Differential Dx/Cognition Flashcards
Red Flag EMERGENCY situations to identify on subjective exam include:
- Loss of ___, or difficult to ___
- Extreme ___ (not consistent with premorbid diagnosis)
- Uncontrolled ___
- ___ stiffness with fever
- [Slow / rapid] onset of [diffuse / focal ] neuro signs
- Severe ___ with other neurologic signs (c/f subarachnoid hemorrhage)
- Non-responsive ___ ___
Red Flag EMERGENCY situations to identify on subjective exam include:
- Loss of CONSCIOUSNESS, or difficult to AROUSE
- Extreme CONFUSION (not consistent with premorbid diagnosis)
- Uncontrolled SEIZURES
- NECK stiffness with fever
- RAPID onset of FOCAL neuro signs (e.g. sudden onset double vision, slurred speech, etc)
- Severe HEADACHE (“worst headache of my life”) with other neurologic signs (c/f subarachnoid hemorrhage)
- Non-responsive AUTONOMIC DYSREFLEXIA (emergent! individual could have a large stroke as a result)
Non-emergent situations to note on subjective exam, but warrant referral:
- __ and __ dysfunction
- Neurologic signs inconsistent with ___
- Change in ___ status
- Report of symptoms of ___
- Signs/symptoms of systemic illness (e.g. __ or __)
Non-emergent situations to note on subjective exam, but warrant referral:
- BOWEL and BLADDER (and sexual) dysfunction
- Neurologic signs INCONSISTENT with DIAGNOSIS: e.g. progressive neuro signs in a non-progressive diagnosis; bulbar or other CN changes; significant changes in personality or cognition - E.g. with UTI in pt with PD; Evidence of motor neuron dz (fascinations, atrophy, weakness) not previously diagnosed)
- Change in AUTONOMIC status
- Report of symptoms of TRANSIENT ISCHEMIC ATTACK (TIA)
- Signs/symptoms of systemic illness (e.g. FEVER or DIAPHORESIS)
These all warrant an email or phone call to MD, but not an emergency!
Localizing symptoms, e.g. with weakness
Start with - is it CNS vs PNS?
Then…
UMN: Cortex, brainstem, spinal cord - the whole motor pathway
LMN: Motor CN & nuclei, anterior horn cells in the spinal cord (note, these are special because they’re the start of the LMN even though they technically sit in the CNS!), spinal peripheral n, nerve root, NM junction, or th muscle itself!
CNS: might see sensory pattern: cortical, brianstem, spinal cord; BG, Cb, cortical association areas
Other brainstem signs (e.g. arousal, visceral function)
Other spinal cord issues (e.g. autonomic control of bowel, bladder, and sexual dysfxn)
PNS: sensory - CNs that provide sensation or special sensation. Peripheral nerves and nerve roots also provide sensation from the body. Autonomic component: may be noticing autonomic signs/symptoms!
Central motor patterns - distinguishing between UMN/LMN lesions
- Weakness?
- Atrophy?
- Fasciculations?
- Reflex changes?
- Tone?
Central motor patterns - distinguishing between UMN/LMN lesions LMN: - +Weakness - Profound ATROPHY - +Fasciculations (e.g. w/ALS) - DECREASED Reflexes - DECREASED tone
UMN:
- +Weakness
- No atrophy (except in chronic conditions d/t disuse)
- NO fasciculations
- Increased (except in setting of spinal shock right after an acute lesion, see initial hypo or a-reflexia)
- Increased TONE (except in acute lesions)
General patterns of weakness - localize lesion location and common patterns of weakness
- Cortex (hemisphere)
- Brainstem
- Spinal Cord Injury
- Polyneuropathy
- Neuromuscular junction
- Myopathy
General patterns of weakness - localize lesion location and common patterns of weakness
- Cortex (hemisphere): contralateral face and body
- Brainstem: IPSILATERAL face, CONTRALATERAL body (because a lesion that involves the facial NUCLEUS/nerve will affect face on same side, but if it hits motor tracts there, you’ll catch contralateral body! But definitely depends on where lesion is in the brainstem)
- Spinal Cord Injury: at and below level of the lesion
- Polyneuropathy: distal > proximal (e.g. weakness in “stocking-glove” pattern)
- Neuromuscular junction: Patchy weakness (e.g. shoulders, face), face is a common location for weakness (e.g. with Myastheina gravis - think about the mm you use a lot that are at a higher risk for fatigue, that is a common neuromusc junction pattern!)
- Myopathy: Proximal > distal (depends on the type of myopathy)
Structures:
UMN: Cortex, brainstem, spinal cord - the whole motor pathway
LMN: Motor CN & nuclei, anterior horn cells in the spinal cord (note, these are special because they’re the start of the LMN even though they technically sit in the CNS!), spinal peripheral n, nerve root, NM junction, or the muscle itself!
Distinguish CNS vs PNS sensation loss patterns
CNS sensation patterns:
- Follows the homunculus: body regions are together, so sensation loss tends to follow similar areas!
- Selective loss of certain modalities (e.g. pain and temp)
- Loss of higher-order perceptual functions (e.g. stereognosis, graphesthesia, extinction)
PNS sensation loss:
- Follows peripheral nerve distribution
- Follows dermatomes (spinal nerve roots)
- Patterns like “stocking glove” loss (e.g. polyneuropathy)
Common cerebellar patterns
Cb patterns:
- Dysmetria, dysdiadochokinesia, hyper/hypometria
- Nystagmus
- Dysarthria
- Ataxia (usually Cb, but sometimes sensory!)
Common basal ganglia patterns
BG patterns
- Bradykinesia, hypokinesia
- Athetosis / chorea
- Tremor
- Dystonia
___ is an inability to perform skilled tasks that cannot be explained by weakness, sensory loss, or ataxia.
APRAXIA is an inability to perform skilled tasks that cannot be explained by weakness, sensory loss, or ataxia.
___ is a disorder of higher-order perception, includes astereognosis, agraphesthesia.
AGNOSIA is a disorder of higher-order perception, includes astereognosis, agraphesthesia.
Brainstem dysfunction might result in…
Brainstem dysfunction might result in impaired…
- Visceral control
- Consciousness/alertness
- Sleep regulation
- Autonomic
Spinal cord dysfunction may result in
Spinal cord dysfunction may result in:
- Bowel and bladder dysfunction
- Sexual dysfunction
Classifying etiology/pathogenesis of a lesion - helpful pneumonic is “TIM VaDeTuCoNe” - what does it stand for?
Classifying etiology/pathogenesis of a lesion - helpful pneumonic is "TIM VaDeTuCoNe:" Trauma Inflammation/ Infection Metabolic Vascular Degenerative Tumor Congenital Neurogenic/Psychogenic
What is Tabes Dorsalis?
- What is impacted?
- Cause?
- Symptoms? Sensation changes? DTRs? Balance?
What is Tabes Dorsalis?
- What is impacted? DEMYELINATION OF THE POSTERIOR COLUMNS OF THE SPINAL CORD (IMPACTS TRAVELING DCML TRACT), CAUSED BY SYPHILIS
- Symptoms?
- –Lightning-like back and leg pain
- – ABSENT position and vibratiory sense
- – ABSENT DTRs
- –+Rhomberg
- –SENSORY ATAXIA
Pain is as a complex, multi-system [input / output] to the brain. It is produced by the brain when the brain perceives ___. Not all pain is bad! It helps for survival.
Pain is a complex, multi-system OUTPUT of the brain! It is produced by the brain when the brain perceives DANGER, but not all pain is bad! It helps for survival.
____ are sensory receptors that transduce and encode damage or potential tissue damaging stimuli. Specifically, they are a ___ nerve ending which convert ___, ___, and ___ energy into electrical signals and carry it to the CNS. They are located in [what parts of the body? (6)]. They can become sensitized, which results in [central / peripheral / both] changes.
NOCICEPTORS are sensory receptors that transduce and encode damage or potential tissue damaging stimuli. Specifically, they are a FREE nerve ending which convert MECHANICAL, THERMAL, and CHEMICAL energy into electrical signals and carry it to the CNS. They are located in skin (cutaneous), muscles, joints, tendon, intervertebral discs, VISCERA, and around nervi nervorum of peripheral nerves. There are also “silent” nociceptors! Nociceptors can become sensitized, which results in BOTH CENTRAL AND PERIPHERAL changes.
Cutaneous nociceptors respond to [one / many] noxious stimulus: ___, ___, or __
Cutaneous nociceptors respond to ONE noxious stimulus: MECHANICAL, HOT, or COLD
Polymodal nociceptors respond to [one / many] stimuli (e.g. __, __, or __)
Polymodal nociceptors respond to many stimuli (e.g. MECHANICAL, CHEMICAL, or THERMAL)
Role of Nociceptors:
- A nociceptor is a sensory receptor that encodes __stimuli and carries it to the __.
- With acute tissue damage, there are __ changes along with tissue __ which activates nociceptors. Once ___ goes away, the pain should go away! But if it doesn’t, we have a chronic pain problem due to impaired ____.
- In persistent or chronic pain, continued input changes the nociceptor’s ___ and CNS inputs, which maintains the ongoing pain.
- Ongoing nociceptor activity stimulates ___ responses, such as ___ nervous system and ___ modulation pathways.
Role of Nociceptors:
- A nociceptor is a sensory receptor that encodes NOXIOUS stimuli and carries it to the CNS.
- With acute tissue damage, there are INFLAMMATORY changes along with tissue INJURY which activates nociceptors. Once INFLAMMATION goes away, the pain should go away! But if it doesn’t, we have a chronic pain problem due to impaired CNS processing.
- In persistent or chronic pain, continued input changes the nociceptor’s SENSITIVITY and CNS inputs, which maintains the ongoing pain.
- Ongoing nociceptor activity stimulates ___ responses, such as SYMPATHETIC nervous system and BRAINSTEM modulation pathways.
Pain that persists after an injury is termed ___ pain. This is also known as ___ pain or ___ ___. This is a is a [PNS/CNS] [output / input]. It is [disproportionate / proportionate ] to tissue injury, [stays local to the site of injury / may move around from 1 side to another], and may produce abnormal __ and __. This happens because the CNS undergoes ___ ___ post-injury, especially if nociceptors continue to fire - can be maladaptive if left untreated! Long and short, the underlying pathology [is / may not be] the primary problem.
Pain that persists after an injury is termed PERSISTENT PAIN. This is also known as CENTRAL pain or CENTRAL SENSITIZATION. This is a CNS OUTPUT. It is DISPROPORTIONATE to tissue injury, may MOVE from one side to another, may produce ABNORMAL SENSATION and MOTOR DYSFUNCTION. After an injury, the CNS undergoes PLASTIC REORGANIZATION particularly if the nociceptors continue to fire - this can be maladaptive if left untreated!
The underlying pathology MAY NOT BE the problem.
In central sensitization, we see [central / peripheral / sympathetic ] involvement. Centrally, the multiple areas of the brain are involved and become ___, meaning they fire in response to sub-threshold (i.e. non-painful) stimuli. Specific areas within the brain involved with pain include the ___, ___, ___, and ___. Additional areas involved in the brainstem include the ___ [white / grey] matter and the __. Also involves [volitional / reflexive ] responses within the spinal cord; ascending [facilitatory / nociceptive / inhibitory] pathways; and descending [facilitatory / nociceptive / inhibitory]
In central sensitization, we see peripheral damage as well as involvement of both the CNS and sympathetic nervous system. Centrally, the multiple areas of the brain are involved and become SENSITIZED, meaning they fire in response to sub-threshold (i.e. non-painful, e.g. to soft touch) stimuli. Specific areas within the brain involved with pain include the THALAMUS, AMYGDALA, ANTERIOR CINGULATE CORTEX, and PREFRONTAL CORTEX. Additional areas involved in the brainstem include the PERIAQUEDUCTAL GREY MATTER and the SUPERIOR COLLICULUS. Also involves REFLEXIVE responses within the spinal cord; ascending NOCICEPTIVE pathways; and descending FACILITATORY AND INHIBITORY pathways
In peripheral sensitization, we see increased spontaneous response, [increased / decreased] threshold firing, [increased/decreased] responsiveness to the same noxious stimuli, resulting in an increase or spreading of symptoms. This is directly responsible for increased input to the ___ via the ___. In the context of an acute injury, this is [unexpected / expected] - explain the pathophysiology: ____. With an acute injury, continuous pain input into the CNS causes ____ and this [is expected/ should be avoided] - so, manage pain, avoid ___, and promote gentle mobility!
In peripheral sensitization, we see increased spontaneous response, DECREASED threshold firing, INCREASED responsiveness to the same noxious stimuli, resulting in an increase or spreading of symptoms. This is directly responsible for increased input to the CNS via the SPINAL CORD. In the context of an acute injury, this is EXPECTED!
With an injury inflammatory cytokines are released and are sensitizing the peripheral nociceptors, which is expected during the acute healing process. But! With an acute injury, continuous pain input into the CNS causes HYPERSENSITIVTY and this SHOULD BE AVOIDED - so manage pain, avoid IMMOBILIZATION, and promote gentle mobility!
What types of neurons exist in the dorsal horn to respond to various types of sensory inputs? Which ones respond to pain/noxious stim?
Dorsal horn includes:
High threshold neurons
Low threshold neurons
Wide dynamic range neurons
*Both HIGH threshold and WDR neurons respond to noxious stim! (NOT low threshold neurons)
How does central sensitization change the firing of neurons in the dorsal horn of the spinal cord?
High threshold and wide dynamic range neurons (both of which respond to noxious stim normally) continue to fire together after an injury. If pain persists, it is often due to the WIDE DYNAMIC RANGE NEURONS interpreting a non-painful stimulus as a PAINFUL stimulus.
High threshold neurons in the dorsal horn respond to __ stimuli.
Low threshold neurons in the dorsal horn respond to __ stimuli.
Wide dynamic range neurons in the dorsal horn respond to __ stimuli.
High threshold neurons in the dorsal horn respond to NOXIOUS stimuli.
Low threshold neurons in the dorsal horn respond to INNOCUOUS (i.e. NOT noxious) stimuli.
Wide dynamic range neurons in the dorsal horn respond to both NOXIOUS and NON-NOXIOUS stimuli.
In central sensitization, we see increased responsiveness to [what types of?] stimuli. Symptoms [stay local / spread beyond the injured area aka the ___ ___]. The firing threshold [is decreased / is increased / stays the same]. These patients typically have [bouts of pain / constant pain even at rest]. Patients often report unusual sensations including __, __, or ___ sensations. What changes do we see on inspection of the limb itself?
In central sensitization, we see increased responsiveness to BOTH NOXIOUS and NON-NOXIOUS stimuli. Symptoms SPREAD BEYOND THE INJURED AREA (aka the RECEPTIVE FIELD), commonly in the limbs - pain area is often larger than primary injury, may not be located near primary injury. The firing threshold IS DECREASED. These patients typically have CONSTANT pain even at REST. Patients often report unusual sensations including BURNING, SHOOTING, or TEARING sensations. Pain area is often larger than the primary injury and may not be located near the primary injury. We see increased EDEMA as well as a change in COLOR and/or TEMPERATURE, as well as occasionally unusual movements (e.g. restless leg syndrome).
Increased response or specifically a PAINFUL response) to innocuous stimulus following injury is called ___. This can also result in motor dysfunction, including abnormal __, ___, and ___. Increased CNS receptors activity post injury further intensifies CNS input = ___.
Increased response (or specifically a PAINFUL response) to innocuous stimulus following injury is called ALLODYNIA. This can also result in motor dysfunction, including abnormal MOVEMENTS (e.g. restless leg syndrome), TREMORS, and local DYSTONIA. Increased CNS receptor activity post injury further intensifies CNS input = HYPERALGESIA.
Central sensitization causes changes in the body map, which at the brain level is the ___. When brain areas normally devoted to specific body parts/functions start to overlap, we call this ___. In the motor cortex, this may make it more difficult to __ and move that body part. In the sensory cortex, the limb might feel too __ to move, perhaps as a protective strategy. This may result in body perception disturbances, including __, __, lack of ___, dysfunction in ___ ___ ___, ___ of the limb, or a desire to __. Research shows that with increased body perception disturbance, it correlates with increased ___ and impaired ___ (e.g. 2-pt discrimination).
Central sensitization causes changes in the body map, which at the brain level is the HOMUNCULUS. When brain areas normally devoted to specific body parts/functions start to overlap, we call this SMUDGING. In the motor cortex, this may make it more difficult to ISOLATE and move that body part. In the sensory cortex, the limb might feel too SENSITIVE to move, perhaps as a protective strategy. This may result in body perception disturbances, including DISLIKE (“I don’t like this limb”), DISTORTED perception, lack of OWNERSHIP (“that’s not my hand”), dysfunction in TWO-POINT DISCRIMINATION, DENIAL of the limb, or a desire to AMPUTATE. Research shows that with increased body perception disturbance, it correlates with increased PAIN and impaired TACTILE ACUITY (e.g. 2-pt discrimination).
Syndromes associated with central sensitization includes… (4)
Examples of central sensitization…
- Complex Regional Pain Syndrome (CRPS), including Shoulder-Hand Syndrome
- Phantom limb pain
- Neuropathic pain, shingles, pain following SCI (interestingly, most pain is below level of injury, despite perhaps absent sensation there!), and diabetes
The amygdala is one area that is impacted in central sensitization. It responds to __, __, __, and __.
The amygdala is one area that is impacted in central sensitization. It responds to THREAT, FEAR, STRESS, ANGER.
Give pt control back: “Those are just my sensitive nerves! I don’t need to give those my attention!”
Techniques to help “calm the brain down” in the setting of central sensitization. Pt needs to be given confidence that they are in control of their mind, understand that movement and pain doesn’t mean harm, need strategies to stay in control and decrease abnormal response. Mindfulness helps! It helps to decrease __, __, __, __, __ an d__.
Techniques to help “calm the brain down” in the setting of central sensitization. Pt needs to be given confidence that they are in control of their mind, understand that movement and pain doesn’t mean harm, need strategies to stay in control and decrease abnormal response. Mindfulness helps! It helps to decrease PAIN, SYMPTOM SEVERITY, DEPRESSION, ANXIETY, ATTENTION and CRAVINGS.
Fear of movements = __ __. Goal of PT interventions is to reduce their fear of movement and catastrophizing. Educate pt that pain doesn’t mean that they can’t move! Neuroscience education reduces __, __, __, and improves __. This must be individualized based on pt’s education level, learning preferences, and complexity of pain. Must include paced education, movement pacing, graded exposure, pt goal setting, and HEP.
Fear of movements = FEAR AVOIDANCE Goal of PT interventions is to reduce their fear of movement and catastrophizing. Educate pt that pain doesn’t mean that they can’t move!
Neuroscience education reduces PAIN, DISABILITY, CATASTROPHIZATION, and IMPROVES MOVEMENT. Must be individualized based on pt’s education level, learning preferences, and complexity of pain. Must include paced education, movement pacing, graded exposure, pt goal setting, and HEP.
Per Loeser’s research, pain is stated as 4 concepts: …
Nociception
Pain recognition at the cortical level
Pt perceived suffering
Pain behaviors
Pain is an interaction of the biological, psychological, and sociocultural variables
“When do you see yourself getting better? What do you hope to do?”
Individuals with CRPS often have persistent __, __ disturbances, and dysfunctional MOVEMENT that are not immediately identified. The longer symptoms persist, the more _ __ occurs. Needs a biopsychosocial approach and early intervention.
Individuals with CRPS often have persistent PAIN, SENSORY disturbances, and dysfunctional MOVEMENT that are not immediately identified. The longer symptoms persist, the more CORTICAL REORGANIZATION occurs. Needs a biopsychosocial approach and early intervention.
Diagnosis of CRPS 1 (aka ___) requires 2 to 4 of the below criteria:
- ____ event or period of ___
- Pain is ____ and includes either __ or __
- ___ or changes in blood flow to the ___, or ___ activity
- Diagnosis is excluded by the existence of conditions that would account for pain
Diagnosis of CRPS 1 (aka previously called REFLEX SYMPATHETIC DYSTROPHY) requires 2 to 4 of the below criteria:
- NOXIOUS event or period of IMMOBILIZATION
- Pain is DISPROPORTIONATE and includes either ALLODYNIA or HYPERALGESIA
- EDEMA or changes in blood flow to the SKIN, or SUDOMOTOR activity
- Diagnosis is excluded by the existence of conditions that would account for pain
Diagnosis of CRPS II aka ___ requires all three of the following to be present:
- Continuing pain and ___. Could also be __ after a nerve injury, though is not limited to an injured nerve
- ___ or changes in blood flow to the ___, or ___ activity in the region of pain
- Diagnosis is excluded by the existence of conditions that would account for pain
Diagnosis of CRPS II aka CAUSALGIA requires all three of the following to be present:
- Continuing pain and ALLODYNIA. Could also be HYPERALGESIA after a nerve injury, though is not limited to an injured nerve
- EDEMA or changes in blood flow to the SKIN, or SUDOMOTOR activity in the region of pain
- Diagnosis is excluded by the existence of conditions that would account for pain
Cognitive impairments include an interrelationship between executive function, working memory, and attention. Specifically, the overlap between executive processes and attention includes [what aspects of attention], and all three overlap to contriubte to [what 3 aspects of memory?]
Cognitive impairments include an interrelationship between executive function, working memory, and attention. Specifically, the overlap between executive processes and attention includes SELECTIVE ATTENTION, DIVIDED ATTENTION, ALTERNATING ATTENTION, and TASK PERSISTENCE, and all three overlap to contribute to WORKING MEMORY, PROSPECTIVE MEMORY, and AWARENESS.
Executive functions are those that drive and self-regulate behavior. Specifically, they allow us to:
- Make __
- Evaluate __
- __ and __ actions
- Manage __ or __ situations
- Evaluate progress toward __
- ___ behavior if necessary
Executive functions are those that drive and self-regulate behavior. Specifically, they allow us to:
- Make DECISIONS
- Evaluate RISK
- PLAN and PRIORITIZE actions
- Manage NEW or NOVEL situations
- Evaluate progress toward GOALS
- CHANGE behavior if necessary
What areas of the brain are involved in the processing of executive function?
- Frontoparietal attention network (Dorsolateral prefrontal cortex, inferior frontal sulcus, middle frontal gyrus, infraparietal sulcus)
- Lateral prefrontal cortex
- Anterior cingulate
- Brodmann area 10
What disorders may affect executive function / frontal lobe function?
Frontotemporal dementia Alzheimer's dz Progressive supranuclear palsy Corticobasal degeneration Vascular dz Parkinson's dz Infectious or inflammatory diseases of the CNS TBI Psychiatric disorders Creutzfeldt-Jakob Disease Wilson's Disease Huntington's Disease
Dysexecutive syndrome is associated with dysfunction to which cortical area? Specifically, we see problems with what activities?
Dysexecutive syndrome is associated with damage to the DORSOLATERAL frontal cortex.
We see problems with planning, strategy development, problem solving despite distractions, and cognitive persistence, as well as emotion, and behavior regulation. Involves integrating sensory info & making decisions! Trouble developing a plan (evaluating options, not thought out), not good at evaluating performance/integrating feedback/ recognizing errors
Disinhibition is associated with dysfunction to which cortical area? There are connections between the ___ frontal cortex to the __ and the __ region. Main issues include… (5)
Disinhibition (and attention/ distractibility!) = ORBITOFRONTAL cortex damage. Connections between the INFERIOR PREFRONTAL CORTEX to the AMYGDALA and the TEMPORAL region. Main issues include…
- DISINHIBITION
- EMOTIONAL LABILITY
- DECREASED JUDGEMENT
- DISTRACTABILITY
- PERSEVERATION
Might be restless, impulsive, socially inappropraite (immaturity, lacking self-control, inappropriate cheerfulness or optimism), denial of deficits, and behaviors, as well as attentional signs (distractability, impulsive responses), difficulty shifting (disengaged, perseveration), slow processing of info
