Neuro

Question 1

What causes parkinsons

Answer 1

Apoptosis of dopamine producing neurons leads to depletion in dopmanine. Dopamine is a neurotransmitter made in substantia niagra and helps basal ganglia to control and regulate movment. It is also sent to the thalamus and therefore a depletion in it leads to inhibition of movement from thalamus leading to bradykinesia

Question 2

Assessment for parkinsons

Answer 2

Gait
Balance
Tone

Question 3

How to assess sensation

Answer 3

Light touch - going to touch you with cotton wool I want you to tell me if you feel it and if it feels the same in both sides
Do in sporadic pattern unless using ASIA scale for SCI

Now I’m going to touch you on your left and right and I want you to say where I touched you
- left right
Do both at same time for stroke as may have sensory in attention
Can also do proprioception by doing joint position sense on fingers and toes to rest fasiculus cuneatus and gracilis
And do mirroring

Question 4

How to assess balance

Answer 4

Sitting first to determine sitting balance and safety
Eyes open normal base of support with back unsupported - have AO2
Then close eyes to remove visual aspect
Then turn head in sitting
Can do reaching in sitting
Then in standing do:
Normal BOS eyes open/ shut to remove visual aspect of balance
Narrow BOS eyes open and shut (Romberg) if sway with eyes shut has removed vision and proprioception so shows problem with proprioception.
Head turning to test vestibular

Question 5

How to assess tone

Answer 5

Patient in side lying or supine for LL flexion and extension of knee and ankle
UL sitting
Do 3 times slowly and then do quickly as this will elicit stretch reflex and identify spasticity

Question 6

What is spasticity and stretch reflex

Answer 6

Spasticity is a velocity dependent change in muscle tone due to exaggerated spinal reflexes e.g. Stretch reflex
This is when the muscle is stretched the body panics and counteracts this stretch by contracting the muscle

Question 7

How to record tone

Answer 7

Modified ashworth scale

1-catch and release with easy movement through rest of rom
2- catch and release with slight inc In tone for remainder
3-constant resistance through rom
4-rigid in flexion/extension

Question 8

How to record sensation

Answer 8

Shade body chart for where there is impaired sensation
Record on Nottingham sensory scale (0- absent 1- identifies touch but not 3/3 2- identifies touch all 3 times)
Or for SCI record on Asia impairment scale

Question 9

What is the vestibular ocular reflex

Answer 9

It’s a reflex that excites muscles on the opposite eye to the direction the head is moving to maintain gaze/focus on a stimulus

Question 10

What makes up the vestibular system

Answer 10

Peripheral - otoliths (saccule and utricle) &vestibular nerve
Central - vestibular nuclei in brain stem and cerebellum - integrate the info from peripheral

Question 11

What is balance

Answer 11

Ability to maintain line of gravity within base of support with minimal postural sway

Question 12

Components of balance

Answer 12

Visual - somatosensory
Proprioception - where joints are in space
Vestibular - equilibrium

Question 13

How do vision vestibular and proprioception affect balance

Answer 13

Information from all 3 are sent to cerebellum which coordinates movements and posture, this then sends signals to make VOR kick in to control eye movements and signals to muscles to make postural adjustments

Question 14

Pathophysiology of MS

Answer 14

Nerves are covered in myelin to allow quick and effective conduction of messages. In ms this myelin is attacked by the immune system and is damaged. This reduces the ability of the nerves to send messages and signals. When the myelin is damaged it can cause scarring and cause plaques to form which disrupts nerve communication even more. The axons can become damaged leading to long term disruption.

Question 15

Why may MS have sensation impairment

Answer 15

If plaques have formed in ascending pathways of spinal cord or in sensory cortex of brain will have altered sensation such as paraesthesia

Question 16

Assessment for vestibular

Answer 16

VOR - head thrust to see if eyes focus on nose while head is moved
Smooth pursuit - see if can smoothly follow moving target
Saccades - flick between two moving targets

Balance - vision, proprioception and vestibular

Sensation -light touch on lower limbs, touch either side, joint position sense. Do this because will influence balance

Question 17

Outcome measures for balance

Answer 17

Berg balance scale

Tinetti

Question 18

Managing spasticity/ hypertonia

Answer 18

Educate patient on triggers
Stretching - maintain muscle length prevent contractures
Range of motion exercises
Weight bearing early on to reduce decrease in bone density and osteoporosis
Strengthen weaker muscles
Promote exercise to reduce fatigue

Question 19

What are triggers of spasticity

Answer 19

Tight clothes 
Changes in temperature 
Constipation
Anxiety
Dehydration
Infection

Question 20

What does each descending tract do

Answer 20

Corticospinal - voluntary movment skilled movement dexterity tone
Reticulospjnal - tone, posture
Vestibulospjnal - balance - innervates limbs to change position
Rubrospinal- head movements, activates flexor muscles

Question 21

What does each ascending tract do

Answer 21

Spinothalamic - pain touch temperature vibration
Spinocerebellar - proprioception tells brain how tight the muscle is UNCONSCIOUS
Fasiculus cuneatus - crude touch proprioception vibration above T6
Fasiculus gracilis - same as above but below
Fasiculus synapse in medulla -> thalamus -> sensory cortex
CONSCIOUS

Question 22

Parkinsonian gait

Answer 22

Flexed posture 
Reduced knee extension 
Bradykinesia
Akinesia (freezing) 
Trouble initiating and turning
Festinating
Reduced trunk rotation and arm swing
Look at ground 
No heel strike 
Small step length and clearance

Question 23

MS gait

Answer 23

Possible ataxia - uncoordinated large BOS, wide bos due to bad balance (if messages between brain and ear affected?)
spasticity - may lead to scissoring gait
Weakness leading to toe drag and therefore vaulting hip hitching circumduction to clear floor
Fatigue may lead to increase weakness of muscles
Bad eyesight look at floor & if sensory ataxia will look at floor for position of limbs

Question 24

Treatment for parkinsons gait

Answer 24

Draw lines on floor to increase step length
Promote heel strike to make you more steady so less likely to fall
Work on posture
Give objects to walk around e.g. Obstacle course
Shifting weight before initiating movement and say ‘ready steady step’
Practising big arm swings
Sit to stands to increase LL strength
Lifting knees up to encourage inc clearance
10 week exercise programme
Trunk exercises for flexibility Morris et al 2010 found this improved balance and gait

Question 25

Rx for vestibular

Answer 25

Rehabituate VOR - hold card in front while moving head side to side and maintain focus on it. Do in sitting then standing. Then walk and turn head side to side and can do VOR while walking Practise smooth pursuit follow thumb with eyes sitting standing walking Do C spine exercises flex ext lateral rotation Balance exercises on wobble board eyes open shut turning head So until vertigo kicks in

Question 26

Possible reasons for spasticity to occur

Answer 26

Interruption of messages from brain to muscle Interruption of descending inhibitory tracts from brain or SC increase excitability of neurones

Question 27

Prognosis if one sided vestibular problem

Answer 27

Good as other side can compensate

Question 28

Positive signs in Vestibular Ax

Answer 28

``` Nausea Dizziness Unable to maintain gaze in VOR using catch up saccades in smooth pursuit rather than smooth eye movement Overshoot or undershoot in saccades ```

Question 29

Definition of muscle tone

Answer 29

Resting activity of muscles keeping them primed for activity and reflexes Resistance to passive movement

Question 30

Why test balance

Answer 30

``` If increased risk of falls (PD, stroke, tbi) Vision problems may affect balance If tremor may affect balance Inc tone or weakness Spasticity Decreased sensation ```

Question 31

Stretching

Answer 31

``` Do fingers Then wrist Supination pronation Flexion and extension of elbow Rolling ball or towel on table Exercise shoulder to decrease risk of subluxation ```

Question 32

SCI balance

Answer 32

Try supported, unsupported, vision, vestibular, dynamic(weight shifting) If can stand do this 30 mins a day to reduce loss of bone density

Question 33

Assessment MS

Answer 33

Tone Sensation Gait

Question 34

TBI Ax

Answer 34

Sensation Tone Balance

Question 35

Stroke Ax

Answer 35

Sensation tone (1/3 stroke pt have inc tone) Balance

Question 36

What other factors could affect balance

Answer 36

``` Sensory Cerebellum damaged Tone changes Weakness Vision Lack of concentration ```

Question 37

SCI Ax

Answer 37

Tone- less inhibition from descending pathways because the inhibitory reticulospinal tract has been damaged Knut leaving the excitatory reticulospinal tract Sensation - because if a unilateral lesion will affect the DCML pathway and the spinothalamic tracts Balance - decreased sensation, weakness, tone will affect balance

Question 38

What is tbi

Answer 38

Can be open - penetration of skull Or closed - bang to the head tearing cellular structures May be worse at first due to inflammation and oedema and this can cause long term damage as can move other structures and close blood vessels

Question 39

Spinal cord injury

Answer 39

Laceration or damage to spinal cord due to inflammation, arthritis, accident, fracture etc This means messages from brain down spinal cord may not get past the lesion to the muscles causing impaired movement and sensation

Question 40

Position of stroke patient

Answer 40

Supine - head in midline supported by towels or pillow weak am on pillow to support Pillow under knees to prevent DVT contractures ``` In side lying strong side: Put pillow between legs Rest weak arm on pillow Make sure pt is well rolled over Pillow under feet for Dorisiflexion to avoid foot drop ``` Side lying weak side: Weak arm away from body so not crushing it Shoulder aligned so not pulling behind body Pillow between legs Sitting: Feet flat on floor, body in midline and head, arm supported

Question 41

Self management

Answer 41

Give exercises to do when on medication Advise support groups Accept help from friends and family Set goals for yourself every day

Question 42

Vestibular disorders

Answer 42

BPPV Labrythitis if crystals are knocked they move the hairs in SCC making head think it's moving when it's not SCC detect horizontal movement and otoliths detect linear

Question 43

Stroke

Answer 43

Can be ischemic due to thrombus/embolus Or haemorrhaging which is a bleed in the brain. The brain can't function in this environment and the intracranial pressure can increase higher than arterial pressure leading to collapse of vessels and ischemic

Question 44

Secondary problems

Answer 44

Contractures due to decreased muscle length and disuse Pressure sores Decreased ROM due to contractures Weakness due to disuse can result in subluxed shoulder

Question 45

How often should change position

Answer 45

2-3 hours to prevent contractures pressure sores and increase stimuli to the brain

Question 46

Other ms symptoms

Answer 46

``` Vision Balance Fatigue Bladder and bowel Stiffness Tremor Speech Swallowing Memory Emotions Sexual function ```

Question 47

Parkinson's symptoms

Answer 47

``` Tremor Bradykinesia Rigidity Balance Bowel and bladder problems Dizziness Depression ```

Question 48

Possible causes of PD

Answer 48

Genetic link | Exposure to pesticides

Question 49

What is cogwheel rigidity

Answer 49

When have rigidity through range but tremor makes it jerky

Question 50

Treating PD medically

Answer 50

L dopa - taken orally. Crosses blood brain barrier and is converted to dopamine in the brain. Often given with carbodopa to recuse sickness

Question 51

Asia scale what does it test and grading

Answer 51

Mytomes Dermatomes - light touch and pin prick Graded A-E, a is complete injury e- normal function

Question 52

Spasticity medication

Answer 52

Baclofen blocks GABA 2 receptors So neurotransmitter can't bind (Ach) so messages aren't conducted to muscle to contract and therefore they relax Botox works in the same way Tizanidine blocks alpha2 receptors

Question 53

Complete vs Incomplete injury

Answer 53

Complete is no motor or sensory function below lesion | Incomplete may retain some

Question 54

Retraining functional tasks

Answer 54

Do it passively to show movement Then active assisted to feel the movement done by patient Get pt to do actively to inc input from corticospinal tract Practise components separately and then put them together

Question 55

Why move spastic muscles

Answer 55

To maintain length of muscles Maintain ROM prevent contractures Keep them from becoming weak and immobile therefore contracting (trompetto et al 2014)

Question 56

Problems with baclofen

Answer 56

Global weakness | Drowsiness which will affect function

Question 57

Gait cycle

Answer 57

``` Initial contact - heel strike? Loading response - equal weight bearing? Mid stance Terminal stance - is there big step length Pre swing - knee flexion? Vaulting? Mid swing Terminal swing ```

Question 58

Improving gait

Answer 58

Assist in knee flexion Weight shifting side to side to promote weight bearing on weaker leg (in sitting and standing) Sit to stands to increase LL strength Feel bottom of foot to promote sensation Practise heel striking movement Stand and step facilitating knee flexion and ankle dorsiflexion Mention use of orthotics AFOs

Question 59

Why do visual cues work

Answer 59

They allow us to activate a different pathway to overcome the block at the substantia niagra

Question 60

How to improve freezing

Answer 60

Auditory cues such as a rhythm when walking

Question 61

Where to do senaation testing

Answer 61

Upper limbs as lower limbs to test the tracts e.g. Spinothalamic, fasiculus.. Do on bottom of foot (s1/l5) as this will affect balance

Question 62

What is proprioception

Answer 62

How long and tense the muscles are

Question 63

Improving limb after stroke

Answer 63

PROM not into pain or over head to avoid subluxation or impingement Try and weight bear through arm Sit at table push ball or towel. If this is too hard just get them to stabilise ball If have neglect can do mirroring to increase awareness This helps as repetition will increase plasticity - new pathways will form to re learn

Question 64

Why is tizanidine better than baclofen

Answer 64

Doesn't cause global weakness and works with ms that has occurred in brain and spinal cord whereas baclofen just works at spinal cord

Question 65

Trompetto et al 2014 pathophysiology of spasticity

Answer 65

Important to mobilise muscles otherwise they will contract and this can contribute to hypertonia

Question 66

How does the stretch reflex work

Answer 66

When muscle is stretched the muscle spindle is activated and sensory fibres send input to motor fibres which send impulse to make the muscle contract This is exaggerated in umnl patients either the muscle spindle gets over exited or too many motor neurone are activated

Question 67

Treating ataxia

Answer 67

Balance - regain sitting balance first by sitting supported, unsupported, shifting weight Practise weight bearing on lower limbs to gain strength Visual cues to coordinate their foot movement and before moving to the target use eyes to look at target Educate on exercise

Question 68

Treating low tone

Answer 68

``` Weight bearing Balance Strengthening Rom Functional tasks ```

Question 69

Retraining functional task

Answer 69

Do bilateral exercises such as lifting large object, unscrewing container lids, catching throwing ball Reach and grasp to a cup or to put socks on Dexterity exercises like writing Balance - reaching to touch Physio hand Increase sensation by using it to stabilise an object

Question 70

If patient has neglect

Answer 70

Approach from unaffected side Use their neglected arm and passively move it while saying what you are doing so you combine touch and auditory senses Get them to look over to the hand and use their good hand to move it

Question 71

Things to look for in gait

Answer 71

A- is it ataxic or antalgic (short stance phase to avoid weight bearing) B- base of support is it large or small C- foot clearance is it high or are they compensating by vaulting or hip hitching D- deviation are they walking straight E- knee, is it flexed G- good step length

Question 72

Increasing sit to stand and walking in those with NM disorders

Answer 72

Move the weak side first when transferring as can use strong side to move the weak side Practising sit to stands and mini squats can hold on at first to improve LL strength, can then move to no hands Work on core stability such as bridging Hip hitching - stand on one leg and lift other hip up, LL strengthening Trunk flexibility - sideways lean on plinth or lean forward pushing something on table (3-5 times) MORRIS ET AL 2010 SHOWED TRUNK FLEXIBILITY INC GAIT AND BALANCE

Question 73

Why is there an increase in tone

Answer 73

Tone is usually modulated by descending tracts that both excite and inhibit tone. If there is damage to the inhibitory tract then there is constant firing from the excitatory one leading to increased firing from anterior horn cells and therefore an increase in muscle activity

Question 74

Flow chart for UMN lesion

Answer 74

An UMNL can lead to muscle over activity (spasticity, dystonia) or muscle weakness - in which disuse leads to contractures. These both lead to hypertonia and reduced ROM, thereby affecting posture and function

Question 75

Types of MS

Answer 75

Relapsing remitting - 80%. Have relapses and never fully recover so after every relapse the symptoms worsen Primary progressive - gradually worsens over time without relapse Secondary progressive - starts as RR and then gradually worsens Benign- no symptoms between relapses

Question 76

Test for increase ROF

Answer 76

``` TUAG Sit in chair with hands on arm chair Stand up from chair walk 3m turn around walk back sit down Time how long and look at gait If longer than 12s = ROF ```

Question 77

What does the vestibular give info on

Answer 77

Spatial orientation Postural control Ocular motor system

Question 78

Speech intro

Answer 78

Hi I'm Louise a second year physiotherapy student, I understand you have MS is that correct? Ok well today I would like to do 3 assessments which will involve me placing my hands on you and moving you around is that ok? Ok so the first assessment we are going to do is Testing for tone - so this will involve me running your arms and legs through a few movements is that ok? Ok so if you Can lie back on the plinth for me, are you comfortable? *PROM* does that feel ok? Let me know if you're in any pain or uncomfortable at any time Ok so this patient has no increase in tone however I would expect some increase in tone due to (in parkinsons - lack of motor activity of inhibitory pathway?) (ms- damage along the inhibitory reticulospinal pathway) (SCI- damage to inhibitory pathway of RTS or Dec inhibitory signals passing lesion) etc..

Question 79

Why an increase in tone in stroke or TBI

Answer 79

Death of cells due to lack of blood supply will damage the axons and tracts as they all need blood to work In tbi the injury can affect the inhibitory pathways and axons and therefore less inhibitory signals get sent to the muscle Afer injury there is less cortical control over reflexes leading to spasticity

Question 80

Why an increase in tone in parkinsons

Answer 80

Dopamine is produced in substantia niagra and sent to basal ganglia to help initiate movement and control it. Lack of dopamine leads to loss of input/output from basal ganglia. The extraprymaidal tracts eg reticulospinal arise from the basal ganglia and are therefore affected

Question 81

Problems with voluntary movement

Answer 81

Due to corticospinal tract damaged e.g. In stroke or tbi if somatosensory cortex or parietal lobe is damaged will affect corticospinal tract as this arises from here

Question 82

What RST is involved in inhibiting tone

Answer 82

Lateral

Question 83

exercises stroke

Answer 83

Bridging sit on feet help push through legs Move objects from one side of table to another Internal and external rotation and flexion and extension of shoulder but support humerus Flexion and extension of fingers and wrist Squeeze Physio hand Apply resistance to flexion and extension by holding the hand and pushing in opposite direction Push towel forward back and side to side on table and round in circle x10 Shrug shoulders

Question 84

What to look for in normal gait

Answer 84

Initial contact is it heel strike or not &is o they have some hip flexion Loading response Are they weight bearing is knee and hip in flexion Mid stance are they in extension Terminal stance - can they plantarflex Is single support and double support equal time What is step length like Do they have arm swing What's posture like

Question 85

What to look for in normal gait

Answer 85

Initial contact is it heel strike or not &is o they have some hip flexion Loading response Are they weight bearing is knee and hip in flexion Mid stance are they in extension Terminal stance - can they plantarflex Is single support and double support equal time What is step length like Do they have arm swing What's posture like

Question 86

Cerebellar ataxia treatment

Answer 86

Bridging Legs flexed to 60 and bend side to side Sit to stands Picking up and moving objects side to side Picking things up and putting behind head and back down Rapid alternating movements Passing object from one side over head to other side Follow pattern with foot Tandem walking, normal walking and having to start and stop to a command (use visual cues) Side stepping Nudging in balance Catching and throwing all Bouncing ball alternating left and right hands

Question 87

Managing flaccidity and low tone

Answer 87

Range of motion of shoulder to 90 Elvow flexion and extension Supination pronation Wrist flexion extension Finger flexion and extension Finger abduction adduction Thumb adduction abduction Get patient to do it as well to inc muscle activity Roll arm on a ball supported by other hand Roll towel forwards backwards side to side round

Question 88

Sensory rehab what do u do

Answer 88

Touch hand in different points and get pt to point where Get pt to hold different objects with eyes closed and try and describe the objects and then look st them and then re close eyes and focus on them when you know what they are Do it 2-3 times a day for 10 minutes Get pt to hold over your hand while drawing shapes or alphabet

Question 89

What to look for in gait

Answer 89

Is there a short stance phase or ok Is the trunk straight or anterior or posterior to the hips are they leaning to one side do they have arm swing Do they have good hip extension and knee extension Is there good ankle plantatflexion