NPTE — Neuro

Reflex scoring scale

—0: absent —1+: tone change, no visible movement of extremities —2+ visible movement of extremities —3+ Exaggerated, full movement of extremities —4+ obligatory and sustained movement, lasting for >30 seconds

Autonomic Nervous System (ANS)

—Concerned with innervations of involuntary structures: smooth muscle, heart, glands; helps maintain homeostasis —Two divisions: 1) Sympathetic Nervous System (thoracolumbar division): prepares body for flight or fight; emergency response; increases HR and BP, constricts peripheral blood vessels, and redistributes blood; inhibits peristalsis 2) Parasympathetic Nervous System (cranio-sacral division): conserves and restores homeostasis; slows HR and reduces blood BP; increases peristalsis and glandular activity —autonomic plexuses: cardiac, pulmonary, celiac, hypogastric, pelvic —Modulated by brain centers 1) Descending autonomic system 2 Cranial nerves: visceral Afferent sensations via Glossopharyngeal and vagus nerves, efferent outflow via Oculomotor, facial,Glossopharyngeal, and vagus nerves

Examination: Examine for Increased ICP/Cerebral Edema/Brain Herniation

1) Altered level of consciousness 2) Altered vital signs: Examine for increased systolic BP; widening pulse pressure and bradycardia; irregular respiration's including Bradypnea (<12breaths/min), periods of apnea, Cheyne-strokes respiration's, elevated temp 3) Headache 4) Vomiting secondary to irritation of CN 10 5) Pupillary changes 6) Papilledema at entrance to eye 7) Progressive impairment of motor function 8) Seizure activity

Examine for gait deviations

1) Ataxia: wide-based gait with uncoordinated movements. Multiple causes: —Polyneuropathy: ataxic gait that is typically improved with looking down —Cerebellar disorder: ataxic gait that is also associated with postural and limb intention tremor. Not improved with looking down —Cervical myelopathy: ataxic gait if dorsal columns involved. Patient may also demonstrate spasticity related deformities if the corticospinal tracts are also compressed 2) Hemiplegic gait: gait is altered following stroke. Gait is typically slow and asymmetrical with decreased stance time and push-off on stroke-affected side. The stroke-affected UE and LE move as a unit rather than with a dissociating arm swing from the LE on forward progression 3) Festinating/Parkinson gait: characterized by freezing with initiation/termination and short, rapid steps once gait starts 4) Myopathic gait: pelvic girdle and proximal uncle weakness results in hyperlordosis and compensated Trendelenberg on weight-bearing limb 5) Deviations secondary to weakness at hip, knee, and ankle.

Anatomy of the spinal cord:

1) Central Gray Matter: —Anterior horns contain cell bodies that give rise to efferent (motor) neuron —Posterior horns contain afferent (sensory) neurons with cell bodies located in the dorsal root ganglia —Two enlargements for origins of nerves of UEs and LEs —Lateral horn is found in thoracic and upper lumbar segments for preganglionic fibers of the ANS 2) White matter: anterior (ventral), lateral, and posterior (dorsal) myelinated columns or funiculi —Ascending fiber systems (sensory pathways) A) Dorsal columns/medial lemniscal system: convey proprioception, vibration, and tactile discrimination B) Spinothalamic tracts: convey sensations of pain and temperature (lateral spinothalamic tract) and crude touch (anterior spinothalamic tract) C) Spinocerebellar tracts: convey proprioception information from muscle spindles, Golgi tendon, and touch and pressure to cerebellum for control of voluntary movements D) Spinoreticular tracts: convey deep and chronic pain to reticular formation of brainstem —Descending fiber systems (motor pathways) A) Corticospinal tracts: important for voluntary motor control B) Vestibulospinal tracts: important for control of muscle tone, antigravity muscles, and postural reflexes C) Rubrospinal tracts: assist in motor function D) Reticulospinal system: modifies transmission of sensation, especially pain, and influences gamma motor neurons and spinal reflexes E) Tectospinal tracts: Assists in head-turning responses to visual stimuli

Anatomy of the brain: Brainstem

1) Midbrain: mesencephalon —Connects pons to cerebellum, superior peduncle connects midbrain to cerebellum. Contains cerebral peduncles (anterior part = cruscerebri and substantia nigra, posterior part = tegementum) —Tegementum contains all ascending and descending tracts, important for coordination —Substantia nigra: large motor nucleus important for motor control and tone —Superior colliculus: relay station for visual reflexes 2) Pons: Connects medulla oblongata to midbrain 3) Medulla oblongata: contains important centers for vital functions: cardiac, respiratory, vasomotor centers 4) Reticular activating system (RAS): anterior-most segment of brainstem —Assists with attention, arousal, and modulation of muscle tone —damage to area results in days regulation of sleep-wake cycles, impaired arousal, and ability to focus

Examination: Examine motor function (page 173)

1) Examine muscle tone: Use PROM to assess muscle stretch reflexes and responsiveness —Flaccidity (absent tone), hypotonia (decreased tone): A) seen in segmental/LMN lesions: nerve roots and peripheral nerve injury B) Seen initially after suprasegmental/UMN lesions (brief period of spinal shock) —Spasticity (hypertonia): tested with PROM. Determined if increasing the speed increases the resistance (spasticity is velocity dependent) A) Clasp-Knife response: marked resistance to PROM suddenly gives way B) Clonus: maintained stretch stimulus produces a cyclical, spasmodic contraction; common in ankle PFs, wrist flexors and jaw C) Hyperactive cutaneous reflexes, positive babinski: DF of great toe with fanning of other toes in response to stroking up the lateral side of the sole of foot D) Hyperreflexia: increased DTRs —Modified Ashworth Scale: grades increasing spasticity 0- no increase in tone 1 - slight increase in tone; minimal resistance at end of ROM 1+- slight increase in tone, minimal resistance through less than half of ROM 2- more marked increase in tone, through most of ROM, affected part easily moved 3- considerable increase in tone, passive movement difficult 4- affect part rigid in flexion or extension —Rigidity: increased resistance to PROM that is independent of velocity of movement A) Can be leadpipe (uniform throughout range) or cogwheel (interrupted by series of jerks( B) Associated with PD, resting tremor, Bradykinesia —Opisthotonos: prolonged, severe spasm of muscles causing the head, back, and heels to arch backward; arms and hands are held rigidly flexed. Seen in severe meningitis, tetanus, epilepsy. —Use AROM to assess tone in automatic postural adjustments. Check stiffness of limbs and trunk in maintaining against gravity

Examination: Examine Speech and Communication

1) Expressive Function: —Nonfluent aphasia (Broca's Aphasia, expressive aphasia): language disorder in which speech is typically awkward, restricted, interrupted, and produced with effort. —Verbal aphasia: impairment of volitional articulatory control —Dysarthria: Impairment of speech production resulting from damage to the central or peripheral nervous system; causes weakness, paralysis, or Incoordination of the motor-speech system (respiration, articulation, phonation, and movements of law and tongue) 2) Receptive Function: Examine comprehension —Fluent aphasia (Wernicke's aphasia, receptive aphasia): language disorder in which spontaneous speech is preserved and flows smoothly, while auditory comprehension is impaired 3) Global Aphasia: examine for marked impairments in comprehension and production of language 4) Conduction/Association Aphasia: Causes word finding issues and problems with repeating phrases —Treatment strategy: give patient time to correct and repeat phrases. Also allow patients to write down words or sentences they hear to assist with recall 5) Nonverbal communication: use of gestures, symbols and pictographs

Anatomy of the brain: Cerebral Hemispheres (Telencephalon)

1) Fissures: —Lateral central fissure (fissure of sylvius): separates temproal lobe from frontal and parietal —Longitudinal cerebral fissre: separates two hemispheres —Central sulcus: separates frontal lobe from the parietal lobe 2) Frontal lobe: —Precentral gyrus: primary motor cortex for voluntary muscle —prefrontal cortex: controls emotions and judgements —Broca's area: controls motor aspects of speech 3) Parietal lobe: —Postcental gyrus: primary sensory cortex for integration of sensation —Receives fibers conveying touch, proprioceptive, pain and temp from OPPOSITE side of body 4) Temporal lobe: —Primary auditory cortex: receives/processes auditory stimuli —Associative auditory cortex: processes auditory stimuli —Wernicke's area: language comprehension —Primary vestibular area: head position and movement, perception of vertical 5) Occipital lobe: —Primary visual cortex 6) Insula: deep within lateral sulcus, associated with visceral functions 7) Limbic system: Consists of Limbic lobe (cingulate and parahippocampal gyri), hippocampal formation, amygaloid nucleus, hypothalamus and anterior nucleus of thalamus —Concerned with instincts and emotions contributing to preservation of the individual —Basic functions include feeding, aggression, emotions, and endocrine aspects of sexuality —Critical role in memory (especially emotional memories), motivation, and learning 8) White matter: myelinated nerve fibers located centrally —Transverse (Commissural fissures): interconnect the two hemispheres, including the corpus colassum —Projection fibers: Connect central hemispheres with other portions of the brain and spinal cord —Association fibers: Connect different portions of the cerebral hemispheres, allowing cortex to function as an integrated whole 9) Basal Ganglia: Masses of gray matter deep within the cerebral hemispheres, including the striatum, globus pallidus, subThalamic nucleus and substantia Niagra. Forms an associated motor system with other nuclei in the sub thalamus —Oculomotor circuit (caudate loop): functions with saccadic eye movements —Motor loop (putamen loop): functions to scale amplitude and velocity of movements; reinforces selected pattern, surprises conflicting patterns, predatory for movement —Limbic circuit: functions to organize behaviors (executive functions, problem-solving, motivation) and for procedural learning

Examination: Examine for Meningeal Irritation/brain Infection

1) Impaired neck mobility: stiffness and pain with limitation and guarding into neck flexion —Kernig's: Performed by having the supine patient, with hips and knees flexed, extend the leg passively. The test is positive if extension causes pain —Brudzinski sign: positive when forward flexion of the neck causes patient to involuntarily raise his knees or hips into flexion 2) Irritability, visual discomfort with bright light 3) Altered level of consciousness 4) Severe headache 5) Altered vital signs, high fever 6) Generalized weakness

Examination: Examine Cognitive Function

1) Memory —Immediate recall: name three items previously presented after a brief interval —Recent memory (short-term): Recall of recent events (Ex: what did you eat for breakfast) —Remote memory (long-term): Recall of past events (Ex: Where did you grow up) 2) Attention —Length of attention span: Digit span retention test (ability to recall seven numbers in order presented) —Ability to attend to tasks without redirection (sustained attention); determine time on task, frequency of redirection —Ability to shift attention from one task to another (divided attention); assess ability of dual task control; assess also for preservation (mental inertia); getting stuck on a task —Ability to stay on task in presence of detractors (focused attention); assess impact of environmental versus internal detractors —Ability to follow commands: 1 or multi step —Documentation: ability to follow specific requests 3) Emotional Responses/Behaviors 4) Higher-level cognitive abilities: —Judgement, problem-solving —Fund of general knowledge —Calculation: serial 7 test (count backward from 100 by 7s) —Sequencing 5) Mini-Mental State Examination (MMSE): Brief screening test for cognitive dysfunction. Includes screening items for orientation, registration, attention and calculation, recall, and language —Maximum score is 30; 21-14 indicates MCI, 16-20 indicates moderate impairment, 15 or less indicates severe impairment 6) RLA scale: assesses cognitive recovery from TBI —No response (1), decreased response levels (2 and 3), confused levels (4-6), appropriate (automatic, purposeful levels (7-8)

Peripheral Nervous System

1) Peripheral Nerve (Lower Motor Neuron) —Motor (efferent) fibers originate from motor nuclei (cranial nerves) or anterior horn cells (spinal nerves) —Sensory (afferent) fibers originate in the brainstem or spinal cord with sensory ganglia (cranial nerves) or dorsal root ganglia (spinal nerves) —Autonomic nervous system fibers: sympathetic fibers at thoracolumbar spinal segments and parasympathetic fibers at craniosacral segments 2) Cranial Nerves: 12 pairs; all nerves are distributed to the head and neck except CN 10, which goes to thorax and abdomen. —CN 1, 2, 8 are pure sensory, carry special senses of smell, vision, hearing, and equilibrium —CN 3, 4, 6 are pure motor, controlling eye movements and pupillary constriction —CN 11 and 12 are pure motor, innervating SCM, traps, and tongue —CN 5, 7, 9, and 10 are mixed odor and sensory involved in chewing (5), facial expression (7), swallowing (9 and 10), vocal sounds (10), sensations from head (5,7,9), alimentary tract, heart, vessels, and lungs (9 and 10), and taste (7, 9, 10) —CN 3, 7, and 10 carry parasympathetic fibers of ANS; involved in control of smooth muscles of inner eye (3); salivatory and lacrimal glands (7); parotid gland (9); muscles of heart, lung, and bowel (10) 3) Spinal Nerves: 31 pairs (8 Cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal) —Ventral (anterior) root: efferent motor fibers to voluntary muscle and to viscera, glands, and smooth muscles —Dorsal (Posterior) root: afferent (sensory) fibers from skin, joints, and muscles. There is no dorsal root for C1 —Dermatome refers to a specific segmental skin area innervated by spinal sensory axons —Myotome refers to the skeletal muscle innervated by motor axons in a given spinal root. A muscle unit consists of the alpha motor neuron and the muscle fibers it Innervates —Nerve root exits: A) In C/S, numbered roots exit horizontally above the corresponding vertebral body, with C8 exiting below C7 and above T1 B) in T/S, L/S and sacral the roots exit below corresponding vertebral body C) Spinal cord ends at L1; in lumbosacral region, the nerve roots descend almost vertically below the cord to form the cauda equina. —After emerging from the IV foramen, each nerve divides into a anterior and posterior Ramus; each Ramus contains motor and sensory —The anterior rami join at the root of the limbs to form nerve plexuses. A) Cervical plexus: C1-C4 B) Brachial Plexus: C5-T1 C) Lumbar Plexus: T12-L4 D) Sacral Plexus: L4-S3

Examination: Vital Signs

1) Pulse: bounding, thready (fine, barely perceptible), tachycardia or bradycardia 2) BP: increase or decrease in BP 3) Changes in response to activity: Normally HR increases in direct proportion to intensity of exercise, SBP increases while DBP remains the same or slightly decreases 4) O2sat should be >94 in patients with CNS damage and ideally between 97-100 5) Respiration: RR, depth, rhythm —Cheyne-Strokes respiration: period of apnea lasting 10-60 seconds followed by gradually increasing depth and frequency of respiration's; accompanies depression of frontal lobe and diencephalic dysfunction —Hyperventilation: Increased RR and depth; accompanies dysfunction of lower midbrain and pons —Apneustic Breathing: abnormal respiration marked by prolonged inspiration; damage to upper pons 6) Temp

Typical Patterns of Spasticity in UMN

1) Scapula: retraction, downward rotation —Rhomboids 2) Shoulder: Adduction and IR, depression —Pec major, lats, teres major, subscapularis 3) Elbow: flexion —Biceps, brachialis, brachioradialis 4) Forearm: pronation —Pronator teres, pronator quadratus 5) Wrist: flexion, adduction —FCR 6) Hand: Finger flexion, clenched fist, thumb adducted in palm —FDP, FDS, AdPB, FPB 7) Pelvis: retraction (Hip hike) —QL 8) Hip: adduction (scissoring), IR, Extension —Add longus/Brevis, add Magnus, gracilis, Glute max 9) Knee: Extension —Quads 10) Foot and ankle: PF, inv, equinovarus, toes claw, toes curl —Gastroc/soleus, tib posterior, long toe flexors, ext Hallucis longus, peroneus longus

CNS support structures

1) Skull (cranium): rigid, bony chamber that contains the brain and facial skeleton, with an opening (foramen magnum) at its base 2) Meninges: —Dura mater: outer, tough, fibrous membrane attached to inner surface of cranium, forms falx and tentorium —Arachnoid: Delicate, vascular membrane —Pia mater: thin, vascular membrane that covers the brain surface; forms tela Choroidea of ventricles —Subarachnoid space: formed by arachnoid and pia mater, contains CSF and cisterns, major arteries 3) Ventricles: Four cavities or ventricles that filled with CSF and communicate with each other and with the spinal cord canal. —Lateral ventricles: Communicates with 3rd ventricle via foramen of monro —Third ventricle: communicates with fourth ventricle via cerebral aqueduct. —Fourth ventricle: foramina of Luschka and magendie communicate with fourth ventricle via subarachnoid space 4) CSF: Provides mechanical support (cushions brain), controls brain excitability by regulating ionic composition, aids in exchange of nutrients and wastes. —Produced in choroid plexuses in ventricles 5) BBB: selective restriction of blood-borne substances from entering the CNS —Associated with capillary endothelial cells 6) Blood supply: brain is 2% of body with 18% of body's circulation —Carotid system: internal carotid arteries arise from common carotid and branch to form anterior and middle cerebral arteries. Supplies large area of brain and deep structures —Vertebrobasilar system: vertebral arteries arise from subclavian and unite to form the basilar. It bifurcates into two posterior cerebral arteries. Supplies brainstem, cerebellum, occipital lobe, and parts of thalamus —Circle of Willis: formed by anterior communicating artery, connecting the two anterior cerebral, and the posterior communicating artery which connects each posterior and middle cerebral. —Venous drainage: includes cerebral veins and rural venous sinuses

Spinal Level Reflexes: Basic functions and Motor Control

1) Stretch (Myotatic) Reflex: —Stimulus: stretch —Functions: maintenance of muscle tone, support agonist muscle contraction, and provide feedback about muscle length —Clinically, sensitivity of the stretch reflex of the stretch reflex and intactness Of spinal cord segment are tested by applying tap to the deep tendons, thus resulting in a muscle stretch reflex (aka DTRs) —Reciprocal inhibition: via an inhibitory interneurons, the same stretch stimulus inhibits the antagnoist muscle —Reciprocal innervation: describes the effect of a stretch stimulus on agonist (auto genie facilitation), antagonist (Reciprocal inhibition) and synergistic muscles (facilitation) 2) Inverse Stretch (myotatic) reflex) —Stimulus: muscle contraction —Functions to provide agonist inhibition, diminution of force of agonist contraction, stretch-protection reflex 3) Gamma reflex loop: —Stretch reflex forms part of this loop —Allows muscle tension to come under control of descending pathways —Descending pathways excite gamma motor neurons causing contraction of muscle spindle, and in turn, increased stretch sensitivity and increased rate of firing from spindle Afferents. 4) Flexor withdrawal reflex: —Stimulus: cutaneous sensory stimuli —Functions as protective withdrawal mechanism to remove body part from harmful stimuli 5) Crossed Extension Reflex —Stimulus: noxious stimuli and reciprocal action of antagonists; flexors of one side are excited, causing extensors on same side to be inhibited; opposite occur in opposite limb —Function: coordinates reciprocal limb activities such as gait

Anatomy of the brain: Diencephalon

1) Thalamus: —Sensory nuclei: integrate and relay sensory information from body, face, retina, cochlea, and taste receptors to cerebral cortex; smell (olfaction) is the only exception —Motor nuclei: Relay motor information from cerebellum and globus pallidus to precentral motor cortex —Other nuclei: assist in integration of visceral and somatic functions 2) Subthalamus: involved in control of several functional pathways for sensory, motor, and reticular function 3) Hypothalamus: integrates and controls functions of the ANS and neuro-endocrine system. Maintains body homeostasis (temp, eating, water balance, etc) 4) Epithalamus: —Havenular nuclei: integrate olfactory, visceral, and somatic afferent pathway —Pineal gland: secretes hormones that influence the pituitary gland and several organs, influences circadian rhythm

UMN vs LMN

1) UMN —CNS lesion —Stroke, TBI, corticospinal tract, SCI —Increased tone, velocity dependent —muscle spasms: flexor or extensor 2) LMN: —PNS lesion —Polio, GBS, PNI, Peripheral neuropathy, radiculopathy —Decreased or absent tone, not velocity dependent —Denervation: fasciculations

Examination: Examine Level of Consciousness

—Determine level of consciousness 1) Alertness: alert patient responds appropriately; can open eyes, look at examiner, respond fully and appropriately 2) Lethargy: patient appears drowsy; can open eyes and look at examiner, respond to questions, but falls asleep easily 3) Obtundation: Patient can open eyes, look at examiner, but responds slowly and is confused; demos decreased alertness and interest in environment 4) Stupor: Patient can be aroused from sleep only with painful stimuli; verbal responses are slow or absent; patient returns to unresponsive state when stimuli are removed; demos minimal awareness of self environment 5) Coma: a state of unconsciousness from which patient cannot be aroused, eyes remain closed; no response to external stimuli or environment 6) Unresponsive Wakefulness Syndrome (AKA Vegetative State): characterized by the return of sleep/wake cycles, normalization of vegetative functions (respiration, heart rate, blood pressure, digestion) and lack of cognitive responsiveness (can be aroused but is unaware). —Persistent vegetative state: a state lasting >1 for traumatic TBI and >3 months for anoxic brain injury 7) Minimally Conscious State (MCS): severely altered consciousness with minimal but definite evidence of self or environmental awareness —Glasgow Coma Scale: Relates consciousness to three elements: eye opening, motor response, and verbal response. Scores range from 3-15. Typically used to assess acute consciousness/TBIs 1) 1-8 = Severe Brain injury 2) 9-12 = Moderate Brain Injury 3) 13-15 Minor Brain Injury —Coma Recovery Scale: Examines multiple domains of consciousness and function. Includes brain stem reflexes (pupillary light reflex, corneal reflex, spontaneous eye movements, oculocephalic reflex, and postural reflex).

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

—Disabling and complex illness —Etiology unknown —Symptoms include: severe or prolonged fatigue and drop in activity level lasting 6 months or longer, post-exertional malaise, muscle pain (myalgia), cognitive impairments, difficulty sleeping (sleep that is not refreshing), sore throat, headaches, multi joint pain, dizziness, deconditioning —Dx: must have two major criteria (persistent or relapsing fatigue and reduced physical activity for at least 6 months) and four or more of the eight presenting symptoms —PT exam: examine exercise tolerance levels, examine posture, monitor activity levels and degree of fatigue, examine for depression and degree of emotional support —PT goals, outcomes, interventions: 1) Teach activity pacing, balancing activity with rest. 2) Teach energy conservation techniques 3) ACSM recommendations: —Overall goal is to prevent deconditioning —Aerobic exercise prescription of low to moderate intensity with gradual progression and a distributed practice schedule —Maintain flexibility —Maintain or improve muscle strength —Avoid overexertion

Stroke (continue on page 193)

—Etiological categories: 1) Ischemic stroke: occurs in about 80% of cases A) Cerebral thrombosis: formation or development of a blood clot or thrombus within the cerebral arteries B) Cerebral embolism: traveling bits of matter that produce occluding and infarction in the cerebral arteries 2) Hemorrhagic stroke: abnormal bleeding as a result of rupture of a blood vessel. Occurs in 20% of cases 3) Transient ischemic attack (TIA): a temporary period of symptoms resulting from decrease blood supply to the brain, no permanent damage —Pathophysiology: 1) Cerebral anoxia: lack of oxygen supply to the brain (irreversible damage after 4-6min) 2) Cerebral infarction: irreversible damage 3) Cerebral edema: Accumulation of fluids within brain; causes further dysfunction; elevates ICP 4) Secondary cell death —Occlusions: 1) Internal carotid syndrome: includes MCA, ACA 2) Vertebrobasilar artery syndrome: medial medullary syndrome and lateral medullary aka Wallenberg, basilar artery syndrome, medial inferior pontine syndrome, lateral inferior pontine syndrome, PCA 3) Lacunar syndromes

Examine for presence of involuntary movements

—Extrapyramidal disorders, BG dysfunction 1) Tics: spasmodic contractions of specific muscles, commonly involving face, head, neck, or shoulder muscles 2) Chorea: Relatively quick twitches or "dancing" movements 3) Athetosis: slow, irregular, twisting, sinuous movements, occurring especially in UEs 4) Tremor: continuous quivering movements; rhythmic, oscillatory movements observed at rest 5) Myoclonus: Single, quick jerk —Cerebellar disorders: intention tremor occurring when voluntary movement is attempted —Cortical disorders: Epileptic seizures, tonic/clonic convulsive movements

Infectious Diseases: Encephalitis

—Inflammation of the brain, often due to infection 1) Primary encephalitis: caused by a virus that infects the brain. Effects may be concentrated in one area or widespread 2) Secondary encephalitis: (postinfection encephalitis): caused by a faulty immune system reaction resulting from an infection in another area of the body. The immune system attacks the healthy brain —Mind inflammation may case no symptoms or flu-like symptoms. —Severe inflammation may be life-threatening. Symptoms include confusion, agitation, or hallucinations, seizures, muscle weakness or paralysis, loss of sensation, and loss of consciousness. —Dx: made by physical exam, med history, brain imaging, lumbar puncture, lab tests, EEG, and brain biopsy. —Tx for mild: bed rest, fluids, anti-inflammations —Care may include breathing assistance, IV fluids, corticosteroids, and anticonvulsants

Infectious Diseases: Meningitis

—Inflammation of the membranes of the brain or spinal cord, typically caused by an infection —Etiology: Can be bacterial or viral; patients with bacterial meningitis are usually sicker with more rapid time course —Symptoms: headache, fever, and stiff neck. Also common: irritability, mental confusion, sensitivity to light, increased HR and RR, sleepiness, and sluggishness —Diagnosis: medical history, physical exam (kernig's sign and symptoms with Dura stretch), and lab tests —Treat infective organism (bacterial meningitis) with antibacterial therapy; maintain fluid and electrolyte balance —Treatment of viral meningitis is symptomatic: bed rest, fluids, OTC pain meds. Corticosteroids may be used to reduce brain swelling. —Provide supportive symptomatic therapy, including bed positioning, PROM, skin care to prevent complications.

Anatomy of the brain: Cerebellum

—Located behind dorsal pons and medulla in posterior fossa —Archicerebellum (flocculonodular lobe): concerned with equilibrium and regulation of muscle tone; helps coordinate VOR —Paleocerebellum (Spinocerebellum): concerned with modifying muscle tone and synergistic actions of muscles; important in maintenance of posture and voluntary movement control —Neocerebellum (Cerebrocerebellum): concerned with the smooth coordination of voluntary movements; ensures accurate force, direction, and extent of movement. Important for motor learning, sequencing of movements, and visually triggered movements.

Examine for balance

—Sensory organization test (SOT): patients who are vision dependent are unstable in 2,3,5, and 6. Patients dependent on somatosensory are unstable in 4,5,6. Patient with vestibular deficits are unstable in 5,6. 1) Eyes open, stable surface 2) Eyes closed, stable surface 3) Visual conflict, stable surface 4) Eyes open, unstable surface 5) Eyes closed, unstable surface 6) Visual conflict, unstable surface —CTSIB: same conditions but uses a foam pad to substitute for a moving platform and a modified visual dome instead of a moving visual surround. —Postural strategies: in order of magnitude 1) Ankle strategy: ankle muscles and leg/foot proprioception utilized to maintain balance. 2) Hip strategy: hip and lower trunk muscles maintain balance by shifting COM using hip motions 3) Stepping strategy: rapid steps taken to realign COM over BOS 4) Suspensory strategy: bending the knees to lower the COG —Functional Balance grades: static and dynamic 1) Normal: —Patient is able to maintain steady balance without hand-hold support (Static) —Patient accepts maximal challenge and can shift weight easily at fully range in all directions (dynamic) 2) Good: —patient is able to maintain balance without hand-hold support, limited postural sway (static) —Patient accepts moderate challenge, able to maintain balance while picking object off floor (dynamic) 3) Fair: —Patient is able to maintain balance with hand-hold support; may require occasional min assist (static) —Patient accepts minimal challenge; able to maintain balance while turning head/trunk (dynamic) 4) Poor —Patient requires hand-hold support and moderate to max assist to maintain position (static) —Patient unable to accept challenge or move without loss of balance (dynamic) 5) Absent: patient unable to maintain balance

Neurons

—Structure: 1) Cell body with dendrites (receptive surface area to receive information from synapse 2) Axons: conduct impulses away from the cell body 3) Synapses: allow communication between neurons. Chemical synapses communicate via NTs and electrical synapses communicate via electrical signals passed between cells —Neuron groupings: 1) Nuclei are compact groups of nerve cell bodies; in the PNS these are called ganglia 2) Projection neurons carry impulses to other parts of CNS 3) Interneurons are short relay neurons and assist in the inhibition or excitation of projection neurons and/or alpha motor neurons 4) Axon bundles are called tracts or fasciculi, in the spinal cord they are called tracts or funiculi —Neuroglia: support cells that do not transmit signals, import for myelin production (CNS = oligodendrocytes, PNS = Schwann cell) —Function: Neuronal signaling 1) Resting membrane potential is positive outside and negative inside (-70mV) 2) Action potential: Na+ influx and K+ outflow causes depolarization and is all-or-none 3) Myelinated axons: axons are covered with myelin with small gaps (called nodes of ranvier) where myelin is absent. Action potential jumps from one node to the next (process called saltatory conduction). Myelin increases speed of conduction and conserves energy —Nerve fiber types 1) A-fibers: degree of myelination and fiber size decreases from a-alpha to a-delta A) alpha: proprioception, somatic motor B) Beta: touch, pressure C) Gamma: motor to muscle spindles D) Delta: fast/sharp/localized pain, temp, and crude touch 2) B-fibers: small, myelinated, conduct less rapidly; preganglionic autonomic 3) C-fibers: smallest, unmyelinated, slowest conducting A) Dorsal: Pain, temperature, and reflex responses B) Sympathetic: Postganglionic sympathetics

Examination: Examine Sensory function

—Subjective: ask patient to describe (map out areas) where sensation doesnt feel normal —Testing consideration: type of impairment and body area. Does it follow a specific nerve root? Is the impairment unilateral, bilateral,, all extremities, sporadic? —Sensory exam: in correct order 1) Superficial sensations: Pain, temp, light touch 2) Proprioceptive (deep) Sensations: Joint position sense, kinesthesia (Movement sense), vibration sense (Pallesthesia) 3) Combined (cortical sensations): stereognosis, tactile localization, two-point discrimination, barognosis, graphesthesia, bilateral simultaneous stimulation

Transverse Myelitis (TM)

—TM is an inflammation of one section of the spinal cords. Myelin is damaged with interruption of signals that the spinal cord sends to the body —Etiology: can be caused by: 1) Viral, bacterial, or fungal infection 2) Immune system disorder 3) Autoimmune/inflammatory disorders 4) Myelin disorders such as MS —Symptoms: typically develop gradually over hours to days and may progress over weeks. Usually affects both sides of the body below level of lesion; may also affect only one side. Includes: 1) Pain: back pain, sharp shooting pains down extremities depending on level of lesion 2) Abnormal sensations (paresthesias) including numbness, tingling, coldness, or burning. 3) Weakness that may progress to paralysis 4) Stiffness/tightness, painful spasms or spasticity 5) Fatigue 6) B&B issues —Dx: med history, assessment of nerve function, imaging, lumbar puncture —Medical interventions: IV steroids, plasma exchange, etc. —Prognosis: most patients achieve at least a partial recovery; most recovery occurs in first 3 months and may continue for 2 years. About a third of patients are left with permanent disability. Recurrent or relapsing TM can occur particularly when MS is found to be the cause —PT exam, goals, outcomes, and interventions: 1) PTs can approach the patient with TM and paralysis using exam procedures/outcome measures and interventions similar to those used in SCI. 2) Improving strength, coordination, and functional performance are the majorly goals of treatment. Activity-based rehab with task-specific practice is indicated including weight bearing exercise and locomotor training 3) Training in use of ADs 4) Be mindful of the recovery processs; ongoing and periodic examination is indicated in order to modify the plan of care as appropriate.

Examination: Examine Perceptual Function

—Test for visual field impairments: slowly bring two fingers from behind head into the patient's visual field while asking the patient to gaze straight ahead; the patient indicates when and where the fingers first appear 1) Homonymous Hemianospia: Loss of half of visual field in each eye, contralateral to the side of a cerebral hemisphere lesion 2) Bitemporal hemianospia: loss of outer half of both the right and left visual field resulting in a loss of peripheral vision. Occurs with damage at the optic Chiasm —Examine for body scheme/body image disorders: 1) Body scheme disorder (somatognosia): have patient identify body parts or their relationship to each other 2) Visual Spatial Neglect (unilateral neglect): Determine whether patient ignores one side of the body and stimuli coming from that side 3) Right/left discrimination disorder: Have patient identify right and left sides of his or her own body and your body 4) Anosognosia: severe denial, neglect or lack of awareness of severity of condition; determine whether patient shows severe impairments in neglect and body scheme —Examine for spatial relations syndrome: 1) Figure-ground discrimination: have patients pick out an object from an array of objects (ex: brake from rest of wheelchair) 2) Form constancy: have patient pick out an object from an array of similarly shaped but different-sized objects 3) Spatial relations: have patient duplicate a pattern of two or three blocks 4) Position in space: have patient demonstrate different limb positions 5) Topographical disorientation: Determine whether patient can navigate a familiar route on his or her own 6) Depth and distance imperceptions: determine whether patient can judge depth and distance 7) Vertical disorientation: determine whether patient can accurately identify when something is upright —Examine for Agnosia: inability to recognize familiar objects with one sensory modality while retaining ability to recognize same object with other sensory modalities —Examine for Apraxia: inability to perform voluntary, learned movements in the absence of loss of sensation, strength, coordination, attention, or comprehension; represents a breakdown in the conceptual system or motor production system or both 1) Ideomotor: patient cannot perform the task on command but can do it on their own 2) Ideational: patient cannot perform the task at all