neuro eval lecture 1

neuro is less well understood, and it'll give subjective and objective data

• PT diagnosis not same as MD diagnosis
• ex. PT says MS is a disease of mobility, MD says it's of demyelination

most of all, do a neuro eval to figure out what to treat, to choos correct interventions

• ID if disease process or impairment is impacting the nervous system
• localize the lesion - recognize patterns and deduce pathology

Pathology. Impairment. Function. Society.

• the underlying disease/defect occuring at cellular level
• stroke: impaired BS to CNS due to thrombo-embolus or bleed
• TBI: acute trauma to brain
• Parkinsons: damage to substantia nigra
• MS: autoimmune CNS demyelination

PTs don't really treat at the cellular level

disruption of a motor, sensory, or cognitive process

ex: spasticity, sensory loss, bradykinesia (slow movement), fatigue, thermosensitivity

PT usted to be here

• the functional limitation
• ex. inability to walk, balance, reach, stand, etc. ...

PT is here

disability - decreased ability or inability to perform social roles

ex: parenting, work

This is where PT should go.

• Impairment level - sensory, motor, spatisticity, ROM, etc
• Functional limitation - gait, balance, transfers
• Disability - QOL measures, self report measures

• focal vs diffuse
• CNS vs PNS
• upper motor neuron vs lower motor neuron
• dermotomal/myotomal vs non dermotomal/myotomal
• nervous system vs other

all upper motor neuron lesions are in the CNS

can have CNS damage w/o UMN lesion

• focal - lesion in one spot, maybe due to a stroke
• diffuse - spread over wider area of brain, maybe due tue a big stroke or a disease like alzheimer's
• multifocal - seen in MS or trauma
• focal + diffuse - trauma creates a focal one on site of impact, it runs thru brain to make another focal one on opposite side, and all in the middle it's diffuse

• cortical
• subcortical
• cerebellar
• basal ganglia
• spinal cord

• anterior horn cell
• nerve root
• plexus
• peripheral nerve

in a muscle exam you look for it in peripheral nerve, NMJ, and muscle itself -- says another slide

• observation
• subjetive history (pt and fam)
• med record
• know when to refer

reliability - is test repeatable (inter-rater reliablility - diff raters get same results. intra-rater reliability - same rater gets same results)

validity - does test measure what it claims to

• ability to pick up various signs and symptoms of pathology
• ex: high BBS accurately predicts fall risk

• ability to rule out other pathologies
• ex: low BBS accurately predicts low falls risk

• age, R or L handedness, occupation
• chief complaint (CC)
• HPI (history of present illness)
• PMH/PSH (previous medical/surgical history)
• medications
• SH (social history - support system)
• family history - involvement, support from fam

• nature of problem
• localized vs diffuse (pain only under specific conditions vs constant)
• onset (when symptoms began, not when diagnosis was made)
• frequency
• duration (how far can pt walk? how long does pain last?
• severity

• chronology
• date onset
• what worsens or improves symptoms
• what can't you do that you could do before?

• illnesses, injuries
• hospitalizations, surgeries
• meds, medical treatments
• other conditions that can be associated w chang in neurologic status (cardiac...)

• motor, sensory, cerebellar, balance/gait (mobility)
• cranial nerve (involves vestibular system)
• cognitoin, perception, language

• observation
• arousal
• posture
• appearance
• motor patterns
• speech patterns
• behaviour

• muscle strength (force output)
• muscle function (tasks)
• motor control (nervous system-muscle relationship ie rel btwn brain and movement)

• symmetry - is there wasting on one side?
• hypertrophy/pseudohypertrophy - in muscular dystrophy a muscle will look big but it's just connective tissue in the muscle belly
• atrophy

• movement to command
• synergies (normal movement patterns - the expected poetry/grace)
• strength (MMT)
• equal mvmnt on both sides

a normal resting state of a muscle, created by ongoing activation of muscle units

resting tone increases if you just did a strenuous exercise

• decreased: hypotonia, flaccidity
• increased: hypertonia, spasticity, rigidity - if it's increased, you know there's CNS involvement

velocity dependent reaction to stretch

• velocity dependent reaction to stretch
• increased "gain" of the stretch reflex - so if you do a quick stretch it responds quicker and stronger than we'd like, - the muscle jerks into contraction
• hallmark of UMN syndrom

extensor spasticity - seen when you try to move a limb into flexion (so you're stretching the extensor muscle, and it'll respond by jerking you back towards ext. - think of the tricep)

flexor spasticity - arises when you try to quickly extend a limb, stretching the flexor

MAS tests for presence of spasticity under certain conditions

• 0 - no increase in tone
• 1 - slight increase in tone - catch and release or minimal resistance at the end of the ROM when the affected part is moved into flex or ext
• 1+ - slight increase in muscle tone - catch and release followed by minimal resistance thru remainder (less than half) of ROM

• 2 - more marked increase in muscle tone (no catch and release) thru most of ROM but affected part moves easily
• 3 - considerable increase in muslce tone, passive motion difficult
• 4 - affected par rigid in flex or ext

elbow, writst, fingers, thumb, hamstrings, quads, gastroc, soleus

• neglects shoulders and trunk
• doesn't look at spasticity during functional exercises
• useful for research, maybe not for making clinical decisions
• ignores how spasticity changes w intensity of exercise

• spasticity that changes with intensity of exercise
• ex: a runner who was fine for the first few strides, then got spastic (this pt may get 0's on the MAS)

• NON-velocity dependent reaction to stretch
• type of hypertonia

• cogwheel - successive catches and releases - seen in Parkinsons
• lead pip - stiffness and inflexibility that remains uniform thru the range of passive movement (put a limb somewhere, and it'll stay - seen in elderly and catatonics)

• minimal or absent tone
• minimal or absent muscle contraction ot command or reflexibely
• absent or diminished stretch reflex

• normal
• lower motor neuron (LMN) lesion - motor portion of peripheral n.
• muscle damage
• component of spinal or cortical shock (so this flaccidity is due to CNS damage)

• spinal cord or cortical shock
• affected parts will be totally flacid for a while, then spastic, then maybe normal
• unable to prognosticate til shock is resolved

• 1 - spasticity (spastic paralysis)
• 2 - hyperreflexia (over responsive reflexes - twitching or spastic tendancies)
• 3 - pathological reflexes (clonus and babinski)

• flaccidity (flaccid paralysis)
• hyporeflexia/arreflexia
• occasional fasciculations - worm-like wiggling of individual muscle fibers -- can hapen w/o lower motor neuron lesion, so it's only indicative if there are other symptoms

• assess for normal mvmnt quality, mvmnt to command, strength
• check for symmetry
• repeat w resistance

• take joint thru PROM slowly to asses joint for ROM limitations
• then repeat it a few times fast to see if spasticity kicks in

locate and expose the tendon, put it into a bit of a stretched position, wack the tendon or muscle belly with a hammer at a right angle, causing a quick stretch, see if the muscle responds by contracting

raising the background tone by doing a strenous exercise (ex: press hands together hard)

if a muscle has higher background tone this makes it a bit easier to trigger a deep tendon reflex

• 0  eval: absent. response: no visible or palpable contraction
• 1+ eval: hyporeflexia. response: slight contraction
• 2+  eval: normal. response: slight ms contraction w joint mvmnt
• 3+  eval: hyperreflexia. response: brisk contraction w moderate joint mvmnt
• 4+  eval: abnormal hyperreflexia. response: strong contraction. response: strong contraction w 1-3 beats of clonus
• 5+ eval: abnormal hyperreflexia. response: sustained clonus

• C5 - biceps
• C6 - brachioradialis
• C7 - triceps
• L3-4 - quads
• S1-2 - achilles

• draw a blunt prob across sole of foot from heel to ball
• negative response (this is good) - toe flextion and adduction, plantarflextion aka downgoing toes
• positive response (bad unless you're a baby) toe fanning and extension, dorsiflexion,  aka upgoing toes
• equivocal response - toes go up and down
• no response - LMN lesion
• triple flexion response - dorsiflexion, knee flexion, hip flexion - severe UMN involvement

• UNM lesion
• toe fanning + extension, dorsiflexion (upgoing toes)

LMN lesion

triple flexion response: ankle dorsiflex, knee flex, hip flex --  it's a withdrawal reflex

• rhythmic beating of a joint in response to sustained stretch
• most often at ankle joint, but can be anywhere

quick stretch then hold

• normal: 1-1.5 beats
• abnormal: 2-5 beats
• abnormal sustained: > 5 beats
• absent LMN or normal low toned

remove the stim - so take the person out of stretch by shortening the muscle. Hold there, then slowly return to norm