RHS 332: Clinical Neurology

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RHS 332 Clinical Neurology

• Ahmad Alghadir, M.S. Ph.D. P.T.
• Room 2071
• aalghadir_at_hotmail.com
• alghadir_at_ksu.edu.sa

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Recommended texts

• S.B. Osullivan, T.J. Schmitz, Physical
  Rehabilitation Assessment and Treatment, F.A.
  Davis Company. 3rd ed. 1994.
• R.L. Braddom, Physical Medicine Rehabilitation,
  W.B. Saunders Company. 1st ed. 1996.

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Motor Control Assessment
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Introduction

• Motor control evolves from a complex set of
  neurologic and mechanical processes that govern
  posture and movement.
• Reflex patterns genetically predetermined.
• Motor skills learned through interaction and
  exploration of the environment and required
  practice and experience.

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• Sensory feedback is required to shape and guide
  the development of the motor program.
• Motor program a set of commands that, when
  initiated, results in the production of a
  coordinated movement sequence.
• Motor plan combination of several motor
  programs into an action strategy.

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• Motor subprogram smaller subroutine of
  coordinated muscle action.
• Motor memory involves the storage of motor
  programs or subprograms and includes information
  on how the movement felt (sense of effort),
  movement components, and movement outcome.

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• Memory allows for continued access of this
  information for repeat performance or
  modification of existing patterns of movement.

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• Levels of CNS command hierarchies
• Association cortex organize sensory information
  and elaborate the overall motor plan.
• Sensorimotor cortex shape and define the
  specific motor programs and initiate commands.

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• Brainstem and spinal cord executes the
  commands, translating them into the final muscle
  actions.
• Command levels vary depending upon the specific
  task executed.

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• Rigid top-down vs. rigid down-top hierarchy (e.g.
  reflex, vision, loss of sensory feedback, neural
  activity at spinal level, different reactions to
  one stimulus, loss of motor memory).
• Distributed or flexible motor control.
• Control commands proceed in both descending and
  ascending manner.

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Closed-loop system

• Definition a control system employing feedback,
  a reference of correctness, computation of error,
  and subsequent correction in order to maintain a
  desired state of the environment.
• Feedback sources to monitor movement visual,
  vestibular, proprioceptive, and tactile inputs.

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• Primary role
• Monitoring of constant states such as posture
  and balance.
• Control of slow movements or those requiring a
  high degree of accuracy.
• Learning of new motor tasks.
• Compensation with other sensory systems e.g.
  Romberg test.

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Open-loop system

• Not all movements are controlled by closed-loop
  system.
• Stereotypical movements e.g. gait.
• Rapid, short duration movements, which do not
  allow sufficient time for feedback to occur.

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• Independent of error-detection mechanisms.
• Control originates centrally from a motor
  program, which is a memory or preprogrammed
  pattern of information for coordinated movement.

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Validity vs. reliability

• Validity if the tool accurately measures the
  parameter of performance being examined, it is
  said to have validity.
• Intra-rater reliability consistency of results
  obtained by an examiner over repeat trials.
• Inter-rater reliability consistency of results
  obtained by multiple examiners.

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Qualitative vs. quantitative

• Assessments can be qualitative, focusing on a
  subjective estimation of performance, or
  quantitative, using objective measures.

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UMN and LMN syndromes
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I. Flexibility

• ROM is an important element of functional
  movement.
• Limitations restrict the normal action of
  muscles as well as the biomechanical alignment of
  body parts.
• Longstanding immobilization results in
  contracture, a fixed resistance resulting from
  fibrosis of tissues surrounding a joint.
• Variability, side to side comparison.

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• AROM
• Definition amount of joint motion obtained with
  unassisted voluntary joint motion.
• Influenced by muscle strength and coordination.
• Goniometer.
• Full AROM without pain ? PROM is not necessary.

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• Determine
• The presence of pain (when appears, how severe).
• Movement of associated joints or substitutions.
• The cause of limitation if present.

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• PROM
• Definition amount of joint motion available
  when an examiner moves the joint through the
  range without assistance from the patient.
• Joint play small amount of joint motion that
  occurs at the end range and is not under
  voluntary control ? PROM gt AROM.

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• Goniometer.
• Determine the cause of limitation if present.

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• End feel
• Definition characteristic feel each specific
  joint has at the end ROM.
• Soft, firm, or hard.
• Joint capsule, ligaments, muscle tension, soft
  tissue approximation, or joint surfaces.
• Special tests