NEURO

Question 1

What is the pathology of a right CVA?

Scenario 1

Answer 1

An acute stroke, specifically a right-sided cerebrovascular accident (CVA), occurs when there is a sudden disruption of blood flow to the brain, leading to the death of brain cells. This can happen due to a thrombotic or embolic ischemic stroke, or a haemorrhagic stroke caused by bleeding within the brain. A stroke on the right side of the brain often affects motor control, sensation, and spatial-perceptual abilities on the left side of the body. Symptoms may include:
* Hemiparesis or hemiplegia: Weakness or paralysis on the left side.
* Left-sided neglect: Difficulty in perceiving stimuli on the left side of the body.
* Sensory deficits: Altered sensation, including numbness or lack of proprioception.
* Visual deficits: Possible visual field cuts or neglect on the left.
* Cognitive and perceptual issues: Problems with attention, judgment, or orientation.

Question 2

How does a Right CVA clinically present?

Scenario 1

Answer 2

The patient may present with weakness or paralysis of the left arm and leg, difficulty maintaining posture, and issues with balance. They may have left-sided neglect, visual deficits, and difficulty with voluntary movements on the affected side.

Question 3

What assessment do you do for a right CVA?

Scenario 1

Answer 3

1. Motor Assessment: Evaluate muscle strength, tone, and active movement, using scales like the Modified Ashworth Scale for spasticity.
2. Sensation Testing: Check for touch, proprioception, and pain on the affected side.
3. Balance and Coordination: Assess sitting balance, standing balance, and coordination through functional tasks.
4. Cognitive Screening: Brief assessment of attention, orientation, and ability to follow commands.
5. Visual Assessment: Check for visual field deficits or neglect.

Question 4

What management strategies do you use for a right CVA?

Scenario 1

Answer 4

• Positioning and Early Mobilization: Prevent contractures, maintain skin integrity, and encourage early upright sitting to promote circulation and reduce the risk of complications like deep vein thrombosis (DVT).
• Functional Exercises: Task-oriented exercises focusing on improving motor skills and movement patterns, such as reaching or grasping.
• Balance Training: Sitting and standing balance exercises, with a focus on postural control.
• Sensory Stimulation: Techniques to improve sensation and awareness on the affected side, especially if there is neglect.
• Family Education: Information on how to assist with mobility, safety, and home adaptations.

Question 5

What is the pathology of a left CVA with right shoulder pain?

Scenario 2

Answer 5

Pathology/Condition/Dysfunction: A chronic stroke (more than 6 months post-CVA) may lead to long-term functional impairments, including hemiplegic shoulder pain. Stroke can damage the motor cortex, leading to spasticity, weakness, and reduced motor control on the opposite side of the body. Shoulder pain is often due to:

• Shoulder subluxation: Partial dislocation caused by weak rotator cuff muscles. In this case, the right shoulder muscles, including the rotator cuff (supraspinatus, infraspinatus, teres minor, subscapularis) and deltoid, may become significantly weaker. These muscles play a critical role in stabilizing the shoulder joint by keeping the head of the humerus (upper arm bone) within the glenoid cavity of the scapula (shoulder blade).
  When these muscles are weak, they can no longer maintain the normal alignment of the joint, leading to a partial dislocation or subluxation.
• Adhesive capsulitis: Reduced joint mobility due to prolonged immobility.
• Spasticity: Increased muscle tone leading to improper positioning and muscle imbalance. This is caused by a change in exitation of the muscle inhibitors causing for an increase in the muscle tone of these muscles.

Question 6

How may you assess for right shoulder pain after L CVA?

Scenario 2

Answer 6

1. Pain Evaluation: Use pain scales to understand the severity, and palpate the shoulder for tenderness.
2. ROM and Muscle Tone Testing: Assess the range of movement in the shoulder, and check for spasticity or contractures.
3. Functional Assessment: Observe tasks like reaching, lifting, and transfers, to understand how pain affects function.
4. Subluxation Check: Gently assess the shoulder joint for any signs of subluxation. Can do this by palpating and visually seeing a gap on the arm. During PROM if there is more movement or pain and apprehension whilst moving the arm passively.
5. Postural Assessment: Examine the alignment of the shoulder girdle and trunk.

Question 7

How do you treat shoulder pain after an L CVA?

Scenario 2

Answer 7

• Pain Management: Use of modalities like heat, cold, TENS (transcutaneous electrical nerve stimulation), or gentle manual therapy.
• Stretching and Mobilization: Passive and active ROM exercises to maintain or improve joint mobility.
• Strengthening Exercises: Targeting the rotator cuff, scapular stabilizers, and core muscles to support proper alignment.
• Positioning and Support: Use slings or supports to maintain shoulder integrity and prevent subluxation.
• Education: Advice on proper arm positioning and how to manage spasticity.

Question 8

What is the pathology of Parkinson’s disease and freezing within it?

Scenario 3

Answer 8

Parkinson’s Disease (PD) is a progressive neurodegenerative disorder characterizsd by the loss of dopamine-producing neurons in the substantia nigra, a part of the basal ganglia that is crucial for motor control.

Question 9

What is the pathophysiology of a R CVA?

Scenario 1

Answer 9

Ischemic strokes occur due to the occlusion of a cerebral artery by a thrombus or embolus. The lack of blood supply leads to cell death in the affected area of the brain, causing neurological deficits.

The right side of the brain controls the left side of the body; therefore, a right-sided stroke can lead to left-sided hemiplegia (paralysis) or hemiparesis (weakness).

Question 10

What is the prognosis of a R CVA?

Scenario 1

Answer 10

Recovery depends on the extent of brain damage, the patient’s age, and how quickly treatment was initiated. Rehabilitation can help improve functional outcomes, but residual deficits may persist.

Question 11

What are the signs and symptoms of a R CVA?

Scenario 1

Answer 11

Hemiplegia or hemiparesis on the left side of the body, facial droop, slurred speech, difficulty swallowing, neglect of the left side, and potential visual field deficits.

Question 12

What are risk factors of a R CVA?

Scenario 1

Answer 12

Hypertension, diabetes, atrial fibrillation, smoking, hyperlipidemia, and a history of transient ischemic attacks (TIAs).

Question 13

What is the pathophysiology of an L CVA with right shoulder pain?

Scenario 2

Answer 13

HSP arises due to a combination of factors including subluxation of the shoulder joint, muscle imbalance, spasticity, and reduced movement. Stroke affects upper motor neurons, leading to spasticity and altered muscle tone, which can contribute to shoulder pain.

A left-sided stroke may affect speech (Broca’s or Wernicke’s aphasia) and cognition due to the involvement of language-dominant brain areas.

Question 14

What is the prognosis of an L CVA with right shoulder pain?

Scenario 2

Answer 14

Long-term rehabilitation can lead to improvements, but persistent deficits in motor function and pain management may be challenging. Pain can impede participation in therapy, affecting overall recovery.

Question 15

What are the signs and symptoms of l CVA with right shoulder pain?

Scenario 2

Answer 15

Right-sided weakness, limited arm movement, spasticity, and pain, particularly when the arm is moved or stretched. Possible neglect of the affected limb and reduced shoulder joint integrity (subluxation).

Question 16

What are the risk factors of L CVA?

Scenario 2

Answer 16

History of stroke, poor diabetes and blood pressure management, sedentary lifestyle, smoking, and atrial fibrillation.

Question 17

What is the pathophysiology of Parkinson’s Disease?

Scenario 3

Answer 17

The loss of dopamine disrupts communication between neurons in the basal ganglia, leading to impaired control of movement. This causes symptoms like bradykinesia (slowness of movement), rigidity, and tremors.

Freezing of Gait (FOG) is a common symptom where the patient suddenly feels as if their feet are glued to the ground, making it difficult to initiate or continue walking.

Question 18

What is the prognosis of parkinson’s disease?

Scenario 3

Answer 18

PD is a chronic, progressive condition with no cure. Symptoms worsen over time, but medications and therapy can help manage them and improve quality of life.

Question 19

What are the signs and symptoms of Parkinson’s Disease?

Scenario 3

Answer 19

Bradykinesia, tremors at rest, muscle rigidity, postural instability, and non-motor symptoms like depression, sleep disturbances, and autonomic dysfunction.

Question 20

What are risk factors of Parkinson’s?

Scenario 3

Answer 20

Age, genetic predisposition, exposure to environmental toxins, and history of concussions.

Question 21

How does Parkinson’s disease present clinically?

Scenario 3

Answer 21

The patient may present with shuffling gait, difficulty initiating movement, and frequent episodes of freezing, especially in narrow or crowded spaces.

Question 22

How would you assess for freezing of gait?

Scenario 3

Answer 22

Gait Analysis: Observe the patient’s walking pattern, focusing on stride length, speed, and balance.

Muscle Tone and Rigidity: Evaluate for increased muscle tone, especially in the limbs.

Cognitive and Motor Interaction: Assess the patient’s ability to follow cues or multitask while walking, as this may trigger freezing.

TUG test and questionnaire.

Question 23

How would you manage gait freezing in Parkinson’s?

Scenario 3

Answer 23

Cueing Strategies: Use visual (e.g., stepping over lines), auditory (rhythmic beats), or verbal cues to help overcome freezing episodes.

Gait Training: Focused exercises to improve stride length and rhythm, incorporating the use of walking aids if needed.

Balance Exercises: To reduce the risk of falls, incorporating static and dynamic balance drills.

Factors Influencing Choice: Severity of motor symptoms, medication schedule, and patient’s response to different cueing techniques.

Question 24

What is the pathology of relapsing remitting MS?

Scenario 4

Answer 24

Multiple Sclerosis (MS) is a chronic autoimmune disorder that affects the central nervous system (CNS). It is characterised by inflammation, demyelination, and axonal damage. In Relapsing-Remitting MS (RRMS), patients experience periods of neurological dysfunction (relapses) followed by partial or complete recovery (remissions).

Question 25

What is the pathophysiology of RRMS? Scenario 4

Answer 25

MS involves the immune system attacking the myelin sheath that covers nerve fibers, leading to disrupted electrical conduction and communication between the brain, spinal cord, and other parts of the body. In RRMS, the patient may have periods where the immune attack subsides, allowing some repair and remission of symptoms. However, over time, repeated attacks can lead to permanent nerve damage.

Question 26

What is the prognosis of RRMS? Scenario 4

Answer 26

RRMS is the most common form of MS and has a variable prognosis. While some patients can have long periods of remission, others may progress to a more severe form known as secondary progressive MS. Early treatment can help manage symptoms and delay progression.

Question 27

What are signs and symptoms of RRMS? Scenario 4

Answer 27

Symptoms vary based on the location of lesions in the CNS but can include ataxia (lack of muscle coordination), balance issues, muscle weakness, vision problems, numbness or tingling, fatigue, and cognitive difficulties. Patients may also experience tremors, spasticity, and bladder or bowel dysfunction.

Question 28

What are risk factors for RRMS? Scenario 4

Answer 28

Genetic predisposition, viral infections (e.g., Epstein-Barr virus), low Vitamin D levels, smoking, and being female (as women are more likely to develop MS).

Question 29

How does RRMS clinically present? Scenario 4

Answer 29

The patient may exhibit signs of ataxia, unsteady gait, and difficulty with coordinated movements. There may also be visible tremors, spasticity, or muscle weakness.

Question 30

What can you assess for RRMS? Scenario 4

Answer 30

Balance and Coordination: Assess gait stability, ability to maintain balance during static and dynamic activities, and coordination with finger-to-nose or heel-to-shin tests. Muscle Tone and Strength: Check for signs of spasticity, particularly in the legs, and assess muscle strength. Functional Mobility: Evaluate the patient’s ability to perform daily tasks such as standing, walking, and turning.

Question 31

What intervention strategy would you use for RRMS? Scenario 4

Answer 31

Balance Training: Exercises that challenge static and dynamic balance, including the use of a balance board or stability ball, can help improve stability. Coordination Exercises: Activities like heel-to-toe walking, stepping over obstacles, and arm-leg coordination exercises. Strengthening Exercises: Focus on lower limb strength to improve mobility and reduce the risk of falls. Factors Influencing Choice: Severity of ataxia, presence of spasticity, patient’s ability to participate in therapy, and medication side effects.

Question 32

What is primary progressive Multiple Sclerosis? Scenario 5

Answer 32

Primary Progressive Multiple Sclerosis (PPMS) is a type of MS characterized by a steady progression of neurological symptoms from the onset, without clear relapses or remissions. It affects about 10-15% of MS patients and is typically diagnosed later in life compared to RRMS.

Question 33

What is the pathophysiology for PPMS? Scenario 5

Answer 33

MS involves the immune system attacking the myelin sheath that covers nerve fibres, leading to disrupted electrical conduction and communication between the brain, spinal cord, and other parts of the body. PPMS involves a continuous degeneration of the CNS, leading to progressive loss of function. It is marked by widespread axonal damage and demyelination, with fewer inflammatory lesions compared to RRMS. The progressive nature of PPMS can lead to significant mobility impairments and muscle weakness over time. Since it primarily affects the spinal cord, it often presents with motor difficulties, particularly in the legs.

Question 34

What is the prognosis for PPMS? Scenario 5

Answer 34

PPMS tends to be more severe than RRMS, with a faster progression of disability. Patients may gradually lose their ability to walk independently, and managing symptoms can become challenging as the disease progresses. There are fewer treatment options, but early physical therapy and symptom management can help maintain function and quality of life.

Question 35

What are some signs and symptoms of PPMS? Scenario 5

Answer 35

Gradual onset of muscle weakness, particularly in the legs, spasticity, impaired coordination, and balance difficulties. Patients may also experience fatigue, bladder issues, and cognitive changes. Progressive loss of motor function can lead to the need for mobility aids, such as canes, walkers, or wheelchairs.

Question 36

What are risk factors of PPMS? Scenario 5

Answer 36

Similar to other types of MS, risk factors include genetics, age (onset typically in the 40s-60s), environmental factors, and smoking.

Question 37

How does PPMS clinically present? Scenario 5

Answer 37

The patient may show signs of muscle weakness, particularly in the lower limbs, spasticity, and difficulty coordinating movements during transfers. Fatigue may also be a limiting factor during activities.

Question 38

What to assess in PPMS struggling to transfer? Scenario 5

Answer 38

Functional Mobility: Assess the patient’s ability to perform transfers, stand up from a chair, and move from bed to chair. Focus on how safely and efficiently they can perform these actions. Strength and Tone: Evaluate the strength of the lower limbs, paying attention to any spasticity or rigidity that may be present. Balance and Gait: Although the patient uses a frame, assessing balance can help determine the risk of falls and the need for further support.

Question 39

What are interventions for someone struggling with transfers with PPMS? Scenario 5

Answer 39

Transfer Training: Practice transfers using appropriate techniques to minimise effort and prevent injury. Include the use of assistive devices like transfer boards or gait belts if needed. Strengthening Exercises: Focus on lower limb and core muscles to improve the patient’s ability to perform transfers and walk. Progressive resistance training can be tailored to the patient’s abilities. Spasticity Management: Stretching exercises, positioning strategies, and possibly the use of medications to reduce muscle stiffness. Factors Influencing Choice: The extent of motor impairment, spasticity, fatigue levels, and patient’s safety during transfers. Ensuring a balance between activity and rest is important to manage fatigue.