neuro eval lecture 1

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neuro eval lecture 1
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2012-09-19 20:42:07
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neuro eval lecture 1
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  1. real basic diff betwen neurologic and orthopedic systems
    neuro is less well understood, and it'll give subjective and objective data
  2. why do a PT neuro eval?
    • PT diagnosis not same as MD diagnosis
    • ex. PT says MS is a disease of mobility, MD says it's of demyelination

    most of all, do a neuro eval to figure out what to treat, to choos correct interventions
  3. objectives of neuro eval/exam
    • ID if disease process or impairment is impacting the nervous system
    • localize the lesion - recognize patterns and deduce pathology
  4. 4 categoris in Nagi model of disablement
    Pathology. Impairment. Function. Society.
  5. Pathology, in the Nagi model of disablement
    def, and what it is in stroke, TBI, Parkinsons, MS
    • the underlying disease/defect occuring at cellular level
    • stroke: impaired BS to CNS due to thrombo-embolus or bleed
    • TBI: acute trauma to brain
    • Parkinsons: damage to substantia nigra
    • MS: autoimmune CNS demyelination

    PTs don't really treat at the cellular level
  6. Impairment, in the Nagi model of disablement
    disruption of a motor, sensory, or cognitive process

    ex: spasticity, sensory loss, bradykinesia (slow movement), fatigue, thermosensitivity

    PT usted to be here
  7. Function, in Nagi model of disablement
    • the functional limitation
    • ex. inability to walk, balance, reach, stand, etc. ...

    PT is here
  8. Society in the Nagi model of disablement
    disability - decreased ability or inability to perform social roles

    ex: parenting, work

    This is where PT should go.
  9. In a PT eval, each of the following look at what?
    Impairment level
    Functional limitation
    Disability
    • Impairment level - sensory, motor, spatisticity, ROM, etc
    • Functional limitation - gait, balance, transfers
    • Disability - QOL measures, self report measures
  10. charactersistics of lesions
    • focal vs diffuse
    • CNS vs PNS
    • upper motor neuron vs lower motor neuron
    • dermotomal/myotomal vs non dermotomal/myotomal
    • nervous system vs other
  11. the thing about UMNs and CNS
    all upper motor neuron lesions are in the CNS

    can have CNS damage w/o UMN lesion
  12. focal, diffuse, multifocal, focal + diffuse lesions
    • focal - lesion in one spot, maybe due to a stroke
    • diffuse - spread over wider area of brain, maybe due tue a big stroke or a disease like alzheimer's
    • multifocal - seen in MS or trauma
    • focal + diffuse - trauma creates a focal one on site of impact, it runs thru brain to make another focal one on opposite side, and all in the middle it's diffuse
  13. 5 locations for lesions in the CNS
    • cortical
    • subcortical
    • cerebellar
    • basal ganglia
    • spinal cord
  14. 4 locations for lesions in the PNS
    • anterior horn cell
    • nerve root
    • plexus
    • peripheral nerve

    in a muscle exam you look for it in peripheral nerve, NMJ, and muscle itself -- says another slide
  15. 4 keys to examination
    • observation
    • subjetive history (pt and fam)
    • med record
    • know when to refer
  16. reliability vs validity
    reliability - is test repeatable (inter-rater reliablility - diff raters get same results. intra-rater reliability - same rater gets same results)

    validity - does test measure what it claims to
  17. sensitivity
    • ability to pick up various signs and symptoms of pathology
    • ex: high BBS accurately predicts fall risk
  18. specificity
    • ability to rule out other pathologies
    • ex: low BBS accurately predicts low falls risk
  19. elements in subjective history
    • age, R or L handedness, occupation
    • chief complaint (CC)
    • HPI (history of present illness)
    • PMH/PSH (previous medical/surgical history)
    • medications
    • SH (social history - support system)
    • family history - involvement, support from fam
  20. elements to look for in Chief Complaints (CC)
    • nature of problem
    • localized vs diffuse (pain only under specific conditions vs constant)
    • onset (when symptoms began, not when diagnosis was made)
    • frequency
    • duration (how far can pt walk? how long does pain last?
    • severity
  21. what to get in HPI (history of present illness)
    • chronology
    • date onset
    • what worsens or improves symptoms
    • what can't you do that you could do before?
  22. what to look for in PHM/PSH
    • illnesses, injuries
    • hospitalizations, surgeries
    • meds, medical treatments
    • other conditions that can be associated w chang in neurologic status (cardiac...)
  23. what we focus on in an eval - 8
    • motor, sensory, cerebellar, balance/gait (mobility)
    • cranial nerve (involves vestibular system)
    • cognitoin, perception, language
  24. objective info in neuro eval
    • observation
    • arousal
    • posture
    • appearance
    • motor patterns
    • speech patterns
    • behaviour
  25. motor exam looks at these 3 things
    • muscle strength (force output)
    • muscle function (tasks)
    • motor control (nervous system-muscle relationship ie rel btwn brain and movement)
  26. in muscle exam look for these 3 points
    • symmetry - is there wasting on one side?
    • hypertrophy/pseudohypertrophy - in muscular dystrophy a muscle will look big but it's just connective tissue in the muscle belly
    • atrophy
  27. 4 points to assess in motor exam when pt's doing AROM
    • movement to command
    • synergies (normal movement patterns - the expected poetry/grace)
    • strength (MMT)
    • equal mvmnt on both sides
  28. tone
    a normal resting state of a muscle, created by ongoing activation of muscle units

    resting tone increases if you just did a strenuous exercise
  29. 2 types of decreased tone, 3 of increased
    • decreased: hypotonia, flaccidity
    • increased: hypertonia, spasticity, rigidity - if it's increased, you know there's CNS involvement
  30. his 5 word def of spasticity
    velocity dependent reaction to stretch
  31. spasticity
    • velocity dependent reaction to stretch
    • increased "gain" of the stretch reflex - so if you do a quick stretch it responds quicker and stronger than we'd like, - the muscle jerks into contraction
    • hallmark of UMN syndrom
  32. extensor spasticity
    flexor spasticity
    extensor spasticity - seen when you try to move a limb into flexion (so you're stretching the extensor muscle, and it'll respond by jerking you back towards ext. - think of the tricep)

    flexor spasticity - arises when you try to quickly extend a limb, stretching the flexor
  33. Modified Ashworth Scale (MAS)
    describe 0, 1, and 1+
    MAS tests for presence of spasticity under certain conditions

    • 0 - no increase in tone
    • 1 - slight increase in tone - catch and release or minimal resistance at the end of the ROM when the affected part is moved into flex or ext
    • 1+ - slight increase in muscle tone - catch and release followed by minimal resistance thru remainder (less than half) of ROM
  34. Modified Ashworth Scale (MAS)
    describe 2, 3, 4
    • 2 - more marked increase in muscle tone (no catch and release) thru most of ROM but affected part moves easily
    • 3 - considerable increase in muslce tone, passive motion difficult
    • 4 - affected par rigid in flex or ext
  35. MAS lookes at spaticity in these 8 sites
    elbow, writst, fingers, thumb, hamstrings, quads, gastroc, soleus
  36. limitations of MAS
    • neglects shoulders and trunk
    • doesn't look at spasticity during functional exercises
    • useful for research, maybe not for making clinical decisions
    • ignores how spasticity changes w intensity of exercise
  37. exertional spasticity
    • spasticity that changes with intensity of exercise
    • ex: a runner who was fine for the first few strides, then got spastic (this pt may get 0's on the MAS)
  38. rigidity def
    • NON-velocity dependent reaction to stretch
    • type of hypertonia
  39. 2 types of rigidity
    • cogwheel - successive catches and releases - seen in Parkinsons
    • lead pip - stiffness and inflexibility that remains uniform thru the range of passive movement (put a limb somewhere, and it'll stay - seen in elderly and catatonics)
  40. flaccidity def
    • minimal or absent tone
    • minimal or absent muscle contraction ot command or reflexibely
    • absent or diminished stretch reflex
  41. 4 types of flaccidity
    • normal
    • lower motor neuron (LMN) lesion - motor portion of peripheral n.
    • muscle damage
    • component of spinal or cortical shock (so this flaccidity is due to CNS damage)
  42. diaschisis
    • spinal cord or cortical shock
    • affected parts will be totally flacid for a while, then spastic, then maybe normal
    • unable to prognosticate til shock is resolved
  43. triad of symptoms following CNS lesions
    aka Upper Motor Neuron syndrome
    • 1 - spasticity (spastic paralysis)
    • 2 - hyperreflexia (over responsive reflexes - twitching or spastic tendancies)
    • 3 - pathological reflexes (clonus and babinski)
  44. lower motor neuron syndrome - 3 pathologies
    • flaccidity (flaccid paralysis)
    • hyporeflexia/arreflexia
    • occasional fasciculations - worm-like wiggling of individual muscle fibers -- can hapen w/o lower motor neuron lesion, so it's only indicative if there are other symptoms
  45. AROM assessment steps
    • assess for normal mvmnt quality, mvmnt to command, strength
    • check for symmetry
    • repeat w resistance
  46. spasticity eval steps
    • take joint thru PROM slowly to asses joint for ROM limitations
    • then repeat it a few times fast to see if spasticity kicks in
  47. deept tendon reflexes aka monosynaptic stretch reflex  - how to test?
    locate and expose the tendon, put it into a bit of a stretched position, wack the tendon or muscle belly with a hammer at a right angle, causing a quick stretch, see if the muscle responds by contracting
  48. Jendrassic maneuver
    def and a use
    raising the background tone by doing a strenous exercise (ex: press hands together hard)

    if a muscle has higher background tone this makes it a bit easier to trigger a deep tendon reflex
  49. grading for DTR
    0, 1+, 2+, 3+, 4+, 5+
    the eval and the response
    • 0  eval: absent. response: no visible or palpable contraction
    • 1+ eval: hyporeflexia. response: slight contraction
    • 2+  eval: normal. response: slight ms contraction w joint mvmnt
    • 3+  eval: hyperreflexia. response: brisk contraction w moderate joint mvmnt
    • 4+  eval: abnormal hyperreflexia. response: strong contraction. response: strong contraction w 1-3 beats of clonus
    • 5+ eval: abnormal hyperreflexia. response: sustained clonus
  50. spinal cord levels for biceps, brachioradialis, triceps, quads, achilles
    • C5 - biceps
    • C6 - brachioradialis
    • C7 - triceps
    • L3-4 - quads
    • S1-2 - achilles
  51. babinski (plantar response) reflex
    how to elicit it, and the good and bad responses
    • draw a blunt prob across sole of foot from heel to ball
    • negative response (this is good) - toe flextion and adduction, plantarflextion aka downgoing toes
    • positive response (bad unless you're a baby) toe fanning and extension, dorsiflexion,  aka upgoing toes
    • equivocal response - toes go up and down
    • no response - LMN lesion
    • triple flexion response - dorsiflexion, knee flexion, hip flexion - severe UMN involvement
  52. what does a positive babinski response indicate?
    • UNM lesion
    • toe fanning + extension, dorsiflexion (upgoing toes)
  53. what does no respons in the babinski test indicate?
    LMN lesion
  54. what response to babinski indicates severe UMN involvement (or a strong tickle reflex)?
    triple flexion response: ankle dorsiflex, knee flex, hip flex --  it's a withdrawal reflex
  55. clonus
    • rhythmic beating of a joint in response to sustained stretch
    • most often at ankle joint, but can be anywhere
  56. how to test for clonus
    quick stretch then hold
  57. clonus 4 categories
    • normal: 1-1.5 beats
    • abnormal: 2-5 beats
    • abnormal sustained: > 5 beats
    • absent LMN or normal low toned
  58. how to get someone out of clonus
    remove the stim - so take the person out of stretch by shortening the muscle. Hold there, then slowly return to norm

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