Neuro Flashcards

Question

What system interactions are required for postural control?

Answer 1

Sensory (afferent) input Visual Vestibular Somatosensory CNS integration Processes afferent input and determines appropriate output Motor (efferent) output Execution of motor response (muscle synergies, timing and force) *feedback system*

Answer 2

Hypertension Heart disease Disorders of heart rhythm Diabetes mellitus Hypercholesterolemia High levels of LDL Low levels of HDL Elevated hematocrit End stage renal disease and chronic kidney disease Sleep apnea Female Early menopause Estrogen supplementation Pregnancy, birth, first 6 weeks post -partum Preeclampsia - increased BP during pregnancy Modifiable Smoking Physical inactivity Obesity Diet Excessive alcohol use Non-modifiable Family history Age Gender (M>F) Race (african american)

Answer 3

Postural orientation and postural balance (need to maintain stability and orientation (CoM over BoS))

Answer 4

Ischemic stroke without tissue death - symptoms resolve in 24 hours or less “mini-stroke or “warning stroke)

Answer 5

Postural stability Balance Control and accuracy of movement VOR training Add wrist / ankle weights to slow movement to work on accuracy Viscous loading (swimming) Normalize gait constrain the timing, increase or alter accuracy demands, speed, direction or force, use novel tasks, change components of task, change setting, reduce or change somatosensory or visual feedback, increase balance requirements / reduce support, increase attentional demands, add unexpected demands Also use external constaits, practice in variety of speeds and amplitudes while maintain quality, practice tasks that required predictive timing

Answer 6

MRI Blood work to rule out other conditions

Answer 7

1. Peripheral - benign paroxysmal positional vertigo, unilateral vestibular hypofunction, bilateral vestibular hypofunction 2. Central

Answer 8

Gaze stabilization, postural stabilization, spatial orientation

Answer 9

An external device used to restrict or assist motion, or to transfer load to different part of body (also brace, splint - temporary) choose based on patient's impairments and activity limitations

Answer 10

Too high -difficulty propelling w/c due to reach -difficulty standing up for transfers -poor posture when forearms rest Too low -poor posture when forearms rest -difficulty standing up for transfers

Answer 11

General principles - clear obstacles, proper footwear, guard appropriately (weaker side), monitor for for signs of fear/unsteadiness, start with most to least stable then challenge from least to most difficult movements, regress if needed -External harder than internal (but actually CoG displacement closed to LoS makes it harder) Challenges - altered BoS, internal perturbations, reactive balance strategies (expected vs. unexpected), altered vision, speed, moving CoM higher, include cognitive demanding tasks

Answer 12

Full use of hand intrinsics allowing for grasping with ease and less need for adaptive equipment ** Independent with ADLs, may require adaptation Manual wheelchair with standard hand rims

Answer 13

Modality tested Surface areas affected Degree or severity of involvement Subjective feelings about altered sensation Potential impact of sensory impairment on function

Answer 14

Internal -shoe insert -heel spur insert orthosis - cushion that slopes forward - shifts load to forefoot -longitudinal arch support -scaphoid pad - same as above -metatarsal pad - good for metatarsalgia and morton's neuroma (helps also with transverse arch) External -heel wedge - helps rearfoot (medial - fix pronation or valgus, or rigid varus to even out) -metatarsal bar -rocker bar *transfers from pressure intolerant area to pressure tolerant to help with pain - correct alignment with flexible or accommodates with rigid*

Answer 15

1. Progressive deterioation -1-4 weeks, demyelination and axonal damage occur 2. Plateau -no further deterioration 3. Recovery -6 months - 2 years -axonal regeneration and myelination -complete recovery common, sometimes mild weakness (foot drop - bilateral) -low mortality

Answer 16

decomposition of movement reduce degrees of freedom use assistive devices and technology use verbal / visual cues to assist with walking speed and stride length

Answer 17

-Muscle weakness - in UE, LE or bulbar muscles - leads to secondary impairments -Fasiculations -Atrophy -Muscle cramps -Hyporeflexia -Hypotonicitiy

Answer 18

Hemiplegic gait - arm flexed, leg extended and stiff - leg circumducts (from stiffness and to clear the foot drop). if not severe, arm might just not be swinging Parkinson's gait: everything flexed, small steps (festinating gait), may have tremor Cerebellar / Ataxic gait: broad BoS, staggering quality - fall towards side of lesion, stand still get trunk sway (titubations) Proprioceptive impairment: rely on visual cues = stomp/stamp gait - slap foot down, creates vibrations in trunk - more prominent in the dark Diplegic / CP gait - extensor spasm LE- walking on tip toes, adductor spasm - get scissoring if severe, some circumduction, arms flexed Myopathy / waddling gait: lift leg up to take step - pelvis drops (myopathy) - to compensate you lean over and waddle - trendelenberg sign Neuropathic gait / steppage gait - peripheral neuropathy with foot drop - high stappage to clear foot Choreiform gait - writhering movements - involuntary - happens at rest too

Answer 19

Damage to the center of the SC, peripheries intact *most common* Due to a hyperextension injury in the cervical region or compressive force causing hemorrhage and edema on the SC Loss of motor (UE>LE)> sensory (picture upper motor injury) Sacral sensation spared, sacral motor often spared

Answer 20

Cerebellar -motor impairments present (e.g., dysdiadochokinesia, dysmetria, hypotonia) -EO = EC in rhomberg test -Cerebellar gait - ataxic gait Sensory -EO better than EC (+ve rhomberg - suggests proprioception issue) -Hx of EC/ dark = not steady -Sensory gait - high stepping / stomping gait to get auditory or proprioceptive feedback -Pseudo- athetasis - EC = withering movements

Answer 21

Vertebral artery - supplied cerebellum and medulla Basilar artery - supplies pons, internal ear and cerebellum *injury occurs after forced Cx motion (WAD, manipulation) Produced ipsilateral (cerebellum) or contralateral S + S Common characteristics Ataxia (ipsilateral), impaired sensation over face, impaired pain and thermal sensation (contralateral), vertigo, diplopia, dysarthria, dysphagia

Answer 22

See chart in book

Answer 23

Respiratory management -NLI C5 and above - ventilatory support using intermittent positive pressure ventilator -deep breathing -glossopharyngeal breathing (high Cx lesion - gulp air) -Respiratory muscle strengthening (decrease WOB, prevent compliaction) -Assisted cough -Abdominal binder - help with orthostatic hypotension Skin care -positioning - every 2 hours -Pressure relief - every 15 mins when in w/c or tilt in space/reclining wheelchair (HELD FOR 2 MINS) -skin inspection -education -wound care Early strength / ROM -Daily -Pelvis in neutral when LE ROM -Lx - SLR >60 and hip flexion >90 (NO PPT) -Tetraplegia - no movement of head/neck, shoulder flexion/abduction >90 degrees -selective stretching - good in lower trunk, long finger flexors - NEED - SLR ~100 for long sitting and LE dressing (and assistive cough) -Splinting - in hamburger hands (wrist 20 extension, MCP flexion, IP full extension or slight flexion, thumb natural opposition) Early mobility -if postural hypotension - gradual exposure, abdnominal binders and elastic stockings, monitor vitals and document, recline trunk and elevate legs if experience symptoms Active rehab -continue with resp care, skin care and ROM -strength -CV and endurance -wheelchair skills -bed mobility -balance -transfers -gait training

Answer 24

Difficulty swallowing - aspiration can occur Lead to respiratory distress, aspiration pneumonia or death If severe - nothing-per-oral precautions are given Even water Through tube feeding - NG or G tube Associated with dehydration and poor nutritional status

Answer 25

Hemianopia - loss of visual field on one side of midline Homonymous - loss on the same side of both eyes *can’t see the area but know it is there so can turn head* Where as neglect - can’t perceive the side so doesn’t know it exists

Answer 26

Sensory retraining / stimulation approach Mirror therapy Sensory discrimination activities Compression techniques - weight bearing, pneumatic compression Electrical stimulation Thermal stimulation Safety education - improve awareness and protect Hemianopia and unilateral neglect Encourage awareness and use of environment on hemiparetic side Active visual scanning movements Cueing to direct attention UE exercises crossing midline towards hemiparetic side Functional activities involving bilateral interaction Prism glasses (unilateral neglect)

Answer 27

A chronic inflammatory disease, causing demyelination of the CNS (through damage of the myelin sheath and myelin producing cells (oligodendrocytes) This is replaced by plaques which prevents normal transmission of nerve impulses causing neurological S + S Believed to be an autoimmune disease Etiology -unknown -induced by viral or other infectious agent -genetic susceptibility Epidemiology -F>M -age between 15-50, typically 30

Answer 28

Tetraplegia -all 4 limbs and trunk -motor and sensory -Injuries above the level of T1 (cervical SC) Paraplegia -legs and all/some of trunk -injuries below the level of T2 (thoracic, lumbar or CE) -motor and sensory

Answer 29

SUPPLIED Both the MCA and ACA Results in large obstruction of area supplied by MCA ACA has collateral circulation from circle of willis, but if absent - area supplied by ACA will also be affected Significant edema - increased ICP - leading to uncal herniation (inner part of temporal lobe has so much pressure - herniates down and pressure on brain stem), coma or death

Answer 30

Medical -no cure medications to slow - levodopa (dopamine precurser) and carbidope (sinemet) - which allows for higher uptake (lower dose of levodopa) -initially big improvements then body use to it so need to increase dose -do not have sudden discontinuation or reduction = side effects PT -motor learning strategies -exercise training - relaxation, flexibility, strength, function -balance -gait -cardiopulmonary

Answer 31

As more motor - anticipate, correct and modify movement based on sensory inputs organized and integrated by CNS Feedback: sensory input received and adjusted for motor output Feedforward:sensory input from past used as anticipatory adjustments

Answer 32

SUPPLIES - medial aspect of cerebral hemisphere (frontal and parietal lobes) subcortical structures (basal ganglia, anterior fornix, corpus callosum) Anterior communicating artery allows perfusion to proximal ACA If proximal to artery - minimal deficits If distal to artery - greater deficits Characteristics Contralateral hemiparesis and hemi-sensory loss LE affected > UE Because of homunculus and the LE sits more towards medial aspect Urinary incontinence Abulia - absence of will power and can’t act decisively Akinetic mutism - don’t move/speak much Apraxia - difficulty with motor planning Broca’s aphasia (frontal lobe) - trouble with speech production

Answer 33

Stages of motor recovery Twitchell and Brunnstrom *through different stages - see chart - not everyone goes through, can plateau at one of the stages Tone Initial flaccidity (cerebral shock) - days to weeks then spascity UE - scapular retraction, shoulder adduction, depression and internal rotation, elbow flexor and forearm pronator, wrist and finger flexors LE - pelvic retractors, hip adductors, extensors, and internal rotators, knee extensors, plantarflexion and supinators, toe flexors In neck and trunk, strong spascitiy - cause increased lateral flexion to hemiplegic side (pusher syndrome - lean towards weak side) Reflexes Initial hyporeflexia (cerebral shock) then hypereflexia comes when spasticity and synergies emerge DTR: hyperreflexia, clonus, babinkski, clasp knife response Associated reaction - all or none - strong obligatory synergies occur (can be both sides) (can be in response to a stimuli - e.g., cough/sneeze) Volunatry movements Obligatory synergies - unable to perform isolated movements - interfere with functional mobility and normal ADLs May vary from one limb to another *see book for UE and LE synergy patterns Coordination Sensory ataxia (proprioceptive losses) Cerebellar ataxia Bradykinesia. Choreoarthetosis (involuntary, twisting movements), hamiballismus (basal ganglion affected) - sudden uncontrolled movements Use unilateral and bilateral movement - may vary depending on position - due to postural demand and degrees of freedom Could go into spasm or synergies if more postural demand Motor programming -Apraxia - difficulty planning and performing tasks or purposeful movements No primary motor impairments More evident with L side hemisphere impairment -Ideational apraxia Inability to produce purposeful movement on command or automatically No idea how to do the movement -Ideomotor apraxia Inability to produce purposeful movement on command but is able to perform movement automatically Often perseverates

Answer 34

Independent self-propulsion -traditional manual wheelchair -One arm drive system - 2 rims (rotation, together = forward) -Self-propulsion using feet - if cognitive impairment, decreased strength Power mobility system -unable to manually propel but cognitively aware (and safe) -or can't do in community - excessive stress to muscles and joints, postural problems, CV strain / excessive fatigue

Answer 35

Proprioception Determine joint position and awareness at rest Grasp joint at sides, get patient to describe or mirror the joint position Kinesthesia Determine awareness of movement - same as above but just throughout the range of movement Vibration Ability to perceive vibratory stimuli Strikes tuning fork, place on bony prominences - random applications of it (*strike for auditory though every time)

Answer 36

Able to perform limited self-care with tenodesis grasp Independent to min assist with sliding board** - use posterior deltoids to go into extension, lock elbow using CKC, then can push up (and depress scapula) and scooch over onto sliding board and repeat Independent with manual cough Wheelchair propulsion possible with the use of hand rim projections for short distances Power wheelchair for community Independent with pressure relief maneuvers in wheelchair Can drive a car/ van using adaptive hand controls Capable of living independently **

Answer 37

Patient is aware and awake - complete paralysis of all voluntary muscles except for eyes but otherwise cognitively intact - communication through blinking/ vertical eye movement Sudden onset Preserved consciousness and sensation Eye paralyzed too = total locked - in syndrome

Answer 38

-Finger to nose (dysdiadochokinesia, dysnergia, dysmetria) -Finger to therapist finger (dysdiadochokinesia, intention tremor) -Finger to finger (intention tremor) -Alternate nose to finger (dysdiadochokinesia, dysnergia, dysmetria, intention tremor) -Finger opposition (dysdiadochokinesia) -Mass grasp (dysdiadochokinesia) -Pronation / supination (do not slap) (dysdiadochokinesia) -Rebound test (rebound phenomenon) -Tapping - on lap or feet (dysrhythmia) -Alternate heel to knee, heel to toe (dyssynergia) -Toe to examiner finger (dyssynergia, intenion tremor, dysmetria, dysdiadochokinesia) -Heel on shin (dysmetria, dysdiadochokinesia) -Drawing a circle -Position holding (fixation) (resting tremor)

Answer 39

GI - anorexia, nausea, vomitting, constipation Cognitive - confusion, hallucinations CV - arrhythmias, hypotension Genitourinary - dysuria - painful urination NM - dyskinesia (tremor to cholera), dystonia, motor flucutations Sleep disturbances

Answer 40

Hand control (joystick) Head array system Sip n' puff Other - modified based on where they have function

Answer 41

CVA - disruption in cerebral circulation causing sudden loss of neurons and neurological function - problem with blood flow causing tissue/cell death

Answer 42

Early -loss of sense of smell masked face dysphasia dysphonia (esp volume) micrographia festinating gait stooped posture Later difficulty arising from chair, turning in bed cognitive changes/ dementia Sialorrhea (drooling) GI dysfunction (constipation, decrease appetite Foot dysthonia (turns inwards cause of contractures)

Answer 43

Neuromuscular Cognitive Neurobehavioural Communication Swallowing Dysautonomia Visio-perceptual post-traumatic seizures secondary impairments and complications

Answer 44

Flexion (Lx) Flexion-rotation (Cx) Axial compression Hyperextension Penetrating injuries *can have secondary inflammation, BV changes, pressure changes that can compress SC and cause further damage

Answer 45

Body weight support and motorized treadmill training Controls upright posture when postural stability is poor Decrease fear of falling Not much difference between that and regular PT FES DF Quads (prevent buckling) Orthosis and assistive devices Temporary vs. permanent AFO - in DF, prevent hyperextension Post leaf spring - common, control foot drop Solid AFO - max stability at subtalar and talocrural Wheelchairs Hemi height (foot propulsion) One arm drive wheelchair - rare - needs strength and coordination Power wheelchair *watch for PPT and pressure sores

Answer 46

Long -increased pressure in popliteal area leading to compromised circulation and/or skin discomfort Short -decreased trunk stability due to decreased weight distribution across SA of posterior thighs -decrease balance due to reduced BoS -improper weight distriubtion (increased ischial tuberosity pressure)

Answer 47

Patient history Systems review Tests and measures

Answer 48

Neurological level of injury -most caudal level with intact motor and sensory bilaterally motor level -most caudal level with intact motor sensory level -most caudal level with intact sensory complete SCI -complete paralysis (no motor or sensory) below level of injury - including S4/S5 Incomplete SCI -motor and/or sensory function preserved below the neurological level -Zones of partial preservation: does not have S4/S5 but these are the areas below the neurological level with intact motor and/or sensory function

Answer 49

Most severe paralysis of arms, legs, trunk, hands (tetraplegia) Assistance with breathing (C1-C3) - NEED C4 for independent, secretion clearance (ineffective cough, no muscles of expiration and not big enough inhalation) Dependent in ADLs, transfers (mechanical lift) Power wheelchair (tilt in space, reclining seat, head, chin or sip and puff)

Answer 50

Exacerbation - new and recurrent symptoms greater than 24 hours Psuedo - less than 24 hours -Uhthoff's phenomenon - adverse reaction to heat (internal and external) -TAKE IT UHTHOFF

Answer 51

High improver weight distribution (increase ischial pressure) and leg positioning (might not fit under tables) decreased trunk stability due to decreased weight distribution across SA of posterior thighs Low increased pressure on posterior aspect of thighs insufficient clearance of foot plates decreased trunk stability due to decreased weight distribution

Answer 52

Medial - disease modifying agent (long term), corticosteroids - decrease inflam, immune suppressant which could be good or bad, medication for symptoms PT - dependent on symptoms, exercise good a long as fatigue and overheating considered

Answer 53

PROM / AROM daily Scapula - emphasis on protraction / upward rotation to prevent impingement with overhead activities Overhead pulley CONTRAINDICATED if haven’t achieved proper scapula-humeral movements Weight bearing with open hands and extended wrist - work on tightness - given proprioception through shoulder Positioning to maintain ST length and encourage joint alignment - always opposite of spasticity Use of protective devices *resting splints Positions (*see book for more details) -Sidelying on affected shoulder -Allows more awareness, regulates abnormal muscle tone, inhibits abnormal postures -Side lying on unaffected side -Inhibits extension synergy in LE, allows control for abnormal movement patterns -Supine-Prevents knee flexion contractures, allows symmetry of trunk and limbs

Answer 54

Occlusion of small penetrating arteries supplying brain and deep structures Associated with hypertension and diabetes Symptomatic or silent Consistent with specific anatomical sites Pure motor lacunar stroke Pure sensory lacunar stroke Other lacunar syndromes: dysarthria/ clumsy hand syndrome, ataxic hemiparesis, sensory / motor stroke, dystonia / involuntary movements Higher cortical areas are perceived (consciousness, language, visual fields)

Answer 55

-Ischemic (80%) -Hemorrhagic (20%)

Answer 56

Tests the sensory input See book for image - hold for 20 sec, if arms or feet change, or open eyes = fails Eyes closed fails - too much visual reliance Dome fails - vestibular issue Foam - somatosensory problem

Answer 57

*based on stage of recovery, degree of disability, and patient goals Preventative - minimizing complications and secondary impairments Restorative - improving impairments and limitations Compensatory - aimed at modifying the task, activity, or environment to improve function and participation

Answer 58

Transient period of areflexia following a SCI -Absence of reflexes (approx 24 hours) -impaired autonomic regulation (hypotension, loss of control of sweating, piloerection (goosebumps) Recovery -Total areflexia (24 hours) -Gradual increase in reflexes (1-3 days) -Increasing hypereflexia (1-4 weeks) -Hypereflexia (1-6 months)

Answer 59

Too wide -difficulty propelling due to increased distance to rims -difficulty moving through narrow hallways Too narrow -excessive pressure on greater trochanter -inadequate spacing for things

Answer 60

Receives input from all sensory systems (NOT SMELL AND TASTE) which is essential in motor control It compares internal and external feedback and sends correction signals for future movements to reduce errors (feedforward system) Outputs are mostly uncrossed - most damage will lead to unilateral and ipsilateral motor impairment (some may be bilateral)

Answer 61

Agitation, apathy, emotional lability, mental inflexibility, disinhibition, anxiety, aggression, impulsiveness, irritable, lack of initiation, psychotic ideation, egocentricity (can’t see others side of things), poor self-image, sexual apathy or disinhibition

Answer 62

Compensatory approach Make accommodations to accomplish tasks (alternate strategies or environmental adaptations) Sensory integration approach Achieve functional skill through guided practice with controlled sensory intake - activate sensory receptors and higher brain centers Presented through meaningful activities Goal enhances sensory input (e.g., sensory avoidance for autism - gradual introduction, sensory seeking - giving tactile feedback)

Answer 63

Exercise considerations -loose clothing -stay hydrated -cooler environment -take frequent breaks (every 10 mins x 3) -use fans -perform exercise in morning -don't do hot baths / showers -use submaximal exercise intensities -do not overwork patient Manage fatigue -important since wants to exercise but not overheat/ overwork -characterized by sudden or severe sleepiness, tiredness and sense of weakness -Diurnal - lease in morning, worse in afternoons -use activity diary - then teach energy effective strategies

Answer 64

Interventions Prevent secondary complications and begin mobilization Cognitive and behavioral impairments makes treatment difficult Role in education Special consideration Consistency - same everything, and address inappropriate behaviours in consistent manner Expect no carry over - teaching new skills unrealistic, if automatic/procedural learning might not have take place, pictures might help Model calm behaviour - calm and focused Expect egocentricity - not see others point of view Flexibility / options - short attention span, give control when can Safety

Answer 65

LMNL Motor signs always present, sometimes sensory signs Symptoms distal to proximal, LE first then UE Symmetrical presentation Early S + S -Motor weakness - paresis - distal LE -Distal sensory disturbance (glove or stocking) -Muscle aches / tenderness

Answer 66

Observation (resting) Abnormal posturing or limbs, trunk, head Palpation Hypertonia (hard and taut), hypotonia (soft and flabby) PROM/AROM Response to stretch Modified ashworth * see chart 0 is normal 1 - slight increase with catch and release and minimal resistance at end 1+ - minimal resistance less than half of ROM, slight increase, manifested by a catch 2 - more marked increase through ROM, easily moved 3 - increased tone, passive movement difficult 4 - rigid Modified tardieu scale Moving at different speeds (V2 = normal, gravity) If happens at different speeds - spacitiy, if constant - rigidity Asymmetry vs. symmetry Hypertonia - stiff and resistance Hypotonia - heavy and unresponsive *if can fix posture = not neurological

Answer 67

Asthenia - generalized motor weakness specific to cerebellar lesion Ataxic gait - Wide BOS, high guard position, stepping pattern irregular, unsteady, irregular and staggering with deviations from line of progression Delayed reaction time - increased time to initiate voluntary movement Dysarthria - motor speech disorder affecting muscles used to produce speech (scanning speech - word by word, slow and slurred) Dysmetria - inability to judge length or distance of movements (hyper or hypo) Dyssynergia - inability to perform movement as single, smooth activity - movement decomposition Dysdiadchokinesia - impaired ability to perform rapid alternating movements Dysrhythmia - abnormal rhythm and timing Hypotonia - decreased muscle tone - disappears within weeks Motor learning problems - feedforward impaired so harder to learn motor movements Nystagmus - rhythmic, oscillatory movements - cerebellar influence on extraocular muscles' synergy and tone Rebound Phenomenon - inability to stop movement when resistance removed (check reflex) Tremor - involuntary oscillatory - intention (during voluntary movement) and postural (static - can be titubation)

Answer 68

Repetitive Blocked vs. random decrease cognitive demands clear area use structured instructional sets external cues - auditory, visual, tactile, cognitive

Answer 69

Poliomyelitis reappearing after 15 years (average 35 years - typical age 35-60). Believed to be from neural fatigue (denervation > reinnervation) - neighbouring reinnervation becomes overwork - increased metabolic stress = failure (terminal axons and nerve bodies) Need to find balance between MSK disuse and overuse to optimize function

Answer 70

*need at least 2 and exclusion of alternate diagnosis Tremor (at rest) -involuntary oscillations of body part at rest and disappears with voluntary movement -pill rolling, sup/pro, jaw, tongue -LE is apparent when supine -Postural tremor in upright -Increased with emotional stress / fatigue -Decrease when relaxed / asleep Rigidity -increase resistance to passive movement (independent speed or posture) -heavy or stiff complaints, asymmetrical, proximal to distal (trunk first) -types: cogwheel (ratchety), leadpipe (constant) -increased rigidity = increase loss of function = contractures = increased resting energy expenditure Akinesia/ Bradykinesia -Problems with voluntary movement at all stages of motor planning -Akinesia - no movement - freezing -Bradykinesia - slow movement, range and amplitude -Hypokinesia - reduced amplitude Postural instability -Abnormalities in posture / balance -develops later - no normal synergies when recovery strategies for balance - abnormal co-activation -Adopt flexed (stooped) posture because of weakness in trunk extensors -Kyphosis and scoliosis may form (more rigidity on one side of trunk) -Increased falls

Answer 71

*prior to motor and coordination testing Eyes closed, test at random, give reference for normal

Answer 72

extend elbow allowing for easier use of sliding board transfers most ADLs independent, bed mobility easier manual wheelchair with friction surface hand rims - assistance with ramps, curbs, uneven surfaces **

Answer 73

Thrombus Forms within the vessel wall and interrupts cerebral blood flow Embolus Forms elsewhere and dislodges and travels through circulatory system to lodge in cerebral arteries’ vessels interrupting cerebral blood flow SUDDEN Low systemic perfusion Cardiac failure or significant blood loss (decrease blood circulating, decrease BP, decrease perfusion, systemic hypotension, decrease cerebral blood flow

Answer 74

GCS Meausres consciousness and classifies severity and tracks progress 3 response scores - eyes opening, motor, verbal Total 3-15 Severe <=8 Moderate 9-12 Mild >=13 * see chart for comparison Racho Los Amigos Level of Cognitive Funcitoning (LOCF) Use if hit ceiling for GCS Track cognitive and behaviour recovery - may plateau at any level See book for summary Galveston Orientation and Amnesia Test Determines outcome or prognosis Asks orientating questions

Answer 75

-wear socks that can wrap over top -wear shoes that fit all the way in -build up time wearing (e.g., day 1 - 30min, day 2 1hr) -inspect the skin - regularly (esp. bones)

Answer 76

Pain sharp/dull Indicates function of protective sensation Temperature Hot (warm) / cold Light touch Assess perception of tactile touch Lighty stroke and ask if they feel it Can quantify using monofilaments Pressure Assess perception of pressure by deep receptors (firm pressure to indent skin)

Answer 77

Functional balance grades 0-4 - see chart (used for charting) The romberg test Static Eyes open / eye closed - fails on eyes open (cerebellar or vestibular), on eyes closed = proprioceptive (+ve test) Functional reach tests Measure from 3rd MCP and get them to lean forward without moving feet or touching wall - measure The berg balance scale Static and dynamic balance and determind risk of falls 0 to 4 (good), total 56 41-56 = low risk, 21-40 = medium risk (walking with assistance), 0-20 high fall risks (w/c) Decreased sore = increased risk of falls Performance-orientated mobility assessment (Tinetti) Static and dynamic balance <19 = high risk, 19-24 = moderate, total is 28 Get up and go test Dynamic balance and mobilty Measure at normal speed the look of how they do it from 1-5 (severely abnormal) Use an assistive device if this is what they normally use Timed up and go test Assess mobility, balance, walking ability, and falls Time how long is takes to walk 3 m and back down <10 sec = normal, >12sec = falls, 11-20 = normal limits of frail elderly or individuals with disability >30 sec impaired functional mobility

Answer 78

Arousal, attention and cognition Integumentary integrity Sensory integrity Motor function ROM Reflexes Ventilation and respiration

Answer 79

-Sensory changes - paraesthesia, numbness -Pain - trigeminal neuralgia, paroxysmal limb pain (usually worse at night), headache. Other pain - hyperpathia (hypersensitivity to minor sensory stimuli), chronic neuropathic pain, Lhermitte's sign (flex neck, get electric shock down spine and legs), MSK pain -Visual changes - blurred vision, diplopia, loss of acuity/ vision, optic neuritis (pain behind eyes), scotoma, nystagmus -motor dysfunction - weakness, CENTRAL FATIGUE (CNS overloaded - failure of excitation/contraction coupling), spasticity, impaired balance and coordination, impaired ambulation and mobility -speed and swallowing -dysarthria, dysphonia (voice), dysphagia, increase risk of aspiration pneumonia, increase risk poor nutrition and dehydration -Cognitive and affective changes - cognitive impairments (esp. conc and planning), depression, pseudobulbar affect (change in sudden mood), euphoria, anxiety, bipolar disorder -Autonomic - CV dysautonomia, b/b dysfunction, sexual dysfunction

Answer 80

Seat support - firm (if soft get PPT) - good for LE alignment and pressure distribution Back - maintains good sitting posture -height is determined by user's truck control, functional ability and comfort (shorter = good trunk control, ability to maintain alignment, those propelling, taller = those requiring tilt in space) Trunk support - lateral - maintain midline, chest belt / harness - increases trunk stability, maintain upright body posture, prevents user from falling Pelvic support - maintain good pelvic positioning and prevents from sliding forward UE support - pushing up for standing or ischial relief, arm trays or troughs, helps maintain correct alignment of GHJ, influences tone and decreases pulling LE support - affect position of LE, influence tone and posture

Answer 81

Respiratory tract infection Respiratory failure DVT Pressure sores Autonomic instability - arrhythmias, BP fluctuation, tachycardia

Answer 82

ANS dysfunction - CRPS Atrophy Hypotonia Hyporeflexia Fatigue - both from muscle weakness and generalized Pain - aching, throbbing, worse with SLR, low back and leg pain Sensory deficits - stocking or glove - paresthesia or hypoesthesia If phrenic nerve involvement - may be on mechanical ventilation Paresis - distal to proximal, LE >UE, some cranial nerve - facial (CN VII)

Answer 83

Dysarthria - motor speech disorder affecting muscles that produce speech (may be slow/slurred/ difficult to understand) Aphasia - impairment of language affecting comprehension / productive -Receptive aphasia - Wernike’s aphasia (instructions simple, one by one) Difficulty with comprehension of language Speech flows smoothly and melody of speech is preserved -Expressive aphasia - Broca’s aphasia (instructions with hand signals) Difficulty with speech production Flow of speech is slow, hesitant, limited vocab and impaired syntax (agrammatism)-mostly content words Comprehension is not affected -Global aphasia (instructions are simple and with hand signal) Difficulty with language comprehension and productive Indicative of extension brain damage Limits ability to learn, therefore affects outcomes of rehab

Answer 84

Damage to posterior SC *very rare* - likely tumour or abscess compressing the area Loss of proprioception, pressure sense, vibratory sense (dorsal / posterior column) NO MOTOR LOSS

Answer 85

-Dizziness - catch all vague term to describe sensation like lightheadedness, faintness, whirling, unsteadiness -Vertigo - illusion of movement "spinning" - due to BPPV, UVH or lesion affecting vestibular nuclei -Lightheadedness - feeling that fainting may occur - due to hypotension, anxiety, hypoglycemia -Dysequilibrium - sensation of off balance - due to vestibular problems, cerebellar or motor pathway lesion, decrease somatosensation or weakness in LE -Oscillopsia - subjective experience of objects moving in visual environment that are stationary - may occur with head movements in patient with vestibular hypofunction -Nystagmus - rhythmic eye movement (most often involuntary)

Answer 86

*more common, extensive damage SUPPLIES Lateral aspect of cerebral hemispheres (frontal, temporal and parietal lobes) Subcortical structures - internal capsule, corona radiata, globus pallidus, caudate and putamen Common characteristics Contralateral hemiparesis and hemi-senosry loss of face, UE and LE UE affected > LE - due to homunculus again Contralateral homonymous hemianopia Wernicke aphasia (temporal lobe) - trouble with comprehension/ receptive speech Broca’s (frontal) - trouble with speech production Global aphasia - both broca’s and wernicke’s - nonfluent speech and poor comprehension Perceptual deficits - unilateral neglect, anosognosia, apraxia, spatial disorganization/depth perception Typically lesion in non-dominant hemisphere (e.g., usually right)

Answer 87

too high -irritation on skin over inferior angles of scapula -difficulty with balance due to trunk inclined forward by high upholstery too low -decreased trunk support leading to decreased trunk stability

Answer 88

Respiratory - weakness, dyspnea, fatigue, disorder sleep, morning headaches, secretion retention, increase risk of pneumonia / atlectasis Cognitive - frontotemporal dementia, bulbar onset = more likely cognitive but have intellect and memory not affected

Answer 89

AFO with assistance device L4 - wheelchair for long distances

Answer 90

PRIMARY 1. Autonomic dysreflexia 2. Postural hypotension (orthostatic hypotension - gravity pulls blood down, loss of SNS, v/c and decrease muscle tone = blood pooling) 3. Impaired temperature control (depends on level of lesion, Cx more common - hypothalamus cannot regulate) 4. Respiratory impairment (esp. high lesion) 5. B/b dysfunction 6. Sexual dysfunction SECONDARY 1. Respiratory complications - pneumonia/atelectasis (diaphragm, respiratory muscles, esp inspiration - can't clear sputum = infection, or restrictive = atelectasis) 2. Pressure sore - prolonged pressure.shearing 3. DVT - immobility 4. Contractures - immobile, spastic 5. Heterotopic ossification - bone in ST muscles 6. Pain -Nociceptive - repetitive us of other muslces or neuropathic - injury to central or peripheral NS (allodynia, hyperalgesia), burning/shooting 7. Fracture / OP - not loading bone, decrease muscles

Answer 91

Help with differential diagnosis by identifying pattern of sensory involvement Peripheral nerve - pattern of innervation of affected nerve Nerve root - dermatomal pattern Spinal cord - diffuse pattern of sensory involvement below the level of the lesion (bilaterally usually) (depends on spinal tracts affected) Brainstem - ipsilateral facial impairments, contralateral trunk and limb impairments Brain involvement - cortical: dependent on area of somatosensory cortex (homunculus) or deeper lesion involving thalamas and adjacent structures - diffuse unilateral dysfunction. Contralateral side affected (crossing of tracts)

Answer 92

Medical -corticosteroids -immune suppressant meds -pain meds -intubation and mechanical ventilation PT -strengthening in recovery phase (pointless in other phases) -pulmonary rehab - prevent complications, education of energy conservation (recovery), improve respiratory function and CV fitness (recovery), respiratory muscle strengthening (recovery) -gentle stretching / positioning -mobility, wheelchair, assistive device -education

Answer 93

Postural orientation - control of body segments in relation to each other Balance: ability to maintain CoM within BoS- forces acting on body must be balanced CoM: imaginary balancing point - average position of all part of system according to masses -Changes based on weight, amputation- moves forward as you move forward Bos: area of body or extension in contact with support surface LoS: max distance that one can lean to without losing balance or having to change BoS (step, grab something) -Or else you fall

Answer 94

Arnold- Chiari malformation

Answer 95

Chronic degenerative disease of the motor neurons in brain, brainstem and SC UMN and LMN lesion!!!!! Amyotrophic - muscle atrophy, fascilutation, weakness (LMN) Lateral sclerosis - hardness of palpation of lateral column of SC (UMN) Etiology - 5-10% in family - autonomic dominant trait otherwise unknown Epidemiology - onset is around mid to late 50s

Answer 96

Altered vital signs Decreased consciousness (stupor or coma) Non-reacting pupils (CNIII) Papilledema (optic disc or nerve swelling) Widened pulse pressure Irregular (Cheyne-Stokes) breathing -Breathing increased in depth then decrease and have a period of apnea Vomiting Headache Seizures Progressive impairment of motor function

Answer 97

Area surrounding ischemic event Remain viable or several hours due to supply of collateral arteries Need thrombolytic agents (NOT HEMORRHAGIC STROKE) within 4.5 hours to decrease ICP from cerebral edema (compressive load on brain)

Answer 98

May use orthoses (HKAFO, KAFO, AFO) with assistive device for short distances Wheelchair for community

Answer 99

Contraversive pushing or ipsilateral pushing Disorder of postural control - lead to loss of balance Push weight from strong side to hemiparetic side with resistance to passive correction Fall towards hemiparetic side Altered sense of verticality Occurs in 10% with posterolateral thalamus involvement (either side) Clinical assessment scale for contraversive pushing (SCP) Tilting towards paretic side often Abduction and extension of unaffected limbs Resistance to passive correction *done in sitting and standing - if all three = pushers Implications Avoid transfers to paretic side Avoid gait aids - help push to side since in opposite hand (can give short one so they lean more) Be aware of where and how you position patient (push off objects, falls, block abduction so they can’t do it)

Answer 100

1. Relapse remitting -Relapse, recovery following by stabilization and repeated 2. Primary progressive -Steady disease progression 3. Secondary progressive -Starts a relapse remitting the has steady disease progression with no remission 4. Progressive-relapsing -progressive with acute attacks or relapses that may or may not have recovery

Answer 101

Constantly changing Early - restorative/preventative - strength, endurance, ROM, compensatory - energy conservations, education, assistive devices, ergonomic modifications Middle - preventative - strengthening, endurance, pressure relieving device, ROM. Compensatory - adaptive equipment, modification to environment, wheelchair, education Later - preventative - ROM, pulmonary rehab, pressure relieving, prevent skin breakdown. compensatory - education, mechanical lifts

Answer 102

Superficial sensations Pain Temperature Light touch Pressure Deep sensations Proprioception Kinesthesia Vibration Combined cortical sensation Stereognosis Tactile localization Two point discrimination Double simultaneous stimulation Graphesthesia Recognition of texture Barognosis

Answer 103

UMN Hyperactive stretch reflex Involuntary flexor and extensor spasm Clonus Babinski’s sign Exaggerated cutaneous reflexes Loss of precise autonomic control Dyssynergic movement patterns E.g., ALS, brain injury, CP, MS, SCI, stroke, tumour in brain or SC LMN Decreased or absent tone Decreased or absent reflexes Paresis Muscle fasciculations and fibrillations with denervation Neurogenic atrophy E.g., ALS, bell’s palsy, CES, GBS, peripheral nerve injuries, poliomyelitis, post-polio syndrome

Answer 104

Otoconia (aclcium carbonate crystals) is displaced from utricle into the semi circular canals (anterior, posterior, horizontal) Occur at any age, most likely older or trauma if younger S + S -occur with change in head position- dysequilibrium, nausea, vertigo, nystagmus -duration of symptoms <60 sec Special tests - Dix hallpike - long sitting, head to 45 degrees, then supine and head into 30 degrees extension. +ve if nystagmus, posterior canal or central lesion - Roll test - head flexion to 20 degrees with rotation to either side. +ve if nystagmus and vertigo, horizontal canal Intervention -Epley's - for posterior and horizontal canal - Liberatory (Semont) - cupula - for cupulolithiasis - Brandt- Daroff - canals and cupula *5-10 reps 3x/day for 2 days

Answer 105

Flaccid: -No innervation at ditruser -LMNL -No sensation of feeling full, urinary leakage - unable to detect because of sacral anesthesia -More likely stress incontinence - bladder so full that leakage when cough/ sneeze -self-catheterized - prevent UTI Spastic: -UMNL -Ditruser muscle reflexively contracts - bladder empties way less than normal (since spastic) - get urinary frequency and incontinence

Answer 106

Damage to the anterior aspect of the SC (or its vascular supply) Typically from cervical flexion MOI Loss of motor function (corticospinal tract), pain and temperature (spinothalmic tract) below the level of the lesion

Answer 107

Peripheral vestibular receptors or vestibulocochlear nerve (CN VIII) is affected Infection, trauma, vascular event, Meniere's disease S + S -vertigo -spontaneous nystagmus -oscillopsia during head movement -postural instability -dysequilbrium Intervention -improve gaze stability - VOR training -Improving static and dynamic postural stability - decrease sensititivty to motion - habituation

Answer 108

Paresis, abnormal tone, coordination, motor function, postural control, abnormal gait, somatosensory function

Answer 109

Autonomic reflex causing sympathetic over-activity (occurs above T6) - 3-6 months post -SCI is most common More common in near complete or complete EMERGENCY Pathophysiology -Noxious stimuli below level of lesion -Increase sympathetic outflow (mass reflex response) -Wide spread vasoconstriction (increase BP, HR) -Baroreceptors stimulated leading to increased vagal output causing decrease HR, but insufficient to counteract increased BP (GET DECREASED HR, INCREASED BP) Etiology -bladder/bowel distention / irritation - first thing you check -stimuli that normally would be painful below level of lesion -GI irritation -Sexual activity -Labor -Skeletal fractures below level of injury -Electrical stimulation below level of injury (IFC, TENS) -Pressure sores S + S -hypertension (rise 20-30mmHg) -bradycardia (initially tachycardia) -severe headache -profuse sweating -increased spasticity / hypertonia -V/D above level of lesion (flushed skin) -Constricted pupils -Nasal congestion -Goose bumps -Blurred vision Interventions -Sit patient up to decrease BP (lying down is C/I) -Notify someone -Check catheter -Loosen tight clothing -Look for other potential noxious stimuli -Document

Answer 110

Cerebellar, Sensory and vestibular

Answer 111

Elevated HOB to 30 degrees -Promotes venous drainage -Time to onset of effect: immediate -*lowering this may be C/I for treatment - especially flat or trendelenburg, also for suctioning - monitor especially for hypoventilation (as someone will vasodilate as they feel they need O2) Intubate and hyperventilation - vasoconstriction IV mannitol (osmotic agent) - promotes removal of fluid from CNS while maintain perfusion to brain Ventricular drainage - CSF removed to decrease ICP If above fails -Barbiturate induced coma - gets vasoconstriction and decreased metabolic demands -Surgical decompression (hemicraniectomy - remove skull to reduce pressure) -Steroids

Answer 112

-Pressure relief maneuvers - push up, lateral lean, leaning forward (>45) -elevation of caster wheels - clear objects, ascend or descend curbs, navigate irregular surfaces -ascending or descending ramps -entering and exiting doors and doorways -falling in the wheelchair - forward fall on elbows and roll, backwards - tuck chin, cross hand -moving from wheelchair to floor and floor to w/c

Answer 113

bilatearl loss of peripheral vestibular function Etiology - ototoxicity - or meningitis, autoimmune disorder, head trauma, tumours on CN VIII, vascular episodes, sequential unilateral vestibular neuritiis S + S -Dysequilbrium -oscillopsia -gait ataxia Intervention -improve gaze stability - VOR training -improve static and dynamic postural stability -enhanced decision-making skill recording performance of basic and instrumental ADLs - education

Answer 114

From aneurysm, artery, arteriovenous malformation (AVM) Weakening of artery wall causes an abnormal localized dilation of an artery - can burst and create bleeding Types 1.Intracerebral -Due to rupture or leak of weak blood vessels in brain 2.Subarachnoid -Due to AVM or ruptured aneurysm causing bleeding in subarachnoid space -Edema also goes into space causing compressive load and increased ICP -Need rapid intervention (decompression and clip hemorrhage do doesn’t continue to bleed)

Answer 115

Resistance to passive elongation Hypertonia - increased 1. Spasticity Velocity dependent (increased speed= increased resistance) Clasp-knife - spastic catch, follwed by sudden inhibition Associated with abnormal posturing, contractures, functional limitations and disabiltiy 2. Rigidity Velocity independent Leadpipe - constant through entire range Cogwheel - ratchet-like jerkiness Associated with contractures, stiffness, inflexibility, functional limitations and disabiltiy Hypotonia - decreased Decreased or absent muscle tone, decrease resistance to passive elongation, decrease or absent stretch reflex, difficulty with anti-gravity positions, difficulty moving against gravity, associated with hyperextensibility of joints, floppy limbs, LMN syndrome *temporary states may be seen in UMNL during spinal shock ro cerebral shock - duration is variable Dystonia - disorder tonicity Characterized by involuntary twisting and repetitive movements, abnormal fixed postures and disordered tone Dystonic posturing - co-contraction causing sustained abnormal posturing Types - generalized, focal (only one body part), segmental (2 or more adjacent areas)

Answer 116

Arousal level Coma -Arousal systems not functioning -Eyes closed, no sleep/wake -Ventilator dependent -Abnormal motor and postural reflexes may be present (decorticate usually) Vegetative state -Eyes may be open, but awareness absent -Brainstem able to maintain cardiac, resp, and other function (no ventilator) -sleep/wake present -May startle to visual or auditory stimuli -Meaningful motor, cognitive or communicative function absent Minimally conscious state -Minimal evidence of awareness Cognitively mediate behavior occurs inconsistently -sleep/wake present -Localize to noxious stimuli and may inconsistently reach -May localize to sound and demonstrate visual fixation and pursuit Stupor - almost unresponsive - brief arousal with vigorous, repeated stimulation Obtunded - decreased alertness, sleeps often Attention Concentration Memory Anomia - difficulty remembering names, proper nouns and other abstract nouns Anterograde amnesia - not remembering anything from the injury forward (can remember prior to insult/ injury) Retrograde amnesia - not remembering events prior to injury (can partially recover, may never) Post-traumatic amnesia - time between injury and when able to recall events Learning Executive functions

Answer 117

Train active movement shift towards strong side Encourage to problem solve Visual, verbal and tactile cues (e.g., on quad on strong side)

Answer 118

Damage to one half SC, typically due to penetrating injury Ipsilateral loss: - All sensory modalities at the level of the lesion (LMNL) - Flaccid paralysis at the level of the lesion (LMNL) - Loss of vibration and joint position sense below lesion (dorsal / posterior column - PROPRIOCEPTION, DESCRIMINATIVE TOUCH, VIBRATORY SENSE) - Spastic paresis below the lesion (lateral corticospinal tract - MOTOR) Contralateral loss: -Pain and temperature - spinothalamic tract

Answer 119

Left Slow, cautious, anxious, unorganized Hesitant to try new tasks - requires more feedback, support and encouragement Aware of deficits Difficulties with communication, processing information in sequential linear order Right Quick, impulsive, poor judgment Overestimate abilities, unaware of deficits Increased safety risk - focus on slowing down, recognize risks and consequences Difficulties with spatial-perceptual tasks and grasping whole idea of an activity or task

Answer 120

surfaces that touch user's body and additional components needed to maintain postural alignment Poor positioning - increase risk of respiratory and UTIs -sacral sitting - harder to empty bladder = UTI (also in PPT, tightens hamstrings) -kyphotic or scoliotic - affects breathing and ability to clear secretions effectively (due to restriction - can inhale and get big enough breath for a cough) -poor alignment while eating = aspiration

Answer 121

Act as mobility device and seating support - allows person to achieve maximum function and help them reintegrate into the community

Answer 122

Normal: 5-20 cm H20 Severe elevated ICP - results in brain herniation and needs medical emergency treatment ASAP Icp >20 cm H20 = elevated, ICP >25 cm H20 = critical *older adults may take longer for ICP to rise - senile atrophy - brain smaller from aging

Answer 123

Aphasia, auditory processing deficits or subtle language processing deficits Disorganized communication, imprecise language, difficulty with word retrieval, socially inappropriate, difficulty communicating in distracting environments, difficult reading social cues or adjusting to the situation

Answer 124

Viral / bacterial infection Disease of major systems Emotional / bodily stress

Answer 125

Injury caused by an external force All info applies to a non-TBI as well (infection, tumor, stroke) Etiology 1. Primary injury Immediate trauma to brain parenchyma at moment of insult or injury 2. Secondary injury Result of secondary effects of initial injury hypoxia/ischemia, edema and increased ICP - evolves over time after initial insult or injury MOI Contact - open vs. closed penetration Acceleration - deceleration - compression, tension, shearing Rotation - angular acceleration

Answer 126

Body schema/body image Body scheme: internal awareness of relationship of body parts to each other and the environment Body image: the mental image and feelings of one’s own body Impairments -Unilateral neglect ---Visual, auditory and somatosensory - no reaction when presented on the affected side ---Lack of awareness of one’s own body or of external environment ---Limited use on more affect limb, could lead to injury ---Seen in right hemisphere --------L side can perceive just the R --------R side can see both --------So R hemisphere lesion = just see the R side now --------Also assocaited with L sided hemi-paresis and then can’t see the L so big bag of no fun --------Increased falls risk and injury -Anosognosia - lack of insight -Somatagnosia - disordered body awareness - can’t recognize spatial awareness -Right left discrimination -Finger agnosia - loss in ability to recognize and distinguish own fingers Spatial relations Difficulty perceiving relationships between self and objects in space - can’t recognize vertical, horizontal, depth and distance Agnosia Inability to interpret sensory information (despite intact sensations) - impairment in recognition Visual / auditory / tactile - if impaired use cues that don’t involve this Nothing actually wrong with it, just can’t perceive it

Answer 127

Maintain when internal (from self) or external (from external source) perturbations occur Strategies 1.Reactive - external pertubations - feedback (dependent on sensory feedback) 2.Proactive (anticipatory) - internal perturbations - feedforward (predict what is going to happen)

Answer 128

Lack of muscle control or coordination of voluntary movement

Answer 129

Low GCS Lower education level Very young (<7 or older >40) Longer periods of post-traumatic amnesia - <34 days have good recovery

Answer 130

Lower the level, better trunk control - more abs and paraspinals May use orthoses (HKAFO, KAFO) with assistive device for short distance Wheelchair for community

Answer 131

Inner ear disorder leading to low-frequency hearing loss and episodic vertigo or chronic leading to UVH Unknown etiology, though to be abnormal amount of endolymph fluid in inner ear S + S -low frequency hearing loss -episodic vertigo -aural fullness -tinnitus

Answer 132

Damage to cauda equina (below L1) - variable damage Areflexive bowel / bladder, sacral anesthesia, LMN injury

Answer 133

Mixed palsy - UMN (spastic), LMN (flaccid) Bulbar muscle weakness Dysphagia - increase risk of aspiration (thick liquids), increase weight loss and potential cachexia (weakness/ wasting from illness) Dysarthria - weakness in tonge, muscles of lips, jaw, larynx, pharynx. Initial - inability to project voice and enuciate, later - anarthric - speechless Sialorrhea - absence of swallowing to clear saliva (can't close lips as well) Pseudobulbar affect - poor emotional control

Answer 134

Midline - truncal ataxia, titibations, orthostatic tremor (e.g., when standing - shaky leg syndrome), gait imbalance Hemispheres - limb ataxia, dysarthria, hypotonia Posterior - Nystagmus, VOR deficits, postural and gait abnormalities

Answer 135

1. Flaccid stage Proprioceptive impairment, lack of tone, muscle paralysis = decreased support and positioning from RC (supra, deltoid, biceps and some coracobrachilais) Get shoulder abduction, flexion; or scapular depression and downward rotation = instability of GH = inferior subluxation Pain does not equal subluxation Predictor of pain = decrease external rotation (subscap and pec major - tight into internal rotation) Shoulder impingement syndrome may develop - pain with flexion or abduction 2. Spastic stage Abnormal muscle tone - poor positioning (scapula retraction, depression and downward rotation) = movement restrictions and subluxation Adhesive capsulitis CRPS- type 1 Interventions Support at all times (e.g., transfers, education) -Proper position / handling -Tray for w/c -Arm sling ---Only when transferring or need hands to keep out of way -Strapping / tapping Gentle guided exercises PROM - for upward rotation and protraction FES/NMES Don’t pull arm or leave unsupported

Answer 136

Impairs alertness, orientation, attention, memory or executive function Memory Short term - affected, long - not Memory gaps - made up stories or inappropriate words Perseveration Repetition of words, thoughts or gestures without appropraite context- gets “Stuck”

Answer 137

Breathe independent but may be laboured - abnormal binder may be used to contain and lift contents to give diaphragm a base ** Dependent in transfers (CANNOT USE SLIDING BOARD) Manual wheelchair with propulsion aids for short/flat distances Drive a van with adaptive hand controls** Power wheelchair with adapted joystick for community

Answer 138

Decorticate Corticospinal tract lesion at diencephalon (thalamus and hypothalamus) Abnormal flexor response UE - shoulder adduction, elbow flexion, wrist flexion, finger flexion LE - legs extended and internal rotation*, ankle PF Decerbrate Corticospinal tract lesion at brainstem Abnormal extensor response UE - shoulder adduction, elbow extension, forearm pronation, wrist/ finger flexion LE - leg extension, ankle PF

Answer 139

Swallowing -Dysphagia common -Treatment with SLP Dysautonomia Increased SNS activity following TBI (paroxysmal - sudden increase, sympathetic hyperactivity) Increased HR, RR, BP, diaphoresis and hyperthermia Visio-perceptual Damage to occipital lobe can result in visual impairments Perceptual impairments: apraxia, spatial neglect, somatognosia and etc post-traumatic seizures Less than half of people with severe TBI develop secondary impairments and complications See list in book - mostly due to immobility

Answer 140

foot orthosis ankle-foot orthosis knee-ankle-foot orthosis - prevents hyperextension, med/lat stability hip-knee-ankle-foot orthosis - pelvic band - restricts everything but flex/ext at hip trunk-hip-knee-ankle-foot orthosis - covers thorax - argeo - helps with reciprocal gait through cables

Answer 141

*dependent on what area of brain affected, size of lesion, hemisphere involved, blood vessel involved, collateral blood flow availability, neural redundancies, individual anatomical differences

Answer 142

Characteristics -Slow progression, periods of stability followed by new decline -LMN -Weakness/ paralysis that is patchy -Asymmetrical -LE>UE -Brainstem less commonly affected S + S -fatigue -muscle atrophy -weakness -pain -cold intolerance -breathing or swallowing disorders if brainstem involved Interventions -education on energy conservation -weight loss -work and home adaptations -exercise therapy - avoid overuse, fatigue, balance rest and activity, exercise when least fatigued -hydrotherapy (warm water) -brainstem affected - positive pressure ventilation, prevent resp complications, education on swallowing technique and training (SLP)

Answer 143

Face dropping Arms - can you raise both Speech - slurred/jumbled Time - call 911

Answer 144

AVM - congenital defect resulting in tangle of abnormal arteries and veins which bypass the capillary system Progressive dilation with age Eventual bleeding in ~50% of AVM cases

Answer 145

ASIA A - Complete - no motor/sensory persevered in sacral segments S4/S5 ASIA B - Incomplete - sensory but not motor function in persevered below the NLI and includes sacral segments S4/S5 ASIA C - Incomplete - Motor is preserved below the NLI and more than half of key muscles have a muscle grade less than 3 ASIA D - Motor is preserved below the NLI and more than half of key muscles have a muscle grade greater or equal to 3 ASIA E - Motor and sensory function is normal

Answer 146

Pseudobulbar Sudden and unpredictable outbursts of crying, laughing or other emotional displays not consistent with mood Quickly changes from one extreme to another Apathy Blunted emotional response - mislabelled as depressed or poor motivation Euphoria Exaggerated feelings of well being and happiness Depression Persistence feeling of sadness Psychomotor slowing - motor changes due to depressed state Patients with left hemisphere lesions may experiences more frequent and severe depression

Answer 147

High poor trunk supprt due to back upholstery being too low legs might not fit under table problems propelling w/c due to difficulty in reaching hand rims poor posture when forearms rest on armrest Low difficulty standing for transfers due to CoG improve weight distribution (increased ischial tuberosity pressure) and leg positioning when feet rested on foot places

Answer 148

Circumduction - Leg is in extension synergy - can’t clear limb - PF (tone, contracture, weak DF) Decrease time on stance for affected - weakness, decrease confidence, pain Hyperextension at knee - poor quad control, weak quads, in PF at ankle In PF at ankle - poor motor control, weakness at DF, contracture/spasticity in PF

Answer 149

Motion assistance - helps movement - for LMN -posterior leaf spring -steel dorsiflexion spring assist - bulky so less common *used with foot drop *do not use with spasticity - as it is a spring, could make things worse* Motion resistance -Plastic hinged - stop PF - contracture in PF -posterior stop - stop PF - contracture in PF -anterior stop - stop DF - weakness in PF -solid AFO - stop subtalar and talocrural -Hinged AFO - only allow DF - for subtalar OA

Answer 150

Disorder and speech Dysphagia Difficulty swallowing - aspiration can occur Cognitive dysfunction Altered emotional status Pseudobulbar Hemispheric behavioral differences **** Perceptual dysfunction Seizures Bladder and bowel dysfunction CV and pulmonary dysfunction DVT and PE OP and fracture risk *above 3 are more a consequence of inactivity

Answer 151

Stereognosis Assess tactile object recognition Tactile localization Assess ability to localize touch sensation Point exact location where therapist touches (distance between is senstiviity) Two point discrimination Ability to perceive two separate points - measure between the last point before it becomes one - this is minimum detectable distance Double simultaneous stimulation Assess ability to perceive touch on Identical locations on opposite sides Proximal and distal on similar extremity Proximal and distal on one side of body Extinction - only proximal stimulus is perceived Graphesthesia Ability to identify numbers, letters or designs (with orientation first) Recognition of texture Assess and differentiate between various textures Barognosis Assess recognition of weight (if no han then do in series)

Answer 152

High excessive stretch on tight hamstrings, causing PPT or sacral sitting, also slides out of chair

Answer 153

Traumatic - young males, Non-traumatic older M=F Etiology Traumatic - MVA, falls, etc Non-traumatic - secondary to disease or pathology -vascular malformations (AMN, thrombosis, embolus, hemorrhage) -vertebral subluxations secondary to other pathologies (RA, down syndrome, degenerative joint disease) -Infections (syphilis, transverse myelitis) -Spinal neoplasm -Abscess in SC -Syringomyelia - cyst in SC -Neurological disease (ALS, MS)

Answer 154

Caused by loss of sensory input Etiology 1. Peripheral - peripheral nerve (e.g., peripheral neuropathy) or dorsal nerve root 2.Central - dorsal column or spinal cord (DCML pathway responsible for proprioception), parietal cortex, thalamus

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