Stanbridge - T5 - Neuro1 - W1 - CNS Neuroanatomy, Intro to CVA Part 1, Scapular PNF Patterns

• Neurologic Interventions I (PTA 1012) is the title of this presentation, which is about neuroanatomy according to PPT #1.

Learning Objectives

• Review the central and peripheral nervous systems.
• Review significant structures within the central nervous system.
• Review the primary functions of structures within the brain.
• Describe the vascular supply to the brain.

Quiz #1

• Cell bodies make up gray matter in the brain.

Quiz #2

• Information processing occurs in the gray matter of the brain.

Quiz #3

• The limbic system is primarily in charge of controlling emotion in the brain.

Nervous System Components

• The nervous system has central and peripheral components.
• The central nervous system includes the brain and spinal cord.
• The peripheral nervous system includes the autonomic and somatic systems.
• The autonomic system is divided into the sympathetic and parasympathetic branches.

Central Nervous System

• Key components include the brain, cerebellum, brain stem, and spinal cord.

Nerve Cells

• Sensory neurons (afferent) transmit messages from the periphery of the body (PNS) to the spinal cord and brain (CNS), for example, touch, proprioception, pain, and temperature.
• Interneurons connect neurons to one another and process information or transmit signals.
• Motor neurons (efferent) transmit information from the brain and spinal cord (CNS) to the extremities (PNS) to signal muscles to produce movement.

Neuroglia - Supporting Cells

• Astrocytes provide vascular supply to neurons.
• Oligodendrocytes wrap myelin sheets around axons in the CNS and promote ion exchange between neurons.
• Microglia engulf and digest pathogens and contribute to nervous system repair after injury.
• Ependymal cells assist with the movement of CSF through the ventricles.
• Schwann cells wrap myelin around axons in the PNS.

Neuron structure

• The neuron structure processes information.
• The dendrites transfer information to the cell body.
• The axon sends messages and takes information to the body, including muscles, glands, etc.

Neuron Structure - Axon

• Axons of sensory and motor neurons are covered in "insulation" that forms a protective sheath called myelin.
• Myelin increases the speed of information across the axon.
• When myelin degeneration becomes profuse, it causes misfiring or incomplete impulses, as in multiple sclerosis (MS).
• Nodes of Ranvier and saltatory conduction are vital elements of axon structure and function.

Neuron Structure - Synapse

• A synapse is the connection between the axon of one neuron and the dendrite of another.
• It allows different parts of the nervous system to communicate with one another.
• The synaptic cleft is the space where synapse occurs.

Neurotransmitters

• Chemicals transmit information across the synaptic cleft.
• Many pharmacological interventions for neurological disorders inhibit or facilitate neurotransmitter activity.
• Acetylcholine, glutamate, GABA, dopamine, serotonin, norepinephrine, and epinephrine are some common neurotransmitters.

Types of Neurotransmitters

• Acetylcholine is used by all neurons that synapse with a muscle fiber and regulates heart rate and other autonomic functions.
• The NT exictatory that facilitates neuronal change during development is Glutamate: excessive glutamate release can cause neuron destruction in CNS after injury.
• GABA is the major inhibitory neurotransmitter of the brain.
• Dopamine influences motor activity, motivation, and cognition.
• Serotonin plays a role in mood and behavior and inhibits pain.
• Epinephrine and Norepinephrine are NTs used by the autonomic nervous system to produce the fight or flight response.

Brain - White Matter vs. Gray Matter

• White matter is composed of axons that carry information away from cell bodies and is found in the brain and spinal cord.
• Gray matter is composed of cell bodies and dendrites, covers the entire surface of the cerebrum, and presents deep within the spinal cord as well.

Meninges

• The meninges are three membranous coverings that protect the delicate nerve tissues.
• The innermost layer is the pia mater, which contains cerebral circulation.
• The subarachnoid space is the area between the pia and arachnoid layers and contains CSF.
• The arachnoid mater is the middle layer.
• The subdural space is the area between the arachnoid and dura.
• The dura mater is the outermost layer, connects to the skull, and is tough ("dura = tough; mater = mother").
• The epidural space is the area between the dura and the skull.

Neuroanatomy

• The central nervous system (CNS) includes the brain, cerebrum, cerebellum, and brain stem.

Brain - Cerebrum

• The Cerebrum has 4 lobes, 2 cerebral hemispheres, and is the largest portion of the brain.
• The cerebrum features a highly convoluted surface with elevations (gyrus) and depressions (sulcus).
• The outer surface (cortex) consists of gray matter, and the inner surface is mostly white matter.

Cerebral Lobes

• The cerebral lobes consist of the Frontal lobe, parietal lobe, temporal lobe, and occipital lobe.

Frontal Lobe

• The frontal lobe contains the primary motor cortex and Broca's Area (motor production of speech).
• The frontal lobe is responsible for voluntary control of complex motor activities, judgment, attention, awareness, abstract thinking, mood, and aggression.

Parietal Lobe

• The parietal lobe is the location of the primary sensory cortex [touch, kinesthesia, vibration, temperature].
• This area is responsible for perceptual learning, spatial and visual, short-term memory functions, and provides meaning for objects.

Temporal Lobe

• The Temporal Lobe has a location of the primary auditory cortex and Wernicke's Area (speech comprehension).
• It is responsible for hearing, visual perception, musical discrimination, long-term memory, and olfaction.

Occipital Lobe

• There is a primary visual cortex in the occipital lobe.
• This lobe is responsible for the organization, integration, and interpretation of visual information.
• The eyes take in visual info and send it to the occipital cortex for processing.

Cerebrum - Two Hemispheres

• 95% of the population is left hemisphere dominant.

Left Hemisphere

• The left hemisphere is the verbal and analytical side of the brain, and is responsible for processing information in a sequential organized linear manner.
• The hemisphere deals in language production and processing, reading comprehension, mathematical calculations, motor sequencing, and expression of positive emotions.

Left Hemispheric Damage

• Deficits observed in patients with this damage include planning motor tasks (apraxia), initiating sequencing, processing tasks, producing and comprehending speech, perseveration (repetition of a particular response), and anxiousness.

Right Hemisphere

• The right hemisphere handles nonverbal and artistic abilities.
• The hemisphere processes information in a complete and holistic fashion, grasping general concepts and visual-perceptual functions.
• It also deals with non-verbal communication, drawing inferences, mathematical reasoning and judgment, sustaining movement/posture, and expressing negative emotions and perceiving emotion.

Right Hemispheric Damage

• Patient deficits observed include poor judgment and safety awareness, unrealistic expectations, denial of deficits, disturbances in body image, irritability, and lethargy.

Cerebrum Deep Structures

• Within the cerebrum are the diencephalon, hippocampus, basal ganglia, limbic system, and amygdala.

Cerebrum - Deep Structures

• The Diencephalon is composed of the thalamus, hypothalamus, epithalamus, and subthalamus.

Cerebrum - Deep Structures Diencephalon - Thalamus

• The thalamus relays sensory information from the body to the appropriate association areas in the brain.
• This area also relays motor information from the basal ganglia and cerebellum to appropriate motor regions.

Cerebrum - Deep Structures Diencephalon - Hypothalamus

• The hypothalamus regulates homeostasis internal balance.
• It is primarily involved in autonomic functions such as hunger, thirst, digestion, body temp, BP, sexual activity, and the sleep-wake cycle.

Cerebrum - Deep Structures Diencephalon - Epithalamus

• The epithalamus includes the pineal gland and secretes melatonin, a hormone that induces sleep.
• Epithalamus functions with the hypothalamic nuclei to help regulate the sleep-wake cycle.

Cerebrum - Deep Structures Diencephalon - Subthalamus

• The subthalamus is located close to the thalamus and hypothalamus and regulates movements produced by skeletal muscles.
• Subthalamus works in conjunction with the basal ganglia and substantia nigra.

Cerebrum - Deep Structures Hippocampus

• The hippocampus rests deeply within the temporal lobe.
• It is responsible for forming and storing new memories of one's personal history and is also important in learning a new language.
• The hippocampus operates as a "memory indexer", sending memories to the appropriate areas of the cerebral hemispheres for long-term storage and retrieving memories when needed.

Cerebrum - Deep Structure Basal Ganglia

• The basal ganglia are made up of the caudate nucleus, putamen, globus pallidus, substantia nigra, and subthalamic nuclei.
• They regulate posture and muscle tone and control movement.
• The most common condition associated with dysfunction of the substantia nigra is Parkinson's Disease.
• Patients with Parkinson's Disease exhibit Bradykinesia, Akinesia, Tremors, Rigidity, and Postural Instability.

Cerebellum

• The cerebellum controls balance and posture, sequencing initiation, timing, and order of muscle firing in multi-joint movements.

Brain Stem

• The brain stem is the location for cranial nerve nuclei and is divided into three sections: midbrain, pons, and medulla.
• The midbrain contains reflex centers for visual, auditory, and tactile responses.
• The pons contains reflex centers for orientation of the head and regulates breathing [CN V - VIII].
• The medulla is an extension of the spinal cord with reflex centers for vomiting, sneezing, and swallowing.

Ventricles

• The ventricles are four fluid-filled cavities that contain CSF within the central nervous system (CNS).
• Each ventricle contains a tissue called the choroid plexus that makes CSF.

Cerebral Circulation: Major Arteries

• The common carotid artery supplies the bulk of the cerebral circulation.
• The external carotid artery supplies the face.
• The internal carotid artery supplies the cerebral hemispheres, optic nerves, and retina and bifurcates, splitting into the anterior and middle cerebral arteries.

Neuroanatomy Cerebral Circulation

• Cells within the brain depend on the continuous supply of blood, without which, neurons in the brain are unable to carry out their function.

Cerebral Circulation Anterior Circulation

• The anterior cerebral artery supplies the superior border of the frontal and parietal lobes.
• The middle cerebral artery is the largest cerebral artery and the most often occluded.
• It supplies blood to the lateral surface of the brain and deep portions of the frontal and parietal lobes.

Cerebral Circulation: Vertebral Artery

• The Vertebral Artery supplies the brain stem and cerebellum.
• The Basilar Artery supplies the brain stem and the medial portion of the temporal and occipital lobes.
• The Posterior Cerebral Artery connects with the posterior communicating artery and supplies the midbrain, plus the occipital and temporal lobes.
• The Anterior and Posterior Communicating Arteries interconnect at the base of the brain to form the Circle of Willis, providing a protective mechanism so that occlusion of one cerebral artery does not critically decrease blood flow to that region.

Neuroanatomy Injury to CNS

• Arterial destruction of significant duration produces cell and tissue death within minutes.
• After death from lack of oxygen Neurons do not possess the capacity of regeneration.
• Changes in the neurons become noticeable in 24-36 hours at which point they become soft and swollen, liquefy, then the necrotic tissue coverts into a cyst that scar tissue covers, resulting in the neurons not replaced and the original function is lost.

Neuroanatomy Reaction To Injury

• With motor neuron Injury to the motor neuron results, UMN: Injury or lesion.
• A result of damage to the corticospinal tract with the site of lesion from the frontal lobe, anywhere along track to its end in spinal cord.

Clincial signs

• Include Spasticity = velocity-dependent, increased resistance to passive stretch.
• Hyperreflexia = increased reflexes
• Babinski sign
• Clonus = repetitive stretch elicited by passive dorsiflexion.

CVA – Definition and Epidemiology

• A CVA (cerebrovascular accident) shows as a sudden onset of neurologic signs and symptoms resulting from a disturbance in blood supply.
• Statistics from 2021 show the 1 in 6 deaths from cardiovascular disease due to CVA.
• Over 795,000 people a year in the United States have a stroke.
• About 87% of strokes are ischemic.
• Between 2018-2019, stroke-related costs came to $56.5 billion.
• Stroke is a leading cause of long-term disability.
• Stroke reduces mobility in over half of stroke survivors who are age 65+.

CVA – Risk Factors

• Health conditions, such as high blood pressure, high cholesterol, heart disease, diabetes, obesity, and sickle cell disease, can increase the risk of stroke.
• Lifestyle behaviors, such as diet, and sedentary activity, alcohol, and smoking, can increase the risk of stroke.
• Other factors that increase the risk of strokes are genetics, a family history of health issues, age (doubles every 10 years after 55), and gender.

Types of CVA

• Ischemic CVA includes thrombotic and embolic.
• Hemorrhagic CVA includes intracerebral, subarachnoid, and arteriovenous malformation (AVM).

Ischemic: Thrombotic CVA

• Atherosclerosis is the most frequent cause.
• An atherosclerotic plaque can completely occlude the vessel, creating a cerebral infarction.
• Cerebral infarct = actual death of the portion of the brain.

Ischemic Embolic CVA

• Embolic CVA: Associated with cardiovascular disease.
• A blood clot (embolus) breaks away from the inner lining of the artery and is carried to the brain

Ischemic Embolic CVA

• The embolus can occlude a cerebral blood vessel, leading to death of cerebral tissue –Core ischemic zone= blood flow is reduced to 10-25% of normal causing neuron and glial cell death -Ischemic penumbra= the zone surrounding the core with mild to moderate ischemia making this the target zone for treatment.

Hemorrhagic CVA

• This shows as an abnormal bleeding event resulting from the rupture of a blood vessel.
• This is subdivided into 3 major types: intracerebral, subarachnoid, arteriovenous Malformation (AVM).

Intracerebral Hemorrhage

• Intracerebral Hemorrhage results in bleeding in the brain if a vessel is damaged. That vessel damage is brought about by the malformation of vessels as age increases or uncontrolled hypertension (HTN).

Subarachnoid Hemorrhage

• Bleeding which occurs in the subarachnoid space, is typically caused by vascular damage or berry aneurysm.

Arteriovenous Malformation (AVM)

• Congenital defects can weaken the arterial, and venous walls, and cause eventual rupture called CVA with AVM.
• Blood vessels dilate, causing masses to form in the brain.

CVA vs TIA

• Cerebral Vascular Accident shows blood supply interruption for prolonged periods, involves cell death, is present for various months/year, has brain damage present, and has functional/cognitive deficits present.
• A Transient Ischemic Attack resembles a stroke and involves temporarily interrupted blood supply.
• Deficits completely resolve in 24 hours with no residual deficits; recurrent TIAs = increased risk of CVA.

Cerebrovascular Accidents Diagnosis

• Hospitalization can determine the etiology of the infarct.
• Neuroimaging - MRI or CT can determine whether stroke is ischemic or hemorrhagic.
• PET scan: Use imaging to check the regional blood flow, and cerebral metabolism + determines where ischemia isreversible.

Cerebrovascular Accidents Diagnosis

• Cerebral Angiography is an invasive procedure which shows narrowing or the blockage of an artery inside of the brain.
• That aids in diagnosis with CVAs, brain tumors, aneurysms, or vascular malformation's, by giving path for Catheter through- body -> up a small artery inside of the neck-> Contrast dye Release ->X-rays are taken during the procedure.

Cerebrovascular Accidents Diagnosis (MRI Vs CT SCAN)

• MRI can help diagnose an ischemic injury within 2–6 hours of stroke; more accurate then CT. But Is more costly, along the time it is being taken.
• CT Scan; not as accurate to diagnosis injuries within the smaller areas of the brain. It is may take as little as 7days after incident for diagnosis. Which is more affordable, time administration is not long, and results are faster.

Cerebrovascular Accidents Vascular Syndromes

• Vascular Syndromes include occlusion of the anterior and middle cerebral arteries.

Cerebrovascular Accidents Vascular Syndromes: Anterior Cerebral Artery Occlusion

• Anterior Cerebral Artery supplies the superior border of the cerebral hemisphere, including the frontal and parietal lobes, with the highest prevalence of a possible embolus.
• Common characteristics: Aphasia and Incontinence, Contralateral hemiparesis and sensory loss greater in the LE than the UE.

Cerebrovascular Accidents Vascular Syndromes: Middle Cerebral Artery Occlusion

• The dominant and Subcortical hemisphere for The Middle Cerebral Artery occlusion is the most prevalent with Global Aphasia,and Contralateral hemiparesis to also sensory loss in the face+ Extremities > UE>LE, along with; vision loss in temporal vision.

Cerebrovascular Accidents Impairments

• Motor and Sensory impairments can occur due to (CVA).
• Motor impairments are: Altered Tone- Flaccidity,spasticity,synergy,contracture. Paresis (muscle Weakness) is usually in a: Unilateral hemiparesis / Plegia= paralysis (with the patient possibly unable to move) Unilateral hemiplegia with loss of plan motor deficits all being sensory impairments.

Motor Tone after a CVA

• Low tone in muscles post-CVA can lead to flaccidity or hypotonia because Muscles lack normal levels with movement and contraction also are lead to instability + Subluxation with the patient in the joints >in the shoulder due to the patients tone in extremities/torso. That is why positioning and education on movement that is normal along with safe practice is important.

CVA: Spasticity/Hypertonia

• Spasticity/Hypertonia that come on high tone with exaggerated DTR, causing resistance to passive stretch when the patient is either moving or at rest with the movement.

Modified Ashworth Scale: Spasticity:

It allows more concrete numbers and a baseline with the clinician in these points:

• 0 The limb is without a increase in tone to the patients limbs.
• 1 Slight catch and the clinician can easy release, with the patient, while resistance to end ROM shows in minimal form.
• 1+ The patient show mild catch then minimal resistance from the doctor in ROM.
• 2 The patient shows a mild-moderate level of resistance as the doctor moved through ROM.
• 3-4 Patient movement show difficulty that is extremely heavy to where movement is rigid or fixed.

Impairments: Motor impairments

• Atrophy will develop for A stroke, and patient are unable to make force/ torque with Tension, and generate in levels to support motor torque. Paresis can cause weakness,while Plegia may show paralysis which could alter a patients tone/ ability to move or preform movement.
• Interventions,

Neurodevelopmental Treatment (NDT)

• Develop in the 1940 By the Bobaths NDT is use to facilitate normal control mechanisms while providing the patient normal sensations of movement/Function is provided with patient transitions.

Handling Techniques to increase movement for NDT.

• Facilitation is use during the approach with a quick stretch, tapping, vibration, approximation increases co-contraction of: the muscles limb that will need less tone, weight bearing is to activate muscles and for joint stability,and/or quick to apply to icing. .
• Inhibition with slow/Thymic rotating that is used for proximal->distal,Weight bearing that tone and spasticity, using longer bouts of ice to activate muscles.

Documenting NDT

A narrative is key which means:

• The patient subjective complaints , the NDT technique -> impairment and functional limitation,Describing patient needs,Response to,and a plan in PNF-Progressives are the components to the notes. The functional limitations are described for NDT.

Documenting NDT Narrative Assessment Components:

• To best perform treatment;The patient needs to work and the clinician should understand and assess what is done.
• Check also The muscles, and compensatations, what is use.
• If The patient is working right, did task can be do perfectly- did modifications adjustment if task needed?
• If patient Took breaks with the therapist or on own?
• Compare to the last time; did Verbal/Tactile- cues, and then, Evaluation and reasoning.
• The patient is performing right; did result wanted,compare with last time?

Quiz #6

• Damage of (B) MCA / Middle Cerebral Artery results in the upper Extremity with or and sensory (face) damage.

Quiz #7

• (B) The statement ""According to Brunnstrom Stages of Motor Recovery, a patient can pass through each level at variable rates and can skip stages as they recover"", is: False.

Werenickes Aphausa

• "Wernicke's area in that has to do with; The (D)- Temporal Lobe."

Introduction to PNF

• PNF is a way to increase the movement, and has had great success is getting the patient more movement capabilities, for example;
• The goal, with therapy for that movement of (Intro to/Proprioceptive/Neuromuscular Facilitation", involves these key ingredients.
• Pt (PTAs/therapy.
  • Treatment management with patients .
• Well known ways are are with PNF -> (Neurological developmental with tx.
  • Has (LSVT) big focus as well for therapy success for patients.

History of (PNF).

• It helps with a (most interventions) or(Neuronal rehab, ( Dr Herman + Maggie).

PNF Philisophy

• to create change you challenge , with patient care.
• is the "active help" to develop well, in the potential function needed. (Approach " with positivity, and find patient help+ what to create from there! .
• -Create for the PT feeling, what creates success.

-Strength 2. Flexibility 3:ROM 4:Motor C 5-

Improve it: can use Pnf. Can be use. / Functional:

• can use that in what patient.

Intro to (PNF)-Basic Principles:

Ten Principles:.

• (Manual; contacts)

1. *Body P with M)
2. (Stretch)-manual / Resistance
3. (Irradiation)

• Joint is to be

• Time and movement..

• Patterns in M) .

• (Verbal. / Input)

##( Review (PNF) extremties):

• Patterns is about two,with D and D2.
• Namming to be to Direction, what it to be a good joint..

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