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RHS 332: Clinical Neurology

RHS 332: Clinical Neurology. Ahmad Alghadir, M.S. Ph.D. P.T. Room: 2071 aalghadir@hotmail.com alghadir@ksu.edu.sa. Recommended texts. S.B. O’sullivan, T.J. Schmitz, Physical Rehabilitation: Assessment and Treatment , F.A. Davis Company. 3 rd ed. 1994.

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RHS 332: Clinical Neurology

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

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

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

  4. Introduction • Considering the close relationship between sensory input and motor output, sensory deficits influence motor performance and result in significant functional impairments. • Therefore, sensory assessment should be conducted prior to motor, functional, and coordination assessments. Ahmad Alghadir M.S. Ph.D. P.T.

  5. Dysfunction may happen at any point within the sensory system: • Receptors. • Peripheral nerve. • Spinal cord. • Nuclei. • Sensory tracts. • Brainstem. • Thalamus. • Sensory cortex. Ahmad Alghadir M.S. Ph.D. P.T.

  6. Diagnoses that generally demonstrate some level of sensory impairment: • Normal aging process. • Disease or injury to the peripheral nerves. • Disease or injury to the spinal cord. • Head disease or injury. • Hemiplegia. • Multiple sclerosis. • Burns. • Fractures. Ahmad Alghadir M.S. Ph.D. P.T.

  7. Changes in sensory function: • Changes in response to tactile stimuli. • Changes in response to vibratory stimuli. • Decreased two-point discrimination. • Decreased kinesthetic awareness. • Alterations in the perception of pain. Ahmad Alghadir M.S. Ph.D. P.T.

  8. Functional impairments: • Postural instability. • Exaggerated body sway. • Wide-based gait. • Balance problems. • Tendency to drop items held in the hand. • Difficulty in recognizing body positions in space. Ahmad Alghadir M.S. Ph.D. P.T.

  9. Difficulty in executing appropriate motor responses during some functional activities. • Inability to safely accomplish some functional activities. • Difficulty in learning new motor skills. Ahmad Alghadir M.S. Ph.D. P.T.

  10. Purposes of sensory assessment • “Determine the level of sensory feedback affecting movement (including influence of sensory deficits on performance of functional activities).” • “Provide a basis for initiating a program of desensitization (use of tactile stimuli to decrease hypersensitivity) or sensory retraining (learning the sensation of a movement or sensory stimuli).” Ahmad Alghadir M.S. Ph.D. P.T.

  11. “Determine the need for instruction in techniques to compensate for the sensory loss, such as use of visual cues during movement.” • Assure patient safety and prevent secondary complications (e.g. prevention of burns during application of heating modalities, prevention of ulcers, and so forth). Ahmad Alghadir M.S. Ph.D. P.T.

  12. “Formulate goals and plan for appropriate therapeutic intervention.” • “Help determine, over a period of time, the effects of rehabilitation, or surgical or medical management.” Ahmad Alghadir M.S. Ph.D. P.T.

  13. Classification of the sensory system • Classification according to the function: • Protopathic system: • Responsible for protection by warning or defending the organism against potential harm.” • Concerned with unpleasant sensations: Ahmad Alghadir M.S. Ph.D. P.T.

  14. Pain. • Extreme changes in temperature. • Unpleasant light touch sensations such as itching and tingling. Ahmad Alghadir M.S. Ph.D. P.T.

  15. Epicritic system: • “Exert a controlling function over the protopathic system.” • Concerned with highly discriminative sensations: Ahmad Alghadir M.S. Ph.D. P.T.

  16. Localization of cutaneous stimuli. • Two-point discrimination. • Subtle changes in temperature. • Object recognition. Ahmad Alghadir M.S. Ph.D. P.T.

  17. Classification according to the type or location of the receptors: • Superficial (exteroceptive) sensations: • Exteroceptors: • Skin and subcutaneous tissue. • Pain, temperature, pressure, and light touch. Ahmad Alghadir M.S. Ph.D. P.T.

  18. Deep (proprioceptive) sensations: • Proprioceptors: • Muscles, tendons, ligaments, fascia, and joints. Ahmad Alghadir M.S. Ph.D. P.T.

  19. Vibration: “ability to perceive a rapidly oscillating or vibratory stimuli.” • Sense of position: “awareness of the position of joints at rest.” • Sense of movement (kinesthesia): “awareness of movement.” Ahmad Alghadir M.S. Ph.D. P.T.

  20. Combined (cortical) sensations: • Tactile localization. • Two-point discrimination. • Bilateral simultaneous stimulation. • Recognition of texture. Ahmad Alghadir M.S. Ph.D. P.T.

  21. Stereognosis: “ability to recognize the form of objects by touch.” • Barognosis: “ability to recognize weight.” • Graphesthesia: “recognition of numbers, letters, or symbols traced on the skin.” Ahmad Alghadir M.S. Ph.D. P.T.

  22. Classification according to the system by which sensations are mediated: • Anterolateral spinothalamic system: • Nocioceptive information (pain). • Thermal information (temperature). • Crudely localized touch. • Tickle. • Itch. • Sexual sensations. Ahmad Alghadir M.S. Ph.D. P.T.

  23. Dorsal column medial lemniscal system: • Pressure. • Vibration. • Discriminative touch. • Sense of position. • Sense of movement. Ahmad Alghadir M.S. Ph.D. P.T.

  24. Classification of the sensory receptors • Mechanoreceptors: respond to mechanical deformation. • Thermoreceptors: respond to changes in temperature. • Nocioceptors: respond to noxious stimuli (pain). • Chemoreceptors: respond to chemical substances (taste, smell, oxygen levels, and carbon dioxide concentration). Ahmad Alghadir M.S. Ph.D. P.T.

  25. Photic receptors: respond to light. • “High intensities of stimuli to any type of receptor may be perceived as pain.” Ahmad Alghadir M.S. Ph.D. P.T.

  26. Anterolateral spinothalamic system • Tracts: • Anterior (ventral) spinothalamic tract: crudely localized touch. • Lateral spinothalamic tract: pain and temperature. Ahmad Alghadir M.S. Ph.D. P.T.

  27. Fibers originate from the dorsal roots  cross to the opposite anterolateral segment of the white matter  ascend in the anterior (ventral) and lateral white columns  terminate at all levels of the lower brainstem and the thalamus. Ahmad Alghadir M.S. Ph.D. P.T.

  28. Slow conducting fibers, small diameter, and less myelination. • Activated primarily by mechanoreceptors, thermoreceptors, and nocioceptors. • Concerned with non-discriminative sensations. • Compared with the DCML system, the ALST system is cruder and more primitive. Ahmad Alghadir M.S. Ph.D. P.T.

  29. “Sensory signals transmitted by this system do not require discrete localization of signal source or precise graduations in intensity.” • “Diffuse pattern of termination results in only crude abilities to localize the source of a stimulus on the body surface, and poor intensity discrimination.” Ahmad Alghadir M.S. Ph.D. P.T.

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

  31. Dorsal column medial lemniscal system Fibers originate from the dorsal roots  enter the dorsal column ascend to the medulla  synapse with the dorsal column nuclei (nuclei gracilis and nuclei cuneatus)  cross to the opposite side  pass up to the thalamus through the medial lemniscus pathway  terminate in the ventral posterolateral thalamus  third-order neurons project to the somatosensory cortex. Ahmad Alghadir M.S. Ph.D. P.T.

  32. Fast conducting fibers, large diameter, and greater myelination. • Activated primarily by specialized mechanoreceptors. • Concerned with discriminative sensations. Ahmad Alghadir M.S. Ph.D. P.T.

  33. “Sensory modalities that require fine graduations of intensity and precise localization on the body surface are mediated by this system.” Ahmad Alghadir M.S. Ph.D. P.T.

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

  35. General guidelines for sensory assessments • “The testing procedure consists of two components: (1) application of the stimulus and (2) patient response to the stimulus.” Ahmad Alghadir M.S. Ph.D. P.T.

  36. Information gathered from sensory assessment should include: • “The type of sensation affected.” • “The quantity of involvement or body surface areas affected.” • “The degree of involvement (e.g., absent, impaired, delayed responses, hyperesthesia, and so forth).” Ahmad Alghadir M.S. Ph.D. P.T.

  37. “The superficial (exteroceptive) sensations are usually assessed first, inasmuch as they consist of more primitive responses, followed by the deep (proprioceptive), and then combined (cortical) sensations.” Ahmad Alghadir M.S. Ph.D. P.T.

  38. “If a test indicates impairment of the superficial responses, it is likely that some impairment of the more discriminative (deep and combined) sensations also will be noted.” Ahmad Alghadir M.S. Ph.D. P.T.

  39. “The application of stimuli should be applied in a random, unpredictable manner with variation in timing.” • “This will improve accuracy of the test results by avoiding a consistent pattern of application, which might provide the patient with “clues” to the correct response.” Ahmad Alghadir M.S. Ph.D. P.T.

  40. “General knowledge of the patient’s cognitive status and hearing and visual acuity is required.” • “The patient should be in a comfortable, relaxed position.” Ahmad Alghadir M.S. Ph.D. P.T.

  41. “Occluding the patient’s vision during the testing should be used.” • “Scar tissue or callused areas are generally less sensitive and will demonstrate a diminished response to sensory stimuli.” Ahmad Alghadir M.S. Ph.D. P.T.

  42. Tests are usually carried out in a distal to proximal direction to save time. • Tests should be performed following the main peripheral nerves and the dermatomes. • Dermatomes: “cutaneous areas that correspond to the spinal segments that provide their innervation.” Ahmad Alghadir M.S. Ph.D. P.T.

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  47. Testing protocol • Superficial sensations: • Pain: • Test: large-headed pin (one sharp end and one dull end). • Response: sharp, dull, or unable to tell. Ahmad Alghadir M.S. Ph.D. P.T.

  48. Temperature: • Test: two test tubes (hot water and crushed ice). • Response: hot, cold, or unable to tell. • Pressure: • Test: firm pressure using therapist’s thumb or fingertip. • Response: yes or now. Ahmad Alghadir M.S. Ph.D. P.T.

  49. Light touch: • Test: tissue or piece of cotton. • Response: yes or now. Ahmad Alghadir M.S. Ph.D. P.T.

  50. Deep sensations: • Vibration: • Test: vibrating tuning fork. • Response: vibrating or non-vibrating. Ahmad Alghadir M.S. Ph.D. P.T.

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