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Neuro 3 Final > Complex Neuro Presentations and Clinical Interventions > Flashcards

Complex Neuro Presentations and Clinical Interventions Flashcards

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1
Q

Ataxia =

A

Impaired coordination, balance, and voluntary movement

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2
Q

Ataxia

Poor motor control: symptom presentations may include

A

Impaired trunk/limb coordination

Impaired gait and all functional mobility

Oculomotor and speech incoordination

Dysphagia

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3
Q

Ataxia Key Features:

A

Unsteady gait

Dysmetria (poor targeting of movement)

Dysdiadochokinesia (trouble with rapid alternating movements)

Intention tremor

Slurred speech (scanning dysarthria)

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4
Q

Ataxia symptoms reflect involvement of the _____ pathways

A

cerebellum, brainstem, or sensory

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5
Q

Impaired trunk/limb coordination =

A

Difficulty with multi-joint movements, overshooting/undershooting targets (dysmetria), unsteady posture

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6
Q

Impaired gait and functional mobility =

A

Wide-based, staggering gait; frequent falls; poor transitions between positions

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7
Q

Oculomotor incoordination =

A

Nystagmus, difficulty with smooth pursuits/saccades

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8
Q

Speech incoordination =

A

Slurred, broken-up speech (scanning dysarthria)

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9
Q

Dysphagia =

A

Swallowing difficulty due to poor coordination of oral and pharyngeal muscles

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10
Q

Etiologies of Ataxia:

A

Hereditary/genetic
Acquired
Sporadic

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11
Q

Hereditary/Genetic Ataxia:

A

Example: Spinocerebellar ataxias (SCAs), Friedreich’s Ataxia

Often progressive and involve cerebellar degeneration

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12
Q

Acquired Ataxia:

A

Examples: Stroke (CVA), Traumatic Brain Injury (TBI), Cerebellar tumor (CA)

Symptoms depend on lesion location

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13
Q

Sporadic/Neurodegenerative Ataxia:

A

Example: Olivopontocerebellar atrophy (OPCA)

Etiology unknown, often progressive and without family history

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14
Q

Clinical question: is motor learning and adaptation possible ???

A

Important for PTs: Even with cerebellar damage, research shows that some motor learning is still possible.

Approach: Emphasize repetitive task training, external feedback, and compensatory strategies to optimize learning despite coordination deficits.

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15
Q

🧬 What is Spinocerebellar Ataxia (SCA)?

A

A group of autosomal dominant genetic disorders that cause progressive degeneration of the cerebellum and sometimes the spinal cord, brainstem, and peripheral nerves

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16
Q

Key Features of SCA =

A

Progressive gait and limb ataxia

Dysarthria (scanning speech)

Oculomotor abnormalities (nystagmus, saccadic intrusions)

Tremors and poor coordination

Impaired balance and trunk control

In some subtypes: cognitive dysfunction, peripheral neuropathy, or spasticity

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17
Q

SCA Onset & Progression =

A

Onset can range from childhood to adulthood depending on the subtype.

Symptoms worsen over time, often leading to wheelchair dependence.

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18
Q

SCA PT Implications:

A

Treatment is compensatory and adaptive:

Balance and gait training

Core and postural stability

Visual and vestibular compensation

Use of ADs (canes, walkers) and fall prevention strategies

Motor learning is still possible with repetition and external cues

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19
Q

General Treatment Principles for Ataxia

A

Neuromotor exercises that focus on coordination and balance have been shown to improve or stunt the progression and functional decline

Evidence has shown that balance training may improve gait quality and safety

Newer approaches using tech
E.g. proprioceptive stabilization

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20
Q

Neuromotor Training =

A

Goal: Improve coordination, postural control, and functional mobility

Repetitive, task-specific movement patterns

Emphasis on trunk stability and limb coordination

Examples: Frenkel exercises, reaching tasks with postural challenge, controlled gait drills

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21
Q

Balance Training =

A

Static/dynamic balance on uneven surfaces

Transitional movements

Dual-task or reactive balance activities

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22
Q

Technology-Assisted Interventions =

A

Emerging tools to enhance motor learning and feedback:

Proprioceptive stabilization: vibration, balance boards, and wearable feedback tools to enhance joint awareness

Virtual reality (VR): gamified environments that challenge coordination

Exergaming: interactive games focused on balance/movement

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23
Q

While ataxia is often ___, PT can:

A

progressive

slow decline, improve safety, and maintain independence.

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24
Q

Treatment should be ___, ___, and incorporate ___ strategies.

A

individualized

progressive

both restorative and compensatory

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25
evidence-based recommendations for treating ataxia:
Focus on QUALITY of movement (motor planning and control) Sitting/standing dynamic balance exercises 4-5x/wk for at least 20 minutes Endurance activities 3x/wk for at least 20 minutes
26
Prioritize Movement Quality =
Emphasize motor planning and control, not just task completion Use verbal/tactile cues, visual feedback, and slow, deliberate movement execution Encourage symmetrical movement and minimize compensations
27
Dynamic Balance Training =
Frequency: 4–5 times per week Duration: At least 20 minutes per session Activities: Sitting or standing with reaching tasks Weight shifts, trunk rotations Functional tasks with unstable bases (foam, BOSU)
28
Endurance Activities =
Frequency: 3 times per week Duration: 20+ minutes per session Modes: Stationary bike, elliptical, treadmill walking Aquatic therapy (great for unloading joints) Functional endurance: prolonged standing, stairs, ambulation with AD
29
Balance-Based Torso-Weighting in pt with Ataxia and MS:
Applying small, asymmetrical weights to the torso—targeted based on a patient's specific directional balance deficits—appeared to improve both static and dynamic balance in this case This approach may have broader implications for treating individuals with ataxia, MS, or similar conditions affecting balance Further research is needed to explore its generalizability and effectiveness across larger populations
30
Pusher Syndrome also called:
Contraversive Pushing or Lateropulsion
31
What is Pusher Syndrome?
post-stroke phenomenon where the patient actively pushes themselves toward their hemiparetic (weaker) side They also resist passive correction or weight shift toward the unaffected side. It's a mismatch between their perception of vertical and their actual body orientation.
32
Pusher Syndrome Key Features:
Patient uses the non-affected extremities to push toward the hemiparetic side. Often occurs with right hemisphere strokes involving the posterolateral thalamus. Leads to balance deficits, postural misalignment, and increased fall risk.
33
Pusher Syndrome Outcome Measures:
Scale of Contraversive Pushing (SCP): Assesses posture, extension, and resistance to passive correction. Burke Lateropulsion Scale: More detailed, quantifies severity of lateropulsion in sitting, standing, transfers, and walking.
34
Pusher Syndrome / Body Lateropulsion (BLP) Key Study Insights:
Anatomical Stroke Locations: Medulla – Most common (59%) Pons and Cerebellum – Each ~15% Less common: Midbrain, Cortex, Thalamus, Internal Capsule
35
Pusher Syndrome / BLP Key Clinical Points:
Medullary infarctions are the most frequent cause of BLP. In 1/3 of cases, BLP was the only neurological finding, which highlights the importance of not overlooking this subtle sign. Most strokes were due to: Large-artery atherosclerosis Large-vessel occlusion
36
BLP Prognosis:
Recovery is typically early and complete Recovery is not dependent on stroke side or BLP direction
37
Post-stroke lateropulsion is prevalent and is associated with:
poorer rehabilitation outcomes reduced likelihood of discharge home
38
Key Characteristics of lateropulsion:
Overactivation of the less affected side May reach/lean across midline, pushing away from the less affected side Altered perception of upright/midline (think they're straight when they’re tilted) Behavior is involuntary/unintentional and often unrecognized by the patient Variable mobility depending on severity
39
No formal evidence-based guidelines, so clinicians rely on ____
expert consensus and readily available resources
40
Impact and Prognosis of Lateropulsion:
High Fall Risk: Patients are at increased risk for falls due to poor postural control. Caregiver Training: Families and caregivers often need education and support. Resolution Possible: Symptoms can improve over time, but may require extended rehab. Ongoing Needs: Long-term care planning may be necessary for some individuals.
41
Factors That Can Worsen Lateropulsion:
Poor attention or distractibility Fatigue Fear of falling
42
Recovery Outlook:
Recovery tends to be slower and requires longer rehabilitation. Daily mobility and function are significantly impacted.
43
Additional Factors That Can Hinder Progress:
Spatial inattention/neglect Unawareness of the deficit Cognitive impairment Severity of hemiparesis
44
Key Factors Influencing Management:
Severity of lateropulsion (100%) Awareness of lateropulsion (90%) Stroke-related/person-related factors (90%)
45
What Severity Impacts:
Assistance/equipment needs (100%) When family training begins (90%) Starting position for treatment (85%) Progression of treatment (85%)
46
What Awareness Affects:
Type of cues: Explicit cues if unaware Implicit cues as awareness improves (94%) Goal: Self-identify midline body position when unaware (89%)
47
Recommended strategies to optimize positioning in bed:
encourage reaching/rolling toward less affected side facilitate side-lying on less affected side, aiming to augment activity of the more affected side, promote weight-bearing/weight acceptance on the less affected side, and/or reduce over-activity of the less affected side
48
Recommended strategies to optimize positioning in sitting:
position upright as soon as appropriate provide support to facilitate midline alignment (may include use of wedges) ensure wheelchair is well-fitted with firm support at the back and under the buttocks incorporate functional tasks whilst maintaining optimal alignment in wheelchair encourage trunk activity to increase stability (may include thoracic extension and rotation through active movements, functional reaching, upright position with selective trunk movements in all planes) maximize time spent in vertical position encourage weight acceptance on less affected ischium and make person aware
49
Pusher Syndrome (Contraversive Pushing) – Treatment Highlights from ANPT Video Treatment Goals:
Restore perception of vertical alignment Reduce active pushing toward the hemiparetic side Improve symmetry and midline control
50
Key Strategies from the Video
Use of Visual Cues Tactile & Verbal Cues Safe Lateral Shifts Positioning and Set-Up Progress to Standing & Gait
51
Use of Visual Cues
Mirrors, vertical lines, and upright targets Encourage visual focus on vertical alignment
52
Tactile & Verbal Cues
Hands-on midline correction Verbal reinforcement to shift weight away from affected side
53
Safe Lateral Shifts
Facilitate controlled weight shift toward less affected side Practice reaching tasks to promote dynamic midline control
54
Positioning and Set-Up
Seated work with firm back support Use of wedges or bolsters to block pushing side if severe
55
Progress to Standing & Gait
Mirror use and therapist-guided upright practice Emphasis on symmetrical stance and step initiation
56
Evolving Intervention: Haptic Feedback for Balance & Postural Control
ReMoD V5.0 Type 1 Walking Aid Purpose: Improve postural alignment and motor control through real-time sensory feedback (tactile cueing).
57
ReMoD V5.0 Type 1 Walking Aid (vest and device) Key Components:
Connection Cables & Electrodes: > Transmit electrical stimulation signals to the skin > Electrodes placed based on patient’s postural deficits Vest-Integrated Sensors: > Detect asymmetries or deviations in posture and movement Control Device (Handheld Unit): > Adjusts stimulation intensity > Allows therapist to tailor input in real time Pouch for Portability: > Stores device discreetly for mobility during gait or static training
58
ReMoD V5.0 Type 1 Walking Aid (vest and device) Used to retrain balance in populations with:
Ataxia Post-stroke impairments Directional balance loss (e.g., Pusher Syndrome) Promotes upright posture, symmetry, and motor learning via proprioceptive stimulation
59
Pusher Syndrome + Hemispatial Neglect: Visual Deprivation Intervention Study Focus:
Patient with stroke in right basal ganglia + superior temporal gyrus Resulted in: Left spatial neglect Pusher behavior (contraversive pushing)
60
Visual Deprivation Theory:
Stroke causes imbalance in visuospatial input Overactivity of left hemisphere (due to neglect of left space) causes patient to push right Covering the left eye reduces right-sided input → rebalances spatial perception
61
Visual Deprivation Intervention:
Left eye masking used during therapy Result: ↓ Over-attention to right ↓ Excitability in left motor cortex ✅ Improved postural alignment and reduced pushing behavior
62
Visual Deprivation Clinical Takeaway:
Visual field manipulation may be a promising adjunct to treat Pusher Syndrome complicated by spatial neglect Always consider perception of verticality and integration of sensory input in stroke patients with postural control issues
63
Spatial Neglect (SN) / Inattention =
A syndrome where individuals show reduced or no awareness of stimuli on one side of body or space—not due to sensory loss, but rather impaired attention.
64
Spatial Neglect (SN) / Inattention Pathophysiology =
Caused by damage to neural networks for spatial attention, cognition, and motor planning Involves: frontal, parietal, temporal cortices, subcortical structures, and white matter tracts
65
Spatial Neglect (SN) / Inattention Key Features:
Bias toward the ipsilateral side of the lesion Neglect of the contralesional side: Right brain damage → neglect left space Left brain damage → neglect right space
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Spatial Neglect (SN) / Inattention Types of Space Affected:
Personal space (on the body) Peripersonal space (within arm’s reach) Extrapersonal space (beyond arm’s reach) Mental space (internal representation)
67
Spatial Neglect (SN) / Inattention Emerging Treatments:
Behavioral strategies Pharmacologic approaches Neuromodulation (under investigation)
68
Motor Neglect =
Underuse of the affected limb despite intact motor function Difficulty initiating movement toward the contralesional side
69
Sensory Neglect =
Fails to detect or respond to sensory stimuli (visual, auditory, tactile) on the contralesional side
70
Perceptual Neglect =
Distorted sense of space—e.g., aligning objects or body off-center Misjudging midline or orientation
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Personal Neglect =
Ignores contralesional side of the body (e.g., grooming/shaving only one side)
72
Peripersonal Neglect =
Ignores objects within arm’s reach on one side (e.g., food on plate, buttons on shirt)
73
Extrapersonal Neglect =
Disregards people/objects in far space on one side (e.g., ignoring someone entering from the left)
74
Representational Neglect =
Fails to include the contralesional side in mental imagery (e.g., drawing only one side of a clock)
75
Motor Apraxia =
A disorder of voluntary, purposeful movement that is not due to weakness, spasticity, sensory loss, or cognitive impairment
76
Motor Apraxia Key Features:
Difficulty planning or executing skilled movements Movements are awkward, clumsy, or incorrect—despite full understanding of the task Often noticed with tool use, dressing, or gestures
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Types of Apraxia
Ideational Ideomotor Conceptual Task-specific
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Ideational –
Difficulty sequencing multistep tasks; doesn’t understand what to do Loss of neural encoding of the concept of a previously known skill (sequencing)
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Ideomotor –
Understands the task but cannot coordinate the movement Impaired connection between the concept of a skill and its motor output Limb-kinetic: Loss of the motor output associated with a given skill
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Conceptual –
Cannot recognize or use tools appropriately Loss of conceptual understanding, inability to use tools
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Limb-Kinetic –
Loss of fine motor control (e.g., clumsy hand use)
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Constructional –
Trouble copying or constructing images/shapes
83
Task-specific –
Errors occur only in specific actions Speech Constructional: Difficulty drawing, constructing, or copying
84
Apraxia of Speech –
Impaired ability to plan speech motor movements
85
Pusher syndrome is characterized by a. active pushing using the paretic side towards the non-paretic side and resistance to midline posture b. resistance to posterior weight shifting where the patient pushes forwards and flexes the trunk c. resistance to weight shifting onto the paretic side d. active pushing using the non-paretic side towards the paretic side and resistance to the passive correction of posture
active pushing using the non-paretic side towards the paretic side and resistance to the passive correction of posture

Neuro 3 Final (10 decks)

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