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Peripheral Nervous System
- Efferent fibers: anterior root carying MOTOR info AWAY from CNS
- Afferent fibers: posterior root carrying SENSATION info TO CNS
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Autonomic Nervous System
- Sympathetic: prepares body for emergency response, norepinephrine, stimulating response
- Parasympathetic: conserves/restores energy, acetylcholine, inhibitory response
- impulses often unconcious
- controls BP, HR, RR, body temp, digestion, metabolism, electrolyte balance
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Somatic Nervous System
- motor nerve fibers send info directly to skeletal muscle wihtout intervening synapses
- controls voluntary movements and all five senses
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Limbic system
- control and expresses mood/emotion
- processes and stores recent memory
- control olfaction and appetite
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General Hemisphere Descriptions
- Left: language, analytical, logical, rational, sequence, language comprehension, express positive emotion
- Right: nonverbal response, hand-eye coordination, kinesthetic awareness, music, body image awareness, express negative emotions
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Hippocampus
- lower temporal lobe
- forms and stores new memories (personal & declarative)
- memory indexer for long term storage
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Basal ganglia
- white matter of cerebrum
- caudate, puatmen, globus pallidus, substantia nigra, subthalamic nuclei
- voluntary movement, regulation of autonomic movement, posture, muscle tone, motor response control
- Parkinson's, Huntingtons, Tourettes, ADD, OCD
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Amygdala
- Temporal Lobe
- emotional and social processing
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Thalamus
- relay or processing station- sensory & movement with other parts of brain and SC
- can cause thalamic pain syndrome (spontaneous pain on contralateral side
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Hypothalamus
- receives and integrates info from ANS & assists hormones
- hunger, thirst, sexual behavior, body temp, adrenal & pituitary gland
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Subthalamus
- regulates movements produced by skeletal muscles
- associates with basal ganglia & substantia nigra
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Epithalamus
- Secretes melatonin
- circadian rhythm and internal clock
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Midbrain
- includes tectum and tegmentum
- relays info passing from cerebrum, cerebellum and SC
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Cerebellum
- Fine tunes movements and assists with posture
- rapid alternating movements
- muscle tone
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Pons
- regulates RR
- orients head to visual and auditory info
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Medulla Oblongata
influences ANS and regulates RR and HR
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Typical Problems with Specific Lobe Damage
- Frontal: paralysis and apraxia to loss of executive functions and goal directed behaviors, Broca's area
- Parietal: sensory awareness, interpretation, perception, abnormal movement patterns
- Temporal: short and long term memory, Wernickes, require more demonstrations for therapy
- Occipital: cortical blindness will affect pt's ability to receive but not perceive visual info
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Blood Supply to Brain and Main impairmetnts
- Anterior Cerebral Artery: paraplegia, incontinence, aphasia, personality changes, apraxia & agraphia, neglect
- Middle Cerebral Artery (most common): contralateral hemiplegia & sensory impairment, Wernickes or Brocas aphasia, impairments are lobe dependent
- Posterior Cerebral Artery: thalamic pain syndrome and cortical blindness
- Vertebral-Basilar Artery: locked in syndrome, coma, vegetative state
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Meninges of SC
- dura mater: outer most meninge
- arachnoid: middle meninge, surrounds the brain
- pia mater: inner most meninge, covers contour of brain
- Meningitis: inflammation of meninges, fever, headache, vomitting, stiff and painful neck, Brudzinski's sign, Kernig's sign
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Hydrocephalus
- increase of CSF (which provides nutrients to CNS)
- spina bifida, choroid plexus, neoplasm, CP, tumor, meningitis, encephalocele
- signs of hydrocephalus or blocked shunt: headache, vision change, large veins on scalp, seizures, vomitting, sunsetting
- BLOCKED SHUNT = MEDICAL EMERGENCY
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Ascending (sensory) tracts
- Fasiculus cuneatus & gracilis (posterior & dorsal column): proprioception, vibration, 2 point discrimination, graphesthesia
- Spinocerebellar tract (dorsal and ventral): joint sense, trunk & LE posture, tension in muscles
- Spino-olivary tract: cutaneous and proprioceptive organs
- Spinoreticular tract: reticular formation that influences level of conciousness
- Spinotectal tract: spinovisual reflexes, eye movements & head orientation to stimuli
- Anterior Spinothalamic: light touch and pressure
- Lateral Spinothalamic: pain and temperature
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Descending (motor) tracts
- Corticospinal anterior: ipsilateral voluntary, discrete, skilled movement
- Corticospinal lateral: contralateral voluntary, discrete, silled, movement
- Reticulospinal: voluntary and reflex activity through alpha and gamma motor neurons
- Rubrospinal: gross postural tone, facilitating flexors, inhibiting extensors
- Tectospinal: contralateral postural muscle tone
- Vestibulospinal: gross postural adjustments after head movement, facilitate extensors, inhibit flexors
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Peripheral Nerve Classification (A, B, C)
- A fibers: large & myelinated so high conduction rate- alpha (motor, Golgi organs), beta (touch, kinesthesia), gamma (touch, pressure), delta (pain, touch, pressure, temp)
- B Fibers: medium & myelinated- fibers of ANS
- C Fibers: small & poorly myelinated- pain, temp & touch
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Cranial Nerves
- I Olfactory: smell
- II Optic: sight
- III Oculomotor: eye movement
- IV Trochlear: eye movement
- V Trigeminal: face sensation, jaw movement
- VI Abducens: lateral eye movement
- VII Facial: face muscles, taste
- VIII Vestibulocochlear: hearing and balance
- IX Glossopharyngeal: taste, gag reflex, swallow
- X Vagus: taste, gag, swallow, Ahh
- XI Accesory: SCM and Trap
- XII Hypoglossal: tongue movement
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Superficial Reflexes
- abdominal reflex: T8-L1, abdominal contraction after touching umbilicus
- corneal reflex: trigeminal and facial nerves, both eyes will blink when touch 1 with a cotton swab
- cremasteric reflex: L1-L2, scratch medial thigh and ipsilateral testicle will elevate
- gag reflex: glossopharyngeal and vagus nerve, stimulate back of throat and will gag
- plantar reflex: L5-S1, stroke lateral aspect of sole of foot and should get flexion (if you don't = +Babinski sign)
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Deep Tendon Reflexes
- Biceps Tendon: C5-C6
- Brachioradialis tendon: C5-C6, over radius 2 inches superior to wrist
- Triceps tendon: C6-C7
- Patellar tendon: L3-L4
- Achilles tendon: S1-S2
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Reflex grading
- 0: no response
- 1+: diminshed
- 2+: normal
- 3+: exaggerated
- 4+: hyperactive
- (same grading for measuring pulse)
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Different sensation (superficial, deep, cortical)
- Superficial: temp, light touch, pain
- Deep: proprioception, kinesthesia, vibration
- Cortical: stereognosis, 2 point discrimination, barognosis, localization of touch
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Sensation Terms
- graphesthesia: identify # or letter drawn on skin
- kinesthesia: identify direction and extent of movement
- proprioception: identify static position of extremity
- stereognosis: identify object without sight
- barognosis: perceive with of objects
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Peripheral Nerve Lesions
- double crush: 2 seperate lesions on same nerve
- mononeuropathy: isolated nerve lesion
- neuroma: abnormal growth of nerve cells
- peripheral neuropathy: dysfunction of peripheral nerves
- polyneuropathy: symmetrical diffuse nerve dysfunction (Guillain Barre)
- wallerian degeneration: degeneration occurring distally to myelin sheath and axon
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Classification of nerve injuries (neurotmesis, neurapraxia, axonotmesis)
- Neuropraxia: mildest form, nerve fibers aren't damaged, symptoms are muscle atrophy/ numbness/ motor loss/ sensory dysfunction/ diminished proprioception-- complete recovery in 4-6 weeks
- Axonotmesis: more severe, reversible damage to axons, nerve can regenerate distal to lesion at 1 mm per day, distal wallerian degeneration can occur, recovery is spontaneous and spotty
- Neurotmesis: most severe, irreverible damage, flaccid paralysis and muscle wasting, all motor/sensory lost distal to lesion permanently
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UMN vs LMN lesions (S/S)
- UMN: hyperactive reflexes, mild atrophy from disuse, absent fasiculations (spontaneous contraction under the skin that may be visible), hypertonicity
- LMN: diminshed reflexes, atrophy, fasiculations present, hypotonicity
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UMN & LMN examples
- UMN: (within cerebral motor cortex, internal capsule, brainstem, SC) CP, hydrocephalus, ALS, CVA, MS, huntington's, TBI, brain tumor
- LMN: (below level of brainstem) poliomyelitis, ALS, guillain-barre, SC tumors, trauma, progressive muscular atrophy, Bell's palsy, carpal tunnel, SMA
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Involuntary movement disorders (tremors, tics, dystonia, athetosis)
- Tremors: rhythmic, oscillatory movements, can have resting (Parkinsons) /postural (hyperthyroidism) /intention (MS) tremors
- Tics: brief, repetitive coordinated movements, irregular intervals-- Tourettes
- Chorea: brief, rapid, irregular contractions -- Huntingtons
- Dystonia: sustained muscle contraction causing twisting, abnormal postures, repetitive movements -- Parkinsons, CP, encephalitis
- Athetosis: slow, twisting and writhing movements, large in amplitude, brief = choreoathetosis, sustained = merge w/ dystonia -- CP, basal ganglia pathology
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Movement Impairment Terminology
- akinesia: inability to initiate movement
- asthenia: general weakness
- ataxia: inability to perform coordinated movements
- athetosis: involuntary movements combined with instability of posture
- chorea: sudden, random, involuntary movements
- clonus: UMN lesion, spastic contraction elicited by quick stretch reflex
- cogwheel rigidity: resistance to movement with phasic quality -- Parkinsons
- lead pipe rigidity: uniform and constant rigidity through ROM-- basal ganglia lesion
- dysdiadochokinesea: rapid, alternating movements
- dysmetria: inability to control range of movement
- fasiculation: muscle twitch, suggesting LMN
- kinesthesia: inability to perceive direction/extent of movement
- tremor: involuntary, rhythmic, oscillatory movement
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Automatic Postural Strategies
- 1st: ankle
- 2nd: hip
- suspensory: lower COG (squat, knee flexion)
- stepping: regain new BOS
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Peripheral vs. central vertigo
- peripheral: episodic/short, autonomic symptoms, pallor, N/V, auditory fullness, tinnitus -- BPPV, menieres, infection, DM, alcohol
- central: autonomic symptoms less severe, loss of consciousness, diploplia, hemianopsia, weakness, numbness, ataxia, dysarthria -- meningitis, migraine, cerebellar degeneration, MS
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Benign paroxysmal positional vertigo
- peripheral
- episodes of vertigo that occur after change in head position
- otoconia loosens and travels into the posterior semicircular canal
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Balance Outcome Measures
- Berg Balance: risk for falling, 14 tasks, 56 max score, 45 increased risk of falling
- Fregley-Graybiel Ataxia Test Battery: 8 test conditions, assess and treat balance dysfunction
- Fugl Meyer Sensorimotor Assessment of Balance: assess balance for hemiplegia, 14 max score
- Functional Reach Test: standing balance & risk for fall, 20-40yo normal is 14.5-17 inches
- Romberg Test: balance and ataxia
- Timed Up and Go: mobility and balance, walk 10 ft & sit to stands, 10 seconds independent, 30 seconds high risk for fall
- Tinetti: increased risk for fall, assessing components of gait and sit to stands, max score 28, high risk for fall 19
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Fluent vs. Non-fluent Aphasia
- Fluent Aphasia (Wernickes): aka receptive aphasia, don't really understand what they are hearing/reading and then just babble, are able to talk but have no real substance to what they are saying
- Non-Fluent Aphasia (Brocas): aka expressive aphasia, can understand everything, but impaired with motor ability and have difficulty speaking
- Verbal Aphasia: unable to initiate articulation of speech even though they understand task
- Dysarthria: UMN lesion, speech is slurred
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Neuromuscular Pharmacology Management
- Antiepileptics: reduce or eliminate seizures
- AntispasticityL promote relaxation
- Cholinergic Agents: mimics acetylcholine and binds to cholinergic receptor to create response at cellular level
- Dopamine Replacement Agent (levadopa): relieve symptoms of parkinsons- can cause arrhythmias, hypotension, dyskinesias, want pts to take an hour before PTMuscle Relaxant Agent: promote relaxation in muscles
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Alzheimers
- progressive deterioration and irreversible damage to cerebral cortex and subcortical areas
- S/S: difficulty learning new and subtle changes, loss or orientation, word finding difficulty, depression, rigidity, poor judgement, shuffling ggait
- no cure
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Amyotrophic Lateral Sclerosis
- chronic degenerative disease
- UMN and LMN impairments
- demyelination oof corticospinal and corticobulbar tracts
- symptoms vary based off initial lesion
- S/S: asymmetrical muscle weakness (spreads distal to proximal), fasiculations, cramping, hand atrophy, movement incoordination, spasticity, clonus, positive babinski
- later on focus on quality of life and caregiver training
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Bell's Palsy
- temporary unilateral facial paralysis
- demyelination or axonal degeneration of facial nerve
- S/S: assymetrical facial appearance, eye drooping, eye dryness, inability to close eyelid
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Carpal Tunnel
- compression of median nerve in carpal tunnel
- etiology: repetitive use, RA, pregnancy, DM, hypothyroidism, wrist sprain
- S/S: sensory change and parasthesia
- treatment: splinting, ergonomic measures, corticosteroid injections
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Cerebellar Disorders
- Congenital malformation
- Hereditary ataxia: friedreichs ataxia
- spinocerebellar ataxia
- acquired ataxia
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Diabetic Neuropathy
- nerve ischemia from microvascular disease from hyperglycemia on neurons
- S/S: weakness and sensory distributions occur distally in symmetrical pattern
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Epilepsy
- chronic conduction causing dysfunction of brain resulting in seizures
- want to time seizures, if greater than 5 minutes CALL 911
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Guillain Barre Syndrome
- acute polyneuropathhy
- temporary inflammation and demyelination of peripheral nerves' myelin sheaths
- motor weakness in distal to proximal progression
- sensory impairment and possible respiratory paralysis
- peaks within 2-4 weeks of onset
- can be life threatening with respiratory impairment
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Huntington's Disease
- degeneration and atrophy of basal ganglia and cerebral cortex
- autosomal dominant- doesn't show up till 35-55 yo
- movement disorder the includes affective dysfunction and cognitive impairments
- involuntary choreic movements, mild personality alteration, grimacing, protrusion of tongue, ataxia
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Multiple Sclerosis
- patches of demyelination of myelin sheaths in brain and SC decreasing nerve impulse transmission
- S/S: visual problems, paresthesia, sensory change, clumsiness, weakness, ataxia, balance dysfunction, fatigue
- have exacerbations and remissions
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Myasthenia Gravis
- autoimmune disease affecting transmission of nerve impulses at neuromuscular junction
- antibodies block receptors for acetycholine uptake preventing muscle contraction
- DM, RA, lupus
- S/S: extreme fatiguability and muscle weakness, dysphagia, dysarthria
- can be a medical emergency if have sudden respiratory difficulty, swallowing issues, or labored talking- need anticholinesterase
- typically on long term corticosteroids (can cause secondary osteoporosis and muscle wasting)
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Parkinson's Disease
- decrease in dopamine from basal ganglia
- S/S: resting tremor, festinating gait (shuffling), akinesia, cogwheel or leadpipe rigidity, freezing, mask like appearance of face
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Post Polio Syndrome
- LMN pathology affecting anterior horn cells previously affected by polio, compensated reinnervation fails and results in ongoing muscle denervation
- S/S: slow and progressive weakness, fatigue, muscle atrophy, pain, swallowing issues
- emphasize lifestyle modification, adaptive equipment, functional independence
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Left hemisphere CVA characteristics
weakness, R side paralysis, increased frustration, decreased processing, possible aphasia and dysphagia, possible motor apraxia, decreased discrimination, right hemianopsia
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Right hemisphere CVA characteristics
- weakness
- L side paralysis
- decreased attention span
- left hemianopsia
- decreased awareness and judgement
- memory deficits
- decreased abstract reasoning
- impulsive behaviors
- decreased spatial orientation
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Brainstem CVA characteristics
- unstable vitals
- decreased conciousness
- decreased swallowing ability
- weakness/paralysis on both sides
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Cerebellum Characteristics
- decreased balance & coordination
- ataxia
- nausea
- nystagmus
- decreased ability for postural adjustment
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Synergy Patterns
- result when higher centers of brain lose control
- have flexor/abduction/supination and extensor/adduction/pronation synergy patterns of UE and LE
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Seven Stages of Recovery (synergy patterns)
- 1: no volitional movement initiated
- 2: basic limb synnergies, spasticity begins
- 3: synergies performed voluntarily, spasticity increases
- 4: spasticity decreases, movement outside synergy patterns
- 5: spasticity decreases, movement independent of synergy patterns
- 6: isolated joint movements with coordination
- 7: normal motor function
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Describe the three state model of motor learning
- Cognitive Stage: initial stage of learning where high concentration of conscious goes to processing the information- large amounts of errors with inconsistent performance
- Associative Stage: intermediate stage where the person is able to distinguish better what is correct vs. incorrect- decreased errors, skill refinement
- Autonomous Stage: improves efficiency of activity without great cognitive control- automatic stage, extrinsic feedback very limited
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Types of feedback
- intrinsic
- extrinsic
- knowledge of results
- knowledge of performance
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Types of practice
- massed
- distributed
- constant- task under uniform conditions
- variable- task under varied conditions
- random- different tasks
- blocked- practice single task
- whole training- entire task
- part training
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Different types of learning
- non-associative: single repeated stimulus (habituation)
- associative: understand relationship of 2 stimuli (classical/operant conditioning)
- procedural: learning tasks can be performed without attention- do it out of habit (repetitive practice)
- declarative: requires attention, awareness, and reflection to obtain knowledge (mental practice)
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Neuromuscular Developmental Treatment (NDT)
- patient should learn to control movement through activities that promote normal movement patterns that integrate function
- postural control can be learned, is initiated from base of sport, and required for skill development
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Brunnstrom Movement Therapy in Hemiplegia
- encouraged use of synergy patterns during rehab
- synergies are considered primitive patterns occuring at the spinal cord
- rarely used now because reinforced synergy patters are very difficult to change
- developed seven stages of recovery
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Levels of Motor Control
- Mobility: initiate movement through functional ROM
- Stability: maintain position through cocontraction and tonic holding
- Controlled Mobility: move within a weight bearing position or rotate around long axis (prone on elbows, quadruped)
- Skill: consistently perform functional tasks and manipulate environment w/ normal posture reflexes/reactions
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Rood (facilitation/inhibition techniques)
- believed all motor output was result of present and past sensory input
- goal is to obtain homeostais in motor output and activate muscle to perform a task independent of a stimulus
- once a response is obtained, the stimulus should be withdrawn
- facilitation techniques: approximation, joint compression, icing, light touch, quick stretch, resistance, tapping, traction
- inhibition techniques: deep pressure, prolonged stretch, warmth, prolonged cold
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Decorticate vs. Decerebrate Rigidity
- Decerebrate Rigidity: corticospinal lesion at the brainstem resulting in extension of trunk and extremities
- Decorticate Rigidity: corticospinal lesion at the dencephalon where trunk and LEs are extended and UEs are in flexion
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Specific Incomplete Spinal Cord Lesions
- Anterior Cord Syndrome: loss of motor function and pain/temp sense below the lesion from damage to corticospinal and spinothalamic tracts
- Brown-Sequard Syndrome: (hemisection) paralysis and loss of vibratory/position sense on same side from corticospinal tract and dorsal column, loss of pain/temp on opposite side from lateral spinothalmic tract
- Cauda Equina Injuries: below L1 spinal level, peripheral nerve injury- flaccidity, areflexia, B&B impairment -- full recovery is typical
- Central Cord Syndrome: damage to spinothalamic, corticospinal and dorsal columns-- UEs have greater involvement than LEs, and greater motor deficits than sensory
- Posterior Cord Syndrome: loss of pain perception, proprioception, 2 pt discrimination, and stereognosis-- motor function is preserved
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ASIA scale
- A: Complete, no sensory/motor function preserved in sacral segments S4/S5
- B: Sensory Incomplete, sensory but no motor function is preserved below neurologic level and extends through sacral segments S4-S5
- C: Motor Incomplete: motor functioned preserved with key muscles having < 3 MMT
- D: Motor Incomplete: motor function preserved with key muscles having >3 MMT
- E: sensory and motor functions normal
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Complications of SCI
- DVT
- ectopic bone: spontaneous formation of bone in soft tissue (usually adjacent to large joints)
- orthostatic hypotension: systolic BP decreased greater than 20 mmHg
- pressure ulcers
- autonomic dysreflexia: sit them up, check for painful stimulus/catheter, call for help- high blood pressure, severe headache, blurred vision, stuffy nose, profuse sweating
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Fuctional Outcomes for SCI
- C1-C5: mod I with power w/c, mod I with manual w/c over smooth for C5, dependent for most other things
- C6: min to mod I for transfers, min to mod I for weight shift, mod I with power chair, mod I for manualĀ over smooth, mod to min for manual w/c over rough terrain
- C7-C8: mod I for smooth or rough terrain, mod I for weight shift (side/forward lean)
- Paraplegia: mod I for everything except max to min A for ascending steps in manual w/c, household gait with KAFOs
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Levels of Consciousness
- Coma
- stupor: generally unresponsive
- obtundity: reduced alertness to arousal, delayed responses
- delirium: disorientation, confusion, agitation
- clouding of consciousness: quiet behavior, confusion, poor attention
- consciousness: alert, aware, oriented
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Types of Brain Injury
- Open- direct penetration
- Closed- no penetration (concussion, hematoma, drug overdose, drowning)
- Primary: injury caused by impact- coup (direct lesion of brain from impact) or contrecoup (lesion is rebound effect on opposite side of brain)
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Rancho Los Amigos Levels
- I: no response
- II: generalized response
- III: localized response
- IV: confused/agitated
- V: confused/inappropriate
- VI: confused/appropriate
- VII: automatic/appropriate
- VIII: purposeful/appropriate
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Glasgow Coma Scale
- 15 possible
- 8 or less = severe brain injury
- 9-12 = moderate brain injury
- 13-15= mild brain injury
- eye opening (4), verbal response (5), best motor response (6)
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Memory Impairments
- anterograde: inability to create new memory
- post traumatic amnesia: can't recall events since injury
- retrograde: inability to remember events prior to injury
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Concepts of development
- cephalic to caudal
- mass to specific
- proximal to distal
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Arthrogryposis Multiplex Congenita
- non-progressive
- restriction in utero allows for fibrosis of muscles and structures within joints
- cylinder like extremities with minimal definition, contractures, muscle atrophy
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Cerebral Palsy
- movement disorder due to brain damage, non-progressive, before or during birth
- spastic or athetoid
- monoplegia, diplegia, hemiplegia, or quadriplegia
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Down Syndrome
- trisomy 21
- mental retardation, hypotonia, jt hypermobility, narrow eyelids, flat feet, scoliosis, congenital heart disease, respiratory issues
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Duechenne Muscular Dystrophy
- progressive, X-linked recessive trait
- muscle contractility is lost and all muscle is replaced by fat/connective tissue
- death usually by 25 from cardiopulm issues
- progressive weakness, and disinterest in running, falling, toe walking
- progressive impairment with ADLs and mobility
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Prader-Willi Syndrome
- diagnosed by physical attributes and behavior patterns
- small hands, feet and sex organs, hypotonia, almond shaped eyes, constant desire for food, coordination impairments
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Spina bifida
- neural tube doesn't close sufficiently by day 28
- occulta: no associated disability
- meningocele: herniation of meninges and CSF into sac
- myelomeningocele: meninges, CSF, and spinal cord extend in sac
- motor loss below defect, sensory deficits, hydrocephalus, Arnold-chiari, osteoporosis, clubfoot, scoliosis, tethered cord, latex allergy, B&B
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Spinal Muscular Atrophy
- progressive degeneration, autosomal recessive
- Acute infantile: life expectancy less than a year
- chronic childhoold: life expectancy into adulthood, slower progression
- Juvenile SMA: typically survive into adulthood
- S/S: progressive muscle weakness and atrophy, diminished deep tendon reflexes
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Legislation Acts for Children
- IDEA: individuals with disabilities education improvement act- required children with disabilities to be served in regular school setting
- No child left behind: requires accountability for all children, including disabled individuals
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