Cranial nerve testing is an important part in the neurology evaluation. Recently, I did a thorough article on how to perform an efficient neurology evaluation in physical therapy. In this article, I want to discuss cranial nerve testing in little depth.
Corona Virus has made its way globally. At this point, we all are aware of COVID 19 and the majority of symptoms caused by COVID 19. While every nation around the globe is fighting hard to design some method that can either manage symptoms or viruses, exercise remains one important factor. This includes various options like vaccines, medicines, antibodies, blood transfusions, etc. In this article, I am going to share some proven exercise strategies, and core outcome measures for patients with COVID 19.
This article is all about how to perform a neurology evaluation. Neurology evaluations are long and sometimes time-consuming. It is not really possible to perform every single item during a session.
A while back I did a Physical Therapy general evaluation format. This was more of a general intake form. Here I want to go a little deep in a specific neurological diagnosis/ category in physical therapy.
For me, I go over the categories and check if there are any deficits, and I move to another category. If a patient is unable to answer or shows deficits in one area, then I will perform a detailed assessment of that area. This helps me to go over the eval quickly and also allows me to concentrate on the areas that are weak.
Stroke is the fifth leading cause of death in the US and a leading cause of disabilities. There are two main different types of strokes. As we know, the neurological recovery and returning of functions after stroke mainly depend on the type and severity of the stroke. There are a few other outcome predictors like age, prior level of function, and how long it took for a patient to receive medical treatment, etc, that can also assist us in determining the outcomes. But none of these predictors can tell us the level of function a person will achieve in six months or in a year post-stroke. The goal of this post is to discuss how to predict the functional recovery of a patient after a stroke!!
Since I have been in physical therapy, I have been looking for a tool that can predict an outcome for a patient after an injury. Almost every field in medicine is able to predict some sorts of outcomes for their patients after a disease or an injury. Unfortunately, the therapist did not have that ability.
The ability to predict outcomes after any injury is crucial. This not only helps the patient to set the expectations right but also assists in preparation for the discharge. The level and independence at discharge determine the house modification, assistance required, and so on.
Knowing the functional outcomes assists us in :
- Developing an appropriate plan of care
- Providing appropriate nursing and therapy assistance
- Explain and educate the patient as well as families how to prepare for post-discharge
- To provide appropriate assistance to the patient and families to deal with the loss they may suffer
- To set the right expectations
You will be surprisingly happy when I tell you that you can really predict a functional return of your patient within 7 days of a post-stroke!! Yes, you read that correctly, a therapist can predict functional recovery of 6 months or 1 year in the first 7 days of stroke onset. Isn’t that COOL!!!
So here how it goes!
Currently, there are two algorithms that can help you determine the functional recovery of the upper limb for a patient after a stroke. They are called PREP algorithms.
Both PREP algorithms use the SAFE score of a paretic upper extremity. The SAFE score is a total score of manual muscle testing of shoulder abduction and finger extension.
As we know, manual muscle testing score ranges from 0 (no trace of contraction) to 5 (full range of motion, against gravity, against maximal resistance). So the maximum possible SAFE score is 10.
PREP Algorithm in Stroke Recovery:
The algorithm begins with a simple bedside assessment of upper limb impairment and progresses to neurophysiological and neuroimaging assessments if required. The SAFE score is recommended 72 hours after stroke.
The term for recovery determines the amount of recovery a person will have after 12 weeks of rehabilitation. That also assists therapists to develop appropriate goals and plans of care.
You can find the full definitions of recovery and the type of goals a therapist can have at tbe end of the article.
PREP2 Algorithm in Stroke Recovery:
This algorithm predicts upper limb functional outcome at 3 months post-stroke. The most beneficial thing about this algorithm is that it takes age into the account. Also, we do not have to rely on a strong diagnostic tool like MRI to predict the outcome with this algorithm.
Therefore, PREP 2 not only makes it easy for clinicians to use but also makes it realistic in a day to day clinical setting to utilize such an important tool.
Just like original PREP, PREP 2 also starts with a SAFE score on day 3 post-stroke.
Along with the SAFE score, a clinician may have to use Transcranial Magnetic stimulus (TMS) to determine Motor Evoked Potential (MEP) status in the paretic upper limb.
If the MEP can not be elicited, a clinician will go further into the algorithm to use the NIHSS score on the third-day post-stroke.
You can PREP 2 attachment where I discuss the definition of the recovery. Additionally, I have included NIHSS and Berg scale.
So What about Recovery in Ambulation?
As you just read, the PREP algorithm only talks about upper limb recovery after a stroke. It does not assist a therapist in determining if community ambulation is going to be a realistic goal or not.
Another research done using the Berg balance scale (BBS) during the first week of stroke onset, helps us to determine just that!! The Berg balance score done at the admission during inpatient rehabilitation stay significantly predicts independence with ambulation.
As we know, BBS is a 14 items scale, with a total score of 56. The cut-off score of 29 on admission predicts that an individual will be a community ambulator. While a cut-off score of 12 at admission predicts a non-ambulatory to regain unassisted ambulation.
As I mentioned earlier, I have attached a full BBS with the slides.
Hope this information helps you to develop your plan of care and answers any questions your patient or families have! As always, if you have any questions, please feel free to reach out to me.
Subscribe below to download:
- Stinear, M.C., Barber A.P., Petoe, M., Anwer, S., & Byblow, D.W.. The PREP algorithm predicts potential for upper limb recovery after stroke. Brain: 135 (8); 2527-2535.
- Stinear, M.C., Byblow, D. W., Ackerley, J.S., smith M., Borges, M.V., Barber, A.P. PREP2: biomarker-based algorithm for predicting upper limb function after stroke: Annals of Clinical and Translational Neurology; 2017, 4(11): 811-820.
- Maeda,N., Irabe,Y., Murakami, M., Itotiani, K., Kato, J. Discriminant analysis for predictor of falls in stroke patients by using the Berg Balance Scale. Singapore Med J. 2015; 56 (5): 2880-283
- Louie, D.R., Eng, J.J. Berg Balance Scale Score at Admission Can Predict Walking Suitable for Community Ambulation at discharge from Inpatient Stroke Rehabilitation. Journal of Rehabilitation Medicine 2018: 50(1); 37-44.
- Smith MC, Ackerley SJ, Barber PA, Byblow WD, Stinear CM. PREP2 Algorithm Predictions Are Correct at 2 Years Post Stroke for Most Patients. Neurorehabil Neural Repair. 2019 Aug; 33(8):635-642. Epub 2019 Jul 3.
- Louie, R.D., & Eng, J.J. Berg Balance Scale Score at Admission Can Predict Walking Suitable for Community ambulation at discharge From Inpatient Stroke Rehabilitation. Journal of Rehabilitation Medicine 2018;50 (1).
As I write this article, the world is changing every minute. What was being considered standard a few days ago, is not so standard anymore. The way health care professionals learn to practice for decades all around the world is not the norm anymore. And this change brings many questions and many opportunities!!
What is Ulnar Tunnel syndrome?
Ulnar tunnel syndrome is a compression of the ulnar nerve at the wrist. The compression of this major nerve at the wrist is a relatively uncommon condition. The nerve usually is compressed at the elbow, in the cubital tunnel leading to a condition called cubital tunnel syndrome.
Anatomy of Ulnar Tunnel:
The ulnar nerve passes through Guyon’s canal in the wrist. From here, the nerve innervates to the digits. This is the most distal end of the nerve. The ulnar nerve becomes vulnerable to compression while traveling through this narrow tunnel.
It is important to remember that clinically, the cubital tunnel is most frequently seen ulnar nerve compression. The compression of the Ulnar nerve at Guyon’s canal is a relatively uncommon condition.
Causes of Ulnar Tunnel Syndrome:
- A benign tumor is the most important cause of ulnar tunnel syndrome.
- A ganglion cyst in the wrist can also compress the nerve at the wrist area.
- Repetitive trauma and chronic pressure to the area can also lead to compression of the nerve.
- Ulnar artery Thrombosis or aneurysm.
- Fracture of the hook of Hamate bone
- Repetitive trauma of the hypothenar muscle is a condition called Hypothenar Hammer Syndrome. This condition also leads to ulnar nerve compression in Guyon’s canal.
Clinical presentation of Ulnar Nerve Compression:
- A person reports with an onset of a gradual weakness and numbness of the little finger and partial ring finger. This is the area of the hand that innervated by the Ulnar nerve.
- A patient may or may not complain of pain.
- The patient also complains of difficulty with gripping, pinching, typing or playing a musical instrument. Opening a jar, holding objects as well as tasks that require finger coordination becomes difficult to perform.
Diagnosis of Ulnar Tunnel syndrome:
Physical examination and clinical presentation are crucial in the case of ulnar tunnel syndrome. Additionally, a physician may ask for a nerve conduction velocity test to identify the function of the nerve. In some cases, a patient needs to get an MRI or CT.
Treatment of Ulnar Tunnel:
Treatment of the ulnar tunnel syndrome is to find the root cause that compresses the nerve and attempt to remove it. Anti-inflammatory and analgesic medications help to relieve the symptoms temporarily.
Ergonomics are crucial especially if the nerve is getting compressed due to a faulty position or improper biomechanics. For example, typing or playing musical instruments with improper wrist support can compress the nerve. Correcting the biomechanics not only relieve the symptoms but also prevent the recurrence.
There are a variety of the braces available in the market that can help reduce the symptoms as well as prevent further compression. These braces help maintain the correct ergonomics of the wrist and digits.
Exercises for Ulnar nerve compression:
Nerve gliding exercises help to maintain normal nerve course and prevent any physical symptoms. Also, wrist and finger strengthening and stretching exercises help to perform daily activities in a pain-free range.
I describe exercises specific to the ulnar nerve in the article Cubital tunnel syndrome.
Additionally, you can find strengthening and stretching exercises for wrist and fingers in my previous article exercises for carpal tunnel syndrome.
What is Gamekeeper’s thumb:
Chronic Injury to Ulnar collateral ligament (UCL) of the metacarpophalangeal joint (MCP) of the thumb is known as Gamekeeper’s thumb. It is a common type of sport-related injury. Sports like hockey, soccer, basketball, volleyball, handball as well as skiing can lead to gamekeeper’s thumb.
What is Medial Epicondylitis?
Medial epicondylitis is a pain and inflammation on the inside of the elbow. A person complains of pain from the elbow down to the wrist on the inside (medial) of the elbow. Repetitive forceful movements of the wrist usually cause the medial epicondylitis. These movements lead to micro-tears or inflammation of the tendons of the forearm muscles resulting in pain at the medial epicondyle.
What is hip impingement?
Hip impingement syndrome is otherwise known as Femoroacetabular impingement (FAI). It is an impingement of the cartilage or labrum of the acetabulum with the movement of the femoral head.
What is a Tension Headache?
Tension headache is also called a stress headache. As the name suggests, it is triggered by tension or stress and it is the most common type of headache. Tension headache is very closely related to headache due to migraine and often misdiagnosed.
What is Radial Tunnel Syndrome?
Radial Tunnel syndrome is a compression of the radial nerve in the proximal forearm. The radial tunnel is not commonplace for radial nerve compression and so many times it can go undiagnosed. Cubital Tunnel, carpal tunnel, brachial plexus are some common places for the nerve compression.
What is Skier’s Thumb:
Skier’s thumb is defined as an injury to the ulnar collateral ligament (UCL) of the thumb at the Metacarpophalangeal joint (MCP). This injury is usually acute in nature.
Migraine affects around 37 million people nationwide and is the seventh leading cause of disability in the world. It occurs most commonly between the ages of 15 to 55 and has a strong relation to family history.
The exercise bike is a very popular way of getting your workout checked off for the day. Most of the exercise bikes provide different exercise programs that include cardio, resistance training, weight loss training as well as the manual setting for beginners. Some newer models also include anaerobic exercise setting or high-intensity training. Thus, exercise bikes give users the flexibility to choose the desired work out session for the day, comfort to perform the work out any time of the day, as well as ability to perform the session in own homes. No worries about snow days or rainy days, one can still continue this important healthy habit and be proud of himself for doing it!
What is Cubital Tunnel Syndrome:
Cubital Tunnel Syndrome is a compression of the ulnar nerve at the level of the elbow. This is the most common place for ulnar nerve entrapment. The nerve gets compressed behind the inside part of the elbow, causing numbness and tingling in the little and ring fingers and hand.
The Ulnar nerve passes from the neck and runs down to the arm. At the elbow, it travels through the tunnel of tissue called “cubital tunnel”. Here, the nerve runs behind the medial epicondyle -a part of the humerus bone. The nerve is very superficial here and can get irritated just by pressing very hard at the site. Continue reading “Cubital Tunnel Syndrome”