Neurology - Part 2 Flashcards
Balance
Orient to surrounding environment while maintaining center of gravity within base of support
Can be static or dynamic
Requires integration of many body systems
MUST ASSESS FALL RISK
Body Systems contributing to Balance
- Sensory
- Visual
- Somatosensory (Bottom of foot, monofilaments)
- Vestibular - Sensorimotor
- Integration in CNS (Cerebellum) - Motor Output for postural control
- Cognition
Each system must function effectively to maintain balance
- If they lose balance, which system is affected…drives intervention
Visual System
Visual System
* Light
* View obstacles
* Position of head relative to environment
* Relative motion of other objects in environment
Damage to visual system
* CVA (CN involvement)
* Central brain issues
* Pathologies of the eye
Assessment: Vision Testing and CN assessment (oculomotor testing)
Somatosensory System
-Provides information from receptors of the skin, mm, tendons, joints relative to position of body parts relative to other body parts
-Damage/Injury to somatosensory system:
(Central: CVA, SCI, MS, etc. ; Peripheral: Neuropathies)
- Assessment: Sensory Testing
Vestibular System
- Provides information about position and movement of head relative to gravity and inertial forces
- Controls Posture
- Pathology to vestibular system: (Central and Peripheral)
- Vestibular system dysfunction leads to Vertigo and balance deficits when head is moving
- Assessment: Complex and specialized.
Vestibular System: Peripheral System
- Semicirular canals (detect angular movements of head)
- Otholithic organs of inner ear (detect linear movement of head and orientation of gravity
Sensorimotor integration in CNS
Information is processed in:
- Basal Ganglia
- Cerebellum
- Motor Cortex
Assessment
- Balance
- Pattern recognition of conditions (Ex: Parkinson’s Stroke)
Fear of Falling
- Changes movement patterns
- Fear can increase tone in muscles
- Decreased activity (decline in strength, endurance)
- Social isolation
Base of Support
- Area beneath a person that incudes every point of contact that person makes with the supporting surface
- Ex: Split stance is larger than narrow stance; Babies use whole body for support
Cone of Stability
Distance center of gravity can move over base of support without losing stability
Motor Output
Sensory motion received and processed in the brain results in a motor response
Motor strategies – Typically reflexive (arm, Stepping, Ankle, Hip)
- Arm toward ground before falling
Assessment:
- MMT
- Assessment during balance testing
Balance Assessment
Must ensure patient safety (proper guarding, gait belt, etc.
Prior to standing balance screen:
-General screen first (Vision, motion, strength)
-Cognitive screen
-Somatosensory screen
-Questionairres (Confidence of balance)
-Sitting balance
After balance screen
-Gait assessment: Deviation noted consistent with balance deficits
Balance Assessment – Tests
Sitting
Static standing balance tests
- Romberg test
- Single-limb stance test
Anticipatory balance tests
- Functional reach tests
- Catching
Reactive balance tests
- Nudge/push test
Dynamic balance tests
- Berg Balance Scale
- Tinetti Balance and Gait
Balance Testing Priority
- History of falls or episodes of instability
- Known or suspected CNS dysfunction that affects postural stability
- Somatosensory loss to lower extremities
- Frequent injury or surgery of lower extremity (affects motor)
- Gait deviations or in need of an assistive device
- Patients of the age of 65 or older
CN - Common causes of dysfunction
12 pairs of peripheral nerves
Common causes
- Trauma
- Tumor
- Ischemia
- Diseases that affect peripheral nerves
Why would a PT complete a cranial nerve assessment?
Collect data to help with a diagnosis
Develop a baseline
Repeated testing to determine change from baseline
CN 1 – ?
Change in sense of taste and smell?
CN 2 - ?
Change in vision
Observation: Difficulty reading items, squinting, etc.
CN 3 - Observe
Ptosis (drooping eyelid) or asymmetrical eye movement
CN 4 – Test
Convergence of eyes (6 inches)
H pattern
CN 5 - ? And Ob
Any numbness/tingling in face?
Observe: Inability to clench jaw
CN 6
Expect conjugate eye motion
CN 7 - ? And Ob
Loss of sense of taste?
Dry eye?
Observe: Facial expression changes
CN 8 - ?
Any hearing loss?
Coordination of CN 3, 4, 6, 8
Saccades: Rapid movement of the eye between fixation points
- Test: Jump eyes to new target on command
(Abnormal: Overshoot or undershoot of eyes: Central sign)
Gate stabilization: Ability to hold gaze on object as head moves up and down and/or side to side
- Assess vestibulocochlear relfex
- Test: Have pt focus on object and move head
(At end range individuals will have nystagmus for 15% of individuals)
CN 9 and 10 - ?
Recent change in voice?
Have you had frequent coughing?
Issues clearing your throat?
CN Assessment Priority
- Known or suspected injury to brain, brain stem or upper cervical spine
- Progressive disease affecting the brain or brain stem
- Sudden or unexplained change in function/cognition
- Side to side differences in facial expressions
- Atrophy in muscles of face or lateral neck
- Headaches (acute or chronic) or neck pain (acute or chronic)
What are upper motor neurons?
Start in cerbral cortex and brainstem
Activate lower motor neurons anterior horn of spinal cord
Resting muscle tone
How are upper motor neurons assessed?
Muscle tne during passive movement
Deep tendon reflex testing (Reflexes w/Hammer)
Special tests
- Clonus
- Superficial reflexes
—Babinski Test (foot swipe)
—Hoffman’s Test (Finger flick)
- Pronator Drift
Tone Assessment
Patient in supine position
Perform ROM several times and increase speed with each cycle
- Spasticity will more often be felt moving out of flexion into - extension
- If resistance is greater as speed increases, spasticity if present
Ex: Elbow Flexion and Extension, Hip Flexion and Extension
Hypotonia
Hypotonia – pathological decrease in tone
- Little to no resistance (floppy) ROM
Also seen in:
Down Syndrome
Cerebral Palsy
Peripheral Nervous Systems
Hypertonia
- Hypertonia – pathological increase in tone
- Increased resistance to PROM, especially when muscle is stretched
- Impaired modulation from the CNS
- Spasticity: When dropped will catch
- Rigidity: Constant resistance
Spasticity
Resistance to passive motion is dependent on RATE or VELOCITY of the limb movement
Faster the rate, the more resistance to movement
Generally flexors for arms and extensors for legs
Rigidity
Resistance throughout the ROM is consistent throughout the ROM
Plastic rigidity (bending plastic): resistance throughout the motion
Cogwheel rigidty: cogwheel like jerks during motion assessment
Parkinson’s
Deep Tendon Reflex Testing
Hypotonia: potential LMN lesion – disruption of sensory or motor nerve
Hypertonia: potential UMN lesion – inability to modulate the LMN
Grades:
0 – absent
1+ - Minimal response
2+ - Normal
3+ Brisk Response
4+ Brisk response with Clonus
Areas to assess:
Biceps (C5-C6)
Brachioradialis (C5-C6)
Triceps (C7)
Quads (L3-L4)
Gastrocnemius (S1)
Clonus
A rapid back and forth motion that repeats several times
Positive test is 3 or more beats.
Gently move through Dorsiflexion and Plantarflexion several times then rapidly DF the ankle and hold
Pronator Drift
Patient is asked to stand with arms at 90 degrees flexion with palms up, EYES CLOSED
Positive if one of the arms moves into pronation and “drifts” down and toward midline
Indicates lesion In corticospinal tract
UMN Testing
Suspicion of CNS lesion (Rule in or Out)
Determine extent and severity of known CNS lesion
Determine presentation of CNS condition
