Neurological system disorders (ch 7) COPY Flashcards
1
Q
Lateral central fissure (aka_____) separates _____ lobe from _____ and _____ lobes.
A
Lateral central fissure (aka SYLVIAN FISSURE) separates TEMPORAL lobe from FRONTAL and PARIETAL lobes.
2
Q
Longitudinal cerebral fissure separates ____________.
A
THE TWO HEMISPHERES.
3
Q
Central sulcus separates ______ lobe from the ______ lobe
A
Central sulcus separates FRONTAL lobe from the PARIETAL lobe.
4
Q
Frontal lobe: precentral gyrus contains….
A
primary motor cortex for voluntary muscle activation
5
Q
Frontal lobe: prefrontal cortex controls…
A
emotions, judgements, higher order cognitive functions (ideations and abstraction)
6
Q
Frontal lobe: premotor cortex controls…
A
motor aspects of speech (related to planning of movements including Broca’s area)
7
Q
Parietal lobe: poscentral gyrus is…
A
primary sensory cortex for integration of sensation
8
Q
Parietal lobe also contains…
A
receptive fibers conveying touch, proprioceptive, pain and temperature sensations from opposite side of body
9
Q
Temporal lobe: which cortexes are here??
A
Primary auditory (receives/processes auditory stimuli);
associative auditory cortex (processis auditory stimuli);
Wernicke’s area (language comprehension).
10
Q
Occipital lobe contains 2 cortexes…?
A
Primary visual cortex (recieves/processes visual stimuli);
Visual association cortex (processes visual stimuli).
11
Q
Insula is located where and does what?
A
deep within lateral sulcus; associated with visceral functions
12
Q
The limbic systems consists of what? and has what functions?
A
consists of limbic lobe (cingulate, parahippocampal, and subcallosal gyri), hippocampal formation, amygdaloid nucleus, hypothalamus, anterior nucleus of thalamus.
Oldest part of the brain- concerned with instincts and emotions contributing to preservation of individual. Functions include feeding, aggression, emotions, endocrine aspects of sexual response, and long-term memory formation.
13
Q
What is white matter?
A
myelinated nerve fibers located centrally.
14
Q
What are the three kinds of white matter?
A
- transverse fibers: interconnect the 2 hemispheres (including corpus callosum (largest), anterior commissure, and hippocampal commissure.
- projection fibers: connect cerebral hemispheres with other portions of the brain and spinal cord.
- Association fibers: connect different portions of the cerebral hemispheres (within the same hemisphere), allowing cortex to function as an integrated whole.
15
Q
What/where is the basal ganglia?
A
Masses of gray matter deep within the cerebral hemispheres, including corpus striatum, amygdaloid nucleus, and claustrum. (Lenticular nuclei= putamen and globus pallidus).
16
Q
What does basal ganglia do?
A
forms an associated motor system (extrapyramidal system) with other nuclei in the subthalamus and midbrain. Has numerous fiber interconnections…. caudate loop works with association cortex in motor planning; putamen loop work with sensorimotor cortex to scale/adjust movements.
17
Q
What are three parts of thalamus and what do they do?
A
- sensory nuclei: integrate/relay sensory info from body, face, retina, coclea, and taste receptors to cerebral cortex and subcortial regions; smell is the exception.
- motor nuclei: relay motor info from cerebellum and globus pallidus to precentral motor cortex.
- other nuclei: assis in integration of visceral and somatic functions
18
Q
What does subthalamus do?
A
involve din control of several functional pathways for sensory, motor, and reticular function.
19
Q
What does hypothalamus do?
A
- integrates and controls functions of the autonomic nervous system and neuroendocrine system;
- maintains body homeostasis (regulates temp, eating, water balance, anterior pituitary function/sexual behavior, and emotion).
20
Q
Epithalamus is made of 2 things and does what?
A
- Habenular nuclei: integrates olfactory, visceral, and somatic afferent pathways.
- Pineal gland: secretes hormones that influence the pituitary gland and several other organs; influences circadian rhythm.
21
Q
Brainstem is made of 3 things:
A
midbrain, pons, and medulla oblongata
22
Q
Midbrain: tegmentum contains what and does what?
A
- contains all ascending tracts and some descending tracts
- red nucleus receives fibers from cerebellum and is origin for rubrospinal tract (important for coordination); contains cranial nerve nuclei (oculomotor and trochlear).
23
Q
Midbrain: substantia nigra
A
a large motor nucleus connecting with basal ganglia and cortex; is important in motor control and muscle tone.
24
Q
Midbrain: superior colliculus
A
important relay station for visual and visual reflexes; inferior colliculus is important relay station for hearing and auditory reflexes.
25
Pons! Where and what?
- Connects medulla oblongata to the midbrain, allowing passage if important ascending and descending tracts.
- acts as bridge to cerebellum
- midline raphe nuclei project widely and are improtant for modulating pain and controlling arousal
- tegmentum contains cranial nerve nuclei of abducens, trigeminal, facial, vestibulocochlear.
26
Medulla oblongata! where and what?
- connects spinal cord with pons; contains relay nuclei of dorsal columns; fibers cross to give rise to medial lemniscus.
- inferior cerebellar peduncle relays dorsal spinocerebellar tract to cerebellum.
- corticospinal tracts decussate in pyramids.
- medial longitudinal fasciculus arises from vestibular nuclei and extends throughout brain stem and upper cervical spinal cord; important for control of head mvmts and gaze stabilization.
- cranial nerve nuclei: hypoglossal, dorsal nucleus of vagus, and vestibulocochlear
- contains centers for vital functions: cardiac, respiratory, and vasomotor centers.
27
Cerebellum is located where?
behind dorsal pons and medulla in posterior fossa.
28
3 parts of the cerebellum and what they do:
1. archicerebellum (flocculonodular lobe) connects with vestibular system and is concerned with equilibrium and regulation of muscle tone.
2. paleocerebellum (anterior lobes and vermis) recieves input from proprioceptive pathways and is concerned with modifying muscle tone and synergistic actions of muscles; imprtant in maintenance of posture and voluntary mvmt control.
3. Neocerebellum (middle lobes) receives input from cortiopontocerebellar tracts and olivocerebellar fibers; is concerned with smooth coordination of voluntary mvmts; ensures accurate force, direction, and degree of mvmt.
29
Segments of the spinal cord:
```
8 cervical
12 thoracic
5 lumbar
5 sacral
and a few coccygeal segments
```
30
Dorsal column/medial lemniscus tract
convey sensations of proprioception, vibration, and tactile discrimination.
- divided into fasciculus cuneatus (UE tracts, laterally located) and fasciculus gracilis (LE tracts, medially located)
- neurons ascend to medulla where fibers cross (lemniscal decussation) to form medial lemniscus, ascend to thalamus and then to somatosensory cortex
31
Spinothalamic tracts:
convey sensations of pain and temperature and crude touch; tracts ascend 1 or 2 ipsilateral spinal cord segments, synapse and cross in spinal cord to opposite side and ascend in ventrolateral spinothalamic system.
32
Spinocerebellar tracts:
convey proprioception info from muscle spindles, Golgi tendon organs, touch, and pressure receptors to cerebellum for control of voluntary movements; dorsal spinocerebellar tract ascends to ipsilateral inferior cerebellar peduncle.
33
Spinoreticular tracts:
convey deep and chronic pain to reticular formation of brain stem via diffuse, polysynaptic pathways
34
Corticospinal tracts:
- descending; important for voluntary motor control
- arise from primary motor cortex, descend in brain stem, cross in medulla, via lateral cortiospinal tract to ventral gray matter; 10% of fibers do not cross and travel in anterior cortiospinal tract to cervical and upper thoracic segments.
35
Vestibulospinal tracts:
- descending; important for control of muscle tone, antigravity muscles, and postural reflexes.
- arise from vestibular nucleus and descend to spinal cord in lateral and medial vestibulospinal tracts.
36
Rubrospinal tract:
- descending; assists in motor function
| - arises in contralateral red nucleus and descends n lateral white columns to spinal gray.
37
Reticulospinal system:
- descending; modifies transmission of sensation, especially pain; influences gamma motor neurons and spinal reflexes.
- arises in the reticular formation of the brain stem and descends in both ventral and lateral columns, terminates both on dorsal gray and ventral gray.
38
Tectospinal tract:
- descending; assists in head turning responses in response to visual stimuli.
- arises from superior colliculus and descends to ventral gray.
39
What does the autonomic nervous system do?
innervations of involuntary structures (smooth muscle, heart, glands; helps maintain homeostasis).
40
What are the 2 divisions of autonomic nervous system and what do they do?
1. Sympathetic (thoracolumbar)- fight or flight, emergency, raises heart rate and BP, contstricts peripheral BVs and redistributes blood; inhibits peristalsis.
2. Parasympathetic (craniosacral)- conserves and restores homeostasis; slows heart rate and reduces BP, increases peristalsis and glandular activity.
41
What are the autonomic plexuses (name them)?
cardiac, pulmonary, celiac (solar), hypogastric, pelvic
42
What are the 3 meninges of the brain (and name them)?
3 membranes that envelop the brain!
1. Dura mater (outer, tough, fibrous membrane attached to inner surface of cranium)
2. arachnoid (delicate, vascular membrane)
2. 5... then subarachnoid space (formed by arachnoid and pia mater, contains CSF and cisterns, major arteries).
3. Pia mater (thin, vascular membrane that covers the brain surface; forms tela choroidea of ventricles.)
43
Ventricles of brain- there are 4!
Filled with CSF and communicate with each other and with spinal cord canal....
1. Lateral ventricles: large, irregularly shaped, with anterior posterior and inferior horns; communicates with third ventricle through foramen on Monro.
2. Third ventricle: located posterior and deep b/w the two thalami; cerebral aqueduct communicates third with fourth ventricle.
3. Fourth ventricle: pyramid-shaped cavity located in pons and medulla
44
What does cerebrospinal fluid do?
provides mechanical support (cushions brain), controls brain excitability by regulating ionic composition, aids in exchange of nutrients and waste products.
- produced in chorioid plexuses in ventricles.
- normal pressure 70-180 mm/H2O.
- total volume: 125-150 cc.
45
What is the blood-brain barrier
the selective restriction of blood borne substances from entering the CNS; associated with capillary enothelial cells.
46
Blood supply to the brain: brain is 2% of body weight with a circulation of 18% of total blood volume. Just a fun fact
:)
47
What is the carotid system of blood supply?
internal carotid arteries arise off of common carotids and branch to form anterior and middle cerebral arteries;
supplies a large area of brain and many deep structures.
48
What is the vertebrobasilar system of blood supply?
vertebral arteries arise off of subclavian arteries and unite to form the basilar artery; this vessel bifurcates into two posterior cerebral arteries;
supplies the brain stem, cerebellum, occipital lobe, and parts of thalamus.
49
What is the Circle of Willis?
formed by anterior communicating artery connecting the two anterior cerebral arteries and the posterior communicating artery connecting each posterior and middle cerebral artery!
50
What are ganglia?
compact groups of peripheral nerve cell bodies (nuclei)
51
Projection neurons carry impulses to....
other parts of the CNS
52
Interneurons are...
short relay neurons
53
Axon bundles are called...
tracts or fasciculi (in spinal cord, collections of tracts are called columns, or funiculi)
54
What are neuroglia?
support cells that do not transmit signals; important for myelin and neuron production; maintenance of K+ levels and re-uptake of neurotransmitters following neural transmission at synapses.
55
Resting membrane potential is ____ on outside and ____ on inside
positive on outside and negative on inside.
56
What is action potential?
increased permeability of Na+ and influx into cell with outflow of K+ results in polarity changes and depolarization; generation of an action potential is all-or-none!!!
57
Just know this: Conduction velocity is proportional to axon diameter; the largest myelinated fibers conduct the fastest.
:)
58
The small gaps in myelination are called...
nodes of Ranvier
59
what is saltatory conduction
when the action potential jumps from one node of Ranvier) to the next.
60
Nerve fiber types: "A" fibers characteristics and types?
large, myelinated, fast conducting
- Alpha (proprioception, somatic motor
- Beta (touch, pressure)
- Gamma (motor to muscle spindles
- Delta (pain, temp, touch)
61
Nerve fiber types: B fibers characteristics?
small, myelinated, conduct less rapidly; preganglionic autonomic.
62
Nerve fiber types: C fibers characteristics and types?
smallest, unmyelinated, slowest conducting.
- dorsal root (pain, reflex responses)
- sympathetic (post-ganglionic sympathies)
63
Lower Motor Neurons: structures, and symptoms of a lesion
Structures: cell bodies in the anterior horn of spinal cord, spinal nerves, and cranial nerve fibers that travel to target muscles.
Symptoms of lesion: flaccidity, decreased or absent deep tendon reflexes, atrophy.
64
Upper Motor Neurons: structures, and symptoms of a lesion
Structures: any nerve cell body or nerve fiber in the spinal cord (except the anterior horn cells), all superior structures (gray and white matter affecting motor function and descending nerve tracts), cranial nerve nuclei.
Symptoms of lesion: increased depp tendon reflexes, spasticity, clonus, emergence of primitive reflexes including Babinski sign, exaggerated cutaneous reflexes, autonomic dysreflexia, flaccidity may occur at the level of lesion.
65
What is a myotome?
the skeletal muscles innervated by motor axons in a given spinal root.
66
A motor unit consists of...
the alpha motoneuron and the muscle fibers it innervates
67
The spinal cord ends at the level of ____. Below that, nerve roots descend vertically to form the ________.
L1; cauda equina.
68
Ventral (anterior) root of spinal cord contains...
efferent (motor) fibers to voluntary muscles, and to viscera, glands and smooth muscles.
69
Dorals (posterior) root of spinal cord contains...
afferent (sensory) fibers from sensory receptors from skin, joints, and msucles; each dorsal root possesses a dorsal root ganglion; there is no dorsal root for C1.
70
Dermatome is...
a specific segmental skin area innervated by sensory spinal axons.
71
What are spinal level reflexes?
involuntary responses to stimuli; basic, specific and predictable; dependent upon intact neural pathway (reflex arc).
72
Stretch (myotatic) reflex: stimulus, reflex arc, and function
- stimulus: muscle stretch
- reflex arc: afferent 1a fiber from muscle spindle to alpha motoneuron projecting back to muscle of origin (monosynaptic)
- functions to maintain muscle tone, support agonist muscle contraction, and provide feedback about muscle length.
- clinically, sensitivity of the stretch reflex and intactness of spinal cord segment are tested by applying stretch to the deep tendons (DTR)
- reciprocal innervation: describes the responses a stretch stimulus can have on agonist, antagonist, as well as synergistic muscles.
73
Inverse stretch (myotatic) reflex: stimulus, reflex arc, and funciton
- stimulus: muscle contraction
- reflex arc: afferent 1b fiber from Golgi tendon organ via inhibitory interneuron to muscle of origin (polysynaptic)
- functions to provide against inhibition, diminution of force of agonist contraction.
74
Gamma reflex loop: _____ reflex forms part of this loop. Allows what? How does it happen?
STRETCH reflex forms part of this loops.
Allows muscle tension to come under control of descending pathways.
Descending pathways excite gamma motor neurons, causing contraction of the muscle spindle, and in turn increased stretch sensitivity and increased rate of firing from spindle afferents; impulses are then conveyed to alpha motor neurons.
75
Flexor (withdrawal) reflex: stimulus, reflex arc, function.
- stimulus: cutaneous sensory stimuli
- reflex arc: cutaneous receptors via interneurons to largely flexor muscles; multi-segmental response involving groups of muscles (polysynaptic).
- functions as a protective withdrawal mechanism to remove body part form harmful stimuli.
76
Crossed extension reflex: stimulus, reflex arc, function
- stimulus: noxious stimuli and reciprocal action of antagonists ; flexors of one side are excited causing extensors on same side to be inhibited; opposite responses occur in opposite limb.
- reflex arc: cutaneous and muscle receptors diverging to many spinal cord motor neurons on same and opposite side (polysynaptic).
- function: coordinates reciprocal limb activities such as gait.
77
CVA: ischemic vs hemorrhagic
```
ischemic= clot
hemorrhagic= bleed
```
78
Cerebral insufficiency
due to transient disturbances of blood flow (like TIA- brief interruption of blood supply). TIA symptoms don't last as long as stroke (usually only hour to 24 hours).
79
Cerebral infarction
due to either embolism or thrombosis of the intra or extracranial arteries.
80
thrombus vs embolus
thrombus: mass of clotted platelets and other parts of blood;
embolus: when a piece of the thrombus moves and then gets stuck somewhere else.
81
Cerebral hemorrhage
bleed secondary to hypertension or aneurysm
82
Cerebral arteriovenous malformation (AVM)
abnormal, tangled collections of dilated blood vessels that result from congenitally malformed vascular structures
83
Middle cerebral artery (MCA) stroke results in...
contralateral hemiplegia, hemianestehesia, homonymous hemianopsia, aphasia (usually left MCA), and/or apraxia (usually left MCA), unilateral neglect (usually R MCA), spatial dysfunction (usually R MCA)
84
Internal carotid artery (ICA) stroke results in...
symptoms similar to those associated with MCA CVA.
contralateral hemiplegia, hemianestehesia, homonymous hemianopsia, aphasia (usually left MCA), and/or apraxia (usually left MCA), unilateral neglect (usually R MCA), spatial dysfunction (usually R MCA)
85
Anterior cerebral artery (ACA) stroke results in...
contralateral hemiplegia, grasp reflex, incontinence, confusion, apathy, and/or mutism.
86
Posterior cerebral artery (PCA) stroke results in...
homonymous hemianopsia, thalamic pain, hemisensory loss, and/or alexia.
87
Vertebrobasilar system stroke results in...
pseudobulbar signs (dysarthria, dysphagia, emotional instability), tetraplegia
88
Hemispheric specialization: left hemisphere
- mvmnt of right side of body; processing of sensory info from R side
- visual reception from r field
- visual verbal processing
- BIL motor praxis
- verbal memory
- BIL auditory reception
- speech
- processing of verbal auditory info
89
Hemispheric specialization: right hemisphere
- mvmnt of L side of body; processing sensory info from L side
- visual reception from L field
- visual spatial processing
- L motor praxis
- nonverbal memory
- attention to incoming stimuli
- emotion
- processing of nonverbal auditory info
- interpretation of abstract info
- interpretation of tonal inflections
90
Risk factors for stroke: modifiable and non-modifiable:
Modifiable: hypertension, cardiac disease, A-fib, diabetes, smoking, ETOH, hyperlipidemia
Non-modifiable: age, gender (males higher risk), race (black/latino), heredity
91
bed sores are also known as...
decubiti
92
decorticate rigidity looks like....
flexed UE, extended LE
93
decerebrate rigidity looks like...
all extended UE and LE
94
Glasgow Coma Scale (purpose and scores)
- purpose- for initial eval and continuing assessment to determine person's level of consciousness after head injury. Its a neurologic scale providing a method to record state.
- assessed on criteria of eye, verbal, and motor responses
- scoring: highest is 15 (fully conscious); lowest is 3 (deep coma or death).
95
Rancho level 1
No response: total assistance
| -coma
96
Rancho level 2
Generalized response: total assistance
- generalized reflex response to pain stimuli
- responses to repeated auditory stimuli with decreased/increased activity
- responds to external stimuli w/ physiological changes, gross body mvmnt, or nonpurposeful vocalization
- may be significantly delayed responses though
97
Rancho level 3
Localized response: total assistance
- withdrawal or vocalization to painful stimuli
- turns toward/away from auditory stimuli
- blinks with strong light
- follows moving object passed w/in visual field
- pulls tubes/restrains
- inconsistent response to simple comands
- may respond to friends/family but not others
98
Rancho level 4
Confused/agitated: max assist
- alert and in heightened state of activity
- purposeful attempts to remove restraints/tubes and get out of bed
- brief and usually nonpurposeful moments of sustained alternatives and divided attn
- absent short-term memory
- may perform motor activities like sitting, reaching, walking; but w/out apparent purpose
- may scream out of proportion to stimulus
- aggressive/flight behavior
- mood swing from euphoric to hostile with no apparent cause
- uncooperative with tx efforts
- verbalizations often incoherent or inappropriate to activity
99
Rancho level 5
Confused, inappropriate non-agitated: max assist
- alert, not agitated but may wander randomly or w/ vague intention of going home
- not oriented x3
- brief periods of nonpurposeful sustained attn
- severely impaired recent memory
- absent goal directed, problem solving, self-monitoring behavior
- unable to learn new info
- able to respond appropriately to simple commands fairly consistently with cues.
- converse on social automatic level for brief time with cues
100
Rancho level 6
Confused, appropriate: mod assist
- inconsistently oriented x3.
- can attend to highly familiar tasks in non-distracting enviro for 30 min w/ redirection
- remote memory deeper than recent memory
- vague recognition of staff
- emerging awareness of appropriate response to self, family, and needs
- mod assist to problem solve task barriers
- supervised for old learning (self care)
- unaware of impairments, disabilities and safety risk.
- verbal expressions are appropriate in highly familiar and structured situations.
101
Rancho level 7
Automatic, appropriate: min assist for daily living skills
- consistently oriented to person & place in familiar enviro; mod assist for orientation to time
- able to attend to familiar tasks for at least 30 min with min assist
- min supervision for new learning
- carries out steps of familiar personal and household routine (shallow recall of what he's been doing).
- superficial awareness of condition but unaware of impairments and limited safety awareness.
- unaware of others' needs/feelings
- unable to consider consequences of actions
- oppositional/uncooperative
- unable to recognize inappropriate social interaction behavior
102
Rancho level 8
Purposeful, appropriate: SBA
- consistently oriented x3
- indep attends to/completes familiar tasks for 1 hour in distracting enviro
- recall and integrate past and recent events
- no assistance once new tasks learned
- aware of impairments, but req SBA to take appropriate corrective action
- depressed, irritable, low frustration tol, argumentative, self-centered
- able to recognize inappropriate social interaction behavior while occurring and take corrective action with min assist
- over/underestimates abilities
- acknowledges others' needs/feelings and responds appropriately with min assist.
103
Rancho level 9
Purposeful, appropriate: SBA on request
- indep completes tasks for at least 2 hours
- uses assistive memory devices, to do lists.
- initiates/carries out steps to familiar tasks indep and unfamiliar tasks with assist when requested.
- able to consider consequences with assist when requested
- depression maybe, irritability maybe, low frustration tolerance maybe
- self monitor appropriate social interaction with SBA
- acknowledges others' needs/feelings and responds appropriately with SBA
- requires SBA to anticipate a problem.
104
Rancho level 10
Purposeful, appropriate: modified independent
- able to handle multiple tasks simultaneously in all enviros with periodic breaks.
- indep procure, create, maintain assistive memory devices
- indep do familiar and unfamiliar tasks with incr time
- anticipates impact of impairments/ on ability to complete daily living tasks and avoids problems, with incr time and/or compensatory strategies
- periodic depression, irritability, and low frustration tolerance
- consistently appropriate social behavior
- accurately estimates abilities
- recognizes needs/feelings of others and responds appropriately
105
ASIA Impairment Scale for SCI
A=complete, no sensory or motor function is preserved in the sacral segments S4-S5
B= incomplete, sensory but no motor function is preserved below neurological level and extends through the sacral segments
C= incomplete, motor function is preserved below the neurological level, and the majority of key muscle groups below the level have a muscle grade less than 3/5
D= incomplete, motor function is preserved below neurological level, and the majority of key muscle groups below level have a muscle grade greater or = to 3/5.
E= normal, sensory and motor function are normal.
106
what is spinal shock?
(4-8 weeks) all reflex activity is obliterated below level of injury presenting as flaccid paralysis.
107
Changes in muscle tone with SCI... _______ in UMN lesions; _______ in lesions below L1.
SPASTICITY in UMN lesions; FLACCIDITY in lesions below L1.
108
Central cord SCI results from... and presents as...
results from hyperextension injuries and presents as more UE deficits than LE.
109
Brown-Sequard SCI is...
hemi-section of cord. causes disruption of the descending lateral coricospinal tracts, ascending DC/ML, and ascending lateral spinothalamic tracts. Result is ipsilateral paralysis, ipsilateral loss of position sense, ipsilateral loss of discriminative touch, contralateral loss of pain, and contralateral loss of thermal sense.
110
Anterior cord SCI caused by _____. What is lost and preserved?
caused by flexion injuries.
Lost BIL below lesion: motor function, pain, pinprick, and temp sensation
Preserved: proprioception and light touch.
111
Posterior cord SCI caused by _____. What is lost and preserved?
injury to the posterior columns.
Lost: proprioception.
Preserved: pain, temp, touch; motor function preserved to varying degrees.
112
Conus medullaris SCI is injury of ____ resulting in....
injury of sacral cord and lumbar nerve roots resulting in LE motor and sensory loss and areflexic bowel and bladder.
113
Cauda equina syndrome:
injury at L1 level and below resulting in LMN lesion; flaccid paralysis with no spinal reflex activity; areflexic bowel and bladder.
114
Complications of SCI
- respiratory complications, decreased vital capacity, pneumonia.
- decubitus ulcer formation
- orthostatic hypotension
- deep vein thrombosis
- autonomic dysreflexia
- UTI
- heterotropic ossification (the formation of bone in abnormal anatomical locations)
115
Autonomic dysreflexia (define)
abnormal response to noxious stimulus that results in extreme rise in blood pressure, pounding headache, and profuse sweating. Medical emergency. Can be caused by bowel irritation/over-distension, bladder infection/over-distention, skin irritants, sexual irritants (menstrual cramps, labor/delivery), heterotopic ossification/myositis ossificans, fractures, appendicitis.
116
Management of autonomic dysreflexia
- identify the offending stimulus and relive the issue immediately.
- medications if no impact can be made by removing irritant.
117
Prevention of autonomic dysreflexia
- teach person/caregiver frequent pressure relief principles
- compliance w/ intermittent catheterization
- well-balanced diet
- medication compliance
- educate person/caregivers on prevention methods; recognize signs/symptoms; initiate first aid to deal effectively with condition.
118
Medical management of SCI
- prevention of further cord damage via stabilization
- traction and rest for unstable injuries
- surgery
- diuretic prescription to decrease inflammation
- bladder care
- decubiti prevention
- control of autonomic dysreflexia and orthostatic hypotension
- prevention of thrombus formation
- tx for heterotopic ossification
119
Cerebral Palsy (CP) etiology
injury and/or disease prior to, during, or shortly after birth resulting in brain damage and secondary neurological and muscular deficits.
Common prenatal causes= lack of oxygen, intracranial hemorrhage, meningitis, chronic alcohol abuse, toxicosis, infection, genetic factors, endocrine, and metabolic disorders.
120
Spastic CP...
lesion of the motor cortex will result in spasticity with flexor and extensor imbalance. Spasticity can express itself as: hypertonic (increased muscle tone) and hyperreflexia (increased intensity of reflex responses).
121
Dyskinetic CP...
a lesion in the basal ganglia results in fluctuations in muscle tone. Symptoms:
- dystonia (excessive/inadequate muscle tone)
- athetosis (writing involuntary mvmnts which are more distal than proximal)
- chorea (spasmodic involuntary mvmnts which are more proximal than distal and a lack of cocontractions.
122
Ataxic CP...
a lesion in the cerebellum results in hypotonia and ataxic mvmnts; characterized by a lack of stability so coactivation is difficult, resulting in more primitive total patterns of mvmnt. Classification is according to level of severity.
123
Diplegia involves .....
less UE involvement and greater LE functional impairment
124
Common complications of CP
- seizures (50% of children)
- language and cognitive deficits (50-75%)... speech/language deficits, difficulty coordinating breathing with swallowing, dysarthria, aphasia, cognitive deficits more associated with seizures.
- visual impairments (40-50%) (strabismus, nystagmus, myopia, hyperopia, presbyopia)
- feeding disturbances
- diminished sensation (common in spastic hemiplegia)
125
What is strabismus?
deviation of how one eye aligns with the other
126
What is nystagmus?
reflexive response of the eyes triggered by head movement
127
What is myopia?
nearsightedness
128
What is hyperopia?
farsigntedness
129
What is presbyopia?
decreased elasticity of the lenses causing difficulty in accommodation when focusing on objects nearby and when shifting focus from near to far.
130
What is a dyskinesia?
involuntary, nonrepetitive, but occasionally stereotyped movement affecting distal, proximal, and axial muscles in varying combinations. Most are representative of basal ganglia disorders.
131
What is myoclonus?
a brief and rapid contraction of a muscle or group of muscles.
132
What is chorea?
brief, purposeless, involuntary mvmnt of distal extremities and face; usually considered to be a manifestation of dopaminergic overactivity in basal ganglia.
133
What is dystonia?
alterations of muscle tones resulting in sustained abnormal postures and disruptions of ongoing mvmnt. Dystonias may be generalized or focal.
134
What is ataxia?
a lack of coordination while performing voluntary movements. It may appear as clumsiness, inaccuracy, or instability. Movements are not smooth and may appear disjointed/jerky.
135
What is hemiballismus?
usually characterized by involuntary flinging motions of the extremities. The movements are often violent and have wide amplitudes of motion. Are continuous and random and can involve proximal and/or distal muscles on one side of the body.
136
Cardinal signs of Parkinson's...
tremor, rigidity, resistance to passive motion that isn't velocity dependent (cogwheel or led pipe), akinesia, postural instability, festinating gait, falling backwards (retropulsion), or forwards (propulsion), mask face, micrographia.
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5 stages of Parkinson's...
1. unilateral tremor, rigidity, akinesia, minimal or no functional impairment.
2. bilateral tremor, rigidity or akinesia, with or without axial signs, independent with ADL, no balance impairment.
3. worsening symptoms, first sins of impaired righting reflexes, onset of disability in ADLs, can lead indep life.
4. requires help with some/all ADLs, unable to live along without assistance, able to walk and stand unaided.
5. confined to wheelchair or bed, maximally assisted
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What is spina bifida?
failure of spinal column's vertebral arches to fully form to enclose and protect the neural tube. May result in protrusion of the neural tube. Idiopathic (genetic, intrauterine, and/or enviro causes). Most common neural tube disorder. Decreased incidence with folic acid during pregnancy.
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Prognosis and degree of impairment from spina bifida is dependent on the level of the lesion and extent of the neural tube defect. Lesions usually occur in the ____ or ____ spine
thoracic or lumbar spine.
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Spina bifida occulta...
a bony malformation with separation of vertebral arches of one or more vertebrae with no external manifestations; may not be discovered until late childhood.
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What is occult spinal dysraphism (OSD)
when external manifestations of spina bifida are present covering the site, such as red birthmark, patch of hair, dermal sinus, fatty benign tumor, or dimple.
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Spina bifida cystica...
an exposed pouch comprised of the spinal cord and meninges.
- with meningocele: protrusion of a sac through the spine containing CSF and meninges but NOT spinal cord.
- with myelomeningocele: protrusion of a sac through spine containing CSF and meninges AND the spinal cord or nerve roots. Most commonly lumbar.
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Symptoms of spina bifida
- none for spina bifida occulta
- occult spinal dysraphism: may result in spinal cord being split (diplomyelia) or tied down and tethered (diastematomyelia) which may lead to neuro damage and developmental abnormality as child grows.
- spina bifida meningocele: usually no symptoms impacting function. Occasionally slight instability and neuromsucular impairment (gait, bowel/bladdar problems).
- spina bifida myelomeningocele: sensory and motor deficits occurring below lesion level; may result in LE paralysis or deformities, bowel and bladder incontinence, decubitus ulcer and DVT. Lesions S2-S4 result in bladder/bowel problems.
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What is tethered cord syndrome?
Occurs in the tail end of the spinal cord when cord is stretched as a result of compression, being trapped with a fatty mass or scar tissue, developmental abnormality, or injury. Signs include hairy patch of skin, hemangioma (small strawberry mark), and/or dimple of lower spine.
-trouble with bowel/bladder control, gait, deformities, of feet, low back pain, scoliosis.
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What is Arnold-Chiari syndrome?
a portion of the cerebellum and medulla oblongata slip down through foramen magnum to the cervical spinal cord (due to increased pressure in cranium- associated with spina bifida); can cause dizziness, muscle weakness, numbness, vision probs, headaches, balance probs.
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Muscular dystrophies are due to an absent muscle protein product called
dystrophin
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etiology of muscular dystrophies/atrophies
degenerative disorders resulting in muscle weakness and decreased muscle mass due to hereditary disease process
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In muscular dystrophies blood tests demonstrate a high elevated level of...
creatine kinase (CK)
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Common symptoms of muscular dystrophies...
hypotonia, muscle weakness, and atrophy
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Most common form of muscular dystrophy is
Duchenne's
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Duchenne's muscular dystrophy symptoms
- pseudohypertrophy (enlargement of calf muscles) and at times enlargement of forearm and thigh muscles, giving appearance of healthy;
- weakness of proximal joints to where child has signif functional mobility impairments such as ambulating with trendelenburg (waddling) gait and difficulty getting up from floor to standing (uses hands to crawl up thighs to get to standing- called Gower's sign).
- weakness in all voluntary muscles, including heart and diaphragm
- behavioral and learning difficulties and delayed speech maybe
- rarely survive beyond early 20's b/c of respiratory problems, infections, or cardiovascular dystrophy
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Becker muscular dystrophy symptoms
(variant of Duchenne's that is slower progressing)
- loss of motor function of hips, thighs, pelvic area, and shoulders.
- enlarged calves
- cardia system can be involved
- survival can be into late adulthood (normal lifespan if min cardiac involvement)
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Arthrogryposis multiplex congenita symptoms
(at birth; associated with loss of anterior horn cells)
- weakness, deformities, and associated joint contractures.
- position of rest of UE tends to internal rotation of shoulders, ext of elbows, and flexion of wrists; LE flexion and internal rotation of hips and clubfeet.
- may be stable, mildly progressive, or improve.
- related problems= congenital heart defects, spinal defects, torticollis (abnormal head/neck position), and involvement of diaphragm
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Limb-girdle muscular dystrophy symptoms
(Onset between 0-20 years)
- proximal muscles of pelvis and shoulder are initially affected
- typically progresses slowly
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Fascioscapulohumeral muscular dystrophy symptoms
(occurs in early adolescence)
- involves face, upper arms, and scapular region, causing masking, weakness, decreased mobility of the face, and inability to lift the arms above shoulder level.
- as it progresses, weakness can extend to abdominal muscles and sometimes hip muscles.
- progresses slowly; rarely affects the cardiac or respiratory systems (life expectancy can be normal)
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Spinal muscular atrophy symptoms
(caused by decrease of a motor neuron protein called Survival of Motor Neuron, chromosome 5.)
- weakness of voluntary muscles of shoulders, hips, thighs, and upper back which can result in spinal curvatures
- muscles for breathing and swallowing can be affected.
- earlier the age of diagnosis, greater the severity of functional deficits and shorter life expectancy.
- 4 types (1-4): birth/infancy (Werding-Hoffman), children, older children, adolescent/adult
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Congenital myasthenia gravis
(disorder involving transmission of impulses in the neuromuscular junction). Onset stating near birth and occurring more frequently in males.
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Specific symptoms of muscular dystropies
- low muscle tone and weakness contributes to abnormal movement patterns and delayed developmental milestones.
- may be difficulty with oral motor feeding
- weakness contributes to deformities of extremities and spine
- difficulty with breathing may require tracheostomies/ventilators (frequently death occurs)
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Progressive supranuclear palsy... etiology, onset, death?
- etiology: manifested by loss of voluntary but preservation of reflexive eye movements, bradykinesia, rigidity, axial dystonia, pseudobulbar palsy, and dementia.
- onset: occurs in later middle life
- death occurs approx 15 years after onset
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Huntington's chorea... etiology, onset, symptoms?
- etiology: autosomal dominant disorder
- onset: begins in middle age
- symptoms: choreiform movements and progressive intellectual deterioration, psychatric distrubance (personality change, manic-depressive symptoms, and schizophreniform illness may occur).
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Spinocerebellar degenerations (3 types....)
Friedrich's ataxia, cerebellar coritcal degeneration, and multiple systems degeneration
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Friedrich's ataxia (etiology, onset, symptoms)
- etiology: autosomal recessive inheritance
- onset: childhood/early adolescence
- symptoms: prototype of spinal ataxia... gait unsteadiness, UE ataxia, dysarthria; maybe tremor; areflexia and loss of large fiber sensory modalities; scoliosis and cardiomyopathy common as progresses.
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Cerebellar cortical degeneration (etiology, onset, symptoms)
- etiology: pathological changes seen in cerebellum and inferior olives
- onset: between ages 30-50
- symptoms: cerebellar symptoms are only detectable signs
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Multiple systems degeneration (etiology/symptoms and onset)
- etiology/symptoms: spasticity, extraphyramidal, sensory, LMN, and autnomic dysfunction
- onset: young to mid-life
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Etiology of ALS (amyotrophic lateral sclerosis)
motor neuron disease of unknown etiology characterized by progressive degeneration of corticospinal tracts and anterior horn cells or bulbar efferent neurons
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ALS average age? gender? symptoms?
average age of onset 57. Slightly more men. Death in 2-5 years.
Symptoms: muscle weakness/atrophy, evidence of anterior horn cell destruction, often begins distally and asymmetrically. Cramps and fasciculations (twitching) precede weakness. Signs usually begin in hands.Then spasticity, hyperactive deep tendon reflexes, and corticospinal tract involvement; dysarthria & dysphagia.
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Brachial plexus disorder (etiology? symptoms?)
- etiology: secondary to traction during birth, invasion of metastatic cancer, after radiation tx secondary to fibrosis, or traction injury.
- symptoms: mixed motor and sensory disorders of corresponding limb; rostral injuries produce shoulder dysfunction while caudal injuries produce dysfunction in the hand.
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Erb's palsy (brachial plexus injury)
a paralysis of the upper brachial plexus including the 5th and 6th cervical nerves, and sometimes 7th. Muscles most often paralyzed: supraspinatus, infraspinatus, deltoid, biceps, brachialis, and subscapularis. Arm cannot be raised, elbow flexion weak, and maybe weakness in retraction and protraction of scapula. Arm straight and wrist fully bent ("waiter's tip"). After age 6 contractures develop.
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Klumpke's palsy (brachial plexus injury)
a paralysis of the lower brachial plexus including the 7th and 8th cervical and 1st thoracic nerves. Relatively rare compared to Erb's palsy. Results in paralysis of hand and wrist, often with ipsilateral Horner's syndrome (miosis, ptosis, and facial anhidrosis). Hand is limp and fingers do not move.
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What is anhidrosis?
inability to sweat
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Peripheral neuropathies (etiology)
single nerve may be result of trauma, pressure paralysis, forcible overextension of joint, hemorrhage into a nerve, exposure to cold or radiation, or ischemic paralysis. Multiple nerves may be affected in cases of collagen vascular disease, metabolic diseases (diabetes mellitus), or infectious agents (Lyme disease). Other causes: nutritional deficiency, malignancy, microorganisms, exposure to toxic agents, and chronic ETOH.
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symptoms of peripheral neuropathy
- sensory, motor, reflex, and vasomotor symptoms
| - pain, weakness, paresthesias in the distribution of affected nerve
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treatment of peripheral neuropathy
not guided by symptoms, but rather by underlying disease process. Tx of systemic disorder may slow progression, but recovery is slow.
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Guillain-Barre Syndrome (etiology, onset, recovery time)
etiology- unknown. may occur after infectious disorder, surgery, or immunization.
onset- affects both sexes at any age.
Recovery time is 2-4 weeks after first symptoms. 80% are ambulatory in 6 months; 5% die of complications; 50% exhibit mild neurological deficits; 15% exhibit residual functional deficits.
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Symptoms of Guillain-Barre syndrome
acute, rapidly progressive form of polyneuropathy characterized by symmetric muscular weakness and mild distal sensory loss/parestheisas. Weakness always more apparent than sensory findings and is at first more distal. Patient may complain of painful extremities; sensory disturbances common initially. Sometimes respiratory failure and dysphagia.
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Myasthenia gravis (etiology, onset)
etiology: caused by autoimmune attack on acetylcholine receptor of postsynaptic neuromuscular junction. Considered a disorder of neuromuscular transmission.
Onset- any age but more younger women and older men. Usually progressive disabling process.
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Myasthenia gravis symptoms
- ptosis, diplopia, muscle fatigue after exercise, dysarthria, dysphagia, and proximal limb weakness.
- sensation and deep tendon reflexes are intact
- symptoms fluctuate over course of the day
- quadriparesis maybe during relapsing period
- sometimes life threatening respiratory muscle involvement
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Post-polio syndrome (PPS) (etiology, onset)
- etiology: some motor neurons infected with the polio virus die (leaving paralyzed muscle cells), others survive. Recovered motor neurons develop new terminal axon sprouts that reinnervate muscle cells. After years of stability, these motor units break down, causing new muscle weakness.
- Onset: typically 15 years after recovery from polio; progress is slow with good prognosis unless breathing/swallowing difficulties occur.
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Post-polio symptoms
- new onset of weakness
- easily fatigued
- muscle pain
- join pain
- cold intolerance
- atrophy
- loss of functional skills
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Medical management of post-polio
- bracing with orthoses and pacing daily activity
- stretching programs
- exercise program
- low doses tricyclic antidepressants to relieve muscle pain
- pyridostigmine to reduce fatigue and improve strength
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Multiple sclerosis (MS) (etiology, onset)
- etiology: unknown. Myelin damage probably mediated by immune system. Perhaps disease or enviro causes. Slowly progressive CNS disease characterized by patches of demyelination in the brain and spinal cord. Multiple CNS lesions and evidence of at least 2 episodes of neurological disturbance.
- onset: 20-50 years old; variable prognosis.
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MS symptoms
- multiple and varied neurologic symptoms and signs, usually with remissions and exacerbations.
- weakness/clumsiness in leg or hand
- visual disturbance (diplopia, partial blindness, nystagmus, eye pain, etc)
- emotional disturbances (lability, euphoria, reactive depression
- balance loss and/or vertigo
- bladder dysfunction
- cognitive features may include apathy, memory loss, lack of judgment, and inattention
- sensorimotor may include spasticity, increased reflexes, ataxia, weakness, gait instability, easy fatigue, hemiplegia or quadriplegia.
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Medical management of MS
- during acute exacerbation, anti-inflammatory drugs
- antispasmodics
- Management f bowel and bladder dysfunction (catheterization)
- drugs to slow progression (Avonex, Betaseron, Copaxone, and Rebif)
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Fast pain is transmitted over _____ fibers
A delta
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Slow pain is transmitted over _____ fibers
C
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Neuropathic pain is...
pain as a result of lesions in some part of the nervous system (central or peripheral); usually accompanied by some degree of sensory deficit.
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Thalamic pain:
continuous, intense pain occurring on the contralateral hemiplegic side; the result of a stroke involving the ventral posterolateral thalmus; poor rehab potential.
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Complex regional pain syndrome (type I):
pain maintained by efferent activity of sympathetic nervous system. Abnormal burning pain (causalgia), hypersensitivity to light touch, and sympathetic hyperfunction (coldness, sweating). Usually associated with traumatic injury. (Some nerve damage noted)
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Complex regional pain syndrome (type II):
pain occurring along the branches of a nerve; frequently paroxysmal (aka sudden and intense). No known physiological problem.
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What is allodynia?
pain due to stimulus that doesn't normally cause pain
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What is parestesias?
tingling, tickling, pricking, or burning of a person's skin with no apparent long-term physical effect.
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What is Herpes Zoster (aka?)....
shingles! An acute, painful mononeuropathy caused by the varicella-zoster virus. Vesicular eruption and marked inflammation of the posterior root ganglion of affected spinal nerve or sensory ganglion of the cranial nerve; ventral root involvement (motor weakness) in 5-10% of cases.
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Dunn's sensory processing model- 4 categories of thresholds/behavioral responses
1. Poor registration= high threshold and passive behavioral response.
2. Sensory seeking= low thresholds and active behavioral response.
3. Sensory sensitivity= low neurological thresholds and passive behavioral response.
4. Sensory avoiding= low thresholds and active behavioral response.
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what is dyspraxia?
difficulty with planning movements, particularly those that are complex or new.
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Seizures are often associated with other conditions:
oxygen deprivation, severe head injuries or brain hemorrhage, CP, stroke, brain tumors, other neurologic disorders (Alzheimer's), hydrocephalus, metabolic disorders, infections, meningitis, rubella.
196
Two broad groups of seizures...
1. primary generalized seizures- begin with widespread involvement of both sides of the brain.
2. partial seizures- begin with involvement of a smaller, localized area. Can still spread within seconds/minutes to widespread areas of brain (known as secondary generalized seizure).
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Tonic-clonic seizures (aka ____)....
aka grand mal seizures. Most common type in children. Brief aura (numbness, taste, other sensation), then tonic phase (loss of consciousness, stiffening of body, heavy/irregular breathing, drooling, skin pallor, sometimes incontinence), then clonic phase (alternating rigidity and relaxation of muscles). Then postictal state (period of drowsiness disorientation, or fatigue).
198
Myoclonic-akinetic seizure...
brief, involuntary jerking of the extremities, with or without loss of consciousness. Loss of tone. Difficult to control.
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Petit mal seizures (also called absence seizures)
typically occur b/w ages of 4-12. Loss of consciousness without loss of msucle tone. Rapid blinking or staring into space. Child does not fall down, but does not recall the episode or any lapse in time.
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Partial focal seizures: simple partial seizures
abnormal electrical impulses occur in a localized area of brain, often in motor strip of frontal lobe. Involuntary repetitive jerking of left hand and arm occurs, but person can maintain interaction with environment. Focal seizures may become generalized and result in loss of consciousness.
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Partial focal seizures: complex partial or psychomotor seizures
Symptoms vary. Alterations in consciousness and unresponsiveness. May appear confused/dazed, unable to respond to questions/directions. Automatic motions (lip smacking, chewing/swallowing, and nervous mvmnt of hands/fingers) and repetitive mvmnts occur. Visual or auditory sensations occur just before seizure.
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Infantile spasms or West syndrome, infantile myoclonic seizures or jackknife epilepsy
Begins at 3-9 months of age. Dropping of head and flexion of arms; seizures may occur hundreds of times per day; poor prognosis; spasms sometimes decrease after several years. Often indicate an underlying disorder such as tuberous sclerosis.
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Lennax-Gastaut syndrome
children with severe seizures, mental retardation, and a specific EEG pattern. Seizures of different types begin during first 3 years of life and difficult to control. Associated with various brain disorders from structural abnormalities to birth asphyxia. Sometimes regression of developmental status can occur.
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Landau-Kleffer syndrome (aka ____)
aka acquired epileptic aphasia. progressive encephalopathy; loss of language skills; auditory agnosia; behavior disturbances such as inattention.
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Simple febrile seizures
Most common type of seizure, precipitated by a fever. lasts less than 10 minutes and includes a loss of consciousness and involuntary, generalized jerking of grand mal seizure; usually do not cause damage and do not lead to epilepsy. .
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Status epilepticus
prolonged seizures or seizures in rapid succession. Can be life threatening; sometimes triggered when medication is stopped abruptly. Rarely does sudden death occur; however it is possible due to resulting erratic heart rhythm. Typically occurs with tonic-clonic seizures that are not well controlled.
