Red flags for headache that are caused by excessive pressure, hydrocephalus, or tumor include the following: 

-Headache present at waking -Pain triggered by coughing, sneezing, or straining -Vomiting (may also indicate migraine) -Symptoms worsen when lying down

Signs that a headache is caused by serious intracranial disease, tumor, encephalitis, or meningitis    

-Progressive, worsening over days or weeks -Neck stiffness, vomiting (irritation of meninges) -Rash, fever (bacterial meningitis, Lyme disease) -History of cancer, HIV infection

-Headache after a head injury -Abrupt onset -Headache associated with onset of paralysis, mental status changes, or reduced level of consciousness (confusion, drowsiness, memory loss, loss of consciousness) is a strong indication for neuroimaging

•  refers to the simultaneous contraction of antagonist muscles    
• Stabilizes joints

In the lower limbs, it allows an individual to stand on an unstable surface    

Lower Motor Neurons

alpha motor neurons   

Multimodal areas of the CNS Areas that Send Information to Multimodal areas of the CNS

Medial Upper Motor Neuron Tracts

Multi Modal association Areas

are also called convergence association areas

Allow us to give meaning to information received- in other words- these areas receive inputs from a variety of sensory areas and send outputs to multiple areas

Posterior , anterior and limbic association areas

Integrates sensory information processed by the somatosensory, visual and auditory association areas and the olfactory and gustatory cortices

This is where scent, vision, touch taste and sound are all connected to form a sensory experience

After integrating the 5 types of sensory data-  then sends the data to the: 1) anterior multimodal association area for initiation of action in response to this sensory data and 2) the limibic area to form memories associated with the emotions generated by the sensory data

Takes the integrated sensory data from the posterior multimodal association area- and uses it to make decisions about which motor plan to implement.

Once a decision is made this area sends the information to the premotor area to access the appropriate motor plan.

Once the appropriate motor plan is accessed- the primary motor area MM1) implements the motor plan.

Which association area?

Where is workingWorking memory- abstract ideas, judgement, reasoning, planning?

- This s a region of our brains that matures slowly

cingulate gyrus, para hippocampal gyrus, hippocampus

Emotional impact and memories

Emotional impact-- Danger

Because the multimodal association area in the R hemisphere plays a role in perception ( how one perceives the environment and our relationship to the environment)= damage to the R multimodal association area can result in perceptual disorders– and these can be very debilitating for our clients.

Visual perception- includes spatial perception

Body schema

Language perception ( expressive and receptive)

Motor planning or praxis

Tactile perception

Auditory perception

Classification of perceptions involved in R hemisphere impairment. (6)

 the inability to interpret sensations and thus recognize things.

umbrella term for the inability to identify and recognize familiar objects– despite having normal eye anatomy– Lesions usually located in the R hemisphere in the posterior multimodal association area

inability to identify familiar faces- people cannot see or perceive the unique bone structures or face musculature that makes up each human face- and makes them different from one another.

difficulty interpreting a visual stimulus a s a whole– often will confabulate to compensate for what they cannot see– “make it up”. May even appear blind- just too  much visual stim for them to accurately interperet.  Typically are unable to describe a complex scene

cannot attach the appropriate color to the object- despite having normal eye anatomy

understanding and using the concepts of L and R

Involves difficulty distinguishing the foreground from the background

Stereopsis- how close are objects to one another. Near and far

Detecting- concepts related to positions. Understanding and executing directions of next to, on top of, beside- under- Twister would be hard

Can a person tell if the tree is close or far away? Easily seen in ADL tasks- like reaching for cup, faucet.

Relationships location

These patients have what we call poor pathfinding skills. At risk for getting lost-

Impaired perception that revolves around identifying and localizing one’s own fingers or hand= difficulty naming finger on command or identify which one was touched-

Perceptual Motor Dysfunction

• Ideational
• Ideamotor I
• Ideamotor 2

Ideational - perceptual motor dysfunction

loss of the kinesthetic memory for motor patterns. Can understand that the shirt is something to be worn but not how to put it on.

cannot implement the appropriate motor plan.

A client understands that you asked her to brush teeth and understands the demands of the task- but is not able to access the right motor plan. Given deodorant- puts it in their mouth- or uses toothbrush to brush hair

Pain defined by 3 things

Stages of Pain

occurs when the free nerve endings in the periphery ( the nociceptors) become stimulated

Nociceptors are located in the skin, muscles, connective tissue, circulatory system, and our viscera

Nociception stimulation results from damage to nerve endings or from the release of chemicals at the injury site    

 involves the conduction of pain signals along afferent pathways in the periphery to the spinal cord and brain

2 primary fibers are involved in the transmission process: A delta, and C fibers

A delta fibers are large, thinly myelinated fibers that transmit signals quickly in response to tissue damage. Pain signals propagated along these fibers are sharp, stinging, highly localized and short-lasting

 C fibers are small unmyelinated and conduct pain more slowly- poorly localized- dull, aching, longer lasting.

Perception of pain: 

process where the cortex attaches meaning to or interprets pain signals. The perception of pain involves threshold and tolerance.

 The primary somatosensory area (SS1) secondary somatosensory area (SS2) posterior multi modal association area, and limbic system structures all have a roll in the perception of pain

-occurs from the body and can be divided into superficial and deep pain

-results from nociceptor stimulation in the skin or superficial tissues- usually well localized– pin prick

pain from the internal organs, glands, smooth muscle dull and diffuse- not well localized ( at least initially)

Acute pain= commonly considered to lass less than 30 days- quickly resolves

Chronic pain lasts overtime. Some sources define chronic pain is pain that lasts longer than 3 to 6 months. Pain that lasts longer than the expected length of recovery

Can be sharp/dull

Dull pain tend to be diffuse and long lasting because they are carried by those slow conducting and unmyelinated C fibers

Sharp pain tends to be well localized b/c it is carried by the fast conducting large A delta fibers

Major Pathways of Pain

 ascending somatic sensory pathways that receive pain info from the skin and skeletal muscles --Sensory nerves carry pain info in the periphery to the dorsal horn of the spinal cord.

- When these spinal nerves synapse in the dorsal horn- there is release of  substance P- this neuropeptide acts as a neuro transmitter in the detection of and response to inflammatory processes and pain.

- thalamic tracts travel from the spinal cord to the thalamus- and send projections to the cortex for conscious pain detection and interpretation.

descending sensory tracts that receive pain information from the periphery through afferent spinal nerves that synapse at the reticular formation of the brainstem

These tracts have their origin in the medullary reticular formation

tract with origin in the trigeminal lemniscus- CN5- to the thalamus and then to the cortex– specifically carries pain sensation from the face

pain messages from the Spinal tracts are projected to the thalamus and then to the cortex for conscious detection and interpretation. 

many components have been disproven. Very simply- if the transmission of pain info can be blocked in the dorsal horn- then it closes the gate to pain. --asserts that non-painful input closes the "gates" to painful input, which prevents pain sensation from traveling to the central nervous system. Therefore, stimulation by non-noxious input is able to suppress pain

an absence of pain in response to stimulation that would otherwise cause pain–

Analgesic mechanisms can be activated by: (3)

Diminished transmission of pain

Diminis–Periphery

–Cortical levelhedDiminished Transmission of Pain

 Transmission of Pain    

Diminished Transmission of Pain:

Periphery 

non-narcotic analgesics ( aspirin) decrease the synthesis of prostaglandins- this prevents prostaglandins from sensitizing peripheral pain receptors.  NSAIDS – (ibuprofen)- analgesic effects- by interrupting the peripheral transmission.

Local anesthetics- administered to nerve endings

Heat and cold- reduces the peripheral pain signals by altering blood flow and inflammation

inhibitory neurons in the what release encephalin or dynorphin- these diminish the pain sensation through interneurons that bind to the excited nociceptor (principle of counter irritant theory)

release of hormonal endorphins from the pituitary gland- and from the adrenal medulla

detection and interpretation of pain can be altered by an individuals expectation- distraction levels, anxiety Example: belief in a placebo (level of pain)

Sensitization by prostaglandins lowers the threshold of pain fibers– this is allodynia- where non painful stimuli is now interpreted as painful

pain that is perceived to originate from on body region when it actually starts in a different area. Usually- this occurs from visceral pain. Example: heart attack and arm pain

massage- stimulation to reduce pain is based on that counterirritant theory-

Proximal branches of the mechanoreceptors in the dorsal horn activate interneurons that synapse on the excited nociceptors

 “tens units” E-stim is a form of pain management  that works to

Usually involves placement of electrodes- with gel pads or sticky electrodes-  over the painful area- can treat both acute and chronic pain  Transcutaneous Electrical Nerve Stim ( TENS) , Interferential Current Therapy (ICT), Microcurrent Electrical Neuromuscular Stim (MENS)

use of heat to treat chronic and acute pain- works through vasodilation- hotpacks, paraffin, ultrasound

Cryotherapy- use of cold to anesthetize sensory receptors- vasoconstriction

water therapy- the body likes homeostasis- will vaso constrict/ dialate to achieve

dry superficial thermal modality- ground corn husks- to the size of sand.

 one of the oldest documented medical treatments in the world

 learning how to release the body’s own naturally occurring endorphins and raise pain thresholds by using visual imagery

 learn to consciously control body functions that are typically involuntary- uses a measurement tool- something that can measure contraction of a muscle or measure heart/respiratory rate

injections of local anesthetics and steroids in the are of a spinal nerve causing pain– can be used to determine if a surgical intervention will be successful

Examples: facet medial branch blocks, root blocks, epidural

discogram, discectomy, laminectomy, foraminotomy, spinal fusion

hese are implanted devices. – deliver medication to the spinal cord region.

 do not alter cognition- non narcotic- not addictive

Tylenol- long term use can impact liver and kidneys

bind to opioid receptors in the CNS, PNS – highly addictive- side effects include sedation, respiratory depression, constipation, addiction

(morphine, codeine, Demerol, OxyContin

 can be indicated to alleviate severe musculoskeletal pain- muscle spasticity. Blocks transmission at the neuromuscular junction

• hypoesthesia
• hyperasthesia
• paresthesia
• dysesthesia
• thermethesia
• thermohyperesthesia
• thermohypoesthesia
• analgesia
• hypalgesia
• hyperalgesia
• allodynia

Peripheral Neuropathy

damage to 1 single nerve.  Usually due to compression r entrapment.

Example : wrist drop radial nerve entrapment : foot drop peroneal nerve entrapment

nerve root impingement that results from a lesion affecting the dorsal or ventral roots- Example: herniated discs, osteoarthritis, spondylolisthesis

damage in one of the plexuses brachial or lumbar– multiple peripheral nerve damage

involves bilateral damage to more than one peripheral nerve. Stocking and glove- diabetes is a common example

Functional regeneration occurs primarily in the PNS-

Recovery is SLOW- 1mm of growth per day or  1 inch per month. Example: a severed nerve in the upper arm- such as C6 can take at least 1 year.

painful sensation localized to the residual limb or stump- mediated by peripheral nerve signals.

• Somatognosia