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Neurology Notes

Spastic Pattern of UL: Scapula retraction and depression, shoulder adduction,

flexion and internal rotation, elbow flexion and pronation, wrist flexion, finger flexion
and thumb adduction
Spastic Pattern of LL: Pelvic retraction and elevation, hip extension, internal rotation
and adduction, knee extension, ankle plantarflexion and eversion, toe clawing
Spastic Pattern of the Trunk: extensor tone, ipsilateral spasticity or flaccidity
*Crossed-extensor Reflex: a withdrawal reflex. When the reflex occurs the flexors in
the withdrawing limb contract and the extensors relax, while in the other limb, the
opposite occurs.
Pusher Syndrome:

Postero-lateral thalamus
Altered perception of body posture in relation to gravity
Visually and vestibularly intact
Pushing towards the affected side

Visiospatial Neglect:

Parietal lobe
Problems with orientating body to space and objects
Vestibular and visual intact
Falling to affected side

Shoulder locking: when the scapula is positioned medially it will pull on the labrum
which will in turn loosen the capsule and the HOH will slip downwards this is a
misposition and not a dislocation
The Serratus Anterior brings the scapula out laterally to help with reaching.
NB = put hands underneath the patient buttocks to feel where they are weight
bearing more
Scapula: look at the angles, borders for retraction, depression and medial rotation
Flaccidity does not equate to low tone
Check for shoulder subluxation work on serratus anterior to get shoulder into

Weight shifts to lateral: can degress to a bear hug if the patient cannot perform, need
dynamic control and dissociation in the trunk and pelvis
Bum lift: looking at obliques and glutes can cross their legs over assesses the
lower trunk
Sit up: assess the influence of oblique versus abdominals in order to complete the
Sit to stand: use a chair for ease and safety
Gait: assist with a chair at the normal side and support the affected knee
Bridging: bilateral and one-legged to assess selective control
*weight bearing activates the antagonists of the spastic muscles and correct
alignment will inhibit tone
In extension: patient will struggle to get flexion due to extensor pattern
In flexion: patient will struggle to get extension
E.g. In sitting: cannot get to sit upright (i.e. back extension) because they are in a
flexed position
What is normal for the roll?
Activity in serratus anterior and upper abdominals and obliques, neck flexion and
rotation, shoulder abduction and flexion
Lying to sitting: needs weight bearing control (deltoids and serratus) of the other side
and elongation of the trunk requires side flexion of the affected side
During roll, the hip does flexion, adduction and internal rotation but the muscles used
are actually the flexors, abductors and external rotators
For visio-spatial awareness impairments: want to address patient on the affected
side and use visual imagery as treatment, have to be walked, use as little
distractions as possible e.g. walking down a corridor where there are few people
rather than a busy gym.

Things to look for during gait: arm swing, pelvic rotation and tilting, hip and knee
active movements, step length and stride length, support required, how much sway,
distance they can walk, strategies
Muscle Activity During Gait:
Prior to initial contact: eccentric control of the glut max and med and quads which
controls the momentum of the swinging leg and body
At heel strike: concentric control of the hip extensors, adductors and hamstrings to
keep the body upright. Abductors act eccentrically as well and the quads to cushion
the weight.
Iliopsoas and adductors then act eccentrically as hip flexors then concentrically to
pull hip forwards during swing phase.
At ankle: eccentric activity of tibialis anterior at heel strike and eccentric activity of
calf group to control tibial movement. Push off/toe off has concentric activity of the
calf group again to push off the ground. Concentric activity of the tibialis anterior
during swing phase to keep the foot off the ground.
At sub-talar joint: tibialis posterior is controlling eccentrically throughout stance to
pronate and then concentrically to supinate.
Gait Defects in stroke: knee hyperextension common due to weakness in the quads
and is clear in the stance phase.
Trendelenburg: The glut medius maintains the level of the pelvis during stance
phase. Trendelenburg is positive when the contralateral pelvis drops. This patient
can usually not abduct their leg due to the weakness of the glut med. Excessive
lateral lean to the ipsilateral side as the Trendelenburg sign is known as
compensated Trendelenburg gait and they usually do this to maintain their COG over
the stance leg.
General exercise progressions: decrease BOS, increase the lever arm, advance
their balance limits, increase the holding time, increased the repetitions