Disease Specific Examination

Parkinson’s Disease

● Pathophysiology: Progressive loss of dopamine in the basal ganglia

● Basal ganglia’s role: Initiates, stops, monitors and maintains movement. Functions as a "braking

system" to inhibit undesired movement and permit desired ones.

● 4 Cardinal Signs

   ○ Tremor

   ○ Rigidity (Cog Wheeling)

            ■ Use activation maneuver

   ○ Bradykinesia

            ■ Detected in functional mobility, coordination testing

   ○ Postural Instability

         ■ Pull Test

  ● Coordination Testing

        ○ Finger Tapping

        ○ Mass grasp

        ○ Pronation/Supination ("turning door knob")

        ○ Toe tapping

        ○ Leg Agility

● Things to look for:

       ○ Rhythm broken/hesitations in movement

       ○ Slowing of movement

       ○ Decreased amplitude of movement

● Things not affected: strength, sensation, reflexes, cranial nerves (though many have loss of smell as an early symptom)

● Balance Considerations:

      ○ Loss of balance reactions

      ○ Loss of automatic postural control

      ○ Abnormal sequencing

● Parkinsonian Gait:

      ○ Shuffling

■ Short step length bilaterally, mid foot contact, flexed forward at hips, often lack

arm swing unilaterally

     ○ Festinating gait

■ Unable to control forward movement of trunk -->leads to falling

     ○ Freezing

Multiple Sclerosis:

● Pathophysiology: demyelination occurs in the central nervous system in the brain and/or spinal cord. Signs and symptoms will depend on the areas of demyelination

● Common Signs:

     ○ Sensory impairment with complaints of numbness or paresthesias in a cortical or

dermatomal pattern

    ○ Motor impairment in cortical or myotomal pattern

    ○ Spasticity

    ○ Vision and oculomotor deficits including deficits in acuity, ocular alignment, and

oculomotor

    ○ Coordination and ataxia

    ○ Dizziness

    ○ Fatigue - primary and secondary

    ○ Bowel and bladder impairment (spasticity)

    ○ Heat sensitivity

    ○ Balance deficits >> falls

● Examination considerations

    ○ Main points: UMN signs, localization in cortex, brainstem, cerebellum, or spinal cord

         ■ Objective findings may lead you to at least two localization points (historically or

objectively)

        ■ To be diagnosed, must have demyelination in two different areas

    ○ Cranial nerve evaluation, especially oculomotor

    ○ Coordination testing: ataxic, dysmetric movements if cerebellum is involved

       ■ rapid alternating movements

       ■ finger to nose

       ■ heel to shin

○ Tone assessment: Modified Ashworth Scale - expect hypertonicity

○ Reflex assessment: expect hyperreflexia, presence of abnormal reflexes - babinski and clonus

○ Sensory Testing: light touch, sharp/dull, proprioceptive testing

○ Manual Muscle Testing

○ Cognitive Screen: alertness and orientation, MoCA

○ Fatigue assessment: Modified Fatigue Impact Scale (full and 5 item)

○ Complete vestibular exam as indicated

● Balance assessment

     ○ Important to consider static and dynamic balance

     ○ Likely to have poor sensory input (visual loss, vestibular loss, and poor somatosensation)

as well as inability to produce good motor output - poor muscle strength, sequencing,

and coordination

● Gait assessment

     ○ Impairments that will lead to gait deficits:

      ■ Weakness

      ■ Poor sensory input

      ■ Spasticity

      ■ Impaired coordination

○ Common deficits seen:

      ■ Poor foot clearance due to: foot drop, weak hip flexors, and/or spasticity in

plantarflexors

● steppage gait

● circumduction

● vaulting

      ■ Trendelenburg due to weak glute medius

     ■ Ataxia

     ■ Evidence of balance issues:

● path deviation

● wide BOS

       ■ Slow cadence

Stroke:

● Pathophysiology: vascular event leading to damage of brain tissue supplied by that vessel

● Signs and symptoms vary significantly depending on vessel affected (appendix 2)

     ○ Most common: MCA, ACA, PCA

    ○ Other common: lacunar, cerebellar, and vertebrobasilar

● Common impairments to examine:

     ○ Motor:

        ■ Loss in cortical distribution unilaterally >> hemiplegia

       ■ Consider proximal strength of scapular stabilizers, pelvis, and hip

       ■ UE often more affected than LE

       ■ LE muscles often affected: dorsiflexors, quadriceps, hamstrings, and gluteus maximus

○ Sensory

      ■ Loss in cortical distribution in unilateral

     ■ May be complete sensory loss or partial

    ■ Test light touch, proprioception, sharp/dull

○ Cranial Nerves

     ■ Oculomotor impairment

     ■ Palate and uvula deviation

     ■ Tongue deviation

      ■ Facial droop with forehead/eyebrow movement preserved

○ Reflexes

     ■ Hypertonicity unilaterally

     ■ Unilateral abnormal reflexes

○ Cognition

    ■ Executive dysfunction

    ■ Memory impairments

    ■ Emotional lability

○ Postural assessment: sitting and standing

     ■ Ability to sense upright

     ■ Even weight distribution left to right

     ■ Signs of pusher syndrome

○ Speech deficits

     ■ Word finding deficits

     ■ Slurred speech

     ■ Non-sensical words/paraphrasing

     ■ aphasia

● Balance evaluation

     ○ Static and dynamic balance assessment is important

     ○ Deficits with co-contraction of muscles, torque, and sequencing

● Gait Evaluation

      ○ Swing Phase

         ■ Foot drop

         ■ Difficulty with limb advancement due to hip weakness

        ■ Limb external rotation with pelvic retraction

       ■ Compensations:

         ● circumduction

         ● steppage

         ● vaulting

             ■ Ability to achieve positive step length

○ Stance Phase

      ■ Foot slap with initial contact

      ■ Decreased knee stability in midstance

     ■ Difficulty with weight acceptance and weight shift

     ■ Trendelenburg

     ■ Pelvic retraction

     ■ Time in single limb stance

Cerebellar Disorders:

● WIDE variety of various pathologies that can affect the cerebellum. Most common is cerebellar

CVA or cerebellar degeneration, though there can be inherited conditions which also affect the

cerebellum

● Function of the Cerebellum:

○ Motor Coordinator

      ■ Controls activity of multiple muscles across several joints

      ■ Regulates force, distance, timing, duration

      ■ Predicts to generate feed forward motor commands

○ Timer

      ■ Site of temporal representation of movements

      ■ Encodes sequencing of muscle activations

○ Motor Learning

       ■ Site of stored knowledge to generate predictive motor commands

      ■ Updates movement using error feedback

● Coordination Impairments

○ Dysdiadochokinesia- rapid alternating movements

○ Dysmetria- inaccurate movements

○ Action Tremor

● Vestibular & Visual Changes

○ Oculomotor Impairments

     ■ Saccadic intrusions with smooth pursuit

     ■ Dysmetric saccades

○ Impaired VOR cancellation

○ Impaired VOR- unable to maintain gaze with head movement

● Gait & Postural Control

○ Ataxia: Difficulty initiating and controlling rate, rhythm and timing of responses

○ Dyssynergia

    ■ Multiple joint movements more difficult than single joint ones

○ Decomposition

    ■ Breaking down multiple joint movements into single joint ones

○ Over-corrections for loss of balance

Peripheral Neuropathies/Radiculopathies/Myelopathies

● Peripheral Neuropathy

○ Typically affects distal extremities

     ■ Glove/stocking distribution

○ Symptoms vary depending on whether sensory or motor nerves are damaged

     ■ Impaired/absent light touch

     ■ Impaired/absent proprioception

     ■ Muscle wasting/atrophy

     ■ Neuropathic pain

○ Balance: sensory integration issues

○ Gait

    ■ Weakness: may lead to drop foot, knee hyperextension

   ■ Sensory ataxia

● Radiculopathy: at nerve root site

○ Signs & Symptoms

    ■ Sensation

● Follows dermatomal pattern

    ■ Weakness

● Follows myotomal pattern

● Consider testing muscles with similar innervations

     ■ Reflexes: diminished

     ■ Bowel/Bladder- not impaired

○ The following criteria are predictive for cervical radiculopathy:

     ■ Positive limb upper tension test A

     ■ Cervical rotation less than 60 degrees to involved side

     ■ Positive distraction test

     ■ Positive Spurling's Test

● Myelopathy: Spinal Cord Involvement

○ Reflexes: Hyperreflexia below level

○ Strength: impaired below level

○ Increased spasticity

      ■ + Babinski's and/or Hoffman's reflexes

○ Loss of bowel/bladder control

○ Coordination: impaired due to weakness