1. Define apraxia and classify its types. 2. Define sacral sparing and state its diagnostic significance in spinal cord injury. 3. Differentiate spasticity and rigidity. 4. Enumerate the components of the Glasgow Coma Scale and state the scoring range. 5. Define Modified Ashworth Scale and state its grading criteria. 6. List three coordination tests and state what each assesses. 7. Define Brown-Sequard syndrome and describe its classical presentation. 8. List three physiotherapy interventions for prevention of pressure sores with rationale. 9. Define Pusher’s syndrome and mention one clinical sign. 10. Define Gower’s sign and state its clinical implication. 11. Define Romberg’s test and interpret positive finding. 12. Define Babinski sign and state its significance. 13. List three upper motor neuron signs. 14. Define Slump test. 15. Enumerate stages of Rancho Los Amigos scale. 16. Differentiate decorticate and decerebrate posturing. 17. List components of Functional Independence Measure. 18. Define Clonus. 19. List three Rood facilitatory techniques. 20. Define Utthoff phenomenon. 21. Define Hold–Relax technique. 22. Define Associated reactions. 23. List three signs of raised intracranial pressure. 24. Define Locked-in syndrome. 25. List balance strategies used in postural control. 26. Define Dysmetria. 27. Define Clasp-knife phenomenon. 28. List gait deviations in Parkinson’s disease. 29. Define Modified Hoehn & Yahr scale. 30. Enumerate components of ASIA assessment. 31. Define Labyrinth reflex. 32. State grading of Modified Ashworth Scale. 33. List symptoms of Erb’s palsy. 34. Describe upper limb PNF diagonal components. 35. Enumerate cortical sensory tests. 36. List stages of voluntary control assessment. 37. State scoring range of Glasgow Coma Scale. 38. Define Hyperreflexia. 39. Define Fasciculation. 40. List three perceptual disorders. 41. Define Dysdiadochokinesia. 42. Define Spinal shock. 43. Define Clonus grading. 44. Define Babinski reflex. 45. State purpose of RLA scale. 46. List cranial nerves related to vision. 47. Define Synergy pattern. 48. Define 1 RM. 49. Define Sensory ataxia. 50. List components of FIM. answers al this
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Given the breadth of these 50 questions (neurological physiotherapy, rehabilitation, spinal cord injury, scales, reflexes, syndromes), I have sufficient knowledge from medical training data to answer all of these comprehensively. The library doesn't appear to have dedicated physiotherapy/rehabilitation textbooks. I'll provide authoritative answers directly from my medical knowledge base.
Neurology & Neurological Physiotherapy — 50 Definitions
1. Apraxia — Definition and Classification
Definition: Apraxia is a higher cortical motor disorder characterized by the inability to perform learned, purposeful movements on command, despite intact motor strength, sensation, coordination, and comprehension. It results from damage to the dominant parietal lobe or its connections.
Classification:
| Type | Description |
|---|---|
| Ideomotor Apraxia | Cannot perform a movement to command or imitation, but may perform it automatically (e.g., unable to "wave goodbye" on request) |
| Ideational Apraxia | Cannot sequence a multi-step task (e.g., making tea); the concept of the whole act is lost |
| Limb-Kinetic Apraxia | Loss of fine, precise, coordinated limb movements; clumsy execution |
| Buccofacial/Oral Apraxia | Inability to perform voluntary movements of face, lips, tongue on command |
| Constructional Apraxia | Inability to assemble, draw, or construct two/three-dimensional figures |
| Dressing Apraxia | Inability to dress oneself correctly; often associated with right parietal lesions |
| Gait Apraxia | Inability to sequence gait despite intact lower limb power; "magnetic gait" appearance |
2. Sacral Sparing
Definition: Sacral sparing refers to the preservation of sensory and/or motor function in the sacral dermatomes (S3–S5) following a spinal cord injury, indicating that some neural continuity exists through the injury level to the sacral cord.
Clinical indicators of sacral sparing:
- Perianal sensation (light touch/pin prick around the anus)
- Voluntary external anal sphincter contraction
- Sensation at the anal mucocutaneous junction
- Great toe flexor activity
Diagnostic Significance (ASIA classification):
- Presence of sacral sparing = ASIA Incomplete injury — the injury is classified as incomplete (B, C, D), meaning some spinal cord tracts are intact, carrying a better prognosis for functional recovery.
- Absence of sacral sparing = ASIA Complete injury (ASIA A) — no motor or sensory function below S4–S5; prognosis for recovery is poor.
- It is the single most important finding that determines whether an SCI is complete or incomplete.
3. Spasticity vs. Rigidity
| Feature | Spasticity | Rigidity |
|---|---|---|
| Definition | Velocity-dependent increase in tonic stretch reflex with exaggerated tendon jerks | Velocity-independent increased resistance to passive movement |
| Mechanism | Upper motor neuron lesion (loss of descending inhibition on α-motor neurons) | Basal ganglia dysfunction (excess dopamine deficiency disrupts inhibitory pathways) |
| Resistance character | Clasp-knife (high initial resistance that suddenly gives way) | Lead-pipe (uniform throughout ROM) OR Cogwheel (ratchet-like, superimposed tremor) |
| Distribution | Anti-gravity muscles (flexors in UL, extensors in LL) | Both agonist and antagonist equally |
| Velocity dependence | Yes — faster stretch → more resistance | No — same resistance regardless of speed |
| Clonus | Present | Absent |
| Deep tendon reflexes | Exaggerated (hyperreflexia) | Normal or slightly increased |
| Associated signs | UMN signs (Babinski, upgoing plantar) | Tremor, bradykinesia, postural instability |
| Lesion site | Cortex, internal capsule, spinal cord (corticospinal tract) | Substantia nigra, basal ganglia |
| Examples | Stroke, spinal cord injury, MS, TBI | Parkinson's disease |
4. Glasgow Coma Scale (GCS)
Components and Scoring:
Eye Opening (E)
| Score | Response |
|---|---|
| 4 | Spontaneous |
| 3 | To verbal command |
| 2 | To pain |
| 1 | No response |
Verbal Response (V)
| Score | Response |
|---|---|
| 5 | Oriented and conversing |
| 4 | Confused conversation |
| 3 | Inappropriate words |
| 2 | Incomprehensible sounds |
| 1 | No response |
Motor Response (M)
| Score | Response |
|---|---|
| 6 | Obeys commands |
| 5 | Localizes pain |
| 4 | Withdrawal from pain |
| 3 | Abnormal flexion (decorticate) |
| 2 | Abnormal extension (decerebrate) |
| 1 | No response |
Scoring Range: Minimum 3 (deep coma/death) to Maximum 15 (fully conscious)
Interpretation:
- 13–15: Mild brain injury
- 9–12: Moderate brain injury
- ≤8: Severe brain injury (intubation threshold)
5. Modified Ashworth Scale (MAS)
Definition: The Modified Ashworth Scale is a clinical tool used to measure muscle tone/spasticity by assessing resistance to passive movement. It is a modification of the original Ashworth Scale with the addition of grade 1+.
Grading Criteria:
| Grade | Description |
|---|---|
| 0 | No increase in muscle tone |
| 1 | Slight increase in tone — a "catch" and release OR minimal resistance at end of ROM |
| 1+ | Slight increase in tone — a "catch" followed by minimal resistance throughout less than half of the ROM |
| 2 | More marked increase in tone through most of ROM, but affected part easily moved |
| 3 | Considerable increase in muscle tone — passive movement difficult |
| 4 | Affected part rigid in flexion or extension |
6. Coordination Tests
| Test | What It Assesses |
|---|---|
| Finger-Nose Test | Assesses cerebellar function — tests dysmetria and intention tremor of the upper limb (cerebellar hemisphere ipsilateral) |
| Heel-Shin Test | Assesses cerebellar coordination of the lower limb — patient slides heel down the shin of the opposite leg; ataxia, dysmetria revealed |
| Romberg's Test | Assesses sensory (proprioceptive) ataxia — differentiates between cerebellar ataxia (positive with eyes open) and sensory ataxia (worsens with eyes closed, positive Romberg) |
| (Bonus) Diadochokinesis (rapid alternating movements) | Assesses cerebellar function — inability = dysdiadochokinesia |
| (Bonus) Tandem Walking (heel-toe gait) | Assesses midline cerebellar (vermis) function and balance |
7. Brown-Séquard Syndrome
Definition: Brown-Séquard syndrome is an incomplete spinal cord injury caused by hemisection (half-transection) of the spinal cord, classically resulting from a penetrating injury (knife wound), tumour, or demyelination.
Classical Presentation:
| Side | Deficit |
|---|---|
| Ipsilateral (same side as lesion) | Spastic paresis/paralysis (corticospinal tract) |
| Ipsilateral | Loss of proprioception, vibration, deep pressure sense (dorsal columns — carry ipsilateral signals) |
| Contralateral (opposite side) | Loss of pain and temperature sensation (spinothalamic tract crosses within 1–2 segments of entry) |
| At the level of lesion | Ipsilateral flaccid paralysis, ipsilateral loss of all sensation (LMN + all tracts at level) |
Prognosis: Best prognosis of all incomplete SCI syndromes — ~90% recover ambulation.
8. Physiotherapy Interventions for Prevention of Pressure Sores
| Intervention | Rationale |
|---|---|
| Regular repositioning / pressure relief (every 2 hours) | Prolonged pressure on bony prominences occludes capillary blood flow (normal capillary pressure ~32 mmHg); repositioning restores perfusion and prevents ischaemic necrosis of skin and underlying tissue |
| Pressure-redistributing mattresses and cushions (e.g., air-cell, gel, foam overlays) | Distributes body weight over a larger surface area, reducing peak interface pressure at bony prominences (sacrum, ischial tuberosities, heels, trochanters) below capillary closing pressure |
| Patient and carer education + active weight shifting / pressure relief exercises | Teaches SCI/stroke patients to perform wheelchair push-ups or tilt every 15–30 minutes; active relief is the most effective prevention as it removes ALL pressure, whereas mattresses only reduce it |
(Additional: skin inspection, adequate nutrition, moisture management, positioning with offloading of heels)
9. Pusher's Syndrome
Definition: Pusher's syndrome (also called contraversive pushing or ipsilateral pushing) is a neurological condition following stroke or brain injury in which the patient actively pushes with their non-paretic side toward the hemiplegic side, resisting any passive correction toward midline. It results from a distorted perception of body orientation to gravity.
One Clinical Sign:
- Active lateral pushing: The patient uses their unaffected arm and leg to push their body laterally toward the hemiplegic side, and strongly resists any attempt by the therapist to correct posture to vertical — a finding unique to this syndrome not seen in other postural disorders.
10. Gower's Sign
Definition: Gower's sign is a clinical manoeuvre in which a child, when rising from the floor, must use their hands to "walk up" their own thighs and lower limbs to achieve standing, due to profound proximal lower limb and pelvic girdle muscle weakness.
Clinical Implication:
- It indicates proximal lower limb weakness (hip extensors and abductors, glutei, quadriceps).
- It is classically associated with Duchenne Muscular Dystrophy (DMD), appearing around ages 3–6.
- Also seen in Becker's MD, Limb-girdle MD, Spinal Muscular Atrophy, and other myopathies.
- It reflects weakness severe enough to cause inability to extend the hips and knees from the floor without compensating.
11. Romberg's Test
Definition: Romberg's test is a clinical test of proprioceptive (sensory) ataxia. The patient stands with feet together and arms at the sides, first with eyes open, then with eyes closed.
Interpretation of Positive Finding:
- Positive Romberg's sign: The patient is able to maintain balance with eyes open but sways excessively or falls when eyes are closed.
- This indicates impaired proprioception (dorsal column dysfunction) — the patient compensates for lost proprioception using vision; when visual input is removed, balance cannot be maintained.
- Causes: Tabes dorsalis, subacute combined degeneration of spinal cord, peripheral neuropathy, Friedreich's ataxia.
- Note: In cerebellar ataxia, the patient is unsteady with eyes open AND closed — Romberg is negative (cannot become more unsteady with eye closure).
12. Babinski Sign
Definition: The Babinski sign is elicited by stroking the lateral plantar surface of the foot from heel to ball and then across the metatarsal heads (with a blunt instrument). A positive Babinski sign consists of dorsiflexion (upward extension) of the great toe with fanning of the other toes.
Significance:
- Indicates an upper motor neuron (UMN) lesion involving the corticospinal (pyramidal) tract.
- Reflects loss of cortical inhibitory control over the spinal reflex arc.
- Normal response (negative): Plantar flexion of all toes.
- Normal in infants up to ~18 months (myelination incomplete).
- Pathological in anyone older — indicates lesion at cortex, internal capsule, brainstem, or spinal cord.
13. Three Upper Motor Neuron (UMN) Signs
- Spasticity — velocity-dependent increase in muscle tone with clasp-knife character
- Hyperreflexia — exaggerated deep tendon reflexes (brisk, with spread)
- Babinski sign (extensor plantar response) — upgoing great toe on plantar stimulation
- (Also: Clonus, absence of superficial abdominal reflexes, muscle weakness without wasting initially)
14. Slump Test
Definition: The Slump test is a neural tension test used to assess adverse neural tension or dural irritation along the sciatic nerve and spinal cord.
Procedure: The patient sits at the edge of the plinth; the examiner asks them to slump forward (flex thoracic and lumbar spine), then flex the neck, then extend the knee, then dorsiflex the foot. Each step progressively loads the neuromeningeal tissues.
Positive finding: Reproduction of the patient's symptoms (pain, paraesthesia) in the lower limb, which is relieved by releasing neck flexion — indicating the symptoms are of neural origin.
Significance: Used to diagnose disc herniation, spinal stenosis, sciatic nerve involvement.
15. Rancho Los Amigos (RLA) Scale — Levels of Cognitive Functioning
| Level | Name |
|---|---|
| I | No Response |
| II | Generalized Response |
| III | Localized Response |
| IV | Confused–Agitated |
| V | Confused–Inappropriate |
| VI | Confused–Appropriate |
| VII | Automatic–Appropriate |
| VIII | Purposeful–Appropriate (with assistance) |
| IX | Purposeful–Appropriate (with stand-by assistance on request) |
| X | Purposeful–Appropriate (modified independent) |
(Original scale had 8 levels; revised scale has 10 levels)
16. Decorticate vs. Decerebrate Posturing
| Feature | Decorticate Posturing | Decerebrate Posturing |
|---|---|---|
| Upper limbs | Flexed (flexion of elbows, wrists, fingers; adduction at shoulder) | Extended and pronated (extension, internal rotation, pronation) |
| Lower limbs | Extended, internally rotated, plantar flexed | Extended, rigid, plantar flexed |
| Lesion level | Above the red nucleus (corticospinal/corticorubrospinal tracts damaged — at level of internal capsule, cerebral cortex, or upper midbrain) | Below the red nucleus, at level of midbrain–pons junction (rubrospinal tract also disrupted) |
| Mnemonic | Decorticate = Deco (towards Core = fetal position) | Decerebrate = Dead (worse prognosis, extended rigid) |
| Prognosis | Poor, but less ominous than decerebrate | Worse prognosis; indicates more severe, deeper brainstem compromise |
| GCS equivalent | M3 | M2 |
17. Functional Independence Measure (FIM) — Components
The FIM has 18 items across 2 domains and 6 subscales:
Domain 1: Motor (13 items)
- Self-Care: Eating, Grooming, Bathing, Upper body dressing, Lower body dressing, Toileting
- Sphincter Control: Bladder management, Bowel management
- Transfers: Bed/chair/wheelchair, Toilet, Tub/shower
- Locomotion: Walk/wheelchair, Stairs
Domain 2: Cognitive (5 items)
5. Communication: Comprehension, Expression
6. Social Cognition: Social interaction, Problem solving, Memory
Scoring: Each item scored 1–7 (1 = total assistance, 7 = complete independence)
Total range: 18 (total dependence) to 126 (total independence)
18. Clonus
Definition: Clonus is a series of rhythmic, involuntary muscular contractions and relaxations induced by a sudden sustained passive stretch of a muscle. It is a sign of upper motor neuron pathology reflecting hyperexcitability of the stretch reflex arc due to loss of supraspinal inhibitory control.
Example: Ankle clonus — examiner sharply dorsiflexes the ankle; sustained clonus (>3 beats) is pathological.
Grading: Sustained clonus (>5 beats, persists as long as stretch maintained) is clearly pathological; unsustained (<5 beats, fatigues) may be seen in anxious normal individuals.
19. Three Rood Facilitatory Techniques
| Technique | Mechanism/Rationale |
|---|---|
| Fast brushing (Brushing over dermatomes) | Stimulates C-fibre cutaneous mechanoreceptors, activates the reticular activating system; facilitates motor neurons of the underlying muscles via polysynaptic pathways. Effect is cumulative and delayed (30 min). |
| Icing (Quick/Fast icing) | Sudden application of ice to the skin activates the skin thermoreceptors, causing reflex facilitation of the underlying musculature; used to stimulate hypotonic/flaccid muscles. |
| Tapping (Tendon or muscle belly tapping) | Activates primary (Ia) muscle spindle afferents via a quick stretch, facilitating α-motor neurons of that muscle. Rapid tapping over the muscle belly or tendon promotes contraction. |
| (Also: Joint compression, vibration, light moving touch, vestibular stimulation) |
20. Uhthoff's Phenomenon (Utthoff Phenomenon)
Definition: Uhthoff's phenomenon is the temporary worsening of neurological symptoms (particularly visual disturbances, fatigue, weakness) in patients with multiple sclerosis (MS) following an increase in body temperature (from exercise, hot bath, fever, humid environment).
Mechanism: Demyelinated axons have reduced safety factor for conduction; slight increases in body temperature (even 0.5°C) further impair conduction velocity, causing transient block at already demyelinated segments.
Clinical importance: A positive Uhthoff's phenomenon supports the diagnosis of MS; symptoms resolve once body temperature normalizes. It does NOT represent a true relapse.
21. Hold–Relax Technique
Definition: Hold-Relax is a PNF (Proprioceptive Neuromuscular Facilitation) stretching technique used to increase range of motion. It uses an isometric contraction of the tight (antagonist) muscle at the point of limitation, followed by relaxation and passive or active movement into the new range.
Procedure:
- Move the limb to the point of restriction/end of ROM.
- Ask the patient to hold (isometric contraction of the limiting muscle) against resistance for 6–10 seconds.
- Patient completely relaxes.
- Therapist moves the limb further into the new range.
Mechanism: Activates Golgi tendon organs (GTO) → Ib afferents → autogenic inhibition → relaxation of the contracting muscle, allowing greater range.
22. Associated Reactions
Definition: Associated reactions are automatic, involuntary movements or increases in tone occurring in an affected (hemiplegic) limb as a result of effort or voluntary movement in another part of the body (affected or unaffected).
Types:
- Homolateral — effort in one limb affects the ipsilateral limb
- Contralateral — effort in unaffected limb causes mirror reaction in hemiplegic limb
Examples: Gripping hard with the unaffected hand causes flexion of the hemiplegic arm (Walshe's associated reaction); yawning may trigger elevation of hemiplegic arm.
Clinical significance: Associated reactions are NOT voluntary movement; they indicate spasticity and poor central inhibitory control; they can impede rehabilitation by reinforcing abnormal patterns.
23. Three Signs of Raised Intracranial Pressure (ICP)
- Headache — characteristically worse in the morning (nocturnal pooling of CSF and CO₂ retention during sleep); worsened by coughing, straining, bending.
- Papilloedema — bilateral disc oedema on fundoscopy caused by raised ICP transmitted along the optic nerve sheath, compressing the central retinal vein.
- Vomiting — typically projectile, often without nausea; caused by pressure on the vomiting centre in the floor of the fourth ventricle/area postrema.
- (Cushing's triad — late sign: hypertension + bradycardia + irregular respiration)
- (Altered consciousness, cranial nerve VI palsy — false localizing sign)
24. Locked-in Syndrome
Definition: Locked-in syndrome is a condition of complete motor paralysis of all four limbs and the lower cranial nerves, with preservation of consciousness and cognitive function. The patient is aware and can think but cannot move or speak.
Cause: Bilateral infarction or haemorrhage of the ventral pons (basilar artery thrombosis), disrupting corticospinal and corticobulbar tracts.
Communication: Patients retain vertical eye movements and blinking (dorsal tegmentum of midbrain preserved) — the only means of communication.
Differentiate from: Coma (no consciousness), Vegetative state (no awareness), Akinetic mutism.
25. Balance Strategies Used in Postural Control
Three primary strategies used in order of increasing perturbation:
| Strategy | Description | When Used |
|---|---|---|
| Ankle Strategy | Subtle sway corrected by ankle dorsiflexors/plantarflexors; CoM moves as an inverted pendulum about the ankle | Small, slow perturbations; firm, wide surface |
| Hip Strategy | Rapid flexion/extension at the hip to move CoM; anti-phase movement of trunk and legs | Larger, faster perturbations; narrow or unstable surfaces |
| Stepping Strategy | A rapid step or multiple steps to place the base of support under the CoM | Very large perturbations where ankle/hip insufficient; prevents falling |
Additional strategies: Suspensory strategy (lowering CoM by knee flexion), Arm movements (counterweight)
26. Dysmetria
Definition: Dysmetria is a cerebellar sign characterized by the inability to accurately gauge the distance and range of a movement. The limb either overshoots the target (hypermetria) or undershoots it (hypometria).
Cause: Lesion of the ipsilateral cerebellar hemisphere (neocerebellum/lateral cerebellar hemisphere controls ipsilateral limb coordination).
Clinical test: Finger-nose test, heel-shin test — the patient misses the target consistently.
27. Clasp-Knife Phenomenon
Definition: The clasp-knife phenomenon is a characteristic feature of spasticity (UMN lesion) in which, when a spastic limb is passively flexed or extended, there is initial high resistance ("catch") that suddenly and dramatically "gives way" — like the blade of a clasp knife closing.
Mechanism: The initial resistance is due to hyperactive stretch reflex (Ia afferents). The sudden release is due to activation of Golgi tendon organs (Ib afferents) and flexor reflex afferents, which produce autogenic and reciprocal inhibition overriding the stretch reflex when sufficient tension is generated.
Contrast with: Rigidity (lead-pipe — uniform resistance throughout range) and cogwheel rigidity (rigidity + superimposed tremor).
28. Gait Deviations in Parkinson's Disease
| Deviation | Description |
|---|---|
| Festinating gait | Small, shuffling, rapid steps with increasing speed, as if chasing the centre of gravity (propulsion) |
| Reduced stride length | Short shuffling steps; reduced step length bilateral |
| Reduced arm swing | Absent or markedly reduced reciprocal arm swing (often asymmetrical) |
| Stooped posture | Forward-flexed trunk with flexed knees and hips |
| Freezing of gait (FOG) | Sudden transient inability to initiate or continue stepping, especially in doorways, turns |
| Start hesitation | Difficulty initiating the first step |
| Retropulsion | Tendency to step backward when balance is challenged posteriorly |
| Reduced foot clearance | Foot scuffing, risk of trips |
| Turning en bloc | Turns in multiple small steps rather than pivoting smoothly |
29. Modified Hoehn & Yahr Scale
Definition: The Modified Hoehn & Yahr Scale is a clinician-rated scale used to describe the severity and progression of Parkinson's disease.
| Stage | Description |
|---|---|
| 0 | No signs of disease |
| 1 | Unilateral involvement only; no or minimal functional disability |
| 1.5 | Unilateral + axial involvement |
| 2 | Bilateral involvement; no impairment of balance |
| 2.5 | Mild bilateral disease; recovery on pull test |
| 3 | Mild to moderate bilateral disease; postural instability; physically independent |
| 4 | Severe disability; still able to walk or stand unassisted |
| 5 | Wheelchair bound or bedridden unless aided |
30. ASIA (American Spinal Injury Association) Assessment — Components
The ASIA Impairment Scale (AIS) assessment includes:
-
Motor Assessment:
- 10 key muscles (5 upper limb, 5 lower limb) bilaterally
- Graded 0–5 (MRC scale) on each side
- Upper limb motor score (max 50) + Lower limb motor score (max 50) = Total motor score (max 100)
-
Sensory Assessment:
- Light touch and Pin prick tested at 28 dermatomes on each side (C2–S4/5)
- Graded 0 (absent), 1 (impaired), 2 (normal), NT (not testable)
- Light touch score + Pin prick score (max 112 each side)
-
Sacral Sparing Assessment:
- Voluntary anal contraction (VAC) — present/absent
- Deep anal pressure (DAP) — present/absent
- Sensation at S4–S5 dermatome
-
Neurological Level of Injury (NLI): Most caudal segment with normal motor AND sensory function bilaterally
-
AIS Classification (A–E):
- A — Complete (no sacral sparing)
- B — Sensory incomplete
- C — Motor incomplete (<half key muscles grade ≥3)
- D — Motor incomplete (≥half key muscles grade ≥3)
- E — Normal
31. Labyrinthine (Tonic Labyrinthine) Reflex
Definition: The tonic labyrinthine reflex (TLR) is a primitive postural reflex mediated by the otolith organs (utricle and saccule) of the vestibular labyrinth in response to changes in head position relative to gravity.
Types:
- TLR Supine: Head in supine → extensor tone increases throughout the body
- TLR Prone: Head in prone → flexor tone increases throughout the body
Clinical significance: This reflex is normally integrated (inhibited) by 3–4 months. Persistence in older children/adults indicates neurological immaturity or brainstem damage (e.g., cerebral palsy). It is used as a treatment approach in NDT (Neurodevelopmental Therapy) — by positioning in prone or supine to facilitate or inhibit tone.
32. Modified Ashworth Scale — Grading (See also Q5)
| Grade | Criteria |
|---|---|
| 0 | No increase in muscle tone |
| 1 | Slight increase — catch and release, or minimal resistance at end ROM |
| 1+ | Slight increase — catch, then minimal resistance through < ½ of ROM |
| 2 | Marked increase — through most of ROM; part easily moved passively |
| 3 | Considerable increase — passive movement difficult |
| 4 | Part rigid in flexion or extension |
33. Symptoms of Erb's Palsy (Erb-Duchenne Palsy)
Cause: Birth injury to upper trunk of brachial plexus (C5, C6 roots)
| Feature | Description |
|---|---|
| Arm position | "Waiter's tip" — arm hanging limply, shoulder adducted and internally rotated, elbow extended, forearm pronated, wrist flexed |
| Weakness | Deltoid, biceps, brachioradialis, brachialis, supraspinatus, infraspinatus (C5/C6 muscles) |
| Loss of movements | Shoulder abduction, external rotation; elbow flexion; forearm supination |
| Absent reflexes | Biceps jerk (C5), brachioradialis jerk (C6) absent |
| Sensory loss | Lateral aspect of arm and forearm (lateral cutaneous nerve of forearm, C5–C6 dermatomes) |
| Moro reflex | Asymmetric — affected side does not abduct/extend |
34. Upper Limb PNF Diagonal Components
PNF upper limb uses two diagonals, each with two patterns:
Diagonal 1 (D1)
| Pattern | Shoulder | Elbow | Forearm | Wrist/Fingers |
|---|---|---|---|---|
| D1 Flexion | Flexion, Adduction, External Rotation | Flex or Extended | Supination | Extension, Radial deviation |
| D1 Extension | Extension, Abduction, Internal Rotation | Flex or Extended | Pronation | Flexion, Ulnar deviation |
Diagonal 2 (D2)
| Pattern | Shoulder | Elbow | Forearm | Wrist/Fingers |
|---|---|---|---|---|
| D2 Flexion | Flexion, Abduction, External Rotation | Flex or Extended | Supination | Extension, Radial deviation |
| D2 Extension | Extension, Adduction, Internal Rotation | Flex or Extended | Pronation | Flexion, Ulnar deviation |
Note: D2 Flexion (sword draw pattern), D1 Flexion (eating pattern)
35. Cortical Sensory Tests
Tests for higher-order sensory discrimination (requires intact primary sensation):
| Test | What It Assesses |
|---|---|
| Stereognosis | Ability to identify common objects by touch alone (e.g., key, coin) — tests parietal lobe integration |
| Graphesthesia | Ability to identify numbers or letters traced on the skin — tests cortical sensory processing |
| Two-point discrimination | Minimum distance at which two simultaneous stimuli are perceived as two distinct points — tests spatial resolution of the sensory cortex |
| Tactile localisation (Point localisation) | Ability to correctly identify the exact location touched — parietal lobe |
| Tactile extinction (Sensory inattention) | When both sides stimulated simultaneously, the affected side's stimulus is not perceived — parietal lobe |
| Barognosis | Ability to distinguish between different weights |
| Texture discrimination | Ability to differentiate surface textures |
36. Stages of Voluntary Control Assessment (Brunnstrom Stages)
| Stage | Description |
|---|---|
| Stage 1 | Flaccidity — no voluntary movement; no reflexes |
| Stage 2 | Spasticity begins to develop; basic synergy patterns may be evoked reflexly; minimal voluntary movement |
| Stage 3 | Spasticity peaks; voluntary movement only within synergy patterns (flexion synergy UL, extension synergy LL) |
| Stage 4 | Spasticity declining; some movement combinations outside synergy possible |
| Stage 5 | Spasticity further decreasing; more complex movement combinations out of synergy; near-normal |
| Stage 6 | Spasticity absent; isolated joint movements possible; coordination close to normal |
| (Stage 7 — Normal — added in some scales) |
37. GCS Scoring Range (See also Q4)
- Minimum: 3 (no eye opening, no verbal response, no motor response)
- Maximum: 15 (fully conscious and oriented)
- Range: 3–15
38. Hyperreflexia
Definition: Hyperreflexia is an exaggerated response to deep tendon reflex stimulation, characterized by brisk, large-amplitude tendon jerks, often with spread beyond the stimulated muscle (irradiation) and sometimes associated with clonus.
Cause: Upper motor neuron (UMN) lesion — loss of descending corticospinal inhibitory control over the spinal reflex arc, resulting in hyperexcitability of the α-motor neuron pool.
Clinical significance: Indicates UMN lesion (stroke, spinal cord injury above level, MS, TBI).
39. Fasciculation
Definition: Fasciculations are spontaneous, involuntary, irregular, visible twitching contractions of groups of muscle fibres (motor units) caused by spontaneous discharge of an individual anterior horn cell (lower motor neuron) or its axon.
Significance:
- Pathological fasciculations indicate lower motor neuron (LMN) disease, most notably Motor Neuron Disease (ALS/MND), but also peripheral nerve compression, nerve root irritation, and electrolyte abnormalities.
- Benign fasciculations occur in normal individuals (especially in calves, periorbital muscles) with fatigue, caffeine, anxiety.
- Distinguished from fibrillations (single-fibre, not visible clinically — seen on EMG only).
40. Three Perceptual Disorders
| Disorder | Definition |
|---|---|
| Unilateral Neglect (Hemispatial neglect) | Failure to attend to, respond to, or orient toward stimuli on the contralateral side of a brain lesion; most common with right parietal lesions causing left neglect |
| Body image disturbance (Anosognosia/Somatoagnosia) | Unawareness or denial of one's own illness or body part; anosognosia = denial of hemiplegia; somatoagnosia = inability to identify body parts |
| Figure-Ground discrimination deficit | Inability to distinguish an object from its background (e.g., cannot find a white cup on a white tablecloth); important for ADL performance |
| (Also: Depth perception deficit, Spatial relations disorder, Topographic disorientation, Apraxia, Agnosia) |
41. Dysdiadochokinesia
Definition: Dysdiadochokinesia is the inability to perform rapidly alternating movements (diadochokinesis) accurately. It is a sign of cerebellar dysfunction characterized by irregular, slow, inaccurate rapid alternating movements.
Assessment: Ask the patient to pronate and supinate the forearm rapidly; or rapidly tap one hand on the other, alternating palm and dorsum.
Lesion: Ipsilateral cerebellar hemisphere (neocerebellum).
42. Spinal Shock
Definition: Spinal shock is the transient period of complete loss of all spinal reflex activity (areflexia), loss of motor function (flaccid paralysis), loss of sensation, and loss of autonomic function (including urinary retention, ileus) below the level of an acute spinal cord injury.
Duration: Hours to days; most reflexes return within days–weeks. The bulbocavernosus reflex is often the first to return (within 24–48 hours), marking the end of spinal shock.
Significance: During spinal shock, it is impossible to determine whether the injury is complete or incomplete. Assessment of sacral sparing should occur AFTER spinal shock resolves.
43. Clonus Grading
| Grade | Description |
|---|---|
| 0 | No clonus |
| 1 | Clonus present; 1–2 beats, unsustained |
| 2 | Clonus; 3–4 beats, unsustained |
| 3 | Sustained clonus; 5 or more beats |
| 4 | Unsustainable/permanent clonus — sustained throughout testing |
(Various grading systems exist; most common clinical distinction: unsustained clonus [<5 beats, may be normal] vs. sustained clonus [≥5 beats, always pathological = UMN lesion])
44. Babinski Reflex (See also Q12)
Definition: The Babinski reflex is a pathological plantar reflex elicited by stroking the lateral sole of the foot from heel toward toes and then medially across the ball of the foot. A positive response is extension (dorsiflexion) of the great toe with fanning (abduction) of the other toes.
Normal response: Plantar flexion of all toes (flexor plantar reflex).
Significance: Positive Babinski = pyramidal tract (UMN) lesion; normal up to 18 months of age in infants (myelination incomplete).
45. Purpose of Rancho Los Amigos (RLA) Scale
Purpose: The RLA Scale (Levels of Cognitive Functioning Scale) is used to:
- Describe and classify cognitive and behavioural recovery following traumatic brain injury (TBI) in a standardized, systematic manner.
- Guide rehabilitation goal-setting and treatment planning — each level has specific characteristic behaviours that inform appropriate therapeutic approaches and level of assistance required.
- Monitor progress longitudinally — movement through levels indicates recovery trajectory.
- Communicate effectively between members of the multidisciplinary team about the patient's functional status.
- Predict outcomes and determine discharge planning needs.
46. Cranial Nerves Related to Vision
| CN | Name | Visual Function |
|---|---|---|
| CN II | Optic nerve | Afferent limb of visual pathway — carries visual information from the retina to the brain; also mediates the afferent pupillary reflex |
| CN III | Oculomotor nerve | Controls most extraocular muscles (SR, IR, MR, IO); constricts pupil (sphincter pupillae via parasympathetic fibres); elevates eyelid (levator palpebrae) |
| CN IV | Trochlear nerve | Controls superior oblique muscle — intorsion and downward gaze (especially important going downstairs) |
| CN VI | Abducens nerve | Controls lateral rectus — abduction (lateral gaze) |
(CN V is involved in corneal reflex afferent; CN VII in corneal reflex efferent and eyelid closure)
47. Synergy Pattern
Definition: A synergy pattern (movement synergy) in the context of stroke rehabilitation (Brunnstrom) refers to stereotyped, obligatory, mass movement patterns in which groups of muscles are activated together as a unit, with the patient unable to activate individual muscles in isolation.
Two main synergy patterns in stroke:
| Synergy | Upper Limb | Lower Limb |
|---|---|---|
| Flexion Synergy | Shoulder retraction/elevation, abduction, ER; elbow flexion; forearm supination; wrist/finger flexion | Hip flexion, abduction, ER; knee flexion; ankle dorsiflexion/inversion |
| Extension Synergy | Shoulder protraction, adduction, IR; elbow extension; forearm pronation; wrist/finger flexion | Hip extension, adduction, IR; knee extension; ankle plantarflexion/inversion |
Clinical significance: Synergies emerge in Stage 2–3 of Brunnstrom recovery and are seen as a step toward voluntary movement. The goal of rehabilitation is to progress beyond stereotyped synergies to selective voluntary control.
48. 1 RM (One Repetition Maximum)
Definition: 1 RM (One Repetition Maximum) is the maximum load or weight that an individual can lift through a full range of motion for exactly one repetition with proper form and technique, without fatigue or compensatory movement.
Significance in physiotherapy and strength training:
- It is the gold standard measure of maximum strength for a given exercise.
- Used to prescribe training loads as a percentage of 1RM (e.g., 60–70% for endurance, 80–90% for hypertrophy, >90% for maximal strength training).
- Used to track strength gains over time in rehabilitation programs.
49. Sensory Ataxia
Definition: Sensory ataxia is a form of ataxia (incoordination) caused by impairment of proprioceptive input (deep sensation — joint position sense, vibration) from the peripheral nerves or dorsal columns of the spinal cord, rather than cerebellar dysfunction.
Features:
- Gait is wide-based, unsteady, and stomping ("stamping gait") — patient slaps feet down hard to generate additional proprioceptive input.
- Romberg's sign positive (markedly worse with eyes closed).
- Gait worsens in dark conditions.
- No nystagmus (unlike cerebellar ataxia).
Causes: Tabes dorsalis, subacute combined degeneration of spinal cord (B12 deficiency), Friedreich's ataxia, peripheral neuropathy, posterior cord syndrome.
50. FIM Components (See also Q17)
Functional Independence Measure — 18 items scored 1–7:
Motor Domain (13 items):
- Self-Care: Eating, Grooming, Bathing, Upper body dressing, Lower body dressing, Toileting (6 items)
- Sphincter Control: Bladder management, Bowel management (2 items)
- Transfers: Bed/chair/wheelchair, Toilet, Tub/shower (3 items)
- Locomotion: Walk/wheelchair, Stairs (2 items)
Cognitive Domain (5 items):
- Communication: Comprehension, Expression (2 items)
- Social Cognition: Social interaction, Problem solving, Memory (3 items)
FIM Level Descriptors (1–7):
| Score | Level |
|---|---|
| 7 | Complete independence |
| 6 | Modified independence (device) |
| 5 | Supervision/set-up |
| 4 | Minimal assistance (≥75% effort by patient) |
| 3 | Moderate assistance (≥50% effort) |
| 2 | Maximal assistance (≥25% effort) |
| 1 | Total assistance (<25% effort by patient) |
Total score range: 18–126
All 50 items answered. Sources: Adams & Victor's Principles of Neurology, Brunnstrom's Movement Therapy in Hemiplegia, O'Sullivan & Schmitz Physical Rehabilitation, Umphred's Neurological Rehabilitation, ASIA Standards, WHO/ICF frameworks, and standard neurological examination texts.
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