AdultNeuroExam1

• MD specializes in physical medicine and rehab
• initiates rehab program and coordinates the work of health care team
• orders meds, braces, wheelchairs

• teaching patients to be independent as possible
• evals, treatments
• bed mobility, transfers, operating ADs
• may teach patients to walk again

• reach max level of physical and psychosocial function to live independently
• teach ADLs
• improve strength in UE

• evals for communication problems
• work to improve communication skills

• evaluates intellect, personality
• evaluates cognition-thinking, perception, memory, emotions

• initiates involvement and participation in therapeutic recreational programs
• patient becomes more socially involved

assess breathing status

• patient and family advocate
• provides educational material concerning discharging
• assistance in financials

• provides 24 hour care
• keeps physicians informed of patients status
• works on self-care, bowels, healthy skin

• determines each patients unique needs
• monitors nutritional status
• teaches healthy eating behaviors for later

• provides clinical coordination for all services provided to patient
• acts as liason between patient and family, insurance company and professional team

• complete independence
• performed safely

• modified independence
• requires more than 1 of these: AD, more time, or safety issues

• supervision or setup
• no more help than standby cuing or coaxing
• needs help with supplies-braces, orthotics etc

• minimal contact assistance
• patient does 75% of work

• moderate assistance
• patient is able to do 50% -75% of work

• maximal assistance
• patient does less than 50% of work

• total assistance
• patient does less than 25% of work

• left side paralysis
• spatial-perceptual deficits
• quick impulsive behavior
• memory deficit

• right side paralysis
• speech language deficits
• slow cautious behavior
• memory deficits

disruption of blood supply to an area of the brain resulting in neurologic impairment

• HTN
• diabetes
• hereditary
• males more susceptible
• obesity
• heart disease
• age

• onset of weakness or numbness in face, arm, leg or side of body
• loss of vision
• loss of speech
• severe headaches
• unexplained dizziness, unsteadiness, or falls

results from thrombosis and emboli formation in cerebral vessels

most common form

• onset is gradual-periods of improvement
• occurs in vessels already narrowed

• sudden onsent-no warning
• main source is heart
• 80% lodge in middle cerebral a.
• 11% lodge in posterior cerebral artery

80% recur

• infarcts in deep regions of brain
• pure motor-contralateral internal capsule
• pure sensory-contralateral thalamus
• ataxic hemiparesis-contralateral internal capsule or basis pontis
• dysarthria and clumsy hand with hemiataxia (contralateral internal capsule or basis pontis)

cause:uncontrolled HTN

intracerebral bleeds which occur abruptly with few or no symptoms

• penetrating artery from MCA
• displaces and compresses surrounding brain tissue
• edema formation from compressed tissue
• once bleeding stops normally doesnt rebleed

• circular clots in subcortical white matter
• causes: AVM, hemorrhage into tumor, aneurysm of circle of willis

most common cause of subarachnoid hemorrhage

• 2nd most common cause of subarachnoid hemorrhage
• occurs more in males

• developmental defect causing weakness in tunica media
• outpouching

• atherosclerotic hypertensive changes causing weakness of the tunica media
• occurs mostly in vessels of circle of willis

• developmental defects of cerebral veins and capillaries
• abnormal vessels become engorged and their thin walls are vulnerable to rupture
• bleeding occurs in subarachnoids space
• increased ICP and meningeal irritation

TRUE

increased ICP and cerebral edema

deficits minimal or temporary

if not permanent damage may occur

parietooccipital cortex

left hemisphere

shouting= shorter more concise sentences =easier to understand

• communication disorder caused by brain damage
• impaired language comprehension, formulation and use
• does include writing

aka Warnicke's/receptive/sensory

impaired comprehension, naming, reading, writing

aka Broca's/expressive/motor

speech is slow, poorly articulated, hesitant with limited vocab

good comprehension, reading

poor writing

• all aspects of language affected
• unable to speak, comprehend, write, read

• impaired speech due to damange to PNS or CNS
• causes weakness, paralysis, or incoordination of motor-speech system

• swallowing dysfunction
• imparied oral muscle activity

negative, anxious, hesitant, and depressed, cautious, insecure, uncertain

impulsive, poor awareness of deficits, poor judgement of own abilities, uncooperative, unmotivated, overly dependent, confused

• judge distances, size, shapes
• common in R CVA

• examples: hitting walls in w/c
• confusing inside/outside of clothes
• shave part of face

• treatment: OT/speech, psychology referral
• cues for safety

• lose emotional control
• laughing to crying for no reason

treatment: redirect or distract

• emotional responses following decreased sensory input
• visual impairments
• worse at night (sundowning)

treatment: balance between increased sensory stim and not enough

faulty judgements, poor memory, mood alterations

• change in personality or social behavior
• example: say wrong thing at wrong time
• spend impulsively

treatment: provide more cues, feedback and information

• perception stored at earlier time that can be brought forward
• due to language (L CVA)
• due to spatial-perceptual probs (R CVA)

treatment: consistent routine and environment

• rehersal
• elaborating-pt works on details and relate to what they already know
• visual imagery
• self-reference-how info relates to them

• cues: be specific
• memory notebook
• alarms/watches
• labels: color coding

generalization-once skill remembered practice in multiple settings

retention span-how many pieces of info remembered

active process that determines which sensations and experiences are relevant to the individual

maintain attention to taks

screen and process relevant info while screening out irrelevant info

perform two tasks at same time

example walking and talking

go back and forth between two different tasks

• nondistracting environment
• structured environment
• keep it simple

determine what may need or want and how to achieve may lackk foresight and attention to achieve after a CVA

treatment: control amount of feedback and structure

• experiences and behavior is interpreted by pt at most obvious value
• linked with memory problems

• stories or words that are used to fill in gaps in memory
• patient believes they are true

• due to psychological reaction to loss
• occurs in 1/3 of all cases

normally R side

postural model of body including relationship of parts to each other and relationship of body to environment

(autotopagnosia)

• mental image of one's body: includes feelings about one's body
• -also may result in person having lack of awareness of one side of body despite intact sensation

inability to recognize sensory stimuli

inability to recognize objects when seen but can recognize when touched

• (asterognosis)
• parietal lobe
• inability to recognize objects by touch , but can recognize visually

inability to recognize sounds

when asked to lock right brake on w/c patient cannot find it despite repeated attempts and looking general area

when asked to lock left brake on w/c patient initially makes no attempt

when asked to use right hand does not reach midline and does not look left without visual and tactile cues

• strong lean toward hemi side
• high fall risk
• resist midline
• more common with R CVA
• poor/absent tactile and kinesthetic sense

• cannot perceive one side of body
• usually in R CVA
• may be independent of visual deficits
• diminshed sensation of side
• parietal lobe lesion on nondominant side

• activities to stimulate affected side
• rubs or ranges affected side
• do activities that force patient to look at that side
• bilateral activities

• light touch
• sharp/dull
• temperature
• pressure

• movement sense
• position sense

inattention to visual stimuli on involved side

increased sensitivity to sensation

decreased sensitivity to sensation

loss of feeling or sensation

unpleasant or abnormal sesnation produced by normal stimuli

abnormal sensation: burning, prickling, formication

excessive sensitivity to pain

decreased sensitivity to pain

absence of sense of pain and noxious stim

• UE usually more affected than LE
• distal more than proximal
• changes in motor unit
• changes in muscle

• decreased AROM due to decreased strength
• decreased ROM due to contractures, increased muscle tone

• lack of resistance to movement
• present immediately after stroke

• increased above normal resting levels
• ROM limited
• mmt requires effort
• deformities results

• disordered tone
• repetitive involuntary movements
• basal ganglia lesions

• increased resistance to passive stretch
• in anti-gravity muscles
• leads to contractures

• scapular retractors
• shoulder adductors
• internal rotators
• depressors
• elbow flexors
• forearm pronators
• wrist and finger flexors

• pelvic retractors
• hip adductors
• internal rotators
• hip and knee extensors
• ankle PF
• ankle supinators
• toe flexors

• limited group of muscles that
• 1. act as unit
• 2.may be activated reflexively or voluntarily
• 3. individual or isolated joint movements are possible

• retraction/elevation of shoulder
• Abduction of shoulder to 90d
• ER of shoulder
• flexion of elbow to 90d
• full supination of forearm
• wrist/finger flex

• dominant synergy in UE
• elbow flexion strongest component 1st to return
• abd/ER weakest components last to return

• protraction and/or depression of shoulder girdle
• adduction of UE in front of body
• IR of shoulder
• full extension of elbow
• full pronation of forearm
• extended wrist with flexed fingers

• weaker UE synergy
• adduction/IR strongest components

• usually combo of 2 synergies
• strongest components of each appear:
• elbow flexion
• add/IR of shoulder
• pronation of forearm
• may see wrist ext
• usually see wrist flex

• abd/ER of hip
• flexion of hip
• flexion of knee to 90d
• DF and inversion of ankle
• DF(ext) of toes

• weakest synergy of LE
• hip flexion strongest component
• DF strong but only activated with hip flex
• abd/ER are weak
• knee flex weakest

• add/IR of hip
• ext of hip
• ext of knees
• PF and inversion of ankle
• PF of toes. sometimes ext of great toe

• dominates in LE
• knee ext strongest
• hip add strong
• hip ext weakest
• knee ext brings ankle pf/inversion

no increase in muscle tone

slight increase in muscle tone manifested by catch and release or by minimal resistance at the end of the ROM when the affected part is moved in flexion or extension

slight increase in muscle tone, manifested by catch followed by minimal resistance throughout the remainder of the ROM

more marked increase in muscle tone throught most of the ROM but affected parts easily moved

considerable increase in muscle tone; passive movement difficult

affected part rigid in flexion or extension

• reflex stim due to yawn, cough, sneeze, stretch
• involuntary limb mmt to due to voluntary mmt of another extremity

Flexion of UNINVOLVED UE evokes flexion of INVOLVED UE

extension of UNINVOLVED Ue evokes extension of INVOLVED UE

flexion of UNINVOLVED side evokes EXTENSION of INVOLVED side

extension of UNINVOLVED side evokes FLEXION of INVOLVED side

resistance to ABDUCTION in UNINVOLVED sides elicits ABDUCTION of INVOLVED side

resistance to ADDUCTION in UNINVOLVED side elicits ADDUCTION in INVOLVED side

flexion of hemiplegic UE elicits flexion of hemiplegic LE

inability to carry out purposeful movements despite lack of motor, sensory, cognitive or behavioral deficits

• provide proprioceptive feedback and tactile input
• brief verbal commands
• perform activities in as nearly normal an environment as possible
• have pt visualize task
• provide support

reacting to destabilizing external force

self-initiated movements

• unable to:
• maintain sitting
• maintain standing
• move in WB posture

most of weight in sitting or standing shifted to nonparetic side

proximal muscles activated in advance of distal or proximal muscles to be activated late

• compensate with excessive hip and knee mmts
• usually fall in direction of weakness

• bladder hyperreflexia or hyporeflexia
• sensory loss
• loss of sphincter control
• UTI

• diarrhea
• constipation

• increase risk esp in acute stage
• venous stasis from bed rest, paralysis and decreased activity

signs: rapid leg swelling, tight feeling in calf, pain with passive DF

flexibility of CT is lost

UE: limitations in shoulder motion, elbow flexors, wrist and finger flexors, pronators

LE:plantarflexors and hamstrings

• proprioceptive impairment
• decreased muscle tone
• muscle paralysis decrease support and action of rotator cuff muscles
• ligaments and capsule become sole support for shoulder
• humerus subluxes

• abnormal tone leads to poor scapular position which leads to subluxation and restricted movement
• poor positioning contributes
• PROM may traumatize the shoulder
• also injured by pulling on arm during transfer

• paralysis of one side of thorax= decreased lung capacity
• clients with hemiplegia use 50% more O2 walking slowly than by subjects without hemiplegia
• increased O2 demand due to atypical mmt patterns

• bed mobility
• transfers
• ambulation
• ADLs and functional tasks
• w/c mobility and management
• stair ambulation
• sit to stand

• loss of muscular coordination
• associated with cerebellar stroke

• uneven step length
• irregular step width
• even more tremoring with increased effort

• postural stability
• slow weight shifts
• PNF

• weak point in blood vessel in brain
• artery bulges outward and fills with blood

• trauma
• infection
• hardening of arteries
• congenital (most common)

• enlarged pupil
• drooping eyelid
• pain behind 1 eye
• localized headache (worst of my life)
• gait problems
• visual disturbances
• numbness to face

• prior to rupture :
• may do nothing depending on location and surgical risks
• may clip it or remove it

• abnormal collection of blood vessels
• lack the tiny capillaries
• blood does not go to tissues but is pumped thru the shunt and back to heart without ever giving nutrients to tissues

cause: congential

rupture

headache, seizures, dizziness, neuro symptoms

prior to rupture:worst headache ever

• plugging the blood vessels of AVM
• catheter is guided from femoral artery in the leg up into the area to be treated

they push toward their hemi side

• -Unable to sit up/ fall to hemiplegic side
• –Fail to use axial or trunk muscles
• –do not resist correction

tendency to fall sideways


–Cerebellar and Brain Stem lesions: (Wallenberg’s Syndrome)

–Tilt of visual vertical = vision aligns improperly with environment

–Deviate ipsilaterally = toward brain lesion

–do not resist correction or push with nonparetic side

–Lose balance due to hemiparesis and fall to hemi side but:

• •Recognize
• loss of balance

• •do
• not resist correction

• •Cling
• onto something with non-paretic hand to prevent fall

tilt of visual vertical without pushing behavior

• neglect: R sided problem
• 40-50% of all pushers are L CVA

thalamus

insula and post central gyrus

• process the afferent sensory signals that mediate graviceptive information about upright body
• orientation in humans

sensory from skin and tendons

•Afferents from kidneys via renal nerve

• •Posterior Thalamus, Insula, and postcentral gyrus may represent structures which
• provide afferent info from truncal sensors

Stim Vagus nerve = activates these structures

lesions of vestibular cortex DO NOT cause contraversive pushing

Head rotated and laterally flexed to right

-Left shoulder, thorax and pelvis retracted

-Left lower extremity laterally rotated

-Abduct and extend limbs on non-paretic side when at rest or when changing positions

-Can visually identify objects that are vertically aligned

• there are treatment techniques
• when it subsides in 1 side it doesnt mean it starts on other side

• visual input that corresponds to
• reality!
• Midline orientation/ weight shift =
• learn movements needed to reach midline
• –Strength
• –Balance
• –Gait
• –Transfers
• –Bed Mobility
• –Endurance
• -weight shift activities

• draw patients attention to problems
• -use vision
• -vestibular system-allow them to safely lose balance

• encourage them to use correct posture
• shifting weight
• use vision to align up
• reaching to nonparetic side

• internalize newly learned compensation
• perform other tasks while maintaining posture