Neurological Physiotherapy
This domain tests lesion localisation, accurate impairment measurement, and the translation of neuroplasticity principles into task-specific training. Items commonly ask you to identify a stage, a scale score, or the next functional goal.
Upper versus lower motor neuron signs
Upper motor neuron: hyperreflexia, spasticity, Babinski sign, clonus, minimal atrophy, no fasciculation. Lower motor neuron: flaccidity, marked atrophy, fasciculation, areflexia. Amyotrophic lateral sclerosis mixes both.
Localisation in stroke
Middle cerebral artery: contralateral face and arm weakness greater than leg, aphasia, neglect. Anterior cerebral artery: leg greater than arm. Posterior cerebral artery: visual field loss. Recovery is fastest in the first 3 months and continues more slowly thereafter; plateau is not the same as no further gain.
Measurement you must know
- Modified Ashworth Scale for tone: 0, 1, 1+, 2, 3, 4 (1+ is a catch followed by minimal resistance through less than half the range).
- ASIA Impairment Scale A–E for spinal cord injury, with key muscles C5 elbow flexors, C6 wrist extensors, C7 elbow extensors, L2 hip flexors, L3 knee extensors, L4 ankle dorsiflexors, L5 long toe extensors, S1 ankle plantarflexors.
- Brunnstrom stages I–VII describe synergy-dominated recovery of the hemiplegic limb.
- Berg Balance Scale: a score of 45 or below is widely used as a falls-risk indicator.
Applying neuroplasticity
Training must be repetitive, salient, task-specific and sufficiently intense. Constraint-induced movement therapy suits patients with some active wrist and finger extension. Use variable practice and an external focus of attention, and fade feedback as skill consolidates. Strength training in spasticity is safe and does not increase tone.
Worked example
Four weeks after a left middle cerebral artery infarct, a patient shows right elbow flexion with forearm supination and wrist flexion whenever they reach, and walks with circumduction. Reasoning: this is Brunnstrom stage III, with flexor synergy limiting reach. Prioritise trunk control, task-specific stepping, and reaching practice that demands elbow extension and wrist extension in a functional context. Avoid heavy resisted biceps work, which reinforces the synergy. Measure with Berg and a timed walk to track change.
Traps that cost marks
- Recording clonus as rigidity.
- Over-scoring ASIA by testing a muscle in a synergy rather than in isolation.
- Assuming sustained stretching reduces spasticity; it changes tissue length, not neural drive.