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Details of PT eval for neuro
these notes come from the handout
195
Anatomy
Graduate
09/25/2012

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Term
what is the maximum score of the glasgow coma scale
Definition
15
Term
what is the minimum score of the glasgow coma scale if you're alive
Definition
3
Term
what are the 3 categories of the glasgow coma scale
Definition
eye opening, best motor response, verbal response
Term
what is the range of eye opening in the glasgow coma scale
Definition
no response, to pain, to speech, spontaneous
Term
what is the range of best motor response in the glasgow coma scale
Definition
no response, extensor response, abnormal flexion, withdraws, localizes, follows motor commands
Term
what is the range of verbal response in the glasgow coma scale
Definition
no response, incomprehensible sounds, inappropriate words, confused conversation, oriented
Term
what is the point of using the glasgow coma scale
Definition
determine mental status
Term
what is the point of the ashworth scale
Definition
determine spasticity and tone
Term
what is the best grade of the Modified Ashworth Scale
Definition
0: no increase in muscle tone
Term
what is the 2nd best grade of the Modified Ashworth scale
Definition
1+ Slight increase in muscle tone manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM
Term
what is a grade 2 on the Modified Ashworth scale
Definition
more marked increase in muscle tone through most of the ROM but affected part easily moved
Term
what is a grade 3 on the Modified Ashworth scale
Definition
considerable increase in muscle tone; passive movement difficult
Term
what is a grade 4 on the Modified Ashworth scale
Definition
affected part rigid in flexion or extension
Term
what is the worst grade of the Modified Ashworth Scale
Definition
4
Term
when would someone lose the entire right eye's visual field
Definition
damage to the right eye's retina or optic nerve
Term
describe bitemporal hemianopsia
Definition
damage to the optic chiasm affects the fibers that cross. All you will see is what comes from the fibers that don't cross (you lose what the nasal retinas see.) You have tunnel vision because you can't see out at the peripheries
Term
what is a common cause to damage of the optic chiasm resulting in bitemporal hemianopsia
Definition
pituitary tumors
Term
describe homonymous hemianopsia
Definition
damage to one optic tract results in loss of sight of the opposite visual field.
Term
if you have homonymous hemianopsia because of damage to the right optic tract, what will you be able to see
Definition
you will be able to see left nasal field and right temporal field: you can see to the right only (blindness of the left visual field)
Term
describe superior homonymous quadrantoanopsia
Definition
damage along a portio of the optic radiations results in partial anopsias
Term
describe homonymous hemianopsia with macular sparing
Definition
damage to primary visual cortex results in loss of large area of visual field with macular sparing
Term
what should be considered first in a physical therapy evaluatoin of neurological disorders
Definition
functional issues/concerns and goals of the patient and/or family
Term
after determining functional problems, what is the next step of a pt eval for neurological disorders
Definition
try to determine which impairments contribute to the functional problems.
Term
after determining functional problems and impairments, what should be done next in a PT eval
Definition
identify which impairments and functional limitations can be changed with PT and use this to plan your intervention
Term
what information should you get in a patient's history
Definition
nature of the problem; circumstances/time frames/environmental factors; results of radiology/EMG/NCV; surgeries; medications/treatment; social history; equipment
Term
what are the components of a PT examination
Definition
vitals, PROM, movement control, posture, function
Term
what is the order of components of a neurological exam
Definition
mental status/communication, vitals, motor screen, function, gait, sensation, reflexes, cranial nerves, cerebellar
Term
what is involved in mental status component of neurological PT exam
Definition
check level of consciousness, orientation, communication, and memory. May be assessed through history taking
Term
when to check vital signs
Definition
at baseline and then after exercise
Term
what to check for in motor screen component of neurological PT examination
Definition
ROM, tone, voluntary movement abilities, strength
Term
if sensation is intact distally, do you need to test proximally?
Definition
no
Term
for what disorder should a very detailed sensory testing including dermatomes be performed
Definition
SCI
Term
when is checking reflexes most useful
Definition
when diagnosis has not yet been established
Term
when to test cranial nerves
Definition
only when indicated by patient history or diagnosis and not yet reported in medical record
Term
when to do cerebellar tests
Definition
if patient's diagnosis suggests possible cerebellar involvement (brain injury, tumor, or cerebellar artery CVA
Term
what is the continuum of mental alertness/consciousness
Definition
alert, lethargic, obtunded, stuporous, comatose
Term
what are 3 ways to test alertness/consciousness objectiely
Definition
glasgow coma scale, continuum, level of consciousness
Term
what to determine in level of consciousness
Definition
non-focal, non-lateralizing
Term
how to test and document orientation
Definition
ask for person, place, location, situation. Always be specific in documenting which ones they answered and how specifically
Term
should you check memory if you can't verify
Definition
no
Term
what are some ways to check memory
Definition
ask for last even recalled, immediate recall, give 3 words then ask them to recall in 3 minutes, test longterm memory by asking birthdate/hometown/age
Term
how to test attention span
Definition
how accurately do they follow directions, digits forward/backward, read a few sentences and ask them to raise hand on certain words, distractibility
Term
how to test general knowledge/presence of dementia
Definition
ask president, state, capital, governor
Term
how to test calculation ability
Definition
serial 7's, percentages, # quarters in a dollar
Term
how to test abstract thinking
Definition
simple proverbs, what would you do if….
Term
other things to test in mental status
Definition
presence of hallucinations, delusions, phobias, compulsive behavior, personality, affect, behavior, cooperation, judgement
Term
who does the formal speech evaluation
Definition
SLP
Term
how to assess communication/language if a patient doesn't respond to questions or speak spontaneously
Definition
try yes/no questions and check ability to follow commands
Term
what are other terms for non-fluent aphasia
Definition
Broca's, expressive, oral motor
Term
what brodmann's areas are damaged in broca's aphasia
Definition
44, 45
Term
what are the indicators of Broca's aphasia
Definition
non-fluent, restricted vocabulary, aware of deficits, delayed responses, perseveration
Term
what are other terms for fluent aphasia
Definition
Wernicke's, reception
Term
in what lobe of the brain is broca's
Definition
frontal lobe
Term
in what lobe of the brain is Wernicke's
Definition
brodmann's area 22
Term
are broca's and wernicke's typically in L or R side of brain
Definition
L
Term
what are the symptoms of Wernicke's aphasia
Definition
hyperfluency, empty speech, little awarenss
Term
what is global aphsia
Definition
loss affects both Wernicke's and Broca's, combining elements of the 2 with severe deficits.
Term
what is anomia
Definition
inability to name objects
Term
what is dyslexia
Definition
impaired ability to read
Term
what is dysgraphia
Definition
impaired ability to write
Term
what is oral apraxia
Definition
motor planning problem; usually seen with parietal lobe injury
Term
what is dysarthria (describe0
Definition
problems with oral-motor mechanism due to CN involvement. Speech is difficult to understand. Slurring may be due to meds or disease/injury
Term
what motor things to look for in observation
Definition
atrophy, hypertrophy
Term
how to look for atrophy specifically
Definition
aymmetry, fasciculations
Term
describe hypotonia
Definition
flaccid, limp
Term
describe hypertonia
Definition
high tone, spastic, rigid
Term
is hypertonia or hypotonia associated with decerebrate/decorticate posturing
Definition
hypertonia
Term
describe resting tremors
Definition
involuntary movements typically seen in Parkinsons. High oscillations at rest that decrease with movement
Term
describe intention tremors
Definition
seen in cerebellar disease with regular oscillations that are absent at rest
Term
are essential tremors regular
Definition
not as regular as resting or intention tremors
Term
what is chorea
Definition
rapid, explosive movements, distal or proximal, irregular and upredictable, associated with low tone
Term
describe athetosis
Definition
slow, writhing, continuous distal movements associated with high tone
Term
describe dystonia
Definition
similar to athetosis but involves large portions of the body and may result in posturing
Term
general suggestions for testing muscle strength in neuro patients
Definition
use gross or specific depending on diagnosis; be systematic; use 5/5 system; observe for patterns of weakness; note substitutions
Term
things to focus on in movement control evaluation for neuro patient
Definition
posture, spontaneous movement, sustainability of positions, stability, isolation of movements
Term
what functional activities should be assessed
Definition
bed mobility, sitting balance, transfers, standing balance, ambulation, self care, endurance, safety, higher level skills/sports
Term
should you use assistive devices when observing gait
Definition
observe gait with as little reliance on assistive devices and physical assistance as possible
Term
what to look for in observing gait
Definition
gait pattern, speed, gait deviations
Term
what are some common gait deviations
Definition
hemiplegic, spastic, steppage, ataxic, parkinsonian, antalgic, waddling, astasia/abasia
Term
what should environment be like for sensation/perception testing
Definition
quiet room, avoid fatigue
Term
define anesthesia
Definition
complete loss of touchsensation
Term
define analgesia
Definition
complete loss of pain sensation
Term
define hypalgeisa
Definition
partial loss of pain sensation
Term
define hyperalgesia
Definition
pain sensation more keenly felt than normal
Term
define hyperesthesia
Definition
touch sensation more keenly felt than normal
Term
define paresthesia
Definition
abnormal spontaneous burning, pricking, numbness
Term
define dysesthesia
Definition
noxious sensation produced by ordinary stimulus
Term
what tract carries pain and temperature to the brain
Definition
spinothalamic
Term
how to test for pain sensation
Definition
use broken q tip, begin distally.
Term
where do pain fibers cross
Definition
at/near entry into spinal cord
Term
what pathway carries light touch and vibration to the brain
Definition
dorsal columns
Term
is vibration a crossed or uncrossed pathway
Definition
uncrossed
Term
how to test for vibration sensation
Definition
use C 128 tuning fork over bony areas
Term
what pathways carrie proprioception to the brain
Definition
posterior column and spinocerebellar tracts
Term
how to test proprioception
Definition
move distal joints first, then move proximally if they can't feel distal; place extremity in one positoin and hve them match with other extremity; thumb find test
Term
how much movement can be detected with an intact proprioception systsem
Definition
1-2mm
Term
how to test cortical sensatiosn
Definition
2 point discrimination, tactile localization, graphesthesia, stereognosis
Term
what is tactile localization
Definition
knowing where someone is touching
Term
what is graphesthesia
Definition
knowing what letter someone is writing on your skin
Term
what is stereognosis
Definition
ability to identify objects without seeing them
Term
what are some types of perceptual deficits
Definition
unilateral neglect, right/left discrimination, agnosia, spatial deficits, many more
Term
what is right/left discrimination
Definition
inability to distinguish right from left
Term
definte agnosia
Definition
inability to recognize familiar stimuli (visual, tactile, auditory)
Term
define somatognosia
Definition
inability to recognize own body parts
Term
define anosognosia
Definition
inability to recognize existence of impairment
Term
define finger agnosia
Definition
inability to identify fingers
Term
define prosopagnosia
Definition
inability to recognize faces
Term
define visual spatial agnosia
Definition
inability to perceive spatial relationships
Term
define tactile agnosia
Definition
inability to recognize objects through handling
Term
define auditory agnosia
Definition
inability to recognize sounds
Term
define spatial relations deficits
Definition
impairment in preceiving spatial relations between objects or between self and objects
Term
define figure ground
Definition
inability to differentiate foreground from background
Term
define form constancy
Definition
inability to distinguish subtle variations in form
Term
define position in space
Definition
inability to interpret concepts of spatila positioning of objects
Term
how to see if a person has difficulty with depth and distance
Definition
note when pouring liquids or reaching for objects
Term
define topographical disorientation
Definition
inability to perceive relationships between places (can't find way back to room)
Term
define apraxia
Definition
inability to perform certain skilled, purposeful movements in the absence of motor, sensory, or coordination deficits
Term
define constructional apraxia
Definition
impariment in producing designs by copying, drawing, or constructing
Term
define dressing apraxia
Definition
inability to put on clothing correctly or in proper sequence
Term
define ideometer apraxia
Definition
inability to use, imitate, and understand gestures
Term
define ideational apraxia
Definition
inability to conceive of how to carry out a movement
Term
define verbal/oral motor apraxia
Definition
inability to form and organize intelligible words
Term
define unilateral neglect
Definition
inattention to the affect side of the body
Term
how to test for unilateral neglect
Definition
observations, draw a clock, draw a person, test for extinction
Term
what is a normal grade deep tendon reflex
Definition
2
Term
what is a hyporeflexive deep tendon reflex
Definition
0-1
Term
what is a hyperreflexive deep tendon reflex
Definition
3 to 4
Term
what is the level of the biceps tendon
Definition
C5
Term
what is the level of the tendon DTRq
Definition
C7
Term
what is the level of the brachioradialis DTR
Definition
C6
Term
what is the level of the quads DTR
Definition
L4
Term
what is the level of the achilles DTR
Definition
S1
Term
are superficial reflexes normally present
Definition
yes
Term
are superficialy reflexes commonly tested by PTs?
Definition
no
Term
what are examples of superficial reflexes
Definition
corneal, pharyngeal, scapular, abdominal, plantar
Term
what are brainstem reflexes important for
Definition
diagnosis of brain death
Term
what are the 3 brainstem reflexes
Definition
oculocephalic, oculovestibular
Term
how to test oculocephalic reflex
Definition
doll's eyes: turn head. Eyes lag at first then conjugately come to midline. Normally present
Term
how to test oculovestibluar reflex
Definition
cold water in ear canal. Normal response is tonic deviation of eyes toward stimulus.
Term
what are 3 pathological reflexes
Definition
clonus, babinski, hoffman's
Term
describe clonus
Definition
quick stretch produces repetitive, oscillating contractions. May be sustained or unsustained. Can estimate # of beats.
Term
Describe babinski
Definition
stroke lateral sole of foot across toes. Positive if hallux extends
Term
describe hoffman's
Definition
flick the middle fingernail. Positive if thumb adducts
Term
are tonic reflexes pathological if present or not present?
Definition
pathological if present
Term
who usually tests cranila nerves
Definition
neurologist
Term
describe CN I testing
Definition
olfactory nerve. One nostril at a time. Pungent, common odors like coffee, lemon, vanilla
Term
describe CN II testing
Definition
1. exam with ophthalmoscope; 2. visual acutiy with Snellen chart; 3. visual fields/hemianopsia
Term
describe CN III, IV, VI testing
Definition
ptosis, eye movements, PERRLA, EOM intact (follows H)
Term
what is PERRLA
Definition
pupils equla, round, reactive to light, accommodating
Term
describe CN V testing
Definition
motor: clench teeth, palpate masseter, temporalis, pterygoid; sensory: sensation to ophthalmic, maxillary, mandibular
Term
describce CN VII testing
Definition
facial motor: facial expressions; facial sensory taste anterior 2/3 tongue
Term
how to differentiate between central and peripheral facial
Definition
central: lose contralateral lower face muscles; peripheral: lose ipsilateral upper and lower face muscles
Term
describe CN VIII testing
Definition
vestibulocochlear; cochlear branch = test hearing: whisper, rub fingers; vestibular branch observe saccades, nystagmus, postional effects, caloric tests
Term
describe CN IX testing
Definition
glossopharyngeal; test swallowing, gag reflex, taste to posterior 1/3 tongue
Term
decribe CN X testint
Definition
vagus: test swallowing, gag reflex, hoarseness. Look for symmetry of uvula (uvula deviates to strong side unless both sides are weak, then no deviation.) check palatal reflex.
Term
what is the palatal reflex
Definition
touch plate, uvula elevates
Term
describe CN XI testing
Definition
spinal accessory: motor to SCM and traps
Term
describe CN XII testing
Definition
hypoglossal: stick out tongue, will deviate to weak side
Term
what tracts does Romberg test for
Definition
posterior column and spinocerebellar tracts
Term
how to test Romberg
Definition
close eyes and maintain standing position: positive if patient loses balance or takes a step
Term
what are some cerebellar tests
Definition
RAM, FNF, H-S, rebound, tandem walking, balance test (look for differences L to R, ataxia)
Term
for the next questions, determine if it is UMN or LMN lesion
Definition
ok
Term
may involve brain, spinal cord, or both
Definition
UMN
Term
may be segmental (spinal root distribution) or peripheral (peripheral nerve distributlion)
Definition
LMN
Term
generally see decreased tone
Definition
LMN
Term
generally see increased tone after initial "neural shock"
Definition
UMN
Term
little atrophy
Definition
UMN
Term
atrophy and fasciculations
Definition
LMN
Term
increased DTRs
Definition
UMN
Term
decreased superficial reflexes
Definition
both UMN and LMN
Term
decreased DTRs
Definition
LMN
Term
pathological refflexes present
Definition
UMN
Term
pathological reflexes absent
Definition
LMN
Term
mental status changes may be present
Definition
UMN
Term
sensory disturbances not sharply defined
Definition
UMN
Term
EMG changes
Definition
LMN
Term
distinct pattern of sensory changes and/or pain
Definition
LMN
Term
what are the anatomical levels of localization
Definition
supratentorial, posterior fossa, spinal, peripheral
Term
what are peripheral levels of localization of lesions
Definition
mononeuropathies, mononeuritis multiplex, polyneuropathies
Term
whata re mononeuropathies
Definition
lesion involving a single nerve
Term
what is mononeuritis multiplex
Definition
several individual nerves are involved
Term
describe polyneuropathies
Definition
usually symmetrical, usually distal limbs
Term
describe presentation of cerebellar lesions
Definition
difficulty with intentional movements, ataxia, dysmetria
Term
describe presentation of basal ganglia lesions
Definition
decreased overall movement or excessive, unintentional, meaningless movement
Term
describe presentation of unilateral cortex lesions
Definition
sensory and motor deficits dominate on contralateral side
Term
describe presentationsof cortex lesions
Definition
possible aphasia, agnosia, amnesia, apraxia
Term
describe presentations of brainstem lesions
Definition
unilateral: contralateral sensory and motor but ipsilateral cranial nerves; bilateral: major sensory/motor loss. Lower CN involvement
Term
describe presentations of spinal cord lesions
Definition
unilateral: contralateral pain and temp loss, ipsilateral motor and proprioceptive loss below lesion; complete: total motor and sensory loss below lesion
Term
describe lesions involving radicular pain
Definition
involvement is below foramen magnum. Follows nerve root distribution
Term
will peripheral lesions be ipsilateral or contralateral
Definition
ipsilateral
Term
what is the sequence of recovery for unilateral neglect
Definition
1. patient fails to respond to stimulus on contralateral side of lesion or thinks the stimulus is on ipsilateral side; 2. patient responds to stimulus on contralateral side of lesion; 3. patient responds only to ipsilateral stimulus when bilateral stimuli are given; 4. patient responds to bilateral stimuli
Term
list perceptual tests
Definition
stereognosis, graphesthesia, right/left discrimination, draw a person test
Term
what does agraphesthesia indicate
Definition
left parietal lobe damage
Term
what is left/right discrimination
Definition
ability to identify left and right
Term
what part of the brain might be damaged in the case of inability to discriminate leftright?
Definition
left pairetal lobe
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