PT: Developmental Sequence & Rating Scales

Developmental Sequence

• Progresses from least to most difficult
• Starts with prone on elbows, advancing through quadruped (4pt, 3pt, 2pt), kneeling, half kneeling and finally to modified plantigrade

PT Rating Scales

• Includes scales for tone, spasticity, Ashworth, Brunnstrom, Glasgow Coma Scale, and Rancho Los Amigos

Tone Grades

• Range from flaccid to hypertonic
• 0 indicates no response and flaccidity
• 1+ indicates a decreased or hypotonic response
• 2+ indicates a normal response
• 3+ indicates an exaggerated or hypertonic response
• 4+ indicates a sustained or severe hypertonic response

Spasticity

• Assessed using the Modified Ashworth Scale
• A score of 0 indicates no increase in tone
• A score of 1 indicates a slight increase in tone, with catch and release or minimal resistance at the end of range of motion
• A score of 1+ indicates a slight increase in tone, with catch and minimal resistance throughout less than half of the range of motion
• A score of 2 indicates a more marked increase in muscle tone through most of the ROM, with the affected part easily moved
• A score of 3 indicates considerable increase in muscle tone along with difficult passive movement
• A score of 4 indicates that the affected part is rigid in flexion or extension

Brunnstrom Stages of Recovery

• Stage I: Flaccidity
• Stage II: Spasticity begins to develop
• Stage III: Spasticity increases and peaks
• Stage IV: Spasticity begins to decrease
• Stage V: Spasticity continues to decrease
• Stage VI: Spasticity is essentially absent
• Stage VII: Return to normal function
• Individuals may plateau at certain stages

Glasgow Coma Scale (GCS)

• Assesses levels of consciousness
• Used to assess arousal, functional cerebral cortex, and predict TBI outcomes
• Eye Opening is rated from 1 to 4, with 4 being spontaneous and 1 being no response
• Best Motor Response is rated from 1 to 6, with 6 obeying commands and 1 being no response
• Best Verbal Response is rated from 1 to 5, with 5 being oriented and 1 being no response
• Total scores range from 3 to 15
• Scores below 8 indicate coma and severe brain injury

Mild TBI

• GCS score of 13-15
• Loss of consciousness lasts less than 20 minutes
• Associated with least long-term impairment

Moderate TBI

• GCS score of 9-12
• Often results in permanent physical, cognitive, and behavioral deficits

Severe TBI

• GCS score of 3-8
• The patient is in a coma
• Indicates permanent functional and cognitive impairments

Ranchos Los Amigos Scale

• Levels of cognitive functioning
• It is an eight-point scale to examine cognitive and behavioral recovery in patients emerging from coma

Levels of Consciousness

• No response (coma)
• Generalized response: Inconsistent, non-purposeful reactions
• Localized response: Specific, inconsistent reactions to stimuli
• Confused-Agitated: Bizarre, non-purposeful behavior, incoherent verbalizations
• Confused-Inappropriate: Responds somewhat consistently to simple commands
• Confused-Appropriate: Consistently follows simple directions with carryover
• Automatic-Appropriate: Appears appropriate during daily routine but behaves robotically
• Purposeful-Appropriate: Aware and responsive to the environment; may have decreased abilities relative to premorbid status

Cerebrum: Frontal Lobe

• Located in the precentral gyrus
• Controls motor cortex, motor function, behavior, thoughts, and memories
• Controls voluntary movement of contralateral face, arm, leg, and trunk
• The homunculus represents motor input into each part of the body
• The pre-motor area is the supplementary motor area
• Participates in planning and execution of movements and executive functioning
• Frontal eye fields enable voluntary motor eye movements
• Broca's area regulates speech in dominant hemisphere
  • Left hemisphere dominates in 90-95% of the population and plans mouth movements for speech
  • Right hemisphere is responsible for non-verbal communication, gestures, and tone of voice
• Prefrontal areas involved in complex behaviors and personality

Cerebrum: Parietal Lobe

• Contains sensory cortex and processes and interprets sensory information
• Primary sensory area location is in the postcentral gyrus
• It receives sensory information from the contralateral side of the body
• The sensory homunculus describes areas that receive sensory input from each part of the body
• Sensory association area is posterior to the primary sensory area, integrates and interprets sensations and allows one to determine the shape of an object without looking at it
• Stores memories for sensory experiences

Cerebrum: Temporal Lobe

• Contains auditory cortex; interprets sound, including the role of emotion
• Wernicke's area aids hearing and comprehending spoken language

Cerebrum: Occipital Lobe

• Contains visual cortex and interprets visual information
• Receives visual information from the eyes and sends it to the occipital cortex; organizes, integrates, and interprets
• Visual association areas receive visual information from the thalamus and recognizes and evaluates what is seen

Hemispheric Specialization

Left Hemisphere

• Dominant for most of the population.
• Controls motor function and receives sensory information from the right side of the body
• Expresses positive emotions
• Important for language - includes Broca's and Wernicke's areas
• Responsible for motor language function and translates thoughts into words
• Recognizes and interprets meaning of speech and translates words heard into thoughts
• Interprets concrete, literal meaning of words
• Controls concrete function, math calculations, writing letters, reading sentences, categorizing shapes, and sequencing steps

Right Hemisphere

• Has longer recovery time involving how to maintain concrete function
• Controls motor function and receives sensory information from the left side of body
• Perceives and expresses negative emotions
• Interprets information that is abstract and creative
• Interprets perception of environment
• Enables visual and spatial and language perception
• Facilitates motor planning and tactile and body perception

Apraxia

• Motor planning disorder where the patient is unable to perform a motor task, despite the willingness to execute, having the task in their repertoire and having the mm system needed to hear and perform the task

Ideational Apraxia

• Patient is unable to carry out a task due to the inability to select and carry out a motor program
• Patient is unable to produce movement in proper sequence, either on command or automatically and may not be able to use tools for the correct task. For example, the patient may put shoes on before socks or butter bread before putting in a toaster, or try to comb hair with a toothbrush

Ideomotor Apraxia

• Patient is unable to produce movement on command, although they can perform the task automatically
• Patient also able to describe how they perform task, like being unable to put on glasses if asked, but can put them on to read

Aphasia

• Includes Wernicke's aphasia
  • Receptive disorder
  • Inability to recognize or interpret the meaning of speech and translate words heard into thoughts
• The types include Broca's aphasia
  • Expressive disorder and inability to translate thoughts into words
  • Involves Broca's area and the motor language function
• Global aphasia impacts both speech comprehension and expression due to extensive brain damage

Abnormal Reflexes

• Includes hyperreflexia and the Babinski Reflex
• Primitive reflexes include:

Asymmetrical Tonic Neck Reflex

• ATNR: head rotation to the side causes extension of the same-side extremities and flexion of the opposite side

Symmetrical Tonic Neck Reflex (STNR)

• Flexion of the neck causes flexion of upper extremities and extension of lower extremities
• Extension of the neck causes extension of upper extremities and flexion of lower extremities

Tonic Labyrinthine Reflex (TLR)

• Prone position causes flexion of extremities
• Supine position causes extension of extremities

Synergy Patterns

Flexion

• Scapular retraction

Extension

• Scapular protraction

Associated Reactions

• Unintentional movements of an affected limb with voluntary action of another limb

Souque's Phenomenon

• Flexion of the affected upper extremity above 150 degrees causes extension and abduction of fingers

Raimiste's Phenomenon

• Resisted hip abduction or adduction of the unaffected lower extremity produces the same response in the affected lower extremity

Homolateral Limb Synkinesis

• Flexion of the affected upper extremity causes flexion of the affected lower extremity

Meninges Layers

Pia Mater

• Innermost layer
• Connective tissue adhered to surface of the spinal cord and brain
• Vascular

Arachnoid Mater

• Middle layer exhibiting spider-web like arrangements of collagen and elastin fibers
• Avascular

Dura Mater

• Outermost layer composed of thick connective tissue

Subarachnoid Space

• Space between the pia and arachnoid mater
• Contains cerebrospinal fluid
• Site for lumbar puncture or tap

Subdural Space

• Space between the arachnoid and dura mater
• Contains interstitial fluid

Epidural Space

• Separates dura mater from wall of vertebral canal
• Space inferior to L2, is the site for injection for anesthetics

Brain Circulation

• Brain supplied by two main artery pairs
  • Internal carotid arteries
  • Vertebral arteries
• Venous drainage occurs through veins, ultimately emptying into internal jugular veins

Internal Carotid Arteries

• They divide into anterior and middle cerebral arteries

Vertebral Arteries

• Join as the basilar artery and it divides into posterior cerebral arteries
• Branches of the vertebral/basilar arteries supply to cerebellum and stem of the brain

Clinical Effects of Occlusions

Middle Cerebral Artery Occlusion (MCA, UE>LE)

• It is the most common site of CVA
• Left hemi occlusion causes
  • Contralateral right hemiparesis of upper body regions that are R>L, UE>LE
  • Contralateral hemiparesthesia of upper body regions and aphasia
  • Impaired cognitive function and emotional ability
• Right hemi occlusions causes
  • Contralateral left hemiplegia of upper body regions
  • Contralateral hemiparesthesia of upper body regions
  • Impaired cognitive function
  • Euphoria, denial of deficits, apraxia and perceptual deficits, and neglect

Anterior Cerebral Artery Occlusion (ACA, LE>UE)

• The supplied areas are the medial, superior, and lateral aspects of frontal and parietal lobes
• Primary motor and sensory area lesions cause hemiplegia and hemiparesthesia of the lower body
• Frontal lobe lesions cause cognitive involvement and apraxia

Posterior Cerebral Artery Occlusion (PCA)

• Supplies the occipital lobe, hypothalamus, brain stem, and cerebellum