Exam I Flashcards
What are factors that should be taken into account in clinical decision making?
-P.T and patient goals, values, pyschosocial skills, knowledge, expertise, and problem solving abilities
What are the 5 key elements that contribute to a comprehensive conceptual framework?
-Model of practice, Model of Disablement/Enablement, Hypothesis Oriented, Theories of Motor Control, and Evidence Based Practice
What is the emphasis on in a task oriented approach?
-Emphasis is on functional performance of very specific tasks (what function the patient can perform and how)
What type of strategies are looked at with the task oriented approach?
-Movement strategies
What is examined in the task oriented approach?
-The impairments that are limiting the functional task; why the patient is having difficulties
What is a direct impairment?
-Impairment that affect body structure/function
What is a secondary impairment?
-Secondary conditions resulting from the primary injury or disease; ie conditions due to sedentary lifestyle
What is a composite impairment?
-Impairment having multiple causes, can be direct or indirect
What two theories drive contemporary practice?
-Systems Theory and task oriented approach
What are the 4 P’s?
-Participation, Prediction, Plasticity, and Prevention
What is Participation as it relates to the 4 P’s?
-Functioning of a persons as a member of society
What is a participation restriction?
-Problems an individual may experience in involvement of life situations
What is Prediction as it relates to the 4 P’s?
-Predicting optimal response to intervention choice and is essential as it relates to primary prevention
What is Plasticity as it relates to the 4 P’s?
-The capacity of neurons and neural circuits to change, structurally and functionally in response to experience
What is Prevention as it relates to the 4 P’s?
-Actions taken to prevent the onset of diseases, to stop its progression and minimize its consequences
What is primary prevention?
-Prevention before the disease occurs
What is secondary prevention?
-Focuses on controlling the progression of the disabilities related to the disease
What is tertiary prevention?
-Focuses on minimizing the impact of a moving disorder
What is muscle weakness?
-The inability of a muscle to generate normal levels of force
What is muscle weakness a result of?
-mechanical properties and neural imput
Muscle weakness as a direct impairment is a result of what?
-Upper Motor Neuron Lesion
A result of an upper motor neuron lesion results in an immediate reduction of what?
-Neural input
Any lesions that occurs before the synapse at the ventral horn with result in an impairment on which side?
-Contralateral
What is an upper motor neuron lesion?
-A lesion before the synapse at the ventral horn
What is a lower motor neuron lesion?
-A lesion after the synapse at the ventral horn
A Lower Motor neuron lesion is considered a lesion to what?
-Spinal Nerves, peripheral nerves
A Lower Motor Neuron Lesion will affect what side of the body?
-Ipsilateral side
What is paralysis or plegia?
-Complete absence of muscle strength, inability of voluntarily recruit motor units
What is paresis?
-Muscle weakness
Damage to one sided of the motor cortex of the brain will affect what side of the body?
-Contralateral side
The anterior cerebral artery supplies the motor hommunculus to what part of the body?
-Lower Extremity
The middle cerebral artery supplies the motor hommunculus to what part of the body?
-Upper Extremity
When examining someone with upper or lower extremity muscle impairments, it is important to look at what two factors?
-Vascular Distributions and the Motor Hommonculus
What is important to consider when performing strength assessments on patients with upper motor neuron lesions?
-The patient may not be able to assume the testing position or perform isolated movements
What is an abnormal synergy pattern?
-When joint movement cannot be isolated due to an inability to activate or abnormal mass patters of movement occur
What type of patients generaly present abnormal synergy patterns?
-Stoke Patients
Why do synergy patterns occur?
-Muscle that move within the same mass pattern are strongly linked so movement usually occur in the same fixed pattern
What is muscle tone?
-resistance felt in the muscle during passive elongation
What is hypotonia?
-Decreased resistance of a muscle to passive elongation; Low tone
What is Flacidity?
-Complete lack of resistance to passive elongation
What is hypotonia/Flaccidity due to?
-Lack of voluntary Muscle Activation
What is Hypotonia associated with?
-Lower Motor Neuron Lesions, Could be spinal shock with an upper motor neuron lesion before tone increases
What is Hypertonia?
-Increased Resistance to Passive Elongation, Elevated Muscle Tone
What is Spacticity, Muscle Stiffness, and Rigidity associated with?
-An upper motor neuron lesion
When does Spacticity occur?
-When there is damage to the descending motor system
Damage to what descending tract is mainly responsible for spacticity?
-Corticospinal Tract
Is Spacticity or Rigidty velocity dependent?
-Spacticity
With a patient with spacticity, Increased the speed of the passive motion will have what effect with in the resistance?
-It will increase it
With a patient with Rigidity, Increased the speed of the passive motion will have what effect with in the resistance?
-It will not effect it
Hypertonia in the form for muscle stiffness, is what type of impairment?
-Indirect
What is muscle stiffness usually due to?
-being sedentary
What is Rigidity cuased by?
-A lesion to the basal ganglia
What two diseases affect the basal ganglia and may cause rigidity?
-Parkinson’s and Huntingtons
What structures contribute to normal coordination?
-The motor cortex, Basal Ganglia, Cerebellum, and Dorsal Columns
How can an upper motor neuron lesion affect coordination?
-It can cause delayed awkward and inaccurate movement
What is Dystonia?
-Excessive twisting and bizarre repetitive movement caused by axial and proximal musculature
Dystonia is commonly associated with a lesion to what?
-Basal Ganglia
What is Choria?
-Rapid and jerking limb movements
Choria is commonly associated with a lesion to what?
-Basal Ganlia
What is Athetosis?
-Slow, twisting snake like movements
What is athetosis associated with?
-Cerebral Palsy
What is the Spinothalamic system responsible for?
-Protective sensation (Pain, temp, touch, crude touch and pressure)
What is the dorsal column medial lemniscal system responsible for?
-Descriminative Touch ((Vibration, Proprioception, Descriminative Touch, and combined cortical sensation
What are cortical Senations?
-Barognosis, Sterognosis, Graphethesia, Tactile Location, Texture Regulation, & 2-point descimination
What does Vision help Control?
-Posture
An upper motor neuron lesion can cause what visual impairments?
- Blurred Vision, Diplopia (double vision), Stabismus, Occipital Blindness, Nystagmus, Homonymous Hemianopsia
What nerve Is responsible for visual activity?
-Optic Nerve, CN II
What nerves are responsible for eye movement?
- Occulomotor (CN III), Trochlear (CN IV), Abducens (CN VI)
The Semicircular Canal is responsible for perception of what?
-Angular Velocity of the nead and neck in space
The Utricle is responsible for perception of what?
-Linear Acceleration
What is Agnosia?
-The inability to recognize and process incoming information, The inability to recognize shapes or objects though sense are normal
What sided brain damage is agnosia associated with?
-Right Sided(non-dominant)
What is Apraxia?
- the inability to perform a movement despite having normal sensation and strength
- Inability to execute upon command
What sided brain damage is apraxia associated with?
-Left Sided (dominant)
What is a cognitive impairment?
-A deficit in the ability to sort, retain and manipulate informatoin
What structures of the brain is memory associated with?
-Limbic System, hippocampus and fornix
What is the continuum for Consciousness
-Normal-Lethargy-Obtunded-Stupor-Coma
What sided brain damage causes aphasia?
-Left (Dominant)
What is Expressive Dysphagia?
-Patients knows what they want to say but cannot; Comprehension is intact
What structure of the brain is damages with Expressive Dysphagia?
-Broca’s Area
What is Receptive Aphasia?
- Patients comprehension of language is impaired
- Patient rambles on, unaware of the impairment
What Structure of the brain is damaged with receptive apahasia?
-Wernicke’s Area
What is Dysarthria?
-Slurred Speech, Lacks coordiation of muscle used for articulation
What type of patients is Dysarthria common in?
-C.P., TBI, Stoke, M.S., and PD
What is Dysphasia?
-Impaired swallowing
What patients is Dysphagia common in?
-Stroke patients
What are composite impairments?
-A combination between direct and indirect impairments, or involve more than 1 system
What type of lesions are Cranial Nerve lesions considered?
-Lower Motor Neuron Lesion
What sided deficits will present with a cranial nerve lesion?
-Ipsilesional impairments
80% of all stroke are what type of strokes?
-Ischemic
Which type of stroke has a higher mortality rate?
-Hemorragic
Where are emboluses most commonly thrown through?
-The heart
What are hemorrhagic strokes commonly associated with?
-Anuerisms or trauma
How can a blood clot cause neuronal death?
-By irritating the neurons
What is an intracranial Hemorrhage?
-A brain bleed from smaller ruptured arteries that penetrate the brain, usually more deadly and leads to significant impairments
What is a subarachnoid hemorrhage?
-Bleeding from larger vessels in the subarachnoid space, usually due to a barry aneurism
What is the Cascade of events leading to neuronal death in a stroke?
-Blood flow is occluded>Neurons release excessive glutamate>This opens calcium ions channels in the neurons>Influx of calcium>Influx of calcium sensitive destructive enzymes>Enzymes are activated and cause cell death
What extremity would be most effected with an Anterior Cerebral Artery Stroke?
-Lower Extermity
What else is commonly seen with Anterior Cerebral Artery Strokes?
-Mental Confusion due to involvement of the frontal lobe
What is the most common artery for strokes?
-Middle Cerebral Artery
What extremity is mainly effected with a Middle Cerebral Artery Stroke?
-Upper Extremity
What else becomes impaired due to Middle Cerebral Artery Stoke?
-Vision
Stroke of this artery is likely to result in death?
-Vertebrobasilar
What features are associated with a right sided stroke?
-Unilateral Neglect, Agnosia, quick Impulsive Behaviors, Poor Judgement, and not being aware of impairments
What features are associated with a left sided stroke?
-Aphasia, Apraxia, Hesistent behavior, and depression
What is the etiology of Parkinon’s?
-Idiopathic
What percent of the population over the age of 65 have PD?
-2%
What is the average age of onset for PD?
-50-60 y/o
What is secondary parkinsonism?
-Mimicks true pd but is caused but the cause is known
What most commonly causes secondary parkinsonisms?
-Normal Pressure Hydrocephalus
What are the signs/symptoms of normal pressure hydrocephalus?
-shuffling gait, incontinence, and confusion
How does normal pressure hydrocephalus differ from PD?
-NO Tremor
What two symptoms do Parkinsonism plus syndromes present with that true parkinsons also presents?
-Bradykinesia and Rigidity
What are the two most common types of parkinsonism plus syndromes?
-Progressive Nuclear Atrophy, and Multi system Atrophy
What is the pathophysiology of PD?
-Neural Degeneration of the Basal Ganglia, specifically the substantia nigra, resulting in the reduction of dopamine acting on the striatum
What two loops does the lack of dopamine effect in PD?
- The Direct look-initiates voluntary movement
- The Indirect Loop- inhibits involuntary movement
What happens in the direct loop with pd?
-It is over active= causes tremors or rigidity
What happens in the indirect loop with pd?
-too much inhibition= bradykinesia and poor balance
What are the cardinal features of PD?
- TRAP
- Tremors
- Rigidity
- Akinesia/ Bradykinesia
- Postural Instability
Which tremors come first, Resting or acting?
-Resting
What is the common gait pattern for those with PD?
-Shuffling; reduction of stride length and foot clearance (reduced dorsiflexion due to tight plantar flexors)
Where does rigidity start?
-Proximally
What is an early symptom that may be a predictor of PD?
-Lack of smell
What is a major sign that is used to diagnose PD?
-Response to dopamine therapy
What are the two clinical subgroups of PD?
-Tremor (main one), and PIGD
What clinical subgroup of PD usually has an earlier onset?
-Tremor
Which clinical subgroup of PD progresses faster?
-PIGD
Which clinical subgroup of PD is more likely to develop cognititive impairments and dementia?
-PIGD
A patient that has a tremor and rigidty on thier right side, and is still able to work would be considered what on the H&Y scale?
-I; Unilateral symptoms, can still work
A patient that has a bilateral tremor and rigidity but can normal mobility would be considered what on the H&Y scale?
-II; Bilateral symptoms but no mobility impairments
A patient that has bilateral tremors, and some balance impairments but is still able to live independently would be considered what on the H&Y scale?
-III, First signs of Postural Instability but can still live indedpendetly
A patient with bilateral symptoms, and significant postural instability would be considered what on the H&Y Scale?
-IV, diseased is progressed
A patient that is W/c bound with out help would be considered what on the H&Y scale?
-V
What two drugs are combined to make sentimet?
-levadopa and carbidopa
What is levadopa?
-A dopamine precursor that inhibits the metabolsm of dopamine and allows it to cross the blood-brain barrier
What is end of dose deterioration?-
-When a drug is wearing off son before the next dose is to be administered, symptoms return, is predictable
What is the on-off phenomenon?
-Unpredictable return of symptoms; a fluctuation of symptoms
How long have a person been taking a dopamine drug when the on-off phenomenon normally starts to occur?
-4-6 years
What are two side effects associated with the on-off phenomenon?
-dyskinesia and dystonia
What do dopamine agonists do?
-stimulated post synaptic dopamine receptors, allow for less dopamine to be taken
What are anitocholinergenics use to treat?
-Tremors
What do minoamine oxidase b-inhibitors do?
-inhibits the enzyme that degrades dopamine, allows for less dopamine to be administered
What must a person show to be a candidate for DBS?
-They must respond to dopamine treatment
What are the leading causes of TBIs?
-Falls (32%), MVAs (19%), Being struck by an object (18%), Assualts (10%)
What is a TBI defines as?
-An alteration in brain function or evidence of a brain pathology caused by an external force
What is the most common cause of TBIs in people aged 5-65?
-MVA’s
What is the most common cause of TBIs in people younger than 5 or older than 65?
-Falls
What is an open head injury?
-A TBI where the skull is fractured
What is commonly associated with open head injuries
-Intracranial hemorrhages and dural tears, which often lead to intracranial infections
What is a focal brain injury?
-The injury that occurs at the site of impact, may cause a contusion, laceration or both
What normally causes brain lacerations?
-bony irregularities of the skull cutting the surface of the brain
What are lacerations always associated with?
-Hematomas
What is a coup-countercoup injury?
- Where the brain bounces to make contact with the skull opposite the side of impact
- Coup: site of initial impact
- Counter coup: impact opposite initial site
Polar brain injuries are common in what type of injuries?
-Head on collisions
What two lobes are most susceptible to polar brain injuries?
-Frontal and temporal lobes
In a blast injury, what causes the primary injury?
-the blast shockwave causes pressure on the organs
What causes the secondary injury in a blast injury?
-Shrapnel
What causes the tertiary injuries in a blast injury?
-Hitting the ground
What is a diffuse axonal injury?
-widespread tearing of the neural axons and myelin sheaths; subcortical white matter shearing
What would happen is a diffuse axonal injury involved the brain stem?
-Come an abnormal posturing
What does secondary brain damage involve?
-intracranial hematomas, causing a rise in ICP and leading to the shifting and compression of the brain structures
What is a epidural hematoma?
-blood accumulating on the top of the dura
Damage to what artery is associated with an epidural hemtoma?
-Medial Meningeal
What is a subdural hematoma?
-Blood accumulating beneath the dura
What population are subdural hematomas common in?
-Elderly patients
What is an intracerebral hematoma?
-Blood floow accumulation
What type of hematoma is the most deadly?
-Intracerebral
What is an uncal herniation?
-herniation involving the midbrain, hypocampal gyrus, Occulomotor nerve, cerebral pundecles ( cuases hemiparesis), RAS (can cause coma), PCA (causes homonymous hemianopsia)
What structure are involve with a central herniation?
-Midbrain and pons (cause regidity), and the RAS (causes coma)
What structures are involve with a tonsillar herniation?
-Cerebral tonsils of the medulla (Cuases neck pain and stiffness), RAS (causes coma), Vasomotor centers (causes alteration of pulse, respiration and BP)
What two things can cause a hypoxic ischemic
-Arterial Hypoxia, and Arterial Hypotension
What is an arterial hypoxia?
-A systemic injury such as an obstruction of an airway, pneumothorax or pulmonary embolism which reduced the amount of oxygen in the blood
What is arterial hypotension?
-occurs when there is systematic blood loss due to injury that may lead to low bp, and as a result the brain does not receive enough blood floow
How can increased ICP lead to a hypoxic ischemic injury?
-can cause the brain to shift and cut off circulation
What is the top priority of acute management of a TBI?
-Restore vital function and prevent secondary brain injuries
What is normal ICP?
4-15
What is abnormally high ICP?
->20
What ICP is expected after a TBI?
-15-20
A mean value of ICP great that what calls for means to reduce the pressure?
-25
An ICP greater than what can impair blood flow to the brain?
-40
If a patient has an ICP greater than 20, what should the PT do?
-notify the medical team and modify treatments to not spike ICP
if a patient has an ICP great than 30, what should the PT do?
-Stop intervention and notify medical team
What should you never do with a patient with high ICP?
-Invert them
What cognitive functions can be affect with a TBI?
-Arousal levels, attention, concentration, memory, learning, and executive function
What nueromuscular impairments can an TBI cause?
-Paresis, abnormal tone, motor function, and balance
What neurobehavioral impairments can a TBI cause?
-agressiveness, disinhibition, frustration, iriitation, cmmunication and swallowing
A patient that cannot be aroused, does not open their eyes and has no sleep/wake cycle would be considered to be in what state?
-Coma
A patient that does have an active sleep/wake cycle, and demonstrates reflexive movement is considered to be in what state?
-Vegetative (awake but not aware)
A person in a vegetative state for longer than 3 months is considered to be in what state?
-Persistent vegetative state
A patient that responds to local stimulation, and may reach for object is considered to be in what state?
-Minimally conscious
A patient scoring between 3 and 8 on the GCS is considered to have a what TBI?
-Severe
A patient scoring between 9 and 12 on the GCS is considered to have a what TBI?
-Moderate
A patient scoring between 13 and 15 on the GCS is considered to have a what TBI?
-Minor
What is a concussion?
-a brain injury defined as a complex physiological process affecting the brain, induced by biomechanical forces
Is a concussion a functional or structural injury?
-Functional, no evidence of injury with concussion
What is an important symptom when diagnosing a concussion?
-Slowed Reaction time
What is the pathophysiological cascade of event of a concussion?
- Ion Channel Dysfunction: Potassium ions rush out and desructive calcium and sodium ions rush in
- Metabolic Energy Crisis: Glucose demand is increased but blood flow is decreased, which causes the crisis
- Axonal Stretching: Axonal Dysfunction
What is the biggest predictor of prolonged recovery with a mTBI?
-On feild dizziness
