REVISION LECTURE Flashcards

Question

Spasticity - causes

Answer 1

UMNL from motor cortex to spinal motor neurons common causes: stroke, SC compression, brain damage, inflammatory lions of the spinal cord MS

Answer 2

Characteristic involvement of certain muscle groups – predominantly antigravity muscles e.g. UL flexors, LL extensors. Increased responsiveness of muscles to stretch. Hyper-reflexia – increased tendon reflexes. Abnormal resistance to passive movement – the more rapid a limb is moved the greater the increase in tone. Clasp knife – ‘catch’ followed by ‘melting’ away of resistance. Clonus – rhythmic oscillations (usually of ankle & foot).

Answer 3

``` positioning stress fatigue pain full bladder infection fear pressure sore constipation increased effort ```

Answer 4

``` ash worth scale modified ash worth scale movement grading severe- no mvmt moderate - poor mvmt mild - good mvmt assoc reactions effort on unaffected side leading to increased tone on spastic side involuntary mvmt - yawning tendon jerks ```

Answer 5

``` implications Weakness Decreased movement Abnormal movement Poor posture Soft tissue shortening - contracture Pain Loss of function & adaptive motor behaviour ``` ``` Normalise tone Maintain normal muscle length Improve ROM Decrease pain Reduce unnecessary complications Improve function Positioning - Abnormal reflex activity Supine -  extensor activity Sitting - symmetry and stability Passive movement Movement proximal region of limb Slow passive movements ```

Answer 6

baclofen GABA derivative, pre and postsynaptic inhibitory effect diazepam - enhances action of GABA on inhibitory NTS botulinum toxin - toxin into affected muscle causing presynaptic blockade of Ash release

Answer 7

increased resistance to passive movement, constant throughout range of movement in flexors and extensors lead pipe rigidity - resistance throughout movement cogwheel rigidity - additional tremor - superimposed rigidity causes - extrapyramidal lesions - Parkinson's disease - caused by functional disturbance of the basal ganglia

Answer 8

Increased resistance to relatively slowly imposed passive movements. Present in both flexor & extensor muscle groups. Characterised by ‘lead-pipe’ resistance. Tendon reflexes are normal in contrast to spasticity. May have superimposed tremor, leading to ‘cogwheel’ rigidity.Scales tend to disease/condition specific e.g. Parkinson’s disease. Hoehn and Yahr Scale Universal Parkinson’s Disease rating Scale (UPDRS)

Answer 9

``` Assessment Normalise tone Relief of symptoms – stiffness/pain Review – posture, gait, mobility, transfers Record functional performance ``` Regular re-assessment Normalise tone Management of stiffness/pain – heat, Neurotech Educate re posture Gait, mobility, transfers – re-education Optimise functional independence

Answer 10

Medical Mx - Medications include: levodopa, dopamine agonists, anticholinergics and selegiline.

Answer 11

decreased resistance to passive movement | decrease reflexes

Answer 12

``` causes Central cerebral shock - post UMNL spinal shock peripheral nerve lesion cerebellar ``` ``` Clinical features loss of function inability to move against gravity unable to sustain upright posture can't WB ./ TF ```

Answer 13

``` Paralysis / Loss of movement post stroke Muscle weakness Muscle imbalance Abnormal tone Sensory loss Altered alignment / biomechanics Perceptual deficits Immobility Weakness Adaptive soft tissue changes Dependent limb Poor handling Trauma Forced ROM Immobility Prolonged positioning Secondary changes Degeneration ```

Answer 14

Supraspinatus: Shoulder abduction Post stab: Infraspinatus: External rotation of the shoulder post stab: Teres Minor: External rotation of the shoulder Ant stab: Subscapularis: Internal rotation of the shoulder

Answer 15

The Scapulothoracic articulation contributes to both flexion and abduction of the humerus by upwardly rotating the glenoid fossa 60 from its resting position.

Answer 16

``` Pain (distraction) Recovery & outcome of rehabilitation Interferes with rehabilitation Interferes with transfers ADL and Independent function Depression Sleep disturbance ```

Answer 17

``` Common post stroke May present early or late Presence of abnormal tone + / - subluxation Sharp pain at end of ROM Experience night pain / diffuse ``` ``` causes Loss of co-ordinated joint motion Abnormal scapulo-humeral rhythm Inadequate external rotation Lack of downward glide Muscle imbalance, abnormal tone ``` Forced passive ROM Incorrect handling / trauma

Answer 18

Mechanism Scapula depressed or retracted ``` Impaired locking mechanism Orientation of scapula & glenoid fossa – up, forward, lateral Slope of fossa - prevents downward subluxation Reinforced by supraspinatus ‘Locking mechanism’ Subluxation Causative factors Paralysis rotator cuff Mal-alignment Abnormal tone Loss of locking mechanism Gravity Weight of limb Presentation + / - painful Classification of subluxation*** Inferior subluxation Superior subluxation Anterior subluxation ``` Mal-alignment shoulder & displaced humeral head Subjective ‘dragging’ Relieved by passive elevation diagnosis palpable dip pt in sitting palpate along clavicle out from sc joint check for gap between lateral cordial border and head of humerus gap = 1-2 fingers - subluxation.

Answer 19

``` Stage 1 Tender swollen hand Diffuse aching pain Sensitivity Discoloration Warm / moist Loss of movementStage 2 Marked pain and swelling Progressive loss of movement Oedema loss of skin elasticityStage 3 Resolution of pain and oedema Decreased ROM Bone demineralisation Muscle atrophy Soft tissue changes Joint contracture Deformity (flexion) ```

Answer 20

``` Positioning Handling Normalise tone Education Normalise alignment Posture Facilitate muscle activityPrevent ST shortening Joint mobilisation Restore function Strapping / taping Supports / slings FES/NMES Medication Constraint induced movement Robotics ```

Answer 21

sling only used for TF and walking | when in bed or chair remove the sling

Answer 22

The patient leans towards the hemiplegic side in any posture and resists any attempt at passive correction of posture that would move his / her weight towards or across the midline of the body toward the non-affected side’ (Davies, 1985) Altered perception of body’s orientation in relation to midline / gravity No correlation with right sided stroke (i.e. L Hemi +/- UN) Impairment in judging vertical - a change in the perception of midline of their body

Answer 23

Patient leans to hemi side Resists any attempt to correct posture which moves bodyweight to midline / normal side Apprehensive re leaning over / WB Unable to accept weight through unaffected side (if able to WB, may WB on medial border of foot with adduction also) Demonstrates resistance to passive / active movement toward midline / unaffected side Over-activity unaffected side UL, LL, trunk

Answer 24

Damage to sensory pathways Role of posterolateral thalamus Disturbed neural representation of truncal graviceptive system Cortical involvement Insular, opercular as well as temporal regions are possibly involved in the control of upright body position. Current research indicates that PS in right-hemispheric lesion patients depends on vestibular otolith input, suggesting a link between the system for postural control and the system responsible for processing vestibular otolith information. Such close interaction would seem useful for processing in multisensory integration centers at the cortical level. (Baier et al 2011 J Neurol)

Answer 25

Balance control (sitting, standing, walking) Functional mobility Recovery of ADL Safety during movement / transfers

Answer 26

``` Assessment Diagnosis made by observation Asymmetrical posture Lack of midline sitting Actively pushes to affected side Verticality & sense of midline Right / Left awareness Visuo-spatial neglect Attention to physical & perceptual deficits to enable appropriate management ``` Management Restore sense of verticality Facilitate midline awareness Balance training Regain ability to move actively towards that side with visual cueing & feedback Regain ability to move actively about in sitting & standing

Answer 27

Observation based diagnosis. No reliable measures. Patient distressed when attempts made to move to normal side. Preferable to lead patient to move actively to that side. Balance retraining. Visual feedback / actively move  midline / normal side. Positioning. Sitting - small pillow under affected buttock. Functional movements. Mirror therapy

Answer 28

Normal gait – what are the characteristics? Hemiplegic gait Characteristics that are common after stroke Assessment approach Management/Rx Walking essential independent living / function & ADL

Answer 29

health condition - disorder or disease body functions and structures activities participation environmental and personal factors

Answer 30

instrument used to test or rate a part of your Ax make sure its valid and reliable

Answer 31

``` 25% contributory factors cognitive impairment, inattention anosognia balance co-ordination muscle weakness sensory loss visual disturbance BERG Falls are difficult to predict Assess at individual level: balance, history of falls, perception, what activities they need to do after discharge, risk of consequences Falls are difficult to prevent Focus on patient’s participation goals and undertaking activities safely, consider education to cope with falls, education to rise from the floor and bone health ```

Answer 32

``` How to conduct a sensory system exam Light touch Sharp blunt Vibration Sensory inattention Special sensory tests Graphaesthesia / stereognosis How to assess JPS? How to assess coordination? How to assess tone?How to assess balance? Gait exam How to examine trunk ? How to assess for subluxation? How to describe a functional mobility task? How to facilitate a STS? ```

Answer 33

cutaneous sensations pain temp light touch pressure 2 point discrimination prop sensation vibration joint position sense movement integrative sensation bilateral simultaneous sensory application

Answer 34

Conveys: Proprioception (awareness of position of muscles, tendons, joints & body movements). Fine discriminative touch (ability to feel exactly which part of body is being touched). Stereognosis (ability to recognise by feel the size,shape and texture of an object). Vibration sense. Weight discrimination (ability to determine the weight of an object). DISTAL TO PROXIMAL

Answer 35

``` Including spinothalamic tract (anterior & lateral) and other associated tracts that convey: Pain Temperature sense (hot / cold) Crude touch (poorly localised) touch Pressure Tickle Itch ```

Answer 36

Joint Position Sense Upper limb Patients eyes open demonstrate. Hold distal phalanx DIP joint index finger . Illustrate bent & straight. Patient closes eyes & is asked to report if joint is bent or straight. Test distal joints first. Lower limb As above DIP joint, test hallux.

Answer 37

Higher Order Sensation* Graphesthesia - ability to recognize writing on the skin purely by the sensation of touch. Stereognosis/tactile gnosis - ability to perceive & recognise the form of an object using cues from texture, size, spatial properties, and temperature (mediated by the posterior column-medial lemniscus pathway). Stereognosis tests determine whether or not the parietal lobe of the brain is intact. Sensory inattention /sensory neglect - patient recognises stimuli when presented independently but recognises only one side when stimulus is presented simultaneously. Indicates Parietal lobe lesion. The above cannot be tested unless primary sensation intact bilaterally.

Answer 38

Finger-tip to nose test Hold finger at arms length in front of patient. Ask patient to touch the finger with index finger then touch their nose. Change speed/position of target. Repeated movements

Answer 39

heel to shin patient in supine lift leg and place heel on knee slide heel down along shin

Answer 40

tandem walking

Answer 41

rapid alternating pronation supination

Answer 42

Muscle Tone Assessment Procedure Assessment Steps (position supine lying) 1. OBSERVE Appearance of limb 2. Palpation / Feel muscle How does it react to stretch PROM – UL, LL, Trunk 3. PROM; Proximal to distal direction for test Grading Ashworth Scale or Modified Ashworth – next slide

Answer 43

``` No increase in muscle tone. Slight increase in muscle tone - manifested by a catch & release or by minimal resistance at the end of the range of movement when the affected part(s) is moved in flexion/extension. Slight increase in muscle tone, manifested by a catch followed by minimal resistance through the remainder (less than half) of the range of movement. More marked increase in tone through most of the range of movement but affected part(s) easily moved. Considerable increase in muscle tone, passive movement difficult. Affected part(s) rigid in flexion or extension. ```

Answer 44

``` balance sitting, standing, static dynamic, functional bed mobility rolling lying to sitting transfers level of Ass pattern of mvmt? BOS Stability posture balance tests ```

Answer 45

``` Appropriately undressed Starting position Initiation of gait Level of assistance Use of aid/device Alignment StabilityBase of support Swing phase Stance phase Arm swing Trunk rotation Foot placement/clearance Timing/co-ordination ```

Answer 46

neuron who's cell body lies in the CNS and whose axon leaves the CNS through a foramen and terminates on an effector

Answer 47

a neuron which lies entirely in the CNS and causes movement because it terminates on the LMN

Answer 48

What types of Abnormal Movement are there? Loss of co-ordination - cerebellar lesion Bradykinesia - Parkinson’s disease (slowed movement) Involuntary movement - tremor / chorea (brief, involuntary, non-rhythmic movements) Intention tremor - cerebellar Non-intention tremor - Parkinson’s Loss of range - contracture Loss of voluntary movement UMNL, CVA.

Answer 49

``` Possible Causes of Abnormal Muscle Power (Weakness), can you discuss them? Muscle pathology Neuromuscular junction defect Central - UMNL Anterior horn cell damage/pathology Nerve root injury Nerve plexus Peripheral – Peripheral nerve lesion (PNL) ```

Answer 50

``` How to Assess Muscle Tone - Assessment Steps Appropriately undress, prepare model, expose limbs Patient comfort/safety Preparation of environment and patient Supine lying Observation; Appearance of limb Palpation; Feel muscle Passive ROM, How does it react to stretch – UL, LL, Trunk, Proximal to distal direction for test Compare both sides Grading – Use Ashworth Scale ```

Answer 51

Proprioception (awareness of position of muscles, tendons, joints & body movements). Fine discriminative touch (ability to feel exactly which part of body is being touched). Stereognosis (ability to recognise by feel the size,shape and texture of an object). Vibration sense. Weight discrimination (ability to determine the weight of an object).

Answer 52

``` Including spinothalamic tract (anterior & lateral) and other associated tracts that convey: Pain Temperature sense (hot / cold) Crude touch (poorly localised) touch Pressure Tickle Itch ```

Answer 53

``` Primary Sensation Light touch Temperature Pinprick / pain Vibration sense Joint position sense 2 point discrimination ``` ``` Dermatomes – remember CNS vs PNSSensory Testing Instructions Clear instructions / demonstration What you need? Light touch - cotton wool Vibration - tuning fork Pinprick - neurotips Temperature - test-tubes hot / cold Find level of normality Test both sides Review rules for sensory testing Distal to proximal testing See handout ``` joint position sense Upper limb Patients eyes open demonstrate. Clear communication Hold distal phalanx DIP joint index finger . Illustrate bent & straight. Patient closes eyes & is asked to report if joint is bent or straight. Test distal joints first. Lower limb As above DIP joint, test hallux. Don’t hold the nail, REMEMBER…

Answer 54

``` Upper Limb Finger-tip to nose test Hold finger at arms length in front of patient. Ask patient to touch the finger with index finger then touch their nose. Change speed/position of target. Repeated movements Lower Limb Heel to shin test - Patient in supine. Lift leg and place heel on knee. Slide heel down along shin. Trunk Tandem walking Other test - dysdiadokokenesis ```

Answer 55

Broca’s Area Inferior frontal gyrus of dominant hemisphere (usually the left) Associated with motor or expressive dysphasia Wernicke’s Area Temporal lobe Sensory or receptive dysphasia dysphasia expressive / motor - broca's receptive / sensory - wernickes Speech problems common in left sided stroke with right sided hemiparesis WHY – Dominant speech centre in Left cerebral hemisphere Note - there can be exceptions to this simple clinical rule

Answer 56

Unilateral Neglect common in right sided stroke with left sided hemiparesis WHY – Dominant visuoperceptual centre in right cerebral hemisphere, parietal lobe

Answer 57

Sit to stand Risk assessment 1 or 2 physios, brakes on, position of plinth Moving to edge of bed patients feet on floor, physio supports pelvis, depress unilaterally and walk opposite pelvis forward and vice versa. Foot position, and support hemiplegic lower limb as appropriate Preparation environment, use of lifting belt Care of hemiplegic UL web arm sling, proximal arm support, note thumb grip from MH notes Rocking, trunk forward ‘nose over toes’ Flexion and extension Steady in initial standing, caution re hypotension/unsteadiness

Answer 58

Stand to sit Risk assessment 1 or 2 physios, brakes on WC, position of chair Moving to edge of chair Turn around until can feel chair at back of legs Foot position, and support hemiplegic lower limb as appropriate Physio assists patient to place unaffected hand on arm rest Care of hemiplegic UL web arm sling, proximal arm support, note grip from MH notes Bending knees, controlled descent into chair Reposition in sitting, hips back, support to UL

Answer 59

Patient in sitting Palpate from the SC joint along the clavicle to the AC joint Check for a gap between the lateral acromial border and the head of the humerus A gap of 1-2 fingers indicates subluxation is present

Answer 60

``` reduce pain Counteract traction imposed on joint by weight of limb + gravity Prevent stretch to capsule +ST Stabilisation / align Provide proprioceptive feedback Promote awareness ```