The Nervous System Anatomy Note Cards

Coma

(correlates to Rancho Scale-Revised Level 1) A state of complete unresponsiveness to both external and internal stimuli. No response to external or internal stimuli and eyes closed; pathological unresponsiveness. Posturing is frequently observed in the comatose patient and indicates abnormal reflexive activity at the brainstem level.

Minimally Conscious State

(correlates with Rancho Scale-Revised Level III) Usually represents a transitional State of Consciousness during which there are inconsistent signs of consciousness "with some preserved awareness of self or environment". Some research indicates that there are two different minimally conscious levels, which required repeated evaluations with reproducible results to truly establish and distinguish, higher level and lower level.

Unresponsive Wakefulness Syndrome

(correlates with Ranchos Scale-Revised Level II) Patient is awake, with eye opening, but is unresponsive and has no awareness of the environment or self. The patient does not follow commands or visually track. After 12 months following a traumatic brain injury and 3 months with an initial diagnosis other than traumatic injury, this state becomes characterized as persistent.

Huntington's disease symptoms

(degeneration of caudate nucleus) - Chorea- jerky involuntary movements affecting especially the shoulders, hips, and face. - Athetosis- a symptom characterized by slow, involuntary, convoluted, writhing movements of the fingers, hands, toes, and feet and in some cases, arms, legs, neck and tongue. - Ballismus- is a severe movement disorder that is characterized by spontaneous involuntary movements, muscular weakness and incoordination of movements of the proximal extremities. - Tics - Dementia

Parkinson's disease symptoms

(reduced dopamine production) - Akinesia (loss or impairment of the power of voluntary movement) and bradykinesia (slowness of movement) - Abnormal postural adjustments - Frequent retropulsion (posterior) falls and losses of balance - Pill-rolling - Rigidity- cogwheel tone - Masklike facial expression - Shuffling gait - Micrographia (small writing) - Reduced speech intelligibility and volume - Multiple visual deficits - Blepharospasm- Uncontrolled spasms of the eyelid

Simple Seizures (sometimes called simple focal or partial seizures)

- Affects a small part of one lobe - No loss of consciousness, alert and oriented, but cannot control seizure manifestations - Will remember the seizure afterward - Sudden jerking, especially of the thumb or cheek - Sensory phenomena or auditory hallucinations - No change in vital signs

CVA Non-modifiable Risk Factors

- Age (older age = higher risk; risk doubles for each decade after age 55) - Heredity (family history) - Sex (female > male) - Race (African-Americans at highest risk) - History of prior stroke, transient ischemic attack, or heart attack

Precautions for TBI

- Agitation - Neurogenic fever - Cerebral perfusion pressure - Intracranial pressure - Drains - "Storming" or paroxysmal sympathetic hyperactivity - Craniectomy

Anatomical functional correlation of injury in the brain: Cerebellum (three lobes: anterior, posterior, flocculonodular)

- Ataxia - Impaired proprioception - Dysdiadochokinesia: inability to coordinate alternating rapid movements (turning palms up and down rapidly, rubbing heel up and down shin) - Dysmetria, dyssynergia - Intention tremor - Nystagmus: eyes oscillating involuntarily and rhythmically; can be vertical, horizontal, rotary, or a combination - Vertigo - Diplopia - Anterior lobe affected by alcohol abuse- usually affect legs with an ataxic, wide-stance gait - May have cognitive deficits

Anatomical functional correlation of injury in the brain: Pons

- Bilateral horizontal gaze paresis - Facial droop - Motor deficits can progress especially in lower pons lesions - Coma - Locked-in syndrome - Dysarthria - Sensation decreased or absent - Ataxia - Vth, VIth, VIIth, and VIIIth nerve involvement - Pinpoint pupils - Diplopia - _Infarct on the parapontine area of the reticular formation- patient cannot turn eyes past midline and is unable to initiate horizontal gaze

Inclusion criteria for t-PA

- Diagnosis of ischemic stroke causing measurable deficits - Onset of symptoms <3 hours (and in some cases 4.5 hours) before initiation of treatment, and - Age >18 years (or 18 years)

What to do during a seizure?

- Do not leave the patient alone; press the call light or call for help. - If there is enough warning, get the patient back to bed quickly and safely, flatten the bed, and put up the padded bedrails. If hard edges are not already padded, use towels, blanket, or pillows. If there is a known seizure disorder, the bedrails should already be padded. - Protect the patient's head with something soft and flat. - Be aware that incontinence can occur; if possible, provide privacy. - Do not put anything in the patient's mouth. - Turn the patient on his or her side. - Do not hold the patient down or forcefully position their arms, legs, or neck once the seizure has started. Do not use restraints. The use of force could cause an injury such as muscle strain, fracture, or shoulder dislocation. Loosen tight clothing, especially items around the neck. - Remove items from the head and neck, such as glasses and necklaces. Do not remove any type of neck collar. - Time the seizure if at all possible. - Clear the area around the patient if on the floor to prevent injury (e.g., walkers, tables, chairs).

General guidelines for working with patients who have drains:

- Do you not get the patient up without specific orders if the drip chamber is external and actively draining. Speak directly with the neurosurgeon or neurologist if necessary. - VP shunts do not require clamping. - Orders must be written before the drain can be clamped, and a nurse must clamp the drain. - The nurse will clamp the intraventricular catheter and lumbar drain before all transitional movements, including moving the bed, the patient, or both, because the drainage flow may be disturbed. Raising the bed just a few degrees could cause unrestricted CSF drainage because the drain will then be set to follow gravity. - The head of the bed is usually elevated to assist in controlling ICP, but check with the nurse, physician, or both. The patient may need to remain flat to ensure medical stability. The best practice guidelines recommend keeping the bed at 30 degrees to maintain or increase CPP and maintain or decrease ICP. - Instruct the patient to avoid straining, coughing, or sneezing so as to avoid increasing the pressure.

Horner's Syndrome

- Dysphagia - Ipsilateral face or neck pain or monocular vision loss indicate carotid artery dissection - Partial ptosis - Miosis- Constriction of pupil - Anhydrosis- Loss of perspiration on the side of the face as a result of losing innervation

Temporal Lobe Seizure Symptoms

- Feeling of deja vu - Unusual smell or taste - Sudden feeling of intense joy or fear - May fiddle with clothing or pick up and object for no reason - Chewing or lip smacking - Repeating words that make no sense - Wandering in a confused manner

Craniectomy Precautions

- Helmets are generally recommended when getting patients with a craniectomy up. However, some neurosurgeons oppose the use of helmets because the helmets themselves may compress the brain and can cause incisional wounds. - If no helmet is used, be cautious not to press on areas in which there is no bone. - When ordering helmets for patients, measure the circumference of the head approximately 1 inch above the ears. - Ensure the helmet is not compressing any of the craniectomy areas. - Do not roll the patient onto the side of the craniectomy because it will put pressure on the portion of the brain that is unprotected by the skull. - Restrict the patient from bending forward with ADLs or mobility.

Anatomical functional correlation of injury in the brain: Brainstem

- Hemiparesis - Vertigo/dizziness - Imbalance - Ipsilateral cranial nerve involvement with contralateral hemiparesis - Swallow dysfunction - Autonomic nervous system dysfunction - Locked-in syndrome

Therapeutic implications for coma

- If possible, try to increase the patient's upright position, either through a bed - chair position or sitting the patient up on the side of the bed with a two person assist, to assess activation of the reticular activating system. - Use prom, splinting, or both to reduce contractures. Include nursing training for putting on and taking off a splint, care, and schedule. - Reduce the amount of stimuli in the room to prevent overstimulation; for instance, the TV or radio should be off most of the time, and mute the sounds on the machines as much as possible. - Maintain normal day - night schedules to address the sleep - wake cycle, and begin incorporating normal routines into the patient's daily activities. For instance, the lights should be on during the day and all that night, and baths should be completed during the day. - Inform the patient before performing any intervention. - Speak positively in the presence of the comatose patient.

Anatomical functional correlation of injury in the brain: Temporal Lobe

- Left-side lesion- Short-term verbal memory loss - Right-side lesion- Short-term memory loss - Auditory input deficits - Wernicke's aphasia (fluent speech, but not comprehensible)

Anatomical functional correlation of injury in the brain: Midbrain

- May have decreased reflexive movement of the head, neck, and eyes in response to visual information in the superior colliculus is damaged - Inability to perform voluntary vertical eye movements if the medial longitudinal fasciculus or the posterior commisure is damaged - Pupil doesn't constrict with light, but will with convergence - Oculomotor nerve (cranial nerve III) palsy often associated with motor symptoms such as weakness or ataxia - Ataxia (red nuclei) - Hemiparesis or weakness

Parietal Lobe Seizure Symptoms

- Numbness or tingling - Feeling that the arm or leg is a different size than it really is

What are the symptoms of Myasthenia Gravis (MG)?

- Ocular dysfunction, especially ptosis and diplopia - Bulbar symptoms, including facial, speech, swallowing, and chewing muscle weakness - Fluctuating muscle weakness and fatiguability (cardinal sign of MG), progressing to generalized weakness within 3 years of initial onset in 80% of patients - Respiratory muscle weakness Complications depend on which muscles have been affected. The hallmarks of a myathenic crisis that necessitates hospitalization are progressive weakness, tachycardia, tachypnea, dysphagia, impaired speech, anxiety, restlessness, and respiratory musculature weakness.

Complex Seizures (sometimes called complex focal or complex partial seizures)

- Originates in a large area of one hemisphere - Usually preceded in aura - Automatisms (lip smacking, picking at clothes, fumbling, eye blinking, walking aimlessly) - Unaware of environment and may have a loss of consciousness - May behave oddly or interpret other's behavior inappropriately, for instance, may misinterpret someone loudly speaking as aggressive behavior and react aggressively. - May describe experience as an "out-of-body" experience, may have memory flashbacks or extreme emotions such as rage, terror, or fear - Not likely to have a change in vitals, but possible - Eye deviation in contralateral direction from the seizure focus in the brain in the frontal eye fields are involved

Absence seizure (formally known as petit mal)

- Patient noted to have a blank stare and eyelids fluttering - Abruptly stops then resumes activity; appears to be daydreaming, but will not respond when called - Usually lasts 5-30 seconds and may go unnoticed - Unaware of environment - May have a mild loss or decrease in muscle tone - No changes in vital signs

Anatomical functional correlation of injury in the brain: Frontal Lobe

- Poor executive function skills - Broca's aphasia- impaired fluency of speech, especially telegraphic speech, expressive aphasia - Impaired pragmatics especially loss of inhibition - Personality changes - Impulsivity and/or delayed initiation - Bowel and bladder incontinence - Contralateral hemiparesis - If there is injury to the frontal eye fields, there will be a gaze preference and head deviation

Spinal cord injury therapeutic implications

- Preventing the loss of strength and passive and active ROM.; - Initiating and improving functional mobility and the ability to be in an upright position as much as possible; - Strategies to maintain skin integrity via positioning , pressure relief, and safe methods for transfers that prevent shearing injuries; - Pain prevention strategies, including positioning splinting, and ROM; - Preventing the loss of respiratory capacity with trunk and intercostal muscle flexibility for improved vent-weaning potential; and - Preservation of functional hand position for potential neurological return in the hands.

Anatomical functional correlation of injury in the brain: Medulla Oblongata

- Respiratory arrest and death can result from large lesions that compress these structures - Medullary reticular formation infarct results in coma - IXth, Xth, XIth, and XIIth nerves may be involved - Autonomic dysfunction ** Failure of automatic respirations ** Tachycardia and bradychardia ** Orthostatic hypertension without increased heart rate ** GERD, gastric retention, and reduced gastric motility - Wallenberg's syndrome - Horner's syndrome

What are the most common characteristics of MS?

- Sensory symptoms in the limbs or face, described as numbness and tingling, tightness, coldness, or feeling like swelling, intense itching (especially in the cervical dermatomes, or it could be unilateral) - Weakness in varied and unpredictable distributions - Limbs or truncal ataxia - Difficulty with ambulation, balance deficits, and vertigo - Swallowing deficits - Dysarthria - Visual changes or loss or diplopia; scotoma (spot of vision loss) usually affects central vision, decreased vividness of color (especially red), mild dimming of vision - Bladder and bowel dysfunction - Pain including Lhermitte sign (noted in 9% of patients; when the neck is flexed, feelings of electric shock radiate down the back or limbs) and ocular pain that is unilateral and worsened by eye movement.

CVA Modifiable Risk Factors

- Smoking - High blood pressure - Diabetes mellitus - Carotid or other artery disease - Atrial fibrillation - Peripheral artery disease - Heart disease - Sickle cell disease - High cholesterol - Obesity and poor diet - Sedentary lifestyle

Anatomical functional correlation of injury in the brain: Parietal Lobe

- Spatial relations deficits - Neglect or inattention - Sensory input and integration deficits - Poor personal space boundaries - Proprioceptive deficits - Emotional or labile behavior - Apraxia - Reading deficits - Receptive speech deficits - Decreased taste

Frontal Lobe Seizure Symptoms

- Stiffness or twitching of a body part - Cry out or scream loudly - Make strange movements, such as kicking or riding a bicycle

Anatomical functional correlation of injury in the brain: Meninges

- Subdural hematoma occurs between the dura and the arachnoid later - Subarachnoid hemorrhage forms between the arachnoid and pia mater usually as a result of trauma or rupture of an aneurysm of a cerebral artery - Meningitis- Inflammation of the meninges because of infection (viral, fungal, or bacterial), a reaction to certain medications or medical interventions, or inflammatory diseases such as lupus, cancer, or TBI - Meningioma- Tumor that arises from the arachnoid

Seizure Precautions

- The patient can be taken out of the room, but be aware of sudden changes in demeanor or physical ability, and be ready for protective action. - If the patient has frequent seizures, have an assistant follow you with a chair. - Pad bedrails with seizure pads or blankets. - Do not leave the patient unattended out of the bed if seizures are frequent. Return the patient back to bed with bedrails up. - Avoid flashing lights; even flickering fluorescent lights can induce a seizure. - Conditions such as fever, low blood sugar, stress, lack of sleep, and fatigue can increase susceptibility to seizures. - Pain can cause a seizure; however, this is unusual. After a generalized tonic-clonic seizure, pain can be present because of the massive amount of muscle activity. - Seizures can occur even while the patient is on antiseizure medications. - Determine whether the patient has an aura- a sensory signal that is imminent- because the aura may be a warning. An aura is actually a simple partial seizure and generally just involves sensory manifestations. An aura may be visual (seeing lines, colors), auditory (ringing), or olfactory (e.g., smell of roses, vanilla). If the patient has an aura, return the patient to bed if possible; otherwise, lay the patient down on the nearest surface possible, protecting his or her head.

Occipital Lobe Seizure Symptoms

- Visual disturbances, such as flashing lights or colors - Hallucinations

Anatomical functional correlation of injury in the brain: Occipital Lobe

- Visual field cuts - Perceptual deficits - Visual input and processing deficits

What are the movements of the eye?

1. Elevation 2. Depression 3. Adduction 4. Abduction 5. Intorsion 6. Extorsion

How to test for proprioception

1. Have the patient flex both shoulders at 90 degrees, close their eyes, and name 5 states. If the patient's affected arm drifts, ask them if their arm is still in the same place. If the answer is yet, then proprioception is likely impaired. If the person seems to have difficulty maintaining the arm in place (i.e., uses subtle finger movements or self-corrects drift), then the deficits might be mild. 2. The thumb localization test

Three different drains inserted into the brain to remove excess fluid (CSF or blood) to prevent a pressure build-up in the CNS.

1. Intraventricular catheter 2. Lumbar drains 3. Ventriculoperitoneal (VP) shunts

What are the nerves that arise from the brachial plexus?

1. Musculocutaneous 2. Axillary 3. Median 4. Radial 5. Ulnar

What are the four types of Multiple Sclerosis?

1. Relapsing remitting 2. Secondary progressive 3. Primary progressive 4. Progressive relapsing

What are the 5 major types of TBI?

1. Subdural hematoma (blood below the dural level of the brain) 2. Concussion (head trauma) 3. Contusion (bruising of the brain) 4. Diffuse anoxal injury (white matter shearing) 5. Anoxia (lack of oxygen to the brain)

What are the two segments of the autonomic nervous system?

1. Sympathetic nervous system 2. Parasympathetic nervous system

How many thoracic vertebrae are there?

12 (T1-T12)

How many pairs of cranial nerves are there?

12 pairs

How many hemispheres?

2

How many pairs of spinal nerves are there?

31 pairs

How many lobes are in the cerebrum?

4 1. Frontal 2. Parietal 3. Temporal 4. Occipital

How many lumbar vertebrae are there?

5 (L1-L5)

How many sacral vertebrae are there?

5 (L1-L5)

intracranial Pressure (ICP) Levels

5-15: Ideal levels, therapy proceeds as normal. 16-19: Therapy can be performed but should be limited to light activity. >20: Defer therapy. Cerebral auto-regulation becomes impaired at approximately 50. >30: Indicates a poor prognosis, resulting in irreversible neuronal hypoxia.

How many cervical vertebrae are there?

8 (C1-C8)

Orthostatic hypotension

A decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position.

Craniectomy

A portion of the skull is removed, then placed into a subcutaneous pocket in the abdomen or a flap in the subgaleal space (in the scalp on the other side), a deep freezer, or discarded.

Functional reach and grasp

A simple and easily accessible test in most hospital settings is to use a foam cup to assess the patient's ability to control strength and coordination. This informal test is especially useful to judge ataxia and the patient's response to intervention such as weight-bearing. The patient should reach for an empty cup and raise it up toward the mouth. Assess whether the patient can control the force of the cup as it is grasped and coordination when reaching for and moving the cup. To assess response to treatment and initiate neuromuscular reeducation, incorporate 5 minutes of UE weight-bearing, then repeat the finger-to-nose test and a functional task such as reaching for the cup. If the patient is successful, provide instruction to incorporate weight-bearing into normal activities (i.e., leaning on the armrest of a chair). This sets the stage for functional recovery in later care.

Intention tremor

A slow tremor of the extremities that increases on attempted voluntary movement and is observed in certain diseases (as multiple sclerosis) of the nervous system

Locked-in syndrome

A state of wakefulness and awareness with quadriplegia and paralysis of the lower cranial nerves, resulting in inability to show facial expression, move, speak, or communicate, except by coded eye movements.

Autonomic Dysreflexia

A syndrome in which there is a sudden onset of excessively high blood pressure.Patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above).

Telegraphic Speech

A term referring to regressing minimalist speech that occurs in adults with progressive neurologic disease (e.g., multiple sclerosis), which is similar to developing speech in children. A pattern of speech typical of expressive aphasia, in which prominent words in a sentence, usually nouns, are uttered but most other words are omitted. Usually 1 to 2 word sentences.

Cranial Nerve VI

Abducens Function: Motor - Innervates lateral rectus- abduction of the eye (eyeball moves out toward the temple horizontally) - Controls eye movement that allows for distance vision

Diadochokinesis

Ability to rapidly perform alternating movement, commonly evaluated via rapid bilateral pronation or supination.

Edema

Abnormal swelling in a particular region.

Hypoxic-Ischemic Brain Injury (also called anoxic brain injury and global cerebral ischemia)

Absence oxygen and blood supply to the brain for more than several minutes. Usually seen in patients with cardiac or respiratory arrest, hanging, or near-drowning. Damage begins occurring as soon as two minutes after loss of perfusion, but successful resuscitation may also lead to a reperfusion injury. This might occur in drug overdoses, near drownings, or carbon monoxide poisoning where the circulatory system has not yet shut down.

Alexia without agraphia

Alexia without agraphia is a dramatic disorder of higher visual function in which patients can still write but are unable to read. This has been variably conceptualized as a disconnection syndrome or a word-form agnosia.

Alien hand syndrome

Alien hand syndrome is a phenomenon in which one hand is not under control of the mind. The person loses control of the hand, and it acts as if it has a mind of its own. The etiology includes neurosurgery, tumor, aneurysms, and rarely stroke.

Angioplasty

Also called percutaneous coronary intervention, is a procedure used to open clogged heart arteries. Angioplasty uses a tiny balloon catheter that is inserted in a blocked blood vessel to help widen it and improve blood flow to your heart. Angioplasty is often combined with the placement of a small wire mesh tube called a stent. The stent helps prop the artery open, decreasing its chance of narrowing again. Most stents are coated with medication to help keep your artery open (drug-eluting stents). Rarely, bare-metal stents may be used. Angioplasty can improve symptoms of blocked arteries, such as chest pain and shortness of breath. Angioplasty is also often used during a heart attack to quickly open a blocked artery and reduce the amount of damage to your heart.

Amyotrophic Lateral Sclerosis

Also known as Lou Gehrig's disease, is the most common motor neuron disease affecting adults. Onset generally occurs between ages 40 and 60, and men are affected more than women. This disease involves a progressive degeneration of the motor neurons in the brain stem, anterior horn cells of the spinal cord, and the motor cortex that eventually affects all voluntary muscles. This disease is eventually fatal, with a median life expectancy of three years after diagnosis unless it is diagnosed at an early age and medical care is provided diligently.

Tissue Plasminogen Activator (t-PA) administration

Alteplase, or t-PA as it is generally called, is a super anticoagulant that breaks up blood clots in the brain and is the only FDA-approved thrombolytic agent for the treatment of stroke. This treatment has shown to be the most effective within the first 3 hours of symptom onset and up to 4.5 hours in carefully selected patients.

Ventriculoperitoneal Shunt

Alternate path to redirect excess CSF from one area to another (from the ventricles to the peritoneal cavity) using an implanted tube.

Retrograde amnesia

Amnesia in which the lack of memory relates to events that occurred before a traumatic event.

Acute and chronic hydrocephalus

An excessive increase of CSF. Acute hydrocephalus is generally treated with an extraventricular drain (EVD) or by lumbar drainage. If the patient develops chronic hydrocephalus, a neurosurgeon will place a ventriculoperitoneal shunt.

Neurogenic Fever

An uncontrolled fever is associated with patients with TBI but can also occur in patients with stroke or any CNS injury. A diagnosis of neurogenic fever is usually a diagnosis of exclusion after all sepsis etiologies have been ruled out. Defer therapy is the patient's temperature is higher than 100.9 degrees with no infectious process indicators present.

AVM

Aneurysm Bulging area at a weak portion of the vascular wall, sometimes called berry aneurysms. AVMs are usually congenital, tangled connections between the arteries and veins and can occur in the spinal cord or brain.

Anterograde amnesia

Anterograde amnesia refers to a decreased ability to retain new information. This can affect your daily activities. It may also interfere with work and social activities because you might have challenges creating new memories.

Seizures

Are abnormal electrical impulses in the brain that manifest in many ways, which can involve alterations in sensation, movement, behaviors, levels of consciousness, or all of these.

Pathological Reflexes

Are abnormal responses that indicate signs of upper or lower motor neuron dysfunction. Upper motor neuron reflexes usually produce a hyperactive response (i.e., increased tone) and lower motor neuron reflexes are hypoactive.

Peripheral Nerve Injuries

Are damage to any of the peripheral nerves in the body. They are frequently treated in the acute care setting; however, they are typically not the primary diagnosis. These injuries are often the result of complications from surgical procedures or trauma. For instance, during a long surgery, the blood pressure cuff may have been too tight, thus constricting the radial nerve as it passed through the radio groove, which then causes a radial nerve palsy.

Coma Stimulation

At Rancho levels I-III, the coma stimulation intervention includes establishing or modifying a sensory-appropriate environment to increase the state of consciousness. Coma stimulation is a controversial intervention and is not generally reimbursed by insurance companies because there is little research that clearly establishes it as effective. Sensory input can include acoustic (e.g., sounds of music, voices of loved ones, loud clapping, tuning fork, bell, singing), tactile or kinesthetic (e.g., massage, touch, temperature, noxious stimuli such as bed pressure, ROM exercises), olfactory (e.g., scents of perfume, vinegar, lemon, vanilla, coffee), gustatory (e.g., tastes of sour, salty, sweet, mouthwash on mouth swab during oral care), and visual (e.g. colored paper, light pens, pictures of family faces, manually opening eyes momentarily).

Cauda Equina

At the bottom of the spinal cord is the cauda equina, consisting of a bundle of nerves made up of spinal nerves and roots from L2-L5, S1-S5, and the coccygeal nerve.

Alert

Awake and participates in therapy with no efforts to increase arousal.

Carotid Artery Stenosis

Be extremely cautious if narrowing of the carotid artery is 90%-100% bilaterally because this indicates that blood flow is compromised. Inappropriately aggressive therapy could result in another stroke. An activity that does not increase blood pressure and does not allow hypotension is optimal. Basic activities of daily living (BADLs) should be completed with careful monitoring of vital signs and observation of the patient's symptoms. Therapy may be the medium for improving the patient's overall conditioning to optimize survival of the surgical procedure.

Function of the Temporal Lobe

Behavior Hearing Memory Speech Vision

Function of the Frontal Lobe

Behavior Intelligence Memory Movement

Deep Brain Stimulator

Blocks abnormal electrical activity that causes symptoms. Electrodes are implanted into target areas of the brain tat will deliver electrical impulses. A wire that extends down toward the chest, where a pacemaker-like device, called an impulse generator, is implanted. This device controls the impulses and is activated automatically or can be activated volitionally if symptoms worsen or the patient feels them coming. The impulse generator us turned on 2-3 weeks after implantation.

Subdural hematoma

Blood below the dural level of the brain

Function of the brainstem

Blood pressure Breathing Consciousness Heartbeat Swallowing

Contusion (TBI)

Bruising of the brain

Minimally Conscious State, Lower Level

Characteristics such as visual pursuit of stimulus, noxious stimulation localization, and appropriate emotional responses. Serial evaluations should be performed at this level, especially to confirm that they are occurring in response to specific stimuli.

Pia mater

Clings tightly to the brain and is highly vascularized, supplying blood to the CNS.

Endovascular Coil Embolization

Coils are placed in an aneurysm or vascular area via a catheter. The body responds by forming a blood clot around the coil, blocking off the aneurysm.

Hematomas

Collection of blood outside of blood vessels.

Amygdala

Controls emotional interpretation of environmental and internal stimuli, especially emotional arousal responses to fear and anger.

Progressive Relapsing MS

Demonstrates clear progression with occasional relapses. It may be initially diagnoses as PPMS until a relapse occurs. Therefore, this type if often considered a subtype of PPMS that is not necessarily active but still progressing.

Central Cord Syndrome

Destruction of the central cord versus the periphery of the cord. Paralysis or weakness and sensory loss are greater in the UEs than in the LEs. Intrinsics will return last, if at all. The most common etiologies are fracture subluxations and acute disc herniations. Bowel and bladder dysfunction are possible. Central cord syndrome is more common in older people because of narrowing of the spinal cord.

Mechanical thrombectomy with or without IA thromolytics

Device used to retrieve and remove clots or insert IA thromolytics to achieve primary reperfusion. Mechanical thrombectomy is type of minimally-invasive procedure in which an interventional radiologist uses specialized equipment to remove a clot from a patient's artery. Using fluoroscopy, or continuous x-ray, the doctor guides instruments through the patient's arteries to the clot, extracting the clot all at once.

Dyspraxia

Difficulty with planing movements, especially complex or new movements

Diplopia

Double vision

Ventriculoperitoneal (VP) Shunts

Drain CSF directly from the ventricles, but the drip chamber is located inside the abdominal cavity. VP shunts do not require leveling.

Lumbar drains

Drain directly from the lumbar region, usually at L2-L3 of the spine so the catheter will be next to the cauda equina, thus avoiding the spinal cord. The lumbar drain is leveled with the bed and the umbilicus. If the patient develops a severe headache with position changes, the drain may be allowing too much fluid to drain.

Lethargy

Drowsy, requires loud verbal stimulation to arouse, responds slowly. May need to be sitting to maintain arousal but will be able to participate minimally (i.e., follow occasional one-step directions).

Nystagmus

Eyes oscillating involuntarily and rhythmically; can be vertical, horizontal, rotary, or a combination

Cranial Nerve VII

Facial Function: - Conveys sensation from part of the tongue and interior of the mouth - Motor- Biting and chewing, face movement (expressions) - Taste from the anterior 2/3 portion of the tongue - Parasympathetic: lacrimal, submaxillary, and submandibular glands

Wernicke's Aphasia

Fluent speech, but not comprehensible

Right hemisphere

Focuses on the perceptual, attention, and judgement skills associated with task completion.

Subcortical white matter areas

Form communication pathways

How many ventricles/meninges are in the brain?

Four ventricles, three meninges Together they provide a fluid-filled system to protect the nervous tissue.

Left hemisphere

Generally provides recall and detail information that helps identify objects and is responsible for the language components of a task.

Concussion

Head trauma

Cranial Nerve VIII (vestibulo-cochlear nerve) Testing

Hearing Test: - Rub fingers together loudly or use a ticking watch on one side and ask on which side the patient hears the sound. Repeat on other side. This should occur about 5 cm away from the ear - Oculocephalic reflex (doll's eyes) - Vestibular test - Nystagmus: note response during extraocular musculature testing - Gait assessment- looking for ataxia and balance dysfunction Normal response: - Patient can hear normally - Vestibular system rarely affected, but if it is refer to chapter 26, "Dizziness" - Oculocephalic reflex: eyes move in the opposite direction of the head turn before return to midline

TBI Agitation

Heightened cognitive, behavioral, and physical activity, usually at Rancho Level IV. Behaviors associated with Rancho Level IV stage of recovery are physical aggression, impulsivity, verbal outbursts, and inappropriate social behavior. Therapeutic intervention at this stage may be limited to staff and family instruction in environmental and task modifications.

Hyperkinetic

Hyperkinesia is a state of excessive restlessness which is featured in a large variety of disorders that affect the ability to control motor movement, such as Huntington's disease. It is the opposite of hypokinesia, which refers to decreased bodily movement, as commonly manifested in Parkinson's disease.

Which type of movement does Huntingtons present with?

Hyperkinetic

Cranial Nerve XII

Hypogloassal Function: Supplies the muscles of the tongue

Which type of movement does Parkinsons present with?

Hypokinetic

Cranial Nerves IX and X

IX: Glossopharyngeal X: Vagus Function: Glossopharyngeal: - Supplies sensation to pharynx, posterior 1/3 of tongue, and tympanic membrane - Gag reflex - Symmetrical elevation of soft palate - Blood pressure regulation - Autonomic innervation of salivary gland Vagus: - Motor fibers to the pharynx and larynx - Parasympathetic innervation of throat, heart, lungs, and abdominal viscera

Treatment of Stroke

If the patient arrives at the hospital within 4.5 hours of the initial onset, then restoration of blood flow (recanalization) will be attempted via the use of antithrombolytics (t-PA), mechanical thrombectomy, or angioplasty. However, if the patient arrives at the hospital more than 4.5 hours after onset, options are limited to the treatment of symptoms to prevent further degeneration or a thrombectomy with or without intra-arterial t-PA.

Hypertensive Urgency

If your blood pressure is 180/120 or greater, wait about five minutes and try again. If the second reading is just as high and you are not experiencing any other associated symptoms of target organ damage such as chest pain, shortness of breath, back pain, numbness/weakness, change in vision, or difficulty speaking, this would be considered a hypertensive urgency. Your healthcare provider may just have you adjust or add medications, but rarely requires hospitalization.

Hypertensive Emergency

If your blood pressure reading is 180/120 or greater and you are experiencing any other associated symptoms of target organ damage such as chest pain, shortness of breath, back pain, numbness/weakness, change in vision, or difficulty speaking then this would be considered a hypertensive emergency. Do not wait to see if your pressure comes down on its own, Call 911.

Ataxia

Impaired balance or coordination, can be due to damage to brain, nerves, or muscles.

Tretraplegia (Quadriplegia)

Impaired movement in all four limbs. Tetraplegia is now the preferred term for research purposes and documentation so that all English-speaking professionals and patients can use a common language.

Paraplegia

Impaired movement in both LEs, but movement in the UEs is preserved. The trunk may also be impaired.

Self-protection of the arm

In all stages of UE recovery, the therapist should indicate whether the patient protects the arm appropriately. Lack of self-protection provides a goal for evaluation and is appropriate for the acute care setting because injury can cause further complications.

Dysdiadochokinesia

Inability to coordinate alternating rapid movements (turning palms up and down rapidly, rubbing heel up and down shin).

Dysdiadochokinesia

Inability to coordinate alternating rapid movements (turning parls rapidly, rubbing heel up and down shin)

Apraxia

Inability to perform particular purposive actions, as a result of brain damage.

Somatic nervous system

Includes the cranial and spinal nerves that control voluntary skeletal muscle activity and external sensory information.

Transverse Myelitis

Inflammation across one level of the spinal cord. The myelin sheath is damaged and causes paralysis below the level of inflammation, which can progress over the course of several weeks. One-third of patients recover fully, one-third recover partially but are left with significant deficits, and one-third demonstrate no recovery at all. Patients are generally treated with aggressive rehabilitation and corticosteroids for their immunosuppressive and anti-inflammatory properties. Plasma exchange may be used in some cases.

Meningitis

Inflammation of the meninges because of an infection (viral, fungal, or bacterial), a reaction to certain medications or medical interventions, or inflammatory diseases such as lupus, cancer, or TBI

Conus Medullaris Syndrome

Injury to the sacral cord and lumbar nerve roots, resulting in the loss of bowel and bladder function and LE function.

Function if the Parietal Lobe

Intelligence Language Reading Sensation

Tardive Dyskinesias

Involves face, lips, and tongue; manifested by involuntary chewing motion with smacking of lips and tongue

"Storming" or Paroxysmal Sympathetic Hyperactivity

Is a brain injury complication known most commonly as "storming", but it has more than 30 different names in the literature. The most common include autonomic dysfunction syndrome, sympathetic storming, autonomic dysreflexia, dysautonomia, and paroxysmal autonomic instability with dystonia. This event is caused by stimulation of the SNS that triggers a stress response. Because of the brain injury, the body is unable to mediate the response.

Dysmetria

Is a lack of coordination of movement typified by the undershoot or overshoot of intended position with the hand, arm, leg, or eye. It is a type of ataxia. It can also include an inability to judge distance or scale.

Vasospasm

Is a narrowing Approximately one-third of patients who have has a SAH or ruptured aneurysm are at high risk for vasospasm, especially 4-14 days after the initial episode. Vasospasm is a narrowing of the cerebral arteries, which can cause ischemia to the portions of the brain supplied by that vessel. Therapy should be suspended when vasospasm is suspected.

Shoulder Subluxation

Is a neurological dislocation in which the humeral head is not properly seated in the glenohumeral capsule. The muscles responsible for maintaining the humerus in the joint are so weak that they stretch with the force of gravity, which leads to the humeral head slipping out of the joint. Slings should be used to prevent traction during transfers and ambulation.

Spinal Shock

Is a physiological loss or depression of all reflexes below the level of injury. It can last from 24 hours after the injury to as long as 6 weeks. Symptoms of spinal shock include areflexia (no reflex activity below the level of injury), flaccid bladder and bowel, decreased deep tendon reflexes, and impaired sympathetic functioning. Diminished sympathetic responses include decreased heart rate and blood pressure, no perspiration below the injury level, and decreased constriction of the blood vessels.

Reperfusion Injury or Syndrome

Is a rare but serious complication that can occur after revascularization. This is the increase in blood flow that causes an inflammatory response beyond the needs and capabilities of the microvasculature to manage. The blood-brain barrier is not always able to manage the increased blood pressure without a chemical production that causes a breakdown in the structural integrity of the vasculature and cerebral homeostasis. This can lead to a cascade of events, including hemorrhagic transformation or cerebral edema. In general, this will occur within 24-36 hours if revascularization.

Multiple Sclerosis (MS)

Is a recurrent or progressive, unpredictable, and chronic demyelinating disorder caused by plaques that form in the white matter of the brain. Plaques can also form on the spinal cord, on the optic nerve, and in the gray matter. It is thought to be an autoimmune or immune-mediated disease that affects people who are generally predisposed to it. The disease's effects range from a mild weakness or visual disturbance to complete debility. These effects depend on the location of the plaques in the nervous system. Ms most frequently occurs between ages 20 and 40. The primary feature of MS is its unpredictability - exacerbations and remission can occur without warning. Where the next plaque will form is not predictable.

Parkinson's Disease

Is a reduction of the dopaminergic production in the substantia nigra, with the most prevalent symptoms being shuffling and festinating gait, resting tremors, bradykinesia, and freezing.

Quadcoughing

Is a technique during which the patient performs maximal inspiration; then an assistant exerts pressure at the abdomen to increase the strength of the cough.

Guillain-Barre Syndrome

Is an acute, rapidly progressing inflammatory demyelination polyneuropathy of the peripheral nerves and spinal nerve roots and is sometimes called AIDP. GBS is considered an autoimmune disease that in two-thirds of cases follows an infection. This syndrome has no known cure or cause. The cardinal sign of GBS is the pattern of progression from distal to proximal motor and sensory impairments. The first symptoms are generally numbness and tingling in the palms or soles of the feet, with eventual progression to paralysis of the proximal musculature. Patients with GBS demonstrate an 80% full or nearly full recovery within 200 days of onset. In the acute phase, patient's are generally hospitalized.

Myasthenia Gravis (MG)

Is an autoimmune disease that affects the acetylcholine receptors at neuromuscular junctions of voluntary skeletal muscles. The onset age is between 20 and 30 years old. A second Peak age of onset occurs around ages 60 to 80. Triggers for an exacerbation of MG include an acute or impeding illness, pregnancy and the postpartum period, menstruation, being undermedicated or missing doses of medication, major surgery, and some antibiotics in cardiac medications.

Cerebral Perfusion Pressure (CPP)

Is an indirect measure of perfusion in the brain (or the blood pressure of the brain). 60-65: Ideal levels, therapy proceeds as normal. 50-59 & 65-70: Therapy can be performed but should be limited to light activity. <50 or >70: Defer therapy. Cerebral auto-regulation becomes impaired at approximately 50. <30: Indicates a poor prognosis, resulting in irreversible neuronal hypoxia.

Traumatic brain injury

Is an injury to the head either by a blow, penetrating injury, or jolt that causes damage to the brain.

Dyssynergia

Is any disturbance of muscular coordination, resulting in uncoordinated and abrupt movements. This is also an aspect of ataxia. It is typical for dyssynergic patients to split a movement into several smaller movements.

Hemorrhagic Stroke

Is bleeding in the brain, as in an intracerebral hemorrhage (ICH), or around the brain, as in the case of a subarachnoid hemorrhage (SAH).

Ischemic Stroke

Is caused by blockage of a blood vessel via an embolism, thrombus, or dissection.

Normal Pressure Hydrocephalus

Is communicating hydrocephalus without an associated rise in ICP due to decreased absorption of CSF. The most prevalent symptoms are cognitive decline, drop attacks (sudden fall with no antecedent event), urinary incontinence, and shuffling gait.

Complex Regional Pain Syndrome (CRPS)

Is considered a disease of the SNS and is a chronic pain syndrome. The current etiology theory is that the SNS overreacts disproportionally to a noxious stimulus, becoming a continuous, sympathetically maintained reflex arc despite elimination of the stimulus. The symptoms may be present in one limb, or, in more advanced cases, in multiple limbs, the face, eyes, or whole body.

Intracranial Pressure (ICP)

Is defined as the pressure exerted on the brain by extra tissue or fluid (CSF or blood) inside the cranium. Increased ICP can cause brain herniation (the brain displaces though the anatomic opening). The intraventricular system transducer is leveled with the tragus of the ear, and a lumbar drain is maintained at the same level as the bed and umbilicus.

Autonomic nervous system

Is further subdivided into the sympathetic and parasympathetic nervous systems and enables the body to control stress reactions and maintain homeostasis.

Intraventricular Catheter

Is inserted into the ventricles (usually the lateral ventricle) of the brain and drains excess CSF via am external ventricular drain. The drop chamber is external and level with the ear at the external auditory meatus or tragus.

Diencephalon

Is made up of the thalamus, hypothalamus, pituitary, and limbic system and is the oldest region of the brain in terms of evolution.

Nondeclaritive or implicit memory

Is more subjective and focused more on motor engrams; learned, emotional responses; and procedural recall.

Cerebrospinal Fluid (CSF)

Is produced in the brain's ventricles, which are its draining system. CSF starts flowing in the lateral ventricles and then is channeled into the third ventricle via the foramina on Monro. It is shunted from the third ventricle through the cerebral aqueduct into the fourth ventricle, then passes through the foramina of Magendie and Luschka into the subarachnoid space around the spinal cord and the brain.

Neuroplasticity

Is the ability of the brain to adapt or change through habituation, learning, and memory to facilitate recovery from injury.

Executive Function

Is the integrative cognitive processes that determine goal-directed and purposeful behavior that pulls all other cognitive skills together.

Secondary Progressive MS

Is the least common type. It begins as the relapsing-remitting type, but then most patients with RRMS will progress to SPMS, although the diagnosis is made retrospectively. The disease progresses steadily with or without relapses, generally occurring 10-20 years after onset.

Arachnoid mater

Is the middle layer, which loosely surrounds the brain. It looks like a spider web, thus its name.

Relapsing-Remitting MS

Is the most common type, affecting 85% of people with MS. Each exacerbation occurs over several days to a few weeks, then stabilizes and resolves over another few weeks, leading to either a full recovery or residual deficits that do not worsen until another episode occurs. The deficits are cumulative because the disease has periods of exacerbation followed by remission. There is no disease progression between exacerbations. The average number of relapses is one every 2-3 years.

Dura mater

Is the outermost and most fibrous later and is actually made up of two layers. It surrounds and protects the CNS and separates specific sections, including the longitudinal fissures between the hemispheres and between the occipital lobes and the cerebellum. The roots of the spinal nerves pierce the dura mater in the spinal canal.

Cerebellum

Is the primary controller of balance and coordination.

Declaritive or explicit memory

Is the recall of facts, concepts, and events.

Autonomic Dysreflexia

Is the response of the ANS to noxious stimuli. Examples include distended bladder, fecal mass, ingrown toenail, toe pushed against the footboard of the bed, kinked catheter, or overheating. It is frequently characterized by autonomic symptoms such as perspiration, flushing, chills, nasal congestion, hypertension, and lowered heart rate. the cause must be quickly ascertained because autonomic dysreflexia can be a life-threatening situation with rapid onset. Place the patient in an upright position (in his or her wheelchair or bed) to help reduce elevated blood pressure. Remove any constricting clothing (thromboembolic deterrent hose, abdominal binder) or objects that may be noxious stimuli. Check for kinked catheter, and empty the catheter bag. Notify the nurse immediately.

Parasympathetic nervous system (PSNS)

Is usually inhibitory in nature, conserving and restoring body functions. It arises from the craniosacral region- specifically the oculomotor (III), facial (VII), glossopharyngeal (IX), and vagus (X) nerves and spinal segments S2-S5. It is most involved in slowing the heart rate to conserve energy, increasing intestinal and gland activity, and relaxing sphincter muscles to allow for voiding activities.

Incidence of strokes

Ischemic (thrombic and embolic)- 87% Hemorrhagic, SAH- 3% Hemorrhagic, ICH- 10%

What are the two different types of mechanisms in which CVAs occur?

Ischemic and hemorrhagic

Spinal Cord

It is considered the core of the lower motor neuron region. The spinal cord is a cylindrical tube, approximately 18 inches long, encased within the vertebral column, ending between the first and second vertebrae.

Ataxia

Lack of muscle coordination

Anoxia (TBI)

Lack of oxygen to the brain

Brown-Sequard

Lateral damage as a result of damage to one side of the spinal cord, usually because of a stabbing or gunshot wound. The patient experiences motor paralysis and loss of deep touch and proprioception on the ipsilateral side of the injury and loss of pain, temperature, and touch discrimination on the contralateral side.

Wallenberg's syndrome

Lesion of the posterior inferior cerebellar artery syndrome. It is a lesion of the dorsolateral medulla (often called lateral medullary syndrome) - Severe sharp pain on ipsilateral side of face or eye is often the first symptom - Nystagmus with horizontal and rotational components - Hoarseness - Hiccups - Ipsilateral poor gag - Ipsilateral ataxia/dysmetria - Diplopia, blurred vision, or oscillopsia (objects jigging) - Vertigo, impaired vestibulo-ocular reflex causing severe dizziness - Truncal imbalance > limb ataxia - Lean, veer, or fall toward the ipsilateral side - Crossed sensory loss (sensory loss on ipsilateral face; poor pain and temperature sensation on contralateral body) - Central pain most commonly on the contralateral ipsilateral face; poor pain and temperature sensation on contralateral body) - Central pain most commonly on the contralateral limb and ipsilateral cheek, described as constant, burning, exacerbated by movement and ipsilateral cheek, described as constant, burning, exacerbated by movement and cold

Anterior Spinal Cord Syndrome

Loss of all motor function and sensation (except light touch and proprioception) below the injury due to damage to or infarction of the anterior spinal artery, which supplies all but the posterior (or dorsal) column of the spinal cord. The dorsal column contains the pathway for light touch and proprioception, which is why this is preserved with an infarct of the anterior spinal cord artery.

Broca's Aphasia

Loss of motor control of speech Impaired fluency of speech, especially telegraphic speech, expressive aphasia

MAP Acronym

Mean Arterial Pressure

How to measure a shoulder subluxation

Measuring a subluxation using the fingerbreadth method is acceptable for identifying and quantifying the size of the subluxation. However, this method may not detect minor subluxations. This technique should be completed with the patient sitting up and the arm hanging down. The occupational therapist feels the gap between the bottom of the acromion and the humeral head. This gap is described in terms of the size of the finger width, going in half-finger increments. Ex. 1-finger subluxation, 2-finger subluxation

Stupor

Minimally arousable (i.e., eye opening, withdrawing, or pushing therapist away) only with noxious stimuli such as sternal rub (rubbing knuckles up and down the sternum), calling the patient loudly, pinching arm or leg, deep nail bed pressure (use a pen, not just pinching the nail bed), shaking the patient's shoulders, shaking the bed, washing face with a cold cloth. Will not actively participate in therapy and has minimal awareness of self.

Symptoms of Conversion Disorder

Motor Symptoms: - Paralysis of one or more extremities with ataxia or tremor - Dystonia and chorea movement patterns (most common) - Urinary retention or incontinence - Speech impairments (hoarseness, aphonia, dysarthria) - Swallowing deficits or a choking sensation - Seizure - Bronchospasms - Blepharospasms (twitching or blinking of the eyelid) - Loss of speech (aphasia) Sensory symptoms: - Visual deficits (i.e., double vision, blindness) - Hallucinations - Deafness - Sensory loss (may follow a stocking-glove distribution, with uniform loss of touch, pain, and temperature)

Complete SCI

No motor or sensory function preserved at and below the level of the injury.

What are the two types of memory?

Nondeclaritive and declaritive

Coma

Not arousable with any type of stimulus, including a noxious stimulus. The patient may exhibit physiological reflexive responses that are abnormal or normal.

Complex seizure

Occurs in both sides of the brain, usually producing an absence, tonic-clonic, or atonic seizure.

Simple seizure

Occurs only in one part of the brain.

Thrombotic Stroke

Occurs when a clot or plaque (fatty deposit) forms in the vessel, eventually blocking it.

Embolic Stroke

Occurs when a clot or plaque dislodges and travels to a vessel that is too small to allow it to pass, thus forming a blockage.

Cauda Equina Syndrome

Occurs with burst fractures, epidural abscess or hematoma, or herniated discs at levels L2-L4 with flaccid paralysis without spasticity as the primary feature. Cauda equina syndrome is considered a peripheral nerve or lower motor neuron injury and as such has the potential to regenerate with improvement generally ending about 1 year after the injury. This injury can have a sudden onset or may progress over time. This injury requires emergency surgery for spinal decompression. Symptoms include: - Bladder and anal sphincter muscles are flaccid; therefore, patient is incontinent; - LEs are hypotonic and weak with pain and weakness generally more prominent in one leg; presents as stumbling gait, bilateral foot drop, and difficulty standing up from a seated position (weak hip extensors and quadriceps); - Perineal numbness in saddle distribution; - Deep tendon reflexes are absent.

Cranial Nerve III

Oculomotor Function: - Autonomic function- reflexive pupillary construction and accommodation - Motor- innervates muscles of the eye: * Levator palpebrae superioris- elevates eyelid * Superior rectus- elevation, intorsion, and adduction * Inferior rectus- depression, extorsion, and adduction

Cranial nerve I

Olfactory nerve Function: Sensory and smell

Cranial Nerve II

Optic nerve Function: - Sensory - Vision including acuity, visual field, and brightness

Sympathetic nervous system (SNS)

Originates at spinal levels T1 to L2 or L3 in the intermediolateral cell column. The primary function of the SNS is to mobilize energy, stimulating (remember the s-sympathetic = simulates) the internal organs and inhibiting digestion. It prepares the body for the fight-or-flight response.

Emergence from the minimally conscious state

Patient demonstrates functional communication and consistent and reliable functional use of objects. At this point the patient is no longer considered to be in a coma. The patient will often be described as in a confusional state level, in the levels established by the Rancho scale revised can be better use starting at level four.

Halo Vest

Patients with an unstable cervical fracture may wear a halo vest for stability. This vest will increase safety and neck ability for functional mobility. The halo weighs only 7 lb even though it feels very heavy to the patient. Encourage the use of button up shirts. Do not pull or push on the halo, especially when performing bed mobility. The Halo is stabilized by being directly screwed into the skull. In the event that the halo becomes dislodged, the therapist should keep the head and neck stable and in midline. The situation is emergent; obtain medical assistance immediately.

Peripheral neuropathies

Peripheral neuropathy, a result of damage to the nerves outside of the brain and spinal cord (peripheral nerves), often causes weakness, numbness and pain, usually in your hands and feet. It can also affect other areas of your body.

Complex tonic-clonic (grand mal)

Phases: Tonic - Motor: stiffening of extremities; all limbs and spine extend, jaw clamps shut. If standing, will usually fall backward - May cry out due to sudden force exhalation - May bite tongue or cheek - Pupils dilate and are nonreactive - Loss of consciousness Respiratory muscle spasm, causing apnea Clonic - Motor: Bilateral jerking of limbs, trunk, and neck as muscles relax and tighten rhythmically - Labored breathing - Skin may turn pale or bluish - Profuse sweating - Frothing at the mouth - Incontinence - Clenched jaw - Hypertension and tachycardia or bradycardia (look at the monitors if possible) Typical tonic-clonic seizure lasts less than 5 minutes - Probably changes in vital signs

What are the specific stages of a seizure?

Preictal (aura), ictal (the actual seizure activity), and postictal (recovery phase).

Incomplete SCI

Preservation of some sensation or motor capabilities at or below the injury depending on the level of injury.

What is the main cause of Parkinson's disease?

Reduced dopamine production

Brainstem

Regulates information flow between the brain and the spinal cord and controls the body's functions, such as breathing and swallowing.

Craniotomy

Removal of a portion of the skull (bone flap) and subsequent opening of the dura. The skull is then replaced. Purpose: - Remove a tumor - Relieve pressure - Drain blood from a hemorrhagic area - Repair damaged area

Cranioplasty

Replacement of the bone flap in the skull.

Obtunded

Requires constant tactile or motor stimulation to obtain and maintain arousal. May need to be sitting to maintain arousal. When awake, the patient is confused and not able to productively participate in therapy.

Spasticity

Results from muscles' inability to inhibit messages to contract and tighten, thus forming an overactive muscle response. The brain's efficient reflex centers are not able to control muscle function below the level of the SCI, so the spinal cord sends messages that do not allow the nerves to on control voluntary movement. Spasticity can be very painful. Many patients see a spasm for the first time and think that muscle function is returning. Educate patients on the nature of spasticity and handle the situation gently- they are probably hopeful or desperate for movement.

Scaption

Shoulder motion in a diagonal direction about 45 degrees between flexion and abduction.

What are the two types of Partial Seizures?

Simple and Complex

What are the two general types of seizures?

Simple seizure and complex seizure.

Hypokinetic

Slowed or reduced muscle movement. Hypokinesia is a type of movement disorder. It specifically means that your movements have a "decreased amplitude" or aren't as big as you'd expect them to be. Hypokinesia is related to akinesia, which means absence of movement, and bradykinesia, which means slowness of movement.

Clipping

Small metal clip placed around the base of an aneurysm.

Aura

Some people have triggers that immediately precede a seizure, including pain, flashing lights, strong emotions, and intense exercise. These sensory manifestations are typically called an aura but are actually a simple, partial seizure that manifests as a change in sensorium.

Conversion Disorder

Sometimes called functional disorder. This is a psychiatric disorder listed in the DSM as a subset of somatic symptom disorders. Conversion disorder is a mental condition in which a person has blindness, paralysis, or other nervous system (neurologic) symptoms that cannot be explained by medical evaluation. Symptoms are inconsistent and may include motor or sensory pseudo-neurological symptoms that frequently resemble a stroke or SCI.

Cranial Nerve XI

Spinal Accessory Function: Motor: - Trapezius: shrug shoulders - Sternocleidomastoid (SCM): turn head side to side

Homeostasis

Stable equilibrium

Hoffman's Sign

Stimulus: Flick the middle-finger nail bed. Normal Response: No response Abnormal Response: Extension of the distal interphalange with subsequent flexion of the thumb, fingers, or both. Usually present in pyramidal test lesions.

Romberg Sign

Stimulus: Patient stands with feet together and eyes closed. Do not perform test if patient cannot maintain balance with eyes open. Normal Response: Mild sway with no loss of balance Abnormal Response: Inability to maintain balance, indicating a loss of position sense or reduction of peripheral sensation.

Babinski

Stimulus: Performed by running a blunt object (pen or thumbnail) from heal to toes in an arc along the metatarsals. Normal Response: Flexion of all toes with plantar foot eversion Abnormal Response: Extension of one big toes and fanning of other toes; indicative of upper motor neuron damage.

Doll's Eyes (noted only in comatose patients)

Stimulus: Turn head manually while watching the eyes. May need to hold the eyes open. Normal Response: While turning the head, the eyes should continue to look at the ceiling. Abnormal Response: If the eyes follow the movement of the head, this movement indicates brainstem involvement.

Spinal cord infarct

Stroke within the spinal cord vascular distribution. The pattern of deficits is dependent on the level of the infarct and the vascular distribution.

Neurosurgical Procedures (precautions)

Surgeries performed on the CNS Precautions: - Check neurosurgical order set. - Avoid bending over for prolonged periods of time (i.e., when tying shoes or donning pants). - Confirm lifting restriction limits with neurosurgeon. - Avoid Valsalva maneuvers such as straining to have a bowl movement, holding breath, and lifting. - Monitor vital signs, including blood pressure, heart rate, and oxygen saturation, especially the first time the patient gets up. - Check for elevated intracranial pressure. - Monitor for reperfusion injuries.

Debulking

Surgical excision of a CNS mass.

Cranial Nerve V (trigeminal nerve) Testing

Test: - Facial sensation: sharp or dull, light touch, hot/cold - Clench mouth- palpate masseter as the jaw is clenched. This should also cause the temoralis muscle at the temple to contract, which is palpable - Corneal reflex- touch a wisp of cotton to the patient's cornea - Jaw jerk- stroke middle of the jaw with a reflex hammer Normal response: - No facial sensory deficits - Masseter strong and no atrophy noted - Corneal reflex test- blinks with light touch of cotton to cornea - Jaw jerk- Should note slight jaw closing

Cranial Nerve I (olfactory nerve) Testing

Test: - Patient identifies various strong, easily identifiable scents (i.e., vanilla, peppermint, coffee, garlic) - The scent must not be noxious - Test east nostril with patient's eyes closed. Normal response: Correctly identifies scents

Cranial Nerve XII (hypoglossal nerve) Testing

Test: - Stick out tongue and check for deviation from midline - Instruct the patient to move the tongue from side to side - Instruct the patient to push his or her tongue into the side of the cheek while providing counter pressure from the outside Normal response: Tongue is in midline when patient sticks it out and is able to move it side to side

Cranial Nerve VI (abducens nerve) Testing

Test: - Test both eyes at the same time - Tracking- Move a target in the shape of an H so all cardinal planes pf movement are evaluated Normal response: - Eyes move in a normal manner with no diplopia

Cranial nerves IX and X (glossopharyngeal nerve and vagus nerve) Testing

Test: - The nerves are tested together because the tests are the same and essentially looking for the same responses - Speak without hoarseness (i.e., "ah") - Stimulate back of throat to elicit gag using a tongue depressor or long cotton swab Normal response: - Palate usually elevates symmetrically with uvula centered - Gages with stimulus - Voice quality and pitch is normal - Able to tell the difference between salt and sweet - Can feel light touch on the outside of ear

Cranial Nerve II (optic nerve) Testing

Test: - The patient should be wearing any glasses he or she usually wears - The following tests will only provide gross results; if deficits are noted, recommend further testing with an eye doctor - Ideally test acuity with a Snellen chart, but if one is not available use your badge, a pamphlet, or a newspaper - Test one eye are a time, then together. It is normal for the acuities to be different in each eye and binocularly - Test visual fields in all quadrants monocularly (patient covers one eye). The patient should look at the therapist's nose (therapist is directly in front of the patient). Using a pen, start just behind the ear and bring it forward in an arc. Instruct the patient to indicate (i.e., by saying "yes" or "now") when the stimulus is first seen. - If the patient is obtunded, wave your hand in the periphery to determine if the patient "blinks to threat" Normal response: Intact acuity and full visual field

Cranial Nerve IV (trochlear nerve) Testing

Test: Note: Cranial nerves III, IV, and VI are generally tested at the same time using the 6 cardinal directions of gaze. The physician will document this as "EOM" (extraocular movement) - Test both eyes at the same time - Tracking and smooth pursuits Normal results: Eyes should move together with no diplopia

Cranial Nerve III (oculomotor nerve) Testing

Test: Note: Cranial nerves III, IV, and VI are generally tested at the same time using the 6 cardinal directions of gaze. The physician will document this as "EOM" (extraocular movement) Test both eyes at the same time: - Tracking and smooth pursuits - Convergence: instruct patient to watch your finger and move it toward the nose - Pupillary response: shine flashlight into one eye at a time to observe pupil construction Normal response: - Tracking- both eyes will continue to track the stimulus in a smooth manner and equally. It is normal for the eyes to move in a yoked manner, i.e, when the left eye looks left, the right eye will also look left - Convergence- eyes should adduct smoothly and equally. The nondominant eye will diverge momentarily at the point of convergence - Pupillary response- both pupils should construct - Normal pupil size is 2-4 mm in the light or 4-8 mm in the dark. A 1 mm difference can be normal

Cranial Nerve XI (spinal accessory) Testing:

Test: Resistant to shoulder shrugs (trapezius) and turning the head to the side as if looking over the shoulder (SCM). The right SCM (right cranial nerve XI) is responsible for turning the head to the left; therefore, the therapist would resist the left turn to test the right SCM. Normal response: Full active ROM and strength

Cranial nerve VII (facial nerve) Testing

Testing: - First look at the face - Wrinkle forehead - Smile so examiner can see top and bottom teeth, frown, and puff out cheeks - Shit eyes tightly and keep them shut while therapist tries to open them manually - Taste- Use sugar, salt - Expose to a stimulus that would make the patient tear up, such as cutting an onion (therapists generally will not test this in the hospital) Normal response: - Face should appear symmetrical, including symmetrical wrinkles on the forehead, equal size and shape of the nasolabial fold (lines coming down from the nose toward the corner of the mouth), and the corners of the mouth should be equal - Symmetrical smile and should be able to see both top and bottom teeth in equal amounts - Cheeks puff out equally - Eyes shut and strength is normal - Salivates and tears - Tastes salt and sweet

ASIA Assessment

The ASIA classification will assist in determining in the degree and pattern of paralysis and sensory loss. ASIA testing is crucial for determining the level of injury, which is not always at the same level as the vertebral fracture. Generally, unless the occupational therapist is working in a specialized spinal cord unit and is specifically trained, a physician or nurse performs this test.

Labile Behavior

The main symptoms of mood lability are sudden, exaggerated, unpredictable, or uncontrollable changes in moods and emotions. These are usually exaggerated or inappropriately intense emotional reactions. Other symptoms of mood lability include: - Short emotional outbursts that don't last for more than a few minutes - Mixed emotional states, such as laughing that turns into crying - Laughing or crying in situations that other people don't find funny or sad - Emotional responses that are over-the-top for the situation - Emotional outbursts that are out of character

Central Nervous System Tumors

The most common: Astrocytoma (most common, can grow slowly or quickly) Glioblastoma multiforme (grows and spreads rapidly) Metastatic tumors (cancer cells that have traveled to the CNS) Symptoms depend on where the tumor is located. However, there are no sensory nerve endings in the brain, so patients do not feel tumors growing until they push on structures that cause pain. Treatments include debulking via craniotomy, radiation, and chemotherapy.

The Thumb Localization Test

The patient is instructed to close his or her eyes, and then the occupational therapy practitioner moves the patient's hand and arm passively into various positions. Where this test deviates from traditional proprioceptive testing is that once the hand is positioned, the patient is asked to grasp their thumb with the other hand. If the patient grasps their thumb with no hesitation, there is no loss of proprioception. The patient shows a mild loss if the thumb is missed by a small amount, a moderate loss if the patient uses the arm as a landmark to locate the thumb, and a severe loss if the patient cannot locate the thumb.

Minimally Conscious State, Higher Level

The presence of higher-level skills such as following commands and intelligible verbalizations with non functional communication such as the definitive yes and no responses.

Primary Progressive MS

The second most common type. The symptoms are continuous with no remission and continue to worsen, although there may be acute relapses, plateaus, or temporary minor improvements. The most common symptoms are spinal cord-related with no specific sensory level and spastic paraparesis.

What are the parts of the peripheral nervous system?

The somatic nervous system and the autonomic nervous system

Complex Regional Pain Syndrome (CRPS) Symptoms

The stages are acute, dystrophic, and atrophic. The acute stage generally involves burning or aching pain of the limb, extreme sensitivity to touch, and increased hair and nail grown. The dystrophic stage features edema, cold or cyanotic skin, increased muscle tone with tremors and spasms, burning radiating pain, and increased sweating. The atrophic stage includes contractures with fixed joints, cyanosis, subcutaneous skin atrophy, painful motion, and temperature tolerances.

Decerebrate Posturing

This is a type of extended posturing and can indicate damage to the brain stem. This is the worst type of posturing between the two. There will be adduction and extension and pronation of the hands and the fingers will be flexed along with extended legs and plantar flexion of the feet. Look at all the E's in the word. There are a lot of them, so remember the word EXTENDED. The arms are going to be Extended rather than flexed.

Decorticate Posturing

This is a type of flexed posturing and can indicate damage to the cerebral hemispheres. There will be adduction and flexion of the arms and the hands will be closed shut (flexed). The legs will be rotated internally and feet flexed. Remember the letters COR in the word deCORticate for the word "core". The patient will bring their arms to the cord of the body (middle).

How many meninges are there and what are they?

Three meninges provide protective membrane layers around the spinal cord. 1. Dura mater 2. Arachnoid mater 3. Pie mater

Burr Hole

Tiny hole drilled into the skull

TPA Acronym

Tissue Plasminogen Activator

TIA

Transient Ischemic Stroke A transient ischemic attack (TIA) is a temporary period of symptoms similar to those of a stroke. A TIA usually lasts only a few minutes and doesn't cause permanent damage. Often called a ministroke, a transient ischemic attack may be a warning. About 1 in 3 people who has a transient ischemic attack will eventually have a stroke, with about half occurring within a year after the transient ischemic attack. A transient ischemic attack can serve as both a warning of a future stroke and an opportunity to prevent it.

Cranial Nerve V

Trigeminal (3 branches) - Opthalmic - Maxillary - Mandibular Function: Supplies sensation and motor function to the face, nasal/buccal mucosa, teeth

Cranial Nerve IV

Trochlear Function: Motor - Innervates superior obliques- intorsion, depression, and abduction

Meningioma

Tumor that arises from the arachnoid

The National Institutes of Health Stroke Scale

Used since 1983, is the primary evaluation tool used for strokes that present to the hospital. The scale includes symptoms from all major vascular distributions, but there is greater emphasis on damage to the left hemisphere. It has been shown to be a strong predictor of disposition as well as functional outcomes. An NIHSS score of <5 predicts disposition for home with good functional outcomes; patients with a score of 5-15 will likely discharge to a rehabilitation facility with moderate functional outcomes; and scores .15 will probably go to a nursing facility with poor functional outcomes or mortality.

Evacuation

Usually done in conjunction with a burr hole, craniectomy, or craniotomy to remove excess intracerebral blood or a clot.

Vertigo

Vertigo is a sensation of feeling off balance. If you have these dizzy spells, you might feel like you are spinning or that the world around you is spinning.

Cranial Nerve VIII

Vestibulo-cochlear Function: - Crochlear branch is sensory and carries sound from the cochlea to the brain - Vestibular branch maintains equilibrium - Position of head in space - Provides stable visual image during hear movement - Postural control

Function of the Occipital Lobe

Vision

Dysarthria

Weakness in the muscles used for speech, which often causes slowed or slurred speech.

How to document on tone

When evaluating tone, note whether it is primarily flexor or extensor synergistic patterning, hypertonic or hypotonic, and if muscle spasms are present.

How are TBIs organized/categorized?

Whether they are open or closed and where the initial injury was: on the side of the initial impact (coup), the opposite side of the initial impact (countercoup), or if damage is a combination of coup-countercoup. The injury is further described as focal (specific location of impact) or diffuse (as in a shearing injury).

Diffuse Anoxal Injury (TBI)

White matter shearing

How long is someone on bedrest after receiving t-PA?

t-PA has a half life of 5-10 minutes in the bloodstream, so bedrest is not necessary required for 24 hours after administration. However, check the hospital's policies and procedures for therapy time restrictions after t-PA administration. Patients who receive t-PA are generally admitted to the intensive care unit (ICU) for continuous monitoring of vital signs, symptoms of neurological change, and hemorrhagic transformation.