Week 1 HC & Rehab, Week 2 CVA, Review this for MOD 4 Finals, Week 3 HC II & Rehab - Pediatric Development, Week 5 Traumatic Brain Injury HC & Rehab, PNS Disorders, SCI

Bipolar Disease

"A brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks." Characterized by dramatic mood swings with periods of normal mood in between Symptoms are severe Different from the normal ups and downs AKA manic depressive illness Manic Episode = an overly joyful or overexcited state Depressive Episode = an extremely sad or hopeless state TX: Lifelong disorder, continuous treatment is necessary Can be well managed with medications Mood stabilizers are usually the initial choice Lithium is an effective mood stabilizer Side effects of Lithium: Restlessness, dry mouth, bloating or indigestion, acne, unusual discomfort to cold temperatures, joint or muscle pain, brittle nails or hair Anticonvulsants are also used as mood stabilizers Example: Valproic acid, preferred alternative to Lithium Side effects of Valproic acid: drowsiness, dizziness, headache, diarrhea, constipation, heartburn, mood swings, stuffed or runny nose, or other cold-like symptoms

Schizophrenia

"A severe brain disorder in which people interpret reality abnormally." "Schizophrenia may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior." Schizo in DSM-IV-TR 2 or more of these symptoms for at least 1 month: Delusions Firmly held beliefs; contrary to reality; resistant to disconfirming evidence Hallucinations Sensory experiences in the absence of sensory stimulation Types of hallucinations (audible thoughts, voices commenting, voices arguing) Disorganized speech Incoherence - inability to organize ideas Loose associations (derailment) - rambles, difficulty sticking to one topic Extremely disorganized or abnormal motor behavior, catatonic behavior Odd or peculiar behavior Silliness, agitation, unusual dress e.g., wearing several heavy coats in hot weather Negative symptoms: associated with disruptions to normal emotions and behaviors "Flat affect" (a person's face does not move or he or she talks in a dull or monotonous voice) Lack of pleasure in everyday life Lack of ability to begin and sustain planned activities Speaking little, even when forced to interact

How to Talk to an Infant

"Baby Talk" has a purpose Infants respond more to playfully exaggerated and high pitched tones But also use some adult language Limit environmental distractions One on one is best Make eye contact Pay attention to responses Keep it simple Keep it positive 1-3 months Lots of smiles, and act excited when the baby makes sounds and smiles Mimic the baby's sounds 4-7 months Use noises they make to encourage words Speak slowly and emphasize specific words 8-12 months Use positive statements to direct behavior When you need to stop the child from doing something, say a firm "no." Don't yell or give long explanations

Dementia

"Describes a group of symptoms affecting thinking and social abilities severely enough to interfere with daily functioning." Alzheimer's is the most common cause of progressive dementia

Motor Learning

"How" motor skills are acquired A set of processes associated with experience and practice leading to relatively permanent changes in the capacity for motor/skill performance. A permanent change in motor performance that occurs as a result of repetition Learning has occurred when one demonstrates consistency and efficiency over the control of the elements needed to generate movement Acquisition of new skills Retention of and transfer of skills to novel (new) situations Re-acquisition of formerly learned skills after injury

Motor Learning Defined

"How" motor skills are acquired A processes associated with experience and leading relatively permanent changes in the capacity for motor/skill performance A permanent change in motor ... repetition

Psychosocial Adaptation

"Psychosocial adaptation to disability and chronic illness is an ongoing, dynamic, evolving process through which a patient strives to attain an optimal state of function within his or her environment." Successful adaptions may include: A sense of personal mastery Participation in social, recreational or vocational pursuits Successful negotiation of the environment Realistic awareness of one's strengths, deficits and function Adjustments is the final phase of adaptation

Panic Attacks

"Sudden onset of intense, overwhelming fear that may include feelings of imminent danger or impending doom." Signs of a panic attack may include: SOB, hyperventilation Chest pains; heart palpitations; increased heart rate Smothering or choking sensations Fear of loss of control, dying or going crazy May report fear of immediate death Therapist may initiate emergency procedures if terror and severe panic ensue

Neuromuscular Facilitation

"The facilitation, activation or inhibition of muscle contraction and motor response" (O'Sullivan) Facilitation: " enhanced capacity to initiate a movement response through increased neuronal activity and altered synaptic potential." (O'Sullivan) Techniques: Manual resistance Quick stretch Tapping/repeated quick stretch Joint approximation Joint traction Irradiation (Overflow) Co-contraction Precautions Monitor for hypersensitivity to tactile stimulation High tone Decrease activity level if tone increases Increase support if tone increases Low tone Provide increased external stability Increased abnormal reflexes Decrease level of activity Increase support Inhibition: "the decreased capacity to initiate a movement response through altered synaptic potential." (O'Sullivan)

Mechanisms Primary Blast Injury

(1) Direct impact of transcranial blast wave (2) Transfer of kinetic energy from the wave through the vasculature Oscillations of the blood vessels leading to the brain (3) Elevations in CSF and venous pressure secondary to compression of the thorax and abdomen by the wave

If your patient with dementia experiences difficulty with memory, which strategies will you use to help your patient learn?

** Blocked Practice** Closed environment- eliminate distraction Break down tasks Reorient patient if they get lost High reps Task specific Use pictures Watch videos

Anterior cord syndrome

- Caused by flexion injuries -Bilateral loss of motor function, pain and temp sensation below lesion Corticospinal and spinothalamic tracts

Tone Assessment

0 = No response (flaccidity) 1+ = Decreased response (hypotonia) 2+ = Normal response 3+ = Exaggerated response (mild to moderate hypertonia) 4+ = Sustained response (severe hypertonia)

Motor Impairments post CVA

1) Weakness (paresis) Almost always contralateral MMT inacurate secondary to spasticity, use functional strength testing instead 2) Change in tone: Flaccidity, Spasticity / Hpertonicity (Muscle Tone = The amount of tension in a muscle at rest and its resistance to passive stretch Flaccidity is a type of hypotonia - complete lack of muscle activity Spasticity is a type of hypertonia - excessive muscle tension at rest Post CVA Resting Tone Initial Flaccidity develops into strong Spasticity ) 3) Abnormal Synergistic movement patterns (spasticity, flexor and extensor synergy patterns) (What is the difference btw resting tone and synergistic movement? Tone at rest vs. muscle activity w/ attempted mvmt.

Cerebrum

2 cerebral hemispheres 5 lobes

Types of Learning: Associative

2 events (stimuli) are paired Detect and establish predictive & causal relationships in the environment Two Types: Classical Conditioning Operant Conditioning Classical conditioning An initially weak stimulus becomes more effective as a result of being paired with a stronger stimulus Operant Conditioning Learner associates a certain response (from among many that have been made), with a consequence. Rewarded behaviors are often repeated

Cerebellum

5th lobe of the cerebrum

Motor Program

A motor program is stored information about a coordinated movement sequence Order of events Timing of events What muscles used Force of muscle contractions Synergistic component parts Many motor programs make up one motor plan Motor plan = idea Motor program = exact specifications of the idea

Motor Programs

A motor program is stored information about coordinated movement sequencee Order of events Timing of events What muscles used Force of muscle contractions Synergistic component parts Many motor programs make up on Motor plan idea Motor program exact specifications of the idea

Types of Learning: Nonassociative

A single stimulus is repeated Nervous system learns the characteristics of the stimulus Types: Habituation Decrease in responsiveness to a non-painful stimulus due to repeated exposure Sensitization Increased responsiveness to a threatening or noxious stimulus following a period of ongoing stimulation

Decerebrate Rigidity

A sustained contraction & posturing Rigid tone with upper extremities and lower extremities held in extension Indicates lesion at the brainstem Abnormal extensor response Upper Extremities Shoulders held in adduction, elbows in extension/forearms pronated, wrist/fingers in flexion Lower Extremities Hips, knees in extension Ankles in plantarflexion

Decorticate rigidity

A sustained contraction & posturing Rigid tone with upper extremities held in flexion and lower extremities in extension Indicates lesion above the brainstem Abnormal Flexor Response Upper Extremities Elbow, wrist and finger flexion with shoulder adduction Lower Extremities Extension & internal rotation of hips Extension of the knees Plantar flexion of the ankles/feet Lower extremity Pillow under the knees to get hip and knee flexion Heels up so there won't be a pressure ulcer Pillow between legs to prevent adduction Brace to hold them up at 0 Upper extremity Pillow under arm- out / abduction Wrist extension with MCP flexion

Circulation of the Brain...

ACA MCA PCA Medial striate artery (comes off the ACA) Lateral striate artery (comes off the MCA)

Complex Regional Pain Syndrome

AKA Reflex Sympathetic Dystrophy (RSD) or Causalgia Chronic pain condition Continuous, intense pain out of proportion to the severity of the injury Develops after extremity trauma/injury (5%) Causes dysfunction of the sympathetic nervous system Most often affects one arm, leg, hand, or foot Increased sympathetic activity release of norepinephrine vasoconstriction Females 3x more likely than males 35-60 y.o. Injured sensory nerve fibers at one somatic level initiate a sympathetic efferent activity that affects many segmental levels Injury to extremity of origin and well as adjacent areas Many resolve spontaneously while others progress and become a disabling disorder Ongoing symptoms for years or pattern of remissions and recurrences Prognosis better for treatment initiated within the first 6 months of the disease process Requires prolonged medical management ID underlying cause and stage of disease Medications include: NSAIDs and corticosteroids for pain relief Amitriptyline for sleep Calcium channel blockers for increasing peripheral circulation Bisphosphonate to combat bone loss Surgical options include a sympathetic nerve block to removal Stage I : Early intervention Modalities, retrograde massage, elevation, increase mobility (ROM, nerve glide), improve muscle function (load bearing), low impact aerobic, desensitization, education Stage II and III: Intervention Modalities, desensitization, passive and self stretching, functional performance

PD Interventions- Fleixibility Exercises

AROM & PROM Ideally, AROM performed 2-3X/day Elongate tight, shortened flexor muscles in PD PNF patterns UE D2 flexion - promotes upper trunk extension, counteract kyphosis LE D1 extension - promotes hip and knee extension Hold-Relax or Contract-Relax Traditional stretching Ideally, held 20-30" and repeated 3-5 X's

Significance of Rolling

Ability to differentiate segments of their bodies Head, trunk, and legs learn to move independently of one another Learn to differentiate between left side and right side of the body Allows for reciprocal movements between the arms and legs when crawling, walking and bike riding Rolling: 6-8 months Prone supine occurs first Log roll: 4-6 months Segmental rolling: 6-8 months

Neuroma

Abnormal growth of nerve cells

Motor Impair. post CVA

Abnormal synergistic movement patterns Associated with spasticity Flexor and extensor synergy patterns Synergy: functionally linked muscles that are constrained by the CNS which act cooperatively to produce an action. Abnormal Synergies Obligatory, highly stereotyped mass patterns of movement Selective movements out of synergy are difficult (O'Sullivan, Table 15.6, p. 671)

Acknowledgement

Acknowledgement Recognition of present situation Exploration of new possibilities or goals Development of new self identity

Summary of principles of promoting function- induced recovery

Active practice of motor skills Repetition is important Intensity is important Focus on modifying motor skills Enhance selection of behaviorally important stimuli Enhance attention and feedback Target goal-directed skills Timing is important Age

Pusher's Syndrome

Active pushing of the uninvolved side towards the involved side Offsets muscle control of the involved side (falls, leaning) Type of perceptual dysfunction, but not a parietal lobe issue; stems from the thalamus Improving Pusher's syndrome: Focus is on the vertical Can use mirrors, the wall, a ball, or even the therapist to assist with active, appropriate shifting rather than pushing Ask the patient, "Which way are you leaning?"; "Which direction should you move to be vertical?" Encourage weight shift to the uninvolved side Assist with weight bearing and pushing on the involved side

Pusher's Syndrome

Active pushing of the uninvolved side towards the involved side Offsets muscle control of the involved side (falls, leaning) Type of perceptual dysfunction, but not a parietal lobe issue; stems from the thalamus Strategies to improve pusher's syndrome Focus is on the vertical Can use mirrors, the wall, a ball, or even the therapist to assist with active, appropriate shifting rather than pushing Ask the patient, "Which way are you leaning?"; "Which direction should you move to be vertical?" Encourage weight shift to the uninvolved side Assist with weight bearing and pushing on the involved side

Guillain Barre Syndrome

Acute inflammatory polyneuropathy Associated with autoimmune attack of the Schwann cells Often occurs after recovery from an infectious disease Results in demyelination of Lower Motor Neuron: cranial and peripheral nerves Motor > sensory Results in slowed nerve conduction velocity Distal symmetrical motor weakness with sensory impairments and transient paresthesias Weakness progresses towards UEs and head Level of disability peaks within 2-4 weeks after onset Static for 2-4 weeks after and then gradual recovery from months-years Life threatening if respiratory involvement 30% of patients require mechanical ventilation during the acute stage Symmetrical weakness Tingling or numbness, loss of sensation Absent DTRs Difficulty breathing* Risk of death Progresses from lower extremities to upper extremities and from distal to proximal May result in complete paralysis, respiratory failure; vision and speech impairments Treatment includes hospitalization (to monitor for disease progression) Medications include immunosuppressants Recovery is slow and can last up to 2 years post onset Intervention: Treatment follows the pace of peripheral nerve recovery and usually begins with patient and family education in range of motion exercises to prevent contractures PROM, positioning, and light exercise Incentive spirometry - pulmonary rehab Progresses through wheelchair and/or ambulation training with assistive devices, strengthening, endurance training, and balance activities. It is important not to over fatigue the patient. PT does not alter the course of disease progression, but helps with functional improvements

Compensatory Strategies

Adaptive Compensation: alt or new movement patterns Substitutive Compensation: use different (unaffected) body parts to accomplish task. Doesn't promote neuroplasticity Ex: Simplify activities Establish a new functional pattern Task analysis - identify key task elements Repetition & practice Energy conservation & pacing of activity techniques Environmental adaptation to facilitate relearning of skills/promote ease of movement & enhance performance Simplify set up for optimal performance Use of orthotics/supportive devices for affected areas

What is necessary to achieve standing and walking skills

Adequate body proportion Adequate ROM Adequate strength, and motor control Coordination of visual, proprioceptive & vestibular systems for balance (TE-text)

How is level of Consciousness Assessed?

Alert and Oriented Questioning Person Place Time Situation Glasgow Coma Scale Will discuss during TBI

Cognitive Impairments

Altered consciousness Low or high state of arousal (responsiveness to stimuli) Attention Ability to select and attend to a specific stimulus while simultaneously suppressing extraneous stimuli Memory Ability to store experiences and perceptions for later recall Confusion Pre-frontal cortex Acute = Delirium Often due to perceptual losses coupled with unfamiliar hospital environment and inactivity Perseveration "stuck on a thought" Continued repetition of words, thoughts or acts, not related to the current context Executive functions Problem solving, abstract thinking, purposeful behaviors, judgment, suppressing "animal" instincts (think before act), risk taking behaviors Altered emotional status Emotional lability Outbursts of uncontrolled or exaggerated laughing or crying that are inconsistent with mood Irritability Social inappropriateness

Cognitive Impairments

Altered consciousness Low or high state of arousal (responsiveness to stimuli) Attention Ability to select and attend to a specific stimulus while simultaneously suppressing extraneous stimuli Memory Ability to store experiences and perceptions for later recall Confusion Pre-frontal cortex Acute = Delirium Often due to perceptual losses coupled with unfamiliar hospital environment and inactivity Perseveration "stuck on a thought" Continued repetition of words, thoughts or acts, not related to the current context Executive functions Problem solving, abstract thinking, purposeful behaviors, judgment, suppressing "animal" instincts (think before act), risk taking behaviors Altered emotional status Emotional lability Outbursts of uncontrolled or exaggerated laughing or crying that are inconsistent with mood Irritability Social inappropriateness

Altered Emotional Status

Altered emotional status- abilities that enable a person to engage in purposeful behaviors Emotional lability - emotional outbursts of uncontrolled or exaggerated laughing or crying that is inconsistent with mood Quick changes with minimal provocation Apathy - shallow affect and blunted emotional responses Euphoria - exaggerated feelings of well-being Increased levels of irritability/frustration Social inappropriateness Depression Anxiety

Specific motor impairments post CVA...

Altered motor programming = Apraxia Inability to perform a purposeful movement when cued despite the patient's strength, tone coordination, sensation, cognition Ideomotor Apraxia The patient can perform habitual tasks automatically, and remain unable to initiate the same task upon command Effects eating, dressing, drinking, self-care, walking Ideational apraxia inability of the patient to produce movement either on command or automatically represents a complete breakdown in the conceptualization of the task

Apraxia

Altered motor programming. Inability to perform a purposeful movement when cued despite the patient's strength, tone coordination, sensation, cognition

Progressive dementia

Alzheimer's, Lewy Body, Vascular, Frontotemporal Dementia

Aphasia

An acquired communication disorder caused by brain damage and is characterized by an impairment of language comprehension, formulation and use.

Aphasia

An acquired communication disorder caused by brain damage and is characterized by an impairment of language comprehension, formulation and use. (O'Sullivan, pg. 722) L CVA

PTSD

An anxiety disorder resulting from exposure to a traumatic event or ongoing chronic abuse." Who is at risk? Not everyone who experiences a trauma develops PTSD Triple Vulnerability Model 3 vulnerabilities need to be present to develop an anxiety disorder: A biological vulnerability A generalized psychological vulnerability Existing from past experiences of lost control over unpredictable events A specific psychological vulnerability that links anxiety to specific situations PT: Chronic pain often accompanies the PTSD Can negatively affect outcomes Avoidance, fear, anxiety, oversensitivity and catastrophizing may contribute as well PTs need to examine patients with PTSD for chronic pain Yale Multidimensional Pain Inventory McGill Pain Questionnaire Outcome for TX: Engagement in a healthy lifestyle Build positive self-efficacy Development of healthy coping skills Learn to use the relaxation response Education regarding how PTSD and chronic pain can facilitate one another and result in avoidance Healthy activities can result in decreased incidence of co-occurring disorders such as depression, substance abuse, etc. = higher quality of life

Pathophysiology of TBI

An external force to the skull that causes brain tissue damage Direct contact (bony skull or penetrating object) Rapid Acceleration Force/Deceleration Force Rotational Forces Blast waves from an explosion Brain tissue can become compressed, torn or displaced Brain tissue also can die from hypoxia These are all examples of primary brain injury Open head injury Skull fracture Meninges tear with brain exposure Closed head wound Contact of brain with skull Shearing forces Anoxia Cardiac arrest or near drowning Neurons can survive without oxygen for only 3 minutes

Circulation of the brain

Anterior Cervical Spine: Carotid Artery Internal Carotid Artery (ICA) Anterior Cerebral Artery (ACA) and the Middle Cerebral Artery (MCA) Posterior Cervical Spine: Subclavian Artery Vertebral Artery joins with other vertebral artery Basilar Artery Posterior Cerebral Arteries (PCA) Circle of Willis All major cerebral vessels receive blood through this arterial circle Connects the anterior and posterior brain circulation Allows for collateral flow if one artery is blocked Time dependent: slowly developing occlusions allow more collateral vessels to take over than in acute events Anterior Circulation Anterior Cerebral Arteries Middle Circulation Middle Cerebral Arteries Posterior Circulation Posterior Cerebral Arteries Cerebellar/Brain-stem circulation Vertebrobasilar arteries

Memory Impairments

Anterograde amnesia Inability to create new memories Last thing to recover after a comatose state Post-traumatic amnesia Time between the injury and when the patient is able to recall recent events Can be used as an indicator of the extent of damage Retrograde amnesia Inability to remember events prior to the injury Can progressively decrease with recovery

Phobia

Anxiety disorder characterized by intense anxiety resulting from thoughts of, or exposure to, a specific feared situation or object."

Anxiety

Anxiety: "Apprehensive anticipation of future danger or misfortune accompanied by feelings of tension and agitation." Physical manifestations (sympathetic response) Increased heart rate Shortness of breath Confusion Impaired cognitive skills Disorganization

Impairments in coordination

Ataxia Inability to perform coordinated movements Dysdiadochokinesia Impaired ability to perform rapid alternating movements (RAM) Dysmetria Impaired ability to judge the distance, range of a movement or force of muscular contraction Dyssynergia movement decomposition: impaired coordination of muscular contractions and movement Asthenia Generalized muscle weakness Tremor - rhythmic, involuntary movements resulting from alternating contraction and relaxation of opposing muscles Intention - occurs during coordinated voluntary movements Postural - of the head and trunk when muscles are used to maintain an upright posture against gravity Resting - at rest, diminished with voluntary movement and sleep (BG) Bradykinesia Extreme slowness of movement Posture disturbances Difficulty with position holding (especially with narrowed BoS), postural sway (oscillatory) Gait disturbances Wide BoS, difficulty walking in a straight line, difficulty with head motion, ataxic gait

Primary Risk Factors

Atherosclerosis HTN heart disease diabetes smoking TIA (Transient Ischemic attack)

Cognitive Impairment- Attention

Attention - the ability to select and attend to a specific stimulus while simultaneously suppressing extraneous stimuli Sustained attention - being able to stay focused on a task over time Selective attention - pick a stimulus to focus on, while ignoring others Divided attention - ability to perform 2 tasks simultaneously Alternating attention - aka attention flexibility - ability to alternate back and forth btw two different activities Attentional needs vary with task complexity and familiarity Environment is a large influence

Auditory Agnosia

Auditory Agnosia Inability to recognize non speech sounds or to distinguish between different sounds Cannot identify the sound of a ringing of a doorbell or telephone, siren, bird sounds Cannot identify a dog bark or a sound of thunder Treatment Practice the identification of different sounds Visual cues to distinguish between sounds

Receptive Aphasia aka Wernicke's

Auditory and reading comprehension impaired Speech is functional, comprehension is not Constantly talking but often out of context and with confabulations Left temporal lobe Confabulations: production of fabricated, distorted or misinterpreted memories about oneself or the world, without the conscious intention to deceive.

Righting Reactions

Automatic responses that causes the head and other body parts to align relative to head position and the ground Responses of the head and eyes that occur as the body processes sensory input from the visual and vestibular systems Enables us to maintain the correct orientation of the head and body with respect to vertical Develop starting at 4 months and become part of posture

Protective (Parachute) Reactions

Automatic responses that trigger upper extremity extension to protect proximal body parts when falling Develop order: downward, anterior, lateral, then posterior

Common PNS Impingements / Injuries

Axillary Humeral neck fx, anterior GH dislocation Musculocutaneous Clavicular fx Radial Humeral fx, compression in radial tunnel Median Pronator teres entrapment, carpal tunnel Ulnar Guyon's canal or cubital tunnel compression Femoral THA, displaced acetabular fx, anterior femoral dislocation, hysterectomy, appendectomy Sciatic Blunt force trauma to the buttocks, THA, accidental injection, piriformis syndrome Obturator THA, femur fx fixation Peroneal Femoral, tibial or fibular fx, positioning during surgical procedures Tibial Tarsal tunnel entrapment, popliteal fossa compression Sural Calcaneal or lateral malleolar fx

Erbs Palsy

Axillary Lateral pectoral Upper and lower subscapular Suprascapular Partial long thoracic and musculocutaneous

Righting, Protective, and Equilibrium Reactions

Balance responses that begin to appear around 4 months They continue to develop and mature throughout early childhood and should last throughout life

Midbrain

Basal Ganglia movement initiation and inhibition responsible for regulation of posture and muscle tone Parkinson's Disease Cranial nerves III and IV branch off this area

Flexibility/ Posture / Alignment

Basic Principles: <1 y.o. have normal physiologic flexion Younger children are usually more flexible than older ones Girls are usually more flexible than boys Growth spurts can cause an elongation of the muscle as the bone grows until the muscle has had time to catch up

Locked in Syndrome

Basilar artery Bilateral infraction of the pons Complete paralysis of all four limbs, the diaphragm and face Intact cognition Intact sensation Only able to perform eye movements

Prenatal Dev. of the Nervous System

Begins developing at 18 days post fertilization Basic form of the CNS is completed by 6th week of gestation Begins as a neural tube Rostral end becomes the brain The remainder closes to become the spinal cord Closure begins at the end and travels caudally At day 28 the cranial end of the neural tube forms into: Forbrain --> 2 cerebral hemispheres, thalamus, hypothalamus Midbrain --> stays the same Hindbrain --> pons, medulla, cerebellum Axonal myelination begins at 20 weeks, peaks in 3rd trimester and continue until age 2 Prefrontal cortex doesn't fully myelinate until early adulthood (25)

Hemorrhagic Stroke

Blood vessels rupture, blood leaks into the brain 1˚ Cerebral Hemorrhage results from ruptured blood vessels weakened by atherosclerosis Results in ↑ ICP and restricts blood flow to the brain Subarachnoid Hemorrhage (SAH) - bleeding btw arachnoid layer and pia mater Common cause: aneurysm & Atriovenous Malformation (AVM) Subdural Hemorrhage (SDH) - bleeding btw dura mater and arachnoid layer Common cause is trauma Mortality rates of 37-38% at one month

Body Image and Body Scheme Impairments

Body scheme - relationship of body parts to one another as well as the body's relationship to the environment Body image - visual and mental image of one's body may be altered following a stroke Includes the individual's feelings about this image Both of these are stored in our brain Impairments in these symptoms can result in Somatoagnosia

Perception Impairments

Body scheme - relationship of body parts to one another as well as the body's relationship to the environment Body image - visual and mental image of one's body may be altered following a stroke Includes the individual's feelings about this image Examples of body scheme/image impairments: Unilateral Neglect Visual recognition or attention on involved side Limb neglect or attention on involved side Anosognosia - denial, neglect or unawareness of one's paralysis Somatoagnosia - lack of awareness of one's body structure and its relationship to the environment Right-left discrimination Agnosia - inability to recognize incoming information despite intact sensory capabilities (O'Sullivan, pg 723) Visual object agnosia Auditory agnosia Tactile agnosia (astereoagnosia) Spatial relationship - difficulty determining the relationship between the body and 2 or more objects in the environment

CNS

Brain Brain stem Spinal Cord

UMN / CNS

Brain, Brain-stem, spinal cord

CVA / Stroke

CVA is used interchangeably with the term "stroke" Neurological deficits must remain for > 24 hours to be classified as a stroke Transient Ischemic Attack (TIA) Temporary interruption of blood flow to brain Symptoms resolve quickly (within 24 hours) Few if any permanent signs or symptoms Precursor to stroke

Lacunar Infarct

Caused by small vessel disease deep in cerebral white matter

Motor Developmental Progression

Cephalad --> caudal Proximal --> distal Gross --> fine Flexion --> extension

Patients w/ Psychiatric Disorders

Choose a purposeful activity with anxiety in mind Consider an activity that is repetitive, rhythmic, calming Gross motor movements can reduce muscle aches, agitation and restlessness that often accompany anxiety Consider an easy activity to begin and progress to more complex as the patient becomes more comfortable Choose activities that provide the patient with opportunity to succeed Consider stress management techniques such as imagery, meditation, relaxation, stretching, biofeedback, massage, music therapy, etc.

Multiple Sclerosis

Chronic, inflammatory demyelinating disease of the CNS White matter is most affected early Pain ~ 80% of patients with MS experience pain Most common Trigeminal neuralgia - occurs from demyelination of trigeminal nerve; pain in face, jaw and cheeks Lhermitte's sign - neck flexion produces "electric shock" down the spine and into the LEs Paroxysmal limb pain - burning, aching pain; most commonly in the LEs Worse at night & after exercise Aggravated by ↑ temperatures Headaches are frequent Balance Lesions affecting cerebellum & vestibular pathways Dizziness, vertigo, nausea Diplopia Eye patch to have signal from only one eye - no conflicting information Examples: Hydrocortisone, Prednisone, Prednisolone, Dexamethasone Mechanism of Action: reduce inflammation Uses: reduce inflammation either systemically (oral) or locally (injection) Risks: tissue degradation with prolonged exposure, GI distress, glaucoma, adrenocortical suppression, hypertension Symptoms of toxicity: (hormone related): moon face, buffalo hump, mood changes Implications for the PTA: patients at risk for osteoporosis, injected patients at risk of localized ligament and tendon laxity

Gestational Age vs. Chronological Age

Chronologic Age = numbers of days since birth (regular age) Gestational Age = number of weeks since conception Normal pregnancy = 38-42 weeks Premature = prior to 37 weeks Corrected Age = Chronologic Age minus weeks premature

TBI: Cognitive Impairments

Cognitive Deficits Impaired in orientation to time, person and place Impaired reasoning and problem solving abilities Attention Deficits Hyperactive, impulsive, distractive, ↓ concentration Behavior Problems Low frustration tolerance Depression Disinhibition: emotions, aggression, apathy, sexual Memory Deficits Retrograde Amnesia Inability to remember events prior to the injury Post Traumatic Amnesia The time between the injury and when the patient is able to remember recent events. The patient does not recall the injury circumstances. The patient cannot retain new information or hold recent memories. This affects their ability to learn new skills. Anterograde Memory Inability to create new memories

Development

Cognitive development is promoted through combining sensory and motor experiences and repetition

Coma

Coma A state of unconsciousness and the level of unresponsiveness to all internal and external stimulation No sleep/wake cycles Ventilator dependent May see abnormal reflexes Temporary Progress to: brain dead vegetative state, minimally conscious, or full recovery

Altered Levels of Consciousness

Coma - a non-functioning arousal system Eyes closed, no sleep/wake cycles, ventilator dependent, no auditory, visual, cognitive, or communicative function Abnormal motor and postural reflexes may be preset Usually temporary: either improve towards full recovery or progress into brain dead, vegetative state of minimal consciousness Vegetative state - disassociation between wakefulness and awareness Lack of integration of the cortex with the brainstem Brainstem can manage (on its own): basic cardiac and respiratory function - pt. may be able to wean off the ventilator Presence of sleep/wake cycles, eyes may be open, but without awareness of surroundings Some generalized responses to stimuli, reflexive muscle activity only Minimally conscious state - minimal evidence of self and environmental awareness Cognitively mediated behaviors occur inconsistently - they are reproducible or sustained, and therefore different from reflexive behavior Localize to noxious stimuli and may inconsistently reach for objects Localization to sounds, possible sustained visual fixation and pursuit Stupor An unresponsive state from which the patient can be aroused briefly with vigorous and repeated sensory stimulation Obtunded Sleeps often, when aroused exhibits decreased alertness and interest in the environment. Reactions are delayed

Speech and Language impairments

Communication is essential for successful PT PT/PTA team need to work closely with SLPs to assess these impairments Alternate forms of communication need to used Gestures, demonstration, pictures Aphasia - an acquired communication disorder caused by brain damage and is characterized by an impairment of language comprehension, formulation and use. - O'Sullivan, pg. 722 Receptive versus expressive Dysarthria Related to respiration, articulation, phonation, resonance, sensory feedback, chewing, swallowing, jaw and tongue movement

Compensitory Interventions / Strategies

Compensation "allows a patient to perform a task using alternate limbs and/or alternate movement patterns." (O'Sullivan) Ex: patient with hemiplegia successfully dresses using the less affected UE and increased trunk movements Adaptive Compensation: alternative or new movement patterns Substitutive Compensation: use different (unaffected) body parts to accomplish task. This does not promote neuroplasticity May be necessary to optimize safety and/or function Examples: Simplify activities Establish a new functional pattern Task analysis - identify key task elements Repetition & practice Energy conservation & pacing of activity techniques Environmental adaptation to facilitate relearning of skills/promote ease of movement & enhance performance Simplify set up for optimal performance Use of orthotics/supportive devices for affected areas

Requirements of Neuroplasticity

Complex High intensity Sensory stimulating Task specific

Causalgia

Complex regional pain syndrome

causalgia

Complex regional pain syndrome

Common PNS disorder etiologies

Compression Crush Laceration Penetrating trauma Stretch/ traction High velocity trauma (mva) Cold (frostbite)

Trigeminal Neuralgia

Compression/inflammation of trigeminal nerve (CN V) Caused by tumor or swollen blood vessel, MS, or triggered by herpes zoster (shingles) Symptoms: episodes of intense pain (electric shock) in the face with possible spasms/tics Symptoms often triggered by touch or sound Shaving chewing, oral care Most common in women >50 y.o. Medical treatment depends on the cause

Neurapraxia

Conduction block usually due to myelin dysfunction but NO DAMAGE TO NERVE FIBER **Pressure injuries are most common

Neurobehavioral Impairments

Confabulation - memory gaps are filled with inappropriate words or fabricated stories Perseveration - abnormal compulsive and inappropriate repetition of words or behaviors; observed in patients with diseases of the frontal lobes of the brain or schizophrenia Multi-Infarct Dementia - deteriorative mental state characterized by reduction in intellectual faculties; the result of small strokes Delirium - a clouding of consciousness with dulling of cognitive processes and general impairment of alertness; patients may demonstrate confusion, agitation, disorientation, and illusions or hallucinations

Brain Stem

Connects cerebrum and diencephalon w/ spinal cord Composed of: midbrain , pons, medulla oblongata all descending motor pathways except CORTICOSPINAL tract originate here.

Confused and Agitated Patients

Consistency Establish a daily routine: Same person, same time, same location everyday Provide orientation frequently Do not expect carryover New learning is unrealistic Focus on formerly learned and essential skills Model calm behavior Patients perceive and reflect demeanor Demonstrating emotional and behavioral control makes the patient feel safe Expect egocentricity Unable to see another's point of view Focus on self, versus environment Flexibility/options Limited attention span Be prepared with multiple activities Give safe options rather than open ended questions "Would you rather play ball or go for a walk?" Enables the patient to feel in control Safety Lack of understanding of own strength May be in a locked unit

Constant Practice/ Variable Practice

Constant Practice Best for tasks that require minimal variation and will be performed in constant conditions Variable Practice Better for learning More carryover to novel variations of the task

Function of Nervous System

Coordinates all body systems detects and responds to stimuli brain acts as the integration center spinal cord = freeway PN carry messages to and from spinal cord and brain stem

UMN

Cortex, Brainstem, Corticospinal Tracts, Spinal Cord CVA TBI SCI MS Huntington's Chorea Cerebral Palsy Brain Tumors ALS Tone: increased, velocity dependent Reflexes: Increased hyperreflexia, clonus, + Babinski, +Hoffman's Involuntary Mvmt: Muscle Spasms- flexor or extensor Muscle Function: Weakness or paralysis unilateral (stroke) Bilateral (SCI) corticospinal: contralateral if above decussation in medulla, ipsilateral if below Muscle Bulk: disuse atrophy: variable, widespread distribution, especially antigravity muscles

LMN

Cranial nerves: nuclei spinal cord: anterior horn cell, spinal roots Poliomyelitis Guillan-Barre PN Injuries Peripheral Neuropathy Radiculopathy Muscular Dystrophy Myasthenia Gravis ALS Tone: decreased or absent, not velocity dependent Reflexes: decreased or absent, hyporeflexia Decreased or absent cutaneous Muscle Function: distribution is never focal. Ipsilateral weakness or paralysis Limited distribution: segmental or focal pattern, root-innervated. Musle Bulk: Neurogenic atrpohy: rapid, focal distribution, severe wasting

Axonotmesis

Damage to the axons with preservation of neural connective tissue sheath Schwann cells

Myopathy

Damage to the muscle tissue

Hypotonia

Decreased resistance to passive motion Stretch reflexes are diminished or absent Hypoactive Limbs appear "floppy" Joint laxity Hyperextension Have a soft/flabby feel upon palpation Lower motor neuron (LMN) syndrome Lesions affect anterior horn cell & peripheral nerve Peripheral neuropathy, Cauda Equina, Radiculopathy, Guillan Barre, Polio ↓or absent tone and reflexes Paresis Muscle fasciculations - "muscle twitch" Muscle fibrillations with denervation Neurologic atrophy Spinal or Cerebral Shock Temporary hypotonia or flaccidity Can be seen with UMN - hemiplegia, paraplegia Duration is variable Typically followed by spasticity Cerebellar lesions present with mild decreases in tone along with asthenia (weakness)

Delirium / Lethargic / Full Consciousness

Delirium A state of consciousness that is characterized by disorientation, confusion, agitation and loudness Lethargic (Clouding of Consciousness) A state of consciousness that is characterized by quiet behavior, confusion, poor attention and delayed responses Full Consciousness A state of alertness, awareness orientation and memory

Anosognosia

Denial or lack of awareness of the presence of paralysis Limits patient potential for rehabilitation Treatment Cueing Safety instruction, family and caregiver education

Denial

Denial: Defense mechanism to alleviate anxiety and pain Protective response and allows the patient to gradually change and accept the situation Behavioral manifestations Disbelief or refusal to accept the presence of disease, impeding death or loss of function Patient expects the disease or condition to get better and heal Patient may appear euphoric, indecisive, act as if nothing has changed or refuse to participate in medical treatment plan Patient may select facts that supports their belief Selective listening Patient projects unrealistic goals

Depression

Depression:Refers to feelings of despair and hopelessness, negative shifts in perception, and decreased interest in activities that once provided pleasure Reactive response to bereavement and losses Associated with neurochemical changes, patient personality, family history, coping mechanisms Behavioral manifestation Patient experiences feelings of hopelessness, decreased concentration, tearful, loss of interest Fatigue, withdrawal from social activity

Symptoms of cranial nerve disorders

Destruction of optic fibers, visual disturbances Damage to hearing nerves Paralysis of muscles Bell's palsy Neuralgia - very painful Vestibular neuritis Dysphagia Dysarthria

Glasgow Coma Scale..

Determines the patient's level of arousal and cerebral cortex function Eye Opening, Verbal Responses, Motor Responses Score between 13 - 15 indicate mild impairment Score between 9 -12 indicate moderate impairment Score below an 8 indicate severe impairment and comatose state May be used as an outcome measure for progressions in level of consciousness Contributes to prognosis

Rehab Pediatric Mobility

Developing Milestones A set of functional skills or age-specific tasks that most children can do at a certain age range Encompass all domains of development Milestones help to monitor how a child is developing Children learn new physical skills by practicing them until each skill is mastered (controlled mobility skill) Although each milestone has an age level, the actual age when a normally developing child reaches that milestone is highly individualized as every child is unique!

C5-8

Diaphragm Pec major and minor Serratus anterior Rhomboids Lats

Expressive Aphasia aka. Broca's

Difficulty finding words to express ideas Slow spoken, individual words with high effort Left frontal lobe

Spatial Relations Disorders

Difficulty in perceiving the relationship between the self and two or more objects Figure-Ground Discrimination Inability to visually distinguish a figure from the background Difficulty dressing, buttoning or tying shoes Gait difficulties with curb, ramps, and steps Treatment Location of objects in a simple design Compensatory: use a touch to lock wheelchair brakes Brightly colored tape to identify items or on steps Structured routine exercises Safety education Inability to perceive the relationship of one object in space to another object or to one's self Difficulty crossing the midline affects all ADL Dressing, eating, positioning of body Treatment Instruct the patient to position himself by an object or a person " Sit next to me." " Stand behind the table." Mid line activities

Depth and Distance Perception disorder

Difficulty to determine or judge direction, distance and depth Difficulty navigating steps Stepping past a position or chair Spilling water or juice Treatment Safety education for gait and transfers Movement through space Manipulation of objects in space

Polyneurapathy

Diffuse nerve dysfunction that is symmetrical and typically 2 to pathology

Spinal Cord

Direct continuation of the brainstem (medulla oblongata) 2 major functions: Communication of sensory information Communication & coordination of motor information and movement patterns

Dorsal column tract (ascending)

Discriminative touch, kinesthesia, proprioception, vibration

Dorsal column tract (Ascending)

Discriminative touch, proprioception / kinesthesia, vibration

Radiculopathy

Disease of spinal the nerve roots

Barriers to Successful PT

Disorientation Confusion Physical aggression Memory deficits Limited attention span Cognitive abilities/potential to relearn motor skills May have to use observation and functional measures more than standard measures such as goniometry etc. Observe function in multiple environments

ALS Early Signs & Symptoms

Distal weakness Difficulty with foot dorsiflexion Weakness in legs, feet or ankles Hand weakness or clumsiness, difficulty w/fine motor Slurring of speech, changes in voice or difficulty swallowing Cervical extensor weakness Muscle cramps, twitch in arms, shoulders, tongue UMN loss is characterized by spasticity, hyperflexia Fatigue

TBI Pharmacological Intervention

Diuretics: ↓ intracranial pressure and fluid in the brain Anticonvulsants: Control seizures Antidepressants: Behavioral problems Electrolytes: Brain metabolism and healing Neurotransmitters: Serotonin (behavior & emotions)

Other Speech and Language Impairments

Dysarthria Slurred speech Related to: respiration, articulation, phonation, resonance and/or sensory feedback related Dysphagia Difficulty in swallowing Contributed to by: altered mental status, alerted sensation, poor jaw and lip closure, impaired head control, and poor sitting posture Thickened liquids to prevent aspiration

Neuropathies

Dysfuncrion of a peripheral nerve

Involuntary Mvmt

Dystonia Syndrome dominated by sustained muscle contraction Abnormal postures Twisting or writhing movements Athetoid vs. Choreiform Usually result from basal ganglia disturbances Associated Movements Involuntary movement of one body part during voluntary movement of another part Often seen with abnormal muscle tone ↑ with stress, effort and fatigue Tremor Rhythmical, involuntary, oscillatory movement Results from damage to the CNS Resting tremor - 2˚ basal ganglia dysfunction Intention tremor - 2˚ cerebellar lesions

PNF Technique

Each technique is designed to address one or more of the following: Mobility Range of motion to achieve necessary positions Stability Ability to remain in a posture against gravity Controlled Mobility Ability to transition form one position to another Skill Able to consistently perform a task under a variety of conditions with efficiency

TBI Treatment Guidelines

Early mobility Sensory stimulation, especially for low arousal Patient and family participation CONSISTENCY IS KEY Same therapist, daily schedule, offer orientation (person, place, time) - limit variables and change Goal directed, familiar, functional and recreational activities Focus on behavior modification activities May use positive reinforcement (rewards system) Feedback is important Initially, focus may be on activity endurance, rather than challenging the patient to learn new skills May not have capacity to learn early on Mental fatigue can lead to irritability, ↓ attention, etc. Simple commands, calm voice Practice without overstimulation Do not expect carryover - minimal learning/retnetion Therapeutic activities need to be SAFE and flexible, - change interventions based on patient's level of awareness and function in that moment Design programs appropriate for the patient's Rancho level Give the patient control, if appropriate As the patient advances: Community & social reintegration will be important Involve that patient in decision making Encourage independence & cooperative work

What does this mean for PT?

Education based Physical therapy is mandated to work on goals that will enhance the child's educational experience. Ability to sit and perform activities at a desk Ability to move around the classroom Ability to play during recess IEPs are a multidisciplinary plan that is re-assessed and updated annually

How to reduce abnormal synergies

Encourage out of synergy movement Flexion at one joint, with extension at the other Example: standing knee flexion: maintain hip extension while performing knee flexion

Strategies to Improve sensory function:

Encourage use of the affected side!! Increase the amount of sensory feedback on the impaired side Training should focus on functional tasks Examples: Stroking skin with various fabrics Drawing shapes, letters onto the skin of affected side Approximation Inflatable pressure splints Patient and family/caregivers must be educated on impairments as well as safety measures to protect the involved limbs

Strategies to improve sensory function

Encourage use of the affected side!! Increase the amount of sensory feedback on the impaired side Training should focus on functional tasks Examples: Stroking skin with various fabrics Drawing shapes, letters onto the skin of affected side Approximation Inflatable pressure splints Patient and family/caregivers must be educated on impairments as well as safety measures to protect the involved limbs

Impairment Interventions: Treating Specific Impairments

Enhancing Muscle Strength, Power & Endurance -Indications Decreased strength Contraindications Severely impaired cardiac status Monitor for Valsalva Maneuver Unstable muscle and tendon structure Precautions-Partially denervated muscles (Lower Motor Neuron Injury) Proceed slowly with sub-maximal strengthening Do not over fatigue High tone Decrease activity level if tone increases Increase support if tone increases Low tone Provide increased external stability - avoid ligamentous damage Increased abnormal reflexes Decrease level of activity Increase support Avoid resistive ex's that are likely to ↑ abnormal reflexes Aerobic Capacity Flexibility (Aerobic Training) Indications Debilitation Decreased endurance Fatigue Contraindications Severe cardiac condition Metabolically fragile End stage kidney failure End stage COPD or emphysema -Precautions: Beta Blockers - inaccuracy of HR monitoring Use RPE to monitor intensity Severe fatigue - proceed slowly with close monitoring of vital signs Metabolically fragile patients Uncontrolled Diabetes mellitus Dialysis patients Patients with extensive surgery and/or trauma Monitoring Close monitoring of vital signs w/ gradual progression of activities Keep running records of assessment Managing Muscle Tone Postural Control and Balance Coordination and Agility Improving Gait and Locomotion Relaxation Training ROM Beta Blockers - inaccuracy of HR monitoring Use RPE to monitor intensity Severe fatigue - proceed slowly with close monitoring of vital signs Metabolically fragile patients Uncontrolled Diabetes mellitus Dialysis patients Patients with extensive surgery and/or trauma Monitoring Close monitoring of vital signs w/ gradual progression of activities Keep running records of assessment Precautions: Monitor for pain reactions to motion Bone fragility (consider age & forces used in motion) Joint instability with motion -Stretching: Indications Potential for contracture Decreases in passive ROM Contraindications Acute muscle injuries Surgical incisions Precautions Avoid inflicting pain Bone fragility Do not stretch too aggressively

Impairment Interventions Treating specific impairments

Enhancing Muscle Strength, Power & Endurance Enhancing Aerobic Capacity Enhancing Flexibility Managing Muscle Tone Enhancing Postural Control and Balance Enhancing Coordination and Agility Improving Gait and Locomotion Relaxation Training

Brain Injury and the Meninges

Epidural Hematoma Bleeding btw skull and dura mater Subdural Hematoma Bleeding btw dura mater and arachnoid layer

Antihypertensice Medication

Examples: ACE Inhibitors, beta-blockers, calcium channel blockers, diuretics Mechanism of Action: various with type* Uses: control hypertension Risks: lightheadedness, syncope, orthostatic hypotension Implications for the PTA: careful with changing patient position 2⁰ to orthostatic hypotension

Thrombolytic Medication

Examples: Activase aka tPA Mechanism of Action: converts plasminogen to plasmin and degrades fibrin in clots. Plasmin breaks down clots and allows occluded vessels to reopen and maintain blood flow Uses: when administered within 3 hours of an ischemic event, can reduce extent of ischemic cell death Risks: bleeding and brain hemorrhage Implications for the PTA: watch for signs and symptoms of increased intracranial pressure

Antithrombotic (Antiplatelet) Meds

Examples: Aspirin, Plavix Mechanism of Action: inhibit platelet aggregation Uses: long term, low dose use decreases the risk of thrombus formation and recurrent stroke Risks: increased risk of bleeding, GI distress Implications for the PTA: careful with patient handling and bruising, reduce fall risk 2⁰ to risk of bleeding

Antispasmodic Medications

Examples: baclofen, Valium, Dantrium Mechanism of Action: relax skeletal muscle and decrease muscle spasm Uses: reduce increased muscle tone/spasticity Risks: drowsiness, confusion, headache, dizziness Implications for the PTA: sedation after administration of medication, reduction in function 2⁰ to loss of muscle tone

Anticoagulation Medication

Examples: warfarin (Coumadin), heparin - IV and fast acting Mechanism of Action: inhibit platelet aggregation Uses: reduce risk of clot formation, prevent existing clots from getting bigger Risks: increased risk of bleeding, hemorrhage and hematomas Implications for the PTA: careful with patient handling and bruising, reduce fall risk 2⁰ to risk of bleeding

Executive Functions

Executive Functions - abilities that enable a person to engage in purposeful behaviors Volition Planning Purposeful action Effective performance Impairments include: Impulsiveness Inflexible thinking Lack of abstract thinking Impaired organization and sequencing Decreased insight Impaired planning Impaired judgment

Externalized Hostility

Externalized Hostility: Anger projected to other people or objects in the environment Behavior often obstructs and hinders PT treatment Behavioral Manifestation Hypercritical ,demanding, false blaming to others, verbal abuse, physical violence, sarcasm

Visual Impairments

Eye movements (sluggish, reflexive, ataxic) Hemianopsia: Blindness in half of each eye's visual field (loss on the nasal side and half on temple side) Visual neglect Difficulties w/ depth perception & spatial relationships Forced gaze deviation Brainstem strokes may result in diplopia, oscillopsia or visual distortions

Spacial Relations Disorders

Figure-Ground Discrimination Inability to visually distinguish a figure from the background Difficulty dressing, buttoning or tying shoes Gait difficulties with curb, ramps, and steps Treatment Location of objects in a simple design Compensatory: use a touch to lock wheelchair brakes Brightly colored tape to identify items or on steps Structured routine exercises Safety education

Final Adjustment

Final Adjustment Self acceptance of self and functional limitations Reinforcement of new behavior patterns with other and the environment Restoration of self esteem

Week 3: Prenatal Development Germinal Stage

First Week sperm + ovum = zygote Multiply in mitosis of zygote --> blastocyte Ectoderm: epidermis, nails, teeth, sensory organ, nervous system Endoderm: digestive system, liver pancreas, salivary glands, respiratory system Mesoderm: dermis, muscles, skeleton, excretory system, circulatory system

Abnormal Synergy Patterns

Flexion - Upper Extremity Scapula - elevation, retraction Shoulder - abduction with External Rotation Elbow - flexion Wrist - flexion, adduction (ulnar deviation) Fingers - flexion, adduction Flexion - Lower Extremity Pelvis - elevation with posterior pelvic tilt Hip - abduction, ER Knee - flexion Ankle - dorsiflexion, supination Extension - Upper Extremity Scapula - protraction, downward depression Shoulder - IR, adduction Elbow - extension, pronation Wrist - flexion, adduction Fingers - adduction Extension - Lower Extremity Hip - extension, adduction, IR Knee - extension Ankle - plantarflexion Toes - flexion, adduction

Circulation of Cerebral Spinal Fluid

Formation of CSF: Choroid plexuses of the arachnoid layer CSF is housed in the sub-arachnoid space Production of CSF is not pressure regulated Impaired reabsorption does not alter production Production > reabsorption = hydrocephalus Removal Dural venous sinuses (into venous circulation) Spinal & Cerebral arachnoid villi Composition Similar to blood plasma Lower concentrations of K+, Bicarb, Ca++, & glucose Higher concentrations of Mg+ & Cl- Functions Preserves homeostasis in the nervous system Buoyancy for the brain Decreases the weight on the brain on the skull Mechanical cushion Drains unwanted substances away from the brain

What is the best way to structure the therapy session in order to optimize learning?

Frequency of practice Feedback Practice Conditions

Concussions

From the American Academy of Neurology Grade I No LOC, transient confusion, symptoms resolve within 15 min, full memory of the event Return to play if symptoms free after one week rest Grade II Transient confusion lasting >15 min, poor concentration, retrograde and anterograde amnesia, needs medical evaluation, needs CT scan if symptoms worsen Return to play after being asymptomatic for two weeks at rest and with exertion Grade III LOC, needs transport to ER for full neurological evaluation, diffuse axonal injury Return to play after asymptomatic for a minimum of one month

CVA - Outcome Measures

Fugel-Meyer Assessment of Physical Performance (FMA) Action Reach Arm Test Stroke Impact Scale National Institute of Health Stroke Scale (NIHSS) Stroke Rehabilitation Assessment of Movement (STREAM) Motor Assessment Scale (MAS) FIM

FES / NMES

Functional E-stim/Neuromuscular E-stim Indications Decreased strength Impaired muscle control Precautions Impaired cognition Provide written, pictorial instruction/Primary Care Giver training Areas of diminished sensation ES that increases abnormal synergistic patterns ES that causes patient agitation

Gagne's Nine Events to Instruction

Gain attention Inform learner of objectives Stimulate recall of prior learning Present stimuli with distinctive features Guide learning - small steps (chunking) leading from simple to complex Elicit performance Provide feedback Assess performance Enhance retention and learning transfer (skill application to various environments)

Myasthenia Gravis

Grave muscular weakness Autoimmune disorder Production of antibodies that combine with acetylcholine receptors at motor end plates Block and destroy the ACh receptor sites Destruction of up to 80% of receptor sites Results in extreme weakness Fluctuating weakness of proximal>distal muscles **Normal reflexes and sensation Quick to fatigue Muscles function better after rest Cranial Nerve NMJs effected: Facial weakness and loss of expression Diplopia, ptosis Dysphagia, gagging Dysarthria Symptoms triggered by activity, heat, stress, illness, menstruation and pregnancy Myasthenic Crisis = involvement of respiratory muscles Medications to inhibit acetylcholinesterase (enzyme that breaks down ACh) Allows for more build up of ACh at the NMJ Only offers temporary improvement Corticosteroids to suppress the immune system Removal of thymus Symptoms tend to plateau and/or improve after a few years Interventions: Strength and endurance training with caution to avoid overexertion Isometric strength training Prevent osteoporosis 2 to medication Breathing techniques to improve respiratory function Energy conservation

Types of Learning: Procedural

Habits Learning tasks that can be performed automatically without attention or conscious thought Develops slowly through repetition

Examples of Nonassociative Learning

Habituation Reduction in response to stimulus Living in a noisy city stop hearing sirens

Fine Motor Milestones (Rehab)

Head Control: 4 months Rolling: 6-8 months Prone supine occurs first Log roll: 4-6 months Segmental rolling: 6-8 months Sitting: 8 months Cruising: 10 months Walking: 12 months Creep upstairs: 15 months Ascend/descend stairs with 1 hand hold: 23 months

Vestibulospinal tract (descending)

Head/neck position, posture and balance

Sensitization

Heightened response to stimulus Post traumatic stress: over respond to noise or other stimulus

Sensitization

Heightened response to stimulus Post traumatic stress: over respond to noise or other stimulus

Hemispheric Differences

Hemispheric Behavioral Differences Left Hemispheric Damage Difficulties in communication Difficulty with processing information Cautious, anxious, disorganized Often very aware of impairments Right Hemispheric Damage Difficulty in spatial-perceptual tasks Difficulty with grasping overall idea of task or activity Quick, impulsive Overestimate their abilities, poor judgment in CVA: Right Hemisphere CVA Right facial involvement Left side weakness or paralysis Hemianopsia Decreased awareness and judgment Memory deficits Inattention and less reasoning Emotional labile Impulsive behaviors Left Hemisphere CVA Left facial involvement Right side weakness Aphasia Motor Apraxia Dysphagia Hemianopsia

Secondary Musculoskeletal Impairments

Heterotopic ossification Chronic pain Contractures Decreased endurance Muscle atrophy Fracture Peripheral nerve damage

Frequency

High frequency of practice is important for motor learning Rate of improvement is linearly related to amount left to improve Early Practice: performance improves rapidly Later Practice: performance improves more slowly Performance can always improve

Disorders linked to Dementia

Huntington's, TBI, HIV, Secondary Dementia (Parkinson's)

Dystonia

Hyperkinetic movement disorder Disordered tone & involuntary movements of large portions Caused by co-contraction dyskinesia Similar to Athetoid Twisting/writhing movements Results from a CNS lesions (basal ganglia) May be inherited Primary idiopathic dystonia Associated with neurodegenerative disorders Parkinson's & Wilson's Disease Associated with metabolic disorders Focal Dystonia affects only 1 part of the body [torticollis] Segmental Dystonia affects 2 or more adjacent areas Dystonic posturing - sustained abnormal postures that last for minutes to permanency

Ideomotor Apraxia Tx

Ideomotor Apraxia Treatment Simple commands Activities broken down into steps Repetition Activities performed in their natural environment Modeling pictures or films demonstrating the activity

Premature Birth and Neurologic Development

Impair ability to interact with the environment premature brains more susceptible to trauma (disruption of blood flow / oxygen to the brain) high risk if interventricular hemorrhage (IVH) in brains <30 weeks gestation

Sensory Perception Impairments

Impaired ability to perceive and process sensory information in the brain (afferent system intact but central processing is impaired) R > L hemispheric strokes --> Parietal lobe Results in : -Agnosia: inability to recognize incoming sensory info despite intact sensory capabilities -unilateral neglect -Anosognosia: unawareness of the existence of own disability. Denial or lack of awareness of the presence of paralysis Limits patient potential for rehabilitation Treatment Cueing Safety instruction, family and caregiver education Somatoagnosia: lack of awareness of one's body structure and its relationship to the environment, Inability to identify body parts Inability to initiate movement Patients may experience the limb as heavy Proprioception needs to be assessed Difficulty with transfers, turns, reaching, to sit, exercise and motion of limb and in relation to other body parts Treatment Simon Says "Point to body part", "Show me your elbow" Tactile stimulation of body part : Rubbing with lotion, wash cloth Tactile Agnosia (Stereognosis)- inability to recognize form/objects by handling them -Visual Agnosia: an inability to recognize familiar objects even w/ an intact visual system. TX: Identification of familiar photographs, colors, common objects Compensatory techniques with the use of touch or hearing to distinguish people and objects -Auditory Agnosia Inability to recognize non speech sounds or to distinguish between different sounds Cannot identify the sound of a ringing of a doorbell or telephone, siren, bird sounds Cannot identify a dog bark or a sound of thunder Treatment Practice the identification of different sounds Visual cues to distinguish between sounds

TBI: Neuromuscular Impairments

Impaired muscle tone Generally follows the Stages of Motor Recovery of initial flaccidity, followed by the onset of spasticity with synergies Flaccidity to Spasticity (can be low, moderate or severe tone) Affected extremities vary per area of the brain effected Impaired motor function (depends on site of brain damage) Monoplegic, Hemiplegic, Tetraplegic, Quadriplegic Impaired reflex responses (mild to severe) Abnormal synergistic movement patterns Impaired balance and coordination responses Possibility of impaired somatosensory function Diminished muscle performance for ADL Strength, Power, Endurance

Mobility Training

Important pt. is upright as soon as medically stable Sitting in chair, wheelchair or using a tilt table Bed mobility Transfer training May require co-tx with OT for initial transfers Sitting balance Standing balance Gait training Tilt Table, II Bars, Suspended Gait Device, TM, ADs Wheelchair Fitting and Mobility Training

Gait After a Stroke

Important to look at movements occurring at the ankle, foot, knee, hip, pelvis, trunk and UEs. Observe the different planes of motion Quantitative measures include distance, time, cadence, velocity, and stride times What type of AD may be necessary? May consider videotaping Ex:; Shortened Tst -Limited Hip Extension ROM hip flexor spasticity -Limited Dorsiflexion ROM gastrocsoleus spasticity inadequate dorsiflexion secondary to plantar flexor spasticity (equine gait) -Weakness of Plantarflexors tibialis anterior spasticity

Dysphagia

Inability or difficulty swallowing 51% of stoke patients High risk of aspiration Penetration of food, liquid, saliva or gastric reflux into the airway Can lead to acute respiratory distress within hours Aspiration pneumonia OT and Speech Thickened Liquids or NPO precautions Nothing by mouth NG tube or G tube PT: no water

Position in space impairment

Inability to perceive and interpret spatial concepts such as up, down, under, over, in, out, in front of, behind Unable to place their feet on the wheelchair footrests Difficulty following instructions for exercise Treatment Similar objects are placed with one object In a different orientation. The patent selects that object

Agnosia

Inability to recognize incoming information despite intact sensory capabilities (O'Sullivan, pg 723) Visual object agnosia Auditory agnosia Tactile agnosia (astereoagnosia) Somatoagnosia - lack of awareness of one's body structure and its relationship to the environment Anosognosia - denial, neglect or unawareness of one's paralysis

Dementia Complications

Inadequate nutrition Reduced hygiene Difficulty taking medications Deterioration of emotional health Difficulty communicating Delusions and hallucinations Sleeping difficulties Personal safety challenges

Blast Injury

Increase in prevalence secondary to increase in number of people returning from combat in the past 2 decades Blast injury is considered a signature injury of the US military conflicts in the Middle East Explosives emit a transient shock wave Primary blast injury Blast overpressure in the brain (and other organs) Secondary blast injury Shrapnel and objects hit the person Tertiary blast injury Person flung backwards and hits an object Wide variance in resulting severity of injury More research needed

Rehab Goals- LOCF I-III Severe to Moderate Brain Injury

Increase physical function and level of alertness Decrease risk of secondary impairments Improve motor control Manage effects of abnormal tone Improve postural control Increase tolerance to activities and positions Maintain or improve joint integrity and mobility Family and caregiver education on diagnosis, interventions, goals, and outcomes Contribute to the coordination of care with other team members

ICP

Increased ICP is the leading cause of death in acute stroke Decreasing level of consciousness Increased heart rate Irregular respiration s (Cheyne-Stokes) Speed up, slow down, apnea, cycle repeats Vomiting Headache (1st and worst) Un-reacting pupils Visual disturbances

Spasticity

Increased resistance to passive motion Characterized by velocity dependent resistance to passive stretch The quicker the stretch, the stronger the resistance Hyperactive DTR's Decreased or absent superficial cutaneous reflexes (abdominal/Plantar Reflex) Arises from injury to corticospinal pathway & is part of upper motor neuron (UMN) syndrome Muscle has a taut, hard feeling upon palpation Often see a "Clasp-Knife Response" Joint resistance is followed by a sudden inhibition or relaxation in response to a stretch stimulus Chronic spasticity usually causes associated: Contractures at the joints Abnormal posturing Deformity Functional Limitations & Disability Hyperactive stretch reflex Involuntary flexors & extensor spasms Re-appearance of Developmental Reflexes Increased deep tendon reflex (DTR) activity Clonus Maintained or quick stretch produces cyclical spasmodic contractions - common in the plantar flexors Abnormal Superficial Cutaneous Reflexes Babinski Reflex is ABNORMAL response with great toe extension Hoffman's Reflex

Aerobic Training

Indications Debilitation Decreased endurance Fatigue Contraindications Severe cardiac condition Metabolically fragile End stage kidney failure End stage COPD or emphysema Precautions Beta Blockers - inaccuracy of HR monitoring Use RPE to monitor intensity Severe fatigue - proceed slowly with close monitoring of vital signs Metabolically fragile patients Uncontrolled Diabetes mellitus Dialysis patients Patients with extensive surgery and/or trauma Monitoring Close monitoring of vital signs w/ gradual progression of activities Keep running records of assessment

Gait / Locomotion Training: Indications & Contraindications

Indications Decreased functional ambulation ability / gait Decreased functional ability with wheelchair mobility Decreased balance Impaired protective & reactive balance Decreased endurance Contraindications Unstable fracture of weight bearing bone Unstable vital signs Unsafe response to balance activities Precaution: FALL RISK High tone and patterned synergies ↓ activity level if tone ↑ ↑ support if tone ↑ Rigidity and akinesia Low tone Provide increased external stability Increased abnormal reflexes ↓ level of activity ↑support Severe balance dysfunction Impaired endurance Monitor for fatigue Monitor vital signs Impaired perceptual status Increase guidance & orientation Impaired cognitive status Modify commands & assistance as needed

Gait / Locomotion Training: Indications and Contraindications

Indications Decreased functional ambulation ability / gait Decreased functional ability with wheelchair mobility Decreased balance Impaired protective & reactive balance Decreased endurance Contraindications Unstable fracture of weight bearing bone Unstable vital signs Unsafe response to balance activities Precautionis: FALL RISK High tone and patterned synergies ↓ activity level if tone ↑ ↑ support if tone ↑ Rigidity and akinesia Low tone Provide increased external stability Increased abnormal reflexes ↓ level of activity ↑support Severe balance dysfunction Impaired endurance Monitor for fatigue Monitor vital signs Impaired perceptual status Increase guidance & orientation Impaired cognitive status Modify commands & assistance as needed

Biofeedback

Indications Decreased proprioception Impaired awareness Decreased strength Muscle spasm/pain/increased tone Precautions Impaired cognition Provide written, pictorial instruction/Primary Care Giver training Areas of diminished sensation

Strength Training

Indications Decreased strength Contraindications Severely impaired cardiac status Monitor for Valsalva Maneuver Unstable muscle and tendon structure precautions: Partially denervated muscles (Lower Motor Neuron Injury) Proceed slowly with sub-maximal strengthening Do not over fatigue High tone Decrease activity level if tone increases Increase support if tone increases Low tone Provide increased external stability - avoid ligamentous damage Increased abnormal reflexes Decrease level of activity Increase support Avoid resistive ex's that are likely to ↑ abnormal reflexes

Orthotic/ Protective or Supportive Device

Indications Impaired motor control Abnormal tone Decreased strength Decreased ROM Contraindications Skin breakdown Avoid use if skin shows signs of breakdown or undue pressure Monitor for signs of pain or discomfort with device Frequent visual skin checks if impaired sensation Precautions: Precautions Reddened pressure areas Monitor closely - daily checks Report & document carefully Fluctuating edema Monitor very closely Minimize skin &/or bone contact

ROM

Indications Loss of joint flexibility Prevention of a contracture Used to maintain joint motion Lack of active control (weakness/innervations) Contraindications Unstable fracture Joint infection Bone cancer Precautions: Monitor for pain reactions to motion Bone fragility (consider age & forces used in motion) Joint instability with motion

Stretching

Indications Potential for contracture Decreases in passive ROM Contraindications Acute muscle injuries Surgical incisions Precautions Avoid inflicting pain Bone fragility Do not stretch too aggressively

mechanism of injury

Indirect force produced by head or trunk Flexion force Lateral flex Jon force Compression force Hyper extension force Flexion and rotation force Direct force trauma

Postnatal Development

Infant 0-12 Toddler 2-3 Early Childhood 3-6 Late Childhood 6-12 Adolescence 13-20 Young Adult 20-40 Middle Adult 40-65 Late Adult 65+

Dementia causes that can be reversed

Infection and immune disorders, metabolic problems, nutritional deficiencies, reaction to medication, poisoning, brain tumor, anoxia, etc.

Neurodevelopmental Tx NDT Bobath

Inhibition of abnormal motor patterns: Do not reinforce synergistic movement patterns Learn to control movement through activities that promote normal movement patterns that integrate function Sensory feedback is critical in treatment of sensory & motor deficits of limited range and abnormal tone The PTA utilizes keys points of control to guide movement Postural sets/Reflex inhibiting postures Static positions that inhibit abnormal tone Key Points of Control: Specific handling of designated areas of the body Used to influence and facilitate posture, alignment and control through neuromuscular facilitation and/or inhibition Carefully matched to the patient's abilities to adapt movements

Reticulospinal tract

Inhibition of muscle tone Postural tone and proximal motor function

Week 5: Traumatic Brain Injury

Insult to the brain caused by an external force, that results in an impairment of cognition or physical functioning. Leading cause of death and disability in the US. **Falls*** 32% MVA 19% Violence 10-28% Explosions Sports and recreation

Primitive Reflexes

Integration of a reflex is when the Central Nervous System learns to inhibit the reflex to produce voluntary motion Frontal lobe is primarily responsible for the inhibition of primitive reflexes Reflexes re-manifest under situations of stress and with Upper Motor Neuron lesions Delayed integration of reflexes inhibits normal development

T6-10

Intercostal Abdominals

Internalized Anger

Internalized Anger: Reaction to anxiety, sense of abandonment, misperceptions, helplessness, fear of unknown Manifested Behavior Manipulation, Passive aggressive behavior, social isolation, sudden outbursts May direct anger toward PTA - Patient's reflection of projected feelings

Autonomic Nervous System

Involuntarily Effectors are smooth & cardiac muscle and glands Controls homeostasis & responds to stress Parasympathetic Sympathetic

Community Re- Integration

Judgement Problem Solving Planning Self-awareness Health and wellness Social interaction

Types of Extrinsic Feedback

Knowledge of performance (KP) Concurrent feedback Usually given while the person is performing the task Feedback about the movement pattern used to achieve the goal Knowledge of results (KR) Terminal feedback Usually given towards the end of the task or after it is completed Feedback about the outcome of the movement Was the goal achieve or not?

Somatoagnosia

Lack of awareness of body structure and the relationship of body parts to oneself, others and the environment Inability to identify body parts Inability to initiate movement Patients may experience the limb as heavy Proprioception needs to be assessed Difficulty with transfers, turns, reaching, to sit, exercise and motion of limb and in relation to other body parts Treatment Simon Says "Point to body part", "Show me your elbow" Tactile stimulation of body part : Rubbing with lotion, wash cloth

Corpus Callosum

Largest anatomical connection for hemispheric communication

spinothalamic tract (Ascending)

Lateral: pain and temperature Anterior : crude touch and pressure

How do we learn

Learning (process): The acquisition of knowledge or ability Knowledge/Skill (product): The retention & storage of that knowledge or ability Memory: Short Term aka working memory - information must be integrated or it will be lost Long Term: stored in brain, available for later retrieval True learning comes from long-term memory As learning progresses, information shifts from short term memory into long term memory Long term memory allows for continued access to this information for repeat performance or modification of existing patterns of movement

Left Hemisphere CVA

Left Hemisphere CVA Left facial involvement Right side weakness Aphasia Motor Apraxia Dysphagia Hemianopsia

Left Hemispheric Behavior

Left Hemispheric Damage Difficulties in communication Difficulty with processing information Cautious, anxious, disorganized Often very aware of impairments

Left Hemisphere CVA

Left facial involvement Right side weakness Aphasia Motor Apraxia Dysphagia Hemianopsia Behavioral Difficulties: Difficulties in communication Difficulty with processing information Cautious, anxious, disorganized Often very aware of impairments

cauda equina syndrome

Lesion below L1 Bowel bladder sexual dysfunction LMN injury Falccidity absent reflexes

LOCF

Level I No response Patient appears to be in a deep sleep and completely unresponsive to any stimulation Level II Generalized response Patient exhibits a generalized, inconsistent , non-purposeful response. Physiological changes, gross body movements or localization Level III Localized response Patient exhibits an inconsistent, localized response May follow simple commands such as opening eyes or squeezing hand Level IV Confused /agitated Patient exhibits a high state of unorganized activity; Bizarre behavior and non-purposeful relative to immediate environment; Does not discriminate among persons or objects Frequent incoherent verbalizations Decreased gross attention span Level V Confused/inappropriate Consistent response to simple commands Highly distractible and lacks ability to focus attention to a specific task May be able to converse for short periods of time Memory impaired and unable to retain new information Level VI Confused/appropriate Goal directed behavior in structured situation Follows simple directions consistently Carryover for relearned tasks; No carryover new tasks Level VII Automatic /appropriate Performs routine daily activities automatically Robot like with minimal to absent confusion Shallow recall of activities .Structured social interaction Beginning to show new learning carry over Level VIII Purposeful/appropriate Level 8: Purposeful and Appropriate Patient is responsive to environment Patient is able to demonstrate recall memories and integrate past and recent events Able to learn and needs no supervision once activities are learned Decreased tolerance to stress, and complex reasoning skills

Gait after Stroke Example: Shortened Tst

Limited Hip Extension ROM hip flexor spasticity -Limited Dorsiflexion ROM gastrocsoleus spasticity inadequate dorsiflexion secondary to plantar flexor spasticity (equine gait) -Weakness of Plantarflexors tibialis anterior spasticity

Motor Performance vs. Motor Learning

MP: Can improve without actual learning Performance will improve within one practice session Performance is highest with maximum feedback ML: Is demonstrate through retention and adaptability Retention is demonstrating the skill over time and after a period of no practice Adaptability is demonstrating the skill with changing task and environmental conditions

Neuromuscular Facilitation Techniques

Manual resistance Quick stretch Tapping/repeated quick stretch Joint approximation Joint traction Irradiation (Overflow) Co-contraction Precautions Monitor for hypersensitivity to tactile stimulation High tone Decrease activity level if tone increases Increase support if tone increases Low tone Provide increased external stability Increased abnormal reflexes Decrease level of activity Increase support

Massed Practice / Distributed Practice

Massed Practice Amount of practice time > amount of rest time between trials Can lead to fatigue, which impairs performance Shown to be more effective in learning continuous tasks Varies for discrete tasks Distributed Practice Amount of rest time >= amount of time of the practice Better for patients prone to fatigue

External Support

May be necessary to promote safety, independence and stability with functional activities Examples include: AFO or HKAFO, wheelchair trough, arm sling, arm platform for a walker <3/5 ankle AFO <3/5 knee KAFO <3/5 hip HKAFO

Postural Control Impairments

May experience difficulty with balance 2˚ to an external force or during self-initiated exercises Corrective responses to perturbations are often inadequate fall Asymmetry typically noted in posture Truncal flaccidity or paresis Typically see falls to the same side as weakness

Basal Ganglia

Mediated by cortical motor areas Secondary pathways/functions include regulation of saccadic eye movement, sleep/wakefulness and arousal, memory and cognitive functions

Cognitive Impairment- Memory

Memory - the ability to store experiences and perceptions for later recall Immediate, short - term, and long - term Symptoms can include confabulation and perseveration Confabulation - filling in memory gaps with inappropriate words, or fabricated stories Perseveration - getting "stuck" on a thought. Continued repetition of words, thoughts, or acts not related to the current context Assessed with Mini Mental Status Exam (MMSE) or Montreal Cognitive Assessment (MoCA)

Dementia Signs and Symptoms

Memory loss Difficulty communicating Difficulty with complex tasks Difficulty with planning and organizing Difficulty with coordination and motor functions Problems with disorientation, such as getting lost Personality changes Inability to reason Inappropriate behavior Paranoia Agitation Hallucinations

Minimally Conscious State

Minimally Conscious State Minimal evidence of awareness of self or of the environment Cognitively mediated behaviors are able to be differentiated form reflexive behaviors and are reproducible, but are inconsistent Sleep/wake cycles are present Patient will localize to noxious stimuli and sound Inconsistent reach for objects Some sustained visual fixation and pursuit

Types of Strokes -Ischemic

Most common ( -90 % blocks or impairs blood flow to the brain generally result from a restriction of flow - 80 % Can result from a thrombosis platelet adhesions & aggregation on plaques Thrombosis: Blood clot forms in cerebral artery Thrombi ischemia cerebral infarction Can result from an Embolus Dislodged matter, blood clot, plaque, fat, gas, air, tissue that dislodges i the body and travels to the brain occluding cerebral circulation Mortality rates of 8-12 % at 1 month

Ischemic Stroke

Most common (~90%) A clot blocks or impairs blood flow to the brain Symptoms generally result from a restriction of flow >80% Can result from a Thrombosis Results from platelet adhesions & aggregation on plaques Cerebral Thrombosis: Blood clot forms in cerebral artery Thrombi lead to ischemia = cerebral infarction Can result from an Embolus Dislodged matter; blood clot, plaque, fat, gas, air, tissue that dislodges in the body and travels to the brain occluding cerebral circulation Mortality rates of 8-12% at 1 month Cerebral Infarction = tissue death Ischemic strokes produce cerebral edema, can result in tissue necrosis and widespread rupture of cell membranes with movement of water from the blood into the brain tissue. Significant edema can lead to increased intracranial pressure = intracranial HTN and neurological deterioration associated with caudal and contralateral shift of brain structures. Cerebral edema is the most frequent cause of death after stroke.

Motor Memory

Motor Memory is stored as a motor program Recall of details of the motor program: .Initial movement conditions Sensory consequences of movement: how look, Knowledge of performance: specific movement parameters - how the movement is performed Knowledge of results: outcomes of the movement

Motor Memory

Motor memory is stored as a motor program Recall of details of the motor program: Initial movement conditions Sensory consequences of movement: how the movement look, felt, and sounded Knowledge of performance: specific movement parameters - how the movement was performed Knowledge of results: outcomes of the movement

Complications 2 Impairments

Musculoskeletal Loss of ROM & Contractures Edema & pain Disuse atrophy & weakness Osteoporosis Fall risk Neurological Seizures Hydrocephalus - an excessive accumulation of CSF within the cranial cavity Cardiovascular Thrombophlebitis/DVT Impaired Cardiac Function Impaired cardiac output, decompensation, rhythm disorders Can restrict exercise/activity tolerance Pulmonary Decreased lung volume Decreased pulmonary perfusion & vital capacity Altered chest wall excursion Greater energy expenditure Aspiration Integumentary Skin breakdown and decubitis ulcer Pressure, friction, shearing

LMN to Anatomic Location

Myasthenias gravis = ACH receptors Post-polio syndrome = PNS cell body Guillan-Barre= PNS myelin schwann cells CRPS= autonomic nerves Diabetic Neuropathy= microvascular

PD Interventions

NO 4WW

Managing Muscle Tone: HYPERtonia

Need to reduce muscle activity PNF and Manual Techniques Inhibitory Techniques (to be discussed in more detail next week) Facilitate NORMAL muscle activity and patterns Examples: Prolonged Stretch - increases muscle spindle threshold decreasing muscle tone Inhibitory pressure - gentle but deep tendon pressure inhibit tone Manual maintained touch/pressure contact - Slow stroking Causes sensory accommodation and inhibits tone Neural warmth - retention of body heat causes generalized inhibition of tone Slow vestibular stimulation Low-intensity, slow and rhythmic vestibular stimulation Slow rocking, slow movement on a ball, in hammock, in rocking chair Generalized relaxation; decreased arousal causes inhibition or dampening of tone and motor output Example: Patient with UE spasticity following CVA Weight Bearing to decrease flexor spasticity: Therapist grabs patient's hand by the thumb, moves the elbow into extension with hand open Palm is then placed down onto the mat at patient's side, weight bearing position Weight shifting forward and backward inhibits the spastic muscles and maintains range Keeps muscles in lengthened positions and then loads the extensors through weight bearing force

Managing Muscle Tone: HYPOtonia

Need to stimulate muscle activity PNF and Manual Techniques Facilitory/Stimulatory (to be discussed in more detail next week) Examples: Positioning at the optimal length-tension Weight bearing to stimulate extensor activity and co-contraction Overflow - Irradiation Using stronger synergist to facilitate weaker synergists Activating same muscle in opposite limb Verbal patient directed commands Visual cueing - patient visual awareness of the movement Quick stretch - stimulation of stretch to elicit contract response Approximation - joint compression to facilitate extensor activation and stabilizing muscle contraction Electrical stimulation for muscle reeducation EMG biofeedback - muscle contraction awareness Protect limb from end range over stretching and subluxation During PROM, therapist needs to be cognizant of end range instability and risk of hyperextension injury May consider supportive devices during functional training Braces, orthotics, supports such as an arm sling

Augmented Interventions

Neurological Developmental Treatment (NDT) Key Points of Control: Specific handling of designated areas of the body Used to influence and facilitate posture, alignment and control through neuromuscular facilitation and/or inhibition Carefully matched to the patient's abilities to adapt movements Sensory Stimulation Techniques / Neurophysiologic approach Proprioceptive Neuromuscular Facilitation (PNF) Each technique is designed to address one or more of the following: Mobility Range of motion to achieve necessary positions Stability Ability to remain in a posture against gravity Controlled Mobility Ability to transition form one position to another Skill Able to consistently perform a task under a variety of conditions with efficiency Biofeedback Indications Decreased proprioception Impaired awareness Decreased strength Muscle spasm/pain/increased tone Precautions Impaired cognition Provide written, pictorial instruction/Primary Care Giver training Areas of diminished sensation NMES Functional E-stim/Neuromuscular E-stim Indications Decreased strength Impaired muscle control Precautions Impaired cognition Provide written, pictorial instruction/Primary Care Giver training Areas of diminished sensation ES that increases abnormal synergistic patterns ES that causes patient agitation

Patho of CVA

Neurons without blood supply die within minutes Just outside of the primary ischemic area is the penumbra Neurons here can survive slightly longer Cells need 20-25% of regular blood flow to survive Without timely reperfusion, the infarcted area will expand Ischemic cascade is triggered Inability of brain cells to produce ATP Release of free radical, nitric oxide, and cytokines cause further cell damage Development of cerebral edema begins within minutes and reaches a maximum at 3-4 days Gradually subsides over 2-3 weeks Significant edema Increased ICO further brain damage

TOS

Neurovascular compression Compression of the subclavian artery and vein, axillary artery, and brachial plexus Compression between the anterior and middle scalene, between the clavicle and first rib or under pec minor Results in edema & ischemia of the nerves Signs & symptoms reflect the structures that have been compressed Paresthesias and pain in the arm Primarily nocturnal Upper Plexus injury (C5 to C7) Pain in neck and radiating to face Lower Plexus injury (C7 to T1) Pain numbness in posterior neck down the arm Weakness in muscles that correspond to the impaired nerve root Coldness & edema in arm & hand Raynaud's Phenomenon Interventions: Conservative - when symptoms are mild Postural education and exercise Ergonomic training Pain management Breathing exercises Soft tissue mobilization ROM Neural glides/flossing Strengthening traps, levator scapulae & rhomboids Avoiding overhead exercises

Post-Polio Syndrome

New onset of weakness and severe fatigue occurring years after recovery from acute poliomyelitis Associated with neuromuscular fatigue of the collateral nerve sprouts These nerves experience increased demands which leads to deterioration of the axons over time 25-50% of patients with polio develop PPS More serious initial onset is associated with higher chance of PPS Woman > men Symptoms: Severe long lasting fatigue that does not go away with rest New onset of weakness in muscles thought to be strong Effects formerly effected motor neuron > new muscles New loss of functional abilities Sometimes experience muscle/joint pain Pain and weakness increase with physical activity and cold Can have periods of stability without disease progression Only life threatening when respiratory muscles are involved Interventions: Aimed at general conditioning Improve aerobic capacity, muscle strength and muscle endurance Avoid overuse fatigue Lifestyle modification / activity prioritizing PT improves functional capacity and quality of life Energy conservation techniques including rest and use of a wheelchair or other assistive/adaptive equipment Low-impact aerobic program Strengthening program without fatiguing Low to moderate intensities, low load, higher reps, long rests Gait and balance training Safety education Training in use of ADs and/or orthotics, if necessary Exercise every other day for adequate rest and recovery

Is the spinal cord the same length as the spinal column?

No. Spinal Cord ends at L1

Gait / Locomotion Interventions

Often a patient's #1 goal Often a significant factor in determining a patient's discharge placement* PT must evaluate and establish a realistic POC Must consider functional demands of the patient's home (carpet vs. hardwood, stairs), community, work environments Is an assistive device appropriate to ↑ safety and independence? Handling techniques, verbal cues, visual feedback Body weight supported treadmill training (BWST) Allows for assisted gait Means of progression: Decrease body weight supported percentage Treadmill speed Amount of manual assistance Evidence shows that BWSTT must be followed by over-ground gait training for maximum benefit Advantage: BWST deloads the patient Key thing: it's max benefit it needs to be followed by overground training (practice on actual ground)

Feedback

Once the movement is initiated, sensory feedback from the moving limb and from the environment travels back to the brain about the success of the execution This is called Feedback Feedback is used to make adjustments to the movement Timing Accuracy

Reflex Model

Original model of Sherrington was predicated on the reflex being the basic unit of movement Reflexes are pre-determined/automatic responses Movement results as a combination of reflexes Reflexes require a sensory stimulus There is no response without sensory input, because reflexes must be stimulated by an outside agent

Managing Abnormal Tone and Spasticity

PROM Avoid forceful or aggressive movements Inhibitory techniques Strengthening the antagonist Proper positioning Serial casting Remember that high tone can sometimes be beneficial for function (ie., LE tone can improve WBing for transfers)

Abnormal Muscle Performance

Paresis - weakness Plegia - absence of muscle strength, cessation of movement Hemiparesis/Hemiplegia - one sided weakness/paralysis Paraplegia - lower extremity paralysis Quadriplegia/Tetraplegia - paralysis of all 4 limbs Diplegia - paralysis of B LEs Atrophy - loss of muscle contractile elements Disuse atrophy Loss of functional mobility Neurogenic atrophy - UMN and LMN Disease Protein-calorie malnutrition Fasiculations - random, spontaneous twitching of muscle fibers visible through the skin [LMN] Fatigue - failure to generate required or expected force during sustained or repeated contractions Exhaustion - the limit of endurance beyond which no further performance is possible.

IDEA- Individuals w/ Disabilities Education Act

Part B- assistance education for all children 3-21 Part C- early interventions 0-3

C3-4

Partial diaphragm Scalenes Levatore scapulae

Ther Ex

Passive exs, stretching exs, active assistive exs, active exs, and strengthening exs Developmental Positioning and Mobility Retraining Prone, Sit, Quadruped, Kneeling, Plantigrade, Standing Neuromuscular Facilitation Techniques Strength and Endurance Training

ALS

Pathology: Rapid neuronal degeneration Cerebral cortex Corticospinal tract Cell bodies of LMNs and anterior horn cells Results in denervation of muscle Onset between 40-70 y.o. Average survival post diagnosis is 5 years

Mild TBI PT interventions

Patient education Return to play/activity Activity intolerance Aerobic activity - intensity dependent Vestibular dysfunction Gaze stability and head motion High level balance dysfunction Headache TMJ disorder Attention and dual task performance Cognitive and physical tasks mTBI return to Play/ Activity High risk of second injury if primary injury is not completely healed Second injury is almost guaranteed to be worse in severity Results from baseline neurocognitive, balance and self-reported symptoms tests When in doubt, wait it out

mTBI PT Interventions

Patient education Return to play/activity and dangers of second impact syndrome Activity intolerance Aerobic activity - intensity dependent Vestibular dysfunction Gaze stability and head motion High level balance dysfunction Headache and TMJ disorder Musculoskeletal treatment of the neck, shoulders and jaw Attention and dual task performance Cognitive and physical tasks Return to Play / Activity Physical AND cognitive rest until resting symptoms resolve Physical activities and activities that require attention and concentration can exacerbate symptoms Then a graded exercise program (gradual increase in intensity and complexity) Each step should take 24 hours High risk of second injury if primary injury is not completely healed Second injury is almost guaranteed to be worse in severity Results from baseline neurocognitive, balance and self-reported symptoms tests When in doubt, wait it out

Conversion disorder

Physical malfunctioning without any physical or organic pathology Malfunctioning often involves sensory-motor areas Persons show la belle indifference A naive, inappropriate lack of emotion or concern for the perceptions by others of one's disability Retain most normal functions, but without awareness of this ability Emphasis is on the role of trauma (stress), conversion, and primary/secondary gain Treatment: detachment from the trauma and negative reinforcement seem critical; remove sources of secondary gain **Knowing this... what might you do as a PTA to promote successful outcomes for a patient with a conversion disorder?

Secondary Brain Injury

Physiological changes in the brain due to trauma resulting in secondary cell death Hypoxic ischemic injury Lack of oxygen to brain tissue Brain hemorrhage or hematoma between the skull and the dura mater (epidural) or within the brain (subdural) Hypotension ↑ Intracranial Pressure Edema Brain herniation - out of skull into spinal canal Midline shift - (pictured) Develops over hours and days Limited tolerance to edema secondary to inflexible skull

Communication Impairments

Post TBI is usually non-aphasic and more related to reduced cognitive function Disorganized and tangential oral communication Imprecise language Word retrieval difficulties Disinhibited and socially inappropriate language Increased difficulty in distractible environments Poor reading of social cures Poor adjustment of communication style per the situation

spinocerebellar tract (ascending)

Posture and coordination

posterior cord syndrome

Preserved motor function, sense of pain and temp and crude touch. Loss of proprioception and epicritic sensation (2pt discrimination) below level of lesion

Interventions

Prevent Secondary Impairments In low cognitive function states, the patient has an inability to move Increases risk of contractures, ulcers, [pneumonia, and DVT Preventative interventions include: Positioning and position changes Serial casting Postural drainage and percussion Positioning Bed positioning to decrease abnormal posturing and primitive reflexes (O'Sullivan Table 22.7, page 908) Head in neutral, cone in hand if fingers flexed, hips & knees slightly flexed, roll behind hips if rotation, roll between legs if strong adduction, turn the patient every 2 hours Wheelchair positioning Head and pelvis should be in neutral, may require splinting or multipodus boot; reclining or tilt-in-space chair may be necessary as well Sensory Stimulation Will help to ↑ arousal & elicit movement with low consciousness patients All systems are stimulated in a structured and consistent manner Auditory, Olfactory, Gustatory, Visual, Tactile, Kinesthetic, Vestibular Must monitor closely for subtle changes in vital signs Lots of theoretical evidence supporting this, but little evidence of its effects in long term recovery for low LOCF patients

Cognitive Impairments

Primarily controlled by the frontal lobe But complex nature of knowing and applying information makes it hard to localize specifically ↓ alertness ↓ attention Altered orientation Diminished memory Impaired executive function Planning Response inhibition Serial ordering Sequencing

Temporal Lobe

Primary Auditory Cortex - receives auditory info and the auditory association cortex interprets auditory info Wernicke's area - comprehension of spoken word (receptive aphasia) Limbic system Emotion and long term memory Amygdala - strong negative emotions (connects to the hypothalamus) Hippocampus - involved in creating long term memories Primary olfactory cortex - perceiving and interpreting smells (anosmia) Damage may result in: difficulty understanding spoken word, recognizing faces, memory & increased aggression

Primary Brain Injury

Primary Injury Direct trauma to the parenchyma Secondary Injury Cascade of biomechanical, cellular and molecular responses post TBI that may cause further damage to brain tissue When neurons die, they react by swelling The neuron cell body ruptures and spills its contents into the extracellular space which can cause damage to the neighboring cells Minimal room for swelling results in further ischemia Direct Contact Coup - Contracoup Injury (Bouncing) Rapid Acceleration and Deceleration Diffuse Axonal Injury When an axon is damaged by shearing, the cell body is initially left intact The axon will swell and die, and the cell body begins to grow another axon by putting out a small growth cone However at this point, the axon cannot elongate and eventually the entire neuron dies This is different than in the PNS Growth cones can elongate and form new axons Growth rate of about 1mm/day

Parietal Lobe

Primary Sensory Cortex on the post central gyrus - incoming sensory information from the contralateral side is processed Perceives touch, pain, temperature, proprioception Organized in a sensory homunculus Somatosensory Association Cortex - interprets sensory information and gives it meaning (stereognosis) Parietotemporal Association Cortex -reading, writing, mathematics, and spatial relationships Short term memory, attention Damage may result in difficulty with naming an object (anomia), writing, reading, math, hemi-spatial neglect, inability to execute learned purposeful movements (apraxia), eye-hand coordination or a lack of body awareness

Acute Management Goals

Primary goal: prevent secondary complications due to the TBI and prolonged bedrest/immobilization Improve or maintain functional joint integrity and mobility Manage the effects of tone Begin early mobilization when medical clearance is received Increase level of physical function and alertness Improve motor control Improve postural control Increase tolerance of activities and positions Initiate family and patient education on diagnosis, PT interventions, goals and outcomes Coordinate care among all team members

Occipital Lobe

Primary visual cortex - processing of visual information (hemianopsia and cortical blindness) Visual association cortex - interpretation of visual information (visual agnosia) Damage may result in: visual deficits, visual hallucinations and illusions, and difficulties with reading and writing, locating objects & recognizing colors

Internal Carotid Artery Syndrome

Produces massive infarctions because both ACA and MCA will be affected Significant edema is common which increases risk of brain herniation, coma, and death Incomplete occlusion = mix of ACA & MCA syndromes

ALS - Late Signs & Symptoms

Progressive weakness until completely paralyzed Includes respiratory muscle weakness resulting in respiratory impairments, difficulty breathing Also affects chewing, swallowing & speaking Death is usually from respiratory complications, such as pneumonia, and usually occurs within 2 to 5 years from onset of symptoms Rehabilitation goals: maximize and preserve function as long as possible, especially respiratory fitness Cannot overload the muscular system because it is a LMN injury and overload will cause further nerve degeneration

Inhibitory Techniques

Prolonged stretch Rocking Stroking Rhythmic repetitive movement Rotation Reciprocal innervation / Autogenic inhibition (ex. Biceps spastic.. You stretch the triceps to get it to fire)

Neuromuscular Inhibitory Techniques

Prolonged stretch Rocking Stroking Rhythmic repetitive movement Rotation Reciprocal innervation / Autogenic inhibition (ex. Biceps spastic.. You stretch the triceps to get it to fire)

CVA- Functional Training

Promote Neuroplasticity --> relearn movement patterns affected by CNS damage Promote neuroplasticity to minimize behavioral compensation (non-use) Focus on early training

Functional Training

Promotion of neuroplasticity Neural systems affected by the CNS damage and the surrounding spared areas are reestablished Relearn movement patterns affected by CNS damage Promote neuroplasticity in order to minimize behavioral compensation (non-use) USE and challenge the affected body part/system

Developmental Positions

Prone- tummy time Supine Sitting Standing

Sense Receptors

Proprioceptors: made up of muscle spindle, GTO, and joint receptors

IDEA- PART B Early Childhood Special Education

Provides services for children 3 years old through 21 years of age & provides: Free, appropriate, public education in the least restrictive environment Utilizes the IEP - Individualized Educational Plan Identifies the present level of performance Sets forth a plan for implementation of needed services Identifies who, what ,when, and specific goals and outcomes Goals based upon the classroom/school setting Services include: Adaptive education Appropriate related services Physical Therapy Occupational Therapy Speech Therapy Transportation Psychological services and counseling Medical, dental, hearing, or optical services needed in support a child's education

IDEA- PART C Early Intervention

Provides services for children under 3 years of age Provides for family-directed services Services occur in the child's natural settings if possible Utilize the IFSP - Individualized Family Support Plan Identifies the strengths and needs of the child and family Sets forth a plan for implementation of needed services Identifies who, what, when, and specific goals and outcomes

Rancho Los Amigos: Level of Cognitive Functioning (LOCF)

Rancho Los Amigos: Levels Of Cognitive Functioning (LOCF) Based upon patient's level of consciousness, cognition, behavior and functional status as a patient recovers from a TBI A valid and reliable measure of cognitive and behavioral function post TBI The patient usually progresses through the stages in sequence Patient brain recovery varies and not all patients achieve higher levels Eight levels total

Requirements for Successful Movement

Range of Motion (Mobility) Alignment with stabilization (Stability) Static postural control Transition to new position (Controlled Mobility) Aka transitional mobility Dynamic postural control Reproducible success in accomplishing a task (Skilled Mobility) Improved coordination, timing, and efficiency

CVA Medical Management Goals

Re-establish cerebral circulation and oxygenation *Time: options lessen as the time form symptoms onset increases Control blood pressure Maintain sufficient cardiac output Restore/maintain fluid & electrolyte balance Maintain blood glucose levels Control ICP Maintain bladder function Maintain integrity of skin and joints

Speech and Language Impairments....

Receptive Aphasia aka. Wernicke's/Sensory/Fluent Aphasia Auditory and reading comprehension impaired Speech is functional, comprehension is not Constantly talking but often out of context and with confabulations Left temporal lobe Expressive Aphasia aka. Broca's/Nonfluent Aphasia Difficulty finding words to express ideas Slow spoken, individual words with high effort Left frontal lobe Global Aphasia Receptive and Expressive

Global Aphasia

Receptive and Expressive

Global Aphasia

Receptive and Expressive Can be unable to verbally communicate at all

Managing HYPERtonia

Reduce muscle activity PNF Inhibitory Techniques EX: Prolonged stretch inhibitory pressure manual maintained touch / pressure contact- slow stroking neural warmth (retention of body heat causes generalized inhibition of tone) Slow vestibular stimulation --> low-intensity, slow and rhythmic rocking, relaxation **WB to decrease flexor spasticity

Sub-Acute Management Goals

Reduce risk of secondary impairments Increase performance of functional mobility and ADLs skills Improve ability to assume or resume self-care and home management roles

Habituation

Reduction in response to stimulus Living in a noisy city stop hearing sirens etc.

Reflex Integrity

Reflex - motor response to a sensory stimulation, used to assess integrity of nervous system The Reflex Arc Receptor detects stimulus Sensory neuron transmits impulses to CNS CNS coordinates impulses and organizes response Motor neuron carries impulses away from CNS Effectors carry out responses

Muscle Tone

Resistance of muscle to passive elongation or quick stretch when an individual attempts to maintain muscle relaxation

Pons

Respiratory Control Center (medulla too) Reflex center for orientation of the head in relation to visual and auditory stimuli Nuclei of cranial nerves V, VI, VII, VIII If the motor neurons passing through here are damaged, it results in locked-in syndrome Complete paralysis of all four limbs, the diaphragm and face Intact cognition Intact sensation Only able to perform eye movements

Medulla Oblongata

Respiratory Control Center (pons too) Unconscious motor control of breathing Cardiac Control Center Vasomotor control center Reflex centers for vomiting, sneezing, swallowing Nuclei of cranial nerves IV, X, XII Decussation (crossing) of tracts

FeedForward Control

Response Execution- Aka movement output Muscles to execute the movement are selected and an appropriate background of postural control is selected The signals to produce the movement are sent to the periphery prior to the actual movement This is called Feedforward control It allows for anticipatory adjustments in postural control

Frontal Lobe

Responsible for cognitive functions - judgment, attention, mood, abstract thinking & aggression Primary Motor Cortex on the precentral gyrus - responsible for voluntary movement on the contralateral side Organized in a homunculus aka body map Premotor Cortex - related to movement selection and body part ownership (neglect) Supplemental Motor Area (SMA) - stores motor programs and responsible for motor planning (apraxia) Broca's Area - controls expressive and motor component of speech Damage may result in: paralysis, loss of flexibility in thinking, changes in personality, difficulty with language expression

Right Hemisphere CVA

Right Hemisphere CVA Right facial involvement Left side weakness or paralysis Hemianopsia Decreased awareness and judgment Memory deficits Inattention and less reasoning Emotional labile Impulsive behaviors

Right Hemispheric Behavior

Right Hemispheric Damage Difficulty in spatial-perceptual tasks Difficulty with grasping overall idea of task or activity Quick, impulsive Overestimate their abilities, poor judgment

Right Hemisphere CVA

Right facial involvement Left side weakness or paralysis Hemianopsia Decreased awareness and judgment Memory deficits Inattention and less reasoning Emotional labile Impulsive behaviors Behavior Difficulties: Difficulty in spatial-perceptual tasks Difficulty with grasping overall idea of task or activity Quick, impulsive Overestimate their abilities, poor judgment

Cardinal Features of PD

Rigidity (proximal to distal) Bradykinesia Hypokinesia / micrographia (writing) Postural Stability Tremors- Resting: appears at rest, disappears w/ movement Postural- tremor of head and neck when maintaining an upright posture against gravity

C1 -2

SCM Upper trap C/s extensors

Intervention Strength Training

Secondary weakness can lead to postural changes & instability, functional changes, falls and fall injuries Benefits of strength training include improved function, balance, fall risk, gait and quality of life Timing exercise with "on" periods About 45 min - 1 hour after medication taken Consider closed-chain and weight machines to improve control of motion Aquatic exercise may also be a benefit

Non-Motor Impairments post CVA:Sensory PerceptionSpeech & LanguageCognitive

Sensory Perception Impairments Impaired ability to perceive and process sensory information in the brain Afferent systems intact, but central processing is impaired Reduced ability to interpret and give meaning to sensory information Touch, temperature, position, movement and pain Disorders of body scheme and body image and spatial relations Relationship of the body parts to one another and to the environment Feelings about one's body RIGHT > Left hemispheric strokes - Parietal lobe Resulting deficits: Agnosias Inability to recognize incoming sensory information despite intact sensory capabilities Unilateral Neglect R CVA Unawareness of Left side of the body and external environment Anosognosia Unawareness of the existence of own disability

SHICT

Sensory Stimulation High Intensity Complex Task specific

Glasgow Coma Scale

Severe < 8 Moderate 9-12 Mild 13-15 Measure level of consciousness Eye opening Motor response Verbal response Helps classify severity and determine prognosis Predictors of Poor Prognosis Low initial GCS score (immediately post injury) Especially motor score and pupillary reactivity Age Race Lower education level CT Scan findings: Petechial hemorrhages, subarachnoid bleed, obliteration of 3rd ventricle, midline shift, subdural hematoma Length of post-traumatic amnesia (length of time between injury and when patient is able to consistently remember ongoing events) <53 days are likely to be able to live without assistance <48.5 days are likely to have higher FIM scores at discharge from IP Rehab <27 days are likely to be employed

Impact

Severity and symptoms of stroke depend on Location of ischemic process Size of the ischemic area Function of structures involved Availability of collateral flow O'Sullivan, page 649 Knowledge of cerebrovascular anatomy is essential to understand the symptoms, diagnosis, and management of CVA

Shock

Shock:Initial reaction to psychological trauma, sudden physical injury or illness Behavioral manifestations Numbness Inability to speak Inability to move Decreased cognitive skills Disorientation

Management of Increased Intracranial Pressure

Should be < 20 mmHg Keep head elevated at least 30 degrees Medical emergency if increases If pharmacological management fails, then surgical decompression is performed

Charcot Marie Tooth

Signs and Symptoms: Muscle loss in the feet and LEs Foot deformity (very high arched feet) Foot drop and foot slap gait 2⁰ to muscle loss Sensory loss in the feet and LEs Numbness in the feet Difficulty with balance (loss of proprioception) Later, similar symptoms also may appear in the arms and hands.

Dysarthria

Slurred speech Related to respiration, articulation, phonation, resonance, and / or sensory feedback related

T1-5

Some intercostal Erector spinae

Surgical Interventions

Some surgical options to go in and remove the clot Limited by artery size and location In the case of hemorrhage - surgery to repair rupture, prevent further bleeding, or evacuate the clot Difficult for larger, deeper, or brainstem lesions Endarterectomy - surgical removal of lining and plaque in an artery Used to prevent strokes - useful post TIA, but cannot be used actuely Resection of un-ruptured arteriovenous malformation (AVM) if found and risk is high

Hierarchical Model

Specific reflexes are associated with a specific neuroanatomical level Spinal reflexes are phasic (short duration) Deep Tendon Reflexes (stimulus is the quick stretch that goes from the tendon to the spinal cord and makes the muscle contact) brain doesn't get the info Tendon spinal cord muscle contract afferent efferent motor response Brain stem level reflexes are tonic (long duration) Asymmetrical Tonic Neck Reflex Midbrain structures were associated with compensatory behaviors (response to gravity) Righting Reactions Cortex was considered the director of movement Control and inhibit reflexes Initiate purposeful movement Normal motor development occurs because of increasing corticalization of the CNS Emergence of higher levels of control over lower level reflexes Movement becomes more refined because of central nervous system development Weakness: Excludes contribution of other body systems to movement such as the musculoskeletal system, endocrine system, autonomic nervous system,

Communication Impairments

Speech & Communication Disorganized and tangential oral and/or written communication Imprecise language Word retrieval difficulties Disinhibited and socially inappropriate language Difficulty reading social cues Aphasias Dysarthria Lack of control and coordination of speech muscles Auditory comprehension Reading comprehension and written expression Difficulty communicating in distracting environments Difficulty adjusting communication style to meet the needs of the situation Swallowing Problems Dysphagia

PNS

Spinal Nerves Peripheral Nerves Cranial Nerves Sensory Receptors

Brown-Sequard Syndrome

Spinal thalamus tract lesion Penetration wound - gsw, stab Ipsilateral sensory loss of sensation reflexes vibration and position sense (lateral and dorsal columns Ipsilateral Motor loss - corticospinal tract Contralateral sensory loss of pain and temp - spinothalamic

Spine

Spine 0-12 months changes from the physiologic flexed & rounded posture with the emergence of cervical and lumbar curves (lordosis) Provides increased stability of the back and neck 1-6 years Curves continue to increase 1-2 years - standing and walking (weight bearing)

Recovery of Function

Spontaneous Recovery Cellular repair processes restore function in initially lost CNS tissue First 3-4 weeks Resolution of temporary blocking factors such as shock, edema, decreased blood flow, and decreased glucose utilization Function-induced Recovery Restoration of function in response to changes in activity and the environment Promotes Neuroplasticity Unmasking of neuronal pathways results in cortical remapping Compensation Old movement performed in a new manner by adopting an alternative movement strategy Substitute with alternative movement strategies or assistive devices

Stages of Motor Recovery post CNS Injury

Stage 1: Flaccidity Stage 2: spasticity appears Stage 3: spasticity prominant Stage 4: activation Stage 5: spasticity decrease Stage 6: coordinated manner , spasticity disappears and approaches normal

Stages of Motor Recovery post CNS Injury

Stages of Motor Recovery Stage 1 - Flaccidity Stage 2 - Minimal voluntary movement; may see synergies and spasticity develop Stage 3 - Voluntary control the movement synergies; spasticity may ↑ further Stages of Motor Recovery Stage 4 - movement combinations that do not follow the path of synergy are mastered; spasticity ↓ Stage 5 - Difficult movement combinations are learned Stage 6 - disappearance of spasticity, individual joint movements become possible and coordination approaches normal

Motor Impairments

Stages of Motor Recovery post Stroke Stage 1 - Flaccidity Stage 2 - Minimal voluntary movement; may see synergies and spasticity develop Stage 3 - Voluntary control the movement synergies; spasticity may ↑ further Stage 4 - movement combinations that do not follow the path of synergy are mastered; spasticity ↓ Stage 5 - Difficult movement combinations are learned Stage 6 - disappearance of spasticity, individual joint movements become possible and coordination approaches normal

Ankle / Foot

Stance Phase Equinus gait - heel does not touch down Spastic or contracture of gastrocnemius Varus foot - weight is on the lateral side of the foot Spastic tibialis anterior, posterior tibialis, toe flexors, soleus Unequal step length Hammer toes can cause pain with WB and prevent a full step forward with opposite leg Increased flexor tone in toe muscles Lack of DF ROM on affected side Swing Phase Persistent equinus or varus or a combination of the 2 (equinovarus) Weak dorsiflexors may contribute to this in addition to spastic muscles Exaggerated DF 2˚ strong flexor synergy pattern

Ankle / Foot

Stance Phase Equinus gait - heel does not touch down Spastic or contracture of gastrocnemius Varus foot - weight is on the lateral side of the foot Spastic tibialis anterior, posterior tibialis, toe flexors, soleus Unequal step length Hammer toes can cause pain with WB and prevent a full step forward with opposite leg Increased flexor tone in toe muscles Lack of DF ROM on affected side Swing Phase Persistent equinus or varus or a combination of the 2 (equinovarus) Weak dorsiflexors may contribute to this in addition to spastic muscles Exaggerated DF 2˚ strong flexor synergy pattern

Knee

Stance Phase Excessive knee flexion 2˚ Flaccid or weak LE, especially hip & knee extensors Poor PPC Flexion contracture Ankle DF range past neutral Hyperextension of knee 2˚ Weakness of quadriceps - passive stability ↑ extensor tone of LE Quadriceps spasticity PF contracture past 90˚ Impaired proprioception **With weakness of the knee and lack of PPC, instability is often seen in the knee during stance phase. Important to "block/guard the knee. Swing Phase ↓ Knee flexion 2 ˚ ↑ LE extensor tone, spastic quadriceps Inadequate hip flexion and poor foot clearance Circumduction or hiking pattern often seen as a result Exaggerated, delayed knee flexion 2˚ Strong flexor synergy Inadequate knee extension at initial swing 2˚ Spastic hamstrings Sustained total flexor pattern Weak knee extensors

Knee

Stance Phase Excessive knee flexion 2˚ Flaccid or weak LE, especially hip & knee extensors Poor PPC Flexion contracture Ankle DF range past neutral Hyperextension of knee 2˚ Weakness of quadriceps - passive stability ↑ extensor tone of LE Quadriceps spasticity PF contracture past 90˚ Impaired proprioception Swing Phase ↓ Knee flexion 2 ˚ ↑ LE extensor tone, spastic quadriceps Inadequate hip flexion and poor foot clearance Circumduction or hiking pattern often seen as a result Exaggerated, delayed knee flexion 2˚ Strong flexor synergy Inadequate knee extension at initial swing 2˚ Spastic hamstrings Sustained total flexor pattern Weak knee extensors

Trunk / Pelvis

Stance Phase Forward trunk 2˚ Hip flexion contracture Lateral trunk lean 2˚ Shifting weight away from affected LE Swing Phase ↓ forward pelvic rotation 2˚ Weak abdominal muscles Leaning towards the stronger side to clear the weaker side foot from the floor OR Backward leaning of trunk Both may be due to weak hip flexors

Hips

Stance Phase Poor hip position (adduction or flexion) Trendelenburg limp (lateral drop to sound side) Weak abductors Scissoring gait Spastic adductors Swing Phase Inadequate hip flexion 2˚ Weak hip flexors Poor proprioception Spastic quadriceps Abdominal weakness Gait Deviations as a result of inadequate hip flexion: Hip hiking Weak abdominal mm and inadequate knee flexion may also contribute to this Circumduction ↑ extensor tone, ↑ PF tone or foot drop as well as inadequate knee flexion may also contribute to this External rotation/adduction May see the opposite, exaggerated hip flexion Flexor synergy

Hip

Stance Phase Poor hip position (adduction or flexion) Trendelenburg limp (lateral drop to sound side) Weak abductors Scissoring gait Spastic adductors Swing Phase Inadequate hip flexion 2˚ Weak hip flexors Poor proprioception Spastic quadriceps Abdominal weakness Gait Deviations as a result of inadequate hip flexion: Hip hiking Weak abdominal mm and inadequate knee flexion may also contribute to this Circumduction ↑ extensor tone, ↑ PF tone or foot drop as well as inadequate knee flexion may also contribute to this External rotation/adduction May see the opposite, exaggerated hip flexion Flexor synergy

Standing and walking

Standing & Walking - 1 to 2 y.o. (9 -15 mos) LEs - Begins with cruising and wide base stance UEs - High Guard Position Stands Independently ~ 10.5 mos. Takes first steps ~ 11 mos. Walks independently ~ 11.5 mos. Hip & knee angles - slowly changing from varus to valgus 1-3yrs

PD Functional Training Intervention

Standing activities, upright posture w/ COM over BOS Mobilization facial muscles Dual task of movement w/ voice

Progression of Gait

Start of ambulation: wide BOS UE in high guard LE slight flexion Flat foot contact Toe out As balance improves: Arms move to a low-guard position BOS narrows Step and stride length increase Cadence slows Heel to toe pattern and reciprocal arms movements develop around 17 months

Managing HYPOtonia

Stimulate muscle activity PNF **WB to stimulate extensor activity and co-contraction Overflow- Irradiation: using stronger synergist to facilitate weaker synergists Activating same muscle in opposite limb Approximation visual cuing verbal patient directed commands quick stretch ESTEM for muscle reeducation EMG biofeedback- muscle contraction awareness **Protect limb from end range over stretching and subluxation

Motor Memory

Strongest when the individual controls all aspects of the task: Planning, initiation, execution, termination

Stupor / Obtunded

Stupor A state of general unresponsiveness with only brief arousal occurring from repeated and vigorous stimulation Obtunded Patient sleeps often and when aroused, exhibits decreased alertness and interest in the environment with delayed reactions

CVA

Sudden loss of neurological function caused by an interruption of the blood flow to the brain Higher risk in African Americans, Mexican Americans, American Indians, and Alaska Natives Nearly half of all NH black adults have some form of cardiovascular disease, 47.7% of females and 46.0% of males. Incidence doubles after 65 years of age 28% of strokes occur in individuals < 65 y.o. Young stroke = < 45 y.o. More likely hemorrhagic Causes in children are perinatal arterial ischemic stroke, sickle cell disease, congenital heart disease, thrombophlebitis and trauma

The Meninges

Superficial -> Deep Dura Mater Arachnoid layer Pia mater

Pediatric Developmental Motor Sequence

Supine prone on elbows (puppy propping) prone with unilateral reaching ring sit quadruped high kneeling half kneeling pull to stand cruising walking

Middle Cerebral Artery (MCA) Pink , motor/ sensory loss

Supplies lateral portions of the frontal, parietal, and temporal lobes, posterior internal capsule, and part of the basal ganglia MCA Syndrome Contralateral hemiparesis and hemisensory loss of primarily the face and UE Pure motor hemiplegia (lacunar stroke - internal capsule) Speech impairment: Broca's aphasia, Wernicke's aphasia, global aphasia (Left hemisphere) Perceptual deficits: unilateral neglect, depth perception difficulties, agnosia (Right hemisphere) Apraxia Sensory ataxia of contralateral limbs Contralateral hemianopsia

Anterior Cerebral Artery (ACA) Blue Motor / Sensory loss

Supplies medial part of the frontal and parietal lobe, part of the basal ganglia, part of the internal capsule, and corpus callosum ACA Syndrome Contralateral sensory & motor loss with LEs affected more than UEs Urinary incontinence Mental impairment (confusion, amnesia) Apraxia affecting ability to imitate or perform bi-manual tasks Corpus collosum Abulia (lack of desire to carry out an action), slowness, delayed movements, lack of spontaneous movements Behavioral changes Apraxia - difficulty carrying out a purposeful movement despite having the physical abilities to perform the movements; motor planning difficulties

Posterior Cerebral Artery (PCA) green

Supplies occipital lobe, medial and inferior temporal lobe, upper brainstem, midbrain, posterior diencephalon (thalamus) PCA Syndrome Contralateral sensory loss (hemianesthesia) Possibility of contralateral hemiplegia Hemianopsia, visual agnosia, prosopagnosia (faical recognition) and cortical blindness (B) Amnesia (temporal lobe) Involuntary movements: (thalamus) Choreoathetosis, intention tremor, hemiballismus Thalamic pain - spontaneous pain and dysesthesias Pusher syndrome Oculomotor nerve palsy A complete Oculomotor nerve palsy will result in a characteristic down and out position in the affected eye. The affected individual will also have a ptosis, or drooping of the eyelid, and pupil dilation. Pusher syndrome - pushing towards the hemiparetic side Hemibaalismus - BG dysfunction of flailing, ballistic involuntary mvoements

Autonomic Nervous System

Sympathetic Nervous System Fight-or-flight response Stimulatory Thoracolumbar area, Collateral ganglia, Adrenergic Parasympathetic Nervous System Returns body to normal Inhibitory Craniosacral, Terminal ganglia, Cholinergic Systems generally have opposite effects on organ

Voluntary Mvmt Patterns

Synergy: functionally linked muscles that are constrained by the CNS which act cooperatively to produce an action. Coordination: Synergistic organization of multiple muscles Coordinated movement requires control of: 1) Speed 2) Distance 3) Direction 4) Rhythm 5) Varying levels of muscle tension and 6) Trunk/proximal joint stability Abnormal Coordination: Can result from pathology in a variety of neural structures including Motor cortex Basal Ganglia Cerebellum Uncoordinated movements include: Coactivation Timing Problems Abnormal Synergies Coactivation Agonist and antagonist muscle fire at the same time, preventing functional movement Timing Problems Inability to appropriately time muscle action Can occur with initiation, execution or termination Abnormal Mass Synergies Obligatory, highly stereotyped mass patterns of movement (O'Sullivan, Table 15.6, p. 671) Selective movements are difficult

Stroke Warning Signs

TIME IS BRAIN Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known cause FAST Face: is one side of the face drooping Arm: can the person raise both arms equally Speech: is speech slurred or confusing Time: Time is critical - call 911 *within 3 hours of symptoms is significantly important for the administration of medication

Tactile Agnosia (Stereognosis)

Tactile Agnosia or Stereognosis Inability to recognize form /objects by handling them Tactile, proprioception and thermal sensations may be intact Affects self-care activities that require the manipulation of objects Dressing, eating, gait with device Treatment Visual and tactile stimulation of different objects shapes and textures

***Factors that Effect the Abiltiy to Learn a Motor Task

Task Complexity Environmental conditions Person's cognitive ability

Factors that Effect the Ability to Learn a Motor Task

Task complexity Goal Mobility or Stability Environmental conditions - closed or open Individual Cognition Sensation/perception Motor function Comorbidities Health status

Dienchephalon

Thalamus - relay station Hypothalamus - homeostasis, controls ANS, regulates endocrine, connection btw CNS and blood Pituitary Gland - regulates other endocrine glands

Ideomotor Apraxia

The pt can perform habitual tasks automatically, and remain unable to initiate the same task upon command Ideomotor Apraxia Treatment Simple commands Activities broken down into steps Repetition Activities performed in their natural environment Modeling pictures or films demonstrating the activity

Motor Control

The study of how the CNS regulates the musculoskeletal system and the environment in the generation of movements for the attainment of specific task goals. Ability of an individual to maintain and change posture and movement based on interaction among the individual, the task and the environment.

How to Design a PT Session w/ an infant / child

Therapy sessions should be interactive, involve the caregiver, and be composed of structured play Frequent rest breaks with short duration sessions Plentiful positive reinforcement Family Centered Care The caregiver and family is the primary member of the rehabilitation team They are actively involved in decisions about needs for services, and the goal of those services Must respect the values, beliefs, priorities, foals and performance contexts of the child and family Cultural sensitivity is important

Equilibrium Reactions

These automatically occur when attempting to regain balance Same reactions regardless of position Trunk curves against the direction of displacement Extremities on one side increase in extensor tone Other side extremities abduct Developmental position order: Prone Supine Sitting Kneeling Standing

Sensory Stimulation Technique

These techniques are used to: Improve attention and arousal Enhance sensory selection and discrimination Guidelines: Use appropriate intensities (consider excess stimulation and response, adaptation) Consistency and function are important Interventions used for: Sensory reeducation, tactile kinesthetic guiding, repetitive sensory practice and desensitization Excitatory: Light touch- quick stroking Quick cooling (ice) Mechanical or electrical brushing Rapid vestibular stimulation Vibration Auditory sense Visual sense Inhibitory: Slow, repetitive stroking Maintained deep pressure Prolonged cooling (ice) Neural warmth Slow vestibular stimulation

CVA Pharmacological Mgmt

Thrombolytics: tPA (tissue plasminogen activator) Assists to dissolve clots quickly MUST be administered within the first 3 hours post ischemic stroke 33% more likely to recover with little or no disability after 3 mo Assists to greatly reduce permanent impairments/deficits Anticoagulants Antithrombotic/Antiplatelets Antihypertensives Antispasmodics For symptom management post CVA

Medical Diagnosis of CVA

Time and pattern of onset is key Abrupt onset, worsening symptoms, and decreasing level of consciousness Cerebral hemorrhage "The worst headache of my life" (First and Worst) Subarachnoid hemorrhage Variable and uneven onset Thrombosis History: TIAs, head trauma, CV disease, NIHSS National Institutes of Health Stroke Scale - takes 5-8 min to administer and helps confirm Dx Diagnosis is primarily made with imaging

Prenatal Dev. Fetal Stage

Time between week 8 of gestation and birth motor patterns arise spontaneously and are not reflexive 10-15 weeks- isolated UE mvmt such as hands to face, thumb sucking, full body rotation around the umbilicus FETAL BRAIN IS HIGHLY VASCULARIZED AT 28-32 WEEKS GESTSATION

Reflex Integrity: DTR

UMN syndrome - DTR's are hyperactive = hyperreflexia CVA TBI LMN syndrome - DTR's are hypoactive = hyporeflexia Peripheral neuropathy Nerve root compression Guillane-Barre Muscle disease

Dementia Risk Factors

Unmodifiable risks- Age Family Tests for the ε4 variant in the APOE gene associated with an increased risk of developing late-onset Alzheimer's disease. Down Syndrome Modifiable Risks- Alcohol use Atherosclerosis Blood pressure Cholesterol Depression Diabetes High estrogen levels Homocysteine blood levels Obesity Smoking

Constraint Induced Movement Therapy (CIMT)

Used most often post-CVA Involves constraining the intact limb Facilitates "forced use" of the impaired limb Consists of restraining the less involved limb for 90% of the day Forces the individual to use the more involved limb "Shaping" involves time trials of a repetitive task Intent is to drive specific neuroplastic changes in the cortex and overcome learned non-use Task practice is next, patient performs functional, meaningful tasks for 15-20 minutes Last component includes behavioral strategies aimed at optimizing the home program Most commonly used with patients who are post CVA Initially, therapist may need to assist the extremity with certain tasks May use handling to facilitate movement Patient is expected to force the use of the involved extremity and gradually increase initiation and active movement Multiple studies have found: Significant improvement in motor function and moderate reduction in disability Brain changes with fMRI Maintenance of gains over years

Vegetative State

Vegetative State Disassociation between wakefulness and awareness Brain is not integrated with the brain stem Brainstem can manage basic cardiac, respiratory functions Can wean off a ventilator Present sleep/wake cycles Eyes can be open, but without any awareness of the environment Non-purposeful and reflexive movement to stimuli

The Cerebellum (5th Lobe)

Vermis Left Hemisphere Right Hemisphere Helps maintain balance helps maintain muscle tone (hypotonia)

Vertebrobasilar Artery

Vertebral artery arises from the subclavian artery, travels into the brain and then merge to form the basilar artery Vertebral artery supplies the cerebellum and medulla Basilar artery supplies the pons, internal ear, and cerebellum Syndrome: Wide variety of symptoms with ipsilateral and contralateral signs At this level some axonal tracts have crossed, some haven't Numerous cerebellar and cranial nerve abnormalities Ataxia CN impairments 5 D's Dysphagia Dysarthria Diplopia (nystagmus) Dizziness Drop attacks (syncope) Refer to Table 15.4 in O'Sullivan for details

Poliomyelitis

Viral infection S&S: flu like symptoms, loss of reflexes, muscle ache/spasm, flaccid limbs Virus attacks the anterior horn cell of the spinal cord When horn cell dies, the motor nerves degrade and result in muscle atrophy Recovery occurs due to collateral sprouting Vaccines created in the 1950s which eradicated the disease in developing countries

Special Senses & Receptiors

Vision, hearing, equilibrium, taste, smell Impulses are transmitted through cranial nerves

Sensory Perception Impairments:Visual Dysfunction

Visual Neglect Unawareness of Left side of the self and world Hemianopsia Right or left visual field loss in BOTH eyes Diplopia Double vision Motor incoordination issue Depth perception issues Understanding spatial relationships

Visual Agnosia

Visual Object Agnosia An inability to recognize familiar objects even with an intact visual system Treatment Identification of familiar photographs, colors, common objects Compensatory techniques with the use of touch or hearing to distinguish people and objects

Sensory Impairments

Visual Problems Hemianopsia (1/2 of eye blindness) Cortical Blindness ↓ sensory perception and ability to process sensory information Touch, temperature, position, kinesthetic, pain Spatial orientation

Fine Motor Milestones continued

Visually track to midline only: 1 month Visually track 180: 3 months Grasp toys: 5 months Transfer objects between hands: 7 months Raking: 9 months Inferior pincer : 11 months Fine pincer: 15 months 2 cube tower: 15 months 6 cube tower: 23 months

Factors Influencing tone

Volitional effort of movement Emotional factors - stress & anxiety Positioning & activation of tonic reflexes Medications General health and level of exercise Functional requirements of activity State of arousal or alertness Muscle and physiologic fatigue Autonomic nervous system Metabolic or electrolyte imbalance

Somatic Nervous System

Voluntarily Composed of all receptors & nerves which innervate the skin and muscles

Lateral and Anterior Corticospinal tracts (descending)

Voluntary movement

Postnatal Development of the Nervous System

We have more neurons at birth than as adults Synaptogenesis= growth --> neurons form synapses w/ other cells. Synaptogenesis is driven by experience During the first year of life, the brain uses 50% of the energy the body consumes

Motor Impairments Post CVA

Weakness (paresis) Occurs in 80-90% of all patients after stroke Almost always contralateral Varies depending on location and size of stroke Secondary Factors contributing to weakness Muscle tissue loss secondary to disuse atrophy Abnormal recruitment of motor units with altered timing (coordination) MMT inaccurate secondary to spasticity If a patient is not able to isolate a specific movement, then MMT will not be accurate Use functional strength testing instead Changes in tone Flaccidity - present immediately as a result of cerebral shock; usually short-lived but sometimes persists Spasticity/hypertonicity Occurs in about 90% of patients after stroke Abnormal posturing of limbs is common with mod → severe spasticity What is muscle tone? The amount of tension in a muscle at rest and its resistance to passive stretch Flaccidity is a type of hypotonia - complete lack of muscle activity Spasticity is a type of hypertonia - excessive muscle tension at rest Post CVA Resting Tone Initial Flaccidity develops into strong Spasticity

Considerations for discharge

Wean from external structure provided by the hospital environment Community Re-entry Program ("Neurobehavioral") 4-5 days a week during the day Residential based programs Multi-disciplinary

Milestones for Flex/ Posture/ Alignment

What changes as the child grows? By 18 months the gait pattern is more mature Base of support narrows Stride lengthens Steps are becoming more consistent and rhythmic By 24 months we see heel strike emerging with decreased time in stance phase Lower COG By 3 years the hip & knee angles are similar to adults Gait pattern, balance & coordination all more mature By 7 y.o. - gait pattern is assessed as an adult pattern

Dynamic Systems Model

Whole body = mechanical system Many interacting systems working cooperatively to achieve movement Internal forces on the body + external forces on the body + neural control of the body =movement

Impairments s/p TBI

Wide variety of presenting impairments and complications Requires a strong interdisciplinary approach Appx 5.3 million people living in the US with disabilities secondary to TBI 4/10 are not working 1 year after injury 1/3 have difficulty with social interaction 25% require assistance with ADLs 40% reports poor mental and physical health Cognitive and behavioral impairments are often more disabling than the physical ones

neuroma

abnormal growth of nerve cells

Types of Learning: Declarative

aka Explicit Learning Knowledge that can be consciously recalled Requires awareness, attention and reflection

Expressive Aphasia

aka. Broca's/Nonfluent Aphasia Difficulty finding words to express ideas Person may be impaired with expression or with intonation

Receptive Aphasia

aka. Wernicke's/Sensory/Fluent Aphasia Auditory and reading comprehension impaired Speech is functional Individual may have difficulty interpreting non-verbal signals (facial expressions or gestures) and may cause difficulty with comprehending spatial relationships

Cervical Plexus

c1-c5 phrenic nerve

Brachial Plexus

c5-t1 axillary musculocutaneous radial median ulnar

Levadopa

common medication - replacement dopamine crosses BBB and turns into dopamine Risks: arrhythmias, GI distress, orthostatic hypotension, dyskinesias**, build up tolerance over time (decrease in effectiveness requiring and increase in dosage and frequency) Implications for the PTA: Patients experience "on" and "off" times - maximum effectiveness is 1 hour after drug administration, dyskinesias may get in the way of normal movement and throw the patient off balance, watch for orthostatic hypotension

Neurotmesis

complete severance of a nerve resulting in permanent loss of function Irreversible injury

Dopamine agonists

compound that activates dopamine receptors Examples: Pramipexole aka Mirapex, Ropinirole aka Requip Mechanism of Action: dopamine agonist - increases the activity of dopamine receptors Uses: relieve symptoms of parkinsonism (does not address cause) Risks: less risk of dyskinesias (than levadopa), but increased risk of nausea, somnolence, postural hypotension, hallucinations, and lower extremity edema. Potential for decreased impulse control (gambling, shopping, sexual behaviors) Implications for the PTA: watch for side effects

Common PNS Disorder Etiologies

compression crush laceration penetrating trauma stretch / traction high velocity trauma (MVA) cold (frostbite)

neurapraxia

conduction block usually due to myelin dysfunction, but no damage to nerve fiber Pressure injuries are most common Symptoms: pain, minimal muscle atrophy, numbness, diminished proprioception recovery w/in 4-6 weeks

myopathy

damage to the muscle tissue

radiculopathy

damage to the spinal nerve root. usually related to spine mechanics

polyneuropathy

diffuse nerve dysfunction that is symmetrical and typically 2 to pathology

neuropathies

dysfunction of a peripheral nerve

Ganglia / Ganglion

grouping of neuron cell bodies outside CNS

Nerve

grouping of neurons outside the cns

Tract

grouping of neurons within CNS

Vestibulospinal tract: (Descending)

head / neck position, posture and balance

Ideational Apraxia

inability of the pt to produce movement either on command or automatically. Represents a complete breakdown in the conceptualization of the task

Reticulospinal tract (Descending)

inhibition of muscle tone (hypertonicity if damanged) postural tone and proximal muscle function

mononeuropathy

isolated nerve lesion - usually trauma or entrapment

Mononeuropathy

isolated nerve lesion, associatd conditions include trauma and entrapment

Lumbosacral plexus

l1-s3 sciatic nerve

Spinothalamic tracts (Ascending)

lateral: pain & temp anterior: crude touch & pressure

central cord syndrome

loss of function in upper extremities caused by injury to the middle portion of the spinal cord Sensory more than motor

White Matter

myelinated axons lateral

Neuralgia

non- excitable support cells formation of meylin Ogliodendrocytes (CNS) Schwann cells (PNS)

Secondary Risk Factors

obesity hypercholesteremia physical inactivity increase alcohol consumption

Anticholinergic agents

opposing the actions of the neurotransmitter acetylcholine

LMN / PNS

peripheral nerves

Spinocerebellar tract (Ascending)

posture & coordination

Cutaneous Receptors

pressure, temperature, pain, touch, stretch

Hypomimia

reduction in facial expression

Types of Strokes - Hemorrhagic

rupture, blood leaks into the brain . 1 Cerebral Hemomhage results from ruptured blood vessels weakened by atherosclerosis Results in t ICP and restricts blood brain Subarachnoid Hemorrhage (SAH) -bleeding btw arachnoid layer pia mater Common aneurysm & Atriovenous Malformation (AVM) Subdural Hemorrhage and arachnoid layer Common cause is trauma Mortality rates of 37-38 % one month

Phase Model of Psychological Adaptation

set of behavior patterns that a person experiences sequentially or non-sequentially

Bell's Palsy

temporary unilateral facial paralysis demyelination and or axonal degeneration of the facial nerve age 15-45 TX: antiviral medication and corticosteroids Interventions: Inability to close eye and/or limited tear production: use an eye patch to protect the cornea Electrical stimulation of facial muscles Nerve is inflamed, not dying, so e-stim ok Facial expression exercises - low reps, high frequency

Gray Matter

unmyelinated axons / cell bodies & dendrites Medial

Lateral corticospinal tracts (Descending)

voluntary movement

Prenatal Dev. - Embryonic Stage

weeks 2-8 gestation Considered at high-risk

Sensory Impairments

↓ sensory perception & ability to process sensory information Touch, temperature, position, kinesthetic, pain ASTEROGNOSIS The inability to identify an object by touch without visual input Pain Can experience severe headaches, neck or facial pain Central post-stroke pain aka thalamic pain syndrome: constant, severe burning with intermittent sharp pains