Intro to Neuro Rehab and Exam Flashcards
what are the goals of neuro rehab
- restore mobility and functional skills
- promote recovery via neuroplastic changes
- compensation/adaptation when recovery not likely
what is the continuum of care
- exam
- eval - synthesize info from exam
- diagnosis (PT)
- prognosis - POC and length of recovery
- intervention
- outcomes - did they get better or need to change POC
clinical reasoning vs clinical decisions
reasoning - problem solving
decisions - outcomes of reasoning process
what falls under the umbrella of clinical reasoning
process info
reach conclusions
determine actions
what influences clinical decision making
CLINICIAN: goals, experience, knowledge, values, psychosocial skills
PATIENT: goals, values/beliefs, psychosocial cultural educational physical factors
ENVIRONMENT: setting, resources, payers
what is the evolution of clinical decision making
novice > advanced beginner > competent > proficient > expert
how does clinical decision making differ between novice vs expert
novice - more skill acquisition driven
expert - reflective practice
what are the 3 major components of PT neuro exam
hx and subjective assessment
systems review
exam: BSF, activity and participation
what do the 3 major components of a PT neuro exam inform: (5)
eval -> critical analysis, synthesize exam data
PT diagnosis and prognosis
POC and goals
interventions
dc plan / conclusion of care
how are BSF/activity/participation assessed in the exam portion of a neuro exam
tests and measures - clinical and standardized
what are 3 components in history taking for a neuro exam
- PMH & current health status
- medical dx, imaging, tests/labs, meds, surgery, prior PT or other interventions
- age, gender, ethnicity, language, culture, religion, educational level, work/school hx, social/health habits
why is history important in your neuro exam
helps to create patient centered care
why is PMH and current health status important in a neuro exam
PMH - is what presenting w new or old, do you address this or focus on other areas
current health status - how does this compare to PLOF
what are 6 things to hit on in your subjective assessment
- PLOF *
- home environment
- goals
- culture
- limitations
- PLOF *
- family and friend support *
how is a systems review conducted
brief screening of systems
what does a brief screening of systems inform (2)
- used to identify areas of potential dysfunction that warrant further testing
- decisions regarding scope of care
why is it important to keep your systems review brief
would be too time consuming otherwise
what are the 8 things touched on in a CP systems review
- HR
- heart rhythm
- respiratory rate
- BP
- edema
- read a single lead EKG (if available)
- dyspnea, orthopnea
- cough
why is a CP exam important in neuro rehab
lot of neuro insults can be result of underlying CP issues
- while addressing neuro impairments, think ab if can handle intensity
what are examples of neuro insults due to underlying CP issues
vascular dementia
stroke
what are 4 things hit on in an integ systems review
- color
- cap refill
- integrity
- scars
what are 3 examples of how an integ systems review would important for neuro rehab
- wound could lead to infection
- skin breakdown can reduce ability for PT to work w them
- calluses on their feet - is that why they can’t feel the ground or is it sensory impairments
what are 5 things hit on in a MSK systems review
- gross symmetry / posture
- gross ROM
- gross strength
- height
- weight
why are height and weight looked at in a MSK systems review
can impact how someone moves around
- esp if have a SCI
what are the 3 broad categories looked at in a neuro systems review
cognitive
mobility
motor
what is an important thing to look at when looking at movement in a neuro systems review
quality of the movement - smooth, precise, accurate
what is looked at in the cognitive portion of a neuro systems review
gross cognition
arousal
communication
what is looked at in the mobility portion of a neuro systems review
gross movement patterns
function
what is looked at in the motor portion of a neuro systems review
motor function
motor coordination
what does a green flag mean when identified in a PT exam
go - continue PT (complete exam/eval, determine POC)
what does a red flag mean when identified in a PT exam
STOP
emergency - call 911 or send to ED
what does a yellow flag mean when identified in a PT exam
wait
- referral to MD for non-life-threatening scenarios
what are 6 neuro s/sx that are RED FLAGS
- altered mental status - new onset or exacerbation
- prolonged sz activity or status epilepticus
- acute infection w/ associated neuro signs
- RAPID onset of focal or global deficits
- evidence of spinal column instability
- non-responsive autonomic dysreflexia (SCI pop)
what overall are the red flag neuro s/sx indicating
something might be evolving at that moment
what could cause an exacerbation of an altered mental status
infection
bleed
additional neuro insult
how can sz present and how can you assess this
pt might not be responding
look at VS (super high HR or BP), incontinent episode
how can you assess if there is a rapid onset of focal or global deficits
difference in ms strength
what might be evidence of spinal column instability
not having sensation in certain areas
what are 7 yellow flags in neuro s/sx
- progress/exacerbation of pre-existing neuro signs
- evidence of new NM dz not in PMH
- new onset of involuntary movement, tremor
- change in autonomic status
- constant HA that worsens over time
- vertebral artery insufficiency
- slow, insidious changes in neuro function that are not consistent w known PMH
how should evidence of new NM dz present if yellow flag
not presenting quickly
HA that is red flag vs yellow flag
red flag - dramatically pounding, can’t focus
yellow flag - bothers them, constant
what could vertebral artery insufficiency present as
dizziness
what are the 2 approaches for a neuro PT exam
body structure & function-oriented
activity oriented
what factors influence your choice in the approach to a neuro PT exam
practice setting
pt status
level of expertise
what are components of a body structure/function approach
how strong
can they feel
cranial nerves
can they see
what are components of an activity approach
based on performance
- how they do something
what is the focus on in the ICF components
getting them to be able to participate
what are the 4 steps typically used in an activity-oriented exam
- activities first
- hypothesized contributing factors (HCFs)
- select appropriate tests/measures to perform based on hypothesis
- develop treatment interventions that improve function and address impairments
what is the pro to an activity based approach
can be more efficient
- can knock out a bunch of different things
when do you usually see a BSF approach to exam
less experienced PTs
- will become more efficient and move toward activity oriented exam
might also use this approach if PT isn’t moving how you would have hoped
describe interventions used in an activity-oriented exam
in a functional context
- LAQ vs stairs
what are 9 things assessed in an activity oriented neuro exam
- balance
- trunk control
- reaching and grasp
- bed mobility
- transfers
- amb and gait
- wc mobility
- stairs
- ADLs and IADLs
what is the general process in conducting a BSF oriented exam
impairments common to neuro dx
primary/direct impairments
secondary/indirect impairments
what is an important part in looking at impairments common to neuro dx when doing a BSF oriented exam
identify normal vs abnormal
primary vs secondary impairments (BSF oriented)
primary = result of health condition
secondary = result of adaptive changes
what are the components to the tests and measures part of exam? how does this differ for BSF vs activity?
no difference between BSF vs activity
SELECT - appropriate tests determine/confirm presence & extent of dysfunction
PERFORM - exam procedures correctly to ensure accuracy and validity
OBSERVE - even if unable to formally assess due to cognitive, communication, or time limitations
what are ex of clinical tests and measures
sensory
muscle function - MMT
assist needed - asking them or feeling it yourself
what makes standardized tests and outcome measures different from clinical tests
standardized tests/outcomes have age related norms to compare to other individuals
what are ex of standardized tests
BERG
DIG (dynamic gait index)
Tinetti
what do standardized tests look at
impairment, activity, participation level
psychometric properties
what should be considered w standardized tests
confounding factors
what specifically is assessed for impairments in a BSF oriented neuro exam (11)
- level of arousal/consciousness
- cognition, mental status, communication screen
- sensation
- motor planning
- motor control / ACOM
- muscle tone
- ROM
- reflexes
- coordination
- vestibular function
- cranial nerve integrity
what are 6 reasons why screening attention, cognition, perception, and communication are important
- determine ability to participate in exam/treatment
- ability to provide informed consent
- plan effective instruction / communication methods
- screening / detecting dz
- identify person needing referral to psych, neuropysch, SLP, OT, etc.
- dc planning
what are 4 components of cognition that are looked at
awareness
memory
reasoning/judgement
executive functioning
what are two pieces of awareness as part of cognition
orientation and attention
orientation vs attention
ORIENTATION
- time, person, place, events/situation
- ex: birthday, date, time of day, why are you here
ATTENTION
- ability to attend to & process info of themselves and their environment
- ability to concentrate dual task
- ex: neglect side of room, letting hand hang off bed
what is memory
register, retain, and recall info
what is the relationship between memory and learning
memory is a separate process from learning
short term vs long term memory
short term - recent or working memory
long term - remote
how can amnesia be graded
partial, total, transient or permanent
anterograde vs retrograde amnesia
anterograde - can’t form new memories
retrograde - can’t remember old memories
what is a pt population that anterograde amnesia is typically seen in
dementia
alzheimers
what is short term memory
memory of events that have just occurred
what type of attention and events are associated w short term memory
active attention to events lasting seconds
describe the brain’s capacity when it comes to short term memory
limited capacity
7 items +/- 2
brain accepts new info, but loses short term memory as new info is added
what are two types of long term memory
explicit memory
implicit memory
explicit vs implicit memory
EXPLICIT
- acquisition, retention, and retrieval of info that can be intentionally recollected
- declarative memory
IMPLICIT
- procedural / nondeclarative memory
- recalled thru unconscious systems (ie movement)
what type of instances do you see explicit memory utilized in
required to complete multiple steps in a task
remember events
what is an example of implicit memory
tying shoelaces
- happens automatically
what are two standardized tests/measures for cognition
mini mental state exam (MMSE)
Montreal cognitive assessment (MoCA)
- more common
what does the MMSE look at
orientation
recall
calculation
attention
language
visual construction
what are the benchmarks for MMSE and MoCA
MMSE - 24/30
- <24 indicates cog impairment
MoCA - 26/30 and above indicates norm
- <26 indicates cog impairment
if you score below MMSE and MoCA benchmarks, what does this mean
cognitive impairment
could mean that you need to do another test
what is executive functioning
higher order cognition
what does executive functioning encompass (6)
awareness
reasoning
planning
judgement
intuition
decision making
what are 2 ex of executive functioning
preparing a meal
knowing what to do in case of an emergency such as a fire
what are 4 levels of arousal identified in a clinical exam
- alert
- delirious or obtunded
- lethargic
- stupor or semicoma
what is an alert level of arousal
awake
attentive
interactive
what is a delirium level of arousal
confused
hallucinating
what is an obtunded level of arousal
difficult to arouse
confused when alert
what is a lethargic level of arousal
drowsy
drifts to sleep when not stim
brief response to stim & poor attention
what is a stupor/semicoma level of arousal
not self alerting
responds to vigorous/noxious stim
what are the 3 DOC levels
coma
VS
MCS
VS vs MCS in broad terms of what it means for PT
VS - can’t participating
MCS - they are emerging
what are characteristics of a comatose state of consciousness
complete loss of arousal
no sleep-wake cycles
what are the characteristics of a VS state of consciousness
irregular sleep-wake cycle
can be aroused but no awareness of environment
wakeful unconsciousness
what are characteristics of a MCS state of consciousness
severely altered consciousness
minimal and inconsistent
evidence of self or environmental awareness
purposeful movement
what are standardized tests and measures for consciousness/level of arousal
glascow coma scale (GCS)
coma recovery scale - revised (CRS-R)
rancho los amigos scale level of cognitive function (LOCF)
why is communication an important thing to assess in a neuro exam
critical to validity of PT exam
what parts of assessing communication are within our scope of practice
screen
consult w SLP
review medical records
what are 2 main barriers to communication
aphasia
dysarthria
what are two types of aphasia
receptive
expressive
receptive aphasia
fluent or Wernicke’s
inability to understand info
expressive aphasia
non-fluent or Broca’s
inability to get words out
dysarthria
poor articulation
- weakness in mouth or tongue
know what is being said and how to get words out, but have difficulty saying it
