor
S: Slurred speech
H: HypOtonia
E: Exxagerated broad based gait
D: Dysdiadochokinesia
CB= intention tremor; BG= resting tremors
Cerebellar disorder:
Gait Ataxia explained…
INconsistent step LENGTH: not able to predict proper step length
Diff maint. SLS
Poor balance= INCd gait ataxia and slow gait
Diff predicting amt of wt shift needed
Some more Coord. tests for CB
Finger-> nose
RAM
Heel-> shin
Foot to finger
NOTE for NPTE answering questions
IF 2 answers look SIMILAR to ea. other—-> likely BOTH wrong!!!!
MS: main things to remember
- Autoimmune– inflamm, selective demyelination, gliosis
- Chronic demyelinating of CNS
- ANY area of CNS affected– cortical, subcort, CB, SC
MS: Main characteristics
- MORE in females (2:1)
- Onset 20-40yo, PEAKS 30yo
- Occurs more caucasians
MS: Etiology
Think… Sclerosis literally means scarring… **Multiple sclerosis*
Healthy myelin–> Oligodendrocytes produce myelin in CNS–insulates nerves, speeds conduction, conserves energy
- In MS: Destroyed or damaged myelin (WBCs attack neurons and affects myelin (fatty tissues around nerves in brain/SC)== multiple scarring (sclerosis), nerve signals blocked == MS sx’s
HEAT SENSITIVITY in MS…. WHY?
Bc myelin sheath damaged **
S/S MS:
3 big ones to know**
- Lhermittes’ Sign–Flex neck=> E-shock t/o extremities
- Uthoff’s Phenomenon–HIGH temp exposure=> exxag’d neuro sx’s (make sure they hydrate!!!)
- FATIGUE!
S/S MS:
NOTE: impairs vary based on lesion location
- Visual impairs (Optic Neuritis), sensory impairs, motor impairs
- Intention tremor
- Neuropathic pain
- FATIGUE
- Cog impairs
- B&B dysf.
- Emo. distrubs
- Psychosoc probs
- Lhermittes’
- Uthoff’s Phenom.
MS Dx:
The one to remember
- CSF analysis–> Elevated immunoglobulins and presence of oligoclonal IgG bands, slight PRO elevation
DECd NCV
Common types of MS:
- Relapse-Remitting (RRMS)
- Secondary Progressive (SPMS)– >85% progress to SPMS
- Primary-Progressive (PPMS)
- Progressive-Relapsing (PRMS)
Types of MS:
Relapse-Remitting (RRMS)
- Episodes of rapid, abrupt deterioration w/ variable degs of recover over time
- aka Exacerbating-remitting
Types of MS:
Progressive-Relapsing
Relapses w/ Lg degree of residual impairment
aka Exacerbating-progressive
Types of MS:
Primary-Progressive
“Chronic-Progressive”
its in the name!
- STEADY progressive deterioration
- Pace of deterioration may be steady or varied
Nonetheless, still progressively worse and worse
Types of MS:
Secondary-Progressive
In name, think the one that starts as Relapse-Remitting
- BEGINS as relapse-remitting THEN becomes Primary (chronic)-Progressive
MS:
Fatigue vs Fatigability
They will demo BOTH
Fatigue is symptom
Fatigability is a sign
MS- Gait Related impairs
Big ones to know
Remember its **UMN lesion!! **
- Weakness– Foot drop==toe drag
- Spasticity– Velocity-dep, interferes w/ gait
- Balance probs–Swaying and “drunken” gait–> Ataxia
- Sensory defs– peripheral neuropathy= sensory ataxia
- Fatigue– incd gait probs (remember fatigability also! (sign)
This is usually FIRST SYMPTOM OF MS
Visual impairments!!!
Visual impairs: MS
Usually FIRST symptom!
- Optic neuritis!
- Marcus Gunn– abnorm Pup Lt Reflex (CN II messenger, CN III motor eff.
- Nystagmus
- Diplopia
Practice!
32yo female has abnorm reflexes. “weird sensations” t/o body. Incd IgG in CSF. Asks PT to dec temp bc heat intol.
MS!!!!
- Inc IgG, heat intol, 35 yo (20-40 onset), female (2:1), weird sensations, abnorm reflexes (UMN)
Practice!
43yo pmh includes MS. Reports over past 2 yrs sig. flare ups w/ declining mobility. Which subtype MS?
Flare ups W/ declining funcion
Relapsing-Progressive
Relapse but stiil progressively getting worse!
MS:
Goals of PT interventions
- Exercise and MS:Fatigue + heat intol combo’d w/ weakness/spasticity limits exercise—BUT people w/ MS get same results as normal people– THEY GET MORE FIT!!! DO INTERVAL TRAINING
- Ex. considerations– AM bc decd temp and fatigue
Big one to remember w/ Myasthenia Gravis
PTOSIS
- also WEAKNESS (asthenia)
Side by side MS vs Myasthenia Gravis
see pics
MS Clinical Charactristics
- AcquiredDemyelinating disease w/ AI cause
- weak, parasthesias
- Charcots triad C in Charcots, C in Cerebellar–> INtention tremor, scannign speech, nystagmusCerebeller involve.
- spastic, hypertone, hyperreflex, Babinski
- INcoord, optic neuritis (often first), ataxia, vertigo, dysarthria (speech)
- diplopia, bladder incont, tremor, balance defs, falls, cog defs
Myasthenia Gravis Clinical Characteristics
NOTE that MG RECOVER FASTER FROM FATIGUE VS MS!!!!
- NMSK Junction disorder
- AI mediated AcH receptor damage==> deficit in NMSK transmission
- WEAKNESS–worse during activities, improves after rest
- Variable weakness–> ptosis/diplopia to critical resp weak.
- MMs of speech, facial, mastication, swallowing, breathing, neck and limbs maybe involve.
EARLY sx’s Myasthenia Gravis
*Sometimes the ONLY sx’s
- ptosis (droopy eyelid)
- diplopia (blurry double vision)
Practice!
45yo female w/ recent dx of MS. C/O eye pain, visoin loss ONE eye and visual field loss. Which CN?
CN II (Optic)
*usually involved in MS, sometimes CN V
Guillian-Barre Syndrome (GBS)
UMN or LMN?
LMN!!!!
think stocking glove
Guillian-Barre Syndrome (GBS)
UMN or LMN?
LMN!!!!
think stocking glove
Guillian-Barre Syndrome (GBS)
UMN or LMN?
LMN!!!!
think stocking glove
Guillian-Barre Syndrome (GBS)
UMN or LMN?
LMN!!!!
think stocking glove
GBS
remember LMN!!!
- Autoimmune response– antibodies attack own PERIPHERAL NERVES
- usually onset AFTER resp infx, GI infx
Guillian-Barre or GBS
What is the B?
B stands for BILATERAL
GBS–Pathogen
LMN disorder
- demyelinating of spinal N. roots AND P. nerves
- rapid onset of weakness (DIST–>PROX (stocking-glove) w/ BIlateral sx’s– peak 2-3wks, no > 4wks
- severity and course vary widely –usually norm fucntion w/in 3-6mos
_ and _ usually FIRST SX’Sof GBS
Weakness and Tingling in extremities
GBS Dx
MUST satisfy this criteria
- Symmetrical
- B for Bilateral
- Ascending (dist->prox= stocking-glove)
GBS and Lumbar puncture
CSF contain more PRO than normal
GBS
Sensory Sx’s
- INITIALLY–> B/L and Symmetrical–> Stocking-glove
- PAIN–> Lg mm’sof body–> back, thighs, butt
- Stiff, cramping, deep ache–stretch them first 15mins
- N/T and parasthesias/dysesthesias “ants under skin”
GBS
Motor Sx’s
- DECd signal strength of P. nerves
- MM weak/atrophy
- DTRs diminished
- Partial OR full paralysis
- Resp mm involve—mech. vent maybe
- ## Facial/oral-motor weak– vision, speech, swallowing
Amyotropic Lateral Sclerosis
A stands for_
ALL
UMN and LMN Sx’s
ALS
“Lou Gehrig’s”
S/S
- LMN patho– mm weak, hypOreflex, hypOtone, atrophy, mm cramps, fasciculations
- UMN patho– spastic, patho reflexes, hypERreflex, mm weak
- Bulbar– bulbar mm weak, dysphagia, dysarthria, siolorrhea, pseudobulbar affect (laugh or cry no reason)
- Resp– insp/exp mm weak, dyspnea, DOE
- Frontotemporal dementia–COMMON– loss insight, emo. blunting
- Cog impairs– attn defs, defs in cog flex.
- Behavioral impairs– irritable, social disinhibit.
Dx of ALS= ALL–> UMN + LMN
Weakness HERE very common
CS Extensors!!!!!
MOST COMMON AND DEVASTATING FATAL MOTOR NEURON DISEASE AMONG ADULTS
NOTE: you will see head hanging forward
ALS vs MS
Note the similarities vs diffs
*Note the Sensory issues w/ MS and NOT ALS
Practice!
42 yo female c/o Asymmetrical weak of L/UEs. Fasciculations present (LMN) w/ impaired speech, sensations intact. Randomly starts crying or laughing no reason (bulbar)
ALS
Summary Table: Neuro Diff Dx
MEMORIZE WHOLE TABLE
SEE PICS
