Content for Exam 1 Flashcards
Eye opening GCS grades
(4 = spontaneous opening of eyes; 3 = opening in response to speech; 2 = eye opening to pain; 1 = no eye opening response)
verbal response GCS grades
(5 = verbal response demonstrate personal orientation to location; 4 = confused conversation is the best verbal response; 3 = inappropriate words in response to question; 2 = incomprehensible sounds; 1 = no verbal response)
motor response GCS grades
(6 = follows motor commands; 5 = localizes a painful stimulus; 4 = withdraws specifically from pain; 3 = abnormal flexion response to pain; 2 = abnormal extensor response to pain; 1 = no motor response)
Rancho Los Amigos Levels of Cognitive Function (LOCF)
Widely used in BI
To track cognitive and behavioral responses of pt
Level I (no response, coma) to Level X (purposeful, appropriate)
Coma Recovery Scale (CRS-R)
Better sensitivity for lower levels – coma<->veg state<->min cons state
Terminal Swing
Critical Events: Knee extension to neutral (or within 5 degrees)
Begins with vertical tibia
Ends with initial contact
Anterograde
inability to learn new material after injury
Retrograde
inability to remember things prior to brain injury
PTA (post-traumatic amnesia)
loss of memory of event surrounding brain injury and inability to process info after BI – length of PTA is a prognostic factor for recovery
Amnesia
deficits in memory
Agnosia
inability to recognize familiar objects, persons, sounds, shapes, or smells – visual, tactile (astereognosis), auditory
Dysarthria
Problems in oral motor aspects of articulation
Aphasia
loss of ability to understand or express speech due to brain damage, mostly in dominant hemisphere
Wernicke’s/receptive/fluent aphasia
deficits in auditory/written comprehension with well articulated speech marked by nonsense words or substitutions
Broca’s/expressive/non-fluent aphasia
deficits in expressing thoughts using speech, limited vocabulary, but comprehension relatively preserved.
Stereognosis
Ability to recognize form of objects by touching and feeling, without visual input
Objects like keys, comb, coins
Graphesthesia
ability to recognize letters, numbers or designs ‘written’ on skin
Barognosis
ability to distinguish weights of different objects by holding them
Assessment of Spasticity
Force/Velocity dependent increased resistance to stretch
Clasp-knife response
Modified Ashworth Scale (0-4 grades)
Sign of UMN lesion - pyramidal tracts
Assessment of Rigidity
Resistance to stretch is independent of force/velocity
Lead-pipe response - constant resistance
Cogwheel response – rachet-like jerkiness
Sign of UMN lesion – extra-pyramidal tracts, basal ganglia lesions like Parkinson’s.
Modified Ashworth Scale
Assessed during PROM with pt in supine
If testing a muscle that primarily flexes a joint, place the joint in a maximally flexed position and move to a position of maximal extension over one second
If testing a muscle that primarily extends a joint, place the joint in a maximally extended position and move to a position of maximal flexion over one second
put muscle in its shortened position
MAS scoring for assessing spasticity
0 No increase in muscle tone
1 Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension
1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM
2 More marked increase in muscle tone through most of the ROM, butaffected part(s) easily moved
3 Considerable increase in muscle tone, passive movement difficult
4 Affected part(s) rigid in flexion or extension
General Tone assessment
0 No response (flaccidity)
1+Decreased response (hypotonia)
2+ Normal response
3+ Exaggerated response (mild to moderate hypertonia)
4+Sustained response (severe hypertonia)
Hypotonia
Decreased or absent tone, flaccidity, limbs are floppy, hyper-extensible joints, stretch reflexes are dampened (hyporeflexia)
Primitive/tonic reflexes
should be integrated during infancy, can persist with delayed development or re-emerge following brain injury. Tonic reflexes change postural tone rather than producing overt movements
Reflex integrity scale
0: no reflex
1+: hypo-reflexive
2+ normal
3+: hyper-reflexive
4+ Clonus
UMN Lesion: increased/brisk reflexes
LMN/Peripheral sensory lesion: hypo-reflexive
Babinski Sign
Big toe extends and other toes fan out.
Sign of UMN lesion in adults.
Babinski sign is normal in infants up to 1 years age, should integrate by 2-3 years
Strategy level
decides the goal of movement, best movement strategy to achieve the goal, represented by - association motor areas, basal ganglia and cerebellum
Tactics level
decides sequence of muscle contraction in space and time, represented by primary motor cortex and cerebellum
Execution level
stimulate motor neurons to activate muscles appropriately for movements/postural control, and feedback(cerebellum)
Ataxia
most common problem associated with cerebellum, results on ‘ataxic gait’ – poor trunk control, wide BOS, arms high guard position, irregular stepping.
Dysdiadochokinesia
impaired ability to perform rapid alternating movements, eg, supination/pronation
Dysmetria
inability to judge the distance, over- or under-shooting.
Dyssynergia
inability to perform smooth movements using synergistic muscle, breaking into components
Rebound phenomenon
inability to stop motion when resistance is released, pt might hit himself/herself when resistance is removed, cerebellum problem
Bradykinesia
slow movements, expressed as decreased arm movements and shuffling and festination during gait, Parkinson’s gait. Basal ganglia issue
Akinesia
progression to inability to initiate movements – freezing episodes, basal ganglia issue
Athetosis
involuntary writhing
‘worm-like’ movements.
Also a clinical sign of athetoid CP
Basal ganglia issue
Chorea
involuntary irregular jerky movements mostly seen in UE, cannot be inhibited, clinical sign of Huntington’s disease, basal ganglia issue
Dystonia
sustained involuntary contractions of agonist/antagonist muscle, abnormal posturing, torsion spasms, basal ganglia issue
Hemiballismus
large-amplitude movements, sometimes violent, on one side of body, an arm or leg
Gross motor tests
Involve large muscle groups to test ability to crawl, kneel, stand, walk w/o abnormal postures w/o LOBs
Also test balance – called equilibrium tests
Fine motor tests
Involve small distal muscle groups, test fine motor activities like finger dexterity tasks
Fine motor tests are also called non-equilibrium tests
Steady-state balance
Quite sitting/standing
Ability to control the location of the body’s center of mass within the area defined by the base of support under predictable, quasi-static conditions. This includes the ability to adapt motor behavior to meet the demands of different task and environmental conditions
Proactive/Anticipatory balance
Ability to generate postural adjustments prior to the onset of and during voluntary movement for the purpose of either countering an upcoming postural disturbance due to voluntary movement or realigning the body’s center of mass prior to changing the base of support. This includes the ability to adapt motor behavior to meet the demands of different task and environmental conditions.
Reactive balance
Ability to respond to sensory input that signals a need for a response to ensure successful maintenance of postural control. The need for a response is unanticipated but may be generated externally (perturbation originating external to body) or secondarily to an internally generated movement. This includes the ability to adapt motor behavior to meet the demands of different task and environmental conditions
Ankle strategy
Used when sways are small and slow
Move COM of body as a block about ankle joints
Muscles are activated distal-to-proximal
During forward sway, gastrocnemius hamstrings paraspinals
During backward sway, tib ant quads abdominals
Used on firm support surface
Hip strategy
Used with larger and/or faster sways
Moves COM by flexing/extending/abd/adducting hips
Muscles are activated proximal to distal
Forward sway, abdominals Quads.
Backward sway, paraspinals Hamstrings
Used when support surface is small/narrow/compliant
Suspension strategy
Moves COM down by flexing hips/knees and
flexing trunk
May progress to squating
Regulatory features
specific aspects of the environment shape movement, size, shape, and weight of a cup, type of surface a person walks on. Movement control strategies need to conform to or adapt to these features
NON Regulatory features
aspects that are not critical to accomplishing movement, Gait with lights on vs off, noise and distraction
May affect performance, but movement does not need to conform to these features
Initial conditions
Observe initial posture, environmental conditions to check if person is in a position to perform the task
Preparation phase
Did the person understand your instructions to get in the ‘ready-position/ready-posture” to be able to correctly initiate the task – observe for stability, alignment, verticality, symmetry of posture
Initiation phase
The initial movement of the task – observe for amplitude, timing and direction of movement
Execution phase
The majority of the dynamic movement phase of the task – observe amplitude, coordination (smoothness, sequencing, timing), direction, speed, symmetry of the movements
Termination phase
Posture at the end of the task – observe for stability, alignment, verticality, symmetry of posture
SCOOTING WHILE LYING DOWN essential components
In initiation, the essential component is the hook lying position, in execution phase, essential component is bridging
ROLLING essential components
in initiation phase, essential component is cervical flexion/rotation and hip flexion/adduction
SUPINE-TO-SIT AT EDGE OF BED/MAT essential components
In initiation phase, possible essential component: “Partial sitting posture” by flexing neck, trunk, hips to lift off of surface
Sit-to-Stand essential components
Preparation phase: Essential component: hip flexion with trunk extended (anterior pelvic tilting)(raising height of table will force pelvic into anterior pelvic tilt)
Initiation phase: Essential component: hip flexion with trunk extended (flexion momentum)
Execution phase: Essential components: lift-off/momentum transfer -> triple extension
TRANSFERS essential components
- Initiation phase:
Essential component: hip flexion with trunk extended (flexion momentum) - Execution phase:
Essential components: lift-off/momentum transfer, extension/partial extension, pivoting, weight-shifting between LEs, side-stepping
STEP UP/DOWN essential components
- Initiation phase:
Essential component: weight shift to stance limb - Execution phase:
Essential components: stance limb hip/knee extension -> unilateral stance -> swing limb hip/knee flexion with ankle DF to clear foot for placement -> further hip/knee flexion for weight-shifting to contralateral limb and for ascent -> Hip/knee extension for leading LE and hip/knee flexion and ankle DF of trailing foot
Olfactory Nerve- CN 1 examination
The patient’s eyes should be closed.
Using the distinctive-smelling items, ask the patient to smell the items one at a time (each nostril separately).
The patient should be able to identify the odor, and the strength of the odor should be equal side to side
Optic Nerve- CN II examination
Using a Snellen eye chart, ask the patient to read the lines with progressively smaller letters.
Using a penlight, shine the light obliquely into the patient’s eye.
A normal response is constriction of thecontralateral(opposite) pupil, although the ipsilateral pupil should also constrict (see test for CN III)
Oculomotor Nerve- CN III examination
Assess ability to elevate both eyelids.
With CN 3 lesion, drooping eyelid does not retract with upward gaze
Accomodation
Change in the shape of the lens of the eye through action of the ciliary muscle following activation of the parasympathetic nucleus of CN 3
Convergence
Adduction of the eyes bilaterally through activation of main nucleus of CN 3
Miosis
Constriction of the pupil due to activation of parasympathetic nucleus of CN 3
Medial Rectus
CN-3-Adducts eye
Lateral Rectus
CN 6- abducts eye
Superior Rectus
CN 3- elevates the abducted eye
Inferior Oblique
CN 3- Elevates the adducted eye
Inferior Rectus
CN 3- depresses the abducted eye
Superior Oblique
CN 4- depresses the adducted eye
Medial Longitudinal Fasciculus
Coordination of the two eyes is maintained via synergistic action of the extraocular muscles
Requires connections among the cranial nerve nuclei that control eye movements.
A CN 3 lesion causes…
the ipsilateral eye to look laterally and down (pulled by unopposed muscles innervated by CNs 4 and 6)
A CN 4 lesion causes…
the ipsilateral eye to look slightly upward because the actions of muscles innervated by CNs 3 and 6 are unopposed.
A CN 6 lesion causes…
the ipsilateral eye to look medially (pulled by unopposed muscle that pulls medially, innervated by CN 3).
Trigeminal Nerve- CN V examination
With the patient’s eyes closed, use a cotton ball or the pad of your index finger to lightly touch the patient’s face.
Areas to touch include the forehead, the cheeks, and the lateral jaw (these areas correspond to the three sensory branches of CN V).
The patient should feel the touch equally on the right and left sides
Palpate the patient’s masseter and temporalis muscles bilaterally for strength of contraction as he or she clenches the jaw
Ask the patient to hold the jaw open slightly and then provide resistance to mandibular closing or lateral motion.
The patient should be able to hold the position against moderate force
Facial Nerve- CN VII
Assess motor function by asking the patient to smile, frown, elevate or depress the eyebrows, and puff out the cheeks
Assess for symmetry of facial expression
Ask the patient to close his or her eyes and stick out the tongue.
Taste may be assessed by placing something sweet (piece of hard candy or drop of sweet liquid) on the anterior portion of the tongue and asking the patient to identify the taste
CN VII lesion may result in…
Impaired lacrimation (tear production to clean/lubricate the eyes)
Impaired taste on the anterior 2/3 of the tongue
Impaired corneal “blink” reflex
Vestibulocochlear Nerve- CN VIII
The patient’s eyes should be closed. Hearing can be assessed by rubbing the pads of your thumb and index finger together next to one of the patient’s ears and asking for indication of when the rubbing is heard
Bilaterally symmetrical hearing is expected unless a known hearing loss is present.
Test one ear at a time.
Rinne Test (Special Test)
Place and hold the stem of a vibrating tuning fork on the mastoid bone; when the patient no longer hears it, move the vibrating tuning fork tines into the air approximately 1 in from the ear canal
Sound is conducted through air approximately twice as long as it is conducted through bone, and therefore the patient should be able to continue hearing the vibrating tuning fork after it is removed from the mastoid process.
Weber Test (Special Test)
Place and hold the stem of a vibrating tuning fork on the top of the patient’s head; ask the patient if the sound is louder in one ear than the other. Normally the sound is equally loud in both ears.
Glossopharyngeal Nerve, and Vagus Nerve- CN IX and CN X
Taste is assessed as with CN VII, but the flavor of the candy or liquid should be sour or bitter and should be placed on the posterior third of the patient’s tongue.
Ask the patient to open his or her mouth and say “ahh.” Observe the uvula (no lateral deviation should be present) and listen for loss of phonation (CN X)
Ask the patient to swallow several times; observe for and ask about any difficulty with this action.
Test the gag reflex by carefully moving the tongue depressor toward the back of the patient’s throat until the gag reflex is elicited. (CN IX)
Spinal Accessory Nerve- CN XI
Ask the patient to shrug his or her shoulders.
Press downward, asking the patient to hold the position
The patient should be able to resist your force bilaterally.
Observe for atrophy of the trapezius or sternocleidomastoid muscles (compare side to side).
Hypoglossal Nerve- CN XII
Ask the patient to stick out his or her tongue and observe for any side-to-side deviation or atrophy.
May also ask the patient to move the tongue from side to side, observing for smooth motions
Positive Test: “Lick your lesion”
Tongue deviates toward the affected side
Initial Contact
Critical Event: Heel first contact
Heel contact is essential to take advantage of “heel rocker”
Loading Response
Critical Events:
Hip stability, controlled knee flexion (eccentric control of quads), controlled ankle plantarflexion (eccentric control of pretibials)
Shock Absorption
Weight bearing stability
Progression
Mid-Stance
Critical Event: controlled tibial advancement (concentric pretibials, once tibia is past vertical, posterior compartment takes control)
Progression
Limb and trunk stability
Terminal Stance
Critical Events: Controlled ankle dorsiflexion with heel rise; trailing limb posture to prepare for limb advancement (20 degrees hip extension)
Begins with heel rise
Progression of the body beyond the supporting foot “catastrophe narrowly averted”
Pre-Swing
Critical Events: Passive knee flexion to 40 degrees (forward pelvic rotation is what drives this), ankle plantarflexion
Begins at contralateral initial contact
Ends when the foot leaves the ground
Initial Swing
Critical Events: Slight forward pelvic rotation (protraction) to initiate swing, Hip flexion to 15 degrees, knee flexion to 60 degrees (biceps femoris short head)
Begins when the foot leaves the ground
Mid-Swing
Critical Events: Hip flexion to 25 degrees, ankle dorsiflexion to neutral for foot clearance
Swing limb is even with stance limb
Ends with vertical tibia
Generic OMs
designed to use across all pt populations regardless of health condition, more likely to have normative data , eg SF-36, FIM, Caretool
Disease specific OMs
for specific disease condition, more meaningful to the pt, but less likely to have normative data, eg, PDQ
Performance-based OM
Performance-based measure actual performance in on a set of predetermined tasks in a structured environment
Insight into pt’s actual capabilities at a specific point in time
May not reflect performance in real environment, house/community
Self-report OM
Provide information on pt’s opinions/perceptions about the impact of health condition
Cannot is observed, pt may over-, or under- estimate abilities or report what clinician wants to hear.
GCS scale scoring
less than 8 = severe brain injury/coma
9-12 = moderate injury
13-15 = mild injury
Symmetry
Agreement of external kinetics and kinematics of movement (left vs right)
Speed
speed or movement time
Amplitude
range of motion, step length, stride length, distance
Postural control/verticality
Body segment anterior/posterior lateral to the plumb line
Stability measurement example
Sway, center of pressure
Coordination/Smoothness
Measures derived from kinematic analysis such as acceleration or jerk
Sequencing
A movement in a continual fashion to make it smooth, look for joint coordination
Timing
Reaction time/relative timing measures
Accuracy
Spatial or variable errors
Symptom provocation
Change in oxygen saturation, heart rate, patient reported measures pain, dizziness, fear
spontaneous neuroplasticity
Some processes occur independent of external factors – guided by genetic/biochemical cues, mostly lead to initial improvements in function
activity-induced neuroplasticity
Other processes are influenced by external input - sensory experience, motor experience, task training
Cognitive stage
initial stage, trying out a variety of strategies (abandoning those that don’t work and carrying on with what works), needs a lot of attention and conscious effort, performance quite variable, makes many mistakes, improvements can be large
Associative stage
by now best strategy is selected, makes less mistakes, practices more and more to refine the skill, needs less attention, improvements are slower/smaller
Autonomous stage
performance mostly automatic, can divert attention to other tasks (paying too much attention to elements of task can reduce performance!)
Bernstein’s 3 stage model
mastering the degrees of freedom. The 3 stages are novice, advanced, and expert. Talks about releasing degrees of freedom at different joints with higher stages, eg – learning to use a hammer using just elbows, then wrist, then wrist, elbow, shoulder
Releasing degrees of freedom allows for more efficient and flexible movements according to task and environment demands.
external support may be needed in early stages
Acquisition of skill
successful performance of skill
Retention of skill
successful demonstration of skill at a later time w/o practice during the intervening period
Transfer of skill
successful application of the ‘rules of movement’ of the skill to a related skill in a different environment/context
Massed practice
All practice trials at once, say 30 trials at one go
Amount of practice time is greater than the amount of rest time
May lead to fatigue
Distributed practice
Divide 30 reps into smaller chunks, 5 trials now, 5 more after 10 mins, and so on.
The amount of rest between trials is equal to or greater than the amount of time for the trial
Constant practice
Practice of a given task under constant/unchanging conditions
May improve acquisition of skill
Variable practice
Practice of a given task under variable conditions
Better for retention and transfer of skill
Blocked vs Serial vs Random Practice
Blocked - Practice of one way of task practice before going to the next way, so 10 A’s, then 10 B’s and then 10 C’s
Serial – ABC, ABC, ABC, and so on…10 such reps.
Random - Practicing different types in random order – A, C, B, A, A, C, B, B….30 reps
Whole-task practice
Practice the entire task together
Part-task practice
Practice of an individual impaired component or components of a task - from Movement Analysis of Tasks
Ultimately needs to practice the whole task to improve function
Mental Practice
Performance of skill in one’s imagination without physical action can produce positive effects on performance
Trigger neural circuits responsible for motor planning during mental practice (SMA gets activated during mental practice – motor control physiology class)
Can help with motor learning when physical practice is not yet possible
Constraint-induced movement therapy
Strongest research support. Involves high intensity tx daily for several hours for 2-3 weeks, after constraining the unaffected limb. UE must retain some voluntary function. Best results in subacute/chronic stroke. use after 4 weeks post stroke
High-intensity gait training (HIGT)
Purpose is to improve locomotion function (walking speed and distance)
Gait training at moderate- to high-intensity (65-85% HRmax/60-80%HRR) or based on RPE scale of 14-17
Nagi Disablement Model
Pathology: Disruption/injury to body tissues, examples…
Impairment: Loss/disruption of structure or function at organ/system level, examples…
Functional Limitations: Inability/decreased ability to perform action/activity in a normal manner, examples…
Disability: Restriction of abilities in occupational roles, family roles, recreational roles, examples…
ICIDH Disablement Model
International Classification of Impairment, Disabilities and Handicaps, by WHO, to shift focus from disease to its physical and social consequences, specially in chronic disabling conditions
Disease – Disruptions that occur at cell or tissue level
Impairment - Disruption of anatomic, physiologic and psychologic structure/function
Disability – Decreased ability to perform activities at person level
Handicap – Continued limitations at societal level imposed by physical environmental barriers or attitudes
Gentile Taxonomy of Tasks
classifies different tasks in their environment
4 conditions in Gentile Taxonomy
-Stable body in stationary environment
-Stable body in moving environment
-Body transport in stationary environment
-Body transport in a moving environment
Comprehensive Neurological Examination components
mental status, sensation, motor function, balance/coordination, and functional tasks
Orientation questions
AOx4
Person – What is your name, how old are you? Place – Do you know where you are, What kind of a place is this? Time – What is today’s date, How long have you been here? Situation – What happened to you, why are you here?
Selective attention
Awareness towards a stimuli in the environment w/o being distracted by other stimuli, towards an object (person, thing), task or thought
Sustained attention
time on particular task, repeat letters, words or digits forward or backward, digit span test (normally 7 forward and 5 backward), test of vigilance (tap whenever you hear letter ‘A’, normal 100% accuracy)
Alternating/switching attention
attention flexibility- back and forth between 2 tasks
Divided attention
2 tasks simultaneously, cog+cog, cog+motor, etc – walkie-talkie test (walk 20ft and return while saying A-Z alphabets, or alternate alphabets), c-TUG.
Body image/scheme disorders
Unilateral spatial neglect, tactile/visual extinction, R/L discrimination
Mini Mental State Examination
Objective OM for assessing cognition,
no cognitive impairment=24-30; mild cognitive impairment=18-23; severe cognitive impairment=0-17.
MoCA
Assesses a broad range of cognitive functions - mild cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation
Better sensitivity for detecting mild cognitive impairment
Jendrassik maneuver
If DTRs are difficult to elicit, to enhance responses, eg, hook hands together and pull apart, clench teeth, make fist with contralateral extremity
Cut off scores for 10MWT for stroke
<0.4 m/s household ambulators
0.4-0.8 m/s limited community ambulators
>0.8 m/s community ambulators
Cut off scores for 10MWT for healthy older adults
< 0.7 m/s is indicative of increased risk of adverse events (fall, hospitalization, need for caregiver, fracture, etc.)
Cut off score for FGA for non-specific older adults
Cutoff Score: ≤22/30 = risk of falls
Cut off score for FGA for Parkinson’s disease
Cutoff score <15/30= fall risk
FGA (Functional gait assessment)
The FGA is used to assess postural stability during walking and assesses an individual’s ability to
perform multiple motor tasks while walking. The tool is a modification of the 8-item Dynamic Gait
Index, developed to improve reliability and reduce ceiling effect.
3 = normal
2 = mild impairment
1 = moderate impairment
0 = severe impairment
BBS scores
41-56 = independent
21-40 = walking with assistance
0 –20 = wheelchair bound
Score of < 45 indicates individuals may be at greater risk of falling
Push and release test scores
0(recovers with 1 step), 1(2-3 small steps, independently recovers), 2(>4 steps, independent), 3(multiple steps, needs assistance to prevent fall), 4(falls w/o attempting steps)
ABC cut offs for fall risk
for general population <67%, for vestibular <67%, for PD <69%, for stroke <81%
