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

RHS 332: Clinical Neurology

Ahmad Alghadir, M.S. Ph.D. P.T.Room: 2071

aalghadir@hotmail.comalghadir@ksu.edu.sa

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

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.

Motor Control Assessment

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

Introduction

• “Motor control evolves from a complex set of neurologic and mechanical processes that govern posture and movement.”

1. Reflex patterns: genetically predetermined.

2. Motor skills: learned through interaction and exploration of the environment and required practice and experience.

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

• 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.”

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

• 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.”

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

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

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

• Levels of CNS command hierarchies:

1. Association cortex: “organize sensory information and elaborate the overall motor plan.”

2. Sensorimotor cortex: “shape and define the specific motor programs and initiate commands.”

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

3. Brainstem and spinal cord: “executes the commands, translating them into the final muscle actions.”

• “Command levels vary depending upon the specific task executed.”

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

• 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.

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

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.

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

• Primary role:

1. “Monitoring of constant states such as posture and balance.”

2. “Control of slow movements or those requiring a high degree of accuracy.”

3. “Learning of new motor tasks.”

• Compensation with other sensory systems e.g. Romberg test.

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

Open-loop system

• Not all movements are controlled by closed-loop system.

1. Stereotypical movements e.g. gait.

2. “Rapid, short duration movements, which do not allow sufficient time for feedback to occur.”

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

• Independent of error-detection mechanisms.

• “Control originates centrally from a motor program, which is a memory or preprogrammed pattern of information for coordinated movement.”

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

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.”

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

Qualitative vs. quantitative

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

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

UMN and LMN syndromes

UMN LMN

Possible locations

CNS PNS

Common causes

CVA, tumors, trauma, MS

Trauma, metabolic dis.

Distribution of abnormalities

Groups, ipsi-contra-lateral

Segmental, ipsilateral

Voluntary movements

Paralysis or paresis

Paralysis

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

UMN LMN

Muscle tone Increased Decreased

Myotatic reflexes

Hyperactive or exaggerated

Decreased or absent

Cutaneous reflexes

Abnormalities (Babinski sign)

Decreased or absent

Muscle bulkSlight atrophy due to disuse

Pronounced atrophy 70-80%

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

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.

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

1. 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.

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

• Determine:

a)The presence of pain (when appears, how severe).

b)“Movement of associated joints or substitutions.”

c)The cause of limitation if present.

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

2. 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 > AROM.

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

• Goniometer.

• Determine the cause of limitation if present.

AROM PROM

Contractile structures +ve -ve

Passive structures +ve +ve

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

3. 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.

4. Special tests