neuro exam 1
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. What would you like to do?
what are the 3 main spinal tracks?
- dorsal columns
what is a bundle of axonal fibers with similar connections?
what are long, ascending fibers from sc to brainstem, cerebellum or thalmus and long descending fibers from cortex or brainstem to sc?
what are intersegmental fibers withing the sc?
what is a divison of spinal cord white matter consisting of fasciculi/tracts?
what are the three funiculi in the spinal cord?
what does the dorsal column relay?
sensory info; propreoception, vibration, discrimitive touch
what are the two parts of the dorsal column?
- fasciculus cuneatus; lateral
- fasciculus gracilis; medial
where does the fasciculus cuneatus get its sensory info from?
upper trunk and UEs; T6 and above
where does the fasciculus gracilis get its sensory info from?
lower trunk and LEs; runs the entire length of the spinal cord
where does the info from the dorsal column cross?
the medulla is AKA the?
all sensory info goes through the ________ and is interperted and sent to the correct structure
where does info from the dorsal columns synapse?
postcentral gyrus of the parietal lobe laterally
what kind of info does the lateral corticospinal tract carry?
what tract is the descending efferent fibers from cerebral cortex to spinal cord and is a major pathway for volitional movement?
where does the info that is carried in the lateral corticospinal tract come from?
precentral gyrus of the frontal lobe
where does the info carried in the lateral corticospinal tract cross?
where does the lateral corticospinal tract synapse?
alpha motor neuron/anterior horn
efferent fibers that travel in the lateral corticospinal tract exit at the ventral root and synapse at the _____________ with ____________.
neuromuscular junction; skeletal muslces
what type of info is carried in the spinothalamic tract?
pain, temp., crude touch
where does info carried in the spinothalmaic tract cross?
in the spinal cord within 1 or 2 levels
where does info carried in the spinothalmaic tract finally synapse?
postcentral gyrus/parietal lobe
what is the somatotopic pattern for the dorsal column?
what is the somatotopic pattern for spinothalamic tract?
what is somatotopic pattern for the corticospinal tract?
T/F: all tracts are bilateral
T/F: neuronal axons give off many collaterals on the way to their primary target
T/F: ascending and descending tracts typically influance mulitples sites within the CNS
T/F: the loss of a single tract can not be partially compensated for by remaining tracts
what is brown sequard syndrome?
hemi section of the spinal cord that is damaged
what is the inital damage done with sequard syndrome?
ipsilateral spinal shock below the level of the lesion
what follows spinal shock with brown sequard syndrom?
ipsilateral loss of all motor, proprioception, discriminative touch and increased MSR below the level of the lesion and contralateral loss of pain and temp below the level of the lesion
what is spinal shock?
occurs during the inital period following a traumatic injury to the spinal cord. it begins to resolve within 24 hours, usually resolves completely within a few weeks of injury.
with spinal shock flaccid paralysis, areflexia, and sensory lose typically occurs above or below the lesion?
as spinal shock resolves what happens?
- MSRs return
- hyper reflexia and spasticity develp
what is CN I and is it sensory, motor or both, and how do you test it?
- olfactory; smell
- pt. closes eyes and move the smell from outward in and have them tell you when they smell something
what is CN II and is it sensory, motor, or both and how do you test it?
- optic; the fact of seeing something
- snellen chart
what is CN III and is it sensory, motor, or both and how do you test it?
- pupil constriction (direct or consensual), up, down and medial eyeball movement and elevation of the eyelid
What is CN IV and is it sensory, motor or both and how do you test it?
- down and lateral eye movement
what is CN V and is it sensory, motor, or both and how do you test it?
- sensory: face (ophthalmic, maxillary, mandibular), corneal, anterior tongue, gums and inside lips
- motor: mastication; masseter
what is CN VI and is it sensory, motor or both and how do you test it?
- pure lateral eye movement
what are the 2 main ways you screen CN III, IV, and VI?
- saccadic movement; accuracy
- smooth pursuit
what is CN VII, is it sensory, motor or both, and how do you test it?
- sensory: taste to anterior 2/3 of tongue (sweet & salty)
- motor: facial expression; make funny faces
what is CN VIII, is it sensory, motor or both, how is it tested and how do you know if the results are abnormal?
- vestibulocochlear; hearing and vestibular
- hearing: Rinne (air conduction) and Webber (bone conduction) test
- vestibular: caloric (COWS) head thrust (wiggle, wiggle, thrust)
- abnormal: if eyes move away from nose with thurst
what is CN IX, is it sensory, motor, or both, and how is it tested?
- sensory: touch and taste to posterior 2/3 tongue and pharyngeal wall
- motor: swallowing
- test: gag reflex, swallow a liquid
what is CN X, is it sensory, motor or both, how is it tested?
- sensory: palate sensation, innervation of thoracic and abdominal viscera (parasympathetic "rest & digest")
- motor: palate elevation and larynx innervation
- test: open and say "Ah"; if uvula sags to either side the lesion is on that side
what is CN XI, is it sensory, motor, or both, how is it tested?
- motor: head turning (SCM) and shoulder shrug (traps)
- test: raise shoulders, turn head
what is CN XII, is it sensory, motor, or both and how is it tested?
- motor; tongue movement; symmetry
- test: stick tongue out; if it deviates that the side of the lesion. examine resting tongue for writhing
what are the two basic categories of cells that make up the nervous system?
- nerve cells (neurons)
- glial cells (support cells)
what are the 4 main functions of schwann cells within the PNS?
- produce myelin
- metabolic support
- electrical insulation and conduction
- nodes of ranvier
what are the 4 types of glial cells within the CNS and what are their function?
- oligodendrocytes: myelin sheaths
- astrocytes: structural support/vascular link
- ependymal cells: lines the ventricles
- microglial: NS response to injury
what structures make up the CNS?
what structures make up the PNS?
what are the 2 main classifications for neurons?
what are the 3 different shapes for neurons? and which is most common?
- mulitpolar (most common)
what are the 4 functions of neurons?
- sensory (afferent)
- motor (efferent)
- interneuron (neuron inside a single structure)
- projection (neuron projects inside another structure)
T/F: afferent/efferent doesn't only refer to sensory and motor. It also refers to direction of travel.
what are the neuronal parts?
- cell bodies (grey matter)
- axon (white matter)
- myelin sheath
- axon terminal
- synaptic cleft
neurons are cells specialized for rapid communication also known as _____________
what is the resting membrane potential of a neuron and what is it maintained by?
other than salatory conduction, what is another way that neurons communicate?
synapses: chemical transmitters released by axonal terminals that create stimulation or inhibition
how do axons conduct signals away from the cell body?
action potentials (APs)
action potentials is another name for?
where are the impulses the fastest or the slowest and where are they carried?
- surface membrane of axon
what is an action potential followed by and what happens?
- refractory period
- Na flows in (absolute) and K flows out (relative)
what 2 ways can nerves be classified?
- conduction velocity
- axon size
how do you classify nerves based on conduction velocity?
- type A: largest
- type B
- type C: smallest
what are type A nerves and are they myelinated?
- sensory and motor
- yes; myelinated
what are type B nerves and are they myelinated?
- visceral and autonomic
- yes; myelinated
are type C nerves myelinated?
what are the 4 types of A fibers and which is largest and smallest?
- A alpha: largest
- A beta:
- A gamma:
- A delta: smallest
which is the largest and smallest classifications of PN's based on axonal diameter?
- group I: largest
- group IV: smallest
which groups of PN's are myelinated?
I, II, III
which group of PN's are NOT myelinated?
where does synaptic transmission take place?
what are the three characteristics that synapses share?
- pre-synaptic ending: chemical released
- synaptic cleft: chemical diffuses
- post-synaptic ending: chemical binds
what are the common neurotransmitters?
what is described as site of neuronal information processing and what is one example?
what is described as the connection between sites and what is one example?
ganglia (PNS only)
these are all part of what?
these are all part of what and are specific to what?
- white matter
- specific to CNS
what makes up the cerebrum?
- 2 hemispheres
gyrus and sulcus are found where?
the thalamus and hypothalamus are located where?
what is responsible for conscious behavior?
what is the cerebrum composed of?
- outer cortex: gray matter
- inner cortex: white matter
- embedded with "islands" of gray matter composing nuclei
what are the three functions of the two hemisperes?
- association: intergrating, analyzing, and recongizing input
the two hemispheres are broken down into 5 lobes what are they and what do they do?
- frontal: motor, higher thinking, personality, judegment
- parietal: sensory
- occipital: vison
- temoral: auditory & memory
- limbic: drives, emotions, memory
what is the primary motor area?
where is the brocas area?
where is the primary sensory area?
where does the post-central gyrus receive is information from?
where does visual interpretation take place?
do the central and peripheral vision information travel together or separably?
what is the hippocampus responsible for?
memory: facts and events
what is the amygdala responsible for?
where is the limbic lobe located?
gyrus above corpus collisum in medial brain
what is the hypothalamus mostly responsible for?
what is the basal nuclei responsible for?
movement initiation, fine tuning
what are deep inner islands of gray matter/cell bodies?
what are the major structures associated with basal nuclei?
- globus pallidus
T/F: the basal nuclei work in conjunction with the cerbellum and frontal lobe to produce accurate, controlled refined movement.
the thalamus is involved in?
- mediation of sensation
- motor activites
- cortical arousal
- pain modulation
what is thalamic pain?
pain sensation; always in pain for no reason
what are the 7 homeostatic roles of the hypothalamus?
- autonomic control center
- emotional response and behavior
- body temp. regulation
- regulation of food intake
- regulation of thirst and water balance
- sleep-wake cycle
- control endocrine function
what is the main role of the cerebellum?
the vermis of the cerebellum is responsible for?
coordination of trunk movements
the hemispheres of the cerebellum are responsible for?
coordination of limb movements
T/F: in conjunction with the basal nuclei and frontal lobe, the cerebellum plays a major role in the production of smooth, coordinated and appropriate movement patterns.
the cerebellum receives __________ input from the body as well as ___________ info.
the brain stem houses the cell bodies for CN __ through ___.
what are the three divisions of the brain stem?
the grey matter is _____ located and the white matter is ____ located within the brainstem
- central (grey)
- peripheral (white)
the main purpose of the brain stem is?
life sustaining; heart beat and respiration
what is the relay station for tracts traveling between the cerebrum and spinal cord or the cerebellum?
what functions with the medulla to regulate breathing rate, provides connection of the cerebellum to the cerebrum, and contains reflex centers to postion the head in response to visual and auditory stimuli?
what is the control center for heart and respiratory rate, extension of the spinal cord, reflex center for vomiting, sneezing, and swallowing?
what are the two primary functions of the spinal cord?
- coordination of motor information and movement patterns
- communication of sensory info
_________ reflexes lie in the spinal cord such as withdrawl, as well as plays a role in movement patterns.
what allows for communication between the brain and the peripheral nerves?
the spinal cord ends around level _______ and then becomes the _________
what are the enlargements of the spinal cord and what are they for?
- cervical and lumbar
- where the nerves for the arms and legs come out
where is the grey matter for the spinal cord and what does it contain?
- dorsal/posterior horn: receives and transmits sensory info
- anterior horn: houses cell bodies of LMN
where is the white matter for the spinal cord and what does it do?
- ascending: sensory; afferent
- descending: motor; efferent
what are the coverings of the connective tissue of the spinal cord from superficial to deep?
- epineurium: superficial
- endoneurium: deep
what are the 3 meningeal coverings for the spinal cord?
- dura mater
- arachnoid mater
- pia mater
what are the arteries for the spinal cord and how many of each do you have?
- anterior spinal artery: 1
- posterior spinal artery: 2
what are the 6 arteries that supply the brain?
- anterior cerebral
- middle cerebral
- posterior cerebral
what does the vereterbral artery supply in the brain?
cerebellum and spinal cord
what does the basilar artery supply in the brain?
brainstem and cerebellum
what does the carotid artery supply in the brain?
- internal: becomes MCA
- external: head and face
what does the anterior cerebral artery supply in the brain?
frontal lobes, superior surfaces and medial aspects of the brain
what does the middle cerebral artery supply in the brain?
lateral regions of cerebral hemispheres and temporal region
what does the posterior cerebral artery supply?
occipital lobe and inferior cerebral hemispheres
what carries the CSF in the brain?
what is the purpose of CSF?
- fluid cushion/bouyancy
- cleansing of the brain
where is the CSF made?
chroid plexus (ependymal cells)
how many ventricles do you have?
4: lateral (2) third, and fourth
what are the 3 functions of the meninges?
- cover and protect the CNS
- enclose venous sinuses and protect blood vessels
- provide space for CSF
what composes the dural infoldings and dural venous sinuses between the two layers providing venous drainage of the brain and drainage for the CSF?
what is the intermediate layer that plays a role in transporting the CSF to the dural spaces?
what is the "gentle mother" and attaches directly to the brain and is highly vascular?
what are the three destinations for sensory input?
- local reflex pathways
- directed to the cerebral cortex
a neuron whose axon descends from the cerebral cortex or brain stem to the spinal cord ( or CN nuclei) to affect the activity of the LMN's
what are large neurons in the spinal anterior horn (and in CN motor nuclei) whose axons innervate the extrafusal fibers of skeletal muscles?
what receives direct info from cerebral cortex, brain stem and local reflex?
what includes the corticospinal, vestibulospinal, reticulospinal, tectospinal, rubrospinal and corticobulbar tracts?
what receives indirect info from the cerebellum and basal ganglia?
motor neurons in cerebral cortex and brainstem with descending axons that terminate on LMN's in the anterior horn
alpha motor neurons in anterior horn that terminate on skeletal muscle (effector)
strength is ______ with UMN damage and _____ with LMN damage
muscle tone is ______ with UMN damage and _____ with LMN damage
- increased (spasticity)
- decreased (flaccidity)
MSR's are _____ with UMN damage and ______ with LMN damage
- increased (hyperreflexia)
- decreased (hyporeflexia)
atrophy is _____ with UMN damage and ____ with LMN damage
others signs with UMN damage are ____, _____ and other signs for LMN damage are _____, ______.
- clonus, abnormal reflexes (babinski)
- fasciculations (writhing muscle), fibrillations (eye twitch)
what carries information from the brain through the spinal cord to the motor
what carries information form the peripheral body up to the brain?
a sensory assessment assists in making clinical decisions regarding what?
- identifying goals and outcomes
- establishing POC
documentation of the sensory assessment should include what?
- the type of sensory deficit
- quantity and degree of involvement
- localization and boundaries of the deficit
in order to learn a motor behavior one must be able to?
- take in sensory info
- process it
- use it to plan and organize behavior
T/F: impairments related to intake, processing or organizing sensory info leads to deficits in behavior output (motor movement)
what are the 2 approaches to POC's for pt. with impaired sensation?
- sensory intergration
what is intrinsic feedback and give an example.
- patient feedback
- knowing hand on foot is not painful even though they feel pain
what is extrinsic feedback and give an example
- caregiver feedback
- me telling them that their hand on their foot is not painful even though they feel pain.
what is the compensatory approach?
patient education and functional modification to accomidate for the limitations imposed by the sensory deficit.
what is the sensory intergration approach and what is the purpose?
- ability of the brain to recognize, interpret and use sensory information
- provides an internal representation of the environment that informs and guids movement to allow effective use of the body in the given environment
what is feedback?
sensory information receivd during the movement to stimulate adjustments
what is feedforward?
sensory information obtained from experience to proatively adust output
Do you test sensory or motor function first? why?
- if sensory is jacked up, motor will also be jacked up
what is a skin sensory distribution of a given spinal nerve root level?
what is a motor distribution of a given spinal nerve root level?
what are the three classifications of sensory receptors?
- superficial sensation
- deep sensation
- combined cortical sensation
what are the two tracts that sensory info travels?
- dorsal columns
what are responsible for superficial sensations such as light touch, pain, temperature, and pressure?
what are responsible for deep sensations related to position sense, awareness of joint position, vibration, and kinesthetic awareness?
what is the order of sensory exam?
- mental status
- combined cortical
when doing a mental exam, what are the 4 things you are checking?
what are the 3 things you would ask someone related to orietntation and how would you document that?
- time, person, place
- A&OX3 (or depending on how many they're oritented to)
what would you call someone who is awake and attentive to normal levels of stimuli and has normal interaction that is appropriate?
what would you call someone who appears drowsy and may easily fall asleep without stimuli and may have difficulty focusing or maintaing attention. Their interactions may be easily diverted
what would you call someone who is difficult to arouse from a somnolent state and frequently confused when awake and their interactions are largely unproductive
what do you call someone who is in a semi-coma and only responds to strong, noxious stimuli and then immediately returns to unconsciouness and is unable to interact with anyone around
what do you call someone who cannot be aroused by any type of stimuli and their primitive reflexs may or may not be present
how would you perform an attention screen?
- begin with 1-2 step tasks then add multiple steps...
- 1: pick up pen
- 2: bend over and tie shoe
- 3: bend over and tie shoe and then pick up pen
how would you perform the orientation screen?
- ask them:
- person: "do you know your name, how old are you, when were you born"
- place: "do you know where you are, do you know what city/state we are in, what is your home address"
- time: "what year is it, what is todays date, what season is it, what time of day is it"
what are the three areas tested when screening cognition?
- fund of knowledge: sum total of an individuals learning and experience in life
- calculation ability: foundational mathematical ability
- proverb interpretation: ability to understand the meaning of words/phrases used out of their original context
what types of memory to do you screen? why?
- short term and long term
- short term deficits more liekly to interfere with the ability to assess sensory function as difficulty in following directions will be present
what are a series of brief tests that provide and overview of the system of intrest
administration of the sensory exam involves?
- prepping the environment
- prepping the patient
what is the information documented when doing a sensory screen?
- sensation tested- obj
- body surface affected-obj
- degree or severity of involvement-obj
- feelings of sensation loss-sub
- potential impact of sensory loss-obj
what are the key points to performing a sensory screen correctly?
- vision occulded
- randomly and not too rapid in succession
- stimulus applied to all key points
sharp/dull discrimination is used for what and determines what?
- pain perception
- protective sensation function
how do you screen temp. awareness and what are the temps. used?
two test tubes; 1 hot (104-113 deg) and 1 cold (41-50 deg)
What do you use to screen light touch and what does it determine?
- cotton ball
- perception of tactile input
what are the 4 superficial sensation screens?
- pain perception
- temp. awareness
- touch awareness "light touch"
- pressure awareness
what is the kinestheia awareness screen and how would you perform?
- awareness of movement as it occurs.
- have the pt. tell me what direction their limb is moving (up, down, in, out) as it is moving. Or, if unable to verbalize have them mimic the movement simultaneously with the other limb.
what is propreoceptive awareness and how would you perform the screen?
- joint position at rest.
- fix the pt. limb in a certain position and have the pt. describe to me the position. If unable to verbalize, have the pt. mimic the position with their other limb.
what are the 3 screens for deep sensation?
- kinesthesia awareness
- proprioceptive awareness
- vibration perception
what are the 2 most common ways to screen for combined cortical sensation?
stereognosis and two point discrimination
what are the 7 ways to screen for combined cortical sensation?
- tactile localization
- two-point discrimination
- double simulataneous stimulation
- recognition of texture
what is sterognosis?
- tactile recognition of objects.
- sticking your hand in your pocket and knowing its a quarter
what is tactile localization?
- ability to localize touch sensation on the skin
- someone pokes you on the back of the arm, your able to point directly to that same point even though you never saw it.
what is two point discrimination?
- ability to perceive two points of stimuli.
- determine if its two points or one on your skin while using a aesthesiometer
what is double simulataneous stimulation?
ability to perceive a simultaneous touch stimulus on opposite sides of the body either proximally to distally or one side to the other
what is graphesthesia and what must you do between each drawing?
- abilty to recognize letters or numbers traced on the skin.
- "wipe" the skin
what is recognition of texture?
- use different textures and have the patient differentiate between the different textures.
- wool, cotton, silk, soft, scratchy
what is barognosis?
set of weights the same size but different weights
what is 4+ msr?
very brisk reflex
what is 3+ msr?
normal if bilateral; brisk response
what is a 1+ msr?
present, diminished response vs. opposite side
what is a 0 msr?
what is hypotone?
what is hypertone?
spasticity or rigidity
tone can vary due to?? (7)
- volitional effort and movment
- stress and anxiety
- position and interaction of tonic reflexes
- general health
- arousal level
what is a 0 when it comes to tone?
no response; flaccid
what is a 1 when it comes to tone?
decreased response; hypertonia
what is a 2 when it comes to tone?
what is a 3 when it comes to tone?
exaggerated response; mild-mod hypertonia
what is a 4 when it comes to tone?
sustained response; severe hypertonia
what is a state of hypertone that exhibits velocity dependent resistance to passive stretch that can be associated with injury to the corticospinal tract and can be described as clasp-knife?
what is a state of hypertone with uniform increased resistance throughout the entire ROM that is NOT velocity dependent that is associated with basal-ganglia pathology and is described as cogwheel or lead pipe?
what is the key to elicit spasticity?
speed of PROM- the faster the movement the stronger the spastic response will be.
on the ashworth scale what is a 0?
no increase in muscle tone; normal
on the ashworth scale what is a 1?
slight increase in muscle tone, manifested by a catch and release or by minimal resistance and the end of the ROM when the affected parts is moved in flexion or extension
on the ashworth scale what is a 1+?
slight increase in muscle tone manifested by a catch followed by minimal resistance throughout the remainder (less than half) the ROM
on the ashworth scale what is a 2?
more marked increase in muscle tone throughout most of the ROM but affected parts easily moved
on the ashworth scale what is a 3?
considerable increase in muscle tone, PROM difficult
on the ashworth scale what is a 4?
affected parts rigid in flexion or extension
what are involuntary, predictable and specific responses to stimulus dependent upon an intact arc?
what are DTR's?
- deep tendon reflexes
- indirect stretch of ms spindles
what is an example of a cutaneous reflex?
plantar reflex; babinski
what are the 5 primitive/spinal reflexes?
- flexor withdrawal
what are the 5 tonic/brainstem reflexes "tuning reflexes"?
- asymmetrical tonic neck reflex
- symmetrical tonic neck reflex
- symmetrical tonic labyrinthine
- positive supporting
- associated reactions
what is noxious stimulus to the sole of the foot that ___________
stimulus to cheek causes infant to search for food?
grasp forearm and pull from supine to sitting creates total flexion of the UE?
dropping creates extension, ab-d of UE's, open hand, followed by flexion and ad-d of the arms across the chest
sudden extension or ab-d of extremities; crying
pressure to the palm causes maintained flexion of the fingers or toes
rotation of the head creates "fencing" position
asymmetrical tonic neck reflex
flex of head creates UE flexion and LE extension; extension of the head creates UE extension and LE flexion
symmetrical tonic neck reflex
prone position creates flexion of all limbs; supine creates extension of all limbs
symmetrical tonic labyrinthine
pressure on the ball of the foot creates rigid extension of the LE's
resisted voluntary movement creates involuntary movement in the resting extremity
voluntary movement patterns utilize functinally linked muscle synergies in accordance with the CNS to produce a functional action
involuntary mass synergies that are obligatory, highly sterotypical massed patterns of movement
balance is the result of complex interactions between?
- sensory (afferent)
- motor (efferent)
- CNS intergration
response to external forces acting on the body
reactive postural control
anticipated response to internally generated, de-stabilizing forces imposed on body movements
proactive postural control
allows the indicidual to appropriately "modify sensory and motor systems in response to changing task and environmental demands"
adaptive postural control
responsible for orienting and aligning the head in space and keeping the eyes and mouth horizontal. greatest influence on posture and movement between ages 10-12 months
what are the 4 ways of head righting?
- head/neck on body
- labyrinthine- gravity cues
- body on body
what are the 2 ways of trunk righting?
extremity movements that occur in response to rapid displacement of the body by horizonal or diagonal forces, persist through lifetime
what are the 5 protective reactions?
- downward extension of LE's; 4 months
- forward protective extension of UE's; 6 months
- lateral protective etension of UE's; 7-8 months
- backward protective extension of UE's; 9 months
- protective staggering of LE's; 15-17 months
most advanced postural reactions, the last to develop and persist throughout lifetime that allow the body as a whole to adapt to changes in the relationship of the COG to the BOS
what are the 3 tilt reactions?
- lateral head & trunk righting
- UE & LE opposite from the weight shift ab-d
- trunk rotation in opposite direction from weight shift
what are the 5 equilibrium reactions?
- prone 6 months
- supine 7-8 months
- sitting 7-8 months
- quadruped 9-12 months
- standing 12-24 months
what are the 4 motor balance strategies?
- ankle: small disturbances
- hip: larger & faster disturbances
- change in support: UE or LE used to make new contact
- stepping: fast, large postural perturbations
what is the study of prenatal development?
what is the time span of an embryo and what is the time span of a fetus?
- embryo: 2-8 weeks
- fetus: 9 weeks- 9 months
why do we need to know about embryology?
disruption in the process leads to many of the pathologies we treat in both children and adults
what are the 3 primary germ layers?
- ectoderm: outermost
- mesoderm: middle
- endoderm: innermost
once an egg is fertilized what do we call it?
once approx. 16 blastomeres have developed what forms?
once a cavity form in the morula it is called a?
what part of the blastocyst becomes the placenta? What part gives rise to the embryo?
- outer layer; trophoblast
- inner layer
when does implantation into the uterus typically take place?
when after conception does the embryo have 2 layers and then 3 layers?
- 2 layers: 2 weeks
- 3 layers: 3 weeks
when does the primitive node, neural groove, and neural plate form?
what is a cellular rod along the axis of the embryo?
what does the vertebral column develop around?
in the areas where there is no vertebral bodies the notochord will become the?
the notochord will induce the ectoderm over it to become the neural plate which is the beginning of the?
what does the neural tube become?
brain and spinal cord; CNS
what does the neural crest become?
peripheral and autonomic nervous system
when does the neural tube begin to close?
what happens in week 4 of embryo developement?
- neural tube closes
- takes a c curve shape
- upper and lower limb buds become visable
what do these structures become:
- 1: forebrain
- 2: midbrain
- 3: hindbrain
the ponsencephalon becomes the __________ which later becomes the _______.
the diencephalon houses the _________ and ________.
thalamus and hypothalamus
the rombencephalon becomes the _________ which becomes the __________.
- pons & medulla
the myelencephalon becomes the _________
where do the ventricles develop from?
cavity of the neural tube
if the nervous system is disrupted during fetal development what 4 pathologies might we see?
what is failure of the rostral neuropore to close?
aneephaly; no cerebrum
what is failure of the caudal neurospore to close?
myelonmeningocele; spina biffida
what is failure of the prosencephalone to divide?
holoprosencephaly; no divison of cerebral hemisphere
T/F: babies born with holoprosencephaly can be born cyclops?
what is buildup of CSF in the ventricles in the brain?
rapid brain development
hand plates form
lower limb is paddle shaped
lens and nasal pits visible
what stage of embryo development is this?
at what week does the trunk and neck begin to straighten out in embryo development?
at what week does the gut begin to develop and there is extensive limb developement during embryo development?
regions of the limbs become distinct
head is round and larger than proportionate
auricles of ears take shape
embryonic period is over and is now a fetus
what week of development is this?
what are the 5 principles of lifespan development?
- embedded with history
normal development occurs in a positive direction (acquistion of skills) through early life and in a negative direction late in life (loss of abilities after 65 y/o)
lifelong lifespan approach
movement fosters and supports the development of inteligence and social interaction. What lifespan approach is this?
motor skills can adapt based upon cognitive and social demands of the environment or function. what lifespan approach is this?
flexible and plastic
what lifespan approach refers to the psychological, social, or physical surroundings?
the time in which a person is raised, their life experiences, interactions with family, friends, teachers will also affect the individuals views of life and can acqustion of motor skills as well as sequence of motor development. What lifespan approach does this describe?
embedded in history
what is the most useful way to measure motor changes across the lifespan as it is universally recognized marker of biologic, physologic, and social progression?
age is associated with?
- stages of cognitive development
- societal expectations
what is considered infancy?
what are the phases of infancy according to piaget and erickson?
- piaget: sensorimotor, pairing of sensory and moter reflexes lead ot meaningful movement
- erickson: trust vs. mistrust and attachments formed
what is considered the time frame for childhood?
what are the marked characteristics of childhood?
- initiative to plan and execute movement stratigies to solve daily problmes
- extremly aware of enviroment
- begins to use symbols such as language or objects to represent things that are not physically present
what does preoperational thinking begin?
works industriously for recognition; able to classify objects based upon characteristics. Starts to experiment and gains self confidence. What is this called and what is the typical age?
- concrete operations
- school age
What development time period is marked by these characteristics and what is the age span?
Right before, during and after puberty
girls exhibit more advanced social and emotional behavior earlier
know oneself, journey ahead, and how to get there
move away from egocentrism, sense of community
- females: 10-18 years
- males: 10-20 years
what is typically achieved by age 20, but is variable?
what are the ages for these time frames:
- early adulthood: 18/20- 40
- middle adulthood: 40-65
- older adulthood: 65- death
- young old: 65-74
- middle old: 75-84
- old old: 85 and greater
T/F: with cognitive challenges, the rate of development is decreased across all domains (psychological, social, and physical)
T/F: motivation to move comes from intellectual curiosity
what are the 5 stages of development according to piaget and briefly describe them.
- infant: sensorimotor, pairing of these two lead to purposeful movement
- preschool: preoperational, unidimesional awareness of universe, begins to use symbols
- school age: concrete operational, solves problems with real objects, classification conservation
- prepubescent: formal operational, solves abstract problems, induction and deduction
what are the 8 stages of development according to erickson and briefly describe them
- infancy: trust vs. mistrust
- late infancy: autonomy vs. shame/guilt
- childhood: initative vs. guilt
- school age: industry vs. inferiority
- adolescent: identity vs. role confusion
- early adulthood: intimacy vs. isolation
- middle adulthood: generativity vs. stagnation
- late adulthood: ego integrity vs. despair
what is maslows heirarchy of needs from the bottom to the top?
- survival needs
- love, belonging, affection
- self actualization
according to directional concepts of development what does cephalo-caudal mean?
head control > trunk > extremities
according to directional concepts of development what does proximal-distal mean?
from midline of the body outward
according to directional concepts of development what does mass-specific mean?
from simple to complex; progresses to dissociation (requirement for gait)
according to directional concepts for development what does gross-fine mean?
large muscle movement to fine muscle control
what are the 3 factors that affect movement?
- biomechanics of the situation
- muscle strength
- level of neuromuscular control
full-term babies are born with predominant _______ tone.
as development progresses active movement towards extension occurs. What part of extension occurs first?
what is the progression of kinesiologic movements?
- random movements of entire body > bilateral asymmetric movements of the head and trunk against gravity >
- alternating reciprocal movements of limbs >
- unilateral symmetric movements of head and trunk (sidebending) >
- bilateral diagnal movements (rotation) >
- physiologic flexion > antigravity extension > anitgravity > lateral flexion > rotation >
- extremity movement from flexion and ad-d > extension and ab-d
and increase in proportion or dimesion (size, height, weight)
physical changes that are a result of pre-programmed internal body processes that are genetically guided (myelination, fusion of ossification centers)
processes by which environmental influences guide growth and development, external stimulation
when does a baby start to exhibit head control and what type of head control do they exhibit?
- by 4 months head in line with body when pulled supine to sitting
- head righting when tilted
- lift head past 45 deg when in prone
- after 5 mths should be able to flex head in supine
what does segmental rolling mean and when does it start and what direction does it start first?
- log rolling
- 4-6 months
- prone > supine
what is segmental rotation and when does it start?
- separation of shoulders from pelvic girdle
- 6-8 months
when should a baby be able to sit independently alone without back support? can they exhibit trunk rotation when sitting?
when should a baby start cruising and creeping and what do they mean?
- crusing: 9 months; walking sideways with support of hands or tummy on table or couch
- creeping: 10 months; reciprocally creep (crawl) forward on hands and knees
when does a baby typically start walking and what is the typical stance?
- between 12-18 months
- wide BOS, "high guard" position of UE
at what age range do the fundamental patterns of movement that form the basis for sports skills later start to develop?
3-6 years old
what age range do they master running, throwing and catching?
according to Sherrington, what played a primary role in movement?
according to Sherrington, movements result of ________________________
stimulus response sequence of events
Sherringtons reflex theory had 3 limitations. What are they briefly?
- fails to consider that voluntary movements in absence of sensory stimulus
- movements can be too fast for feedback
- different movements for the same stimulus
according to Hughlings Jackson what are the 3 levels of the CNS?
according to huglings jackson, control proceeded in a ______________ from _____ to _______ control
- descending fashion
- high to low; "top down progression"
according to the combined reflex theory and hierarchial theory, reflexes are componets of ________ that intergrate during maturation and ___________ assume control.
- lower centers
- higher centers
according to the flexible hierarchies, association cortices are the _________ and what do they do?
- highest level
- elaborating perceptions and planning strategies
what is the middle level of the flexible hierarchies and what does it do?
- sensorimotor cortex BG, brainstem, cerebellum
- convert strategies to motor programs and commands
according tot he flexible hierarhies, what is the lowest level and what does it do?
- spinal cord
- translating commands mm actions
why is it called the flexible hierarchie?
it does not function in a rigid top-down form. Control is dependent upon demands and complexity of the task. Each level can exert control on any of the levels, but the higher centers assume control with the command task is too high.
what theory says that motor control is the result of cooperative actions of many interacting systems working to accommodate the demands of a specific task
systems theory; bernstein
according to the systems theory, __________ factors and ________ factors are taken into consideration when planning movement?
internal and external
according to the systems theory, assumes shifting neural control means what?
large areas of the CNS are engaged during complex movements vs. few for discrete movements
shifting neural control allows for what?
control of a number of seperate independent dimensions of movement
executive level freed of responsibility of control of simple movements or the demands of having to control many ____________ at one time.
degrees of freedom
what are motor programs running without the influence of peripheral feedback or error detection procress?
open loop system
what theory allows for movements to happen in the absence of sensation or in situations which limitations in speed of processing feedback negate control?
motor programming theory
what theory frees the nervous system from conscious decisons about movement reducing the problem of multiple degrees of freedom
motor programming theory
what employs feedback and reference for correctness to compute error and initiate subsequent corrections?
closed loop system
what 2 processes are critical for learning a new motor skill, shaping and correcting ongoing movements?
what is essential for maintaining posture and balance?
who proposed blending of the open and closed loop control processes as they bother operate as part of a larger system?
according to schmidt, ___________ provide generalized code for movement and use __________ to refine movment.
schmidts theory is also known as?
Adams theory is bad on what?
closed loop control
according to adams, _____________ feedback from ongoing movement is compared with ____________ of the intended movement.
according to adams, __________ are used to produce appropriate actions and evaulate outcomes and ________________ are developed through practice.
- memory traces
- stronger memory traces
The schema theory is based on whose motor control theory?
according to the schema theory, slow movements are ________ based and rapid movements are _______ based.
what is a rule, concept, or relationship fromed on the basis of experience?
clinically this theory supports the concept that practicing a variety of movement outcomes would improve learning through the development of expanded rules
what are the 3 stages of motor learning?
physically assisting the learner during a task is called what?
Feedback about the end result or overall outcome of movement is also known as what and what stage of motor learning would this be most appropriate?
- knowledge of results (KR)
- associative and autonomous
feedback about the nature or quality of movement is also known as what and what stage of motor learning would this be most appropriate?
- knowledge of performance (KP)
what is a sequence of practice and rest times in which rest time is much less that the practice time?
what is spaced practice intervals in which practice time is equal to or less than rest time
what is practice sequence organized around 1 task, performed repeatedly, uninterrupted by practice of any other task and what state of motor learning would it be most appropriate>
- blocked practice
what is practice sequence where a variety of tasks are ordered randomly across trials and what stage of motor learning is it most appropriate?
what is performance of a motor task that is visualized by the learner?
what is an environment that is stable and predictable?
what is an environment that has variable features?
PNF and NDT theories are largely based on the assumptions drawn from ______ and ___________ approaches to motor control
PNF and NDT theories are helpful in _______ pathologies but not in CNS lesions.
NDT and PNF are techniques designed to do what?
facilitate or inhibit different movement patterns
what are intervention techniques that increase the pt's ability to move in ways judged appropriate by a clinician?
what are techniques taht are used to decrease the patients use of movement patterns considered to be abnormal?
T/F: normal function cannot occur unless the higher centers of the CNS regain control over lower centers
T/F: functional skills will automatically return once abnormal movement patterns are inhibited and normal movement patterns are facilitated.
T/F: repetiton of normal movement patterns will automatically transfer to functional tasks.
What is the TOA theory and what is it?
- task oriented approach
- normal development emerges as an interaction among many different systems, each contributing different aspects of control
T/F: with the TOA it is essential to work on identifiable functional tasks rather than on movement patterns for movements sake alone
The TOA theory assumes that pt's learn by _____________ inherent in a functional task rather than by _______________ normal patterns of movement
- attempting to solve problems
- repetitively practicing
what is the CIT theory and it requires hours and hours of what?
- constrainted induced movment
- restraining of a non-limb to force use of an involved side
- hours and hours of "practice"
what is defined as the abilty to maintain and change posture and movment?
motor control is the result of what?
complex neurological and mechanical processes
as the nervous and muscular system matures, ____________ emerges.
motor control allows the nervous system to direct what 3 things?
- what muscles should be used
- what order to use those muscles
- how quickly to solve a movement problem
what 2 things play a role in motor control?
motor control occurs because of physiological processes that occur at what 3 levels?
what are the 4 stages of motor control and briefly describe them
- mobility: get into position
- stability: maintain position
- controlled mobility: move within positon and keep balance
- skill: mastered
according to the systems theory there are 7 components to the postural control system, what are they?
- 1. limits of stability
- 2. environmental adaptation
- 3. musculoskeletal system
- 4. predictive central set
- 5. motor coordination
- 6. eye head stabilization
- 7. sensory organization
according to the systems theory, what is limits of stability?
boundaties of the BOS of any given posture
according to the systems theory, what is environment adaption?
sensory systems provide input that allows the generation of a movment pattern that dynamically adapts to current conditions
according to the systems theory, the musculoskeletal system does what?
provides mechanical structure for any postural response
according to the systems theory, what is predictive central set?
- "postural readiness"
- sensation and cognition are used as anticipatory cues prior to movement
according to system theory, what is motor coordination?
abiltity to sequence muscle response in a timely fashion to respond to displacement of the COG over the BOS
according to the systems theory, eye-head stabilization is used to do what and what type of reflex is it?
- provide accurate info about the environment dring movement and gait
- vestibulochocular reflex
according to the systems theory there is sensory organization. What 3 systems are used primarily for posture and balance and therefore motor control?
what are the 3 stratigies for postural control according to Nashners model?
what is defined as the process that brings about a permanent change in motor performance as a result of practice or experience? early in life are considered __________ and later in life there are considered __________
- motor learning
- motor milestones
- motor skills
what phase of motor learning is the task completely new, is associated with the closed lopp model of control and much attention is devoted to learning the task?
during what phase of motor learning are they now able to associate aspects of task with success or failure and learning takes place with each new trial?
during what phase of motor learning is the task mastered and can be carried out with little attention to detail?
what type of task in done in enviornments that change over time?
what type of tasks have skills with set parameters and stay the same?
T/F: the more closely the practice environment resembles the actual environment the better the transfer of learning will be.
should a person practice the entire task or is it easier to learn if it is broken down into components according to the research?
- research supports breaking into components if the components are TRULY part of the whole task
- weight shifting prior to walking
T/F: a person is only as good of a mover as its weakest part.
what is defined as a sudden onset of neurologic signs and symptoms resulting from a disturbance of blood supply?
CVA's have variable impairments of what?
- sensory function
- motor function
- psychological function
clinical presentation s/p CVA is dependent upon what 2 things?
- extent and size of lesion
- region/area of brain involved
what is the third leading cause of death in the US and is the most common cause of disability in adults?
22% of men and 25% of women will die within _____ of a stroke
T/F: the type of stroke is significant factor in survival.
what type of stroke accounts for 70% of all strokes and results from blockage that leads to lack of cerebral blood flow?
what type of stroke accounts for 20% of all strokes and results from rupture of cerebral vessel or trauma with increase intercranial pressure.
what are the two types of ischemic stroke?
- thrombotic: blood clot within the arteries
- embolic: bits of matter form elsewhere and travel to the brain and gets stuck
what are the two types of hemorrhagic stroke?
- aneurysm: typically congenital
what is a TIA and what makes different from a stroke?
- transient ischemic attack
- TIA s/s fully resolve within 24 hours without even severely mild s/s lingering
are TIA's a clue in predicting future strokes?
yes; 35% of those who suffer a TIA are expected to have a stroke
what are some major risk factors for strokes?
people with high blood pressure are ___ to ___ times higher to have a stroke.
4 to 6
what are the 7 modifiable risk factors for a stroke?
- lack of exercise
- excessive alcohol consumption
- control of associated diseases
- awareness of early warning signs
survival rate after a stroke is lessened by what 4 things?
- increased age
- heart disease
other predictors for mortality after stroke include what 5 things?
- loss of consciousness at onset
- lesion size
- persistent sever hemiplegia
- multiple neuro deficits
- history of previous stroke
what are the 6 early warning signs for a stroke?
- SUDDEN numbness/weakness; ask them to smile
- SUDDEN confusion, difficulty speaking or understanding; ask them to repeat a simple sentance
- SUDDEN trouble seeing
- SUDDEN trouble walking, loss of balance or coordination; ask them to raise arms
- SUDDEN dizziness
- SUDDEN severe HA with no known cause (<- hemorrhagic)
what are the 7 s/s that are unique to women when having a stroke?
- SUDDEN face and limb pain
- SUDDEN hiccups
- SUDDEN nausea
- SUDDEN general weakness
- SUDDEN chest pain
- SUDDEN SOB
- SUDDEN palpitation
clot dissolving enzymes ____ for thrombotic strokes must be given within ___ hours of onset.
how long do most people wait to seek help after having a stroke?
the MD exam upon arrival at the hospital after a stroke would include what 6 things?
- motor exam
- sensory exam
- crainial nerve exam
- CT scan, MRI
Most beneficial intervention after stroke is typically within the first ________ months.
the greatest gains in stroke recovery happen within the first ___ months.
what is critical for neuroplasiticy after a stroke?
when do strokes typically become symptomatic?
80% restriction of blood flow is reached in bran
T/F: irreversible damage due to ischmeia with a core area of infarction occurs within minutes of having a stroke.
what type of stroke leads to cerebral edema?
cerebral edema is most common with strokes in which two arteries?
- Middle cerebral
- internal carotid
cerebral edema reaches its max by how many days?
cerebral edema swelling gradually subsides and disappears within how many weeks?
once cerebral edema resolves what do you start to see?
is blood cytotoxic to brain cells? What does that mean it does?
what are the 6 signs of ICP?
- decreasing level of consciousness (stupor, coma)
- widened pulse pressure
- increased heart rate
- irregular respirations (cheyne-stokes)
- non-reactive pupils
what are the 5 arteries that you can have a stroke in?
- anterior cerebral
- middle cerebral
- posterior cerebral
contralateral hemiparesis mainly in LE
contralateral hemisensory loss mainly in LE
motor inaction, slowness, delay, lack of spontaneity
These are s/s of a stroke in which artery?
the anterior cerebral artery supplies what part of the brain?
- medial aspect of hemispheres (frontal and parietal)
- basal ganglia
contalateral hemiparesis and hemisensory loss mainly in the UE and face
motor and speech (brocas) and receptive speech (wernickes)
left hemisphere (global aphasia)
right hemisphere: perceptual deficits like unilateral neglect, agnosia, depth perception, spatial relationships (parietal sensory ass. cortex)
loss of conjugate gaze, contralateral homonymous hemianopsia
sensory ataxia of contralateral limb
these are s/s of a stroke in which artery?
which is the most common artery for a stroke?
what areas does the middle cerebral artery supply?
- entire lateral aspect of hemispheres (frontal, temporal, parietal)
- basal ganglia
what does aphasia mean?
lack of understanding
what does conjugate gaze mean?
both eyes look at the same thing
brocas area damage would sound like what?
not fluent; robotic speech
wernickes area damage would sound like what?
typical fluent speech that doesnt make sense; "pink rainbow over moon cows."
the posterior cerebral artery supplies what in the brain?
- occipital lobe
- medial inferior temporal lobe
dyslexia, agraphia, anomia, color discrimination
these are s/s of a stroke in what artery?
what does the internal carotid artery supply in the brain?
major branchs to the cerebral cortex
what two arteries can the carotid artery cause issues with?
- middle cerebral
- anterior cerebral
what areas of the brain are supplied by the vertebrobasilar artery?
- internal ear
locked in syndrome
both ipsilateral and contralateral presention
cranial nerve abnormalities
these are s/s related to a stroke in what artery?
what is defined as caused by small vessel disease in the cerbral white matter/penetrating arteries?
what are 4 lacunar syndromes?
- dysarthrial clumsy hand
- ataxic hemiparesis
- sensory/motor strokes
- dystonia/involuntary movements
what do you call unusual motor behavior where the patient pushes towards the hemiplegic side-> lateral postural imbalance -> tendancy of falling towards the hemiplegic side?
what is pushed syndrome caused by?
severe misperception of body orientation in relation to gravity
pusher syndrome is rarely still evident after how many months and happens in around ___% of stroke pts?
musculoskeletal impairements that follow a stroke include (8)?
- fall risk
- UE functional tasks
- manual dexterity
- functional movement patterns
- loss lof voluntary motor control
- contractures due to immobility
Neurological impairments after a stroke include what 2 things?
cardiopulm impairements that follow are stroke include what 3 things and they are directly related to what else?
- DVT, cardiac function, pulm function
skin impairments that can typically follow a stroke include what 4 things to do and monitor?
- pressure, immobility, maceration, decreased sensation, poor nutrition, decreased level of consciouness
- needs daily inspection
- keep clean, dry, proper positioning, pressure relieving devices, positioning schedule
what are the 11 possible impairments associated with strokes?
what is apraxia and agnosia?
- apraxia: inability to plan and execute coordinated movement
- agnosia: lack of recognition
what are the two different types of apraxia and whats the difference between the two?
- ideational: can't perform on command or automatically due to inability to conceptualize the movement
- ideomotor: can move automatically but not on command
what are the two types of asphasia and what areas are associated with each?
- expressive: brocas
- receptive: wernickes
what is left/right & binasal and bitemporal homonymous hemianopsia?
- left/right: the left/right visual field loss
- binasal: central vision loss
- bitemporal: peripheral vision loss
T/F: right visual info travels in the left optic nerve and vice versa. Left info gets processed in the left occipital lobe and vice versa.
what are the common emotional deficits associated with strokes?
- pseudobulbar affect "emotional incontinence"
immobilty after a stroke as effects on what 3 things?
T/F: reflexes after a stroke typically start off hypo and then become hyper
spasticity after a stroke typically has what impairments?
- restricts volitional movement
- causes posturing of the limbs
- painful spasms
- automatic postural tone impairment
- obligatory synergistic movement
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