Neuro Stroke, Concussion, TBI Flashcards
Flexor Synergy of the UE
- Scapula: Elevation and retraction
- Shoulder: abd and ER
- Elbow: Flexion
- Forearm: Supination
- Wrist: flexion
- Fingers: flexion and add
- Thumb: flexion and add
Extensor Synergy of the LE
- Hip: Ext, IR, and add
- Knee: Extension
- Ankle: PF and inversion
- Toes: Flexion and adduction
Flexor Synergy of the LE
- Hip: Abd and ER
- Knee: Flexion
- Ankle: DF and inversion
- Toes: extension
Extensor synergy of the UE
- Scapula: Depression and protraction
- Shoulder: Add and IR
- Elbow: Extension
- Forearm: Pronation
- Wrist: Extension
- Fingers: Flexion and adduction
- Thumb: Flexion with adduction
What is always out of the UE synergy patterns?
wrist and finger extension with abduction
What is always out of the LE synergy patterns?
ankle eversion
Fluent Aphasia
Lesion varies based on the type of fluent aphasia but frequently involves the temporal lobe, Wernicke’s area or regions of the parietal lobe
*Word output and speech production are functional
*Prosody is acceptable, but empty speech/jargon
Speech lacks any substance, use of
paraphasias
* Use of neologisms (substitution within a word that is so severe it makes the word unrecognizable)
Non-fluent aphasia
Lesion varies based on the type of non-fluent aphasia, but frequently the frontal lobe (anterior speech center) of the dominant hemisphere is affected
*Poor word output and dysprosodic speech
*Poor articulation and increased effort for speech
*Content is present, but impaired syntactical words
2 types of fluent aphasia
Wernicke’s Aphasia (i.e., receptive aphasia)
* Lesion: posterior region of superior temporal gyrus
* Comprehension (reading/auditory) impaired
* Good articulation, use of paraphasias
Impaired writing, naming ability
* Motor impairment not typical due to the distance from Wernicke’s area to the motor cortex
Conduction Aphasia
*Lesion: supramarginal gyrus, arcuate fasciculus
*Severe impairment with repetition
* Intact fluency, good comprehension
* Speech interrupted by word-finding difficulties
Reading intact, writing impaired
2 types of non-fluent aphasia
Broca’s Aphasia (i.e., expressive aphasia)
*Lesion: 3rd convolution of frontal lobe
* Intact auditory and reading comprehension
* Impaired repetition and naming skills
* Frustration with language skill errors
* Motor impairment typical due to proximity of Broca’s area to the motor cortex
* pictures
Global Aphasia
* Lesion: frontal, temporal, parietal lobes
* Comprehension (reading/auditory) is severely impaired
* Impaired naming, writing, repetition skills
* May involuntarily verbalize, usually without correct context
* May use nonverbal skills for communication
What is associated with poor prognosis with aphasia?
- perseveration of speech
- severe auditory comprehension
- unreliable yes/no
- use of empty speech without recognition of impairments
Brunnstrom 7 stages of recovery
Stage 1: (flaccidity) No volitional movement initiated.
Stage 2: (spasticity begins) The appearance of basic limb synergies. The beginning of spasticity.
Stage 3: (most spasticity) The synergies are performed voluntarily; spasticity increases.
Stage 4: (spasticity decreases) Spasticity begins to decrease. Movement patterns are not dictated solely by limb synergies
Stage 5: A further decrease in spasticity is noted with independence from limb synergies.
Stage 6: (can move much easier out of synergy patterns/spasticity) Isolated joint movements are performed with coordination.
Stage 7: Normal motor function is restored.
Symptoms varying on location of CVA – ACA
ACA
- contralateral hemiparesis
- > LE involvement
- sensory loss m (contralateral cortical sensory deficits)
- frontal signs
- altered mental status
- impaired judgement
- Gait apraxia
- Urinary incontinence
Symptoms varying on location of CVA – MCA
MCA
- UE > LE loss
- contralateral spastic hemiparesis
- sensory loss of face
- ipsilateral gaze
- Homonymous hemianopsia (loose either R or L visual field of B eyes)
- L infarct (if dominant) - aphasia and apraxia
Symptoms varying on location of CVA – PCA
PCA
- contralateral homonymous hemianopia
- acute vision loss
- thalamic branches: hemianesthesia
- posterior limb of IC or thalamus: contralateral sensory loss and hemiparesis
- left occipital cortex: alexia without agraphia
Others from crash course
- confusion
- new onset posterior cranium headache
- paresthesias
- limb weakness (contralateral)
- dizziness
- nausea
- memory loss
List out the Cranial Nerves
On Old Olympus Towering Tops A Finn And German Viewed Some Hops
I. Olfactory
II Optic
III Oculomotor
IV Trochlear
V Trigeminal
VI: Abducens
VII: Facial
VIII: Vestibulocochlear
IX: Glossopharyngeal
X: Vagus
XI: Spinal (accessory)
XII: Hypoglossal
Olfactory nerve
I
Afferent (Sensory): Smell (Nose)
Test: Identify familiar odors (chocolate, coffee)
Damage can lead to anosmnia
Optic Nerve
II
Afferent (Sensory): Sight
Test: visual fields and visual acuity
Oculomotor Nerve
III
Efferent (Motor): Voluntary motor
- levator of eyelid, superior, medial, and interior recti; inferior oblique m of eye.
- Autonomic: smooth m of eye
Test: upward, downward, and medial gaze; reaction to light
Trochlear Nerve
IV
Efferent (Motor): Voluntary motor
- superior oblique muscle of the eye
Test: downward and inward gaze
Trigeminal Nerve
V
Afferent (Sensory): Touch, pain
- skin of face, mucous membranes of nose, sinuses, mouth, anterior tongue
Efferent (Motor): Voluntary motor
- m of mastication
Test: Corneal reflex, face sensation, clench teeth; push down on chin to separate jaw
Abducens Nerve
VI
Efferent (Motor): Voluntary motor
- lateral rectus of the eye
Test: lateral gaze
Facial
VII
Afferent (Sensory): Taste Anterior tongue
Efferent (Motor):
- Voluntary motor: facial muscles
- Autonomic: lacrimal, submandibular, and sublingual glands
Test: close eyes tight; smile and show teeth, whistle and puff cheeks, identify familiar tastes
Vestibulocochlear
VIII
Afferent (sensory): Hearing and balance from ear
Test: hear watch ticking; hearing tests; balance and coordination test
Glossopharyngeal
IX
Afferent (sensory):
- touch, pain: posterior 1/3 of tongue, pharynx
- taste: posterior tongues 1/3
Efferent:
- voluntary: select m of pharynx
- autonomic: partoid gland
Test: Gag reflex; ability to swallow
Vagus
X
Afferent (sensory):
- touch, pain: pharynx, larynx, bronchi
- taste: tongue, epiglottis
Efferent (afferent):
- voluntary motor: m of palate, pharynx, and larynx
- autonomic; thoracic and abdominal viscera
Test: gag reflex; ability to swallow; say “ahh”
Accessory
XI
Efferent (motor):
- volunatry motor: SCM and trapezius m
Test: resist shld shrug
Hypoglossal
XII
Efferent (motor):
- Voluntary motor: m of tongue
Test: tongue protrusion (if injured, tongue deviates toward injured side)
Glasgow Coma Scale (and scoring of mild, moderate, and severe)
Neurological assessment tool used initially after injury to determine arousal and cerebral cortex function.
< 8 (3-8): severe brain jury or coma
9-12: moderate brain injuries
13-15: mild brain injury
Glasgow Coma Scale Categories
Eye Opening
- Spontaneous: 4
- To speech: 3
- To pain: 2
- Nil: 1
Best Motor Response:
- Obeys commands: 6
- localizes pain: 5
- withdraws: 4
- abnormal flexion: 3
- extensor response: 2
- nil: 1
Verbal Response:
- oriented: 5
- confused conversation: 4
- inappropriate words: 3
- incomprehensible sounds: 2
- nil: 1
MVE (6,5,4)
Eye Opening Category Scoring on GCS
Eye Opening
- Spontaneous: 4
- To speech: 3
- To pain: 2
- Nil: 1
Motor Category Scoring on GCS
Best Motor Response:
- Obeys commands: 6
- localizes pain: 5
- withdraws: 4
- abnormal flexion: 3
- extensor response: 2
- nil: 1
Verbal Response Category Scoring on GCS
Verbal Response:
- oriented: 5
- confused conversation: 4
- inappropriate words: 3
- incomprehensible sounds: 2
- nil: 1
What is the Glasgow Coma Scale score of a patient who withdraws from pain, converses but is confused, and opens his eyes spontaneously?
12
Anterograde amnesia
- Pts inability to create new memories after sustaining a TBI.
- In pts who become comatose, anterograde memory is typically the last to be recovered
Retrograde amnesia
- Pts inability to recall events that occurred prior to sustaining a TBI.
- Depending on severity of injury, retrograde amnesia may progressively decrease with recovery.
Post-traumatic amnesia
- typically associated with TBI.
- Characterized by inability to recall specific details associated with the event that caused a TBI, and those occurring soon after the injury.
Dissociative amnesia
- Psychological cause rather than physical injury.
- Forms include repressed memories, dissociative fugue, and post-hypnotic amnesia.
Why can cerebellar disorders have hypotonia?
- A decrease in the cerebellum’s ability to provide a faciliatory influence on the motor system
- Typical of cerebellum pathologies: difficulty performing accurate, smooth, controlled movement.
For a pt with a TBI that is at Lvl 4….they are currently being treated with 60 min session 3x/week though becoming increasingly combative as the session progresses. Best option to reduce pt fatigue?
Increase the rest periods during existing treatment sessions
- susceptible to changes in behavior based on fatigue. So first try adding in more rest breaks and then try modifying other aspects such as total time.
Coma definition
A state of unconsciousness and a level of unresponsiveness to all internal and external stimuli.
Stupor definition
A state of general unresponsiveness with arousal occurring from repeated stimuli.
Vigorous or unpleasant stimuli can arouse
Obtundity definition
A state of consciousness that is characterized by a state of sleep, reduced alertness to arousal, and delayed responses to stimuli.
State of sleep (irregular sleep-wake cycles)
Decreased alertness to arousal
Once aroused appears confused
Pt responds slow and has little interest in the environment (and decreased awareness)
Delirium definition
A state of consciousness that is characterized by disorientation, confusion, agitation, and loudness.
Clouding of consciousness definition
A state of consciousness that is characterized by quiet behavior, confusion, poor attention, and delayed responses.
Consciousness definition
A state of alertness, awareness, orientation, and memory.
Rancho Los Amigos Level 1
I. NO RESPONSE
Patient appears to be in a deep sleep and is completely unresponsive to any stimuli.
Rancho Los Amigos Level 2
II. GENERALIZED RESPONSE
Inconsistently and non-purposefully to stimuli in a nonspecific manner.
Responses - limited and often the same regardless of stimulus presented.
Responses with physiological changes, gross body movements, and/or vocalization.
Rancho Los Amigos Level 3
III. LOCALIZED RESPONSE
Reacts - specifically, but inconsistently to stimuli.
Responses - directly related to the type of stimulus
Follow simple commands (closing the eyes or squeezing the hand) inconsistent, delayed manner.
Rancho Los Amigos Level 4
IV. CONFUSED-AGITATED
Heightened state of activity.
Behavior - bizarre and non-purposeful relative to environment.
Unable to cooperate directly with treatment efforts.
Verbalizations - incoherent &/or inappropriate to the environment;
Confabulation may be present (false memory without purpose of deceit)
Gross attention - very brief;
Selective attention - often nonexistent.
Patient lacks short and long-term recall.
Rancho Los Amigos Level 5
V. CONFUSED-INAPPROPRIATE
Respond to simple commands fairly consistently.
Complex commands or lack of any external structure - responses non-purposeful, random, or fragmented.
Gross attention to the environment, highly distractible, lacks the ability to focus attention on a specific task.
Social conversation with structure is possible for short periods of time.
Verbalization often inappropriate and confabulatory.
Memory is severely impaired; often shows inappropriate use of objects;
May perform previously learned tasks with structure, but is unable to learn new information.
Rancho Los Amigos Level 6
VI. CONFUSED-APPROPRIATE
Goal-directed behavior (dependent on external input or direction)
Follows simple directions consistently and shows carryover for relearned tasks such as self-care.
Responses may be incorrect due to memory problems, but appropriate to the situation.
Past memories show more depth and detail than recent memory.
Rancho Los Amigos Level 7
VII. AUTOMATIC-APPROPRIATE
Appropriate and oriented within the hospital and home setting.
Daily routine automatically (more robot-like)
Minimal to no confusion and has shallow recall of activities.
Carryover for new learning (decreased rate)
With structure is able to initiate social or recreational activities;
Judgment remains impaired.
Rancho Los Amigos Level 8
VIII. PURPOSEFUL-APPROPRIATE
Recall and integrate past and recent events and is aware of and responsive to environment.
Carryover for new learning (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.
Name of a hemorrhage between the dura and arachnoid mater
In a coup-contrecoup brain injury resulting from an anterior impact, which side of the brain will be injured in addition to the site of impact?
Posterior
It is opposite the side of the impact
Which diagnosis is heterotopic ossification relatively common in?
In patients following head injury
S&S: decreased ROM, local swelling, and warmth.
NIH scale stroke
25 (very severe)
15-24 (severe)
5-14 (mild to moderate)
1-5 (mild impairment)
Bell’s Palsy is damage to which nerve?
Facial (CNVII)
What is impaired if unable to protrude the mandible?
Trigeminal nerve (motor for mastication)
Which nerve would be affected to cause diplopia?
Trochlear
innervates the superior oblique
Which two cranial nerves are responsible for the corneal reflex?
Trigeminal (Afferent)
Facial (Efferent)
Which 3 CN sense taste?
Glossopharyngeal
Facial
Vagus
Which 2 CN originate from the midbrain?
Trigeminal
Trochlear
Which 3 CN only possess sensory tracts?
Optic
Olfactory
Vestibulocochlear
When administering the Rinne test, what is the normal expected ratio of bone conduction to air conduction?
1 (bone conduction):2 (air conduction)
How to perform the Rinne test?
Rinne test, the examiner holds the vibrating tuning fork against the mastoid process until sound is no longer heard, then it is placed 1-2 cm from the auditory canal until sound is no longer heard. The normal expected ratio of bone conduction to air conduction is 1:2.
For which cranial nerve test do you use the Snellen chart?
Optic (CN II)
the patient stands 20 feet from the chart and proceeds to read the letters on the chart. The patient’s score is reported as 20 over the size of type the patient can read comfortably (e.g., 20/40).
Which nerve is commonly affected when a patient presents with nystagmus?
cranial nerve VIII
Nystagmus refers to rapid involuntary movements of the eyes. The presence of nystagmus can be identified by administering vestibuloocular reflex testing. Nystagmus can present in certain head positions with selected medical conditions such as benign paroxysmal positional vertigo.
Grades of Concussions?
Grade 1- (mild) transient confusion; no LOC; symptoms and mental status abnormalities resolve < 15 mins.
Grade 2 - (mod) transient confusion; no LOC; symptoms and mental state abnormalities last >15 mins.
Grade 3 - (severe) severe loss of consciousness.
Signs of increased intracranial pressure?
Headache, ataxia, loss of coordination.
What is NDT?
Neuro-developmental treatment
control initiation and sequencing control constructs
based on facilitation of normal postural control while inhibiting abnormal postural control and muscle tone.
- Pt is tasked at directing movements so the pt can experience normal movement.
- Then functional activities and movements are added.
- Focus on muscle tone first, them stability, and lastly mobility.
If the cerebellar lobe has a lesion will the effects be contralateral or ipsilateral?
Ipsilateral
