Neurology Flashcards
(109 cards)
1
Q
ANATOMY & BLOOD SUPPLY
A
•Blood Supplies to the brain
–Frontal – Anterior Cerebral Artery
–Parietal – Anterior & Middle Cerebral Artery
–Temporal – Middle Cerebral Artery
–Occipital – Posterior Cerebral Artery
2
Q
Lobes of the brain
A
•Lobes of the the brain
–Frontal
–Parietal
–Temporal
–Occipital
3
Q
FRONTAL LOBE FUNCTION
A
Dr. Brain - higher level thinking
•Frontal Lobe
–Personality
–Reasoning
–Motor planning
–Judgment
–Emotional regulation
4
Q
TEMPORAL LOBE FUNCTION
A
MEMORY - VISUAL - UNDERSTANDING AND COMPREHENSION
–Hearing
–Comprehension
–Visuospatial Orientation
–Conceptual Understanding
–Visual Memories/Visual Processing
5
Q
PARIETAL & OCCIPITAL LOBE FUNCTION
A
•Parietal Lobe
–Pain
–Touch (all types)
–Temperature
–Pressure
•Occipital Lobe
–Sight
6
Q
RIGHT BRAIN FUNCTION
A
RIGHT = PERCEPTION
•Right side
–Non-verbal and artistic abilities.
- Visuo-perceptual function (hand-eye coordination)
- Spatial relationships
- Perception of one’s position in space
- Nonverbal communication (facial gestures)
- Judgment
- Self perception
7
Q
LEFT BRAIN FUNCTION
A
8
Q
2 Types of strokes
A
Ischemic stroke – Blockage
Hemorrhagic – Burst
Middle Cerebral Artery = 90% of cases
Aneurysm is BURSTING of the blood vessel
9
Q
A patient is evaluated and is found to have drooping of the mouth on the right side but no significant drooping of the eyes are noted. The patient also has an incoherent speech but with a normal speed. Which of the following is the MOST likely present?
A) Right anterior cerebral artery stroke
B) Right Bell’s Palsy
C) Left middle cerebral artery stroke
D) Left Lateral medullary stroke
A
A: Causes stroke on the contralateral side.
B: Eyes are not drooped, Bells Palsy is eyes and face
C: CORRECT
D: Also know as a PICA stroke or Wallenburg stroke – causes facial dropping on the same side
10
Q
MCA STROKE supplies what?
A
Middle Cerebral Artery (MCA) supplies the Temporal, parietal and parts of the frontal lobes
MCA supplies superior-lateral aspects of the parietal lobe
Therefore suplies teh UE and Face
“My Crappy Arm”
11
Q
MCA Stroke Signs and Symptoms
A
Top 3 Signs and Symptoms
•Affects contralateral upper extremity more
•Affects contralateral lower face
•Affects right or left hemisphere causing variable symptoms
____
–Upper part of the face is NOT IMPAIRED
–Affects right or left hemisphere causing variable symptoms
- Broca’s / Wernicke’s Aphasia (Left side)
- Perceptual deficits (unilateral neglect) (Right side)
- Sensory Ataxia (left or right)
- Apraxia (left or right)
12
Q
ACA STROKE supplies what?
A
- Anterior Cerebral Artery supplies the Frontal & Parietal Lobes
- ACA also supplies superior and medial aspects of the parietal lobe
–
So more LE is affected
“A Crappy Ass”
13
Q
Motor or Somatosensory?
Precentral Gyrus
Post Central Gyrus
A
Precentral Gyrus – Motor
Post Central Gyrus - Somatosensory
14
Q
ACA Stroke S+S
A
•Signs and Symptoms
–Affects contralateral lower extremity more
–Urinary incontinence
–Affects right or left hemisphere causing variable symptoms
- Ideomotor Apraxia
- Problems with imitation
- Akinetic Mutism
–
15
Q
A patient presents with a left ACA stroke and is asked to utilize a comb to groom his hair. Despite demonstration and verbal cueing, the patient is unable to understand how the comb is used. Which of the following impairments is the patient MOST likely displaying?
A) Agnosia
B) Anosognosia
C) Ideomotor apraxia
D) Ideational apraxia
A
A: Inability to perceive objects or people
B: When pt can’t perceive that they have a illness (right sided perceptual problem)
C: Apraxia is inability to initiate the task (on demand) but if they have a specific que, they can.
D: Pt cannot perceptualize it at all.
16
Q
A patient presents to the outpatient clinic six weeks post CVA displaying a primary LE flexor synergy pattern with some hip extension and knee extension movements. Which of the following Brunnstrom stages would you characterize this patient?
A) Stage 1
B) Stage 3
C) Stage 6
D) Stage 4
A
17
Q
BRUNNSTROM STAGES
A
1.Flaccidity
2.Onset of primitive reflexes
3.Max spasticity
- Spasticity declines and some movements are performed out of synergy
- Selective control of movement
6.Near normal with coordinated motions out of synergy
7.Normal
–
18
Q
SYNERGY
A
Group of muscles that work together as a unit to assist with some daily function (feeding, ambulation)
–
19
Q
LOWER EXTREMITY SYNERGY - Flexion
A
Dog peeing on a fire hydrant
•FLEXOR
–Hip Flexion*
–Hip Abduction
–Knee Flexion
–Ankle Dorsiflexion
–Ankle Inversion
–Toe Extension
–
20
Q
LOWER EXTREMITY SYNERGY - Extension
A
Michael Jackson
•EXTENSOR
–Hip Extension
–Hip adduction*
–Hip Internal Rotation
–Knee Extension *
–Ankle Plantarflexion *
–Ankle Inversion
–Toe Flexion
–
21
Q
LOWER EXTREMITY DOMINANT
A
DOMINANT PATTERN
–Hip Flexion
–Knee Extension
–Ankle Plantarflexion
22
Q
UPPER EXTREMITY SYNERGY - Flexion
A
•FLEXOR
–Scapular Retraction & Elevation
–Shoulder Abduction
–Shoulder External Rotation
–Elbow Flexion*
–Forearm Supination
–Wrist and Finger Flexion
–
23
Q
UPPER EXTREMITY SYNERGY - Extensor
A
•EXTENSOR
–Scapular Protraction
–Shoulder adduction*
–Shoulder Internal Rotation
–Elbow Extension
–Forearm Pronation*
–Wrist and Finger Flexion
24
Q
UPPER EXTREMITY DOMINANT
A
DOMINANT PATTERN
–Shoulder adduction
–Elbow Flexion
–Forearm Pronation
One particular PNF pattern that really does the trick.
D2 flexion
25
A 56-year-old patient is currently being treated in the neurological recovery center post anterior cerebral artery stroke. The therapist has noticed a gradual reduction in the patient’s lower extremity spasticity over the past two weeks. The patient has started to initiate movements out of synergy. Which of the following intervention would BEST facilitate motion out of synergy.
A.Seated marching alternating lower extremities
B.Seated bilateral shoulder extension weight-bearing though upper extremities
C.Seated heel slides maintaining dorsiflexion and alternating lower extremities
D.Transitioning from quadruped to tall kneeling
They want you to know the dominant pattern
Which intervention is going to move the most joints out of synergy
Which is going to move the most and biggest joints out of synergy?
A: Hip flexion and knee flexion – ONE JOINT
B: Upper extremity
C: Hip flexion, knee flexion, ankle dorsiflexion – TWO JOINTS
D: Hip Extension, knee flexion, ankle plantarflexion/dorsi… -TWO-THREE Joints
26
A patient presents with a right anterior cerebral artery (ACA) stroke and marked LE extensor tone. Which of the following gait deviations is the MOST likely present on the affected side?
A.Forward trunk lean
B.Delayed heel off
C.Bilateral scissoring gait
D.Circumduction gait
A: For extension than flexion
B: Due to weak plantarflexors; would be toe walking
C: Not bilateral
D: Correct – to clear affected leg – long leg
27
ASIA SCALE
–A = Complete no sensory or motor function preserved in the sacral segments S4-S5
–B = Incomplete, sensory but no motor function is preserved below the level of the lesion
–C – Incomplete, more than half of the key muscles below the NLI have an MMT grade of less than 3/5
–D = Incomplete, at least half of the key muscles below the NLI have an MMT of 3/5 or more
–E = Normal Sensory and Motor function
28
LE MYOTOMES ASSOCIATED WITH ASIA
* L1 – HIP FLEXOR
* L2 – HIP FLEXOR
* L3 – KNEE EXTENSOR
* L4 – ANKLE DORSIFLEXION
* L5 – GREAT TOE EXTENSION
* S1 – PLANTARFLEXION – EV
* S2 – KNEE FLEXION
29
A 65-year-old patient with primary progressive multiple sclerosis and extensor tone is being examined to determine the best recommendation for an orthotic for basic home use. The patient has 2-/5 dorsiflexion strength, 2/5 plantarflexion strength, and 1/5 medial and lateral ankle strength. Which of the following is the MOST appropriate recommendation:
A.Solid ankle foot orthosis
B.Posterior leaf spring orthosis
C.KAFO with metal uprights
D.Articulated AFO with a posterior stop
Primary progressive MS – most progressive
Key word – Home Use
A: Fits everything
B: Does nothing for dorsiflexion or medial/lateral strength
C: Immediate out because it’s bulky and high energy expendiature
D: Not for basic home use
30
UPPER EXTREMITY SCI FUNCTIONAL OUTCOMES C7
•C7 Level SCI
–Key Muscles (Think “The Phelps”)
•Triceps, Lats, Pronator Teres
–PT Implications
•Mobility
–All of the above
–Mod I transfers, wheelchair propulsion, pressure relief, upper and lower extremity dressing
–Will eventually achieve independent pop over transfers without sliding board
–Limitations
•Transfers to floor require mod to maxA
–
31
A 24-year old patient presents with an ASIA A L3 SCI requiring assistance with choosing the most independent and efficient use of an assistive device for gait. Which of the following assistive devices is the MOST appropriate for this patient?
A.Reciprocal Gait orthosis and loft-strand crutches
B.Bilateral KAFO's and loft-strand crutches
C.HKAFO and bilateral canes
D.Bilateral GRAFO and bilateral canes
What do we know
They’re 24yo
L3 – means that quads are 3/5 or better – muscles at that level are 3/5 or better
A: To Bulky
B: Not bad – but is there better options
C: At the hip
D: Used for knee buckling – pt is at risk for it – can be used for 3/5 quad strength
32
A child is being treated in physical therapy for gait and functional mobility. The patient has an L1 myelomeningocele however demonstrates good reciprocal lower extremity movements and coordination. Which of the following assistive devices would BEST fit the patient’s functional level?
A. Household ambulation with RGO and Lofstrand crutches
B. Community ambulation with an RGO and Lofstrand crutches
C. Household ambulation with KAFOs and rollator walker
D. Community ambulation with HKAFOs and Lofstrand crutches
Cannot use bulky equipment for community ambulation
**A: Can**
B: NO, too bulky
C: Does not stabilize the hip
D: NO, too bulky
33
MYOTOME UE and LE
* C4 – SCAPULAR ELEVATORS
* C5 – ELBOW FLEXORS
* C6 – WRIST EXTENSORS
* C7 – ELBOW EXTENSORS
* C8 – FINGER FLEXORS
* T1 – FINGER ABDUCTORS
* L1 – HIP FLEXOR
* L2 – HIP FLEXOR
* L3 – KNEE EXTENSOR
* L4 – ANKLE DORSIFLEXION
* L5 – GREAT TOE EXTENSION
* S1 – PLANTARFLEXION – EV
* S2 – KNEE FLEXION
34
A patient with an ASIA A L3 spinal cord injury is being educated on safe and effective long-term solutions for voiding. Which of the following methods is the MOST appropriate for this patient:
•
A. Suprapubic tapping for a hyperreflexive bladder
B. Indwelling catheter for a flaccid bladder
C. Crede maneuver for a flaccid bladder
D. Valsalva maneuver for a flaccid bladder
ASIA L3 = No motor or sensory below L3
Bladder component
UMN and LMN – This is a LMN
Spinal cord ends at L1
A: This is UMN
B: Long-term solution – reduces risk for infection
C: Hands over bladder to force voiding – Is this safe and effective long-term solution?
D: Valsalva maneuver – Hold breath and bearing down – not safe.
C+D are very similar – so can remove
35
UPPER EXTREMITY SCI FUNCTIONAL OUTCOMES C1-C4
•C1-C4 SCI
–Key Muscles (Think Nodding and Facial)
C3-C4-C5, diaphragm is alive.
•SCM, Facial Muscles, Capital Muscles, Diaphragm, Trapezius
–PT Implications
•PW with mouth stick or chin control
–Tilt in space/recline for pressure-relief
–Limitations
* Dependent on ventilator (partial diaphragm only)
* Dependent with all ADL’s, transfers and bed mobility
36
UPPER EXTREMITY SCI FUNCTIONAL OUTCOMES C5
•C5 Level SCI
–Key Muscles (Think “I dunno”)
•Deltoid, Biceps, Rhomboids, External Rotators
–PT Implications
•Mobility
–Power wheelchair with hand controls (preferred)
–Manual wheelchair with rim projections (energy-costly)
**–Max Assist with transfers (sliding board) - don't have tenodesis**
**–Independent forward raise for pressure relief**
–Limitations
* Prone to elbow flexion contractures
* Dependent with bathing and dressing
–
37
UPPER EXTREMITY SCI FUNCTIONAL OUTCOMES C6
•C6 Level SCI
–Key Muscles
•Extensor Carpi Radialis, Pectoralis Major, Teres Major
–PT Implications
•Mobility
–Manual wheelchair with rim projections
**–Independent to MinA with sliding board**
–Independent pressure relief w/ weight shift
–Independent rolling / feeding
–Limitations
•No Elbow extension
–
38
UPPER EXTREMITY SCI FUNCTIONAL OUTCOMES C8
•C8 Level SCI
–Key Muscles (Think “Hand Intrinsics”)
•ECU, FCU, Hand intrinsics
–PT Implications
•Mobility
–Same potential as C7
**–Wheelies in WC**
**–Negotiation of 2-4 inch curbs**
–Limitations
•Transfers from WC to floor require minA
–
39
A patient with a recent SCI has been prescribed a new wheelchair and is now at risk for pressure sores. The therapist would like to train the patient to perform independent pressure relief. Which of the following is the HIGHEST level the patient can perform independent pressure relief?
A. C5
B. C7
C. C6
D. C4
40
LOWER EXTREMITY SCI FUNCTIONAL OUTCOMES T12-L2
•T12-L2 Level SCI
–Key Muscles
•Quadratus Lumborum, iliopsoas
–PT Implications
•Mobility
–Household ambulation
»Independent coming to stand and ambulation with HKAFO OR KAFO’S
–WC used for all community ambulation
–Limitations
•No quad control
–
41
LOWER EXTREMITY SCI FUNCTIONAL OUTCOMES L3
•L3 Level SCI
–Key Muscles
•Quadriceps, hip adductors
–PT Implications
•Mobility
–Community ambulation with orthoses\*\* (GRAFO)
–WC for independence, efficiency
**•If SCI is complete (ASIA A) will need more restrictive AFO to prevent ankle instability.**
–Limitations
* No gluteus maximus function
* Foot clearance
42
LOWER EXTREMITY SCI FUNCTIONAL OUTCOMES L4-5
•L4-5 Level SCI
–Key Muscles
•Tibialis Anterior, Extensor Digitorum, Extensor Hallicus
–PT Implications
•Mobility
–Community ambulation with AFO and canes
»Will need good med/lat stability to use Posterior Leaf Spring
–Limitations
•No gluteus maximus function
43
A therapist is considering different types of orthotics to prescribe to a 23-year-old active patient who has an L2 ASIA C SCI. The orthotic MOST recommended is:
•
A. HKAFO’s with rollator walker for home and wheelchair for community ambulation
B. KAFO’s with loftstrand crutches for community and home ambulation
C. KAFO’s with axillary crutches for home and wheelchair for community ambulation
D. Bilateral AFO’s with canes for community and home ambulation
A: NOPE
B: KAFO are not for community ambulation
C: Yes
D: Not enough
44
Biofeedback
•What is Biofeedback (BF)
–Sensory modality used to measure muscular activity through electrical signals that are detected through the skin.
* Signals are produced by the unit in the form of visual and auditory outputs
* What is it used for?
–Biofeedback is used to teach patients how to control involuntary muscular activity by controlling the displayed signals.
45
sEMG for Spastic Muscle
46
Biofeedback (sEMG) sensativity
–Sensitivity
•The ability to detect muscle electrical activity through the skin
**•The higher the sensitivity, the more muscle activity you will detect**
**•The lower the sensitivity, the less muscle activity you will detect**
–Example
•If I want to detect electrical activity in a quad muscle that is inhibited, should I increase or decrease the sensitivity? INCREASE
–Gain
* Unit of measure on the biofeedback unit that determines the ability to detect muscle electrical activity through the skin
* Inversely proportional to your sensitivity
–”As you increase the gain you are decreasing the sensitivity”
–Tester beware!!
•If your answer choice has, “Sensitivity (Gain) will be increased,
–base your decision on sensitivity and not gain.
47
sEMG for weak MM
•If I have a patient with a weak, low activating, rectus femoris
–Do I want to facilitate or Inhibit the muscle?
•Facilitate
–What is the size of the tissue?
•Large tissue
–What electrode placement is needed?
•Wide electrode placement to start and narrow to finish
–What electrode size is most appropriate?
• Normal to Large
–What is the appropriate level of sensitivity to start, high or low?
•High sensitivity to start and low sensitivity to finish
48
A patient with diagnosed cervicogenic headaches presents with overactive suboccipitals. The therapist would like to initiate biofeedback to manage the patient's symptoms. Initial set-up for the biofeedback unit should be:
•
A. Narrow electrode placement, high sensitivity
B. Wide electrode placement, low sensitivity
C. Narrow electrode placement, low sensitivity
D. Wide electrode placement, high sensitivity
C. Narrow electrode placement, low sensitivity
49
A 34-year-old patient 2 weeks postpartum presents with complaints with neck pain and a persistent headache after sleeping on a couch. The patient has tenderness to palpation to right suboccipital muscles. Which of the following interventions is the LEAST recommended:
•
A. Thermotherapy
B. Electrical stimulation
C. Cervical traction
D. Biofeedback
Primary Impairment: Pain
A: Can use to reduce pain, and with this pt
B: Can use, with pt
**C: Can use, not with pt**
D: Can use, with pt
50
ALS (Leu Gherig's Disease)
* Progressive neurodegenerative disease
* Corticospinal Tracts (UMN)
* Neurons in the motor cortex and brainstem (UMN)
* Anterior horn cells in the spinal cord (LMN’s)
* Patient Profile
* Gender: Male
* Age of Onset: 50’s (Can be 20-30)
•
* Early Symptoms
* Distal Asymmetrical & Focal Muscle Weakness
* Bulbar weakness (Dysarthria, Dysphagia, Dysphonia)
* Spasticity in extremities (UMN signs come first)
•
Distal weakness first
51
A patient presents with early onset of Amyotrophic Lateral Sclerosis. During a routine examination, which of the following is the MOST likely to be found?
A.Distal sensory loss
B.Ineffective cough
C.Proximal muscle weakness
D.Unilateral hyperreflexia
A: No, sensory is typically spared in this population
B: Not early – distal problems to start
C: DSITAL not proximal
D: Asymmetrical UMN
Death occurs 3-5 years once diagnosed
52
A patient with ALS is being treated in a long term care facility. The patient complains of neck pain and has poor head control and severe cervical extensor weakness. Which of the following is the MOST recommended to address the primary impairment?
A.Soft collar
B.Cervical extensor PRE’s
C.Rigid collar
D.Stretching of the pectorals
Primary Impairment: Weakness
A: Does not address weakness – not with severe weakness – maybe mild
B: Condition is progressive, so loading them with exercises is not going to get anywhere
**C: Yes – something needs to stabilize it**
D: Not going to target
53
ALS Impairments
* Lung Secretion Clearance
* Effective clearance
* Widespread Weakness
* Cervical extensor weakness
* Respiratory weakness
•
* Energy Conservation & Fatigue
* Spasticity (Decreased ROM)
54
Cranial Nerve Mneumonics
•Oh Oh Oh To Touch And Feel Very Good Velvet Ah Heavenly
-Oh Oh Oh To Touch And Feel Very Good Vagina Ah Heaven
•Some Say Money Matters But My Brother Says Big Brains Matter Most
•
55
OLFACTORY (1)
•Olfaction (Smell)
**•Parkinson’s Disease and Alzheimer’s Disease**
* Test: Sense of Smell
* Close off other nostril
* Use of common, non-irritating odors
ANOSMIA
Parkinsons disease - early on, they have problems with smell
56
Exercise with ALS
* Frequency
* 2-3 days/week on alternate days (non-endurance)
* Intensity
* Moderate level intensity 70%-80% 1RM
* Time
* 30 minutes per session or 10 minutes sessions x 3
* Type
* Strength, aerobic
* Time of day
* Early morning - more energy
WHEELCHAIR PRESCRIPTION - Rent for Early to middle stages. Purchase power wheelchair for late stage. Have the future in mind.
57
Orthotic for ALS
Which orthotic is best?
A.HKAFO - too bulky
B.KAFO - too bulky
C.SAFO - possibly too limiting
D.Hinged AFO (Articulated) - Most mobility for someone who is still active.
58
Treating Spasticity And
ALS
* Spasticity
* Avoid contractures
* Positioning out of synergy
* 30 mins to 3 hours
* Splinting (air splint/cast)
* Reduce Spasticity
* Gentle prolonged stretching and PROM
* Spasticity
* Gentle rhythmic rotation
* Start proximal first
* Heat
* Prolonged pressure on muscle belly
59
What are Cranial Nerves
* Cranial nerves are LMN’s that originate from the brain/brainstem instead of the spinal cord
* Cranial nerves relay information between the head and neck and the brain
60
Cranial Nerve Origin
* The nuclei of the cranial nerve (origination point) is considered a part of the brainstem and is therefore an UMN.
* Cerebrum (2) - O - O
* Midbrain (2) - O - T
* Pons (4) - T -A - F - V
* Medulla (4) - G - V - A - H
61
OPTIC (2)
* Sight/Vision
* Multiple Sclerosis (Optic Neuritis), Middle/Posterior Cerebral Artery Stroke
* Test: Central/Peripheral Vision
* Snellen Chart (Central) – Visual Acuity
* Pathologies – Cataracts, Macular degeneration
* Confrontation Test (Peripheral)
* Pathologies – Glaucoma (pressure in the eye) – Pressure - peripheral
Myopia – impaired far-sidedness
Presbyopia – impaired near-sidedness
Diplopia - Double VIsion
62
A patient is being evaluated for frequent falls. The patient is negative on the visual confrontation test however is unable to identify letters and numbers held directly in front of the visual field at a 20-foot distance. Which of the following pathologies is MOST likely present?
A.Glaucoma
B.Cataracts
C.Presbycusis
D.Homonymous hemianopsia
B.Cataracts
63
OCULOMOTOR (3)
* Eye Movement
* Upward, Downward, & Inward
* Multiple sclerosis & Horner’s Syndrome\*
* Test
* Follow finger into upward, downward and inward directions
* Look for lateral strabismus
* Look for ptosis (drooping of eyelid)
•
Horners – Brainstem stroke that happens in the medulla – symptoms with sympathetic system – anhidrosis, meiosis (pupil constriction) Ptosis (droppy eyelids)
64
Pupillary Reflex
* Direct Pupillary light reflex
* Constriction of the right pupil when light is shined into the right eye (Right CN II / Right CN III)
* Consensual Pupillary Reflex
* Constriction of the left pupil when light is shined into the right eye (Right CN II / Left CN III)
65
A patient with multiple sclerosis is being examined for cranial nerve functioning. During testing, a light is shined into the right eye which produces constriction of the left pupil, but not the right. Which of the following is the MOST likely present?
A.Right CN II impairment
B.Left CN II impairment
C.Right CN III impairment
D.Left CN III impairment
C.Right CN III impairment
66
TROCHLEAR (4)
* Eye Movement
* Turns eye down when adducted.
* Multiple sclerosis
* Test
* Ask patient to look down when eye is adducted
* (CONVERGENCE TEST)
67
TRIGEMINAL (5)
* Sensory of the face; Muscles of Mastication
* Trigeminal Neuralgia, ALS
* Test
* Pain and light touch
* Corneal reflex
* Clench teeth & hold against resistance
* Jaw Jerk reflex
68
FACIAL (7)
•Facial expression & _taste anterior two thirds of tongue_
**•Bells Palsy, Guillian-Barre, ALS**
* Test
* Motor function of the face
* Raise eye brows
* Frown
* Show teeth, smile
* Close eyes tightly
* Puff out both checks
* Apply saline solution and sugar solution using a cotton swab
69
A therapist is using the H-test to examine the patient’s eye movements. During the test, the patient’s right eye is unable to converge and remains abducted. Which of the following is MOST likely?
A.Amyotrophic lateral sclerosis
B.Bell’s Palsy
C.Cranial nerve VI palsy
D.Midbrain stroke
Oculomotor or Trochlear
A: ALS Spares the eyes
B: Bell Palsy doesn’t affect eye muscles
C: Eyes would be Adducted
D: Has oculomotor AND Trochlear
70
GLOSSOPHARYNGEAL (9)
* Taste
* ALS, Medullary stroke (Wallenberg Syndrome), Guillain-Barre
* Test
* Apply saline solution and sugar solution to posterior one third of tongue
71
VAGUS +
GLOSSOPHARYNGEAL (10)
* Phonation, Palatal Control, Gag Reflex
* ALS, Medullary stroke (Wallenberg Syndrome), Guillain-Barre
•
* Test
* Swallowing a glass of water
* Say “AH” (Uvula deviates away from weak side)
* Gag reflex
72
HYPOGOSSAL (12)
* Tongue Movements
* ALS
* Test
* Listen to articulation
* Protrude tongue
* (deviation to weak side)
Move tongue side to side
73
Vestibular System Function
* Stabilizes visual images to allow for clear vision during head movement
* Maintains postural stability, especially during head movement
* Provides critical information used for spatial orientation
74
Tonic Firing Rate
* Tonic Firing Rate \*\*P\*\*
* When you turn your head right, the right labyrinth is excited and the left is inhibited
* When you turn your head to the right, the [BLANK] ear is being tested
[RIGHT]
75
Vestibular Ocular Reflex
* Think stabilization during head movement
* VOR must generate eye movements opposite of the head movement to stabilize image
76
•VOR Gain
* Speed at which the head and eye move in opposite directions.
* VOR Gain = -1
-1 means that they are going in opposite direction; +1 means going in the same direction; 0 means they’re not connected
77
•Nystagmus \*\*P\*\*
* Involuntary eye movement characterized by slow movement in one direction followed by a rapid return to the original position
* Named by the FAST PHASE
* Upbeating / downbeating
* Pendular
* Right/Left beating
•
**•WHEN SITTING THE AFFECTED SIDE IS OPPOSITE OF THE FAST PHASE**
**Example - eyes slow to left, quick to right**
**Right nystagmus, but left ear affected**
78
A patient presents with complaints of difficulty reading approaching street signs while ambulating. The therapist should test for:
A.VOR dysfunction
B.Positional vertigo
C.Dysmetria
D.Pupillary reflex
A: Correct
B: Yes, but why would this person have a problem – spinning, or tilting the head
C: Overshooting/undershooting – cerebellum dysfunction
D: No mention of light, Horner syndrome, MS
79
The Four NPTE Peripheral Vestibular Pathologies
* Benign Proximal Positional Vertigo (BPPV)
* Meniere’s Disease
* Unilateral Vestibular Hypofunction (UVH)
* Bilateral Vestibular Hypofunction (BVH)
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Benign Paroxysmal Positional Vertigo
* Canalithiasis
* Otoconia become dislodged and enter canals
* Change the density of the endolymph (green)
* Cupulolithiasis
* Otoconia break free and get stuck on Cupula
* The otoconia change the weight of the Cupula
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Benign Paroxysmal Positional Vertigo
Patient History and Symptoms
* Patient history
* Idiopathic onset or head injury
* Positional related vertigo
* Arising from bed
* Shampooing hair – Shower
* Symptoms
**•Vertigo (lasts for up to 60 seconds if canalithiasis)**
* Nystagmus
* Disequilibrium
Emesis is not typical\*
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Meniere’s Disease
* What is this condition?
* Abnormal accumulation of endolymph in the vestibular system which alters the pressure and volume within the closed system.
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Meniere’s Disease
Patient history
* Patient history
* 40-60 year old females
* Multifactorial Etiology
* Symptoms
* Vertigo (lasts for 30 mins to 24+ hours)
* Unilateral hearing loss
* Tinnitus
* Sensation of fullness
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A patient is being tested for horizontal BPPV by using the roll test. During the assessment, strong geotropic nystagmus is observed while the head is rotated to the right. Which of the following conditions is the MOST likely present?
A.Left horizontal cupulolithiasis
B.Right horizontal cupulolithiasis
C.Left horizontal canalithiasis
D.Right horizontal canalithiasis
Canalithiasis – geotrophic – eyes beat down towards the ground (geo)
Cupulolithiasis – ageotrophic – eyes beat away from the ground
Head rotated to the right, than right is being tested.
**D.Right horizontal canalithiasis**
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Unilateral Vestibular Hypofunction (UVH) Disease
* What is this condition?
* Decreased functioning of the right or left vestibular system leading to asymmetrical signaling
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Unilateral Vestibular Hypofunction (UVH)
Patient History and S+S
* Patient history
* Occurs at any age
* Causes
* Viruses
* Trauma
* Vascular accidents
* Symptoms
**•Vertigo (that resolves in 3 to 7 days)**
* Not positional
* Nystagmus
* Disequilibrium
* Postural Instability
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Bilateral Vestibular Hypofunction (BVH) Disease
* What is this condition?
* Decreased functioning of both the right and left vestibular system.
THINK SYSTEMIC
* Patient history
* Causes
* Ototoxicity
* Gentamycin
* Streptomycin
* Meningitis
* Systemic infection
* Symptoms
**•Will not have vertigo**
* Disequilibrium
* Gait ataxia
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A patient with a left unilateral vestibular hypofunction is being assessed with the head shaking nystagmus test. After a round of twenty oscillations, the patient’s eye movements are assessed. Which of the following signs is the MOST expected:
A.Right beating nystagmus
B.Left beating nystagmus
C.Pendular nystagmus
D.Pure vertical nystagmus
A.Right beating nystagmus
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The Four NPTE Central Pathologies
* Cerebral Vascular Accident (CVA)
* Vertebral Basilar Artery Insufficiency (VBI)
* Multiple Sclerosis (MS)
* Wallenberg Syndrome (PICA)
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Cerebral Vascular Accident (CVA)
* Patient history
* 60+ years of age
* Hypertension, Thrombus
* Symptoms
**•Contralateral hemiparesis**
* Contralateral facial drooping/sensory loss
* Spasticity
* Motor planning/initiation deficits
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Vertebral Basilar Artery Insufficiency (VBI)
(5D's 3N's)
* Patient history
* 60+ year old
* Causes
* MVA, cervical spondylosis
**•Symptoms (5D's 3N's)**
* Dizziness
* Drop attacks
* Diplopia
* Dysphagia
* Dysarthria
**•Nystagmus (pure vertical)**
* Nausea & Vomiting
* Numbness/tingling
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Multiple Sclerosis
Patient history
40-60+ year old
Female
Autoimmune attack on CNS
Symptoms
**Spasticity (extensor tone)**
**Gait Ataxia (cerebellar lesions)**
**Heat intolerance**
**Nystagmus (pure vertical)**
Vertigo
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**Wallenberg Syndrome**
Lateral Medullary Stroke or PICA
Patient history
40-60+ year old
Female
Lateral Medullary Stroke
Symptoms
Vertigo
Nausea
**Hoarseness**
**Dysphagia**
**Impaired sensation on _ipsilateral face_**
**Contralateral Hemiparesis**
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A patient is referred to physical therapy for intermittent flare-ups of persistent vertigo and nystagmus that seem to resolve over a period of weeks. Which diagnosis is the MOST likely the cause of the observed findings:
A.Traumatic brain injury
B.Relapsing-remitting multiple sclerosis
C.BPPV
D.Rheumatoid arthritis
A: No ntermittent flare-up
**B: Central NS so more persistent vertigo**
C: Has intermittent flare-up – not persistent vertigo and nystagmus
D: Tends to be bilateral and BVH
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Dix-Hallpike
WHICH SIDE SHOULD BE TESTED FIRST?
Examine Involved side FIRST
Examines
•Anterior/Posterior SCC function
Procedure
* Patient is long sitting with head rotated 45 degrees to suspected side
* Patient is brought into supine with head extended 30 degrees while maintaining the 45 deg rotation
Interpretation
* Presence of nystagmus and vertigo is indicative of posterior SCC dysfunction
* Ear side down is the tested side
STEPS
Step 1: The patient is placed into long sitting on a table with head rotated 45 degrees to the suspected side
Step 2: The patient is moved from the long sitting position with head rotated 45 degrees, to supine with the head extended 30 degrees beyond horizontal with the head maintained at 45 degrees rotation.
Step 3: This position is held while the therapist looks for nystagmus and/or reports of vertigo.
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Head Impulse Test (Head Thrust)
LOOKING FOR UVH
* What does it examine:
* Horizontal SCC function
* Procedure:
* Patient head is flexed to 30 degrees
* Head is rotated rapidly into an unpredictable direction
* Interpretation:
* UVH is present when head is rotated and eyes cannot remain on target
Positive for UVH – Problem is on the side that is being rotated to
STEPS
Step 1: Have the patient fixate on the clinician’s nose
Step 2: When testing the horizontal SCC, the head is flexed 30°. Patients are asked to keep their eyes focused on a target while their head is manually rotated in an unpredictable direction using a small-amplitude (5° to 15°), moderate-velocity (approximately 200°/sec) rotation.
Provides reliable insight when one side of the vestibular system has a complete loss of functioning.
Want to check out this exam? Go here: https://vimeo.com/164992889
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BBQ Roll Test
* What does it examine:
* Horizontal SCC function
* Procedure
* Patient is supine and head is flexed to 20 degrees
* Head is rotated rapidly to both sides
* Interpretation
* Presence of nystagmus and vertigo is indicative of horizontal SCC dysfunction to the side opposite of the fast beating nystagmus
STEPS
Step 1: The patient is positioned supine with the head flexed 20°.
Step 2: Rapid rotations to the sides are done separately and the clinician observes for nystagmus and vertigo.
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Head Shaking Nystagmus Test
* What does it examine:
* Horizontal SCC function
* Procedure
* Patient is seated with eyes closed
* Clinician manually rotates patient’s at 2Hz, for 20 cycles
* Patient opens eyes after 20 cycles and eyes are assessed.
* Interpretation
* Presence of nystagmus and vertigo is indicative of horizontal SCC dysfunction to the side opposite of the fast beating nystagmus
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Differential Chart for Central and Peripheral
100
A patient with intermittent vertigo is being evaluated. The therapist suspects right canalithiasis. Which of the following should be performed to rule in this diagnosis:
A.Dix-Hallpike with right rotation first
B.Epley’s Maneuver with right rotation first
C.Dix-Hallpike with left rotation first
D.Epley’s Maneuver with left rotation first
Epley’s is a treatment
A: Correct
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Epley’s Manuever
* Epley’s Manuever (CRM)
* To treat canalithiasis
* The patient’s head is moved into different positions in a sequence that will move the debris out of the involved SCC and into the vestibule
•
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Brandt-Daroff Exercises
* Used to treat canalithiasis or cupulolithiasis
* The patient’s head is rotated to 45 degrees while sitting at edge of bed, the patient quickly lies down to the side opposite of the rotation.
* This is repeated 5-10 times, 3x a day
HEP
Habituation for Vertigo
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Liberatory-Semont Exercises
Liberatory - to LIBERATE
* **#1 treatment for cupulolithiasis** but can treat canalithiasis
* The patient’s head is rotated to 45 degrees while sitting at edge of bed, the patient quickly lies down to the side opposite of the rotation x 1 minute. Then quickly moved to lying down on the opposite shoulder with the head kept in the same position throughout.
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A physical therapist is treating a patient with an acute right-sided cupulolithiasis. Which of the following interventions is the MOST indicated:
A.Liberatory-Semont Maneuver
B.Canalith Repositioning Maneuver
C.Epley’s Maneuver
D.Rinne’s Test
A.Liberatory-Semont Maneuver
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Gaze Stability
| (VOR)
* Training / adaptation training to improve the patients to maintain a target in focus and disallow blurring of the target
* VOR x1
* Move the head horizontal or vertically while maintaining focus on an object
* VOR x2
* Move the head and target in opposing directions while maintain gaze on target and target in focus
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A physical therapist is working with a patient who has a right vestibular hypofunction and a chief complaint of vertigo. When creating the plan of care: , what should be the PRIMARY focus
A.Improving somatosensory compensation
B.Habituation training
C.VOR training
D.Dix-hallpike maneuver
A: Would want this, but doesn’t address primary complaint - vertigo
**B: DOES ADDRESS**
C: doesn’t address primary complaint - vertigo
D: Assessment, not treatment
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Vestibular Rehab Precautions & Contraindications
* Unstable vestibular disorders (C)
* Meniere’s Disease
* Fluid draining from the ears or nose
* Uncontrolled migraine
* Undiagnosed vestibular disorders or conditions (C)
* Sudden onset of hearing loss
* Onset of fullness in ear to the point of discomfort
* Severe ringing in the ear (tinnitus)
* Acute neck injuries (P)
•
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A patient with frequent falls and sensorineural hearing loss was recently assessed using the foam and dome test. The patient demonstrated increased postural sway during conditions 5 and 6. Which intervention would BEST improve the patient’s balance?
A.Eyes closed, on foam in tandem stance
B.Walking on foam in a dimly lit environment
C.Eyes open on foam with tandem stance
D.Epley’s Maneuver
Know
Can We Infer
What can’t we assume?
A: NO, using vestib
B: Relying on Vestib
C: OKAY
D: NO, doesn’t address anything related to question
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Glascow Coma Scale
