Lab Exercise 10
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Focusing on the Re-Emergence of Primitive Reflexes Following Acquired Brain Injuries
33 Focusing on The Re-Emergence of Primitive Reflexes Following Acquired Brain Injuries Resiliency Through Reconnections - Reflex Integration Following Brain Injury Alex Andrich, OD, FCOVD Scottsdale, Arizona Patti Andrich, MA, OTR/L, COVT, CINPP September 19, 2019 Alex Andrich, OD, FCOVD Patti Andrich, MA, OTR/L, COVT, CINPP © 2019 Sensory Focus No Pictures or Videos of Patients The contents of this presentation are the property of Sensory Focus / The VISION Development Team and may not be reproduced or shared in any format without express written permission. Disclosure: BINOVI The patients shown today have given us permission to use their pictures and videos for educational purposes only. They would not want their images/videos distributed or shared. We are not receiving any financial compensation for mentioning any other device, equipment, or services that are mentioned during this presentation. Objectives – Advanced Course Objectives Detail what primitive reflexes (PR) are Learn how to effectively screen for the presence of PRs Why they re-emerge following a brain injury Learn how to reintegrate these reflexes to improve patient How they affect sensory-motor integration outcomes How integration techniques can be used in the treatment Current research regarding PR integration and brain of brain injuries injuries will be highlighted Cases will be presented Pioneers to Present Day Leaders Getting Back to Life After Brain Injury (BI) Descartes (1596-1650) What is Vision? Neuro-Optometric Testing Vision writes spatial equations -
Blink Reflex, H-Reflex and Nerve-Conduction Alterations In
Lepr Rev (2006) 77, 114–120 Blink reflex, H-reflex and nerve-conduction alterations in leprosy patients ANA BERTHA MORA-BRAMBILA*, BENJAMI´N TRUJILLO-HERNA´ NDEZ**, RAFAEL COLL-CARDENAS***, MIGUEL HUERTA***, XO´ CHITL TRUJILLO***, CLEMENTE VA´ SQUEZ***, BERTHA ALICIA OLMEDO-BUENROSTRO*, REBECA O. MILLAN-GUERRERO** & ALEJANDRO ELIZALDE*** *Facultad de Enfermerı´a, Universidad de Colima, Colima, Me´xico **Unidad de Investigacio´n en Epidemiologı´a Clı´nica, Hospital General de Zona y Medicina Familiar No. 1, Instituto Mexicano del Seguro Social, Colima, Colima, Me´xico ***Centro Universitario de Investigaciones Biome´dicas, Universidad de Colima, Colima, Me´xico Accepted for publication 14 February 2006 Summary Peripheral nerve lesions are the most important cause of disability in leprosy patients. Electrophysiological studies are used in the diagnosis and prognosis of neuropathy. Nerve conduction is the most frequently used electrophysiological test method to detect neuropathy, although it evaluates only a part of the peripheral nervous system. Blink reflex and H-reflex are electrophysiological tests which evaluate facial and trigeminal nerve function. This study determined the frequencies of blink reflex, H-reflex and motor and sensory nerve conduction alterations in twenty five heterogeneous, clinic patients with lepromatous leprosy and a control group of 20 healthy subjects. Study results showed a decrease in motor and sensory nerve conduction in 40% and 30%, respectively. In blink reflex (BR), right R1 was altered in latency. in 20% of patients, left R1 in 20%, right ipsilateral R2 in 16%, left ipsilateral R2 in 20%, and right and left contralateral R2 were altered in 32% of patients. There was an absence of H-reflex in 16% (n ¼ 4) and prolonged latency in 4% (n ¼ 1). -
What's the Connection?
WHAT’S THE CONNECTION? Sharon Winter Lake Washington High School Directions for Teachers 12033 NE 80th Street Kirkland, WA 98033 SYNOPSIS Students elicit and observe reflex responses and distinguish between types STUDENT PRIOR KNOWL- of reflexes. They then design and conduct experiments to learn more about EDGE reflexes and their control by the nervous system. Before participating in this LEVEL activity students should be able to: Exploration, Concept/Term Introduction Phases ■ Describe the parts of a Application Phase neuron and explain their functions. ■ Distinguish between sensory and motor neurons. Getting Ready ■ Describe briefly the See sidebars for additional information regarding preparation of this lab. organization of the nervous system. Directions for Setting Up the Lab General: INTEGRATION Into the Biology Curriculum ■ Make an “X” on the chalkboard for the teacher-led introduction. ■ Health ■ Photocopy the Directions for Students pages. ■ Biology I, II ■ Human Anatomy and Teacher Background Physiology A reflex is an involuntary neural response to a specific sensory stimulus ■ AP Biology that threatens the survival or homeostatic state of an organism. Reflexes Across the Curriculum exist in the most primitive of species, usually with a protective function for ■ Mathematics animals when they encounter external and internal stimuli. A primitive ■ Physics ■ example of this protective reflex is the gill withdrawal reflex of the sea slug Psychology Aplysia. In humans and other vertebrates, protective reflexes have been OBJECTIVES maintained and expanded in number. Examples are the gag reflex that At the end of this activity, occurs when objects touch the sides students will be able to: or the back of the throat, and the carotid sinus reflex that restores blood ■ Identify common reflexes pressure to normal when baroreceptors detect an increase in blood pressure. -
Territorial and Extraterritorial Trigeminocardiac Reflex: a Review for the Neurosurgeon and a Type IV Reflex Vignette
Open Access Review Article DOI: 10.7759/cureus.11646 Territorial and Extraterritorial Trigeminocardiac Reflex: A Review for the Neurosurgeon and a Type IV Reflex Vignette Daniel S. Leon-Ariza 1 , Juan S. Leon-Ariza 2 , Mayra A. Gualdron 3 , Jaime Bayona-Prieto 4 , Fidias E. Leon- Sarmiento 5, 6, 7 1. School of Medicine, Santander University-UDES, Bucaramanga, COL 2. Neuroscience, Mediciencias Research Group, Miami, USA 3. Faculty of Medicine, Unicolsanitas, Bogota, COL 4. Cirineo Research Group, Unicolciencias, Bucaramanga, COL 5. Environmental Health, Florida International University, Miami, USA 6. Neurology, Baptist Health South Florida, Miami Neuroscience Institute, Miami, USA 7. Internal Medicine, National University, Bogota, COL Corresponding author: Fidias E. Leon-Sarmiento, [email protected] Abstract The trigeminocardiac reflex (TCR) is a complex and, sometimes, fatal event triggered by overstimulation of the trigeminal nerve (TN) and its territorial and spinal cord branches. We reviewed and compiled for the neurosurgeon key aspects of the TCR that include a novel and straightforward classification, as well as morphophysiology, pathophysiology, neuromonitoring and neuromodulation features. Further, we present intraoperative data from a patient who developed extraterritorial, or type IV, TCR while undergoing a cervical surgery. TCR complexity, severity and unwanted outcomes indicate that this event should not be underestimated or overlooked in the surgical room. Timely TCR recognition in surgical settings is valuable for applying effective intraoperative management to prevent catastrophic outcomes. Categories: Otolaryngology, Neurosurgery, Anatomy Keywords: trigeminocardiac reflex trigeminal nerve, spinal cord, neurophysiology, neuromonitoring, neuromodulation Introduction And Background The trigeminocardiac reflex (TCR) is a complex neurovascular reflex triggered by overstimulating the trigeminal nerve (TN) and its anastomosis. -
Brainstem Dysfunction in Critically Ill Patients
Benghanem et al. Critical Care (2020) 24:5 https://doi.org/10.1186/s13054-019-2718-9 REVIEW Open Access Brainstem dysfunction in critically ill patients Sarah Benghanem1,2 , Aurélien Mazeraud3,4, Eric Azabou5, Vibol Chhor6, Cassia Righy Shinotsuka7,8, Jan Claassen9, Benjamin Rohaut1,9,10† and Tarek Sharshar3,4*† Abstract The brainstem conveys sensory and motor inputs between the spinal cord and the brain, and contains nuclei of the cranial nerves. It controls the sleep-wake cycle and vital functions via the ascending reticular activating system and the autonomic nuclei, respectively. Brainstem dysfunction may lead to sensory and motor deficits, cranial nerve palsies, impairment of consciousness, dysautonomia, and respiratory failure. The brainstem is prone to various primary and secondary insults, resulting in acute or chronic dysfunction. Of particular importance for characterizing brainstem dysfunction and identifying the underlying etiology are a detailed clinical examination, MRI, neurophysiologic tests such as brainstem auditory evoked potentials, and an analysis of the cerebrospinal fluid. Detection of brainstem dysfunction is challenging but of utmost importance in comatose and deeply sedated patients both to guide therapy and to support outcome prediction. In the present review, we summarize the neuroanatomy, clinical syndromes, and diagnostic techniques of critical illness-associated brainstem dysfunction for the critical care setting. Keywords: Brainstem dysfunction, Brain injured patients, Intensive care unit, Sedation, Brainstem -
The Neurological Exam
The Neurological Exam Introduction to the Neurological Exam The neurological exam consists of the following components: 1. Higher cognitive function as assessed by the mental status examination. (This will be addressed elsewhere in the course.) 2. Cranial nerves 3. Motor system 4. Sensory systems 5. Stance and gait I Olfactory Nerve Examination Technique: stimulant should be non-irritating test one nostril at a time with the opposite side occluded patient should not be able to see the stimulus cloves ideal stimulant since it preserves it’s scent improvise at bedside with soap, toothpaste, or perfume Normal Response: to perceive the scent with either nostril Abnormal Response: a unilateral loss is more likely to be significant and may imply a structural brain lesion affecting the olfactory bulb or tract, but could also be due to local causes such as a deviated septum or blocked nasal passage bilateral loss can occur with rhinitis or damage to the cribriform plate II Optic Nerve - Visual Acuity Examination Technique: each eye is tested separately. test best corrected vision using eyeglasses. any patient with uncorrected visual acuity of less than 20/20 should be examined with a pinhole. Improvement of vision through a pinhole indicates that the error is refractive. test distant vision using a Snellen chart at 10 or 20 feet. II Optic Nerve - Visual Fields A. Peripheral visual field (a) wiggling fingers (b) counting fingers (c) white pin B. Central visual field (a) red pin Examination Technique: visual fields are assessed by confrontation , i.e. the examiner compares the patient’s visual field to their own and assumes that theirs is normal. -
Brainstem Dysfunction in Critically Ill Patients
Benghanem et al. Critical Care (2020) 24:5 https://doi.org/10.1186/s13054-019-2718-9 REVIEW Open Access Brainstem dysfunction in critically ill patients Sarah Benghanem1,2 , Aurélien Mazeraud3,4, Eric Azabou5, Vibol Chhor6, Cassia Righy Shinotsuka7,8, Jan Claassen9, Benjamin Rohaut1,9,10† and Tarek Sharshar3,4*† Abstract The brainstem conveys sensory and motor inputs between the spinal cord and the brain, and contains nuclei of the cranial nerves. It controls the sleep-wake cycle and vital functions via the ascending reticular activating system and the autonomic nuclei, respectively. Brainstem dysfunction may lead to sensory and motor deficits, cranial nerve palsies, impairment of consciousness, dysautonomia, and respiratory failure. The brainstem is prone to various primary and secondary insults, resulting in acute or chronic dysfunction. Of particular importance for characterizing brainstem dysfunction and identifying the underlying etiology are a detailed clinical examination, MRI, neurophysiologic tests such as brainstem auditory evoked potentials, and an analysis of the cerebrospinal fluid. Detection of brainstem dysfunction is challenging but of utmost importance in comatose and deeply sedated patients both to guide therapy and to support outcome prediction. In the present review, we summarize the neuroanatomy, clinical syndromes, and diagnostic techniques of critical illness-associated brainstem dysfunction for the critical care setting. Keywords: Brainstem dysfunction, Brain injured patients, Intensive care unit, Sedation, Brainstem -
Diagnosis of Brain Death, Back to Medical Diagnosis!
Anaesth Crit Care Pain Med 38 (2019) 117–118 Editorial Diagnosis of brain death, back to medical diagnosis! ARTICLE INFO be different in real life. Similarly, the results are purely declarative and may therefore be different. Second, there are some things that can help Keywords: the doctor improve the way BD is diagnosed. In France, in most Absent brain stem reflexes hospitals, transplant coordinators (nurses or doctors) come to the ICU Apnoea test to help the team in the donation process. The impact of the transplant Brain death Brain death diagnosis Irreversible brain coordinator on the diagnosis of BD is not discussed. In addition, many injury ICU have developed procedures and checklists for the diagnosis of BD. It is important to know if they have the documents available. Thirdly, the criteria for identifying the "experienced doctor" are questionable. Experience, educational programs followed, number of donors Brain dead donors are the most common source of organs. The diagnosed are criteria that could be more relevant. diagnosis of brain death is a very important step in organ donation. Nevertheless, this work raises the issue of the diagnosis of BD. It ICU physicians must know how to make a correct diagnosis. seems that doctors do not diagnose BD in a correct way and as required The concept of brain death (BD) is different between countries. by law. The concept of "whole brain death" characterised by irreversible With regard to the different laws and recommendations cessation of hemispheric neurological functions and brain stem is between countries, it is important that the diagnosis of BD the most common. -
Intracranial Stimulation of the Trigeminal Nerve in Man II
Journal of Neurology, Neurosurgery, and Psychiatry 1986;49:419-427 Intracranial stimulation of the trigeminal nerve in man II. Reflex responses GIORGIO CRUCCU, DAVID BOWSHER From the Pain ReliefFoundation and Department ofNeurosciences, Walton Hospital, Liverpool, UK SUMMARY The reflex responses evoked by direct electrical stimulation of the intracranial portion of the trigeminal nerve have been studied in 16 subjects undergoing percutaneous retrogasserian ther- mocoagulation for the treatment of trigeminal neuralgia affecting the second or third division. In the obicularis oculi muscle, early and late responses similar to the RI and R2 components of the blink reflex were recorded. The former could be evoked only by stimulation of the second division and its latency was consistent with intermediately fast afferents. A late reflex (50-70 ms) was occa- sionally recorded from the anterior belly of the digastric muscle. The response was sometimes followed by a later activity and showed the features of a polysynaptic reflex. No response was obtained in the jaw elevators when fully relaxed. With the subject voluntarily clenching his teeth, both an early "H-like" response and two silent periods in the background EMG were obtained. The second silent period was similar in the muscles ipsi- and contralateral to intracranial stimulation, while the first silent period was longer in the ipsilateral muscles. Possible mechanisms contributing to the inhibition following stimulation of the mixed portion of the nerve are discussed. Owing to difficulties -
Skeletal Muscle Reflexes
Experiment NP-2: Skeletal Muscle Reflexes Background Studying the vertebrate stretch reflex is a good way to introduce students to the topics of stretch receptors, nerve conduction velocity, electromyograms (EMG), and motor control. Specialized receptors in the muscle respond to the stretching of the tendon attached to the muscle, and then send signals to motor neurons through a single synapse. The muscle fibers depolarize and twitch (contract) in response to the incoming impulse from the motor neuron. The Stretch Receptor Skeletal muscles have specialized receptors which convey information about muscle length, tension, and pressure to the central nervous system. The sensory receptors responsible for providing information about the length, or the rate of change of the length, of a muscle are called muscle spindles. Arranged in parallel with muscle fibers (Figure NP-2-B1), the spindles are stretched when the muscle is stretched by an external force. Therefore, these receptors play a significant role in developing antigravity reflexes and maintaining muscle tone. Muscle spindles contain a small bundle of intrafusal fibers which do not contribute to the overall tension of the muscle, but regulate the excitability of the sensory afferent spindle nerves by mechanically deforming the receptors. These fibers are innervated by gamma motor neurons. The majority of a muscle consists of extrafusal fibers, which are innervated by alpha motor neurons and are responsible for developing muscle tension. Figure NP-2-B1: A monosynaptic stretch reflex arc. The Stretch Reflex When a muscle is stretched, excitation of its muscle spindles causes a reflex contraction of the muscle. This reflex response is known as a stretch (myotatic) reflex. -
Testing the Reflexes
Page 1 of 6 ESSENTIALS Testing the reflexes 1 2 A J Lees neurologist , Brian Hurwitz former general practitioner 1The National Hospital, Queen Square, London WC1N 3BG, UK; 2King’s College London, London WC2B 6LE, UK with muscles via the nerve roots, plexuses, peripheral nerves, What you need to know and neuromuscular junction) and an upper motor neurone lesion • Tendon reflex testing allows lower and upper motor neurone lesions to (due to damage upstream from the anterior horn cell, including be distinguished reliably the corticospinal tracts, the brain stem, and motor cortex). This • Interpret reflexes alongside a clinical history and any abnormalities of distinction is the first stage in locating the site of neurological power, tone, and sensation found on examination damage. • Reflex testing is essential if you suspect spinal cord and cauda equina compression, acute cervical or lumbar disc compression, or acute There are situations where all the neurological symptoms occur inflammatory demyelinating polyradiculoneuropathy above the neck (such as bulbar symptoms due to motor neurone disease) where reflex testing is also essential. Eliciting the deep tendon reflexes is a vital component of Box 1 lists some clinical scenarios where testing the deep tendon medical assessments in general practice (where 9% of medical reflexes is discriminatory when coming to a diagnosis. problems are believed to be neurological in origin1) and in hospital (where 10-20% of admissions have a primary Box 1: Presentations in general practice where tendon reflex -
Of 17 Keywords A-Waves Sometimes Called Axon Reflex. Seen
Keywords A-waves Sometimes called Axon reflex. Seen when using sub- maximal stimulation during the F-wave recording. Consistent in latency and amplitude and usually occurring before the F-wave. Thought to be a result of reinnervation of the nerve. Abduct Move away from the median plane Abductor digiti minimi Sometimes called abductor digiti quinti. Ulnar innervated (ADM or ADQ) muscle on the medial side of the little finger along side the 5th metacarpal. The most superficial muscle in the hypothenar eminence. Commonly used when recording ulnar motor studies. Abductor digiti quinti Lateral plantar, thus tibial nerve, innervated muscle on the pedis (ADQp) lateral side of the foot along side the 5th metatarsal. Abductor hallucis (AH or Sometimes called abductor hallucis brevis. Medial plantar, AHB) thus tibial nerve, innervated muscle on the medial side of the foot below the navicular bone. Commonly used when recording tibial motor studies. Abductor pollicis brevis Median innervated muscle just medial to the 1st metacarpal (APB) bone. The most superficial muscle of the thenar eminence. Commonly used when recording median motor studies. Accessory peroneal nerve A branch of the superficial peroneal nerve that partly supplies the extensor digitorum brevis (EDB) in 18-22% of people. The EDB is normally innervated by the deep peroneal. The accessory peroneal nerve is seen when the peroneal amplitude, recording from the EDB, is larger when stimulating at the fibular head than when stimulating at the ankle. It can be confirmed by stimulating behind the lateral malleous, adding that amplitude to the ankle amplitude. The sum of which should closely equal the amplitude when stimulating at the fibular head.