Neuromuscular Flashcards
Akinesia
The inability to INITIATE movement
Agnosia
The inability to recognize familiar objects with one form of sensation
Broca’s aphasia
Expressive. Severe difficulty in verbal expression, impairment and object naming and writing
Brokas aphasia is mostly found with what other comorbidity
Right hemiplegia
What is the most common form of aphasia
Global
Global aphasia
Characterized by reduced speech and comprehension; reading and writing are impaired as well
Astereognosis
The inability to recognize objects by touch alone
Asynergia
Inability to move muscles together In a Cordinated manner
Ataxia
Uncoordinated movements especially gait
Athetosis
Slow involuntary wormlike twisting motions. Usually seen in forms of cerebral palsy
Causalgia
Burning sensations which are painful. Associated with complex regional pain syndrome.
Complex regional pain syndrome used to be known as
Reflex sympathetic dystrophy
Cheyne-Stokes respiration
It’s a breathing pattern characterized by period of apnea lasting 10 the 60 seconds followed by gradually increasing and decreasing the depth and frequency of respirations
What are the pathologies associated with Cheyne-Stokes respiration
Severe cases of TBI or CHF
Chorea
Rapid involuntary jerking movement. Especially in Huntington’s
Clonus
Rhythmic oscillation of a muscle in response to sustain stretch in patients with upper motor neuron disease
Decerebrate rigidity
Contraction of extensor muscles of the upper and lower. Due to injury at level of brainstem
Decorticate rigidity
Contraction of flexors of uppers and extensors of lowers
Delirium
Temporary confusion and loss of mental function
Dementia
Loss of memory or intellectual functioning
Dysmetria
Inability to judge distances. Seen especially in cerebellar dysfunction
EMG or electromyography
Study of the contraction of a muscle as a result of electrical stimulation.
Used to evaluate voluntary electrical activity of a muscle
Glove and stocking anesthesia
Generalized peripheral neuropathies distal portions of nerves degenerate resulting in anesthesia of distal extremities as if gloves or stockings.
Occasionally seen in Guillain-Barré syndrome
Shingles or herpes zoster
Painful inflammation of posterior root ganglion caused by virus, formation of vesicles or fluid filled sacs a long course of nerve or Dermatome
Horner’s syndrome
- Ptosis of the eyelid
- Constriction of pupil
- Lack of feeling in the ipsilateral face
- Often accompanying stroke involving:
anterior inferior or
posterior inferior cerebellar arteries
Morton’s neuroma
Excessive pronation during stance. Compression between third and fourth metatarsal’s
NCV or nerve conduction velocity test
Determines the speed of propagation of an action potential along the nerve or muscle fiber
What is the latency of a nerve
The time the potential takes to travel between two points
If latency is increased what does this signify
The nerve is compressed or damaged
Reciprocal inhibition
Inhibition of muscles antagonistic to those being facilitated. Essential for coordination
Somatagnosia
Lack of awareness of the relationship of one’s own body parts or the body parts of others
Vegetative state
A deep coma, with abnormal posturing
Homonymous hemianopsia
A deficit of either the right or left halves of the visual field. Caused by damage to the contralateral optic tract
Bitemporal hemianopsia
A deficit of the temporal or peripheral visual fields. Caused by injury at the optic chiasm. Also known as Tunnel vision
What are the most common sites for lesions to occur with a cerebrovascular accident
- Bifurcation of the common carotid artery
- Main bifurcation of the middle cerebral artery
- Junction of the vertebral arteries with the basilar artery
What is the most commonly involves artery associated with a stroke
Middle cerebral artery
What are the signs and symptoms associated with a middle cerebral artery stroke
- Contralateral hemiplegia, mostly upper extremity involvement, loss of sensation primarily in arm and face
- homonymous hemianopsia
- Aphasia, apraxia, or global aphasia depending on site and severity of occlusion
Occlusion of which hemisphere well cause aphasia and apraxia
Dominant Left hemisphere
What can cause global aphasia
Occlusion of the main stem of the middle cerebral artery
What signs and symptoms are associated with anterior cerebral artery occlusion
- Rarely involved
- Lower extremity more frequently affected
- Contralateral hemiplegia and sensory loss
- Possible mental confusion, aphasia, and contralateral neglect if involvement is extensive on dominant side
What signs and symptoms are associated with posterior cerebral artery occlusion
- Persistent pain syndrome or contralateral pain
- Temperature sensory loss
- Possible Homonomous hemianopsia, aphasia, and thalamic pain syndrome
What signs and symptoms are associated with vertebrobasilar artery occlusion
- Often results in death from the edema associated with the infarct
- If lesion affects of the Pons, results in quadriparesis and bulbar palsy AKA locked in syndrome
What are the signs and symptoms associated with anterior inferior cerebellar artery occlusion
- Unilateral deafness
- Loss of pain and temperature on the contralateral side
- Paresis of lateral gaze
- Unilateral Horner’s syndrome
- Ataxia, vertigo, and nystagmus
What are the signs and symptoms associated with superior cerebellar artery occlusion
- Severe ataxia
- Dysarthria (Loss of muscle articulation control)
- Dysmetria (Finger to nose test)
- Contralateral loss of pain and temperature
Dysarthria
Loss of muscle articulation control
What are the signs and symptoms of posterior inferior cerebellar artery occlusion
- AKA Wallenburg’s syndrome
- Vertigo, nausea
- Hoarseness, dysphagia
- Ptosis, decreased impairment of sensation in ipsilateral face and contralateral torso and limbs
- Horner’s syndrome might also appear
What is stage one of recovery following a stroke
Flaccid, no limb movement
What is status two of recovery following a stroke
Synergies may appear. Spasticity begins to develop. Minimal voluntary movement
Stage III recovery following a stroke
Spasticity increases, may become severe. Voluntary control of movement synergies appear
Stage 4 recovery following a stroke
Some movement independent of synergies. Spasticity begins to decline
Stage five recovery following a stroke
Synergies no longer dominate and movement becomes more complex
Stage six recovery following a stroke
Spasticity is gone. Coronation a movement approach normal
How would you describe the upper extremity flexion synergy
Trying to scratch the back of your head with Your 5th MCP joint
How would you describe the extension synergy of the upper extremity
Trying to pull down your tail between your legs if you have one
What is usually the strongest component in the upper extremity flexion synergy
Elbow flexion
What is usually the strongest component in lower extremity flexion synergy
Hip flexion
How would you describe the lower extremity Flexion synergy
Trying to scratch the contralateral MCL with your heel
How would you describe lower extremity extension synergy
Ballerina Toe with kneecap facing contralateral MCL
What are some treatment ideas for Hypotonicity
- Avoid joint hyperextension
- Joint compression
- Resistance of functioning muscles, isometric holds
- Joint approximation facilitates co- contraction
What are some risks with hypertonicity
- Spastic high tone with hyperactive reflexes and decreased thoracic mobility
- Risk of contractures and deformity
- Changes in body position can affect tone
What are some treatment ideas for hypertonicity
- Work to inhibit reflex activity via postures, positions
- Prolong static muscle stretch, inhibitory casting, slow repetitive rocking, very low-frequency vibration
- Limb movements emphasizing rotation
- Reciprocal inhibition (Facilitate non-spastic muscles to inhibit spastic muscles)
Define a Equinus gait
The heel does not touch the ground due to spasticity or contractures of gastroc-soleus
Spastic toe flexors can cause what gait deviation
Unequal step length due to hammertoes
Weak abdominal muscles can cause what in the swing phase
Insufficient forward pelvic rotation
A spastic anterior tibialis, weak peroneals, And toe extensors Would cause what in the swing phase
Varus position of the foot throughout swing phase
List seven problems associated with a stroke in the right hemisphere
- Left hemiparesis
- Problems with spatial relationships and hand eye Coordination
- Irritability, short attention span
- Poor judgment affecting personal safety
- Diminished body image with left-sided neglect
- Quick and impulsive
List seven problems associated with a stroke in the left hemisphere
- Right hemiparesis
- Apraxia
- Difficulty starting and sequencing tasks
- Perseveration
- Easily frustrated with high levels of anxiety
- Inability to communicate verbally
- Cautious and slow
Rancho level one
No response. Completely unresponsive to any stimuli
Rancho level two
Generalized response. Reacts inconsistently and non-specifically to stimuli
Rancho level III
Localized response. Reacts inconsistently but specifically to stimuli
Rancho level four
Confused/agitated.-State of activity, behavior is bizarre and not purposeful. Poor attention span and recall
Rancho level five
Confused/inappropriate. Responds to simple commands, can’t do complex tasks. Verbalization inappropriate
Rancho level six
Confused/appropriate. Dependent on external input, can perform consistently, memory improved
Rancho level seven
Automatic/appropriate. Perform automatically and appropriately and structured environment. Judgment remains impaired
Rancho level eight
Purpose/appropriate. Ask appropriately but not perfectly. May have some problems and stressful or unusual circumstances
A Glasgow coma scale score of eight or less indicates what
Severe brain injury
What three categories does the Glasgow coma scale test
Eye-opening. Best motor response. Verbal response.
What are some signs and symptoms for ALS
Muscle weakness is progressive. Affects muscle respiration. Weakness may appear in hands first. Dysphasia. LMN signs. UMN signs. Often no sensory changes
What should treatment focus on for ALS
Maintain respiratory function and activity levels
PROM exercises
Prevent further deconditioning
Avoid overworking muscles and teach energy conservation
What nerve is affected in Bell’s palsy
Facial nerve cranial nerve seven
What signs and symptoms might you see you with Bell’s palsy
- Difficulty in reaching the four head, closing the eye tightly, smiling
- Uncontrolled salivation, one sided facial muscle weakness, NORMAL sensation
- Decrease taste sensation anterior two thirds of tongue
What is Guillan-barré syndrome
- LMN DISEASE
- Polyneuropathy of probable immune-mediated viral origin
- Symmetric motor paralysis and progressive muscular weakness
- Ascending pattern, LE before UE
What are signs and symptoms of Guillan-barré syndrome
Sensory loss (stocking/gloves). Muscle weakness progresses from lower to upper extremities, distal to proximal. Recovery is slow of up to one year. 3% mortality rate
What is thalamic pain and what is it associated with
Continuous intense pain occurring on contralateral hemiplegic side. Associated with a stroke involving the posterior cerebral artery
What is the difference between CRPS 1 and CRPS 2
CRPS one causes tissue injury without nerve damage.
CRPS 2 involves innervate injury
Neuralgia
Pain occurring along the nerve
Causalgia
Burning pain
Radiculalgia
Neuralgia of nerve roots
Asymmetrical tonic reflex ATNR
Birth
Integration: 4-6 months
Prolonged influence can result in scoliosis or hip subluxation
If ATNR reflex is severe what must patient due to grasp objects
Look away from the object so that the extended arm has less influence from reflex
Crossed extension reflex
Opposite lower extremity flexes then adducts and extends when noxious stimuli Is applied to ball of the foot
Onset: 28 wks
Integration: 1-2 mos
Onset of equilibrium reaction in prone
Six months
Onset of equilibrium reaction in supine
7 to 8 months
Onset of equilibrium reaction in sitting
7 to 8 months
Onset of equilibrium reaction in kneeling
9 to 12 months
Onset of a equilibrium reaction in standing
12 to 21 months
Palmer grasp
Onset: At birth
Integrated: 4-6 months
Plantar grasp
Onset: 28 weeks gestation
Integrated: 9 months
Landau’s reflex
Onset: three months
Integrated: two years
Superman, extend head first then legs
Moro reflex
Onset: 28 weeks gestation
Integrated: 5 to 6 months
Optical and labyrinthian righting reflexes
Eyes covered when testing labyrinthine reflex
Onset: birth - two months
Positive supporting reaction
Onset: birth
Integrated: six months
Protective extension reaction
Onset: arms four to six months
Legs 6 to 9 months
Integrated: persists
Rooting reflex
Onset: present in premature infants
Integrated: three months
Symmetrical tonic neck reflex STNR
Onset: 4-6 months
Integrated: 8 – 12 months
Note: can strongly influence the ability to assume a quadruped position as well as the ability to crawl
Tonic labyrinthine reflex
Prone: increased flexor tone
Supine: increased extensor tone
Onset: birth
Integrated: six months
Traction reflex
Onset: 28 weeks just station
Integrated: 2 – 5 months
What should a one-month-old be able to do
Lifts head, follows a moving object and exhibits reflex stepping, positive support reflex, decreased flexion, hands fisted with indwelling thumbs most of the time, reciprocal and symmetrical kicking, neonatal reaching
What should a two month old be Able to do
Lifts head 45° in prone, head lags on pull-to-sitting, smiles, begins prone on elbows with elbows behind shoulders, head bobs in supported sitting
What should a three-month old be able to do
Prop self into prone on elbows with weight on forearms, coos, chuckles, takes weight with toes curled in supported standing, head elevation to 90°
What should A four-month old be able to do
Prop head and chest for a long time pivot Prone, head no longer lags in pulled to sitting, sits with support, laughs out loud, rolls prone to side, supine to side, optical and labyrinthine head righting present, and ulnar Palmer grasp
What should a five-month-old be able to do
Roll from prone to supine, head control and supported sitting, weight shifting from one forearm to the other in prone
What should a six-month-old be able to do
Rolls from supine to prone, Independent sitting, pulls to stand, prone on hands with Elbows extended while weight shifting from hand to hand
What should a seven-month old be able to do
Maintain quadruped, Pivots on belly, prone extension position (pivot prone), assumes Sitting from quadruped, trunk rotation in sitting, recognizes tone of voice
What should and 8 - 9 month old be able to do
Belly crawls, quadruped creeping, side sitting, pulls to stand through kneeling, cruising sideways, can stand alone, has pincher grasp with thumb and forefinger, can transfer object from one hand to the other, moves quadruped to sitting
What can a 10 to 15-month-olds do
Stands and begins to walk unassisted, begin self-feeding, searches for hidden toys, plays pattycake and peekaboo, imitates, reaches with supination, meet pincher grasp with release.
What can an 18 to 20 months old do
Walk up and down stairs with assistance, Ascends stairs with step-to pattern, sits on a small chair, begins to run more coordinated, jumps off the bottom step, plays make-believe
What should a two-year-old be able to do
Runs well, can go upstairs one at a time reciprocal, active, restless, tantrums
What should a three-year-old be able to do
Goes downstairs or reciprocally, rides tricycle, begins to catch a ball, Jumps with 2 feet, understands sharing, stands on 1 foot briefly
What should be 3 1/2 year-old be able to do
Hops on 1 foot, kicks a ball
What should a four-year-old be able to do
Hops on 1 foot several times, climbs, throws a ball overhand, stands on tiptoes, and relates to friends
What’s a five-year-old be able to do
Skips, kick the ball well, dresses and undresses self
What is Apgar scoring
The system to evaluate the status of a newborn.
Measured at birth then at one, five, 10, and 15 minutes after birth
What is the range of an Apgar scoring
The total score of seven or more is normal.
5 to 6 require some care.
4 or less requires immediate care
What nerve roots on involved with Upper Erb’s palsy
C5 and C6 nerve roots are stretched during the birth process
What are classic signs and symptoms of upper Erb’s palsy
Weakness in shoulder abduction and external rotation, elbow flexion, supination.
Shoulder is abducted and internally rotated and presents with the “waiters tip” deformity
What nerve roots are involved with Lower Klumpke’s Palsy
C8 and T1 stretched during birth.
Resulting in weakness of hand and wrist flexors. Common “claw hand” appearance
Is cerebral palsy a progressive or nonprogressive disorder
Nonprogressive resulting from CNS damage
List the major causes for cerebral palsy
- Hemorrhage below the lining of the ventricles
- Hypoxic encephalopathy
- Malformations
- Trauma of the CNS
What are the four main syndromes of cerebral palsy
- Spastic: most common, UMN
- Athetoid: basal ganglia involvement
- Ataxic: Uncommon, results from cerebellar involvement
- Mixed forms: Spasticity and athetosis And less often ataxia and athetosis
What are some signs and symptoms of spastic cerebral palsy
Spasticity affecting both limbs on one side hemiplegia both legs paraplegia, all four limbs tetraplegia, or intermediate form between Para and tetraplegia that affects mostly the legs diplegia.
Affected limbs have:
increased deep tendon reflexes, increased muscle tone,
abnormal postures,
Scissors gate and tell walking are characteristic
What activity should be limited with a patient with Trisomy 21
Forceful neck flexion and rotation secondary to atlantoaxial ligamentous laxity and potential for subluxation or SCI
Duchenne’s muscular dystrophy affects males or females; Progressive or nonprogressive; distal proximal; what age range?
- Males
- Progressive weakness
- Proximal to distal
- 3 to 7 years old
Exhibit waddling gait pattern, toe walking, Gower’s sign, difficulty climbing stairs secondary two weak Gluteal and quadriceps muscles
Quadricep muscles
Charcot Marie tooth disease is also known as; pathology
Peroneal muscular atrophy
Hereditary disorder of the Peroneal and distal leg muscles
What is the most common problems associated with Charcot Marie tooth disease
Footdrop and “stork leg deformity”
What is Legg-Calvé-Perthes disease
Idiopathic aseptic necrosis of the femoral capital epiphysis
Usually unilateral, affecting mostly boys between five and 10 years
Common treatment for Legg-Calvé-Perthes disease
- Special hip abduction orthosis
- Casting
- Mobile traction and slings
- Prolonged bedrest
What percentage of spinal cord injuries are atraumatic
10%
The most common areas injured for cervical spine cord injuries are
C5 and C7
What is the most common site for Spinal cord injury in thoracic region
Less likely to be injured from traumatic causes due to rib cage and higher stability.
T12 – L1 Junction is most common site of injury
What are the most common levels for spinal cord injury in the lumbar area
L1 or L2. Below these levels the cauda equina is less likely to sustain a complete injury.
Trauma usually incomplete due to large vertebral canal and relatively good vascular supply
How is the spinal cord Usually damaged
Physical impingement on the cord or by interruption of the cord vascular supply.
Actual transection of the cord is rare
What are some pathological changes that accompany trauma to the spinal cord
- Blunt trauma results and some primary destruction of neurons at level of injury
- Most damage is caused by secondary sequela (Progressive tissue destruction within the cord)
- Tissue damage may travel up and down the cord 1-3 segments
- The chronic tissue gradually reabsorbed replaced by scar tissue
List three mechanisms of secondary tissue distruction of the spinal cord
- Ischemia
- Edema
- Demyelination
Describe the mechanism of secondary tissue destruction via demyelination
Calcium ions accumulate in the injured cells. Abnormal concentration disrupts functioning and causes demyelination and destruction of cell membrane and axonal cytoskeleton
Describe spinal shock
Temporary phenomenon occurs after trauma to spinal cord.
Cord ceases to function below lesion.
Usually resolves within 24 hours of injury with return of anal and bulbocavernosus reflexes.
Designation of spinal level regarding spinal cord injury means what to a clinician
Spinal level is defined as the most caudal level of the spinal cord that exhibits INTACT sensory and motor functioning
Must be 3+/5
Define A complete spinal cord lesion
Total and permanent functional (sensory and motor) destruction of the spinal cord more than THREE segments below the level of the lesion
Describe spinal cord pathology with Brown Sequard syndrome
Hemi section of the spinal cord, usually from stab or gunshot wounds
What are signs and symptoms of Brown Sequard syndrome
- IPSILATERAL side of lesion has weakness, Loss of proprioception, Vibratory sense, two point discrimination
- Decreased reflexes
- clonus, spasticity
- Contralateral side has loss of pain and temperature starting a few levels below lesion
Describe a spinal cord pathology with anterior cord syndrome
Trauma to anterior cord or damage of the anterior spinal artery usually related to flexion injuries of the cervical region
What are signs and symptoms of anterior cord syndrome
Loss of motor function and pain and temperature below level of lesion
Describe Spinal cord pathology with central cord syndrome
Commonly occurs from hyperextension injuries with minor trauma to cervical region
Describes signs and symptoms with central cord syndrome
Absent UE sensation and motor functioning with normal LE functioning
Describe signs and symptoms of posterior cord syndrome
Very rare. Deficits of kinesthesia (stereognosis, two point discrimination) and proprioception
Ataxic gait with wide base of support may result
Describe sacral sparing
Refers to incomplete lesion where most central located Sacral tracts are spared.
Perianal sensation, rectal sphincter contraction, cutaneous innervation of saddle, and active contraction of sacral innervated toe flexors intact
Paralysis of voluntary motor control occurs from damage to what tracts, cells or nerves?
- Descending motor tracts
- Anterior horn cells
- Spinal nerves
After spinal shock resolves what happens to the effects of the reflexes
Reflexes return and progressively become stronger resulting in spasticity
Spasticity is more prevalent with higher or lower lesions, complete or incomplete?
Higher lesions and incomplete lesions
Quick stretching of the muscles elicits What from reflexive responses?
Exaggerated reflexive response
Voluntary control of urination and defecation is controlled by which spinal cord levels
S2, S3, and S4
Describe a reflexive bladder
Upper motor neuron.
Empties in response to a certain level of filling pressure
Describe autonomous or non-reflexive bladder
Lower motor neuron.
Flaccid bladder emptying by increasing intra-abdominal pressure or manually compressing lower abdomen.
Describe what happens when an injury blocks communication between the brainstem and thoracolumbar cord
- Sympathetic import to the heart is lost but parasympathetic input remains
- Results and bradycardia, peripheral vasodilation and hypotension
Describe what happens when a cord injury interrupts communication with the hypothalamus
Thermoregulation is altered. Causes hypothermia due to peripheral vasodilation.
Reflexive tone returns and prevents peripheral vasodilation.
Later hyperthermia occurs secondary to loss in sympathetic control of Sweat glands
Sweating does not occur below lesion. To compensate diaphoresis occurs above lesion
What is autonomic dysreflexia and what are the signs and symptoms
Medical emergency. Severe increase in blood pressure, bradycardia, pounding headache, Flushing, diaphoresis and anxiety.
Occurs in lesions above T6. Prevalent in the first three years after SCI
What is the most common cause of autonomic dysreflexia
A distended bladder
If the patient is supine and starts to exhibit signs and symptoms of autonomic dysreflexia what should you do next
Sit the patient up to lower blood pressure And check for a kink in Foley catheter
What is the main reasons SCI injury patients experience orthostatic hypotension
Lack of muscle tone and loss of sympathetic vasoconstriction causes venous pulling in the periphery.
Immobilization of 6 to 8 weeks results and postural hypotension
What is heterotopic bone formation
Different from myositis ossificans. Occurs in 16 to 53% of all patients with SCI
Appears 1 to 4 months post injury.
Treatment consists of drug therapy and regular exercise during early stages of ectopic bone formation
A SCI C1-C3 is capable of what and has which key muscles?
- Requires ventilator; can use sip-n-puff WC
2. Face and neck
A SCI C4 is capable of what and has which key muscles?
- Ind Respiration, scap elevation, drive WC c chin control
2. Diaphragm & trapezius
A SCI C5 is capable of what and has which key muscles?
- Elbow flexion, supination, shldr ER, abduction to 90, ltd shldr flex
- Biceps, brachialis, brachioradialis, deltoid, infraspinatus, rhomboids, supinator
A SCI C6 is capable of what and has which key muscles?
- Shldr flex/ext/IR/ADDuction, scapular abduction/upward rotation, pronation, wrist ext, TENODISIS GRIP
- ECR, infraspinatus, Lat dorsi, Pec major, SA, teres minor
A SCI C7 is capable of what and has which key muscles?
- Elbow extension, wrist flexion, finger extension
2. EPL,EPB, FCR, TRICEPS!
A SCI C8 is capable of what and has which key muscles?
- Can use all UE except INTRINSICS of hand
2. FCU, FPL, FPB, extrinsic finger flexors
A SCI T1-T5 is capable of what and has which key muscles?
- Ind UE, better trunk control, inc resp reserve
* can use wheelie technique - Top half of: intercostals, long muscles of back, intrinsic finger flexors
A SCI T6-T8 is capable of what and has which key muscles?
- Inc trunk, inc resp reserve
- Sacrospinalis, semispinalis
*Ind swing to gait in II bars c KAFOs (short distances)
A SCI T9-T12 is capable of what and has which key muscles?
- Inc endurance, inc trunk control
- Lower abs, all intercostals
*ind swing through gait c B KAFOs (household dist)
A SCI T12-L3 is capable of what and has which key muscles?
- Hip flexion/ADDuction, knee ext
- Gracilis, iliopsoas, quadratus lumborum, rectus femoris, sartorius
*ind swing to/through/4 point c B KAFOs (ind home ambulators)
A SCI L4-L5 is capable of what and has which key muscles?
- Strong hip flex & knee ext, weak knee flex, inc trunk control
- Low back muscles, medial ham weak, posterior tibialis, quads, tibialis anterior
- ind home ambulator
- *can be community ambulators
