Exam 1 Flashcards
1
Q
Define CVA
A
A sudden loss of neurological function caused by an interruption of the blood flow to the brain
2
Q
Stroke kills almost ______ Americans each year.
A
130,000
3
Q
Every year, more than ______ people in the US have a stroke.
A
795,000
4
Q
Stroke is the ______ leading cause of death in the US.
A
5th
5
Q
Stroke is the leading cause of ______ in the US.
A
Long-term disability
6
Q
What percentage of strokes are a 1st stroke incidence?
A
77%
7
Q
What percentage of strokes are a recurrence?
A
23%
8
Q
How much do strokes cost annually?
A
34 billion
9
Q
What are some stroke risk factors that can’t be changed?
A
- Age
- Race
- Gender
- TIA
- Sickle cell anemia
10
Q
What are some stroke risk factors that CAN be changed, treated, or controlled?
A
- High blood pressure
- Diabetes
- Cigarette smoking
- Atrial fibrillation
- High blood cholesterol
- Carotid or other artery disease
- Obesity
- Poor diet
- Physical inactivity
11
Q
CVA risk factor: age
A
- Risk increases with age
- Risk is doubled for each decade after 55 y/o
12
Q
CVA risk factor: race
A
- African Americans are twice as likely as Caucasian Americans to have a first stroke
- African Americans are more likely to die following a stroke than are Caucasian Americans
13
Q
CVA risk factor: gender
A
- Stroke incidence is more common in men than women
- Women who use contraceptive pills are at higher risk than those who don’t
- Women may have a stroke during pregnancy or labor
14
Q
CVA risk factor: TIA
A
- TIA = transient ischemic attack
- “mini-stroke”
- Resolves within 24 hours
- A person who has had 1 or more TIAs is 10x more likely to have as stroke
- A person who has had a heart attack is 3x more likely to have a stroke
- 5-14% of persons who had a stroke will have another stroke within 1 year
15
Q
CVA risk factor: sickle cell anemia
A
- Defective RBCs tend to accumulate, stick to blood vessel walls, which block arteries and may cause a stroke
- More prevalent in African American and Hispanic children
16
Q
CVA risk factor: carotid or other artery disease
A
- Atherosclerosis: plaque build ups in artery walls
- May narrow an artery and/or become blocked by a blood clot
- Most common in coronary arteries, carotid artery and lower peripheral arteries
- Peripheral artery disease: the narrowing of blood vessels carrying blood to leg/arm; higher risk of stroke and heart attack
17
Q
CVA risk factor: obesity
A
- Associated with an increased risk of DM, HTN, and hyperlipidemia
- Thus an increased risk of stroke
18
Q
CVA risk factor: poor diet
A
- High in saturated fat and cholesterol
- High sodium
- Excess calories
- 5 or more servings of fruits/veggies per day may reduce risk of stroke
19
Q
CVA risk factor: physical inactivity/obesity
A
- Being inactive, obese, or both can increase your risk of high BP, high blood cholesterol, diabetes, heart disease and stroke
- Physical activity: recommended 30 minutes of moderate to vigorous exercise 4-5 days per week
- Maintain normal weight (BMI 20-25)
20
Q
Ischemic stroke
A
- 83-87% of all strokes
- Oxygen deficiency due to obstruction or narrowing of the artery diameter
2 types
- Cerebral thrombus
* ** blood vessel narrows due to atherosclerosis - Cerebral embolism
* ** clot from heart, upper body or neck dislodges and moves to brain to block an artery
21
Q
Hemorrhagic stroke
A
- 17% of all strokes
- Weakened arterial vessel that ruptures and bleeds into the surrounding brain
- Blood accumulates and compresses the surrounding brain tissue
2 types
- Aneurysm
* ** ballooning of a weakened blood vessel - AVM- arteriovenous malformation
* ** a cluster of abnormally formed blood vessels
* ** vessels can rupture, causing bleeding into the brain
22
Q
Stroke locations
A
- Middle cerebral artery (MCA)
- Anterior cerebral artery (ACA)
- Posterior cerebral artery (PCA)
- Vertebral artery
- Basilar artery
23
Q
Middle cerebral artery syndrome
A
- Most common stroke location
- Contralateral hemiparesis, arm > leg
- Contralateral sensory impairment, arm > leg
- Aphasia (left hemisphere MCA stroke)
- Apraxia
- Contralateral homonymous hemianopia
- Also supplies the internal capsule and basal ganglia so could thus result in both UE and LE involvement
24
Q
Expressive aphasia
A
- Non-fluent aphasia
- Damage to Broca’s area in the frontal lobe
- Impedes the ability to form words
25
Receptive aphasia
- Fluent aphasia
- Damage to Wernicke's area in the temporal lobe
- Impairment of the ability to understand what is said and also in the ability to create and monitor the verbalizations that are uttered
- Gibberish talking
26
Global aphasia
- Due to a large stroke impacting both Wernicke's and Broca's areas
- Unable to understand OR produce speech
27
Apraxia
- Inability to plan or carry out a motor plan
2 types
1. Ideomotor apraxia
2. Ideational apraxia
28
Contralateral homonymous hemianopia
- Loss of the visual field contralateral to the lesion
| - Results from damage to the optic fibers (radiations) at some point after they leave the optic chiasm
29
Anterior cerebral artery syndrome
- Contralateral hemiparesis, leg > arm
- Contralateral sensory impairment, leg > arm
- Loss of bowel/bladder control
- Apraxia
- Mental impairment with perseveration, confusion, memory loss
30
Perseveration
Do the same thing or say the same words repeatedly
31
Posterior cerebral artery syndrome
- Contralateral hemiparesis
- Contralateral homonymous hemianopia
- Dyslexia
- Memory deficits
- Topographical disorientation
- Cranial nerve III palsy
- Thalamic pain syndrome
- Pain and temperature sensory loss
- Ataxia, athetosis, or choreiform movements
- Visual agnosia
32
Visual agnosia
An impairment in recognition of visually presented objects, testing using stereognosis kits
33
Paresthesias
An abnormal sensation such as tingling, tickling, pricking, numbness or burning of a person's skin
34
Thalamic pain syndrome
- Sensory impairment in all modalities
- Pain
- Paresthesias
35
Choreiform movements
Involuntary, forcible, rapid, jerky movements which are mostly manifestations of basal ganglia diseases
36
Athetosis
A symptom characterized by slow, involuntary, convoluted, writhing movements of the fingers, hands, toes, feet and in some cases arms, legs, neck and tongue
37
Dyslexia
A learning disorder characterized by difficulty reading due to problems identifying speech sounds and learning how they relate to letters and words
38
Basilar artery CVA
- Brainstem
- Coma
- Quadriplegia
- "Locked In" syndrome
- Bilateral cerebellar ataxia
- Thalamic pain syndrome
- Diplopia or other visual field deficits, including blindness
39
Diplopia
Double vision
40
"Locked in" syndrome
- Intact consciousness
| - No motor ability other than eye blinks to respond
41
Vertebral artery syndrome
- Ataxia
- Vertigo
- Nausea
- Vomiting
- Nystagmus
- Impaired pain and temperature sensation in ipsilateral face
- Horner's Syndrome
- Dysphagia
- Sensory impairment in contralateral arm, trunk, leg
42
Horner's Syndrome
- Sympathetic dysfunction causing ptosis
- Combination of signs and symptoms caused by the disruption of a nerve pathway from the brain to the face and eye on one side of the body
- Results in a decreased pupil size, drooping eyelid, and decreased sweating on the affected side of your face
43
Dysphagia
- Difficulty swallowing
- Oropharyngeal dysphagia (difficulty starting a swallow)
- Esophageal dysphagia (sensation of food being stuck in the neck or chest)
44
Brunnstrom Stages
Stage 1. Flaccid (no voluntary movement)
Stage 2. Associated Reactions/Beginning Spasticity (no voluntary movement)
Stage 3. Synergy Stage (voluntary movement present)
Stage 4. Movements Deviating from the Basic Synergies
Stage 5. Relative Independence of the Basic Synergies
Stage 6. Near Normal (impaired strength, coordination and speed)
Stage 7. Normal (except when fatigued)
45
Brunnstrom Upper Extremity Synergy Patterns
- Flexion synergy is dominant
- Flexion synergy
* Scapula (elevation & retraction)
* Shoulder (abduction, ER)
* Elbow (flexion)
* Forearm (supination)
* Wrist (flexion)
- Extension synergy
* Scapula (depression & protraction)
* Shoulder (adduction, IR)
* Forearm (pronation)
* Wrist (extension)
- Associated reactions in UE are the same (do extension on uninvolved side, elicit extension on involved side)
46
Brunnstrom Lower Extremity Synergy Patterns
- Extension synergy is dominant
- Flexion synergy
* Hip (flexion, abduction, ER)
* Knee (flexion)
* Ankle (DF)
* Foot (inversion, toe flexion)
- Extension synergy
* Hip (extension, adduction, IR)
* Knee (extension)
* Ankle (PF)
* Foot (inversion, toe extension)
- Associated reactions in LE are the opposite (do flexion on uninvolved side, elicit extension on involved side)
47
Brunnstrom - which stage do you start testing at?
Start at stage 4 then move up or down depending on results
48
Brunnstrom - how do you "pass" stage 4?
To pass stage 4, must be able to perform the action out of synergy (ex: isolated hip flexion)
49
Brunnstrom - stage 4, why do you perform knee extension last?
For LE, you do knee extension test last because extension is the dominant synergy (start with flexion movements since synergy is not dominant)
50
Brunnstrom - which movement is indicative of a good prognosis and why?
If patient can evert, indicates good prognosis since eversion is not part of flexion or extension synergies
51
Brunnstrom - at what stage is it appropriate to do MMT?
Stage 6
52
Pupillary Response
Dark conditions- dilate
Bright conditions- constrict
Direct response- constriction in response to light shined in eye being tested
Consensual response- constriction in response to light shined in opposite eye
53
Cranial nerves III, IV, VI
Possible findings
CN III - inability to look upward, downward, and inward (lateral shift)
CN IV - inability to look down when eye is adducted
CN VI - inability to look outward (medial shift)
54
Central Pattern Generators
- Groups of neurons and interneurons that produce rhythmic or oscillatory motor activity
- "Hard-wired", less variable, less flexible than more complex, goal-directed motor control
55
CPGs - evarts
- Spinal rhythm generators
- A group of neurons that inherently present a pre-arranged sequence of muscle activity arranged temporally and spatially
- You need some kind of input to get the circuit going and keep it going (input trigger)
56
CPGs - cats vs humans
Cats
- CPG neural network for gait appears to be in the spinal cord, midbrain and cerebellum
Humans
- it is suggested that the gait CPG extends higher into MI area (Brodmann area 4), but may not
57
Dermatome
Area of skin innervated by the sensory axons within each segmental nerve (root)
58
Myotome
The collection of muscle fibers innervated by the motor axons within each segmental nerve (root)
59
Key muscle functions
10 muscle functions that are tested in all patients and scores from the examination are documented on the worksheet
60
Non-key muscle functions
Muscle functions that are not part of the 'key muscle' functions listed on the worksheet
- With an apparent AIS B classification, non-key muscle functions more than 3 levels below the motor level on each side should be tested to most accurately classify the injury (differentiate between AIS B and C)
61
Sensory level
Most caudal dermatome with normal function (score 2) for both PP and LT sensation
62
Motor level
Defined by the lowest key muscle function that has a grade of at least 3 [on MMT performed supine], where the key muscles above that level are graded a 5
63
Neurological level of injury (NLI)
The most caudal segment of the spinal cord with normal sensory and antigravity motor function on both sides of the body, provided there is intact sensory and motor function rostrally
4 segments: L sensory, R sensory, L motor, R motor
NLI: most rostral of these levels
64
Skeletal level
This term has been used to denote the level at which, by radiographic exam, the greatest vertebral damage occurred
65
How many cases per million population in US of SCI?
54
66
How many people alive with SCI in US?
291,000
67
What is the average age at injury for SCI?
43
68
What percentage of males vs females get SCIs?
78% males
| 22% females
69
Percentage of SCIs based on race
60% non-hispanic white
23% non-hispanic black
13% hispanic
4% other
70
Percentage of SCIs based on cause
```
40% vehicular
32% falls
14% violence
8% sports
6% other
```
71
Complete injury
- Loss of all sensation and motor function below the level of the lesion
- Absence of sacral sparing
- Zeros for LT and/or PP (S4-5)
72
Incomplete injury
- Partial loss of sensation and motor function below the level of the lesion
- Sacral sparing is present
- 1 or 2 for LT and/or PP (S4-5)
- DAP present
73
Tetraplegia
- Often quadriplegia
- Impairment or loss of motor function and/or sensory function in the cervical segments of the spinal cord due to damage of neural elements within the spinal canal
- Typically arms, trunk, legs, pelvic region (4 extremities)
74
Paraplegia
- Impairment or loss of motor and/or sensory function in the thoracic, lumbar, or sacral segments of the spinal cord due to damage of neural elements within the spinal canal
- Arm function is spared
75
Percentage of SCIs based on type
48% incomplete tetraplegia
20% incomplete paraplegia
20% complete paraplegia
12% complete tetraplegia
76
Length of stay
Hospital acute care
- Decreased from 24 days to 11 days
Inpatient rehabilitation
- Decreased from 98 days to 31 days
77
SCI cause of death
Pneumonia
| Septicemia
78
Contusions
- Bruising of spinal cord following fractures and dislocations of the vertebrae
- Clinical presentation
* Initially severe symptoms from loss of SC function
* Usually relatively rapid return of function
* Amount of return depends on severity of injury
79
Why do contusions have the best prognosis?
Spinal cord is still intact
80
Compression
- From fractures and dislocations of vertebrae, tumors, disc herniation
- Clinical presentation
* Amount of return depends on severity of injury
81
Lacerations
- From knife, gunshot or other projectile/foreign object
- Clinical presentation
* Partial to complete loss of function below level of lesion
* Impairment depends on extent of lesion
82
Loss of vascular supply
- From thrombosis, embolus, AVM or direct disruption of blood vessels
- Clinical Presentation
* Partial loss of SC function below level of lesion in distribution of blood supply
83
DCML
- Proprioception
- Vibration
- Fine touch
- 2 point touch
84
Anterolateral system
- Crude touch
- Sharp/dull
- Temperature
- Pain
- Tickle/itch
- Sexual sensations
85
Nerve root exits
- Above C8, nerve root exits above its corresponding vertebrae
- Below C8, nerve root exits below its corresponding vertebrae
86
Hyperextension of C4 on C5 would compress which nerve root?
C5
87
Where does the C8 nerve root exit?
Above T1
88
Above T3, the nerve roots exit __________ to the corresponding spinal cord level.
immediately and horizontal
89
Below T3, the nerve root runs ___________ to the spinal cord for a distance before exiting below the spinal cord level.
parallel
90
Below the L2 bony level exits the ____________. Only damage possible is to the nerve roots (not the spinal cord) as they pass through the spinal canal.
cauda equina
91
Anterior cord syndrome
- Damage to the anterior (ventral) SC
- Partial or full loss of bilateral ALS, lateral and anterior CST below level of lesion
* * loss of motor function
* * loss of pain and temperature sensation at or below level of injury
- Spared posterior columns (DCML) bilaterally below level of lesion
* * preservation of light touch and joint position sense
- Relatively rare syndrome related to a decreased or absent blood supply to the anterior 2/3 of the SC
92
Posterior cord syndrome
- Damage to the posterior (dorsal) SC
- Loss of DCML sensory modalities below level of lesion
- Preservation of bilateral ALS sensory modalities and partial or full preservation of CST motor function bilaterally
93
Central cord syndrome
- Most common of the clinical syndromes
- Often seen in individuals with underlying cervical spondylosis who sustain a hyperextension injury (most commonly from a fall)
- May occur with or without fracture and dislocations
- Central area of SC more susceptible to damage due to poor arterial supply (degeneration from inside out)
- Most often in cervical region
- An incomplete injury with greater weakness in the UE than LE
- SACRAL SPARING
94
Brown-Sequard syndrome
- Hemisection (damage to one side) of SC
- Rare in its pure form (some features of central cord too)
- Traumatic SCI, penetrating injuries, burst fractures
- Ipsilateral DCML
* * loss of proprioception, vibration, fine touch, etc.
- Ipsilateral CST
* * loss of voluntary motor control
- Contralateral ALS
* * loss of crude touch, sharp/dull, temperature, pain, etc.
95
Cauda Equina syndrome
- Involves the lumbosacral nerve roots of the cauda equina and may spare the SC itself
- Injury to the nerve roots (LMNs) produce flaccid paralysis of muscles of LE
- Areflexic bowel/bladder
- Partial or complete loss of sensation
96
Conus Medullaris syndrome
- Clinically similar to Cauda Equina syndrome but injury is more rostral in the SC (L1-L2)
- Depending on level of injury, may be a mixed picture of UMN (nerve cell body damage in the SC/conus) and LMN (nerve roots) damage
97
Sacral sparing
- Presence of sensory or motor function in the most caudal sacral segments as determined by examination
- Preservation of LT or PP in S4-5 on one or both sides
- OR presence of DAP
98
AIS A
- Complete
| - N0000N sign
99
AIS B
- Sensory incomplete
- Sensory (not motor) function preserved S4-5 (DAP, LT, PP)
- No N0000N sign
AND
- no motor function preserved more than 3 levels below motor level on either side of body
100
AIS C
- Motor incomplete
- Motor function preserved S4-5 (VAC)
OR
- Sensory incomplete
- Sensory function preserved S4-5 (DAP, LT, PP)
AND
- Sparing of motor function more than 3 levels below motor level
- More than half the key muscles below NLI have a muscle grade of < 3
101
AIS D
- Motor incomplete
- Sensory incomplete as defined in AIS C
- At least half or more of the key muscles below NLI have a muscle grade of >/= 3
102
AIS E
- Normal
| - Someone without an SCI does not get an AIS grade
103
ASIA key muscles
```
C5 - elbow flexors
C6 - wrist extensors
C7 - elbow extensors
C8 - finger flexors
T1 - finger abductors
```
```
L2 - hip flexors
L3 - knee extensors
L4 - ankle DFs
L5 - long toe extensors
S1 - ankle PFs
```
104
Zone of partial preservation
1-3 neurological levels below the NLI
105
Spasticity
A motor disorder characterized by a velocity dependent increase in tonic stretch reflexes with exaggerated DTRs (phasic) resulting from the hyper-excitability of the monosynaptic stretch reflex as one component of the UMN syndrome
106
Heterotopic Ossification (HO)
- Calcium deposits in soft tissues around joints that receive stress
- Limitation of ROM
- Treatments
* Radiation (slows doesn't stop)
* Gentle PROM
* Surgery (likely to come back and be worse)
107
Sympathetic NS
T1-L2
108
Parasympathetic NS
CN X
| S2-4
109
Bradycardia
Slow HR
| < 60 bpm
110
Tachycardia
Fast HR
| > 100 bpm
111
Dysrhythmias
Abnormality in physiological rhythm of the heart
112
Hypertension
Tested in supine
| BP > 140/90 mmHg
113
Hypotension
Tested in supine
| Systolic BP < 90 mmHg
114
Autonomic control of sweating
Hyperhidrosis above lesion
| Hypohidrosis below lesion
115
Flaccid Neurogenic Bladder
- AKA "areflexic bladder"
- Neurological injury includes S2-4 level
- Only empties a little when it "overflows"
- Must be artificially or manually emptied
- Bladder fills to normal or larger capacity before being emptied artificially
- Self-catheterization
116
Reflexic Neurogenic Bladder
- AKA "spastic bladder"
- S2-4 reflexes must be intact (SC injuries above S2)
- MOST COMMON
- Detrusor muscle becomes spastic and contracts
- Empties at smaller than normal volumes
- May be able to stimulate reflex emptying
117
Neuropathic pain
- Experienced by 90% of all SCI patients
- Burning sensation
- Use of medical marijuana
