Examining a Patient with a CNS Disorder

(1)

Neurorehabilitation Centre at CNA, Breda, Noord-Brabant, The Netherlands

Summary

The following common symptomatology is typical of a CNS disorder and therefore frequently present in the case of CVA, Parkinson’s disease, dementia, and MS: (1) impairments in coordination, flexibility, stamina, strength, and speed; (2) sensation impairments; (3) central muscle-tone dysregulation (CMD); (4) cognitive problems; (5) chronic fatigue; (6) presence of depression; (7) an impairment in one or more feedback systems; and (8) imbalance in burden versus resilience. This means that, with respect to neurorehabilitation, a uniform strategy may be applied to the common symptomatology. This chapter explains how the physiotherapist can obtain information about this symptomatology.

6.1 Introduction

Below is a list of which common symptomatology is typical for a CNS disorder and thus often present more in the case of Parkinson’s, dementia, MS, and a CVA:

Impairments in the coordination, flexibility, stamina, strength, and speed(CoFSSS)
Sensorimotor impairments
Central muscle-tone dysregulation (CMD)
Cognitive problems
Chronic fatigue
Presence of depression
An impairment in one or more feedback systems
Imbalance in burden versus resilience

This means that, with respect to neurorehabilitation, a uniform strategy may be applied to the common symptomatology. This chapter explains how the physiotherapist can obtain information about this symptomatology.

► Chapter 7 will explain which interventions are available to get the patient with a CNS disorder functioning at as high a level as possible.

6.2 CoFSSS

6.2.1 Coordination

The cerebellum’s functions include acting as the control center for coordination of random muscle activity, balance, and muscle tonicity. To be able to perform these three important functions, the cerebellum has to receive constant feedback from:

The position of the muscle and joints and the muscle tone
The balance
The cortical impulses that go to the muscle

Integration of these elements allows the cerebellum to coordinate and control the movements. Although coordination is not the same as is balance, we define coordination in the context of CoFSSS as balance. Balance is the ability to maintain one’s balance in changing situations, and to do this, well-coordinated control of the various muscle groups is essential (◘ Fig. 6.1).

Fig. 6.1

MRC 4

On the other hand, it is also possible that the control from the cerebellum is adequate but that the muscle tension or, for example, the propriocepsis is not sufficient.

Coordination/balance is assessed with the Berg Balance Scale (BBS) and/or the timed get up and go (TUG).

6.2.2 Flexibility

What is meant by flexibility is the mobility in the joints, also known as the range of motion (ROM). An attempt must be made to try and establish which structure is responsible for the mobility restriction, because that determines what can be influenced and to what extent by physiotherapy interventions; see ► Chap. 7. Structures involved are:

Myogenic contractures: through the catch and springy end feeling
Collagen contractures: full length not attainable and stiff end feeling
Neurogenic restrictions: recognizable from the loss of mobility in combination with stimuli elsewhere
Osseous restrictions: severe contractures and a hard end feeling («bone on bone»)

You can determine mobility with a protractor or with a classification rising from a slight mobility restriction to a severe restriction in the mobility of the joint.

6.2.3 Stamina

Stamina is essential to be able to persist in doing certain activities. We can test this in several ways, whereby the «6-min walking test» and the Åstrand cycle test are the most commonly used.

6.2.4 Strength

The added value of strength assessment by means of the Medical Research Council Scale (MRC) in patients with CNS disorders is dubious, particularly if there is a clear CMD present, which is manifested as hypo- or hypertonia. It is then probably better to test functional activities and to assess whether selective movements can be carried out. Selective movements are those movements that do not fit into the pattern that was described in ► Chap. 1.

In a number of cases, conducting a muscle test according to the MRC scale is appropriate, where one allows the patient to make the movement against a manual resistance of the physiotherapist. The following scale can be used:

5 = normal strength.
4 = the complete movement can be made but not against much resistance.
3 = the complete movement can be made against gravity.
2 = the complete movement can be made when gravity is eliminated.
1 = a contraction is observable but there is no movement.
0 = total paralysis (◘ Fig. 6.2).

Fig. 6.2

Impaired balance and control reactions

It is also possible to conduct a 1-RM test or a 10-RM test. This will be further clarified in the next chapter in ► Sect. 7.2 _.

6.2.5 Speed

In terms of exercise physiology, the last S in CoFSSS stands for speed. Within this professional field, this is formulated as the speed at which a joint can pass through a number of degrees.

We can also formulate this as speed but then as the walking pace. Studies have shown that a walking pace of higher than 2.8 km/h leads to greater social participation. It is thus absolutely worthwhile training walking pace, and it is certainly possible to do so. Walking pace is measured with the 10-m walking test (◘ Fig. 6.3).

Fig. 6.3

Walking pace is very important

6.3 Sensation Impairments

Sensation is very prominent in terms of evoking motor skills. For instance, when we pick up something, then we register within a fraction of a second how heavy it is, and then we immediately set the tonicity of our muscles to match. Thus that comes about within a non-impaired sensorimotor collaboration.

But what happens if one of the two is impaired or both? The chance of this is very real in the case of a CNS disorder. This leads irrevocably to an impaired movement pattern, and therefore it is extremely relevant to know which forms of sensation there are and how we can examine them.