Neurological Conditions – Basics, Assessment and Evaluation

Objectives:
The course shall enable the candidate to expertise in early intervention acquisition and application of neuromotor and sensory integration skills on adults and paediatric neurological conditions as a first contact practitioner. Such candidate shall also attain an ability to acquire a position as consultant in the team of health care professionals involved in electro-diagnosis, disability evaluation, as well work in the management of patients at the intensive care area and \or in the rehabilitation neurologically affected adults and children/neonates. The sub-specialities are:

• Adult neurological and psychosomatic conditions and applied neurophysiology.
• Developmental and paediatric Neuro pathological conditions.
• Applied bio-mechanics and bio-engineering
• Geriatrics
• Electro-diagnosis
• Intensive care

Section-I: Neurological Conditions – Basics

NEUROANATOMY

• Embryological development, growth & maturation of nervous system.
• Normal Sequential behavior and physiological changes throughout the developmental arc.
• Introduction and organization of nervous system, normal development of brain and spinal cord.
• Neuro biology of neurons and Neuroglia
• Coverings of the nervous system
• Nerve fibres
• Dermatomes and myotomes
• Cerebrum and cerebral hemispheres, Cerebral cortex
• Cerebellum and its connections
• Brain stem, Midbrain, Pons, Medulla
• Thalamus, hypothalamus and their connections
• Limbic system, reticular formation
• Internal capsule, corpus straitum
• Basal ganglia and its connections
• Ventricular system and CSF
• Blood brain barrier
• Spinal cord, tracts ascending & descending
• Blood supply of CNS and peripheral nervous system, venous drainage of CNS
• Peripheral nervous system
• Autonomic nervous system
• Cranial nerves and their nuclei

* It is mandatory to see/ comprehend the dissected parts of the nervous system.

NEUROPHYSIOLOGY
Functions of all the organs including:

• Nerve fibers & Coverings of the nervous system
• Dermatomes and myotomes
• Cerebrum and cerebral hemispheres, Cerebral cortex
• Cerebellum and its connections
• Brain stem, Midbrain, Pons & medulla
• Thalamus, hypothalamus, connections
• Limbic system, reticular formation
• Special senses
• Internal capsule, corpus striatum
• Basal ganglia and its connections
• Ventricular system and CSF
• Blood brain barrier
• Spinal cord tracts, ascending & descending
• Peripheral nervous system
• Autonomic nervous system
• Neurophysiology of balance, co-ordination & locomotion
• Cranial nerves and their nuclei
• Motor control
• Neural development of posture and gait
• Physiology of pain
• Physiology of reflexes – normal and abnormal
• Physiological basis of motor learning and recovery of functional motor control

PATHOMECHANICS
The student should get well acquainted with the pathomechanics of individual joints and Posture related to neurological diseases.

Section-II: Neurological Conditions – Assessment and Evaluation

• Measurement and assessment; what and why?
• Classification of impairment, disability and handicap
• How to choose a measure?
• Measurement in practice
• General neurological examination
• Measures for use in neurological disability

• Measures of cognitive impairment and disability;
  • Glasgow coma scales
  • Children’s coma scales
  • Edinburgh – 2 coma scale
  • Blessed dementia rating scales; information concentration – memory test; dementia scale
• Measure of motor impairment;
  • Motor club assessment
  • Rivermead motor assessment
  • Motricity index
  • Trunk control test
  • Motor assessment scale
  • Modified ashworth scale for spasticity
  • Isometric muscle strength
  • Motor neuron disease/ amyotrophic lateral sclerosis
  • Dynamometer
• Measures of focal disability;
  • Standing balance
  • Functional ambulation categories
  • Hauser ambulation index
  • Timed walking test
  • Rivermead mobility index
  • Nine hole peg test
  • Action research arm test
  • Franchay arm test
• Activities of daily living and extended ADL tests;
  • Barthel ADL index
  • Katz ADL index
  • Nottingham ten point ADL index
  • Rivermaid ADL scale
  • Northwick park index of independence in ADL
  • Kenny self care evaluation
  • Nottingham extended ADL index
  • Frenchay activity index
• Global measures of disability;
  • OPCS disability scale: severity categories
  • functional independence measure
  • PULSES profile
• Measures of handicap and quality of life;
  • WHO handicap scale
  • Rankin scale
  • Glasgow outcome scale
  • Quality of life : a measure
  • Environmental assessment – non standard
• Multiple sclerosis;
  • Kurtzke multiple sclerosis rating scale
  • An illness severity for multiple sclerosis
• Stroke scales;
  • Mathew stroke scale
  • National institute of health stroke scale
  • Canadian neurological scale
  • Orgogozo score
  • Hemispheric stroke scale
  • Clinical classification of scale
  • Clinical classification of stroke ( Bamford)
  • Allen score for prognosis of stroke
  • Guy’s hospital score for haemorrhage
• Head injury;
  • Galveston orientation and amnesia test
  • Rappaport disability rating scale
• Parkinson’s disease;
  • Parkinson’s disease impairment index, disability index
  • Hoehn and Yahr grades
  • Unified Parkinson’s diseases rating scale version 3
• Spinal cord injury;
  • Frankel’s scale
  • Motor index and sensory indices
  • American spinal cord injury association assessment chart
  • Pain assessment and evaluation
• Basic elements of Neuro Diagnostic Tests;
  • CT scan
  • MRI
  • Carotid Angiography
  • Myelography
  • X- ray
  • Nuclear imaging
  • Electroencephalogram
  • Electromyography
  • Nerve Conduction Velocity
  • Evoked potential tests
  • Muscle and Nerve Biopsy
  • CSF examination
• Assessment of posture, gait, coordination, voluntary control

Physiotherapeutic Interventions in Clinical Neurological Conditions

Section-I: CLINICAL NEUROLOGICAL CONDITIONS

• Causes, clinical features, pathophysiology, general investigation (blood test, serum creatinine, CSF analysis, etc) Medical and surgical management of the below mentioned conditions
• Intracranial neoplasms, Gliomas, meningiomas, neuromas, angiomas, cranio, pharyngiomas, pituitary adenomas, medical and surgical management.
• Pyogenic infections of CNS: Meningitis, brain abscess, tuberculosis, neurosyphillis.
• Viral infections of CNS: Poliomyelitis, viral encephalitis, substance sclerosing encephalitis, AIDS
• Cerebro vascular disease: Stroke syndrome, ischaemic stroke infarction, thrombo- embolic stroke, Hemorrhagic stroke, Transient ischaemic attack, arterio- venous malformation of the brain, intracranial hemorrhage
• Metabolic disorders of brain : Hypoencephalopathy, hypoglycemic encephalopathy, hepatic encephalopathy
• Degenerative disease of the brain: Parkinson’s disease, motor neurone disease, amyotrophic lateral sclerosis, progressive bulbar palsy, Alzheimer’s disease.
• Cerebral palsy
• Spina bifida
• Polyneuropathy: Post infective Polyneuropathy (gullian bare syndrome) diabetic neuropathy, hereditary sensory neuropathy.
• Disorders of spinal cord: Compression of spinal cord, neoplasm of the vertebral column, inter vertebral disc prolapsed, extra dural or epidural abscess.
• Syringomyellia, multiple sclerosis, myasthenia gravis
• Peripheral nerve and plexus lesions
• Carniovertebral junction abnormalities
• Hydrocephalus
• Cerebral lesions.
• Disorders of motor unit (Neuromuscular disease)
  • Muscle pain and tenderness
  • Muscle weakness
  • Changes in muscle mass
  • Muscle hyperactivity states
  • Muscle fatigability
  • Abnormal muscle tone (Hypotonic)
  • Abnormalities of sensation
  • Reduced or absent stretch reflexes
• Disorders of muscle (Myopathies)
  • Myasthenia gravis and other disorders of neuromuscular transmission
  • Disorders of the peripheral nervous system
  • Disorders of the anterior horn cells (Neuronopathies)
• Disorders of central motor control
  • Abnormal muscle tone
  • Muscle weakness
  • Loss of muscular endurance
  • Altered muscle activation patterns
  • Involuntary movements
  • Associated reactions
  • Abnormalities of coordination
  • Apraxia
  • Hypokinesia
  • Abnormal skeletal muscle reflexes
  • Abnormal balance
  • Abnormalities of sensation
• Other associated manifestations
  • Abnormalities in communications
  • Abnormalities in swallowing
  • Abnormalities of bladder and bowel functions
  • Learning disorders
  • Visual dysfunction
  • Cognitive and perceptual dysfunction

Recommended books:

• Goodman; pathology implications for the physical therapist
• Barbara; muscles, nerves and movement kinesiology in daily living.
• Greame; clinical neurology
• Brandt; neurological disorders course and treatment
• Brains; Disease of the nervous system
• Shirley; diagnosis , treatment of movement impairment syndromes
• Richard; neurological rehabilitation
• Susan; neurological physiotherapy
• Helen; Neuroscience of rehabilitation
• Wade DT 1992 , assessment in neurological rehabilitation, oxford press
• Omer; management of peripheral nerve problems
• Darcy; neurological rehabilitation
• Gerald; evaluation and treatment of chronic pain
• Alfred; Early diagnosis and therapy in cerebral palsy
• Charles; The neuroscience of human movement
• Traumatic brain injury rehabilitation

Section-II: Physiotherapy Interventions in Neurological Conditions
Student should be able to plan appropriate treatment regime based on the knowledge of various subjects learned during the two year programme for the below mentioned conditions. Additionally emphasis should be on special techniques/ approaches like Bobath, Neurodevelopment therapy, Motor relearning programme, Sensory integration, PNF, Roods approach etc. Student should update himself/ herself with latest advancement in the therapeutic approaches.

• Physiotherapeutic interventions for relief of pain
• Physiotherapy management of patients with postural control , mobility control disorders.
• Neurological rehabilitation – neurofacilitation approach
• Intracranial neoplasms; Gliomas, meningiomas, neuromas, angiomas, craniopharyngiomas, pituitary adenomas, medical and surgical management.
• Pyogenic infections of CNS; Msis, Neurosyphilis
• Viral infection on CNS; Poliomyelitis, viral encephalitis, Substance sclerosing encephalitis, AIDS
• Cerebro – vascular Diseases; Stroke syndrome, ischaemic stroke infarction, thrombo-embolic stroke, hemorrhagic stroke, Transient ischaemic attack, Arterio-venous malformations of the brain, Intra cranial hemorrhage.
• Metabolic disorders of the brain; Hypoxic encephalopathy, hypoglycemic encephalopathy, hepatic encephalopathy.
• Degenerative disease of the brain Parkinson’s disease, motor neuron disease, amyotrophic lateral sclerosis, progressive bulbar palsy, Alzheimer’s disease.
• Cerebral palsy
• Spina bifida
• Polyneuropathy Post infective poly radiculo-neuropathy (Gullain-barre syndrome) diabetic neuropathy, hereditary sensory neuropathy.
• Disorders of spinal cord Compression of spinal cord, neoplasm of the vertebral column, inter vertebral disc prolapsed, extra dural or epidural abscess.
• Syringomyellia, multiple sclerosis, myasthenia gravis
• Peripheral nerve and plexus lesions
• Carniovertebral junction abnormalities
• Hydrocephalus
• Cerebral lesions.

Recommended Books:

• Neurological Physiotherapy – Susan Edward.
• Stroke Patient – Principles of Rehabilitation – John Stone (Churchill Livingstone).
• Motor Relearning Programme for Stroke – Carr & Shephered.
• Adult Hemiplegia: Evaluation and Treatment – Bobath & Bobath.
• Neuro Rehabilitation – Farber, WB Saunders, Philadelphia.
• The Neural Basis of Motor Control – Black I, Churchill Livingstone.
• Tetraplegia & Paraplegia – Ida Bromley, Churchill Livingstone.
• Proprioceptive Neuro Muscular Facilitation Techniques Knot M. and Voss, Harper and Row.
• De Jong’s the Neurological Examination, Armin F. Haerer Lippoincott – Raven.
• Abnormal Postural Reflex Activity caused by Brain Lesions. Bobath B. Aspen, Publications Rockville.
• Spinal Cord Injuries – Orthopaedic & Neurological Aspects A.G. Hardy & Rossier A.B.
• Physical Rehabilitation (O’Sullivan, Physical Rehabilitation) by Susan B. O’Sullivan and Thomas J. Schmitz (Aug 4, 2006)
• Rehabilitation for Traumatic Brain Injury by Walter M. High, Angelle M. Sander, Margaret A. Struchen and Karin A. Hart (Jul 7, 2005)
• Neurological Rehabilitation by Darcy Ann Umphred PT PhD FAPTA (Nov 10, 2006)
• Neurological Physiotherapy: Bases of Evidence for Practice, Treatment and Management of Patients Described by Specialist Clinicians by Cecily Partridge (May 15, 2002)
• Motor Control and Learning by Markus Latash and Francis Lestienne (Feb 7, 2006)
• Physical Management for Neurological Conditions: by Maria Stokes and Emma Stack (Apr 25, 2011)
• Neuro-developmental Treatment Approach: Theoretical Foundations & Principles by Janet M. Howle (Jan 2002)
• Guide to Evidenced-Based Physical Therapist Practice, Second Edition by Dianne V. Jewell (Aug 23, 2010)
• Physical Therapy for Children by Suzann K. Campbell, Robert J. Palisano PT ScD and Margo Orlin (Jan 24, 2011).
• Improving Functional Outcomes in Physical Rehabilitation by O’Sullivan and Schmitz (Dec 9, 2009)