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Frontal lobe: contralateral weakness, personality changes/ antisocial behavior, broca's aphasia, delayed or poor initiation.
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Parietal Lobe: constructional apraxia and anosognosia, Wernicke's aphasia, homonymous visual defects, impaired language comprehension.
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Occipital Lobe: variety of visual deficits (homonymous hemianopsia, visual agnosia, cortical blindness), impaired extra-ocular muscle movement
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Temporal Lobe: hearing impairments, memory and learning deficits, wernicke's aphasia, antisocial behaviors
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Cerebellum: Ataxia, lack of trunck and extremity coordination, intention tremors, balance deficits, dysdiadochokinesia, dysmetria
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Basal Ganglia: bradykinesia and akinesia, resting tremors, rigidity, athetosis, chorea,
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Thalamus: thalamic pain syndrome, altered relay of sensory information
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Hypothalamus: altered basic homeostasis of body functions, poor autonomic nervous system function, altered function of anterior pituitary gland (ADH secretion and reproduction)
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brainstem: Altered consciousness, contralateral hemiparesis or hemiplegia, cranial nerve palsy, altered respiratory patterns, attention deficits.
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Right hemisphere: left sided sensory and motor deficits, unable to understand nonverbal communication, difficulty in sustaining movements, poor hand eye coordination and kinesthetic awareness, quick and impulsive, overestimation of abilities.
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Left hemisphere: right sided sensory and motor deficits, difficulty understanding and producing language, difficulty sequencing movements, poor logical and rational thought, slow cautious anxious, self depreciating.
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Frontal Lobe
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primary motor cortex responsible for voluntary movements on contralateral side. Broca's area (motor components of speech), cognition, judgement, attention, abstract thinking and emotional control
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Parietal lobe
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primary sensory cortex integrates sensation from contralateral side of body, short term memory, perception of touch, proprioception pain, and temp sensations
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Temporal lobe
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Primary auditory cortex, associative auditory cortex, wernicke's area (comprhension of spoken word), long term memory, visual perception, primary visual cortex
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Occipital lobe
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visual association cortex (processes visual info and applies meaning)
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Medulla oblongata
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contains centers for vital sign functioning of the cardiac, respiratory, and vasomotor centers,. maintains consciousness and arousal
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Hypothalamus
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critical for maintaing homeostasis. controls primitive drivesrelated to age, agression, emotion, thirst, hunger, sleep wake cycle. Damage to this area can cause problems with temp, water, and behavioral regulation.
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Basal ganglia
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regulates posture and muscle tone
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cerebellum
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maintains posture and voluntary muscle movement control
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Brainstem
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contains cranial nerve nuclei, damage damage can lead to variety of cranial nerve dysfunctions
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Hip
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Retraction
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Increased trunk and LE muscle tone
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Hiking
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Inadequate hip and knee flexion, increased tone in trunk and LE
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Circumduction
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Increased extensor tone, inadequate hip and knee flex, increased PF in ankle or footdrop
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Inadequate hip flexion
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Increased extensor tone, flaccid LE
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Knee
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decreased knee flexion during swing
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Increased LE extensor tone, weak hip flex
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excessive flex during stance
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weakness or flaccidity in LE, increased flex tone in the LE
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hyper extension during stance
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hip retraction, increased extensor tone in LE, weakness in hamstrings, quads, gluteus maximus
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Instability during stance
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increased LE flex tone , flaccidity or weakness of extensor muscles.
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Ankle
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footdrop
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increased ext tone, flaccidity
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ankle inversion/eversion
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increased tone in specific muscle groups, flaccidity
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toe clawing
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increased flexor tone in toe muscles.
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1:olfactory
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sensory
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smell
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2=optic
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sensory
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visual acuity
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3=oculomotor
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motor
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turns eye up, down, and in
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screen: observe position of eye
Test: persuit eye movements |
Impaired eye movments, eye deviation from normal position, ptosis (drooping eyelid), pupillary dilation
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cerebrovasculary accident, myasthenia Gravis
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4= trochlear
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motor
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turns adducted eye down
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5=trigeminal
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sensory
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facial sensation
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screen: test pain; light touch sensations forehead, cheecks, jaw, (eyes closed)
corneal reflex; touch lightly with wisp of cotton palpate muscles; have pt clench teeth, hold against resistance |
Findings: loss of facial sensation, numbness, loss of corneal reflex ipsilaterally; weakness, waisting of muscles for mastication
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trigeminal neuralgia, MS
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motor
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muscle of mastication (temporalis, and masseter
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6=Abducens
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motor
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turns eye out
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7=facial
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sensory
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taste on the anterior 2/3 tongue
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motor
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facial expressions
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screen: test motor function: raise eyebrows, frown, show teeth, smile, close eyes, puff out cheeks
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findings: paralysis, ipsilateral fascial muscles, inability to close eye, droop in corner of mouth, difficulty with speech articulation
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bells palsy, CNS facial paralysis, stroke
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8=vestibulocochlear
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sensory
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vestibular occular reflex balance, hearing accuity
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screen: vestibular function: test balance, eye head coordination (vor gaize stability)
cochlear function auditory accuity, use tuning fork on top of head, on mastoid bone. |
Findings vestibular: vertigo, disequilibrium, nystagmus.
findings coclear: deafness, impaired hearing, tenitis |
balance deficiencies.
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9=glossopharyngeal
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sensory
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taste posterior 1/3 of tongue
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motor
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gag reflex, pharynx control, soft palate rising with "ah" sound
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10=vagus
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sensory
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ANS functions,
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screen: examine fro difficulty swallowing, observe motion of soft palate (elevation remains midline) and when pt says "ahh"
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Finding: paralysis-palate fails to elevate, asymmetrical elevation, unilateral paralysis.
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brain stem or hypothalamus dysfunction
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motor
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gag reflex, pharynx control, soft palate rising with "ah" sound
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11=spinal accessory
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motor
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traps muscle: elevate shoulders, SCM muscle: turn head to side
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Screen: examine bulk of muscle, strength-shoulder shrug against resistance, turn head to each side against resistance
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finding: atrophy, fasciculation, weakness (PNI); inability to shrug ipsilaterally;(ell)shoulder;shoulder droops. Inability to turn head to opposite side
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SCI gullian barr syndrome
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12=hypoglossal
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motor
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tongue movements
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UE
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D1F
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flex-add-ER
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"close your hand, turn, pull arm across face"
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D1E
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ext-abd-IR
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open your hand, turn and push your arm down and out
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D2F
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Flex-abd-ER
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open hand, turn, lft your arm up and out
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D2E
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ext-add-IR
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close hand, turn, pull arm down across body
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LE
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D1F
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flex-add-ER
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bring foot up, turn, and pull leg up and across your body
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D1E
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ext-abd-IR
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push foot down, turn, push leg down and out
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D2F
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Flex-abd-ER
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lift foot up, turn and lift leg up and out
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D2E
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ext-add-IR
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push foot down, turn, and pull leg down and in.
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UMN
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LMN
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Location
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CNS
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PNS
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structures involved
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Cortex, brainstem, corticospinal tracts, spinal cord
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SC: anterior horn cell, spinal roots, peripheral nerves
CN: cranial nerves |
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Disorders
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stroke, TBI, SCI
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Polio, guillan-Barre, PNI, peripheral neuropathy, radiculopathy
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tone
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hypertonia, velocity dependent
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decreased or absent, hypotonia, flaccid
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Involuntary movements
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flexor or extensor muscle spasms
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with denervation: fasciculations
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strength
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stroke: paraparesis,
corticospinal lesions:contralateral if above decussation in medulla, Spinal cord lesions: BL loss below level of lesion |
Limited distribution: segmental or focal pattern, root innervated pattern.
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Muscle bulk
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disuse atrophy
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neurogenic atrophy
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Voluntary movement
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impaired or absent: dyssentric patterns, obligatory synergies
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weak or absent if nerve interrupted
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Hypertonia
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Decorticate rigidity: always an UMN lesion, sustained flexor posturing in the UE, sustained extensor posturing in the LE, Diencephalon lesion, sign of severe impairment
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Decerebrate: always an UMNL, sustained ext posturing in the UE & LE, Brainstem lesion, sign of severe impairment
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Rigidity: Always an UMNL, resistance to passive stretch in agonist & antagonist, Basal ganglia lesion
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Cogwheel rigidity: ratchet-like response to quick passive movement; catches/releases/catches.
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Leadpipe rigidity: constant rigidity
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Hypotonia
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Flaccidity: LMNL, Cerebellar lesion, following spinal or cerebral shock, resolves or changes into spasticity.
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Ashworth Scale
0: No increased tone. 1 or 1+: slight increase in tone. 2: moderate increase in tone. 3: PROM is difficult. 4: affected joints are non-moveable (ankylosed) |
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Deep tendon reflexes commonly tested
Biceps: C5-C6 Brachioradialis: C5-C6 Triceps: C7-C8 Quadriceps: L2-L4 Hamstrings: L5-S3 Achilles: S1-S2 |
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joint mobilization indications: pain, hypomobility, muscle spasm and guarding, functional ROM limitation
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Joint mobilization contra: hypermobility, pregnancy, malignancy, unhealed fx, bone disease, effusion, inflammation, blood thinners
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mob grades:
grade 1: Small amp oscillation at beginning of range. grade 2: Large amp pushing into tissue resistance just short of joint caps. grade 3: Large amp stretches joint caps grade 4: Small amp high velocity manipulation past end of passive range |
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GHJ Anterior instability apprehension test: assessment of anticipated pain when subject maintained 90 degrees Abd and ER of shoulder.
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Posterior and inferior instability Jerk test: sudden jerk applied to shoulder in 90° flexion and IR (humeral head subluxes off the back of the glenoid) Sulcus sign: an indentation occurs inferior to the acromion as distal distraction is applied to the humerus.
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Subacromial impingement Hawkins- kennedy: passive 90° flex and IR reproduce pain Neer’s: Passive IR and full abd reproduce pain Empty can: shoulder placed at 90° abd 30°horiz add, pain c resistance
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Rotator cuff pathology Drop arm: unable to slowly lower arm passively abducted to 120° Lag signs: pt unable to maintain IR/ ER
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ACJ H add: localized pain occurring during H add p/arom. SLAP active compression: painful pop oc click in 90° flex, 10-15° add and full IR when downward force is applied Biceps load 2: apprehension when asked to flex biceps against resistance at 120° abd.
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Thoracic outlet syndrome Adson’s: radial pulse diminish when arm is extended and ER, pt head rotated toward arm. *Roos: radial pulse diminishes when arm placed in 90° abd, slight H add, elbow flex to 90°, open and close fist for 3 mins.
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Elbow Ligament instability Varus/valgus stress: laxity noticed as varus and valgus stress applied to elbow in 20-0° flex Biceps rupture: Distal bunching of muscle noted and complete loss of function. *
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Neuro dys Flex: pain at the medial epicondyle of elbow, numbness and tingling in ulnar nerve distribution. Reproduced when pt hold c max elbow flex and wrist ext 1 min. Indicates cubital tunnel syndrome.
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Wrist & hand De Quervain’s tenosynovitis (tendonitis of abductor pollicis longus or extensor pollicis brevis) eichoff’s: pain reproduced when thumb is flexed across palm while moving into ulnar deviation. Finkelstein: pain reproduced when wrist and thumb are pulled into ulnar deviation with distraction force.
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Neuro dys Phalen’s (wrist flexion): tingling and paresthesia reproduced during max wrist flex and hold together for 1 min, indicates carpal tunnel compression of medial nerve. Tinel sign: tingling and paresthesia are reproduced when tapping over carpal tunnel area compressing medial nerve. 2-pt discrimination: asses ability to detect 2 pts of contact at once on palm.
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Hip DJD Scour/grind: P! when compressive force is applied to femur, hip 90° flex, knee max √
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Dys, mob restriction Patrick (faber): involved leg is unable to assume relaxed posture, P! symptoms c hip √, abd, ER, foot placed proximal to knee in supine
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Muscle length, strength involvement Thomas test: supine slingle leg hip and knee max √ , if opp limb flexes, indicates tightness of psoas major. Ober: Passive hip extension and lowering from abd, sidelying, tightness of tensor facia lata and or iliotibial band. Ely’s : tightness of the rectus femoris when hip of tested limb lifts off testing surface with knee flexion, tested in prone. Trendelenburg sign: observe pelvis of stance leg positive if ipsilateral hip drops when limb support is removed. Indicative of weak glut med or unstable hip
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Knee 1-plain anterior instability Lachman: + excessive anterior translation of the tibia compared to the uninvolved limb and lack of firm end feel. Anterior drawer : + excessive anterior translation of the tibia compared to the uninvolved limb.
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1-plain posterior instability Posterior drawer: + excessive posterior translation of the tibia compared to the uninvolved limb. Posterior sag: tibia sags posteriorly( normally extends 1 cm anteriorly beyond femoral condyle) when positioned supine, hip √ 45° knee √ 90°
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1-plain medial-lateral instability Varus stress test: + excessive lateral mvmt or pain at the lateral knee Valgus stress+ excessive medial mvmt or pain at the knee (both tests performed at 0° and 30°√, + at 0° √ indicates major disruption of the knee and one or more rotary tests +.
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Meniscus tear McMurray: + reproduction of click and or pain in the knee joint with rotary force applied.
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Anklyosing Spondylitis: progressive inflammatory disorder that initially affects the axial skeleton, occurs before 40, affects thoracic and lumbar regions, BL SIJ, restricted P/AROM, flexed posture throughout entire spine.
Interventions: flexibility ex to maintain trunk motions and improve joint motions, especially ext. Implement aerobic such as aquatics for improved activity endurance. Include relaxation techniques such as breathing strategies for improved respiratory function |
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Psoriatic Arthritis: chronic erosive inflammatory disorder that typically occurs in the axial skeleton and digits.
Intervention: joint protection, aerobic activities for reconditioning |
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Rheumatoid arthritis: chronic systemic autoimmune disorder characterized by periods of acute exacerbation and remission. weight loss, fever, extreme fatigue.
Interventions: joint protection strategies, aerobic conditioning, maintain joint mechanics and connective tissue function |
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Osteomalacia: decalcification of bones as a result of vit D deficiency, severe pain, fx, weakness, deformities.
Interventions: bone protections strat, areobic conditioning, improve joint mechanics |
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Osteochondritis dissecans:separation of articular cartilage from underlying bone. Usually involving medial femoral condyle near the intercondylar notch, sometimes occurs on the femoral head or the humeral capitellum.
Interventions stretches, bone protection strats, aerobic conditioning, strengthening, power and endurance ex. |
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Tendinitis: inflammation of tendon caused by microtrauma, direct blow, overuse, excessive tensile force.
Interventions: manual, stretches, endurance conditioning, pt ed. |
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Bursitis: inflammation of the bursa secondary to overuse, gout, or trauma, or infection. Characterized by pain with rest, and decreased P/AROM due to pain, not in capsular pattern.
Interventions: stretches, manual therapy, endurance training, modalities, pt ed. |
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Myositis Ossificans: painful condition of abnormal calcification within muscle belly caused by direct trauma. most commonly located in the biceps, brachialis, and quads.
AVOID AGRESSIVE STRETCHING. gentle stretches, manual therapy, endurance conditioning |
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GHJ dislocation: most common anterior, caused by abduction and forceful ER. Posterior is caused by H Add, and IR. s/p avoid painful positions which may include: GHJ flex 90 deg, H Abd 90+, ER 80.
Interventions: restore normal GHJ motions, strength, endurance and stability. |
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patellofemoral conditions: abnormal malalignment of the patella. causes pain that is made worse with inactivity.
interventions: McConnel taping, Patellar mobilizations to lessen the abnormality. Correction of muscular imbalances. |
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Osgood-schlatter: jumper's knee, Made worse with activity mechanical dysfunction resulting in traction apophysitis of the tibial tubercle at the patellar tendon insertion. Irregularities of the epiphyseal line.
Interventions: modify activities to prevent excessive stress to irritated site. |
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Anterior compartment syndrome: Increased compartmental pressure resulting in local ischemic condition. caused by trauma, fx, overdose, muscle hypertrophy. characterized by deep achey feeling, swelling, parasthesia, severe pain,
Acute ACS is considered a medical emergency and requires immediate surgical intervention with fasciotomy to prevent tissue death and permanent disability. |
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hyperkalemia: increased potassium, widened PR interval, QRS wave, and tall T waves, tachycardia (potentially leading to bradycardia, potentially leading to cardiac arrest)
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Hypokalemia: ECG changes (flattened T wave, prolonged PR and QT intervals, hypotension, arrhythmias may progress to V-fib .
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Hypercalcemia: hypertension, signs of heart block, cardiac arrest
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hypocalcemia: arrthmias, hypotension
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hypernatremia: increased sodium, hypertension, tachycardia, pitting edema, excessive weight gain
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hyponatremia: hypotension, tachycardia
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chest x-ray: lung condition, impact on lung from other conditions, blood vessels, fx, other objects
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considerations: radiation
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ECG: records electrical activity, Exercise tolerance test
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consider: monitored in room via radio transmission, continuous monitoring during intervention, prvide ex guidlines following cardiac procedure
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myocardial perfusion imaging: ischemic areas of the heart,
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considerations: can visualize areas of old infarct
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cardiac catheterization, (coronary angiogram): x-ray images capture to evaluate BP in heart and O2 saturations, Stint
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considerations: invasive, dye in arteries, requires IV, 2-3 hrs
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clubbing: associated with chronic O2 deficiency and CHF
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pale, shiny, dry, loss hair: PVD (arterial insufficency)
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abnormal pigmentation, ulceration, dermatitis, gangrene: PVD
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Right atrium: receives blood from systemic circulation from superior and inferior vena cava
SA-node: near superior vena cava; pacemaker of the heart AV-node: node floor of Right atrium, receives signal from SA-node/ bundle of HIS, to depolarize and contract ventricles |
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Right ventricle: receives blood from RA which pumps blood through pulmonary artery to lungs for oxygenation
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Left Atrium: receives oxygenated blood from lungs and 4 pulmonary veins
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Left ventricle: walls are thicker and stronger than the RV and form most of the left side and apex of the heart.
receives blood from the LA and pumps blood via the aorta throughout the entire circulatory system. |
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Heart valves
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Atrioventricular valves: prevent backflow of the blood into the atria during ventricular systole. close when ventricular walls contract.
right heart valve tricuspid, left heart valve,(bicuspid, mitral) |
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semilunar valves: prevent backflow of blood from the aorta and pulmonary arteries into the ventricles diastole
pulmonary valve prevent right backflow. aortic valve prevents left backflow |
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Arteries, veins and capillaries
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Arteries: transport oxygenated blood from the heart, decrease in size and become arterioles and end as capillaries. have contractile abilities, arterial walls are thicker in order to tolerate high BP. Influenced by elasticity and elasibility of vessle walls and peripheral resistance, amount of blood in body change in diameter when triggered by sympathetic activity of the ANS, vasoconstriction or vasodilation
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Veins: transport dark unoxygenated blood from peripheral tissues back to the heart. larger capacity and thinner, weaker walls than arteries, greater in number, one way valve to prevent backflow of blood because they do not have contractile abilities. rely on movement of muscle to squeeze blood back to the heart. Venous reflux occurs when the valves dont function properly caused by enlarged or weakened veins. deep veins accompany arteries while superfical's do not. increased blood return with inspiration, compliancy of right heart.
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capillaries: minute blood vessels that connect the ends of arteries with the beginning of veins, functions for exchange of nutrients and fluids between blood and tissues. capillary walls are thin and permeable
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Left ventricular failure
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S&S pulmonary congestion:dyspnea, dry cough, orthopnea, paroxysmal nocturnal dyspnea, pulmonary rales, wheezin.
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S&S low cardiac output: hypotension, tachycardia, lightheaded/ dizziness, cerebral hypoxia(irritability, restlessness, confusion, impaired memory, sleep disturbances), fatigue, weakness, poor exercise tolerance, enlarged heart on x-ray, S3 sound, possibly S4. murmurs of mitral or tricuspid regurgitation.
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Right ventricular failure
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S&S pulmonary congestion:dependent edema, weight gain, ascites, liver enlargement
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S&S low cardiac output: anorexia, nausea, bloating, cyanosis in the nail beds, RUQ pain, jugular vein distension, R-sided S3 heart sounds, murmurs of pulmonary or tricuspid insufficiency.
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etiology: primary lymphedema: congenital; Secondary lymphedema: occurs as a result of injury to lymphatic vessels or parasitic infection.
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Progressive over time: w/o tx, may develop into fibrosis, chronic infection, or loss of limb function
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Symptoms: heaviness, tightness, or pain, swelling, and persistent edema, loss of ROM and function in an arm or leg
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Skin changes: hardening and/or discoloration of skin
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Dx: history, visual inspection and palpation, girth measurements.
tests may include: MRI & CT scans; doppler ultrasound, radionuclide imaging of the lymphatic system. |
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Staging:0-latent, 1-spontaneously reversible, 2-spontaneously irreversible, 3- lymphostatic elephantiasis
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Tx: complete decongestive therapy, manual lymph drainage, short stretch compression bandages, exercises, functional training, skin care and lymphedema education
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Resting Inspiration
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Diaphragm (Phrenic nerve, C3-5)
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Deep inspiration
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Diaphragm; SCM, scalenes- elevate 2 upper ribs; levator costarum, scalenes- elevate remaining ribs; pec major, serratus posterior superior(SCM: CN XI, 2, 3, Scalene: lower cervical root)
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forced inspiration
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muscles of resting and deep inspiration, trapezius, pectorals, serratus, levator scapula (traps: CNX1, pect: medial pectoral C8, T1, serratus: long thoracic C5-7, levator: C3-4, dorsal scapular)
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resting expiration
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same as resting inspiration, internal intercostals( intercostal nerve T2-6
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Forced expiration
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muscles of forced inspiration+ abs, quadratus lumborum, lower iliocostalis, serratus posterior inferior. (abs: 7-12 intercostal nerves, iliohypogastric, ilioguinal nerve, QL: 12th thoracic &1st lumbar nerves)
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bacterial
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Viral
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Aspiration
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shaking chills, fever, chest pain if pleuritic involved, productive or purulent, blood streaked, rusty sputum. cackles, tachypnea, increased white blood cell count, hypoxemia, hypocapnea leading to hypercapnea with increasing severity. CXR confirmation of infiltrate.
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recent upper respiratory infection, fever, chills, dry cough, headaches, cackles, hypoxemia and hypercapnea, normal wbc count, CXR confirmation of interstitial infiltrate.
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aspiration event, dry cough leading productive, dyspnea, tachypnea, cyanosis, tachycardia, wheezes and cackles, hypoxemia hypercapnea, chest pain, fevre, wbc count shows varying degrees of leykocytosis, CXR initially shows pneumonitis. chronic aspiration shows necrotizing pneumonia with cavitation .
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TB: airborne, incubation period: 2-10 weeks. to become noninfectious: 2 weeks on antituberculin drugs
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