1
Q
Coma
A
- complete paralysis of cerebral function; a state of unresponsiveness
- eyes are closed; no response to painful stimuli;
- reflexes may be present depending on the site of the lesion
- 2-4 weeks, nearly all patients begin to awaken
2
Q
Consciousness
A
- alert wakefulness
- clearly appreciates environment
- responds quickly and appropriately to visual, auditory, other sensory stimuli
- gradual recovery of orientation and recent memory
3
Q
Minimally Conscious State
A
definite evidence of environmental awareness
characterized by inconsistent behavior but reproducible and localized rather than generalized
4
Q
PT for patients in a minimally conscious state includes:
A
- disorders of consciousness program
- structured stimulation and recording of responses to document emergence
5
Q
Persistent Vegetative State
A
- wakeful, reduced responsiveness
- no evident cerebral function
- eye tracking, minimal motor
- no speaking or response to verbal stimuli
- non-purposeful movement
6
Q
JFK Coma Recovery Scale
A
a research tool used for studying recovery of patient’s in a coma; 23 items that comprise six subscales addressing:
- auditory
- visual
- motor
- oral motor
- communication
- arousal functions
7
Q
What are the two most commonly used clinical rating scales for patients s/p TBI?
A
- Rancho Los Amigos Hospital Level of Cognitive Functioning Scale (LOCF)
- Glasgow Coma Scale
8
Q
Rancho Los Amigos LOCF
A
- consists of 10 levels
- describes pt. during recovery
- not always clearly in one level
9
Q
Rancho Los Amigos LOCF: Levels 1-3
A
total assistance
10
Q
Rancho Los Amigos LOCF: Levels 4-5
A
maximal assistance
11
Q
Rancho Los Amigos LOCF: Levels 6
A
moderate assistance
12
Q
Rancho Los Amigos LOCF: Levels 7-10
A
progressively less assistance
13
Q
Glasgow Coma Scale
A
- quantify degree of coma at time of injury, and every 2-3 days
- three categories (EMV score): Eye opening, best Motor response, and Verbal response
- 3-15 point range; 3 = coma
14
Q
Functional Assessment Measure
A
an adjunct to the FIM to specifically address major functional area less emphasized in the FIM including:
- cognitive
- behavioral
- communication
- community functioning
15
Q
Mortality after TBI
A
over 1600 subjects surviving 1 year after injury, with increased risk of death from:
- aspiration pneumonia
- seizures
- pneumonia
- suicide
- digestive conditions
16
Q
Postural changes following TBI:
A
- decorticate posture - UE flexed, LE extended
- decerebrate posture - UE and LE extended
both indicate low brain function and absence of selective movement
17
Q
Sensory changes following TBI:
A
- light touch
- deep pressure
- pain
- temperature
- proprioception
- kinesthesia
- cranial nerve involvement
18
Q
Motor changes following TBI:
A
- monoparesis
- hemiparesis
- tetraparesis
- coordination, timing, sequencing deficits
*Highly variable between patients
19
Q
Perceptual changes following TBI:
A
- unilateral visuospatial neglect
- hemispatial neglect, hemiagnosia, and contralateral neglect
20
Q
Input vs. Output Neglect
A
input neglect or “inattention” includes ignoring contralesional sights, sounds, smells, or tactile stimuli; output neglect includes motor and pre-motor deficits. A person with motor neglect does not use a contralesional limb despite the neuromuscular ability to do so.
21
Q
The presence of neglect w/in the first ten days following TBI is a strong predictor of ____ __________ ________ after 1 year than several other variables
A
poor functional recovery
22
Q
Perception
A
integration of sensory info into meaningful psychological info, including prior information; more complex than sensation
23
Q
Cognitive impairments following TBI:
A
- memory deficits
- attention deficits
24
Q
Memory deficits
A
post-traumatic amnesia - time between the injury and the time patient remembers ongoing events (short-term); declarative (habit) vs. declarative (facts)
25
Retrograde vs. Anterograde amnesia
retrograde amnesia is the inability to recall memories of prior events, while anterograde amnesia is the inability to make new memories
26
Attention deficits
- decreased attention span
- impulsiveness/lack of safety awareness
- distractibility
27
Emotional/behavioral changes
most enduring and socially disabling of any sequelae
- disinhibition
- lability
- aggression
- low frustration tolerance
- inpatient
28
Secondary body function/structure impairments
- soft tissue contractures
- altered muscle tone/spasticity
- pressure sores
- DVT
- heterotopic ossification
29
Factors in predicting outcomes following TBI
- severity of injury
- duration of coma
- duration of post-traumatic amnesia (≥12 wks = poor; ≤4 wks = good prognosis)
- low Glasgow Coma Scale
30
Predicting outcomes
motor disturbances generally have GOOD prognosis, but cranial nerve injury - hearing, smell, vestibular sense are rarely fully recovered
31
Care Manager/Case Manager
coordination of care, seeking appropriate services, conducting team meetings, family liaison, etc.
32
Physical Therapist
mobility skills, transfers, walking, balance, attention, memory, community reintegration
33
Occupational Therapist
self-care, gross and fine motor skills, emphasis on UE, memory, attention, organization, community reintegration
34
Speech Language Pathologist
communication: rehabilitation of dysarthria, aphasia, swallowing (dysphagia), along with memory, attention, community reintegration
35
Physician
medical management; medication, imaging, testing
36
Nurse
personal care and carrying out medical plan, follow-up care consistent with rehab team
37
Neuropsychologist
assessment of cognition and behavior through testing; psychological, personal, interpersonal, and wider contextual circumstances
38
Precautions during examination of pts. following a TBI
- cervical ROM caution: shunts, head should be elevated in acute phase
- passive ROM: LOCF I-III
- position changes: confirm status of fracture before standing, sitting contraindicated if unstable ICP or BP, tube/line management
39
Essential outcome measures during examination of pts. following a TBI
- FIM
- Modified Ashworth Scale
- Balance assessments
- Timed walking tests (2 min, 3 min)
- Functional reach balance test
- Single-limb stance
- activity limitations
- bed mobility
40
In which two ways should you classify patients following a TBI?
1. Sahrmann & Scheets model
| 2. Rancho Los Amigos LOCF
41
In which two ways should you classify patients following a TBI?
1. Sahrmann & Scheets model
| 2. Rancho Los Amigos LOCF
42
Behavioral Treatment Strategies
- assumption: cognitive recovery can be inferred from progressive behavioral changes
- LOCF is determined by observation throughout the day
43
What are client factors to consider when discharge planning?
1. previous living/social environment
2. family/caregiver availability and competence
3. patient/family wishes/goals
*with current abilities, progression, and safety at the core
44
Prognosis factors
- severity of health condition
- predicted improvement
- self and family care capabilities
- less certainty = more conservative decision
45
What are the options for discharge?
- home with family care
- home with home health care
- home with OP care
- subacute/LTC
- acute rehab center
- assisted living
- nursing home
46
Who decides the discharge location?
- discharge planner/case manager
- the team: PT/OT/nursing/MD/psychology
- family
- admission professionals from outside facilities
47
Who coordinates arrangements?
D/C planner/care manager
48
Patient factors that may indicate the need for subacute care:
- ongoing physical therapy consult required
- specialized devices (catheters, IV use, etc.)
- wound care required
49
Poor discharge outcomes may result from:
- lack of family/social support
- multiple hospitalizations
- hx of depression
- significant co-morbidities/activity limitations
50
PT contributions to the rehab process:
- ongoing rehab needs
- opinion on progress, safety and prognosis
- equipment recommendations
- exercise programs
- communication with the next rehab site/professionals
51
What equipment with medicare/medicaid cover?
- hospital bed rental
- oxygen
- walker OR wheelchair
- bedside commode if bathroom is inaccessible
52
What are the specific recommendations to make regarding ramps?
1" rise per 1 foot of length; pay attention to neighborhood zoning problems
53
Multiple Sclerosis
MS causes the body's immune system to mistakenly attack and destroy the myelin that surrounds the axons of nerves in the CNS (brain, spinal column, and/or optic n.)
54
Gliosis
the damaged myelin forms scar tissue (sclerosis). This scarring along the myelin sheath interferes with the transmission of nerve impulses, which produces the symptoms of MS.
55
T/F: Multiple Sclerosis is considered an auto-immune disease
true; it is also considered an immune-mediated disease
56
Epidemiology of MS
- most common neurological disorder in young people, typically diagnosed between ages 20-50
- more common in women, but more progressive in men
- more frequent in caucasians, especially those of northern European ancestry
57
What are the three types of multiple sclerosis?
1. relapsing-remitting
2. primary-progressive
3. secondary-progressive
58
Relapsing Remitting MS (RRMS)
- most common (85% of diagnoses)
| - clearly defined acute attacks with either full recovery, or with residual deficit upon recovery
59
Secondary Progressive MS
- follows the RRMS course
- most of the 85% with RRMS will transition to SPMS, in which the disease will begin to progress more steadily, with or without any relapses and minor remissions and plateus
60
Primary Progressive MS (PPMS)
- characterized by progression of disability from onset, without any distinct relapses or periods of remission
- the progression is continuous, although the rate of progression may vary over time, with periods of occasional plateaus or temporary improvements
- less prevalent, ~10% of people initially diagnosed with PPMS
61
RRMS vs. progressive types of MS
- people with RRMS have more lesions in the brain and more inflammatory cells, while progressive MS have more lesions on the spinal cord and contain less inflammatory cells
- with RRMS, women are affected 2-3x as often as men
- with PPMS, woman and men affected equally
most people with RRMS are diagnosed in their 20s and 30s, whereas the onset of PPMS is in the 40s and 50s
62
Clinically Isolated Syndrome
a first occurrence of a neurological episode of inflammation or demyelination that lasts at least 24 hours; can involve one or multiple areas
- may or may not be an early sign of MS
- 60-80% likely to develop MS if lesions consistent with MS per MRI
- 20% likely to develop MS if brain scan is normal
63
How is MS diagnosed?
no single clinical test, rather a combination of diagnostic tools:
- medical hx
- physical exam
- MRI
- spinal tap
64
A definitive diagnosis of MS can be made when:
- evidence of plaques or lesions in 2 distinct areas of the nervous system
- evidence that these plaques occurred at different points in time
- there are no other explanations than MS for the plaques in the white matter of the CNS
65
McDonald Criteria
Review on pg. 4 of the MS lecture
66
"Dawson's Fingers"
demyelinating plaques through the corpus callosum; relatively specific to MS
67
Oligoclonal bands indicate:
inflammation of the CNS, and may be a sign of MS
68
MS symptoms may vary due to issues, including:
- side effects of medicines
- fatigue
- UTI
- elevated core body temp
- stress
- affective disorders (ie depression)
- other medical conditions
69
MS Symptoms
- fatigue = 88%
- ataxia
- visual disturbances = 58%
- cognitive problems = 44%
- spasticity
- sensory impairments
- muscular weakness or paralysis
- balance deficits
- ambulation problems = 87%
- bowel and bladder problems = 65%
- tremor = 41%
- movement problems in the arms = 41%
70
Factors that predict a favorable outcome for pts. with MS:
- female
- onset prior to age 35
- single area of CNS involvement
- complete recovery after exacerbation, with little or no residual impairment
71
Factors that predict a less favorable outcome for pts. with MS:
- male
- onset after age 35
- brainstem symptoms (ataxia, nystagmus, tremor, dysarthria)
- poor recovery after exacerbations
- frequent attacks
72
Treatment of multiple sclerosis
1. treatment of acute exacerbations
2. symptom management
3. disease modification
4. rehabilitation
5. psychosocial support
73
Multiple Sclerosis Functional Composite (MSFC)
- 25' walk test
- 9 hole peg test
- paced auditory serial addition test (PASAT)
*may also include a Berg balance test and symbols digit modality test
74
Outcome measures for fatigue/cognition with MS pts.
- visual analog scale
- modified fatigue impact scale
- fatigue scale for motor and cognitive function
75
Outcome measures for pain with MS pts.
- Visual Analog Scale
- Wong Baker FACES Pain Rating Scale
- 24-hour pain report
76
Outcome measures for vision
- tracking
- visual field cut assessment
*vestibular screen if indicated by symptoms
77
What are the three main motor symptoms of Parkinsonism?
shakiness, stiffness/rigidity, and bradykinesia
78
Secondary Parkinsonism
- drug-induced Parkinsonism
- vascular Parkinsonism
- essential tremor
- normal pressure hydrocephalus
- progressive supranuclear palsy
- multiple system atrophy
- corticobasal degeneration
- dementia and lewy bodies
79
Braak's Hypothesis
states that alpha-synuclein aggregation could begin in the nervous system of the gastrointestinal tract and migrate from there to the CNS; evidence of non-motor symptoms may detect PD, such as:
- loss of sense of smell
- sleep disorders
- constipation
80
When approximately ______ of dopamine-producing neurons are damaged, motor symptoms begin to appear
60-80%
81
Motor signs of PD
- shakiness/tremor
- stiffness
- slow movements/bradykinesia/akinesia
- postural instability
82
Tremor
can be resting or postural; tremor-dominant patients generally follow a more benign disease course than non-tremor patients; tremor is linked to altered activity in not one, but two distinct circuits: the basal ganglia and the cerebello-thalamo-cortical circuit
83
Tremor is increased by:
- stress
- fatigue
- excitation
84
Tremor is decreased by:
- relaxation
- during voluntary movement
- disappears during sleep
85
Treatment for bradykinesia
- LSVT BIG
- LSVT LOUD
- PWR!
- visual cues
- auditory cues
- counting steps
86
Strategies when akinesia or freezing of movement occurs?
- STOP moving
- stand tall (or sit tall)
- weight shift/rocking
- take a step backwards or to the side
- aim next step at a specific spot on the floor
- counting (out loud or in your head)
- sing/hum rhythmic tune
87
Rigidity
increased resistance to passive motion throughout the range of motion; present in >90% of people with PD
lead pipe rigidity - resistance to passive movement throughout the entire ROM w/o fluctuation
cogwheel rigidity - combination of lead pipe rigidity and tremor and presents as jerky resistance to passive movement
88
Non-motor symptoms of Parkinson's disease
- depression
- cognitive problems (memory loss and concentration)
- sense of smell
- sleep disturbance
89
Hoen and Yarh: Stage 1
unilateral involvement only; minimal or no functional disability
90
Hoen and Yarh: Stage 2
bilateral or midline involvement without impairment of balance
91
Hoen and Yarh: Stage 3
bilateral disease; mild to moderate disability with impaired postural reflexes; physically independent
92
Hoen and Yarh: Stage 4
severely disabling disease; still able to walk or stand unassisted
93
Hoen and Yarh: Stage 5
confinement to bed or wheelchair unless aided
94
Pallidotomy
permanently destroys the overactive globus palladis to decrease PD symptoms and can include reduction of rigidity, reduction of tremor, bradykinesia, and balance problems.
95
Thalamotomy
destroys part of the thalamus to block the abnormal brain activity from reaching the muscles and causing tremors
96
Deep Brain Stimulation
surgical procedure used to treat the motor symptoms of PD, such as tremor, rigidity, bradykinesia, and walking problems. Also used to treat essential tremor and dystonia.
97
Outcome measures for the PD population
- Berg Balance test
- Mini-BESTest
- FGA
- 10 meter walk test
- TUG test
- Four Square Step test
98
Movement limitations in PD
- difficulty with initiation of movements
- difficulty with ADLs
- balance/postural instability
- walking, esp. turns and in tight spaces
- transitional movements
- activities that require dual/multi-tasking
99
Gait abnormalities
- short shuffling steps
- freezing episodes
- difficulty with turns
- difficulty with initiation of movement and/or stopping a movement
- festinating gait pattern
- decreased arm swing
- decreased trunk rotation
- dual task attention during gait
100
LSVT BIG
applies the principles of LSVT LOUD to limb movement, developed by Becky Farley and Cynthia Fox; most beneficial to patients in stages 1-3/4 of the Hoen and Yarh
101
Principles of neuroplasticity used in LSVT LOUD & BIG
- forced use
- intensive practice
- repetition
- challenging
- motivating
102
LSVT BIG must be:
- high effort: 7-8/10 for effort each exercise
- repetitive: 10 reps each exercise
- dosage: exercises must be done 2x/day every day
103
What are factors that affect resource allocation?
1. task demand
2. performance criteria
3. long-term predispositions
4. arousal
104
What are factors that affect resource allocation?
1. task demand
2. performance criteria
3. long-term predispositions
4. arousal
105
What are the cortical structures commonly implicated in executive functions network?
- orbitofrontal
- ventromedial
- dorsolateral
106
What is the SLP's role in acute care for cognition?
- manage distractability
- monitor post-traumatic amnesia
- awareness training
- family training
107
What is the SLP's role in acute care for cognition?
- manage distractability
- monitor post-traumatic amnesia
- awareness training
- family training
108
Communication recommendations in acute setting
- ALWAYS try to leave sessions on a positive note
- engage eye contact
- speak in simple sentences, active voice
- pause between ideas
- clearly identify topic shifts
- don't quiz patients
- never leave sessions without ensuring all their questions have been answered to their satisfaction
- always make sure the patient has their memory book with them
109
What are the principles of group practice?
1. topic limit and structure
2. group composition
3. task selection
4. mediator style
110
What are the three types of attention?
- sustained
- selective
- alternating
111
What are the two types of memory?
working and new learning (encoding)
112
What are the two types of social cognition?
- emotion recognition
| - theory of mind
113
Guillain-Barre' Syndrome
- a polyradiculoneuropathy
- a primary demyelinating disease
- immune-mediated inflammatory disorder
- typically appears days or weeks after an infection (upper respiratory or GI)
114
Auto-immune vs. Immune-mediated
autoimmune is a well-defined disease process in which the exact cause is known; immune-mediated is not well known
115
Primary impairments of GBS
- abnormal sensation
- muscle weakness
- combination of the two
- pain
116
How is GBS diagnosed?
- clinical presentation
- elevated proteins in the CSF
- nerve conduction/velocity/EMG
117
Chronic Inflammatory Demyelinating Polyneuropathy
- a chronic variation of GBS
- more rare
- develops more slowly
- symptoms persist and are less likely to completely resolve
118
Medical treatment options for GBS
- intravenous immunoglobulin therapy (IVIg) - immunoglobulins are injected intravenously 1x/day for 5 days; act as antibodies
- plasma exchange (plasmapheresis) - plasma cells are removed; RBC, WBC, platelets are returned; administered every other day for 2 weeks
119
Progression of GBS General Timeframe
- 50% of cases-weakness peaks in 1st week
- 80% of cases-within first 3 weeks
- few cases weakness progresses over 1-2 mos.
120
Recovery of GBS General Timeframe
- usually begins 2 wks - 2 mos after disease plateaus
- 80% ambulatory within 6 mos of onset
- 30% have residual distal weakness (ant. tib., hand intrinsics, quads, and glutes)
121
What are the primary impairments of GBS?
- force production deficit
- sensory impairments
- pain syndromes
- autonomic dysfunction
122
Force production deficit in GBS
- progressive
- rapid onset
- symmetrical
- distal to proximal
- self-limiting
123
Sensory impairments
- tend to be mild
- 75% of patients have paresthesia/hyperesthesia)
- stocking/glove pattern
- dysesthesia
124
Pain syndromes (three types)
1. back and leg pain - deep throbbing/aching back pain with radiation into lower extremities
2. Dysethetic extremity pain - burning, tingling, shock-like
3. Myalgic - rheumatic extremity pain (achy or cramping sometimes associated with joint stiffness)
125
Autonomic dysfunction
- tachycardia
- arrhythmia
- blood pressure fluctuation
- hyperhydrosis
- persistent goose bumps
126
Secondary complications of GBS
- DVT
- contracture
- muscle atrophy
- hypercalcemia of immobilization
- pressure sores
- respiratory complications
127
What are important considerations during the examination of a patient with GBS?
- skin inspection
- respiration
- autonomic nervous system
- DVT
- avoid overexertion
- be alert for autonomic dysreflexia, orthostatic hypotension, and DVT
128
Treatment of a pt. with GBS in the ICU should consist of:
- PROM exercises
- transfer by lift to w/c gradually tilted to upright
- monitor VS throughout
- sitting edge of bed
- progressive rolling, transfer-movement organized around functional goals
129
Treatment of a pt. with GBS in the acute phase should consist of:
- breathing strategies/intervention
- skin integrity
- pain relief - positioning
- contracture prevention
- exercise while monitoring overuse/fatigue
130
What factor in patients with GBS is strongly predictive of the need for extended LOS in inpatient rehab?
prior ventilator support
131
Significant factors for a longer LOS in acute rehab
- muscle belly tenderness
- severe LE weakness
- lower FIM mobility score upon admission and d/c (1-2 on admission & 4-5 on discharge)
132
Outcome measures used in pts. with GBS
- Guillain-Barre disability index (0 = best; 6 = death)
- FIM
- Pain intensity numerical rating scale
- Manual muscle testing
133
Exercise precautions in patients with GBS
- avoid exacerbation in acute phase
- allow frequent rest periods
- assess overwork during rest intervals through objective strength tests and evaluation of complaints of soreness
134
Exercise guidelines in patients with GBS
- submaximal strength training
- allow for 24 hours of recovery
- monitor appropriate physiological responses during aerobic training
- recruit/train a variety of muscle fibers - slow/fast twitch (i.e. isometrics, then eccentrics)
135
Amyotrophic Lateral Sclerosis (ALS)
- demyelination and gliosis in the corticospinal tracts and corticobulbar tracts d/t degeneration and drop out of Betz cells (UMN) in motor cortex
- degeneration of the anterior horn cells r/in muscle atrophy
- affects spinal cord and motor cranial nerve nuclei in the lower brainstem (bulbar area)
- lower motor neurons show massive cell loss
- atrophy seen after loss of 30% of cells
136
Cell death in pts. with ALS can happen in which three places?
- cell body dies via apoptosis
- axon via another mechanism
- synapse via a different mechanism
*All do not die simultaneously, so signs may differ between patients
137
What are the two types of ALS?
- sporadic: 85-90% of patients
| - familial: 10-15% of patients (autosomal dominant)
138
ALS Clinical Features
- requires both UMN and LMN signs for definitive diagnosis
- UMN: weakness, spasticity, hyperreflexia
- LMN: weakness, atrophy, fasciculations, hypotonia, areflexia
- generally have bulbar and spinal muscle involvement
139
Clinical features of variations of motor neuron disease
- bulbar muscle weakness (speech and swallowing) -> progressive bulbar palsy
- if pure LMN -> progressive muscular atrophy
- if pure UMN -> primary lateral sclerosis
140
ALS Diagnosis
- combination of clinical exam and diagnostic tests
- EMG, NCV
- blood and urine studies
- thyroid/parathyroid hormone levels
- spinal tap
- MRI
- muscle and nerve biopsy
141
ALS functional problems
- head control
- poor gait posture
- weakness in proximal muscles of gait
- sitting posture which affects speaking swallowing, writing, eating, reading, socialization
- contractures (shoulder/neck)
Neurological Systems I
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