1. NEUROLOGICAL ASSESSMENT FOR CVA AND BRAIN INJURED PATIENTS
Continuous Education Program
Herat ,8-9 July 2007

2. Functional systems in the brain

3. Functional systems in the brain: 3 main blocks

4. Functional organization of the brain; 3 main blocks
BRAIN STEM AND RETICULAR FORMATION :regulates basic tone, waking and global response to stimuli
OCCIPITAL, PARIETAL AND TEMPORAL LOBES: storage , coding and combination of all sensory information
FRONTAL LOBES:INTENTION AND PLANNING OF COMPLEX ACTIONS/ BEHAVIOUR (Direct connection with brain stem
regulate attention and concentration (conscious activities), monitoring progress towards goals, and correcting mistakes

5. VOLUNTARY MOVEMENT: PYRAMIDAL SYSTEM

6. VOLUNTARY MOVEMENT
post central zone (1): sensory feedback from the muscles;
the parieto-occipital zone (2): spatial orientation of movement;
the premotor zone (3) the separate links of motor behavior
the frontal zone (4), which programs movements.

7. COMPONENTS OF VOLUNTARY MOVEMENT
Sensory synthesis
Spatial field: orientation of the movement in a certain point of the space; spatial analysis
Correct sequence of movements
( premotor cortex)
Planning and intention
Loss of sensation and organization of movement
Movement is intact but difficult recognition of direction, left and right
Apraxia
Meaningless repetitions , impulsive actions

8. MUSCOLAR TONE
Definition: resistance felt when part of the body is moved passively
Hypotonus: little or no resistance; the limb is heavy; if not supported, the limb will fall according to the gravity direction ( diaschisis/cerebellum injuries/extra-pyramidal)
Hypertonus: increased resistance in one direction of movement( from slight delay to impossibility to change the position; release of tonic reflex activity; stereotyped patterns; total flexion or extension patterns in pyramidal tract

9. MUSCOLAR TONE Other tone alterations:
In the extra-pyramidal centres ( basal ganglia, cerebellum)
Dystonia: alteration in the patterns of volunteer movement; signs are abnormal twisted postures and repetition of movements:
Co-contractures ( more then one direction of movement)
Tone increases during active movements
Changes with emotional status, tactile stimulation
Don’t depend on the speed of imposed mobilization

10. Alterations of tone Pyramidal tract
Depend on speed of passive stretching
2 Usually one group of muscles
Always the same pattern: flexion or extension
increase for passive, active and postural changes
Extra pyramidal tract
Don’t depend on speed, it’s a constant resistance
Co-contractures: flexors and extensors
Different reactions
Increase more for active and postural changes

11. Increasing tone factors in normal life
Abnormal sensation or lack of feedback
Acquiring new motor skills
Loss of balance or fear of falling
Pain and expectation of pain
Sudden loud noise or loud, imperative voice
Trying to make something in a hurry
Emotional states
Meeting people/establishing contact
Unfamiliar situations/strange apparatus

12. Increasing tone factors in brain injured people
Abnormal sensation or lack of feedback
Acquiring new motor skills
Loss of balance or fear of falling
Pain and expectaion of pain
Sudden loud noise or loud, imperative voice
Trying to make something in a hurry
Emotional states
Meeting people/establishing contact
Unfamiliar situations/strange apparatus

13. Neurological assessment
Movement and perception
Speech
Planning, memory, attention, learning
Behavior

14. Neurological assessment: 1-movement and perception
Sensation
Tactile
Proprioceptive
Kinestetic
Motor recruitment
Which district ( shoulder-elbow-wrist-fingers; hip-knee-ankle)?
In which position: supine-sitting?
Tone and spasticity:
Stretch Reflex:
for slow/quick passive movement? in different position of the body? At rest?
Spasticity;
Which muscular groups?
In which situations it increases?( see previous slide)
How quickly the patient relaxes?
Ashworth scale for spasticity

15. Ashworth Scale for spasticity
1.      No increase in muscle tone.
2.      Slight increase in tone giving a “catch” when affected part is moved in flexion or extension.
3.      More marked increase in tone but affected part is easily flexed.
4.      Considerable increase in tone; passive movement difficult.
5.      Affected part is rigid in flexion or extension.

16. Neurological assessment: 1-movement and perception
Coordination and Balance:
Elements to consider:
Apraxia
Cerebellum and extrapyramidal pathways
Perception ( lower limb)
Neglect
Function
Upper limb: reach an object, grasp, fine finger movements
Lower limb: postural changes-
Oral control: swallowing, chewing, tongue movements

17. Neurological assessment: 1-movement and perception
Apraxia
Motor skill learning
Agnosia
Prosopoagnosia ( human faces)
Neglect ( body and/or space)

18. Neurological assessment: 2-speech
Aphasia is a loss of the ability to produce and/or comprehend language, due to injury to brain areas specialized for these functions.
Usually, aphasias are a result of damage to the language centres of the brain (like Broca's area). These areas are almost always located in the left hemisphere, and in most people this is where the ability to produce and comprehend language contents and meanings is found.

19. Neurological assessment: speech

20. Aphasia:symptoms
Any of the following can be considered symptoms of aphasia:
inability to comprehend language
inability to pronounce, not due to muscle paralysis or weakness
inability to speak spontaneously
inability to form words
inability to name objects
poor enunciation
excessive creation and use of new words with no meaning
inability to repeat a phrase
persistent repetition of phrases
paraphasia (substituting letters, syllables or words)
agrammatism (inability to speak in a grammatically correct fashion)
dysprosody (alterations in inflexion, stress, and rhythm)
uncompleted sentences
inability to read
inability to write

21. Neurological assessment: 2-speech
Dysarthria is a speech disorder characterised by poor articulation. Any of the speech subsystems (respiration, phonation, resonance, prosody, articulation and movements of jaw and tongue) can be affected.
Disarthric speech is due to some disorder in the nervous system, which in turn hinders control over for example tongue, throat, lips or lungs. Swallowing problems, dysphagia, are often present.
Cranial nerves that control these muscles include the facial nerve (VII), the glossopharyngeal nerve (IX), the vagus nerve (X), and the hypoglossal nerve (XII).

22. Cranial nerves

23. Frontal lobe

24. Neurological assessment: 3- Planning, memory, attention, learning
Frontal lobe dysfunctions:
Perseveration
Inertia
Distractibility
Memory ( STM, LTM, amnesia, semantic/episodic)
Lack of planning
Impulses

25. Neurological assessment: 4-behaviour alterations
Lack of awareness
Depression
Aggressive without reason
Impulses
No initiatives

26. Recovery indicators + - Tactile/proprioceptive/ kinestetic
Good perception
Lack of sensation
Voluntary movement
Isolated extension of fingers/wrist
Extension of toes/dorsiflex of ankle in sitting position
Isolated ext of the knee
Global flex/ext patterns of the limbs
Stretch reflex
In creases with slight contact with surfaces
Spasticity
If the patient pay attention it reduces
Increases during automatic movements like snoring, postural changes, ect

27. Recovery indicators + - awareness attention memory
Lack of awareness limit improvement
attention
Good attention and focus skill support correction of mistakes and learning new skills
memory
Deficit in the STM doesn’t help learning new motor skills

28. GLASGOW COMA SCALE GCS Records conscious state of a person
Predicts ultimate outcome
Assess mainly the brain stem pathways: basic response to stimulations: general reaction, localization, appropriate response
Generally, comas are classified as:
Severe, with GCS ≤ 8
Moderate, GCS
Minor, GCS ≥ 13.
GCS=3 deep coma or death
GC=15 fully awake

30. CA /NEAR COMA SCALE CNC

31. RANCHOS LOS AMIGOS SCALE
Level of cognitive functions after injury
Level 1: no response: total assistance
Level 2: general response: total assistance
Level 3: localized response: total assistance
Level 4: confused/agitated: maximal assistance
Level 5: confused/inappropriate, non agitated: maximal assistance
Level 6: confused, appropriate: moderate assistance
Level 7: automatic/appropriate: minimal assistance for ADL
Level 8: purposeful, appropriate: stand by assistance
Level 9: purposeful, appropriate: stand by assistance on request
Level 10: purposeful, appropriate: independent

32. DISABILITY RATING SCALE
AROUSABILITY, AWARENESS AND RESPONSIVITY
( eyes opening, communication, motor response)
COGNITIVE ABILITY FOR SELF CARE ACTIVITIES (feeding, toileting, grooming )
DEPENDENCE ON OTHERS
PSYCHOSOCIAL ADAPTABILITY
employability

33. Functional independence measurement FIM
ADL:
Eating
Washing
Toilet
Continence
Transfers
Gait
stairs
COGNITION:
Speech comprehension
Speech production
Relashionship with people
Problem solving
memory

34. Functional independence measurement FIM
7 levels of autonomy:
Total assistance
Fully independent