OT 703 - Functional Lab Exam

Myelogram

- A radiographic (iodine) dye is injected into the subarachnoid space (via lumbar puncture)

- After the dye is injected x-rays or CAT scans are taken

- Detects abnormalities in the spinal cord, nerves, and surrounding structures

- Used to diagnose neural compression in low back pain

Angiography

- Involves injection of a dye into the cerebral arteries, then x-rays

- The procedure involves inserting a femoral catheter which leads to the carotid artery where dye is injected to reach the cerebral arteries

- The procedure is painful and has a high risk of stroke from dislodging plaques on the arterial walls

Magnetic Resonance Imaging (MRI)

- Provides coronal, sagittal, or axial views of the brain and produces high quality images

- Can detect tiny plaques and tumors

- MRI is based on the principles of nuclear magnetic resonance (NMR), a spectroscopic technique used by scientists to obtain microscopic chemical and physical information about molecules

- The information from MRI scans comes in the form of image contrasts based on differences in the rate of relaxation of nuclear spins following their perturbation by an oscillating magnetic field

Functional MRI (fMRI)

- Detects changes in the brain's blood oxygen levels during activities, with active brain regions requiring more oxygenated blood

Brain Death in Wisconsin

- In Wisconsin, according to Wisconsin Statute 146.71, brain death is legally defined as the irreversible cessation of all functions of the entire brain, including the brain stem

Carpal Tunnel Syndrome

- Due to repetitive movement of the wrist

- Compression of median nerve in the carpal tunnel

- Symptoms:

• Progressive partial paralysis

• Atrophy of thenar muscles

• Weakness of OP and APB

• Sensory loss in radial half of palm and palmar aspect of digits 1-3

- Tinel Sign = Nerve distal from injury sensitive upon stimulation (tapping produces tingling sensation in area of cutaneous distribution of nerve)

Sciatic Nerve

- Major branch of the sacral plexus

- Motor Branches = Supply all muscles of the posterior thigh

- Sensory Branches = Supply the skin of posterior thigh and lateral sides of the leg and lateral foot.

- Sciatica - 95% of compression occurs at the discs between L4-L5 and between L5-S1, 5% occurs between L3-L4

Regeneration of Peripheral Nerves

- Regeneration Depends On = Schwann Cells & Endoneurial Tubes (guide axon)

- Regeneration = (1mm/day; 1"/month)

- Schwann Cells = Reproduce and fill the

gap while axon grows distal through the endoneurial tube

Olfactory Nerve (CN 1)

- Provides sense of smell

- The cribriform plate is part of the ethmoid bone. It supports the olfactory bulb, and is perforated for

passage of the olfactory nerves to the roof of the nasal cavity to convey smell to the brain

- Pathway:

1. Olfactory bulb

2. Mitral cells

3. Cribriform plate

4. Olfactory epithelium

5. Glomerulus

6. Olfactory receptor neurons

Bitemporal Heteronymous Hemianopsia

- A midline lesion of the optic chiasm which interrupts the

decussating fibers only

- Causes blindness in the nasal retinas of both eyes

- Results in blindness of the temporal visual field of each eye causing tunnel vision

Ipsilateral Nasal Hemianopsia

- Lesion to the lateral, non-decussating fibers on one side of the optic chiasm

- Causes blindness in the temporal retinas of the

ipsilateral eye

- The blindness is in one half of the visual field (hemianopsia) - the external nasal visual field of the ipsilateral eye

Trigeminal Neuralgia (Tic Doulourex)

• Excruciating, unpredictable, paroxysmal pain of short duration following irritation of a "trigger zone" - A trigger zone can be a place on the lip, tongue, or face that is sensitive to cold, pressure, or a blast of air

Etiology of Cerebellar Dysfunction

- Dysfunction may result from insults to the cerebellum due to:

• Vascular lesions

• Trauma

• Tumors

• Genetic disorders

• Drug & poison toxicity

• Epilepsy

• Alcoholism

Pseudohypertrophic Muscular Dystrophy (Duchenne's)

- Genetic disorder of the skeletal muscle, leads to progressive atrophy of muscles, muscle paresis & paralysis

- Symptoms

• Waddling gait

• Difficulty rising to stand (Gower's Sign: uses arms

to "climb up" legs)

- Pseudohypertrophic (Duchenne's)

• Most common type

• Sex linked recessive, males only

• Onset age 3-6 years

• Characteristic pseudohypertrophy of calves

• Rapid course with death by age 20

Friedreich's Ataxia

- Autosomal recessive inherited disorder

- Affects spinal cord white matter

• Spinocerebellar tracts - posterior (dorsal) & lateral white columns

- Results in the inability to coordinate voluntary muscle

movements (ataxic gait and incoordination)

Lesions of Vestibulocerebellum

- Those that affect the vestibulocerebellum (flocculonodular lobe) and vermis

- Symptoms:

• Disturbances in balance

• Swaying

• Unsteady, wide gait

• Nystagmus

• Titubation in trunk

• Signs may be bilateral because midline structures are involved

Signs & Symptoms of Cerebellar Lesions

- Hypotonicity = Low muscles tone, excessive ROM

- Ataxia = Incoordination of voluntary movements

- Dysdiadochokinesis = Decreased ability to perform rapid alternating movements (rapid forearm rotation)

- Dysmetria = Over or underestimation of distance that limb needs to move to contact an object ("past pointing")

- Decomposition of Movement = Movements are broken into parts, not smooth & continuous (move-stop-move-stop - "puppet-like")

- Asthenia = Generalized weakness in limbs, with complains of heaviness

- Intention Tremor = Occurs during action, most noticeable at end of movement (terminal tremor) - not present when limb is at rest

- Speech Dysarthria = Incoordination of speech muscles, speech is slurred with words produced slow & staccato-

like with pauses in wrong places

- Rebound Phenomenon = Inability to stop movement once started

Multiple Sclerosis

- Definition = Demyelinating disorder of the CNS characterized by a variety of symptoms with exacerbations & remissions

- Etiology = Thought to be due to a virus that results in an autoimmune response, body attempts to attack virus by attacking its own neural tissue

- Pathology:

• Distinct areas of myelin loss scattered throughout the

white matter

• Cell bodies & unmyelinated axons are spared

• Destruction of myelin causes scar tissue, or plaques

• Neurotransmission is disrupted & speed of impulses is slowed or stopped

Causes of Spinal Cord Injury

- Traumatic Events

• Auto Accidents (38.5%)

• Gunshot / knife wounds (24.5%)

• Recreational accidents (7.2%)

• Falls (21.8%)

- A male adult who is active in sports and drives is more at

risk for developing:

• Traumatic Brain Injury

• Spinal Cord Injury

- Disease

• Multiple Sclerosis

• ALS (Amyotrophic Lateral Sclerosis)

• Tumors

• Congenital Deformities

- Other

• Spinal Compression

• Herniated Disk

Complete vs. Incomplete Spinal Lesions

- Complete = No function (motor or sensory) below level of

lesion

- Incomplete = Some sensory and/or motor function below level of lesion

Paraplegia vs. Tetraplegia

- Tetraplegia (a.k.a. Quadriplegia) = Any degree of paralysis of the 4 limbs and trunk musculature

- Paraplegia:

• Paralysis of the LE with some involvement of trunk depending upon level of lesion

• Lumbar level lesion results in paralysis of LE but the UE are

functional

Central Cord Syndrome

- Cellular destruction at center of cord

- Greater paralysis and sensory loss in UEs

Heterotopic Ossification (Etopic Bone)

- Abnormal deposition of osseous material in muscles

around hip, knee, elbow, shoulder

Autonomic Dysreflexia

- Serious and life-threatening medical emergency in patients with lesion above the T4 to T6 level

- Symptoms:

• Perspiration, chills below the region of injury (sympathetic symptoms)

• Flushing of the region above the injury (parasympathetic symptoms)

• Nasal congestion

• Paroxysmal hypertension (sudden and severe HTN)

• Bradycardia

Hemorrhagic vs. Ischemic CVA

- Hemorrhagic = Rupture causing a bleed into the brain

- Ischemic = Occlusion or blockage of a blood vessel

Causes of CVA (Ischemic)

- Thrombosis = Total occlusion of blood vessel d/t atherosclerosis

• Most common cause (53-58% of cases)

- Embolism = Moving clot that eventually occludes a blood vessel

• 19 to 31% of cases

Right Sided CVA Symptoms

- Topographical Disorientation = Inability to orient oneself in familiar or unfamiliar environments

- Anosognosia = Patient unaware of their own cognitive decline

Transient Ischemic Attack (TIA)

- Caused by a temporary state of reduced blood flow in a portion of the brain

- Results in a sudden, brief decrease in brain function with mild, isolated, or repetitive

neurologic symptoms

- Full recovery within 24 hours

Course of Recovery following CVA

- Usual Course of Return:

• Proximal → Distal

• Mass movement → Fine movement

Sensory Fibers Transmitting Pain

- A-Delta Fibers = sensory nerve fibers that transmit fast, sharp, "first pain" and temperature signals to the brain

Pain Affect

- As people can have mixed feelings with respect to events,

people in pain can have multiple emotions associated with their painful experience

- Verbal Descriptors = Distracting, depressing, dreadful, or unbearable

Pain Quality

- Verbal Descriptors = Sharp, dull, hot, cold, deep, superficial,

sensitive and itchy.

Pain Intensity

- Defined as "how much a

person hurts"

- Verbal Descriptors = Intensity of

a painful experience varying from 'no pain' to 'worst imaginable

pain'

Pain Location

- Pain assessment tools use line diagrams of whole body or specific parts of the body to describe the pain location

Traumatic Brain Injury (Stats)

- Most Common Causes:

• Motor vehicle accidents

• Falls

- Most injuries in ages 15 to 29 and > 70

- Males 2x more likely than females

- 50% survival rate, crucial period is immediately following injury

Brain Contusions

- Destruction of tissue due to impact of the brain against skull

- Coup = Damage to the area where direct blow occurred

- Counter-Coup = Damage to the area at the opposite side of the blow

Skull Fractures

- Linear = Linear fracture w/o communication with neural tissue

- Comminuted = Multiple linear fractures w/o communication of neural tissue

- Compound = Communication w/ neural tissue

- Depressed = Piece of skull breaks, drives inward

- Basilar = Fracture of anterior, middle, or posterior fossa at base of skull

Symptoms of Increased ICP

• Severe headache

• Vomiting

• Loss of consciousness

• Breathing becomes slow and deep

• HR becomes slow

• BP increases

• Papilledema = Edema & inflammation of the optic nerve

• Herniation of brain parts

Glasgow Coma Scale

- Assesses level of consciousness (LOC) based on responsiveness of 3 behavioral areas:

1. Eye opening

2. Verbal responses

3. Motor responses

- Each category given a numeric score; scores are totaled for a range of 3 to 14 overall.

- Persons with a score <7, guarded prognosis

DSM-5 Definition of Depression

- Depressive Disorders = Group of mental health conditions characterized by persistent feelings of sadness, loss of interest or pleasure, and cognitive and physical symptoms that significantly impair daily functioning

- The symptoms should persist for at least two weeks in order to consider the diagnosis of depression according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

Cognitive Behavioral Therapy (CBT)

- Core Principle = Depression is maintained by negative automatic thoughts, distorted beliefs, and maladaptive behaviors

- CBT teaches individuals to identify, challenge, and restructure these patterns

- Cognitive Restructuring = Patients learn to spot cognitive distortions (e.g., catastrophizing, overgeneralization) and replace them with realistic, balanced thoughts

- Behavioral Activation = Encourages re-engagement with meaningful activities that patients have withdrawn from, to break the cycle of inactivity and low mood

- Skill Building = Patients develop problem-solving skills, stress management techniques, and

relapse prevention strategies.

Anxiety

Anxiety disorder is present when persistent, excessive, uncontrollable, and causes functional impairment

Neurological Basis of Anxiety

- Amygdala Hyperactivity = Overactive fear processing, especially in generalized anxiety disorder and PTSD

- Prefrontal Cortex Dysfunction = Impaired top-down regulation of fear and anxiety responses

Occupational Therapy Anxiety Interventions

- Activity Scheduling & Behavioral Activation

- Relaxation Training

- Sensory Modulation Strategies

- Psychoeducation

Neurological Examination - Test for Cranial Nerve 2

- CN II = Optic nerve

- Tools = Snellen chart, Rosenbaum pocket vision screener, and a light source

- Procedures = Testing includes visual acuity (Snellen chart), checking visual fields, and observing the pupillary light reflex (constriction) by shining a light into the eyes

Neurological Examination - Test for Cranial Nerve 5

- CN V = Trigeminal nerve

- Tools = Pin (safety pin), facial tissue, and cotton wool or a brush

- Procedures = Sensory testing involves applying a pinprick to the face and tongue and using facial tissue. It also provides the sensory (afferent) component of the corneal reflex. Motor testing assesses the muscles of mastication

Neurological Examination - Test for Cranial Nerve 7

- CN VII = Facial Nerve

- Tools = Visual observation; tools for the corneal reflex (like cotton) are shared with CN V.

- Procedures = The patient is asked to perform facial expressions such as smiling, wrinkling the forehead, and closing their eyes. It provides the motor (efferent) component of the corneal reflex

Neurological Examination - Test for Cranial Nerve 8

- CN VIII = Vestibulochoclear nerve

- Tools = 128-Hz tuning fork and the examiner's voice or fingers

- Procedures (Cochlear) = Rubbing fingers together or whispering tests general hearing

• Weber Test (tuning fork on the forehead) and

• Rinne Test (comparing bone vs. air conduction by the ear) check for hearing asymmetry.

- Procedures (Vestibular) = The Romberg Test is used, where the patient stands with feet together and eyes closed while the therapist observes for swaying or falling

Motor Testing - Tone & Classification

- Motor Testing Procedure = The examiner compares left to right, proximal to distal, and arms to legs. Evaluation includes muscle bulk, tone (tested via passive manipulation), strength (via Manual Muscle Testing 0-V), speed, and endurance.

- Muscle Tone Classifications:

• Spasticity = Hypertonia due to upper motor neuron (UMN) lesions, where the muscle belly feels hard and resistance is usually greater on one side of a joint

• Rigidity = Hypertonia affecting all muscle groups around a joint (flexors and extensors)

• Cogwheel Rigidity = Alternating relaxation and contraction during passive movement, often associated with Parkinson's.

• Hypotonia = Less tone than normal; the patient may appear "double-jointed"

• Flaccidity = Extreme hypotonia resulting from lower motor neuron (LMN) lesions, making the muscle feel "squishy"

- Ashworth Scale (Muscle Tone Grading):

• 0: No increase in tone.

• 1: Slight increase (a "catch" during movement).

• 2: Marked increase, but limb is easily flexed.

• 3: Considerable increase; passive movement is difficult.

• 4: Limb is rigid in flexion or extension

Deep Tendon Reflexes (DTRs)

- Tools = Percussion hammer (reflex hammer)

- Testing Procedures = The examiner uses the hammer to strike a tendon and observes the resulting movement.

- Standard reflexes include the Biceps (C5-6, Musculocutaneous), Triceps (C6-7, Radial), Patellar (L2-L4, Femoral), and Ankle (S1-S2, Tibial).

- DTR Grading Scale:

• 0: Absent.

• 1+: Hypoactive.

• 2+: Normal.

• 3+: Brisk/Hyperactive.

• 4+: Markedly hyperactive with clonus

Pathologic Reflexes

- Babinski Sign (Plantar Reflex):

• Procedure = Stroking the lateral aspect of the sole of the foot

• Normal Response = Flexion (toes point down)

• Positive (Abnormal) Sign = Extension of the great toe with abduction (flaring) of the other toes. This indicates hyperexcitability and corticospinal dysfunction

- Rooting Reflex = Stroking the skin next to the mouth causes the head to turn toward the stimulus; its presence in adults denotes a frontal lobe lesion

- Sucking Reflex = Placing an object on the lips triggers a sucking response; its presence in adults denotes a frontal lobe lesion.