Pta 250 Exam 2

Front 1

Coup/countercoup

Back 1

a severe enough blow to the head that not only causes damage under the site of impact but also on the opposite side.

Front 2

Local brain damage

Back 2

localized to the area of the brain that is under the site of impact on the skull. The damage can be in the form of contusion or laceration or both.

Front 3

Autonomic dysreflexia

Back 3

pathological reflex that occurs is lesions above T-6. Can be a hazardous complication. A noxious stimulus can produce this clinical syndrome. After stimulus, a mass reflex at spinal cord level will elevate blood pressure. Due to the lesion, there is no vasomotor response to decrease BP. This will cause a critical, emergency situation. Death can occur if not treated immediately. The noxious stimuli can include pressure anal/genital area, bowel/bladder distension, abdominal distension, mechanical stretch and long sitting. Symptoms include sudden hypertension, bradycardia, HA, profuse sweating, increased spasticity, blotchy appearance. Intervention: checking the drainage system, if patient is lying, bring to sitting, and check patient’s body for any irritating stimuli. If stimulus cannot be relieved, medical/nursing is required

Front 4

Hemiparesis

Back 4

is the result of direct unilateral trauma to the cortex, but can also result from secondary injuries.

Front 5

Brown Sequard Syn

Back 5

hemisection of the spinal cord (damage to one side) and is usually caused by stab wounds. Symptoms are asymmetrical. There is loss of sensation and proprioception on ipsilateral side with loss of pain and temperature on contralateral side several layers below the level of injury

Front 6

Central Cord Syn

Back 6

hyperextension injuries to cervical region. UE will be more involved than LE. There will be a varying degree of sensory and motor impairment with complete preservation of sacral tracts, normal sexual, bowel and bladder function.

Front 7

Sacral Sparing

Back 7

an incomplete lesion. There is perianal sensation, rectal sphincter contraction, and cutaneous sensation in “saddle area”. It is the first sign that a cervical lesion is incomplete

Front 8

Root Escape

Back 8

the preservation or return of function of nerve roots at or near the level of lesion

Front 9

Incomplete SCI

Back 9

there is some preservation of sensory or motor function below the level of the injury. This is due to contusions produced by pressure on the cord from fractures, soft tissue, swelling within spinal canal. The clinical picture is unpredictable

Front 10

Polar brain damage

Back 10

due to an acceleration and deceleration injury. Damage occurs at the poles and the undersurface of the temporal and frontal lobes. May be in the form of a contusion and/or laceration with no abnormal neurological signs until 2-3 days later due to what is known as the mass effect (edema causing the brain the shift).

Front 11

Diffuse brain damage

Back 11

widespread damage results from the stretching and tearing of nerve fibers. When the brain mass twists and shifts, billions of thread-like nerve connections are pulled and stretched. With this type of injury, the person is usually comatose

Front 12

TBI

Back 12

defined as brain damage from some external inflicted trauma to the head that results in significant impairment to an individual’s physical, psychosocial, and/or cognitive functional abilities.

Front 13

Hemiplegia

Back 13

paralysis on one side of the body

Front 14

Anterior Cord Syn

Back 14

due to flexion injuries in cervical region. There is loss of motor function, pain and temperature below the level of the lesion.

Front 15

Posterior Cord Syn

Back 15

rare. There is preservation of motor function, pain and light touch. There will be a loss of proprioception and two-point discrimination.

Front 16

Cauda Equina Injury

Back 16

lesions are peripheral nerve injuries. They have potential to regenerate, but full recovery is not common

Front 17

Complete SCI

Back 17

no sensory or motor function below the level of the lesion. This is due to a complete transaction, severe compression or vascular impairment of the spinal cord

Front 18

DVT with SCI

Back 18

1.Deep Vein Thrombosis) blood clot within the vessel. The contributing factor for DVT is the loss of normal “pumping” mechanism provided by contraction of LE musculature. The clinical features are localized swelling, erythema and heat. These symptoms are very similar to ectopic bone formation, but differentiated b Doppler studies. Management is prevention, prophylactic anticoagulant therapy, turning program, PROM, elastic support stockings and and positioning of LE’s to promote venous return.

Front 19

Recovery stages for CVA concerning tone

Back 19

sequential recovery stages: initially, there is flaccidity with no voluntary movement. Then, there may be a development of spasticity, hyperflexia and synergy patterns (mass patterns of movement). Finally spasticity and synergies start to decrease and normal movement patterns begin.

Front 20

What are 2 basic synergy patterns?

Back 20

flexion and extension

Front 21

What are some reflex patterns?

Back 21

areflexia, then hyperreflexia, positive Babinski, tonic reflex pattern can be present, STNR, ATNR

Front 22

What is the timetable for recovery of CVA?

Back 22

Recovery from stroke is fastest in the first few weeks after onset, with most measurable neurological recovery (90%) within the first 3 months. The patient may continue having functional gains 6 months to a year after insult. The rate of improvement depends on the amount of damage sustained

Front 23

Procedures for CVA positioning

Back 23

1.) Lying in the supine position, the trunk should be positioned in midline with head/neck in slight flexion. A small pillow or towel under the scapula will assist in scapular protraction. The affected upper limb rest on a support pillow externally rotated and abducted with elbow extension, wrist neutral, and finger extension. 2.) Lying on the unaffected side The head/neck should be neutral and symmetrical with the trunk aligned straight. A pillow under the rib cage can be used to elongate the hemiplegic side. The affected upper limb is protracted and placed well forward on a supporting pillow, elbow extended. 3.) Lying on the affected side the head/neck should be neutral and symmetrical with the trunk aligned straight. The affected upper limb is is positioned well forward with elbow extended, forearm supinated, wrist neutral, fingers extended, and thumb abducted. The altered lower limb is positioned in hip extension with knee flexion. 4.) Sitting in a bed and Wheelchair The patient should sit with the head/

Front 24

What are the primary functions of brain lobes?

Back 24

Temporal lobes – ability to register new information and later retrieve it; time, distance, perception, areas of speech, communication. Parietal lobes – motor/sensory interpretation. Occipital lobes – visual processing and interpreting. Frontal lobes – thinking skills, executive functions – abilities to plan, initiate, organize, carry out, monitor, and correct one’s own behavior; problem solving skills (not fully developed until age 21).

Front 25

What are the different types of aphasia?

Back 25

Fluent aphasia (wernicke’s/sensory/receptive aphasia) – speech flows smoothly with a variety of grammatical constructions and preserved melody of speech. Auditory comprehension is impaired. Pt demonstrates difficulty in comprehending spoken language and in following commands. Lesion located in the auditory association cortex in the left lateral temporal lobe.

Nonfluent aphasia (broca’s/expressive aphasia) – flow of speech is slow and hesitant, vocabulary is limited and syntax is impaired. Speech production is labored or lost completely while comprehension is good. Lesion located in the premotor area of the left frontal lobe.

Global aphasia – severe aphasia characterized by marked impairments of oth production and comprehension of language. Indication of extensive brain damage. Severe problems in communication may limit pts ability to learn and often impedes successful outcomes in rehab.

Aphasia is a general term used to describe an acquired communication disorder cause by brain dam

Front 26

Remember with CVA recovery strength and development is from.

Back 26

proximal to distal

Front 27

CVA begins with what?

Back 27

approximation and weight bearing

Front 28

What are some indications for shoulder slings?

Back 28

Slings are appropriate for initial transfer and gait training, but overall use should be minimized during rehab.

· Slings that position the UE in flexion are less desirable and should be used only for select upright activities and only for short time frames.

· No one sling is appropriate for all patients; selection and use should be carefully monitored.

Slings are contraindicated for patients with spasticity.

Front 29

What are some tone reduction activities for CVA patients?

Back 29

· Positioning out of reflex dependent postures

· Avoid excess effort or heavy resistance

· Rhythmic rotation of limbs out of spastic pattern

· Postures in SL, sitting or hook lying are used

· PNF patterns

· Stimulating the weak antagonist through tapping, vibration

· WB activities (upper extremity, kneeling, quadruped)

· Use of cold (decrease conduction velocity)

Front 30

TBI – low-level management

Back 30

Low level management (Level I-III)

Decreased level of responsiveness.



Goals – prevention of contractures, skin breakdown and increase patient’s level of interaction with environment



Treatment – ROM is decreased for numerous reasons with a patient that is brain injured. These would include decreased consciousness, prolonged bed rest, spasticity, and lack of voluntary movement. A combination of treatments is necessary which include oral medications, nerve/motor point blocks, serial casting and positioning. Sometimes manipulation under general anesthesia. PROM should be aggressive; caution should be made with stretching secondary to low LOC. When ranging shoulder, place patient in SL position to allow scapular movement. Rotation is effective with decreasing spasticity.



Sensory stimulation – used for arousal and to elicit movement. Stimulation is effective when administered for short treatment sessions, and should be presented in an orderly fashion to prevent overstimula

Front 31

TBI mid level management

Back 31

Level IV: patient is usually confused, agitated; therefore, patient requires structured environment, activities need to be familiar and liked by the patient.



Goals – maintain/improve ROM, prevent deconditioning, improve response to simple commands, and prevent agitated outbursts, need to redirect patient, first to therapist then back to activity, need quiet environment



Patient is confused – same person needs to see patient every day, establish a routine, provide orientation information so patient will not be agitated



Expect no carryover – do not teach new skills, use charts to help progress patient



Model calm behavior – patient will perceive and reflect the demeanor of caregiver, the therapist needs to assume a calm and focused attention



Be prepared with numerous activities – patient has limited attention span and decreased concentration



Offer options – gives the patient a sense of control, would you rather do this or this?



Expect egocentri

Front 32

TBI high level management

Back 32

Levels VII and VIII: patients are usually discharged from inpatient facilities. The patient should be weaned from structure. When a patient can control their behavior, a controlled environment is lessened. Need to maintain performance while decreasing structure and supervision. Still may need some external memory aids. Assist the patient in integrating the cognitive, physical and emotional skills needed to function in the real world. Physical fitness is important and the patient should be able to continue at home. With Level VIII, patient will need vocational and driving services. Overall goal is for the patient to function optimally in society.

Front 33

Types of deficits with TBI

· Residual deficits

Back 33

Decreased level of consciousness

Altered level of consciousness (LOC) occurs with majority of head injuries. Make sure to be consistent with terminology.

Front 34

Cognitive deficits

Back 34

Deficits will range from selective attention to problems understanding a task, to problems planning strategies for solution. Deficits can have a great impact on rehab if patient has attention deficit, etc.

Front 35

Communication deficits

Back 35

Patients can have receptive and expressive communication disorders and should be evaluated by a speech/language pathologist. Also, will have a significant impact on rehab.

Front 36

Behavioral deficits

Back 36

Are the most enduring and socially disabling of any of the dysfunctions seen with TBI. These would include apathy, aggression, low frustration tolerance, depression and sexually disinhibiting. Usually the psychologist plays an important role in determining behavioral programs.

Front 37

Sensorimotor deficits

Back 37

The PT will evaluate, assess deficits/strengths, and set appropriate short and long term goals as well as develop a treatment plan.

Front 38

What are the steps of gait training with TBI?

Back 38

· Do not want to begin ambulating too early, may increase risk of developing persistent and faulty habits

· Quad canes can distort balance, promote excessive WS onto unaffected side if used too early in rehab

· Focus on controlling selective movements of gait with appropriate timing (lower trunk rotation practiced in SL, then kneeling, plantigrade, finally standing and walking)

· Advanced gait training includes practicing forwards, backwards, sidewards, and braiding

· An orthosis may be needed to allow safe ambulation (KAFO, AFO, AFO with DF assist)

Front 39

4 types of stabilization tech for SCI and advantages of each

Back 39

Stabilization/immobilization in cervical spine – unstable cervical fractures are immobilized by skeletal traction (tongs) or halo device.

· Tongs – inserted on outer area of skull; traction is accomplished by attachment of a rope to skull fixation and weights at the other end. Tongs are a temporary mode of skeletal traction or for uncomplicated low cervical injuries.

· Turning frames/beds – 1.) Stryker frame allows positioning changes while maintaining anatomic alignment of the spine, but only allows turning supine to prone position. This does not interrupt the cervical traction. 2.) Roto Rest Kinetic Treatment Table is an electronically operated bed that provides continuous side to side rotation along its longitudinal axis. An advantage is maintaining spinal alignment with the decrease effects of bed rest; improve pulmonary/kidney function; and prevent pressure ulcers.

· Halo devices – most frequently used to immobilize cervical fractures. A halo ring with four s

Front 40

Primary and secondary damage with TBI

Back 40

· Primary damage is damage sustained to the brain at the time of the injury; Local brain injury, coup/countercoup, polar brain damage, diffuse brain injury

· Secondary damage is damage that occurs to the brain later.

o Hypoxic-ischemic injury (HII) – infarction to a particular area in the brain due to compromise of circulation secondary to shifting brain structures.

o Intracranial hematomas – extended bleeding. Can be a life-threatening situation. Patients “talk and die”. Patient who is lucid for a period of time after the initial injury but who later lapses into coma and dies. This is due to compression of the brain by expanding hematoma. The hematomas are classified by their site: (epidural, subdural, intracerebral) and by the time after injury in which they develop: acute (3 days), subacute, or chronic (greater than 2-3 weeks).

o Cerebral edema – swelling of the damaged brain tissue than can increase intracranial pressure (ICP). Increased ICP can result in

Front 41

What are the differences in left and right hemiparesis?

Back 41

Left CVA – difficulty with initiation and performing sequences of movement. Right CVA – demonstrates motor impersistence

Front 42

Clinical Rating Scales for TBI and levels of each.

Back 42

Pg 900 O’Sullivan

Front 43

What are some levels of consciousness with head injury?

Back 43

· Coma – not obeying commands, not uttering words, and not opening the eyes, coma usually lasts only a few weeks at most.

· Persistent vegetative state – continuing decreased LOC, patient will have responses i.e. eye opening, visual tracking, however, patient will not speak or produce any type of behavior that is purposeful or psychologically meaningful.

· Post-traumatic amnesia – the time when the patient is again able to remember ongoing events, there is no carryover of information from hour to hour or day to day during treatment, implications are obvious for functional training

Front 44

What are the grades of spasticity?

Back 44

Grade
Description

0
No increase in muscle tone

1
Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the ROM when the affected part(s) is moved in flexion or extension.

1+
Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (ess than half) of the ROM.

2
More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved.

3
Considerable increase in muscle tone, passive movement difficult.

4
Affected part(s) rigid in flexion or extension.

Front 45

What is a lab tech able to do?

Back 45

decrease abnormal tone

Front 46

What are some primary causes of TBI peds?

Back 46

· Falls – account for 35% of all pediatric TBIs that require hospitalization or result in death. 2/3 are from heights or stairs, but of these only 8% result in severe injury.

· Motor Vehicle Accident (MVA) – account for approximately 25% of all pediatric TBIs and are the most common cause of trauma death in children 5-9 yrs old. MVAs cause the vast majority of serious injuries with multiple trauma in children, and approximately 70% of the children injured in an MVA will be in a coma for some period of time.

· Gunshot Wounds – more than twice as many children survive their injuries as die, with approximately 25% having permanent sequelae.

· Abuse/Assault – physical abuseis prevalent in children 0-4 yrs old. Approximately 24% of the children require hospital admission and approximately 80% of the head trauma deaths in children under 2 yrs of age are due to physical abuse.

· Sports/Recreational Activities – account for approximately 21% of the brain injuries to

Front 47

Why teach bridging?

Back 47

it develops pelvic control, advanced limb control, and early LE weight bearing.

Front 48

Examples of Dual task training

Back 48

(last test

Front 49

Rates of exertion Borg Scale

Back 49

Pg577 O’Sul

Front 50

Know clinical picture after SCI

Back 50

· Spinal shock – occurs immediately after spinal cord injury where there is complete loss of reflex activity (areflexia), sensation below the level of injury. It is thought to be due to the abrupt withdrawal of connections between the spinal cord and the brain. It can last several hours to several weeks, but usually subsides within 24 hours. Resolution is distal to proximal; begins at sacral to lumbar to thoracic to cervical. Bulbocavernous reflex is the first indicator that spinal shock is resolving.

· Motor and sensory deficits – there will be complete or partial loss of sensation and muscle function below the lesion level.

· Autonomic dysreflexia (hyperreflexia) – pathological reflex that occurs is lesions above T-6. Can be a hazardous complication. A noxious stimulus can produce this clinical syndrome. After stimulus, a mass reflex at spinal cord level will elevate blood pressure. Due to the lesion, there is no vasomotor response to decrease BP. This will cause a criti

Front 51

Characteristics of sensory stimulation:

Back 51

· Latency – the time delay between stimulus and response

· Consistency – how many times out of a given number of stimulus presentations does the patient respond the same?

· Intensity – the response should be proportionate to the stimulation

· Duration – brief forms of stimuli should result in brief forms of response

· Auditory – use normal conversation, identify yourself, explain what is to be done, constant background noise is detrimental

· Visual – use objects that are familiar i.e. pictures of family members, note visual attentiveness and visual tracking

· Olfactory – place scents under patient nose for 10-15 seconds

· Tactile – done during most functional activities, can use the patient’s own hands

· Vestibular – rolling, rocking

Front 52

What does a SCI patient have to have to be able to ambulate?

Back 52

In order to be successful with ambulation, a patient needs adequate strength, postural alignment, ROM, and cardiovascular endurance. The trunk musculature needs to be grades as fair or better; therefore, this limits lesions above T8 including T8. Full hip extension is required because the patient with a SCI uses the anterior ligaments to maintain balance in upright position.

Front 53

Know sexual dysfunction with SCI

Back 53

Male – erectile capacity is greater in UMN lesions and incomplete lesions. Reflexogenic erection is the physical stimulation of genitals and requires an intact reflex arc. Psychogenic erection occurs through cognitive activity such as erotic fantasy and is required with LMN lesions. Ejaculation is higher with LMN lesions vs. UMN lesions, lower-level vs. higher-level, and incomplete compared with complete lesions. Very few patients with SCI are able to sire children with success.

Female – sexual response also follows a pattern related to location of lesion. With UMN lesions, the reflex arc is intact. Therefore, sexual arousal components will occur through reflexogenic stimulation. With LMN lesions, psychogenic responses will be preserved while reflexive responses will be lost. The menstrual cycle will be interrupted temporarily for a period of 1-3 months. Females are able to conceive, but pregnancies are closely supervised. Due to impaired sensation, the initiation of labor may not be perceiv

Front 54

Mat activities with SCI

Back 54

a) Rolling – patient learns to use head, neck, UEs, and momentum

· Flexion of head and neck with rotation moving supine to prone.

· Extension of head/neck with rotation using moving prone to supine.

· Bilateral, symmetrical UE rocking with outstretched arms with head and neck. Patient slings themselves to the side.

· Manual placement of leg over leg for rolling by therapist.

· Can begin with pillow propped when moving supine to prone, then progress to one pillow then to no pillows.

· PNF patterns are useful during early rolling. D1 flexion, D2 extension and reverse chop will facilitate supine to prone. Lift will facilitate rolling to supine.

b) Prone on elbows – improves bed mobility, preparation of assuming quadruped and sitting positions. Caution with lumbar and thoracic injuries due to increased lordosis. WB will increase stability. WS will increase controlled mobility beginning lateral then to forward/back. Rhythmic stabilization to in

Front 55

What level of SCI is electric W/C indicated?

Back 55

C4 lesions and above

Front 56

What is the pressure relief schedule for SCI patient?

Back 56

should be turned every 2 hours

Front 57

What are the levels of coughing?

Back 57

1. functional, strong enough to clear secretions.
2. weak functional, adequate force to clear upper respiratory tract secretions in small quantities.
3. nonfunctional, unable to produce any cough force.

Front 58

Respiratory management after SCI

Back 58

Depends on the level of the lesion. If the cord is injured/severed at C1/C3, phrenic nerve innervation, spontaneous respiration is impaired or lost. Quadriplegic and high level paraplegia will result iin some compromise in respiratory function due to innervation of both primary (diaphragm) and secondary (neck, intercostals, and abdominal) respiratory muscles.

Front 59

What affects spasticity?

Back 59

positional changes, cutaneous stimuli, environmental temperature, light clothing, bladder/kidney stones, fecal impactions, catheter blockage, urinary tract infections, ulcers, and emotional stress.

Front 60

Can further progress be made after a plateau has been reached?

Back 60

YES

Front 61

Procedures for CVA positioning

Back 61

Enhance patient's awareness of the hemiplegic side. The patient may spend a significant amount of time in bed initially, you must position to prevent contractures, pressure ulcers, tone dependent and reflex dependent postures. Upright posture is assumed ASAP.
-Positions to avoid: sidebending of the head/trunk toward affected side with head rotation toward unaffected side, depression/retraction of the scapula, IR/adduction of the UE, elbow flexion/forearm pronation, wrist/finger flexion, retraction/elevation of the hip/knee extension, hip adduction, ankle PF.
-positions to promote: supine, sideling, and sitting.