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Demonstrations in Physiotherapy in Neurological Conditions (BPT)

UNIT 1 — Neurological Assessment

Step 1: History Taking

• Chief complaints (onset, duration, progression)
• Present history, past history, medical/surgical history
• Family and personal history

Step 2: Observation

• General appearance, posture, involuntary movements (tremors, fasciculations, spasms)
• Gait pattern observed during walking
• Facial symmetry, drooling, ptosis

Step 3: Higher Mental Function

• Consciousness — GCS (Glasgow Coma Scale)
• Orientation — to time, place, person
• Memory — short-term and long-term
• Speech — dysarthria, dysphasia, aphasia
• Perception — ask patient to identify objects (agnosia)
• MMSE — Mini Mental State Examination (score out of 30)
• Rancho Los Amigos Scale — for TBI

Step 4: Cranial Nerve Examination (CN I–XII)

• CN I: Smell identification
• CN II: Visual acuity, visual fields, Snellen chart
• CN II/III: Pupillary light reflex (direct and consensual)
• CN III/IV/VI: Eye movements (H-test), ptosis
• CN V: Facial sensation, jaw muscles, corneal reflex
• CN VII: Facial muscle strength (raise eyebrows, puff cheeks, close eyes)
• CN VIII: Rinne and Weber test, finger rub test
• CN IX/X: Palatal movement, gag reflex, voice quality
• CN XI: Sternocleidomastoid and trapezius strength
• CN XII: Tongue protrusion and deviation

Step 5: Motor Examination

• Muscle power — MRC grading (0–5) for all muscle groups
• Muscle tone — flaccidity vs spasticity; Modified Ashworth Scale (0–4)
• Spasticity assessment — passive ROM, catch angle
• Reflexes:
  • Deep Tendon Reflexes: biceps (C5/C6), triceps (C7), knee (L3/L4), ankle (S1) — graded 0–4+
  • Superficial reflexes: abdominal, plantar (Babinski sign)
  • Developmental/pathological reflexes: Hoffman's sign, clonus, grasp reflex

Step 6: Sensory Examination

• Superficial sensation: light touch, pin-prick (pain), temperature
• Deep sensation: proprioception (joint position sense), vibration (tuning fork 128 Hz)
• Cortical sensation: two-point discrimination, stereognosis, graphesthesia

Step 7: Special Tests

• Romberg's test — cerebellar/proprioceptive ataxia
• Kernig's sign — meningeal irritation
• Brudzinski's sign — meningeal irritation
• Tinel's sign — peripheral nerve irritation
• Slum test / SLR — radiculopathy
• Lhermitte's sign — cervical cord irritation (MS)
• Bell's phenomenon — CN VII palsy
• Gower's sign — proximal muscle weakness (DMD)
• Sunset sign, Battle's sign, Glabellar tap sign — specific neurological signs

Step 8: Balance & Coordination Examination

• Berg Balance Scale (0–56) — 14 tasks
• Finger-nose test, heel-shin test, dysdiadochokinesia
• Tandem gait, walking on heels and toes
• FIM (Functional Independence Measure) scoring

Step 9: Gait Analysis

• Kinetic & Kinematic analysis (quantitative and qualitative)
• Observe: step length, stride length, cadence, base of support, velocity
• Identify abnormal gait pattern (see Unit 7)

Step 10: Assessment Scales (Must Know for Demo)

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UNIT 2 — Neurophysiological Techniques (Demonstrations)

1. Concept — what is the technique based on?
2. Principle — neurophysiological basis (e.g., proprioceptive facilitation)
3. Technique steps — patient position, therapist position, hand placement, verbal command
4. Effects — facilitation or inhibition of tone/movement

Techniques to Demonstrate:

• PNF (Proprioceptive Neuromuscular Facilitation) — diagonal patterns D1/D2 for UL and LL, irradiation, rhythmic initiation, hold-relax
• Rood's Sensory Motor Approach — icing, brushing, tapping, slow stroking, joint compression
• Brunnstrom Movement Therapy — use of synergy patterns in stroke; stages 1–6
• Motor Relearning Program (MRP) — task-specific training, eliminate unnecessary muscle activity, retrain essential components
• Contemporary Task Oriented Approach — person-environment-task interaction, real-world task practice
• Muscle Re-education — EMG biofeedback, facilitation techniques
• Constraint Induced Movement Therapy (CIMT) — restraint of unaffected limb, intensive use of affected limb (massed practice)

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UNIT 4 — Brain & Spinal Cord Disorders (Bedside Demonstrations)

Step-by-step Clinical Demo Format:

1. History — onset, mode, progression, associated symptoms
2. Observation — posture, asymmetry, involuntary movements
3. Palpation — tone, tenderness, muscle wasting
4. Motor & Sensory Examination — power, tone, reflexes, sensation
5. Reflex Testing — DTRs, pathological reflexes
6. Differential Diagnosis — how to differentiate (e.g., UMN vs LMN lesion)
7. Balance & Coordination — Berg scale, coordination tests
8. Gait Analysis — observe and classify gait deviation
9. Functional Analysis — FIM/Barthel index
10. List of Problems & Complications — short and long term
11. Goal Setting — short-term (4–6 weeks) and long-term goals
12. Management of Systemic Complications — DVT, pneumonia, pressure sores, UTI, contractures
13. Management of Mechanical Complications — spasticity, subluxation, foot drop
14. Neurophysiological Approaches — which technique and why
15. Modalities — TENS, FES, ultrasound, hydrotherapy — application and parameters

Conditions Covered:

• Cerebrovascular Accident (CVA/Stroke)
• Meningitis
• Encephalitis
• Head Injury (TBI)
• Brain Tumors
• Perceptual Disorders
• Amyotrophic Lateral Sclerosis (ALS)
• Multiple Sclerosis (MS)
• Spinal Cord Injury (SCI)

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UNIT 5 — Cerebellar, Spinal Cord & Muscle Disorders

• Ataxia (cerebellar) — demonstrate Romberg, heel-shin, finger-nose
• Sensory Ataxia — positive Romberg, impaired proprioception demo
• Parkinson's Disease — UPDRS, festinating gait, rigidity (cogwheel/lead-pipe), micrographia
• Muscular Dystrophy (DMD) — Gower's sign demo, pseudohypertrophy of calves
• Myasthenia Gravis — fatigability, ptosis, ice pack test
• Eaton-Lambert Syndrome — reverse of MG (improves with repetition)
• Spinal Tumors, Transverse Myelitis
• Bladder & Bowel Dysfunction — neurogenic bladder assessment
• Spinal Muscular Atrophy (SMA), Poliomyelitis, Post-Polio Syndrome

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UNIT 6 — Peripheral Nerve Injuries (Demonstrations)

Nerve Injury Assessment Format:

1. Mechanism of injury (where, how)
2. Motor loss — muscles affected, test each
3. Sensory loss — dermatome/autonomous zone
4. Deformity/posture — e.g., wrist drop (radial), claw hand (ulnar), ape hand (median)
5. Special tests — Tinel's over affected nerve, Froment's sign (ulnar), Phalen's test (median)
6. EDX findings — NCS, EMG interpretation (in viva)

Nerve Palsies to Demonstrate:

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UNIT 7 — Neurological Gaits (Demonstration)

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UNIT 8 — Pre & Post-Surgical Conditions (Demo Format)

• Spinal disc herniation — SLR, neurological level, slump test, traction
• Spinal stenosis — claudication history, extension worsens symptoms
• Spinal cord trauma — ASIA classification (A–E), dermatomal/myotomal testing
• Head trauma — GCS, Rancho Los Amigos, orientation testing
• Brain tumors, cerebral aneurysms, Parkinson's disease, Epilepsy — pre/post-op physiotherapy protocol
• Hemiballism, Chorea, Psychiatric disorders
• Malformations of NS, Carotid artery stenosis, AVMs, Spina bifida

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Summary: Common Demo Exam Questions

1. Demonstrate the neurological assessment of a patient with stroke.
2. Show how to test cranial nerves II, VII, and XII.
3. Demonstrate assessment of spasticity using the Modified Ashworth Scale.
4. Perform a balance assessment using the Berg Balance Scale.
5. Demonstrate PNF diagonal patterns for the upper limb.
6. Demonstrate Brunnstrom assessment stages in a hemiplegic patient.
7. Identify and demonstrate the gait pattern of a patient with Parkinson's disease.
8. Demonstrate assessment of a patient with foot drop (common peroneal palsy).
9. Show how to classify a spinal cord injury using ASIA scale.
10. Demonstrate Romberg's test and interpret the result.
11. Demonstrate CIMT technique and explain its neuroplasticity basis.
12. Demonstrate neurological examination for cerebellar ataxia.

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DEMONSTRATION 1: Complete Neurological Assessment

(History Taking → Reflexes) — Step by Step

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BEFORE YOU BEGIN — Materials Required

• Reflex hammer (patella hammer)
• Tuning fork (128 Hz and 512 Hz)
• Cotton wool, pin/neurotip
• Ophthalmoscope / torch/penlight
• Two test tubes (hot & cold water)
• Snellen chart
• Measuring tape
• Assessment forms (MMSE, GCS, Berg scale, Barthel index)
• Gloves

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STEP 1 — INTRODUCTION & CONSENT

1. Greet the patient — "Good morning, I am [your name], a physiotherapy student. I will be examining you today."
2. Explain the procedure — "I will be doing a neurological examination which includes asking you some questions and testing your nerves and muscles."
3. Take informed consent — "Are you comfortable with this? Do you have any questions?"
4. Position the patient — sitting on a chair or edge of the bed (unless bedridden, then supine)
5. Expose the area adequately — ensure privacy with screen/curtain

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STEP 2 — HISTORY TAKING

A. Chief Complaints

• "What is your main problem? Since when?"
• Record: symptom + duration + progression
• Common complaints: weakness, numbness, difficulty walking, tremors, speech problems, headache, seizures, loss of balance

B. History of Present Illness

• Onset — sudden or gradual?
• Duration — days/weeks/months/years
• Progression — improving, worsening, or static?
• Associated symptoms — headache, vomiting, visual disturbance, bladder/bowel changes, falls
• Aggravating and relieving factors

C. Past History

• Any previous similar episodes?
• Hypertension, diabetes, cardiac disease, epilepsy?
• Previous surgeries or hospitalizations?

D. Family History

• Any similar condition in family members?
• Hereditary conditions (DMD, Huntington's, Friedreich's ataxia)?

E. Personal History

• Occupation, diet, sleep, bowel-bladder habits
• Smoking, alcohol, drug use
• Activities of daily living — independent or dependent?

F. Drug History

• Current medications (anticoagulants, antiepileptics, steroids, levodopa?)

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STEP 3 — GENERAL OBSERVATION

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STEP 4 — HIGHER MENTAL FUNCTION ASSESSMENT

A. Consciousness

• Use Glasgow Coma Scale (GCS)
  • Eye opening: Spontaneous (4) / To voice (3) / To pain (2) / None (1)
  • Verbal response: Oriented (5) / Confused (4) / Inappropriate words (3) / Sounds (2) / None (1)
  • Motor response: Obeys commands (6) / Localizes pain (5) / Withdraws (4) / Flexion (3) / Extension (2) / None (1)
  • Total: 3–15 — Mild (13–15), Moderate (9–12), Severe (≤8)

B. Orientation

• "What is your name?" (Person)
• "Where are you right now?" (Place)
• "What is today's date/day/month/year?" (Time)

C. Memory

• Immediate: Give 3 words → ask to repeat immediately (e.g., apple, table, penny)
• Short-term: Ask those 3 words again after 5 minutes
• Long-term: "Where were you born? What was your last job?"

D. MMSE (Mini Mental State Examination)

• Orientation to time (5) + place (5)
• Registration — repeat 3 objects (3)
• Attention & calculation — serial 7s or spell "WORLD" backward (5)
• Recall — repeat the 3 objects (3)
• Language — name two objects (pen, watch) (2)
• Repeat a phrase — "No ifs, ands, or buts" (1)
• Follow 3-step command — "Take this paper in your right hand, fold it, and place it on the floor" (3)
• Read and obey — show card "CLOSE YOUR EYES" (1)
• Write a sentence (1)
• Copy a design (intersecting pentagons) (1)

• 24–30 = Normal
• 18–23 = Mild cognitive impairment
• 0–17 = Severe impairment

E. Speech Assessment

• Dysarthria — slurred speech, ask to say "British Constitution" or "baby hippopotamus"
• Dysphasia/Aphasia — ask to name objects, follow commands, repeat sentences
  • Broca's (expressive) — non-fluent speech, understands
  • Wernicke's (receptive) — fluent but nonsensical speech

F. Other Higher Functions

• Calculation: "What is 100 minus 7?" (serial 7s)
• Reading: Show a sentence on a card
• Writing: Ask to write their name
• Right-left confusion: "Raise your right hand"
• Judgment: "What would you do if you found a wallet on the road?"
• Reasoning/Abstract thinking: "How are a tree and a bird similar?"

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STEP 5 — CRANIAL NERVE EXAMINATION (I–XII)

CN I — Olfactory (Smell)

• Close patient's eyes, occlude one nostril
• Present familiar smell (coffee, soap) to each nostril
• Ask: "Can you smell this? What is it?"
• Abnormal: Anosmia (no smell) — frontal lobe tumor, head trauma

CN II — Optic (Vision)

1. Visual acuity — Snellen chart at 6 meters; cover one eye
2. Visual fields — confrontation test; wiggle finger in 4 quadrants from periphery while patient looks at your nose
3. Color vision — Ishihara plates if available
4. Fundoscopy — papilledema, optic atrophy (in viva/clinic)

CN III, IV, VI — Oculomotor, Trochlear, Abducens (Eye Movements)

1. Ask patient to keep head still, follow your finger with eyes
2. Move finger in H pattern — test all 6 directions
3. Check for nystagmus (beating eye movements)
4. Ptosis — CN III palsy
5. Pupillary reflex:
   • Shine torch → pupil constricts (direct reflex)
   • Shine in one eye → other eye also constricts (consensual reflex)
   • RAPD (Marcus Gunn pupil) — afferent defect

CN V — Trigeminal (Face Sensation + Chewing)

• Ask patient to clench jaw → palpate masseters and temporalis bilaterally
• Ask to open mouth against resistance (pterygoids)
• Deviation to weak side on jaw opening

• Test 3 divisions — ophthalmic (forehead), maxillary (cheek), mandibular (chin) — use cotton wool (light touch) and pin (pain) bilaterally
• Corneal reflex — touch cornea gently with cotton wisp → blink (afferent CN V, efferent CN VII)

CN VII — Facial (Facial Muscles)

1. Raise eyebrows → observe forehead wrinkles
2. Close eyes tightly → try to open them (test orbicularis oculi)
3. Bell's phenomenon — eye rolls up when trying to close eye in palsy
4. Puff cheeks → press to test orbicularis oris
5. Show teeth → check symmetry of smile
6. Whistle

• UMN lesion (Central) — lower face only affected (stroke) — forehead spared (bilateral cortical representation)
• LMN lesion (Peripheral) — whole face affected (Bell's palsy) — forehead also affected

CN VIII — Vestibulocochlear (Hearing + Balance)

• Whisper test — stand behind patient, whisper numbers, occlude other ear
• Finger rub test — rub fingers near each ear
• Rinne's test (tuning fork 512 Hz):
  • Place on mastoid (bone conduction) → when not heard, hold in front of ear (air conduction)
  • Normal (Rinne positive): AC > BC
  • Conductive loss: BC > AC (Rinne negative)
• Weber's test:
  • Place tuning fork on vertex/forehead
  • Normal: Heard equally bilaterally
  • Conductive loss: Lateralizes to affected ear
  • Sensorineural loss: Lateralizes to normal ear

CN IX, X — Glossopharyngeal & Vagus (Palate + Swallow + Voice)

1. Ask patient to open mouth, say "Aaah" → observe soft palate — rises symmetrically
2. Uvula deviation — deviated away from lesion
3. Gag reflex — touch posterior pharynx with spatula (do gently)
4. Voice quality — hoarseness (CN X), nasal voice
5. Ask: "Any difficulty swallowing?"

CN XI — Accessory (SCM + Trapezius)

1. Sternocleidomastoid — Ask patient to turn head to left → resist with your hand on their right cheek → palpate right SCM contraction (tests left SCM)
2. Trapezius — Ask to shrug shoulders against resistance → look for wasting or asymmetry

CN XII — Hypoglossal (Tongue)

1. Ask patient to protrude tongue — observe for deviation, wasting, fasciculations
2. Deviation toward the side of lesion (LMN)
3. Ask to press tongue against cheek → resist from outside
4. Rapid tongue movements: "La-la-la"

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STEP 6 — MOTOR EXAMINATION

A. Inspection

• Muscle bulk, wasting, hypertrophy (calves in DMD)
• Fasciculations (LMN)
• Involuntary movements (UMN)
• Posture of limbs

B. Muscle Tone Assessment

1. Ask patient to relax completely
2. Passively move each joint through full range — vary speed
3. Compare bilateral limbs

• Flaccidity — no resistance, floppy (LMN, cerebellar)
• Spasticity — velocity-dependent (UMN, stroke)
• Rigidity — constant resistance (Parkinson's)
  • Cogwheel — ratchety, with tremor
  • Lead-pipe — uniform throughout ROM

C. Muscle Power (MRC Scale)

• Shoulder abduction (deltoid — C5)
• Elbow flexion (biceps — C5/C6)
• Elbow extension (triceps — C7)
• Wrist extension (ECRL — C6/C7)
• Finger extension (EDC — C7)
• Finger abduction (dorsal interossei — T1)
• Thumb opposition (opponens pollicis — C8/T1)

• Hip flexion (iliopsoas — L2/L3)
• Knee extension (quadriceps — L3/L4)
• Ankle dorsiflexion (tibialis anterior — L4)
• Ankle plantarflexion (gastrocnemius — S1)
• Toe extension (EHL — L5)

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STEP 7 — REFLEX TESTING

How to elicit a reflex (technique):

1. Patient relaxed — limb in semi-flexed/neutral position
2. Use pointed end of reflex hammer for tendons
3. Strike briskly — single, sharp tap
4. Observe/feel for muscle contraction
5. Reinforce if reflex absent — Jendrassik maneuver (for lower limbs: patient locks fingers and pulls)

Deep Tendon Reflexes (DTRs):

• 0 = Absent (areflexia) — LMN, peripheral nerve lesion
• 1+ = Diminished
• 2+ = Normal
• 3+ = Hyperreflexia (UMN lesion)
• 4+ = Clonus with hyperreflexia

Superficial Reflexes:

1. Use blunt object (key or end of reflex hammer)
2. Stroke lateral sole of foot from heel to ball, then curve medially
3. Normal (Flexor): Toes curl downward (plantarflexion) — normal in adults
4. Abnormal (Extensor — Babinski sign): Big toe extends (dorsiflexes), other toes fan out → UMN lesion

1. Patient supine, relaxed
2. Stroke each quadrant with a blunt object from lateral to medial (toward umbilicus)
3. Normal: Umbilicus deviates toward the stroked side
4. Absent: UMN lesion above T10

Pathological Reflexes:

Developmental Reflexes (ask to explain in viva):

• Moro, ATNR, STNR, Galant, Stepping — normally disappear by 6 months; persistence suggests CP

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STEP 8 — SENSORY EXAMINATION

Rules:

• Always test with eyes closed
• Test symmetrically — compare left vs right, proximal vs distal
• Start from distal to proximal (for peripheral nerve lesions)
• Or distal to level of lesion (for spinal cord lesions)

A. Superficial Sensations

• Use cotton wool, touch lightly
• Ask: "Can you feel that? Is it the same on both sides?"
• Map area of reduced/absent sensation (dermatome chart)

• Use neurotip or fresh pin — never reuse
• Ask: "Is this sharp or dull?"
• Compare both sides

• Fill two test tubes — one hot (~40°C), one cold (~15°C)
• Touch alternately
• Ask: "Is this hot or cold?"

B. Deep Sensations

• Strike 128 Hz tuning fork, place on bony prominences
• Sequence: great toe (IP joint) → medial malleolus → tibial tuberosity → iliac crest → sternum
• Ask: "Do you feel vibration? Tell me when it stops."
• Stop the fork — check if patient can detect cessation

• Hold the sides of the distal phalanx (not dorsum/pulp — prevents pressure cues)
• Demonstrate UP and DOWN movements with eyes open
• Then eyes closed — move toe up or down
• Ask: "Which way am I moving your toe — up or down?"
• If incorrect distally, test more proximally (ankle → knee)

C. Cortical Sensations

• Use two pins or blunt compass
• Touch simultaneously — vary distance
• Normal fingertip: 2–5 mm
• Ask: "One point or two points?"

• Place familiar object in hand (coin, pen, key) with eyes closed
• Ask: "What is this?"
• Astereognosis — parietal lobe lesion

• Write a number/letter on patient's palm with a blunt object
• Ask: "What did I write?"
• Loss — parietal lobe lesion

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STEP 9 — RECORDING YOUR FINDINGS

"On assessment, patient is conscious, oriented to time, place, and person. GCS is 15/15. Higher mental functions are intact. Cranial nerve examination reveals right facial nerve palsy of UMN type. Motor examination shows increased tone (MAS grade 2) in right upper and lower limb with power grade 3/5 in right upper limb and 2/5 in right lower limb. Deep tendon reflexes are exaggerated on the right side with positive Babinski sign on the right. Sensory examination shows decreased sensation on the right side. Proprioception and vibration are reduced in right lower limb."

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KEY TIPS FOR DEMONSTRATION EXAM

1. Always explain what you are doing as you do it — examiners want to hear your reasoning
2. Compare bilaterally for every test
3. Demonstrate proper patient positioning before each test
4. Know the neurological level for every reflex
5. Distinguish UMN vs LMN findings at every step:

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