Autonomic Nervous System

Regulates homeostasis without cortical input. Homeostasis is the maintenance of optimal internal environment.
This includes regulation of viscera, vasculature, and glands.
Functions include: respiration, digestion, temperature, metabolism, secretions, and reproduction
Differs from the somatic nervous system in that autonomic functions occur nonconsciously

HOW?
Receptors are located within the viscera. They include: different organs that tell you what is happening
Mechanoreceptors: pressure and stretching (blood vessels, blood pressure change, blood volume change)
Chemoreceptors: chemical change within your viscera/ blood: blood sugar (detecting blood sugar within the
blood)
Nocireceptors: any sort of detection of pain: damage of the tissue
Thermoreceptors: change in temperature: body detects temp change

Afferent pathways: information travels INTO CNS via

o spinal cord via dorsal roots
o into the brainstem via CN 9 and 10, converging to the solitary nucleus in the medulla
o Sensory information (information coming in)
o CN 9 and 10 only 2 nerves that take…

Medulla and Pons help to regulate heart rate, respiration, vasoconstriction and vasodilation
Hypothalamus is a major control center to regulate temperature, thirst, feeding, endocrine secretions. It also
regulates brainstem centers that control vegetative functions
Visceral information that reaches the thalamus is mainly projected to the emotion/motivation system.
Autonomic responses influenced by emotion would be:
 Anxiety: heavy breathing. Increase heart rate, sweating, tummy pain____________
Embarrassment: redness, cry________________
This is the information that is coming into the body

Efferent pathways: information traveling from CNS to effector organs via a two-neuron pathway. The two neurons
synapse in a peripheral ganglion.
The neuron extending from CNS is called preganglionic or first order neurons
The neuron connection the ganglion with the effector organ is called postganglionic or second order neurons (land
on the lungs to increase your breathing)

Sympathetic vs Parasympathetic Nervous System:

Sympathetic Nervous System:
Cell body—located in the intermediolateral horn of the thoracic and first 2 lumbar sections of the spinal cord
Function—primarily to maintain optimal blood supply in the organs; activates fight or flight response during
stressful situations
o accelerate heart rate
o increased blood pressure
o shift of blood flow from skin and GI tract to the muscles and brain (to run)
o increased blood sugar levels
o dilation of bronchioles and pupils
o constriction of stomach intestine, urethral sphincter

Parasympathetic Nervous System:

Cell body—located in the brainstem and sacral regions
Function—primarily responsible for energy conservation, maintain heart rate, metabolism, and digestion in a state
of homeostasis; activates “rest and digest” following a stressful situation

ANS and Disease/Illness vs Healing

Chronic stress is correlated with more disease, illness, physical and mental health disorders
Stress activates sympathetic nervous system causing release of adrenaline and stress hormones
Links to cardiovascular disease, depression, anxiety, inflammatory responses, sleep disturbances, pain

Parasympathetic nervous system activity promotes homeostasis and cellular repair

Activity heightened during stage 4 restorative sleep
Slow, controlled breathing can be used as a relaxation technique to interrupt panic attacks.
Pain
Unpleasant sensation detected by nociceptors, receptors designed to detect harmful stimuli

While pain is associated with tissue damage, it can be experienced independently of tissue damage
Pain experiences vary between individuals
Our pain experience can be affected by our emotional state, medications, weather, and prior knowledge

Four stages of nociception

1. Transduction: free nerve endings in the periphery become stimulated
2. Transmission: conduction of pain signals along afferent pathways from periphery to SC and brain
a. A delta fibers—large, thin myelinationàquick response, highly localized, short-lasting
b. C fibers—small, unmyelinatedàslow pain signals, dull, poor localization, longer-lasting
3. Perception: cortex attaches meaning to the sensation
a. threshold
b. tolerance
4. Modulation: Modification of pain signals at various levels
 Somatic Pain Visceral Pain
Where Bones, skin, muscles Internal organs, glands, smooth
muscle
Localization Superficial somatic (skin/tissue): well Dull and diffuse, not well
localized localized
Deep superficial (tendons/ligaments):
poorly localized

Acute Chronic
Lasts less than 30 days, resolves quickly Lasts more than 3-6 months,
typically longer than expected for
recovery
Defined location, quality, duration Vague, ill defined

Protective function Possibly function with secondary

gains

When you hurt yourself, how does pain stop?

Gate Theory: (Melzack and Wall 1965) postulated that pain could be blocked in the dorsal horn due to convergence
of 1st order mechanoreceptors and nociceptors on same 2nd order neurons

Counter-irritant Theory: based on Gate Theory; non-nociceptors in dorsal horn inhibit nociceptors. In layman’s
terms: this mechanism is helping the brain through distraction
Mechanical— related to pressure
Chemical— anything that will change the chemical makeup
Thermal— temperature change
Pain control=antinociceptive systems!

At periphery: topical and oral analgesics including Aspirin, application of heat/cold.

Dorsal horn: suppression via inhibition and counterirritation. (back portion of the spinal cord)
Brainstem: descending systems or tracts/pathways in the spinal cord that interrupt/suppress pain
Hormonal: release of endorphins bind to opiate receptors of the nociceptorsàantinociceptive
Noninvasive pain management
• Stimulation of mechanoreceptors – Massage (prolonged pressure on the pain site)
• Electrical stimulation – Transcutaneous Electrical Nerve Stimulation (TENS) –
block pain signals, release endorphins, and vasodilation (widening of blood
vessels to increase oxygen)
Thermotherapy--
• Hot packs – vasodilation (temporary)
• Paraffin wax baths – superficial heat conduction – reduce pain/joint stiffness.
• Ultrasound – effective heat modality for deep structures.
• Cold packs – anesthetizing/analgesic (lack of sensation)
• Hydrotherapy (aquatic) – allows for exercise with reduced stress to joints.
• Fluidotherapy – heated air and corn husk circulation machine.

Kinesio tape – special tape over muscles to assist function/provide support/alignment

Acupuncture – insertion of hair thin needles into skin in order to balance the forces of yin and yang.
Meditation – using visual imagery to release endorphins and raise pain thresholds
Biofeedback – using EEG based machine to learn to control unconscious body functions
Invasive pain management (not going to test us on this)
Nerve blocks – Anesthetic and steroid injections to nerve

Intrathecal Pump – pump placed in abdomen, which delivers medication directly to SC (CSF) via
a catheter in a controlled fashion.

Spinal surgery – some form of surgery to reduce back/vertebral/SC pain

• Discogram – used to identify painful vertebral disc
• Discectomy – removal of herniated disc
• Laminectomy – removal of the lamina (posterior vertebral plate) – to relieve spinal stenosis - narrowing of
spinal canal causing impingement
• Foraminotomy – enlarge openings of foramina where nerves exit SC
• Spinal fusion – fusion of vertebrae

Pharmaceutical Management of Pain

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) – reduce swelling
• Acetominophen – Analgesic – Tylenol, Anacin, and Valadol
• Opioids – Bind to opioid receptors – highly addictive – only indicated when other options have been exhausted
• Side effects – respiratory depression, sedation, constipation, addiction
• Morphine, Codeine, Demerol, and Oxycontin
• Muscle relaxants – alleviate muscle pain and spasticity
• Anticonvulsants – antiseizure medication increasingly used to treat pain.
ANS Syndromes:

POTS: postural orthostatic tachycardic syndrome

Triggered from standing up
Heart rate increases from sit to stand
Excessive pooling of blood in lower extremities when upright
Chronic condition
Symptoms: Lightheadedness, fainting, rapid heart beat

ANS: lack of vasoconstriction causes blood to flow down to legs upon standing and makes the heart beat faster

Therapist: Check BP pre and post; compression socks, abdominal binder, diet/lifestyle changes: water intake, salt
tablets; exercise daily

Syncope: fainting when going from supine to standing due to low blood pressure
Fainting, weakness, blurriness, changes in vision, headaches

ANS: overactive sympathetic response

Therapist: drink more water, compression socks, lay with feet elevated, tensing leg muscles when standing

Orthostatic hypotension: low BP after standing too quickly

Weakness, blurriness, seeing stars, black spots

ANS: overactive sympathetic response

Therapist: drinking fluids, using walker for steadiness upon standing, compression socks, movement, getting up
slowly

Horner’s Syndrome: effects face and eye, oculomotor nerve CN 3 lesion

Ipsilateral meiosis, ptosis, flushed and dry skin, one sided effect. headaches

ANS: disrupted nerve pathway

Therapist: occupational assessment; pain management

Peripheral Nerve Injury and Regeneration

WEEK 7

Spinal Cord Anatomy

The spinal cord extends from the magnum foramen to the conus medullaris. It has an hourglass shape with
enlargements at the cervical and lumbar sections due to high density of white matter, or axons of sensory and
motor tracts providing inputs/outputs from the limbs.
White matter: consists of myelinated axons; Divided into 3 pairs of funiculi: anterior, lateral, dorsal
Gray matter: contains cell bodies of sensory SC tracts in the dorsal horn and the motor spinal nerves in the ventral
horn
Sensory –
Dorsal Root Ganglion: cell bodies of sensory nerves in PNS; each sensory nerve has its own DRG
Dorsal Root: ascending spinal nerves carrying sensory information from receptors in PNS
Dorsal Rootlets: axons that synapse onto the dorsal horn of spinal cord (SC)
Dorsal Horn: dorsal rootlets synapse with interneurons in the dorsal horn that then synapse with SC tracts to ascend
up the CNS (SC, brainstem, cortex)

Motor—
Descending tract from CNS (cortex, brainstem, SC)
Ventral Horn: SC tracts synapse with interneurons in Ventral Horn
Ventral Rootlets: After synapsing with motor spinal nerves, they exit the Ventral Rootlets
Ventral Roots: motor information flows away from SC to the skeletal muscles
There are 31 pairs of spinal nerves:
Ascending= sensory Descending=motor

8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
Dermatomes
Dermatomes are skin segments that are innervated by one specific spinal nerve. Dermatomes help us to determine
sensory level affected by spinal cord injury.

Peripheral Nerves: connect sensory or motor end-organs with the central nervous system
 Ø Afferent axons innervating
posterolateral forearm &
hand, enter the spinal cord
through the C7 dorsal root
Ø Therefore the dermatome
innervating the
posterolateral forearm and
hand is C7.
Ø 3 peripheral nerves carry
axons of sensory neurons
to the periphery.
§ afferents from the
posterolateral hand
travel in the median and
radial nerves
§ afferents from the
posterolateral forearm

Ø Reflex Arc
Spinal
Reflex solely at the Spinal Cord level (no cortical involvement)
Trace pathway of information flow through the SC
Allows sensory information to be processed and acted upon quickly PROTECTIVE!
Deep Tendon Reflex
Withdrawal Reflex
Peripheral Nerve Injury
Neuropathy is the term for pathology of one or more peripheral nerves
Complete severance of nerveàloss of sensation, motor control, reflexes in the structures innervated by that
specific nerve
Compressionàfollows an order of sensory loss
1. proprioception and discriminative touch
2. cold
3. fast pain or sharp pain
4. heat
5. slow pain or dull, diffuse pain
Paresthesia occurs as compression is relieved. A person typically experiences tingling, burning, prickling
sensations. (I.e. when your foot falls asleep). Sensation returns in the opposite order listed above!

Flaccidity: with nerve injury, the nerve becomes flaccid and atrophies eventually. Can cause reduced tone of
muscle leading to weakness or paralysis

Signs of peripheral nerve damage include sensory, autonomic, and motor changes
Sensory changes: see textbook pg 171 for terminology
Autonomic changes: vasomotor nerve disturbances; difficulty regulating BP, sweating, bowel/bladder dysfunction
Motor changes: weakness or paralysis
Brachial Plexus: network of peripheral nerves including C5-T1 supplying the upper extremities
common site of compression syndromes:
Radial Nerve
Median Nerve
Ulnar Nerve
Lumbar Plexus: network of peripheral nerves including L1-L5
Sciatic Nerve
Peroneal Nerve

1. Mr. Nunez has chronic pain in his lumbar section after a fall from a ladder. The therapist applies electrical
stimulation through conductive gel pads placed on the identified painful region. This procedure is referred to as:
a. cryotherapy
b. hydrotherapy
c. transcutaneous electrical nerve stimulation
d. fluidotherapy

2. Ms. Lehmann has chronic neck and back pain with an unknown origin. She is learning to manage her pain
by consciously becoming aware of and modifying the tension in and position of her muscles and joints based
on feedback from an instrument that measures physiological functions such as muscular tension. This is
referred to as:
a. stress management and visualization
b. biofeedback
c. nerve blocks
d. acupuncture

3. Sophia has chronic pain and tenderness throughout her neck, back, shoulders, and legs. She also reports
extreme fatigue, sleep dysfunction, common headaches, and periods of cognitive fog. Sophia’s physicians cannot
find an anatomical cause of her pain. Patients with this condition are also likely to be diagnosed with chronic
fatigue syndrome, rheumatoid arthritis, Lyme disease, and irritable bowel syndrome. This condition is known as:
a. lupus
b. myasthenia gravis
c. Epstein-Barr virus
d. fibromyalgia

4. Mr. Shibata has intense burning that extends down both legs. This condition is called ____________ and
is a form of ________________.
a. causalgia; dysesthesia
b. thermohypoesthesia; thermesthesia
c. paresthesia; hyperalgesia
d. allodynia; hyperalgesia

5. After a soccer injury in which 16-year-old Tommy injured his left shoulder and arm, he developed a
chronic neurovascular disease characterized by debilitating pain, edema, restricted movement, and muscular
atrophy in his left upper extremity. Tommy also experiences burning, stabbing, and throbbing sensations that make
touch to his left upper extremity intolerable. This syndrome is called:
a. fibromyalgia syndrome
b. causalgia
c. stocking and glove syndrome
d. complex regional pain syndrome

6. Mr. Zimmerman has foot drop and a steppage gait in which he lifts his right bent knee high enough to
avoid dragging his foot. Compression of which nerve results in foot drop?
a. sciatic nerve
 b. peroneal nerve
c. ulnar nerve

7. After an acute infectious illness, Mr. Benfenati has developed a progressive ascending muscular weakness
in his limbs (flaccid paralysis occurs first in his lower extremities and progresses to his upper extremities), with a
symmetric pattern. He also reports paresthesias and numbness in his distal extremities. After 1 month, Mr.
Benfenati experiences a complete recovery. This disease process is called:
a. diabetes neuropathy
b. poliomyelitis
c. Guillain-Barré syndrome
d. myasthenia gra

9. Mr. Kaminski, in the above question, was diagnosed with:

a. stocking and glove neuropathy
b. radial nerve compression
c. sciatic nerve compression
d. reflex sympathetic dystrophy

10. After his below-the-knee amputation, Bill reports that he can still feel his lower left leg and foot. The phenomenon of
phantom limb sensation is likely caused by which of the following:
a. peripheral damage to the nerves that were surgically severed during amputation.
b. the formation of nerve fibromas in the residual limb of the amputated body part.
c. the cortical map of the body (homunculus) still retains the anatomical image of the amputated body
WEEK 8

Spinal Cord Tracts

Review: Spinal nerves include--
o 8 cervical; 12 thoracic; 5 lumbar; 5 sacral; 1 coccygeal

Ascending Tracts: carry sensory information received through receptors

Review: ascending spinal nerves carry sensory information from the periphery to the spinal cord via the
dorsal horn. They then synapse with an interneuron, which then synapses with as ascending spinal cord tract
Descending Tracts: carry motor information from the cortex, thalamus, brainstem to the spinal cord via the ventral
horn. They then synapse with an interneuron, then synapsing on a motor neuron, finally synapsing on a descending
motor spinal nerve
https://www.youtube.com/watch?v=qUtUNc_0pLI
https://www.youtube.com/watch?v=-JRQ-0Z_Kxc
Fill in the chart:

Tract Decussation Function Lesion

Ascending Tracts
Dorsal Columns (Medial Caudal medulla Discriminative touch Complete severance
Lemniscus) and proprioception below decussation:
 bilateral loss of
sensation
Hemilesion below
decussation:
Ipsilateral loss
Above decussation:
contralateral sensory
loss
Spinothalamic SC level Lateral: sensory info Complete severance:
(Anterior and Lateral) regarding pain and temp Bilateral loss of
Anterior: crude touch, sensation below
light touch lesion
Hemilesion: at
lesion—bilateral loss
Below: contralateral
sensory loss

Posterior None Ipsilateral

Spinocerebellar
Anterior Spinocerebellar Cerebellum Unconscious sensory Complete severance:
from LE regarding Bilateral loss of prop
proprioception and below lesion
coordination Hemilesion: at
Sensory info from MS, lesion—bilateral prop
GTO, joint receptors loss
Below: contralateral
prop loss

Cuneocerebellar None Unconscious sensory Ipsilateral

from trunk and UE
 regarding proprioception
and coordination
Sensory info from MS,
GTO, joint receptors
Rostral Spinocerebellar None Unconscious sensory Ipsilateral
from trunk and UE
regarding proprioception
and coordination
Sensory info from MS,
GTO, joint receptors
Descending Tracts
Lateral and Anterior Pyramidal decussation Conscious/voluntary M1: contralateral loss
Corticospinal (UMN) of the medulla movement from M1 of mvmt; spasticity;
Anterior does not cross hyperactive reflexes
Decorticate rigidity
Corticobulbar (LMN) Does not cross Controls CN 3-12 Flaccidity of CN 3-12
Medial Longitudinal None Coordination of head Dyscongugate eye
Fasciculus and eye movement, eye movement,
tracking, extraoccular involuntary eye gaze
eye mvmt
Vestibulospinal None Extensor muscles, Decerebrate rigidity
postural muscles, stance
Rubrospinal Midbrain Antagonist of antigravity Decerebrate rigidity
muscles—facilitates
flexor groups
Medullary Mostly no crossing Inhibits extensor tone Increased extensor
Reticulospinal tone, decerebrate
rigidity
Pontine Reticulospinal None Facilitates extensor tone Decerebrate rigidity
Spinal Cord Injury and Disease
Complete vs Incomplete: sensory and motor functions below the lesion level determine; if any functions remain,
then incomplete
Upper Motor Neurons: Motor information traveling from cortex up to but not including the ventral horn

Lower Motor Neurons: Information traveling from cell bodies in ventral horn to skeletal muscles

1. Since her head injury causing cerebellar damage, Mrs. Johnson has difficulty understanding where her limbs
are in relation to each other and where her body is in space. Which neurological system is responsible for the
recognition of an organism’s position in relationship to the environment?
a. vestibular system
b. proprioceptive system
c. basal ganglia system
d. ventricular system
2. After her stroke, Mrs. Williams’s occupational therapist fabricated a wrist cock-up splint for her spastic right
wrist and hand. Splinting is a therapeutic technique that works on which of the following principles?
a. A quick stretch of a spastic muscle group facilitates the Golgi tendon organs, which inhibit the spastic
muscles.
b. Placing pressure on the muscle belly of a spastic muscle group facilitates the Golgi tendon organs, which
inhibit the spastic muscles.
c. A sustained stretch of a muscle group facilitates the Golgi tendon organs, which inhibit the spastic
muscles.

3. Mr. Tomlinson had a right hemisphere stroke 2 weeks ago. When his therapist passively moves his left elbow
joint into extension, the elbow joint is initially highly spastic and cannot be moved. With sustained stretched on the
elbow flexors, the spasticity suddenly gives way and the elbow joint can be moved into extension. This type of
spasticity is referred to as:
a. cogwheel rigidity
b. lead pipe rigidity
c. clonus
d. clasp knife phenomenon
4. Mr. Okonjo has been diagnosed with Parkinson disease. When the therapist attempts to range his elbow joint, the
joint resistance is jerky and characterized by a pattern of release/resistance. This type of rigidity is known as:
a. cogwheel rigidity
b. lead pipe rigidity
c. clonus
d. clasp knife phenomenon
5. Mandeep’s SCI occurred at level T6, and he uses a wheelchair for mobility. When his wife attempts to move
his foot onto the footplate of the wheelchair, his ankle flexor muscles uncontrollably oscillate, causing his
lower extremity to rhythmically jerk and spasm. This phenomenon is called ______________ and can be
reduced by ___________________.
1. cogwheel rigidity
2. clonus
3. placing the spastic muscle (ankle flexors) on a sustained stretch, thereby facilitating the Golgi
tendon organs
4. performing a quick stretch of the spastic muscles (ankle flexors) to facilitate the muscle spindles
a. 1, 3
b. 2, 3
c. 1, 4
d. 2,4
 6. Mrs. Goldstein has been diagnosed with Parkinson disease. When the therapist attempts to passively range
her elbow joint, the movement is characterized by a uniform and continuous resistance to passive movement.
This form of hypertonicity is known as:
a. cogwheel rigidity
b. clasp knife phenomenon
c. clonus
d. lead pipe rigidity
7. After his stroke, Mr. Nakai is observed to exhibit scapular elevation and retraction, shoulder abduction and
external rotation, elbow flexion, forearm supination, and wrist and finger flexion. This upper extremity
pattern is a stereotyped set of movements that occur in response to neurological damage and may be further
promoted by an environmental stimulus or by the patient’s voluntary movement. This movement pattern is
known as:
a. an associated reaction
b. decerebrate rigid
c. a synergy pattern
8. After Mrs. Perloff’s stroke, she demonstrates increased spasticity in her right upper extremity when she
brushes her hair or engages in any effortful movement using her left arm. This phenomenon is called
________________ and results from an inability to selectively inhibit the interneurons that synapse on
motor cell bodies of the opposing limb.
a. an associated reaction
b. a synergy pattern
c. decorticate rigidity
9. Mackenzie is a 3-year-old child with low muscle tone. To increase tone in her upper extremities and trunk, her
occupational therapist is likely to use which of the following techniques?
a. placing pressure on the muscle belly of Mackenzie’s hypotonic muscles
b. performing sustained stretches of Mackenzie’s hypotonic muscles
 c. performing quick stretches of Mackenzie’s hypotonic muscles

10. Mr. Kronberger is in a progressed stage of Parkinson disease. He has the type of hypertonicity in which his
muscles are resistant to passive stretch on both sides of a joint and the resistance is not velocity dependent. This
type of hypertonicity is called ______________ and is caused by _________________ motor neuron damage.
1. spasticity
2. rigidity
3. upper
4. lower
a. 1, 3
b. 1, 4
c. 2, 3
d. 2, 4
Section 22
1. Mr. Iwu has lost voluntary motor control of the right side of his body as a result of a brain injury. Mr. Iwu’s
brain injury is likely located in the ______________ hemisphere and in the _____________ motor area.
a. 1. left
b. 2. right
c. 3. primary
d. 4. premotor
a. 1, 3
b. 2, 3
c. 1, 4
d. 2, 4
2. As a result of his head injury, Jayson has difficulty implementing the correct motor plan for a specific task. For
example, when given a shirt, he attempts to slip his head through the sleeve. This is referred to as ______________
and results from injury to the _________________ motor area.
1. aphasia
2. apraxia
3. primary
4. premotor
a. 1, 3
b. 2, 3
c. 1, 4
d. 2, 4
3. Toneal sustained a traumatic brain injury in a motorcycle accident. His physician flicks the nail of his third
finger and in response, Toneal involuntarily exhibits thumb adduction and index finger flexion. This primitive
reflex is called _________________, and its re-emergence after neurological injury indicates damage to the
________________.
1. Babinski sign
2. Hoffman sign
3. cortex
4. cerebellum
a. 1, 3
b. 1, 4
c. 2, 3
d. 2,4
4. When the therapist displaces Toneal’s center of gravity, he falls to the left instead of extending his arms and legs
to prevent falling. The ability to extend the arms and legs to prevent falling when one’s center of gravity is
displaced is a higher level reaction called __________________. When this reaction is lost, it is indicative of
________________ damage and places the patient at risk for falls.
1. protective extension
2. equilibrium reaction
3. brainstem
4. basal ganglia
a. 1, 3
b. 1, 4
c. 2, 3
d. 2, 4
5. Mr. Bhandari, who was diagnosed with Parkinson disease 2 years ago, displays difficulty initiating, continuing,
and stopping movement; muscular rigidity (eg, cogwheel and lead pipe rigidity); and resting tremors. Parkinson
disease results from a lesion in the ______________ and depletion of the neurotransmitter _______________.
1. cerebellum
2. basal ganglia
3. norepinephrine
4. dopamine
a. 1, 3
b. 1, 4
c. 2, 3
d. 2,4
6. Mr. Shaw has a neurological motor disorder in which he displays violent thrashing of his contralateral extremity.
This condition is known as _____________ and results from a lesion to the ______________.
1. hemiballismus
2. chorea
3. basal ganglia
 4. cerebellum
a. 1, 3
b. 2, 3
c. 1,4
d. 2,4

7. After taking neuroleptic medication all of her adult life for schizophrenia, April has developed tongue
protrusions, facial grimacing, blepharospasm, and lip smacking. These involuntary movements are collectively
called _______________ and result from long-term treatment with dopamine receptor antagonists.
a. tics
b. chorea
c. tardive dyskinesia
d. idiopathic dystonia
8. Ms. Graham displays ataxia, intention tremors, broken speech, and nystagmus. Her physician suspects a lesion
of the ________________.
a. basal ganglia
b. brainstem
c. cortex
d. cerebellum
9. Sean commonly displays tics such as shoulder shrugging, throat clearing, eye blinks, and head jerks.
Occasionally, he exhibits vocal tics and shouts out repetitive words or noises. Sean states that he feels compelled to
engage in these repetitive motor and vocal tics and that although he is able to suppress these for a time, his
compulsion builds until he can no longer control his urges. This condition is known as _______________ and
results from pathology of the ________________.
1. obsessive compulsive disorder
2. Tourette syndrome
 3. dopamine system
4. norepinephrine system
a. 1, 3
b. 2, 3
c. 1, 4
d. 2, 4
10. Henry is a 6-year-old child who, from birth, has displayed abnormal and repetitive movements caused by
severe muscle contractions producing twisting postures. These muscle contractions can last up to several hours,
disappear during sleep, and worsen with anxiety. For example, Henry experiences muscle contractions that force
his neck into hyperextension (called retrocollis ). Such abnormal twisting movements are collectively called
____________ and result from ______________ pathology.
1. dystonia
2. chorea
3. cerebellar
4. basal ganglia
a. 1, 3
b. 2, 3
c. 1, 4
d. 2, 4

Section 23, 24, 25, 26, 27

1. Mr. Choi has been diagnosed with a tumor in his right secondary somatosensory area. As a result, he has
difficulty identifying objects with his left hand (with vision occluded). The umbrella term for this disorder is
called:
a. tactile agnosia
 b. b. primary sensation
2. For example, when small objects are placed in Mr. Choi’s left hand (with vision occluded), he cannot
interpret them. This is called:
a. a. two-point discrimination
b. b. agraphesthesia
c. c. astereognosis
d. d. atopognosia
3. Mrs. Malinowski has a tumor located in V4. She is able to accurately see and interpret objects when they are
still. However, she is unable to interpret objects in motion (such as moving cars on a street). This is referred
to as:
a. achromatopsia
b. akinetopsia
c. abarognosia
d. topographical disorientation
4. Mrs. Novak had a left cerebral hemisphere stroke located in the inferior gyrus of the premotor area. She can
understand language that is spoken to her, but when she tries to respond, she cannot form meaningful
sentences. This type of aphasia is called _______________.
1. Broca aphasia
2. Wernicke aphasia
3. receptive aphasia
4. expressive aphasia
a. 1, 3
b. 2, 3
c. 1, 4
d. 2,4
 5. Jose lost consciousness after a traumatic brain injury and has not regained it 2 months status post-injury. He
is able to open his eyes and appears to display regular sleep-wake cycles, but does not have cognitive
function or awareness. Jose’s cough, gag, and swallowing reflexes all remain intact. This state of altered
consciousness is called _______________ and is caused by severe damage to the __________________:
1. brain death
2. persistent vegetative state
3. cortex
4. brainstem
a. 1, 3
b. 2, 3
c. 1, 4
d. 2,4
6. Jose’s friend Alejandro, who was in the car accident with Jose, also sustained a traumatic brain injury. Alejandro
is in a state of sleep-like (eyes closed) unarousability. All cognitive function has been lost as well as cough, gag,
and swallowing reflexes. Alejandro’s heartbeat continues from ANS regulation; however, Alejandro has been
hooked up to life support because of a severe respiratory infection. This type of coma is called _____________ and
results from severe damage to the _______________.
1. brain death
2. persistent vegetative state
3. cortex
4. brainstem
a. 1, 3
b. 2, 3
c. 1, 4
d. 2,4
7. After a drug overdose that damaged her ventral pons, Lin lost all voluntary muscle control, including the ability
to speak. The muscles controlling her eyeball movements are the only muscles over which she still retains control.
Lin lies in a hospital bed and is conscious but cannot communicate. This state is called:
a. brain death
b. persistent vegetative state
c. coma
d. locked-in syndrome
8. After his stroke, Mr. Donatelli has difficulty expressing meaningful verbal communications to others and has
hemiparesis and hemiparesthesia of his right side. His stroke likely occurred in which cerebral hemisphere?
a. left
b. right
9. After her stroke, Ms. Jenkins has developed hypersensitivity to sensation on the contralateral side of the lesion.
The hypersensitivity progressed into burning, agonizing pain that causes Ms. Jenkins nausea and sleep disruption.
This syndrome is called _______________ and can result from ______________.
1. central post-stroke pain
2. central hypersensitivity syndrome
3. vascular insufficiency to the thalamus and nearby CNS structures
4. vascular insufficiency to the sensory spinal cord tracts
a. 1, 3
b. 1, 4
c. 2, 3
d. 2,4
10. Mr. Morrissey had a stroke to his brainstem, which damaged the structure responsible for states of wakefulness.
As a result, he lies in a stuporous, unarousable state. The structure likely damaged was the:
a. reticular inhibiting system
b. reticular activating system
 1. Mrs. Elliot has had a benign brain tumor removed from area V4 of the occipital lobe. After recovery from
surgery, she reports that she sees the world in shades of gray and cannot remember what objects looked like in
color. She believes that she always saw objects as gray and does not recognize any change in her visual perception.
Ophthalmological tests confirm that all visual anatomical structures are intact (all rods and cones are functional).
Seeing everything as shades of gray as a result of cortical loss of area V4 is called:
a. color anomia
b. achromatopsia
c. metamorphopsia
d. simultanagnosia
2. After Mr. Li’s stroke, his therapist has observed visual-spatial problems. The therapist gives a pencil, eraser, and
small box to Mr. Li and asks him to follow her directions: “Put the box on top of the table. Place the eraser inside
of the box. Place the pencil next to the box.” Mr. Li has difficulty following these directions. This visual-spatial
problem is known as:
a. figure-ground discrimination disorder
b. topographical disorientation
c. position in space dysfunction
d. right-left discrimination disorder
3. Andrew, who sustained a traumatic brain injury 5 years ago, now lives in a supervised apartment in the
community, which he shares with a roommate. Although Andrew only lives 1 mile from the bank, he continuously
gets lost each time he attempts to walk to the bank from his house. This visual-spatial disorder is called:
a. position in space dysfunction
b. right-left discrimination disorder
c. figure-ground discrimination disorder
d. topographical disorientation
4. Mr. Tarantino had a right hemisphere stroke and as a result has hemiplegia and hemiparesthesia in both left
upper and lower extremities. Despite this severe impairment, Mr. Tarantino is cheerful and has no awareness of his
deficits. This morning, he asked his nurse to remove the leg that was in his bed all night. This severe neglect
syndrome is called:
a. anosognosia
b. unilateral neglect
c. body image dysphoria
d. aggramation
5. Along with Wernicke aphasia, Ms. Walsh has difficulty understanding gestures and symbols commonly used in
social communication. This form of receptive aphasia is called:
a. aprosodia
b. dyslexia
c. asymbolia
d. dyslexithymia
6. When given a toothbrush, Mr. Samuelson verbally indicates that a toothbrush is used to clean teeth; but when he
attempts to use it, he instead brushes his hair with it. This motor planning problem is called:
a. ideational apraxia
b. ideomotor apraxia
7. When Samantha hears music, she also sees the music as colors. The ability to generate multiple sensations in
response to a single sensory experience is called _________________ and is a perceptual phenomenon.
a. synesthesia
b. chromathesia
8. Mr. Owusu sustained a left hemisphere middle cerebral arterial stroke. He may experience all of the following
except for which one?
a. right side hemiplegia and hemiparesthesia
b. cognitive impairment
c. affective (emotional) involvement
d. ataxic gait
9. Ms. Brayden had a cerebrovascular accident caused by an occlusion to the superior cerebellar arteries. She may
experience all of the following except for which one?
a. ataxic gait
b. hypotonicity and hyporeflexia
c. dysmetria and nystagmus
d. loss of pain and temperature on the contralateral side
10. Mr. Kagan is experiencing numbness and weakness in his left arm and leg, blurred vision, dizziness, and
confusion. His daughter calls 911, because she recognizes these signs as indicative of a:
a. visual-perceptual disorder
b. migraine-induced aura
c. transient ischemic attack
d. tactile agnosia
WEEK 9

Disorders of Muscle Tone

Muscle Tone: Unconscious phenomenon; the amount of resistance to passive stretch exerted by a resting muscle
cannot consciously increase or decrease muscle tone
Tested by passive ROM
NOTE: there is a normal range of muscle tone from low normal to high normal

Tone is mediated by several structures throughout the central and peripheral nervous system including the
brainstem, basal ganglia, cerebellum, descending motor tracts, lower motor neurons in the ventral horn, and
peripheral nerves.
Hypotonicity: abnormal decrease in muscle tone caused by lower motor neuron lesions or lesions to the posterior
cerebellar lobe

Hypertonicity: abnormal increase in muscle tone accompanied by resistance to active and passive movement;
caused by upper motor neuron lesions or lesions to the anterior cerebellar lobe
Spasticity: velocity dependent difficulty moving a specific muscle group; either flexor or extensors, not both
Ridigity: velocity independent difficulty moving a specific muscle group; occurs on both sides of the joint

Clonus: uncontrolled oscillations of the muscle in a spastic muscle group

Contractures develop in muscles that maintain their shortened positions

Therapeutic Techniques to Influence Tone

• Sustained stretch to activate GTOs of the agonist – promotes muscle relaxation
• A quick stretch to activate MSs – promotes increased tone in those with flaccidity
• Never place pressure on the belly of a spastic muscle – as this will activate MSs to further
increase tone.
• Place pressure on tendon to activate GTO of agonist – promote muscle relaxation
• Splinting – sustained stretch
• Serial casting

Assessing Tone—
Modified Ashworth Scale:
0 – No increase in muscle tone
1 – Slight increase in tone manifested by minimal resistance at the end ROM
2 – More marked increase in muscle tone through most of ROM, but easily moved.
3 – Considerable increase in muscle tone, making passive movement difficult
4 – Affected joint is rigid

Muscle synergies are movement patterns that occur to achieve a specific task in an effort to simplify movements.
For example, to reach for a fork your triceps contracts, while the biceps relaxes. Synergy patterns develop
stereotyped movement patterns involving pathological muscle tone after neurological damage such as CVA or TBI

Associated reactions is when voluntary movement of one extremity produces unintentional movement in another
extremity. Abnormal associated reactions post-neurological damage would produce increased tone in the affected
side when the unaffected side is in use.

Motor Functions and Dysfunctions of the CNS

Primary Motor area (M1) – initiation of voluntary/conscious movement
Motor homunculus – the brain map that denotes each body part’s cortical
representation for voluntary movement.
• The more control that body part needs; the larger the brain map.
• Use it or lose it – cortical representation for that body part disappears with
disuse.

Premotor and Motor Association area – anterior to M1

• Performs motor planning – praxis
• Ideational praxis – ability to cognitively understand the motor demands of a
task, such as – when shown a shirt: understanding that a shirt is to be worn,
and how to go about putting it on.
• Ideomotor planning – identifying the appropriate motor plan, through stored library of plans; and
implementation or execution of the plan.
Primitive reflexes
• These develop during gestation and infancy and become integrated into normal motor movements
throughout the first months/years of life.
• These reflexes facilitate infant development
• Neurological damage can impede integration or cause re-emergence of primitive reflexes
https://www.youtube.com/watch?v=rHYk1sYsge0
Higher Level Reactions—
o These reactions are reflexes that develop during infancy and early childhood and remain
o Includes righting reflexes, equilibrium reactions, and protective extension
o Important for postural control and movement
o Neurological damage results in these higher level reactions to disappear

Basal Ganglia – responsible for stereotypic and automated movement patterns, goal directed behavior, social
behavior, and emotional regulation
• Research suggests ADHD may be caused by pathology in the basal ganglia in balancing inhibitory and
excitatory actions.
• May also be implicated in processing decisions related to rewards and addicting behaviors
• Lesions
o Difficulty initiating, continuing, or stopping movement
o Muscle tone (rigidity)
o Undesired movements (tremors, chorea)
 o Athetosis – slow flailing (slow/twisting quality) of the UEs - continuous
o Chorea – fast and more proximal sudden, involuntary, jerky movements that appear dance-like.
o Huntington Chorea – chronic degenerative inherited disorder that also involves progressive dementia.
o Dystonia – involves muscles contractions producing twisting movements that are repetitive and often
result in abnormal postures. These abnormal postures/contractures can last from seconds to hours.
o Dyskinesia – rhythmic, repetitive movements that have an odd quality; typically impacting the face,
mouth, jaw, and tongue rather than the limbs.
o Tardive Dyskinesia – movement disorder caused by chronic use of neuroleptics (antipsychotic) and
antiemetics (motion and morning sickness) medications.
o Parkinson’s – caused by degeneration of the substantia nigra.
§ Disjointed uncontrollable resting movements
§ As movements slows, mental processes also become delayed.
§ Associated with anxiety and depression.
§ Some develop dementia.
§ Symptoms – hypertonicity, rigidity, tremors, difficulty initiating and stopping gait, impaired
postural reflexes
o Tremor – involuntary oscillating movements – commonly upon movement – alternating contractions
between opposing muscles.
o Tics – Repetitive, brief, rapid, involuntary movement involving single muscle or groups of muscles –
can be motor, verbal or sounds (grunts or throat clearing)
o Tourette Syndrome – tics occurring at a young age, and commonly associated with OCD.
Cerebellum – Coordination of movement, maintenance of posture, spatial orientation, and equilibrium. Improves
precision of motor control.
• Cerebellar lesions
 o Ataxia – uncoordinated movements
o Dysmetria – inability to judge distance
o Adiadochokinesia – inability to perform rapid alternating movements
o Intention tremors – occurs during movement

Sensory Functions and Dysfunctions of the CNS

Primary somatosensory cortex (SS1) – responsible for detecting incoming sensory information; but not
interpretation
• Sensory homunculus – cortical representation of body part sensations map in the cortex (similar map to the
motor homunculus)
• Lesions – result in loss of sensation of the contralateral body part
Secondary somatosensory cortex (SS2) – responsible for interpretation of sensory information
• Lesions – agnosia – inability to attach meaning to sensory data, such as two-point discrimination,
astereognosis
• “Use it or lose it” principle
Primary Visual Cortex – detection of visual input – color, shape, orientation and direction (not interpretation)
• Lesions – visual information may be rerouted to the Visual Association Areas (V2-V5)– where visual
information is interpreted – meaning is attached to vision.
Auditory Cortex – located within temporal lobe. Primary auditory cortex (A1) detects sound and sends it to
Auditory Association Areas for interpretation
Broca Area – Verbal expression of language
• Lesions – Expressive aphasia
Wernicke Area – Comprehension of spoken word
• Lesions – Receptive aphasia

Thalamus and Brainstem Sensory and Motor Roles

Thalamus – almost every major structure for sensory and motor data has connections with the thalamus.
• Lesions
o Central post-stroke pain – contralateral loss of sensation at first, leading to onset of burning and
agonizing pain sensation.
Brainstem – controls vegetative functions essential for survival – respiration, primitive reflexes, pupillary response,
cough/gag reflex, spontaneous swallow
• Reticular formation – part of brainstem responsible for filtering/screening sensory and outgoing motor
information.
o Regulating consciousness
o Control of muscle tone
o Control of pain
o Regulating circadian rhythms
Disorders of Consciousness
§ Persistent vegetative state: cerebral damage leading to lack of consciousness; cough, gag,
swallow reflexes intact due to lack of brainstem damage
§ Brain death: brainstem functions have been lost, heartbeat continues from ANS
regulation
§ Locked-in syndrome: appears to be loss of consciousness, but remains aware yet no
means of communication except eye movement
• Peripheral Nerves Lab Summary

•
• Entrapment injuries from inflammation, compression and overuse
• Median N compression: carpal tunnel syndrome
• Radial N compression: Saturday night palsy, radial tunnel
• Ulnar N compression: cubital tunnel, guyon canal
•
• Neurological Screenings:
• Tactile Agnosias--
• Stereognosis – with vision occluded – place a common object in the patient’s hand and have them identify it.
• Graphesthesia- with vision occluded- draw a figure (number, letter) in the patient’s palm and have them identify it
• Visual Agnosia—
• Visual identification – show common object to patient and ask them to identify it.
• Motor planning (apraxia) – ask patient to perform complex yet common motor planning task, such as brushing hair,
buttoning, using screwdriver, paper clip, etc.
• Spatial relationships
• Drawing – Ask pt to copy a simple drawing or draw a common simple object (house, flower, clock, etc.)
• Body scheme drawing – draw a person
• Patient draws on only one side would signal unilateral neglect
• Proprioception(awareness of body in space)—
• Joint position – with vision occluded, place affected limb in one static position and ask pt to “match that position with
the other limb”
• Finger to nose test – pt reaches to examiner’s finger then their own nose and repeats quickly; vision included for 3 reps;
vision occluded for 3 reps.