1. Elements of Motor Function Exam
   1. Mental Status
      1. Consciousness
         1. 5 Levels:
            1. 1. Full Consciousness
            2. 2. Lethargy
            3. slowing of motor processes: speech & movement
            4. 3. Obtundation
            5. dulled/blunted sensitivity
            6. hard to arouse from sleep and if arouse appear confused
            7. 4. Stupor
            8. state of semiconsciousness
            9. lack responsiveness & aroused only by intense stimuli
            10. 5. Coma
            11. Gold Standard: Glasgow Coma Scale to doc the levels
            12. total score 3-15
            13. <8=severe brain injury & coma
            14. 9-12=moderate brian injury
            15. 13-15=mild brain injury
      2. Orientation
         1. Time
         2. Place
         3. Person
         4. Documented as:
            1. Pt. is AO x 3 (time, person place)
            2. Pt. is AO x 2 (person & place)
            3. May also doc Circumstance
            4. what happened to you?What kind of place is this?
      3. Attention
         1. Types
            1. Selective attn
            2. screen & process sensory info about both task & environment while screening out irrelevant info
            3. Sustained attn/vigilance
            4. determine how long pt is able to maintain attn on a particular task
            5. Alternating attn (attn flexibility)
            6. request pt to alternate back & forth btwn 2 diff tasks
            7. Divided attn
            8. request pt to perform 2 tasks simultaneously
      4. Memory
         1. Declarative
            1. conscious recollection of facts & events
         2. immediate memory
            1. recall after a few sec
         3. STM
         4. LTM
         5. Anterograde Amnesia
            1. inability to learn new material acquired after brain insult
         6. Retrograde Amnesia
            1. inability to recall previous learning acquired prior to brain insult
      5. Higher Cognitive Functions
         1. exam consists of:
            1. Info & vocab
            2. Calc ability
            3. Abstract thinking
            4. Constructional ability
            5. the ability to copy figures
   2. Arousal
      1. inverted-U theory (Dodson law)
         1. very low or high levels of arousal cause deterioration in motor performance
      2. examination of baseline levels:
         1. representative sampling of ANS responses
            1. incl. HR, BP, RR, pupil dilation & sweating
         2. determination of pt reactivity
            1. incl. degree & rate of response to sensory stimulation
         3. determination of compensatory mechanisms in response to physiological stressors
   3. Sensory Integrity & Integration
      1. Sensory Examination Chap 5
         1. Superficial Sensations
            1. Pain
            2. Temperature
            3. Touch (light)
            4. Pressure (deep touch)
         2. Deep Sensations
            1. Kinesthesia
            2. Proprioception
            3. Vibration
         3. Combined Cortical Sensations
            1. Stereognosis
            2. tactile object recognition
            3. Tactile localization
            4. 2-pt Discrimination
            5. Double Simultaneous Stimulation
            6. Graphesthesia
            7. traced figure ID
            8. Recognition of texture
            9. Barognosis
            10. Recognition of weight
      2. closed-loop syst of motor control
         1. control syst employing feedback, a ref of correctness, computation of error, & subsequent correction in order to maintain a desired state
      3. open-loop syst of motor control
         1. control syst w/preprogrammed instruction to an effector that doesn't use feedback info & error-detection processes
   4. Joint integrity, Postural Alignment, and Mobility
   5. Tone
      1. Abnormal Tone
         1. Spasticity
            1. hypertonic motor disorder characterized by VELOCITY-DEPENDENT resistance to passive stretch
            2. Clonus
            3. cyclical, spasmodic alternation of muscular contraction & relaxation in response to sustained stretch of a spastic muscle
            4. UMN syndrome
            5. Typical Patterns of Spasticity in UMN Syndrome
            6. UE
            7. • Scapula: Retraction, downward rot • Shoulder: Add & IR; Dep • Elbow: Flex • Forearm: Pronation • Wrist: Flex, ADD • Hand: Finger flex, clenched fist thumb, Add in palm
            8. LE
            9. • Pelvis: Retraction (hip hike) • Hip: ADD, IR, Ext • Knee: Ext • Foot & Ankle: PF, IV, Equinovarus, Toe claw (MP ext, PIP Flex, DIP ext); Toes Curl (PIP, DIP flex) • Hip & Knee prolonged sitting: Flex; Sacral sitting • Trunk: Lat flex w/concavity; Rotation • COG fwd (prolonged sitting): Excessive fwd flex; Fwd head
         2. Rigidity
            1. hypertonic state characterized by increased uniform resistance that persists throughout the whole ROM & is independent of the velocity of movement
            2. leadpipe
            3. constant, uniform resistance to passive movement w/no fluctuations
            4. Cogwheel
            5. hypertonic state w/superimposed rachetlike jerkiness
         3. Hypotonia
            1. LMN syndrome
         4. Dystonia
            1. focal dystonia
            2. segmental dystonia
         5. Decorticate & Decerebrate Rigidity
            1. Decorticate rigidity
            2. Abnormal flexor response UE; LE=ext
            3. corticospinal tract lesion @ level of diencephalon above superior colliculus
            4. Decerebrate rigidity
            5. Abnormal extensor response of trunk & extremities; wrist & fingers=flex
            6. corticospinal brainstem lesion btwn superior colliculus & vestibular nucleus
      2. Examination consists of:
         1. Initial Observation of resting posture & palpation
         2. PROM testing
         3. AROM testing
      3. Grading
         1. • 0 No response (flaccidity) • 1+ Decreased response (hypotonia) • 2+ Normal response • 3+ Exaggerated response (mild to moderate hypertonia) • 4+ Sustained response (severe hypertonia)
         2. Modified Ashworth Scale for Grading Spasticity 0-4 p. 236
            1. • 0 No increase in mm. tone • 1 Slight increase in mm. tone manifested by a catch & release or by min resistance @ end of ROM when affected part(s) is moved in flex or ext • 1+ Slight incr in mm. tone manifested by a catch, followed by min resistance throughout remainder (less than half) of ROM • 2 More marked increase in mm. tone through most of ROM, but affected part(s) easily moved • 3 Considerable incr in mm. tone, PROM difficult • 4 Affected part(s) rigid in flex or ext
      4. other tests:
         1. Pendulum test; isokinetic dynamometer
         2. Myotonometer
   6. Reflex Integrity
      1. DTR
         1. result from stim of the stretch sensitive IA afferents of the NM spindle producing muscle contraction via monosynpatic pathway
         2. Grade 0-4+ scale p. 237
            1. • 0 No response • 1+ Present but depressed, low normal • 2+ Avg, normal • 3+ Increased, brisker than avg; possibly but not necessarily abnormal • 4+ Very brisk, hyperactive, w/clonus; abnormal
         3. DTR Examination p. 237
            1. Jaw (CN V)
            2. Biceps (Musculocutaneous n C5, C6)
            3. Brachioradialis (Supinator n; Radial n C5, C6)
            4. Triceps (Radial n C6, C7)
            5. Finger flexors (median n C6-T1)
            6. Hamstrings (Tibial-Sciatic n L5-S2)
            7. Quads (Femoral n L2-L4)
            8. Achilles (Tibial n S1-S2)
      2. Superficial Cutaneous Reflexes
         1. Examination p. 238
            1. Plantar Reflex ( S1, S2)
            2. Confirming Toe Signs (Chaddock sign)
            3. Abdominal Reflexes
            4. above umbilicus= T8-T10
            5. below umbilicus= T10-T12
      3. Primitive & Tonic Reflexes
         1. Examination of p. 239; 240
            1. Primitive/Spinal Reflex
            2. Flexor withdrawal
            3. Crossed extension
            4. Traction
            5. Moro
            6. Startle
            7. Grasp
            8. Tonic/Brainstem Reflexes
            9. Asymmetrical tonic neck (ATNR)
            10. Symmetrical tonic neck (STNR)
            11. Symmetrical tonic labyrinthine (TLR or STLR)
            12. Positive Supporting
            13. Associated reactions
         2. Grades 0+-4+scale p. 239
   7. Cranial Nerve Integrity p. 241-242
   8. Muscle Performance
      1. Strength & Power
         1. fasciculations-
            1. random, spontaneous twitching of muscle fibers that are visible through the skin
            2. fasciculations + atrophy=LMN disease
         2. MMT Grades 0-5 p. 243
      2. Endurance
         1. Fatigue
            1. VAS
            2. Borg Scale for Ratings of Perceived Exertion
            3. Modified Fatigue Impact Scale (MFIS)
   9. Voluntary Movement Patterns
      1. Abnormal Synergistic Patterns
   10. Functional Task Analysis
       1. Functional mobility skills that must be analyzed:
          1. Bed mobility
          2. Sitting skills
          3. Transfer skills
          4. Standing skills
          5. Walking
          6. Stair climbing
       2. Static Postural Control
       3. Dynamic Postural Control
   11. Postural Control & Balance
       1. Postural Alignment & Weight Distribution
       2. Sensory Organization
          1. Sensory Organization Test
       3. CNS Integration
          1. Clinical Test for Sensory Interaction in Balance (CTSBIS)
             1. examines body sway during quiet standing under 6 diff sensory test conditions
             2. can be used to determine the effectiveness of an pt to utilize diff sensory inputs
             3. scored based on changes in amt & direction of postural sway
             4. Score 1-4 p. 252
       4. Motor Strategies
          1. Ankle Strategy
             1. when disturbances are small & well w/in the LOS
          2. Hip Strategy
             1. recruited w/larger & faster disturbances of the COM or when standing on a BOS that's narrower than the length of the feet
          3. Stepping Strategy
             1. recruited in response to fast, large postural perturbations
          4. Dynamic Posturography
             1. The Movement Coordination Test (MCT)
       5. Functional Balance Tests
          1. Romberg Test
          2. Functional Reach & Multidirectional Reach Test
          3. Berg Balance Scale
          4. Performance-Oriented Mobility Assessment (POMA)
          5. Timed Get Up & Go Test
             1. GUG
             2. TUG
          6. Timed walking Test
          7. Balance Efficacy Scale
2. Overview of Motor Function
3. Examination of Motor Function
   1. Patient Hx
   2. Systems Review
   3. Test & Measures
4. Motor Learning
   1. Performance Changes
   2. Practice Observations
   3. Retention Tests
   4. Transfer Tests
   5. Learning Styles
5. Evaluation
   1. Dx: