neuro rehab Flashcards
where do the lowest level reflexes originate?
spinal cord (then brainstem, then midbrain/cortical areas)
true or false, fast movements can be performed without sensory feedback
true (open loop control)
open loop control systems
instructions for the action (motor programs) are prepared in advance and carried out without feedback
feedforward control
“setting” of muscles prior to initiation of movement
closed loop is used ____ (more/less) during learning
more because we need the feedback when we are learning a movement
true or false, it is impossible for the brain to store motor programs for every movement
true, this is a limitation on this idea
which theory talks about times of stability and instability
dynamic systems theory
discrete tasks
have a beginning and end
serial tasks
discrete movements strung together
continuous movements
no recognizable beginning or end
open environment
unpredictable
closed environment
predictable
intrinsic feedback
from sensory receptors
extrinsic feedback
supplied from external sources
which type of feedback schedule is most effective?
faded
external focus of attention is better for learning (T/F)
true
which type of task works better for massed practice?
discrete, or for a novel skill
fatigue can be an issue for continuous
massed or distributed practice are about ….
the amount of time of practice vs. rest
massed is more practice than rest
meissner’s corpuscle
fine, discriminative touch
merkel’s disc
fine touch, superficial pressure
pascinian corpuscle
deep pressure, vibration
Ruffini corpuscles
stretch, vibrations
which type of reflex is monosynaptic?
deep tendon reflex (stretch)
function of the brainstem
receives and integrates somatosensory, vestibular, and visual inputs for postural control
regulate cardiovascular, respiratory and visceral activity
regulates arousal and awareness through ascending reticular system
basal ganglia goes with which cortical area?
supplementary motor
cerebellum goes with which cortical area?
premotor
vicarious function theory
assumes that functions can be learned or taken over by areas not previously done
CNS redundancy theory
CNS has back-up systems
functional substitution
areas of the brain become reprogrammed (increased sensitivity of hands as sensory information for the blind)
wallerian degeneration
the distal end that was separated (cut) will degenerate
recovery of synaptic effectiveness
edema resolves and function is restored
synaptic hyper effectiveness
when one presynaptic branch is destroyed, the rest release more NT
denervation super-sensitivity
increase in number of receptors on postsynaptic membrane
recruitment of silent synapses
unmasking, functional connections were silent before injury
axonal regeneration
sprouts from injured axons grow to form new synapses with other cell
collateral sprouting
presynaptic will sprout to synapse with a postsynaptic neuron that lost its presynaptic
angiogenesis and what substances promote it
formation of new blood vessels
BDNF and TGFa
retentive memory
immediate recall
recent memory
recall immediate and then 5 min later
remote memory
chronological order of events
difference between non-equilibrium and equilibrium coordination
equilibrium requiers upright balance
what does a wide based gait and ataxic movement indicate?
cerebellar issue
what is the gait speed of a community ambulatory?
.8 m/s
what is the tinetti used for?
fall risk in the elderly
tests to determine risk…
TUG functional reach tinoetti Berg BESTest
floor effect
they will score too low
ceiling effect
they will score too high
SIRS
systemic inflammation response syndrome
severe infection
risk for ICU acquired weakness goes up after how long
1 week
what is early mobility? how early?
within 24-48 hours after admission
PICS
post intensive care syndrome
who gets SCI?
young males, often preventable causes
what level are wedge compression fractures most common in?
thoracic
___ has regeneration, ___ has reorganization
PNS, CNS
spinal shock is caused by … and is…
edema,
temporary suppression of SC ruction at and below level
first to come back are sacral reflexes
spinal precautions
No BLT
bending
lifting more than 10 lbs
no twisting
who would you expect to have issues with generating a forceful cough (SCI level)?
above C6
level of autonomic dysreflexia
above T6
what to do for autonomic dysreflexia
raise HOB to decrease BP
look for noxious stimuli
keep checking vitals
ER immediately if BP does not come down
spasticity is ___ dependent
velocity
neuropathic pain therapies
anticonvulsants
tricyclic antidepressants
Brown-sequard syndrome
SC hemisection
ipsilateral: motor at that level and below, DCML below, AL at the level
contralateral: AL at level and below
anterior cord syndrome
AL loss at and below level, motor at and below
central cord syndrome
loss of motor pools at the level, loss of AL at the level (crossing fibers)
posterior cord syndrome
loss of DCML below lesion
likely have antalgic gait as a result
cauda equina
LMN
sensory impairment and flaccid paralysis
conus medularis
UMNs and LMNs
maybe see spasticity, hyperreflexia
root escape
preservation or return of function of nerve roots at, or near, level of lesion
neurologic level of inury
loest segment w/ normal sensory and or motor function (3/5) on both sides of the body
ASIA levels
A = complete B = sensory only C = less than 1/2 motor normal D = more than 1/2 motor normal E = normal
how much HS length does an SCI patient need for functional long-sit?
110-120
secondary complications of SCI (think bone)
heterotrophic ossification
osteoporosis
sympathetic affects on bladder
hypogastric nerve –> relaxes bladder muscles and contracts internal urethral sphincter
parasympathetic effects on bladder
pelvic nerve –> contracts detrusor muscle –> voiding
somatic effects on bladder
pudendal nerve –> contracts external urethral sphincter (voluntary control)
location of lesion for spastic bladder
above conus medullar is because micturition reflex is still intact
location of lesion for flaccid bladder
lesion of conus medlars or cauda equina (the reflex is disrupted)
failure to store urine can be from 2 causes
detrusor hyperreflexia sphincter incompetence (corticospinal tract damage or sympathetic denervation)
failure to empty bladder
hyporeflexia of detrusor
outlet obstruction
spastic external sphincter
location of lesion for spastic bowel
lesion within SC above conus medullaris
intact defecation reflex
bowel program success
SELF Schedule exercise liquids food
reflexogenic erections happen from
direct stimulation to the genital area
psychogenic erection happen from
result of audiovisual stimuli or fantasy (from brain)
NIHSS score is for what?
stroke severity 0 = no symptoms 1-4 = minor stroke 5-15 = mod stroke 16-20 = mod to severe 21-42 = severe stroke
ASTRAL score is for what?
stroke Age Severity (NIHSS) Time delay pResence of visual field deficit glucose at Admission Level of consciousness
an embolism is a clot that comes from…
the heart normally
intracerebral hemorrhage
blood vessels within brain rupture
subarachnoid hemorrhage
blood vessels outside of the brain ruptures, filling subarachnoid space with blood
Arteriovenous malformation
congenital defect consisting of abnormal tangle of blood vessels that pass blood directly from arteries to veins
CAN RUPTURE
common stroke seen in young people
watershed strokes
affect areas of the brain supplied by the most distal branches of major cerebral arteries
-proximal arm and leg weakness (man in a barrel)
warning signs of stroke
FAST Face Arms Speech Time
worst headache of their life
what type of drugs do you give someone with a TIA of cardiac origin?
anticoagulants (warfarin, heparin)
what type of drug is aspirin?
platelet antiaggregant (antiplatelet, antithrombotic)
When do you use thrombolytic therapy?
tPA, altaplase… within 4.5 hours of an ischemic stroke
what is a cryptogenic stroke?
the underlying cause is unknown after extensive testing
what to do for intracerebral hemorrhagic stroke
stop antithrombotics, debased BP, decrease ICP
dorsolateral prefrontal cortex deficit
executive functioning(memory retrieval) perseveration, disinhibition
ventromedial prefrontal cortex deficit
motivational aspect of decision making
impulsive, risk-taking
inability to interpret emotions or act appropriately
anterior cingulate cortex is important for
connected with VMPC and DLPFC and limbic system
shifting attention, awareness of emotion
(considered part of limbic system)
posterior cingulate cortex is important for
working memory, comparing, evaluating info, orienting objects in space mentally
declarative memory
facts and events
nondeclarative memory
procedural and emotional learning
non-associative learning
habituation and sensitization
associative learning
classical and operant conditioning cellular mechanisms (LTP and LTD)
where does long term potentiation happen?
hippocampus and neocortex
where does long term depression happen?
cerebellum and hippocampus
bottleneck theory
two tasks with similar neural network requirements create a bottleneck during dual tasking (decreasing performance in one or both tasks)
capacity sharing model
processing capacity for an individual is limited… multiple tasks could require more capacity
at the areas of broca’s and wernicke’s on opposite hemisphere, what do they do?
nonverbal planning (broca’s) and nonverbal interpretation (wernicke’s)
verbal dorsal stream processing…
transforms what we want to say to sentences
verbal ventral stream processing…
converts what is said into its meaning and plans what we want to say
anomic aphasia
inability to retrieve words an individual wants to say
most common after stroke
conduction aphasia
thought to be due to damage to arcuate fibers connecting broca’s and wernicke’s
speak in gibberish
wernicke’s allows for repeating words (T/F)
true
transcortical motor aphasia
disconnected broca from BG or premotor… non-fluent aphasia, but can repeat words
transcortical sensory aphasia
fluent aphasia, but can repeat words, often echolalia
mixed transcortical aphasia
least common (isolation aphasia)
all areas intact, but isolated
can repeat
can’t comprehend or produce spontaneous speech
global aphasia
most severe, large left hemisphere lesion
can improve sometimes
no speech made or understood
dysarthria types
spastic (UMN)
flaccid (cranial nerves)
diaschisis
loss of function in a remote area, but neuronally connected
On day 2 post stroke, if the following are present, predicts independent gait at 6 months with 98% chance
independent sitting for 30s
25 degree motion of DF, Knee extension, hip flexion
palpable contraction of DF, KE, AND HF
fair+ strength in DF, KE, HF
3 stages of stroke recovery according to Bobath
1: flaccidity
2: spasticity
3: relative recovery
(recovery continues for 1 year)
muscles not included in the synergy patterns
lats teres major serrates anterior finger extensors ankle evertors HARD TO ACTIVATE
UE movement is in ___ direction as other for unmasked reflexes post stroke
SAME
LE movement is in the _____ direction as other for unmasked reflexes post stroke… except
OPPOSITE
except for ABD and ADD
sougue’s phenomenon
raise arm above horizontal and get finger extension and abduction
raimiste’s phenomenon
resisted abduction elicits abduction in the contralateral limb (same for add)
perceptual deficits usually occur in the ____ lobe
right parietal
asonognosia
denial of presence or severity of disability
agnosia
dont know what to do with an object
dysphagia
delayed triggering of the swallowing reflex
posture and head control can contribute
which type of hemiplegics tend to be more impulsive?
L
thalamic syndrome
severe burning pain in the area weeks or months after thalamic stroke
Gordon’s Investment Principle
performance will degrade during learning process, then it will improve as it becomes integrated
shoulder problems associated with hemiplegia
pain and subluxation
body scheme
postural model of body, relationships between body parts
body awareness
integration of tactile, proprioceptive and interoceptive sensation, in addition to feelings
(these legs are mine)
somatognosia
failure to recognize a part of their body (maybe think dead person in bed), includes naming a body part
where does a lesion causing unilateral neglect happen?
right posterior inferior parietal lobe (they think right said is dominant in choosing what to pay attention too)
anosognosia
deny symptoms such as paralysis, safety problem, they will say it’s not their arm
pusher syndrome
uses non paretic extremities to push away
prosopagnosia
inability to recognize familiar faces
perceptual disorder classifications (4)
body image/scheme
spatial relations
agnosias
apraxia
screening is more than a test, it is a program (T/F)
true
orientation
adjustment of the body and head to vertical
stability
ability to maintain the center of mass within the base of support
anterior canals detect
nodding your head
posterior canals detect
side bend
saccule detects
motion in the sagittal plane
superior vestibular nucleus
VOR (semicircular)
lateral vestibular nucleus
LVST (Utricle and saccule)
medial vestibular nucleus
MVST (semicircular)
inferior vestibular nucleus
RF, cerebellum, SC
when learning new motor skills you rely more on (visual/somatosensory) input
visual (same with children)
suspensory strategy for balance
lower the COG towards BOS, crouch down
acoustic neuroma
tumor of vestibulocochlear nerve
vestibular hypofunction (unilateral)
feels like you are moving toward uninvolved side (more activity)
cupulolithiasis
dislodged otoconia adhere to cupula
canalithiasis
dislodged otoconia are free-floating (more common)
Meniere’s Disease
fluctuations in fluid and electrolyte control in inner ear
stupor
barely conscious state, can only be aroused briefly
obtunded
sleeps often, and when aroused has decreased alertness
post-traumatic amnesia
period of both retrograde and anterograde amnesia after mod/severe TBI
Glascow Coma Score
13-15 = mild concussion 9-12 = moderate 3-8 = severe
Ranchos Level 1
no response
Ranchos Level 2
general response (inconsistent, nonpurposeful)
Ranchos Level 3
localized response (specifically, but inconsistently)
Ranchos Level 4
confused - agitated (bizarre, nonpurposeful)
Ranchos Level 5
confused - inappropriate
Ranchos Level 6
confused - appropriate (dependent on external input or direction)
Ranchos Level 7
automatic - appropriate (shows carryover for NEW learning, impaired judgement)
Ranchos Level 8
purposeful - appropriate (needs no supervision once activity is learned)
key to manage agitation
prevent escalation, modify environment
key to manage confusion
external structure
key to manage impulsivity
consistency across caregivers, verbal rehearsal
key to manage disinhibition
calm, provide concrete feedback
key to manage perseveration
curing and pacing to interrupt repetitive behavior, stimulus to move onto next step
key to manage confabulation
may be serving a purpose like reducing anxiety… ignore it if low functioning, nonthreatening feedback of inaccuracy in higher functioning, redirection
key to manage inability to self-reflect
use concrete goals
key to manage apathy
treatment should target choices and acknowledge accomplishment
key to mange lack of initiation
cueing to start activity
anoxic brain injury
incidents that alter the amount of oxygen in the blood (poor prognosis)
most adult tumors are ___(supra/infra)tentorial
supra, children are more likely infra (cerebellum, brainstem)
adenoma
gland (usually benign)
blastoma
malignant tumor whose cells have underdeveloped characteristics
glioma
any tumor that arises from supportive tissue of the brain (can be benign or malignant)
most common type of glioma
astrocytoma
most common malignant primary CNS tumor in children
medulloblastoma
most common benign CNS tumor
meningioma
craniotomy
resection of skull overlying tumor and replacement of bone flap
normal ICP
0-15, emergency is over 20
ALS
most common form of adult-onset progressive motor neuron disease, UMN and LMN, spreads from one focal region to another adjacent area, axonal degeneration distal to proximal
ALS on EMG
spontaneous potentials at rest (acute denervation)
reduced motor recruitment (reduced number of motor units)
re-innervation changes (chronic denervation with re-innervation)
ALS on nerve conduction study
reduction combined motor AP (fewer functioning motor axons) normal latency and velocity (myelin unaffected) normal sensory (unaffected)
ALS on muscle biopsy
grouping of fiber types (checkerboard)
ALS disease modifying drugs
Rilutek and Radicava
exercise guidelines for ALS
concentric
moderate intensity
energy conservation
post-polio syndrome
overwork weakness of giant motor units 20-40 years after resolution, energy conservation is big for this group
GBS
autoimmune disease, progressive muscle weakness and respiratory paralysis (PNS)
types of GBS
AIDP: demyelination, better prognosis
AMAN: axon, nodes of ranvier
medical treatment of GBS
plasmapheresis
intravenous human immunoglobulin
NOT COTRICOSTEROIDS
PT for acute GBS
pain management
ROM
positioning
gentle stretching
peripheral nerve injury seddon classification
neurapraxia
axonotmesis
neurotmesis
peripheral nerve sunderland classification
1-5
mononeuropathy multiplex
asymmetrical involvement of several nerves
polyneuropathy
distal and symmetrical involvement of many nerves
MS
most common inflammatory demyelinating disease of CNS
early symptom: optic neuritis (cellophane in one eye)
HEAT INTOLERANCE, fatigue, ANS dysfunction
Diagnosis of MS
dissemination in space (2 sites) and time (1 month apart) periventricular juxtacortical infratentorial spinal cord
primary vs. secondary progressive MS
secondary is when you start out with relapsing-remitting and then start just progressing over time
treatment of relapse in MS
corticosteroids
risk factors in MS
living far from equator (Vit. D)
epstein barr
types of MS
clinically isolated syndrome
RRMS
PPMS
SPMS
how many drugs are there to treat MS
22
uthoff’s sign
worsening of neuro symptoms in MS due to heat intolerance
which drug is used for PPMS
ocrevus
when is PT contraindicated for MS?
acute exacerbation + corticosteroids
cardinal motor signs of PD
TRAP tremor at rest rigidity akinesia/bradykinesia postural instability
types of PD
primary
secondary (from brain injury)
parkinson-plus
parkinson-plus syndromes
progressive supranuclear palsy
multiple system atrophy
corticobasal ganglionic degeneration
Lewy body dementia
which circuits are involved in PD
motor associative (DLPFC = executive functioning) limbic = emotional regulation effects
where are lewy bodies first seen?
low in brainstem, work their way up, see symptoms in midbrain,
more cognition problems towards end due to cortical areas
cogwheel vs. lead pipe rigidity
cogwheel = jerky leadpipe = constant, uniform resistance
microgrpahia
writing starts out big but gets smaller
hypophonia
voice amplitude is smaller
PD prodromal symptoms that occur before motor
OH, bladder dysfunction, constipation, anosmia (loss of smell), excessive daytime somnolence, rapid eye movement
progresive supranuclear palsy
most common PP supranuclear ophthalmoplegia (cant look down), postural instability
multiple system atrophy
dont respond to levodopa, hyperkinetic dysarthria (6 years survival)
corticobasal ganglionic degeneration
cortical atrophy of frontal and parietal + loss of D in SN
early cognitive dysfunction
dementia with lewy bodies
early cognitive symptoms
visual hallucinations
really exaggerated responses to antipsychotics
diagnosis of PD
must have bradykinesia w/ tremor and/or rigidity, absence of secondary cause, definite dx made w/ autopsy
HD
HD gene, more than 40 repeats will causes disease
more repeats = younger onset
early: loss of GABA pathway neurons (D2) –> more movement
late: loss of D1 and D2 –> less movement
can have movement, cognitive, and psychiatric issues
age of onset 30-50
how does HD present in kids (less than 20 y.o.)
more like PD
HD dx
family history, presence of extrapyramidal movement disorder
medical treatment for HD
chorea: DA blockers and DA-depleting drugs
depression: tricyclic antidepressants
irritability/aggressive behaviors: atypical antipsychotics
