NM 3 COMBINED FINAL!!

How do we check for VOR in PT?

Passively move patients head slowly in horizontal and vertical direction ***look for equal and opposite movement of the eyes with the head

The inability to maintain visual fixation is called what?

Patient cannot look straight at nose, or they bounce around. Spontaneous nystagmus

What are the domains of STG for patients with PPS?

Energy conservation and fatigue management Lifestyle mod: loos weight Use of AD and orthotics Postural correction and modified strength and endurance

What is a treatment for fatigue for patients with post-polio syndrome?

Energy conservation PAcing, rests, naps Lifestyle changes Lightweight orthotics, power mobilty

What is key factor for exercise with progressive NM diseases?

Importantly, patients must "listen" to their levels of exertion and time needed for recovery THEY FATIGUE VERY QUICKLY

What is the best type of stretching to avoid contractures?

Low load and sustained stretching to protect from contractures resting or night splints as well.

Are the following upper motor neuron, lower motor neuron or bulbar impairments of ALS? Muscle weakness Hyporeflexia Hypotonicity Atrophy Muscle cramps Faciculations

Lower motor neuron

CMT affects mainly the UMN or lower motor neurons?

Lower motor neuron

What pathology has a hallmark of hammertoe deformity in great toe with pes cavus or high arch?

MArie's TOOTH

What are the main incidence of brain tumors by types?

MEningionma- benigh, 33% of all tumors Blioblastoma multiform: malignant and in 17% of primary tumors Astrocytoma is 15% Pituitary is 8%

What are the impariments related to lower motor neurons signs of ALS?

Muscle weakness Hyporeflexia Hypotonicity Atrophy Muscle cramps Faciculations

What are normal characteristics of impairments for Huntington's disease?

Muscle weakness and fatigue Hyperreflexia/Hypertonicity Difficulty swallowing and communication Atrophy Poor balance and trunk control and falls Impaired mood and cognition UMN signs!

What are the main goals for patients with brain tumor?

Must: Maximize function Provide task oriented movement strategies Emphasize various movement options to promote mobility

What is the hallmark sign of charcot marie tooth?

"Inverted coke bottle" shape of legs

What are the deformities with gait and the foot with charcot marie?

"Steppage gait" - dragging toes, high likelihood of stumbles and falls Hallmark = hammertoe deformity in great toes with pes cavus; high arches Intrinsic foot musculature atrophy alters rear-mid-forefoot mechanics and WB phases of gait Dry or shiny and flaky skin, hair loss in distal LE's, cool to touch Can progress to affect hands and wrists in later stages: May see cool hands and deformities similar to late stage RA

Describe the characteristics gait of CMT

"steppage gait" - dragging toes, high likelihood of stumbles and falls

The semicircular canals are connected to the occulomotor muscles. What is the relationship of the anterior canal to the muscles?

(+) ipsilateral inferior oblique muscle; Contralateral superior rectus muscle (-) Ipsilateral superior oblique muscle: contralateral inferior rectus muscle ***Know horizontal more than anterior and posterior canals

The semicircular canals are connected to the occulomotor muscles. What is the relationship of the horizontal canal to the muscles?

(+) ipsilateral medial rectus muscle; Contralateral lateral rectus muscle (-) Ipsilateral lateral rectus muscle: contralateral medial rectus muscle

The semicircular canals are connected to the occulomotor muscles. What is the relationship of the posterior canal to the muscles?

(+) ipsilateral superior oblique muscle; Contralateral inferior rectus muscle (-) Ipsilateral inferior oblique muscle: contralateral superior rectus muscle

Persistant symptoms are report in what % of concussions?

10-15%

What are cervical symptoms associated with post concussion?

HA, dizziness, balance impairment, visual symptoms, nausea

What is most common complaint of concussion?

HA: 73% Dizziness predicts prolonged symptoms

What type of HA indicate a brain tumor HA?

HA: interrupts sleep, worse on waking, but improves throughout the day. Elicited by postural change, coughing and exercise More severe or of a different type than usual Associated with N&V, papilledema and focal neurological signs

What are the general signs and symptoms of a brain tumor?

HA: interrupts sleep, worse on waking, but improves throughout the day. Elicited by postural change, coughing and exercise More severe or of a different type than usual Associated with N&V, papilledema and focal neurological signs Seizures in 10-20% Altered mental status- initial symptoms are subtle, associated with frontal lobe and increased ICP Papilledema- swelling of optic nerve Vomiting and vertigo with posterior fossa types

How are signals sent to brain in regards to vestibular input?

HAIR CELLS. Sensory Stereocilia and kinocilia

What is the main difference between PD and HD?

HD is hyperkinetic movement disorder PD is hypokinetic movement disorder

What is the nature of HD impairments?

HD is hyperkinetic movement disorder Too much movement in limbs and trunk Unwanted and involuntary that can be rapid and jerky, or non-jerky Can be slow and writhing, rhythmical or continuous or unpredictable Hallmark sign is choreiform movements

What are objective factors for ocular subtype of concussion?

HX: ocular dysfunction or strabisumus Objective": VOMs is positive for pursuits/saccades, near point convergence test >6 cm Cover/uncover and maddox are positive Balance may have sensory organization difficulties Cognitive testing positive for visual memory, rx time and encoding information

What does the literature say about exercise with ALS?

What is too much or too little, as you don't want to overexerte them Fine balance between inadequate exercise and excessive exercise Moderately intense exercise may slow progression of disease, especially with copper gene mutation High intensity exercise can hasten disease and lead to death Evidence is limited though Exercise inconclusive of overall benefit. ***USE CLINICAL JUDGEMENT***

When is rotary chair test indicated?

When a vestibular hypofunction is suspected but caloric testing not definitive Assists in determining if a patient has had a central compensation for a hypofunction

When does cerebellar stroke have best recovery?

When deep cerebellar nuclei are not involved

What is the "push-pull": relationship of the horizontal canals?

When head is rotated to the R, you see reciprocal relationship between semicircular canal partners. With R head rotation you max stimulate horizontal canals. Increase of firing rate on R side. R side excitation. L horizontal canal has decrease firing rate. Called, "push-pull relationship" One goes up and one goes down

With labrinthitis there is a faulty push-pull mechanism. What does this mean?

If you have hyporesponsiveness on R. Then it will fire less, when the head rotates. Therefore brain thinks the brain is moving to the L when there is not movement at all.

What is the difference between imbalance vs. leg incoordination during ataxic gait?

Imbalance has much greater impact on gait than leg incoordination Critical element of walking: stability during dynamic mobility while maintaing forward propulsion Patients with minimal balance deficits but (+) leg incoordination present with less gait abnormalities

What are the classic presentation of ataxic gait?

Imbalanced: leads to falls backward or ipsilesional Shortened steps Slow, irregular timing Unequal step lengths Wide BOS Veering along path with trunk and limbs Difficulty with turning and stopping, especially with speed.

Concussion testing looks at what abilities?

Impairments with learning, memory, attention, concentration, verbal fluency, processing speed, reaction time, divided attention.

What are the types of neurocognitive testing for patients with concussion? What do they test?

Impairments with learning, memory, attention, concentration, verbal fluency, processing speed, reaction time, divided attention. Computerized testing: baseline and post-injury ImPACT test, AxonSports test, CNS vital signs Neuropsychology testing: comprehensive testing by a trained neuropsychologist sensitive to subtle deficits Most often detected in the post acute phase

Describe the impairments, activity limitations and participation restrictions for the middle phase of ALS

Impairments: Increased number of symptoms and severity AL: Minimal to moderate limitations PR: Begin to develop

What is the framework for middle rehab stages of HD in relation to ICF model?

Impairments: Increased severity and symptoms AL: Mild to mod limitations PR: More pronounced Prevent secondary complications and try and maintain best quality of life. Change POC as needed

Describe the impairments, activity limitations and participation restrictions for the late phase of ALS

Impairments: Numerous and severe AL: Becomes dependent in all aspects of care PR: Dependent

What is the framework for late rehab stages of HD in relation to ICF model?

Impairments: Numerous and severe AL: Dependent in all aspects of mobility and self-care PR: Total dependence LOOK AT PAillative care

What is the framework for early rehab stages of HD in relation to ICF model?

Impairments: Variety of abnormal S&S AL: Minor limitations PR: Variable Don't seek to make large gains or improvements since it's progressive

Describe the impairments, activity limitations and participation restrictions for the early phase of ALS

Impairments: Variety of abnormal signs and symptoms AL: Minor limitations present PR: none

Diagnose: Decreased muscle strength, muscle endurance, atrophy Fatigue, pain, NM weakness Cold intolerance

Post-polio

The following is part of rehab framework for what condition? No overexertion No intense exercise Compensation of function within capabilities and use of AD and social support Energy conservation

Post-polio syndrome

Which canal has the following relationship to the eye muscles? (+) ipsilateral superior oblique muscle; Contralateral inferior rectus muscle (-) Ipsilateral inferior oblique muscle: contralateral superior rectus muscle

Posterior canal ***Know horizontal more than anterior and posterior canals

What is the most common canal affected by BPVV?

Posterior canal most common. Horizontal canal rarely involved.

How do you determine a posterior vs. anterior canal BPPV?

Posterior canal: Upbeating, torsion to affected side Anterior canal: Downbeating, torsion to affected side

Describe what happens when we move head back and to the R. What muscles are stimulated? What canals are stimulated?

Posterior canals are max stimulated. Connected to superior oblique on ipsilateral side and inferior rectus on contralateral side. Keeps us looking straight ahead

Where is cerebellar brain tumor most common?

Posterior fossa

Name the cerebellar stroke based off impairments: Vertigo, unsteadiness, walking ataxia, nystagmus

Posterior inferior cerebellar artery

What is the relationship of the tonic firing rate?

When head is stationary the system is active. CN VIII is firing. Always has resting firing rate

How do we check for VOR with movements?

***look for equal and opposite movement of the eyes with the head

When is aerobic endurance recommended for patients with ALS?

10-15 minutes, due to their decreased fatigue

What are the most common neuromuscular disorder outcome measures? Great for Charcot Marie, since it doesn't have own outcome measure

10 m walk test 4-stair climb Time to rise from floor TUG 30 sec chair stand test 2 or 6 MWT GMFM

What the typical NMD outcome measures commonly used?

10 m walk, 6 MWT 4-stair climb Time to rise from floor TUG, 30 sec STS Brook/Vignos scale GMFM All common for neuromuscular disorder

What % of polio patients have PPS 15 years later?

15-80%

How does the VOR control gaze stability and why doe the eyes move when the head moves?

1:1 ratio Extraocular muscles are paired to semiciruclar canals

What is the prognosis for NON-progressive cerebellar ataxia?

1st time ischemic cerebellar stroke: Recovery is EXCELLENT 83% have minimal to no residual deficits Deep nuclei incur damage = poorer outcome

How do you complete the oculomotor exam?

1st: check for occular alignment Ocular ROM and vergence by looking at smooth pursuit movement and gaze evoked nystagmus Saccadic movement between targets Cross cover test...

What are the risk factors of ALS?

20% is hereditary cases by defect with gene encoding copper-zinc super oxide dismutase Neurotoxic exposure and diet Age Family history Gender and Western pacific desent: Men more than women

Describe Labrinthitis/Neuronitis

2nd most common cause of vertigo. Inflammation of inner ear or CN 8 nerve: caused by bacterial or viral infection Hyporesponsiveness: Faulty Push-Pull mechanism

How many symptoms of the 8 imply post concussion symptoms within 4 weeks? HA Dizziness Fatigue Irritability Impaired sleep Impaired concentration Impaired memory Impaired tolerance for stress, emotional situations or alcohol use

3 out of 8

The Peripheral sensory apparatus is one of the 3 main structures of the vestibular system. What is part of this?

3 semicircular canals on each side: with hair cells in each ampulla 2 otolith organs (saccule and utricle on each side): with hair cells in each Vestibulocochlear nerve in each side

What is Brok string training?

3 strings with beads. . Green, yellow and red bead. With binocular vision, they will see an X at the green bead when you tell them to look at it. They will see 2 yellow and 2 red beads.. With difficulty of one eye, they will only see 1 of each bead which is an abnormal finding. Make it easier by moving green bead further away from the patient's nose ABNORMAL: See 1 green bead, 1 yellow and 1 red, when asked to focus on green NORMAL: 1 image of green 2 images of other beads and strings when asked to look at green bead

Describe spinocerebellar ataxia

30 different types Onset is mid-later life Genetic counseling needed before testing No pharm intervention

Describe the epidemiology and etiology of ALS

30,000 individuals live with this High incidence in Japan and Guam and western pacific Onset is typically mid to late 50's Men 7x greater than women Sporadic ALS > familial ALS 70-80% is limb onset 20-30% is bulbar onset

Describe the ALS assessment questionnaire

40 questions related to Quality of life 5 areas of health: mobility, aDL, eating, communication, emotional functioning 0-4 scale: worst to best health status

How is the anterior and posterior semicirucular canal oriented?

45 degrees angle to the midline

What are the 5 areas of health assessed on ALS assessment questionnaire

5 areas of health: mobility, ADL, eating, communication, emotional functioning 0-4 scale, based on worst to best health status

What are common examination findings in regards to sleep for patients with PPS?

50% prevelance Periodic limb movement

What is part of the BESS scoring test for sports related concussion?

6 test positions with eyes closed: legs together, on one leg, tandem stance, on foam pad repeat. Most people can hold position for 20 seconds Errors are balance reaction, or open eyes. Or they change posture such as hands off hips. Count errors on firm vs. foam surface for 3 positions

What is the normal tonic firing rate of CN VII when the head is still?

80 pulses per second

Describe the incidence and etiology of brain tumor

>60000 new adult cases and 4000 pediatric cases each each Increases in indicidence may be due to being better at diagnosising the probelm

What is arua fullness? What is tinnitus?

Arua fullness: Ear feeling full Tinnitus: Hear ringing.

One Fluctuating sensory information disorder is a perilyphatic fistula, what causes this?

A pressure change from tear in round or oval window between the middle and inner ear causing a flow of fluid between the middle and inner ear and distorts the SC and utricle

The following are Red Flags for what condition? Affects of swallowing and breathing Present with : Dysphagia, hypoventilation, sleep apnea and CP insufficiency

Acute onset of bulbar muscle dysfunction: especially with PPS

What is normal and abnormal response to brock string training?

ABNORMAL: See 1 green bead, 1 yellow and 1 red, when asked to focus on green NORMAL: 1 image of green 2 images of other beads and strings when asked to look at green bead

What are the 3 domains of the FIM?

ADL function Mobility activities Speech and cognition Used for patients with brain tumors

The following are strengthening factors for what population? Concentric focus Moderate resistance Grade >3+/5 only strengthen these muscles Monitory for overwork weakness

ALS

The following is the appropriate exercise prescription for what population? Manual resistance exercises using PNF implemented early in disease progress Supervised gentle exercises: decreased pain and stiffness and improved psychosocial Aerobic endurance of 10-15 min, decreased due to central fatigue or decreased motor units

ALS

The following is the pathophysiology of what disorder? Progressive degeneration and loss of motor neurons in the SC, brainstem and motor cortex Affects: UMN in cortex Corticospinal tract and motor output affected Brainstem nuclei for CN 5, 7, 9, 10 and 12 are effected. Usually anterior horn cells are lost

ALS

The key differences for what population during the examination include the main 2 things: Evaluate patient subjective or observed functional problems related to respiration, caregiver tasks, rate of disease progression and enviornmental blocks Activity logs of pain, fatigue and effort

ALS

What is the degeneration and loss of motor neurons in SC, brainstem and brain?

ALS

What is the most common motor neuron disease?

ALS (amyotrophic lateral sclerosis)

What is the main outcome measure used for ALS?

ALS functional rating scale: Activity limitations ALS assessment questionnaire: for participation

Patients with progressive NM disorders love what type of exercise?

AQUATICS They love being able to move muscles more and carry less weight

The following describes the process of what pathology? Benign tumor in internal auditory canal. 1st symptom is loss of hearing. Then balance is affected. When tumor is removed there is inflammation to CN8, but may result in hypfunction and Bell's palsy. PT may assist with new vertigo and assist with compensation.

Acoustic Neuroma

What will an MRI rule out with vestibular problems?

Acoustic Neuroma

What are the types of hypofunction of the vestibular system?

Acoustic neuroma, --> microsurgery causes unilateral hypofunction and inflammation Neuronitis/Labrinthitis Bilateral vestibular hypofunction from meningitis. Ototoxic drugs Sequential vesitibular neuronitis.

Describe the prevalence of major cerebellar pathologies

Acquired: stroke <5% happen in cerebellum Degenerative non-hereditary: MS most common and cerebellar signs present in 10-50% of cases hereditary: Friedrichs ataxia SCA #6 most common

What are some acquired disorders of cerebellum?

Acquired: stroke, tumor, trauma, infection, toxicity, endocrine, MS

What are the 3 types of cerebellar pathology?

Acquired: stroke, tumor, trauma, infection, toxicity, endocrine, MS Degenerative non-hereditary: Multiple systems atrophy, idiopathic late-onset cerebellar ataxia, MS is both Hereditary: SCAtaxia or episodic ataxia, autosomal dominant disorders, Autosomal recessive dissorders. Friedrichs ataxia

What is Poliovirus?

Acute anterior poliomyelitis virus or heine-medin disease Affect motor neurons of anterior horn cells of CNS Parital recovery can occurs, as motor unit is denervated, adjacent motor neurons and reintervating the large motor units

What are the exam red flags for patients with PPS?

Acute onset of bulbar muscle dysfunction: Affects of swallowing and breathing Present with : Dysphagia, hypoventilation, sleep apnea and CP insufficiency

What is the mechanism for recovery for unilateral hypofunction?

Adaptation via central vestibular system Spontaneous reestablishment of the tonic-firing rate. Exercise can push system and facilitate a faster recover. Habituation

What is the main function of the cerebellum?

Adjusts and maintains the gain of the VOR Cancels the VOR The adaptive processor

What does evidence suggests for treatment approach in regards to cerebellar ataxia aerobic exercise and resistance training?

Advocated for those who won't return to baseline Aerobic endurance trainging and submax resistance trianing can reduce fatigability-which may reduce falls Caution with Friedrich's ataxia and cardiac comorbidity

What causes CMT (charcot marie)

Affects patients due to genetic variations. All present as hereditary, motor and sensory neuropathy Can be autosomal dominant or recessive Demyelinating or axonal degeneration affects afferent and efferent nerve conduction velocity and motor unit action potential

ALS usually affects what tracts and upper or motor neurons?

Affects: UMN in cortex Corticospinal tract and motor output affected Brainstem nuclei for CN 5, 7, 9, 10 and 12 are effected. Usually anterior horn cells are lost

Cupuloithiasis: ageotropic Canalithiasis: geotropic. What does this mean in relation to horizontal canal BPVV?

Ageotrophic: If eyes beat upwards, then stones are in cupula. Means away from ground Geotrophic: Eyes beat down towards ground. Means the stones are in the canal Test horizontal canal. Tilt head 30 degrees and rotate 90 degrees. Tilt test.

What impacts the persons stability of state of health for PPS?

Aging Comorbidities Overuse

What are the main theories with postpolio?

Aging Physical activity and weightgain over time have caused metabolic failure to thrive of axons... due to previous polio ocndition Neurons that are previously affected are vulnerable

What is a role that plays a major part with onset of PPS, since poliovirus isn't reactivated in patients who had polio?

Aging!

Where are the most common locations of primary tumors?

All accross cortex in frontal, parietal and occipital = 17% 16% in cerbellum 11% in brianstem

The following describes exercise for patients in what population? Light to moderate resistive exercise is NOT contraindicated in progressive neuro disorders Light to moderate aerobic exercise can be beneficial for persons with neuro disorders Patients, MUST MUST MUST "listen to their levels of exertion and time needed for recovery after bouts of exercise Physical activity should be encouraged within the limits

All progressive neuromuscular diseases. Exercise doesn't HURT muscles. It doesn't make progression more rapid.

Each semicircular canal has it's own what? What does it house?

Ampulla. Sensory cells, hair cells, which detect motion of head

What is skew deviation?

An acquired vertical misalignment of the eyes resulting from asymmetric disruption of supranuclear input from the otolithic organs (utricle, saccule) which input to the vertically acting ocular motoneurons and the interstitial nucleus of Cajal (all in midbrain). One eye is lower than another lol

Name the cerebellar stroke based off impairments: Dysmetria, vestibular signs, facial sensory loss

Anterior

Which canal has the following relationship to the eye muscles? (+) ipsilateral superior rectus muscle; Contralateral inferior oblique muscle (-) Ipsilateral inferior rectus muscle: contralateral superior oblique muscle

Anterior canal ***Know horizontal more than anterior and posterior canals

What happens when you move head forward and to the L, in terms of canal firing rate?

Anterior canal on L fires max stimulation Posterior canal on R goes down in firing rate. Inhibited Push-Pull relationship

Describe the relationship of aging with PPS?

Anterior horn cells start to become lost in 5th decade By age 60, loss of neurons may be 50% or more Limited motor neuron pool with patients with polio now exists Overuse and fatigue of already weakend neurons Neurons previously affect are at risk for premature aging and failure

What are the 3 regions of the cerebellum?

Anterior lobe Posterior lobe Flocculonodular lobe

Vestibular problems usually go hand in hand with what other emotional problem?

Anxiety

The following are characteristics of what subtype of concussion? Key complaints: hypervigilance/rumination, symptoms present during downtime... Overwhelemed Difficulty initiating sleep and maintaining sleep Limited socialization Hx of anxiety, panic attacks, mood disorders, migraine, vestibular Objective findings: Negative unless vestibular overlay is present. Balance is negative Cognitive testing is fine

Anxiety/Mood

How long LOC is concering for recovery?

Anything greater than 1 min predicts recovery complications

What are causes for central vestibular disorders?

Anytime cerebellum or vestibular nuclei in brainstem are damaged you have central vestibular disorder. Severe balance deficits and vertigo

What is a treatment for cardiopulmonary for patients with post-polio syndrome?

Aquatic therapy, endurance train Cycle ergometer

Near point convergence is commonly impaired for people with concussion. What is this? Strong association with post-concussion

Ask someone to do crazy eyes. Hold at arm length a target and bring toward face and ask when X turns double. Stop and measure distance from face to object If <5 cm it's normal. If >5 cm it is abnormal

Describe the ICARES scale:

Assess cerebellar ataxia International cooperative ataxia rating scale: Activity level 4 categories: postural control, limb movements, speech, occulomotor Used for progressive and non-progressive ataxia

How do you do the gait assessment for patient with vestibular examination?

Assess walking pattern: Add head turns Look for signs of disequilibruim or ataxia Look for changes in stride length Eyes open, eyes closes, head to side and up and down Quick turns Look for balance loss or increase in symptoms

What are the central mechanisms related to fatiguability of patients with PPS?

Assessed using TMS, with observed motor evoked potentials in the brain Weaker motor evoked potentials in those polio survivors Suggests changes in motor cortex ability to command that motor output = fatiguability?

What are the main motor impairments present with cerebellar ataxia?

Ataxia or drunken gait... Dysmetria Dyssynergia Dysdiadochokinesia: impaired rapid alternating movement between antagonist and agonist Rebount affect: inability to stop movement following isometric contraction action tremor: ilicited during movement Hypotonia Imbalance and gait, occulomotor and speech and motor learning

Your patient presents with the following diagnosis: Overly high step with excessive hip and knee flexion in swing. Forceful and uncontrolled lowering of leg in stance. Shortened steps, slow, wide BOS and unequal step length with walking They are imbalanced and fall backwards often

Ataxic gait

Describe Huntington's disease

Autosomal Dominant inherited movement disorder. "Hereditary cortical Neurodegeneration" Disease of the basal ganglia structures

Describe what the treatment approach should be for the following impairment for someone with cerebellar ataxia: Altered timing of stepping

Avoid dual task Conscious attention to gait

What are typical STG for patients with PPS?

Balance with functional activities Pain reduction Functional endurance and respiratory function Transfer ability

What causes a perilymphatic fistula?

Barotrauma, middle ear tumor, head trauma. Pressure changes from labor. "Pts hear a pop and have sudden loss of hearing loss"

What must you do prior to VOR training?

Binocular vision and covergence training via brockstring training prior to VOR training.

PT's have a unique knowledge in assessment and rehab of what for the help of concussion?

Balance system Vestibular and oculomotor systems Cervical spine CV system Sports injury. Always collaborate with other specialties since we all do better in one area than another

The following describes what test? Developed for sports related concussion Baseline scoring and post injury Assessed static postural control Done preseason and after injury

BESS Test:

The following describes what post-concussion test? 6 test positions with eyes closed: legs together, on one leg, tandem stance, on foam pad repeat. Most people can hold position for 20 seconds Errors are balance reaction, or open eyes. Or they change posture such as hands off hips. Count errors on firm vs. foam surface for 3 positions

BESS test

What is the most common cause of vertigo and nystagmus?

BPPV

When the otoconia continue to float around after head movements, you get vertigo, as the brain thinks you are still moving when you are not actually. What causes this?

BPPV

The hallpike-Dix maneuver is used for diagnostic for what?

BPPV of posterior and anterior canal or cupula

What are the most common types of vertigo?

BPPV, Hypofunctions

What is the main function of the VSR?

Balance and orientation: Postural control Via medial and lateral vestibulospinal tract

What type of ALS is characterized by loss of swallowing and breathing?

Bulbar onset: 20-30%

What is the classification system for tumors? What is it based on?

Based on microscopic characteristics PRimary vs. secondary tumor (metastatic)

Describe the clinical diagnosis for Charcot Marie Tooth

Based on: Onset and characterization of symptoms Family history and pedigree Genetic testing to confirm CMT allele EMG findings to confirm demyelination or axonal degeneration through decreased NCV, MUAP or increased F wate latency Nerve biopsies

For patients with ALS, that exercise unsupervised, what do you warn them about?

Be cautious about the following: Morning fatigue, muscle pain beyond 48 hours Patient feels weaker within 30 min of exercise Excessive soreness, muscle cramping and SOB.

Where does the nystagmus beat with labrinthitis/neuronitis or a hypofunction?

Beats fast towards the univolved side

Why is CMT a zebra?

Because when you see it you will know!!! Foot is super high arch, with a thor like hammer toe and flakey skin hands have super bony deformities that looks like RA

What are typical activity limitations for a patient with cerebellar ataxia?

Bed mobility Transfers Gait: Pertubations, inclines, obstacle negotiation, wide vs. narrow BOS Stair climbing ADL for limb use: help from OT

Describe the clinical presentation and treatment of stage 6 of ALS

Bedridden and completely dependent on ADL Treatment: Continue family education, positioning, turning schedule, use of lift devices to change position and transfer Impairment specific: dysphage, soft diet, adaptive feeding, tube feeding Salivation- surgery and suction Dysarthria-speech amplication and palatal life Respiratory-clera airway, trach, vent Requires many health care members

What are the basic principles of vestibular training?

Begin treatment early Exercise for brief periods of time initially. Exercise may increase patient's symptoms: Don't provoke N&V. If still provoked >30 min after exercise you have done too much. HEP; 2x/day Maintenance exercises need to maintain compensation Treat in clinic 1-2/wk

Describe the DC planning and hospice considerations for patients with Brain tumor?

Begins as early as possible Palliative or hospice if medical treatment is no longer beneficial Therapy may still may be indicated Community resources and support Provide comfort to patient as they go through end of life.

What happens when the hair cells bend in the cupula?

Bending of hair cells causes an increase or decrease in baseline firing rate of CN VIII

When are kinocilia excited and inhibited?

Bending toward the kinocilia: excitiation Bending away from kinocilia: inhibition

What is an acoustic neuroma?

Benign tumor in internal auditory canal. 1st symptom is loss of hearing. Then balance is affected. When tumor is removed there is inflammation to CN8, but may result in hypfunction and Bell's palsy. PT may assist with new vertigo and assist with compensation.

Secondary to meningitis, sequential vestibular neuronitis and ototoxic drugs, we have what vestibular problems?

Bilateral hypofunction disorders

What are some things with questionable research for patients with cerebellar ataxia?

Biofeedback and EMG: with limited carryover for auditory feedback for stepping speed Can improve feeding and postural sway TMS: or deep brain stimulation: reduction of motor cortex excitability. Does improve hand function and clinical measures Weighting: slows movement but no carryover Reducing upper limb tremor or ataxia: manipulation of visual information can improve movement from memory Lycra compression: insufficient evidence Promote independence of mobility: only with adequte trunk support and alternative control

What does the evidence say for biofeedack and transcranial magnetic stimulation or DBS for patients with cerebellar ataxia?

Biofeedback and EMG: with limited carryover for auditory feedback for stepping speed Can improve feeding and postural sway TMS: or deep brain stimulation: reduction of motor cortex excitability. Does improve hand function and clinical measures. Research is all in on this! ***Focus more on gait and balance training though***

Describe blurred vision dizziness

Blurred/double vision- occular: difficulty with binocular vision, convergence insufficiency Difficulty reading

What makes up the 3 semicircular canals of the peripheral sensory apparatus?

Bony labyrinth (filled with perilymph) Membranous labyrinth (filled with endolympph) Otolith (gravity sensitive) Saccule and Utricle

The following are S&S of what pathology? HA: interrupts sleep, worse on waking, but improves throughout the day. Elicited by postural change, coughing and exercise More severe or of a different type than usual Associated with N&V, papilledema and focal neurological signs Seizures in 10-20% Altered mental status- initial symptoms are subtle, associated with frontal lobe and increased ICP Papilledema- swelling of optic nerve Vomiting and vertigo with posterior fossa types

Brain tumor

The following are red flags for what? HA, Seizures Focal weakness Ataxia, Aphasia Mental and behavioral limitations Signs of increased ICP

Brain tumor

What cranial nerves are usually affected with ALS?

Brainstem nuclei for CN 5, 7, 9, 10 and 12 are effected. Usually anterior horn cells are lost

What is the brandt-Daroff Habituation exercises used for?

Brandt-Daroff habituation exercises: HEP for anterior and posterior canal

Describe episodic ataxia

Brief bouts of ataxia usually due to excitement, stress or exercise Lasts minutes to hours Responds to medication

What are the symptoms of BPPV?

Brief episodes of motion induced vertigo and nystagmus. Vertigo goes away even if provoking position is maintained. There are no complaints of aura fullness, hearing loss or tinnitus May see imbalance and gait ataxia

Are the following upper motor neuron, lower motor neuron or bulbar impairments of ALS? Bulbar muscle weakness Dysarthria Dysphagia Sialorrhea: increased salivation Pseudobulbar affect: affects emotions

Bulbar

What are the impairments associated with bulbar associated ALS?

Bulbar muscle weakness Dysarthria Dysphagia Sialorrhea: increased salivation Pseudobulbar affect of emotions

What is the most commoly inherited neuropathy?

Charcot marie tooth disease

What pathology has the following gait? "steppage gait" - dragging toes, high likelihood of stumbles and falls

CMT

PES CAVUS with high arch with some flaky skin in LE with steppage gait is characteristics of what?

CMT

What population has the following rehab management? Major aim is to maintain independence and QOL as disease progresses Frequent skin checks on feet to avoid ulceration consult OT Fall prevention/balance program. BALANCE INTERVENTIONS IS KEY!!! AD for mobility matching level of progression Home assessment/evaluation and modifications Family and caregiver education/safety planning!!! this is ALSO KEY!! for safety and optimal function

CMT

The following describes the epidemiology and etiology of what disease? Affects patients due to genetic variations. All present as hereditary, motor and sensory neuropathy Can be autosomal dominant or recessive Demyelinating or axonal degeneration affects afferent and efferent nerve conduction velocity and motor unit action potential

CMT Charcot marie tooth

What pathology often has signs and symptoms with chronic inflammatory demyelinating polyneurothaty. But there chief complaints don't involved numbness or tingling?

CMT (Marie tooth)

What pathology do they often NOT complain of paradoxically numbness or tingling, pain or weakness in distal LE?

CMT (tooth)

What kind of crystals are in the otoconia?

Calcium carbonate crystals

What is on top of the hair cells in the macula?

Calcium carbonate crystals that make otolith, gravity sensitive

What causes "coke bottle shape" LE with CMT?

Calf and ankle DF musculature atrophy is hallmark sign of CMT

What is the Caloric test?

Calorics: Cold stimulus and seeing where they eyes go. Eyes move away. Nystagmus to L with cold air in R ear. Warm air will have nystagmus to same side of air blow. COW: Cold away

What are the secondary effects of chemo following a brain surgery?

Can be very taxing and fatiguing.

Describe the cover/uncover test for occular alignment problems

Can have esotropio or inward movement or exotropia or outward movement of eye. When looking at objects, images usually fuse together when working properly. We may lose this with concussion, eyes may be lazy and only one eye is making vision. Mal-aligment is apparent on observation and cannot be corrected... Reveal on the cover portion of test, uncovered eye will move to center to fixate on target

What is the major goals and aims of Huntingtons disease?

Can't alter disease trajectory and will get worse: Therefore --> Maintain independence and QOL as disease progressions. Utilize other professions. SPEECH is HUGE for feeding/swallowing/talking Fall prevention/balance program Family and caregiver education and safety planning Home assessment and evaluation

What is the canalith repositioning maneuver used for?

Canalith repositioning maneuver: AKA epley for posterior and anterior canal. CRM or CRP or Epley

BPPV is the most common type of vertigo. What are the common maneuver's used to treat this?

Canalith repositioning maneuver: AKA epley for posterior and anterior canal. Supine dinner roll: horizontal canal Liberatory maneuver: for posterior and anterior cupula or canal AKA semon Brandt-Daroff habituation exercises: HEP for anterior and posterior canal Surgical for posterior canal plugging

How do you figure out if the otoconia stones are in canal or stuck to the cupula with BPPV?

Canalithiasis: <60 sec with short delay, since they are just floating in canal. Cupulolithiasis: Immediate onset. >60 sec since the crystals are STUCK.

What is canalithiasis?

Canalithiasis: Otoconia from utricle are free floating into the canal <60 sec with short delay in onset

With BPPV, the otoconia from the utricle get into a canal and are either free floating or stuck onto the cupula. What are those called?

Canalithiasis: Otoconia from utricle are free floating into the canal Cupulolithiasis: Otoconia from utricle are stuck onto the cupula

What are hair cells located?>

Capula: Sterocilia: Short hair cells Kinocilia: Long hair cells that send sensory information to brain. Bending toward the kinocilia: excitiation Bending away from kinocilia: inhibition

What are the typical home or outpatient interventions for a patient with a brain tumor?

Caregiver training in home Continued recovery and compensatory methods Exercise principles for cancer related fatigue: Aerobic and resistance training.

What are the brain structures most commonly affected with Huntington's?

Caudate nucleus atrophy and enlarged lateral ventricles

What usually causes larinthitis/neuronitis or inflammation of inner ear?

Caused by bacterial or viral infection.

What is cervicogenic dizziness?

Caused by whiplash injury Affected by proprioceptors of the suboccipital muscles and facets If damaged you get sensory mismatch of sensory position and head position. Check with cervical joint position error test. Have patient close eyes and turn head 80 degrees to R. Then close eyes and return to midline, based on feel. Repeat with head extension and rotation to R and L..

A pressure change from tear in round or oval window between the middle and inner ear is called a perilyphatic fistula what does this cause?

Causing a flow of fluid between the middle and inner ear and distorts the SC and utricle

Peripheral or central vestibular problem? N&V: moderate Imbalance: Severe Hearing loss: Rare Oscillopsia: Severe Neuro symptoms: common Compensation: slow

Central

The following are characteristics of peripheral or central nystagmus? Persists Will be spontaneous Changes direction with gaze changes Often vertical or "pure" rotational or "pure" horizontal Will be immediate onset with positional vertigo

Central

Vertical nystagmus is always associated with what problems?

Central

If you move 30 degrees out to L and the eye beats fast to the R, where is the problem if this test is repeated if it stays R when we go to the R now?

Central problems indicated

The following makes up what part of the vestibular system: Vestibular nuclei Cerebellum

Central processor

Describe what conditions you may be thinking if someone has oscillopsia?

Central vision problems.

What are signs of central nystagmus?

Central: Persists Will be spontaneous Changes direction with gaze changes Often vertical or "pure" rotational or "pure" horizontal Will be immediate onset with positional vertigo

If direction of nystagmus changes in response to hand movement direction that is indicative of what problem?

Central: purely torsional or rotational

The following are systems review considerations for what population? Fatigability: this pathology leads to increased effort of movement Monitor 2 or 6 min walk test, sustained aerobic workload, monitor vitals and RPE MSK endurance: max reps recorded of various muscle groups before reduced force or ROM observed

Cerebellar ataxia

The following are key body structure function considerations for a patient with what pathology? Muscle tone is usually hypotonic voluntary movement coordination is important to test: finger taping, supination/pronation, handwriting, toe tapping Static and dynamic balance with pertubations or narrow BOS Oculomotor performance: smooth pursuit, saccades, gaze evoked nystagmus

Cerebellar ataxia or pathology

What does the VOR cancellation test for?

Cerebellum function and cancels VOR when head and eyes want to move . Test integrity of cerebellum Extend arms and glasp hands together. Stay looking at thumbs as head and arms move together. If the eyes bounce off target and cannot cancel VOR, this is positive for central vestibular problem

If you have a peripheral vestibular problem, like due to infection. What works to compensate?

Cerebellum is adaptive processor

What adjusts and maintains the gain of the VOR controlling eye and head movement?

Cerebellum. If damaged you no longer have that good 1:1 head to eye ratio

What is the adaptive processor of the vestibular system?

Cerebellum: With permanent damage to peripheral nervous system, you can recover with compensation via the cerebellum!

The VSR will send signals to what muscles in the spine?

Cervial muscles and extensor muscles. Important for postural reactions and tone

What is part of our systems review for concussions? like what are the red flags to screen for

Cervical instability and fractures CNS red flags such as sensation changes, ataxia, spasticity and reflexes Seizures Prolonged LOC Altered mental status Hypertension Would require medical consultation

The following are characteristics of what subtype of concussion? Key complaints: Neck pain worse with sitting and reading. Decreased ROM HA in the occipital region May have dizziness from decresed Csp ROM Hx: MVA, LBP, cervical injury Objective findings: VOM is normal Balance is positive for sensory organization Cognitive testing is normal

Cervical type concussion

Compensation mechanism of partially denervated motor units in muscles and rehab is a peripheral mechanism for loss of strength with PPS. Describe this

Changes the structural muscle fiber and changes from type II to type I Altered phenotypic expression of light and heavy myosin chains may affect changes in speed of contraction of type I fibers This structure change may explain challenge for the muscles to adapt to mechanical constraints

The following is the rehab summary for what condition: Multidisciplinary Utilize aquatics when safe and no contraindications Incorporate non-WB and partial WB cardiorespiratory fitness Allow for longer rest breaks in between bouts of work/exercise. Light-mod strength training is NOT contraindicated and there is no evidence that it shows disease progression Patient and family caregiver education is imperative Consider who factors and females may complain about AFO wearing

Charcot Marie

The following is the medical management for what disease? NSAID's or corticosteroids: consider the timing treatments of fatigue from ADL's Patients may be on antidepressants as well. On NSAIDS or corticosteroids to target the inflammatory degeneration process.. Multidisciplinary Symptomatic mangement and use of lyrica for neuropathic pain

Charcot Marie Tooth disease

The following is the pathophysiology of what pathology? Genetic mutation causes abnormalities in mostly peripheral nerve function Over time, demylination and axonal degeneration leads to neuromuscular impairment as seen in other disorders like MS Leads to gross motor weakness and sensory dysfunction Progression is natural in time Preferentially selective to distal extremities Advances in distal to proximal fashion

Charcot Marie Tooth disease

The following are gait and foot abnormalities with what pathology? "Steppage gait" - dragging toes, high likelihood of stumbles and falls Hallmark = hammertoe deformity in great toes with pes cavus; high arches Intrinsic foot musculature atrophy alters rear-mid-forefoot mechanics and WB phases of gait Dry or shiny and flaky skin, hair loss in distal LE's, cool to touch Can progress to affect hands and wrists in later stages: May see cool hands and deformities similar to late stage RA

Charcot Marie's tooth

The following are characteristics of what pathology? Intrinsic foot musculature atrophy alters rear-mid-forefoot mechanics and WB phases of gait Dry or shiny and flaky skin, hair loss in distal LE's, cool to touch

Charcot marie tooth

The following are rehab management and care considerations for what population? Will often need increased support from caregivers as disease progresses and increasingly impact function Often requires AFO's, GRAFO's and AD for ambulation. High risk for LE sprains SPC and walking sticks preferred initially Females don't ususally want AFO's for cosmetic reason

Charcot marie tooth

The following are the main impairments with what pathology? Muscle Weakness and fatigue Hyporeflexia Selective hypotonicity Atrophy Poor balance and trunk control Falls LMN deficits

Charcot marie tooth

What is one of the most common disorders of the rare disorders?

Charcot marie tooth disease

The following is the clinical manifestation of what pathology? Disease presentation: S&S can mimic chronic inflammatory demyelinating or alcoholic polyneuropathy Paradoxically often DO NOT c/o numbness or tingling, pain or weakness in distal WL Calf and ankle DF musculature atrophy (hallmark = "inverted coke bottle" shape) Stumbles, falls, clumsy gait are very common Falls tend to be underreported

Charcot marie tooth's

The following are rehab interventions for what population? Stretching to avoid contractures in hands, may need bracing or splints in later stages. Low load and sustained stretching to protect from contractures Resting or night splints, serial casting of ankles Continual evaluations for DME and assistive devices May need protective socks similar to diabetic neuropathy

Charcot marie tooth. Protect them feet as well...

The following are exam considerations for what pathology? Pt Hx and systems review Tests and measures for fall questionnaires, balance outcomes, and functional ambulation GMFM and LEFS Disease-specific measures and patient reported impacts

Charcot marie tooths

The following describes the severity of what disease Variable in severity and age of onset of symptoms ranges from early childhood to early adulthood. Extremely variable in disease presentation

Charcot mariet tooth CMT

The following describes the prevalance and information for what pathology? rare neuromuscular disorder Most commonly inherited neuropathy: One of most commonly inherited human disease and 10x more common than ALS and HD combined! 125-150,000 in US Often undiagnosed or misdagnosed due to its overlapping symptomology

Charcot-Marie Tooth disease

What does a head thrust check for?

Check for corrective saccades

How do you perform the head thrust for VOR?

Check for corrective saccades. Tip the head down 30 degrees to line horizontal canals parallel to ground to max stimulate them Hold head with firm grip. "Staying Look at nose." QUICKLY THRUST HEAD TO R and then L then R. Normal response to L is looking straight at you.

How do you perform the head thrust for VOR indications?

Check for corrective saccades. Tip the head down 30 degrees to line horizontal canals parallel to ground to max stimulate them Hold head with firm grip. "Staying Look at nose." QUICKLY THRUST HEAD TO R and then L then R. Normal response to L is looking straight at you. If they don't move back OR overcompensate then there is problem with VOR

What is typical medical treatment for patients with brain tumors?

Chemo, radiation and sterotatic radiosurgery Chemo: used with radiation, surgery or alone Methotrexate used for CNS Radiation: For malignant tumors. 6 weeks, 1-5 minutes a day Adverse effects of healthy tissue and burns Sterotatic radiosurgery: Gamma knife: deeply embedded small tumors, robotic arm to focus beams of radiation to target tumor. Minimal damage to healthy cells

What is hallmark sign of Huntington's?

Choreiform movements

What characterizes Huntington's disease?

Choreiform movements Later stage profound dementia associated with cortical destruction Atrophy of Caudate Nucleus- enlarged lateral ventricles seen on imaging

The following describes what charactertic? Hyperkinetic movements in limbs Rapid-jerky-involuntar-writhing and uncontrollable In late stages: present as mixed neurodegenerative movement disorder with elements of hypokinetics due to obliteration of basal ganglia structure

Choreiform movements in regards to Huntington's

For our interventions how should we adapt for fatigue, low blood count or GI complaints for patients with brain tumor?

Clinical decision making should be used: will my patient's health and safety be compromised? Flexibility of providing intervention: timing and patient presentation Considerations of cognitive effects: similar to patients with stroke or TBI

WHat is the medical management of Huntingtons'

Clonazepam to depress CNS and control chorea Haldol or tetrabenzine. Consider timing of treatments due to lethargy and somnolence. Pt may be on anti-psychotics, anti-anxiety or antidepressants Multidiscipinary Symptom management: Palliative care in later stages

What are the PT examination and considerations of ALS?

Cognition/psychosocial function Pain Joint integrity/rom and muscle length Muscle performance and motor function CN integrity and tone and reflexes Sensation/integumentary Postural alignment, control/balance, gait functional status, enviornmental barriers and fatigue Respiratory failure

The following are characteristics of what subtype of concussion? Most common in acute phase. Characterized: fatigue that worsens as day goes on. HA that is non-localized Decreased energy Poor attention, distractible Symptoms worsen with activity potential sleep deficits. Hx of learning disability-- Risk Factor Objective findings: VOMS is normal Balance is normal Cognitive testing is positive, with impairments of memory and reaction time. Global deficits

Cognitive/fatigue

What are the goals for PPS?

Collaborative effort between family you and patient Focus on symptom management Achievement depends on commitment and compliance LTG: Self management of HEP and lifestyle changes STG: symptoms mangement QOL considered

What is primary purpose of peripheral apparatus?

Collects all information about head position and head motion and sends it to central processor via CN VIII

What connects the anterior and posterior canals of the peripheral sensory apparatus?

Common crus Feeds into the utricle. Bony labyrinth to the membranous labyrinth

Your patient has a concussion and is in the cognitive/fatigue subtype. What is the main intervention, and what should we do?

Commonly acute, and require rest. Consider referring out to Doc Reduce cognitive and physical demands, walk daily, avoid provoking symptoms and accommodations needed at work and school Get sleep schedule, and medication management. May need cognitive or speech is symptoms are severe

For patients with cerebellar ataxia, are the following compensatory or recovery strategies: Slow down movement, visual cues, widen gait, minimize distraction. Using AD only if can be managed safely

Compensation

What are peripheral mechanisms of PPS leading to loss of strength?

Compensation mechanism of partially denervated motor units in muscles and rehab Denervation can induce metabolic changes in muscles Enlarged motor units due to recovery process of initial virus create instability and may lose axons with intense overuse

What is the suggested treatment focus for patients with gait ataxia, based on the location of lesion who had a vestibular problem?

Compensatory head fixing or train VOR Strength/balance exercises

The following are intervention principles for what problem? Substitution: increase patient's reliance on somato-sensation and vision. Use cervical spine proprioception to replace the VOR

Complete loss of vestibular function bilaterallly

What are the differences of concussion testing?

Computerized testing: baseline and post-injury ImPACT test, AxonSports test, CNS vital signs Neuropsychology testing: comprehensive testing by a trained neuropsychologist sensitive to subtle deficits Most often detected in the post acute phase

When strengthening muscles, what do you focus on for patients with ALS?

Concentric focus Moderate resistance Grade >3+/5 only strengthen these muscles Monitory for overwork weakness

The following are red flags potentially associated with what pathology? Cervical instability and fractures CNS red flags such as sensation changes, ataxia, spasticity and reflexes Seizures Prolonged LOC Altered mental status Hypertension

Concussion Would require medical consultation

Describe what the treatment approach should be for the following impairment for someone with cerebellar ataxia: Reduced automaticity of walking

Conscious attention to what they are doing.. Gait training, have them pay attention a lot High intensity!!!!!!!!!

What are the PT considerations for examination of Huntington's?

Consider early hyperkinetic stages and later stages may display hypokinetic features Pt Hx Disease specific measures: Patient reported impacts UHDRS- unified HD rating scale

What side effects should we consider for a patient with a brain tumor?

Consider fatigue from chemo or radiation Fatigue due to central fatigue from CNS Low blood count Gastrointestinal complaints

If a patient has a brain tumor and a poor prognosis, what should we focus on?

Consider focus on family training, DME, palliative care/Hospice needs

Why you need continuous reassessment for patients with a brain tumor?

Continuous reassessment due to side-effects of treatment include cerebral edema, hydrocephalus, tumor regrowth and infection

Describe room spinning type of dizziness?

Could be room spinning/swaying: vestibular such as BPPV, hypofunction and perilyphatic fistual

What are concussion specific vestibular test?

Cover and uncover test Maddox rod VOMS: vestibular-occulomotor screen Make sure to ask if they have history of VOR problems, cause blow to head can make worse

What is critical element of walking?

Critical element of walking: stability during dynamic mobility while maintaing forward propulsion

What is the gelatinous membrane in the ampulla?

Cupula, that houses the hair cells

What is the cupula? What happens when the hair cells bend?

Cupula: Gelatinous mass, hair cells and hairs are embedded in the cupula and bend with head rotation Bending of hair cells causes an increase or decrease in baseline firing rate of CN VIII

What is Cupulolithiasis?

Cupulolithiasis: Otoconia from utricle are stuck onto the cupula >60 sec with immediate onset

How do you differentiate between cupulolithiasis vs. canalithiasis?

Cupulolithiasis: Otoconia from utricle are stuck onto the cupula >60 sec with immediate onset Canalithiasis: Otoconia from utricle are free floating into the canal <60 sec with short delay in onset

What are some superior cerebellar artery stroke impairments?

Dysmetria of ipsilateral arm. Unsteady walking, dysarthria and nystagmus Common coordination and dysmetria are always IPSILATERAL!!!

Damage to normal muscle fibers with repetitive eccentric work is a negative outcome for ALS exercise prescirption. Describe why this occurs

Damage to normal muscle fiber with repetitive eccentric work: Normal muscle in a patient with ALS may not have the repair capabilities

If someone has days of vertigo symptoms indicates what pathologies?

Days: Acute hypofunction

What happens with normal aging?

Decreased muscle strength and endurance Joint pain and limitations Multifactorial health issues-leading to functional loss

What are the primary symptoms of post-polio?

Decreased muscle strength and endurance in both previously affected and unaffected muscles Pain and fatigue

What is the main MS problem with PPS?

Decreased muscle strength, endurance and fatigue

When is supervised gentle exercise recommended for patients with ALS?

Decreased pain and stiffness Improved psychosocial

What are some anterior cerebellar artery stroke impairments?

Dysmetria, vestibular signs, facial sensory loss

What are the late effects of polio syndrome from chronic impairments?

Degenerative arthirtis from overuse Bursitis and tendonitis

WHat are some degenerative non-hereditary cerebellum disorders?

Degenerative non-hereditary: Multiple systems atrophy, idiopathic late-onset cerebellar ataxia, MS is both

What is the main phyisological problems with CMT? marie tooth

Demyelinating or axonal degeneration affects afferent and efferent nerve conduction velocity and motor unit action potential

What are the 5 functions of the semicircular canals?

Detect rotational movement of acceleration and deceleration Most sensitive to fast head movements Canals are oriented at 90 degrees to each other Horizontal canal is tilted up 30 degrees from transverse plane Anterior and posterior are oriented at 45 degree angle to midline

What is poor visualmotor dizziness?

Difficulty in a dynamic/visually rich enviornment- motion sensitivity. At movie theater or walking in grocery store

What helps tell the canal and side affected with BPPV?

Direction and rotation of nystagmus

How is nystagmus associated with BPVV?

Direction and rotation of nystagmus indicate the canal and side effected Posterior canal: Upbeating, torsion to affected side Anterior canal: Downbeating, torsion to affected side HOrizontal: Rare, no torsion

What is the clinical manifestations of CMT?

Disease presentation: S&S can mimic chronic inflammatory demyelinating or alcoholic polyneuropathy Paradoxically often DO NOT c/o numbness or tingling, pain or weakness in distal WL Calf and ankle DF musculature atrophy (hallmark = "inverted coke bottle" shape) Stumbles, falls, clumsy gait are very common Falls tend to be underreported

What are the disease specific outcomes measures for HD?

Disease specific measures: Patient reported impacts UHDRS- unified HD rating scale Also use balance scales and fall reporting since this is very common

Peripheral vestibular disorders refer to what structures?

Disorders of semicircular canals, otoliths, and CN VIII.

What is the outcome measure to screen the vestibular symptoms in post-concussion?

Dizziness handicap inventory

What are important patient complaints for a history vestibular exam?

Do they have: Hearing loss Oscillopsia Imbalance N/V Tilt Vertigo: Person or environment spinning and duration

BPPV is positional vertigo caused by what factors?

Due to mechanical disruption: Ototconia from the utricle get into a canal and are either free floating (canalithiasis) or stuck onto the cupula. (cupulolithiasis) Involved canal becomes gravity sensitive. From idiopathic cause or blow to head.

For people with PPS, they may have trouble with Walking Climbing stairs and dressing PR with meeting demands of work or home. For what reasons?

Due to primary weakness from overuse, or secondary disuse

How do we check for gaze evoked nystagmus?

During H-test pause at 30 degrees away from nose and check for nystagmus. Look for which direction is fast beating

What is part of the balance screening for post-concussion patients?

Dynamic gait index HiMAT Dual task such as TUG cog Sensory organization: CTSIB, Romberg BESS Test: Developed for sports related concussion Baseline scoring and post injury Assessed static postural control

What are the gait assessment tests for vestibular systems?

Dynamic gait index Obstacle course Gait speed Singleton test TUG

How do you test for VOR?

Dynamic visual acuity test VOR cancellation HEAD THRUST

What helps detect seizure activity?

EEG

What are diagnostic tests for vestibular disorders?

ENG: Electronystagmography Hearing tests Rotation tests: Rotary chair Posturography: SOT MRI or CAT scans

What does each of the following semiciruclar canals produce? Left anterior with right posterior Right anterior canal with posterior canal Horizontal canals are paired with each other

Each produces reciprocal signals

When you consider a treatment approach for CMT you should consider what?

Early in the day to prevent ADL fatigue Multidisciplinary approach. they may be on antidepressants too control disease

Describe the Framework for rehab for CMT stages

Early: Variety of abnormal S&S, with minor limitations present with AL and variable PR. Middle: Increased number of S&S and severity: moderate to minimal limitations with ADL's, PR are more pronounced Late": Numerous and severe impairments, AL become dependent in all aspects of mobility and self-care. Total dependence in PR.

What is the two main purposes of the Buffalo concussion treadmill test?

Establish a safe exercise intensity Differentiate physiological reproduction of symptoms with exertion from other causes of symptoms of dizziness, such as cervicogenic disorders or migranes or BPPV.

What does the research say about exercise and brain tumor?

Evidence supports aerobic and resistive program related to: Reversing effects of muscle wasting from prolonged steroidal use Cancer related fatigue syndrome

How do we examine nystagmus?

Examine in room lighting and with vision removed: Frenzel lenses removes visual fixation

What happens when hair cells bend toward kinocilia during movement?

Excitation of CN VIII

Describe the relationship of exertional training on concussions?

Exercise below symptoms thershold is safe and effective for return to sport Beneficial for cognitive/fatigue, anxiety but all subtypes as well. Stepwise: Walking on flat ground, walking on incline Walking with head turns Jogging on TM while looking outside and counting cars HR monitored, symptoms monitored See return to play protocols for progression

Exercise intolerance is a negative outcome for ALS exercise prescirption. Describe why this occurs

Exercise intolerance: Mitochondrial dysfunction, abnormal muscle metabolism, impaired activation and central activation failure

What is treatment of bilateral vestibular hypofunction?

Exercises designed to ramp up non-vestibular sensory capacities. Eyes open, narrow BOS. Work vision and somatosensory

What are we looking for with nystagmus with oculomotor exam?

Eye beat fast toward uninvolved side with hypofunction. Moves toward side with more input

What is CN 6 pathology symptoms?

Eye deviated inward

Why does symptoms of a hypofunction or labrinthits/neuronitis go away?

Eyes and central brain compensates! Vertigo becomes episodic during fast head movements. But is not longer happening all the time.

True or False: The vestibular system is a sensory only system?

False it is sensory and motor

True or False:L Vertical malalignment is common in general population, but horizontal malalignment is a red flag

False: Horizontal is common, but vertical malalignment may signal major problem Note with concussion

True or False: For patients with PROGRESSIVE neurodenerative disorders, light to moderate resistive exercises is NOT contraindicated

False: They CAN!! But be gentle and allow patient to listen to body and give patient extra time between bouts like CMT and ALS

What are the main portions of systems review of examination of cerebellar pathology?

Fatigability: cerebellar damage leads to increased effort of movement Monitory 2 or 6 min walk test, sustained aerobic workload, monitor vitals and RPE MSK endurance: max reps recorded of various muscle groups before reduced force or ROM observed

What is the clinical trio that diagnosis PPS?

Fatigue Pain Deterioration of motor deficits

What fills the membranous labyrinth in the peripheral sensory apparatus?

Filled with endolymph

What fills the bony labyrinth in the peripheral sensory apparatus?

Filled with perilymph

If someone has a chronic hypofunction they will compensate by doing what?

Fixating on something in room. ONLY with room light. Need to use frenzel lenses, like pair of swim goggles

Describe floating sensation dizziness

Floating sensation: cervicogenic --> associated with whiplash

What part of the vestibular system does the cerebellum house?

Flocculonodular lobe

What zone of cerebellum controls eye movement and balance with regards to health of VOR?

Flocculonodular lobes

What is hallmark sign of Meniere's disease? (IT's PROGRESSIVE AS WELL)

Fluctuating vertigo and hearing loss

Describe Meniere's Disease

Fluid level disorder Symptoms of "spell/episodic" Triad of: Fluctuating hearing loss, tinnitus, vertigo (>30 min to 24 hours) Imbalance and fullness of ear Treatment: restricting sodium intake, avoidance of alcohol and caffeine, nicotine Meds, PT not helpful

Due to weak DF, what could be seen with CMT?

Foot slap, but they compensate with steppage gait pattern

Describe the recovery-restorative approach framework for rehabilition

For non-progressive cerebellar ataxia Anticipated improvement based on examination

What is part of the physical exertion screening for patient's with post-concussion syndrome?

For patients that are tired all the time and have dizziness or HA with exertion. Use Buffalo concussion treadmill test: DD of physilogic post concussion symtoms. See what level of activity brings on symptoms. This becomes upper threshold for exercise Don't want to keep them resting in chronic phase and get them moving again. HR and BP recorded when symptoms are exacerbated and becomes basis for exercise prescription

What is the main reason the acoustic neuroma causes hypofunction?

From the microsurgery, it results in unilateral hypofunction and may result in Bell's Palsy. Inflammation causes transient hypofunction

What is Fukuda step test and what does it indicate?

Fukuda step test: March in place and look for drift. Side they drift too is indicative of hypofunction.

What is the PT role for a patient in the hospital for a brain tumor?

Functional Eval, family support Schedule home eval and education Mobility and positioning, mobility training and safety Family training, AD and f/u

What is the main outcome measure PT's use for brain tumors?

Functional independence measures: ADL function, mobility activities and speech and cognition Analysis of 3 domains to guide POC

What are the main outcome measurements for brain tumor?

Functional independence measures: ADL function, mobility activities and speech and cognition Physician evaluative tool: Karnofsky Performance sclae index: 0-100, level of independence. Health related Quality of life: physical, emotional, spiritual and intellectual functioning State-trait anxiety inventor Self-rating depression scale

What is the common gait analysis for patients with PPS?

Gait analysis --> Overuse and substitution of vastus lateralis, biceps femoris, glutes max and soleus not functioning

What are Red flags for referal because you suspect a primary brain tumor or a gliomas?

HA, Seizures Focal weakness Ataxia, Aphasia Mental and behavioral limitations Signs of increased ICP

What does the research say about interventions for cerebellar ataxia?

Gaps in evidence. Most effective intervention approahc has NOT yet been established Non randomized, non controlled, smalle sample size literature only avaliable. Not randomized control trails

The following are interventions for what pathology? Use of Snellen chart Environments that are visually rich with stimulus. Oculomotor exercises: x1 and x2

Gaze instability with uniltarel function

What is the purpose of the superior and medial vestibular nuclei?

Gaze stability and controlling VOR. Connected to CN III, IV and VI, which control movements of eye

VOR is critical for what?

Gaze stabilization

What is the purpose of vestibulo-ocular reflex as part of the vestibular nuclei complex?

Gaze stabilization

What are the 2 main functions of the vestibular system?

Gaze stabilization- VOR: allows head to focus on what you are doing when moving. (vestibulooculomotor reflex Postural control- VSR: Controls when falling and changes in COM

Describe the pathophyiology and natural history of Charcot marie tooth

Genetic mutation causes abnormalities in mostly peripheral nerve function Over time, demylination and axonal degeneration leads to neuromuscular impairment as seen in other disorders like MS Leads to gross motor weakness and sensory dysfunction Progression is natural in time Preferentially selective to distal extremities Advances in distal to proximal fashing

What is important when testing static and dynamic balance for a patient with cerebellar ataxia?

Give pertubations and do in sitting and standing

What is the part of POC for ALS?

Goal development that is collaborative with patient for psychosocial components Progressive diagnosis, so don't cure or delay progression Broad goals: Maximize independence and positive quality of life Address psychosocial and caregiver issues

What is the next steps after a brain tumor is found on imaging?

Goal of surgery to maximize tumor resection Biopsy to make diagnosis with ultimate goal for complete resection Ciopsies- open, needle or sterotactic Resections occur with craniotomy as patients are sometimes awake. Scary terry.

What are the interventions based on for patients with brain tumor?

Goals from patient

Describe what the treatment approach should be for the following impairment for someone with cerebellar ataxia: Reduce adaptability in environment

Graded exposure, sensory cues Conscious attention to what they are doing

What effects the otolith?

Gravity sensitive

What is the occulomotor ROM test?

H-test Look for smooth pursuit of eye. Does eye track smoothly. During H-test pause at 30 degrees away from nose and check for nystagmus

Post concussion symptoms occur when patient has at least 3 of 8 symptoms within 4 weeks. What are the symptoms?

HA Dizziness Fatigue Irritability Impaired sleep Impaired concentration Impaired memory Impaired tolerance for stress, emotional situations or alcohol use

Describe the clinical presentation and treatment of stage 4 of ALS

Hanging arm syndrome, shoulder pain, edmatous hand , W/C dependent, severe LE weakness, can perform ADL with fatigue Treatment: Heat/massage for spasm, edema prevention, AA and PROM of limbs Isometric contractions to tolerance, orthotic UE support- sling/trays and power mobility

What is spontaneous nystagmus?

Happens with acute onset of Labrinthitis or Neuronitis during hypofunctioning. Mismatch of signals that move eyes. May last for days

How do you test saccadic movement?

Have R hand up and L hand up 10 inches apart. "Look at r hand and then look at L" Don't move head Are they accurate to target? If not, they have corrective saccade Move past target if cerebellum is damaged

The VOR control gaze stability during head movements. What is the main relationship of the head movement to eyes?

Head movement to the left causes an equal and opposite eye movement to the right. (1:1 ratio) Extraocular muscles are paired to semiciruclar canals

What is the test to check for VOR indications?

Head thrust

What are the key differences for examining someone with PPS?

Health hx: growth and developmental history and family history More complex systems review includes: sleep, temperature intolerance, fatigue, pain and ageing process Tests and measures with emphasis on MSK system Ask about systems beyond the main ones... sleep? temperature?

What is the main self-questionnaire for a patient with brain tumor?

Health related quality of life to address physical, emotion and intellectual functioning and spiritual

What are the commonly utilized questionnaires for post concussion?

Help objectify subjective complaints Rivermead post-concussion symptoms questionnaire Post-concussion symptoms scale Grade symptoms checklist Post-concussion symptoms inventory Neurobehavioral symptoms inventory for military

The following are the 6 dimensions that help use with what for concussions? Vestibular Ocular Cervical Cognitive/Fatigue Post traumatic Migraine Anxiety/Mood

Help to guide interventions

What is the ALS functional rating scale used for?

Helps measure how patient functions with activity limitations. 12 questions about UE function, putting clothes on, walking and turning in bed and respiration. Will guide treatment planning and make goal important to patient. Also can refer to OT and pulmonary

What causes brain tumors?

Hereditary in theory Casual relationship with: toxins, chemical, organic solvents and rubber Farming, manufacturing Ionizing radiation or electromagnetic fields

What are some hereditary cerebellum disorders?

Hereditary: SCAtaxia or episodic ataxia, autosomal dominant disorders, Autosomal recessive dissorders. Friedrichs ataxia

Who is most affected by ALS?

High incidence in western pacific Men > Women 7x

CMT is associated with what ankle problems and gait considerations?

High risk for LE sprains. Usually require AFO's and need SPC or walking sticks for gait to not fall

When is MRE using PNF recommended for patients with ALS?

Implemented earlier in disease progression Muscle grades of 4/5-5/5, hold up well to MRE. Focus on stronger muscles Generally no deletrius effects

Describe the clinical manifestation of ALS

Highly variable Depends on extent of motor neuron loss, degrees and combination of UMN and LMN, pattern of onset, and progression, body regions affected stage of disease Usually symptoms are focal and asymmetrical at onset

How is the medical diagnosis of a brain tumor completed?

History of present illness Neurologic exam Tumor imaging

What are objective factors for Traumatic migraine subtype of concussion

History of: Migraine (personal or family), motion sensitivity Objective findings: VOMS normal unless vestibular overlay Balance is positive for difficulty with sensory organization. Cognitive testing positive for visual and verbal memory

What does the utricle of the otolith sense?

Horizontal acceleration: like stopping in car

If someone has hours of vertigo symptoms indicates what pathologies?

Hours: Acute hypofunction, Meniere's disease

The following are impairments related to what pathology? Muscle weakness and fatigue Hyperreflexia/Hypertonicity Difficulty swallowing and communication Atrophy Poor balance and trunk control and falls Impaired mood and cognition UMN signs!

Huntington's

The following care considerations are important for what pathology? Can't alter disease trajectory and will get worse: Therefore --> Maintain independence and QOL as disease progressions. Utilize other professions. SPEECH is HUGE for feeding/swallowing/talking since UMN disease Fall prevention/balance program Family and caregiver education and safety planning Home assessment and evaluation

Huntington's

The following happens with what pathology? Too much movement in limbs and trunk Unwanted and involuntary that can be rapid and jerky, or non-jerky Can be slow and writhing, rhythmical or continuous or unpredictable

Huntington's

The following is medical management for what pathology? Clonazepam to depress CNS and control chorea Haldol or tetrabenzine. Consider timing of treatments due to lethargy and somnolence. Pt may be on anti-psychotics, anti-anxiety or antidepressants Multidiscipinary Symptom management: Palliative care in later stages

Huntington's

The following is the pathophys of what disorder? Over time, gene mutation leads to neuro impairment Cortical destruction and atrophy occurs in caudate nucleus Late stage profound dementia May have mood/psychiatric involvement Life expectancy: 15-25 years beyond symptoms Progressive degeneration with enlarged lateral ventricles

Huntington's

The following describes what pathology? Autosomal Dominant inherited movement disorder. "Hereditary cortical Neurodegeneration" Disease of the basal ganglia structures

Huntington's Disease

The following are characteristics of what pathology? Choreiform movements Later stage profound dementia associated with cortical destruction Atrophy of Caudate Nucleus- enlarged lateral ventricles seen on imaging

Huntington's disease

What is the purpose of the inferior vestibular nuclei?

Important for reticular activiating system and with reticular formation

Are there CMT specific outcome measures?

Nope

The following is the epidemiology and etiology of what pathology? Typically between 45-50 y.o 5/100000: Affects males slightly more than females >40 "CAG" repeats on HTT allele of Chromosome #4. Genetic mutation = abnormal folding of protiens in neurological structures of brain and basal ganglia

Huntington's disease

The following are care considerations for what pathology? Rhythm and cadence via auditory stimulus (metronome) had positive effects on gait disturbances Smaller amplitude motor control emphasized like Tia Chi Relaxation techniques may be helpful in reducing hallmark sign of this pathology PNF techniques and rhythmic stabilization for trunk control Timed therapy after meds to maximize session

Huntingtons' disease

What are objective factors for anxiety/mood subtype of concussion?

Hx of anxiety, panic attacks, mood disorders, migraine, vestibular Objective findings: Negative unless vestibular overlay is present. Balance is negative Cognitive testing is fine

What are objective factors for cognitive/fatigue subtype of concussion?

Hx of learning disability-- Risk Factor Objective findings: VOMS is normal Balance is normal Cognitive testing is positive, with

What is the main part of examination and evaluation for a patient with brain tumor?

Hx of occupational status, support, leisure and personal goals Neurological exam, multisystem assessment and functional assessment Evaluation includes clinical problem list, realistic and meaninguful goals Discharge planning Address patients as a whole!!!

What are objective factors for vestibular subtype of concussion?

Hx of sensitivity, Migraines and Anxiety Objective findings: Positive for VOR, and motion/optokinetic sensitivity. Positive Balance test may or may not happen. cognitive testing positive rxn time, processing speed, intact memory

What are objective factors for cervical subtype of concussion

Hx: MVA, LBP, cervical injury Objective findings: VOM is normal, but VOR may increase pain... Balance is positive for sensory organization difficulties Cognitive testing is normal

With a hyperfunction or BPPV, the nystagmus is going to go to ____________________.

Hyperfunction: Nystagmus goes to affected side

Huntington's disease is a hyper or hypo kinectic movement?

Hyperkinetic Choreiform movements are hallmark of disease

What is choreiform movements found in Huntington's?

Hyperkinetic movements in limbs Rapid-jerky-involuntar-writhing and uncontrollable In late stages: present as mixed neurodegenerative movement disorder with elements of hypokinetics due to obliteration of basal ganglia structure

With a hypofunction of the R vestibular system the nystagmus is going to go ___________________________.

Hypofunction: Nystagmus goes to unaffected side

With a hypofunction of the R vestibular system the nystagmus is going to go ___________________________. With a hyperfunction or BPPV, the nystagmus is going to go to ____________________.

Hypofunction: Nystagmus goes to unaffected side Hyperfunction: Nystagmus goes to affected side

Over time a gaze evoked nystamus occurs and vertgio occurs intermittently with head movements, with what pathology?

Hypofunctions: Labrinthitis/neuronitis

The following are symptoms of what disorder? Severe sudden onset of vertigo, nausea and spontaneous nystagmus Nystamus beats fast towards the uninvolved side Difficulty with vision and balance

Hypofunctions: Labrinthitis/Neuronitis

What is the difference between a neuronitis and BPPV?

Hyporesponsivenss with labrinthitis and neuronitis Hyperresponsiveness with BPPV

PPS is a disorder of exclusion. What do we need to rule out?

Hypothyrodism and other endocrine Respiratory and sleep apnea Cardiac symtoms RA, joint affections SMA, ALS, Cauda equina, MS, radiculopathy, lumbar stenosis

What are the diagnosis specific outcome measurements for cerebellar ataxia?

ICARES: international cooperative ataxia rating scale SARA: scale for the assessment and rating of ataxia

What are the S&S of bilateral hypofunction disorders?

If loss is symmetrical there will be no vertigo or spontaneous nystagmus Oscillopsia Ataxic gait and impaired balance

According to the research of ALS exercise prescription, what did it say about moderate intensity aerobic and resistance exercise?

Improved ALSFRS and Ashworth scores at 3 months, but not 6 months vs. usual care

According to the research of ALS exercise prescription, what did it say about moderate intensity resistance and stretching programs?

Improved ALSFRS, and short form 36 and voluntary maximum isometric contraction scores vs. non exercise group

According to the research of ALS exercise prescription, what did it say about treadmill walking to anaerobic threshold with ventilation for 1 year?

Improved functional independence, lowered rate of decline of respiratory and muscle endurance vs. control

BPPV most commonly causes what?

Inaccurate sensory information Most common cause of vertigo and nystagmus

Describe the disorder BPPV

Inaccurate sensory information Most common cause of vertigo and nystagmus AKA: positional vertigo Due to mechanical disruption: Ototconia from the utricle get into a canal and are either free floating (canalithiasis) or stuck onto the cupula. (cupulolithiasis) Involved canal becomes gravity sensitive. Posterior canal most common. Horizontal canal rarely involved.

What are the 3 categories of peripheral disorders?

Inaccurate sensory information: BPPV Hyofunctions: neuronitis/laryinthitis, acuoustic n. ototoxicity. Fluctuating sensory information: Meniere's disease, perilymphatic fistula

Describe how to perform and the use for liberatory maneuver?

Indicated for cupulolithiasis: anterior or posterior and also for canalithiasis turn 45 degrees away from affected ear so nose is pointed up for posterior. (lay down toward affected side) Point nose first down for anterior canal. Then quickly move patient from R/L sidelying to the other side. Otoconia are gravity dependent then you flick them off. Wait 5 minutes and go back to short sitting

What vestibular nuclie is Important for reticular activiating system and with reticular formation

Inferior vestibular nuclei

What happens when hair cells bend away form the kinocilia during movement?

Inhibition of CN VIII

What initial S&S predict prolonged recovery with concussion?

Initial S&S of dizziness and fogginess: predict prolonged recovery

Why is the rehab framework for PPS, hard for patients to grasp?

Initially after polio virus, it was all about no pain no gain and going balls to the wall to intense exercise and recovery. For PPS they need to chill and protect themselves from muscle overuse. Use AD and be a bro

Describe the framework for rehab for patients with PPS that is used in regards to initial viral infection protocol. Is this a good concept for PPS?

Intense exercise Stretching and strengthening regimen daily Use of ambitious compensations methods to function: muscle substitution, ligaments for stability and use of muscles at high levels of capacity Use of AD and orthotics NO! don't use this. do the opposite for PPS

What zone of cerebellum controls coordination of agonist-antagonist muscle pairs during variety of movement- walking and limb control? Dysdiadokinesia occurs as result of dysfunction

Intermediate zone

If you move 30 degrees out to R and the eye beats fast to the R, where is the problem?

On the L

Describe the intermediate zone functions of the cerebellum

Intermediate zone: controls coordination of agonist-antagonist muscle pairs during variety of movement- walking and limb control

The following describe what scale? Activity level 4 categories: postural control, limb movements, speech, occulomotor Used for progressive and non-progressive ataxia

International cooperative ataxia rating scale ICARES

What is part of energy conservation for patients with PPS?

Is one trip sufficient? Can you make activity less effort full? Use AD? Break activity into parts? Can someone else help?

What is part of functional rehab of PPS?

Isokinetic and isometric endurance training PT for compensatory needs Energy conservation through behavioral changes

Why is locomotor training with BWS on treadmill not good for patients with gait and balance?

It doesn't address balance

What is the major rehab management for Charcot marie tooth?

It will get worse over time, so we must try our best to preserve function. Major aim is to maintain independence and QOL as disease progresses Frequent skin checks on feet to avoid ulceration consult OT Fall prevention/balance program AD for mobility matching level of progression Home assessment/evaluation and modifications Family and caregiver education/safety planning

What are the typical presentations of vestibular subtype of concussion?

Key complaints of dizziness, Nausea, Anxious in busy enviornments in store or restaurant. Off balance Hx of sensitivity, Migraines and Anxiety Objective findings: Positive for VOR, and motion/optokinetic sensitivity. Positive Balance test may or may not happen. cognitive testing positive rxn time, processing speed, intact memory

What are the typical presentations of cervical subtype of concussion?

Key complaints: Neck pain worse with sitting and reading. Decreased ROM HA in the occipital region May have dizziness from decresed Csp ROM Hx: MVA, LBP, cervical injury Objective findings: VOM is normal Balance is positive for sensory organization Cognitive testing is normal

What are the typical presentations of Post traumatic migraine subtype of concussion?

Key complaints: Unilateral pulsating HA (may be severe, may interrupt sleep) Photo and phone phobia, Nausea, Worsened with exertion Stress, anxiety and sleep problems History of: Migraine (personal or family), motion sensitivity Objective findings: VOMS normal unless vestibular overlay Balance is positive for difficulty with sensory organization. Cognitive testing positive for visual and verbal memory

What are the typical presentations of anxiety/mood subtype of concussion?

Key complaints: hypervigilance/rumination, symptoms present during downtime... Overwhelemed Difficulty initiating sleep and maintaining sleep Limited socialization Hx of anxiety, panic attacks, mood disorders, migraine, vestibular Objective findings: Negative unless vestibular overlay is present. Balance is negative Cognitive testing is fine

What causes hyporesponsiveness of the inner ear?

Labrinthitis or neuronitis. From a Faulty Push-Pull mechanism

What are the types of hypo-functions?

Labrinthitis/Neuronitis

What are the main non-motor impairments of cerebellar pathology?

Language processing working memory Learning associations between objects High order executive functions Loss of control over emotional behaviors

What is 2nd most common cause of vertigo, inflammation of inner ear or nerve and causes hyporesponsiveness?

Larinthitis/Neuronitis

What is the #1 indicator of prolonged recovery?

On-field dizziness Fogginess is key too

Describe the epidemiology of PPS?

Last epidemic of polio was in 1950... Before 600,000 children per year affected Causes the most motor deficits in the world! Prevelance of PPS is 15-80%

CN 6 controls what muscle?

Lateral rectus and eye drifts inward

What vestibular nuclie is responsible for postural reflexes and VSR

Lateral vestibular nuclei

What zone of cerebellum controls complex, multijoint voluntary limb movement , especially with visual guidance; planning of complex movements and error detection?

Lateral zone

Describe the lateral zone functions of the cerebellum

Lateral zone: controls complex, multijoint voluntary limb movement , especially with visual guidance; planning of complex movements and error detection.

How are the 3 semicircular canals paired?

Left anterior with right posterior Right anterior canal with posterior canal Horizontal canals are paired with each other Each pair produces reciprocal signals

Where are the vestibular nuclei located?

Level of pons. with some inferior at medulla

What maneuver is indicated for the following? Indicated for cupulolithiasis: anterior or posterior and also for canalithiasis

Liberatory maneuver or semont

What is the liberatory maneuver used for?

Liberatory maneuver: for posterior and anterior cupula or canal AKA semon

What is a steppage gait that is seen with CMT?

Lift knees and hike hips to compensate for DF weakness

Describe the exercise considerations for Nueromuscular disease

Light to mod resistive exercises is not contrainidcated in progressive NM disorders Light to mod aerobic exercise can be beneficial for persons with NM disease Importantly, patients must "listen" to their levels of exertion and time needed for recovery Physical activity should be encouraged

Describe the effects of exercise on patients with Charcot Marie tooth

Light to moderate resistive exercise is NOT contraindicated in progressive neuro disorders Light to moderate aerobic exercise can be beneficial for persons with neuro disorders Patients, MUST MUST MUST "listen to their levels of exertion and time needed for recovery after bouts of exercise Physical activity should be encouraged within the limits

What does the sacule of the otolith sense?

Linear acceleration: like going in elevator

Where is the peripheral sensory apparatus located?

Located in inner ear... between external and middle ear canal

What are the kinocilia?

Long hair cells that send sensory information to brain. Bending toward the kinocilia: excitiation Bending away from kinocilia: inhibition

What is part of the cervical screen for post-concussion syndrome?

Look for HA, dizziness, balance impairment, visual system and nausea Assess: Neck disability index, pain intensity (what makes it better or worse) Ligament integrity and imaging results A/PROM, accessory movements Peripheral UE symptoms Screen for cervicogenic dizziness: cervical joint position error test

How do you differentiate teh cupula problem or canal problem with supine roll test?

Look for beating toward ground. Up toward ceiling: ageotrophic -->cupulolithasis Nystagmus down toward ground: geotrophic -->canallithasis

What is significant with the dynamic visual acuity test?

Look for change of more than 2 lines.

What conditions are best to look at vestibular for posturography or SOT test?

Looking at condition 5 and 6. Eliminate vision or make it inaccurate. Making somatosensory information inaccurate

What is the conceptual framework for individualized exam and rehab for post concussion syndrome?

Looks at 6 dimensions: Vestibular Ocular Cervical Cognitive/Fatigue Post traumatic Migraine Anxiety/Mood

How do we categorize a patient in the 6 subtypes of concussion for intervention strategies? Either: Vestibular, Ocular, Cervical, anxiety/mood, post-trumatic migraine, or cognitive/fatigue

MOI Symptoms Past medical history Tests and measures such as VOM and cover uncover test.. Can be 1 dominant subtype but other subtype overlays

What are the concussion specific history questions to review?

MOI: whiplash or blunt force LOC and duration AMnesia Initial S&S of dizziness and fogginess: predict prolonged recovery History of migraines HIstory of prior concussions and recovery History of learning disorders/mood disorders History of visual impairments and strabismus, amblyopia Sport/work/recreation related risks and cognitive demands

The hair cells of the otolith are located where?

Macula

What is the sensory receptor of otolith?

Macula

What are some good specific goals for patients with ALS?

Maintence of mobility and independence and safe function for patient and caregiver Maintain max muscle strength and endurance within limits of ASL Prevention of secondary complications Management of energy conservation and respiratory function Determine adaptive equipment and mobility needs Eliminate or prevent pain

What does it mean to push the system for faster recovery of central compensation?

Make patient get into positions that cause vertigo.

How do you score VOR with a head thrust?

Make sure eyes stay looking at nose Normal response to L is looking striaght at you. If they don't move back OR overcompensate then there is problem with VOR

What are the main ways to introduce exercise for patients with ALS?

Make them formal but enjoyable! Activities include participation and social opportunity

How do we see a mal-alignment with cover/uncover test?

Mal-aligment is apparent on observation and cannot be corrected... Reveal on the cover portion of test, uncovered eye will move to center to fixate on target

What is the main population that has brain tumors?

Males > Females White > Black americans Children 0-15 y/o or adults in 5th-7th decades of life

What is best exercise prescription of ALS?

Manual resistance exercises using PNF implemented early in disease progress Supervised gentle exercises: decreased pain and stiffness and improved psychosocial Aerobic endurance of 10-15 min, decreased due to central fatigue or decreased motor units

Which pathology is based on the following clinical diagnosis? Based on: Onset and characterization of symptoms Family history and pedigree Genetic testing to confirm CMT allele EMG findings to confirm demyelination or axonal degeneration through decreased NerveConducationVelocity, MUAP or increased F wate latency Nerve biopsies

Marie charcot tooth

What canals fire when you move head back and to the R?

Max stimulate posterior canal on the R. Firing rate goes up. Anterior canal on L goes down in firing rate

What is the Rotary chair test?

Measures VOR: eyes move in equal and opposite direction Done in dark with no visual feedback eyes should move in opposite direction during step rotation of chair

Describe the ALS functional rating scale: What is ICF domain? How is it scored?

Measures functional status for patients with ALS 0-4 scale: with 4 being normal function Reliable and valid for measuring decline in function related to muscle weakness. such as turning in bed Revised version includes respiratory function

What are the only areas to receive afferent information from the spinal cord. AKA spinal cerebellum

Medial and intermediate zones of cerebellum

Describe the medial zone functions of the cerebellum

Medial zone: afferent sensorimotor state of the limbs. Efferent output of posture, muscle tone, upright stance, locomotion and in gaze

Describe the functions of the three longitudinal zones

Medial zone: afferent sensorimotor state of the limbs. Efferent output of posture, muscle tone, upright stance, locomotion and in gaze Intermediate zone: controls coordination of agonist-antagonist muscle pairs during variety of movement- walking and limb control Lateral zone: controls complex, multijoint voluntary limb movement , especially with visual guidance; planning of complex movements and error detection.

What is the abnormal endolymph levels within lymph system, which causes episodic vertigo and hearing loss?

Meniere's disease

Hearing tests are used to rule out what pathology?

Meniere's disease Perilymphatic fistual

Describe what conditions you may be thinking if someone has hearing loss

Meniere's disease Perilymphatic fistula W/O hearing loss: Think hypofunction or BPPV

What does evidence say about aerobic training for patients with PPS?

Methodology of studies is questionable.. Suggest 3 or more times per week protocol

What is treatment for a perilyphatic fistula?

Microsurgery, with rest after. no lifting or straining May or may not need PT

Describe the clinical presentation and treatment of stage 1 of ALS

Midly weak, clumsiness, ambulatory and independent with ADL Treatment: Continue normal activity or increase if sedentary Gentle PRF strengthening, no overuse, stretching and psych referral if needed

What is the main overview and aspects involved with a primary brain tumor?

Mimic presentation of CNS disorders Improved survival rate due to advances of medical field Aggressive nature of disease and treatment create barriers to intervention Understanding natural history and complications of treatment

If someone just has minutes of vertigo symptoms indicates what pathologies?

Minutes: Possibly cupulolithiasis of BPPV, central vestibular disorder, Meniere's disease

What are the typical acute or ICU interventions for a patient with a brain tumor?

Mobilization in and out of bed Monitoring ICP and vitals Ventriculostomy or tube inserted in the CSF to drain Communication with RN Mobility equipement

Describe the clinical presentation and treatment of stage 2 of ALS

Mod- selective weakness, ambulatory, with slight decrease in ADL independence- climbing stairs and buttoning cloths Treatment: Stretching, cautious strengthening for MMT >3+/5. Orthotic and AD

What is the appropriate exercise intensity to work with patients with ALS?

Moderately intense exercise may slow progression of disease, especially with copper gene mutation High intensity exercise can hasten disease and lead to death

With huntington's how does atrophy of caudate nucleus affect normal function

Moderates output of motor information. Therefore you get too much movement

What are the exercise prescription factors for patients with ALS in regards to endurance?

Monitor closely for fatigue Limit to <15 min Include rest Monitor fluids and oxygen, Supportive, adaptive, patient and family focused

Describe the pathology of a cerebellar brain tumor

More common in children: Most common in posterior fossa Recovery of function and ataxic movement: poorer prognosis in adults Damage of deep cerebellar nuclei may predict recover better than age

What are the typical presentations of cognitive/fatigue subtype of concussion?

Most common in acute phase. Characterized: fatigue that worsens as day goes on. HA that is non-localized Decreased energy Poor attention, distractible Symptoms worsen with activity potential sleep deficits. Hx of learning disability-- Risk Factor Objective findings: VOMS is normal Balance is normal Cognitive testing is positive, with impairments of memory and reaction time. Global deficits

What is the Hallpike-Dix maneuver used for?

Most commonly used test Posterior and anterior canal or cupula. BPPV. Canals are Aligned 45 degrees away from midline

What is ALS?

Motor Neuron Disease Inherited or sporadic disease Clinical disorder of UMN, LMN Or both Most common is ALS, which is degeneration and loss of motor neurons in SC, brainstem and brain

What does the poliovirus usually affect?

Motor neurons in the anterior horn cells. Apoptosis of affected motorneurons

The following makes up what part of the vestibular system: VOR VSR

Motor output system

What are the responsibilities of the cerebellum for normal function?

Movement! Coordination of movement, Adaptation of movement Vestibular Balance Motor learning. Connects to prefrontal cortex and impacts cognition-memory, emotional regulation and language processing

What is the approach with concussion symptoms?

Multi-disciplinary: Pt, physician Athletic trainer with on-field management Neuropsychologist PT, OT, coach, school personnel

What is the overall rehab summary for charcot marie tooth?

Multidisciplinary Utilize aquatics when safe and no contraindications Incorporate non-WB and partial WB cardiorespiratory fitness Allow for longer rest breaks in between bouts of work/exercise. Light-mod strength training is NOT contraindicated and there is no evidence that it shows disease progression Patient and family caregiver education is imperative Consider who factors and females may complain about AFO wearing

What are the main impairments related to CMT?

Muscle Weakness and fatigue Hyporeflexia Selective hypotonicity Atrophy Poor balance and trunk control Falls LMN deficits

What are the key body structure function differences for a patient with ataxia or cerebellum pathology?

Muscle tone is usually hypotonic voluntary movement coordination is important to test: finger taping, supination/pronation, handwriting, toe tapping Static and dynamic balance with pertubations or narrow BOS Oculomotor performance: smooth pursuit, saccades, gaze evoked nystagmus

What does it mean how each semicircular canal has reciprocal signals?

One partner increases signal, while other partner decreases it's signal

Describe the typical symptoms of peripheral vestibular disoders

N&V: Severe Imbalance: Mild Hearing loss: Common Oscillopsia: Mild or not present Neuro symptoms: Rare Compensation: Rapid

Describe the typical symptoms of central vestibular disoders

N&V: moderate Imbalance: Severe Hearing loss: Rare Oscillopsia: Severe Neuro symptoms: common Compensation: slow

Describe the horizontal canal BPPV?

NO torsion with nystagmus. Cupuloithiasis: ageotropic Canalithiasis: geotropic Horizontal canal BPPV, has longer duration of symptoms and pt is more sick.

What is a treatment for pain for patients with post-polio syndrome?

NSAID Stretching Lifestyle changes that promote --> Pacing of activity Orthotic/AD/power mobility Heating modalities and cryotherapy

Describe the medical management for marie charcto tooth's

NSAID's or corticosteroids: consider the timing treatments of fatigue from ADL's Patients may be on antidepressants as well. On NSAIDS or corticosteroids to target the inflammatory degeneration process.. Multidisciplinary Symptomatic mangement and use of lyrica for neuropathic pain

What eye problem is commonly seen for people with concussion?

Near point convergence

What is good outcome measure for neck pain post-concussion?

Neck disability index

What is post-polio syndrome?

Nervous condition that is sequelae from the poliovirus PPS occurs up to and beyond 15 years after initial viral infection Considered a chronic neurological impairment

Describe the peripheral disorder, related to hypofunctions?

Neuronitis/labryinthitis, acoustic n. ototoxicity. Can be unilateral or bilateral

What are the new symptoms usually associated with PPS muscle weakness?

New symptoms of: fasciculations, cramps, atrophy, elevation of muscle enzyme in blood

What is medical management of ALS?

No cure Palliative treatment Symptomatic mangement Medications such as riluzole help prolong life Cannabis helps patients with spasms and spasticity

What causes Meniere's disease?

No know cause, but endolyphatic fluid increases. PROGRESSIVE DISEASE

When would you see no vertigo or spontaneous nystamus with vestibular problems?

No mismatch between R and L ear with bilateral hypofunction... but you may have oscillopsia or ataxic gait

What is the framework for rehab with PPS?

No overexertion No intense exercise Compensation of function within capabilities and use of AD and social support Energy conservation Protect joints and shift from recovery to health promotion.

What is the main thing to determine before developing POC for someone with cerebellar ataxia?

Non-progressive or Progressive!! Do we promote recovery/restoration or do we promote compensation or health promotion

What is a treatment for Pulmonary for patients with post-polio syndrome?

Noninvasive ventilator assistance Pulmonary therapy and breathing exercises N *Need referral

Does central vestibular disorders respond to therapy?

Not really. Compensation areas are damaged, since vestibular system can no longer compensate

What are the key differences when examining someone with ALS vs. other populations?

Note bulbar and respiratory impairments Environmental blocks to independence Caregiver demands and education of disease Rate of disease progression Activity log of : pain level, fatigue and effort of tasks

What is a phoria, which is common with concussion injuries?

Nystagmus as child and now it's back due to blow to head. When you look at patient they look normal. for the most part unless it's end of day an it's fatigued Then do cover/uncover test... Cover affected eye, which it will go to rested strabismus position, since it's lazy. When you cover eye it doesn't focus and falls into uncompensated position. When you uncover it you will see it away from midline

What happens to the eyes for patients with BPPV?

Nystagmus with fast and slow phase

During the oculomotor exam what are we looking for?

Nystagmus: direction of fast phase Quality of eye movement: Corrective saccades Subjective complaints Inability to maintain visual fixation

How do you screen for VOR and ocular movements post concussion?

Observation alignment, head tilt and position, dynamic visual acutiy test Visual field testing, pupillary light reflex Ocular ROM and alingment Cover and uncover test, maddox rod, and VOMS, pursuits, saccads and covergence, vor ***MOST ARE NEGATIVE WITH VESTIBULAR DUE TO CONCUSSION

What is part of the clinical examination for vestibular problems?

Occulomotor examination: H-test Positional testing: Hallpike dix Motion sensitivity Balance and gait assessment Sensation: proprioception

What are intention tremors? How may this effect our treatment session?

Occur in terminal portions of visually guided movement If reduced with eyes closed it's intention tremors. Reduced with decreased vision and isometric contractions, so plan accordingly

What two things control out motor output of the vestibular system?

Occurs via VOR and VSR

The following are characteristics of what subtype of concussion? Primary complaint of frontal HA oir pressure behind the eyes. Reading worsens it. Blurry or double vision Fatigue, distractible and difficulty reading and taking notes. HX: ocular dysfunction or strabisumus Objective": VOMs is positive for pursuits/saccades, near point convergence test >6 cm Cover/uncover and maddox are positive Balance may have sensory organization difficulties Cognitive testing positive for visual memory, rx time and encoding information

Ocular ****Refer out to eye specialist if they have bad pursuits and saccades

The VOR sends signals to what cranial nerve?

Ocular motor nuclei, which houses CN 3, 4 and 6

What occurs within an ENG test? (Electronystagmorgraphy)

Oculomotor exam Calorics: Cold stimulus and seeing where they eyes go. Eyes move away. Nystagmus to L with cold air in R ear. Warm air will have nystagmus to same side of air blow. COW: Cold away Nystagmus Positional testing

What is part of oculomotor performance for a patient with cerebellar ataxia?

Oculomotor performance: smooth pursuit, saccades, gaze evoked nystagmus ***Very important to assess***

BPPV for the anterior an posterior canal are diagnosed how with regards to the Hall-pike dix test? How do you differentiate between cupula and canal

On cupula there is a more sudden complain If canal there is a delay in symptoms

What is part of the clinical diagnosis of HD?

Onset of symptoms Family history of HD? Genetic testing to confirm HTT allele or CAG repeats Neuroimaging to identify changes in basal ganglia and cortical atrophy

What are the typical Inpatient interventions for a patient with a brain tumor?

Optimize function to reduce burden of care and safely DC: use fim Personal goals and interest with community integration and rec therapy Combined recovery and compensatory approach Caregiver training/problem solving Motor learning and repetition!!!!!

How is the horizontal semicircular canal oriented?

Oriented at 30 degrees from trasnverse plane

How are the canals in oriented to each other?

Oriented at 90 degrees to each other. Horizontal canal is bottom and anterior and posterior canals make the wall

What is oscillopsia, in simple terms? What is a skew deviation?

Oscillopsia: world is bouncing Skew deviation: When one eye is lower than another

What are common examination findings in regards to mobility/posture for patients with PPS?

Osteoarthritis of wrist and hand Gait analysis --> Overuse and substitution of vstus lateralis, biceps femoris, glutes max and soleus not functionning Decreased activity up to 16 hours sedentary

The otolith responds to gravity via what?

Otoconia

Where are the gravity sensitive calcium carbonate crystals located?

Otoconia

Why do people have BPPV from a physiological level?

Otoconia in utricle break away and get into posterior semi-circular canal. The semi-circular canal is gravity sensitive!

How do you perform the liberatory maneuver or Semont maneuver?

Otoconia is stuck to cupulolithiasis. flick otoconia off cupula and back into normal position. turn 45 degrees away from affected ear so nose is pointed up for posterior. (lay down toward affected side) Point nose first down for anterior canal. Then quickly move patient from R/L sidelying to the other side. Otoconia are gravity dependent then you flick them off. Wait 5 minutes and go back to short sitting

What senses position of the head during R and L tilting?

Otolith

Skew deviation occurs with what pathology?

Otolith disorder One eye displaced inferiorly

What is the vestibular mechanism for motor output?

Output for VOR. Ocular motor nuclei... (3, 4 and 6) Output for VSR (medial and lateral vestibulospinal tracts and reticulospinal tract)

Describe the patholophysiology of Huntington's

Over time, gene mutation leads to neuro impairment Cortical destruction and atrophy occurs in caudate nucleus Late stage profound dementia May have mood/psychiatric involvement Life expectancy: 15-25 years beyond symptoms Progressive degeneration with enlarged lateral ventricles

What are considerations of perscription for PPS?

Overall inconclusive but... Apply to muscles with 3+/5 NONFATIGUING!!!!!!! supervised and testing every 3 months avg 12 wk program

Overwork damage is a negative outcome for ALS exercise prescirption. Describe why this occurs

Overwork damage: occurs in denervated muscles with <1/3 motor units Impairs dollateral sprouting

What does evidence suggests for treatment approach in regards to cerebellar ataxia intensity and duration of intervention training?

Partial relearning is possible with select cerebellar population- 10 hrs/wk and 6 months

Although exercise sometimes works with ALS, what are the negative outcomes of exercise prescription?

Overwork damage: occurs in denervated muscles with <1/3 motor units Impairs dollateral sprouting Damage to normal muscle fiber with repetitive eccentric work: Normal muscle in a patient with ALS may not have the repair capabilities Exercise intolerance: Mitochondrial dysfunction, abnormal muscle metabolism, impaired activation and central activation failure ***Be attentive to their reports after program after instituting program With reports of morning fatigue or significant weakness

What are the main differences between post concussions and acute concussions?

PCS is different than acute concussions PCS: predominately psychology: irritability, anxiety, problems concnetrating, depression and sleep problems Acute are more physiological: N&V, slurred speed, disorientation, impaired coordination Overlap with dizziness, fogginess, HA

Which typical concussion symptoms are psychological in nature? Whic are typically physical?

PCS: predominately psychology: irritability, anxiety, problems concnetrating, depression and sleep problems Acute are more physiological: N&V, slurred speed, disorientation, impaired coordination

The following describes what problem with the cover/uncover test: When you look at patient they look normal. for the most part unless it's end of day an it's fatigued Then do cover/uncover test... Cover affected eye, which it will go to rested strabismus position, since it's lazy. When you cover eye it doesn't focus and falls into uncompensated position. When you uncover it you will see it away from midline

PHORIA: Commonly with post-concussion to explain blurred vision and HA with readings. Corrective saccade when shifted back

Cold intolerance is part of what pathology?

PPS

The following are functional rehab conditions for what pathology? Isokinetic and isometric endurance training PT for compensatory needs Energy conservation through behavioral changes

PPS

The following are secondary symptoms with what pathology? Sleep disorder, REspiratory disorder Dysphagia, dysarthria Fascicualations Joint deformities

PPS

The following are the primary symptoms of what disorder? Decreased muscle strength and endurance in both previously affected and unaffected muscles Pain and fatigue

PPS

The following is exercise prescription for what population? Overall inconclusive but... Apply to muscles with 3+/5 NONFATIGUING!!!!!!! supervised and testing every 3 months avg 12 wk program

PPS

This is the clinical trio of what disorder? Fatigue Pain Deterioration of motor deficits

PPS

The following are key differences when examining what population? Health hx: growth and developmental history and family history More complex systems review includes: sleep, temperature intolerance, fatigue, pain and ageing process Tests and measures with emphasis on MSK system

PPS ***Polio affected them as a kid, so what changed with them... GO MORE COMPLEX with respiration and potential issues surfacing

Drugs usually lack efficacy and effect on fatigue and strenght!!! for what condition?

PPS Therefore functional rehab is better

In the vestibular nuclei complex, what is housed in there?

Part of central processor. Vestibulo-ocular reflex: gaze stabilization Vestibulospinal reflex: postural control

What does evidence suggests for treatment approach in regards to cerebellar ataxia gait and balance training?

Part task such as kneeling, sitting and quadruped Multifactoria training: gaze, static and dynamic activities. Address balance such as ankle mobility Treadmill training, visually guided stepping. Interventions MUST provide challenge and trail and error

The following are symptoms of what pathology? hearing loss, positional vertigo, oscillopsia, skew deviation

Perilymphatic fistula

What are the types of Fluctuating sensory information vestibular problems?

Perilymphatic fistula Meniere's disease

What is a pressure change from tear in round or oval window between the middle and inner ear causing a flow of fluid between the middle and inner ear and distorts the SC and utricle?

Perilyphatic fistula

Peripheral or central vestibular problem? N&V: Severe Imbalance: Mild Hearing loss: Common Oscillopsia: Mild or not present Neuro symptoms: Rare Compensation: Rapid

Peripheral

The following are characteristics of peripheral or central nystagmus? Fatigues with testing Acutely will see spontaneous nystagmus in room light --> quickly suppressed with visual fixation by person Often a delay with positional vertigo

Peripheral

Gaze evoked nystagmus is in one direction with what problem?

Peripheral problems: Will be both torsional and rotational Central will change direction of nystagmus

The following makes up what part of the vestibular system: 3 semicircular canals on each side: with hair cells in each ampulla 2 otolith organs (saccule and utricle on each side): with hair cells in each Vestibulocochlear nerve in each side

Peripheral sensory apparatus

What are the 3 main structures of vestibular system?

Peripheral sensory apparatus Central processor Motor output system

What are the differences between peripheral and central nystagmus?

Peripheral:: Fatigues Acutely will see spontaneous nystagmus in room light --> quickly suppressed with visual fixation by person Often a delay with positional vertigo Central: Persists Will be spontaneous Changes direction with gaze changes Often vertical or "pure" rotational or "pure" horizontal Will be immediate onset with positional vertigo

What are signs of peripheral nystagmus?

Peripheral:: Fatigues with testing Acutely will see spontaneous nystagmus in room light --> quickly suppressed with visual fixation by person Often a delay with positional vertigo Such as BPVV, or hypofunction

For patients that are tired all the time and have dizziness or HA with exertion. What are you going to look at?

Physical exertion screen

What is the main outcome measure Physicians' use for brain tumors?

Physician evaluative tool: Karnofsky Performance sclae index: 0-100, level of independence.

What causes the most motor deficits in the world?

Polio

The following are late concerns with what pathology? Degenerative arthirtis from overuse Bursitis and tendonitis

Polio virus

Denervation can induce metabolic changes in muscles for patients with PPS. Describe more about the peripheral mechanism

Possible decrease energy production in type I fibers- fatiguability

How do you differential between concussion and post concussion syndrome

Post concussion: >10 days of persistent symptoms in adults >3 weeks of persisten symptoms in high school and young athletes

Quick or progressive loss of muscle strength/endurance of previously unaffected muscle in conjuction with cold intolerance and muscle fatigue, 15 years after another condition helps with diagnosis of what?

Post polio disease

The following are goals for what patient population? Collaborative effort between family you and patient Focus on symptom management Achievement depends on commitment and compliance LTG: Self management of HEP and lifestyle changes STG: symptoms mangement QOL considered

Post polio syndrome

The following are characteristics of what subtype of concussion? Key complaints: Unilateral pulsating HA (may be severe, may interrupt sleep) Photo and phone phobia, Nausea, Worsened with exertion Stress, anxiety and sleep problems History of: Migraine (personal or family), motion sensitivity Objective findings: VOMS normal unless vestibular overlay Balance is positive for difficulty with sensory organization. Cognitive testing positive for visual and verbal memory

Post traumatic Migraines

The following are the causes of what pathology? Remaining genetic viral material could create immune response in CNS or PNS Imbalance between the dysfunction of degenerative and regenerative physiologic function of motor units Structural and functional impairments of muscle fibers

Postpolio

What is the purpose of the vestibulospial reflex in the vestibular nuclei complex?

Postural control

What is the presentation of muscle weakness with PPS?

Presentation is asymmetrical, proximal, distal or patchy, Noted more in repetitive and stabilization contractions Decreased ability to recovery rapidly after contraction Note noted with individual MMT as much

What are the things to note about muscle weakness with PPS?

Primarily affects muscles severely affected with initial infection Presentation is asymmetrical, proximal, distal or patchy, Noted more in repetitive and stabilization contractions Decreased ability to recovery rapidly after contraction New symptoms of: fasciculations, cramps, atrophy, elevation of muscle enzyme in blood

What are the typical presentations of ocular subtype of concussion?

Primary complaint of frontal HA oir pressure behind the eyes. Reading worsens it. Blurry or double vision Fatigue, distractible and difficulty reading and taking notes. HX: ocular dysfunction or strabisumus Objective": VOMs is positive for pursuits/saccades, near point convergence test >6 cm Cover/uncover and maddox are positive Balance may have sensory organization difficulties Cognitive testing positive for visual memory, rx time and encoding information

What are the classifications of primary vs. secondary brain tumors?

Primary: Gliomas, astrocytomas, glioblastoma multiforme exts Secondary: Metastatic and malignancies come from outside of CNS 25% with systemic cancer develop brain tumor 80% of cerebral tumor- frontal lobe 20% is posterior fossa 33% metastasizes to lungs

Describe the medical diagnosis process of PPS?

Prior episodes of paralytic polio --> Period of partial or complete neurologic recovery --> Extended interval of stability lasing >15 years --> Quick or progressive loss of muscle strength/endurance of previously unaffected muscle in conjuction with cold intolerance and muscle fatigue --> Symtoms progress for more than 1 year

The vestibular nuclei complex and cerebellum house what function of vestiublar system?

Processes sensory information and execute motor command via VSR and VOR

What is the pathophysiology of ALS in connection to neuroantomical disease state of ALS?

Progresive degeneration and loss of motor neurons in the SC, brainstem and motor cortex Affects: UMN in cortex Corticospinal tract and motor output affected Brainstem nuclei for CN 5, 7, 9, 10 and 12 are effected. Usually anterior horn cells are lost

Describe the health promotion-compensatory approach framework for rehabilition

Progressive ataxia Anticipate worsening of impairments and activity

CMT leads to gross motor weakness and sensory dysfunction. How does this progress?

Progressive over time and advances in distal to proximal fashion

What is the prognosis for progressive cerebellar ataxia?

Progressively worsening clinical signs and symptoms

On-field dizziness is predictive of what for concussion?

Prolonged recovery #1 predictor

With the rivermead post-concussion symptoms questionnaire what does is predict?

Prolonged recovery is predicted by an increased number and increased severity of symptoms

Postural control is one of the main functions of the vestibular system. What 3 things comprise of postural control?

Provides sensory input regarding position and motion of head Role in controlling position of the body's COM Role in stabilizing and orienting the head with respect to gravity.

Describe the important PT exam considerations for Charcot Marie Tooth disease

Pt Hx and systems review Tests and measures for fall questionnaires, balance outcomes, and functional ambulation GMFM and LEFS Disease-specific measures and patient reported impacts

What is a cross cover test?

Put hand over one eye then remove it. See if eye moves up or down

What are the main things to differentiate between non-vestibular and vestibular disorders as well as peripheral vs. central disorders?

Question: TRUE vertigo vs. dizziness/lightheadness from a-fib/hypotension or other non-vestibular disorders Question: Ask how long vertigo lasts, history of illness, recent trauma to head, ask special tests by physician

What is firing at a tonic rate when the head is still?

R and L CN VIII. 80 pulses per second

When turning head to R, what happens to maintain eyes level forward? What muscles are activated by the horizontal canals?

R eyes medial rectus muscle is facilitated and L eye lateral rectus is facilitated and contracted

What happens to the kinocilia when you rotate head towards R?

R horizontal canal will have excitation: hair cells bend toward the kinocilia L horizontal canal will have inhibition.: Hair cells bend away from kinocilia

What happens when head is tilted to R. What part of semicircular canals are firing?>

R otolith has increase firing. L otolith is inhibited

WHo is in charge of a brain tumor patient POC in the hospital? What do they do?

RN Initiate care plan, education Dx, tx, coordinate teams, train family on tube feeds, skin care and review home care and meds

What is radiation therapy used for?

Radiation: For malignant tumors. 6 weeks, 1-5 minutes a day Adverse effects of healthy tissue and burns

The synthesis should focus on what aspects for care of ALS?

Rate of disease progression goals Distribution of weakness, spastcity, respiratory factors, fatiguability and bulbar involvement Phase of disease Pre-existing impairments or activity limitations

How do you perform the dynamic visual acuity test with a snellen chart?

Read snellen chart while the head is stationary, forward bent and passively rotated.

How do you perform the dynamic visual acuity test?

Read snellen chart while the head is stationary, forward bent and passively rotated. For VOR testing Look for change of more than 2 lines.

How do you screen for cervicogenic dizziness with concussion?

Screen for cervicogenic dizziness: cervical joint position error test Have patient close eyes and turn head 80 degrees to R. Then close eyes and return to midline, based on feel. Repeat with head extension and rotation to R and L..

Describe the key differences that you may encounter for someone with a brain tumor?

Really consider ICF and emotional impacts of care Pain is prominent Progressive decline Continuous reassessment due to side-effects of treatment include cerebral edema, hydrocephalus, tumor regrowth and infection Foundational knoledge on nature, flutuating stuats and anticipating progressive decline of brain tumor

What predicts recovery function for a cerebellar brain tumor?

Recovery of function and ataxic movement: poorer prognosis in adults Damage of deep cerebellar nuclei may predict recover better than age

Who has a huge role to eval their leisure activities, skill builing and community resources for a patient with a brain tumor in the hospital?

Recreational therapist

What is a treatment for dysphagia for patients with post-polio syndrome?

Referral to dietician Breathing and swallowing techniques and monitor fatigue

What is a treatment for Psychosocial for patients with post-polio syndrome?

Referral to support polio group Counseling services/vocational counseling/interdisciplinary Behavioral modifications

Describe the peripheral disorder, related to Flunctuating sensory information.

Related to MEniere's disease and Perilymphatic fistula

What does evidence say about the pathophysiology of PPS?

Remaining genetic viral material could create immune response in CNS or PNS Imbalance between the dysfunction of degenerative and regenerative physiologic function of motor units Structural and functional impairments of muscle fibers

What is the clinical diagnosis process of ALS?

Requires presence of LMN, UMN or progression of disease within a region or to other regions Absence of electrophysical and pathological evidence of other disease Neuroimaging evidence of other disease processes

What is the purpose of the otoconia in the otolith?

Responds to gravity

What is the purpose of the lateral vestibular nuclei?

Responsible for postural reflexes and VSR

What is the suggested treatment focus for patients with gait ataxia, based on the location of lesion who had a CCA problelm

Retrain gait in all functional enviornment, avoid obstacles

What is the main focus for persons with huntingtons' rehab?

Rhythm and cadence control via metronom... SMaller amplitude movements PNF with focus on trunk control Look for End of dose or On:Off medications effects

Describe what works for the rehab management of Huntington's disease

Rhythm and cadence via auditory stimulus (metronome) had positive effects on gait disturbances Smaller amplitude motor control emphasized like Tia Chi Relaxation techniques may be helpful in reducing Choreiform movements PNF techniques and rhythmic stabilization for trunk control Timed therapy after meds to maximize session

What are the balance outcomes measures for vestibular problems?>

Romberg/Sharpened romberg: LOB with acute vestibular problem SLS Functional reach test CTSIB/SOT: foam and dome LOS test: limits of stability test Movement strategies Fukuda step test: March in place and look for drift. Side they drift too is indicative of hypofunction. Berg balance scale

Exam Review:

Room 301 at 8 am on Tuesday No SCI questions! Vestibular questions -> Think about Dix-Hallpike and results of this. Know findings and how to diagnose it What are brock-strings? Cupulothesis and Canalisthesis and what treatments you may use. Instead of Epley, it may say canal repositioning. Know different names, also with Libertarian and Semont Know different eye muscles and VOR Know sacule and utricle and what the purpose is and other anatomy. Know BPVV What is brant-daroff and what is hypofunction, what is presentation, when u suspect it what test would you use and treatments for hypofunction Review head-thrust results and head shaking and what it means Know clinical sub-groups of concussions and the clinical sub-group and acute symptoms LOTS OF QUESTIONS What would you expect with recovery, and VOMS RARE diseases: Pathologies of each, know clinical presentations HD, CMD, Brain tumor, PPS, ALS and cerebellar lesions. Know treatment approaches, understand short-terms vs. long-term approaches Know primary and secondary complications of HD, know how many people are diagnosed with _____ Describe presentations of diagnoses, know impairments, prognosis. What is evidence showing of CMD with research. Know requirements to diagnose post-polio. Know ataxia and describe it and outcome measures with ataxia and treatment goals that are most appropriate. Think about different outcome measures for each diagnoses. Don't forget about role of hospice when it comes to rare disease planning

What Assists in determining if a patient has had a central compensation for a hypofunction?

Rotary Chair test

How do you perform the Hallpike-Dix maneuver to the L?

Rotate head 45 degrees to L to test L, then you very quickly put position in supine position and extend neck Will align posterior canal and make it gravity dependent. Otoconia fall into canal if present and will stimulate the hair cells.. Patient will complain of vertigo and nystagmus in place

How do you perform the Hallpike-Dix maneuver to the R?

Rotate head 45 degrees to R to test R, then you very quickly put position in supine position and extend neck Will align posterior canal and make it gravity dependent. Otoconia fall into canal if present and will stimulate the hair cells.. Patient will complain of vertigo and nystagmus in place

The following describes what outcome measure? Activity level 8 items, quantifies performance and not categorized Reliable and valid for SCerebellumAtaxia

SARA

The following tests for what? Have R hand up and L hand up 10 inches apart. "Look at r hand and then look at L" Don't move head Are they accurate to target? If not, they have corrective saccade Move past target if cerebellum is damaged

Saccadic movement

What makes up the otolith?

Saccule (verticle) and Utricle (horizontal)

What senses linear acceleration?

Sacule: like going in elevator

Describe the SARA

Scale for the assessment and rating of ataxia: Activity level 8 items, quantifies performance and not categorized Reliaable and valid for SCA's

What is part of vestibular/visual screen for post-concussion syndrome?

Screen for BPPV which is common with blow to head Screen, Nystagmus, VOR and ocular movement Dizziness Handicap inventory Observation alignment, head tilt and position, dynamic visual acutiy test Visual field testing, pupillary light reflex Ocular ROM and alingment Cover and uncover test, maddox rod, and VOMS, pursuits, saccads and covergence, vor

The following is characteristics of primary or secondary brain tumors? Metastatic and malignancies come from outside of CNS 25% with systemic cancer develop brain tumor 80% of cerebral tumor- frontal lobe 20% is posterior fossa 33% metastasizes to lungs

Secondary

Why would bilateral vestibular hypofunction occur?

Secondary to meningitis, sequential vestibular neuronitis, ototoxic drugs

If someone just has seconds of vertigo symptoms indicates what pathologies?

Seconds: BPPV, chronic hypofunction BPPV is positional vertigo which is how to differentiate the two.

Describe how the duration of vertigo can lead to a diagnosis

Seconds: BPPV, chronic hypofunction Minutes: Possibly cupulolithiasis of BPPV, central vestibular disorder, Meniere's disease Hours: Acute hypofunction, Meniere's disease Days: Acute hypofunction

The macula is to the otolith like the cupula is to what?

Semiciruclar canals

What is oscillopsia?

Sensation of objects moving around in the visual field when looking in any direction. This happens with bilateral vestibular hypofunction.. Impairs balance and gait

What is the main function of the semicircular canals?

Sense acceleration and deceleration of head Most sensitive to fast head movements. Head looking R and L and up and down

What detects motion of the head?

Sensory hair cells in ampulla. sends informtion to brain

What is the crista?

Sensory mechanism of the semicircular canals. Located in the ampulla of each canal

What does a Posturography test indicate?

Sensory organization test. Measure postural sway in different conditions. Looking at condition 5 and 6. Eliminate vision or make it inaccurate. Making somatosensory information inaccurate

What is macula?

Sensory receptor of the otolith

Describe the clinical presentation and treatment of stage 5 of ALS

Severe LE weakness, Moderate to severe UE weakness, w/c dependent, dependent with ADL, skin breakdown. Treatment: Family training for transfers, positioning to reduce skin breakdown, turning schedule, home modifications for mobility Hospital bed with air mattress and possible home mechanical vent

What are symptoms after a central vestibular disorder pathology?

Severe balance deficits and vertigo

What are symptoms of hypofunctions or labrinthitis/neuronitis?

Severe sudden onset of vertigo, nausea and spontaneous nystagmus Nystamus beats fast towards the uninvolved side Difficulty with vision and balance

Describe the clinical presentation and treatment of stage 3 of ALS

Severe weakness in ankles, wrists and hands Increase in respiratory effort Treatment: Continue stage 2 program- monitor fatigue closely , maintain physical independence through activity and AD Deep breathing exercises, chest stretching, postural drainage Potential for W/C prescription now

What is the clinical manifestation of Huntington's?

Severity may be variable at onset of symptoms Depends on extent of atrophy and number of deleterious CAG repeats and rate of progression. Chorieform movements: Hyperkinetic movements in limbs Rapid-jerky-involuntar-writhing and uncontrollable In late stages: present as mixed neurodegenerative movement disorder with elements of hypokinetics due to obliteration of basal ganglia structure

What are the sterocilia?

Short hair cells in cupula (gelatinous membrane)

Is there evidence for strength gains for patients with PPS?

Shows retention of strength gains through performance No muscle damage If hypertrophy it is not shown, but motor learning may be occuring within muscle

Describe type 1 CMT

Type 1 CMT's display peripherally demylinating

True or false, there is muslce damage with strength training for someone with PPS? What actually happens with strengthening and PPS

Shows retention of strength gains through performance No muscle damage If hypertrophy it is not shown, but motor learning may be occuring within muscle

What is treatment for Post-traumatic migraine subtype with concussions?

Skilled PT not that helpful Medications: beta blockers, CA channel blockers, tricyclic antidepressants, anticonvulsants Graded exertional training Sleep scedules

What are the secondary rare symptoms of PPS?

Sleep disorder, REspiratory disorder Dysphagia, dysarthria Fascicualations Joint deformities

What does evidence suggests for treatment approach in regards to cerebellar ataxia compensatory training?

Slow down movement Decomposition Visual cue, minimize distraction Widen gait Use of AD if managed safely

What are the typical impairments of Upper motor neuron disease?

Spasticity Hyperreflexia Clonus Pathological reflexes such as babinski

Describe what the treatment approach should be for the following impairment for someone with cerebellar ataxia: Reduced postural control, tone and tremor

Specific strength and balance compensation Enviornmental cues Aids

What are the types of nystagmus?

Sponatneous Gaze-evoked Head-shaking

80-90% of people with concussion with recover in what way?

Spontaneously recovery on own

What type of ALS is most common?

Sporadic ALS > familial ALS 70-80% is limb onset 20-30% is bulbar onset

The following characteristics and treatment describe what stage of ALS? Midly weak, clumsiness, ambulatory and independent with ADL Treatment: Continue normal activity or increase if sedentary Gentle PRF strengthening, no overuse, stretching and psych referral if needed

Stage 1

The following characteristics and treatment describe what stage of ALS? Mod- selective weakness, ambulatory, with slight decrease in ADL independence- climbing stairs and buttoning cloths Treatment: Stretching, cautious strengthening for MMT >3+/5. Orthotic and AD

Stage 2

The following characteristics and treatment describe what stage of ALS? Severe weakness in ankles, wrists and hands Increase in respiratory effort Treatment: Continue stage 2 program- monitor fatigue closely , maintain physical independence through activity and AD Deep breathing exercises, chest stretching, postural drainage Potential for W/C prescription now

Stage 3

The following characteristics and treatment describe what stage of ALS? Hanging arm syndrome, shoulder pain, edmatous hand , W/C dependent, severe LE weakness, can perform ADL with fatigue Treatment: Heat/massage for spasm, edema prevention, AA and PROM of limbs Isometric contractions to tolerance, orthotic UE support- sling/trays and power mobility

Stage 4

The following characteristics and treatment describe what stage of ALS? Severe LE weakness, Moderate to severe UE weakness, w/c dependent, dependent with ADL, skin breakdown. Treatment: Family training for transfers, positioning to reduce skin breakdown, turning schedule, home modifications for mobility Hospital bed with air mattress and possible home mechanical vent

Stage 5

The following characteristics and treatment describe what stage of ALS? Bedridden and completely dependent on ADL Treatment: Continue family education, positioning, turning schedule, use of lift devices to change position and transfer Impairment specific: dysphage, soft diet, adaptive feeding, tube feeding Salivation- surgery and suction Dysarthria-speech amplication and palatal life Respiratory-clera airway, trach, vent Requires many health care members

Stage 6

How do you perform Brandt-Daroff habituation exercises?

Start in short sitting, then turn head away from affected side 45 degress. Go down S/L toward affected side. Wait 30 s after symptoms go away. Go back to short sitting and stop... Like liberatory manuever but you just go back to long sitting when moving from each side. NOSE IS ALWAYS TURNED UP!!!

What is static vs. dynamic types of imaging?

Static: CT and MRI Dynamic: PET, SPECT, MRS and fMRI

How does imaging occur for brain tumor?

Static: CT and MRI Dynamic: PET, SPECT, MRS and fMRI Computer integration: Biopsy- stereotatcic EEG

Describe what the treatment approach should be for the following impairment for someone with cerebellar ataxia: Reduced learning from error

Stepwise prompts, high reps, conscious attention is important

What are the two types of hair cells?

Sterocilia: short hair Kinocilia: long hair

What is the medical management for PPS?

Steroid medication Immunoglobulin Amantadine Drugs usually lack efficacy and effect on fatigue and strenght!!!

What is sterotactic radiosurgery?

Sterotatic radiosurgery: Gamma knife: deeply embedded small tumors, robotic arm to focus beams of radiation to target tumor. Minimal damage to healthy cells Used for smaller tumors

What is the suggested treatment focus for patients with gait ataxia, based on the location of lesion who had a superior cerebellar artery stroke?

Strength/balance, walking aides, cortically control walking, cue

WHat are the best interventions and rehab mangement for HD?

Stretching to avoid contractures Low load and sustained stretching or resting or night splints and serial casting Continual eval for DME or assistive devices Consider TENS for pain

Describe the rehab interventions for Charcot Marie tooth

Stretching to avoid contractures in hands, may need bracing or splints in later stages. Low load and sustained stretching to protect from contractures Resting or night splints, serial casting of ankles Continual evaluations for DME and assistive devices May need protective socks similar to diabetic neuropathy

What are the main central vesitublar disorders?>

Stroke (PICA, AICA) or cerebellum MS Head trauma Migraine related vestibulopathy After surgery for meningioma in brainstem Other infarct that affects the central vestibular projections

What kind of ambulation occurs with CMT?

Stumbles, falls and glumsy gait are common with CMT

What does evidence say for exercise with PPS?

SubMAX and max contractions in low reps Aquatic therapy Correlations of improved strength with stair climing, walking and rising from chair

What kind of exercise do you do for someone with PPS?

SubMAX and max contractions in low reps LOW REPS IS KEY

How do we treat a complete loss of vestibular function bilaterally?

Substitution: increase patient's reliance on somato-sensation and vision. Use cervical spine proprioception to replace the VOR

What does evidence say about frequency of aerobic training for patients with PPS?

Suggest 3 or more times per week protocol

For patients with PPS, they have weaker motor evoked potentials. What does this suggest in regards to central fatiguability?

Suggests changes in motor cortex ability to command that motor output = fatiguability

What are the 4 vestibular nuclei in the central processor?

Superior Inferior Medial Lateral. Located at level of pons, with some inferior at medulla

Which vestibular nuclei control the following? Gaze stability and controlling VOR. Connected to CN III, IV and VI, which control movements of eye

Superior and medial

Name the cerebellar stroke based off impairments: Dysmetria of ipsilateral arm. Unsteady walking, dysarthria and nystagmus Common coordination and dysmetria are always IPSILATERAL!!!

Superior cerebellar artery

CN 4 controls what muscle?

Superior oblique. (causes eye deviation and trouble looking down)

What is the supine dinner roll maneuver used for?

Supine dinner roll: horizontal canal Liberatory maneuver: for posterior and anterior cupula or canal AKA semont Brandt-Daroff habituation exercises: HEP for anterior and posterior canal Surgical for posterior canal plugging

What is the HAllpike-Dix position?

Supine position

What is the main surgical procedure for BPPV?

Surgical for posterior canal plugging: rare instances Prevent otoconia stones from drifting into canal

Describe the ampulla's

Swelling off of each semi-circular canal. Houses the crista and cupula Cupula: Gelatinous mass, hair cells and hairs are embedded in the cupula and bend with head rotation

Describe some swing phase and stance phase presentations of ataxic gait

Swing phase: overly high step: excessive hip and knee flexion Stance phase: forceful, uncontrolled lowering of leg to contact the floor

How do you perform the Supine roll test?

TEst for horizontal canal. Pt in supine Move head in 30 degree plane to max stimulate the canals. Then rotate the head 90 degree to R and 90 degrees to L. R to test for R and L to test for L Look for beating toward ground. Up toward ceiling: ageotrophic -->cupulolithasis down toward ground: geotrophic -->canallithasis

Describe what the treatment approach should be for the following impairment for someone with cerebellar ataxia: Poor coordination and grading of muscle power

Taking someone into standing to tall kneeling to reduce degrees of freedom External device Postural control Put in quadruped is great for this!!

Describe the clinical pathways of care for a patient with a brain tumor

Team includes patinet in middle --> MD, nurse, RN, SLP, OT, PT

What are common examination findings in regards to Temperature tolerance for patients with PPS?

Temperature tolerance: Abnormally cold extremities- sympathic nerve cell damage and heat loss Prevention of intolerance through proper outerwear.

List some common exam findings with mobility, temperature and sleep with PPS?

Temperature tolerance: Abnormally cold extremities- sympathic nerve cell damage and heat loss Prevention of intolerance through proper outerwear. Sleep: 50% prevelance Periodic limb movement Mobility: Osteoarthritis of wrist and hand Gait analysis --> Overuse and substitution of vstus lateralis, biceps femoris, glutes max and soleus not functionning Decreased activity up to 16 hours sedentary

What is the VOMS?

Test post-concussion Vestibular/occular motor screening Rate HA, dizziness, Nausea, fogginess >2 above baseline is positive >5 cm average with convergence is abnormal Looks at smooth pursits, saccades, covnergence, VOR horizontal and v

What is the supine roll test?

Tests for horizontal canal or cupula. Much more rare Horizontal canals are tipped upward 30 degrees

Why is vestibuar depression through medications not good over time?

The brain must learn to compensate via central system to learn to deal with hypofunction.

What helps us move our eyes the same direction as head movement?

The cerebellum cancels the VOR response

What causes the cupula to deflect and stimulate hair cells during movement?

The endolymphatic fluid swooshes around the canals causing cupula to defect

What does the hair cells bend in the cupula during head movement?

The endolymphatic fluid swooshes around the canals causing cupula to defect

What happens when the cupula deflects?

The hair cells deflect too: since they are embedded in cupula.

What will you may see, and not see with BPPV symptoms?

There are no complaints of aura fullness, hearing loss or tinnitus May see imbalance and gait ataxia

Why is the utricle gravity sensitive?

There is gelantoious membrane with calcium carbonate crystals in them. The cystals can float to bottom when going up elevator changing with gravity.. Hair cells are now stimulate

What is a treatment for generalized weakness for patients with post-polio syndrome?

Therex- strengthening that is non-fatiguing Aerobic exercise Orthotics/AD Lifestle changes and weight loss

How is someone positioned with vertigo?

They are tilted in posture!

What is the physiologic ocular tilt reflex?

Tilt head to L: Increased firing rate on L and decreased firing rate on R

What is head-shaking nystagmus?

Tip head to 30 degrees to align horizontal canals to the ground. Shake head and check for nystagmus.

What pathology is the Demyelinating or axonal degeneration affects afferent and efferent nerve conduction velocity and motor unit action potential

Tooth marie charcot CMT

What must you get in place before working on head movements?

Train binocular training first!

What are the goals of the Brock String training?

Training convergence and binocular vision... Bead you are looking at should stay in focus. Other two beads should appear to double String should also appear doubled and forms and X position with the center of the X crossing the bead you are looking at. Anything that isn't this you are using monocular vision and make task easier by moving the first bead away from nose

What is part of the vestibular interventions for patient's post-concussion?

Treat like normal vestibular patient: BPPV repositioning maneuvers Balance/sensory organizatoin Gait training with vestibular challenges Reactive balance training and head righting reflex. (use TB and tilt board) VOR training: x1 viewing Use medications if there is anxiety overlay refer out.

Your patient has a concussion and is in the Ocular subtype. What is the main intervention, and what should we do?

Treating binocular dysfunction... Brock string: Convergence training for binocular vision... Avoid prolonged reading/computer work Exertion training may begin.. ONE TREAT IF they JUST HAVE PROBLEMS WITH CONVERGENCE IF THEY HAVE SACCADES AND PURSUIT INVOLVEMENT THEN REFER TO VISION SPECIALIST

What is the traid of symptoms of Meniere's disease?

Triad of: Fluctuating hearing loss, tinnitus, vertigo (>30 min to 24 hours)

True or False: Patients with minimal balance deficits but (+) leg incoordination present with less gait abnormalities

True!

True or False: Brain has no sensory nerves

True!! Therefore you can have brain surgery when the patient is awake

True or False: ALS is variable, but progressive in nature

True: Death usually within 3-5 years with respiratory failure Better survival rate with limb-onset, and increased psychological well-being

How do you perform the epley manuever or canalith repositioning maneuver?

Turn head 45 degrees. makes canal perpendicular to canal. Quickly lie patient into supine to make canal gravity dependent and otoconia go to bottom. 30 seconds after nystagmus ends, turn head to side you are treating. Roll patient to side and then have then sit up. Otoconia are rolled into canal and into common crus to dump back to utricle. Otoconia are not out of canal

Describe the full cycle of turning the head to the R and it's effect on the vestibular system

Turn head to R --> Endolymph is going to swoosh around in canal and stimulate the hair cells --> Horizontal canals on R are max stimulated and L are inhibited --> Canals are connected to ocular motor muscles to get equal and opposite reaction --> R eyes medial rectus muscle is facilitated and L eye lateral rectus is facilitated and contracted We stay looking in front

Describe the 3 types of Charcot marie tooth disease

Type 1 CMT's display peripherally demylinating Type 2 CMTs: display peripherally axonal degeneration Type X CMT's: more rare and be central and peripheral

Describe type 2 CMT

Type 2 CMTs: display peripherally axonal degeneration

How does muscle fibers change with PPS, and what impairments may arise from this?

Type II fibers change to type I, which may affect gait and explosive muscles like the gastroc/soleus

Descrie type X CMT

Type X CMT's: more rare and be central and peripheral

What is the epidemiology and etiology of Huntington's disease?

Typically between 45-50 y.o 5/100000: Affects males slightly more than females >40 "CAG" repeats on HTT allele of Chromosome #4. Genetic mutation = abnormal folding of protiens in neurological structures of brain and basal ganglia

The following is the mechanism for recovery for what pathology: Adaptation via central vestibular system Spontaneous reestablishment of the tonic-firing rate. Exercise can push system and facilitate a faster recover. Habituation

Unilateral hypofunction

What is the Buffalo Concussion treadmill test used for?

Use Buffalo concussion treadmill test: DD of physilogic post concussion symtoms. See what level of activity brings on symptoms. This becomes upper threshold for exercise. Exercise is reproducing symptoms. Use to make sure. Symptoms may be from something else besides lack of blood flow or exercise Gradual increase in TM workload HR and BP recorded when symptoms are exacerbated and becomes basis for exercise prescription

What balance problem is very common for people with post-concussion syndrome?

Use TUG cognitive Dual-tasking is commonly impaired

How can you use gaze instability interventions to treat unilateral hypofunction?

Use of Snellen chart Environments that are visually rich with stimulus. Oculomotor exercises: x1 and x2

Overall should you exercise someone with ALS?

Use your clinical decision making: Risks don't necessarily outweigh benefits, so use collaborative effort to try and focus on goals

What are Brandt-Daroff Habituation exercises used for and how to perform?

Used as HEP for anterior or posterior canal or cupula WAit 30s after each position. Used for stubborn cases of BPPV. repeat for several minutes 3x/day. Pt will feel nausea and vertigo, but you provide brain with abnormal input so brain starts to habituate and ignore bad symptoms Start in short sitting, then turn head away from affected side 45 degress. Go down S/L toward affected side. Wait 30 s after symptoms go away. Go back to short sitting and stop... Like liberatory manuever but you just go back to long sitting when moving from each side. NOSE IS ALWAYS TURNED UP!!!

What is VOR testing?

Usually come in after information from caloric or rotaory chair exam, indicated VOR impairment

Your patient has a concussion and is in the Cervical subtype. What is the main intervention, and what should we do?

Usually manual therapy Cervical spine, ROM, strengthening, flexors and extensor muscles as well as deep neck stabilization training Sub-occipital release Postural re-education Cervical propriception target practice Modalities Refer to ortho/manual therapy PT

Describe the peripheral disorder, related to inaccurate sensory information?

Usually related to Benign paroxysmal positional vertigo. BPPV

What is typical treatment of BPPV?

Usually self limiting: resolves spontaneously in 6-12 months Performing vestibular exercises or maneuvers may aid in the removal of otoconia and hasten recovery.

How do symptoms of ALS usually present with at first?

Usually symptoms are focal and asymmetrical at onset

What makes up the horizontal canal in the otolith?

Utricle

What senses horizontal acceleration?

Utricle: like stopping in care

What is the relationship of dizziness on post-concussion syndrome? What are the types of dizziness?

VAgue term used by patient's to describe a variety of conditions. Could be room spinning/swaying: vestibular such as BPPV, hypofunction and perilyphatic fistual Floating sensation: cervicogenic --> associated with whiplash Blurred/double vision- occular: difficulty with binocular vision, convergence insufficiency Difficulty reading Difficulty in a dynamic/visually rich enviornment- motion sensitivity. At movie theater or walking in grocery store

The following is what outcome measure? Test post-concussion Rate HA, dizziness, Nausea, fogginess >2 above baseline is positive >5 cm average with convergence is abnormal Looks at smooth pursits, saccades, covnergence, VOR horizontal and v

VOMS Vestibular/ocular motor screening

What controls the following? Head movement to the left causes an equal and opposite eye movement to the right (1:1 ratio)

VOR - gaze stabilization during head movement

The motor output system is one of the 3 main structures of the vestibular system. What is part of this?

VOR: gaze stability VSR: postural control

The reticuloispinal tract and vestibulospinal tract recieve input from what reflex?

VSR

What reflex creates the following effect? Maintains the head and body posture Via lateral and medial vestibulospinal tracts To motor neuron in the cervical and lumbar spinal cord

VSR- postural control and balance and orientation

CMT describe the severity

Variable in severity and age of onset of symptoms ranges from early childhood to early adulthood. Extremely variable in disease presentation

Describe the typical disease course and prognosis of ALS

Variable- average duration 27-43 months Death within 3-5 years, with respiratory failure <35-40 years have better 5 years survival rate Survival time greater with limb onset vs. bulbar Increased survival time with psychological well-being

The following is the typical prognosis for what pathology? Variable- average duration 27-43 months Death within 3-5 years, with respiratory failure <35-40 years have better 5 years survival rate Increased survival time with psychological well-being

Variable- average duration 27-43 months Death within 3-5 years, with respiratory failure <35-40 years have better 5 years survival rate Survival time greater with limb onset vs. bulbar Increased survival time with psychological well-being

What does evidence mainly support of exercise with PPS?

Various methods of nonfatiguing strengthening exercises

What causes CMT?

Vary on genetic allele on a specific chormosome

What are the findings for the Hallpike-Dix maneuver?

Vertigo and nystagmus begin about 1 or more seconds after the head is tilted towards the affected ear Severity increases for about 10 sec then symptoms reduced If maneuver is repeated the nystagmus will fatigue

What happens with hypofunctions in time and what is the treatment?

Vertigo begins to occur intermittently with head movements. Gaze evoked nystagmus Treatment includes: Meds, and central compensation

What are some postierior inferior cerebellar artery stroke impairments?

Vertigo, unsteadiness, walking ataxia, nystagmus

How does someone describe vertigo?

Vertigo: Person or environment spinning and duration

The flocculonodular lobe is important for what main function?

Vestibular

The following are characteristics of what subtype of concussion? Key complaints of dizziness, Nausea, Anxious in busy enviornments in store or restaurant. Off balance Hx of sensitivity, Migraines and Anxiety Objective findings: Positive for VOR, and motion/optokinetic sensitivity. Positive Balance test may or may not happen. cognitive testing positive rxn time, processing speed, intact memory

Vestibular

What do we need to differentiate between vestibular problems in our history?

Vestibular and non-vestibular disorders. Central vs. peripheral vestibular disorders. Question: TRUE vertigo vs. dizziness/lightheadness from a-fib/hypotension or other non-vestibular disorders Question: Ask how long vertigo lasts, history of illness, recent trauma to head, ask special tests by physician

The Central processor is one of the 3 main structures of the vestibular system. What is part of this?

Vestibular nuclei Cerebellum

What are the central vestibular disorders?

Vestibular nuclei and cerebellum

What controls gaze stabilization as part of the vestibular nuclei complex and central processor?

Vestibulo-ocular reflex

What controls postural control as part of the vestibular nuclei complex and central processor?

Vestibulospinal reflex (VSR)

If a patient has vestibular and occular overlay after a concussion, what will you train?

Visual motion sensitivity: treat dizziness from visually rich environments Treat visual, vestibular and cervical dysfunction first Habituate to noxious stimuli

What is part of the rehab framework for a patient with a brain tumor?

Vital component is rehab framework for patients living with brain tumor Functional outcomes are similar to those post stroke and TBI Rehab plan should be flexible, allow for worsening impairments and sensitive to emotional impact Recovery, health promotion and palliative or end of life care all need to be considered.

Who do we consult for patients with brain tumor in regards to return to work, sport or leisure?

Vocational rehab Recreational therapy Neurophyschology

How does PT affect BPPV?

WE can get ride of it in 1 day, by removal of otoconia and hasten recovery.

What are common AL with PPS? What are PR?

Walking Climbing stairs and dressing PR with meeting demands of work or home

What are typical interventions to complement your positional vestibular exercises and gaze stabilization?

Walking with head turns. Walking and reading letters on wall. Pt education on illness. Perturbation training and stepping Treatment of postural control problems and physical deconditioning. Balance training and on foam. Static and dynamic and gait training. HEP

What is the postoperative care and risks for a patient following brain surgery removal?

Watch for INtracranial hemorrhage and observe in ICU for 24 hours BP monitoring, DVT and PE monitor Use of compression stockings not anticoagulants Watch for hydrocephalus, infection, infarction and hemorrahge

What is the precaution with Friedrich's ataxia?

Watch for aerobic exercises and resistance training, as these patients usually have cardiac comorbidity

What is education for temperature intolerance for patients with PPS?

Wear proper outerwear

What is the VOR cancellation test?

When head rotates R, eyes rotate to R sometimes so you can look to side. Test integrity of cerebellum Extend arms and glasp hands together. Stay looking at thumbs as head and arms move together. If the eyes bounce off target and cannot cancel VOR, this is positive for central vestibular problem

WHy do you get positional vertigo with BPPV?

When the otoconia continue to float around after head movements, you get vertigo, as the brain thinks you are still moving when you are not actually.

The cerebellum will cancel the VOR. Why would this occur?

When we want our eyes to move in relationship to the head.

Describe what a tropia looks like with the cover/uncover test

When you cover strong eye, the weak eye immediately bounces to midline to re-correct and locate target. Cover working eye and lazy eye refocuses at center. When uncovered lazy eye it will redirect to lazy position. SEEN WHEN EYE IS COVERED. Not likely with concussion but more likely with brain injury

What are the main rehab management and care considerations for Charcot Marie tooth disease?

Will often need increased support from caregivers as disease progresses and increasingly impact function Often requires AFO's, GRAFO's and AD for ambulation. High risk for LE sprains SPC and walking sticks preferred initially Females don't ususally want AFO's for cosmetic reason

What is the best time of day for therapy for a patient with Charcot tooth marie disease?

Will respond to early in the day treatments

What happens with the firing rate of the horizontal canals with R rotation

With R head rotation you max stimulate horizontal canals. Increase of firing rate on R side. R side excitation. L horizontal canal has decrease firing rate. Called, "push-pull relationship" One goes up and one goes down

What are the most common MS impairments with PPS?

With both new and prior muscles affected by polio.. Decreased muscle strength, muscle endurance, atrophy Fatigue, pain, NM weakness Cold intolerance

What is the best way to see if your benefits outweight the risks when exercising someone with ALS?

With reports of morning fatigue or signifant weakness ***Be attentive to their reports after program after instituting program

What is treatment for post-concussion for anxiety/mood subtype?

With vestibular overlay treat first SKilled PT not that helpful Exertion training very important for an emotional release Sleep schedule Psychotherapy and medication for persistent cases

Are you working compensation or recovery with a bilateral vestibular hypofunction?

Work compensation and train vision and somatosensory to be better since vestibular is lost.

How does the canalith repositioning maneuver work? Used for anterior and posterior canalithiasis for BPPV?

Works by moving debris out of the semicircular canal into the common crus and back into utricle. Turn head 45 degrees. makes canal perpendicular to canal. Quickly lie patient into supine to make canal gravity dependent and otoconia go to bottom. 30 seconds after nystagmus ends, turn head to side you are treating. Roll patient to side and then have then sit up. Otoconia are rolled into canal and into common crus to dump back to utricle. Otoconia are not out of canal

With Charcot marie tooth disease, there is intrinsic foot musculature atrophy leading to poor mechanics during loading and WB. There is also dry or skiny and flaky skin on distal LE. Does it every progress to hand?

Yes can affect hands and wrists in later stages: May see cool hands and deformities similar to late stage RA

Are there hypokinetic features with HD?

Yes in late stages you may see some, but mainly hyperkinetic

Can blood pressure cause dizziness?

Yes, not common in post concussion: but can cause dizziness to check this

Patient presents to your clinic with referral for vertigo. You take a thorough history to reveal subjectively a patient with history of cancer, recent issues with memory, vomiting, HA upon waking in the morning, and imbalance with mobility. Objective findings are poor abilities with the Rhomberg and Sharpened Rhomberg, decreased smooth pursuit with ocular testing, veering of his path during dynamic gait, negative dix hallpike, and inability to reproduce specific symptoms of dizziness with positional testing, + for clonus in Left ankle, 3 beats What might you suspect? What education may you provide? What is your next action as therapist?

You suspect a possible tumor of posterior fossa Educate about findings and that sometimes with inconclusive examination findings, a referral back to the physician may be warranted. Call the physician and report findings. Suggest patient may benefit from further medical evaluation

The following describes what pathology: Brief bouts of ataxia usually due to excitement, stress or exercise Lasts minutes to hours Responds to medication

episodic ataxia

What is a hallmark sign of CMT besides the coke-bottle shape?

hammertoe deformity in great toe with pes cavus or high arch

What are symptoms of perilyphatic fistula?

hearing loss, positional vertigo, oscillopsia, skew deviation

What canal has the following relationship: (+) ipsilateral medial rectus muscle; Contralateral lateral rectus muscle (-) Ipsilateral lateral rectus muscle: contralateral medial rectus muscle

horizontal canals

What reflex is described as the following? Tilt head to L: Increased firing rate on L and decreased firing rate on R

physiologic ocular tilt reflex

Describe Charcot-Marie-Tooth disease

rare neuromuscular disorder Most commonly inherited neuropathy: One of most commonly inherited human disease and 10x more common than ALS and HD combined! 125,000-150,000 in US Often undiagnosed or misdagnosed due to its overlapping symptomology

The following are principles for what? Begin treatment early Exercise for brief periods of time initially. Exercise may increase patient's symptoms: Don't provoke N&V. If still provoked >30 min after exercise you have done too much. HEP; 2x/day Maintenance exercises need to maintain compensation Treat in clinic 1-2/wk

vestibular training

What is part of voluntary movement coordination examination for somone with cerebellar ataxia?

voluntary movement coordination is important to test: finger taping, supination/pronation, handwriting, toe tapping Heel to shin Finger to nose

What are Gaze stabilization exercises x1 and x2?

x1: Head is moving and the target is stationary... x2: progression where head and target are moving. Treat gaze stability.