Neuromuscular Units 1-7 Finals Review Flashcards
What are potential impairments with Perceptual and Cognitive Impairments?
- Perceptual: Agnosia, Neglect, Apraxia
- Cognitive: Orientation, Memory, Arousal
What are potential impairments with Speech and Language Impairments?
- Aphasia
- Dysarthria
- Dysphagia
What are potential impairments with Composite Impairments?
This is both Motor and Sensory Impairments
- Postural control/balance (equilibrium coordination)
If a patient has a Upper Motor Neuron pathology, where would the patient be affected?
- The clinical presentation will be contralateral to the side of the deficit
If a patient has a Lower Motor Neuron pathology, where would the patient be affected?
- The clinical presentation will be on the ipsilateral side of the deficit
In terms of muscle weakness associated with UMN lesions, what is the def. of paralysis?
Complete absence of muscle strength or the inability to voluntarily recruit motor units.
In terms of muscle weakness associated with UMN lesions, what is the def. of Plegia?
The same as Paralysis:
- Complete absence of muscle strength or the inability to voluntarily recruit motor units.
In terms of muscle weakness associated with UMN lesions, what is the def. of Hemiplegia/Hemiparesis?
Hemiplegia: One-sided paralysis
Hemiparesis: One-sided Weakness
In terms of muscle weakness associated with UMN lesions, what is the def. of Paraplegia?
Lower Extremity Paralysis
In terms of muscle weakness associated with UMN lesions, what is the def. of Tetraplegia?
Both upper and lower extremity paralysis to include the trunk
Hypertonia in the form of muscle stiffness is an example of a Direct or Indirect impairment?
This will be an indirect impairment
A lot of times muscle stiffness will occur the longer the patient becomes chronic with their condition, ideally because they’ve become more sedentary
With involuntary movements, what is Dystonia?
Excessive twisting and bizarre repetitive movements caused by axial and proximal limb musculature, typical with basal ganglion lesions (Parkinson’s). Often exhibited in patients that have been using long term parkinson’s medications as a side effect.
With involuntary movements, what is Chorea?
Rapid and jerky movements, associated with basal ganglion lesions, hence the term Huntington’s Chorea
With involuntary movements , what is Athetosis?
Slow twisting, snakelike movements, often associated with Cerebral Palsy
With involuntary movements, what are Resting Tremors?
The tremor that occurs when the muscles and the patients body are at rest. Very common in patients with parkinson’s, especially with the upper extremity. Sometimes referred to as the “Pill Rolling Tremor”
With Visual defects, what are terms associated with UMN lesions?
- Blurred vision: loss of visual acuity
- Diplopia: double vision
- Strabismus: Eyes aren’t parallel, have altered visual axis
- Nystagmus: Rapid, rhythmic, repetitive involuntary eye movements
- Homonymous Hemianopsia: Partial blindness resulting in loss of vision in the same visual fields of both eyes
- Occipital Blindness: Legally blind, loss or absence of the ability to perceive images
What are the subcategories of Aphasia?
- Expressive Aphasia: (aka Broca’s or non-fluent/motor aphasia, occur when there is damage to broca’s area (Frontal lobe on left or dominant hemisphere) Have intact auditory comprehension. They have a hard time expressing what they want to say.
- Receptive Aphasia: (aka Wernicke’s or Fluent/Sensory Aphasia, occurs when there’s damage to Wernicke’s area (Association cortex in Temporal Lobe on left or dominate hemisphere). They have auditory comprehension that is impaired, they dont understand whats being said to them
- Global Aphasia: When patients have elements of both Expressive and Receptive Aphasia, there is going to be widespread, significant damage to the left or dominant hemisphere
With Composite Impairments, what are the main systems for Posture Control/Balance?
Somatosensory System (Dorsal Column-Median Lemniscal tract), Vestibular System (Peripheral sensory apparatus in inner ear), and Visual system
- All these systems will bring information to the CNS where both the brain, brainstem and cerebellum are going to integrate and understand for an appropriate motor plan
What are the 2 main types of stroke?
Type 1 - Ischemic Stroke (occlusive)
Type 2 - Hemorrhagic Stroke (Abnormal bleeding)
What is the Pathophysiology of Stoke? What is the area around the core area? What is the cascade of events that occurs in terms of deprivation of O2 to the cerebral tissue?
MUST KNOW
Complete occlusion of blood flow leads to a core area of neuronal cell death
- Around the core area is what’s referred to as the ischemic penumbra (area where neurons are lethargic, but remain viable)
- Firstly we have ischemia causing the neurons to release excessive glutamate, then we have altered Ca ion channels causing influx of Ca into neuron, because of this you have high levels of intracellular Ca it then activates a series of destructive Ca sensitive enzymes leading further neuronal cell death in ischemic penumbra area.
What are the risk factors and early signs for stroke? What are the 5 “sudden” warnings?
Balance
Eyes
Face
Arm
Speech
Time: Huge in terms of getting medical intervention
Warning signs:
- Sudden numbness or weakness of the face, arm or leg especially one side of the body.
- Sudden confusion, trouble speaking or understanding
- Sudden trouble seeing in one or both eyes
- Sudden trouble walking, dizziness, loss of balance or coordination
- Sudden sever headache with no known cause
What are common problems with ACA Strokes?
Common Problems with ACA stroke are:
- Contralateral Hemiparesis or Hemiplegia
- Contralateral Sensory loss (mostly in LE)
- Mental confusion because of frontal lobe involvement
What are common problems with MCA Strokes?
Common Problems with MCA stroke are:
- Contralateral hemiparesis or Hemiplegia
- Contralateral Sensory loss (mostly in UE)
Can include: - Homonymous Hemianopia or other visual and spatial perceptual deficits, that being neglect if its the non-dominant hemisphere and apraxia if its the dominant hemisphere
The MCA is the most common site for Infarct
What are common problems with PCA Strokes?
Common problems with PCA Stoke are:
- Visual Changes (Pt. may exhibit homonymous hemianopsia
- May have very transient contralateral hemiparesis or hemiplegia
- Transient contralateral sensory loss (mainly because of thalamus and diencephalon involvement)
What happens if there is Vertebrobasilar Artery insufficiency?
What are common problems with is artery?
- If there is Vertebrobasilar Artery insufficiency death may occur because of the life function that are housed in within the brainstem
Common problems with Vertebrobasilar Artery are:
- Ipsilesional or ipsilaterally taction coordination. Pt. could be in a coma, have diplopia, tetraplegia and bulbar paralysis
What is a specific syndrome related to Vertebrobasilar Artery? How does this syndrome occur?
“Locked-In” Syndrome
- Tetraplegia with preserved consciousness, preserved sensation and vertical gaze
This occurs with a basilar artery occlusion and typically with bilateral infarction of the ventral aspect of the pons
*This can be very devastating because an individual is completely dependent and the only type of communication and/or mobility that they have would be to blink their eyes
What are the characteristics of Right Sided CVA /Left sided Hemiplegia/paresis Post Stroke?
- Unilateral neglect as a perceptual impairment.
- Agnosia, also a perceptual impairment
- Quick and impulsive behavior and many times poor judgement
- Unaware of their deficits
- May exhibit emotional lability, cant manage their emotions
Your initial encounter with the patient, your initial assessment of the medical record should be safety concerns
What are the characteristics of Left Sided CVA /Right sided Hemiplegia/paresis Post Stroke?
- More likely to have aphasia (Expressive or Receptive)
- Apraxia
- Slow, cautious and hesitant in their behavior
- They are aware of their deficits
- May be very depressed and have negative attitudes
(These Pt. are more susceptible of being clinically depressed, especially has they move into more chronic disease states) - PT need to provide a lot of motivation, external support and cueing
What is Parkinson’s Disease?
A slowly progressive neuro-degenerative disorder of the CNS
What is Idiopathic PD?
The most common kind of PD, and its referred to as “True Parkinson’s Disease”.
- It has no known cause
What is the Etiology of Secondary Parkinsonism?
- Virus
- Toxins, or medication side effects
- Multi infarct vascular disease (small stokes that can cause symptoms that mimic parkinson’s)
- Normal pressure hydrocephalus (causes an increase in the amount of cerebral spinal fluid in the brain, however pressure doesn’t get elevated, their ventricles become enlarged. The increase of CSF compresses regions of the brain, causes shuffling gait, incontinence, confusion and cognitive decline.) In order to DD NPH with PD is that NPH does not have tremors and parkinson’s does
What is the Etiology of Parkinsonism-plus syndromes?
This is super rare
- Progressive Supranucular Palsy
- Multi-system atrophy
- Lew body disease
- Alzheimer’s disease with Parkinsonism
(All of these present similar with slowness of movement and rigidity, however other symptoms later present themselves and are not characteristics of PD and the diagnosis changes)
What is the Pathophysiology of Parkinson’s?
- Degeneration of Dopamine (DA) producing neurons in the Basal Ganglia.
–Its the Pars compactus of the Substantia Nigra - Net effect is a reduction of DA acting on the striatum that affects:
–Direct loop (initiated voluntary movement)
–Indirect loo (inhibits voluntary movement) - Lewy Body inclusions, protein accumulations that build up inside of neurons causing further damage.
With Motor impairments, what are abnormal synergy patterns?
When joint movement cannot be isolated, due to an inability to activate or coordinate muscle contractions, an abnormal mass pattern of movement occurs
What are the Cardinal Features for PD?
- Tremor (resting, but progresses to action), starts asymmetrical.
-
Rigidity, is hypertonia (Increased resistance to passive movement)
–Leadpipe: uniform increase in resistance in both FLX and EXT
–Cogwheel: is leadpipe with a tremor superimposed
–Masked Face: Rigidity in the face - Akinesia (no movement; freezing)/Bradykinesia (slow movement) PD pts. may also have hypokinesia (small movements) Narrow spaces, turns and obstacles may cause freezing
-
Postural Instability (Occurs later in disease, ~5 years post diagnosis), determined through the Pull test.
–Postural deformity (stooped posture)
What are Secondary Motor Symptoms for PD?
- Stooped kyphotic posture, FHP (forward head posture)
- Reduced extensor strength: may start strong but with repetitions movement weakness and amplitude is reduced.
- Increased flexor tightness:
–neck, hip, elbow flx, ADD of shoulder, IR of shoulder, PF
–fatigue, comes from the rigidity
–joint hypomobility: spine, shoulders, hips, ankles - Start hesitation
- Difficulty with dual tasking (ex. walking and talking)
What are Secondary Motor Symptoms of PD, for GAIT?
- Shuffling: gait pattern with reduced step length (feet are”glued” to floor (typical pattern)
- Asymmetrical: arm swing and reduced trunk rotation
- Festinating (sudden increase in cadence and reduction in step length, COM is also affecting them so their falling and they cant catch themselves)
–Anteropulsive: when the COM is in forward direction
–Retropulsive: when the COM is in backward direction - Freezing of gait (triggers can be narrow spaces, changes in flooring, difficulty with turning may also cause a freeze)
- Bradykinetic
How do patients get Clinically diagnosed with PD?
- There is no definitive test to diagnose PD
Based on signs and symptoms:
- History: lack of smell, constipation, sleep disturbances, postural hypotension
- Clinical Exam: hand writing, speech, 2/4 cardinal signs with asymmetry
- Rule out: other neurodegenerative diseases
- Response to dopamine to replacement therapy
- Observation over time
With the Hoehn and Yahr Classification of Disability, what is Stage 1?
Minimal disability, unilateral symptoms
With the Hoehn and Yahr Classification of Disability, what is Stage 2?
Bilateral, or midline involvement (no balance impairment)
With the Hoehn and Yahr Classification of Disability, what is Stage 3?
Postural instability present but can still live independently
With the Hoehn and Yahr Classification of Disability, what is Stage 4?
All symptoms present, standing/walking only possible with assistance
With the Hoehn and Yahr Classification of Disability, what is Stage 5?
Wheelchair or bed bound
What happens if you were to give Levodopa by itself?
The stomach and small intestines, they would digest most of it and very little would actually get to the brain
What are potential side effects of taking Levodopa and Carbidopa?
Important
- Pt. will experience End-of Dose deterioration (wearing off); predictable worsening of symptoms toward the end of the expected time frame of medication dose
- After 4-6 yrs: the patient may develop Dyskinesia (abnormal movement) and Dystonia (Severe muscle posturing). They may also experience “On-Off” Phenomenon which is unpredictable worsening of symptoms
What is the Pathophysiology of TBI?
Primary Brain injury-damage occurs at the moment of impact, they may exhibit:
- Focal Brain Injury
–Coup-contrecoup injury
–Polar Brain Injury - Blast Injury
- Diffuse Axonal Injury (DAI)
With TBI, what is a Focal Brain Injury?
Coup-Contrecoup Vs Polar Brain injuries.
These injuries occur at the site of impact. Damage may take the form of a contusion or laceration or both.
- Coup-contrecoup: If the brain is hit hard enough, the brain will bounce and make contact with the skull at the opposite site of the local brain damage. (Coup=the injury that occurs within the first point of contact. Contrecoup= the injury on the opposite side)
- Polar Brain injury: Occurs in response to an acceleration, deceleration as well as rotational forces (Common in head on collisions), the frontal and temporal lobes are most susceptible to injury
With TBI, what are Blast Injuries?
Defined as an explosive device that may detonate and a transient shockwave is produced and causes the brain damage.
- Result from the direct effect of blast overpressure on the brain
- Secondary injury results from the shrapnel and other objects being hurled at the individual
- Tertiary injury the patient is being pushed or flung backwards and hitting an object
With TBI, What is Diffuse Axonal Injury (DAI)?
These occur in response to acceleration, deceleration as well as rotation and occur in conjunction with focal and polar brain injuries
With Diffuse Axonal Injury, What is the affect of rapid movement of the brain within the skull? What happens if the damage is severe?
This causes widespread stretching and tearing of the neuronal axons within the myelin sheath. This is labeled as the patient having subcortical white matter shearing.
- If the injury is severe, damage will extend to the brainstem and lead to coma and abnormal posturing
- Not usually evident on CT or MRI, if the pt. is exhibiting DAI, this is found during the neurological exam
One of the medical management for TBI is the monitoring of ICP. What is normal ICP and when is it a red flag or a danger?
- Normal ICP is 4-15 mmHG
- After TBI, 15-20 mmHG is expected
- > 25mmHG is a Red Flag and measures will be taken to reduce the pressure
- Danger >40mmHG because impaired blood flow to the brain can cause secondary injury
If ICP goes above 20mmHG notify the nurses &/or doctor and modify intervention
If ICP goes above 30mmHG immediately STOP all interventions and notify nurses and doctors
What is the Sequlae of TBI?
Neuromuscular Impairments
Cognitive Impairments
Neurobehavioral Impairments
With the Sequlae, what are common impairments with Neuromuscular Impairments?
- Paresis
- Abnormal Tone
- Motor Function
- Postural Control
With the Sequlae, what are common impairments with Cognitive Impairments?
- Arousal Level
- Attention
- Concentration
- Memory
- Learning
- Executive functions
What are specific cognitive impairments that are unique to TBI?
They deal with the altered levels of consciousness:
- Coma: Arousal state not functioning,No sleep/wake cycle, Not usually permanent
- Vegetative State: Disassociation between wakefulness and awareness, Sleep/wake cycles are present, patient will demo reflexive, non-purposeful responses
- Minimally conscious state (MCS): The patient will now exhibit localization to stimuli and may inconsistently reach for objects
With perceptual and Cognitive Impairments with TBI, What is Lethargy, Obtunded, Stuper, and Coma?
- Lethargy: Altered consciousness in which a person’s level of arousal is diminished; drowsy but able to answer
- Obtunded: Diminished arousal and awareness; difficult to arouse and when aroused is confused
- Stuper: Altered mental status and responsiveness to one’s environment; can only be aroused with vigorous stimuli
- Coma: Unconscious patient, can not be aroused, eyes remain closed, no sleep wake cycles
With Rancho Los Amigos (RLA), what are the Levels Of Cognitive Functioning (LOCF)?
I. No response
II. Generalized Response
III. Localized Response
IV. Confused-Agitated
V. Confused-Inappropriate
VI. Confused-Appropriate
VII. Automatic-Appropriate
VIII. Purposeful-Appropriate
The first 3 are severe disorder of consciousness on the Coma Recovery Scale (coma, vegetative, MCS)
With the RLA of Cognitive Function, what are the Characteristics of Level 1: No Response?
Complete absence of observable change in behavior
With the RLA of Cognitive Function, what are the Characteristics of Level 2: Generalized Response?
Demonstrates generalized reflex response to painful stimuli
- Responds to repeated auditory stimuli with increased or decreased activity
With the RLA of Cognitive Function, what are the Characteristics of Level 3: Localized Response?
Demonstrates withdrawal or vocalization to painful stimuli
- Turns toward or away from auditory stimuli
- Blinks when strong light crosses visual field
- Follows moving object passing within visual field
With the RLA of Cognitive Function, what are the Characteristics of Level 4: Confused/Agitated?
Alert and heighted state of activty
- Purposful attempts to remove restraints or tubes or crawl out of bed
- Absent ST memory
- May cry out or scream out of proportion to stimulus even after its removal
- May exhibit aggressive or flight behavior
With the RLA of Cognitive Function, what are the Characteristics of Level 5: Confused, Inappropriate Non-Agitated?
Alert, not agitated but may wander randomly or with a vague intention of going home
- May become aggitated in response to exernal stimulation, and/or lack of environmental structure
- Not oriented to person, place, or time
- Unable to learn new information
With the RLA of Cognitive Function, what are the Characteristics of Level 6: Confused, Appropriate?
Inconsistently oriented to person, time and place
- Able to attend to highly familiar task in non-distracting environment for 30 min with moderate redirection
- Max assist for new learning with little or no carry over
With the RLA of Cognitive Function, what are the Characteristics of Level 7: Automatic, Appropriate?
Consistently oriented to person and place, within highly familiar environments. Moderate assistance for orientation to time
- Able to attend to highly familiar tasks in a non-distraction environment for at least 30 min with minimal assist to complete tasks
- Minimal supervision for new learning
- Demonstrates carry over of new learning
- Overstimates abilities
With the RLA of Cognitive Function, what are the Characteristics of Level 8: Purposeful, Appropriate?
Consistently oriented to person, place, and time
- Independently attends to and completes familiar task for 1 hour in distracting environments
- Able to recall and integrate past and recent events
- Uses assistive memory devices to recall daily shedule, “to-do” list and record critical information for later use with stand-by assistance
What is the Glasgow Coma Scale?
An outcome measure that is used to help determine the severity of injury
What are the 3 components of the Glasgow Coma Scale?
- Eye Opening
- Best Motor Response
- Verbal Response
With the Glasgow Coma scale, What are the scores for Severe brain injury, Moderate Brain injury and Minor Brain injury?
- Severe Brain Injury: Score 3-8 (coma if eye opening is absent)
- Moderate Brain injury: Score 9-12
- Minor Brain Injury: Score 13-15
What is a Concussion? What can cause them? What is the result of a concussion?
- A brain injury induced by biomechanical forces
- Concussion is a functional disturbance, not a structural injury
- Can be caused by a direct blow to the head, neck, face or body and result in neuropathological changes
- Results in a set of clinical symptoms and usually does not involve loss of consciousness
What are the Acute Symptomology for Concussion?
If any ONE or more of the following are present its suspected that a concussion is present and further assessed
1) Symptoms (headache, fogginess, emotional lability)
2) Physical signs (LOC, amnesia, neurological deficit)
3) Balance Impairment (gait, unsteadiness)
4) Behavioral Changes (Irritability)
5) Cognitive Impairment (Slowed Reaction Times)
6) Sleep Disturbance (Insomnia)
S/S may be delayed several hours following a blow to the head and concussion should be viewed as an “evolving injury in the acute stage
With the Pathophysiology of Blast-Related Concussion, what are the Primary, Secondary, and Tertiary injuries?
- Primary Injury
–Shock waves from a blast disrupts brain tissue
–Similar to diffuse axonal injury
–More widespread injury - Secondary injury
–Fragments cause penetrating injury - Tertiary Injury
–Blunt trauma from striking solid surface
What is the Pathophysiology of Blunt-Force Concussion?
(Cascade of Events)
Must Know
- Ion channel dysfunction
–Potassium ions rush out of the neurons and destructive calcium and sodium ions rush in - Metabolic Energy Crisis
–Cerebral Glucose demand increased
–Cerebral blood flow decreased - Physiologic axonal stretching
–Microscopic axonal dysfunction (not seen in imaging)
What are the requirements of Normal Gait?
- Progression
- Stability (Posture)
- Adaptation
With Distance and Temporal Factors, what is Step Length?
When Initial Contact of one foot to Initial Contact of opposite foot
With Distance and Temporal Factors, what is Stride Length?
When Initial Contract of one foot to the following Initial Contact of same foot
With Distance and Temporal Factors, what is Cadence? What is the normal?
The number of steps per unit time
(Normal: 112.5 steps/min)
With Distance and Temporal Factors, what is Velocity?
What is the normal?
The average horizontal speed of body
(Normal: 1.46 m/s)
What is the greatest change in degrees at the hip?
Pre-swing going to Initial-swing (25°)
What are Gait Abnormalities with Mid to Terminal Stance?
- Increased Hip Flexion (Forward Trunk)
- Increased Hip Extension (Backward Trunk)
- Increased Knee Flexion (Knee Buckle)
- Increased Knee Extension (Knee Hyperextension/Genu Recurvatum)
What are causes of Gait Abnormalities with Pre swing throughout swing phases?
- Lack of Hip Flexion
- Lack of Knee Flexion
- Lack of Dorsiflexion
Lack of knee flexion and DF are due to weakness of the Flexors and hypertonicity of the Extensors
With Gait Abnormalities with Pre swing throughout swing phases, what are common compensations? Why are these compensations happening?
- Circumduction (weak hip FLX and increase in ADD)
- Vaulting (Excessive PF)
- Foot Drag/Foot Drop (No DF)
- Steppage Gait Good Hip Flexion (Lack of DF)
What is a common gait abnormality in Initial Contact?
Lack of heel strike, due to lack of DF
What is a common gait abnormality in Loading Response?
Foot slap, due to Excessive PF
What is the greatest amount of change in Knee Flexion in gait?
From Terminal Stance to Preswing
Going from 0° to 40° of flexion
What is the Responsibility/Spinal Pathway of the Superficial/Exteroreceptors Sensory Receptor?
Pain, Temp., Pressure, Crude Touch
Anterolateral Spinothalamic Pathway
What is the Responsibility/Spinal Pathway of the Deep/Proprioceptors (Muscle, Tendon, Joint, Fascia) Sensory Receptor?
Joint Awareness, Movement Awareness, Vibration, Discriminative/Light Touch
DCML Pathway
What is the Responsibility of the Combined Cortical Sensory Receptor?
Stereognosis, Two-point Discrimination, Barognosis, Graphesthesia
With Arousal, what is Alert?
When the patient is awake and attentive to normal levels of stimulation. Interactions with the therapist are normal and appropriate
With Arousal, what is Lethargic?
The patient appears drowsy and may fall asleep if not stimulated in some way. Interactions with the therapist may get diverted. The patient may have difficulty focusing or maintaining attention on a question or task
With Arousal, what is Obtunded?
The patient is difficult to arouse from a somnolent state and is frequently confused when awake. Repeated stimulation is required to maintain consciousness. Interactions with the therapist may be largely unproductive
With Arousal, what is Stupor?
(Semi-coma)
This patient responds only to strong, generally noxious stimuli and returns to the unconscious state when stimulation is stopped. When aroused, the patient is unable to interact with the therapist
With Arousal, what is Coma?
(deep coma)
The patient cannot be aroused by any type of stimulation. Reflex motor responses may or may not be seen
What Somato-Sensory Test would you do with Superficial Sensation Examination?
- Sharp/Dull Examination - Pain
–Pin (Sharp vs Dull) - Temperature Awareness
–Test Tube - Touch Awareness
–Cotton swab or brush
What Somato-Sensory Test would you do with Deep Sensation Examination?
- Kinesthesia Awareness (Movement awareness)
- Proprioceptive Awareness (Positional awareness)
- Vibration Perception
With Combined Cortical Sensation Examination, what are you testing for Stereognosis?
The ability to identify/form object (in hand usually)
With Combined Cortical Sensation Examination, what are you testing for Tactile Localization?
Localize touch sensation on skin
With Combined Cortical Sensation Examination, what are you testing for Two-Point Discrimination?
Perceive two distinct point (Smallest distance between 2 points - within the extremity)
With Combined Cortical Sensation Examination, what are you testing for Double Simultaneous Stimulation?
Perceived Simultaneous touch (on the body)
With Combined Cortical Sensation Examination, what are you testing for Graphesthesia?
The ability to recognize letters, numbers, design on skin by touch (drawing on someone)
With Combined Cortical Sensation Examination, what are you testing for Texture Recognition?
The ability to differentiate different textures
With Combined Cortical Sensation Examination, what are you testing for Barognosis?
The ability to perceive weight of an object
When doing the Visual Examination, what visual Impairments may you see?
- Diplopia: Double Vision
- Strabismus: Malalignment (Depth perception issue)
Lazy eye - Nystagmus: Involuntary oscillatory deficit (Vestibular issue)
- Homonymous Hemianopia: The Pts. inability to see one side of the visual field
How is the Senory Examination Graded?
0 : Absent
1: Impaired
2 Normal
This is for Sharp/Dull, Light Touch, Kinesthesia, and Proprioception Testing
What is the Flexion Synergy for the UE?
Scapular - Retraction/Elevation
Shoulder- ABD, ER
Elbow - Flexion
Forearm - Supination
Wrist - Flexion
Finger - Flexion
What is the Extension Synergy for the UE?
Scapular - Protraction
Shoulder- ADD, IR
Elbow - Extension
Forearm - Pronation
Wrist - Extension
Finger - Flexion
What is the Flexion Synergy for the LE?
Hip - Flexion, ABD, ER
Knee - Flexion
Ankle - DF, Inversion
Toe - DF
What is the Extension Synergy for the LE?
Hip - Extension, ADD, IR
Knee - Extension
Ankle - PF, Inversion
Toe - PF
What is a 0 in the Modified Ashworth Scale?
There is no increase in tone (Normal)
What is a 1 in the Modified Ashworth Scale?
Slight increase in tone, end of range (May catch and release)
What is a 1+ in the Modified Ashworth Scale?
Slight increase in tone through less than 1/2 range
What is a 2 in the Modified Ashworth Scale?
Marked increase tone through most of the range
(Still moves easily)
What is a 3 in the Modified Ashworth Scale?
Passive movement difficult
What is a 4 in the Modified Ashworth Scale?
Rigid (No movement)
What is the 1st Stage of the Brunnstrom’s Stage of Recovery?
There is Flaccidity and no movement
What is the 2nd Stage of the Brunnstrom’s Stage of Recovery?
Spasticity begins and no Voluntary movements
What is the 3rd Stage of the Brunnstrom’s Stage of Recovery?
Spasticity worsens, Voluntary movement occurs in only synergy
What is the 4th Stage of the Brunnstrom’s Stage of Recovery?
Spasticity declines, some voluntary movement out of synergy may occur
What is the 5th Stage of the Brunnstrom’s Stage of Recovery?
Spasticity continues to decline, relative independence from synergistic movement
What is the 6th Stage of the Brunnstrom’s Stage of Recovery?
Spasticity disappears; Full isolated/coordinated movement
What is the difference between Decorticate and Decerebrate Rigidity?
Decorticate: refers to sustained contraction and posturing of the upper limbs in flexion and the lower limbs in extension.
Decerebrate: refers to sustained contraction and posturing of the trunk and limbs in a position of full extension
Typically associated with damage to the descending UMN pathway, typical with coma and damage to brainstem
If there is damage to the Cerebellum, how would this affect Nonequilibrium coordination?
- Dysmetria
- Dysdiadochokinesia (Rapid alternating movements)
- Tremor
- Movement Decomposition
- Rebound Phenomenon
If there is damage to the Basal Ganglia, how would this affect Nonequilibrium coordination?
Think PD
- Akinesia
- Bradykinesia
- Rigidity
- Tremor
- Involuntary Movements
If there is damage to the Dorsal Columns, how would this affect Nonequilibrium coordination?
- Dysmetria
- Slowness of movement
When resisting Flexion of uninvolved UE, what would be the response of the involved limb?
Flexion of involved UE
With Sensory, what 3 sources provide input to the body to properly attain normal postural and balance control?
- Visual
- Vestibular
- Somatosensory
Somatosensory inputs provide the greatest and most reliable information, if compromised Visual assumes a greater role
With Motor Strategies, what is the difference between Adaptive Postural Control and Anticipatory Postural Control?
Adaptive Postural Control: The bodies ability to react to external stimulus and respond
Ex.: Getting pushed, walking on a rope bridge
Anticipatory Postural Control: The use of past experience of predict needed motor response
Ex.: Stepping into an escalator
With Compensatory Postural Strategies, what is Ankle Strategy?
- These response to small perturbations on a firm support surface.
- Muscles of the ankle fire distal to proximal
With Ankle Strategy, what are 2 possible responses that may occur and what muscles are active with the responses?
- Forward Sway: Pushed forward or platform moves backward
Gastroc, Hamstrings, Paraspinals - Backward Sway: Pushed backward or platform moves forward
Tibialis Anterior, Quadriceps, Abdominals
With Compensatory Postural Strategies, what is Hip Strategy?
- Responses to larger, faster perturbations or when the support surface is compliant or very narrow, like a balance beam
- Muscles fire proximal to distal
With Hip Strategy, what are 2 possible responses that may occur and what muscles are active with the responses?
- Forward Sway: Pushed forward or platform moves backward (posterior)
Abdominals, Quadriceps - Backward Sway: Pushed backward or platform moves forward (anterior)
Paraspinals, Hamstrings
With Compensatory Postural Strategies, what is Stepping Strategy?
- Response to large and fast perturbation when COM moves near or beyond the limits of stability
- Can also occur due to ankle/trunk weakness or ineffective ankle/hip strategy
When doing a Balance Assessment with patients with a Cerebellar Dysfunction, what would their Weight Bearing/BOS look like?
Wide BOS
When doing a Balance Assessment with patients with a Cerebellar Dysfunction, what would be the Findings with LOB?
- Incoordination and Ataxia with Stepping Strategy
- Difficulty Scaling
- (+) Oscillations before regaining balance
When doing a Balance Assessment with patients with a Cerebellar Dysfunction, will they have more difficulty with Anticipatory or Adaptive Response?
More Difficulty with Adaptive Response due to difficulty with scaling
When doing a Balance Assessment with patients with a Basal Ganglion Dysfunction (PD), what would be their postural alignment?
They would have increased flexion
When doing a Balance Assessment with patients with a Basal Ganglion Dysfunction (PD), what would be the Findings with LOB?
- Use of multiple steps to regain balance (Possible festination)
- (+) Coactivation of agonist and antagonist due to rigidity (increased LOB)
When doing a Balance Assessment with patients with a Basal Ganglion Dysfunction (PD), will they have more difficulty with Anticipatory or Adaptive Response?
More difficulty with Anticipatory due to Bradykinesia
When doing a Balance Assessment with patients with a Cortex Dysfunction (Stroke), what would their Weight Bearing/BOS look like?
Asymmetrical
When doing a Balance Assessment with patients with a Cortex Dysfunction (Stroke), what would be their postural alignment?
Asymmetrical
When doing a Balance Assessment with patients with a Cortex Dysfunction (Stroke), what would be the Findings with LOB?
- They will usually rely on reaching with uninvolved UE or stepping with uninvolved LE
- Overall delay in motor strategies
When doing a Balance Assessment with patients with a Cortex Dysfunction (Stroke), will they have more difficulty with Anticipatory or Adaptive Response?
More difficulty with Adaptive due to lack of hemimotor control
Using the Pic, what system is the patient dependent on if they have increased sway or LOB on conditions 2, 3, 5, and 6 during the Sensory Organization Test and Foam and Dome?
This will indicate that the patient is dependent on Vision for Postural Control
Using the Pic, what system is the patient dependent on if they have increased sway or LOB on conditions 4, 5 and 6 during the Sensory Organization Test and Foam and Dome?
This may indicate that the patient is dependent on Somatosensation for Postural Control
Using the Pic, what system did the patient loss if they have increased sway or LOB on conditions 5 and 6 during the Sensory Organization Test and Foam and Dome?
This may indicate that the patient is has Vestibular Loss
What is the Tinetti Outcome Measure?
- This Assess Gait and Balance in older adults
- Measures Perception of balance during ADLs
- Its an indicator of Fall Risk
What is the 6 Min Walk Outcome Measure?
- This is a sub-maximal exercise test to assess aerobic capacity and functional endurance
To set up, use a chair at both ends of the test to allow seated rest
What is the 10m Walk Outcome Measure?
A 14m walkway is needed; Measure 10m distance that’ll be the start and finish mark; Start the person 2m in front of the start and have the person walk 2m past the finish mark
- Assesses Gait speed which correlates with level of functional independence and participation capacity
- Divide the distance by time, this will give you the speed in meters per second
To set up, use a chair at both ends of the test to allow seated rest
What is the Dynamic Gait Index Outcome Measure?
This is a Gait OM
- Assesses individuals ability to modify balance while walking in the presence of external demands
This test mimics everyday gait activities involving
adjustment to disruptions in balance, direction change, and gait speeds
What is the Functional Gait Assessment (FGA) Outcome Measure?
- Assesses postural stability during walking and an individuals ability to perform multiple motor task while walking
The Functional Gait Assessment is similar to the Dynamic Gait Index and was developed to improve reliability and decrease the ceiling effect
What is the Fall Indicator for the Functional Reach Outcome Measure?
Dynamic Balance with task of reach (Forward, Backward, or Lateral)
*Fall Risk Indicator if they are less than 6 inches *
What is the focus for the Rhomberg/Sharpened Rhomberg Outcome Measure?
Assesses static Balance with task of standing in two postures:
- Rhomberg: feet shoulder width apart with arms crossed
- Sharpened: Feet in tandem with arms crossed; strong leg posterior
(Can be done with eyes open or closed)
Indictor for fall Risk
What is the purpose for the Timed Up and Go?
- TUG assesses mobility, balance and walking ability in one test to determine fall risk.
- Time is taken when the individual stands up walks a distance of 3m, turns around and sits back down; with no physical assistance
The timed up and go is a reliable test of physical mobility and it provides the examiner with a quick snap
shot of the patient’s dynamic balance, gait speed, and functional ability
Fall Risk Indicator
What is the focus for the Berg Balance Outcome Measure?
What score will indicate a fall risk?
- Objectively determines the patients ability to safely maintain postural control/balance during a series of 14 tasks
A total score for this exam is 56; A score of 45 and below indicates a risk for fall
With walking speed, what is the Full Community Ambulation Gait Speed (able to safely cross street)?
> 1.2 m/s
With walking speed, what is the Community Ambulation Gait Speed?
> 0.8 m/s
With walking speed, what is the Household to limited Community Ambulation Gait Speed?
0.4-0.8 m/s
With walking speed, what is the Household only Gait Speed?
<0.4 m/s
What does it mean when the patient completes the test in <10 seconds in the TUG?
They are freely Independent
What does it mean when the patient completes the test in >30 seconds in the TUG?
Dependent in most activities, not a community ambulator, FALL RISK
