Functional Neurology Essentials Notes PDF

Foundational Concepts In Clinical Neuroscience Presented By: Dr. Adam Klotzek  THIS WEEKENDS LEARNING PROCESS Factors Affecting Learning Flipped Classroom LEARNING PARADGMS Assess Think Treat...

Foundational Concepts In Clinical Neuroscience Presented By: Dr. Adam Klotzek  THIS WEEKENDS LEARNING PROCESS Factors Affecting Learning Flipped Classroom LEARNING PARADGMS Assess Think Treat Observe Pair Share Diagnose Comprehend THE RBE GOAL To deliver a clear, concise, and effective system of evaluating neurological integrity, and to provide clinical applications to improve neurological health and performance. “If real is what you can feel, smell, taste and see, then real is simply electrical signals interpreted by our brain”  What is Clinical Neuroscience & Functional Neurology Clinical A branch of neuroscience focused on the study of: Neuroscience Fundamental mechanisms that underlie diseases, disorders, and function of the brain and central nervous system To develop new ways of diagnosing and treating such disorders. Functional Functional neurology (FN) offers a conceptualization of the nervous system as an integrated network that controls the homeostasis of the body through balanced signaling. Neurology It is founded on the principle of neuroplasticity, in that nerve connections in the brain may be modified or shaped by a variety of afferents, including sensory, cognitive, emotional, or motor experiences-and thus amenable to rehabilitation. Functional neurology represents a paradigm of healthcare that utilizes an evidence-based approach to quantify brain function. It does not represent a theory or hypotheses or any diagnostic or treatment application Evidence-Based Medicine EBM The Changing Tide In Medicine Patient Values Research Expectations Clinical Circumstances Experience THE 10 PRINCIPLES OF PLASTICITY HOW WE ARE WIRED  HEBBIAN SYNAPTOGENESIS 3 POTENTIAL OUTCOMES OF NEUROPLASTICITY 1. RECRUITMENT Engaging new (compensated) brain areas to produce a prior behavior 2. RE-TRAINING Training brain areas to perform new (compensated) functions 3. RESTORATION Re-engaging brain areas initially dysfunctional after injury or disease to prior behavior 10 PRINCIPLES OF EXPEREINCE – DEPENEDENT NEURAL PLASTICITY  Neural systems not actively participating in a task for an extended period begin to degrade Systematically Demonstrated: PRINCIPLE 1 Vision USE IT OR LOSE IT Auditory Restriction of movement Reallocation of Function Feeding Tubes  Rats with striatal hemorrhage were divided into 3 groups and exposed to 7 days of treatment PRINCIPLE 2 Group 1: Constraint therapy Group 2: Rehabilitation training USE IT & IMPROVE Group 3: Constraint PLUS Rehabilitation IT Results: Group 3 had the best functional outcomes and the greatest reduction in tissue loss.  Healthy rats trained to reach outside of their cage to retrieve food with their paws demonstrated: 1. Increased paw representation in their motor cortex PRINCIPLE 2 2. Enhanced synaptogenesis compared to USE IT & IMPROVE IT controls 3. Increased synaptic responses Reorganization of the auditory and somatosensory cortex has been demonstrated after sensory discrimination training.  PRINCIPLE 3 SPECIFICITY MATTERS Unilateral reach-and-grasp task rats cause dendritic arborization in the contralateral motor Learning-induced cortex, and only subtle effect on the ipsilateral. brain changes show This principle applies to sensory stimuli It can also apply in regions remote from, but specificity to connected to, the site of injury functional regions of the brain.  Rats with unilateral sensorimotor cortex lesions, were exposed to aseveral week training period Control: Simple exercises COMPLEXITY MAY Experimental: “acrobatic” training (traversing obstacle courses) ENHANCE Experimental group had improved behavioral PLASTICITY function and increased reactive synaptic plasticity in the contralateral cortex vs controls. Jones et al 1999; Biernaskie 2001  Only engaging a neural circuit in task performance is not enough to drive plasticity. Repetition of a newly learned (or relearned) behavior may be required to induce lasting neural changes. PRINCIPLE 4 Trained rats do not show changes in synaptic strength and increases of number of synapses until several days REPETITION MATTERS of training. Plasticity induced through repetition makes the acquired behavior resistance to decay in the absence of training LTP in the sensorimotor cortex required 5 days of stimulation but did not remain permanent until 15 days.  Animals trained on a skilled reaching task to perform 400 reaches per day had increases in synapse number within motor cortex. PRINCIPLE 5 Animals trained to reach 60 times per day did not have increases INTENSITY MATTERS Low-intensity stimulation can induce a weakening of synaptic responses (long-term depression), whereas higher intensity stimulation will induce long-term potentiation  Plasticity is a complex cascade of molecular, structural, and physiological events. During motor skill training, gene expression precedes synapse formation which in turn precedes motor map PRINCIPLE 6 reorganization TIME MATTERS Stimulation experiments have shown that enhanced synaptic responses are more susceptible to degradation during early phases of stimulation than later It has long been known that the stable consolidation of memories requires time  There may be time windows in which training is particularly effective in directing the lesion-induced reactive plasticity. Biernaskie, Chernenko, & Corbett (2004) found that a 5- week period of rehabilitation initiated 30 days after PRINCIPLE 6 cerebral infarcts was far less effective in improving TIME MATTERS functional outcome and in promoting growth of cortical dendrites than the same regimen initiated 5 days postinfarct. Delay of training allows for greater establishment of self- taught compensations, which may interfere with rehabilitation.  TMS studies demonstrate less plasticity when the subject’s attention is directed away from the target function. Acetylcholine (focus) and dopamine (motivation/reward) are important to induction of plasticity. PRINCIPLE 7 In classical conditioning, a tone alone does not create plasticity. SALIENCE MATTERS A tone paired with a reward or activation of the cholinergic system, will induce plasticity. Human subjects demonstrated LESS plasticity when administered acetylcholine antagonist and MORE plasticity with acetylcholine agonist  Neuroplastic responses are altered in the aged brain. PRINCIPLE 8 The onset of neural sprouting in young rats takes 2-4 days; in AGE MATTERS aged rats it takes 20 days Experience-dependent synaptic potentiation synaptogenesis and cortical map reorganization are all reduced with aging.  Transference refers to the ability of plasticity within one set of neural circuits to promote concurrent or sub- PRINCIPLE 9 sequent plasticity. TRANSFERENCE When TMS was applied to motor cortex synchronously during skill training researchers noticed enhanced skill acquisition  Interference refers to the ability of plasticity within a given neural circuitry to impede the induction of new, or expression of existing, plasticity within that same circuitry. PRINCIPLE 10 Trans Direct Current Stimulation given after training reduced the training-dependent increases in cortical INTERFERENCE excitability Compensatory strategies or changes in neural response may change sensitivity to interference or plasticity. Complex tasks may benefit a healthy subject, but hinder learning in subjects with brain injuries Drug Effects On Plasticity  Antipsychotics Atrovent (Asthma) Scopolamine (Nausea (clozapine, quetiapine) and motion sickness) (Seroquel) Orphenadrine (Muscle Relaxer) Solifenacin (Overactive Atropine Bladder) Oxitropium (Asthma) Benztropine (Cogentin) Bupropion Oxybutynin ANTI-CHOLINERGIC Biperiden (Overactive Bladder) (Wellbutrin) Dextromethorphan MEDICATIONS Chlorpheniramine Promethazine (Antihistamine) (Phenergan) (Cough Suppressant) Certain SSRIs Tolterodine (Overactive BLOCKING PLASTICITY (Celexa, Zoloft) Dicyclomine (IBS) Bladder) Tiotropium (COPD) Dramamine Tricyclic antidepressants Benadryl Trihexyphenidyl (For Doxylamine PD) (Antihistamine)  Ginger Root Extract Artichoke Extract ACETYLCHOLINE Luteolin AGONISTS Caffeine Nicotine Huperzine A  Think Describe how you could apply 3 of the 10 principles of Pair plasticity to: Improve patient compliance Improve patient outcomes Share  CORE CONCEPTS OF THE CNS Fundamentals for Success THE SKILL OF OBSERVATION It’s different than just looking at someone… THE LENSES OF A HEALTHCARE PROVIDER Lenz: A device that focuses or otherwise modifies the perception of an object. FedEx® is a registered trademark of the Federal Express Corporation. No affiliation implied THE UNIQUENESS OF THE NEUROLOGIC EXAM Jean Marie Charcot The neurologic examination is one of the most unique exercises in all clinical medicine. Unlike many other fields of medicine in which diseases are tangible. Neurology is characterized by conditions that may be detected only by applying specific examination techniques and logical deduction. BLACK BOX HYPOTHESIS TESTING INPUT OUTPUT The examiner controls the inputs, and calculates errors based upon expected or prior outputs. THE 7 LEVELS OF NEUROLOGICAL DECOMPENSATION RBE 1 2 3 5 6 7 4 End Organ Peripheral Spinal Brainstem Cerebellum Thalamus/ Cortex Nerve Cord Basal Ganglia CAUSES OF FUNCTIONAL DECOMPENSATION 1. Vascular 2. Compressive 3. Metabolic 4. Autoimmune 5. Oncogenic 6. Psychogenic 7. Diaschisis 8. Deafferentation … UNCOVER ROOT-CAUSE DEAFFERENTATION Plasticity: Long Term Potentiation  Targeting Formula: Direct Targeting Your Therapies Association (Nearby) Presynaptic CASE STUDY Importance of Oxygen & Glucose for Neuronal Function Oxygen & Glucose DYSGLYCEMIA 2 CLASSES: HYPOGLYCEMIA DIABETES  Shakiness, Personality Change, Emotional Lability Anxiety, Nervousness, Irritability Fatigue, Weakness, Apathy, Lethargy, Daydreaming, Sleep Palpitations, Tachycardia Confusion, Memory Loss, Sweating, Feeling Of Warmth Lightheadedness Or Dizziness, (Sympathetic Muscarinic Rather Than Delirium Adrenergic) Staring, Glassy Look, Blurred Vision, Pallor, Coldness, Clamminess Double Vision Dilated Pupils (Mydriasis) Flashes Of Light In The Field Of Vision SIGNS OF Hunger, Borborygmus Nausea, Vomiting, Abdominal Automatic Behavior, Also Known As Automatism DYSGLYCEMIA Discomfort Headache Difficulty Speaking, Slurred Speech Ataxia, Incoordination, Sometimes Abnormal Thinking, Impaired Mistaken For Drunkenness Judgment Focal Or General Motor Deficit, Nonspecific Dysphoria, Moodiness, Paralysis, Hemiparesis Depression, Crying, Exaggerated Headache Concerns Stupor, Coma, Abnormal Breathing Feeling Of Numbness, Pins And Needles (Paresthesia) Generalized Or Focal Seizures Negativism, Irritability, Belligerence, Combativeness, Rage CAUSES OF HYPOGLYCEMIA Most Common Causes Stress Not eating enough Refined Carbohydrate Consumption Medications to treat diabetes Alcohol consumption Hypothyroidism Infections CAUSES OF HYPERGLYCEMIA Most Common Causes: Autoimmune Type 1 Diabetes (IDDM) Insulin Resistance Type 2 Diabetes (NIDDM) Tests: Fasting Blood Glucose Hb A1C OXYGEN TRANSPORTATION Plasma, 1.5 % Hemoglobin, 98.5% FACTORS AND SYMPTOMS OF ANEMIA MOST COMMON TYPES OF ANEMIA 1. Iron Deficiency 2. Aplastic 3. Hemolytic 4. Vitamin Deficiency 5. Pernicious 6. Sickle Cell PHYSICAL EXAM FINDINGS SEEN WITH ANEMIA RESPIRATION Acidosis Homeostasis NORMAL VALUES FOR RESPIRATORY RATES 6 years: 18–25 breaths per minute 10 years: 17–23 breaths per minute Adults: 12-18 breaths per minute Elderly ≥ 65 years old: 12-28 breaths per minute. Elderly ≥ 80 years old: 10-30 breaths per minute.  CALCIUM INFLUENCES Calcium and sodium compete against each other to conduct across the nerve cell membrane. The basic relationship is inverse: As free calcium levels rise sodium conductance goes down and vice versa Calcium levels are the bigger influencer. P.H has a big role in influencing free calcium levels and the most common factor influencing blood P.H is Respiratory Rate Chest Expansion Acidosis: Hypoventilation & Hypercalcemia Decreased Oxygen and increased Carbon Dioxide Increase in Acidity/Decreased Ph Causes an Increase in Free Calcium Results in Decreased Neuronal Activity Alkalosis: Hyperventilation & Hypocalcemia Decreased Carbon Dioxide Decreased in Acidity/Increased Ph Decreases Free Calcium Increases Neuronal activity  Hypocalcemia VS Hypercalcemia Hypocalcemia Hypercalcemia < 8.5mg/dl > 12mg/dl Increased Neuromuscular Decreased neuromuscular Excitability excitability Muscle Cramps Muscle weakness Increased neuronal excitability via Decreased neuronal excitability increased sodium conductance via decreased sodium Seizures conductance Coma  Symptoms Hyperventilation Hypoventilation MOST COMMON CAUSE OF FUNCTIONAL HYPOXIA & Respiratory Acidosis Use Of Accessory Muscles During Breathing NORMAL CHEST EXPANSION Measured at the level of T6 upon full deep inspiration The normal range between inspiration and expiration is 5.8 –7.6 cm 1.5-3 inches Abnormal range for men is < 2.5 cm (1 inch) and women < 1.9 cm (0.75 inches). Pulse Oximetry Noninvasive way to measure oxygen saturation (SpO2) and the Perfusion Index Oxygen Saturation (Sp02) Measures the percentage of blood that is loaded with oxygen. More specifically, it measures what percentage of hemoglobin is loaded with oxygen. Normal ranges for patients without pulmonary pathology are from 95 to 99 percent. Correlates with blood flow & lung ventilatory capacity but is not a direct measure of either Side of Decreased O2 SaturationRepresents The Side of Decreased PMRF Output Pulse Oximetry Perfusion Index Is the ratio of the pulsatile blood flow to the non- pulsatile static blood flow in a patient's peripheral tissue, such as fingertip, toe, or ear lobe. Perfusion index is an indication of the pulse strength at the sensor site. The PI's values range from 0.02% for very weak pulse to 20% for extremely strong pulse. PI is also a good indicator of the reliability of the pulse oximeter reading. For most pulse oximeters for general use, the reading is unreliable or unavailable if PI is at or below 0.4% PERCUSSION MYOTONIA What To Do If You Find Percussive Myotonia? Improve Oxygenation: SMT/ Manual Therapies to the Ribs Improve Lumbar lordosis Breathing Exercises Reduce Thoracic Kyphosis Nutritional Support: Anemias Mg/Ca Levels Thyroid Check for peripheral Nerve Entrapment Check for UMN signs from the contralateral Brain CMA: FUEL DELIVERY (CHEST MECHANICS) 1. Measure the use of accessory muscles during full inspiration 2. Check for the presence of percussion myotonia. Pay attention to its sidedness if any of bilateralism 3. Measure your patient's chest expansion and pulse oximetry note any differences form side to side paying attention to the impaired side. 4. Have your partner do the following therapies: 2 sets of 8 repetitions of breathing exercises at a ratio of 1:2 (Inspiration/Expiration) Manual therapies to the Ribs/Lumbar Spine 5. Reassess 1. Rib expansion 2. Pulse Oximetry 3. Percussion Myotonia  Describe how the following conditions will influence neuronal activity: Think Anemia Dysglycemia Pair Hypoxia Describe simple measures you could take in your office to: Share Screen for these conditions Treat for them using the techniques you already use in your office.  AUTONOMIC NERVOUS SYSTEM Team Autonomics The Neurovisceral Integration Model SYMAPTHETIC SYSTEM STIMULUS-DRIVEN/BRAIN REGULATED Every Stimulus Drives Sympathetic Activity Immediate (Fast Acting) Sensory Chemical Mechanical Nociceptive Thermal Visual Cognitive Emotional The brain regulates how much sympathetic activity exists. Inhibited by the PMRF (Ipsilateral) Excited by the Mesencephalic RF PARASYMPATHETIC BRAIN-DRIVEN Not as a result of the absence of sympathetic activity Delayed response Complex networks of integration Largely based upon environmental motoring Prefrontal Cortex plays a large role  10% + Brain 90% +  How The Brain Shunts Blood by Regulating The ANS + + Increases + Blood flow to Muscles + + Sympathetic Sympathetic IML - IML AUTONOMIC STRUCTURES (CENTRAL AUTONOMIC NETWORKS) 1. Insular Cortex 2. Anterior Cingulate 3. Amygdala 4. Hypothalamus 5. Periaqueductal Grey (PAG) 6. Parabrachial Nucleus (PBN) 7. Nucleus Tractus Solitarius (NTS) 8. Caudal Ventral Medulla 9. Rostral Ventral Lateral Medulla (RVLM) 10. Locus Ceruleus 11. Medullary Raphe Dysautonomia  Think Describe how your understanding of the presence of Dysautonomia in Pair your patients will change your approach to the care they receive. Share TO BE CONTINUED... We continue talking about the ANS when we get to a special section of the NS called the PMRF SENSORY RECEPTORS THE BODY’S ENVIRONMENTAL TRANSDUCERS PURPOSE OF RECEPTOR SYSTEMS 1. Transduction 2. Transmission 3. Amplification 4. Integration 5. Ultimately all receptors convert an environmental stimulus to an electrical impulse.  KEY RECEPTOR CHARACTERISTICS RECEPTOR POTENTIALS ARE: 1. GRADED 2. NON- PROPAGATED Stronger stimulus intensities produce higher receptor potentials which result in greater frequencies of action potential generation, therefore greater CNS stimulation.  Compression, bending, stretching of Mechanoreceptors: cells. Touch, pressure, proprioception, hearing, and balance. Chemicals become attached to Chemoreceptors: receptors on their membranes. Smell and taste. TYPES OF Thermoreceptors: Respond to changes in temperature SENSORY RECEPTORS Photoreceptors: Respond to light: vision Extreme mechanical, chemical, or Nociceptors: thermal stimuli. Pain. Olfactory Receptors Sensations of smell. Coding Of Information Centrally Labeled Lines Frequency Code © 2016-2018 IPS, LLC. – All Rights Reserved CRITICAL READING IN FLIPPED CLASSROOM Sodium Potassium Pumps © 2016-2018 IPS, LLC. – All Rights Reserved Action Potentials Non-Graded Propagated Information coded by Frequency. © 2016-2018 IPS, LLC. – All Rights Reserved  Effects of Hypoxia Decreased ATP Production Failure of Na/K Pumps Accumulation of Sodium on the inside of the cell Resting membrane rises to threshold © 2016-2018 IPS, LLC. – All Rights Reserved  Think Clinically speaking how does one measure the resting membrane potential of a pool of neurons and their ability to metabolize stimulation. Pair Name 3 things that you can do in your office Monday morning to offset the negative effects of hypoxia on neuronal activity. Share © 2016-2018 IPS, LLC. – All Rights Reserved Long Term Pathway Potentiation Upregulation © 2016-2018 IPS, LLC. – All Rights Reserved WHAT IS LONG TERM POTENTIATION (LTP)? © 2016-2018 IPS, LLC. – All Rights Reserved Calcium & Immediate Early Gene Responses C-Fos C-Jun C-Mer THE NMDA GATE TO LTP Based primarily on Calcium Induction Calcium Induction is based on: 1. Quantity of Glutamate release 2. Degree of the Membrane Depolarization RECEPTOR INTEGRATION INTO THE BRAIN © 2016-2018 IPS, LLC. – All Rights Reserved THE ROLE OF THE BRAIN Incorporate the world through receptors Compare the receptor input to each other and prior input Produce an appropriate motor response Skeletal/Smooth Voluntary/Involuntary Assess the motor response execution through receptors BRAIN REGULATION OF SENSORY INPUT  FUNCTIONAL EMBYONINC DEVELOPMENT TIMELINE (IN WEEKS) VESTIBULAR OLFACTION AUDITION 6-7 8 9-10 12-15 25 32+ SOMATOSENSATION GUSTATION VISION  Think 1. Discuss three ways that you could increase the chance of producing LTP in your patients care when you return to your offices on Monday. Pair 2. Discuss how you would implement your understanding of the timeline of sensory development to the treatment of your patients. Share © 2016-2018 IPS, LLC. – All Rights Reserved What's The Most Effective Approach? How Much & How Long To Do It. © 2016-2018 IPS, LLC. – All Rights Reserved EFFECTIVE DOSE MODEL What are the variables of effort  FIRST EVENT - SECOND EVENT Z = FIRST EVENT + SECOND EVENT THE POCOCK METHOD A 15-SECOND STATISTICAL TEST TO DETERMINE SIGNIFICANCE Z= 2.37 1.00- 0.02=.98 98% PROBABILITY THAT THEY ARE DIFFERENT CMA: EFFECTIVE DOSE MODEL Assess your partner for the following: Assess Deltoid Muscle Weakness Assess Psoas Muscle Weakness Deliver light stimulation from the opposite side of muscle weakness as demonstrated by the instructor. Deliver Light Stimulation at: 5 seconds 30 seconds 3 minutes Wait 30 seconds in between stimulations and reassess Reassess and compare Record No Change = 0 They Worsened = -5 They Improved = +5 MUSCLE SPINDLES PROPRIOCEPTION INNERVATION DISTRIBUTION Less Representation less Feedback & Integration Basic Muscle Physiology/Function © 2016-2018 IPS, LLC. – All Rights Reserved Sensory Fiber Types © 2016-2018 IPS, LLC. – All Rights Reserved Muscle Nerve Supply The Players: 1. Alpha Motor Neurons 2. Gamma Motor Neurons 3. Group 1a Sensory Afferents 4. Group II Sensory Afferents 5. Group 1b Sensory Afferent © 2016-2018 IPS, LLC. – All Rights Reserved Effects of Group 1a/II and Group 1b Afferents © 2016-2018 IPS, LLC. – All Rights Reserved Effects of Gamma Motor Neuron Activity Increased/decreasing gamma motor neuron activity results in continuous tension being kept to the muscle spindle regardless of length. This improves and maintains a steady state of sensory feedback regardless of the type of movement that the muscle is undergoing. © 2016-2018 IPS, LLC. – All Rights Reserved MUSCLE SPINDLE TERMS Sensitivity: Gain: Represents the minimum amount of In electronics, gain is a measure of the ability of a circuit to stretch that would result in a reflex increase the power or amplitude of a signal from the input to contraction of the muscle the output. Product of Gamma Motor Neuronal It often results in signal distortion activity Product of Gamma Motor Neuron activity Directly related to muscle tone and brain Inversely related to muscle tone and brain output. output. Decrease brain output ---Increase muscle spindle gain to Increase brain output ---Increase stretch ---Decrease feedback. muscle spindle sensitivity to stretch --- Increase feedback Increasing gain makes for more noise and more distortion. © 2016-2018 IPS, LLC. – All Rights Reserved  Increase Brain 1. Increase Muscle Tone 2. Increase Muscle Spindle Sensitivity 3. Decreases Muscle Spindle Gain Decrease Brain 1. Decrease Muscle Tone 2. Decrease Muscle Spindle Sensitivity 3. Increase Muscle Spindle Gain © 2016-2018 IPS, LLC. – All Rights Reserved  FACTORS INFLUENCING TENDONOUS LOAD Speed of loading Length of muscle when loaded. Quantum of muscular protein More Tendonous Load Results in 1. Deceased Sensitivity 2. Increased Gain 3. Overall Decreased feedback  Relationship of Muscle length to Group 1a/II & Group 1b Integration 1a /II af fe re Muscle Length nt s & Load nts re affe 1b Activation © 2016-2018 IPS, LLC. – All Rights Reserved Relationship of Movement & Group 1a/II and 1b Afferent Integration Movement 1a/1b II/1b 1a/1b Time  Slow Stretch Incorporates the concept of biasing load onto the muscle belly Results In A bias to group Ia/II muscle spindle afferent activation Increased muscle tone Increased feedback Fast Stretch Incorporates the concept of biasing load onto the muscular tendon Results In: A bias to group 1b afferent activation over Group Ia/II afferents Decreased muscle tone Decreased feedback © 2016-2018 IPS, LLC. – All Rights Reserved  1. Discuss ways that you could do the Think following: 1. Increase the feedback from a particular muscle. Pair 2. Decrease the feedback from a particular muscle. 2. Discuss clinical instances when one of the Share above approaches may be more appropriate. © 2016-2018 IPS, LLC. – All Rights Reserved TYPES OF NEUROLOGICAL STIMULATIONS: BOTTOM-UP AND TOP-DOWN Bottom-Up Rehab Top Down Rehab © 2016-2018 IPS, LLC. – All Rights Reserved TOP-DOWN THERAPIES ANY STIMULATION THAT IS NOT DRIVEN BY RECEPTOR POTENTIALS Imagery Calculations/Contemplation Meditation Transcranial Electric/Magnetic Stimulation Photo-biomodulation CMA: Bottom Up/Top Down Test for touch localization in the upper extremity as demonstrated by your instructor Measureatotalof6points: 2-Hand 2-Forearm 2-UpperArm Totalthemeasurementsandrecord. Perform figure 8’s movements passively of the leg on the side of the worse sensory localization findings. Reassess Have your partner imagine themselves spinning towards the discrepancy side. Perform 2 sets of 8 repetitions of imagined spin Reassess Switch doctor/patient and repeat Models of Brain Function  Localization (Brain Function) Refers to the concept that different areas of the brain control different aspects of behavior. Localization Model Theories of localization first gained scientific credence in the 1860s with Paul Broca's discovery that damage to a specific part of the brain—the left frontal lobe—was associated with speech impairment. © 2016-2018 IPS, LLC. – All Rights Reserved Aggregate Field Model According to the aggregate field view, all areas of the brain participate in every mental function. Pierre Flourens, a French experimental psychologist, challenged the localizationist view by using animal experiment © 2016-2018 IPS, LLC. – All Rights Reserved Hemispheric Model © 2016-2018 IPS, LLC. – All Rights Reserved Corpus Callosum Inhibitory Effects © 2016-2018 IPS, LLC. – All Rights Reserved  The Concept of Hemisphericity Corpus Callosum L - 2 R + 1 Sensory Stimulation End of Day One RBE What Did You Learn? Welcome To Day Two RBE What to Expect RBE FOUNDATIONAL NEUROLOGICAL AREAS OF EVALUATION THE 4 NEUROLOGICAL FINDINGS MOTOR COGNITIVE SENSORY Reflex THE 7 LEVELS OF NEUROLOGICAL DECOMPENSATION RBE 1 2 3 5 6 7 4 End Organ Peripheral Spinal Brainstem Cerebellum Thalamus/ Cortex Nerve Cord Basal Ganglia AREAS OF CENTRAL DECOMPENSATION Basal Ganglia Cortex Frontal Lobe Parietal Lobe Midbrain Temporal Lobe Occipital Lobe Insular Lobe Cerebellum Brainstem (PMRF) Pons Medulla THE BRAINSTEM (PMRF) Pons & Medulla WHAT IS THE PMRF? The reticular formation is a set of interconnected nuclei that are located throughout the brainstem. The reticular formation is not anatomically well defined because it includes neurons located in different parts of the brain. The neurons of the reticular formation make up a complex set of networks in the core of the brainstem that extend from the upper part of the midbrain to the lower part of the medulla oblongata. The reticular formation includes ascending pathways to the cortex in the ascending reticular activating system and descending pathways to the spinal cord via the reticulospinal tracts. BRAINSTEM STRUCTURES PMRF NTS NRM RST RVM/CVM ANS PAIN MUSCLE TONE  NTS (Nucleus Tractus Solitarius) Solitary Tract: Runs through the center of the Solitary Nucleus Includes fibers from the: Facial Nerve Glossopharyngeal nerve Vagus Nerve Projects to: PMRF Parasympathetic Preganglionic Neurons Hypothalamus & Thalamus Function: Forms circuits that contribute to autonomic regulation. Inhibits the IML along with INCREASED output of the PMRF & Vagal Centers Functionality of the CVM/RVM RVM - NTS + CVM The Frontal Lobes FAVOR + The Activation of The CVM Resulting in Decreased Sympathetic Activation + IML  + P V Purkinje + RVM -C + Fastigial - Nucleus NTS + CVM + Why it Matters in Manual Therapy + IML NUCLEUS RAPHE MAGNUS Prime function is pain inhibition RETICULOSPINAL PATHWAYS MUSCLE TONE  ASSESSING THE PMRF Integrity Assessed on The Same Side of The Body  COMMON FINDINGS OF PMRF DYSFUNCTION Category 1 (Dysautonomic) Category 2 (Reflex) Category 3 (Motor) Increased Bld Pressure Decreased Corneal Reflex Soft Pyramidal Paresis Increased Pulse Rate Decreased Gag Reflex Depressed Deep Tendon Decreased HRV Decreased Carotid Sinus Reflex Reflexes Cold Hands/Feet Decreased Valsalva’s Reflex Depressed Soft Palate Elevation Decreased Capillary Refill Decreased Mammalian Dive Decreased Oxygen Saturation Reflex Decreased A:V Ratio Dry Eyes Decreased Gut Motility Constipation Irritable Bowel Syndrome  PMRF ASSESSMENTS Category 1 (Dysautonomic) Category 2 (Reflex) Category 3 (Motor) Compass 31 Corneal Reflex Soft Palate Elevation Bilateral Blood Pressure Gag Reflex Soft Pyramidal Weakness Capillary Refill Valsalva’s Reflex DTR’s Bilateral Pulse Oximetry Orthostatic Intolerance/Tilt HRV Measurements Table Red Desaturation Carotid Sinus Compression Bilateral A:V Ratio Mammalian Dive Reflex Bowell Sounds PMRF THERAPIES/APPLICATIONS Chewing gum/Gargling SSEP (Ipsilateral) Vagal Nerve Stimulation (Ipsilateral) Carotid Sinus Massage (Ipsilateral) EMS/Touch/Vibration to Face (Ipsilateral) Insufflation Therapy (Ipsilateral) Magnetic Auricular Therapy (Ipsilateral) Frontal/Cortical Activation (Ipsilateral)  Think Discuss a clinical scenario that you would treat differently in your office based upon Pair your current understanding of the way the PMRF influences neurological and or muscular function Share © 2016-2018 IPS, LLC. – All Rights Reserved CATEGORY 1 PMRF ASSESSMENTS Dysautonomia THE 8 DOMAINS OF AUTONOMIC FUNCTION 1. Vasomotor 2. Orthostatic Intolerance 3. Pupillomotor 4. Gastrointestinal 5. Secretomotor 6. Bladder 7. Sexual Function 8. Sleep Sletten et al 2012  31 Questions Estimated 5-minute completion time THE COMPASS 31 AUTONOMIC Validated against the previously validated 169-item Autonomic Symptom Profile (ASP) ASSESSMENT Simplified, more time-efficient, statistically more robust, but still comprehensive tool to assess and grade symptoms associated with autonomic dysfunction. SCORE: 0-100 COMPASS 31 LINK Survey Monkey  CATEGORY 1 PMRF ASSESSMENTS Autonomics Blood Pressure, Capillary Refill & Pulse Oximetry Heart Rate Variability (HRV) BLOOD PRESSURE BLOOD PRESSURE Regulated primarily by + sympathetic tone Decreased by output of the: Ipsilateral PMRF Ipsilateral Frontal Lobes BILATERAL BLOOD PRESSURES Assessed in a seated position. Start with right arm. Arm supported at heart level. Bilateral brachial artery pressure. Record blood pressures in mmHg Repeat on opposite side. Side of Increased Blood Pressure Represents Side of Decreased PMRF Output © 2016-2018 IPS, LLC. – All Rights Reserved CAPILLARY REFILL Time taken for color to return to an external capillary bed after blanched by pressure. (Typically Nail Bed) Raise hand higher than heart-level Apply cutaneous pressure for 5 seconds to the nail bed or until it turns white. Record the amount of time it takes for color to return to nail bed once the pressure has been removed Repeat on opposite side Side of Increased Capillary Refill Time Represents The Side of Decreased PMRF Output Pulse Oximetry Noninvasive way to measure oxygen saturation (SpO2). Measures the percentage of blood that is loaded with oxygen. More specifically, it measures what percentage of hemoglobin is loaded with oxygen. Normal ranges for patients without pulmonary pathology are from 95 to 99 percent. Correlates with blood flow & lung ventilatory capacity but is not a direct measure of either Side of Decreased O2 Saturation Represents The Side of Decreased PMRF Output or Increased Sympathetic Tone WHAT IS HEART RATE VARIABILITY Heart rate variability (HRV) is the physiological phenomenon of variation in the time interval between heartbeats. Reduced HRV has been shown to be a predictor of mortality after myocardial A range of other outcomes and conditions may also be associated with modified (usually lower) HRV, including: Congestive heart failure Post–cardiac-transplant depression Susceptibility to SIDS The autonomic nervous system influences the rate of the pacemakers. Vagal tone modulation produces variations in heart periods (R-R intervals) ASSESSING HRV Heart Rate Variability requires technology to assess. $150 Typically needs about a 60 second sample to be accurate. HRV 4 Training (Can Use Camera) Elite HRV (Requires Hardware)  1. Blood Pressure 2. Capillary Refill 3. Pulse oximetry 4. HRV © 2016-2018 IPS, LLC. – All Rights Reserved CMA: HRV 1. Measure your partners: 1. Blood Pressures 2. Capillary Refill 3. Pulse Oximetry (HR/O2 Sat) 4. HRV 2. Expose your partner for 30 seconds to an irritating sound https://www.salamisound.com/siren-sounds 3. Remeasure 4. Have your partner chew gum for 3 minutes while sitting. 5. Remeasure  CATEGORY 1 PMRF ASSESSMENTS Autonomics RED DESATURATION ARTERIAL TO VENOUS RATIO OF THE EYES RETINAL BLOOD FLOW BLOOD FLOW TO THE RETINA The Red Desaturation test assesses the integrity of the optic nerve and retinal blood flow by testing the visual sensitivity to the color red. Test: Occlude one eye. Observe the color red. Switch occlusion back and forth to compare saturation. Note which eye looks more faded or desaturated. LEFT EYE RIGHT EYE RETINAL ARTERIAL TO VENOUS RATIOS RETINAL ARTERY-TO-VEIN RATIOS (A:V RATIO)  Artery A:V RATIOS Vein  1. Red Desaturation 2. A:V Ratios © 2016-2018 IPS, LLC. – All Rights Reserved CMA: A:V Ratio 1. Check the red saturation in your partners eyes and record what you saw. 2. Compare the side of decreased red saturation to the sidedness of prior PMRF Category 1 signs. 3. Have your partner listen to an irritating noise for 30 seconds and reassess the A:V ratios https://www.salamisound.com/siren-sounds 4. Rest 3 min 5. Have you partner chew gum for 3 min and reassess the red saturation  Think Discuss how you would apply and change your care of an individual patient by the Pair results obtained from measuring the CAT 1 PMRF Assessments Share © 2016-2018 IPS, LLC. – All Rights Reserved  CATEGORY 2 PMRF ASSESSMENTS Motor Reflexes Corneal Reflex & Gag Reflex CORNEAL REFLEX Afferent Limb: Trigeminal Nerve (C.N. V.) Ophthalmic Division (Via Chief Sensory Nucleus) Efferent Limb: Facial Nerve (C.N.VII) © 2016-2018 IPS, LLC. – All Rights Reserved Soft Palate/Gag Reflex © 2016-2018 IPS, LLC. – All Rights Reserved Soft Palate Elevation © 2016-2018 IPS, LLC. – All Rights Reserved Examples of Weak Soft Palates © 2016-2018 IPS, LLC. – All Rights Reserved GAG REFLEX Afferent Limb: Glossopharyngeal Nerve (C.N. IX) Efferent Limb Vagus Nerve (C.N. X) The normal gag reflex is a mass contraction of both sides of the posterior oral and pharyngeal musculature The Gag Reflex Response is Decreased on the Same Side of PMRF Dysfunction  1. Corneal Reflex 2. Soft Palate Elevation 3. Gag Reflex © 2016-2018 IPS, LLC. – All Rights Reserved CMA: CORNEAL REFLEX & GAG REFLEX Assess: Corneal Reflex Soft Palate Elevation Gag Rflex Record the diminished side of activity Perform 5 minutes of magnet auricular therapy on the side of the diminished response Reassess Wait 5 min Perform Insufflation stimulation on the side of diminished responses Reassess  CATEGORY 2 PMRF ASSESSMENTS Autonomic Reflexes Valsalva Orthostatic Challenge Carotid Sinus Compression Mammalian Dive VALSALVA MANEUVER Specialized mechanoreceptors that detect stretch in blood vessels. Located in carotid sinus Increased aortic pressure causes activation of baroreceptors Afferent Limb: Glossopharyngeal Nerve (C.N. 9) Efferent Limb: Vagus Nerve (C.N. 10) Central Integration: Nucleus Tractus Solitarius (NTS) Caudal Ventral Lateral Medulla (CVLM) Normally broken down into 4 phases. We are going to focus on the first phase in RBE  VALSALVA MANEUVER Phase 1 In the first phase the patient exhales into a manometer or against a closed glottis for 15 seconds. This creates a markedly positive intra-thoracic pressure. This causes blood to be forced into the carotid system increasing carotid pressure in the Initial Increase In Carotid Sinus carotid sinus Pressure This causes a reflexogenic initial bradycardia As venous return decreases to the heart the CO goes down and blood pressure drops thus HR rebounds. ORTHOSTATIC CHALLENGE Changes of position from lying to standing changes blood flow dynamics Pooling of blood in the lower extremities and inhibition of aortic and carotid baroreceptors Initiates reflex sympathetic activity to increase HR Assessment: Initial Heart Rate on Supine for 3 min Monitor heart rate upon: Lying to sitting Lying to Standing Response: Normal: HR should increase with no symptoms Abnormal: HR Increases by 30 bpm and dizziness occurs HR decreases and dizziness occurs  ORTHOSTATIC CHALLENGE OUTCOMES Abnormal Findings Hypovolemia HR rises, but Blood Pressure falls (POTS) Anxiety, Dizziness, Lightheadedness, Loss of Vision, Vasovagal Syncope Sympathetic Failure HR and Blood Pressure do not rise (Orthostatic Hypotension) Dizziness, Lightheadedness, Loss of Vision, Vasovagal Syncope Parasympathetic Failure HR and Blood Pressure rise Headache, Head Pressure (Pulsatile) TREATMENT FOR ORTHOSTATIC INTOLERANCES Depends on what the cause is Hypovolemia: Increase salt intake Strengthen legs Address dysautonomia Sympathetic Failure Address dysautonomia Cold pressor Parasympathetic Failure Address dysautonomia Vestibular rehab Tilt Table Therapy CAROTID SINUS Contains afferent fibers that travel to the ipsilateral brainstem to innervate areas that lower heart rate and reduce blood pressure. Afferents Limb: Glossopharyngeal Nerve (C.N. 9) Efferent Limb: Vagus Nerve (C.N. 10) PMRF Carotid Sinus stimulation normally should result in a decrease in: HR Blood Pressure Palpating The Carotid Sinus © 2016-2018 IPS, LLC. – All Rights Reserved  MAMMALIAN DIVE REFLEX Multi-faceted reflex thought to evolutionally develop from diving mammals (whales, dolphins) Involves: Valsalva Carotid Sinus Trigeminal-Cardiac Reflex Splenic Contracture The diving reflex is useful to diagnose the integrity of efferent cardiovascular autonomic pathways. (Caspers and Cleveland 2011) Normal response is for the Heart Rate to Drop  MAMMALIAN (TRIGEMINAL-CARDIAC) DIVE REFLEX  1. Valsalva Reflex 2. Orthostatic Challenge 3. Carotid Sinus Massage © 2016-2018 IPS, LLC. – All Rights Reserved CMA: VALSALVA, ORTHOSTATIC CHALLENGE, CAROTID SINUS 1. Perform 1. Valsalva’s Maneuver 2. Orthostatic Challenge 3. Carotid Sinus Compression 2. After each test measure record The degree of HR rate change (BPM) Time to rebound. 3. Choose a direct PMRF therapy from your list and perform it on the side of abnormal carotid compression 4. Reassess and record:  CATEGORY 3 PMRF ASSESSMENTS Motor & DTR’s Soft Pyramidal Weakness Deep Tendon Reflexes Pyramidal Motor Pathways © 2016-2018 IPS, LLC. – All Rights Reserved Spastic Pyramidal Paresis © 2016-2018 IPS, LLC. – All Rights Reserved RETICULOSPINAL PATHWAYS OUTPUT OF THE PMRF RETICULOSPINAL PATHWAYS OUTPUT OF THE PMRF Anterior Group Muscles Above T6 & Posterior Group Muscles Below T6 Have Greater Cortical Representation (Therefore Need To be Inhibited) © 2016-2018 IPS, LLC. – All Rights Reserved SOFT PYRAMIDAL WEAKNESS Posturing: Low Shoulder Internal Shoulder Rotation Elbow Flexion Internal Forearm Rotation Wrist Finger Flexion External Hip Rotation External Foot Rotation Pronation Weakness: External Shoulder Rotation Shoulder abduction Elbow extension Wrist extension Finger Extension Finger Abduction Psoas Big toe extensors DEEP TENDON SUBCORTICAL SENSORY- REFLEXES MOTOR INTEGRATION  IPSP/ EPSP INPUT OUTPUT STRETCH REFLEX MODULATION Descending Influences Descending Influences from the brain originate from various areas and have either excitatory and or inhibitory effects. Motor Cortex Mid Brain Vestibular Nuclei Cerebellum Reticular Formation PROPER GRADING CRITERIA (WALKER 1990) 1+ = Slight But 0 = No Response Definite Present 2+ = Brisk (Always Abnormal) Response (May Or Response (Normal) May Not Be) 4+ = Tap Elicits A 3+ = Very Brisk Asymmetry suggest Repeating Response (May or abnormality Response (Clonus) May Not Be) present (Always Abnormal) “Overflowing” is when one reflex elicits another JENDRASSIK MANEUVER (ERTUGLU 2018) First published on by Gassel 1964 Mechanism of action still Thought to work by increasing muscle spindle sensitivity via gamma motor activation but H-reflex is effected by not understood JM. So cannot be muscle spindle in origin. Historically performed by pulling clenched hands at the No fixed maneuver in moment of reflex testing literature Teeth clenching is alternative Ertuglu found that teeth clenching provides least Clenched hands causes increased tone in the soleus, confounding heel cord responses confounding results  CENTRAL MEDIATED MSR PATTERNS RIGHT CORTICAL LEFT CEREBELLUM REFLEX LEFT PMRF DECOMPENSATION DECOMPENSATION DECOMPENSATION Motor Strip BICEPS L INCREASED (2+) L INCREASED (3+) L DECREASED (1+) TRICEPS L DECREASED(2+) L DECREASED (1+) L DECREASED (1+) BRACHIORADIALIS L DECREASED (2+) L DECREASED (1+) L DECREASED (1+) PATELLA L INCREASED (2+) L INCREASED (3+) L DECREASED (1+) HEEL CORD (ACHILLIS) L INCREASED (2+) L INCREASED (3-4+) L DECREASED (1+) JAW-JERK NORMAL INCREASED (3+) NORMAL (USUALLY)  MUSCLE STRETCH REFLEX ASSESSMENT TECHNIQUE ACCURACY+ REPETITION =STANARDIZATION STRETCH REFLEXES 1. Biceps 2. Triceps 3. Brachioradialis 4. Patella/ Knee Jerk 5. Heel-Cord/ Ankle Jerk (Achilles) 6. Masseter/ Jaw Jerk Reflex TECHNIQUE 1. Patient sits on the side of bed/table 2. Instruct patient to relax to the best of their ability and not think about what you are doing. You may want to try to get them to speak at length about another topic as you check them. 3. Assess using an order related to your investigation 4. Brisk but not painful tap 5. Strike using your wrist, not elbow 6. Observe: Amount of force needed Velocity of contraction Strength of contraction Response of other muscles not being tested BICEPS REFLEX 1. Support forearm on examiner’s forearm 2. Patient arm is midway between flexion/extension 3. Place thumb on biceps tendon with fingers curling around elbow 4. Tap briskly TRICEPS REFLEX 1. Support patient’s arm with shoulder in extension and elbow midway between flexion/extension. – OR – Same position as biceps reflex 2. Locate insertion of Triceps on Olecranon 3. Tap above insertion BRACHIORADIALIS REFLEX 1. Support patient’s forearm at elbow with thumb on biceps tendon, with shoulder in flexion or abduction and elbow in full extension. – OR – have the patient hold arm as if in a sling (neutral shoulder, elbow half flexed/extended) 2. Locate brachioradialis tendon at wrist at the base of the radial styloid process, 1 cm lateral to the radial artery 3. Tap BR insertion at styloid process PATELLA/ KNEE JERK REFLEX 1. Let the knees swing free by the side of the bed. 2. Place one hand on the quadriceps so you can feel its contraction. If the patient is in bed, slightly flex the knee by placing your forearm under both knees. 3. Tap tendon inferior to patella and superior to tibial tuberosity HEEL CORD/ ANKLE JERK/ ACHILLES REFLEX 1. With the patient sitting, place one hand underneath the sole and dorsiflex the foot slightly. 2. Tap on the Achilles tendon just above its insertion on the calcaneus. If the patient is in bed, flex the knee, externally rotate the leg, and invert or evert the foot somewhat, cradling the foot. Then tap on the tendon. JAW JERK/ MASSETER REFLEX 1. Place the tip of your index finger on a relaxed jaw, that is about one-third open. 2. Tap briskly on your index finger and note the speed as the mandible is flexed. How is this reflex useful in differential diagnosis?  Discuss how you would change the Think treatment of a patient with right sided low back pain if they also had right sided pyramidal weakness. Pair Be specific in the kind of therapy and or technique that you would utilize and how Share you would actively measure whether your treatment was appropriate of not. © 2016-2018 IPS, LLC. – All Rights Reserved  FACTORS INFLUENCING TENDONOUS LOAD Speed of loading Length of muscle when loaded. Quantum of muscular protein More Tendonous Load Results in 1. Deceased Sensitivity 2. Increased Gain 3. Overall Decreased feedback © 2016-2018 IPS, LLC. – All Rights Reserved  1. Pyramidal Weakness 2. DTR 3. Central Influences © 2016-2018 IPS, LLC. – All Rights Reserved CMA: SOFT PALATE ELEVATION/PYRAMIDAL WEAKNESS & DTR’S 1. Check your partners 1. Soft Pyramidal Weakness 2. Test & grade your partner’s DTR’s 1. Brachioradialis 2. Patellar 2. From your think pair share about pyramidal weakness apply one of your ideas to treat pyramidal weakness and recheck. End of Day Two RBE What Did You Learn? Welcome to Day 3 RBE What to Expect  CEREBELLAR ANATOMY AND NEUROLOGY Error Correction Motor Coordination MODELS OF CEREBELLAR FUNCTION Knowledge of the anatomical and cerebellar circuitry has outstripped our understanding of the function or functions that the cerebellum performs. Models of Cerebellar Function: Internal Inverse Dynamic Feedback Error Smith Predictor Multiple Paired Forward-Inverse Cortical Input CEREBELLAR ASSESSMENT Motor Output Cerebellar integrity is assessed on the Same Side of the body to its location Sensory Input CEREBELLAR CORTEX  COMMON FINDINGS ASSOCIATED WITH CEREBELLAR DYSFUNCTION MIDLINE INTERMEDIATE LATERAL Impaired Balance Limb Coordination Issues Cognitive Processing Issues Nausea Clumsiness Motor Planning/Execution Dizziness Dyspraxia (Slowness) Emotional Regulation Vertigo Extremity Tremor On Impaired Visual Acuity With Movement Head Movements Hypotonia (Shoulders/Hips) Nystagmus Hypotonia (Midline)  CEREBELLAR ASSESSMENTS Midline Intermediate Lateral Stork Test Finger-Nose-Finger Testing King Devick Saccadic Accuracy Accuracy Cognitive Assessments Tremor Ocular Tracking Fine Finger Movements Rapid Alternating Hand Head Impulse Test Movements Unterberger's Test Rapid Alternating Thigh mCTSIB Taps Heel: Shin to Toe  CEREBELLAR THERAPIES MIDLINE INTERMEDIATE LATERAL Vestibular Rehabilitation Figure 8 Limb Movements King Devick Gaze Stabilization Ex’s From Shoulder & Hips Peak Performance Apps Galvanic Nerve Stimulation Passive Interactive Metronome Active Saccades/Pursuits Resisted SMT Complex Core Stabilization Ex’s Guided Limb Movements MIDLINE CEREBELLAR ASSSESSMENTS Hypotonia, Saccadic Speed & Accuracy Ocular Tracking/Pursuits  HYPOTONIA (Midline) Alteration of A-P Curves  CENTRAL TITUBATION The Essential Tremor of The Spine STORK TEST The Stork Test, also known as the Gillet Test, assesses the movement of the SIJ between the innominate and sacrum through the clinician's palpation, which may be a useful test for clinical evaluation of a subject's ability to stabilize intrapelvic motion. Saccades A saccade is a quick, simultaneous movement of both eyes between two or more phases of fixation in the same direction. Controlled cortically by the frontal eye fields, or subcortically by the superior colliculus, saccades serve as a mechanism for fixation, rapid eye movement, and the fast phase of optokinetic nystagmus © 2016-2018 IPS, LLC. – All Rights Reserved Saccadic Circuitry Contralateral Frontal Lobe to the direction of the saccade FEF Superior Colliculus © 2016-2018 IPS, LLC. – All Rights Reserved Ocular Tracking (Smooth Pursuit) Smooth pursuit eye movements allow the eyes to closely follow a moving object. © 2016-2018 IPS, LLC. – All Rights Reserved Ocular Tracking (Pursuit) Circuitry Ipsilateral Parietal and Frontal Lobe to the direction of the pursuit © 2016-2018 IPS, LLC. – All Rights Reserved OCULAR PURSUITS & SACCADES SHARE COMMON CIRCUITS Saccade & Pursuit Changes in Cerebellar Dysfunction Saccades Pursuits Slowed Slowed Dysmetric Decrease gain Measures the object seed to the eye Hypometric speed. Hypermetric Will often see catch-up saccades © 2016-2018 IPS, LLC. – All Rights Reserved HYPOMETRIC VS. HYPERMETRIC SACCADES NORMAL (METRIC) SACCADES HYPOMETRIC SACCADES HYPERMETRIC SACCADES  Correct Procedure For Testing: Stork Test Saccades/Pursuits Horizontal Vertical © 2016-2018 IPS, LLC. – All Rights Reserved  Think Discuss how slowed/inaccurate saccades and or poor pursuits my influence an individual's neck pain. Pair Describe 3 ways that you may change your treatment approach to your patient knowing this information Share © 2016-2018 IPS, LLC. – All Rights Reserved  OCULAR PURSUITS Start Start Right Parietal/Left Cerebellar Cortex Right Parietal/Right Cerebellar Cortex  OCULAR PURSUITS Start Start Left Parietal/Right Cerebellar Cortex Left Parietal/Left Cerebellar Cortex  OCULAR SACCADES Start Start Right Frontal /Left Cerebellar Cortex Right Frontal /Right Cerebellar Cortex  OCULAR SACCADES Start Start Left Frontal /Right Cerebellar Cortex Left Frontal /Left Cerebellar Cortex  RIGHT BRAIN/LEFT CEREBELLUM Saccades Pursuits  LEFT BRAIN/RIGHT CEREBELLUM Saccades Pursuits  RIGHT BRAIN/RIGHT CEREBELLUM Saccades Pursuits  LEFT BRAIN/LEFT CEREBELLUM Saccades Pursuits CMA: Planes of Cerebellar Influences on Eye Movements 1. Demonstrate on your partner how you would test the following areas of neocortical and cerebellar integration using both pursuit and saccadic eye movements: a. Right cortex/Left Cerebellum b. Right Cortex/Right Cerebellum c. Left Cortex/Right Cerebellum d. Left Cortex/Left Cerebellum © 2016-2018 IPS, LLC. – All Rights Reserved LEFT BRAIN/RIGHT CEREBELLUM © 2016-2018 IPS, LLC. – All Rights Reserved LEFT BRAIN/LEFT CEREBELLUM © 2016-2018 IPS, LLC. – All Rights Reserved RIGHT BRAIN/LEFT CEREBELLUM © 2016-2018 IPS, LLC. – All Rights Reserved RIGHT BRAIN/RIGHT CEREBELLUM © 2016-2018 IPS, LLC. – All Rights Reserved RIGHT BRAIN/LEFT CEREBELLUM © 2016-2018 IPS, LLC. – All Rights Reserved RIGHT BRAIN/RIGHT CEREBELLUM © 2016-2018 IPS, LLC. – All Rights Reserved LEFT BRAIN/RIGHT CEREBELLUM © 2016-2018 IPS, LLC. – All Rights Reserved LEFT BRAIN/LEFT CEREBELLUM © 2016-2018 IPS, LLC. – All Rights Reserved CMA: Pursuit & Saccade Eye Exercises 1. Examine your partners smooth pursuit and saccadic eye movements both in the horizontal and oblique planes. 2. From your examination determine the combined central level of decompensation for the following choices: a. Right cortex/Left Cerebellum b. Right Cortex/Right Cerebellum c. Left Cortex/Right Cerebellum d. Left Cortex/Left Cerebellum 3. Do the following treatments 1. 3 min of pursuits 2. 3 min of saccades 4. Retest between each therapy 5. Note any difference in outcomes between the two approaches © 2016-2018 IPS, LLC. – All Rights Reserved VESTIBULAR SYSTEM (THE BASICS) FISH HUMAN The Vestibular Column Consists of: 1. Cranial Nerves 3,4 6, 12 2. Vestibular Nuclei 3. Intrinsic Spinal Ventral Horn Cells 4. Onuf’s Nucleus MORE THAN BALANCE… THE VESTIBULAR NUCLEI INFLUENCE MANY IMPORTANT FUNCTIONS, IN ADDITION TO BALANCE AN POSTURE. INFLUENCES EYE MOVEMENTS THINKING AUTONOMIC FUNCTION ORIENTATION 3 SEMICIRCULAR CANALS – COPLANAR ACTIVATION Labyrinthine Orientation Labyrinthine Orientation LARP/RALP HEAD POSTIONS & CANAL ACTIVATION & ASSOCIATEDEYE MOVEMENTS HORIZONTAL CANAL RIGHT ANTERIOR CANAL LEFT ANTERIOR CANAL ANTERIOR CANAL ASSOCIATED EYE MOVEMENTS RIGHT POSTERIOR CANAL LEFT POSTERIOR CANAL POSTERIOR CANAL ASSOCIATED EYE MOVEMENTS  Think Discuss how an asymmetry in the output of one of the vestibular canals would influence a patient with low back pain Pair and discuss ways that you may change your treatment to address that influence. Share © 2016-2018 IPS, LLC. – All Rights Reserved CMA: Vestibular Canal Planes Demonstrate to your partner the following terms regarding head movement Roll Pitch Yaw Demonstrate to your partner the head movement that would activate: Right Horizontal Canal Left Horizontal Canal RALP Canals LARP Canals © 2016-2018 IPS, LLC. – All Rights Reserved MIDLINE CEREBELLAR ASSSESSMENTS Head Impulse Test Unterberger mCTSIB VESTIBULAR ASSESSMENT 3 : HEAD IMPULSE TESTING HEAD IMPULSE TEST POSITIVE HEAD IMPULSE TEST UNTERBERGER TEST Key Points: Patient takes at least 50 steps with arms out in front of them and eyes closed. Maximum amount of rotation that is allowed is 30 degrees. Anything more then that is considered abnormal Test basically checks for Labyrinthine imbalance with the general notion that a person will rotate to their weaker sides. mCTSIB CMA: VESTIBULAR ASSESSMENT On your partner perform the following: Head impulse test and record the direction of head impulse that results in a corrective saccade if any. Unterberger’s Test and record the direction of deviation. mCTSIB balance assessment and record the condition that produced the worse balance Perform 3 sets/3repetitions each of head thrusts to the side of deficient vestibular input Retest MIDLINE CEREBELLAR TREATMENT CONSIDRATIONS Vestibular Rehabilitation Gaze Stabilization Exercises GUIDELINES TO VRT (GAZE STABILIZATION EX’S) Gaze instability is due to the decreased gain of the vestibular response to head movements. The best stimulus for increasing the gain of the vestibular response is the error signal induced by retinal slip, which is the image motion on the retina during head motion. Retinal slip can be induced by horizontal or vertical head movements while maintaining visual fixation. Patients should perform exercise for gaze stability four to five times daily for a total of 20-40 minutes/day Each exercise may be performed at least twice per day, beginning with five repetitions of each and increasing to ten repetitions. The key element on how VRT works is via Retinal Slip RETINAL SLIP: THE ERROR SIGNAL TYPES OF GAZE STABILITY EXERCISES TIMES–ZERO (0X) VIEWING EXERCISES Also called “VOR Cancellation” Used when you do not want proprioceptive input from the neck Less neurologically demanding than 1X viewing as it is passive and does not involve proprioceptive input from the neck Uses frontal systems to suppress the VOR Variables (Head, Body, Target) Methods: Hand-Head Movements Whole-Body Rotation w/ Fixation TIMES ONE (1X) VIEWING EXERCISES Involves movement of the head either in the horizontal, vertical, oblique planes while the patient maintains their eyes fixated on a stationary object. Object of fixation is usually at arm’s length away. More demanding then 0X viewing Initially done passively with the treating practitioner watching the eyes for any loss of fixation. Variables: Speed Amplitude Lighting Background TIMES ONE (1X) VIEWING Video by Physiotec EXERCISES TIMES TWO (2X) VIEWING Most metabolically demanding of the VRT (Gaze Stabilization) exercises. Often prescribed when patients complain that busy backgrounds bother them  VRT (GAZE STABILIZATION) PROGRESSION VARIABLE PROGRESSION Duration 3 sets of 5 reps to 3 sets of 10 reps Frequency 2 -> 5 times per day Velocity Slow -> Fast (Ensuring No Retinal Slip) Target Large -> Small / High Contrast -> Low Contrast Target Distance Far to Near Background Plain -> Complex Patient Position Supported Sitting -> Running Surface Firm -> Compliant / Wide -> Narrow  VRT OX 1X 2X © 2016-2018 IPS, LLC. – All Rights Reserved CMA: VESTIBULAR ASSESSMENT Practice performing each of the of the following gaze stabilization exercises on your partner: 0X 1X 2X © 2016-2018 IPS, LLC. – All Rights Reserved  Think Discuss how you would incorporate VRT into your practices. What kind of Pair conditions could it be useful for other then treating dizziness. Share © 2016-2018 IPS, LLC. – All Rights Reserved INTERMEDIATE CEREBELLAR ASSSESSMENTS Hypotonia Finger-Nose-Finger Rapid Alternating Hand Movements Heel Shin to Toe Gait Ataxia CEREBELLUM’S ROLE IN MOVEMENT CORRELATION BETWEEN DIFFICULTY AND CEREBELLAR DEMAND The more difficult a task is, the more demanding of the cerebellum Usually faster is more difficult (except walking) HALLMARK SIGNS OF INTERMEDIATE CEREBELLAR DECOMPENSATION Limb Dysmetria Limb Kinetic Tremor Limb Ataxia Limb Hypotonia  LIMB HYPOTONIA Seen more proximally in the limbs then distal. Distal hypotonia appears more cortically based. Associated with a global reduction in DTR’s and FRA’s withdrawal responses. No soft pyramidal pattern seen with: Muscle testing DTR’s Muscle testing reveals a classic muscle weakness pattern involving the: Posterior Deltoid Glute Max/Medius Tibialis Anterior. Also see Pendular reflexes Hyporeflexia KINETIC HAND TREMOR FINGER-NOSE-FINGER 1. Patient seated, standing, or supine (differences?) 1. Static 2. Random 3. Dynamic 4. Remembered © 2016-2018 IPS, LLC. – All Rights Reserved KINETIC HAND TREMOR MDS-UPDRS: KINETIC HAND TREMOR PRONATION/SUPINATION HAND MOVEMENTS Ask the patient to place one hand on the other as shown and then rapidly turn their hand over and lift it off the other hand. Ask the patient to repeat the movement as rapidly as possible for 10 seconds. Normal: Rhythmic sound is heard Abnormal: Breakdown in movement is both seen and heard. Dysdiadokinesia. RAPID ALTERNATING THIGH TAPS Ask the patient to place their hands on their thighs and then rapidly turn their hands over and lift them off their thighs. Ask the patient to repeat the movement as rapidly as possible for 10 seconds. Normal: Rhythmic sound is heard Abnormal: Breakdown in movement is both seen and heard. Dysdiadokinesia. MDS-UPDRS: RATING SCALE FOR PRONATION SUPINATION OF THE HANDS: HEEL-SHIN TEST  Intermediate Cerebellar Motor Tests Limb Hypotonia Finger-Nose Finger Alternating Hand Movements Alternating Thigh Taps Heel Shin Test © 2016-2018 IPS, LLC. – All Rights Reserved  Active Figure 8 Passive APPLICATIONS Active Mirroring Activities FOR CEREBELLAR Ball Tossing (Weight Same < Different) VRT (Gaze Stabilization Exercises) REHAB Saccades/Pursuits Hand-Eye Coordination Drills Visual Imaging CMA: IMTERMEDIATE CERBELLAR REGION Test & grade the following on your partner. Finger-Nose-Finger Variants (Grade Worse One) Static Random Dynamic Remembered Pronation/Supination Hand Movements (Grade Worse One) Heel-Shin From your testing determine the side of cerebellar decompensation. From the list of Cerebellar Exercises Provided pick one and perform on your patient Reassess Record your results  LATERAL CEREBELLAR ASSESSMENTS Cognitive Processing & Eye Movements  Facilitates purposeful motor control CEREBELLUM Synchronizes central pattern generators (CPGs) Drives higher brain function Dentato –Rubro –Thalamo –Cortical –Olivo feedback loop MIDBRAIN-MESENCEPHALON Pupillary Light Responses Convergence/Accommodation Vertical Eye Movements Cerebello-Rubro- Thalamo-Cortico- Ponto-Cerebellar Tract © 2016-2018 IPS, LLC. – All Rights Reserved Corticomesencephalic & Corticopontine Projections © 2016-2018 IPS, LLC. – All Rights Reserved Internal Capsule 10% To the Midbrain 90% to The Pons & Medulla © 2016-2018 IPS, LLC. – All Rights Reserved COMMON FINDINGS ASSOCIATED WITH MIDBRAIN DYSFUNCTION Visual disturbances in the vertical plane. Diplopia Blurred Vision Anxiety Tremors Eye Strain MIDBRAIN ASSESSMENTS Presence of a Ptosis & Exophoria/Tropia Pupillary Light Reflexes Saccadic Accuracy (Vertical) Ocular Tracking (Vertical) Convergence/Accommodation MIDBRAIN THERAPIES Vertical Eye Exercises Convergence/Accommodation Exercises Contralateral Cerebellar Therapies Ipsilateral Cortical Therapies Frontal Lobe Parietal Lobe Occipital Lobe Temporal Lobe PTOSIS & EXOTROPIA/PHORIA ANISOCORIA  PUPIL LIGHT REFLEX Afferent limb is the optic nerve while the efferent limb is the oculomotor nerve. Cranial Nerves I/III, respectively. Newer research suggests that the reflex though mediated in the midbrain is modulated by other brain regions MODULATION OF THE PUPILLARY LIGHT REFLEX PUPIL RESPONSE TO LIGHT  Measurements made: Latency REFLEX: PLR ANALYZER Max/Min Diameter Constriction Speed Average Diameter  NEAR POINT CONVERGENCE WHAT CONSTITUTES NORMAL NEAR POINT CONVERGENCE There is little consensus on what constitutes normal near point convergence. Measurement can be variable between patients. Measured form the nasal bridge Normal Ranges: Children: 1-2 cm Adults 3-4 cm CONVERGENCE/ACCOMODATION RESPONSE IN CONCUSSION BROCK STRINGS FOR CONVERGENCE EX’s Near Far © 2016-2018 IPS, LLC. – All Rights Reserved VERTICAL EYE MOVEMENTS: SACCADES & PURSUITS 3 Main Midbrain centers exist for controlling vertical saccades & pursuits: INC: Interstitial Nucleus of Cajal riMLF: Rostral Interstitial Nucleus of the Medial Longitudinal Fasciculus cMRF: Central Mesencephalic Reticular Formation Modulated by Frontal Activity Research suggests correlation to breakdown and various brain disorders: Concussion Parkinson’s Progressive Supranuclear Palsy  Mesencephalic/Midbrain Tests Ptosis/Exotropia Anisocoria Pupil Light Reflex Near Point Convergence Vertical Eye Movements Saccades Tracking Brock Beads (Convergence Exercises) © 2016-2018 IPS, LLC. – All Rights Reserved CMA: PUPIL LIGHT REFLEX & VERTICAL EYE MOVEMENTS 1. Assess the following on your partner 1. Ptosis, Anisocoria and or exotropia 2. Pupil responses 3. Near Point Convergence 2. Using your Brock Beads do convergence exercises consisting of 3 sets of 8 reps. 3. Reassess the above findings.  Think Discuss how you may negatively impact midbrain activity as a result of your treatment and how you would measure Pair it. i.e. what would you look for pre and post treatment (Be specific) Share © 2016-2018 IPS, LLC. – All Rights Reserved  (MORE THAN JUST) OUR THE THALAMUS BRAIN’S SENSORY-MOTOR RELAY CENTER "Brain function is fundamentally related, in the most general sense, to the richness of thalamocortical interconnectivity, and in particular to the rhythmic oscillatory properties of thalamocortical loops.” - Rodolfo Llinas THE 3 TYPES OF THALAMIC NUCLEI 1. Thalamocortical Nuclei / Corticothalamic Outweigh Thalamocortical Neurons 10:1 Crandall 2015 2. Reticular Nuclei Receives integration from The basal ganglia The reticular formation The thalamocortical neurons. Involved in all sensory modalities Provides contrast and focus 3. Interlaminar/Thalamic Interneurons 20-25% of all thalamic neurons Set pace of thalamus to provide consciousness CORTICOTHALAMIC MODULATION  THALAMOCORTICAL RESONANCE Sir Charles Sherrington coined the term “CENTRAL STATE” in 1906 CENTRAL STATE: The sum of all excitatory and inhibitory impulses to, and in the thalamus. This produces the thalamic resonance rate or frequency. BRAIN NETWORKS TO STUDY DEFAULT MODE NETWORK: Active when an individual is awake and at rest. It preferentially activates when individuals focus on internally- oriented tasks. DORSAL ATTENTION NETWORK: Voluntary deployment of attention and reorientation to unexpected events SALIENCE NETWORK: Monitors the salience of external inputs and internal brain events. communication, social behavior, and self- awareness through the integration of sensory, emotional, and cognitive information. Associated with PTSC, Dementia & Alzheimer's LATERAL VISUAL NETWORK: Important in complex emotional stimuli Auditory Left Fronto-Parietal Language Motor Cerebellar Left Executive Right Executive Ventral Attention Sensorimotor Network Posterior Default Spatial Attention Physiologic Blindspot A Measure of The Brain’s Central Integrative State FACTS ABOUT THE PHYSIOLOGICAL BLINDSPOT Corresponds to the location of the optic nerve head. This should show up on any visual field test. If it does not, the patient is not fixating. It is centered slightly below the horizontal midline and 15.5 degrees temporal to fixation. The normal blindspot is 5.5 degrees wide and 7.5 degrees high. © 2016-2018 IPS, LLC. – All Rights Reserved LATERAL GENICULATE NUCLEUS © 2016-2018 IPS, LLC. – All Rights Reserved LATERAL GENICULATE NUCLEUS Superior Filed of View: Temporal Lobe Integration Parvocellular Pathway Ventral Stream Inferior Filed of View: Parietal Lobe Magnocellular Pathway Dorsal Stream © 2016-2018 IPS, LLC. – All Rights Reserved MEASURING THE PYSIOLOGIC BLINDSPOT BLIND SPOT MAPPING  Normal Impaired Vertical Fixation Left Hemisphericity Impaired Horizontal Fixation Impaired Temporal Impaired Parietal Lobe Function Lobe Function  Physiologic Blindspot Demonstrate mapping of the physiologic blindspot © 2016-2018 IPS, LLC. – All Rights Reserved CMA: Blind Spot Mapping Map you partners blind spots Use a new piece of paper for re-maps Manipulate of mobilize the fingers and wrist on the side of the enlarged blindspot. Re-map your partners blind spots No Change Worse Improved Switch doctor/patient and repeat End of Day Three RBE What Did You Learn? Welcome to Day 4 RBE What to Expect THE FRONTAL LOBES FRONTAL LOBE DIVISIONS FRONTAL LOBE INTEGRATION  MIXED VIEWS: GRADIENT MODEL The gradient model undermines the traditional discrete models of frontal lobe functions being compartmentalized to highly demarcated zones. The gradient model suggests organization along the rostro- caudal axis. ASSESSING THE FRONTAL LOBES FRONTAL LOBE ASSESSMENTS Frontal Lobe Frontal Lobe integrity is assessed 4 ways: 10 % Crossed 90 % Uncrossed 1. Volitional motor activity on Volitional Motor Non-Volitional Motor the opposite side of the body. 2. Non-Volitional motor activity on the same side of the body. 3. Quality of inhibiting a movement and or thought/behavior 4. Cognitive Function Sensory Input  COMMON FINDING OF FRONTAL LOBE DYSFUNCTION Cognitive/Behavioral Motor Reflexes Sensory Impulsivity Dyspraxia Ipsilateral Hyporeflexia Smell Rigidity Hypotonia Pyramidal Distribution Memory Loss Hypomimia Contralateral Hyperreflexia Depression Soft Pyramidal Pyramidal Distribution Decreased Affect Weakness Contralateral Perseveration Slowed Saccades Reemergence of Lack of Abstract Impaired Vertical Eye Primitive Reflexes Thinking Movements Impaired Anti- Saccades  FRONTAL LOBE ASESSMENTS Cognitive/Behavioral Motor Reflexes Sensory S.A.C Gait: Arm Swing Primitive Reflexes Smell Trail Making Test Saccades (Vertical) OKN (Vertical) Digit Symbol Finger Tapping Glabellar Tap Test Substitution Hypomimia DTR’s (Soft Wisconsin Card Applause Test Pyramidal Pattern) Sorting Go/No-Go Task Cambridge Brain Science Stroop Brain EQ FRONTAL LOBE THERAPIES Vertical/Oblique Patterned Saccades Vertical OKN Stimulation Anti-Saccades Unilateral Naris Occlusion Smell (Essential Oils) Interactive Metronome Motor Sequencing & Patterning Contralateral Cerebellar Therapies Peak App For Motor Planning Stroop/Go No-Go/N Back (Dynavision/App) ASSESSING THE FRONTAL LOBES COGNITIVE/BEHAVIORAL History Digit Symbol Coding SAC Cambridge Brain Science Trails Making Brain EQ PHINEAS GAGE (1823-1860) Standardized Assessment of Concussion (SAC) The Standardized Assessment of Concussion (SAC) is a brief sideline screening tool that requires no formal neuropsychological training. It focuses on the cognitive domains and symptoms most associated with mTBI It has been shown to be effective in detecting cognitive deficits in older teenagers and young adults suffering sports-related concussion; it has not been well studied in younger children,12–14 TRAIL MAKING TEST Originally part of the Army Individual Test Battery (1944), is one of the most used neuropsychological tests in clinical practice. Slowed performance on TMT-B compared to TMT- A can be indicative of impaired ability to modify a plan of action and to maintain two trains of thought simultaneously. It seems that TMT-B is more dependent on prefrontal areas compared to TMT-A, highlighting the role of prefrontal cortex on set-shifting, dual- tasking, and cognitive flexibility © 2016-2018 IPS, LLC. – All Rights Reserved  TRAILS A & B TRAILS A TRAILS B  Digit Symbol Substitution The digit symbol substitution test is an evaluation tool used to assess cognitive functioning. It initially was part of the Wechsler Adult Intelligence Test (WAIS) WISCONSIN CARD SORTING The Wisconsin Card Sorting Test of frontal function or executive (metacognitive) function is scored according to nine categories. The computer administered 128-card (or 64-card) test is employed, and the scoring includes the following: 1. Percentage errors (%) 2. Perseverative responses (%) 3. Perseverative errors (%) 4. No perseverative errors (%) 5. Conceptual level responses (%) 6. Categories completed 7. Trials to complete first category 8. Failure to maintain set 9. Learning to learn  CAMBRIDGE BRAIN SCIENCES CAMBRIDGE BRAIN SCIENCES Check Your e-mails © 2016-2018 IPS, LLC. – All Rights Reserved ASSESSING THE FRONTAL LOBES VOLITIONAL MOTOR Hypomimia Arm Swing (Gait) Finger Tapping Horizontal Saccades HYPOMIMIA  Rating scale using the Unified RATING HYPOMIMIA Parkinson’s Disease Rating Scale (UPDRS) CONTRALATERAL L VOLITIONAL MOTOR ACTIVITY Crossed Motor Activation Look for: Speed Amplitude Latency to start R © 2016-2018 IPS, LLC. – All Rights Reserved ARM SWING Observe gait (approx. 5-7 strides) in two situations: 1. Normal Gait 2. Gait w/ Dual-Tasking Observe your patients arm swing paying attention to the amplitude form side to side Give appropriate task to use cognitive resources. (Subtract 7’s from 100) Observe for arm swing changes Reduced On The Side Opposite of Frontal Activity FINGER TA