Neuromuscular and Nervous System Flashcards
1
Q
What is the CNS comprised of and what are its characteristics?
A
Made up of the brain + brain stem+ spine
- has white and gray matter that has either mylinated on non-mylinated axons and the diff regions of the brain,.
The white matter has 3 diff funiculli regions; dorsal, lateral and anterior columns.
2
Q
What is the PNS comprised of and what are its characteristics?
A
Made up of cranial nerves, associated ganglia and spinal nerves, associated ganglia and plexus
- there are 12 pairs cranial nerves that exit skull foramina
- 31 pairs of spinal nerves exit intervetebral foramina
- 8 cerv, 12 thor, 5 lumbar, 5 sacral 1 coc
take info to the CNS
spinal nerves have anterior efferent fibers take motor info away from CNS (AME) and posterior roots that take sensory info to the CNS via afferent fibers (PAS)
3
Q
What is the autonomic system ANS comprised of and what are its characteristics?
A
makes up the para and sympthetic system which is in part made up of the CNS and PNS anatomy.
- automatic responses for homeostasis and stress that do nto reach conscious level
4
Q
What is the somatic system SNS comprised of and what are its characteristics?
A
made up of peripheral and motor nerve fibers
takes motor info away from CNS and sensory info to the CNS
- somatic motor neurons will innervate skeletal muscle directly without synapsing
- controls all 5 senses
- all fibers are myelinated
5
Q
What is the limbic comprised of and what are its characteristics?
A
made up of the corpus callosum, olfactory tract, mamillary bodies, thalamic nuclei, amygdala, hippocampus and hypothalamic nucli
Purpose: control emption, recent memory, appetite (food+ mood)
- can lead to changes in mood, behavior, fear, sexual behanvior and motivation change.
6
Q
What are physiologic functions that the ANS controls. What could dysfxn of the ANS lead to?
A
- control BP, saliva, sweat, HR, tears,urination, defication, sexual arousal, breathing, homestasis, pupil dilation
- horners, ED, constipation, vasovagal syncope, orthostatic hypotension, tachycardia syndrome
7
Q
what does the left brain do
A
3 Ls: Logic, Love Language language; understand, written and spoken, process verbally coded info in organized manner analytic sequence and perform movements control logical rational math calculations positive emotions; love, happiness
8
Q
what does the right brain do
A
non verbal processing / communication art general concept comprehension hand- eye coordiantion spatial relationships kinestetic awareness non verbal communication math reasoning express negative emotions body image awareness
9
Q
what functions and impairments may occur at the frontal lobe
A
- the frontal lobe includes the primary premotor cortex and the precentral gyrus which enables voluntary movement.
- brocca’s area, usually in the left, produces speech and concentration
- personality, temper, judgement, reasoning, behavior, self awareness, and executive functions come from the frontal lobe
- impairments: CONTRA weakness, persevation, inattention, personality change, antisocial, apathy, Broccas aphasia (expressive), delayed/ poor initiation, emotional liability
10
Q
what functions and impairments may occur at the parietal lobe ?
A
- sense of touch, kinesthesia, perception of vibration and temperature
- gets info about hearing , vision, motor, sensory, and memory
- meaning for objects
- interpret lang/ words
- spatial and visual perception
- impairments: most people will have L cerebrum dominance (Dom R hand) and will have agraphia, alexia, or agnosia.
- non dom hemisphere involvement (R side); dressing apraxia, constructual apraxia and anosognosia
11
Q
what functions and impairments may occur at the temporal lobe ?
A
- auditory and smelling
- wernike’s (on left side) which gives abilty to understand/ produce meaningful speech understanding lang, verbal and general memory
- interpretation of emotions and reactions
impairment: learning deficit, wernike’s aphasia (receptive) antisocial and aggressive behavior . Difficulty to categorize objects, recognize faces, memory loss
12
Q
what functions and impairments may occur at the occipital lobe ?
A
- main center for processing visual info regarding shapes, light, and color. Determines distance and seeign in 3-D
Impairment: homonymous hemianopsia, imparied extra ocular mus movement and visual deficits, impareid color recognition, reading/writing impairment, cortical blindness with lobe involvement
** L homonymous hemianopsia will occur to a lesion on the R occipital lobe or optic tract and will tkae out the L field of vission on both eyes.
13
Q
what does the hippocampus do?
A
- part of the cerebrum
stores memories - what does a hippo look like
- H is for history
14
Q
what do the Basal ganglia do?
A
- part of the cerebrum
- deep in the white matter (white matter of cerebrum= cortex, outside=gray)
- includes the caudate, putamen, globus pallidus, substantia nigra and subthalamic nuclei.
- in charge of voluntary movement, and regulation of autonomic movement such as posture, tone, motor responses.
- WITH DAMAGE: tone does not change with speed and persists on both sides of the joint
- associated with huntingtons, OCD, addictive behavior, parkinsons, ADD, and tourettes.
15
Q
what does the amygdala do?
A
- part of the telecephalon
- in the temporal lobes
- in charge of emotional and social processing
- fear and arousal, emotioanl memories
16
Q
what is the telecephalon made up of?
A
also known as cerebrum
Hemispheres; Lobes (temporal, parietal, frontal, occipital,)
BG, amygala,
hippocampus.
Separated by fissures and sulci.
billions of neurons and glia make up the cerbral cortex
“CAHB” Cerbrun, hippocampus, amygdala, basal ganglia
17
Q
what does the Thalamus do?
A
- Cerebellum, sensory (except olfactory) BG info > cerebral cortex.
- Gather info from sensory perception and movement from the cerebellum, BG and sensory pathways and will take info to appropriate association cortex for contralateral side.
- Thalamic pain syndrome: spontaneous pain on contralateral side of body
18
Q
what does the subthalamus do?
A
- regulates movements for skeletal mus.
- associated with the BG and substanita nigra
19
Q
what does the epithalamus do?
A
- also the pineal gland, which secretes melatonin
- helps with the internal alarm clock, secretion of melatonin and circadian rhythms
20
Q
what does the Hypohalamus do?
A
gets info from the autonomic nervous system to regulate hormones and associated fxns such as sex drive, temp, adrenal glands, pituitary axis thirst and hunger.
21
Q
what is included in the midbrain?
A
tectum - superior / inferior colliculi,
tegmentum - Sub nigra, peri aqueductal gray, cerebral aquaduct, reticular formation, red nucleus
22
Q
what makes up the hindbrain ?
A
pons, medulla, cerebellum
brain stem - pons and medulla oblongata
23
Q
what does the cerebellum do?
A
refines movement like posture and balance by control of proprioception and tone.
Control of rapid alternating movements.
In charge of IPSIlateral movement
impairment: will present on IPSI side of the body. Ataxia, nystagmus, hypermetria, poor coordination and deficits in reflexes, balance and equilibrium
24
Q
What does the pons do? Where is it located in the brain ?
A
located in the cerebellum of the hindbrain (rhombencephalon)
- in charge of respiration
- orientation of the head in response to auditory and visual stimuli
- CN 5-8 originate from the pons
25
What does the medulla oblongata do? Where is it located in the brain ?
- in charge or ANS fxns such as breathing/ HR
- reflexes for coughing, sneezing, vomiting
- control of sleep
- somatic sensory info from organs
- Origin of CNs 9-12
26
What is meningitis? how is it diagnosed? What are the signs and symptoms?
- inflamation of the meninges by bacterial infection most often. Can be deadly in hours
- lumbar puncture is gold standard in dx. Tx with antibiotics, antibacterials and steriods. Epidural/ puncture will be at L3/L4, below where spinal cord ends at L1/2
SIGNS AND SYMPS:
Fever
stiff painful neck
lumbar pain
+ brudinskis sign; flexion of neck helps flex hip and knees
+ kernigs sign: pn with hip flexion and knee extension
light sensitivity
27
what is kernig sign?
pain with Knee extension and hip flexion combined movement
28
what type of info do ascending spinal tracts send and in which direction?
Ascending tracts receive afferent (sensory, DAS) from spinal ganglia interneurons, or gray matter and send the info to the cerebellum/ cerebrum. Tracts include:
- fasciculus cuneatus/gracilus tract
- spinocerebellar; dorsal and ventral tract
- spinoolivary tract
- spinoreticular tract
- spinotectal tract
- spinothalamic; anterior and lateral tract
29
fasciculus cuneatus tract
proprioception, vibration and 2 point discrimination, and graphesthesia for the UE
- dosal tract
30
fasciculus cuneatus/gracilus
cuneatus: proprioception, vibration and 2 point discrimination, and graphesthesia for the UE, trunk and neck
gracilus: proprioception, vibration and 2 point discrimination, and graphesthesia for the LE and trunk
31
spinocerebellar; dorsal and ventral tract
- proprioception
- muscle tension
- joint sense
- posture
dorsal- ispilateral subconscious proprioception, muscle tension, joint sense and posture in the LE and trunk
ventral - ispilateral subconscious proprioception, muscle tension, joint sense and posture in the UE , LE and trunk. decussation at the pons.
32
spinoolivary tract
relays info from cutaneous and proprioceptive organs
33
spinoreticular tract
influences levels of consciousness
34
spinotectal tract
assists with movement of the eyes and the head towards a stimulus
35
spinothalamic; anterior and lateral tract
anterior - crude touch and pressure
| lateral - pain and temperature
36
what type of info do descending spinal tracts send and in which direction?
Descending tracts carry efferent (motor VEM) info such as voluntary mus fxn, tone, equilibrium, and visceral innervation to the spinal cord form area in the brain such as the cerebral cortex, pons, midbrain and medulla
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corticospinal; anterior and lateral tract
reticulospinal tract
rubrospinal tract
tectospinal tract
vestibulospinal tract
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37
corticospinal; anterior and lateral tract
anterior - voluntary, discrete and skilled movements pyramidal motor tracts for ipsi motor movement.
lateral- contralateral fine movement. Very important for fractionated movement by inhibiting unwanted movement
damage to these tracts will result in a + babinski sign, superficial abdominal signs, cremasteric reflex. and loss for voluntary of fine motor control
only tracts that are pyramidal, all others are extra pyramidal.
38
reticulospinal tract
facilitation or inhibition of reflexes via alpha and gamma motor neurons
- Essential for coordinating muscle activity for trunk and proximal muscles of the 4 limbs during walking
- involved with APAs and reaching
- When disrupted can lead to a flexor synergy motor pattern
39
rubrospinal tract
motor input for gross postural tone, facilitates flexor muscles and inhibits extensor muscles
40
tectospinal tract
responsible for contralateral postural tone associated with visual and auditory stimuli
41
vestibulospinal tract
reposnsible for ipsilateral gross postural adjustments before head movement.
Facilitates extensor mus, inhibits flexors.
damage to extrapyramidal tracts leads to exaggerated DTRs and clasp-knife rxn
42
what does damage to the extrapyramidal tracts do?
paralysis, hypertonicity, increased DTR, and clasp knife reaction.
43
How should you asses balance?
assess visual, vestibular and somatosensory integration
44
explain somaosensory input
receptors in the skin, joints, ligaments, tendons and muscle provide propriocpetive info from the ankle, hips, neck ect to the brain about balance
45
Do children rely more or less on the visual system for balance?
more so
46
what is required of the vision system for succcsful balance?
Visual field cuts, hemianopsie, pursuits, saccades, double vision, gaze control, and acutiy are nessesacy
47
What Is the vestibular ocular reflex (VOR)
allows for head and eye movement coordination
stable image is fixed on the retina as the head moves.
Supports gaze stabilization through eye movement
48
What is the vestibulospinal reflex (VSR)
Attempts to stabilize the body and control movement
stability and control of the head and trunk with upright posture
49
What the difference btwn VOR and the VOR cancelation reflex?
VOR exam: the patient looks at 1 target and rotates head
| VOR cancelation: the patient has fixed gaze on moving target while head is moving
50
When is the ankle strategy elicited ?
1st Strategy to be elicited with loss of balance
- will occur with slow velocity and small range perturbation with feet on ground
- muscle contracts distal to proximal to control sway at ankle
51
When is the hip strategy elecited
when greater force, challenge or perturbation happens through hip or pelvis
- hips move in opposite direction of head
- with loss of balance muscles contract proximal to distal
52
What is the suspensory strategy
- Center of gravity is lowered in order to better control balance.
- Knee flexion crouching are squatting or often used.
- Strategy is used when mobility and stability or quired in a task like in surfing
53
What is a step in strategy?
unexpected challenge or perturbation in statis stnading or when center of gravity is outside BOS, the LE or UE reach to regain new BOS postion
54
Can vertigo have a central or perioheral origin?
yes, both can be sources of vertigo
55
what are characteristics of peripheral vertigo? What are causes a peripheral vertigo?
Episodic a short duration.
- Autonomic symptoms present.
- Precipitating factor.
- Pallor, sweating, nausea and vomiting.
- Auditory fullness forms within the ears
- tinitis
```
Can be caised by:
BBPV
Meniere's disease
infection
trauma/tumor
metabolic disorders; diabetes
acute alcohol intoxication
```
56
what are characteristics and causes of central vertigo?
-Atonomic symptoms less severe.
- Loss of consciousness can occur.
Diplopia
hemianoopsia
weakness numbness
ataxia
dysarthria
```
Can be caused by:
meningitis
migraine headache
complications of neuro origin post ear infection
trauma/tumor
cerebellar degeneration (alcoholism)
MS
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57
What canal is mostly affected by BPPV
Posterior semicircular Canal
58
Is congential nystagmous generally mild and not usuallly associated with a patholgy?
yes
59
What causes spontaneous nystagmous ?
imbalnace of vestibular signals to the oculomotor neurons which causes a drift to 1 side that is countered by quick movement to 1 direction
- typically alsts 24 hrs
- typically happens after acute vertibualr nerve leison
60
what is the main differece btwn central and peripheral nnystagmous?
peripheral nystagmus will resolve with fixed gaxe on object, occurs with a lesion to a peripheral nerve
- central nystagum happs when there is a leision on the brainstem or cerebellum. It is not inhibited by visual fixation
- visual fixation and lesion location are 2 main differences
61
what ellicits postional nystagmus?
change in head position
| semicircular canals will stimulate nystagmus that will only last a few seconds
62
what will ellicit gaze evoked nystagmus ?
when eyes go from primary postion to alternate postion
caused by inability to maintian stable gaze postion
- associated with CNS injury, brain injury or MS
63
What are the symptoms of nystagmus due to a central lesion ?
direction : bi or unidirection
visual fixation: no habituation with fiaxtion
verigo: mild
length of symptoms: May be chronic
etiology: demyelination, vascular leision, cancer/ tumor
64
What are the symptoms of nystagmus due to a peripheral lesion ?
direction : unidirectional with fast segment of movement indicating opposite direction of lesion
visual fixation: will inhibit with nystagmus and vertigo
vertigo: significant
length of symptoms: mins, days, weeks, finite period of time, recurrent
Etiology: Meniere's, vascular disorders, trauma, toxicity, infection of inner ear
65
when would you use the berg balance scale ?
Determine fall risk
- 14 tasks scored 0-4 (5 points possible)
- tests sitting and standing postures in static, dynamic, and tranistions
- max score 56
- < 45 = fall risk
66
when would you use the fregly- graybiel ataxia test battery
Assess and treat a balance dysfxn in a high level of motor fxn patient
- does not dx the cause of the balance dysfxn
- pass/ fail different coordination activities
- each leg is tested twice, each condition 5x for how long the position is maintained and how many steps it takes to recover
67
When would you use the fugl - myer outcome?
assess balance in patients with hemiplegia
- 14 is the best score a patient can get, but does not mean they have normal balance
- 7 items scored on 0-2 scale
- subset of fregly battery intended for hemiplegia
68
when would you use the functional reach test ?
Assess standing balance and risk of falls
- location of the 3rd MC is recorded (pt makes a fist)
norms depend on age, but 10.5- 17inches in range with lower # for pts over 70 years and higher reach for pts 20 years old
69
when would you use the rhomburg test
Test balance and ataxia
- 1st test: eyes open, feet together on solid surface
- 2nd test: eyes closed, feet together on solid surface, hold for 30 seconds
- when the vission is taken out, there is a larger somatosensory or vestibular defect causign instability
- if pt cant hold longer than 30 secs its abnormal and sensory ataxia is occurring
70
How can you further challenge to somatory sensory and vestibular system while testing balance after performig the rhomberg test ?
Sharpened rhomburg
eyes open in tandem stance
eyes closed in tandem stance
71
How can you differentiate sensory ataxia from cerebellar ataxia ?
rhomburg test results of not being able to stand feet together, eyes closed (+ rhomburg) and presence of ataxia is sensory ataxia
- not cerebellar
72
When would you use the timed up and go ?
Assess level of mobility and balance
- sit in supported chair, walk 10 feet, must turn around unsupported,reaching or without signs of loss of balance
10 secs- notmal
20- increased risk of falling, limited functional independence
30 secs high risk for fall
when using the scoring scale, 5 is severely abnormal
73
When would you use the Tinetti ?
assess increased risk for falling,
- transfers , perturbation in standing and gait are assessed
- pt 2 assess gait at normal, and fast (but safe) speeds, and other gait components (step length, height, continuity ect)
- 2 sections; max score of 28 from both, score under 19= high risk for fall
74
are people more left hemisphere dominant or right?
Most people are right hand dominant and Left hemisphere dominant (95%)
-65% of lefties are left hemisphere dominant too
75
what are features of poor prognosis in pts with aphasia
persevation of speech, auditory comprehension, unreliable yes/no answers, use of empty speech w.o recognition of impairments
76
What region does fluent aphasia typically affect?
wernike's area
regions in temporal lobe
regions in parietal lobe
77
what is fluent aphasia
- word output and production are functional
- Prosody is ok— the rhythm, stress, and intonation of speech (when i say 'up' i sue a high pitch)
- use of paraphasias- “markbook” instead of “bookmark.” spot instead of pot, use of jarrgon
- use of neologisms- making up new words, sometimes unrecognizable
- talk talk talk, no idea theres an issue
78
what is non fluent aphasia ?
- poor word output
- dysprosidic speech; issue with rhythm and initiation of speech
- increased effort of speech
- content is present but lacks syntax
- broccas aphasia
- hard time finding words, can be frustrating bc they no whats going on
79
what area of the brain is usually affected with non fluent aphasia
- frontal lobe, anterior speech center of the dominant lobe
80
what are types Of fluent aphasia
Wernicke's aphasia
- Lesion in posterior region of superior temporal gyrus
- impaired comprehension and writing
- Poor nameing ability
- motor impairment not typical wernikes is far away from motor cortex
conduction aphasia
- Lesion super marginal gyrus articulate fasciculus
- Severe repetition impairment
- good comprehension
- speech is interrupted due to word finding difficulty
- can read but can't write
81
What are types of non-fluent aphasia?
Broca's aphasia
- Lesion 3rd convulsion of frontal lobe
- expressive aphasia
- most common form of aphasia
- intact auditory and reading comprehension
- impaired repetition and naming skills
- frustration
- paraphysis is common
- motor impairment typical due to proximity of brocas to motor cortex
- common motor impairment typical due to proximity of brokers to motor cortex
global aphasia
lesion: frontal temporal or pareital lobes
- severly impaired comprehension
- Impaired naming writing and repetition skill use of - nonverbal skills for communication
- may verbalize without correct context
82
What would someone with Wernicke's aphasia struggle with the most? no trouble with?
```
"receptive aphasia"
impaired:
naming ability
writing
reading and auditory comprehension
```
intact: typically no issue with motor, and articulation, use paraphasias
83
What would someone with conduction aphasia struggle with the most? no trouble with?
Severe impairment with repetition
Speech is interrupted by word finding
Impaired writing
reading is intact, fluency and comprehension intact
84
What would someone with global aphasia struggle with the most? no trouble with?
Impaired naming writing and repetition skills
comprehension is severely impaired
non verbal to communicate
85
What would someone with brocas aphasia struggle with the most? no trouble with?
Expressive aphasia
- impaired repetition and naming skills
- use of paraphasis
- motor impairment
intact: comprehension
86
How is verbal aphasia different from apraxia
Apraxia:
Non-dysarthric non-aphasic impairment of prosody and articulation of speech secondary to poor motor planning
- Understand learn task of speaking but cannot articulate speech because they were unable to initiate movement
-lesion and left frontal lobe near brocas
Verbal aphasia:
expressive or receptive processing disorder
87
What is dysarthria
Upper motor neuron lesion resulting in impaired muscles used to articulate words and sounds
-Muscle weakness results and slurred speech, respiratory or phonatory systems
88
What does a score of 8, 13, or 9 correlate to on the glasgow coma scale?
8 and under is severe brain injury
9-12 = moderate brain injury
13-15= mild
89
What is the lowest score possible on the glasgow scale?
3
| if you earn a 1 in each category; eye opening , verbal resposnse , motor response
90
What nerves emerge from the rami of the brachial plexus?
Dorsal scapular nerve
| long thoracic nerve
91
What nerves emerge from the trunks of the brachial plexus
Nerve to subclavius
| suprascapular nerve
92
What nerves emerge from the lateral cord of the brachial plexus
Lateral pectoral nerve
musculocutaneous nerve
lateral root of the median nerve
93
Nerves emerge from the medial cord of the brachial plexus
Medial pectoral nerve
ulnar nerve
medial root of the median nerve
94
Which nerves emerge from the posterior cord of the brachial plexus
```
Upper sub scapular nerve
thoracodorsal nerve
lower sub scapular nerve
auxiliary nerve
radial nerve
```
95
what does the modified ashworth scale measure
resistance to passive stretch
96
what does a clinical assessment of spasticity include?
MMT
DTR
ROM
97
Is spasticity a upper motor lesion or lower motor neuron lesion component?
Upper
98
what are the grades of the ashworth scale
0 No increase in muscle tone
1 slight increased muscle tone; catch and release or minimal resistance at end ROM
1+ slight increased muscle tone; catch followed by minimal resistance at less than 1/2 ROM
2 increase in tone in most of ROM but easily moved
3 considerable increase in tone, passive movement is hard
4 affected part ridgid in flexion/ ext
99
What is the difference between Adams close loop theory and Schmidt schema theory?
Adams close loop theory: emphasis on practice as a memory of the past high emphasis on practice
Schmidt schema theory: emphasis on variation of practice and feedback
100
What are the three stages of motor learning
Cognitive stage
associative phage
autonomous stage
101
How would you determine a patient is still in the cognitive stage?
Patient requires high amount of concentration to process info
Participation is necessary a controlled environment is ideal
Patient will display: large amount of errors, inconsistent attempts, repetition of effort improves strategies,Consistent performance increase cognitive workload such as listening observing and processing feedback
102
How would you determine a patient is still in the associative stage?
Patient will be able to tell between correct and incorrect performance. Feedback is correlated to performed movement and ultimate goal.
An controlled environment is not required, the patient may progressed to an open or less structured environment. Avoid excess external feedback
```
Patient will display:
Decreased errors
Decreased concentration
Refined skills
Increased coordination
Increased practice leads to refined motor program around activity
```
103
How would you determine a patient is still in the autonomous stage?
Final learning stage. Improved efficiency of activity without great need for cognition person can perform task in variable environment
Patient will display:
Dramatic responses nearly error free regardless of environment
Movement patterns are non-cognitive and automatic Distractions dont impact activity
One task can be performed
Extrinsic feedback is very limited or not provided internal feedback or sel assessment is dominant
104
What is the difference between extrinsic and intrinsic feedback
Extrinsic (augmented) feedback: feedback that is provided through tactile contact or verbal response
Intrinsic (inherent) feedback: feedback that is provided to the person by sensory systems as a result of movement via visual vestibular proprioceptive and somato sensory input
105
Is knowledge of results and performance and intrinsic or extrinsic type of feedback
Type of extrinsic feedback knowledge of results determines how well the patient performed knowledge of performance include feedback about someone's actual movement pattern in relation to goal
106
What is the difference between mass and distributed practice
Mass practice: Time of practice trials is more than time to rest in btwn trials
Distributed practice: time for rest in between trials is more than each practice trial
107
What is the difference between variable and constant practice
Constant practice: practice of given task under uniform or same conditions
Variable practice: practice of task in different conditions
108
What is blocked practice
Practicing a whole, single task consistently
109
What is random practice
varying practice amongst different tasks
110
What is whole and part training
Practicing the task in entirety or practicing an individual components of a task
111
What is the difference between a closed system model and an open system model
Closed system model: nervous system has an active role in producing movement. Multiple feedback loops And large distribution of control are used to transfer information. Nervous system enables initiation of movement not solely reacting to stimuli
Open system model: single transfer of information without feedback loops nervous system await stimuli in order to react. Also known as reflexive hierarchical theory
112
What is learning
Permanent change in a persons ability to perform an activity or skilled action
113
What is nonassociative learning and associative learning
- Nonassociative learning as a single repeated stimulus such as habituation or sensitization
- Associative learning is an understanding of the relationship of two stimuli, causal relationships, or stimulus and consequence such as classical conditioning or operant conditioning
114
What is the difference between procedural and declarative tasks
Procedural tasks can be performed without attention and concentration the task is learned by performing movement habits
Declarative tasks require attention, awareness, and reflection in order to attain large knowledge that can be consciously recalled (mental practice)
115
What are the three different regions of the brain and what do they include
Forebrain:
telencephalon - Cerebrum Hippocampus basal ganglia amygdala
diencephalon- Thalamus, hypothalamus, sub Thelma's, epithalamus
MId brain
Tectum- Superior and inferior colliculi
Tegmentum- Cerebral aqueduct, periaqueductal gray, reticular formation, substantial Niagara, red nucleus
HInd brain
Metenephalon - Cerebellum, pons
Myelenephalon= Medulla oblongata
116
That makes up the brain stem,
Pons medulla oblongata and midbrain
117
What are signs of hydrocephalus or blocked shunt
Hydrocephalus is in increase of CSF due to poor reabsorption of destruction or excess production of CSF
```
-Enlarged head or bulging frontalis in infants
headache
changes in vision
large veins on scalp
behavioral change
seizure
change in appetite vomiting
sunsetting sign; or downward deviation of the eyes
incontinence
```
118
What are signs and symptoms of meningitis
Meningitis is the inflammation of the meninges,
a medical emergency
- Fever, headache, vomiting
- complains of stiffness/painful neck nuchal ridgidity
- pain and lumbar or the posterior thigh
- Brudinsky sign (flexion of neck facilitate flexion of hips and knees)
- Kernigs sign (pain with hip flexion with the knee extension
- sensitive to light
- lumbar puncture os gold standard
119
Anti-spasticity agents
Action : promote relaxation and a spastic muscle That has become spastic due to an injury of the CNS and an exaggerated stretch reflex. Spasticity is not a primary condition, it is a secondary effect from CNS damage. Spasticity is reduced by agents binding to muscle cells or within the CNS
indications : Increased tone, spasticity SCI, CVA, MS
side effects: Drowsiness, confusion, headache, dizziness general muscle weakness, hepatotoxicity potential with Dantrium, tolerance, dependence
PT implications :Balance loss of function secondary to decreased muscle spasticity.
examples: Baclofen, diazepam dantrolene, Tizanidine
120
Antiepileptic agents
Action : decrease seizure activity by inhibiting neurons
indications : seizure
side effects : Ataxia, skin issues, behavioral changes, G.I. distress, headache, blurred vision, weight gain
PT implications : Pts with epilepsy may be very sensitive to environmental surrounding like light or noise
examples: Barbiturates benzodiazepines carboxylic acids, hydantoins, second generation drugs, Gabapentin, secobarital, clonazepam, carbamazepine,
121
Cholinergic agents
Action : Increased acetylcholine binding or inhibition of acetylcholine esterase (Increasing acetylcholine at the synapse increases transmission)
indications :Glaucoma, Alzheimer's dementia, postop G.I. motility, myasthenia gravis, reversal of anticholinergic toxicity
side effects : G.I. distressed, impaired visual accommodation, bronchoconstriction, bradycardia, flushing, other parasympathetic effects
PT implications : Decreased heart rate and dizziness. Be aware of characteristics of sympathetic and parasympathetic systems and when side effects are unexpected
examples: This can be direct or indirect. Bethanechol, Pilocar or donepezil,
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dopamine replacement agents
Action : Relieve Parkinson's symptoms due to decrease of dopamine. Agents cross the BBB through active transport and transform dopamine in the brain
indications : Parkinson's and parkinsonian
side effects : Arrhythmias (levodopa), G.I. distress, orthostatic hypotension, dyskinesias, mood and behavioral change, tolerance
PT implications :Schedule PT session 1 hour after taking levodopa. Understand debilitating effects of drug holidays and monitor patient blood pressure frequently due to potential of orthostatic hypotension
examples: Sinemet or madopar (levodopa), Symmetrel, (amantadine)
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muscle relaxant agents
Action : Relax muscles that may have spasm, or tonic contraction. Spasms occur due to a musculoskeletal or peripheral nerve injury not CNS injury
indications : Muscle spasm
side effects : Sedation drowsy dizziness nausea vomiting headache tolerance dependence
PT implications : Prevent re-injury by stretching, postural retraining, and education
examples: Valium, diazepam, Flexeril, paraflex,
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What is the definition of level 1 No Response according to the Ranchos los amigos levels of cognitive functioning
You should appears to be in a deep sleep and is completely unresponsive to any stimuli
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What is the definition of level 2 Generalized response according to the Ranchos los amigos levels of cognitive functioning
Inconsistent reaction and non-purposeful movement to stimuli in non-specific manner.
Responses are limited and are the same regardless of stimulus.
Responses may be physiological gross body movement or vocalization
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What is the definition of level 3 Localized Response according to the Ranchos los amigos levels of cognitive functioning
Specific and inconsistent response to stimuli.
Response is directly related to type of stimulus.
Can follow simple commands such as closing eyes squeezing hand in inconsistent and delayed manner
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What is the definition of level 4 Confused Agitated according to the Ranchos los amigos levels of cognitive functioning
- Bizarre behavior
- Non-purposeful relative to immediate environment.
- Cannot discriminate among people or objects
- unable to cooperate directly with treatment efforts.
- Incoherent verbalizations
- Inappropriate gross attention to environment and is very brief.
- Selective attention is non-existent.
- Patient lacks short and long term recall
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What is the definition of level 5 Confused Inappropriate Response according to the Ranchos los amigos levels of cognitive functioning
- Responds to commands fairly consistently.
- Responds to complex commands are non-purposeful random or fragmented.
- Demonstrates gross attention to environment but is highly distractible
- lacks ability to focus attention on specific task
- With structure, can converse on social automatic level for short time.
- Inappropriate verbalization
- . Memory is severely impaired, inappropriate use of objects, nut may perform previous learn tasks with structure, unable to learn new information
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What is the definition of level 6 Confused Appropriate according to the Ranchos los amigos levels of cognitive functioning
- Goal oriented behavior, dependent on external input or direction.
- Follow simple directions consistently, some responses may be incorrect from memory problem, Appropriate to situation.
- Memories are more detailed compared to recent memory
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What is the definition of level 7 Automatic Appropriate according to the Ranchos los amigos levels of cognitive functioning
Appropriate and oriented.
- Daily routine is automatic but robot like.
- Minimal to no confusion shallow recall of activities.
- Carryover for new learning at slow rate.
- With structure can initiate social activities with impaired judgment
131
What is the definition of level 8 Purposeful Appropriate according to the Ranchos los amigos levels of cognitive functioning
- Go to recall and integrate past and recent events.
- Aware and responsive to environment.
- Carryover for new learning
- No need for supervision once activities are learned
- Decreased tolerance compared to pre-morbid abilities for abstract reasoning, tolerance for stress, judgments and emergencies or unusual circumstances
132
What is the difference btwn a superficial reflex and a DTR?
Superficial reflexes require a sensory signal (not muscle stretch) to be sent to the spinal cord and ascend to reach the brain.
The motor component has to descend the spinal cord to reach motor neurons making this a polysynaptic reflex
- examples of superficial reflexes include: the abdominal corneal, creamasteric, gag reflex and planter reflex
-DTRs elicit muscle contractions when tendon is stimulated due to reflex arc involving brain stem or spinal segment That innervates a specific muscle.
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What is the spinal level, procedure and normal response for the abdominal reflex?
- T8 through L1
- Light and brisk stroke along the four abdominal quadrants diagonally into the belly button using Tongue depressor
- Abs should contract and belly button should deviate in the direction of the stimulus
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What is the spinal level, procedure and normal response for the coreneal reflex?
Trigeminal and facial nerves.
- Patient looks up and away from therapist. Stroke cornea using piece of cotton
- Both eyes should blank in response to contact of one eye
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What is the spinal level, procedure and normal response for the Creamasteric reflex
L1- L2
Scratch medial skin of the thigh
brisk, brief elevation of testicle on the ipsilateral side
136
What is the spinal level, procedure and normal response for the gag reflex?
Glossopharyngeal and Vagus nerves
- Light stimulus on each side of the back of the throat
- Patient will gag, Maybe absent in some normal population
137
What is the spinal level, procedure and normal response for the plantar reflex?
L5-S1
-Therapist uses reflex hammer along lateral aspect of foot two ball of foot and base of great toe
-Flexion of the toes = normal
Babinski reflex is the abnormal response that indicates CNS lesion of toes extending
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What does hyper and hyporeflexa indicate?
Hyperreflexia may indicate a suprasegmental lesion; lesion above the level of the spinal reflex pathway.
Hyporeflexia is a diminished/absent response to tendon tapping. May indicate disease that involves multiple components of the reflex arc
139
What is the reflex grading for DTRs?
0 No response. Always abnormal
1+ Diminished/depressed response may or may not be normal
2+ Active normal response
3+ Brisk/exaggerated response may or may not be normal
4+ Very brisk/hyper active always abnormal
Grade 1+ and 3+ may or may not be normal. Zero or 4+ responses are always abnormal
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C5 C6 DTR
Biceps tendon hammer should hit biceps tendon through the therapists thumb
biceps tendon reflex
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Brachioradialis tendon reflex
C 5-6 DTR (another one)
Brachioradialis tendon
Patient should be sitting with hand and lap.
Forearm supported in neutral.
Radius is striked 1 to 2 inches superior to the wrist
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C7 DTR
Triceps tendon. The patient's upper extremity is supported at the humerus with the lower portion hanging down in elbow flexion. Tendon is straight directly above elbow.
143
L3-4 DTR
Patellar tendon
| patient is seated with feet dangling off table the tendon is straight directly inferior to patella
144
S1-2 DTR
Achilles tendon.
The patient is seated with the foot flexed at the ankle putting the Achilles on stretch, the tendon is striked above the foot
145
Patient presents with decreased DTR response and sensory loss what could be the issue? What if there's atrophy?
- Absent DTRs indicates a lesion in the reflex arc
- If absent reflex has sensory loss in the distribution of the nerve supplying the reflex, the lesion is within the afferent (sensory) arc and the lesion is either in the nerve or dorsal horn
- If absent reflexes accompanies paralysis fasciculations or atrophy the lesion is in the efferent (motor) arc And may include the efferent nerve, anterior horn cells or both
146
Will a patient with peripheral neuropathy present with decreased reflexes?
- most common etiology for absent reflexes
- Neuropathy is typically presents with sensory, motor or mixed impairment and may affect components of reflex arc.
- Common conditions include diabetes, alcoholism, vitamin a deficiency pernicious anemia, certain cancers, toxins; lead arsenic.
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What does a hyper active DTR indicate?
Assessment of DTRs can provide information for level of lesion that exists in the CNS.
- Hyperactivity is found with an interruption of cortical supply to lower motor neuron secondary to upper motor neuron lesion.
- Interruption is above the segment of the reflex arc.
- If C6 is an hyperactive, The lesion is above the C6 segment
148
In what order should sensation be tested during a Nuro evaluation
Superficial and deep (proprioceptive) sensation should be tested first followed by cortical (combined) sensation
149
What kinds of sensation are classified as superficial, deep and cortical?
Superficial: temperature light touch, pain.
Deep: proprioception, kinesthetic kinesthesia, vibration.
Cortical: bilateral simultaneous stimulation, stereognosis, two point discrimination,barognosis, localization of touch
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what is barognosis
Your ability to perceive different weight objects in the hand
151
How can deep pain and superficial pain be screened?
Deep pain: squeezing the gastroc or forearm
| Superficial pain: perceive noxious stimulus using a pen Paper clip end or pin
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How can you screen kinesthesia graphesthesia and proprioception
kinesthesia: ID direction and extent of movement of joint or body part
graphesthesia: ID number or letter drawn on the skin without visual input
proprioception: ID Static position of extremity or body part
153
Can you screen light touch and localization?
Light touch: cotton ball
| Localization: ID exact location of light touch usign verbal response or pointing
154
Can temperature two point discrimination and vibration be screened?
Temperature: warm and told test tubes
Two point discrimination: 2 point caliber, Identify one or two points without seeing
Vibration :Perception of vibration or pain with tuning fork
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What is the difference between allodynia, Anesthesia and analgesia?
allodynia:Pain sensation response to a stimulus that would not typically produce pain
Anesthesia: Absence of touch sensation
analgesia: Absence of pain while remaining conscious
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What is the difference between causalgia and dysesthesia?
causalgia: Constant, relentless, burning hyperesthesia and hyperalgesia that developed after peripheral nerve injury
dysesthesia: Distrotion of any of the senses especially the sense of touch
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What is the difference between hyperesthesia hyperpathia and hypesthesia?
hyperesthesia: Hightened sensation
hyperpathia: Extreme or exaggerated responses to pain
hypesthesia: Diminished sensation of touch
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What's the difference between neuralgia and paresthesia
neuralgia: Severe and multiple shock like pain's that radiate from a specific distribution
paresthesia: Abnormal sensation such as tingling and pins and needles or burning sensations
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What is Pallanesthesia
Loss of vibration sensation
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What is a synergy pattern?
Inhibition of mass gross motor programs caused by CNS damage such as a CVA.
161
What is the flexer synergy pattern for the upper limb?
```
Scapula: elevation and retraction
Shoulder: Abd, ER
Elbow: flexion
Forearm: supination
Wrist: flexion
Fingers: flexion with ABD
Thumb: flexion with ABD
*Flexor synergy pattern will be seen when a patient attempts to lift her arms above their head to reach for an object*
```
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What is the extensor synergy pattern for the upper limb?
```
Scapula: Depression and protraction
Shoulder: ADD IR
Elbow: extension
Forearm: pronation
Wrist: extension
Fingers: flexion with adduction
Thumb: flexion with adduction
```
163
What is the flexor synergy pattern for the lower limb?
Hip: Abd, ER
Knee: Flexion
Ankle: Dorsiflexion with supination
Toes: extension (yes extension)
164
What is the extensor synergy pattern for the lower limb?
Hip: Extension, Add, IR
Knee: Extension
Ankle: Plantar flexion with pronation
Toes: flexion and adduction
165
What are the strongest components in the upper extremity synergy pattern
```
Elbow Flexion (flex)
Shoulder ADD (ext)
Forearm Pronation (ext)
Wrist and Finger flexion (present in both flex and ext)
```
166
What are the strongest components in the lower extremity synergy pattern
```
Hip flexion (flex)
Hip ADD (ext)
Knee Ext (ext)
Ankle PF (ext)
Ankle INV (present in both?)
```
167
what is Raimiste’s Phenomenon?
Raimiste’s Phenomenon:
Resistance applied to abduction or adduction of the nonaffected lower
extremity evokes a similar reaction in the affected limb.
168
What is Homolateral Limb Synkineses?
Homolateral Limb Synkineses:
a dependency exists between the synergies of
the involved upper and lower extremities.
Thus, flexion of the involved upper extremity will elicit flexion of the involved lower extremity.
169
What are treatment principles of should be considered for a patient who has a synergy pattern
Treatment principles:
(1) When no motion exists, movement is facilitated using reflexes, associated reactions, proprioceptive facilitation, and/or exteroceptive facilitation to develop muscle tension in preparation for voluntary movement.
(2) Patient responses from such facilitation combine with the patient's voluntary effort to produces semivoluntary movement.
(3) Proprioceptive and exteroceptive stimuli assist in eliciting the synergies.
(4) When voluntary effort appears:
a) The patient should perform isometric contraction.
b) If successful, eccentric (controlled lengthening)
should be done.
c) Finally, a concentric (shortening) contraction.
d) Reversal of the movement between the agonist and antagonist.
(5) Facilitation is reduced or dropped out as quickly as the patient shows voluntary control (primitive reflexes & associated reactions).
(6) Correct movement is repeated.
(7) Practice in the form of ADL.
All pathological and physiological methods of facilitation are indicated during the first three motor stages. While, only the physiological methods of facilitation are indicated during the recovery
stages (stages 4, 5, 6).
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What are examples of upper motor neuron lesion?
```
CP
Hydrocephalus
ALS
CVA
birth injury
MS
Huntingtons
TBI
pseudo-bulbar palsy
Brain tumor
```
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First symptoms of an upper motor neuron lesion?
Found in descending motor tracks, Cerebral motor cortex, brainstem, or spinal cord.
-Damaged tracks will be in the lateral white portion of the spinal cord
Weakness,
hypertonicity,
hyperreflexia,
mild disuse atrophy,
abnormal reflexes
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what Is a lower motor neuron disease or lesion?
Lesion or disease that affects nerves/axons below brain stem usually at the final common pathway.
-Damaged areas will be in the ventral gray columns of the spinal cord
-flaccidity, weakness,
decreased tone,
**fasciculations**,
muscle atrophy,
decreased or absent reflexes
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What are examples of lower motor neuron lesions
```
Polio, ALS, Guillain barre syndrome,
Spinal cord tumors,
trauma,
progressive muscular atrophy
infection
Bell's pallsy
carpal tunnel
muscular dystrophy
spinal muscular atrophy
```
174
What are components of an anterior horn injury
```
PNS pathology
-sensation is intact
-Muscle weakness and atrophy
-Fasciculations
-Decreased DTR
Example: ALS, polio
```
175
What are components of an muscle injury vs a neuromuscualr junction injury?
```
both are PNS pathology
Muscle:
-Sensation intact
-motor weakness and fasciculations are rare.
-Normal or decreased DTR
Example: muscular dystrophy
```
```
NMSK junction:
-Sensation intact
-motor fatigue is greater than actual weakness.
Normal DTR
Example: mystenia gravis
```
176
What are components of an Peripheral nerve injury (mononeuropathy) versus a peripheral polyneuropathy injury
mononeuropathy:
Sensory loss along nerve root.
Motor weakness and atrophy and peripheral distribution. May have fasciculations.
Example: trauma
```
polyneuropathy:
-Sensory impairment is stocking and glove distribution.
-Motor weakness and atrophy.
Weaker distally then proximally.
- May have fasciculations.
-Decrease DTR.
Example: diabetic peripheral neuropathy
```
177
Characteristics of a spinal root and nerve injury
- Sensory component will have corresponding dermatomal deficit.
- Motor weakness in innervated pattern
- may have fasiculations.
- Decreased DTR
- Example: herniated disc
178
What's the difference between a clasp knife response and lead pipe rigidity and cogwheel rigidity
clasp knife response: Increased hypertonicity/ resistance at beginning of range that lessons with movement through the range
Lead pipe rigidity : rigidity that is uniform and constant throughout range of motion often associated with lesion to Basal ganglia
cogwheel rigidity: Resistance to movement has phasic quality. Seen in Parkinson's
179
What types of mechanisms of injury affect the auxiliary, musculocutaneous radial, median, and ulnar nerves
Auxiliary- Fracture of the neck of the humerus, anterior shoulder dislocation
Musculocutaneous- Fracture of the clavicle
Radial- Compression of the nerve in radial tunnel, humerus fracture
Median- compression in carpal tunnel, pronator teres entrapment
Ulnar- Cubital tunnel compression, entrapment in Guyon's Canal
180
What MOIs affect the femoral, sciatica, obturator, peroneal, Tibial, and sural nerves
Femoral THA, Displaced acetabular fracture, femur and tear dislocation, hysterectomy, appendectomy
Sciatic-THA, Blunt force trauma to butt, accidental injection
Obturator- THA, Fixation of femur fracture
Peroneal- Fracture in femur tibia or fibula, positioning during surgical procedure
Tibial- Tarsal tunnel entrapment, popliteal fossa compression
Sural- Fractured calcaneus or lateral malleolus
181
What is the difference between akinesia asthenia and ataxia? Which pathologies are they seen?
akinesia -Seen in Parkinson's. Inability to initiate movement
asthenia - Generalize weakness seen in cerebral pathologies
ataxia- Inability to produce coordinated movements
182
What is athetosis and dystonia ?
athetosis: Involuntary movements combined with instability of posture. Peripheral movements occur without central stability
- Seen in cerebral palsy secondary to BG pathology.
-Presents with slow twisting and writing movement in big amplitude.
- Seen in face tongue trunk and extremities.
Can merge with chorea and when sustained merges with dystonia
Dystonia: Related to athetosis but affects axial muscle movement instead of appendicular muscles
-
183
What is the difference between Bradykinesia and Chorea
Bradykinesia - slow movement
Chorea- Sudden random and involuntary movements
-Brief irregular contractions that are fast but not like myoclonic jerks
-Huntington's .
Damage to caudate nucleus
184
What is hemiballism
Movement of a large body part in involuntary and violent manner
-Another form of Chorea producing flailing movement of limbs secondary to Subthalamic nucleus
185
What is kinesthesia
Ability to perceive direction and extent of movement of joints or body part
