Neuro-Ortho Exam I

What is the epiphyseal line?

Separates diathesis from metaphysis?

Fixing the ankle in a ski boot . . . What can help this?

creates bending loads in the bone. Muscle

What is a counterforce brace?

cuff that attaches just below the tear to pull force off the muscles

How does AMD affect vision?

gradually destroys sharp, central vision. Reduced visual acuity. May have distortion. Scotoma/blind spots. Causes NO pain. In early stages, it advances slowly, but may progress rapidly.

What is the treatment for trigger finger?

steroid injections, release if necessary (70% of the time, adult = nonsurgical cure, babies - always surgical).

What is a swan neck deformity?

hyperextension of the pip joint

Major causes of blindness/vision loss differ substantially by . . . . (Examples)?

race. Fair skin = age related macular degeneration. African americans= more glaucoma, and progresses more rapidly.

What is normal eye pressure?

range between 10-20 mmHg on a diurnal curve.

What are psychosocial consequences of hearing loss?

reduced participation in life activities - depression - withdrawal - social isolation - family/marital discord - financial loss

Osteoarthritis: clinical features: findings in ROM exercises

reduces ROM, crepitus

What is the role of rehabilitation in low vision treatment?

scanning appropriately, move around safely, cane, dog guide (and you need to use white cane first), daily activities, O and M

Dorsal wrist pain could be

scapholunate ligament injury, ganglion

Where do audiologists work?

schools • hospitals • nursing homes • private practice • ENT offices • Speech & Hearing clinics

What is immobilization hypercalcemia?

serum calcium increases within 2 weeks, reaching a max between 1-6 months after injury. Bone resorption is increased due to osteoclast stimulation. There is also impaired excretion of calcium by kidney. Symptoms include nausea, vomiting, anorexia, lethargy, polydipsia, polyuria, dehydration. Treat with IVF, foley catheter. Once hydrated may use Lasix to enhance calcium secretion.(controversial) May also use calcitonin, etidronate, steroids. Standing has been reported to decrease hypercalcemia.

What are the two most important features to help separate among the various types of arthritis in diagnosis?

setting, pattern of joint involvement.

A clavcle is what kind of bone?

short

When returning someone to their former level of activity after being immobilized, we need to think about . . .

slowly returning someone to their physical level slowly, because their ARTICULAR CARTILAGE has gone through changes, and requires compression and distraction to give it nutrition!

In many cases, in higher energy fractures, before you have a fracture, you'll have

soft tissue injury.

How can avulsion facture of the ankle commonly occur? (lauge hansen)

supination, adduction injuries

How is a cataract treated?

surgery

How can you treat a ganglion cyst?

surgery (most effective) Hit with a book (50% effective) aspirate (20% effective) It's one way valve

What is macular edema?

swelling

When might you suspect someone has chronic regional pain syndrome?

swelling and stiffening that gets worse with exercise and treatment

What are the three main kinds of joints affected by arthritis?

synarthroses, amphiarthroses, diarthrosis

What is the "food" for the cartilage?

synovial fluid.

What happens in the ears of people with downs?

tend to have small ear canals and bad eustachian tubes.

the stronger the reading glass . . .

the closer you have to hold the text to the face

What is the best question to ask a patient in order to discern if they need a referral to audiology?

"Does your family think you have problems with hearing?"

What is IVF

(IVF) by injecting a single sperm into a mature egg. The fertilized egg is then placed in a woman's uterus or fallopian tube.

What is stenosing tenosynovitis?

(Trigger Finger) History Pain in palm Catching/locking of digit Examination Palpable nodule

What are the steps of a low vision evaluation?

- Define goals - Measure visual function - Compare to functional visual performance - Evaluate and recommend devices/rehabilitation to meet visual needs and goals

What is a behind the hear hearing aid?

- earmold - power - flexibility - Telephone Coil

What are requirements for the creation of calluses?

-Source of cells: Periosteum, endosteum, marrow (callus) -Cellular blastema: Stimulation to proliferate / differentiate (callus) -Matrix synthesis (callus) -Fusion of "old and new" (by the callus - bridge for osteoblastic/osteoclastic activity) -Sufficient volume of tissue for strength (this is why xverse don't heal well) -Reworkable initial tissues -Narrow enough for the gap to be bridged -Freedom from gross movements, loading, infection and obstruction -Time

What is the purpose of the bone?

-Storage of Ca++ (In form of CaPO4). -protection of vital organs -support for body and mechanical basis for movement

What are some common myths about osteoarthritis and aging?

-That it is invariable. -That it is benign and causes minimal disability. -That little can be done therapeutically for osteoarthritis.

What is the strongest independent predictors of pneumonia

-dependency for feeding. mental status issues, dexterity, etc. BUT some people may be fed by caregivers that may not to be fed by caregivers, resulting at accidental aspiration of food. OTs can help independent feeding. -dependency for oral care -tube feeding

Growth plate damage in an extremity can cause

. . . shortening of the extremity and deformities.

A patient's willingness to participation in treatment . . .

... is predicated on their understanding of the problem.

It takes _______ seconds to perform an oral pharyngeal swallow. So how is it evaluated?

1-2 seconds; imaging.

Describe the inflammatory stage of bone healing.

1-5 days Hemorrhage and cell death Inflammation and clot formation Invasion of blood vessels and macrophages into clot Formation of granulation tissue

Describe the reparative stage of bone healing.

1-6 weeks callous replaces granulation tissue Invasion of blood vessels begins maturation of callous Calcified cartilage forms CC progresses to trabecular bone (matured callous)

What are the four steps to starting the creation of an intervention plan?

1. Begin by listing problems. 2. Link problems to potential impairments. 3. Relate the impact of these problems to the person. 4. Write goals.

How does the assessment process of dysphagia work?

1.) Screen. ----------Pass - resume preferreral oral intake without intervention. But some people have silent aspiration! 2.) Evaluation: @ beside sometimes. imaging is not always 100% necessary, if clinician is good at discrimination.

What percentage of hearing loss can be treated medically?

10%, vs 90% for with hearing instruments.

For every _____ hours of mechanical ventilation, the risk of pneumonia _____? Every ___ years of age in people that get sepsis ____ doubles their pneumonia risk

12, doubles. 10, doubles

What does c5-c8 injury look like?

Low Level Cervical Injuries C5-8. Have at least deltoid, bicep function (C5)- need a way to hold objects, since wrists and hands are paralyzed. Wrist may be stabilized with splint or orthosis. Universal cuff is a simple inexpensive utensil holder that can be attached around palm. Can master table top activities. Lack trunk control and muscles below shoulder so are mostly dependent in dressing and bathing. C6 gives wrist extension. Allows patients to close fingers with a tenodesis grasp. May pick up light objects. Better strength in rotator cuff, increase in upper limb strength. C7- triceps allows patient to reach for objects above head level, transfer with greater ease and push wheelchair. C8- get extrinsic finger muscles and thumb flexors. Hand dexterity and strength limited by absence of intrinsic finger and thumb muscles (T1). A C8 quad grasps objects with MCP joints in extension and PIP and DIP in flexion "claw hand or intrinsic hand. Specific activities to be included therapy: Range of motion- shoulders, elbows, wrists, hips, knees. May benefit from foot drop splints to prevent equinovarus contractures. Hand/wrist splints to prevent contractures in this area. Tetraplegics are typically prone to spasticity and contractures. Modalities- only to level of sensory loss. Below this, risk of burn is high. Only rarely used, other than occasional hot packs. Pressure reliefs- to prevent occurrence of pressure ulcers. Nursing works on rotating q 2 h while in bed. Always trying to develop new bedding/mattresses. OT specialize in finding the best wheelchair cushion that will provide sufficient, comfortable cushioning, without being so soft, and pressure relieving that they end up falling out the wheelchair (RoHo). Standing- with use of a tilt-table or standing frame after an acute SCI decreases hypercalcemia and may retard or lessen bone loss. Does not really help in terms of facilitating ambulation goals. Transfers- a reasonable goal. Start out with sliding board. Key to at least partial independence. Ambulation- when feasible. Ambulation after SCI is often one of first goals that many persons with SCI set for themselves. May use crutches. May use braces. Most often, patients find much more practical to use a lightweight wheelchair

What percentage of adults have hearing trouble? How does that compare to physical functioning disabilities?

15% - almost the same as number of adults with any physical functioning difficulty. It is the 3rd most common chronic condition in older adults

What percentage of physicians routinely screen for hearing loss?

16%

What is the treatment for tennis elbow?

Activity modification Stretching Strengthening Forearm brace Night wrist splint Injection Surgery (recalcitrant sx's)

Who commonly gets many fingers for trigger finger?

diabetics

How can we treat dequervains?

Activity modification Thumb spica splint Injection Surgery (persistent sx's) (non surgical = 30% of time)

What is a completely in the canal hearing aid

Currently very popular • virtually invisible • can't have T coil • use on phone normally • high maintenance • takes advantage of natural gain from auricle and EAM

What percentage of people who could be helped by hearing aids actually get hearing aids?

20%

______ % of people in nursing homes that have pneumonia die

20% to 50%

What is the best possible acuity you can get if you only have rods?

20/200

Without a macula, the best acuity you can get is . . .

20/200

What is the big "E" on the chart?

20/400

Physical stresses causes tension to build up in the muscles and joints of the body. This is why ______% of fibro patients have a current _____.

25-35%, psychiatric dx

What percentage of people after stroke die? vs with pneumonia?

26.9% mortality, vs 4.4% in stroke w/o pneumonia

How might an audiologist make sure a hearing aid will fit?

Custom mold impression.

What is the first symptom of retinitis pigmentosa?

night blindness

Each pound of body weight equals . . .

4-8 lbs extra placed on the joint.

What is a cataract? What causes them?

A cataract is a clouding of the lens in the eye that affects vision. Most cataracts are related to aging. Cataracts are very common in older people. By age 80, more than half of all Americans either have a cataract or have had cataract surgery. Diabetics are more at risk.

What percentage of healthy people aspiration oropharyngeal secretions in their sleep?

40-50%

What is electro ejaculation?

Fertility: Electro-ejaculation Intracytoplasmic sperm injection (ICSI) is an assisted reproductive technology (ART) used to treat sperm-related infertility problems. ICSI is used to enhance the fertilization phase of in vitro fertilization

How long does an average fibro diagnosis take?

5 years

Which cranial nerves implicated in swallowing also have voluntary functions?

5th, 7th, 9th, 10th, 11th, 12th (5, 7, and 9-12)

What is the treatment for mallet finger?

6 weeks in stack splint Stack splint At 6 weeks AROM with removable splint At 8 weeks PROM & night splint

____ % of people who have fibro have sleep disturbances.

75% percent of fibro people have sleep disturbancs, esp heat and humidity

What percentage of people over 80 have some degree of hearing loss?

80%

Noise above ________ decibels, on average over an 8-hour workday is considered hazardous?

80-90

Osteoarthritis: Clinical Features: Age

>50

What is presbycusis?

A decline in hearing as a part of the aging process - results from degeneration along the entire auditory pathway - reduced hearing sensitivity - reduced speech clarity

What is the macula?

A divot in the retina, most detailed apart of vision (color perception, 20/20 vision, fine details). Very small. Avascular.

Who certifies SLP?

ASHA (all SLP's)

How does the ASIA scale work?

ASIA Impairment Scale (2002) A= Complete: No motor or sensory function is preserved in the sacral segments. B= Incomplete: Sensory but not motor function preserved below the neurological level and includes the sacral segments S4-5. C= Incomplete: Motor function is preserved below the neurological level, and more than half of the key muscles below the neurological level have a muscle grade less than 3. D= Incomplete: motor function is preserved below the neurological level, and at least half or key muscles below the neurological level have a muscle grade of 3 more. E= Normal: motor and sensory functions are normal.

What are the tendons affected in dequervains

Abductor pollicis longus, extensor pollicis brevis.

What is the difference between chronic and acute pain?

Acute Pain: Associated with acute disease or traumatic injury and subsides as healing occurs. e.g. low back pain, gout Chronic Pain • Persisting after healing is complete. • Associated with an ongoing disease process. (e.g. OA, RA). • Begins with no identifiable precipitating event or organic cause.(e.g. FM).

What factors affect healing time?

Age of the Patient Site and Configuration of the Fracture Initial Displacement of the Fracture Blood Supply to Fracture Fragments

What are risks for diabetic retinopathy?

All people with diabetes--both type 1 and type 2--are at risk. Duration of disease Between 40 to 45 percent of Americans diagnosed with diabetes have some stage of diabetic retinopathy. Poor glycemic control Hypertension High cholesterol Pregnancy Sudden improvement in control Renal disease

What does a cauda equina injury look like?

Cauda equina Collection of long nerve roots which fill the spinal canal distal to L1-2. Roots subserve nearly all neural functions of the lower extremities, rectal sphincter, bladder and genitalia. Difficult to differentiate conus lesion from cauda equine lesion. prognosis good.

How has incidence of SCI changed?

Although mandatory seat belt laws would have lessened overall number of spinal cord injuries, because of increased rate of gunshot wounds, the overall incidence of traumatic SCI in the US has remained relatively constant, at approximately 40 new cases per million population, or just over 12,000 cases per year. (40 cases per million population)

What is an amphiarthrosis?

Amphiarthroses: slightly moveable, e.g., the intervertebral disks, SI joint, pelvis.

What are the components of aural rehabilitation?

Amplification • Assistive Listening Technologies • Counseling • Speechreading • Communication Strategies

What is the zone of resting cartilage?

Anchors the epiphyseal plate to the epiphysis Contains immature chondrocytes and delicate vessels

What causes RA?

Causes of RA Largely unknown Theories: genetic + environment Possible triggers: -Infection, -gut/gum bacteria (microorganisms, somewhere, that turns -on the immune response.) -Smoking -Obesity -Stress -female hormones

What is articular cartilage made out of? What does it lack?

Articular Cartilage Avascular, aneural Water- 66-79% depending on age (biggest component, begins to dehydrate with age and become less elastic). Collagen- (mostly type II) gives strength and form (infrastructure, like the ironworks in the building that gives it its strength and form.) Ground substance- give flexibility, glycosaminoglycans (long polymers of sugars) and proteins.

What ages/genders are common in RA

Avg 30-60 years old Females 3x as likely as males.

What are audiologists?

Audiologists identify, assess, and manage disorders of auditory, balance, and other neural systems. • provide audiological (aural) rehabilitation to children and adults across the entire life span • select, fit, and dispense hearing aids and related devices • prevent hearing loss through the fitting of hearing protective devices and education

What do audiologists do?

Auditory training for children with cochlear implants • Hearing testing in a Long Term Care Facility • Lip Reading training drills • Hearing aid operation and care • Counseling families on best communication

Beside clinical assessments have what limitations?

Bedside Clinical Assessment - aspiration not reliably detected • poor sensitivity, specificity is better -Non-choking patients are more often not dysphagic - fails to detect 2/3 of pharyngeal disorders - screens patients for test candidacy

What kind of fractures occur from tension failure.

Bending Mechanisms: Tension Failure Transverse Fractures Greenstick Fractures Oblique Fractures

How is a tender point diagnosed?

Blanching of finger (about 9 lbs of pressure)

How does diabetic retinopathy cause vision loss?

Blood vessels damaged from diabetic retinopathy can cause vision loss in two ways: 1) Fragile, abnormal blood vessels can develop and leak blood into the center of the eye, blurring vision. 2) Fluid can leak into the center of the macula, the part of the eye where sharp, straight-ahead vision occurs. The fluid makes the macula swell, blurring vision. This condition is called macular edema. It can occur at any stage of diabetic retinopathy, although it is more likely to occur as the disease progresses

________ light may cause ___________________, which simulates UV effects on the eye.

Blue, pupillary dilation

osteoarthritis: clinical features: changes to muscle and bone

Bony enlargement Muscle atrophy

What is the relationship between SCI and bowel and bladder management?

Bowel and bladder management- a very big deal on rehab units, especially in regards to spinal cord patients. Major determinant whether able to live independently, how much skilled help they will need, whether family will be able to take care of them. (or want to) Problems with these areas can lead to major morbidity in terms of constipation, bowel obstruction, bladder obstruction, urinary tract infections, skin breakdown, and pressure ulcerations. 1/3 of sci patients rank this as the most significant functional loss associated with paraglegia

What do the C1 roots do during the oral stage?

C1 roots Motor fields - Awaiting pharyngeal

Besides shoulder pain, what overuse syndromes are common?

CTS Ulnar nerve entrapment at elbow and wrist De Quervain's syndrome Stress fractures. Education- proper exercise techniques, shoulder protection Slogan "conserve it, to preserve it"

Closed reduction with internal fixation includes . . .

Can reduce fracture without surgery but cant maintain it with immobilization Unstable fracture of femoral neck Place pins and screws after reduction is achieved.

What is 20/200 vision?

Can see at 20 feet what a normal person can see at 200 feet.

Why is arthritis a "vicious cycle?"

Cartilage is also a pressure absorber and is compressed with more weight. This stress is then transmitted along the bone and to the bone underneath the cartilage. Vicious cycle--teardown of cartilage, harder on bones, teardown cartilage, harder on bones, etc. Strong muscles can help to protect joints and decrease pain.

What is central cord syndrome?

Central cord syndrome Most common, almost exclusively cervical injuries Motor weakness in upper extremities greater than lower extremities. (Upper limb motor pathways are more centrally located than lower extremity motor pathways which are peripheral in the cord.) Sacral sparing- sparing of outer most fibers. Bladder dysfunction, and varying sensory loss below level of lesion may also be present. Most frequent with older persons with cervical spondylosis who suffer a hyper-extension injury Compression of the cord both anteriorly and posteriorly by degenerative changes of the bony structures, with inward bulging of the ligamentum flavum during hyper-extension in an already narrowed spinal canal. Very favorable prognosis

What are some ways that hemmorrhage can cause spinal shock? What is done in these cases?

Chest, intra-abdominal, retroperitoneal injuries and pelvic. Long bone fractures. If unstable- diagnostic peritoneal lavage or bedside FAST (Focused Abdominal Sonography for Trauma) may be required to detect intra-abdominal hemorrhage.

Why is classification of SCI important?

Classification- guide to prognosis, treatment strategies, ultimate goals for rehab. Early on, level of injury can give you an idea on what medical problems may occur, what to look out for. Further down road, whether can work vs. disability. What level to play in for wheelchair sports/para-olympics: ASIA classification (get very detailed, heated debates) objective way to quantity people in research

What is the cornea?

Clear covering of the eye. Bends some of the eye/helps refract. Where contacts sit.

What is closed cervical reduction? How is it accomplished?

Closed cervical reduction is accomplished with traction- Gardner-Wells tongs or Halo ring Once reduction is confirmed, 10-15 lbs. of weight used to maintain reduction. Patient can later be brought to the OR for open stabilization.

What are the most common symptoms of a cataract?

Cloudy or blurry vision. Colors seem faded. Glare. Headlights, lamps, or sunlight may appear too bright. A halo may appear around lights. Poor night vision. Double vision or multiple images in one eye. Frequent prescription changes in eyeglasses

What is combined loading?

Combination of all loads causes bone to fail.

What kind of community mobility training is done for SCI

Community- requires independence in performing transfers, capability of going from sit to sand position, and ambulating reasonable distance unassisted in and outside the home (greater than 150 feet.) with or without braces or assistive devices.

How does the level of injury affect the ability to get erections?

Complete upper motor neuron (T10 and above) Psychogenic erections not possible (messages from brain can't get to T10-L2 center of spinal cord) Reflex erections are possible- S2-S4 reflex arc is intact Lower motor neuron (L2 and below) Psychogenic erections are possible (T10-L2 center is largely intact) Reflex erections are often not possible (S2-S4 reflex center may be involved) Ejaculation is almost impossible

What is the proper terminology for complete and incomplete spinal cord injury? What are they?

Complete vs. incomplete: According to ASIA (American Spinal Injury Association) guidelines- the terms paraparesis and quadriparesis, which were used in past to describe incomplete injuries, should no longer be used . Complete injury- defined as the absence of sensory and motor function in the lowest sacral segments, S4-5 Incomplete injury- preservation of motor or sensory function below the NLI that includes the lowest sacral segments (sacral sparing), S4-5 Prognosis is much better in incomplete vs. complete lesions. In incomplete lesion, there is hope for some recovery.

What are some mechanisms of spinal cord injury?

Compression fractures- seen more with diving accidents, direct axial load. Subluxation/dislocation- injuries with high torque- MVA's, hyper-extension injuries

What kinds of cells are in the macula?

Cones only

How does embryonic bone form?

Connective tissue, to cartilaginous matrix (scaffolding), to bone, to reabsorption of the central canal and medullary cavity form, growth plates form.

What are treatment goals in OA?

Control pain and other symptoms. Correct functional limitations and disability. (increase range of motion. Increase muscle strength). Effective use of medications Patient education Patient as Case Manager

What do conus medullaris injuries look like?

Conus medullaris is the tip of the spinal cord that lies at the level of L1-2. Nerves from it supply sensory supply to perianal and perineal region, genitalia, reflex arc of superficial anal reflex. Sacral parasympathetic (S2-4) connections for bowel and bladder sphincters, erectile organs, bulbocavernosus reflex. walk with braces, bowel and bladder issues. prognosis good

What are criteria for referral to orthopedic surgery?

Criteria for Referral to Orthopedic Surgery 1. Intractable pain 2. Loss of function and impaired activities of daily living 3. Unstable knee 4. Other factors: age, health status, weight, level of activity, functional limitations

What is the relationship between SCI and thromboembolic disorders?

DVT, PE common, incidence 47-100%.Major cause of early morbidity and mortality. Period of greatest risk seems to be during the first several months after injury. Risk factors for DVT, PE: immobility less risk if more spasticity present (more risk if flaccid paralysis) SCI may be accompanied by alterations in Factor VIII and platelet function, predisposing to thrombosis. Diagnosis: swelling, warmth, tenderness. Important to measure thigh circumference on a regular basis. A difference between 1 cm or more is suggestive. This is the best sign. Homan's sign may be helpful, but often unreliable.

How is fibromyalgia defined?

Definition: 1. Widespread musculoskeletal pain present for at least 3 months. 2. Pain in 11 of 18 tender point sites with digital palpation.

Describe the ratio of osteoblasts vs. osteclasts?

Describes the ratio of Osteoblasts vs. Osteoclasts Bone balance is the result of osteoblastic vs. osteoclastic activity Juvenile has a (+) bone balance Geriatric has a (-) bone balance

What is the leading cause of blindness in the industrialized world in younger persons.

Diabetic retinopathy

What is a diarthrosis?

Diarthrodial joint: a freely movable joint with a hyaline cartilage surface and a joint cavity lined by a synovial membrane.

What do swallowing specialists principally do: long term care setting

Differential Diagnosis of Pneumonias - Nosocomial vs. aspiration? • Maintenance of adequate nutrition • MAINTENANCE OF ADEQUATE HYDRATION • Thickened liquids produce dehydration

What does snuff box pain possibly mean?

Differential Dx Scaphoid fx Scaphoid fx Scaphoid fx Radial collateral ligament Can tell if 3 weeks later they still hurt in the snuff box, even after ER says no fx (because doesn't show up on x rays)

the stronger the telescope . . .

the smaller the field of view. hence, scanning is really important.

What are future trends for SCI ?

Developing Trends/Future Implantable electrodes, neural prostheses. *Functional Electrical Stimulation- becoming much more mainstream. can propel a bicycle. *Body supported treadmill training- harness supports body on treadmill. ^ neurotransmitters. trains the legs for better function *Exoskeleton Lower Extremity Gait System (eLEGS) Lower extremity exoskeleton or "wearable robot" *Bioness Harness system- Allows waking over ground, steps, various uneven surfaces. May have a more beneficial effect on neuroplasticity than walking on even surface of treadmill *Re-Walk- battery powered exoskeleton device which allows paraplegics to walk with use of crutches. *Robotic training of hand/arm after incomplete SCI- Repetitive training using a robotic exoskeleton improves arm and grip strength. Create plasticity in CNS, which leads to neurologic recovery *Voice Activated Systems- Assist in performing ADL's, answering and dialing the phone e-mail messages and pay bills. *Brain-computer interface- using EEG waves to pick up user's mental intent to rotate objects on a computer screen. Bypass injured spinal cord. *Standup wheel chair design- allow to be at eye level, smaller base means more maneuverability, may lessen incidence of pressure sores, hypercalcemia, contractures and upper extremity overuse disorders. Problems with mechanical breakdown, high cost. Contraindicated in patients with contractures, osteoporosis, and orthostatic hypotension. *Stem cell transplants- success reported in mice. Also reports of success in humans in India, Russia. Not confirmed. Questionable techniques. Ethical concerns. January 2009- the U.S. Food and Drug Administration approved the first U.S. clinical trial of a therapy derived from human embryonic stem cells. Temporarily suspended after animal studies showed development of cysts. FDA allowed resumption of trials in July 2010. Patients with severe spinal cord injuries will be eligible for injections of specialized stem cells. Phase I. Looking more at safety than therapeutic benefit. Geron GNROPC1 clinical trial, Santa Clara Valley Medical Center Trial halted on 11/14/11, but still following patients that are enrolled (5 patients) Cost and regulatory issues were cited as reasons for the closure. Pathway Study- New study, actively recruiting patients at the University of Pittsburgh, Dr. Michael Munin. The investigation will determine the effectiveness, safety and benefits of transplanting tissue-derived adult CNS stem cells above and below the site of cervical spinal cord injury

What is a dislocation?

Dislocation: Total loss of continuity of joint surface.

closed reduction followed by immobilization includes . . .

Displaced fracture where surgeon predicts reduction can be done accurately and maintained without need for surgery.

What kinds of goals might be used in a low vision clinic?

Distance vs near. - Spot (bus numbers/signs/chalkboard) » Monocular HHTS (telescope) » Binoculars » Bioptic spectacle mounted telescope - Sustained (TV/movies) » Full-field spectacle mounted telescope » Binoculars » Jordy

What is dorsal cord syndrome?

Dorsal (posterior) cord syndrome (uncommon) Position sense lost. Motor function and pain function preserved.

Can people drive after SCI?

Driving after Spinal Cord Injury Most patients with a motor level at and below C5 have the potential to return to independent driving with appropriate adaptive equipment. Driver rehab specialist determines modifications- proper controls, lifts, and lock-down and tie down devices.

What are the two types of AMD?

Dry and wet

What is the Acute Physiologic Response to Spinal Cord Injury

During the first seconds after SCI there is release of catecholamines with an initial hypertensive phase. This is rapidly followed by a state of spinal shock, flaccid paralysis and extinction of muscle stretch reflexes below the injury level. Cardiovascular signs of neurogenic spinal shock consist of hypotension, bradycardia and hypothermia. Hypotension especially common in patient with injury at T6 or above (less sympathetic supply intact). Unopposed parasympathetic output(especially vagus nerve) in persons with injury level above T1 contributes to this. (Level T1-L2: sympathetic system) Heart rates typically less than 60 per minute in this phase.

What is congenital atresia?

Ear canal didn't form! (external auditory meatus). Treated with surgery.

What interventions have the most impact with OA of the knee?

Education Exercise Weight reduction Medications Interventions that can impact the course

How is osteoarthritis managed?

Effective drugs and non-pharmacological treatments are available for the management of osteoarthritis. Non-drug treatments should be tried first. E.G., programs that teach people how to examine their own joints. How to understand their triggering tasks--encouraging people to keep a diary. Figure out what your triggering tasks are, and then figure out how to modify those activities of daily living. Surgical intervention should be considered when medical treatment has failed.

What is the pupil made out of ? How is it controlled?

Empty space, controlled by colored part of eye (iris).

What is the zone of maturing cartilage?

Enlargement and maturation of the cartilage cells near the metaphysis

What is the etiology of carpal tunnel?

Etiology Hypertrophy of flexor tendon synovium (swelling, blood from fx) Tenosynovitis Metabolic (e.g., from pregnancy related edema) Tumors Fractures

What is the etiology of trigger finger?

Etiology Nodule caught on A1 Tenosynovitis

What are the steps to getting to a diagnosis?

Etiology > Signs and Symptoms > Clinical Course > Medical Management > Morbidity > Prognosis

In what portion of the plan of care do goals fit?

Evaluation; Progress note.

What do you find on manual examination with thumb cmc joint djd

Examination Pain/crepitus with grind

What are general principles for exercise with osteoarthritis?

Exercise: General Principles Muscles are the major supporting structures of joints. Chose exercises that are convenient and enjoyable. Balance activity and rest- pacing. (don't put too much water in the bathtub.) Avoid significant pain. Understand activity threshold.

What is mallet finger?

Extensor mechanism disruption from the distal phalanx Soft tissue vs. avulsion Obtain radiograph to evaluate for: Fracture Subluxation Physeal Injury (need an xray to make sure too much bone is not pulled off)

How is pain treated in SCI?

Few effective treatments for neuropathic pain. Randomized controlled studies with Elavil, trazodone, mexiletine, and valproate have not shown a consistent benefit. Gabapentin(Neurontin), Pregabalin (Lyrica) - may have benefit. Opioids are gaining acceptance as a therapeutic option in nom-malignant pain syndromes and are rated by SCI patients as one of more effective treatments. No published studies however examining this in SCI patients. Alternative treatments which may be effective- Acupuncture, marijuana, massage, hypnosis Spinal cord stimulation, TENS, neuroablative procedures - little benefit.

What is fibrocartilage?

Fibrocartilage: Meniscus, e.g. of the knee. Intervertebral disks. Creates an anatomic relationship between the two sides of the joint.

What is fibroelastic cartilage?

Fibroelastic: Nose, ear, trachea.

What are the "key points" of fibromyalgia?

Fibromyalgia: Key Points Represent the end of the spectrum of chronic musculoskeletal pain Pain processing abnormalities - central sensitization (amplification) Effective treatments include cognitive behavioral therapy, aerobic exercise, and pharmacologic Rx Extensive cutaneous hyperalgesia

What is a flat bone?

Flat - Protective function (e.g. bones of cranial vault) help to form the walls of cavities

What can we use if IX is not working? (oral stage)

Food modification Lateral flexion

What are the four zones of the epiphyseal plate?

Four Zones of the epiphyseal plate 1. Zone of resting cartilage 2. Zone of young proliferation 3. Zone of maturing cartilage 4. Zone of calcifying cartilage

Fractured bone has lost . . . Continuity, vitality, and?

Fractured Bone Has Lost Continuity of bone Continuity of the periosteum Continuity of the vessels Vitality of the bone ends (damge, necrotic changes) Position and alignment Supporting and resisting functions

What does fractured bone introduce?

Fractured Bone Introduces Inflammatory reaction Hemorrhage and clotting Pain and shock Cellular stimulation (bone marrow activation) Bone fragments Infection Interposed soft tissue Emboli

What do audiograms measure?

Frequency - Pitch, measured in Hz • Intensity - loudness, measured in dB

What is gamekeeper's thumb?

Gamekeeper's Thumb Definition Rupture of UCL of Th MP Radiograph to eval for Fracture Sublux Examination: radial stress in 30 deg flexion to unlick volar plate

What is a ganglion cyst?

Ganglion Cyst Etiology Defect in joint capsule/tendon sheath -1 year old to 90 year olds. -fluid leaks out into sac -common on dorsum of wrist -common on volar of wrist

What is the primary cause of bunions?

Genetics

How do the pain patterns of gout, RA, and OA differ?

Gout: irritating all day long. RA: worse in morning and evening OA worse in the middle of the day

What is the most important geriatric treatment to prevent bone loss?

HEAVY weight lifting with periodization. Can slow osteoporotic process.

What is halo vest immobilization?

Halo Vest Immobilization Used postoperatively as an adjunct to internal fixation as well as the primary method for fracture stabilization. Although it is the most restrictive appliance, it does not guarantee alignment or fusion. It is a non-surgical alterative for patients refusing operative care or for whom surgical intervention is contra-indicated. Permits early mobilization without risk of compromising spinal alignment.

What are the most commonly affected joints in osteoarthritis?

Hands (DIP, PIP, 1st CMC), knees, hips, and 1st MTP joints are the most commonly affected. DIP have a very strong genetic component--10 to 1 females to males

If paralysis is unilateral, during the oral stage . . .

Have patient flex head away from paralyzed side.

What restorative techniques can be used during the oral stage for problems with XII and C1

Head postures to compensate absent lingual motion Exag. Lip closure Head/neck flexion*

What can we use if X is not working? (oral stage)

Head/neck flexion* Food modification, posture

What kind of systemic conditions often overlap with fibromyalgia

Headaches Affective disorders TMJ Idiopathic LBP IBS Restless leg syndrome Menstrual issues Sleep disturbances

What is the history and physical examination of lateral epicondylitis?

History Lateral elbow pain Examination Pain over lateral epicondyle Pain with resisted wrist or long finger extension

What is the relationship between pain, function, and structure?

How do we make decisions as healthcare providers? Pain, Function. Those are the two most important aspects! Pain and function are highly correlated, but pain and structure are NOT. Knee and hip replacements have the greatest qualify of life impact out of any operation, but the patient needs to be in pain!

What is one way to know someone has a fracture?

Huge amounts of swelling, etc., due to blood from haversian system.

What are the three kinds of cartilage?

Hyaline, Fibrocartilage, Fibroelastic

What is hyaline cartilage? What are some of its characteristics.

Hyaline/articular (diarthrodial joint). Characteristics: very smooth surface (coefficient of friction is less than an ice skate on ice!). It has no blood supply, and is instead nourished by synovial fluid. Low nourishment makes iit vulnerable to injury and hard to repair. Components turn over every 3 months. It has no nerve supply, meaning that pain doesn't come from the cartilage! It also has no lymphatic supply.

What are the two components of an amplified pain response?

Hyperalgesia (pinprick-super painful) Allodyna (hugs hurt)

What is the function of XII during the oral stage

Hypoglossal (XII) - Bolus movement for chewing - Anterior containment (pushing bolus toward upper teeth/alveolar ridge. - Posterior containment (pushing food toward soft palate)

Which nerves exit the jugular foramen?

IX, X, XI . So paralysis of head rotation could involve lesion of skull base.

What is the significance of the battery door in a hearing aid?

If the battery door is not closed, the hearing aid will not function (contacts will not work). If you can see the battery or something sticking out, the hearing aid is not configured properly!

What are non-medical treatments for spasticity

In treatment of spasticity, one of first things to do is rule out treatable causes. Any kind of irritation can lead to spasms. This could include UTI, bladder stones, pressure ulcers, abdominal pathology, ingrown toenails, hemorrhoids, bowel impaction. Stretching is a mainstay of treatment and should be done twice a day or more. Standing activities including tilt table or standing frame provide prolonged stretch to joints. Modalities such as ice, e-stim provides only short term benefits. Posture and positioning is extremely important for tone reduction. Inhibitive casting, splinting and orthotic management of muscles and joints at risk for contracture may also be helpful in reducing tone. Standing frame is also helpful to decrease spasticity, improve muscle tone, DVT prophylaxis

FIM level: I

Independent

What are two "clinical pearls" for pain evaluation?

Index finger sign: take your index finger and point right there Movement of the affected area reproduces the symptoms

What are the four processes in the osteoarthritic model?

Insults Repair Compensation decompensation

Where are people transferred with SCI after initial hopsital stay?

Insurance issues- Emphasis on decreasing length of stay. If mostly nursing services needed, transfer to SNF. If only need PT/OT/speech, discharge, do therapy as an outpatien

How can bone grow.

Intramembranous and endochonral ossification

What is an irregular bone?

Irregular - Bones of the face

What do optic nerves problem cause?

Issues with peripheral vision, ultimately affect detail vision, contrast

What are some of the factors in the multifactorial etiology of OA?

Joint instability Age Hormonal factors (estrogen) (but people with osteoporosis have less OA because bones are soft and less mechanical stress). Trauma Altered biochemistry of cartilage Inflammation Genetic predisposition ? Others

Osteoarthritis: clinical feature: swelling

Joint swelling with little or no warmth

Where does the US rate on health indicators?

Last.

Describe cancellous bone? (density, composition, location)

Less dense, more space than compact More metabolically active Contain blood vessels, nerve fibers and fat Hemopoietic tissue Flat bones, metaphyseal regions of long bones More flexible

Osteoarthritis: clinical features: pain patterns

Localized joint tenderness Pain is often steady or intermittent. Only a third of people whose x-rays show OA report pain or other symptoms

What is a bursa?

Lubricating sac. 78 named bursa on each side of the body, superficial and deep. Superficial bursa do not communicate with joints, but deep bursa do. Extra fluid in knee can pump into bursa and give you a baker's cyst.

When it comes to the hands, osteoarthritis affects . . .

MCP's are usually not affected, 1st CMC's are often affected. Except that people who work with jackhammers often get MCP arthritis!

What is the number one cause of SCI? Second? Third? Fourth?

MVA. Falls, especially in the elderly. Gunshots. Recreational sporting activities.

What is the effect on SCI for men?

Men- Often lose fertility due to a reduction in number and quality of sperm Synergistic activity required to ejaculate (sympathetic and parasympathetic systems) Sperm is compromised, particularly for quadriplegics. May be washed into bladder (retrograde ejaculation) Temperature effect decreases sperm viability.

What is the relationship between SCI and pulmonary embolism?

Major cause of mortality in patients with SCI (or any patients who are immobile) Spiral CT scan can now check very accurately for PE in a non-invasive manner. (entire lung circulation can be scanned in one minute)

What is the gender breakdown of SCI?

Males represent 81.2 percent of all reported spinal cord injuries and 89.8 percent of all sports-related SCIs.

What can you do if you have problems with labial closure? (oral stage interventions)

Manual closure Exercise, posture* - head posture/tipping up can help to swallow using gravity - be careful liquids don't go into airway. have to first train the patient to make contact between tongue and soft palate. Utensil adaptation - (OT) Lateral flexion Food modification

What remediations are available during the pharnygeal stage?

Manual, exercise Exag. Lip closure Prosthetic; nasal occ (structurally contain pressure) Glottal valving training Mendelsohn-training; mendelhsohn surgery ? NMES (neuromuscular esophageal electrical certification)--not proven efficacy, and no real certification for this? ? Biofeedback

FIM level: Max A

Max A = Maximal Assist (is able to do between 25% - 49%)

What are the five factors we need to understand to understand rheumatic diseases?

Mechanism (What's the problem/pathophysiology) • Biology (of the individual, e.g., genetics) • Diagnosis (need to understand to help patients understand what they have) (e.g. RA vs Fibro; activity vs. central processing) • Spectrum (of these diseases in presentation) • Treatment

How is diabetic retinopathy treated?

Medical management of glucose levels: HbA1C under 7% Medical management of hypertension- 37% reduction in microvascular disease, risk reduction of VA loss = 47% Medical management of hyperlipidemia- may reduce exudate formation Treatment of nephropathy -transplant better than dialysis for visual prognosis Anemia should be aggressively treated Gradual control measures Laser - destroying formation of blood vessels in retina.

What is endochondral ossification?

Mesenchyme is chondrified into a cartilaginous bone model, bone forms later by replacing with calcified cartilage. NEEDS BLOOD SUPPLY. Advances the end of the cartilaginous model.

What is the etiology of lateral epicondylitis?

Micro-tear extensor origin from lateral epicondyle

FIM level: Min A

Min A = Minimal Assist (is able to do more than 75%)

FIM level: Mod A

Mod A = Moderate Assist (is able to do between 50% - 74%)

FIM level: Mod I

Modified Independence (needs a device)

Describe the remodeling stage of bone healing

Months to years Combo of bone resorption and deposition Restoration of normal architecture (osteons, marrow cavity) Remodeling rate influenced by weight bearing

What is an in-the-canal hearing aid?

More discrete • Can have T coil or use telephone acoustically • Requires little finger/hand dexterity

What is an in the ear hearing aid?

More or less cosmetically acceptable • handles fairly high gain • easier to get in and out

How is RA usually diagnosed?

Morning stiffness Joint pain and swelling Small joint, symmetric Difficulty with activities Joint damage

Osteoarthritis: Clinical Features: Morning stiffness

Morning stiffness < 30 minutes (so very little morning stiffness) (vs. RA, where people get joint fluid edema, causing morning pain).

What are the mechanical properties of bone?

Must deal with various types of loading:Compression, Tension, Torsion, Shear Structure suited best for resisting compression loads

Are swallowing disorders a good independent predictor of pneumonia?

NO! they have to have another associated condition, like non-independent feeding. If we can manage the other factors, we can help someone with dysphagia not get pneumonia.

Non-displaced fractures with _____________ heal twice as fast as displaced fractures.

Non-displaced fractures with intact periosteal sleeve heal twice as fast as displaced fractures.

What is neurologic level diagnosed?

Neurologic level is diagnosed according to motor and sensory level. Motor level is determined by testing 10 key muscles on each side of body. Sensory level is determined by testing sensation of 28 key points on each side of body. The neurological level is the lowest level at which key muscles grade 3/5 on MMT and sensation is intact for this level's dermatome. The level above must have normal strength and sensation. Sensation: A 3 point scale (range 0-2) is used, with the face as normal control point. Absent to pin- 0, inability to distinguish between sharp and dull edge of pin. Impaired sensation- 1- patient can distinguish between sharp and dull but pin not as sharp as face. 2- only if pin is felt as sharp as tested on face NLI- neurological level of injury- the most caudal level at which both motor and sensory modalities are intact on both sides of the body. Example- Radial wrist extension (C5/6) - 3/5. Wrist flexion (C7, C8)- absent. Sensation intact to C6 dermatome- Would be C6 level.

What is the relationship between SCI and pain?

Neuropathic Pain- major common problem. In acute phase- nociceptive pain, usually related to damage to soft tissue and skeletal system from initial trauma. After this subsides, 47-96% of SCI population will develop neuropathic pain severe enough to hinder rehab and reduce quality of life. Often described as burning, tingling, cramping shock-like or intolerance to cold.

What physical changes occur to the joint in osteoarthritis?

Normal vs. OA Irregular thickening and remodeling of subchondral bone (subchondral sclerosis = sclero = hard). Thickening distortion and fibrosis of the capsule Fibrillation, loss of volume and degradation of articular cartilage modest , patchy, chronic synovitis Osteophytosis and soft tissue growth at margin Loss of chondrocytes. Loss of glycosaminoglycans. Chondrocytes try to build but they don't have a food supply and so they can't. Masses of chondrocytes but they can't build cartilage. Tears in cartilage.

What is concentric viewing?

Not looking straight ahead. Turn head to see something because macula giving central vision is destroyed.

What is the effect of glucosamine and chondroitin supplements on osteoarthritis?

Note: no evidence that glucosamine and chondroitin gets into your cartilage.

Why do the fibers in cortical bones go in every direction?

Oppose forces from all directions

What is O and M?

Orientation and mobility - how to get around, use canes, dogs.

Technically, what is osteoarthritis?

Osteoarthritis A group of distinct overlapping diseases characterized by the biomechanical failure of a diarthrodial joint with: 1. Cartilage loss and 2. Accompanying articular bone response. So you can't get osteoarthritis in the intervertebral disk joints! Because those aren't diarthroidial joints.

What conditions can be asssociated with RA?

Osteoporosis Heart disease Atherosclerosis (inflammatory response)

What are changeable risk factors for OA?

Overuse of the joint Major injury Overweight Muscle weakness

What joints are usually affected in RA

Overview of joints affected: PIP, MCP, any diathroidial joint, but USUALLY NOT DIP.

What is the treatment for stoved finger?

PIP Ligament strain vs. volar plate avulsion X-ray to r/o fx Treatment: Edema control (night coban) Immediate A/PROM

What are the two kinds of pain?

Pain Neuropathic- no good purpose. Aberrant, hyperactive nerve pathways. Very common in SCI Nociceptive- overuse syndromes, caused by something. It has a purpose- "listening" to it prevents further injury.

What are the two most important outcome measures that we look for in a disease?

Pain and function are the two most outcome measures that we look at for all disease.

Is there a "pain center" in the body?

Pain is processed through a PAIN Matrix. No single pain center in the body.

What are the symptoms of dequervain's tenosynovitis?

Pain radial styloid Assoc with thumb activity Especially new mothers

What are symptoms of joint disease?

Pain • Stiffness • Loss of function • Systemic illness Patients with RA wake up with morning stiffness. Inflammation causes edema (increase in interstitial fluid), gives you a subjective awareness of the area causes it to feel stiff, which can affect ROM.

What is the cardinal manifestation of a musculoskeletal disorder?

Pain.

What is paraplegia?

Paraplegia- motor and sensory impairment at the thoracic, lumbar or sacral segments of the cord. Sparing of arm function. Depending on level, impairment in the trunk, legs and pelvic organs.

When do you need to treat mallet finger with surgery?

Physeal injury Subluxation Displaced bony mallet Chronic swan neck

What are the key factors in planning SCI rehab?

Planning Rehab Depends on the initial level of injury, initial strength of muscles, whether injury is complete or incomplete as determined by physical exam. Medical problems, stability Patient, family goals. Financial resources and social resources.

How can fractures be treated?

Protection Alone Immobilization by Splinting without Reduction Closed Reduction with Immobilization Closed Reduction with External Fixation Closed Reduction with Internal Fixation Open Reduction with Internal Fixation

What are the two kinds of erection?

Psychogenic erections- controlled by T10-L2 level of spinal cord Reflex erections- controlled by S2-S4 level

What are challenges in treating RA?

RA challenges Variability of disease course Higher expectations for impacting disease Expansion of disease modifying anti-rheumatic drugs Medication costs Targeting disease mechanisms NSAID control symptoms DMARD - modify disease

Reduced vascularization increases risk____________

Reduced vascularization increases risk of non-union. Reduced vascularization increases risk of avascular necrosis

External splinting without reduction includes . . .

Relative immobilization: can still move other aspects of the extremity. Casts, splints Indications: Undisplaced but unstable fracture

What is pain complex? What are the "three questions" you can ask?

Reliance on the patient's perception and description Individual variability of pain Role of psychological and social factors Three questions: Are your symptoms real? Do you think I believe you? Do you want to have this?

How are pulmonary symptoms in fresh injuries managed?

Respiratory compromise may occur- may require assisted ventilation NG tube should be inserted during initial assessment period to prevent emesis and potential aspiration

What is Rigid molded plastic TLSO?

Rigid molded plastic TLSO- maximum immobilization of lower thoracic and lumbar spine. (thoracic fracture?

What are risk factors for fibro?

Risk factors include: Genetic: increased incidence among first-degree relatives, associated with genetic markers Environmental: physical trauma, infections, social stressors Gender: more common in women 70-80%

What are non-changeable risk factors for OA?

Risk factors you cannot change Genetics Sex

When is surgical stabilization used in fracture?

Role of surgery- Decompression, laminectomy, fusion- with bone graft or metal instrumentation.

FIM level: S

S = Supervision (cueing, setup)

What does SCI sex rehab look like?

SCI Sex Rehab Teach that many parts of the body can be aroused and provide a pleasant sexual response Some people report the most sensitive area of their body is at the level of the injury. Encourage to use all senses

Who should get surgically stabilized, versus not?

Select patients with incomplete SCI, such as those with cervical facet fracture dislocations may experience improved neurological recovery if early decompression is performed within 8 hours. In thoracic and lumbar spine with complete injuries, no improvement in neurological function after decompression If incomplete do- they do benefit from surgical intervention

What is a sesamoid bone?

Sesamoid - Protect tendons from wearing (e.g. patella) (resembled sesame seeds)

Closed reduction with external fixation includes . . .

Severely comminuted unstable fractures Open fractures with extensive soft tissue damage including arteries and nerves (severely comminuted unstable fractures)

Does SCI injury affect sexual function or fertility?

Sexual function and fertility- significant concern, but one which is often not addressed on rehab units, where other issues are is thought to be much more important. However, SCI patients are typically young, and this does remain important to them. Ideally, these issues should be discussed soon after injury. Many centers do include sexuality as part of formal SCI education classes during inpatient rehabilitation.

What are short bones?

Short - Cuboidal (e.g. Carpals and Tarsals) found only in the foot or wrist

What are signs of joint disease?

Signs • Heat • Redness • Swelling • Loss of movement • Deformity • Tenderness • Crepitus • Functional abnormality (Insert graphic).

What is a subluxation?

Subluxation: Partial loss of continuity of joint surface.

How can we describe fractures?

Site Extent Configuration Relationship of Fracture Fragments to Each Other Relationship of Fracture Fragments to the External Environment

What is the zone of young proliferation?

Site of the most active interstitial growth

What complications occur with fracture?

Skin Injuries Vascular, Muscular. and Nerve Injuries Visceral Injuries Shock Infection (septic joint, osteomyelitis) Fat Pulmonary Emboli Growth Disturbances Abnormal Healing (malunion, delayed union, non-union

What is spasticity? How does it affect ADL's?

Spasticity. very common in patients with higher level SCI- cervical, upper thoracic levels, especially if incomplete injuries (ASIA grades B and C). May result from preserved connections, using new or aberrant pathways in spinal cord. While spasticity may contribute to improved function is some regards- standing, transfers, ambulation, assisting some ADL's it may often lead to complications including contractures, pain, and decreased function.

What is the most common cause of pain on the ulnar side of the wrist?

TFCC tear

What are gunshot and knife wounds that affect the spinal cord like?

Stab wounds and GSW's generally do not produce spinal instability and therefore may not require surgical stabilization or orthotic immobilization. Objects that are embedded around the spinal canal (i.e. knife) should be left in place with removal performed in the OR under direct visualization of the spinal cord.

What is the immediate treatment for SCI?

Stabilization, immobilize neck, avoidance of additional neurological injury and medical complications. Probably most important part of rehabilitation in the long term. The difference between just one level C6 vs. C7 quad or C5 vs. C6 can make a huge difference. It's the initial medical treatment that makes the difference.

What is the third stage?

Stage transition- time between when bolus enters pharynx and when pharyngeal response begins. In young people, pharyngeal response happens before bolus enters pharynx! In older people, this slows--so pharnyx in not prepared (airway closed) until food is already in the pharynx. Goes from negative when young, to zero when 40, to >1 when old.

What is the zone of calcifying cartilage?

Structurally the weakest zone Active boney deposition on the metaphysis

Broadly, how does swallowing/dysphagia impact health?

Swallowing is not usually the primary diagnosis. Stroke, neuro disease, etc., can cause dysphagia; failure to remediate dysphagia can result in pneumonia, obstruction, malnutrition, dehydration, dependency on feeding tube.

What are the symptoms of Thumb CMC Joint DJD

Symptoms Pain with pinch at base of thumb Woman 40-60s

What is a synarthrosis?

Synarthroses: immovable, sutures of the head is the only one.

What is the primary problem in RA?

Synovitis is the PRIMARY problem. Inflammatory products get into synovial fluid and cause damage. Almost acts like a malignant tissue, eroding into the bone. Thinning of cartilage. Process extends into soft tissues.

How does inflammation affect synovium?

Synovium covered in synoviocytes, make HLA. Inflammation breaks down the polymers.

What is RA?

Systemic autoimmune disease charactertized by inflammatory polyarthritis, which affects peripheral joints, especially the small joints of the hands and feet (diarthroidal) Chronic untreated inflammation may lead to joint erosion and joint destruction. Less likely now due to early treatment (e.g. swan neck, boutinerre's).

Why is exercise very important in fibro patients?

Tend to be very deconditioned

What is a tendon? What is the relationship between tendons and arthritis?

Tendon: muscle to bone. Muscles represent the major support structure to the joint! Weak muscles = more pain in the joint, due to more stress on the joint! Emphasize exercise! For every 1 lb of body weight, xtra 4-8 lbs of pressure on the knee. More muscle strength helps to protect the knee!

How is osteoarthritis diagnosed?

The dx of osteoarthritis is based on clinical presentation and supported by radiography. (Age, sex, affected joints!)

The greater the __________, the longer the healing time

The greater the displacement, the longer the healing time

What is the inner lining of the eye? What does it do?

The retina. Is the sensory layer. Gathers light that enters the eye to be transmitted by optic nerve to brain. (-) retina = not absorbing light, not quality image or signal back to optic nerve.

What happens to the muscles in carpal tunnel?

Thenar atrophy, cannot be able to prepare thumb to pinch.

Does stretching help carpal tunnel (e.g., home exercise programs?)

Theoretically, tendon gliding exercises should help . . . but only helps very early on . . . )

What can sci patients orally to help prevent UTI?

Things we learned from nursing: to keep the urine acidic including vitamin C, cranberry juice (100% pure, not "cocktail") , decrease risk of infection- uncertain if this really works, but we generally do anyway. Prophylactic antibiotics generally not recommended, although in cases of severe recurrent infections, may be used.

What to do if scaphoid fracture suspected but not seen on x-ray?

Thumb spica cast Serial weekly x-rays until pain resolves vs. MRI or CT (80% of scaphoid is covered with cartilage, so it has a poor blood supply)

How are bowel and bladder problems managed in SCI patients?

To avoid complications, must empty bladder routinely, Use Foley catheter initially, but generally like to pull out on rehab unit to avoid infection (which all patients with long term Foleys get, no matter how good care is). Most go to intermittent catheterization. Patients need to learn to do this themselves, have caregivers educated in this and/or have patient be able to instruct people on how to perform this. For patients with reflex bladder: Spincterotomy: surgical process to weaken bladder neck and sphincter muscle to allow urine to flow out more easily. After surgery-urinate involuntarily Condom catheter: usually follows spincterotomy Simulated voiding:

What is the treatment for carpal tunnel?

Treatment Activity modification Wrist splint - night (to prevent flexed wrist. Splinting MP joints improves outcomes) Injection -----Sx <1 yr, ----- No atrophy -----Nl sensation Surgery -----Persistent symptoms -----Expanded 2 pt discrimination -----Atrophy

What is the treatment of thumb cmc joint djd

Treatment NSAID Splint (short opponens) Injection Surgery (recalcitrant)

What is a triggering task?

Triggering Tasks: activities that make joint symptoms worse. Important to understand what makes your symptoms worse.

What can we use if XI is not working (oral stage)

Trunk posturing?

What is a long bone?

Tubular (e.g. Humerus and Femur) have a body and 2 ends

What is a torsion load?

Twisting load. One half of the extremity is fixed.

Describe type 1 salter harris fractures

Type I Plane of separation along the epiphyseal plate through the zone of cartilage transformation Periosteal attachments will sometimes remain intact Usually produced by a shearing type force Blood supply intact and future growth is normal

Describe type 2 salter harris fractures

Type II Most common (75%) Fracture extends across the corner of metaphysis Periosteal hinge remains intact Future growth is considered normal because blood supply remains intact

Describe type 3 salter harris fractures

Type III Rare Usually occurs at distal tibia Future growth usually normal but displaced fractures produce an irregular articular surface Implications for rehab or future issues?? (wear)

Describe type 4 salter harris fractures

Type IV Intra-articular fracture that extends throught the epiphyseal plate and into the metaphysis ORIF with "perfect" fixation needed to have any chance at union May lead to nonunion/malunion with progressive disturbance of growth

Describe type 5 salter harris fractures

Type V Crushing injuries Diagnosis is difficult secondary to lack of displacement May lead to permanent damage with a complete or partial cessation of growth leading to limb length discrepancy and deformity

What is TM perforation?

Typmanic membrane perforation. Can heal on their own, but may need surgery.

What is stenor lesion?

Up to 60 % incidence Interposed adductor Operation required -from gamekeeper's thumb.

What is the average age of SCI?

Used to be considered a young person's disease. Between 1973- 1979 average age of onset was 28.7 Since 2014 however, average age of onset 42

Open reduction with internal fixation includes . . . .

Used when closed reduction is impossible Displace avulsion fractures, intra-articular fractures Soft tissue entrapment in fracture Displaced fracture crossing epiphyseal plate in children.

What cranial nerves, functions by anatomic structure? 1st stage?

VII - lip/labial closure, prevent loss of contents buccal shortening, closes lateral sulcus, salivation, taste, V - mandible-mastication muscles, general sensation, face and mouth.

What is a contraindication for vitamins for AMD?

beta carotine can cause lung cancer in smokers. There is a smokers formula.

Describe cortical bones? (density, organization, directions)

Very dense, little space Highly organized lamellar network of fibers, packaged in osteons. Fibers in each layer or osteon oriented in different directions

What is VFS? What are advantages and disadvantages?

Videofluorosocopy (VFS). See everything in real time, can try out compensation methods to test efficacy right there in x-ray room. Disadvantages: needs a giant machine, not always feasible?

What the role of cataracts in world blindness?

Vision-affecting cataracts not common in the U.S., due to treatments, but one of the leading causes of blindness in the world.

What is the trigger to convert from dry to wet AMD?

We don't know.

How might you test sensory ability when evaluating for carpal tunnel?

Weintstein monofilament test, 3 mm discrimination is normal

What is wet AMD?

Wet: Edjudative: Wet AMD • *Occurs when abnormal blood vessels behind the retina start to grow under the macula. • *These new blood vessels tend to be very fragile and often leak blood and fluid. • *The blood and fluid raise the macula from its normal place at the back of the eye. • Loss of central vision can occur quickly. • An early symptom of wet AMD is that straight lines appear wavy.

What drugs should be used in OA management? What are some considerations for efficacy and safety to be aware of?

What drugs should be used for osteoarthritis? Efficacy & Safety Cost Guidelines for NSAID Use in Knee OA Pharmacologic Rx is used in conjunction with non-pharmacologic measures. • NSAID's or acetaminophen are the initial agents for symptomatic control of knee OA. • Determine risk profile for NSAID using: age, Hx PUD, steroids, concurrent conditions.

What is arthritis?

What is arthritis? Arthritis: Arthron (Gr.) -- joint -itis -- inflammation. But is inflammation a component of all of the kinds of arthritis? Inflammation = physiological response to injury. Pathologic inflammatory response vs. normal inflammation process.

What is simulated voiding?

What methods are there? Simulated voiding: Anal or Rectal Stretch: This method for relaxing the urinary sphincter (insertion of 2 fingers to relax spincters)is usually used along with an abdominal corset and valsalva Credé: This method involves manually pressing down on the bladder. Tapping: The area over the bladder is tapped with the fingertips or the side of the hand, lightly and repeatedly, to stimulate detrusor muscle contractions and voiding. Valsalva: increasing pressure inside the abdomen by bearing down as if were going to have a bowel movement

What is the effect of age on the lens of the eye?

When young, more flexible to allow better focusing on retina to get a clear image. At age 40-45, lens no longer focuses as well as it does, causes presbyopic (need reading glasses or bifocals).

What is wolff's law?

Wolff's Law (Law of Physical Stress) Bone is deposited in sites subjected to increased stress Bone is resorbed from sites of decreased stress Alignment of trabecular systems is along the lines of stress Marked cortical thickening is observed on the concave (compressive) side of a curved bone Electrical properties of bone (-) on the concave side (deposition) (+) on the convex side (resorption)

What is the effect on SCI for women?

Women- do not affect fertility once menses return. Amenorrhea occurs in 85% of premenopausal women with cervical and high thoracic injuries, and 50-60% of women overall. Within 6 months and 1-year post injury 50 and 90% of premenopausal women respectively have return of menstruation. Level and completeness of injury do not appear to influence fertility

Which cranial nerve is the most important during swallowing in general?

X

How does SCI affect bowel and bladder elimination? What are the "kinds" of bladder?

a controlled by S2-S5 segments. All persons with complete lesions at and above the S2-S5 levels lose their ability to void voluntarily. S2- S5 segments innervate bladder, allow it contract, and squeeze urine out. Reflex bladder- increased tone, may contract automatically. Lesions T12 and above Flaccid bladder- decreased tone, risk of overdistension, autonomic dysreflexia. Lesions below T12 which directly affect bladder center.

What is an iatrogenic disease?

caused by the treatment of another disease

What is a nosocomial disease?

acquired in a healthcare setting

Where is the pain in trigger finger?

across palm of hand.

The swallowing mechanism is also called the . . .

aerodigestive tract. Includes the mouth, pharynx, which are conduits for foods, respiratory gases, liquids . . . mechanism alternates between respiratory and digestive functions.

What is meant by "setting" when talking about diagnosis?

age and sex of the patient.

The greatest risk factor amd is . . . other risk factors include . . .

age. • Smoking. obesity, family history, race (white), gender (female), working outside, being farsighted.

when you make fist . . .

all fingers should point to scaphoid tubercle.

Otitis media is . . .

an ear infection.

What types of glaucoma are there?

angle-closure (drainage structure of eye pinches off), pigmentary (pigment brushes off and blocks drainage structure) primary open angle glaucoma, chronic inflammation in the eye (uveitic), pseudo-exfoliative (hereditary, parts of your lens flake off block off drainage structure)

What are some types of incomplete spinal cord injuries?

anterior spinal cord injury, dorsal cord injury, central cord, brown sequard syndrome

What are treatment options for wet AMD?

anti-VEGF, new drugs that are injected in the eye. Multiple injection given as often as monthly. can slow down vision loss from amd and in some cases improve sight.

How does bone WIDTH growth happen?

appositional growth: activity of the osteoblasts, located in the deep layer of the periosteum, intramembranous ossification. -osteoclastic reabsorption of the cortical bone results in . . .

How many events occur in a "swallow"?

approximately 40

_____________ pneumonia cannot be prevented by a pneumonia vaccine

aspiration

Many people are diagnosed with _____, when they really don't have it. This can reduce________

aspiration pneumonia, food intake due to restrictions, causing dehydration, etc.

Changing the length of the bone also . . .

changes forces on other bones, causing risk of arthritic deformations, etc.

How long does lateral epicondylitis take to heal?

avoid activity - 8 months to a year to heal

Who can get trigger finger?

babies (1 year old) to 90 year olds (ring fingers).

Why can diabetes suddenly improve vision?

blood sugar being accumulated in the lens.

What is the choroid?

blood supply to the retina

What is heterotrophic ossification?

bone formation/calcification in places where should not be- usually around joint or in muscle. Occurs in 15-20% of patients, usually 1- 4 months after injury. Warm, swollen extremity, fever, limited ROM. Most often seen in hip, shoulder. Bed positioning, daily ROM important to prevent. Treat with Didronil (prevents further calcium build up). Surgeons typically very hesitant to remove. Messy surgery- very vascular. Like to wait at least a year for bone to "mature" and then only if a major problem.

Diabetic retinopathy affects . . .

both central and peripheral vision.

What kinds of high tech rehab are available for SCI?

brain computer interface, battery powered walking, stem cell rehab

What are angulated factors? translated?

broken and @ angle, bone has moved.

What is autonomic dysreflexia?

can be potentially life threatening. Sudden dangerous increase in blood pressure, severe headache. Seen in patients with T6 level or above. Caused by unopposed sympathetic response to noxious stimuli: obstructed bladder, UTI or other infection, bladder or kidney stones, fecal impaction, pressure sores, Foley cath, enema, pain. Main treatment is to find the cause (usually distended bladder- cath patient cures). If no obvious cause- may use meds like nifedipine. If patient is taking Viagra where nitrates are contraindicated, may use Minipress (prazocin) or captopril Follow-up: Monitor BP for 2 hours after resolution of episode to make sure no recurrence (especially if underlying cause not identified)

Which kind of bone heals more quickly?

cancellous bone.

What is the relationship between SCI and anemia?

common. Cause not known, but bleeding may be a factor in some cases. By 1 year post-injury anemia improves in majority of patients. If persistent usually associated with pressure ulcers or frequent urinary tract infections

What kind of fractures result from compression failures?

compression fracture, buckle/torus fracture.

In connective tissue disease . . .

connective tissues serve as the affected areas - joints, ligaments..

What is dupetryn's contracture?

contracture of palmar fascia

Where are OT's very helpful with low vision patients?

contrast sensitivity in ADL

What do cones do?

detail vision, color

Phalanges are long or short?

distal, short, middle, long

What is meant by "the auditory system is an environmental monitor?"

distance, location, danger

Most patients who are diagnosed for diabetes are diagnosed via . . .

eye exam

What is homan's sign

dorsiflex ankle and it hurts in the calf or ankle. lots of false positives

What are the most significant predictors of pneumonia in people with dysphagia?

dysphagia, tube feeding at pneumonia dx, low or no activity, dependent oral care, dependent feeding, brush teeth occasionally or never, # decayed teeth, dry or excess oral secretions. Notice how many of these OT can help with!

When bone heals, it goes through a lot of the same stages as . . .

embryonic development.

What is interstitial growth?

endochonral ossification

What are the two main functions of the auditory system?

environmental monitor, facilitates communication

There is ____________ for soft palate function

exercise program

How can we get (+) eye pressure?

eye making too much fluid, eye not draining enough fluid.

What can a displacement of the macula cause?

eye term, e.g., in babies. Macula looks straight ahead.

What is finkelsteins manuever?

for dequervains

Which direction do hearing aid microphones face?

forward, so if you are pushing them in a wheelchair or sitting them at a treatment table, they will miss a lot of what you say.

What is a distracted fracture?

fracture sides are pulled apart

When is it necessary to use texture modification?

frail elderly person with advanced directive that says no feeding tubes. pt also has dementia and can't learn, so cannot compensate. ICU: neurovascular icu for day or two to prevent a person from aspirating because you can't take to x-ray and need to get medication b/c otherwise will be stroke.

Terminal behaviors must always be . . .

functional and patient centered.

What is a retinacular cyst?

ganglion cyst on tendon sheath.

What is a mucous cyst?

ganglion located on back of or near distal finger joints. Can cause ridge in nail due to pressure on germinal matrix of nail bed

Where are vertebral compression fractures common?

geriatric, spinal metastises

What is an enthesis?

insertion of tendons, ligaments, or articular capsule into bone. Rich nerve supply, so important for proprioception, but also a site for pain and inflammation. We can have localized irritation in enthesis, or generalized. Tendonitis (e.g., tennis elbow, shoulder) are localized enthesopathy. Generalized: many affected, e.g., ankylosing spondylitis - enthesis of ligaments of spine. Psoriatic arthritis.

Why do greensticks often heal better than completes?

intact periosteal sleeve. Large surface area

In hip osteoarthritis, (external/internal) rotation often causes pain.

internal

Interstitial growth isn't possible alone. Length increases only by

interstitial growth within cartilage and endochonral ossification.

Why is measuring reading acuity important?

it may be easier to spot a single letter than read

Burping is good because . . .

it means something is going into the digestive system

People with glaucoma often don't know they have it because . . .

it's painless, progressive, and affects your peripheral vision first.

What is a joint?

joint is the place of union, classified by mobility, between two or more bones. Examples are the shoulders, elbows, wrists, hips, knees, and ankles. The bony segments of the spine also form joints which may be involved in certain types of arthritis.

Light sensitivity and glare reflect issues with . . .

the pupil.

Which epiphysis is already present at birth?

knee

How do hand prosthesis work vs leg prosthesis?

leg = can run almost as fast; hand = big difference from original arm. Loss of control, due to loss of ability to feel. This somatosensory loss results in poor replacement for a hand, results in push for hand transplants.

How does the auditory system facilitate communication?

listening for learning, listening/emotion link

Why are more people developing AMD as time goes on?

living longer, "wear and tear", environmental toxins?

Why do people need to wear glasses?

long eye = myopic eye. Short eye = farsighted.

What is the treatment for chronic otitis?

long pressure equalization inserted (shorter ones can be inserted). Replaces the function of the eustachian tube. Also allows drainage. Naturally migrate outward over time.

What are the five kinds of bone?

long, short, flat, irregular, sesamoid

Articular cartilage provides the framework for short and long bones. What does the growth occur.

long: growth at the epiphysis short: growth plate for the entire bone.

What do rods do?

lower light, mobility, shadows

What are the three ossicles?

malleus, incus, stapes.

what is the relationship between SCI and thermoregulation?

many people with SCI cannot regulate body temperature which can lead to hypothermia or heat stroke. Because of decreased sensation, may become severely sunburned or frostbitten. Need to educate about maintaining neutral temperature, decreasing skin exposure, sunscreen, proper clothing in the cold.

What are the six (7) mechanisms of rheumatic disease?

mechanical, inflammatory + immunologic, deposition, infection, psychologic, undetermined

Why don't more people get hearing aids?

medicare excludes coverage.

What is mendelsohn-training?

mendelsohn maneuver, hard to learn, prolong duration of traction forces on upper esophagus

In epiphyseal plate cartilage, growth at the . . . and . . . of a long bone

metaphysis and diaphysis of a long bone. -interstitial growth of cartilage moves epiphysis further from metaphysis. -calcification, death and replacement of cartilage (endochondral ossification)

What are the components of a hearing aid?

microphone, battery, volume, amplifier, receiver/speaker

Fracture repair? When do hematoma, tissue granulation, callus formation, remodeling begin?

minutes, hours, immature 4-6 weeks, mature callus, 2+ months, years. (Mature callus is usually where you can be weightbearing)

Cartilage lacks which supplies?

nerves, blood, lymph.

What is the treatment for Dry AMD?

none really. patients can supplement vitamins. (A-RED) can slow down degeneration in the better eye.

Why do patients acquire illnesses in hospitals and nursing homes?

nosocomial, iatrogenic diseases?

Cubital compression causes . . .

numbness and tingling in ring and small finger. It is easier to treat by keeping elbows straighter.

What kind of patients tend to have cerumen impactions?

older adults.

What is a jordy

older sustained assistive device - replaced by e-sight, orcam, read things to you.

Where is gout commonly found?

olecranon process

What is a segmental fracture?

one piece in the middle broken out.

Infection risk is high in what kind of fractures?

open

What is the first stage?

oral preparatory. Food is reduced into swallow-able texture, shape, and position in the oral cavity. Mastication, salivation (enzymes begin digestions), bolus, lubricated, prepared for transfer.

What are some genetic causes of blindness?

ocular cutaneous albinism (lack of pigment causes light not to be absorbed, issues with central or detailed vision). Retinitis pigmentosa (condition of the rods, progressive, affects peripheral vision. @ end stage, affects central vision).

What is the second stage?

oral transit. material is propelled posteriorly toward oral pharnyx. elevation of soft palate and closure of velopharyngeal port. Elevates pressure to propel bolus toward stomach. Leaks in system = residue that can get into airway. During oral transit stage, airway is still partially open, so long delays in this portion=food in airway

Children have more (osteoclastic/osteoblastic) activity, as opposed to older adults.

osteoblastic.

Increase in diameter (appositional growth) occurs by the deposition of . . .

osteoblasts on the interior surface of the diaphysis.

Why do geriatrics have less bone?

osteoclastic, less physical activity, hormonal changes

What's one way people develop ganglions?

pain in back of wrists, especially with loading in extension

Which part of the nervous system is homeostatic?

parasympathetic

What is an overriding fracture

parts of bone are "stacked"

Why is food modification?

patients hate thickened foods. can cause dehydration, e.g., from thickened liquids.

What is a stand magnifier used for?

patients that cannot hold the magnifier, patients that are bothered by visual clutter

What kind of musculoskeletal problems are the most common?

regional

Where do avulsion fractures

relatively strong mucles, ligaments, that pulls off piece of bone, e.g., ischial tuberosity, acl-> tibial tubercle, ankles -> fibula, clavicle.

Arthritis used to be called . . .

rheumatism - since ancient times. Gout has been known since the ancient times (hippocrates) and was described as humors being deposited in and around joints.

Foosh fractures often fracture . . . in pediatric clients.

right through the growth plate

What does the eustachian tube connect? What is its normal position? What does it do?

the middle ear cavity and the nasopharynx. closed. venting middle ear cavity

With mallet finger, the bigger piece of the joint that is avulsed . . .

the more likely the subluxation.

What does glaucoma affect?

the optic nerve itself.

Some facial muscles are unique in that

they originate and insert into soft tissue structures.

What causes tendonitis in the hands?

tight structures around the tendon--this is different that tendonitises in the leg. This is more tight sheat

What kind of bone does osteoarthritis often affect?

trabecular bone.

What is glottal valving training?

training people to more forcefully adduct vocal folds (like valsalva maneuver)

Is glaucoma painful?

usually painless, but angle-closure can be painful, because the drainage structure closes and the pressure shoots up. Medications can also cause irritation.

What is usher syndrome?

variant of retinitis pigmentosa with congenital hearing loss.

What is the relationship between SCI and pressure ulcers?

very prone to pressure ulcers due to decreased sensation, relative immobility. People with normal sensation move naturally, subconsciously to relieve pressure when sitting too long. People with SCI are both unable to do this, and have no need to shift positions when sitting, lying in the same position. This can lead to skin breakdown. Although buttocks most frequently involved, can get skin breakdown anywhere there is pressure- most typically the heels, but anyplace along the back, even back of head. Need to educate patient in carrying out pressure relief themselves or asking assistance in doing so. In bed must change position every 2 hours and in wheelchair, must relieve pressure on buttocks every hour for 1 minute. Special wheelchair cushions including RoHo, and high tech ErgoDynamic™ Therapeutic Seating may be helpful in preventing further pressure sore development while sitting in wheelchairs.

What is a bowel program?

which involves having patient moves bowels on a certain schedule, usually after a meal. This can be daily, every other day, or 3-4X/week. (more frequent in an acute injury than if chronic.). Bowel program is achieved usually with rectal suppository medication after meal. Common to use finger or digital stimulation, or a special tool called a dill stick to facilitate reflex defecation. May also use oral medications to facilitate ( but not usually)

What is the sclera?

white area that gives the eye its shape.

What is the weakest, most easily damaged portion of cartilage?

zone of calcifying cartilage. Often pulls off a piece of bone when shearing, causing an OSTEOCHONDRAL LESION

Accessory nerve (XI) does what during the oral stage?

• Accessory (XI) Fields - Head Posture

What percentage of nursing home infections are pnuemonia?

• Accounts for 13%-48% of all Nursing Home Infections

What is the function of C1 during the pharyngeal stage

• C1: HLE - Airway closure - UES traction - Pharyngeal Constriction

What is screened in a clinical dysphagia examination?

• Cognition • Speech, Language • Oral-Facial Structure and Function • Swallow Observation - Non-instrumental

Cranial nerve IX does what during the oral stage?

• Glossopharyngeal (IX) - Salivation - Taste (posterior), touch

What are V and VII doing during the pharyngeal stage?

• V: Mandible stabilized • VII: Labial tension

What is a visual impairment/low vision?

• Is reduction in vision that cannot be corrected with standard glasses, contact lenses, medications or surgical interventions and it reduces a person's ability to function at certain or all tasks • It includes - Inability to see images clearly and distinctly - Loss of visual field - Inability to detect small changes in brightness - Color blindness - Sensitivity to light

Cranial nerve X does what during the oral stage?

• Vagal (X) Fields - Linguapalatal closure • Prevent loss of contents - Salivation; tact. sens

Endotracheal tubes can cause compromised airway protection. Why?

• Risk Factors for Compromised Airway Protection - Translaryngeal placement - Cuff position (wrong position) - Duration of intubation - Self-extubation (pull tube out.)

What is legal blindness?

• The criteria used to determine eligibility for government disability benefits and which do not necessarily indicate a person's ability to function - Visual acuity of 20/200 or worse in the better eye with corrective lenses (20/200 means that a person at 20 feet from an eye chart can see what a person with normal vision can see at 200 feet or - Visual field restriction to 20 degrees diameter of less (tunnel vision) in the better eye

Which is more common, wet or dry AMD?

• The dry form is much more common. • More than 85 percent of all people with intermediate and advanced AMD combined have the dry form. • However, if only advanced AMD is considered, about two-thirds of patients have the wet form. • Because almost all vision loss comes from advanced AMD, the wet form leads to significantly more vision loss than the dry form. • Can the dry form turn into the wet form? • Yes. All people who have the wet form had the dry form first. • The dry form can advance and cause vision loss without turning into the wet form. • The dry form also can suddenly turn into the wet form • There is no way to tell if or when the dry form will turn into the wet form.

What is the role of X during the pharyngeal stage?

• X: - Linguavelar separation (opening posterior oral cavity) - Velopharyngeal closure (soft palate closes nasal cavity) - Pharyngeal Constriction (persistaltic contractile wave from top to bottom) - Vocal Fold closure • Aspiration - UES "relaxation" (Upper esophageal sphincter)--without opening, food cannot go toward esophagus, common in lateral medullary strokes)

What is the function of XII during the pharyngeal stage

• XII: cont propulsion

What are the four parts of a good goal?

•Time frame •Terminal behavior •Criterion •Condition

_____________ having large surface areas heal faster than ____________ fractures having smaller surface areas.

Long oblique or spiral fractures having large surface areas heal faster than transverse fractures having smaller surface areas.

Why is SCi a model diagnosis for rehab?

"Model" diagnosis for rehab in terms of what we can do to help people rehabilitate from a devastating injury or disease. One of the first interdisciplinary team approaches. Involves all disciplines- PT, OT, speech ( if high level quadriplegic), psychology, recreational therapy,. DME vendor, Spiritual, nursing, multiple physicians (physiatrist, neurosurgeon, urologist, family doctor at a minimum)

What is meant by "rehab begins in the ICU"?

"Rehabilitation begins in ICU setting" Prevent early medical complications, meet with patient and family. Most important aspects include bowel, bladder and pulmonary management, DVT and GI prophylaxis proper bed positioning, turn every 2 hours, ROM to prevent contractures. Most important are shoulders, elbow, hip flexors and heel cords- most frequently observed contractures. Resting splints for paralyzed UE's to prevent contractures, increase comfort. Communication aides for patients with tracheostomy. At some university hospitals, physiatrists see SCI patients in the ER, then round with therapists, neurosurgery/orthopedic surgery in hospital. Prevention of complications has a major effect on the success of rehabilitation.

What kinds of Neurological assessment are used at time of initial injury

* X-rays- cross-table laterals and AP views of the cervical, thoracic and lumbar spine. Image the WHOLE spine. There is a 12% incidence of noncontiguous fractures, therefore once one fracture is identified careful inspection of the rest of the spine is imperative. * CT scanning can help evaluate for presence of cervical fractures most often at the C1 or C7 levels, provide information for surgical stabilization or decompression, and facilitate selection of appropriately sized hardware for operative stabilization. * MRI helpful if ruptured disc or epidural hematoma suspected prior to attempting closed reduction after cervical spine injury to identify disc herniation and its potential for neurological worsening with manipulation. (Fat neck/obesity - can make for things missed in x ray, ct scan catches)

Who is at risk for glaucoma/risk factors?

+60, esp mex americans, family history (esp sibling), 5x more like in AA than white, 15x more likely to causes blindness in AA, (+) eye pressure, thinness of cornea, abnormal optic nerve anatomy, nearsightedness

What do swallowing specialists principally do: in the acute care setting, post-onset neurological, trauma?

- Assessment for deficits; prevent adverse events

What do swallowing specialists principally do: ICU, postoperative.

- Iatrogenic conditions: assessment, prevention

What do swallowing specialists principally do: acute care

- Prevention while patient regains baseline

What is an osteophyte?

A bony projection common in osteoarthritis.

What is anterior spinal cord injury syndrome?

A. Anterior spinal cord, injury syndrome Involves a lesion affecting the anterior 2/3 of the spinal cord while preserving the posterior columns. May occur with retro-pulsed disc or bone fragments, direct injury or lesions of anterior spinal artery. Variable loss of motor as well as pinprick sensation, relative preservation of light touch, proprioception, and deep-pressure sensation. Patients have a 10-20% chance of muscle recovery.d

Who certifies for swallowing management?

ABSSD - only certification to be a dysphagia specialist.

What do you base the plan of care on? (ICF)

Based on: • Health Condition (Disease Process) • Changes to/Expected changes to Body Functions/Structures • Impact on Activities and Participation • Influence of environment & personal factors • Driven by: Client goals

What do you base the plan of care on (OTPF?)

Based on: • Health and well-being • Client factors • Performance skills/patterns • Task execution/involvement in a life situation • Context/environment • Driven by: Client goals

What is Brown Sequard Syndrome?

Brown Sequard Syndrome (BSS)- involves a hemisection of the spinal cord, consisting of asymmetric paresis with hypalgesia more on the less involved paretic side. Features: Ipsilateral loss of all sensory modalities at the level/site of the lesion. Ipsilateral flaccid paralysis at level of lesion. Ipsilateral loss of position and vibration sense below level of lesion. Contra- lateral loss of pain and temperature below lesion Ipsilateral motor loss below the level of the lesion. This is due to crossing of spinothalamic tracts in spinal cord Most commonly associated with knife injuries.

FIM level: D

D = Dependent or Total Assist (is able to do < 25%)

What are laboratory signs of DVT?

D-dimer: Indicates abnormally high level of fibrin degradation products. May indicate DVT but it may also be due to a recent surgery, trauma, or infection, liver disease, pregnancy, eclampsia, heart disease, and some cancers. A negative test and low risk factors- may be safe to skip further testing. (NEJM, Sept 2003) Check Doppler studies- but very dependent on examiner. Most commonly used test for DVT Venogram is gold standard- but can be painful. Very invasive

What is intramembranous ossification?

Direct ossification of the mesenchyme. Embryonic period (without prior cartilage formation.) Forms of periosteum, forms the WIDTH growth of a bone. How flat bones grow.

What is dry AMD?

Dry: non-edjudative. Everyone starts here. Occurs when the light-sensitive cells in the macula slowly break down. Over time central vision is gradually lost. Symptoms include: blurred vision, difficulty recognizing faces, more light forreading and other tasks, visual distortion. Dry AMD generally affects both eyes, but vision can be lost in one eye while the other eye seems unaffected

What separates the epiphysis and metaphysis?

Epiphyseal plate.

What happens after material is transferred into the esophagus? (e.g., what is the name of this stage)

Esophageal stage: Systems rests--stops swallowing, everything goes back to resting state passively/automatically, then esophagus takes over and propels food toward stomach.

What GI problems happen with SCI?

GI- adynamic ileus is usually present because of spinal shock, usually resolves within a week. If it lasts longer erythromycin and reglan can be used to stimulate peristalsis. NGT with intermittent suction may be necessary for persistent abdominal distention. Provide IV fluids. Parental nutrition (TPN) should also be considered when ileus lasts longer than 3 days. In more severe cases, stop narcotics, consider NSAIA's, Celebrex to reduce inflammation. * Higher risk of Peptic ulcer disease. Most occur within a few days following injury. Higher level and more severe injuries have greatest risk. Reason for this is unknown. Use of ulcer prophylaxis is recommended. (zantac, pepcid, prevacid, Nexium) People with T10 lesions and higher have increased risk of biliary stasis and gallstone disease. Impaired gallbladder motility has been implicated as cause. Although altered sensation after SCI can make diagnosis more challenging, majority of patients present with symptoms such as RUQ pain and tenderness. A high index of suspicion and radiographic tests essential in making diagnosis.

What is glaucoma?

Glaucoma is a group of diseases that can damage the optic nerve and result in vision loss and blindness. Glaucoma typically occurs when the normal fluid pressure inside the eyes slowly rises. But you can have glaucoma without having "high eye pressure", the pressure is just too high for that individual eye.

What is an amsler grid?

Grid - can they see the four corners of the big square, see the little square, are the lines straight up and down. Used to monitor change in AMD.

What does high level tetraplegia look like (c1-c4)

High level Tetraplegia C1-C4: Diaphragm is either paralyzed or only partially innervated. Require assistance with ventilation during acute care, and may be able to breathe independently as diaphragm is strengthened. Require the highest level of care Paralyzed from neck down. Suctioning. Almost total care. High amount of assistive technology. Special controllers: . May operate tv, lights, adjust bed, other devices in room, call for nurse, play video games, work on computer Use head and mouth, combining lip controls, puff and sip tubes, and a head operated joystick. Sip of straw, voice, eye movement and/or tap finger Emphasis of rehab is on obtaining assistive technology and education of family/friends/aides. Not much patient can do physically.

What is the anterior chamber?

Hollow chamber filled with liquid between cornea and pupil.

How can SCI patients help manage bowels?

If complete SCI lesion, lose ability to have bowel movement voluntarily. Bowel function is regulated by S2-S5 segments, so all but the most distal cauda equine/conus lesion will have involvement here. Because of immobility, lack of sensation, lack of muscle tone, these patients are very prone to constipation, fecal impaction. This can obviously have severe consequences if not addressed. Reflex bowel dysfunction(upper motor neuron)- may use rectal stimulation or suppository to produce bowel movement Flaccid bowel(lower motor neuron)- stools are hard. Anal sphincter is open. Chemical suppositories don't work. Must use digital stimulation. Typically develop a "bowel program"

Why are steroids given in cases of acute SCI? Is it controversial?

In most trauma centers methylprednisolone (MP) is given after an acute SCI. Improves blood flow to spinal cord, acts as an anti-inflammatory agent, prevents formation of toxic free radicals. Studies suggest it marginally improves neurological recovery. Needs to be given within 8 hours of injury. Whether it makes a difference in terms of functional recovery has yet to be studied. Controversies with high dose steroids: Many have pointed out the increased risk of infection, avascular necrosis with high dose steroids. Is this worthwhile for a questionable benefit? Updated guidelines issued in 2013 by the Congress of Neurologic Surgeons and the American Association of Neurological Surgeons recommend against the use of steroids early after an acute SCI. The guidelines recommend that methylprednisolone not be used within the first 24-48 hours following injury. The previous standard was revised because of a lack of medical evidence supporting the benefits of steroids and evidence that high-dose steroids may be associated with severe side effects The benefit from steroids is considered modest at most in complete or incomplete quadriplegia, but a small improvement in motor strength in one or more muscles can provide important functional gains. The administration of high-dose steroids within 8 hours of injury for all patients with acute spinal cord injury is still practiced by most physicians

What parts of the joint does osteoarthritis affect?

It is a disease that affects the whole joint, not just the cartilage, even though cartilage is a huge part. Muscles and trabecular bone are also affected, due to pain.

What are potential treatments for male sexual issues after sci?

Medication: Viagra, Levitra, Cialis, etc.- safe and effective in patients with SCI, but not for those with baseline complete absence of both reflex and psychogenic function Injection- intracavernosal- prostaglandin E. If used frequently can get scarring. Priapism is a medical emergency. Vacuum assisted devices- help with erection, not ejaculation

What are medical treatments for spasticity?

Medications for spasticity in spinal cord injury (also used a lot for muscular pain, no SCI) a. Baclofen- mainstay. Oral or intrathecal in severe cases. b. Valium c. Klonipin d. Dantrolene e. Zanaflex f. Catapres patch g, Neurontin Baclofen pump- implantable pump, deliver baclofen directly to spinal cord. For patients who are no longer responding to oral medicatons. This allows for a higher concentration of drug without the usual mind-dulling side effects of a high oral dosage. Injections: Botox- takes 4-10 days to work and may last for 3-6 months. Peripheral nerve blocks, motor point blocks focused delivery of drug to manage focal areas of spasticity (typically hip adductors, better perineal hygiene) May use alcohol or phenol, can last up to 1 year or longer

How is glaucoma treated?

Medicines. Medicines, in the form of eye drops or pills, are the most common early treatment for glaucoma. *Some medicines cause the eye to make less fluid. *Others lower pressure by helping fluid drain from the eye . Laser surgery. Lasers applied to the TM helps fluid drain out of the eye. Conventional surgery. Conventional surgery makes a new opening for the fluid to leave the eye.

What are the symptoms of carpal tunnel syndrome?

Numbness and tingling, e.g., dropping objects. (think: median nerve innervates palmar surfaces of thumb and almost all of first fingers. Nocturnal parasthesias Mourning symptoms Weakness/clumsiness

Why does bone growth and remodeling occur (normally)?

Occurs because of the growth of long bones Occurs due to factors that demand removal of calcium from the bone Occurs because the Haversian systems are continually being eroded (artery in the middle)

What is synovial fluid?

Oily lubricant for the joint and how the joint is nourished. Chemicals in it: glucosamine, hyaluronic acid, chondroitin--long polymers of sugar. This is what gives the joint fluid its viscosity. Made by the synovium. Ultrafiltrate.

What kind of bowels do incomplete SCI patients have?

Patients with incomplete injuries may have mixed bowel function. May have only partial voluntary control of sphincter. Need to get to bathroom quickly.

What is 4-D syndrome?

Psychological- four D syndrome- dependency, depression drug addiction and divorce On the rehab unit, spinal cord patients often don't seem that depressed. In part, this just shows the remarkable adaptability of people. Also, patients often don't have time to be depressed, keep very busy. Spouse, family is at least initially very supportive. According to literature however, depression affects 20-45% of SCI patients in first month post-injury. 36% of patients have been found to have raised levels of anxiety and depression up to 2 years post injury. Those who recover have more social supports than those who remain depressed. Suicide rate is 2-6X greater in SCI compared to able bodied population. Most occur within 5 years of injury. Probably a lot more depression, dependency, drug addiction, divorce once leave the unit, no longer seeing doctors, therapists, psychologist.

What is auditory training?

Retraining someone to use new or restored sounds, so that their brain can process it - especially language.

What things should therapists monitor?

Skin Discoloration, reduced pulses, reduced temperature, or severe pain on passive stretch of muscles may indicate vascular injury. Numbness of the extremity or persistent weakness of extremity muscles may indicate neurological injury Fever may be a sign of infection Persistent signs of inflammation (redness, swelling, pain, increased skin temperature) around joint or fracture site may indicate infection (septic joint or osteomyelitis)

What are indications of protection alone?

Sling Indications: Undisplaced stable fractures of ribs, phalanges, metacarpals, clavicle (in children) Mild compression fractures of spine Impaction fracture of proximal humerus

What is tinel's sign?

Tapping nerve (percuss over median nerve for carpal tunnel)

What is Tetraplegia?

Tetraplegia/quadriplegia- impairment in motor and/or sensory function in the cervical segments of the spinal cord. Results in functional impairment in the arms, trunk, legs and pelvic organs.

What could cause ulnar wrist pain?

Traumatic Injury Fx ulnar styloid Ligament TFCC Lunotriquetral

What is the treatment for cardiovascular shock?

Treat hypotension with fluid resuscitation Foley catheter should be inserted for urinary drainage, allows for an accurate assessment of output. Use vasopressors to maintain a mean arterial BP above 85 mmHg- this has been associated with enhanced neurological outcome. May give atropine or even cardiac pacing for severe bradycardia.

What are fracture considerations for rehab?

Treating impairments Limitations in Joint Motion and Muscular Strength Immobilization can also reduce ligament strength and function Certain types of fractures and metal implants may limit the return of full motion. Know the goals so you don't injure the patient. Progressive Weight Bearing

How can shoulder pain be evaluated and treated?

Treatment: Evaluate posture, function- pressure reliefs, wheelchair mobility, transfers, home/work environment. NSAIA's, Tylenol, muscle relaxants Rest (difficult to do) Cortisone injections Modalities- temporary benefit Acupuncture/trigger point injections may be helpful Proper wheelchair and back support Surgery- for those who fail conservative management. Some preliminary studies suggest Platelet Rich Plasma (PRP) injections may be useful in treating bicipital tendinopathy in spinal cord injury patients

How is RA treated?

Treatment: Stop the inflammation. Reduce symptoms. Maintain remission Prevent flares Prevent complications Prevent joint damage Prevent disability Maintain quality of life Treatment is tailed to the individual. BUT EARLIER IS BETTER.

What kind of nociceptive pain is the most common in SCI patients?

Upper extremity neuromusculoskeletal pain- also extremely common after SCI. Arms are used extensively for weight bearing activities- weight shifts, transfers, wheelchair propulsion as well as for ADL's, thereby increasing chance of overuse syndromes. Shoulder pain is most common painful joint. 30-50% complain of shoulder pain severe enough to interfere with function. 2/3 of shoulder pain due to chronic impingement syndrome, ½ involves rotator cuff pathology. Bicipital tendonitis, subacromial bursitis, adhesive capsulitis, acromioclavicular osteoarthritis, cervical radiculopathy are other common causes of shoulder pain. See also spasticity, contractures, heterotopic ossification and presence of syrinx.

Why is the cartilage never the site of musculoskeletal pain?

cartilage has little or no nerve supply.

What is the leading cause of low vision worldwide?

cataract

What is linguapalatal closure?

pressing tongue up against soft palate

How do kids get mallet finger?

grown plate injury, nail pops out, open fracture, but just looks like a small bleeding nail

Perhaps up to 1/5 of older adult inpatient individuals . . .

have hearing loss on a level that is disabling. This is important when looking at medical communication!

In order to use a spectacle mounted telescope while driving?

have to have a rigorous training course, have to have a certain vision through bottom

Glaucoma is the leading cause of blindness in . . .

hispanics over age of 65, african americans.

Glaucoma is like a donut because . . .

hole starts in the middle of the optic nerve and gets bigger.

What is behind the lens? What are the clinical implications of this?

hollow cavity filled with jelly-like vitreous. Location of "floaters" - vitreous gets sticky and forms strands and casts a shadow on the retina.

In strokes, what kind of vision loss will you normally see?

homonymous hemiopia (missing visual field on one side, peripheral vision loss), causes difficulty with mobility, reading. L side vision loss is worse because we read left to right.

Why do women get cmc thumb osteoarthritis more than men?

hormonal changes - causes long term subluxation and arthritis of joint.

What is a torus fracture?

incomplete fracture, more common in peds, one side of the bone stays stable, but the other end folds up on itself, e.g., distal femus. (buckle fracture)

osteoclastic reabsorption of the cortical bone results in . . . .

increases medullary cavity size.

What is the relationship between SCI and orthostatic hypotension?

lowered resting BP and loss of autonomic response to changing body position seen in most patients with cervical cord injury. Often a major portion of initial rehab of quads is spent reconditioning the patient to upright position. May use tilt table or gradually elevating a reclining wheelchair. If still difficulty may add abdominal binder and/or leg hose to decrease lower extremity pooling. In severe cases medications such as fludrocortisones, Midodrine (vasoconstriction) may be considered. Functional electrical stimulation may also be used.

After stroke, there is a period of recovery. In acute care, you want to

prevent an accident during acute recovery. 55% of people have dysphagia immediately following stroke.

In order to visualize what is happening in a fracture, you need . . .

multiple views

Bones surrounded by ___________ heal faster than ___________.

muscle, bones that lie subcutaneously or within joints.

What is a muenster splint?

prevents rotation of forearm but allows for full flexion and extension for tfcc tear.

What is fourth stage?

pharyngeal stage - material propelled through into and through pharynx into esophageal sphincter. Sphincters are tonically closed at rest and relax when activated. upper esophageal sphincter relaxes a bit and then is pulled open via contractions from other muscles. Larynx is pulled out of the way of the food. Epiglottis drops and protects the airway.

What is stoved finger?

pittsburgh term, jammed finger, pip joint gets swollen. Can be PIP ligament strain or volar plate avulsion, sometimes pip fracture

What is the advantage disadvantage of fiberoptic assessment?

portable. No radiation. Allow continuous observation. small field of view. pts don't like a tube stuck down nose/throat. scope can't see anything during the actual swallow when the pharynx collapses, (white-out) so impressions have to be inferred from residue patterns. But anything in oral dysfunction (because scope's too far down) or during pharyngeal stage (white-out) needs VFS?

What kind of fractures occur from twisting failure: torsion

spiral fracture

How can you splint for trigger finger?

splinting the distal tip, especially while sleeping.

What is the most prevalent cause of dysphagia in adults?

stroke - and pneumonia due to dysphagia leads to a 3x risk of dying.

What is the relationship with respiratory complications and sci?

the leading cause of morbidity and mortality for patients with traumatic SCI. Atelectasis and pneumonia are the most common pulmonary complications in the acute post-injury period. Respiratory complications appear to be related to degree of compromise of respiratory muscles. Stepwise loss of abdominal, intercostals and diaphragm muscles with progressively higher spinal cord injuries results in a greater incidence of pulmonary problems in quadriplegic than in paraplegics. Also more pulmonary complications seen with complete injuries than with incomplete injuries. Acute SCI patients have an impaired ability to clear their own secretions. Use Chest PT to clear proximal airways, postural drainage proper positioning, suctioning of secretions if unable to bring secretions to mouth or tracheostomy.