Exam 2 Prep Flashcards
What is locomotion?
An action initiated by the brain, but yet are maintained in its steady-state execution by mostly spinal mechanisms (CPG) with the interaction of peripheral afferent contributions
What is the evidence for CPG in human spinal cord injuries?
-Involuntary LE stepping-like movements were expressed spontaneously
-In supine: rhythmic, alternating, and forceful muscle contractions bilaterally
-Rhythmic movements
-Spontaneous rhythmic patterns
What movements does the CPG control?
-Protective reflexes
-Locomotion
What is the central pattern generator (CPG)? What is its function?
-The rhytmic timing and coordination of muscles generated by the CPG and is located in the spinal cord
-It initiates gait, a locomotor command is generated levels above the spinal cord (brain)
What is the grand initiator of gait that is also involved in the choice and emotion behind gait?
-Basal ganglia
-Mesencephalic locomotor region
How is the basal ganglia involved with initiation of gait?
It selects the pattern
How is the mesencephalic locomotor region (MLR) involved with the initiation of gait?
-It modulates the spinal cord
-Initiates info to the brainstem
-Initiator of neurons
Where does the CPG get sensory feedback from?
-Muscle spindle (muscle length)
-Golgi tendon (muscle force)
-Joint receptors
How are the reticulospinal neurons involved in locomotion?
They innervate the gamma and alpha motor neurons
What is the order in which locomotion is initiated?
-Cortex, basal ganglia, and cerebellum select limb pattern
-Mesencephalic locomotor region initiates the neurons
-Reticulospinal neurons integrate whole body movement and innervate gamma and alpha motor neurons
-Central pattern generator
How does the basal ganglia communicate with the MLR to initiate the gait process?
It releases dopamine into the MLR
What are burst generators?
They activate synergist muscle at each limb joint and ensure it is appropriately timed
What are locomotor networks composed of?
Distributed and interconnected unit burst generators that are selectively recruited to produce specific locomotor patterns
How does alternation of limbs via inhibition and activation of neurons occur?
-During locomotion, flexor and extensor neurons receive inhibitory and excitatory input
-Receive inhibitory input from Renshaw cells and reciprocal Ia interneurons
What are Renshaw cells?
-A population of inhibitory interneurons that project onto motor neurons
-Can synapse onto two motor neurons
How much does Ia and Ib increase extensor activity?
By 50%
How does Ib (GTO) increase extensor activity during gait?
It enhances muscular contraction of extensors during the stance phase and resets when activated during the swing phase (ask Dr. Rivera to explain more)
How does Ia (muscle spindle) increase extensor activity during gait?
Establishes monosynaptic connection with synergistic alpha motor neurons
How is the hip involved with the step cycle? Why is it important?
-The hip movement/position during the step cycle signals which part of the step cycle the limb is at any given moment
-Signals from afferents are influenced by hip position and help regulate the step cycle at the spinal cord level
How are the signals from the hip regarding the step cycle regulated and transmitted to the brain?
-The signal is sent to the spinal cord
-Then the signal is transmitted to the cerebellum via the dorsal spinocerebellar tract
Why is loading in mid to terminal stance a key component of sensory input?
-The longer the loading and increase in hip extension, the more sensory input
-Provides a greater opportunity for pre-swing and trailing limb
-Leads to greater stride length
How does the hip position regulate the transition from stance to swing phase?
Regulates the termination of extensor activity and onset of flexor activity
What is the swing phase mediated by?
-The trailing limb, 20-30 degrees of hip extension
-A quick stretch (extension) is needed to activate the muscle spindle
-Aids in the propulsion of the limb in space
What are the three inputs to help in gait training?
-Input 1: higher the mid-stance load, the more swing phase is improved
-Input 2: Hip position, hip extension and achieve trailing limb
-Input 3: erect posture
What are the rockers that are essential for smooth gait and that we should consider in gait training?
-First ankle rocker (loading at stance phase)
-Second ankle rocker (tibial advancement over fixed foot)
-Third ankle rocker (metatarsal heads are loaded)
What are common things that happen when someone has a CVA?
-Synergistic movement
-Generalized weakness
-Spasticity
What are common gait dysfunctions in CVA patients?
-Lack of heel strike
-Knee hyperextension in midstance
-Knee buckling in mid stance
-Absent trailing limb
What are postures that are associated with Parkinson’s disease during gait?
-Increased cervical flexion (forward head)
-Increased thoracic kyphosis
-Center of mass out of base of support
-Lack of thoracic rotation and arm swing
What are common gait abnormalities in Parkinson’s disease?
-Bradykinesia
-Freezing of gait
-Small steps
-Difficult to initiate gait
-Narrow foot width
-Festination
-Tremors
-Weaving
-Uncoordinated limb movements
What is the definition of pain?
Unpleasant or emotional experience associated with, or resembling that associated with, actual or potential tissue damage
What is pain influenced by?
-Pain is always a personal experience
-Biological, psychological, and social factors
What is the difference between pain and nociception?
-Pain cannot be inferred solely from activity in sensory neurons
-Individual learn the concept of pain through life experiences
-Nociception is the detection of pain via peripheral and central nervous system
What role does pain serve in our lives?
It serves as an adaptive and protective role
What can pain have adverse effects on?
-Function
-Social and psychological well-being
What are biological factors that can affect pain?
-Genetics
-Physiology
-Neurochemistry
-Tissue health
What are social factors that can affect pain?
-Socioeconomic status
-Social support
-Social learning
-Skepticism
-Operant
What are psychological factors that can affect pain?
-Perceived control
-Self-efficacy
-Catastrophic thinking
-Hypervigilance
-Depression
-Anxiety
-Anger
What is the #1 thing that can help with chronic pain?
TENS
How should pain be assessed?
-In a comprehensive, safe, ethical, and consistent manner
-Use valid and reliable assessment tools/outcome measures that help determine prognosis
-Consider risks, benefits, costs, and limitations of interventions
What is Article 1 in the International Association of the Study of Pain (IASP)?
The right of all people to have access to pain management without discrimination
What is Article 2 in IASP?
The right of people in pain to have acknowledgement of their pain and to be informed about how it can be assessed and managed
What is Article 3 in IASP?
The right of all people with pain to have access to appropriate assessent and treatment of the pain by adequately trained healthcare professionals
What are risk factors/habits that contribute to chronic pain?
-Diet
-Sleep
-Stress
-Physical activity
-Sedentary behavior
-Smoking
What is the first thing to ask patients about and tackle with chronic pain?
Sleep!!!
What are the different types of pain fibers?
-Delta fibers
-C fibers
What are delta fibers?
-Myelinated
-Higher conduction velocity than c fibers
-Mechanical or pressure
-Sharp pain
What are C fibers?
-Unmyelinated
-Slow conduction velocity
-Thermal, chemical, or mechanical
-Dull ache
What is the difference between peripheral nerve vs muscle injury?
Peripheral
-Burning, tingling, pins and needles
-Arms, legs, feet, and hands
-Follows peripheral nerve
-Tinel’s sign
-Constant pain
Muscle
-Localized
-Palpation of muscle increases pain
-Tender, throbbing, and stiffness
-Increased pain when contracting
-Reduced pain at rest
What substances are constantly released in chronic pain? How does it work?
-Glutamate
-Substance P
-They increase the pain perception
How can we help override painful sensations?
By giving different sensations
What is acute pain?
-Normal response to painful stimulation
-Contributes to survival by protecting the tissue from further damage
What is adaptive pain?
Protects tissues and promotes healing
What is maladaptive pain?
-Process presenting as a disease
-Represents pathological functioning of the nervous system
What is chronic pain?
-Pain that lasts longer than 3 months
-Tissue is no longer in protective mode but has a maladaptive process
-Tissue is healed
-May involve alternative neuro pathways
What does the normal physiologic response to pain involve?
-Injury: physical and chemical
-Response: nerve, vessels, immune cells, prostaglandins
-Nerves release substance P
-CGRP released: vasodilator from sensory nerves
What is substance P?
-Neuropeptide
-First responder to stress or pain in periphery
-Released by a variety of cells (sensory neurons of the epithelium, muscle, joint, glia)
-Immediate and ongoing
-Causes vasodilation & histamine release
How is substance P correlated with nervous system pain?
-Highly correlated with nervous system pain
-Associated with glutamate
-Released in tissue
-Released in dorsal root ganglion and dorsal horn
-Released for our protection so we don’t move or touch the painful area
What is allodynia?
Pain from “non-painful” stimuli (nociplastic)
What is analgesia?
Absence of pain sensation
What is hyperalgesia?
Increased sensitivity to painful stimuli
What is sensitization?
Increased responsiveness of nociceptive neurons to their normal input, and/or recruitment of a response to normally subthreshold movements
How is pain classified?
-Nociceptive
-Neuropathic
-Nociplastic
What is neuropathic pain subdivided into?
-Peripheral nerve pain
-Central brain or spinal cord pain
What is nociplastic pain subdivided into?
-Peripheral sensitization
-Central sensitization
What is peripheral sensitization?
-Increased responsiveness and reduced threshold of nociceptive neurons in the periphery
-Pain felt from a non-noxious stimuli such as a feather
What is central sensitization?
-Increased responsiveness of nociceptive neurons in the central nervous system to their normal or subthreshold afferent input
-Pain associated with fear and other cognitive issues
What can nociplastic pain cause?
Negative neuroplasticity
What is nociceptive pain?
-Pain arising from a noxious stimuli
-Somatic and non-neural
-Localized
What is neuropathic pain?
Pain initiated or caused by a primary lesion or dysfunction in the nervous system
What is nociplastic pain? What does it cause?
-Pain that arises from altered nociception despite no clear evidence of actual tissue damage
-This pain causes activation of peripheral nociception despite no evidence of disease or lesion of the somatosensory system
What can cause central sensitization?
Increased responsiveness can be due to dysfunction of endogenous pain control systems such as the spinalthalamic tract & reticular formation off shoots
What is the “chemical soup” around an injury?
-Substance P
-CGRP
-Histamine
-Prostaglandin
Where can substance P be found in peripheral sensitization?
-Peripheral areas
-Dorsal horn
What are the tracts that are invovled in centralized pain?
-Anterolateral
-Spinoreticular
What tract synapses onto the brainstem reticular formation (RF)? How is this structure related to pain? What does it connect to?
-Spinoreticular tract
-Awareness and arousal to pain
-Connects to the hypothalamus
What tract synapses onto the periaquedcutal gray? Where is this structure located and how does it relate to pain?
-Located in the midbrain
-Modulation & perception of pain
-Lessen or increases pain perception
-Key in defensive behaviors
-Elevates HR, BP, and RR
-Defense mechanism for future pain
Where do the anterolateral and spinoreticular tracts synapse onto before going to the cortex?
-They both synapse on the thalamus
-Then they synapse onto the cortex
What structures in the brain are involved in central sensitization?
- Thalamus to
-Anterior cingulate cortex (ACC)
-Amygdala
-Prefrontal cortex - Hypothalamus
-Hippocampus
-Amygdala
-ACC - Hippocampus
What is the descending pathway? How does it modulate pain?
-Catecholinergic pathway
-The cortex sends info to the periaqueductal gray
-The periaqeductal gray provides endogenous opioids and serotonin
-The periaqueductal gray sends info to the Nucleus Raphe which inhibits the dorsal horn
-Inhibition of the dorsal horn inhibits pain and inhibits substance P
What are other factors that can affect pain?
-Drug abuse
-Financial difficulties
-Cultural barriers
-Litigation
-Language barriers
-Lack of health insurance
What are some non-pharmacologic ways of managing pain?
-Exercise
-Patient education
-Taping
-PT/OT
-ROM exercises
-Weight loss
What is the best thing a PT can do for someone with chronic pain?
-Listen to them!!!
-Acknowledge their pain
-Promote socialization and activity (hobbies, altruism, family, etc.)
What does effective pain education involve?
-Listening
-Pain science concepts
-Patient understanding
-Reflective questions
-Validation
-Tailored to education level
-Ongoing process
-Individualizing
What is the pain reduction theory?
-Providing a different stimulus that utilizes the dorsal column pathway
-Providing a different sensation, the dorsal column will inhibit the pain pathway
What is the gate control theory?
-Same as pain reduction theory?
-When pain and touch fibers are stimulated at the same time, gate for pain will be closed and pain is not felt
Can negative neuroplasticity be reversed?
It can be reversed, but most of the time, not fully
How can NSAIDs help in pain reduction?
-Reduces prostaglandins
-Prostaglandins plays a role in the peripheral and central sensitization process
What is Capsaicin? How is it used to treat pain? How long does it take to work?
-Chemical from chili peppers
-Binds to open c fiber receptors, which allows calcium ions to flow into the fiber causing desensitization
-It depletes substance P
-It can take several weeks to work
Are there any side effects to Capsaicin? What conditions is it good for?
-No side effects
-Good for arthritis and muscular pain
What are some common pain/chronic pain conditions?
-Phantom limb pain
-Hand shoulder syndrome (post mastectomy)
-Pelvic pain
-Chronic low back pain
-Autoimmune conditions
-Fibromyalgia
What pain condition automatically gets placed in the sensitization category? Is it peripheral or central sensitization?
-Fibromyalgia
-Almost always in both peripheral and central
How does phantom limb pain occur?
-The person is missing sensory input to the somatosensory cortex
-The brain perceives it as pain
-Negative neuroplasticity
What is chronic regional pain syndrome (CRPS)?
-There is an injury to the hand/foot/arm/etc.
-Pain impulse sent to the brain
-This triggers an impulse in the sympathetic nervous system which returns to the original site of injury
-Sympathetic impulse triggers inflammatory response and vessels to spasm and swell
-This causes increased pain, burning, and red mottling skin
-Incorrect response in autonomic nervous system
What kind of pain is CRPS?
Allodynia
What are treatments for CRPS?
-Deep pressure (wrapping with ace bandage) to reduce sensory input for 20-30 minutes
-Movement (increased use of muscle spindles, increases blood flow)
-Tactile information (self initiated, skin movement)
What population are cerebellar tumors in?
Typically only in children
How common are cerebellar strokes?
Cerebellar artery strokes are very rare
How does the cerebellum communicate with the cortex?
Through the thalamus
What is the cerebellum responsible for?
-Motor coordination and correction of movements
-“Motor memory”
-Maintenance of balance/posture: vestibular info/proprioception
-Coordination of multiple motor groups
-Muscle spindle feedback
-Postural adjustments
-Sensory processing
-Adaptability
-Automatic responses
-Modifies motor activity
How does the cortex communicate with the cerbellum?
It sends signals directly to the cerebellum
What is the cerebellum also known as?
The “Little Brain”
How does the cerebellum play a role in motor learning?
-It adapts and fine tunes motor programs to make accurate movements through a trial and error process (ex: learning to hit a baseball)
How is the cerebellum involved in cognition?
It is involved with language
How is the cerebellum related to the eyes?
-Controls eye reflexes
-Fixation on target and eye coordination
How is the cerebellum involved in accuracy of timing movements?
-Predicts the sensory outcome of our movements/actions
-Controls timing of on and off muscle activation and direction of movement
How much of the brain’s volume does the cerebellum make up? How much of the brains neurons are in it?
-10% of the brains volume
-Over 50% of the total number of neurons in the brain are in the cerebellum
What sensory feedback does the cerebellum receive?
-Vestibular
-Muscle proprioceptors (spindle and GTO)
How does the cerebellum modulate commands to motor neurons?
It compensates for shifts in body or changes in load upon muscles
What are the different lobes of the cerebellum?
-Anterior
-Posterior
-Flocculonodular
What are the different zones of the cerebellum? Where are they located in relation to the vermis?
-Intermediate zone (just lateral to the vermis)
-Lateral hemisphere (most lateral zone to the vermis)
What does the primary fissue separate in the cerebellum?
It separates the anterior and posterior lobes of the cerebellum
What does the posterolateral fissure of the cerebellum separate?
It separates the intermediate zone from the lateral hemisphere
What is the function of the flocculonodular lobe in the cerebellum?
-It is the major transport for vestibular information to the cerebellum
-Responsible for equilibrium,balance, and posture
What is the function of the lateral hemisphere of the cerebellum?
-Planning and initiating of movements
-Motor planning for extremities
What is the function of the intermediate hemisphere of the cerebellum?
Distal limb coordination
What is the function of the vermis?
Proximal limb and trunk control
What are the deep cerebellar nuclei (DCN)? Are they inputs or outputs to the cerebellum?
-Purkinje (output)
-Climbing fibers (input)
-Mossy fibers (input)
What are the main cerebellar unconscious input pathways?
-Vestibular feedback
-Visual motor and sensory feedback
What is the superior colliculus involved in?
-Learning and memory connections
-Visuospatial and steering
What is the dorsal spinocerebellar tract?
-Carries proprioceptive information from muscle spindles and golgi tendon organs from ipsilateral trunk and lower limb to cerebellum
-Carries touch and pressure sensation from lower extremities and trunk
What is the ventral spinocerebellar tract?
-Carries info regarding coordinated movement and posture of the entire lower limb and GTO
-Only to lower extremities (L2 and below)
What is the rostral spinocerebellar tract?
-Carries info regarding coordinated movement and posture for the entire upper limb
-Above C8
What is the cuneo spinocerebellar tract?
-Large, myelinated axons
-Carries unconscious proprioception, touch, and pressure sensation
-Above C8
What is a commonality amongst all of the spinocerebellar tracts?
They all carry unconscious perception
What are the cerebellum outputs?
-Red nucleus
-Ventrolateral nucleus of thalamus
What does the red nucleus communicate with?
-The red nucleus receives info from the cerebellum
-Then it sends info directly to the spinal cord
-Motor relay system
What does the ventrolateral nucleus (VLN) of the thalamus communicate with? What is the function of it?
-Receives info from the cerebellum
-Sends info to the pre motor cortex, supplementary cortex, and prefrontal association area
-Aids in postural control, smooth movements, and provides feedback for errors
How do cerebellar injuries present and why?
-They always present unilaterally
-The spinocerebellar tracts either stays unilaterally or crosses over twice
What is decomposition of movement?
-Patients with cerebellar dysfunction are unable to produce coordinated, smooth movements
-The loss of feedforward mechanism (spindle & GTO) does not allow for temporal timing of the activated muscles, sequence of activation, force or awareness in space
What is an intention tremor?
-When someone is moving volitionally, such as moving their hand towards a target, there is a tremor that increases more as the hand gets closer to the target
What is one of the most common signs of cerebellar dysfunction?
Ataxic movement
What is the Romberg & Sharpened Romberg test?
-Romberg is standing with feet together or semi-tandem and eyes open for 10 seconds, then eyes closed for 10 seconds
-Sharpened Romberg is standing tandem with eyes open for 10 seconds, then eyes closed for 10 seconds
What are different cerebellar exams?
-Finger to nose
-Heel to shin
-Dysdiadochokinesia (RAM)
-Tandem walking
-Romberg
-Rapid finger tapping movements
What is dysrhythmia?
Abnormal timing
What is dysmetria?
Overshooting or past pointing
What is dysdiadochokinesia?
Rapid alternating movements
What are common postural dysfunctions in patients with cerebellar disorders? What do these dysfunctions cause?
-Loss of automatic movements
-Loss of ankle & hip strategies
-Static and dynamic postures
-Causes high fall risk
What is hypotonia?
Low tone from loss of muscle spindle and GTO input
What is slow generation of force?
Unable to produce timely force generation
What is loss of rapid alternating movements?
Inability to produce rapid movement patterns and alternating movements
What are deficits in motor learning?
Loss of the ability to anticipate or correct feedback because of loss of proprioceptive, sensory, and muscle force
What is the clinical presentation of peripheral nerve injury?
-Atrophied muscle
-Weakness or paralysis
-Pain along nerve distribution
-Numbness along nerve
-Sensory loss (light touch, position sense) along nerve
-Loss of ROM over time
What is the clinical presentation of carpel tunnel syndrome/median nerve injury?
-Atrophy of thenar eminence
-Pain along median nerve
-Positive Tinel’s sign
What is the clinical presentation of C6 nerve root injury?
-C6 myotome and dermatome pattern
-Muscles: biceps, brachioradialis, wrist extensors
What are signs and symptoms of spinal nerve root injuries?
-Hyporeflexia
-Decreased DTR
-Weakness
-Sensory loss
-Pain
-Numbness and tingling following dermatome pattern
What side should always be tested first during myotome/dermatome testing?
Uninvolved side
What is the clinical presentation of injury to common fibular/peroneal nerve?
-Sensory loss in common fibular distribution (dorsum of foot and lateral portion of shin and leg)
-Hyporeflexia
-Muscles: fibularis longus and brevis, tibialis anterior, EHL, EDL, fibularis tertius
What are some big differences between lower motor neuron injuries and upper motor neuron injuries?
Lower motor neuron
-Hyporeflexia
-Loss of muscle tone
-Rapid muscle wasting
Upper motor neuron
-Hyperreflexia
-No loss of muscle tone
-Maintained muscle mass
-Contralateral symptoms to lesion
How is the basal ganglia involved in motor control?
-Eye movement (helps us plan where to look)
-Associative function
-Limbic system
What structures make up the basal ganglia?
-Caudate
-Putamen
-Globus pallidus
-Subthalamic nucleus
-Substantia nigra
What is the basal ganglia?
-The basal ganglia is a collection of gray matter nuclei
-Contains a variety of complex excitatory and inhibitory connections, utilizing different neurotransmitters
How are the caudate and putamen separated?
-Separated by penetrating fibers of the internal capsule but remain joined by cellular bridges
What are the functions of the basal ganglia?
-Initiates and integrates behavior and movement
-Removes unwanted and inappropriate movement
-Plans motor activity
-Regulates motor habits
-“Rewards and motivation”
-Associations with attention
What influences the basal ganglia and how does it influence other structures?
-The cerebral cortex directly influences the basal ganglia
-The basal ganglia influences the cortex via the thalamus
-It also influences the motor system through spinal cord pathways
What is the basal ganglia circuitry to the brainstem?
-Reticulospinal tract
-Vestibulospinal tract
Where do skilled movements arise from in the motor cortex?
-Corticospinal tracts
-Brainstem
How do we select/initiate motor programs?
-Basal ganglia to brainstem
-Basal ganglia to thalamus
What motor pathways come from the spinal cord?
-Central pattern generation
-Muscle movement
-Reflexes
How is the basal ganglia intimately connected to the cortex?
Through parallel loops
What are the parallel loops subdivided into?
-Motor
-Associative (cognition)
-Limbic
What can dysfunction of the basal ganglia and its connectivity lead to?
-Movement disorders (dyskinesias)
-Akinesia
-Bradykinesia
-Hyperkinesia
What are non-motor loop pathologies of the basal ganglia?
-Emotional, cognitive, and psychiatric deficits
-OCD
-Tourette’s
-ADHD
What does functional data suggest about the basal ganglia?
-It is involved in both the preparation and execution of movements, motor control, and learning of motor sequences and habit (implicit learning aka learning yourself)
How is the basal ganglia related to turning?
-It helps us decide where and when to turn based on perceptual decisions
-BG dysfunction creates gait deficits and can make turning hard for people w/ Parkinson’s
How does the basal ganglia help us turn?
-Planning of cervical and trunk rotation
-Changes the angles of hip rotation, while anticipating any environmental disruptions
What are the two motor loops?
-Body movement loop
-Oculomotor loop
What are the two non-motor loops?
-Prefrontal loop
-Limbic loop
Is the direct pathway of the basal ganglia more inhibitive or excitable?
More inhibitive
Is the indirect pathway of the basal ganglia more inhibitive or excitable?
More excitable
What does dysfunctions in the direct pathway of the basal ganglia lead to?
-Hypokinesia
-Under-stimulation (more inhibition of motor cortex)
-Loss of automatic movements
-PD
-Rigidity
-Bradykinesia
What does dysfunctions in the indirect pathway of the basal ganglia lead to?
-Over-stimulation (less inhibition of cortex)
-Hyperkinetic
-Chorea
-Huntington’s
What is the ranking of basal ganglia movement disorders by movement speed (slowest to fastest)?
-Bradykinesia, hypokinesia
-Rigidity
-Dystonia
-Athetosis
-Chorea
-Ballismus
-Tics
-Myoclonus
-Tremor
What is ballistic movements?
-Flinging with large amplitude
-Hemiballismus: unilateral flinging contralateral to lesion
What is a common cause of ballistic movements?
Infarct of the subthalamic nucleus
What are tics?
-Involuntary small jerks or yelling
-Tourette’s syndrome
-4 times more in girls
-Increased in ADHD
-Symptoms come and go
What are tremors?
-Both agonist and antagonist involved
-Bidirectional movement
-Asymmetrical
-“Pin rolling”
-Resting tremor and intention tremor
-Resting tremor is commonly seen in Parkinson’s
What is lead pipe rigidity?
-Continous throughout whole movement
-Agonist and antagonist involved
What is cogwheel rigidity?
-Ratchet like interruptions as the limb is passively moved
-Normal stretch reflexes
-Shoulders and cervical spine first affected
-Prolonged results in contracture
What is Parkinson’s disease? What are the signs and symptoms?
-Loss of dopaminergic neurons & production in the substantia nigra
-Festinating gait (slow & shuffling, difficult to initiate)
-Difficulty turning corners
-Stooped forward & kyphotic
-Gait impediments coincide with visual, decision making, and motor control deficits
-Freeze with impediments/objects in path
-Resting tremors
-“Reptillian stare”/no expression
What symptoms in Parkinson’s disease can present themselves 5 years before the onset of motor symptoms?
-Sleep issues/insomnia
-GI issues
Where does gait originate from?
-Brainstem and descends to spinal cord
-Descending pathways come from mesencephalic locomotor region and lateral hypothalamus
-The MLR project into neurons in the pons and medulla , then project into the spinal cord to activate the CPGs involved in locomotion
How does the Mesencephalic Locomotor Region (MLR) and lateral hypothalamus help in gait?
It helps us plan and initiate walking
What is the Mesencephalic locomotor region (MLR)?
Area of the brainstem that is implicated in the control of gait and balance
What is the pedunculopontine nucelus (PPN)? How is it related to Parkinson’s disease?
-Located in the MLR
-Plays a crucial role in appearance of axial symptoms in PD
-Dysfunction of cholinergic neurons in the PPN is what causes the axial symptoms in PD
How does deep brain stimulation help PD patients?
Because it activates the MLR and PPN, which helps to alleviate locomotor symptoms
What is labile presentation? What patient population is it commonly seen in?
-Awake, but not engaged
-Seen in PD
What other additional basal ganglia diseases are there?
-Brain anoxia (cerebral palsy, common in babies before 1970)
-Huntington’s disease
-Stroke
Where are cranial nerves located? What part of the nervous system are they apart of?
-Around the brainstem area
-PNS
How many cranial nerves are there?
12
How are cranial nerves identified by?
Roman numerals
What tract do cranial nerves use to communicate with the cortex?
Corticobulbar tract
What is cranial nerve I (CN I)? What is its function?
-Olfactory
-Sense of smell
-Interaction w/ memory
What is cranial nerve II (CN II)? What is its function?
-Optic nerve
-Visual info from retina to optic nerve to optic chiasm
What cranial nerves are all involved in/responsible for coordinated eye movement?
-CNIII
-CNIV
-CNVI
What is cranial nerve III (CN III)? What is its function?
-Oculomotor
-Pupillary constriction
-Innervates muscles surrounding the eye
-Superior rectus
-Medial rectus
-Inferior oblique
-Inferior rectus
What response should be seen during the pupillary eye reflex test if CN III is intact? What is seen if it is not intact?
-Direct and consensual responses should be seen
-If direct is not seen, it is ipsilateral CN III is not intact
-If consensual response is not seen, contralateral CN III is not intact
What is not intact if both consensual and direct responses are not seen when doing the pupillary eye reflex?
CN II
What is cranial nerve IV (CN IV)? What is its function?
-Trochlear nerve
-Innervates the superior oblique muscle around the eye
-Medially rotates the eye
What is cranial nerve VI (CN VI)? What is its function?
-Abducens nerve
-Abducts the eye
-Innervates the lateral rectus muscle
What is cranial nerve V (CN V)? What is its function?
-Trigeminal nerve
-Provides sensation for face, mouth, and nasal cavity
-Innervates the temporalis muscle and muscles of mastication (masseter)
What is cranial nerve VII (CN VII)? What is its function?
-Facial nerve
-Wrinkles forehead, nose, and brings eyebrows upward
-Purses lips
-Smiling
-Provides sensation to anterior 2/3 of tongue (taste)
What is Bell’s Palsy?
-Unilateral injury to the facial nerve
-Causes facial drooping, smoothing of forehead, eyebrow droop, and drooping of the corner of the mouth on one side
What is cranial nerve VIII (CN VIII)? What is its function?
-Vestibulocochlear
-Splits into two branches: vestibular and cochlear
-Vestibular branch: balance, semicircular canals, acceleration, saccule and utricle, gravity
-Cochlear branch: auditory sensation
What is cranial nerve IX (CN IX)? What is its function?
-Glossopharyngeal
-Motor: dilates pharynx
-Visceral motor: salivation from parotid gland
-Visceral sensory: carotid sinus
-Sensory: posterior 1/3 of tongue
What is cranial nerve X (CN X)? What is its function?
-Vagus nerve
-Mixed motor and sensory
-Regulates SA node & HR, decreases BP
-Causes vasovagal syncope
-Regulates breathing
-Regulates intestine and stomach peristalsis
What is cranial nerve XI (CN XI)? What is its function?
-Spinal accessory
-Innervates the SCM and trapezius muscles
What is cranial nerve XII (CN X)II? What is its function?
-Hypoglossal
-Innervates muscles of the tongue
What is a pneumonic to help remember cranial nerves in the correct order (CN I- CN XII)
Only one of the two athletes felt very good, victorious, and happy
-Only (olfactory)
-One (optic)
-Of (oculomotor)
-The (trochlear)
-Two (trigeminal)
-Athletes (abducens)
-Felt (facial)
-Very (vagus)
-Good (glossopharyngeal)
-Victorious (vestibulocochlear)
-And (accessory)
-Happy (hypoglossal)
What drugs work on the spinal cord and brain to alter descending modulation/pain?
-Anticonvulsants
-Opioids
-Tricyclic/SNRI Antidepressants
What drugs work on the dorsal horn to alter central sensitization/pain?
-Anticonvulsants
-Opioids
-NMDA-receptor antagonists
-Tricyclic/SNRI antidepressants
What drugs work on the peripheral nervous system to alter peripheral sensitization/pain?
-Local anesthetics
-Topical analgesics
-Anticonvulsants
-Tricyclic antidepressants
-Opioids
