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Neurology and Rehab

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  • Bells (Bell’s) Palsy
  • Concussion
  • Dementia
  • Headache
  • Headache Imaging
  • Migraine
  • Mini Mental Status Exam
  • Nerve Testing
  • Parkinson's Disease
  • Seizure and Epilepsy
  • Stroke Rehab Orders
  • Swallowing Assessment post CVA
  • Vertigo

  • Links

    Bells (Bell’s) Palsy

    Concussion (sports)

    Assessment and Management of Concussion in Sports - 9/1/1999 - American Academy of Family Physicians (not the best article! Doesn't define terms well enough.)


    Management & Grading

    This is pretty fuzzy, especially for 2nd/3rd concussions in the same season/athelete or if LOC occurs. These guidelines may be conservative. For all but the most mild first concussions patient must be able to exercise without headache or other symptoms for at least 1 week before returning to the game. (rev. 9/99)

    Features Management
      1st concussion 2nd concussion 3rd concussion
    confusion, no amnesia, no LOC.
    Sx < 15 min
    evaluate on site, observe 15-20 min, if no sx at rest/exertion may resume event return to play when asymptomatic for one week terminate season. May return @ 3mo.
    confusion, amnesia lasting < 30 , no LOC
    Sx > 15 min
    evaluate and observe x 24h. May resume event in 1 week if no sx, including headache!, at rest and with exertion. return to play when asymptomatic for 2-4 wk terminate season, return @ 6 months.
    LOC seconds or PTA > 30 min and < 24 hours transport for immediate evaluation. CT/MRI?  Return to play 1-4 weeks after injury when asymptomatic for at least one week. at least one month off, consider terminating season. terminate season. Change sports?
    LOC minutes transport for immediate evaluation. CT/MRI. Admit if any abnormalities. After one month may resume if no sx at rest/exertion prior 2 weeks. at least one month off, consider terminating season. no return


      % of US cases course pathology notes
    Alzheimer's 60%
    • memory loss
    • cognitive decline
    • late: myoclonic jerks, seizure, paranoid delusions, hallucinations
    • amyloid plaques
    • neurofibrillary tangles
    • 5% aged 60 to 40% aged 90
    • may be acceleration of normal brain degeneration, hence a lifelong disorder
    • patients with greater cognitive reserve may function better with disease
    • may be a long course of pre-disability cognitive decline
    • exercise may slow onset
    Lewy body @ 20%?
    • cognitive decline
    • pronounced variations in attention
    • recurrent prominent well formed visual hallucinations
    • parkinsonian-like motor abnormalities
    • intracytoplasmic, eosinophilic inclusion bodies in brain stem and corex
    • some kind of abnormal protein (Prion?)
    • probably long confused with Parkinsonian dementia, but visual hallucinations are not prominent in Parkisons, and in Lewy body dementia is early
    • no response to anti-parkinsonian meds
    • motor disorder most prominent, dementia late onset
    • death of dopamine producing cells in brainstem
    Vascular or multi-infarct  
    • step-wise decline with drop then incomplete recovery
    • pts usually have risk factors for stroke
    Progressive supranuclear palsy  
    • truly rare, some lump this into a superfamily of disorders with Pick's disease
    • men aged 45-75
    • cognitive decline
    • parkinsonian rigidity and gait without tremor
    • paralysis of downward gaze (supranuclear palsy)
    • retraction of eyelids: "wide-eyed" look with other eyelid abnormalities (ptosis, etc)
    • "Parkinson's" but no tremor
    Pick's Frontotemporal dementia  
    • step-wise decline with drop then incomplete recovery
    • strong genetic component
    • two subtypes: one is frontal release (increased sexual behavior), other is loss of language skills


    Intractable Headache (Unresponsive Migraine/Cluster)

    Headache Imaging


    See also Unresponsive Migraine.


    avoid: caffeine, chocolate, alcohol, dairy products, nuts, yeasts, citrus fruits, MSG, nitrates (luncheon meats), missed meals

    Acute Migraine

    (dark room) Beware pregnancy, vascular disease!

    Compazine/DHE HP Protocol

    climaxed headache

    Imitrex (Sumatriptan)


    Misc and Alternative

    Generally compazine or reglan first, then DHE in 3-30 minutes. Compazine is superior to reglan. 8% incidence dystonic reaction with IV!



    Status Migrainosus



    Other Therapies

    Migraine prophylactic therapy

    (>3 h/a week)

    Menstrual Migraine

    Mini Mental Status Exam (uncorrected)

    Scores < 24 are associated with delirium, dementia or severe depression. In community dwelling persons > 65, 95% had a score of > 24.

    1. What is the (year) (season) (date) (month)? (5 points).
    2. Where are we (state) (county) (town) (hospital) (floor)? (5 points).
    3. Name 3 objects: 1 second to say each. Then ask pt all 3 after being said. One point for each correct answr. (3 points).
    4. Serial 7s. 1 point for each correct. Stop after five answers. OR, spell world backwards. (5 points.)
    5. Ask for each of the 3 objects. One pt for each correct. (3 points)
    6. Name a pencil and watch. (2 points)
    7. Repeat: “No ifs, and, or buts.” (1 point)
    8. Follow a 3-stage command: “Take the paper in your right hand, fold it in half, and put it on the floor.” ( 3 points)
    9. Read and obey the following: “Close your eyes.” (1 point)
    10. Write a sentence. (1 point)
    11. Copy design. (1 point)

    Nerve Testing and Innervation

    Cranial Nerves

    3rd (oculomotor)

    Peripheral Nerves

    Nerve Sensory Motor Comment
    radial dorsal thumb web space thumb extension, raise wrist humeral shaft fx, Monteggia fx. Wrist drop, supplies extensors.
    ulnar tip of little finger pinch straight thumb to base of index finger, flex tip of 5th finger, medial/lateral index finger motion humeral head fx, supplies flexors, "claw hand". In wrist passes between pisiform and hook of hamate.
    median tip of middle/index finger flex thumb IP joint or index finger humeral head fx, supplies flexors, "ape hand"
    radial, ulnar, median   flex fingers with MCP extended, then oppose thumb to little finger  
    musculo- tendinous extensor (dorsal) forearm   anterior shoulder dislocation
    axillary lateral upper arm   anterior shoulder dislocation
    peroneal dorsum foot dorsiflex great toe sciatic n, hip fx/dislocn
    tibial back of heel plantarflex great toe sciatic n, hip fx/dislocn
    saphenous medial malleolus   femoral n

    Dermatomes and Spinal Nerve Roots

    Cervical nerve roots issue above disc (no C8 vertebrae), Lumbar below disc of same name. See also diagram of lower ext dermatomes.

    Root Sensory Motor Nerves Comments
    C3 both sides of thumb diaphragm phrenic n  
    C4 both sides of thumb diaphragm phrenic n  
    C5 both sides of thumb diaphragm, deltoid, brachioradialis, biceps phrenic, axillary, radial, musculocutaneous biceps reflex, flex elbow, adbuct arm
    C6 both sides of thumb deltoid, brachioradialis, biceps, triceps radial triceps jerk, extension
    C7 both sides index, middle, ring triceps radial triceps jerk, extension
    C8 both sides little finger triceps, hand intrinsics radial, ulnar, median C8 lesion lose finger extension
    T1 medial mid-arm hand intrinsics ulnar, median hand flexors
    T4 nipple      
    T10 umbilicus      
    L1 groin      
    L2 superior thigh hip extension, adduction femoral cremasteric reflex
    L3 mid thigh, medial knee hip flexion, extension, knee extension femoral knee jerk
    L4 lower thigh, anterior knee, medial foot hip flexion, knee extension, foot inversion & dorsiflexion femoral  
    L5 lateral leg, 1st toe web space, dorsum foot knee flexion, foot eversion & dorsiflexion   ankle jerk
    S1 posterolateral thigh, lateral foot foot eversion    
    S2 penis, base bladder, sphincter pudendal rectal wink
    S3 shaft, penis bladder, sphincter pudendal  
    S4 glans, perianal bladder, sphincter pudendal  

    Parkinson's Disease

    Differential diagnosis

    Therapy changes (2008)

    Stroke Rehab Orders (ref. # 921)

    1. diet and nutrition
    2. frequent repositioning
    3. environmental cues (time and place, pictures)
    4. daily skin inspection
    5. pressure-relieving mattress surface
    6. bowel and bladder management
    7. early mobilization
    8. elastic stockings
    9. range of motion joint exercises
    10. subcutaneous heparin
    11. incentive spirometry and respiratory care

    Swallowing Assessment post CVA

    If abnormal do barium study.

    Time to swallow

    Time from initiation to completion of palpated swallow

    Response to test fluid

    Seizure and Epilepsy


      partial seizure, complex
    (temporal lobe, psychomotor)
    generalized tonic-clonic absence
    (petit mal)
    carbamazepine (Tegretol) x x  
    • rare aplastic anemia and agranulocytosis
    gabapentin (Neurontin) x      
    primidone (Mysoline) x x    
    valproic acid derivatives (Depakote) x   as adjunct
    • liver toxicity
    Levetriacetam (Kepra)      
    • approved for children
    Lamotrigene (Lamictal) x x x
    • approved for children
    • interact with valproic acid
    • Stevens-Johnson syndrome
    Topiramate (Topamax) x x  
    • approved for children
    • nephrolithiasis

    Status Epilepticus

    Epilepsy Therapy (discontinuation criteria)

    Age (mo) < 12: 99 12-144: 142 >144: 0
    Intelligence normal: 111 abnormal: 0  
    Neonatal no: 218 yes: 0  
    Seizures before Rx 1 or 2: 200 3-20: 140 >20: 81




    Warning signs

    When to suspect inferior cerebellar infarct

    Author: John G. Faughnan.  The views and opinions expressed in this page are strictly those of the page author. Pages are updated on an irregular schedule; suggestions/fixes are welcome but they may take weeks to years to be incorporated. Anyone may freely link to anything on this site and print any page; no permission is needed for citing, linking,  printing, or distributing printed copies.