Week 11 to Week 14 Flashcards

Question

Pathology: Diffuse vs. Focal: Focal

Answer 1

Caused by a direct blow to the head with an external object or fall, penetrating injury from a weapon, collision of the brain with the inner tables of the skull Common findings from falls = intracerebral and brain surface contusions (inferior and dorsal-lateral frontal lobes, anterior and medial temporal lobes, and less common inferior cerebellum)

Answer 2

Caused by a direct blow to the head with an external object or fall, penetrating injury from a weapon, collision of the brain with the inner tables of the skull Common findings from falls = intracerebral and brain surface contusions (inferior and dorsal-lateral frontal lobes, anterior and medial temporal lobes, and less common inferior cerebellum)

Answer 3

(the site of direct injury)

Answer 4

(site of indirect injury)

Answer 5

associated with skull fractures and disruption of meningeal arteries

Answer 6

occur between the dura and brain surface due to tearing of bridging veins

Answer 7

Pre-frontal & anterior temporal areas: impaired memory, emotion and motivation Orbitofrontal area: impulsivity Frontolateral cortex:impassivity, hemiparesis, impaired attention and mental flexibility

Answer 8

Often caused by sudden deceleration of the body and head with variable forces and deeper portions of the brain

Answer 9

nearly always present with missile wounds and common after falls and assault

Answer 10

occur when the pia or arachnoid is torn.

Answer 11

= prototypic lesions caused by rapid deceleration and rotation of the brain in the skull

Answer 12

``` Ataxia Diplopia Dysarthria Impulsivity, irritability Apathy, poor initiative Decreased mental processing speed & efficiency Impaired attention Impaired abstract reasoning, planning, problem solving ```

Answer 13

= occurs at the time of trauma

Answer 14

Occur as a result of the effects of brain swelling in a closed space, loss of perfusion, and decreased delivery of oxygen The American Association of Neurological Surgeons has developed guidelines for management of severe TBI to minimize secondary injury Resuscitation of blood pressure and oxygenation, management of elevated intracranial pressure, nutrition after acute trauma and seizure prophylaxis Secondary effects (Radomski, 2008): hypoxia, hypotension, hypothermia, and hyperthermia (most common)

Answer 15

TBI typically results in an altered level of consciousness From Coma to conscious awareness Progression along this continuum varies depending on age, previous health, severity of injury, and medical/therapeutic/environmental management.

Answer 16

As coma resolves client is either partially aware (minimally conscious) or if no awareness = vegetative

Answer 17

- Wakefulness without awareness - Characteristics: no awareness of self or environment, inability to interact with others, no sustained or voluntary behavioral responses, no language comprehension, sleep wake cycle varies, ability to regulate temp, breathing, and circulation with medical care, incontinence of bowels and bladder, variably preserved cranial nerves and spinal reflexes

Answer 18

- Evidence of awareness of self and/or environment. - Must have 1 of the following: ability to follow commands, gesture or verbal yes/no responses, intelligible verbalization, and purposeful movement

Answer 19

- Single best measurable predictor of functional outcomes - Length of time from the injury to the moment the individual regains ongoing memory of daily events - Longer PTA = poorer outcomes (cognitive and motor abilities, and function)

Answer 20

When the brain is injured, it reacts like other parts of the body that may be injured…it swells. Unfortunately, the cranial vault where the brain sits inside the skull has a limited volume of about 1,400 milliliters. When the brain swells, it can damage and kill neurons by squeezing them and stopping oxygen from reaching the cells. If the (ICP) pressure gets too much, the brain can be forced into the hole at the base of the brain, the foramen magnum, and compress the brainstem. The brain stem is where the consciousness, breathing, and heart rate are controlled. Damage here can result in coma or death.

Answer 21

Occurs when an individual suffers a second head injury before the initial injury has fully healed…leads to diffuse cerebral swelling Can potentially result in death within minutes Rare enough condition that its frequency of occurrence is debated Kevin Pearce (snowboarder)

Answer 22

A neurodegenerative disease associated with repeated head trauma Results in generalized global atrophy of the brain, ventricular dilation, thinning of the corpus collosum, and neurofibrillary bundles similar to AD Symptoms include headaches, difficulties with attention and memory, mood disorders, motor dysfunction, and dementia First identified in 1954 and linked to boxing, it has gained more attention in recent years due to the suicides of NFL football players and a recent movie about Dr. Bennet Omalu

Answer 23

humans results from a midbrain lesion and is manifested by an exaggerated extensor posture of all extremities.

Answer 24

Decorticate posture is an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight. ... This type of posturing is a sign of severe damage in the brain

Answer 25

s a loss of memory-access to events that occurred, or information that was learned, before an injury or the onset of a disease.

Answer 26

Anterograde amnesia is a loss of the ability to create new memories after the event that caused amnesia, leading to a partial or complete inability to recall the recent past, while long-term memories from before the event remain intact.

Answer 27

Blurred vision, convergence insufficiency, reduced blink rate……. Also damage to oculomotor nerve

Answer 28

Often result of high right hemisphere damage Visual perception = Right left discrimination, figure ground, position in space Body schema = anosognosia , unilateral neglect Speech & Language = aphasia, dyslexia, dysprosody

Answer 29

``` Self concept Social roles Independent living Dealing with loss Affective changes ```

Answer 30

Common RLA Level IV (agitated/confused) = yelling, swearing, grabbing, biting

Answer 31

Assesses 3 behavioral areas: motor responses, verbal responses, and eye opening

Answer 32

1) pain, no motor response to pinch, 2) body becomes rigid in extension with pinch, 3) flexes body inappropriately to pain, 4) pulls away with pinch, 5) pulls examiner’s hand away with pinch, 6) follows simply commands

Answer 33

1) no noise to 5) carries on conversation correctly

Answer 34

1) does not open eyes to 4) opens eyes on own/spontaneous

Answer 35

Measurement of levels of awareness and cognitive function Typical progression is linear although some with very severe injury may skip a level (typically level IV = agitated and confused)

Answer 36

``` 4 = spontaneous 3 = to sound 2 = to pressure 1 = none NT = not testable ```

Answer 37

``` 5 = orientated 4 = confused 3 = words, but not coherent 2 = sounds, but no words 1 = none NT = not testable ```

Answer 38

Motor Response (M) ``` 6 = obeys command 5 = localizing 4 = normal flexion 3 = abnormal flexion 2 = extension 1 = none NT = not testable ```

Answer 39

Level 1= No reaction - The brain-injured person is unconscious Level 2= Generalized reaction - The brain-injured person will react but inconsistent and without purpose. Level 3= Level 3: Localized reaction - The brain-injured person is improving. Level 4= Level 4: Confused/Agitated - The brain-injured person has become very active but they are not yet able to understand what's going on Level 5= Level 5: Confused/Inappropriate - The brain-injured person has become less agitated. Level 6= Confused/Appropriate - Things are looking up. The brain-injured person is motivated but still depends on others to lead the way. Level 7= Automatic/Appropriate - The brain-injured person seems to act appropriately in the hospital and at home. Level 8= Purposeful/Appropriate - At last! The brain-injured person remembers how the past fits with the future Level 9= Purposeful-appropriate, goes through daily routine aware of need fr stand-by-assistance, depression may continue Level 10= Purposeful-Appropriate/Modified Independent, goes through daily routine but may require more time or compensatory strategies, periodic depression may occur

Answer 40

``` Evaluate: Level of arousal - attend, follow commands, communicate, awake Vision - scan, attend, eye contact Sensation - pain, temp, movement ROM Motor Control - tone, reflexes Dysphagia Emotional and behavioral factors ``` Interventions: Sensory stim, w/c positioning, bed positioning, splinting/casting, dysphagia, behavioral, family/caregiver edu

Answer 41

RLA IV to VIII = client is alert, confused, agitated, and inappropriate with responses, may follow 2-3 step commands, easily distracted Same as Low level with addition of ADLS, work readiness, and reintegration into the community, IADLS Physical status, dysphagia, cognition, vision Interventions: Neuromuscular (NDT, PNF), Ataxia, Cognition, Vision, Behavioral, dysphagia & self feeding, Functional mobility

Answer 42

Allows interaction with the environment, prevents skin breakdown/ joint contractures, facilitates normal muscle tone, inhibits primitive reflexes, increases sitting tolerance, enhances respiration and swallowing, promotes function

Answer 43

Crucial early on to prevent sores, facilitate normal tone/ ROM/ mobility Barriers: spasticity, splints, IVs, tubes, medical precautions Side lying or semiprone = abnormal tone or posturing

Answer 44

Similar to CVA When spasticity impacts function When ROM is limited When there are soft tissue contractures Contraindications: uncontrolled hypertension, open wounds, unhealed fx, impaired circulation, acute inflammation

Answer 45

Goal = increase arousal/awareness with sensory stim Responses measured (Radomski, 2008): respiration, pulse, blood pressure, head movements, eye opening/movements, eye fixation, mimic responses, aimed and non aimed motor responses, and articulations

Answer 46

content that is self generated is remembered better than content that is provided/given

Answer 47

- 1 task of each done with provided conditions the other done with generated conditions - Provided information: “Scramble two eggs in a bowl. Pour into hot pan on stove. Let cook three minutes. Flip.” - Self-generated information: “Scramble two in a bowl. into hot pan on stove. Let cook minutes. Flip.”

Answer 48

- 1 task of each done with provided conditions the other done with generated conditions - Provided information: “Scramble two eggs in a bowl. Pour into hot pan on stove. Let cook three minutes. Flip.” - Self-generated information: “Scramble two in a bowl. into hot pan on stove. Let cook minutes. Flip.”

Answer 49

Post traumatic agitation occurs in 33 - 50% of those with TBI Clinicians need to determine factors contributing to problem behaviors Client factors, Social context and environment, & Physical environment One on one coaching = 24/7 Psychotropic meds = regulate sleep and minimize agitation Environmental modifications = alarm system, helmet, quiet room

Answer 50

- Environmental = alter objects or environment to facilitate behavior, inhibit unwanted, maintain safety - Interactive = used to interact with client, use consistent implementation by all

Answer 51

Systematic review of 10 articles to determine best practice for OT in community integration Assessment: Reintegration to Normal Living Index Community Integration Questionnaire (most widely used) Findings:

Answer 52

Patient's and caregivers report frustration with being discharged from therapy before they feel ready Brain Injury Wellness Program: 6, 1-hour sessions that focus on community integration, wellness, function, and QOL Results: increased community participation, success in implementation of compensatory strategies, gained confidence

Answer 53

May have unrealistic expectations or interpret information differently than medical staff (unresponsiveness may be laziness, deafness…. When it is cognitive status) Provide family with concise information Involved throughout the rehab process Educated on ROM, positioning, transfers……. Substance Use Drug rehab services

Answer 54

Home safety Complete home eval to determine needed home modifications Equipment Eval and Ordering May refer to driver training/eval May refer to work/vocational training

Answer 55

ICD 10: G20 Chronic progressive condition Loss of dopamine-producing cells in the basal ganglia Cause is unknown. Recent studies point to environmental and genetic factors

Answer 56

PD is the second most common neurodegenerative disorder in the US Effects approximately 1 million in the US

Answer 57

``` Bradykinesia Hypokinesia Rigidity Tremor Disturbed postural reflexes ```

Answer 58

slowness of movement and is one of the cardinal manifestations of Parkinson's disease.

Answer 59

partial or complete loss of muscle movement due to a disruption in the basal ganglia.

Answer 60

inability to be to bent or be forced out of shape.

Answer 61

involuntary, somewhat rhythmic, muscle contraction and relaxation involving oscillations or twitching movements of one or more body parts.

Answer 62

``` Mental Functions Sleep Disorders Voice and Speech Depression Psychosis Anxiety Fatigue Smell disorders Constipation ```

Answer 63

Motor symptoms often precede non-motor symptoms Motor symptoms often begin unilaterally Less than 5% end up w/c or bedridden Life expectancy is almost average with medical advances Slower progression: Faster progression:

Answer 64

Progressive resistive, joint mobilization, postural stability/balance training, gait training, aerobic activities More likely to improve performance skills and not task performance itself Encourage clients to engage in regular physical activity

Answer 65

Progressive resistive, joint mobilization, postural stability/balance training, gait training, aerobic activities More likely to improve performance skills and not task performance itself Encourage clients to engage in regular physical activity

Answer 66

Progressive resistive, joint mobilization, postural stability/balance training, gait training, aerobic activities More likely to improve performance skills and not task performance itself Encourage clients to engage in regular physical activity

Answer 67

Auditory rhythmic cues stronger than visual and tactile cues for regulating walking Moderate evidence to support client-preferred external cues during performance of ADLs had positive effects on motor control Provide Targeted external cues

Answer 68

education, goal setting, practice, and feedback to incorporate into daily life Plan for and manage the progression of the disease

Answer 69

``` Optimizing daily schedule Dealing with stress and time pressure Practicing arm/hand motor skills Attention to Task Cognitive movement strategies Minimize dual task Use Cues Rhythmic and single Auditory, Visual, Tactile/Proprioceptive Environmental modifications Caregiver support and education ```

Answer 70

Stage 1: minimal symptoms; usually tremors; symptoms don't affect daily routine Stage 2: Diseases starts to affect whole body; routine activities may take longer to complete Stage 3: loss of balance and coordinaton; routine activities may become difficult Stage 4: nearly impossible to live on your own; routine activities should not be performed alone Stage 5; final & most severe stage; confined to bed; dementia; confusion; and hallucinations begin

Answer 71

: pain, swelling, inflammation, postural malalignment, muscle imbalance, trigger points

Answer 72

May encourage realignment of joint structures Offers proprioceptive feedback Beneficial for shoulder impingement, joint sprains, and multi- directional instability Reposition humeral head with tape to that it is in a neutral position Taping allows client to feel normal alignment Can result in immediate pain relief and improved ROM May help with inflammation by encouraging lymphatic drainage

Answer 73

Y-tape Used to surround a muscle To facilitate or inhibit muscle stimuli, should be 2 inches longer than muscle I-tape - most commonly used Used for more acute injuries Edema and pain management, correct alignment X-tape Used when origin and insertion change depending on movement Donut Specifically for edema Overlapping strips and the center is cut our over areas of focus Web/Fan Primarily used for edema

Answer 74

Insertion to Origin Used to inhibit overused or stretched muscles Light stretch required (15 – 25%) Origin to Insertion Used to facilitate weak or under performing muscles Light to moderate stretch required (50-75%)

Answer 75

``` 1) Identify the 3 landmarks on your client Deltoid Tuberosity Coracoid process Acromial Process Spine of scapula ``` 2) Measure out and cut the 3 pieces of tape 3) Clean and prepare the skin 4) Apply Tape 1) Medial = 1 inch below deltoid tuberosity - 1 inch above acromion process (ends at neck) 2) Posterior = 1 inch below deltoid tuberosity - 1 inch above spine of scapula 3) Anterior = 1 inch below deltoid tuberosity - 1 inch above coracoid process

Answer 76

Origin to insertion method as the deltoid is noted to be weakened or paralyzed 1) Pt positioned with head, trunk, and scapula in best alignment 2) Abduct shoulder to 90 degrees 3) Cut Y tape and place anchor on the acromion process with no stretch 4) Move shldr to Extension and apply first tail to anterior deltoid as it is stretched (end at insertion) with no stretch in tape 5) Move shoulder in horizontal abduction and apply second tail over posterior deltoid ending at insertion

Answer 77

A group of progressive, degenerative neuromuscular diseases:

Answer 78

Destruction in corticobulbar tracts and brain stem Symptoms: speech, swallowing, breathing may be affected

Answer 79

Destruction in LMN in the spinal cord (sometimes brainstem) Symptoms:weakness or muscle atrophy of extremities, cervical extensor weakness, fasciculation, muscle cramps, and loss of reflexes

Answer 80

Destruction of cortical motor neurons Symptoms: results in: general weakness. Spasticity, and hyperreflexia

Answer 81

- Focal weakness in arms, legs, or bulbar muscles - Trip or drop things - Slurred speech - Abnormal fatigue - Uncontrollable laughing/crying

Answer 82

Progresses Marked muscle atrophy Weight loss Spasticity Muscle cramping Fasciculation Difficulty walking, dressing, fine motor, swallowing, breathing

Answer 83

1) Ambulatory, no ADL problems, mild weakness How would you treat? 2) Ambulatory, moderate weakness in certain muscles How would you treat? 3) Ambulatory, severe weakness in certain muscles How would you treat? 4) Wheelchair confined, almost independent, severe weakness in legs How would you treat? 5) Wheelchair confined, dependent, pronounces weakness in legs, severe in arms How would you treat? 6) Bedridden, Dep ADLs, Max A - Dep in all tasks How would you treat?

Answer 84

Fatal degenerative neurologic disorder Genetic, transmitted in an autosomal dominant pattern Damage to the corpus striatum which is responsible for motor control Damage to the caudate nucleus is linked to cognitive and emotional function

Answer 85

Decreased speed of finger tapping | Unified Huntington's Disease Rating Scale

Answer 86

Alterations in behavior, changes in cognitive functioning, choreiform movements of the hands

Answer 87

Memory and decision making skills Help them maintain meaningful habits and routines Better with familiar and routine tasks Gait and balance disturbances

Answer 88

``` Verbal comprehension Dysarthria Depression worsens Bradykinesia and akinesia Increasing difficulty with handwriting Slowed saccadic and ocular eye movements Dysphagia and choking hazard ```

Answer 89

Medical Treatment Can address the symptoms but not stop the progression of the disease Antidepressants Goal: manage symptoms, reduce burden of symptoms, maximize function, and provide pt and family education

Answer 90

Early stages Address memory and concentration: How? Assist with strategies for employment: How? Address anxiety, depression, and irritability: How? Address the effects of Chorea Modifications for fine motor control: How? ``` Middle Stages Provide visual cues to prompt actions Watch for signs of Suicide: How? Address fatigue: How? Address increase chorea: How? Address dysphagia: How? ``` Final Stages Address chorea replaced with rigidity: How?

Answer 91

Progressive, inflammatory neurologic disease Damage to the myelin sheath in the CNS Onset between the ages of 20 - 45 Etiology: unknown, suspected combination of environmental and genetic factors

Answer 92

Early symptoms: Paresthesia, diplopia, visual loss in one eye, fatigue, emotional lability, sensory loss in extremities Trigeminal neuralgia, symptoms exacerbated with increased body temperatures Advance stages: Varying degrees of paralysis, dysarthria, dysphagia, severe visual impairment, ataxia, spasticity, nystagmus, neurogenic bladder, impaired cognition

Answer 93

Patterns of symptoms: 1) Relapsing and Remitting 85% of cases Slow, step like progression as deficits accumulate 2) Secondary Progressive Begins with relapsing and remitting that progresses into primary progressive 50% of those with relapsing/remitting progress to secondary progressive 3) Primary Progressive 10% of MS population Downward slope with little recovery after an exacerbation Become non ambulatory, incontinent, dysphagia, dysarthria, severely compromised LE function, varying UE function

Answer 94

Life expectancy Favorable Prognosis: (chart page 937) Minimal disability after 5 years of onset complete/rapid remission of initial symptoms Age of onset less than 40 y/o Only 1 symptom the first year Onset with sensory symptoms or mild optic neuritis ``` Poor Prognosis: Progressive course Age of onset greater than 40 Cerebellar involvement Polysymptomatic Male sex ```

Answer 95

Assess motor and praxis, sensory perceptual, emotional regulation, cognitive, communication skills As fatigue is often an issue assessments results may vary depending on time of day Self report often inaccurate Assess sleep and sleep patterns Assess visual tracking, scanning, and acuity Assess cognition

Answer 96

Treatment: MS Society resources for clinicians: Articles: Systematic Reviews Part I and Part II (Yu & Mathiowetz, 2014a&b) Part 1 = activity and participation -Goal directed interventions, health promotion programs, and fatigue management programs -Direct training in functional performance -Group fatigue management delivered face to face or long distance ``` Part 2 = Impairment Cognition Emotional Regulation Exercise Motor Training ```

Answer 97

A rare autoimmune disease with no known cure, no established treatment, requiring a long period of recovery, no clear cause Acute, Inflammatory disorder in which the body’s immune system attacks the peripheral nervous system Damage to the myelin sheath prevents nerve conduction that leads to muscle weakness, pain, and/or paralysis of the entire body

Answer 98

Rapidly progressive weakness of bilateral extremities distal to proximal Brain does not receive signals from the body Body does not receive signals from the brain to move Often first symptom is tingling, crawling skin, painful sensations that begin in the hands and feet If demyelination continues may impact breathing, speaking, swallowing, blood pressure, and/or heart rate

Answer 99

Initial Phase: Passive ROM, positioning, splinting to prevent contractures/deformity Passive activities like watching tv Address anxiety, fear, and panic Recovery Phase: Precautions: prevent muscle belly tenderness, fatigue, and further damage to nerves Address proximal joints first as they recovery then move to distal Introduce activities as they are able to tolerate them, just right challenge, opportunities for success AE, compensatory strategies, energy conservation, joint protection Lifestyle redesign

Answer 100

Peak of Polio in the US was 1952 After 30 - 40 years 25% - 40% of these adults deal with new muscle pain, weakness, and/or paralysis = postpolio syndrome PPS

Answer 101

1) Pervious paralysis due to polio 2) Period of partial or complete recovery 3) Gradual or sudden onset of progressive muscle weakness or fatigue 4) New difficulties with breathing and swallowing 5) A year or more of the above symptoms 6) Other causes have been ruled out

Answer 102

Slow progression with periods of stability (plateaus) Fatigue is found to be the most debilitating symptom Risk of muscle atrophy, scoliosis, osteoporosis, fractures, contractures, and depression Difficulty with ADLs, IADLs, ambulation, stairs, home mang, transfers, driving, eating and swallowing, bladder and bowel control While symptoms greatly impact quality of life there are rarely life threatening

Answer 103

Work simplification, pacing and energy conservation, adaptive equipment, passive and active ROM, muscle re-education, proper posture and body mechanics, joint protection Connect with support groups for feelings of denial, anger, hopelessness, feel a burden Introduce changes gradually with just right challenge to provide confidence and success Caution with exercise: In general body weight reduction, work with dietician

Answer 104

Feeding: “the process of setting up, arranging, and bringing food (fluids) from the plate or cup to the mouth, sometimes called self feeding” OTPF Eating: “The ability to keep and manipulate food/fluid in the mouth and swallow it; eating and swallowing are often used interchangeably” OTPF Dysphagia: inability to swallow or difficulty with swallowing Clients who may have difficulty feeding or eating: ???

Answer 105

Preparatory Phase Before the 4 stages of eating Begins when client enters the dining area Considers variety of foods, presentation of food, seating during meals, meal time atmosphere, mealtime habits Sensory quality of the food and items, appetite & hunger 1) Oral Preparatory Phase Action: Visual and olfactory information stimulates saliva production Jaw opens and lips close around food with musculature creating a seal to prevent spillage Chewing: Time to form bolus is shorter for softer foods

Answer 106

Stage 2 & 3 of Swallowing 2) Oral Phase Begins when tongue initiates movement of bolus towards the pharynx Tongue elevates, pushing bolus against the hard palate and guides the bolus back Thicker foods require more pressure of tongue on the palate This is a voluntary phase, person must be alert and involved 3) Pharyngeal Phase Closure of the larynx, the laryngeal entrance, and epiglottis to prevent material from entering airway Bolus moves through the pharynx towards the esophagus, passes through pharynx divided in half at the valleculae and down each side of the pyriform sinuses Upper esophageal sphincter relaxes and opens allowing material to enter the esophagus

Answer 107

4) Esophageal Phase Begins when bolus enters the esophagus through the cricopharyngeal juncture or upper esophageal sphincter (UES) Esophagus is a straight tube 10 inches long that connects the pharynx to the stomach UES separates pharynx from esophagus and LES separates esophagus from the stomach Muscles of esophagus contract and push bolus down = peristaltic wave contractions Epiglottitis returns to a relaxed state to allow airway to open, return to breathing

Answer 108

``` Difficulty shaping food into bolus Loss of food from mouth or nose Coughing, throat clearing Wet or gurgling voice after Changes in mealtime behavior Food residue in mouth Delayed or absent swallow Weak cough Reflux of food Aspiration ```

Answer 109

``` Trunk and head positioning -Improve swallow -Reduce risk of aspiration Rehabilitative: Exercises ``` Compensatory: Oral hygiene Modify food texture 1) facilitate appropriate positioning during eating 2) Improve motor control at each stage of swallowing 3) Maintenance of adequate hydration and nutrition 4) Prevention of aspiration 5) Reestablishment of oral eating to the safest/optimum level on least restrictive diet

Answer 110

Dysphagia Level 1: Dysphagia Puree Dysphagia Level 2: Mechanical Soft Dysphagia Level 3: Dysphagia Advanced ``` Dysphagia Level 4: Normal Liquids Thin Nectar like Honey like Spoon thick ```