RHS 332: Clinical Neurology

1. RHS 332: Clinical Neurology Ahmad Alghadir, M.S. Ph.D. P.T. Room: 2071 aalghadir@hotmail.com alghadir@ksu.edu.sa Ahmad Alghadir M.S. Ph.D. P.T.

2. Recommended texts • S.B. O’sullivan, T.J. Schmitz, Physical Rehabilitation: Assessment and Treatment, F.A. Davis Company. 3rd ed. 1994. • R.L. Braddom, Physical Medicine & Rehabilitation, W.B. Saunders Company. 1st ed. 1996. Ahmad Alghadir M.S. Ph.D. P.T.

3. Coordination Assessment Ahmad Alghadir M.S. Ph.D. P.T.

4. Introduction • Coordination: “ability to execute smooth, accurate, controlled movements.” Ahmad Alghadir M.S. Ph.D. P.T.

5. Coordinated movements are characterized by: • “Appropriate speed, distance, direction, rhythm, and muscle tension.” • “Appropriate synergist influences.” • “Easy reversal between opposing muscle groups.” • “Proximal fixation to allow distal motion or maintenance of a posture.” Ahmad Alghadir M.S. Ph.D. P.T.

6. Incoordination (coordination deficit): “abnormal motor function characterized by awkward, extraneous, uneven, or inaccurate movements.” • Coordination deficits are often related to, and indicative of, CNS involvement including cerebellum, basal ganglia, and dorsal columns. Ahmad Alghadir M.S. Ph.D. P.T.

7. Examples of diagnoses that typically demonstrate coordination deficits: • Multiple sclerosis. • Cerebral palsy. • Cerebellar tumors. • Parkinsonism: elderly; degeneration of basal ganglia; bradykinesia, rigidity, resting tremor, and impairments of posture, balance, and gait. Ahmad Alghadir M.S. Ph.D. P.T.

8. Huntington’s disease: inherited; adults; fatal; degeneration of basal ganglia and cerebral cortex; dementia, chorea, and disturbances of tone, posture, and gait. • Sydenham’s chorea: infectious; children; self-limiting; rheumatic fever; chorea, disturbances of balance and gait, and impairments of speech and memory. Ahmad Alghadir M.S. Ph.D. P.T.

9. Cerebellum • Primary functions: • Coordination of motor activity. • Equilibrium. • Muscle tone. • Lesions produce: • Incoordination. • Impaired balance. • Decreased muscle tone. Ahmad Alghadir M.S. Ph.D. P.T.

10. “The cerebellum compares the commands for movement transmitted from the motor cortex with the actual motor performance of the body segment.” • “This occurs by a comparison of information received from the cortex with that obtained from peripheral feedback mechanisms.” Ahmad Alghadir M.S. Ph.D. P.T.

11. If movements deviate from the intended command, the cerebellum sends corrective signals to the cortex. Ahmad Alghadir M.S. Ph.D. P.T.

12. Clinical features of cerebellar dysfunction: • Hypotonia and hyporeflexia. • Dysmetria: • “Disturbance in the ability to judge the distance or range of a movement.” • Hypometria = underestimation. • Hypermetria = overestimation. Ahmad Alghadir M.S. Ph.D. P.T.

13. Dysdiadochokinesia: • “Impaired ability to perform rapid alternating movements.” • Tremor: • “Involuntary oscillatory movement resulting from alternate contractions of opposing muscle groups.” • Intention (kinetic) vs. resting (static) tremors. Ahmad Alghadir M.S. Ph.D. P.T.

14. Movement decomposition: • “Movement performed in a sequence of component parts rather than as a single, smooth activity.” Ahmad Alghadir M.S. Ph.D. P.T.

15. Disorders of gait: • Broad base support. • Unsteady, irregular, staggering, and deviated gait pattern. • Slow initiation of forward progression of lower extremity. • Difficulty in slowing down the forward progression of the lower extremity once initiated. Ahmad Alghadir M.S. Ph.D. P.T.

16. Ataxia: • General term used to describe uncoordinated movement that results from the combined influence of cerebellar dysfunction (especially dysmetria and decomposition of movement) on gait, posture, and patterns of movement. Ahmad Alghadir M.S. Ph.D. P.T.

17. Dysarthria (scanning speech): • “Disorder of the motor component of speech articulation.” • Speech pattern is slow, slurred, hesitant, with prolonged syllables and inappropriate pauses. • Word selection and grammar remain intact. Ahmad Alghadir M.S. Ph.D. P.T.

18. Nystagmus. • Rebound phenomenon: • “Absence of a check reflex; when resistance to an isometric contraction is suddenly removed, the body segment moves forcibly in the direction in which effort was focused.” Ahmad Alghadir M.S. Ph.D. P.T.

19. Asthenia: • “Generalized muscle weakness associated with cerebellar lesions.” • Difficulty in initiating, stopping, or changing the direction, speed, or force of voluntary movements. Ahmad Alghadir M.S. Ph.D. P.T.

20. Basal ganglia • Components: • Putamen. • Caudate nucleus. • Globus pallidus. • Substantia nigra. • Subthalamic nucleus. Ahmad Alghadir M.S. Ph.D. P.T.

21. Primary functions: • “Initiation and regulation of gross intentional movements.” • “Ability to accomplish automatic movements and postural adjustments.” • Inhibitory effect on motor cortex and posterior fossa brainstem to maintain normal background muscle tone.” Ahmad Alghadir M.S. Ph.D. P.T.

22. Cognitive and perceptual functions.” • Lesions produce: • Slowness of movement. • Involuntary movement. • Disturbance of muscle tone. • Diminished postural reactions. Ahmad Alghadir M.S. Ph.D. P.T.

23. Clinical features of basal ganglia dysfunction: • Bradykinesia: • “Abnormally slow movements.” • “Decreased arm swing; slow, shuffling gait; difficulty initiating or changing direction of movement; lack of facial expression; or difficulty stopping a movement once begun.” Ahmad Alghadir M.S. Ph.D. P.T.

24. Rigidity. • Dystonia. • Resting tremor. Ahmad Alghadir M.S. Ph.D. P.T.

25. Akinesia: • “Inability to initiate movement; seen in the late stages of parkinsonism.” • Associated with fixed postures. • “Tremendous amount of mental concentration and effort is required to perform even the simplest motor activity.” Ahmad Alghadir M.S. Ph.D. P.T.

26. Chorea (choreiform movements): • “Involuntary, rapid, irregular, jerky movements; clinical feature of Huntington’s disease.” • Athetosis (athetoid movements): • “Slow, involuntary, writhing, twisting, “wormlike” movements; clinical feature of cerebral palsy.” Ahmad Alghadir M.S. Ph.D. P.T.

27. Choreoathetosis: • Chorea + athetosis. • Hemiballismus: • “Sudden, jerky, forceful, wild, flailing, motions of one side of the body.” • “Results from a lesion of the contralateral subthalamic nucleus.” Ahmad Alghadir M.S. Ph.D. P.T.

28. Dorsal columns • Primary function: • Mediate proprioceptive input from joint and muscle receptors. Ahmad Alghadir M.S. Ph.D. P.T.

29. Lesions produce: • Coordination and balance deficits that are less characteristic than those produced by other CNS lesions due to compensation from visual feedback. Thus, these deficits are exaggerated in dark or with closed eyes. Ahmad Alghadir M.S. Ph.D. P.T.

30. Clinical features of dorsal columns dysfunction: • Dysmetria: visual feedback reduces the manifestations of dysmetria. • Slowed movements: because visually guided movements are more accurate when the speed is reduced. Ahmad Alghadir M.S. Ph.D. P.T.

31. Disorders of gait: • Wide base. • Sway. • Uneven step length. • Excessive lateral displacement. Ahmad Alghadir M.S. Ph.D. P.T.

32. Watching feet during ambulation. • “Advancing leg may be lifted too high and then dropped abruptly with an audible impact.” Ahmad Alghadir M.S. Ph.D. P.T.

33. Changes in coordinated movement with age • Decreased strength. • Slowed reaction time. • Loss of flexibility. • Faulty posture. • Impaired balance. Ahmad Alghadir M.S. Ph.D. P.T.

34. Coordination tests • Preliminary considerations: • Initial observation of functional activities guides the therapist in test selection. • Initial assessment of motor and sensory functions improves validity. • Apprehension, fear, and fatigue. • Lack of reliability. • Safety. Ahmad Alghadir M.S. Ph.D. P.T.

35. Classifications of coordination tests: • Gross vs. fine motor activities. • Non-equilibrium vs. equilibrium tests. Ahmad Alghadir M.S. Ph.D. P.T.

36. Coordination tests focus on assessment of movement in four areas: • “Alternate or reciprocal motion, which tests the ability to reverse movement between opposing muscle groups.” • “Movement composition, or synergy, which involves movement control achieved by muscle groups acting together.” Ahmad Alghadir M.S. Ph.D. P.T.

37. “Movement accuracy, which assesses the ability to gauge or to judge distance and speed of voluntary movement.” • “Fixation or limb holding, which tests the ability to hold the position of an individual limb or limb segment. Ahmad Alghadir M.S. Ph.D. P.T.

38. Ahmad Alghadir M.S. Ph.D. P.T.

39. Recording test results • Arbitrary scale. • Timed tests. • Videotape recording. Ahmad Alghadir M.S. Ph.D. P.T.

40. Ahmad Alghadir M.S. Ph.D. P.T.

41. Standardized instruments for coordination assessment • Jebsen-Taylor Hand Function Test: • Measures hand function using seven functional activities: writing; stacking; card turning; simulated feeding; picking up small objects; picking up large, lightweight objects; and picking up large, heavy objects. Ahmad Alghadir M.S. Ph.D. P.T.

42. Minnesota Rate of Manipulation Test: • Assesses hand dexterity in five operations: placing, turning, displacing, one-hand turning and placing, and two-hand turning and placing. Ahmad Alghadir M.S. Ph.D. P.T.

43. Purdue Peg board Test: • Assesses hand dexterity using a test board, pins, washers, and collars. Subtests include prehension and assembly using right, left, and both hands. Ahmad Alghadir M.S. Ph.D. P.T.

44. Crawford Small Parts Dexterity Test: • Assesses hand dexterity using a test board, screwdriver, tweezers, pins, screws, and collars. Ahmad Alghadir M.S. Ph.D. P.T.