NPTE Neurological

What does the oculomotor circuit of the BG do?

"Caudate circuit" Originates in frontal and supplementary motor eye fields; projects to caudate; functions with saccadic eye movements

What does the posterior lobe of the cerebellum do?

"Cerebrocerebellum" Receives input from corticopontocerebellar tracts and olivocerebellar fibers It is 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 May have a role in assisting cognitive functions

What does the fissure of Sylvius do?

"Lateral fissure" Separates the frontal and parietal lobes from the temporal

What is Amyotrophic Lateral Sclerosis?

"Lou Gehrigs Disease" Degenerative disease affecting both UMNs and LMNs with degeneration of anterior horn cells and descending corticobulbar and corticospinal tracts 5-10% of cases are genetic Mortality within 2-5 years

What does the motor loop of the BG do?

"Putamen loop" Originates in precentral motor and postcentral somatosensory areas; projects to and excites putamen neurons; putamen cells inhibit globus pallidus neurons, which in turn boosts activity in the ventral lateral nucleus and supplemental motor area; functions to sale amplitude and velocity of movements; reinforces selected pattern, suppresses conflicting patterns, prepartory for movement (i.e. motor set, anticipatory movement)

What does the anterior lobe of the cerebellum do?

"Spinocerebellum" Receives input from proprioceptive pathways and is concerned with modifying muscle tone and synergistic actions of muscles It is important in maintenance of posture and voluntary movement control

What is trigeminal neuralgia?

"Tic douloureux" Lesion of trigeminal nerve CN V Can occur in older population with abrupt onset Signs and symptoms: brief paroxysms of neurogenic pain with frequent reoccurrence along the distribution of CNV (mandibular and maxillary divisions) on one side of phase TENS can be helpful

What does the flocculonodular lobe do?

"Vestibulocerebellum" Connects the vestibular system and is concerned with equillibrium and regulation of muscle tone Helps coordination with the vestibulo-ocular reflex Maintenance of balance, control of eye movements

How do you score reflexes?

0 = absent 1+ = tone change; no visible movement of extremities 2+ = normal; visible movement of extremities 3+ = exaggerated, full movement of extremities 4+ = obligatory and sustained movement, lasting for >30sec

How do you score coordination?

0 = unable to do motion 1 = severe impairment 2 = moderate impairment 3 = minimal impairment 4 = normal performance

What are the 6 stages of recovery for stroke?

1. Initial flaccidity, no voluntary movement 2: emergence of spasticity, hyperreflexia, synergies 3: voluntary movement possible, but only in synergies; spasticity is strong 4: voluntary control in isolated joint movements emerging, corresponding decline of spasticity and synergies 5: increasing voluntary control out of synergy, coordination deficits present 6: control and coordination near normal

What are the stages of ALS?

1: early disease, mild focal weakness, asymmetrical distribution; hand cramping and fasciculations 2: moderate weakness in groups of muscles, some wasting (atrophy) of muscles; modified independence with assistive devices 3: severe weakness of specific muscles, increasing fatigue, mild to moderate functional limitations, ambulatory 4: severe weakness and wasting of LEs, mild weakness of UEs, moderate assistance and assistive devices required; wheelchair user 5: progressive weakness with deterioration of mobility and endurance, increased fatigue, moderate to severe weakness of whole limbs and trunk; spasticity, hyperreflexia; loss of head control; max assist 6: bedridden, dependent ADLs, FMS, progressive respiratory distress

How long can you expect levadopa to be successful?

2-3 years

How many segments in the spinal cord?

30 8 cervical 12 thoracic 5 lumbar 5 sacral +a few coccygeal

What is multiple sclerosis?

A chronic, progressive, demyelinating disease of the CNS affecting mostly young adults Lesions common in pyramidal tract, dorsal columns and periventricular areas of cerebrum, cerebellar peduncles Exacerbating factors: infections, trauma, pregnancy, stress

What is epilepsy?

A disorder characterized by recurrent seizures (repetitive abnormal electrical discharges within the brain)

What does the substantia nigra do?

A large motor nucleus that is a part of the basal ganglia Important for motor control and muscle tone Two parts: compacta and reticulata

What is myasthenia gravis?

A neuromuscular junction disorder characterized by progressive muscular weakness and fatigability on exertion Autoimmune antibody-mediated attack on acetylcholine receptors at NMJ

What is second impact syndrome?

A second concussion is experienced before the brain has a chance to heal from the first event Can produce severe changes including brain swelling, massive increase in intracranial pressure and brain herniation, resulting in permanent brain damage

What does minimally conscious state (MCS) mean?

A state characterized by severely altered consciousness with minimal but definite evidence of self or environmental awareness

What does unresponsive vigilance (vegetative) state mean?

A state characterized by the return of sleep/wake cycles, normalization of vegetative functions (respiration, heart rate, blood pressure, digestion) and lack of cognitive responsiveness 9can be aroused but is unaware) Persistent vegetative state is a state lasting >1yr for TBIs and >3 months for anoxic brain injury

What does coma mean?

A state of unconsciousness from which patient cannot be aroused, eyes remain closed No response to external stimuli or environment

What is the head thrust test?

A test of the vestibular system. The patient focuses on the examiner's nose. The examiner rotates the patient's head. A vestibular deficit manifests with the eyes moving with the head, rather than staying fixed on the nose. If eyes rotate with head and there is a corrective saccade --> peripheral If eyes stay fixed on nose iwth no corrective saccade --> central

What is the general function of CN VI? Where is the exit opening? How do you test? Possible abnormal findings?

Abducens Eye movement (lateral) Superior orbital fissure Look to each side Medial strabismus

What is stereognosis?

Ability to identify familiar objects placed in the hand by manipulation and touch

What is graphesthesia?

Ability to identify numbers, letters or symbols traced on skin, typically the hand

What is barognosis?

Ability to identify similar size/shaped objects placed in the hand with different gradations of weight

What has to occur before repolarization?

Activation of K+ channels

What is Guillain-Barre Syndrome?

Acute, ascending, symmetrical polyneuropathy with progressive muscular weakness that develops rapidly Associated with an autoimmune attack, usually after recovery from infectious illness Involves acute demyelinaton of both cranial and peripheral nerves (LMN disease)

What do the dorsal posterior roots of spinal nerves do?

Afferent (sensory) fibers from sensory receptors from skin, joints, and muscles Each dorsal root has a dorsal root ganglion (cell body of sensory neurons) No dorsal root for C1

What is feedback learning?

Afferent information sent by various sensory receptors to control centers Feedback updates control centers about the correctness of movement while it progresses - shapes ongoing movement Feedback allows motor responses to be adapted to the demands of the environment

What does alterness mean?

Alert patient responds appropriately Can open eyes, look at examiner, respond fully and appropriately to stimuli

What is a generalized seizure?

All areas of brain involved "Grand mal seizures" Symptoms: dramatic loss of consciousness with stiffening then rhythmic movements, eyes open, breathing altered, loss of urine, typically 2-5 min

What are signs and symptoms of epilepsy?

Altered consciousness Altered motor activity (involuntary contractions) - can be tonic (stiff and rigid) or clonic (rhythmic jerking) Sensory impairments Tachycardia, sweating, piloerection Failure of comprehension or inability to communicate, hallucinations

What are the signs and symptoms of increased intracranial pressure/cerebral edema and brain herniation?

Altered level of consciousness Altered vital signs (Cheyne-Stokes respiratios, increased BP, widening pulse pressure) Headache Vomiting Pupillary changes Papilledema at entrance to eye Progressive impairment of motor function - positive babinski, decorticate or decerebrate rigidity Seizures

What is vestibular neuronitis or labyrinthitis?

An acute infection with prolonged attack of symptoms, persisting for several days or several weeks; caused by viral or bacterial infection *Unilateral symptoms

What is a motor plan in motor control?

An overall strategy for movement An action sequence requiring the coordination of a number of motor programs

What speech deficits are found with parieto-occipital cortex lesions in dominant hemisphere?

Aphasia (typically left hemisphere)

What are nodes of Ranvier?

Areas along the axon where there is a gap in the myelin Action potential must jump from one node to the next (saltatory conduction) Increased myelin = increased speed of conduction

What do the corticospinal tracts do?

Arise from primary motor cortex, descend in brainstem, cross in medulla (pyramidal decussation), via lateral corticospinal tract to ventral gray matter (anterior horn cells) 10% of fibers do not cross and travel in anterior corticospinal tract to cervical and upper thoracic segments Important for voluntary motor control

What does the vestibulospinal tracts do?

Arise from vestibular nucleus and descend to spinal cord in lateral (uncrossed) and medial (crossed and uncrossed) vestibulospinal tracts Important for control of muscle tone, antigravity muscles, and postural reflexes

What do rubrospinal tracts do?

Arise in contralateral red nucleus and descend in lateral white columns to spinal gray Assist in motor function

What does the tectospinal tract do?

Arises from superior colliculus (midbrain) and descends to ventral gray Assists in head-turning responses to visual stimuli

What does the reticulospinal system do?

Arises in the reticular formation of the brainstem and descends (crossed and uncrossed) in ventral and lateral columns Terminates both on dorsal gray (modifies transmission of sensation, especially pain) and on ventral gray Influences gamma motor neurons and spinal reflexes

What is characteristic of a CVA in internal carotid artery?

Arises off common carotid and gives off opthalmic, ACA, and MCA ACA syndrome: affects medial cerebral cortex; possible edema, brain herniation, death --> usually minimal deficits through due to collateral circulation in CoW -UE more spared -Contra leg numbness and weakness -Motor aphasia -Ideomotor apraxia MCA syndrome: affects lateral cerebral cortex, basal ganglia, large portions of internal capsule -LE more spared -Contra face/arm numbness and weakness -Aphasa -Gaza preference/neglect

What is characteristic of a CVA in vertebrobasilar artery?

Arises off subclavian as two vertebral arteries --> supplies ventral surface of the medulla and posterior inferior aspect of the cerebellum before joining the basilar artery, which supplies ventral portion of pons and ends in PCA Medial medullary syndrome: affects vertebral anterior branch of lower basilar artery -Ipsilateral paresis of tongue -Contra hemiplegia and sensation loss -Occasional nystagmus Lateral medullary syndrome. "Wallenberg's": affects vertebral, posterior inferior cerebellar, or basilar artery -Ipsilateral ataxia -Ipsilateral Horner syndrome (loss of sweating, droop eyelid, small pupil) -Ipsilateral loss of pain and temp on face - contra on body -Ipsilateral tinnitus Basilar artery syndrome: produces brainstem signs and PCA sign (contra sensory loss), locked-in syndrome ("pseudocoma" - pt is aware but cannot move or communicate due to paralysis of voluntary muscles except for eye blinking and movements) -Complete paralysis Medial inferior pontine syndrome: occlusion of paramedian branch of basilar artery -Contra weakness and numbness -Ipsi face weakness -Diplopia -Ipsi nystagmus Lateral inferior pontine syndrome: occlusion of anterior inferior cerebellar artery -Vertigo -Oscillopsia (visual field oscillates) -Ipsi facial paralysis -Ipsi tinnitus -Contra pain and temp loss over body PCA syndrome "Webers": supplies midbrain, temporal lobe, diencephalon, posterior third of cortex -Conta hemiplegia -Ipsi lateral gaze weakness -Ipsi diplopia

What is typical of a 20mo old?

Ascends stairs step to pattern, running, jumps off bottom step, plays make believe

What is the rancho los amigos levels of cognitive function?

Assesses cognitive recovery from TBI Includes 8 levels of behavior 1 = no response 2 = generalized response - nonpurposeful, few responses, same response regardless of stimuli 3 = localized response - specific response but inconsistent, may follow commands 4 = confused agitated - heightened state of activity, bizarre behavior, nonpurposeful, incoherent and inappropriate phrases, no short or long term recall 5 = confused inappropriate - consistent in simple commands, easily distracted, impaired memory, inappropriate speech, unable to learn new info 6 = confused appropriate - goal directed, dependent on external input, appropriate responses, past memories more detailed than new, task carry over 7 = automatic - goes through daily routine, robot like, initiates social activities, impaired judgement, task carryover 8 = purposeful - able to recall past and current events, is aware of and responsive to the environment, task carryover, no supervision needed once skills are learned Delineates emerging behaviors; patients may plateau at any level

What does the insula do?

Associated with the limbic system Deep within the lateral sulcus Associated with visceral function

What other impairments are common across all cerebellar lesions?

Asthenia: generalized weakness (F to G muscle grades) Hypotonia: especially in acute cerebellar lesions, difficulty with postural control of proximal (axial) muscles Motor learning impairments: decreased anticipatory control, feedback, and learning delays Cognition: deficits in information procession, attention deficits Emotional dysregulation: changes in emotional behaviors

What are risk factors of a stroke?

Atherosclerosis Hypertension Cardiac disease Diabetes TIAs

What does the parietal lobe do (more extensive than above)? What does it include?

Attention, perceptual awareness, processes the sense of touch and pain and participates in cognitive process Postcentral gyrus

What does the temporal lobe do?

Auditory and olfaction, interpretation and meaning to speech and emotion

What are contraindications to exercise training in SCI?

Autonomic dysreflexia Severe infected skin on weight bearing surface Symptomatic hypotension UTI Unstable fracture Uncontrolled hot and humid environments Insufficient ROM

For vertigo, short duration of dizziness with no hearing loss is indicative of what?

BPPV

What is typical of an 8-9mo old?

Belly crawls, quadruped creeping, side-sitting, pulls to stand through kneeling, cruises, stands alone, transfer objects between hands

What is pseudobulbar palsy?

Bilateral dysfunction of corticobulbar innervation of brainstem nuclei; a central or UMN lesion analogous to corticospinal lesions disruption function of anterior horn cells Produces similar symptoms to bulbar palsy Examine for hyperactive reflexes: increased jaw jerk (CN V), snout reflex

Blocked vs variable vs random vs serial practice

Blocked: single motor skill repeatedly Variable: varied motor skills Random: class of motor skills in random order Serial: class of motor skills in predictable order

How might a person with an SCI react to cardiovascular training physiologically?

Blunted tachycardia Lack of pressor response Very low VO2 peak Substantially higher variability of most responses

What is optical righting reflex?

Body tilt Eyes maintain oriented with head Birth - persists

What is in the forebrain?

Brain, hippocampus, basal ganglia, amygdala

What is benign paroxysmal positional vertigo (BPPV)?

Brief attacks of vertigo and nystagmus that occur with certain head positions (lying down, turning over in bed, tilting head back) May be related to degenerative process, mechanical impairment of peripheral vestibular system *Unilateral symptoms

What is the mini-mental state examination?

Brief screening test for cognitive dysfunction Includes screening items for orientation, registration, attention and calculation, recall and language Max score is 30 Mild cognitive impairment = 21-24 Mod cognitive impairment = 16-20 Severe cognitive impairment = 15 or less

What levels result in tetraplegia?

C1-C8

What is the sequence for dermatome and myotome testing?

C1: top of skull - none C2: temple, forehead, occiput - none C3: neck, posterior cheek, temporal area, under mandible - breathing C4: shoulder, clavicular area, upper scapular area - shoulder shrug C5: deltoid, anterior arm to base of thumb - deltoid C6: anterior arm, radial side of hand to thumb and index finger - biceps C7: medial arm and forearm to middle finger - triceps, FCU, FCR C8: ring and pinky, ulnar side of forearm and medial arm - FCU, ECU T1: medial side of forearm - interossei T2: medial upper arm (pit), sub-clavicle area - none T4: nipple line - none T10: belly button - none T12: ASIS - none L1: upper groin, lower back - none L2: lower groin, anterior thigh/knees, upper buttocks - iliopsoas L3: sacral area, knees, medial thigh from groin to knee - quadriceps L4: medial lower leg anterior and posterior - anterior tibialis L5: anterior tibial region, toes - extensor hallicus longus S1: lateral foot, plantar aspect of foot, gastroc - gastroc S2: posterior thigh - hamstrings S3: buttock - none S4: rectum, anal area, lower sacrum - bladder, rectum

What reflex level is tested with biceps tendon?

C5-C6

What reflex level is tested with brachioradialis tendon?

C5-C6

What reflex level is tested with triceps tendon?

C6-C7

What is gag reflex?

CN IX, CN X Stimulate each side of back of throat Gag - may be normally absent

What is the corneal blink reflex?

CN V, CN VII Pt looks up and away, stroke cornea Both eyes blink

What pathological findings could you potentially find from a lumbar puncture?

CSF normally is 90-180 mm H2O pressure Increased pressure = intracranial tumors, abscesses, meningitis, inflammatory processes, subarachnoid hemorrhage, cerebral edema, thrombosis of venus sinuses Decreased pressure = leaking CSF, subarachnoid black circulatory collapse, severe dehydration Changes in color = inflammatory disease, hemorrhage, tumors

What do high lumbar lesions (T12-L3) require for locomotion training?

Can be independent in ambulation on all surfaces and stairs using a swing-through or four point gait pattern and bilateral KAFOs and crutches Patients may also use reciprocating gait orthoses with walker with or without FES Typically independent household ambulators, WC for community

What do low lumbar lesions (L4-5) require for locomotion training?

Can be independent in ambulation with bilateral AFOs and crutches or canes Typically independent community ambulators May still use WC for activities with high-endurance requirements

What does a lesion in the flocculonodular lobe (archicerebellum) of the cerebellum present with?

Central vestibular symptoms: ocular dysmetria, poor eye pursuit, dysfunctional vestibular ocular reflex (VOR), impaired eye-hand coordination Gait and trunk ataxia: poor postural control and orientation, wide-based gait Little change in tone or dyssynergia of extremity movements

What are 3 pathophysiological events of a stroke?

Cerebral anoxia: lack of oxygen to brain, irreversible damage begins after 4-6 min Cerebral infarction: irreversible cellular damage Cerebral edema: accumulation of fluids, causes further dysfunction, elevates intracranial pressures, can result in herniation and death

What is the telencephalon?

Cerebral hemispheres

What nerve roots are associated with the cervical, brachial, lumbar, and sacral plexus?

Cervical: C1-C4 Brachial: C5-T1 Lumbar: T12-L4 Sacral: L4-S3

What is motor learning?

Change in capability of a person to perform a skill - result of practice or experience

What is Parkinson's disease?

Chronic progressive disease of CNS with degeneration of dopaminergic substantia nigra neurons and nigrostriatal pathways Deficiency of dopamine within the basal ganglia corpus striatum with degeneration of substantia nigra Loss of inhibitory dopamine results in excessive excitatory output from cholinergic system of basal gnaglia

What are signs of spastic hypertonia?

Clasp-knife response: marked resistance to PROM gives way suddenly Clonus: maintained stretch stimulus produces a cyclical, spasmodic contraction; common in PFs or wrist flexors or jaw Hyperactive cutaneous reflexes: positive Babinski (spanning of toes with lateral foot stroke) Hyperreflexia: increased DTRs

What are the classes of traumatic nerve injury?

Class 1: neurapraxia -injury to nerve that causes a transient loss of function (conduction block ischemia); nerve dysfunction may be rapidly reversed or persist a few weeks (compression) Class 2: axonotmesis -injury to nerve interrupting the axon and causing loss of function and wallerian degeneration distal to the lesion; with no disruption of the endoneurium, regeneration is possible (crush injury) Class 3: neurotmesis -cutting of the nerve with severance of all structures, complete loss of nerve function, and wallerian degeneration; reinnervation typically fails without surgical intervention because of aberrant regeneration (failure to regenerating axon to find its terminal end)

What are the stages of recovery for TBI?

Coma: unconsciousness, no sleep or wake cycles Unresponsive vigilance/vegetative state: marked by return of sleep/wake cycles and normalization of vegetative functions (persistent = >1 year post TBI) Mute responsiveness/minimally responsive: state in which patient is not vegetative and does show signs of awareness Confusional state: mainly a disturbance of attention mechanisms, no new memories able to form Emerging independence: confusion is clearing and some memory is possible; significant cognitive problems and limited insight remain; frequently uninhibited social behaviors Intellectual/social competence: increasing independence, problem solving is difficult

How do you examine receptive function?

Comprehension Fluent aphasia (Wernicke's, receptive) - spontaneous speech is preserved and flows smoothly, but auditory comprehension is impaired

What is the sensory organization test (SOT)?

Computerized moving platform that tests balance from 6 different sensory conditions 1. Eyes open, stable surface (EOSS) 2. Eyes closed, stable surface (ECSS) 3. Visual conflict, stable support 4. Eyes open, moving surface (EOMS) 5. Eyes closed, moving surface (ECMS) 6. Visual conflict, moving surface Vestibular loss = unstable in 5-6 Dependency on surface = unstable in 4-6 Sensory selection problems = unstable 3-6 Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) is similar but on foam and only does 1-2, 4-5

What is the autonomic nervous system?

Concerned with innervations of involuntary structures (smooth muscle, heart, glands) Helps maintain homeostasis Two divisions: sympathetic and parasympathetic - both have afferents and efferents, and pre and post ganglionic fibers

What do the projection fibers do?

Connects cerebral hemispheres with other portions of the brain and spinal cord

What do association fibers do?

Connects different portions of the cerebral hemispheres, allowing cortex to function as an integrated whole

What does the midbrain do?

Connects pons to cerebrum; superior peduncle connects midbrain to cerebellum Cerebral peduncles - crus cerebri, substantia nigra, tegmentum Superior colliculus Periaqueductal gray

What do the pons do?

Connects the medulla oblongata to the midbrain allowing passage of important ascending and descending tracts Anterior basal part acts as a bridge to the middle cerebellar peduncle Midline raphe nuclei project widely and are important for modulating pain and controlling activity Tegmentum contains several important cranial nerve nuclei (abducens, trigeminal, facial, vestibulocochlear)

What does the medulla oblongata do?

Connects the spinal cord with pons Contains relay nuclei of dorsal columns (light touch); fibers cross to give rise to medial lemniscus Inferior cerebellar peduncle relays dorsal spinocerebellar tract to cerebellum (proprioception) Corticospinal tracts cross in pyramids Medial longitudinal fascisulus arises from vestibular nuclei and extends throughout brainstem and upper cervical spinal cord; important for control of head movements and gaze stabilization (vestibular-ocular reflex) Olivary nuclear complex connects cerebellum to brainstem and is important for voluntary movement control Contains several important cranial nerve nuclei (hypoglossal, dorsal nucleus of vagus and vestibulococohlear) Contains important centers for vital functions, cardiac, respiratory, and vasomotor centers

What is the limbic system?

Consists of the limbic lobe (cingulate, parahippocampal and subcallosal gyri), hippocampal formation, amygdaloid nucleus, hypothalamus, and anterior nucleus of thalamus Phylogenetically oldest part of the brain, concerned with instincts and emotions contributing to preservation of the individual Basic functions include feeding, aggression, emotions, and endocrine aspects of sexual response

What does the tegmentum do?

Contains all ascending tracts and some descending tracts Contains the red nucleus which receives fibers from the cerebellum Is the origin for the rubrospinal tract (influences arm and shoulder muscles - mainly flexors) Important for coordination Contains oculomotor and trochlear nerve nuclei

What does the prefrontal cortex do?

Controls emotions and judgments

What does Broca's area do?

Controls motor aspects of speech

What does the spinoreticular tract do?

Conveys deep and chronic pain to reticular formation of brainstem via diffuse, polysnaptic pathways

What does the spinocerebellar tracts do?

Conveys proprioception information from muscle spindles, Golgi tendon organs, and touch and pressure receptors to cerebellum for control of voluntary movements Dorsal spinocerebellar tract ascneds to ipsilateral inferior cerebellar peduncle Ventrospinocerebellar tract ascends to contralateral and ipsilateral superior cerebellar peduncle

What does the spinothalamic tract do?

Conveys sensations of pain and temperature (lateral spinothalamic tract), and crude touch (anterior spinothalamic tract) Tracts ascend one or two ipsilateral spinal cord segments (Lissauer's tract) --> synapse and cross in spinal cord to opposite side and ascend in ventrolateral spinothalamic system

What does the dorsal column/medial lemniscal system (DCML) do?

Conveys sensations of proprioception, vibration, and tactile discrimination Divided into fasciculus cuneatus (upper extremity, lateral) and fasciculus gracilis (lower extremity, medial) Neurons ascend to medulla where fibers cross (lemniscal decussation) to form medial lemniscus --> ascend to thalamus --> then to somatosensory cortex

How does a peripheral nerve injury occur?

Could be Wallerian degeneration: transection results in degeneration of the axon and myelin sheath distal to the site of axonal interruption -Chromatolysis and repair processes occurs in nerve cell body -Endoneurium (sheath) does not degenerate but forms a tube directing regeneration Could be segmental demyelination: axons are preserved (no wallerian degeneration); remyelination restores function (Guillain Barre) Could be axonal degeneration: degeneration of axon cylinder and myelin, progressing from distal to proximal, "dying back" of nerves (peripheral neuropathy)

What does the parasympathetic nervous system of the ANS do?

Craniosacral division Conserves and maintains homeostasis Slows HR and reduces blood pressure, increases peristalsis

What outcome measures are common for vertigo?

DHI NeuroCom Sensory Organization Test (SOT) Clinical Test for Sensory Interaction in Balance (CTSIB) Dynamic Visual Acuity Test

What is the difference in decerebrate and decorticate rigidity/posturing?

Decerebrate: seen in comatose patients with brainstem lesions between the superior colliculus and the vestibular nucleus - results in increased tone and sustained posturing in rigid extension of all 4 limbs and trunk/neck Decorticate: seen in comatose patients with lesions above the superior colliculus - results in increased tone and sustained posturing of upper limbs in flexion and the lower limbs in extension

What is typical of a 1mo old?

Decreased flexion, momentary head elevation, tracks objects, head usually to one side, reciprocal and symmetrical kicking, positive support and walking reflex, neonatal reaching, brightening expression

What are some things to promote learning with a pt with a left hemisphere lesion?

Develop appropriate communication base Give frequent feedback and support Do not underestimate ability to learn

What is primary brain damage?

Diffuse axonal injury: disruption and tearing of axons and blood vessels from angular acceleration (i.e. MVC); results in neuronal death and petechial hemorrhages Focal injury: contusions, lacerations, mass effect from hemorrhage, and edema (hematoma) Coup-countercoup injury: injury at point of impact and opposite point of impact Fractures

What is polyneuropathy?

Diffuse symmetrical involvement of the peripheral nerves Usually legs more than arms, distal segments earlier than proximal

What is protective extension reflex?

Disrupt BOS Arms or legs extend to catch balance Birth - persists

What do you typically see with neuropathies in terms of weakness?

Distal weakness of extremities

How should you deliver PT to people with MS?

Distributed practice with rest intervals Should begin at low level and increase in duration before intensity

What is slow pain transmitted?

Divergent pathways Transmitted over small diameter, unmyelinated C fibers --> processed in spinal cord lamina (II and III-V) --> cross to excite anterior spinothalamic tract --> terminates in brain stem reticular formation --> excites RAS Functions for diffuse arousal, affective and motivational aspects of pain Also terminates in thalamus with projections to cortex

What is moro reflex?

Drop head backwards from sitting Abd/ext arms to add/flex arms Birth - 2-4mo

What are red flags regarding concussions?

Drowsiness, inability to wake up One pupil larger than other Repeat vomiting Loss of consciousness lasting longer than 30 sec Headache that gets worse Slurred speech, numbness Changes in behavior Confusion

What outcome measures are common for MS?

EDSS - 8 functional CNS categories; pyramidal, cerebellar, brain stem, sensory, bowel, visual, cerebral, other MS Functional Composite - includes T25FW, (hole peg test, paced auditory serial addition test MSQOL-54 - quality of life MFIS - self report, 21 items on fatigue

What do the ventral anterior roots of spinal nerves do?

Efferent (motor) fibers to voluntary muscles, and to viscera, glands, and smooth muscles

What WC do high cervical (C1-4) lesions require?

Electric with tilt in space or reclining back Microswitch or puff and sip controls Portable respirator may be attached

What is the descending analgesic system?

Endogenous opiates produced throughout CNS Can depress pain transmission at various sites through mechanisms of presynaptic inhibition

What is an important intervention for GBS for quick recovery>?

Energy conservation! Avoiding overuse and fatigue

How do you examine expressive function?

Examine fluency of speech, speech production Nonfluent aphasia: Broca's motor aphasia, expressive aphasia - speech is typically awkward, restricted, interrupted, produced with effort Verbal apraxia: impairment of volitional articulatory control secondary to a cortical, dominant hemisphere lesion 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

How do you examine for presence of involuntary movements?

Extrapyramidal disorders or basal ganglia dysfunction leads to: -tics: spasmodic contractions of specific muscles, commonly involving face, head, neck or shoulder muscles -chorea: relatively quick twitches or dancing movements -athetosis: slow, irregular, twisting, sinuous movements, occurring especially in upper extremities -tremor: continuous quivering movements; rhythmic, oscillatory movement observed at rest (resting tremor) -myoclonus: single, quick jerk Cerebellar disorders leads to: intention tremor Cortical disorders lead to: epileptic seizures, tonic/clonic convulsive movements

What is the general function of CN VII? Where is the exit opening? How do you test? Possible abnormal findings?

Facial Facial muscle movement (except chewing muscles) and eyelid closing; taste to anterior two thirds of tongue Stylomastoid foramen Smile - look for symmetry Paralysis ipsilateral facial muscles, inability to close eye, droop of mouth, decreased taste

What are strategies for effective learning?

Feedback given after every trial improves performance, while variable feedback improves learning and retention Early training should focus on visual feedback (cognitive phase of learning) while lateral training should focus on proprioceptive feedback (associative phase of learning)

What is Romberg stance? What does it test for?

Feet in normal stance position, first with eyes open then eyes closed Used to detect posterior column (sensory) ataxia Can make harder with sharpened or tandem Romberg

What does the sympathetic nervous system of the ANS do?

Fight or flight Thoracolumbar divisions Emergency response with increase of HR and blood pressure, redistribution of blood flow

How do you test for spatial relations syndrome?

Figure-ground discrimination: pick out an object from an array of objects (brake from WC) Spacial relations: have pt duplicate a pattern of two or three blocks Form consistency: pick out an object from an array of similarly shaped but different-sized objects Topographical disorientation: navigate a familiar route Position in space: have pt demonstrate different limb positions Judging depth and distance Vertical disorientation: determine if pt can identify when something is not upright

What is body righting on body reflex?

Flex one leg and rotate it over body Upper body follows in log roll 4-6mo - 5years

What are mechanisms of spinal cord injury?

Flexion - most common lumbar injury Flexion-rotation - most common cervical injury Compression Hyperextension Most frequent: C5, C7, T12, L1

What is the circle of Willis? Can you draw it?

Formed by anterior communicating artery, connecting the two anterior cerebral arteries and the posterior communicating artery, connecting each posterior and middle cerebral artery

Where do motor fibers of the PNS originate?

From motor nucleus (cranial nerves) or anterior horn cells (spinal nerves)

What is the flexor (withdrawal) reflex?

Functions as a protective withdrawal mechanism to remove body part from harmful stimuli Stimulus: cutaneous sensory stimuli Reflex arc: cutaneous receptors via interneurons to largely flexor muscles; multisegmental response involving groups of muscles (polysnaptic)

What is the stretch (myotatic) reflex?

Functions for maintenance of muscle tone, support agonist muscle contraction, provide feedback about muscle length "Deep tendon reflex" Stimulus: muscle stretch Reflex arc: afferent Ia fiber from muscle spindle to alpha motor neurons projecting back to muscle of origin (monosynaptic) Reciprocal inhibition: via an inhibitory interneuron - same stretch stimulus inhibits the antagonist muscle Reciprocal innervation: effects of a stretch stimulus on agonist (autogenic facilitation), antagonist (reciprocal inhibition), and synergistic muscles (facilitation)

What is the crossed extension reflex?

Functions to coordinate reciprocal limb activities such as gait Stimulus: noxious stimuli and reciprocal action of antagonists; flexors of one side are excited, causing extensors on same side to be inhibited; opposite responses occur in opposite limb Reflex arc: cutaneous and muscle receptors diverging to many spinal cord motor neurons on same and opposite side (polysnaptic)

What is the inverse stretch (myotatic) reflex?

Functions to provide agonist inhibition, diminution of force of agonist contraction, stretch-protection reflex Stimulus: muscle contraction Reflex arc: multiple sensory receptors and corresponding fiber types activate inhibitory interneuron to muscle of origin (polysnaptic)

What outcome measures are used for TBI?

Glasgow Coma Scale Rancho Los Amigos LOCF FIM/FAM

What is the general function of CN IX? Where is the exit opening? How do you test? Possible abnormal findings?

Glossopharyngeal Tongue and throat motor and sensory; taste on the posterior third of the tongue Jugular foramen Swallow, gag reflux Loss of taste, dysphagia or dsyphonia or dysarthria

What are the different grades of concussion?

Grade 1: Mild - symptoms last less than 15 min, no loss of consciousness Grade 2: Moderate - symptoms last longer than 15 min, no loss of consciousness Grade 3: Severe - loss of consciousness

What does the epithalamus do?

Habenular nuclei: integrate olfactory, visceral, and somatic afferent pathways Pineal gland: secretes hormones that influence the pituitary gland and several other organs; influences circadian rhythm

What are common intervention options for vertigo?

Habituation: repetition of movements and positions that provoke dizziness and vertigo Gaze stability: eye movements side to side on stationary and moving target, head movements up and down with locked eyees Postural stability

What WC do cervical C8-T1 lesions require?

Have hand function so can use manual wheelchair with standard hand rims

What WC do cervical C6-7 lesions require?

Have radial wrist extensors so can use manual wheelchair with friction surface hand rims and be independent

What WC do cervical C5 lesions require?

Have shoulder function and elbow flexion so can use manual chair with propulsion aids (projections) Independent for short distances on smooth flat surfaces May choose electric wheelchair for distances and energy conservation

What is parachute reflex?

Head down position Arms reach out for support 4mo-persist

What is typical of a 2mo old?

Head elevation to 45deg in prone, prone on elbows with elbows behind shoulders, head bobs in supported sitting, friendly expression

What are symptoms of ALS?

Highly variable Bulbar onset (progressive bulbar palsy) -dysarthria, dysphagia, dysphonia Spinal cord onset (progressive muscular atrophy) Muscular weakness that spreads over time -early onset involves limbs progressing to whole body -atrophy, cramping, fasciculations, twitching (LMN) -spasticity, hyperreflexia (UMN) Sensory is typically fine (20% have sensory dysfunction) 33% have autonomic dysfunction Weakness in respiratory impairments Sparing of bowel and bladder function

What is landau reflex?

Hold in prone Head and hips extend 4-5mo - 1yr

What is labyrinthine righting reflex?

Hold in vertical position and tilt in all directions Head orients to vertical Birth - persists

What is typical of a 4yr old?

Hops, stands on tiptoes, overhand throw, friends

What is rigidity?

Hypertonoia that is not velocity dependent Increased resistance to PROM that is independent of the velocity of movement Can be leadpipe (uniform throughout the range) or cogwheel (interrupted by a series of jerks) Associated with Parkinsons (basal ganglia), resting tremor, bradykineasia

What is the general function of CN XII? Where is the exit opening? How do you test? Possible abnormal findings?

Hypoglossal Speech, chewing, and swallowing; tongue movement Hypoglossal canal Stick your tongue out Dysarthria, inability to control tongue

What does a lesion in the spinocerebellum, rostral cerebellum, and anterior lobe of the cerebellum (paleocerebellum) present with?

Hypotonia Truncal ataxia: dysequilibrium, static postural tremor, increased sway, wide BOS, high guard - posture worse with eyes closed and narrow BOS Ataxic gait: unsteady, increased falls, uneven/decreased step length, increased step width

What is secondary brain damage?

Hypoxic-ischemic injury: results from systemic problems (respiratory or cardiovascular) that compromise cerebral circulation Swelling/edema: can result in mass effect with increased intracranial pressures, brain herniation, and death Electrolyte imbalance and mass release of damaging neurotransmitters

What are stages of Parkinsons?

I: minimal or absent disability, unilateral symptoms II: minimal bilateral or midline involvement, no balance involvement III: impaired balance, some restrictions in activity IV: all symptoms present and severe, stands and walks only with assistance V: confinement to bed or wheelchair

When should exercise be avoided for ALS?

If less than 1/3 of motor units are functioning

How do you examine memory?

Immediate recall: name 3 items presented 5min ago Recent memory (short term): what did you have for breakfast Remote memory (long term): where were you born

What is dysmetria?

Impaired ability to judge the distance or range of movement

What is dyssynergia?

Impaired ability to judge the distance or range of movement

What is dysdiadochokinesia?

Impaired ability to perform rapid alternating movements

What are the signs and symptoms of meningeal irritation/brain infection?

Impaired neck mobility: stiffness and pain with limitation and guarding into neck flexion (nucchal rigidity) -Kernig's sign: hip and knee flex to 90deg, ext of knee = pain --> meningitis or subarachnoid hemorrhage -Brudzinski's sign: lay supine with neck, hip and knees flexed = pain --> meningitis' Irritability, visual discomfort with bright light Altered level of consciousness Severe headache, nausea, vomiting Altered vital signs, high fever Weakness

What behaviors are noted with right hemisphere lesions?

Impulsive, quick, indifferent, poor judgement and safety, overestimating abilities and underestimating deficits

Where do sensory fibers of PNS originate?

In cells outside the brainstem or spinal cord with sensory ganglia (cranial nerves) or dorsal root ganglia (spinal nerves)

What is galant reflex?

In prone, stroke paraveretebrals from thoracic to lumbar Laterally flexes towards stimulus Birth - 3-9mo

How do you 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 Ideomotor apraxia: patient cannot perform the task on command, but can when left on own Ideational apraxia: patient cannot perform task at all

How do you examine for agnosia?

Inability to recognize familiar objects iwth one sensory modality while retaining ability to recognize same object with other sensory modalities Pt cannot recognize clock from sight but can by sound

When could you use body weight supported treadmill training?

Incomplete injuries (ASIA B, C, D) Promotes spinal cord learning/activation High intensity, high frequency 4-5 days/wk, 20-30min, 8-12wks

Brain abscess: evaluation, s&s, and treatment

Infectious process in which there is a collection of pyogenic material in the brain parenchyma Signs and symptoms: headaches, fever, brainstem compression, CN II and VI signs Can be extension of an infection - typically frontal or temporal lobes or cerebellum Treat infective organism, surgical intervention PT: provide supportive symptomatic therapy

Meningitis: evaluation and treatment

Inflammation of the membranes of the brain or spinal cord Can be bacterial or viral (bacterial = worse) Treat infective organism with antibacterial therapy - maintain fluid and electrolyte balance PT: provide supportive symptomatic therapy, including bed positioning, PROM, skin care

What does the periaqueductal gray do?

Inhibits pain transmission in the dorsal horn via the rostral ventral medulla (RVM) Important for descending autonomic tracts

What does the hypothalamus do?

Integrates and controls the functions of teh autonomic nervous system and the neuroendocrine system Maintains body homeostasis: regulates body temperature, eating, water balance, anterior pituitary function/sexual behavior, and emotion

What does a lesion in the hemosphere and posterior lobe of the cerebellum (neocerebellum) present with?

Intention tremor: irregular, oscillatory voluntary moements Dysdiadochokinesia: impaired RAM Dysmetria: hypermetria (overshooting), errors or force, direction, amplitude, rebound phenomenon (Holmes) Dyssynergia: abnormal timing (errors of velocity, onset, and stop), movement decomposition of agnoist/antagonist interactions; impairments of multijoint coordination, movement sequences, complex motor tasks Errors in timing related to perceptual tasks

What do transverse (commissural) fibers do?

Interconnects the two hemispheres, including the corpus callosum (the largest), anterior commissure, and hippocampal commissure

Intrinsic feedback vs. augmented feedback

Intrinsic: sensory information normally acquired during performance of a task Augmented: externally presented that is added to the feedback normally acquired during task performance -can be knowledge of results (better in early stages) or knowledge of performance (better in later stages)

What does the subthalamus do?

Involved in control of several functional pathways for sensory, motor and reticular function

How do you examine higher-level cognitive abilities?

Judgment, problem solving Abstract reasoning Fund of general knowledge: current events, new info, generalize learning to new situations Calculation: serial 7 test Sequencing: ability to order components of cognitive or functional task; assess if cueing is necessary

What is the cremasteric reflex?

L1-L2 Scratch skin of upper medial thigh Brief elevation of ipsilateral testicle

What reflex level is tested with patellar tendon?

L3-L4

What is plantar reflex?

L5-S1 Stroke lateral aspect of sole of foot from heel to ball of foot medially to great toe Flexion - if extension = Babinski

What is characteristic of a Cauda Equina Injury?

LMN! Loss of long nerve roots at or below L1 Variable nerve root damage (motor and sensory signs); incomplete lesions common Flaccid paralysis with no spinal reflex activity Flaccid paralysis of bladder and bowel Potential for nerve regeneration; regeneration often incomplete, slows and stops after 1 yr

For vertigo, long duration of dizziness with hearing loss is indicative of what?

Labryinthitis

What does Wernicke's area do?

Language comprehension

What are the lateral ventricles?

Large, irregularly shaped with anterior (frontal), posterior (occipital), and inferior (temporal) horns Communicates with third ventricle through foramen of Monro

What does vertigo roll test examine for?

Lateral BPPV Supine, head from one side to the other

How is fast localized pain transmitted?

Lateral pain system Over thinly myelinated A delta fibers, processed in spinal cord dorsal horn lamina (I and V) --> crosses to excite lateral spinothalamic tract --> terminates in brainstem reticular formation and thalamus with projections to cortex

How do you examine attention?

Length of attention span: digit span retention test (recall 7 numbers) Ability to attend to task without redirection Ability to shift attention from one task to another (divided attention) Ability to stay on a task (focused attention) Ability to follow one or two step commands or multi level commands

What is Bell's Palsy?

Lesion of facial nerve CN VII resulting in unilateral facial paralysis Results from acute inflammatory process resulting in compression of the nerve within the temporal bone

What is rooting reflex?

Lightly stroke cheek Turns head ipsilaterally and opens mouth Birth - 3or4 months

What does the cerebellum do?

Located behind dorsal pons and medulla in posterior fossa Joined to brainstem by three pairs of peduncles (superior, middle, and inferior) Comprises two hemispheres and midline vermis. cerebellar cortex, underlying white matter, and four paired deep nuclei Lobes: flocculonodular, anterior lobe, posterior lobe

What is the third ventricle?

Located posterior and deep between the two thalami Communicates with fourth ventricle through cerebral aqueduct

How do you test for homonymous hemianopsia?

Loss of half of visual field in each eye, contralateral to the side of a cerebral hemisphere lesion 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

What are main PT goals for PPS?

Maintain respiratory function Teach energy conservation techniques Preserve or increase muscle strength - consider pool programs In severe atrophic polio, exercise is contraindicated

What is typical of a 7mo old?

Maintains quadruped, pivots on belly, moves in circle in prone, trunk rotation in sitting, recognizes tone of voice, fear of strangers

Massed vs distributed practice

Massed: relatively continuous practice in which the amount of rest time is small Distributed: rest time is relatively large

What is the basal ganglia? What circuits does it include

Masses of gray matter deep within the cerebral hemispheres, including the striatum (caudate nucleus, nucleus accumbens, putamen), globus pallidus (external segment, internal segment), subthalamic nucleus and substantia nigra (compact part, reticular part) Forms an associated motor system (extra-pyramidal system) with other nuclei in the subthalamus and the midbrain Circuits: Oculomotor circuit Motor loop Limbic circuit

What is a traumatic brain injury?

Mechanism of injury is contact forces to skull and rotational acceleration forces, causing varying degrees of injury to the brain

For vertigo, short duration of dizziness with hearing loss is indicative of what?

Meniere's

What is in the hindbrain?

Met (cerebellum and pons) and Myel (medulla)

What is included in the mesencephalon?

Midbrain

What is included in the brainstem?

Midbrain Pons Medulla oblongata

What is the arachnoid mater?

Middle layer of the meninges Named for it's spider web-like appearance Delicate and vascular membrane

How do you grade spasticity?

Modified Ashworth Scales (6 grades) 0 = no increase in muscle tone 1 = slight increase in muscle tone, minimal resistance at end of ROM 1+ = slight increase in muscle tone, minimal resistance at end of ROM 2 = more marked increase in muscle tone, through most of ROM, affected part easily moved 3 = considerable increase in muscle tone, passive movement difficult 4 = affected part rigid in flexion or extension

What is a concussion?

Most common and least serious type of traumatic injury caused by a sudden direct blow or bump to the head; movement of the brain within the skull can cause bruising, damage to blood vessels, and injury to nerves

What other assessments are used for stroke?

Motor Activity Log = examines ADL function for more affected arm; scale 0-5 National Institute of Stroke Stroke Scale = examines consciousness, motor and sensory function, language function, and inattention Postural Assessment Scale for Stroke Patients (PASS) = examines postural control and balance Stroke impact Scale = brief assessment of physical and social functioning and how stroke has impacted life Functional Independence Measure (FIM) = 18 items of physical, psychological, and social functioning Functional Assessment Measure (FAM) = additional items to FIM for community access, IADLs, safety, etc.

What are signs and symptoms of bells palsy?

Muscles of facial expression on one side are weakened or paralyzed Loss of control of salivation or lacrimation Onset is acute with maximum severity in a few hours or days, commonly preceded by a day of pain behind the ear Most recover fully in several weeks or months Sensation is normal Loss of taste of anterior 2/3 of tongue

What are signs and symptoms of myasthenia gravis?

Muscular strength worse with continuing contraction, improved with rest Classified into four types: ocular myasthenia (extraocular muscles), mild generalized myasthenia, severe generalized myasthenia, and crisis Generalized myasthenia: usually involves bulbar and proximal limb-girdle muscles May progress from mild to severe, typically within 18mo

What is a myasthenic crisis?

Myasthenia gravis with respiratory failure; treat as medical emergency

What is the white matter?

Myelinated axons with no dendrites

What is the white matter and what does it include?

Myelinated nerve fibers located centrally Transverse (commissural) fibers, projection fibers, association fibers

What diagnostic tests are used for peripheral nerve injuries?

NCV for conduction times EMG for motor nerve function

What is a positron emission tomography (PET)?

Neuroimaging technique in which radioiotopes are inhaled or injected and emissions are measured with a gamma-ray detector system Allows physiological mapping; a major clinical research tool for imaging cerebral blood flow, brain metabolism Lacks detailed resolution of CT or MRI

What is postpolio syndrome (PPS)?

New slowly progressive muscle weakness occurring in individuals with a confirmed history of acute polio; follows a stable period of functioning Possibly caused by hyperfunctioning of motor neurons, long-term overuse at high levels resulting in new denervation

What are signs and symptoms of PPS?

New weakness and atrophy, asymmetrical in distribution Abnormal fatigue Pain - cramping, joint pain Difficulty in concentration Sleep disturbances

What are symptoms of a concussion (observed vs reported)?

Observed: Dazed or stunned Can't recall events prior to hit Forgets instruction Moves clumsily Answers slowly Loses consciousness briefly Mood changes Reported: Headache Nausea Balance problems Bothered by light Feeling sluggish Confusion Not feeling right

What is the general function of CN III? Where is the exit opening? How do you test? Possible abnormal findings?

Oculomotor Eye movement - opening of eyelids, eye movement upward/medial, upward/lateral, medial, downward/lateral; pupillary reflex, accomodation, convergence Superior orbital fissure Blink your eyes Absence of pupillary constriction; lateral strabismus (exotropia); unequal pupils (anisocoria)

What is the general function of CN I? Where is the exit opening? How do you test? Possible abnormal findings?

Olfactory Sense of smell Exits at the cribriform plate of the ethmoid bone Test each nostril to see if you can smell peppermint oil or other smelly item Anosmia (inability to detect smells), seen with frontal lobe lesions

What is a partial or focal seizure?

Only one part of brain is involved Symptoms are focal (specific area of body) Temporal lobe = changes in behavior with hallucinations, altered cognitive or emotional function, preceded by an aura

What is the general function of CN II? Where is the exit opening? How do you test? Possible abnormal findings?

Optic Sight (visual acuity) Optic foramen Using the visual acuity chart in the front of the room standing behind the tape line, cover one eye and read chart Blindness, myopia (impaired far vision); presbyopia (impaired near vision); homonymous hemianopsia

What does the limbic circuit of the BG do?

Originates in prefrontal and limbic areas of cortex; to BG; to prefrontal cortex; functions to organize behaviors (executive functions, problem solving, motivation) and for procedural learning

What is the dura mater?

Outer layer of meninges Tough, fibrous membrane attached to inner surface of cranium Forms falx (longitudinal fissure) and tentorium

What is a spinal cord injury?

Partial or complete disruption of spinal cord resulting in paralysis, sensory loss, altered autonomic and reflex activities Primary: interruption of blood supply Secondary: ischemia, edema, demyelination, necrosis of axons, progressing to scar tissue

What does lethargy mean?

Patient appears drowsy Can open eyes and look at examiner, respond to questions, but falls asleep easily

What does stupor mean?

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 Demonstrates minimal awareness of self and environment

What does obtundation mean?

Patient can open eyes, look at examiner but responds slowly and is confused Demonstrates decreased alertness and interest in environment

What is a typical spastic position for the LE?

Pelvis - hiked (retracted) Hip - adducted, internal rotation, extension Knee - extension Foot and ankle - plantarflexed, inverted, equinovarus, toes clawed or curled

What speech deficits are found with lesions of parietal lobe of nondominant hemisphere?

Perceptual deficits (typically right hemisphere)

What is post concussion syndrome?

Persistent post-concussion symptoms lasting three months or longer; an indicator of concussion severity Rare after only one concussion --> more likely after multiple Symptoms may also include post-traumatic seizures, increased risk of depression, and mild-cognitive impairment

What does the frontal lobe do?

Personality and motor

What is the resting membrane potential for neuronal signaling?

Positive on outside, negative on inside -70 mV

What does sidelying test examine for?

Posterior canal BPPV Sitting, turn head away from direction of movement, then down to that shoulder in sidelying

What is an absence seizure?

Posture is maintained, repetitive blinking or other small movements may be present "Petit mal seizures" Lasts only a few seconds, may occur many times a day

What is suck-swallow reflex?

Press finger or nipple downward on tongue Rhythmic sucking Birth-4mo

What is plantar grasp reflex?

Pressure to base of toes Flexes toes around fingers Birth-9mo

What is palmar grasp reflex?

Pressure to palm of hand Flexes fingers around finger Birth-6mo

What does the precentral gyrus do?

Primary motor cortex for voluntary muscle activation

What does the postcentral gyrus do?

Primary sensory cortex for integration of sensation - processes information regarding touch, proprioception, pain, & temperature

What does the associative auditory cortex do?

Processes auditory stimuli

What does the visual association cortex do?

Processes visual stimuli - recognition of faces, dogs, cars, trees, etc.

What is chronic traumatic encephalopathy (CTE)?

Progressive neurodegenerative brain disease resulting from repetitive head trauma, seen in athletes and boxes with a history of multiple concussions and repeated head injury Diagnosis only made at autopsy by studying brain sections --> brain changes include tau-positive neurofibrillary tangles (NFTs), neuropil threads, and neocortical diffuse amyloid plaques Signs and symptoms: recurrent headaches and dizziness, cognitive impairments, mood disturbances, impaired judgment, movement disorders

What is status epilepticus?

Prolonged seizure or a series of seizures (lasting >30min) with very little recovery between attacks; may be life threatening; medical emergency

What is opisthotonos?

Prolonged, severe spasm of muscles, causing the head, back and heels to arch backwards; arms and hands are held rigidly flexed Seen in severe meningitis, tetanus, epilepsy, and strychnine poisoning

What is typical of a 3mo old?

Prone on elbows, WB on forearms, elbows in line with shoulders, head elevated to 90deg, coos and chuckles, optical and labyrinthine head-righting

What is typical of a 6mo old?

Prone on hands with elbows extended, weight shifts hand to hand, rolls supine to prone, independent sitting, pulls to stand, bounces

What is STNR?

Prone/quadruped, passive head flexion = arms flex, legs extend; passive head extension = arms extend, legs flex 6-9mo - 9-11mo

What is the purpose of cerebral spinal fluid?

Provides mechanical support (cushions brain) Controls brain excitability by regulating ionic compositions Aids in exchange of nutrients and waste products Produced in choroid plexuses in ventricles

What do you typically see with myopathies in terms of weakness?

Proximal weakness of extremities

What is traction response reflex?

Pull to sit Elbow flex, shoulder elevation Birth - 2-5mo

What is included in the lenticular nucleus?

Putamen and globus pallidus

What is the fourth ventricle?

Pyramid-shaped cavity located in pons and medulla Foramina (openings) of Luschka and Magendie communicate with fourth ventricle through subarachnoid space

How do you examine respiration?

RR, depth, rhythm, characteristics of inspiratory and expiratory phases Cheyne-Stokes respiration: period of apnea lasting 10-60sec followed by gradually increasing depth and frequency of respirations, accompanies depression of frontal lobe and diencephalic dysfunction Hyperventilation: increased rate and depth of respirations; accompanies dysfunction of lower midbrain and pons Apneustic breathing: abnormal respiration marked by prolonged inspiration; accompanies damage to upper pons

What is feedforward learning?

Readies the system in advance of movement Anticipatory responses that adjust the system for incoming sensory feedback or for future movements I.e. preparatory postural adjustments

What does the frontal lobe do (more extensive than above)? What does it include?

Reasoning, planning, parts of speech, movement, emotions, and problem solving Precentral gyrus Prefrontal cortex Broca's area

What does the primary auditory cortex do?

Receives/processes auditory stimuli

What does the primary visual cortex do?

Receives/processes visual stimuli - detects basic features such as edges, light and dark, location, etc

What does the temporal lobe do (more extensive than above)? What does it include?

Recognition and identification of auditory and olfactory objects - hearing and balance, interpretation of sensory experiences, memory of visual scenery and music Primary auditory cortex, associative auditory cortex, Wenicke's area

What is Menieres disease?

Recurrent and usually progressive vestibular disease; episodic attacks may last from minutes to several hours with severe symptoms Usually associated with tinnitus, deafness, sensation of pressure/fullness within ear *Unilateral symptoms

What are the 5 categories of MS?

Relapsing-remitting (RRMS): discrete attacks with either full or partial recovery; periods in between have lack of disease progression; most common (85%) Primary-progressive (PPMS): disease progression and deterioration in function; modest fluctuations but no discrete attacks Secondary-progressive (SPMS): initial relapsing-remitting, then progressive with steady decline, may include acute attacks Progressive-relapsing (PRMS): steady deterioration with occasional acute attacks; intervals between do have disease progression Clinical isolated syndrome (CIS): first episode, could be MS

What is the Glasgow coma scale?

Relates consciousness to three elements of response: eye opening, motor response, and verbal response Scoring range from 3 to 15 -severe brain injury = 1-8 -moderate brain injury = 9-12 -minor brain injury = 13-15

What is sympathetic storming?

Result of hypothalamic stimulation of the SNS with an increase in circulating corticoids and catecholamines (stress response)

What are signs and symptoms of Parkinsons?

Rigidity (leadpipe or cogwheel) Bradykinesia Resting tremor Impaired postural reflexes

What is typical of a 4mo old?

Rolls prone to side, supine to side, sits with support, no head lag in pull to sit, ulnar palmar grasp, laughs

What is typical of a 5mo old?

Rolls prone to supine, weight shifts from one forearm to another in prone, head control in supported sitting

What is typical of a 24mo old (2years)?

Runs well, ascends stairs step through pattern, active, restless, tantrums

Which cranial nerves are both sensory and motor?

S S M M B - V (Trigeminal) M B - VII (Facial) S B - IX (Glossopharyngeal) B - X (Vagus) M M

Which cranial nerves are only motor?

S S M - III (Oculomotor) M - IV (Trochlear) B M - VI (Trigeminal) B S B B M - XI (Spinal accessory) M - XII (Hypoglossal)

Which cranial nerves are only sensory?

S - I (Olfactory) S - II (Optic) M M B M B S - VIII (Vestibulocochlear) B B M M Some say marry money but my brothers says big boobs matter more

What reflex level is tested with achilles tendon?

S1-S2

How do you examine behavior or emotional responses?

Safety, judgement, impulsivity, lack of inhibition Affect, mood: irritability, agitation, depression, withdrawal Frustration tolerance Self-centerdness Insight into disability Ability to follow rules of social conduct Ability to tolerate criticism

What are common outcome measures for cerebellar lesions?

Scale for Assessment and Rating of Ataxia (SARA) Dizziness Handicap Inventory (DHI) Modified Fatigue Impact Scale (MFIS) Balance tests Functional Gait tests FIM and FAM

What is the American Spinal Injury Association (ASIA)?

Scale for SCIs A - complete, no motor or sensory in S4-5 B - incomplete, sensory but not motor below level and includes S4-5 C - incomplete, motor preserved below level and key muscles below have grade of less than 3 D - incomplete, motor preserved below level and key muscles below have grade of more than 3 E - normal

What is a typical spastic position for the UE?

Scapula - retracted and downward rotation Shoulder - adduction and internal rotation with depression Elbow - flexion Forearm - pronation Wrist - flexion and adduction Hand - fingers flexed, thumb adducted

What is the blood-brain barrier?

Selective restriction of blood-borne substances from entering the CNS Associated with capillary endothelial cells

What does the parietal lobe do

Sensation, hearing, object meaning, spatial perception

What are signs and symptoms of GBS?

Sensory loss, parestehsias, pain Motor paresis or paralysis: symmetrical distribution of weakness; progresses from lower extremities to upper and from distal to proximal Can produce full tetraplegia with respiratory failure Progression evolves over a few days or weeks; recovery usually slow (6mo-2yrs) and usually complete - some mild weakness may persist

What does the thalamus do?

Sensory nuclei: integrate and relay sensory information from body, face, retina, cochlea, and taste receptors to cerebral cortex and subcortical regions; smell (olfaction) is the 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

What does the central sulcus do?

Separates the frontal lobe from the parietal lobe

What does the longitudinal cerebral fissure do?

Separates the two hemispheres

What is a motor program in motor control?

Set of prestructured muscle commands that, when initiated, results in the production of a coordinated movement sequence (learned task) Can be carried out largely uninfluenced by peripheral feedback

What is global aphasia?

Severe aphasia Examine for marked impairments in comprehension and production of language

Encephalitis: evaluation and treatment

Severe infection and inflammation of the brain Arbovirus or sequela in influenza or other infections Treat infective organism PT: provide supportive symptomatic therapy

What is a secondarily generalized seizure?

Simple or complex partial seizures evolving to a generalized seizure

What is a myotome?

Skeletal muscles innervated by motor axons in a given spinal root A motor unit consists of the alpha motor neuron and the muscle fibers it innervates

What is typical of a 5yr old?

Skips, kicks well, dresses self

What behaviors are noted with left hemisphere lesions?

Slow, cautious, hesitant, insecure

What are different body scheme disorders?

Somatognosia: inability to identify body parts or their relationship to others Visual spatial neglect: ignoring one side of the body and stimuli coming from that side Right/left discrimination disorder: inability to identify left or right sides of their body or your body Anosognosia: severe denial, neglect or lack of awareness of severity of condition; determine whether patient shows severe impairments in neglect and body scheme

What is sacral sparing?

Sparing of tracts to sacral segments, with preservation of perianal sensation, rectal sphincter tone, or active toe flexion

What is a dermatome?

Specific segmental skin area innervated by spinal sensory axons

What is the general function of CN XI? Where is the exit opening? How do you test? Possible abnormal findings?

Spinal accessory Head, neck, shoulder movement and swallowing Jugular foramen Shrug your shoulders Paralysis of SCM or trap

What is autonomic dysreflexia?

State that someone with SCI can enter into - medical emergency Body's way of saying something is wrong when they cannot feel it Hypertension, bradycardia, severe headache, feeling of anxiety, constricted pupils, blurred vision, flushing and piloerection, increased spasticity Treat by sitting upright, loosen any tight clothing, examine blockage of urinary drainage, monitor BP and HR

What is the gamma reflex loop?

Stretch reflex forms part of this loop Allows muscle tension to come under control of descending pathways (reticulospinal, vestibulospinal, and others) 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; impulses are then conveyed to alpha motor neurons

What is babinski reflex?

Stroke foot heel to ball lateral to medial Toes extend and flare Birth - 9-10mo

What do midthoracic lesions (T6-T9) require for locomotion training?

Supervised ambulation for short distances May be a limited household ambulator Requires bilateral KAFOs and crutches Swing to gait pattern May prefer standing devices and standing WCs instead of independence

What is tonic labyrinthine reflex?

Supine = extensor tone; prone = flexor tone Utero-3.5years

What is ATNR?

Supine, turn head to one side Ipsilateral arm extended, contralateral arm flexed Birth-6mo

What does the anterior spinal artery supply?

Supplies entire medial of the medulla, including the anterior part of the spinal cord

What does the vertebral artery do?

Supplies the blood to the posterior part of the CoW

What does the posterior inferior cerebellar artery do?

Supplies the cerebellum

What are neuroglia?

Support cells that do not transmit signals Important for myelin and neuron production Maintenance of K+ levels and reuptake of neurotransmitters

What is stepping reflex?

Supported standing, feet touch ground Stepping movements Birth-2mo

What is positive support reflex?

Supported standing, feet touching ground Legs extended Birth-6mo

Where do ANS fiber originate?

Sympathetic at thoracolumbar spinal segments and parasympathetic at craniosacral segments

What is the abdominal reflex?

T8-L1 Brisk/light stroke in each quadrant towards umbilicus Contraction of abs, deviation of umbilicus towards stroke

What is in the midbrain?

Tectum (colliculi) and tegmentum

What is the Hallpike Dix test?

Tests for BPPV Turns into treatment

What is the diencephalon?

Thalamus, subthalamus, hypothalamus, epithalamus

What is Paget's disease?

The thickening and enlargement of the bones (bone metabolism, hat will not fit, dentures will not fit), it also increases alkaline phosphatase in blood Creates BILATERAL symptoms for vertigo

What is the pia mater?

This is the internal layer that clings to the surface of the brain Thin, vascular membrane that covers the brain Forms tela choroidea of ventricles

How do you examine fine motor control?

Thumb finger opposition Manual/finger dexterity (grasp and release)

What is equillibrium reactions tilting reflex?

Tilt body left and right Head, shoulders, hips right and move opposite of force Birth - persists

Which nerves supply the tongue?

Touch: posterior 1/3 = CN IX; anterior 2/3 = CN V3 Taste: posterior 1/3 = CN IX; anterior 2/3 = CN VII

What is spinal shock?

Transient period of reflex depression and flaccidity May last several hours or up to 24 weeks

What is the gate control theory?

Transmission of sensation at spinal cord level is controlled by balance between large fibers (A alpha, A beta) and small fibers (A delta and C) Activity of large fibers at level of first synapse can block activity of small fibers and pain transmission (counterirritant theory)

What is typical of a 3yr old?

Tricycle, brief SLS, jumps with 2 feet, shares

What is the general function of CN V? Where is the exit opening? How do you test? Possible abnormal findings?

Trigeminal Face sensation, chewing movements Superior orbital fissure Clench jaw, touch the forehead check and jaw line gently Loss of facial sensations, loss of corneal reflex ipsilaterally, weakness of muscles of mastication, deviation of jaw

What is the general function of CN IV? Where is the exit opening? How do you test? Possible abnormal findings?

Trochlear Eye movement (downward/medial) Superior orbital fissure Look down Ptosis (drooping of eyelid); medial strabismus

What is neck righting on body reflex?

Turn head to one side Entire body follows 4-6mo - 5yrs

What do the cerebral peduncles do?

Two lateral halves; each divided into an anterior part or basis (crus cerebri and substantia nigra) and a posterior part (tegmentum) Attach the cerebrum to the brainstem Contain the large ascending (sensory) and descending (motor) nerve tracts that run to and from the cerebrum from the pons

What is characteristic of a central cord lesion?

UMN Cavitation of central cord in cervical section Loss of spinothalamic tracts with bilateral loss of pain and temp Loss of ventral horn with bilateral loss of motor function: primarily upper extremities Preservation of proprioception and discriminatory sensation

What is characteristic of a complete cord lesion?

UMN Complete bilateral loss of all sensory modalities Bilateral loss of motor function with spastic paralysis below level of lesion Loss of bladder and bowel function with spastic bladder and bowel

What is characteristic of a Brown-Sequard Syndrome lesion?

UMN Hemisection of spinal cord Ipsilateral loss of dorsal columns with loss of tactile discrimination, pressure, vibration, and proprioception Ipsilateral loss of corticospinal tracts with loss of motor function and spastic paralysis below level of lesion Contralateral loss of spinothalamic tract with loss of pain and temp below level of lesion Bilateral loss of pain and temp at level of lesion

What is characteristic of an Anterior Cord Syndrome lesion?

UMN Loss of anterior cord Loss of lateral corticospinal tracts with bilateral loss of motor function, spastic paralysis below level of lesion Loss of spinothalamic tracts with bilateral loss of pain and temp Preservation of dorsal columns: proprioception, kinesthesia, and vibratory sense

What is characteristic of a Posterior Cord Syndrome lesion?

UMN Loss of dorsal columns bilaterally Bilateral loss of proprioception, vibration, pressure, and epicritic sensations (stereognosis, two-point discrimination) Preservation of motor function, pain, and light touch

How do you differentiate between a UMN and a LMN?

UMN: -hypertonia, spasticity -hyperreflexia LMN: -hypotonia, not velocity dependent -hyporeflexia

What is typical of a 10-15mo old?

Unassisted walking, self-feeding, neat pincer grasp, can release, searches for hidden toys, suspicious of strangers, plays patty cake and peekaboo, imitates

What outcome measures are common for Parkinsons?

Unified rating scale for Parkinsonism (MDS-UPDRS) revision: examines body structure, activity, participation Parkinsons Disease Questionnaire (PDQ-39): quality of life Freezing of Gait Questionnaire: examine gait and community function Parkinson's Fatigue Scale: examines fatigue and effects on life Profile of Function and Impairment Level Experience with PD (PROFILE PD): early to mid stages for impairments

How do you examine for UE coordination?

Unilateral: Finger to nose Rapid alternating movements (RAM) into supination/pronation Bilateral: RAM Clapping (symmetrical) Alternating knee to shoulder (asymmetrical) Knee pat/elbow ext (unrelated)

How do you examine for LE coordination?

Unilateral: Heel to shin Foot tapping Bilateral: Foot tapping (symmetrical) Knee flex/ext (symmetrical) Alternate knee flex/ext (asymmetrical) Knee flex/hip abduction (unrelated)

What is the grey matter?

Unmyelinated neurons and dendrites

What are some things to promote learning with a pt with a right hemisphere lesion?

Use verbal cues - demonstrations may confuse patient with visospatial deficits Give frequent feedback - focus on slowing down and controlling movement Focus on safety Avoid environmental clutter Do not overestimate ability to learn

What is the Fugl-Meyer Assessment?

Used for stroke examining physical performance Scale 0-2; 0 = cannot do, 2 = fully performed

What cranial nerves need to be tested for GBS?

VII, IX, X, XI, XII

What is the general function of CN X? Where is the exit opening? How do you test? Possible abnormal findings?

Vagus Parasympathetic functions; uvula (palate muscles) and swallowing Jugular foramen Check the pulse, check for uvula movement Dysphagia, dysphonia, dysarthria - palate fails to elevate

For vertigo, long duration of dizziness with no hearing loss is indicative of what?

Vestibular neuritis

What is the common cause of dysequilibrium or postural instability?

Vestibular spinal reflex (VSR) dysfunction

What is the general function of CN VIII? Where is the exit opening? How do you test? Possible abnormal findings?

Vestibulocochlear Hearing and balance Internal acoustic meatus Close their eyes, snap fingers beside each ear or use friction of fingers Vertigo, gaze instability with head rotations, nystagmus, deafness, tinnitus

Acquired immunodeficiency syndrome (AIDS): evaluation, s&s, and treatment

Viral syndrome characterized by acquired and severe depression of cell-mediated immunity Signs and symptoms: wide ranging, 1/3 exhibit CNS or PNS deficits -AIDS dementia complex (ADC): symptoms range from confusion and memory loss to disorientation -Motor deficits: ataxia, weakness, tremor, loss of fine motor coordination -Peripheral neuropathy: hypersensitivity, pain, sensory loss Treat with anti-HIV drugs PT: provide palliative and supportive therapy

What does the occipital lobe do?

Vision, color, 3D

What does the occipital lobe do (more extensive than above)? What does it include?

Visual processing area of the brain - visuospatial processing, distance and depth perception, color determination, object and face recognition, and memory formation Primary visual cortex, visual association cortex

What elements are involved in balance?

Visual system (acuity, depth perception) Somatosensory (proprioception, cutaneous sensation) Vestibular Motor response to body position (BOS, COM) Musculoskeletal limits (ROM)

What is bulbar palsy?

Weakness or paralysis of the muscles innervated by the motor nuclei of the lower brainstem; affects the muscles of the face, tongue, larynx, and pharynx Examine for glossopharyngeal and vagal paralysis: phonation, articulation, palatal actions, gag reflex, swallowing Examine for changes in dysphonia (voice quality) Bilateral = severe airway restriction with dyspnea Watch for aspiration pneumonia

What is a stroke?

When blood supply to the brain is interrupted or reduced Can be ischemic, hemorrhagic, or transient ischemic -Ischemic: 80%, either a thrombosis (blood clot in an artery) or embolism (bits of matter in artery) -Hemorrhagic: abnormal bleeding as a result of a rupture of a blood vessel -TIA: temporary period fo symptoms resulting from a decrease in blood supply to brain (<24 hrs)

When does an action potential occur?

When there is increased permeability of Na+ and influx into cell with outflow of K+ results in polarity changes +35 mV Depolarization All-or-none

What is a ventriculography?

X-ray of skull after injection of air into lateral ventricles Delineates ventricles, helps localize tumors Useful with increased intracranial pressures

What is a cerebral angiography?

Xrays of skull after injection of dye into carotid or vertebral arteries or both Has largely been replaced by magnetic resonance angiography (image of arteries in brain, identifies vascular abnormalities similar to angiography) Complications: invasive, may cause meningeal irritation, hemorrhage, vasospasm, or anaphylactic reaction to dye

What is a myelography?

Xrays of spine after injection of air or dye into spinal subarachnoid space Delineates abnormalities impinging on subarachnoid space Complications: dye may result in meningeal irritation