Nervous System

Learning objectives

• Brief review of the structure and function of the nervous system

• An overview of neurologic evaluation, including the physical examination
and diagnostic tests
• A description of common neurologic diseases and disorders, including
clinical findings, medical and surgical management and physical therapy
interventions
Structure and function of the nervous system
 Central nervous system
• Brain
• Cranium
• Meninges
• Ventricular system
• Blood-brain barriers
• Central brain system
• Circulation
• Spinal cord
 Peripheral nervous system
• The peripheral nervous system consists of the cranial and spinal nerves and
the reflex system.
• The primary structures include peripheral nerves, associated ganglia, and
sensory receptors.
• There are 12 pairs of CNs, each with a unique pathway and function
(sensory, motor, mixed, or autonomic). Thirty-one pairs of spinal nerves (all
mixed) exit the spinal cord to form distinct plexuses (except T2 through T12).
• The reflex system includes spinal, deep tendon, stretch, and superficial
reflexes and protective responses.
 Autonomic Nervous System
• The portion of the peripheral nervous system that innervates glands and
cardiac and smooth muscle is the autonomic nervous system.
• The parasympathetic division is activated in time of rest, whereas the
sympathetic division is activated in times of work or "fight or flight"
situations. The two divisions work closely together, with dual innervation of
most organs, to ensure homeostasis.
 Neurologic Examination
• The neurologic examination is initiated on hospital admission or in the field
and is reassessed continuously, hourly or daily, as necessary.

• The neurologic examination consists of patient history; mental status

examination; viral sign measurement; vision, motor, sensory , coordination
testing and diagnostic testing.
 Patient history
• A detailed history, initially taken by the physician, is often the most helpful
information used to delineate whether a patient presents with a true
neurologic event or another process (usually cardiac or metabolic in nature).
• Patient/family member
• What is the patient feeling?
• When did the problem initially occur and has it progressed?
• What relieves or exacerbates the problem?
• What is the onset, frequency, and duration of signs or symptoms?
 Question related to Neurological Examination

• Does the problem involve loss of consciousness?

• Did a fall precede or follow the problem?
• Is there headache, dizziness, or visual disturbance?
• What are the functional deficits associated with the problem?
• Is there an alteration of speech?
• Does the patient demonstrate memory loss or altered cognition?
• Does the patient have an altered sleep pattern?
• What is the handedness of the patient? (Handedness is a predictor of brain
language dominance.)
 Observation
• Level of alertness, arousal, distress, or the need for restraint
• Body position
• Head, trunk, and extremity posture, including movement patterns
• Amount and quality of active movement
• Amount and quality of interaction with the environment or family members
• Degree of ease or difficulty with activities of daily living
• Presence of involuntary movements, such as tremor
• Eye movement
• Presence of muscle atrophy
• Respiratory rate and pattern
 Mental Status Examination

• Level of Consciousness
• Glasgow Coma Scale
• Cognition
• Emotional State
• Speech and Language Ability
• Vital Signs
• Cranial nerves
 Mental Status Examination

• Motor Function
• Strength testing
• Muscle tone
• Reflexes
• Sensation
• Coordination
 Diagnostic Procedures
• X-Ray
• Computed Tomography
• Magnetic Resonance Imaging and Angiography
• Doppler Flowmetry
• Carotid Non-invasives
• Digital-Subtraction Angiography
• Cerebral Angiography
• Lumbar Puncture
• Lumbar puncture
• Positron emission tomography
• Electroencephalography
• Evoked potentials
• EMG and nerve conduction velocities studies
• Mylography
 Pathophysiology

• Traumatic brain injury

• Spinal cord injury
• Cerebrovascular diseases
• TIA
• CVA
• Cerebral aneurysm
• Subarachnoid hemorrhage
• Ventricular dysfunction
• Seizure
• Syncope
 Common Degenerative Central NerooHs
System Diseases

• ALS
• GBS
• MS
• Parkinson’s disease
 General management

• ICP and cerebral perfusion pressure

• Brain herniation
• Mass effect
• Pharmacologic therapy
• Neurosurgical procedure
 Physical therapy intervention

• The primary physical therapy goals in treating patients with primary

neurologic pathology in the acute care setting include
• Maximizing independence
• Promote safety with gross functional activity
• Assist in prevention of secondary manifestation of neurologic dysfunction
and immobility.
 Basic Concepts for the Treatment of Patients with
Neurologic Dysfunction

• A basic understanding of neurologic pathophysiology is necessary to create

appropriate functional goals for the patient. The therapist must appreciate
the difference between reversible and irreversible and between non-
progressive and progressive disease states.
• There are a number of natural changes of the nervous system with aging,
such as decreased coordination, reflexes, balance, and visual acuity.
• Be sure to accommodate for these normal changes in the examination of
and interaction with the elderly patient.
• Take extra time to observe and assess the patient with neurologic
dysfunction, as changes in neurologic status are often very subtle.
• A basic knowledge of the factors that affect ICP and the ability to modify
treatment techniques or conditions during physical therapy intervention for
the patient with head trauma, after intracranial surgery, or other pathology
interfering with intracranial dynamics is necessary for patient safety.
• Patient and family or caregiver education is an important component of
physical therapy. Incorporate information about risk factor reduction (e.g.,
stroke prevention) and reinforce health care team recommendations (e.g.,
swallowing strategies per the speech language pathologist).