Neuro Diff Dx Flashcards
1
Q
Parkinsons Disease is depletion of _ from the _
A
Dopamine from the Substantia nigra
Exercise SLOWS the progression!
2
Q
People w/ PD are TRAPped
CARDINAL SIGNS
A
T:Tremor– shaking, usually starts 1 side; “pill-rolling”
R: Rigidity– stiffness, of limbs, neck, or trunk (1. cogwheel 2. lead pipe)
A: Akinesia– LOSS or impairment in POWER of voluntary mvmt
P: Posture and Balance– Anteropulsion
Bradykinesia also present==> SLOWNESS of mvmt
Shuffling, short-stepped gait pattern
LOSS OF ARM SWING**
3
Q
PD Sx’s: Resting Tremor
A
Often occurs first in ONE hand, resembles pill-rolling
4
Q
PD Sx’s: Rigidity
A
Cogwheel (exactly what it sounds like) and Lead Pipe (exactly what it sounds like)
5
Q
PD Sx’s: Akinesia, BRADYkinesia
A
Hesitation, SLOW mvmt.
Diff rising from a sitting pos is COMMON sign of disordered control over mvmt
6
Q
PD Sx’s: Postural INstability
A
Lean FORWARD or BACKWARD when upright==impaired balance/coord.
7
Q
PD Sx’s
A
see pics
8
Q
This scale stages the SEVERITY of PD:
A
Hoehn and Yahr Stages
Staged 1 (good)-5 (worst)
9
Q
Hoehn and Yahr Stages of PD
ALL: Stage 1 (best): Stage 5 (worst)
A
see pics
10
Q
Hoehn and Yahr Stages of PD:
ALL
A
- Stage 1: Develop MILD sxs but able to go about day-day life (BEST)
- Stage 2: Sx’s such as tremors and stiffness worsen, may develop POOR posture or have trouble walking
- Stage 3: Mvmt begins to SLOW DOWN, LOB (uses AD, falls/unbalanced, rollator
- Stage 4: Sxs are severe and cause significant issues w/ day-day living, UNABLE to live alone and will need care
- Stage 5: Walking or standing may be IMPOSSIBLE @ this point, people in Stage 5 often confined to WC or bed (WORST)
11
Q
PD: Gait related impairments:
2 VERY characteristic ones…
A
- Festinating gait:progressive INC in speed w/ a shortening of stride–can be anteropulsive (forward festinating)
-
Freezing of Gait (FOG)– sudden, abrupt INability to initiate ANY mvmt. Ex’s: doorways, turns
- USE: music, count steps, cognitive tasks
12
Q
PD related Gait impairments:
ALL
A
- Festinating
- Freezing
- Diff turning: incd steps per turn
- Reduced stride length; incd step-step variability
- Reduced speed of walking
- Incd time in DLS
- Insuff hip, knee, and ankle flexion–> shuffling steps
- Insuff heel strike w/ incd FOREFOOT loading
- Reduced trunk rotation: DECd/absent arm swing**
- Diff dual tasking–> simultaneous motor/cog
- Diff w/ attn demands of complex environments
13
Q
Training ideas for gait related impairments
A
Visual/auditory cueing
ex. ladder for equal step length, count steps
14
Q
Medical mgmt PD:
GOLD STANDARD DRUG TX
A
LEVODOPA/CARBIDOPA (Sinemet)
15
Q
Medical mgmt PD:
SEs and **what should you remember about this?? **
A
SEs: Dyskinesias–Dynamic INvoluntary choreoathetotic mvmts occurring @ peak of Levodopa dose–> Initial=facial grimace w/ twitch lips, tongue protrusion–> Severe=involves limbs, trunk, neck
REMEMBER: This is SE of the MEDS (Levodopa) NOT from PD itself!!!!
16
Q
Practice!
PT working w/ 67yo male. Pt displays rigidity, slowed mvmts, INvoluntary oscillatory mvmts, intsability w/ recent uptick in falls. Based on presentation which neuro dx is likely ?
A
PD!!!
TRAPped
17
Q
Huntington’s Disease (HD)
A
- Neurodegen GENETIC (hereditary) disease– degen of BG, cerebral cortex
- Autosomal-dominant illness– CAG repeats
- Combo of–> mvmt disorders, COG decline, behavioral changes
18
Q
NOTE: When you hear Parkinsonism
A
NOT actually PD from DEC in dopamine
Just “PD-like” sx’s
19
Q
HD Sx’s:
AGE????
A
35-55
20
Q
HD- Sx’s
A
- 35-55yo
- mm coord impairs AND cog decline, psychiatric probs
- **Huntingtons Chorea–> **INvoluntary jerking or writhing mvmts (ex. unable to sit still)
- MM probs–> rigidity or mm contracture (dystonia)–think superimposing involuntary mm’s– piano example w/ fingers
- Slow/abnorm eye mvmts
- Impaired gait, posture and balance
- Diff w/ production of speech or swallowing*
21
Q
Cerebellar disorders
THINK* in terms of tremor*…
A
INTENTION tremors
22
Q
Three specialized regions of Cerebellum for controlling multiple types of mvmt
A
- Vestibulocerebellum
- Spinocerebellum
- Cerebrocerebellum
23
Q
Vestibulocerebellum
Input, Output, Deficits as result
A
Input–> Vestibular
Output–> eye mvmts; vestib nuclei; balance/equilib
Deficits–> Nystagmus, TRUNCAL ataxia
24
Q
Spinocerebellum
Input, Output, Deficits as result
A
Input–> Somatosensory, visual/auditory/vestib
Output–> medial upper motor neurons; lateral upper motor neurons
Deficits–> Ataxic gait, Limb ataxia (dysmetria)
25
Cerebrocerebellum
Input, Output, Deficits as result
Input--> Cerebral cortex
Output--> Motor and premotor cortex
**Deficits--> DEC coord of fine finger mvmt**
26
Practice!
Pt w/ NORMAL sensation and reflexes presents w/ DEC mm tone and asthenia (weakness). Which other s/s are MOST likely present?
Truncal Ataxia
**CB disorders--> HypOtonia, lack energy, weakness (asthenia)**
27
Cerebellar Disorder--> **Coordination Testing**
see pics and note **Dx tests**
- finger to nose, heel to shin
28
Finger to nose test-- >
Cerebellar ataxia
*can also see dysmetria (over/under shooting)
29
S/S Cerebellar Disorder
**Mnemonic to remember?**
VANISHED
**V: Vertigo
A: Ataxia
N: Nystagmus
I: Intention tremor
S: Slurred speech
H: HypOtonia
E: Exxagerated broad based gait
D: Dysdiadochokinesia**
## Footnote
CB= intention tremor; BG= resting tremors
30
Cerebellar disorder:
**Gait Ataxia explained...**
INconsistent step LENGTH: not able to predict proper step length
Diff maint. SLS
Poor balance= INCd gait ataxia and slow gait
Diff predicting amt of wt shift needed
31
Some more Coord. tests for CB
Finger-> nose
RAM
Heel-> shin
Foot to finger
32
NOTE for NPTE answering questions
IF 2 answers look SIMILAR to ea. other----> likely BOTH wrong!!!!
33
MS: main things to remember
1. **Autoimmune**-- inflamm, selective **demyelination**, gliosis
2. **Chronic demyelinating** of CNS
3. **ANY area of CNS affected**-- cortical, subcort, CB, SC
34
MS: Main characteristics
1. MORE in **females** (2:1)
2. Onset **20-40yo**, PEAKS 30yo
3. Occurs more **caucasians**
35
MS: Etiology
| Think... Sclerosis literally means **scarring**... **Multiple sclerosis*
Healthy myelin--> **Oligodendrocytes** produce myelin in CNS--insulates nerves, speeds conduction, conserves energy
- **In MS:** Destroyed or damaged myelin (WBCs attack neurons and affects myelin (fatty tissues around nerves in brain/SC)== multiple scarring (sclerosis), nerve signals blocked == MS sx's
36
HEAT SENSITIVITY in MS.... WHY?
Bc myelin sheath damaged ****
37
S/S MS:
3 big ones to know**
1. **Lhermittes' Sign--**Flex neck=> E-shock t/o extremities
2. **Uthoff's Phenomenon--**HIGH temp exposure=> exxag'd neuro sx's (make sure they hydrate!!!)
3. **FATIGUE!**
38
S/S MS:
**NOTE: impairs vary based on lesion location**
- Visual impairs (**Optic Neuritis)**, sensory impairs, motor impairs
- Intention tremor
- Neuropathic pain
- **FATIGUE**
- Cog impairs
- B&B dysf.
- Emo. distrubs
- Psychosoc probs
- **Lhermittes'**
- **Uthoff's Phenom.**
39
MS Dx:
**The one to remember**
- **CSF analysis**--> Elevated **immunoglobulins** and presence of **oligoclonal IgG bands**, slight **PRO elevation**
DECd NCV
40
Common types of MS:
- Relapse-Remitting (RRMS)
- Secondary Progressive (SPMS)-- >85% progress to SPMS
- Primary-Progressive (PPMS)
- Progressive-Relapsing (PRMS)
41
Types of MS:
Relapse-Remitting (RRMS)
- Episodes of rapid, abrupt deterioration w/ **variable degs of recover over time**
- aka Exacerbating-remitting
42
Types of MS:
Progressive-Relapsing
Relapses w/ **Lg degree of residual impairment**
aka Exacerbating-progressive
43
Types of MS:
Primary-Progressive
"Chronic-Progressive"
| its in the name!
- STEADY **progressive** deterioration
- Pace of deterioration may be **steady or varied**
| Nonetheless, still progressively worse and worse
44
Types of MS:
Secondary-Progressive
| In name, think the one that starts as Relapse-Remitting
- BEGINS as **relapse-remitting** THEN becomes **Primary (chronic)-Progressive**
45
MS:
Fatigue vs Fatigability
They will demo BOTH
Fatigue is **symptom**
Fatigability is a **sign**
46
MS- Gait Related impairs
Big ones to know
| Remember its **UMN lesion!! **
1. **Weakness--** Foot drop==toe drag
2. **Spasticity--** Velocity-dep, interferes w/ gait
3. **Balance probs--**Swaying and "drunken" gait--> Ataxia
4. **Sensory defs--** **peripheral neuropathy**= sensory ataxia
5. **Fatigue--** incd gait probs (remember **fatigability also! (sign)**
47
This is usually **FIRST SYMPTOM OF MS**
Visual impairments!!!
48
Visual impairs: MS
**Usually FIRST symptom!**
- **Optic neuritis!**
- Marcus Gunn-- abnorm Pup Lt Reflex (CN II messenger, CN III motor eff.
- Nystagmus
- Diplopia
49
Practice!
32yo female has abnorm reflexes. "weird sensations" t/o body. Incd IgG in CSF. Asks PT to dec temp bc heat intol.
MS!!!!
- Inc IgG, heat intol, 35 yo (20-40 onset), female (2:1), weird sensations, abnorm reflexes (UMN)
50
Practice!
43yo pmh includes MS. Reports over past 2 yrs sig. flare ups w/ declining mobility. Which subtype MS?
| Flare ups W/ declining funcion
Relapsing-Progressive
Relapse but stiil **progressively getting worse!**
51
MS:
Goals of PT interventions
- **Exercise and MS:**Fatigue + heat intol combo'd w/ weakness/spasticity limits exercise---BUT people w/ MS get same results as normal people-- THEY GET MORE FIT!!! **DO INTERVAL TRAINING**
- **Ex. considerations**-- AM bc decd temp and fatigue
52
Big one to remember w/ Myasthenia Gravis
PTOSIS
- also WEAKNESS (asthenia)
53
Side by side MS vs Myasthenia Gravis
see pics
54
MS Clinical Charactristics
- *Acquired***Demyelinating disease w/ AI cause**
- weak, parasthesias
- **Charcots triad C in Charcots, C in Cerebellar--> INtention tremor, scannign speech, nystagmus**Cerebeller involve.
- spastic, hypertone, hyperreflex, Babinski
- INcoord, **optic neuritis (often first)**, ataxia, vertigo, dysarthria (speech)
- diplopia, bladder incont, tremor, balance defs, falls, cog defs
55
Myasthenia Gravis Clinical Characteristics
| **NOTE that MG RECOVER FASTER FROM FATIGUE VS MS!!!!**
- **NMSK Junction disorder**
- AI mediated AcH receptor damage==> **deficit in NMSK transmission**
- WEAKNESS--worse during activities, improves after rest
- Variable weakness--> ptosis/diplopia to critical resp weak.
- MMs of speech, facial, mastication, swallowing, breathing, neck and limbs maybe involve.
56
EARLY sx's Myasthenia Gravis
| ***Sometimes the ONLY sx's**
- ptosis (droopy eyelid)
- diplopia (blurry double vision)
57
Practice!
45yo female w/ recent dx of MS. C/O eye pain, visoin loss ONE eye and visual field loss. Which CN?
CN II (Optic)
*usually involved in MS, sometimes CN V
58
Guillian-Barre Syndrome (GBS)
UMN or LMN?
LMN!!!!
*think stocking glove*
59
Guillian-Barre Syndrome (GBS)
UMN or LMN?
LMN!!!!
*think stocking glove*
60
Guillian-Barre Syndrome (GBS)
UMN or LMN?
LMN!!!!
*think stocking glove*
61
Guillian-Barre Syndrome (GBS)
UMN or LMN?
LMN!!!!
*think stocking glove*
62
GBS
| remember LMN!!!
- **Autoimmune response**-- antibodies attack own **PERIPHERAL NERVES**
- usually onset AFTER **resp infx, GI infx**
63
Guillian-**B**arre or G**B**S
What is the **B?**
B stands for **BILATERAL**
64
G**B**S--Pathogen
LMN disorder
- demyelinating of spinal N. roots AND P. nerves
- **rapid onset of weakness (DIST-->PROX (stocking-glove)** w/ **BIlateral sx's**-- peak 2-3wks, no > 4wks
- severity and course vary widely --usually norm fucntion w/in 3-6mos
65
_ and _ usually **FIRST SX'S**of G**B**S
Weakness and Tingling in extremities
66
GBS Dx
*MUST satisfy this criteria*
1. Symmetrical
2. **B for Bilateral**
3. Ascending (dist->prox= stocking-glove)
67
GBS and Lumbar puncture
**CSF contain more PRO than normal**
68
G**B**S
Sensory Sx's
- INITIALLY--> **B/L and Symmetrical**--> Stocking-glove
- PAIN--> **Lg mm's**of body--> back, thighs, butt
- Stiff, cramping, deep ache--**stretch them first 15mins**
- N/T and parasthesias/dysesthesias "ants under skin"
69
G**B**S
Motor Sx's
- DECd signal strength of **P. nerves**
- MM weak/atrophy
- DTRs diminished
- Partial OR full paralysis
- **Resp mm involve---mech. vent maybe**
- Facial/oral-motor weak-- vision, speech, swallowing
-
70
**A**myotropic **L**ateral **S**clerosis
**A** stands for_
**ALL**
UMN and LMN Sx's
71
ALS
"Lou Gehrig's"
S/S
- **LMN patho**-- mm weak, hypOreflex, hypOtone, atrophy, mm cramps, **fasciculations**
- **UMN patho**-- spastic, patho reflexes, hypERreflex, mm weak
- **Bulbar--** bulbar mm weak, dysphagia, dysarthria, siolorrhea, **pseudobulbar affect (laugh or cry no reason)**
- **Resp**-- insp/exp mm weak, dyspnea, DOE
- **Frontotemporal dementia--COMMON**-- loss insight, emo. blunting
- **Cog impairs**-- attn defs, defs in cog flex.
- **Behavioral impairs**-- irritable, social disinhibit.
72
Dx of ALS= **ALL--> UMN + LMN**
Weakness HERE very common
**CS Extensors!!!!!**
MOST COMMON AND DEVASTATING FATAL MOTOR NEURON DISEASE AMONG ADULTS
| NOTE: you will see head hanging forward
73
ALS vs MS
Note the similarities vs diffs
*Note the Sensory issues w/ MS and NOT ALS
74
Practice!
42 yo female c/o Asymmetrical weak of L/UEs. Fasciculations present (LMN) w/ impaired speech, sensations intact. Randomly starts crying or laughing no reason (bulbar)
ALS
75
Summary Table: Neuro Diff Dx
| MEMORIZE WHOLE TABLE
SEE PICS
