PT NEURO EXAM AND TREAtment: the basics and beyond

• 1= Unilateral Disease
• 1.5= Unilateral + Axial
• 2= Bilateral, No imbalance
• 2.5= Bilateral, recovery on pull test
• 3= Postural instability, Ind
• 4= Severe disability, can still walk unassisted
• 5= wheelchair or bed bound

Smooth Pursuit/ROM

Vestibular-Ocular Reflex (VOR)

Move a target held 18-24” from patient’s face. Go all the way to the end range horizontally and vertically for ROM (smooth pursuit is only to 30 deg).

• Look for smoothness/conjugate gaze
• Ask about double vision

 Interpretation: (+) decreased ROM, double vision; indicates cranial nerve problem (oculomotor III, trochlear IV, abducence VI).

 (+) Saccadic pursuit indicates CNS involvement (pons, cerebellum, vestibular nuclei)

• Ability for eyes to stay stable on object while head is moving
• Have patient look at nose, turning head quickly side to side.
• <2Hz (1 Hz=1 rotation per second, metronome at 120)= using central smooth pursuit system
• >2Hz (2Hz is 2 rotations per second, metronome at 240) using VOR

Testing Considerations

Abnormal Smooth Pursuit

• Do not move finger too fast or slow (your speed could cause saccades)
• Vertical pursuit can breakdown at younger ages and both vertical and horizontal can demonstrate breakdown with normal aging.
• Note: a small jump in eye movement when crossing midline is okay.

VOR Cancellation

Saccades

• Patient should look at your nose while you move their head side to side 30 degrees (you move with them)
• Move at 1 Hz (1 rotation per second)
• Positive is saccadic eye movements = central lesion

Hold a pen about 15 degrees to one side of your nose. Ask the patient to look at your nose, then at your finger, repeating. Be unpredictable. Test horizontally and vertically.  You are looking for # of eye movements to target.

 Saccades should be quick, accurate and should not have latency.

 Interpretation: (+) >2 movements, dysmetric by 10 degrees (hypo or hyper) indicates CNS involvement . (Horizontal: pons, cerebellum; Vertical: midbrain, cerebellum)

Vestibular Exam

Head Thrust (Head Impulse Test)

Gaze Evoked Nystagmus

• Best clinical test for vestibular hypofunction
• Make sure to examine cervical ROM prior to testing
• QUICKLY and UNEXPECTEDLY move head within a small ROM (15 deg) to one side, instructing patient to keep eyes on nose
• Positive = corrective saccade, indicates vestibular hypofunction on that side

Have patient look 30 degrees to the right, left, up and down pausing briefly at the end point to observe for nystagmus. Note direction of nystagmus

• Do not test at ends of ocular ROM. End-point nystagmus is present in ~30% of healthy people and increased after 65 years old.

Interpretation: (+) is presence of nystagmus at 30 degrees.

Direction changing = central

• Horizontal: medulla and vestibulo-cerebellum
• Vertical: midbrain and vestibulo-cerebellum

Non-direction changing = peripheral. If direction changing:

Video Example

Dynamic Visual Acuity Testing

THANK YOU FOR

COMING!

• Patient sits in front of eye chair (wear glasses if needing distance correction)
• Read lowest line they can STATIC
• Read lowest line they can with head movement at 2 Hz
• Positive= likely hypofunction if greater or equal to 3 line difference

Horizontal Gaze Evoked Nystagmus

• Oculomotor Exam
• Spontaneous Nystagmus
• Gaze Evoked Nystagmus
• Saccades
• Smooth Pursuit/Eye ROM
• VOR
• VOR Cancellation
• Head Thrust
• Dynamic Visual Acuity
• Positional Testing
• Dix-Hallpike
• Roll Test

Spontaneous Nystagmus

Posterior Canal

Positional Testing

Have the patient look straight ahead and observe for nystagmus. Best performed with Frenzel lenses (fixation blocked). Stay to the patient’s side.

• Interpretation: (+) presence of nystagmus indicates a central lesion (brainstem or cerebellum) OR acute hypofunction

• Gold standard for BPPV - must do this to actually diagnose!
• Can also detect central problems
• In each position, note the direction and duration of nystagmus + patient's symptoms

Horizontal Canal

Roll Test

Dix-Hallpike

Peripheral Hypofunction

Anterior Canal

• Peripheral Nystagmus: TORSIONAL upbeating or downbeating, typically lasts less than 60 seconds (could be longer if cupulolithiasis)
• Symptomatic
• Central Nystagmus: May not follow a pattern

Gait Cycle

Please see printed reference list available from course instructors

Contact Information:

Abby Park: abby.lee.park@gmail.com

Brittany Kennedy: bekst17@gmail.com

Key Muscles to Consider

Central

Peripheral

• Trunk: abdominals, trunk extensors
• Hip: glute max, glute med, hip flexors
• Knee: quadriceps, hamstrings
• Ankle: tibialis anterior, gastroc/soleus complex, tibialis posterior, peroneals

Acute Dizziness- Central?

HINTS article (Kattah et al, 2009)

Exam Considerations

Common Signs and Symptoms

Swing Phase

System for Evaluation of Gait

• MRI minimally effectively in detecting acute strokes up to 3 days post
• Oculomotor testing nearly 100% accurate
• Negative Head Impulse Test
• + Skew Deviation
• Gaze evoked, direction changing nystagmus

• UMN signs lead to localization in the cortex, brainstem, cerebellum, and/or spinal cord
• Cranial Nerve Examination
• Coordination testing
• Tone assessment
• Reflex assessment
• Sensory testing
• Manual Muscle Testing
• Cognitive Screen
• Fatigue Assessment

• Limb advancement
• Limb clearance
• Coordination of hip/knee/ankle

• Paresthesias in a dermatomal or cortical pattern
• Motor impairment in a myotomal or cortical pattern
• Spasticity
• Vision/Oculomotor deficits
• Incoordination and ataxia
• Fatigue - primary and secondary
• Bowel and bladder impairment
• Heat sensitivity
• Balance deficits
• Falls

Balance Assessment

*Vestibular Exam as indicated*

• May have a vague description of symptoms
• May have dizziness constantly
• VOR: may or may not be impaired
• Nystagmus: atypical (vertical, diagonal, changes directions)
• Fixation may worsen nystagmus

Types

• Typically a sudden, memorable event
• Normal oculomotor exam
• Nystagmus:
• Is upbeating/downbeating and torsional OR Follows Alexander's Law
• VOR: impaired if hypofunction
• Fixation decreases dizziness
• Dizziness primarily with movement only- has specific triggers

• Important to consider static and dynamic balance
• Likely to have poor sensory input as well as poor motor output
• Deficits with : biomechanical constraints, limits of stability, reactive balance, sensory orientation, and dynamic/gait deficits

• Top up or bottom down approach
• Look at the trunk, pelvis/hips, knee, ankle
• ROM, tone, coordination, and strength
• Also look at: arm swing, head position, overall posture

Stance Phase

Multiple Sclerosis

• Clinically Isolated Syndrome
• Relapsing Remitting
• Progressive Relapsing
• Secondary Progressive
• Primary Progressive

• Stability in pelvis and trunk
• Stability in knee
• Weight shift and weight acceptance

Gait and Balance Examination

Other Exam Considerations

Gait Assessment

Things NOT affected

Parkinsonian Gait

• Cranial nerve examination important
• Reflexes
• Cognitive Screen
• Postural Assessment
• Speech

Motor and Sensory Considerations

• Impairments that lead to deficits: weakness, poor sensory input, spasticity, impaired coordination
• Deficits commonly seen:
• Poor foot clearance
• Trendelenberg
• Ataxia
• Evidence of balance deficits
• Slow cadence

Other Considerations

• Sensation
• Reflexes
• Strength
• May have secondary weakness with progression of disease process

Balance Assessment

• Shuffling
• Short step length bilaterally, mid foot contact
• Often lacks arm swing unilaterally
• Festinating gait
• Unable to control forward movement of trunk -->leads to falling
• Freezing

• Weakness
• Spasticity
• Sensorimotor deficits
• Coordination
• Ataxia
• Speed/Cadence

• Motor:
• Loss in cortical distribution >> hemiplegia
• Consider proximal strength (scapula, pelvis, and hip) as well as distal strength
• UE often effected more than LE
• LE muscles commonly effected
• Sensory:
• Loss in cortical distribution
• May be partial or full loss
• Light touch, proprioception, sharp/dull

Gait Impairment can vary significantly

Coordination Testing

• Demyelination occurs in the CNS - cortex, cerebellum, brainstem, and/or spinal cord
• Exact cause unknown but is considered an autoimmune disorder
• For diagnosis, need to have evidence of demyelination over time and space

• Static and dynamic balance assessment important
• May see deficits due to:
• Muscle weakness
• Muscle co-contraction
• Torque
• Sequencing deficits
• May see deficits in:
• Biomechanical constraints
• Limits of stability/verticality
• Anticipatory and Reactive
• Dynamic balance with gait

Stroke

• Finger Tapping
• Mass grasp
• Pronation/Supination ("turning door knob")
• Toe tapping
• Stomping

Example #2

Example

Things to look for

Common Signs/Symptoms

• Rhythm broken/hesitations in movement
• Slowing of movement
• Decreased amplitude of movement

Parkinson's

Disease

Gait Assessment

• MCA distribution
• Contralateral hemiparesis and/or sensory loss UE>LE
• Speech may be affected
• Apraxia
• Perceptual deficits
• ACA distribution
• Contralateral hemiparesis and/or sensory loss LE>UE
• Cognitive deficits
• Motor inaction
• Perseveration

Tremor

4 Cardinal Signs

• Gait deficits seen will depend on areas of CNS affected
• Swing phase
• foot drop
• limb advancement
• pelvic retraction
• common compensations
• Stance phase
• foot slap
• decreased knee stability
• weight acceptance and weight shift
• Trendelenberg
• pelvic retraction

Postural Control and Balance

Rigidity

• Tremor
• Rigidity (Cog Wheeling)
• Use activation maneuver
• Bradykinesia
• Detected in functional mobility, coordination testing
• Postural Instability
• Pull Test

Progressive loss of dopamine producing cells in the basal ganglia

Sensory Input for Balance

Bradykinesia

The Basics of Good Balance

Pathophysiology: MCA, ACA, PCA, vertebrobasilar

- Out circles:

- strength

- coordination

- sensory changes

- CN

- gait deviations: hemiplegic v. ataxic

Postural Instability

Motor Out

Basal Ganglia

• Identify the components of gait and develop a system of evaluation
• Impairments that lead to neuro gait deviations
• Identify components of balance
• Impairments that lead to balance deficits

Initiates, stops, monitors and maintains movement. Functions as a "braking system" to inhibit undesired movement and permit desired ones.

Balance Strategies

How Do We Adjust Balance?

• Feedback: Postural control is adjusted based on the sensory input that is being received
• Feed forward: Anticipate challenge to balance and adjust appropriately prior to performing activity

Anatomy

Peduncles

Abnormal Sequencing: Muscle Activation and Delay

• Cerebellum takes in a lot of afferent information- connects to the rest of the via peduncles

Abnormal Postural Control

3 Lobes of the

Cerebellum

Abnormal Sequencing: Torque v. Sway

• Abnormal sequencing
• Delay in recruitment
• Decreased torque
• Co-contraction of muscles
• Timing of Contraction
• Scaling of balance reactions
• Adaptation to balance challenges

Coordination

Timing of Contraction

• Dysdiadochokinesia
• Dysmetria
• Action Tremor

Scaling of Balance Reactions

Adaptation to Balance Challenges

Cerebellar Disorders

Vestibular & Visual Changes

Systematic Evaluation of Balance

• Oculomotor Impairments
• Saccadic intrustions with smooth pursuit
• Dysmetric saccades
• Impaired VOR cancellation
• Impaired VOR- unable to maintain gaze with head movement

• Motor Coordinator
• Controls activity of multiple muscles across several joints
• Regulates force, distance, timing, duration
• Predicts to generate feed forward motor commands
• Timer
• Site of temporal representation of movements
• Encodes sequencing of muscle activations
• Motor Learning
• Site of stored knowledge to generate predictive motor commands
• Updates movement using error feedback

Six Considerations evaluated in the BestTest

Transitions/Anticipatory

Biomechanical Constraints

Stability Limits/Verticality

• Depend on interaction between the supplementary motor areas and the basal ganglia and brainstem
• Active movement of the body's center of mass in anticipation of a postural transition to another
• Balance required with sit to stand, repetitive weight shifting, arm swing
• Leads to instability with stepping initiation or with rapid arm movement

• Internal representation of how far the body can go before changing support or losing balance
• Internal perception of vertical
• Functional limits of stability in both sitting and standing
• Reliance or lack thereof on vision to understand vertical
• Examples of disorders that can effect this: sensory disorders, stroke

• Base of Support
• Geometric Postural alignment (i.e. center of mass alignment)
• Functional ankle and hip strength and ROM
• Impairments may limit ankle strategy, compensatory stepping
• Examples of disorders that may have limitations in this area: Parkinson's Disease, frail elderly

Dyssynergia

• Multiple joint movements more difficult than single joint ones

Gait & Postural Control

Disease Specific Considerations

Reactive

Sensory Orientation

• Automatic postural responses from short, medium, and long proprioceptive feedback loops
• In-place and stepping compensatory responses to external perturbation
• May be impaired with peripheral neuropathy, multiple sclerosis, Parkinson's Disease, and cerebellar disorders

• Ability to identify increase in sway by altering visual or somatosensory input
• Imbalance noted with deficits in the vestibular system and in the sensory integration areas of the temporoparietal cortex
• Modify visual input or surface a person is standing on

Decomposition

• Ataxia
• difficulty initiating and controlling rate, rhythm and timing of responses
• Dyssynergia
• Decomposition
• Overcorrections for loss of balance

Breaking down multiple joint movements into single joint ones

Stability in Gait

• Dynamic balance with gait includes the body's ability to change center of mass
• Deficits result from impaired coordination spinal locomotor and brainstem postural sensorimotor programs
• Includes ability to ambulate with changing speeds, head turns, turning, and sequencing

Peripheral Neuropathy

• Typically affects distal extremities
• Glove/stocking distribution
• Symptoms vary depending on whether sensory or motor nerves are damaged
• Impaired/absent light touch
• Impaired/absent proprioception
• Muscle wasting/atrophy
• Neuropathic pain

Radiculopathy

Signs/Symptoms

Peripheral Neuropathy, Radiculopathy & Myelopathy

• Sensation
• Follows dermatomal pattern
• Weakness
• Follows myotomal pattern
• Consider muscles with similar innervations
• Reflexes: diminished
• Bowel/Bladder- not impaired

Clinical Prediction Rule Cervical Radiculopathy

The following criteria are predictive for cervical radiculopathy:

• Positive limb upper tension test A
• Cervical rotation less than 60 degrees to involved side
• Positive distraction test
• Positive Spurling's Test

The Neuro Exam Lab

Outline

Neuro Exam

Myelopathy

• Reflexes: Hyperreflexia below level
• Strength: impaired below level
• Increased spasticity
• + Babinski's and/or Hoffman's reflexes
• Loss of bowel/bladder control
• Coordination: impaired due to weakness

Spinal cord involvement

Treatment Considerations

Sensation

Cranial Nerve Testing

• Light Touch
• Sharp/Dull
• Proprioception

• CN I - olfactory
• CN II - optic
• CN III - oculomotor
• CN IV - trochlear
• CN V - trigeminal
• CN VI - abducens
• CN VII - facial

Tips:

• Compare to facial sensation
• Eyes closed
• Sharp/dull will test same tract as temperature
• Test each area more than once
• Extinction phenomenon

Case Study #2

• CN VIII: vestibular
• CN IX: glossopharangeal
• CN X: vagus
• CN XI: spinal accessory
• CN XII: hypoglossal

The patient is an 82 year old male veteran who had a R MCA CVA in 2006. He previously ambulated for up to 200' independently with a quad cane, but developed a UTI and was admitted to inpatient rehab due to weakness.

Gait Video 2

• How will your exam differ since this is a chronic versus an acute CVA?
• How will your treatment plan differ

Case Study #3

Patient is a 62 year old male who comes to outpatient PT with c/o progressive weakness. His PCP sends consults to physical therapy, to a neurologist, and for an EMG at the same time.

His gait looks like this...

Case Study #1

Gait Video 3

Gait Video 1

This individual is a 75 year old male who was admitted to the hospital with a basal ganglia CVA. He is now in inpatient rehabilitation.

• What does your examination include?
• What does the neuro exam look like for the individual?
• What would you expect this patient's gait to look like?

Timed Walking Tests

• What gait impairments do you see?
• What does your examination look like?

5x Sit to Stand

Gait Speed

• 2 Minute Walk Test
• 6 Minute Walk Test
• Keep assistive devices consistent

• 10 meter walk test
• Preferred and fast walking speeds
• Keep device consistent
• Not appropriate if they need assistance

• Measure of functional lower limb strength
• Perform without upper extremity assist, as quick as possible
• Document modifications
• Other variations exist (ex: counting repetitions in 30 sec time period)
• Generally, cut-off for increased falls relating to lower limb strength is ~12.5 seconds (see rehabmeasures for disease specific)

Functional Gait

Assessment

• Modification of DGI- decreased ceiling effect, improved reliability
• Assessment of dynamic balance
• Can perform with or without device
• Fall Risk Cut-off Scores
• <22/30 or <20/30 in community dwelling adults

Commonly Used

NOT an exhaustive list!

Look at references for more ideas of appropriate outcome measures!

The Basics of Neuroplasticity

Berg Balance Scale

Neuroplasticity

• Measure of static balance and fall risk
• In elderly, score of <45 indicates increased fall risk
• See rehabmeasures.org for disease specific MDC's
• Has a floor and ceiling effect

• Driven by changing input
• Brain Reorganization
• Cortical Maps
• Axonal Sprouting
• Synaptic Plasticity
• Brain Derived Neurotrophic Factor

• Balance Tests
• Timed Up and Go
• Berg Balance Scale
• Functional Gait Assessment
• Functional strength
• 5x Sit to STand
• Gait Measures
• 2 Minute Walk Test
• 6 Minute Walk Test
• Gait Speed

Gait Video 4

Timed Up and Go

Case Studies

Cognitive TUG

• Assesses mobility, walking ability, fall risk/balance
• Set up: 3 meter (9.8 feet) walkway
• Starts with "go", ends when patient contacts the chair

Case Study

• Measure of dual task ability
• Perform TUG + Cognitive task --> note time to perform
• Perform cognitive task while seated for duration of TUG time

Dual Task Cost =

((individual - dual)/individual) x 100

• Neuro Examination
• LAB
• Gait and Balance Examination
• Disease Specific Considerations
• Parkinson's Disease
• Multiple Sclerosis
• Stroke
• Cerebellar Disorders
• Peripheral Neuropathies, Myelopathies, Radiculopathies
• Outcome Measures
• General
• Disease Specific
• Vestibular Considerations
• Lab
• Treatment Considerations
• Neuroplasticity
• Motor Learning/Motor Control
• Disease Specific
• Case Studies

Cut off scores indicating fall risk:

• Community dwelling: >13.5 sec
• Parkinson's: >11.5 sec
• Older stroke patients >14.5

52 y/o male patient presents to your clinic for balance impairment. You note that he has MS by chart review (relapsing remitting) and that he just got over a relapse.

- What will your neuro exam look like?

*NOT an exhaustive list! See references for other ideas

Gait Measures

Observation

• Brain's ability to make short and long term changes based off of functional need, sensory input, and experiences
• Changes in synaptic connections (short term) and neural networks (long term) lead to functional changes

• 2 min or 6 min walk test
• 10 m walk test for gait speed
• Timed Up and Go
• Comfortable: >11.5 sec cutoff
• Fast
• Cognitive

Reflexes

Parkinson's Disease

Coordination

Balance Measures

• Mini BESTest
• Functional Gait Assessment
• Cutoff: 15/30
• Berg Balance Scale

Exam starts when you walk in the room!

• Posture
• Posturing
• Tremor
• Devices
• Skin changes/bruising
• Muscle wasting
• Reliance on others
• Room set up

Functional Strength

• 5x sit to stand
• Retropulsion
• Postural set with standing
• Hypokinesia

Considerations for testing:

• Timing of medication
• Practice effect - 2 min walk test, gait speed
• Note quality, not just time

Fine Motor Measures

• 9 Hole Peg Test

III, IV, VI: Oculomotor, Trochlear, Abducens

II: Optic Nerve

Case Study 5

• How would you prioritize the neuro exam and what would you expect to find?
• Based on the brief description, what Hoehn and Yahr stage would you suspect that the patient is in?
• How do you confirm?

V: Trigeminal

Oculomotor also causes pupil to constrict and damage could result in ptosis

Testing visual acuity (can they see), visual fields (areas of vision) and sensory portion of pupillary reflex

Gait Video 5

This patient has drug-induced Parkinson's Disease. He lives alone and was recently admitted to inpatient rehab due to a fall. He states that he just started to notice increased freezing when walking in busy areas and through doorways.

Subjective Outcome Measures

Post-Video:

• What gait impairments do you see?
• What outcome measure would you use to assess this patient's balance?
• What treatment strategies might you utilize to improve these gait impairments?
• What treatment strategies might you utilize to address freezing as mentioned previously?

Neuroplasticity in the Damaged Brain

I: Olfactory

Masseter and temporalis muscles, chewing, facial sensation (3 branches)

Neuro Exam

• Activities Specific Balance Confidence Scale
• Parkinson's Disease Questionnaire - 8 or 39
• Freezing of Gait Questionnaire

Cranial Nerves

Cognition & Behavior

Not typically tested in the clinic. Close off nostril. Seen often with frontal lobe lesions.

VII: Facial Nerve

• UE Reflexes
• Biceps (C5)
• Brachioradialis (C6)
• Triceps (C7)
• LE Reflexes
• Quadriceps (L3-L4)
• Calcaneal (S1-S2)
• Abnormal
• Clonus
• Babinski
• Hoffman's

Facial expression, closes eyes, tears, salivation, taste

Motor Control and Motor Learning

• Driven by changes in behavioral, cognitive, and sensory experiences
• What happens after brain damage?
• How does rehab affect neuroplasticity?
• Maladaptive plasticity
• Adaptive plasticity

• Rapid alternating movements (dysdiadochokinesia)
• supination/pronation
• mass grasp
• finger tap
• alt toe tap
• heel tap
• Distance (dysmetria)
• finger to nose
• heel to shin
• toe to finger
• Fixation/limb holding: Rebound phenomenon

VIII: Vestibulocochlear

Disease Specific Considerations

• Level of alertness
• Orientation
• Person, time & place
• Do they follow directions?
• Sudden change?
• May indicate more acute medical issue
• Apraxia

1. Olfactory

2. Optic

3. Oculomotor

4. Trochlear

5. Trigeminal

6. Abducens

7. Facial

8.Vestibulocochlear

9. Glossopharyngeal

10. Vagus

11. Spinal Accessory

12. Hypoglossal

Hearing, head position relative to gravity

The Ten Principles of Neuroplasticity

IX, X: Glossopharyngeal & Vagus

Tone and Spasticity

Swallowing, salivation, taste

Gait Video 6

• Use it or lose it
• Use it and improve it
• Specificity
• Repetition Matters
• Intensity Matters
• Time Matters
• Salience Matters
• Age Matters
• Transference
• Interference

XI: Spinal Accessory

XII: Hypoglossal

Elevates shoulders, turns head

Outcome

Measures

Abnormal: tongue deviates to the weak side

Gait Measures

Multiple Sclerosis

• 6 min or 2 min walk test
• Timed 25 foot walk test
• Timed Up and Go
• Comfortable
• Fast (as appropriate)
• Cognitive
• Manual

Gives you the following information:

• Info needed for general screen or referral
• Identification of "red flags"
• Range of impairments for baseline and general function
• What you can treat vs. what affects treatment
• Localization for diagnosis

Stages of Learning

Test the following on exam

• Rapid alternating movements
• Accuracy of movement
• Finger to nose
• Fixation/limb holding
• Equilibrium/postural stability
• Also note how it affects gait/function

• Motor Learning
• Practice or training leads to the improvement and acquisition of skills
• Motor Control
• Ability to regulate and direct the mechanisms needed for movement

Coordination

Balance Measures

Case Study 6

• How would you prioritize the neuro exam?
• What would you expect to find on exam?
• How might treatment differ if this was a progressive, degenerative cerebellar disease?

Balance Treatment

Ideas

• Berg Balance Scale
• Functional Gait Assessment
• Dynamic Gait Index

Distributions

Peripheral vs. Dermatome vs. Somatosensory Cortex

• Cognitive Stage: "verbal, motor", learner understands what needs to be done, new skill, large improvements
• Associative Stage: more subtle adjustments, smaller improvements
• Autonomous Stage: appears automatic

Sensation

This is a 64 year old male presenting to the ED with reports of significant balance impairment and dizziness. He is found to have a cerebellar CVA. He is now 1 month post and presents to your outpatient clinic.

• Test in supine
• Test slowly first
• Can do joint by joint or combine

Helps determine where damage is

Ability to use parts of the body together smoothly and effectively

Brain areas involved:

• Motor and sensory cortices
• Cerebellum
• Basal Ganglia

• Fatigue
• Repeat tests in same order on reassessment to minimize effect of fatigue
• Environmental factors: heat, time of day
• Document environmental factors

Fine Motor/Coordination

Importance

Sensation Testing

• 9 Hole Peg Test

Tracts

Functional Strength

• Sensory Tracts
• Dorsal Column/Medial Lemniscus
• Light touch
• Proprioception
• Vibration- typically first affected in diabetic neuropathy
• Two-point discrimination
• Spinothalamic Tract
• Sharp/dull
• Pain/temperature

• 5x sit to stand

Testing Sensation

• Eyes closed
• Move from distal to proximal
• General body areas for light touch if suspect cortical damage
• Dermatomes if you suspect nerve root damage
• Extinction: determines INATTENTION to one side

Proprioception

• Ability to feel where our body is in space
• Biggest effect on movement
• Smallest joints have least amount of extraneous movement when testing

Purpose:

• Identify need for further testing
• Help determine prognosis
• Identify impairments that contribute to functional limitations/disability
• Help to differentiate between neurological disorders

Sensation and motor function are strongly linked- sensation is used as feedback during movement to adjust & correct. It gives information about environment and relation of body to the environment.

Hoehn & Yahr Stages

Subjective Outcome Measures

Practice

Parkinson's Disease

• Cerebellum plays LARGE role in motor learning

• 12-item MS Walking Scale
• Modified Fatigue Impact Scale - full version and 5 item
• Fatigue Scale for Motor and Cognitive Functions
• MS Impact Scale
• MS Quality of Life
• Activities Specific Balance Confidence Scale
• Dizziness Handicap Inventory

• Most important part of motor learning
• Part or whole practice?
• If serial task, can practice parts
• Continuous- mixed research

Cerebellar Disorders

• Determine treatment by H&Y stage
• Understand and treat disease specific impairments
• Forced use beyond self selected effort
• Progressive aerobic exercise
• Manage non-motor symptoms (apathy, impaired self-efficacy)

Practice Schedule

Resources

Other Contributions

• Blocked: may be best initially
• Random: Better for learning and transfer over into real world experience

Strength

• Postural set
• Decreased motor contribution from M1
• Problems with sequencing
• Disuse/atrophy
• Sensory loss
• Attention

• Plays a LARGE role in motor learning
• Responsible for practice-driven, feedforward adaptations

Feedback

HELP PD Exercise Program

Mobility Disability in People with PD Using a Sensorimotor Agility Exercise Program (Horak & King, 2009)

Evidence Based Treatment Approaches

Help the “individual achieve large flexible, reciprocal movement,

in multiple directions, with upright posture that requires

awareness, planning, and pacing.”

Reflexes

LSVT BIG

• Protocol is 1 hour sessions, 4x/week for 4 weeks
• MUST follow this
• Large amplitude exercise, gait tasks, functional activities

• Large Amplitude, whole body exercises
• LSVT BIG vs. PWR
• Progressive Treadmill Training
• Dual Task training
• Coordination/Balance Training
• Freezing Management

Gait Training

PWR! (Parkinson Wellness Recovery)

• Start early!
• 6MWT may pick up on early deficits
• Encourage dual task training
• Vary environment, walking surface, etc.
• Address asymmetry and hypokinesia
• Cueing
• Auditory
• Visual

• Targets bradykinesia/hypokinesia through whole body exercises
• Not as strict as LSVT BIG
• Teaches clinician how to incorporate into clinic/everyday life

Spinal Flexibility

Motor Learning Considerations

• Helps to combat rigidity
• Make sure to work on arm swing if lacking for increased trunk rotation
• Consider cervical spine!

• Within session learning improves with use of cues
• Carryover depends on disease progression
• Context specific training improves skills
• Diffculty performing task when situation is different
• Start early and provide a lot of repetition to reach automaticity
• Make task close to function at home

Freezing Management

Other Treatment Options in Research

• Freezing is loss of rhythmic gait, automaticity
• Loss of complete weight shift
• Auditory and visual cues can assist

Recovery or Compensation?

• Dance
• Tai Chi
• Yoga
• Boxing
• Biking

4 S's

• STOP
• STAND TALL
• SWAY SIDE TO SIDE
• STEP LONG

• Neurology Section Recommended Outcome Measures: http://www.neuropt.org/professional-resources/neurology-section-outcome-measures-recommendations
• Rehab Measures Database: rehabmeasures.org
• Stroke Engine Assessments: http://www.strokengine.ca/find-assessment/

In UMN Lesion, strength deficit is: Decreased force production because of inadequate input to alpha mn

How is strength testing different in the neuro exam?

Multiple Sclerosis

Poor Prognosis

Fair/Good Prognosis

• Faded schedule is best (more early on, less late)
• Intrinsic feedback: information about one's own movement
• sensory feedback
• Extrinsic feedback: augmented feedback

• No other CNS regions involved
• Mild ataxia
• Static lesion
• Work toward recovery primarily

• Degenerative
• Progressive
• Evolving lesions
• Hereditary
• Work toward compensation primarily

Stroke

Motor Control Considerations

Strategies

Reflex Testing for UMN Involvement

• Work toward improving multi-joint movements
• Challenge balance
• Dual-tasking
• Error-based motor learning (allow more time, many repetitions)

• Reduce degrees of freedom
• Aerobic exercise/strength
• Slower movements
• Less distraction

Stroke

Hoffmans

Clonus

Acute Care Specific Measures

Balance Measures

Goals of treatment for an MCA/ACA

• Orpington Prognostic Scale
• NIH Stroke Scale

Babinski

Deep Tendon Reflexes

• Helps distinguish UMN vs LMN problem

Grading

4+: very brisk, hyperactive

3+: Brisker than average, possibly but not necessarily indicative of disease

2+: Normal

1+: Somewhat diminished/ low normal

0: Absent

• Function in Sitting Test
• Trunk Impairment Scale
• Berg Balance Scale
• Functional Reach
• Dynamic Gait Index
• Functional Gait Assessment

Inpatient Rehab Specific Measures

• Functional Independence Measure

• Cerebellum: recieves sensory information and uses this to fine-tune movement
• Basal Ganglia: acts as a braking system, inhibiting and activating various motor systems

• Goals of treatment will depend on where patient is in the disease process and what type of MS the person has
• Overarching themes of management:
• Restorative versus compensatory
• Fatigue management
• Equipment
• Education and caregiver training
• Aerobic, strength, and balance training
• Other considerations: spasticity, cognition, vestibular

• Early Intervention
• Push neuroplasticity
• Aerobic Activity to prevent future strokes
• Prevent learned non-use
• Early gait and functional training
• Minimize compensation early
• Compensatory mechanism later

Gait Measures

Example

Functional Strength

Range of Motion

5 times sit to stand

• 6 min or 2 min walk test
• 10 m walk test
• <0.4 m/s = household ambulators
• 0.4-0.8m/s = limited community
• >0.8 m/s = community
• Timed Up and Go
• Average for older individuals with stroke = 14.5 sec

• Keep assistive device consistent for outcome measures
• Directions may need to be modified for aphasia
• Consider setting when choosing outcome measures to prevent floor and ceiling effects

Tone

Aerobic Exercise

• Consider the role of fatigue
• Moderate intensity
• Management environment and encourage fluids to prevent overheating
• Walking, biking, or any aerobic means patient is comfortable with
• Can help with overall management of disease

Balance Treatment

Evidence Based Treatment

• Static and dynamic
• Very important for fall prevention
• Fatigue has been shown to increase imbalance

Gait Training

Evidence Based Treatment

Strength Training

• Aerobic Exercise
• Balance Treatment
• Strengthening
• Fatigue Management
• Vestibular Management

• Important to include strength training
• Include full body strengthening
• Yoga and pilates have been found to be good options for strength training in MS

• Weight shift
• Weight acceptance
• Perceived upright posture
• Limb advancement and positive step length
• Common Impairments:
• Drop foot - early versus late AFO use
• Knee hyperextension
• Decreased hip extension in terminal stance
• Decreased hip flexion in swing
• Lack of weight shift/weight acceptance

• High Intensity Training (VIEWS)
• Body Weight Support Treadmill Training (LEAPS)
• Constraint Induced Movement Therapy

Fatigue Management

General Rule of Thumb: if a patient excessive fatigue the next day, the exercise was too intense

• Energy Conservation
• Maximize gait efficiency
• Regular exercise

Vestibular Treatment

• Can improve postural control and balance
• Can improve fatigue
• Progressive exercises that include:
• Head movement
• Eye movement
• Balance

Why test ROM?

• Contractures
• PROM: Tone
• AROM: Ideas of strength

*Consider compensations

• Test by performing passive ROM

• Spasticity
• Velocity Dependent
• UMN sign
• Flaccidity
• Rigidity (Basal Ganglia)

Stroke Specific Outcome Measures

Subjective Outcome Measures

• Goal Attainment Scale
• Motor Activity Log
• Stroke Impact Scale - full or 16 item

Static Measures

• Postural Assessment Scale for Stroke (PASS)
• Stroke Rehabilitation Assessment of Movement (STREAM)

• Romberg - Eyes Open and Closed
• Tandem Romberg (Sharpened) - Eyes Open and Closed
• Single Limb Stance

Balance and Fall Risk

Gait Measures

• 6 min walk test
• 2 min walk test
• 10 m walk test
• Timed Up and Go

Comprehensive Balance Evaluations

• Balance Evaluation Systems Test (BESTest)
• miniBESTest
• briefBESTest

Cerebellar Disorders

Dynamic Measures

Balance Measures

• Dynamic versus Static
• Risk versus change over time
• Functional Levels

• Dynamic Gait Index
• Functional Gait Assessment
• Community Balance and Mobility Scale
• HiMAT

Specific to Fall Risk

• Berg Balance Scale
• Functional Gait Assessment
• Dynamic Gait Index
• mCTSIB
• BESTest/miniBESTest
• 5x sit to stand (initial standing balance)
• Single limb stance
• 4 square step test

• Berg Balance Scale
• Denotes need for an assistive device
• <45/56
• Functional Gait Assessment
• <23/30
• Timed Up and Go
• <13 sec
• 5x sit to stand
• <12 sec

Consider:

• Quality of Movement
• Coordination
• Progressive or static condition

Ataxia Scales

Specific to Sensory Integration

Sitting Balance Tests

• Scale for the Assessment and Rating of Ataxia (SARA)
• International Cooperative Ataxia Rating Scale

Function in Sitting Test

• Modified Clinical Test of Sensory Integration and Balance
• Sensory Organization Test

Subjective Outcome Measures

Activities Specific Balance Confidence Scale

Other

Dizziness Handicap Inventory

PT NEURO EXAM AND Treatment: the basics and beyond

Abby Park, PT, DPT, NCS

Brittany Kennedy, PT, DPT, NCS