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S. Amul, M.B. B.CH. B.A.O., M.B.B.Ch., Ph.D.

Deputy Director, University of Oklahoma College of Medicine

Dressing therefore has a significant impact on social adaptation after the onset of disability. In obtaining a history of performance in dressing skills, it is not sufficient merely to ask: Do you dress yourself? An untrained, disabled patient may have, for sometime, abandoned the use of garments that are more difficult to don. Typically abandoned are shoes, socks, pants, clothes with buttons, and close-fitting undergarments. The patient therefore may answer "Yes" to such a question without realizing how few clothes he or she actually wears. A complete probe into dressing history is necessary to gain insight into performance and function. Unlike the activities previously discussed, it is one activity that must still persist even if totally physical assistance is required. The association of passive feeding with dependence is exceedingly strong in our society, and such individuals often isolate themselves socially. Eating skills include the use of fork, spoon, and knife, and the handling of cups and glasses. Personal Hygiene History 16 Personal hygiene activities include the spectrum of skills concerned with cleaning and grooming: tooth brushing, hair combing, shaving, the use of the tub and shower, perineal care, and the successful handling of bowel and bladder elimination. This is particularly true when a patient cannot handle bowel and bladder elimination in a socially acceptable manner. If he or she is concerned with the possibility of becoming soiled with feces, or urine, the emotional stress will be quite severe. Vocational rehabilitation efforts and improvements in social functioning will be unsuccessful until the person can develop a system for elimination that is consistent and successful. It is more important to be continent socially than to restore elminiation patterns that are anatomically and physiologically ideal to those of the nondisabled population. Socially acceptable elimination can be achieved by the majority of disabled patients. Patients with catheters can develop a successful system if they can handle the emptying of collecting bags and can satisfactory incorporate the necessary devices within their clothing. Communication the term communication includes a broad range of skills associated with listening, speaking, reading, and writing. Listening and reading skills that form the receptive component of language function depend on the intact use of auditory and visual organs. Speaking and writing-the more expressive forms of language-depend on the integrity of motor functions associated with articulation and hand dexterity. To obtain an accurate history of communication skills in patients with expressive communication deficits, the examiner will direct the inquiry to family members or others who have had a recent and long-standing relationship with the patient. For communication deficits that are changing, the time course of deterioration should also be ascertained. Recognition of expressive aphasia, dysarthric speech, and so on are logical components of the physical exam and are often elicited during the mental status examination or incidentally noted during the general history. Frequently, specific questions regarding expressive verbal language are unnecessary. Do people often appear to mean something other than what you thought you heard them say? D you have, or use, any special tools or methods to improve your ability to communicate either in speech or in writing General Principals in Determining Disability in Basic Functions Several principles must be kept in mind when exploring disability in the basic functions of ambulation, transfers, dressing, eating, and personal hygiene. When the patient reports that he or she is not independent, determine the extent of assistance required for the particular skill in question. Separately interview the persons (usually family members) who are supplying the assistance. Assistant(s) may report a greater degree of dependence than reported by the patient. A significant difference in their remarks may indicate that one or both are dissatisfied with the situation. When is it expected or anticipated that the patient will be dependent, questions such as "can you" or "do you" should be rephrased. When the disability is one of acute onset, the inquiry should also include the premorbid level of independence. This is particularly important in the older patient or a person suffering an acute exacerbation of a long-term disability.

This is usually monosynaptic, and the internuncial neuron (black) is absent (see p. Summation of Motor Units 103 Motor neuron Axon Motor end-plate Bundle of muscle fibers Figure 3-42 Components of a motor unit. Basically, muscle tone is dependent on the integrity of a simple monosynaptic reflex arc composed of two neurons in the nervous system. The lengthening and shortening in a muscle are detected by sensitive sensory endings called muscle spindles (see p. There, they synapse with the motor neurons situated in the anterior gray column, which, in turn, send impulses down their axons to the muscle fibers. The muscle spindles themselves are innervated by small gamma efferent fibers that regulate the response of the muscle spindles, acting synergically with external stretch. In this manner, muscle tone is maintained reflexly and adjusted to the needs of posture and movement. Should the afferent or efferent pathways of the reflex arc be cut, the muscle would lose its tone immediately and become flaccid. A flaccid muscle, on palpation, feels like a mass of dough that has completely lost its resilience. It is important to realize that the degree of activity of the motor anterior column cells and, therefore, the degree of muscle tone depend on the summation of the nerve impulses received by these cells from other neurons of the nervous system. Muscle movement is accomplished by bringing into action increasing numbers of motor units and, at the same time, reducing the activity of the motor units of muscles that will oppose or antagonize the movement. When the maximum effort is required, all the motor units of a muscle are thrown into action. The reason for this is that the smaller motor units are innervated by smaller neurons in the spinal cord and brainstem, and they have a lower threshold of Posterior root ganglion Neurotendinous spindle Neuromuscular spindle Lower motor neuron Motor end-plate Anterior gray column of spinal cord Muscle fibers Figure 3-43 Simple reflex arc consisting of an afferent neuron arising from neuromuscular spindles and neurotendinous spindles and an efferent neuron whose cell body lies in the anterior gray column (horn) of the spinal cord. Note that for simplicity, the afferent fibers from the neurotendinous spindle and the neuromuscular spindle are shown as one pathway; in fact, the neurotendinous receptor is inhibitory and reduces tone, whereas the neuromuscular spindle is excitatory and increases tone. As the contraction increases,progressively larger motor units are brought into action. This phenomenon causes a gradual increase in muscle strength as the muscle contracts. Nerve impulses continue to arrive at the neuromuscular junction, and normal depolarization of the plasma membrane of the muscle fiber occurs. In the standing position, the line of gravity passes through the odontoid process of the axis, behind the centers of the hip joints, and in front of the knee and ankle joints. In order to stabilize the body and prevent it from collapsing, it is not surprising to find that in humans, the antigravity muscles are well developed and exhibit the greatest degree of tone. Therefore, one can say that posture depends on the degree and distribution of muscle tone, which, in turn, depends on the normal integrity of simple reflex arcs centered in the spinal cord. An individual may assume a particular posture (sitting or standing) over long periods of time with little evidence of fatigue. The reason for this is that muscle tone is maintained through different groups of muscle fibers contracting in relays, with only a small number of muscle fibers within a muscle being in a state of contraction at any one time. In order to maintain posture,the simple muscle reflex,on which muscle tone is dependent, must receive adequate nervous input from higher levels of the nervous system. For example, impulses arising from the labyrinths and neck muscles,information arising from the cerebellum,midbrain, and cerebral centers, and general information arising from other muscle groups, joints, and even skin receptors will result in nervous impulses impinging on the large anterior gray column cells. When an individual assumes a given posture, the tone of the muscles controlling that posture is constantly undergoing fine adjustments so that the posture is maintained. Since the greater part of body weight lies anterior to the vertebral column,the deep muscles of the back are important in maintaining normal postural curves of the vertebral column in the standing position. Normal posture thus depends not only on the integrity of the reflex arc but also on the summation of the nervous impulses received by the motor anterior gray column cells from other neurons of the nervous system. The detail of the different nervous pathways involved in bringing the information to the anterior gray column cells is dealt with in Chapter 4. Posture 105 Cerebral cortex Red nucleus Thalamus Vestibular nucleus Cerebellum Reticular formation Corticospinal tract Rubrospinal tract Vestibulospinal tract Neck muscle Trunk muscle Reticulospinal tract Anterior gray column cells Limb muscle Lower motor neuron Figure 3-45 Nervous input from higher levels of the central nervous system, which can influence the activity of the anterior gray column (horn) cells of the spinal cord. The nucleus plays a key role in the synthesis of proteins, which pass into the cell processes and replace proteins that have been metabolized by cell activity.

While examining a patient with a right-sided hemiplegia caused by a cerebrovascular accident, the neurologist asked the student which clinical signs could be attributed to an interruption of the corticospinal tracts and which signs could be attributed to damage to other descending tracts. A large civilian aircraft was forced to abort its takeoff because three tires had burst as the plane sped along the runway. The pilot miraculously managed to halt the plane as it veered off the runway and came to an abrupt halt in a ditch. All the passengers escaped injury,but one of the stewardesses was admitted to the emergency department with suspected spinal cord injury. On questioning, the 25-year-old patient said that although she had her seat belt fastened, she was thrown violently forward on impact. On examination, there was complete motor and sensory loss of both legs below the inguinal ligament and absence of all deep tendon reflexes of both legs. Twelve hours later, it was noted that she could move the toes and ankle of her left lower limb, and she had a return of sensations to her right leg except for loss of tactile discrimination, vibratory sense, and proprioceptive sense. Her left leg showed a total analgesia, thermoanesthesia, and partial loss of tactile sense. There was a right-sided Babinski response, and it was possible to demonstrate right-sided ankle clonus. Using your knowledge of neuroanatomy, explain the symptoms and signs found in this patient. Why is it dangerous to move a patient who is suspected of having a fracture or dislocation of the vertebral column? An 18-year-old man was admitted to the hospital following a severe automobile accident. After a complete neurologic investigation, his family was told that he would be paralyzed from the waist downward for the rest of his life. The neurologist outlined to the medical personnel the importance of preventing complications in these cases. The common complications are the following: (a) urinary infection, (b) bedsores, (c) nutritional deficiency, (d) muscular spasms, and (e) pain. Using your knowledge of neuroanatomy, explain the underlying reasons for these complications. How long after the accident do you think it would be possible to give an accurate prognosis in this patient? A 67-year-old man was brought to the neurology clinic by his daughter because she had noticed that his right arm had a tremor. Apparently, this had started about 6 months previously and was becoming steadily worse. When questioned, the patient said he noticed that the muscles of his limbs sometimes felt stiff, but he had attributed this to old age. It was noticed that while talking, the patient rarely smiled and then only with difficulty. When asked to walk,the patient was seen to have normal posture and gait, although he tended to hold his right arm flexed at the elbow joint. When he was sitting, it was noted that the fingers of the right hand were alternately contracting and relaxing, and there was a fine tremor involving the wrist and elbow on the right side. When he was asked to hold a book in his right hand,the tremor stopped momentarily,but it started again immediately after the book was placed on the table. The daughter said that when her father falls asleep, the tremor stops immediately. On examination, it was found that the passive movements of the right elbow and wrist showed an increase in tone, and there was some cogwheel rigidity. There was no sensory loss, either cutaneous or deep sensibility, and the reflexes were normal. Name a center in the central nervous system that may be responsible for the following clinical signs: (a) intention tremor, (b) athetosis, (c) chorea, (d) dystonia, and (e) hemiballismus.

Additionally, tube feedings and care for the prolonged immobility and stress ulcers are needed. The case fatality rate is less than 2%; on average, infants will spend 44 days in the hospital. Key findings on his examination include external ophthalmoplegia, reactive pupils, ptosis, facial weakness, and weakness in the arms and legs. Infantile botulism Neonatal myasthenia gravis Guillain-Barrй syndrome Meningitis [27. His examination reveals ptosis, impaired ocular motility, dilated pupils, symmetrical weakness in the arms and legs, and normal cognitive function. The presence of reactive pupils and normal deep tendon reflexes points away from infantile botulism. Fecal cultures and not pharyngeal cultures are the best way to diagnose infantile botulism. This case is illustrative of foodborne botulism, which is known to have normal sensation and normal cognitive function. Classic presentation for infantile botulism includes antecedent constipation with the ascending paralysis, ptosis, dilated or unreactive pupils, and weakness in the arms and legs. The best way to test for infantile botulism is through stool samples via a mouse bioassay. More than 70% of these infants with botulism will eventually require mechanical ventilation. His wife who has accompanied him feels that he is clumsier noting that he is often times tripping. The patient has also noticed that he is clumsier and that he is more forgetful and is having difficulty focusing at work. Depression could also present this way; however, one would not expect there to be problems with coordination. A cytokine called oncostatin M may be the most damaging of the cytokines, although it acts in concert with other cytokines. Finally, there is evidence to support oxidative stress and increases in excitatory amino acids and intracellular calcium. Dementia: A disorder characterized by a general loss of intellectual abilities involving memory, judgment, abstract thinking, and changes in personality. Neuropsychological testing: A battery of tests used to evaluate cognitive impairment. A few patients, however, present with only immunosuppression by laboratory criteria. The forgetfulness is present early on, and patients have increasing difficulty performing complex tasks. Personality changes begin to appear such as apathy, social withdrawal, and quietness. Tripping or falling along with poor handwriting are the more common motor symptoms. Myoclonic jerks, postural tremor, and bowel and bladder dysfunction can be present in the later stages of the disease. Patients at end stage of the disease are unable to ambulate, have incontinence, and are almost in a vegetative state. Early in the disease course, neuropsychologic testing can be normal; however, as time progresses there is evidence of a subcortical dementia. Typical abnormalities include difficulty in concentration, motor manipulation, and motor speed. Initially, the neurologic examination is normal, and at this time, subtle impairment in rapid limb and eye movements can be found. As the disease progresses, hyperreflexia, spasticity, and frontal release signs can be found. Additionally apraxia (inability to perform previously learned tasks) and akinetic mutism (severely decreased motor-verbal output) can develop. Some patients have white matter changes and abnormalities in the thalamus and basal ganglia. This will determine whether or not there is increased intracranial pressure so that a lumbar puncture can be safely performed.

In most cases, however, most surrogates will struggle with the more nuanced question of the degree of loss of self that would make a life worth living. Families may benefit by your asking them to consider the ability to relate to others in the context of a broader consideration about the goals of care. Although all may not agree with the centrality of functional communication, this may be a helpful goal of care when speaking with family members. Appreciating the cen- trality of functional communication will also help to identify those patients who retain this ability but need assistive devices or special techniques to relate to others. For example, if it is agreed that functional communication is a goal of care, it might be prudent to continue to follow a patient for a year following traumatic injury in order for a patient to have the greatest chance of moving into the minimally conscious state from which a capability of functional communication might take root. If a patient remains vegetative a year after injury, the substantially reduced chances of attaining the communicative goal would help support a decision to withdraw care. Guidelines for the management of spontaneous intracerebral hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Brain Trauma Foundation Management and Prognosis of Severe Traumatic Brain Injury. Comparison of mortality, morbidity, and severity of 59,713 head injured patients with 114,447 patients with extracranial injuries. Intensive care management of head-injured patients in Europe: a survey from the European brain injury consortium. Problems with initial Glasgow Coma Scale assessment caused by prehospital treatment of patients with head injuries: results of a national survey. Predicting survival using simple clinical variables: a case study in traumatic brain injury. Patient age and outcome following severe traumatic brain injury: an analysis of 5600 patients. The prognostic value of computerized tomography in comatose head-injured patients. The prognostic value of evoked responses from primary somatosensory and auditory cortex in comatose patients. Use of somatosensory-evoked potentials and cognitive eventrelated potentials in predicting outcomes of patients with severe traumatic brain injury. Favourable outcome of a brain trauma patient despite bilateral loss of cortical somatosensory evoked potential during thiopental sedation. Association of Clinical Signs with Neurological Outcome After Cardiac Arrest [dissertation]. Improved outcome prediction in unconscious cardiac arrest survivors with sensory evoked potentials compared with clinical assessment. Brief report: late improvement in consciousness after post-traumatic vegetative state. Predictors of outcome in posttraumatic disorders of consciousness and assessment of medication effects: a multicenter study. Prediction of recovery from post-traumatic vegetative state with cerebral magnetic-resonance imaging. Thalamic proton magnetic resonance spectroscopy in vegetative state induced by traumatic brain injury. Event-related potential measures of consciousness: two equations with three unknowns. Predictive value of sensory and cognitive evoked potentials for awakening from coma. Basilar artery occlusive disease in the New England Medical Center Posterior Circulation Registry. Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. Grading of subarachnoid hemorrhage: modification of the World Federation of Neurosurgical Societies scale on the basis of data for a large series of patients. The poor prognosis of ruptured intracranial aneurysms of the posterior circulation. Diagnostic and prognostic guidelines for the vegetative and minimally conscious states.