Neuromuscular Unit 1 Exam Flashcards
used to screen patients presenting to therapy to determine if further neurologic evaluation is appropriate + determine body regions with deficits
neurological screen
4 orientation questions
person, place, time, situation
quick memory screen
3 words to remember
normal level of arousal
conscious
decreased level of arousal
hypoarousal
increased level of arousal
hyperarousal
mildly depressed level of consciousness
lethargic
significantly diminished arousal, will respond to noxious stimuli but may be confused
obtund
minimal arousal and requires vigorous noxious stimuli
stupor
no arousal, unable to make purposeful response
coma
conscious but unaware of their environment and no purposeful attention
minimally conscious vegetative state
in a vegetative state for longer than 1 year following a traumatic brain injury
persistent vegetative state
gold standard scale in acute brain injury
Glasgow coma scale (GCS)
outcome measure for stroke severity
national institutes of health stroke scale (NIHSS)
mild GCS score
12-15
moderate GCS score
9-11
severe GCS score
3-8
2 noxious stimuli
sternal rub and nail bed pressure
direction of awareness, necessary to perform a conscious task
attention
5 categories of attention
focused
sustained
selective
alternating
divided
category of attention when the patient can process specific information
focused
category of attention when the patient is attentive continuously over time
sustained
category of attention when the patient can perform with distractions
selective
category of the attention when the patient shifts attention back and forth
alternating
category of the attention when the patient responds to multiple stimuli simultaneously
divided
outcome measure for attention that characterizes behavioral responses after brain injury
moss attention rating scale (MARS)
behaviors that describe mood or emotional state
affect
emotional dysregulation, uncontrolled and exaggerated laughing or crying
psuedobulbar affect
shallow or blunted emotional response
apathy
exaggerated feelings of well being
euphoria
poor perception of self and environment
depression
sorting, retrieving, and manipulating information
cognition
________ and fall risk are directly related
cognition
3 things to assess patient’s alertness
arousal
attention
cognition
patients with dementia and cognitive impairments are at an increased risk of experiencing a _____
fall
giving a patient one minute to name as many animals as possible
animal fluency test
> 65 years old = ___ animals
12
< 65 years old = ___ animals
18
having a patient draw clock on a blank piece of paper with numbers 1-12 and then drawing hands to indicate a time
clock drawing
asking the patient to interpret a phrase
reasoning
giving a patient a list of words for them to remember and repeat back to you
retention
asking later in the screen for the patient to repeat the 3 words back to you
recall
exam used if issue is expected but not diagnosed; measures orientation, recall, short term verbal memory, calculation, language and construct ability
mini mental state exam (MMSE)
max score of a mini mental state exam
30
< ___ indicates cognitive impairment on the mini mental state exam
24
what does MOCA stand for?
montreal cognitive assessment
< ___ on the MOCA is indicative of dementia and further testing needed
26
outcome measure that is similar to the MOCA and mini mental exam but is used for lower level cognitive patients
SLUMS
what does SLUMS stand for?
St. Louis university mental status exam
outcome measure that is more sensitive to identifying dementia
SLUMS
why is it important to perform interventions even if patients cannot remember?
they can develop habits (learn by doing rather than remembering)
what form of practice is better to use as an intervention for this patient population?
blocked practice
less explicit information = better ability to ______ the task
learn
3 Ds
delirium
depression
dementia
disrupted consciousness, cognition, or perception that develops in a short period of time usually postoperatively
delirium
most common mental health disorder in adults 65 years of age and older
depression
medical diagnosis that are highly correlated with depression
stroke
cancer
chronic pain
multiple sclerosis
a good tool to catch depression and patients that are at risk
geriatric depression scale
as as PT, what should your interventions look like for a patient that is depressed?
activities that are engaging and interesting to the patient
clinical syndrome of cognitive and functional decline that is chronic and progressive in nature
dementia
true or false: physical therapists can diagnose dementia
false
4 types of dementia
Alzheimer’s disease
vascular dementia
dementia with Lewy bodies
frontotemporal dementia
altered cognition that fills the gap between normal and dementia
mild cognitive impairment
what are signs of a patient that has a mild cognitive impairment?
losing things
forgetting appointments
trouble finding words
increased forgetfulness of recent events
most common form of dementia that is associated with advanced age
Alzheimer’s disease
predominant symptom of Alzheimer’s
memory decline
pathological changes in the brain that cause Alzheimer’s disease
amyloid plaques, neurofibrillary tangles, atrophy in the inferior prefrontal cortex, and inadequate levels of acetylcholine
mental disorder with the main feature of cardiovascular disease
vascular dementia
with vascular dementia, brain damage results from what type of stroke?
vascular strokes
result of multiple large or small infarcts that causes brain loss (mini strokes)
multi infarct dementia
rate of cognitive decline is similar to AD but the life expectancy is shorter for patients with what type of dementia?
multi infarct dementia
first noted symptoms of vascular dementia
slow processing speed
impaired judgement
impaired ability to make decisions + plan
slow gait and poor balance are associated with _______ dementia depending on where the ischemia is occurring
vascular
form of dementia characterized by early sleep disturbance and hallucinations
Lewy body dementia
pathological changes in the brain that cause Lewy body dementia
build up of Lewy bodies inside the neurons in the cortex that control memory and motor control
Parkinson’s disease is marked by ____ systems and Lewy body dementia is marked by ____ impairments
motor, cognitive
______ _______ (Lewy bodies) linked to Parkinson’s disease and multi system atrophy
alpha synuclein
progressive nerve cell loss in the brain’s frontal and temporal lobes that causes deterioration in behavior, personality, language, and alterations in motor and muscle function
frontotemporal lobe dementia
2nd most common cause of dementia after Alzheimer’s disease
frontotemporal lobe dementia
patients with what form of dementia are less oriented than AD but have more difficulty with executive function and problem solving
frontotemporal lobe dementia
sudden loss of neurologic function caused by interruption of blood flow to the brain
stroke
2 types of stroke
ischemic and hemorrhagic
type of stroke that occurs secondarily to thrombosis, embolism, or hypoperfusion
ischemic stroke
type of stroke that affects 80% of individuals who have strokes
ischemic
type of stroke that occurs when blood vessels rupture, causing leakage of blood in or around brain
hemorrhagic
which type of stroke has more severe complications?
hemorrhagic
deficits of a stroke must remain for at least how many hours?
24
spontaneous improvement that occurs as swelling in the brain goes down
reversible ischemic neurological deficit
3 etiologies of a stroke
thrombosis
embolus
hemorrhage
5th leading cause of death
stroke
leading cause of long term disability in the US
stroke
stroke incidence increases with ____
age
largest number of deaths come from what type of stroke?
hemorrhagic
what are some general risk factors for strokes?
hypertension
diabetes
high cholesterol
heart disease
what are some modifiable risk factors for strokes?
smoking
physical inactivity
obesity
diet
what does the BE FAST acronym stand for?
balance
eyes
face
arms
speech
time
what are some S&S of ACA stroke?
contralateral LE hemiparesis and hemisensory loss, urinary incontinence, apraxia, contralateral grasp and suck reflex, akinetic mutism, slowness, lack of spontaneity, and motor inaction
what are some S&S of MCA stroke?
contralateral UE + face hemiparesis and hemisensory loss, motor and receptive speech impairments, global aphasia, perceptual deficits, limb kinetic apraxia, contralateral homonymous hemianopsia, loss of conjugate gaze to the opposite side, and contralateral limb sensory ataxia
difficulty with planning and sequencing movements
apraxia
2 types of apraxia
ideational and ideamotor
inability of the patient to produce movement either on command or automatically and represents a complete breakdown in the conceptualization of the task
ideational apraxia
example of ideational apraxia
you tell the patient to brush their teeth and they don’t know to pick up the tooth brush
when the patient is unable to produce a movement on command, but is able to move automatically
ideamotor apraxia
example of ideamotor apraxia
you hand the patient the tooth brush, and they know to start brushing their teeth
apraxia is more evident with what side hemisphere damage?
L hemisphere
loss of language
aphasia
type of aphasia characterized by broken speech, limited vocabulary, and slow + hesitant speech
Broca’s/non fluent aphasia
type of aphasia characterized by impaired auditory comprehension, fluent speech, and normal rate and melody
Wernicke’s/fluent aphasia
type of aphasia characterized by nonfluent speech with poor comprehension
global aphasia
type of stroke caused by small vessel disease in the cerebral white matter that can be motor or sensory
lacunar strokes
why are there are deficits in consciousness, language, or visual fields NOT seen with lacunar strokes?
high cortical areas are preserved
occlusions of this artery can produce a wide variety of symptoms with both ipsilateral and contralateral signs + cerebellar and cranial nerve abnormalities are present
vertebrobasilar artery
why are there both ipsilateral and contralateral signs associated with vertebrobasilar artery syndrome?
some brainstem tracks have crossed over and some have not
syndrome where damage caused at PICA
lateral medullary syndrome
what is the other name for lateral medullary syndrome?
wallenburg’s syndrome
what are some signs and symptoms of lateral medullary syndrome/wallenburg’s syndrome?
ipsilateral face and contralateral body loss of pain and temperature, dizziness/vertigo, ataxia, diplopia, dysphagia, dysarthria, Horner’s syndrome
syndrome where damage is caused at the sympathetic trunk
Horner’s syndrome
3 characterizations of Horner’s syndrome
ipsilateral or contralateral side?
miosis, ptosis, anhidrosis
ON THE IPSILATERAL SIDE
drooping eyelid
ptosis
constricting pupil
miosis
loss of sweating on the face
anhidrosis
what are S&S of Horner’s syndrome?
miosis, ptosis, anhidrosis, dysphagia, dysphonia, sensory impariment of the trunk and extremities, impaired pain and thermal sense
syndrome where damage is caused at the basilar artery affecting the ventral pons and S&S include bilateral cranial nerve palsy, coma, and leads to tetraplegia or quadriplegia
locked in syndrome
what two things are spared in locked in syndrome?
cognition and upward gaze
what are S&S of peripheral territory PCA stroke?
bilateral or contralateral homonymous hemianopsia (some degree of macular sparing), visual agnosia, prosopagnosia, dyslexia, memory deficit, and topographic disorientation
what are some S&S of central territory PCA stroke?
central post stroke thalamic syndrome, spontaneous pain and dysesthesias sensory impairments, involuntary movements, contralateral hemiplegia, and occulomotor nerve palsy
what syndrome is a result of a central territory PCA stroke?
central post stroke (thalamic) pain syndrome = LOTS of pain
neurological condition characterized by an inability to recognize or interpret visual stimuli (can see objects clearly but cannot identify them) but normal vision
visual agnosia
neurological condition known as face blindness that impairs the ability to recognize faces but normal vision
prosopagnosia
type of hemiplegia that results from a central territory PCA stroke? ipsilateral or contralateral
contralateral
sensory impairments can contribute to unilateral neglect and learned _______ of limbs
nonuse
located in the distal end of an afferent nerve fiber that give rise to perception of a specific sensation once stimulated
sensory receptors
3 divisions of sensory receptors
superficial, deep, and combined cortical
systems that mediate to higher centers
spinal pathways
sensory receptor that responds to mechanical deformation of the receptor or surrounding areas
mechanoreceptors
sensory receptor that responds to change in temperature
thermoreceptors
sensory receptor that responds to noxious stimuli and result in the perception of pain
nociceptors
sensory receptor that responds to chemical substances
chemoreceptors
sensory receptor that is electromagnetic and responds to light within visible spectrum
photic receptors
sensory receptors located at the terminal portion of the afferent fiber
cutaneous receptors
sensory receptors located in muscles, tendons, and joints
deep sensory receptors
information enters the spinal cord through the ______ ______, and sensory signals are carried to higher centers via ______ pathways
dorsal roots, ascending
2 ascending pathways
anterolateral spinothalamic system and dorsal column medial lemniscal system
spinal pathway of slow conducting fibers that initiates self protective reactions and responds to stimuli that are potentially harmful
anterolateral spinothalamic system
the ALS system is transmission of….
thermal and nociceptive information, pain mediation, temperature, crudely localized touch, tickle, itch, sexual sensations
spinal pathway of fast conducting fibers that is involved with responses to more discriminative sensations
dorsal column medial lemniscus system
the DCMLS mediates the sensations of…
discriminative touch and pressure sensations, vibration, movement, position sense, and awareness of joints at rest
projections to the sensory association areas allow for the perception and interpretation of what type of sensations?
combined cortical
the DCML tract carries discriminative sensations such as ____ and ______
kinesthesia and touch
the ALS tract carries _____ and _______
pain and temperature
the most complex processing of sensory information occurs where?
somatosensory cortex
3 main divisions of somatosensory cortex
primary (post central gyrus)
secondary
posterior parietal cortex
somatotopic map that represents either motor or sensory input and identifies the relative size of the cortex devoted to specific body parts as it relates to function
homunculus
information received from the external environment via the skin and subcutaneous tissue
superficial sensation
______ are responsible for superficial sensations
exteroceptors
4 superficial sensations
pain perception
temperature awareness
touch awareness
pressure perception
information received from muscles, tendons, ligaments, joints, and fascia
deep sensations
________ are responsible for deep sensations and position sense
proprioceptors
3 deep sensations
kinesthesia awareness
proprioceptive awareness
vibration perception
combination of both the superficial and deep sensory mechanisms
combined cortical sensations
combined cortical sensation information comes from both ________ and ________ receptors as well as intact function of cortical sensors association areas in the brain
exteroceptive and proprioceptive receptors
what 3 things does the Glasgow coma scale measure?
eye opening, verbal response, and motor response
combined cortical sensations
stereognosis perception
tactile localization
two point discrimination
double simultaneous stimulation
graphesthesia
recognition of texture
barognosis
route of the anterolateral spinothalamic tract
dorsal roots > immediate crossing to ascend the spinal cord through the medulla, pons, and midbrain > VPL of the thalamus > projections sent to the somatosensory cortex via the internal capsule
route of the dorsal column medial lemniscus tract
dorsal column > ascend to the medulla and synapse with dorsal column nuclei > cross to the opposite side and pass up to the thalamus via medial lemniscus to the VPL > somatosensory cortex
the ability of sharp vs dull discrimination, indicates function of protective sensation
pain perception
the ability to distinguish between warm and cool stimuli
temperature awareness
determines perception of tactile input
touch awareness
awareness of movement + direction through ROM
kinesthesia awareness
awareness of joint position sense at rest
proprioceptive awareness
the ability to recognize the form of objects by touch
stereognosis perception
the ability to localize touch sensation on the skin (topognosis)
tactile localization
the ability to perceive two points applied to the skin simultaneously
two point discrimination
the ability to perceive simultaneous touch stimuli
double simultaneous stimulation
term used to describe a situation in which only the proximal stimulus is perceived with “extinction” of the distal
extinction phenomenon
the ability to recognize letters, numbers, or designs “written” on the skin
graphesthesia
the ability to differentiate various textures
recognition of texture
the ability to recognize different weights of two objects that are the same size and shape
barognosis
normal adult respiratory rate
12-20 breaths per minute
normal adult blood pressure
120/80 mmHg
normal adult heart rate
60-100 bpm
normal adult O2 sats
100%
control center location for blood pressure
pons and upper medulla
hypertension
> 140/90
prehypertension
120-139/80-90
hypotension
systolic < 100
medical emergency blood pressure
> 180/110
slow heart rate < 60 bpm
bradycardia
fast heart rate > 100 bpm
tachycardia
pressure exerted by CSF inside the skull on the brain tissue
intracranial pressure (ICP)
normal ICP value
4-15 mmHg
if ICP is too high, the brain can _______
herniate
signs of high ICP
vomiting and headache
mild ICP hypertension value
20-30 mmHg
severe ICP hypertension
> 39 mmHg
in RBCs, transports O2 throughout the body
hemoglobin (Hb)
male hemoglobin value
14-17 g/dL
female hemoglobin value
12-16 g/dL
PT exercise indication for hemoglobin value of < 8 g/dL
no exercise
PT exercise indication for hemoglobin value of 8-10 g/dL
light exercise
PT exercise indication for hemoglobin value of > 10 g/dL
resistive exercise
percentage of RBCs throughout the body
hematocrit
male hematocrit percentage
40-51%
female hematocrit percentage
36-47%
PT exercise indication for hematocrit percentage of < 25%
no exercise
PT exercise indication for hematocrit percentage of > 25%
light exercise
PT exercise indication for hematocrit percentage of > 35%
resistive exercise
ratio of how well your blood clots
international normalizing ratio (INR)
normal INR value
.8-1.2
PT indication of 4 INR value
no increase in intensity
PT indication of 4-5 INR value
no resistance exercise
PT indication of 5-6 INR value
no exercise
PT indication of > 6 INR value
bed rest
the lower the INR value…
the faster blood will clot
the higher the INR value…
the slower blood will clot + greater risk for excessive bleeding
red flag O2 sat value
< 90%
condition of hemoglobin value < 8 g/dL
anemia
line that is inserted directly into the artery at hip or wrist and measures arterial blood pressure in real time
arterial line/catheter
line that measures ICP + drains CSF
external ventricular drain
line that measures ICP in real time through hole drilled into the skull
bolt
usually patients with these two lines have a low GCS score and are unable to participate in movement
EVD and bolt
line inserted into the neck and goes down large vein through the vena cava into the right atrium
Swan-ganz catheter
line that delivers medication directly into the circulatory system
central line (central venous catheter)
line that is peripherally inserted into the vein and goes directly into the heart, used with longer course antibiotics
PICC line (peripherally inserted central catheter)
patients usually get a ________ if on the vent for more than how many days?
tracheostomy, > 14-21 days
line that gives high amounts of oxygen to a patient without having to intubate
high flow nasal cannula
why is it important not to mobilize or push nasal cannula patients?
patient can desat and have to be intubated
collects fecal matter into a bag, often used with c-diff
fecal management system
urine collection that is gravity dependent
foley catheter
feeding tube through the nose to stomach, short term solution
NG tube (nasogastric tube)
feeding tube directly into the abdomen, long term solute common in patients with more severe brain injuries
PEG tube (percutaneous endoscopic gastrostomy)
if a patient has a feeding tube and are NPO, what can the therapist not do?
give the patient food and water
helps determine if motor deficits are neurological (tone or paresis) or MSK (past or present injury)
motor screen
muscles, joints, and their sensory and motor nerve innervations
peripheral motor system
association areas (cortex and basal ganglia), motor cortex, cerebellum,
brain stem, and spinal cord
central motor system
additional positioning that may be required to fully assess a neurological patient during a motor screen
gravity minimized position
association areas are responsible for….
movement strategy to best achieve goal (cortex and basal ganglia)
motor cortex and cerebellum are responsible for…
sequence of contractions, arranged in space and time, smoothness to achieve goal
brain stem and spinal cord are responsible for…
execution and activation of the motor neurons to generate the movement
what 2 structures do not have direct output to the spinal cord?
cerebellum and basal ganglion
information comes directly from what three areas of the brain?
motor cortex
spinal cord
premotor areas
integration of the sensory input informs and guides the motor ______
response
main area of the brain that involves motor function
motor cortex
has the largest concentration of corticospinal neurons and requires a stimuli of low response to elicit a motor response
primary motor cortex
the primary motor cortex is anterior to the central sulcus and controls contralateral ________ movements
voluntary
anterior to the primary motor cortex, requires a higher intensity stimuli for motor response
supplementary and premotor areas (SMA and PMA)
axons from this area directly innervate motor units involved in initiation of movement, timing, sequential tasks, and action monitoring
SMA
area that innervates motor units that control trunk and proximal limb movements, plan and prepare the body for movement
PMA
the motor cortex receives information from what three things?
somatosensory cortex
cerebellum
basal ganglia
somatosensory information is relayed directly to the primary motor cortex from the __________
thalamus
relays information to the cerebellum and basal ganglia which allow integration and appropriate course of action
thalamus
regulates movement, postural control, and muscle tone
cerebellum
if input from the feedback system does not compare appropriately, the ______ gives a counteractive influence
cerebellum
what does it mean that the cerebellum is error correcting?
the cerebellum sends signals to the cortex to modify the movement
where are basal ganglia located?
cerebral cortex
main basal ganglia nuclei
caudate
putamen
globus pallidus
subcortical basal ganglia
subthalamic nucleus
substancia nigra
why do Parkinson’s patients get rigid?
because basal ganglia maintains normal background muscle tone and is disrupted/diseased in Parkinson’s patients
maintains normal background muscle tone
basal ganglia
what are some functions of basal ganglia?
initiation and regulation of intentional movement, planning and executing motor responses, postural adjustments
the ability to generate sufficient tension in a muscle for posture and movement
strength
_______ results from musculoskeletal properties of the muscle and neural activation
strength
inability to generate normal levels of force
weakness
very common impairment in those with UMN lesions
weakness
decreased voluntary motor unit recruitment or difficulty recruiting motor units to generate movement (still SOME recruitment)
paresis
absence of muscle recruitment and inability to generate movement
paralysis
what is the order of ROM when the patient cannot move through the full range?
AROM > AAROM > PROM
muscle grade for no contraction
0
muscle grade for a visible muscle twitch but no movement of the joint
1
muscle grade for a weak contraction that is unable to overcome gravity
2
muscle grade for a weak contraction that is able to overcome gravity but not able to take additional resistance
3
muscle grade for a weak contraction that is able to overcome gravity and take some resistance
4
muscle grade for a strong contraction that is able to overcome gravity and full resistance
5
muscle’s resistance to passive stretch
muscle tone
is muscle tone velocity dependent?
no
muscle tone is causes by output from what two types of motor neurons?
alpha and gamma
velocity dependent increase in tonic stretch reflex (exaggerated tendon jerk from hyperexcitability)
spasticity
spasticity is a dysfunction of what tract?
corticospinal
spasticity is common in UMN or LMN?
UMN lesions
increased resistance to passive movement but is not velocity dependent
rigidity
disruption or disease of ______ ________ causes rigidity
basal ganglia
type of rigidity, consistent resistance to movement through entire range
lead pipe rigidity
type of rigidity, alternating episodes of resistance to movement throughout the range (catching)
cogwheel rigidity
reduced stiffness of the muscle when lengthened or moved through the range (loose and floppy)
hypotonia
_______ beating is a type of spasticity
clonus
scale used to assess alterations in muscle tone
modified ash worth scale
muscle bulk can be ______ (too much) or _________ (wasting)
hypertrophic or atrophic
small wavelike movements under the skin that indicate denervation of the muscle
fasciculations
rhythmic movements common in patients with Parkinson’s disease
tremors
quick, large, piano like playing movement
chorea
slower, writhing like movement that is a medication side effect of Parkinson’s
dystonia
quick, jerky moving of a joint or limb
myoclonus
multiple joints and muscles are activated at the appropriate time and force
coordination
coordination deficits are commonly seen with lesions in what 3 areas?
motor cortex
basal ganglia
cerebellum
abnormal patterns of movement secondary to lack of ability to move a single joint without simultaneously generating movement in other joints
synergy
MOST common synergy pattern
flexion of the UE
UE flexion synergy pattern
scapular retraction + elevation
shoulder abduction + ER
elbow flexion
forearm supination
wrist and finger flexion
LE extension synergy pattern
hip extension, adduction, and IR
knee extension
ankle plantarflexion + inversion
toe plantarflexion
problems judging distance or range of movement, therefore an inability to scale forces to meet certain tasks
dysmetria
dismetria is a ________ problem
coordination
coordination deficits are common in patients with what type of dysfunction?
cerebellar
overestimation of the force or range of movement needed for a specific task
hypermetria
underestimation of the required force of range to complete a task
hypometria
inability to perform rapid alternating movements (random)
dysdiadochokinesia
common coordination tests
finger to nose
alternating finger to nose
pronation/supination
rebound test
heel to shin
how do therapists treat coordination deficits?
repetition of functional task specific movements and WB activities
therapist applies manual resistance for an isometric elbow flexion contraction, resistance is sudden released and the triceps should contract to keep from having rebound
rebound test
