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S4- Neuro 1 > Week 2- Common Neurological Impairments 1 > Flashcards

Week 2- Common Neurological Impairments 1 Flashcards

1
Q

PART 1: STRENGTH

A

PART 1: STRENGTH

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2
Q
  • __-__% of stroke survivors experience some degree of contralateral weakness.
  • What is the exception to this rule?
A
  • 80-90%

- Most descending drive from the cerebellum descends ipsilaterally.

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3
Q

Why can we also see mild ipsilateral weakness in patients with a CVA?

A

10-25% of CST (corticospinal tract) descend ipsilaterally. (anterior CST)

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4
Q

Do we see extremity involvement or trunk involvement more and why?

A

Extremity, trunk gets bilateral innervation.

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5
Q

The degree of primary weakness related to a stroke is based off the ________ and ______ of the stroke.

A
  • location

- size

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6
Q
  • What is the difference between hemiparesis and hemiplegia?

- What is “Dense Hemiplegia”?

A
  • Hemiparesis is mild to moderate weakness on the contralateral side, while hemiplegia is severe to profound weakness on contralateral side.
  • Dense Hemiplegia = no active movement observed.
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7
Q

With weakness after a stroke there are _________ and __________ effects of the stroke.

A

primary and secondary

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8
Q

Primary Neuromuscular Impairments:

  • Damage to descending _________ drive
  • Type I __, Type II __ leading to a loss of force production.
  • Loss of ______ units
  • Asynchronous and abnormal motor unit firing.
A
  • cortical
  • Type I ↑, Type II ↓
  • motor units
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9
Q

Secondary Neuromuscular Impairments:

  • Increased ___________
  • Delayed _________ times
  • Prolonged movement times
  • Disuse muscular _________
  • Length tension changes
A
  • fatigability
  • reaction
  • atrophy
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10
Q

Do we as PTs treat primary or secondary impairments?

A

Both

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11
Q
  • With strokes, do we see proximal or distal involvement more often? Why?
  • Does distal or proximal involvement return quicker?
A
  • DISTAL, the corticospinal tract is involved with more fine movements of distal extremities.
  • proximal
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12
Q

What are some common patterns of weakness and time to recover between muscle pairs?

A
  • Shoulder extensors > flexors
  • Shoulder ER > IR
  • Elbow extensors > flexors
  • Finger extensors > flexors
  • Hip extensors > flexors
  • Hip ER > IR
  • Hip abductors > adductors
  • Knee flexors > extensors
  • Ankle DF > PF
  • Ankle eversion > inversion
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13
Q

Facial weakness is resulting from damage to contralateral _______ (CN__ and ___) pathways

A

corticobulbar (CNVII and CNVIII)

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14
Q

The __________ is often spared in strokes affecting facial muscles.

A

forehead

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15
Q

PART 2: MOTOR CONTROL

A

PART 2: MOTOR CONTROL

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16
Q

_____________ is the ability of the brain to use what it has.

A

Motor control

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17
Q

Match the definitions below to either motor control, plan, program, learning, recovery, or compensation.

  1. ) An abstract representation that, when initiated, results in the production of a coordinated movement sequence.
  2. ) A set of internal processes associated with feedback or practice leading to relatively permanent changes in the capability for motor skill.
  3. ) The appearance of new motor patterns resulting from changes to CNS.
  4. ) The reappearance of motor patterns present prior to CNS injury performed in the same manner as prior to injury.
  5. ) The underlying substrates of neural, physical, and behavioral aspects of movement.
  6. ) An idea or plan for purposeful movement that is made up of component motor programs.
A
  1. ) Motor program
  2. ) Motor learning
  3. ) Motor compensation
  4. ) Motor recovery
  5. ) Motor control
  6. ) Motor plan
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18
Q

What IS motor control?

A

“The process of initiating, directing, and grading purposeful voluntary movement”

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19
Q

How many stages of motor recovery are there post CVA?

A

6

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20
Q

What are the first (3) stages of motor recovery post CVA?

A

Stage I
- Initial flaccidity, no voluntary movement (cerebral shock)
Stage 2
-Emergence of spasticity, hyperreflexia, and emergence of stereotypical synergies (mass patterns of movement)
Stage 3
-Voluntary movement possible, but only in synergies, spasticity strong if present

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21
Q

Synergies are a ___________ impairment.

A

motor control

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22
Q

What are the most common synergy patterns?

A
  • Flexor Synergy (UE)

- Extensor Synergy (LE)

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23
Q
  • Describe a Flexor Synergy (UE).

- Describe a Extensor Synergy (LE).

A 
Flexor Synergy (UE)
-Scapula retraction and elevation, shoulder abduction and ER, elbow flexion*, supination, wrist and finger flexion
Extensor Synergy (LE)
-Hip extension, adduction*, and IR, knee extension*, ankle PF and inversion, toe PF
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24
Q

Can synergy patterns be reversed?

A

Yes, can have UE Extensor Synergy and LE Flexor Synergy

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25
Q

With synergistic movements, patients lack the ability to _________ muscles.

A

isolate

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26
Q

What are the last (3) stages of motor recovery post CVA?

A

Stage 4
-Voluntary control in isolated joint movements emerging, corresponding decline of spasticity and synergies
Stage 5
-Increasing voluntary control out of synergy; coordination deficits present
Stage 6
-Control and coordination near normal

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27
Q

The last 3 stages of motor recovery progression involves further emergence of __________ and _________ control of movement.

A

voluntary and accurate

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28
Q

What is motor praxis?

A

The ability to plan and execute coordinated movements.

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29
Q

What is apraxia?

A

Inability to plan and execute purposeful movements that cannot be accounted for by any other reason.

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30
Q

Lesions in what areas can causes apraxia?

A
  • Premotor frontal cortex (either side)
  • Left inferior parietal lobe
  • Corpus callosum
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31
Q

What is the difference between ideomotor apraxia and ideational apraxia?

A
  • Ideomotor Apraxia- Inability to produce movement on command, but able to move automatically
  • Ideational Apraxia- Inability to produce movement both on command or automatically.
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32
Q

With ____________ apraxia the conceptualization of the task remains intact.

A

ideomotor

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33
Q

How do we assess Motor Recovery post CVA? (Strength vs Motor Control)

A

MMT

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34
Q

It is often very difficult for patients to ________ specific movements post CVA. How do we document strength deficits then?

A
  • isolate

- Examine and document strength deficits through functional observation (Functional Strength Testing).

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35
Q

What are 2 assessments used for Motor Recovery post CVA?

A
  • Fugl-Meyer Assessment of Physical Performance

- Rivermead Motor Assessment

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36
Q
  • What is the main flaw of the Fugl-Meyer Assessment of Physical Performance?
  • How do we instead use this assessment?
A
  • 155 items meaning it will take about 45 minutes to complete.
  • Focus on just the motor domain.
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37
Q

The motor domain of the Fugl-Meyer Assessment of Physical Performance includes what 3 things?

A
  • movement
  • coordination
  • reflexes
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38
Q
  • What is the Fugl-Meyer Assessment of Physical Performance MDC for UE and LE?
  • What is the Fugl-Meyer Assessment of Physical Performance MCID for UE and LE?
A 
MDC
-5.4 points (UE)
-5 points (LE)
MCID
-10 points (UE)
-10 points (LE)
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39
Q

If we want to consider how motor control is impacting mobility, what test would we use?

A

Rivermead Motor Assessment

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40
Q

What are the 3 sections of the Rivermead Motor Assessment?

A
  • Gross Motor
  • Leg and Trunk
  • Arm
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41
Q
  • How is the Rivermead Motor Assessment scored?

- What is the MCID?

A
  • If the patient can do the task they get a point, if they can’t do the task they don’t get a point and the test stops.
  • 3 points
42
Q

List some UE Outcome Measures used to assess motor recovery post CVA.

A
  • 9 Hole Peg Test
  • Action Research Arm Test
  • Arm Motor Ability Test
  • Box and Blocks Test
  • Motricity Index
43
Q

List some LE Outcome Measures used to assess motor recovery post CVA.

A
  • Five Time Sit to Stand Test

- Motricity Index

44
Q

PART 3: ENDURANCE

A

PART 3: ENDURANCE

45
Q

Are endurance and activity tolerance the same thing?

A

Yes

46
Q

Why do we look at endurance when addressing patient post CVA?

A

All of a sudden, easy tasks become exhausting to these patients. It is highly common post stroke.

47
Q

When addressing Endurance/Activity Tolerance we are looking at ________ capacity. What is the main way to measure this?

A
  • aerobic

- Functional Reserve (VO2) (O2 consumption/min)

48
Q

What is functional reserve?

A

The remaining capacity of cardiovascular/respiratory/neuromuscular systems to respond to metabolic changes.

49
Q

Functional Reserve is a product of what 2 things?

A
  • workload

- energy expenditure

50
Q

With low fitness levels, small tasks require increased energy expenditure. How does this affect functional reserve?

A

Substantially reduces reserve.

51
Q

After a stroke:

  • It is _x the work to do ADLs.
  • It is _x the work to walk short distances over level ground.
A
  • 2x

- 3x

52
Q

Its also been found that post stroke individuals are more __________ to minor reductions in functional reserve.

A

sensitive

53
Q

What are the (3) contributors to reduced endurance in CVA?

A
  • Baseline Cardiovascular Health
  • Primary CVA Impairments
  • Post-stroke Deconditioning
54
Q

Baseline Cardiovascular Health:

  • Up to 80% have ______.
  • 20-40% of patients have ______ ________ _______.
  • What are some common pre-morbid findings in the post-stroke populations?
  • Cardiac dysfunction contributes to a lower aerobic capacity via what 2 principle mechanisms?
A
  • HTN
  • silent cardiac ischemia

-decreased cardiac output, widespread atherosclerosis, cardiac decomposition, rhythmic disorders

  • Ischemia-induced reductions in ejection fraction (EF) and stroke volume (SV)
  • Inability for HR to increase proportionally to metabolic demands (chronotropic incompetence)
55
Q

Primary CVA Impairments:

-What are some primary CVA impairments that can increase energy expenditure, even with simple low-intensity tasks?

A
  • Weakness (primary and secondary)
  • Impaired motor control
  • Cognitive and perceptual deficits
  • Balance
  • Pain
  • Fatigue
56
Q

Post-Stroke Deconditioning:

  • Result of _____ illness, ________, and limited activity levels
  • How does deconditioning affect each of the following systems; Neurological, Cardiovascular, Pulmonary, Musculoskeletal, Behavioral
A

-acute illness, bedrest

  • Neurological: degradation of neural circuits due to loss of active engagement
  • Cardiovascular: decreased cardiac output and HRmax, increase in resting and exercise BP
  • Pulmonary: decreased lung volume, pulmonary perfusion and vital capacity as well as altered chest wall excursion
  • Musculoskeletal: decreased muscle mass, bone mass, and flexibility
  • Behavioral: depression, anxiety, fear
57
Q

For patients post-stroke, it is recommended that they undergo _______ exercise testing with ECG monitoring before beginning an exercise program. Why?

A
  • Graded Exercise Testing

- due to lack of CVA guidance

58
Q
  • What is the problem with graded exercise testing?

- What do we do if we are unable to do graded exercise testing?

A
  • Expensive and not commonly in clinic, hard to do a treadmill test on post CVA patients.
  • Light-to-moderate exercise recommended while monitoring pt response.
59
Q

With graded exercise testing, monitor ___ and ___ closely. May need to use the __________ scale to assess.

A
  • HR and BP

- Borg RPE (below 6)

60
Q

What are two graded exercise testing outcome measures used?

A
  • 6MWT

- 2MWT (acute CVA)

61
Q

PART 4: COORDINATION

A

PART 4: COORDINATION

62
Q
  • What is coordination?

- What is incoordination?

A
  • The ability to use different body parts of the body together smoothly and efficiently.
  • Movements that are awkward, uneven, and inaccurate.
63
Q

What are the (3) critical components of coordination?

A
  • Sequencing
  • Timing
  • Grading
64
Q

Incoordination is found with __________, _______, and _______ lesions.

A

-motor cortex, basal ganglia, and cerebellar lesions

65
Q

What are the big potential findings with a coordination examination?

A
  • Dysdiadochokinesia
  • Dysmetria
  • Dyssynergia
  • Asynergia
  • Rebound phenomenon
  • Tremor
66
Q

What is dysdiadochokinesia?

A

Impaired ability to perform rapid alternating movements.

67
Q

What is dysmetria?

A

Inability to judge distance or range of movement. (hypometria or hypermetria)

68
Q

What is dyssynergia?

A

Fragmented movement patterns.

69
Q

What is asynergia?

A

Loss of ability to associate muscles together for complex movements.

70
Q

What is rebound phenomenon (check reflex)?

A

Inability to rapidly and sufficiently halt movement of a body part after a strong isometric force.

71
Q

What is tremor?

A

Unintentional, oscillatory movement. (resting or intentional)

72
Q
  • What is ataxia?

- What are the 2 types of ataxia?

A
  • Impaired balance or coordination.

- Cerebellar ataxia (due to damage of cerebellum), Sensory ataxia (due to proprioceptive deficits).

73
Q

Ataxia results in difficulties with _______/______,________, and _______ of movements.

A

fluidity/timing, accuracy, and speed

74
Q

When we have coordination deficits, what are the (3) areas the deficits can come from?

A
  • cerebellar pathology
  • basal ganglia pathology
  • disruption of DCML and associated structures
75
Q
  • The __________ is the coordination hub.
  • The _____________ is important in the initiation and execution of movement.
  • The __________ plays a role in coordination by gathering info from peripheral somatosensory receptors that hold crucial info to the status of the environment, body, and how they are interacting.
A
  • cerebellum
  • basal ganglia
  • DCML
76
Q

Damage to the cerebellum, basal ganglia, and DCML pathway can all result in what (3) same exam findings?

A
  • Trunk, limb, and/or gait ataxia.
  • Dysmetria, dyssynergia, and dysdiadochokinesia.
  • Balance deficits.
77
Q
  • Cerebellum = ipsilateral or contralateral?
  • Basal ganglia = ipsilateral or contralateral?
  • DCML = ipsilateral or contralateral?
A
  • Cerebellum = ipsilateral
  • Basal ganglia = contralateral
  • DCML = contralateral
78
Q

Cerebellum Unique Exam Findings:

  • __________ deficits
  • lack of _______ reflex
  • may see mild _________
  • ________ tremor
  • slurred speech (__________)
  • significant difficulties with ____________
A
  • oculomotor
  • check
  • hypotonia
  • intentional
  • dysarthria
  • motor learning
79
Q

Basal Ganglia Unique Exam Findings:

  • __________ (if non-CVA pathology, may see rigidity)
  • _______ and _________ tremor
  • difficulty _________ movement
  • slowed and smaller movements
  • considerable ________ deficits
A
  • spasticity
  • resting and intentional
  • initiating
  • strength
80
Q

DCML Unique Exam Findings:

  • abnormal sensory exam (particularly ____________)
  • unlikely to see _________
A
  • proprioception

- tremor

81
Q

What are some common post-stroke impairments that can impact coordination?

A
  • Weakness
  • Motor control
  • Sensory loss
  • Cognition and communication deficits
  • Vision (diplopia)
82
Q

PART 5: TONE ABNORMALITIES AND REFLEXES

A

PART 5: TONE ABNORMALITIES AND REFLEXES

83
Q
  • What is tone?

- Is a certain amount of muscle tone normal?

A
  • Muscle’s resistance to passive stretch.

- Yes

84
Q

Flaccidity is on the end of _____tonicity, rigidity is on the end of _____tonicity.

A
  • hypotonicity

- hypertonicity

85
Q
  • LMN = ______tonicity

- UMN = ______tonicity

A
  • LMN = hypotonicity

- UMN = hypertonicity

86
Q
  • Spasticity = velocity ___________

- Hypertonicity = velocity __________

A
  • dependent

- independent

87
Q

With strokes, do we see spasticity or hypertonicity? Why?

A

-Spasticity, it is usually a result of damage to pyramidal or extrapyramidal tracts, which are often impacted with strokes.

88
Q

__________ is a form of hypertonia that presents with specific resting positioning, seen with severe brain injury or stroke.

A

Posturing

89
Q

What are the 2 types of posturing, how do they present, and where is their location of injury?

A

Decorticate (UE flexion, LE extension/IR/PF)
-brainstem lesions ABOVE red nucleus

Decerebrate (UE and LE extension)
-brainstem lesions BELOW red nucleus

90
Q
  • With acute UMN injuries, we can see temporary _________.
  • What is the cause?
  • What is the duration?
A
  • hypotonia
  • cerebral or spinal shock
  • highly variable (days to weeks)
91
Q

With Subacute → Chronic UMN injuries we have a development of ____________. Tone gets worse before it gets better.

A

spasticity

92
Q

A reduction in spasticity is needed for an improvement in ______________.

A

motor control

93
Q
  • What is the main scale used to assess tone?

- It measures ___________, and that alone.

A
  • Modified Ashworth Scale

- spasticity

94
Q

Describe the grading scale of the Modified Ashworth Scale.

A 
0 = No increase in muscle tone.
1 = Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end range of motion when the affected part/s is/are moved in flexion.
1+ = Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than 1/2) of the ROM.
2 = More marked increase in muscle tone through most of the ROM, but affected part(s) are easily moved.
3 = Considerable increase in muscle tone, passive movement difficult.
4 = Affected part(s) rigid in flexion or extension.
95
Q

Typical Patterns of Spasticity in UMN Syndromes:

  • Scapula =
  • Shoulder =
  • Elbow =
  • Forearm =
  • Wrist =
  • Hand =
  • Pelvis =
  • Hip =
  • Knee =
  • Foot and Ankle =
  • Hip and Knee =
  • Trunk =

Posture forward (prolonged sitting posture) =

A
  • Scapula = retraction, downward rotation
  • Shoulder = adduction and IR, depression
  • Elbow = flexion
  • Forearm = pronation
  • Wrist = flexion, adduction
  • Hand = finger flexion, clenched fist thumb, adducted in palm
  • Pelvis = retraction (hip hiking)
  • Hip = adduction (scissoring), IR, extension
  • Knee = extension and flexion
  • Foot and Ankle = PF, inversion, equinovarus, toes claw, toes curl
  • Hip and Knee = flexion, sacral sitting
  • Trunk = lateral flexion with concavity, rotation

Posture forward (prolonged sitting posture) = excessive forward flexion, forward head

96
Q

What are DTRs?

A

Deep Tendon Reflexes

-“Involuntary, predictable, and specific response to stimulus that is dependent on an intact reflex arc”

97
Q

What is the grading for DTRs?

A 
0 = absent, no response
1+ = low normal, diminished response
2+ = normal
3+ = brisker or more reflexive than normal
4+ = very brisk, non-sustained clonus
5+ = sustained clonus
98
Q

After a stroke we can see a return of ________ or _______ reflexes.

A

primitive or tonic

99
Q

PART 5 (2): CRANIAL NERVE DYSFUNCTION

A

PART 5 (2): CRANIAL NERVE DYSFUNCTION

100
Q

__________ strokes require in in-depth CN examination.

A

Brainstem

101
Q

How are each of the 12 cranial nerves typically affected with damage?

A
  • I = rarely involved, typically skipped
  • II = field cuts/visual loss, reduced visual acuity (blurry)
  • III, IV, VI = gaze palsies → double vision (diplopia), ptosis
  • V = loss of facial sensory input, asymmetrical jaw movement and strength, loss of mastication → choking risk → aspiration risk
  • VII = facial weakness, loss of sensory tongue, impairment of salivary glands → choking risk → aspiration risk, impairment of lacrimal glands → impaired vision
  • VIII = hearing loss, vestibular dysfunction → vertigo, balance deficits
  • IX = dysphagia, reduced taste and sensation of tongue, loss of gag reflex → choking risk → aspiration risk, ANS: cardiovascular dysfunction (HR, BP)
  • X = pharyngeal and laryngeal weakness, loss of gag reflex → choking risk → aspiration risk, ANS: abnormalities of esophageal motility, gastric acid secretion, gallbladder emptying, cardiovascular dysfunction (HR)
  • XI = UTrap and SCM weakness → inability to rotate head/shrug shoulders
  • XII = tongue weakness → choking risk → aspiration risk

S4- Neuro 1 (12 decks)

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