Neuro: General Comprehensive Flashcards
The patient is awake and attentive to normal levels of stimulation. Interactions with the therapist are normal and appropriate.
Alert
The patient appears drowsy and may fall asleep if not stimulated in some way. Interactions with the therapist may get diverted. Patient may have difficulty in focusing or maintaining attention on a question or task.
Lethargic
The patient is difficult to arouse from a somnolent state and is frequently confused when awake. Repeated stimulation is required to maintain consciousness. Interactions with the therapist may be largely unproductive.
Obtunded
The patient responds only to strong, generally noxious stimuli and returns to the unconscious state when stimulation is stopped. When aroused, the patient is unable to interact with the therapist.
Stupor (semi-coma)
The patient cannot be aroused by any type of stimulation. Reflex motor responses may or may not be seen. There are no sleep wake cycles.
Coma (deep coma)
Return of irregular sleep–wake cycles and normalization of the so-called vegetative functions (respiration, digestion, and blood pressure control). The patient may be aroused, but remains unaware of his or her environment. There is no purposeful attention or cognitive responsiveness.
Minimally conscious (vegetative state) - Persistent if present after 1 yr following TBI - Persistent if present after 3 months following anoxic brain injury
Glasgow Coma Scale: 8 or less
Severe Brain Injury
Glasgow Coma Scale: 9 - 12
Moderate Brain Injury
Glasgow Coma Scale: 13 - 15
Mild Brain Injury
Sustained contraction and posturing of the upper limbs in flexion and the lower limbs in extension. - The elbows, wrists, and fingers are held in flexion with shoulders adducted tightly to the sides while the legs are held in extension, internal rotation, and plantarflexion.
Decorticate Rigidity - Indicative of damage to the corticospinal tract lesion at the level of diencephalon (above the superior colliculus).
Sustained contraction and posturing of the trunk and limbs in a position of full extension. - The elbows are extended with shoulders adducted, forearms pronated, and wrist and fingers flexed. - The legs are held in stiff extension with plantarflexion.
Decerebrate Rigidity - Corticospinal lesion in the brainstem between the superior colliculus and vestibular nucleus.
Noted Impairments: - Inability to plan motor tasks (apraxia) - Difficulty in initiating, sequencing and processing a task - Difficulty in producing or comprehending speech - memory impairment - perseveration of speech or motor behaviors
Left hemisphere damage
Noted Impairments: - Poor judgement and safety awareness - Unrealistic expectations - Denial of disability or deficits - disturbances in body image - irritability -lethargy
Right Hemisphere damage
- Allows for processing of information sequentially, logically for analysis. - Language production - Recognize words and comprehend what has been read - Mathematical calculations - Sequence and perform movements and gestures - Expression of positive emotions
Left Hemisphere
Major motor pathway - Origonates in the frontal lobe in the primary and premotor cortices->internal capsule->synapse on anterior horn cells in the spinal cord
Corticospinal tract
Rancho LOCF: Patient appears to be in a deep sleep and is completely unresponsive to any stimuli.
Level I: no response
Rancho LOCF: Patient reacts inconsistently and nonpurposefully to stimuli in a nonspecific manner. Responses are limited and often the same regardless of stimulus presented. Responses may be physiological changes, gross body movements, and/or vocalization.
Level II: generalized response
Rancho LOCF: Patient reacts specifically but inconsistently to stimuli. Responses are directly related to the type of stimulus presented. May follow simple commands such as closing eyes or squeezing hand in an inconsistent, delayed manner.
Level III: Localized Response
Rancho LOCF: Patient is in a heightened state of activity. Behavior is bizarre and nonpurposeful relative to immediate environment. Does not discriminate among persons or objects; is unable to cooperate directly with treatment efforts. Verbalizations frequently are incoherent and/or inappropriate to the environment; confabulation may be present. Gross attention to environment is very brief; selective attention is often nonexistent. Patient lacks short- and long-term recall.
Level IV: Confused Agitated
Rancho LOCF: Patient is able to respond to simple commands fairly consistently. However, with increased complexity of commands or lack of any external structure, responses are nonpurposeful, random, or fragmented. Demonstrates gross attention to the environment but is highly distractible and lacks ability to focus attention on a specific task. With structure, may be able to converse on a social automatic level for short periods of time. Verbalization is often inappropriate and confabulatory. Mem- ory is severely impaired; often shows inappropriate use of objects; may perform previously learned tasks with structure but is unable to learn new information.
Level V: Confused Inappropriate
Rancho LOCF: Patient shows goal-directed behavior but is dependent on external input or direction. Follows simple directions consis- tently and shows carryover for relearned tasks such as self-care. Responses may be incorrect due to memory problems, but they are appropriate to the situation. Past memories show more depth and detail than recent memory.
Level VI: Confused-Appropriate
Rancho LOCF: Patient appears appropriate and oriented within the hospital and home settings; goes through daily routine automatically, but frequently robot-like. Patient shows minimal to no confusion and has shallow recall of activities. Shows carryover for new learning but at a decreased rate. With structure is able to initiate social or recreational activities; judgment remains impaired.
Level VII: Automatic-Appropriate
Rancho LOCF: Patient is able to recall and integrate past and recent events and is aware of and responsive to environment. Shows carryover for new learning and needs no supervision once activities are learned. May continue to show a decreased ability relative to premorbid abilities, abstract reasoning, tolerance for stress, and judgment in emergencies or unusual circumstances.
Level VIII: Purposeful-Appropriate
Most common CVA type
Middle cerebral artery
CVA: - Contralteral hemiplegia - Upper extremity greater than lower - loss of sensation primarily in arm and face - Infarction in dominant left hemisphere may produce aphasia and apraxia
Middle Cerebral Artery
CVA: - Rarely involved artery - LE with greater involvement than UE – contralateral hemiplegia and sensory loss - mental confusion - aphasia - contralateral neglect with extensive dominant side involvement
Anterior Cerebral
CVA: - Persistent pain syndrome or contralateral loss of pain and sensory - Homonomous hemianopsia - aphasia - thalamic pain syndrome
Posterior Cerebral
CVA: - Most often results in death from infarct associated edema - “locked in” state with only eye blinking available - vertigo - coma - diplopia - nausea - dysphagia - ataxia
Vertebral Basilar - With pons affected: quadriparesis and bulbar palsy
CVA: - unilateral deafness - contralateral pain and temperature loss - paresis of lateral gaze - unilateral Horner’s Syndrome (ptosis, constructed pupil, loss of sweating) - ataxia - vertigo - nystagmus
Anterior Inferior Cerebellar (AICA)
CVA: - severe ataxia - dysarthria - dysmetria - contralateral loss of pain and temperature
Superior Cerebellar
CVA: - Wallenberg Syndrome: — (vertigo, nausea, hoarseness, dysphagia, and decreased impairment of sensation in the ipsilateral face, contralateral torso and limbs. - Horner’s Syndrome also possible
Posterior Inferior Cerebellar (PICA)
An inability of the patient to produce movement either on command or automatically and represents a complete breakdown in the conceptualization of the task. The patient has no idea how to do the movement and thus cannot formulate the required motor programs.
Ideational apraxia
The patient is unable to produce a movement on command but is able to move automatically. Thus, the patient can perform habitual tasks when not commanded to do so and often perseverates, repeating the activity over and over
Ideomotor apraxia
Synergy: Scapular Retraction and elevation (or hyperextension)
UE flexor synergy
Synergy: Shoulder abduction, external rotation
UE flexor synergy
Synergy: Elbow flexion*
UE flexor synergy
Synergy: Forearm supination
UE flexor synergy
Synergy: Wrist and finger flexion
UE flexor AND extensor synergy
Synergy: Scapular protraction
UE Extensor Synergy
Synergy: - Shoulder adduction,* internal rotation
UE Extensor Synergy
Synergy: - Elbow extension
UE Extensor Synergy
Synergy: - Forearm pronation*
UE Extensor Synergy
Synergy: - Hip flexion,* abduction, external rotation
LE Flexor Synergy
Synergy: - Knee flexion
LE Flexor Synergy
Synergy: - Ankle dorsiflexion, inversion
LE Flexor Synergy
Synergy: - Toe dorsiflexion
LE Flexor Synergy
Synergy: - Hip extension, adduction,* internal rotation
LE Extensor Synergy
Synergy: - Knee extension*
LE Extensor Synergy
Synergy: - Ankle plantarflexion,* inversion
LE Extensor Synergy
Synergy: - Toe plantarflexion
LE Extensor Synergy
Stage of Motor Recovery: - Flaccidity — often with no voluntary movement
Stage 1
Stage of Motor Recovery: - Development of spasticity, hyperreflexia, and mass patterns of movement (obligatory synergies) - Minimal voluntary movement
Stage 2 (Early Synergy)
Stage of Motor Recovery: - Spasticity is marked with full strong obligatory synergies - Voluntary control of movement synergies appears
Stage 3
Stage of Motor Recovery: - Synergy influence begins to decline as some isolated out-of-synergy joint movements emerge.
Stage 4
Stage of Motor Recovery: - Relative independence of synergy - Spasticity continues to wane and isolated joint movements become more apparent. - Synergies no longer dominant and movement becomes more complex
Stage 5
Stage of Motor Recovery: - Patterns of movement are near normal. - Spasticity is gone - Coordination and movement approach normal
Stage 6
Which hemisphere affected? - Problems with spatial awareness and E-H coordination
Right hemisphere
Which hemisphere affected? - Irritability and short attention span
Right hemisphere
Which hemisphere affected? - Cannot retain information; difficulty learning individual steps - Difficulty grasping the whole idea of a task or activity.
Right hemisphere
Which hemisphere affected? - Poor judgement affecting personal safety
Right hemisphere
Which hemisphere affected? - Diminished body image with left sided neglect
Right hemisphere
Which hemisphere affected? - Quick and impulsive
Right hemisphere
Which hemisphere affected? - Apraxia
Left hemisphere
Which hemisphere affected? - Difficulty starting and sequencing tasks
Left hemisphere
Which hemisphere affected? - Perseveration
Left hemisphere
Which hemisphere affected? - Easily frustrated with high levels of anxiety
Left hemisphere
Which hemisphere affected? - Inability to communicate verbally
Left hemisphere
Which hemisphere affected? - Cautious and slow
Left hemisphere
Which Aphasia? - The patient demonstrates difficulty in comprehending spoken language and in following commands. - Speech flows smoothly with a variety of grammatical constructions and preserved melody of speech.
Wernicke’s Aphasia (fluent aphasia) - Receptive [impairment] aphasia - Sensory [impairment] aphasia - Damage to: LEFT LATERAL TEMPORAL LOBE - Use word repetition and manual cues to to assist in communicating desired action during rehabilitation
Which Aphasia? - The flow of speech is slow and hesitant, vocabulary is limited, and syntax is impaired. - Speech production is labored or lost completely whereas comprehension is good.
Broca’s Aphasia (non-fluent aphasia) - Expressive [imparment] aphasia - Damage to: PREMOTOR AREA OF LEFT FRONTAL LOBE - Use simple “yes” or “no” questions to avoid confusion and frustration
Which Aphasia? - Characterized by marked impairments of both production and comprehension of language.
Global Aphasia: - It is often an indication of extensive brain damage. - Use symbolic gestures to reduce the chance of overestimating the patient’s ability to understand speech.
Paralysis of: - intrinsic hand muscles (interossei, thenar, hypothenar) - flexors of the wrist and fingers (flexor carpi ulnaris, ulnar half of flexor digitorum profundis) - forearm pronators
Klumpke Paralysis: (C8-T1) - Presents as intrinsic minus or claw hand - Horner’s syndrome may also be present
Order of testing for fall history/balance impairment
Cognition -> sensory testing -> static balance tests (i.e. CTSIB) -> dynamic balance tests.
Gaze stability (X1 viewing) and postural stability are treatments for:
Unilateral and Bilateral Vestibular Hypofunction.
What training is used for UVH patients with continual complaints of dizziness?
Habituation training (motion sensitivity training) - can also help patients with central vestibular lesions.
Patients with lesions that occur above the conus medullaris and sacral segments develop a _______ bladder.
Spastic of hyperreflexive. - manage with suprapubic stroking or tapping
To allow for function in long sitting, hamstrings should be ranged to what degree?
110 degrees.
Sensory: C6 nerve root
Palmar surface of the thumb and radial forearm
Sensory: C7 nerve root
Middle of the hand (second, third and fourth fingers Palmar surface)
Sensory: C8 nerve root
Ulnar border of the hand (fifth finger)
Sensory: T1 nerve root
Medial surface of the forearm
Modified Ashworth: - No increase in muscle tone.
MAS: 0
Modified Ashworth: - Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the ROM when the affected part(s) is moved in flexion or extension.
MAS: 1
Modified Ashworth: - Slight increase in muscle tone, manifested by a catch, followed by minimal resistance through- out the remainder (LESS THAN HALF) of the ROM.
MAS: 1+
Modified Ashworth: - More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved.
MAS: 2
Modified Ashworth: - Considerable increase in muscle tone, passive movement difficult.
MAS: 3
Modified Ashworth: - Affected part(s) rigid in flexion or extension.
MAS: 4
Deep Tendon Reflex Grading: - Absent, no response
DTR: 0
Deep Tendon Reflex Grading: - Slight reflex, present but depressed, low normal
DTR: 1+
Deep Tendon Reflex Grading: - Normal, typical reflex
DTR: 2+
Deep Tendon Reflex Grading: - Brisk reflex, possibly but not necessarily abnormal
DTR: 3+
Deep Tendon Reflex Grading: - Very brisk reflex, abnormal, clonus
DTR: 4+
I present with: Hyperalgesia (increased sensitivity to pain), allodynia (all stimuli perceived as painful), and hyperpathia (increased intensity) What am I?
Complex Regional Pain Syndrome (Stage 1)
I present with: Increased pain with edema and atrophic skin and nail changes. What am I?
Complex Regional Pain Syndrome (Stage 2)
I present with: Spreading pain, hardening of edema, cool dry and cyanotic skin, developing osteoporosis, and ankylosis What am I?
Complex Regional Pain Syndrome (Stage 3)
The MOST useful test to determine whether demyelination has taken place in polyneuropathy.
Nerve Conduction Velocity
Recommendations for pressure ulcers in patients with spinal cord injury who are wheelchair users include:
10 to 15 seconds of pressure relief (push-ups) for every 15-20 minutes of sitting.
Wheelchair for C4 tetraplegia:
Power wheelchair with sip and puff controls - Face, neck, diaphragm, and trapezius innervated. - Also needs tilt in space frame for pressure relief
Wheelchair for C6-C7 tetraplegia
Manual wheelchair with friction surface handrims: - Used when patients do not have functional grip or strength necessary to adequately propel a wheelchair
Wheelchair for C5 tetraplegia
Manual wheelchair with handrim projections OR power wheelchair with joystick controls - Have biceps, brachialis, brachioradialis, deltoids, rhomboids, supinator. - Energy expenditure required may necessitate a power wheelchair with joystick controls
Sensations transmitted by the dorsal column–medial lemniscal pathway include:
- discriminative touch - stereognosis - tactile pressure - barognosis - graphesthesia - recognition of texture - kinesthesia - two-point discrimination - proprioception - vibration.
The three major tracts of the spinothalamic system and the sensations they carry:
Anterior (ventral) spinothalamic tract: – crudely localized touch and pressure Lateral spinothalamic tract: – Pain and temperature Spinoreticular tract: – Diffuse pain sensations.
Seven-point scale which examines 18 items (based on observations of patient performance) regarding self care, sphincter control, transfers, locomotion, communication, and social cognitive abilities.
Functional Independence Measure
Mini Mental State Exam score: less than 20
Associated with dementia, delirium, schizophrenia, or an affective disorder
Mini Mental State Exam score: 24
Minimum score to avoid being classified as having a cognitive impairment
Mini Mental State Exam score: 30
Highest score = cognitively within normal limits
11 question measure that assesses five areas of cognition: - orientation - registration - attention/calculation - recall - language
Mini Mental State Exam - 5 minutes to complete - Scores range from 0-30
This tract is commonly assessed through “heel walking”
Corticospinal tract: - Damage to this tract results in: – positive Babinski – absent superficial abdominal and cremasteric reflexes - loss of fine motor or skilled voluntary movement
Reticulospinal tract responsible for:
facilitation or inhibition of voluntary or reflex activity through the influence on gamma and alpha motor neurons
Rubrospinal tract is responsible for:
Motor input of gross postural tone, facilitating activity of flexor muscles, inhibiting activity of extensor muscles
Tectospinal tract is responsible for:
Contralateral postural muscle tone associated with auditory/visual stimuli
ASIA: - No motor or sensory function is pre- served in the sacral segments S4 to S5.
ASIA A: Complete
ASIA: - Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4 to S5.
ASIA B: Incomplete
ASIA: - Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3.
ASIA C: Incomplete
ASIA: - Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more.
ASIA D: Incomplete
ASIA: - Motor and sensory function is normal.
ASIA E: Normal
- Ipsilateral paralysis and sensory loss and ipsilateral loss of proprioception, light touch, and vibratory sense. - Contralateral loss of sense of pain and temperature
Brown-Sequard - The ipsilateral loss of proprioception, light touch, and vibratory sense is due to damage to the dorsal column; - Ipsilateral paralysis results from damage to the lateral corticospinal tract. - Damage to the spinothalamic tracts results in contralateral loss of sense of pain and temperature.
- Loss of motor function and loss of the sense of pain and temperature below the level of the lesion. - Proprioception, light touch, and vibratory sense are generally preserved.
Anterior cord syndrome: - Frequently related to flexion injuries of the cervical region with resultant damage to the anterior portion of the cord and/or its vascular supply from the anterior spinal artery.
- Characteristically more severe neurological involvement of the upper extremities (UEs) than of the LEs - Varying degrees of sensory impairment occur but tend to be less severe than motor deficits
Central Cord Syndrome - Generally occurs from hyperextension injuries to the cervical region. - It also has been associated with congenital or degenerative narrowing of the spinal canal.
Muscles necessary for crutch use:
- Shoulder depressors and extensors, and elbow extensors
- Lower trapezius
- Latissimus dorsii
- (pectoralis major)
