Content Flashcards
1
Q
What does skew deviation indicate?
A
Vertical deviations are more concerning for central pathology
2
Q
Define tropia.
A
Ocular malalignment that is always present, Cannot correct misalignment when focusing on target.
3
Q
Define phoria.
A
Ocular malalignment only evident when binocular viewing/fusion is blocked. Becomes more appararent with fatigue. Best elicited with cross-cover test
4
Q
What types of nystagmus are considered central signs?
A
Pure vertical, pure torsional, or direction-changing nystagmus
5
Q
What is spontaneous nystagmus associated with?
A
Acute peripheral vestibular lesions; it is direction-fixed and follows Alexander’s Law
6
Q
What does impaired saccades indicate?
A
A central sign
7
Q
What does saccadic/cogwheel pursuit indicate?
A
A central sign
8
Q
What is dysconjugate gaze?
A
A central sign indicating misalignment of the eyes during gaze
9
Q
What does VOR cancellation refer to?
A
The ability to suppress the vestibulo-ocular reflex
10
Q
What does an inability to suppress VOR indicate?
A
A central sign
11
Q
What is the role of the paramedian pontine reticular formation in eye movement?
A
It sends signals to the abducens nucleus.
12
Q
When the connection between the abducens nucleus and the oculomotor nucleus is interrupted, what happens to the eye ipsilateral to the lesion?
A
It cannot adduct past the midline when the contralateral eye moves laterally.
13
Q
What is the effect on the eye contralateral to the lesion when there is an interruption between the abducens nucleus and the oculomotor nucleus?
A
The eye contralateral to the lesion moves normally.
14
Q
How can you distinguish between internuclear ophthalmoplegia and 3rd cranial nerve palsy?
A
Internuclear ophthalmoplegia impairs adduction only, while 3rd cranial nerve palsy impairs both adduction and convergence.
15
Q
What does Alexander’s Law state about nystagmus?
A
The amplitude of the nystagmus increases when the eye moves in the direction of the fast phase
This law explains the behavior of nystagmus in relation to eye movement.
16
Q
What happens to nystagmus when visual fixation is blocked?
A
Nystagmus increases
Nystagmus is an involuntary eye movement that can be affected by visual fixation.
17
Q
What does the term ‘ampullopetal’ refer to?
A
Displacement ‘toward’ the ampulla
The ampulla is a structure located at the base of each semicircular canal.
18
Q
What does the term ‘ampullofugal’ refer to?
A
Displacement ‘away’ from the ampulla
This term describes the direction of fluid movement in the semicircular canals.
19
Q
What does Ewald’s law say?
A
A stimulation of the semicircular canal causes a movement of the eyes in the plane of the stimulated canal
20
Q
What is the function of the cerebellar flocculus?
A
Required to adapt the gain of the VOR
VOR stands for vestibulo-ocular reflex, which helps stabilize gaze during head movements.
21
Q
What does the cerebellar flocculus respond to in order to improve gaze stability?
A
Retinal slip
Retinal slip refers to the movement of the image across the retina due to head motion.
22
Q
What role does the cerebellar nodulus play in VOR responses?
A
Adjusts the duration of VOR responses
The nodulus also processes otolith input related to balance and spatial orientation.
23
Q
What are common effects of lesions in the cerebellar areas discussed?
A
Gait ataxia and nystagmus
Gait ataxia refers to a lack of voluntary coordination of muscle movements, while nystagmus is characterized by involuntary eye movement.
24
Q
What does the cerebellar vermis respond to?
A
Vestibular stimulation
The cerebellar vermis has an inhibitory influence on the vestibular nuclear complex.
25
What is the role of the cerebellar vermis in vestibular reflexes?
Calibrates/modulates vestibular outflow to improve accuracy of vestibular reflexes (VOR and VSR)
## Footnote
VOR stands for vestibulo-ocular reflex, and VSR stands for vestibulospinal reflex.
26
What are the effects of lesions to the anterior/superior vermis?
Profound gait ataxia and truncal instability
## Footnote
These effects can be exacerbated by excessive ethanol intake.
27
What is Acute Vestibular Syndrome (AVS)?
A well-defined clinical syndrome characterized by vertigo or dizziness, nausea or vomiting, head-motion intolerance, gait unsteadiness, and nystagmus lasting days to weeks. Can be caused by peripheral or central lesions.
28
How long does nystagmus last in Acute Vestibular Syndrome?
Days to weeks
29
What is the single best bedside predictor of stroke in acute vestibular syndrome?
A normal HIT
## Footnote
HIT stands for Head Impulse Test.
30
What has been recently added to the HINTS protocol?
HINTS 'plus' that includes assessing the presence of new hearing loss
## Footnote
HINTS stands for Head Impulse, Nystagmus, Test of Skew.
31
What does the bedside hearing test involve?
Finger rub
## Footnote
This test assesses the patient's ability to hear by rubbing fingers together near the ear.
32
Where is the hearing loss generally found in relation to the head impulse test?
Generally unilateral and on the side of the abnormal head impulse test
## Footnote
This indicates that the side with abnormality correlates with the side of hearing loss.
33
What are the required findings for H.I.N.T.S. 'Plus' (peripheral)?
Must have ALL of the following:
* Unidirectional Nystagmus (direction-fixed)
* No Skew Deviation
* Abnormal Head Impulse Test (unilateral, away from fast phase of nystagmus)
* No new hearing loss
## Footnote
H.I.N.T.S. stands for Head Impulse, Nystagmus, Test of Skew, which are clinical tests used in the evaluation of patients with dizziness or vertigo.
34
What are the required findings for H.I.N.T.S. 'Plus' (central)?
If ANY of the following exist:
* Normal head impulse test
* Direction changing nystagmus in eccentric gaze
* Skew deviation
* New hearing loss
## Footnote
These findings suggest a central cause of vertigo, such as a stroke.
35
In what context is hearing loss considered peripheral?
Given the labyrinthine localization of infarction
36
When should the HINTS exam NOT be solely relied on?
Outside the 72-hour time window
37
What age group have the findings of the HINTS exam not been validated in?
Younger patients <18 years old
38
What is unilateral hypofunction in vestibular response?
At least 25% reduced vestibular response to bithermal caloric irrigation on one side
## Footnote
Unilateral hypofunction indicates a decrease in the function of one vestibular system relative to the other.
39
What characterizes bilateral hypofunction?
Abnormal rotational chair gain, phase, and asymmetry
## Footnote
Bilateral hypofunction suggests a loss of function in both vestibular systems, affecting balance and spatial orientation.
40
What is the condition of saccades and smooth pursuit eye movements in both unilateral and bilateral hypofunction?
Both groups should have normal saccades and smooth pursuit eye movements
## Footnote
This indicates that eye tracking and reflexes may remain intact despite vestibular dysfunction.
41
What is the most common cause of acute spontaneous vertigo?
Acute unilateral vestibular hypofunction
## Footnote
It is essential to understand the underlying conditions that can lead to this condition.
42
What is the most common cause of acute unilateral vestibular hypofunction?
Vestibular neuritis
## Footnote
Vestibular neuritis is often associated with viral infections.
43
List other potential causes of acute unilateral vestibular hypofunction.
* Trauma
* Surgical transection
* Ototoxic medication
* Meniere’s disease
* Other lesions of the vestibulocochlear nerve or labyrinth
## Footnote
These causes can lead to varying degrees of vestibular dysfunction.
44
What symptoms are associated with the acute asymmetry in vestibular tone?
* Vertigo
* Nausea
* Unsteadiness of gait
## Footnote
These symptoms result from the imbalance in vestibular input to the central nervous system.
45
What is spontaneous nystagmus and how does it present in acute unilateral vestibular hypofunction?
Spontaneous nystagmus with the fast component beating away from the dysfunctional ear
## Footnote
This is a key clinical sign in diagnosing vestibular disorders.
46
True or False: Nystagmus and vertigo typically resolve within hours to 14 days.
True
## Footnote
However, this does not mean that all symptoms will resolve quickly.
47
What chronic effects may persist after the resolution of nystagmus and vertigo?
Imbalance and the sensation of dizziness
## Footnote
This may significantly impact a person's quality of life.
48
What are some symptoms of Unilateral Vestibular Hypofunction (UVH)?
Symptoms include dizziness, disequilibrium, motion sensitivity, and oscillopsia.
49
Who is excluded from receiving vestibular rehabilitation?
Individuals at risk for bleeding or cerebrospinal fluid leak, those with significantly impaired cognitive function, individuals with very active or frequent vertigo attacks due to Meniere’s disease, and those with severe mobility limitations.
50
Fill in the blank: Individuals with _______ cognitive function may have poor carryover of learning.
[significantly impaired]
51
True or False: Individuals with severe mobility limitations can meaningfully participate in vestibular rehabilitation.
False
52
Do age and gender affect the potential for improvement with VPT?
No, age and gender do not affect potential for improvement with VPT.
53
What comorbidities may negatively impact rehabilitation outcomes?
* Anxiety
* Depression
* Peripheral neuropathy
* Migraine
* Abnormal binocular vision
* Abnormal cognition
54
What is the effect of long-term use of vestibular suppressant medication on recovery?
Long-term use of vestibular suppressant medication may negatively impact an individual’s recovery.
55
What should clinicians consider regarding vestibular suppressant medications?
Clinicians should consider consulting with the referring physician about continued use of these medications.
56
What type of antihistamines may help control symptoms and allow participation in VPT?
Short-term, low-dose antihistamines.
57
What is the primary approach to the management of patients with peripheral vestibular hypofunction?
Exercise-based
## Footnote
This approach emphasizes physical activities to help improve balance and reduce symptoms.
58
What medications may be included in the management of patients in the acute stage after vestibular neuritis or labyrinthitis?
Vestibular suppressants or antiemetics
## Footnote
These medications are used to alleviate symptoms such as dizziness and nausea.
59
True or False: Evidence supports the use of medication for the management of chronic patients with peripheral vestibular hypofunction.
False
## Footnote
No evidence supports the use of medications for chronic management.
60
What is the surgical or ablative approach limited to?
Patients with recurrent vertigo or fluctuating vestibular function and symptoms that cannot be controlled by other methods
## Footnote
Other methods include lifestyle modifications or medication.
61
What is the goal of the ablative approach?
To convert a fluctuating deficit into a stable deficit to facilitate central vestibular compensation for unilateral vestibular hypofunction.
62
What condition is characterized by episodes of vertigo, tinnitus, and hearing loss?
Meniere’s Disease
63
What condition involves a thinning of the bone over the superior semicircular canal?
Superior Canal Dehiscence
64
What is a condition that results from an abnormal connection between the inner ear and the middle ear?
Perilymphatic Fistula
65
What surgical procedure involves the removal of a tumor on the vestibular nerve?
Resection of Acoustic Neuroma (Vestibular Schwannoma)
66
What effect do vestibular suppressants and anti-histamines have on recovery?
They may slow the adaptation process, making recovery more difficult.
## Footnote
This highlights the importance of medication management in vestibular disorders.
67
What is habituation in the context of dizziness?
Habituation involves repeated exposure to the specific stimulus that provokes dizziness, leading to a reduction in symptoms over time.
68
How many times should selected movements be performed during habituation exercises?
2-3 times, 2 times a day.
69
What is the intensity of symptoms required when performing habituation movements?
Should be performed quickly enough to produce mild/moderate symptoms.
70
What is the recommended rest period after each movement during habituation exercises?
Rest until symptoms resolve, typically <60 seconds after exercise or <15-30 minutes after all exercises.
71
How long may it take for symptoms to decrease with habituation exercises?
May take 4 weeks for symptoms to decrease.
72
For how long should habituation exercises generally be performed?
Generally performed for 2 months.
73
What is the recommended frequency of habituation exercises after the initial 2 months?
Gradually decreased to 1 time a day.
74
True or False: Habituation exercises are safe for patients with orthostatic hypotension.
False.
75
What is the requirement for symptoms before continuing with self-movements?
Symptoms MUST return to baseline
76
If exercise overstimulates, what adjustments should be made?
Reduce amount, speed, and/or frequency
77
What is adaptation in the context of vestibulo-ocular reflex?
Long-term changes in the neuronal response to head movements aimed at reducing symptoms and normalizing gaze and postural stability.
## Footnote
Adaptation exercises focus on improving the body's ability to stabilize vision during head movements.
78
What is substitution in the context of vestibulo-ocular reflex?
Promoting alternative strategies to substitute for missing vestibular function, such as smooth-pursuit eye movements or central pre-programming of eye movements.
## Footnote
Substitution exercises are designed for individuals who cannot rely on their vestibular system.
79
Fill in the blank: The goal of _______ is to reduce symptoms and normalize gaze and postural stability.
adaptation
80
Fill in the blank: The goal of _______ is to promote alternative strategies for missing vestibular function.
substitution
81
What are overt saccades?
Corrective eye movements made after the head comes to rest, specifically when head velocity goes through 0 deg/sec
## Footnote
Overt saccades occur when the head is fairly still and visual feedback is available.
82
When do overt saccades occur?
After the head has come to rest
## Footnote
They are defined when head velocity goes through 0 deg/sec.
83
What defines covert saccades?
Saccades made before head velocity returns to 0, typically during the high velocity part of head movement
## Footnote
Covert saccades involve a predictive aspect as they occur prior to the head coming to rest.
84
Why are covert saccades significant?
They allow quicker visual feedback after a head movement
## Footnote
Covert saccades are desirable because they occur before the head stops moving.
85
True or False: Overt saccades are visible to an examiner.
True
## Footnote
Overt saccades occur after the head has come to rest and are therefore observable.
86
What is a key characteristic of covert saccades?
They occur during the high velocity part of head movement
## Footnote
This indicates a predictive aspect, as they happen before the head stops moving.
87
How often should persons without significant comorbidities and with acute or subacute unilateral vestibular hypofunction attend supervised sessions?
1 time per week for 2 to 3 sessions
88
What is the recommended frequency of supervised sessions for persons with chronic unilateral vestibular hypofunction?
1 time per week for 4 to 6 weeks
89
How long should persons with bilateral vestibular hypofunction expect to attend supervised sessions?
1 time per week for 8 to 12 weeks
90
True or False: Persons with bilateral vestibular hypofunction typically require a shorter treatment course than those with unilateral vestibular hypofunction.
False
91
What is a global impact of Unilateral Vestibular Hypofunction (UVH)?
Dysfunctional body strategies
## Footnote
These strategies can lead to various physical limitations and discomfort.
92
What is head-trunk locking?
A dysfunctional strategy for avoiding dizziness
## Footnote
It may result in muscle tension and pain.
93
What is a consequence of minimizing trunk movements during walking?
A rigid trunk that limits the body's capability to meet task and environmental demands.
94
How do dysfunctional strategies evolve over time?
They become automatic after being conscious at first.
95
Why are the strategies counterproductive in the context of UVH?
Symptom-provoking movements are central for recovery, and a flexible body is necessary for optimal balance.
96
How can anxiety and fear impact physical symptoms related to UVH?
They can reinforce problems, including those with respiration.
97
Fill in the blank: Head-trunk locking is a strategy for avoiding _______.
dizziness
98
True or False: A flexible body is necessary for optimal balance.
True
99
What types of balance exercises may clinicians prescribe?
Static and dynamic balance exercises
100
What is the recommended duration for balance exercises in Chronic Unilateral Vestibular Hypofunction?
A minimum of 20 minutes daily for at least 4 to 6 weeks
101
What is the duration for balance exercises for Bilateral Vestibular Hypofunction?
6 to 9 weeks
102
Are there specific dose recommendations for Acute/Subacute Unilateral Vestibular Hypofunction?
No specific dose recommendations
103
Has general conditioning exercise been found beneficial for patients with vestibular hypofunction?
No
## Footnote
General conditioning exercise alone has not shown benefits for these patients.
104
Research suggests that the CRP should be applied cautiously in patients with the following conditions:
Occipitoatlantal or atlantoaxial instability
Cervical myelopathy or radiculopathy
Severe carotid stenosis
Orthopnea
Unstable cardiac conditions
Retinal detachment
Glaucoma
105
Supine Roll test
Performed to detect horizontal canal BPPV. Patient goes from sitting up to straight supine, The head is turned to the right side with observation of nystagmus and then turned back to face up. Then the head is turned to the left side. The side with the most prominent nystagmus is taken to be the affected horizontal semicircular canal.
106
Bow and Lean test for canalithasis
bowing nystagmus beating toward the affected side and a leaning nystagmus beating toward the unaffected side are observed.
107
Bow and lean test for cupulolithasis
bowing nystagmus beating toward the unaffected side and leaning nystagmus beating toward the affected side are persistently observed.
108
Barbeque roll manuever
Start in the supine position, roll head to the unaffected side, continue to roll in the same direction until head is completely nose down or prone, complete final roll and return to sitting. Hold each position for 30 seconds.
109
Gufoni (geotropic) Maneuver
Initial sidelying position is towards the unaffected side for 2 minutes
Rapidly turn 45 degrees down, hold position for 2 minutes
Slowly return to sitting, cervical spine returned to neutral
110
Gufoni (apogeotropic) Maneuver
Initial sidelying should be towards “affected side” for 2 minutes -> Turn head up 45 degrees for 2 minutes -> Slowly return to sitting, return to neutral cervical rotation. May need to follow with BBQ Roll Maneuver.
111
Are vestibular suppressant medications routinely recommended for treatment of BPPV?
No
112
When may vestibular suppressant medications be appropriate?
For short-term management of autonomic symptoms, such as nausea or vomiting, in a severely symptomatic patient
113
What is the effect of Zofran on nausea and nystagmus?
Improves nausea but doesn’t suppress nystagmus
114
What is likely the cause of persistent symptoms following the treatment of BPPV?
Widespread dysfunction within the vestibular system
115
True or False: Vestibular dysfunction can be caused by BPPV alone.
False
116
How can 45 degrees of cervical rotation be achieved in patients with orthopedic limitations?
By rolling the patient instead of rotating the cervical spine
## Footnote
This technique minimizes strain on the cervical spine.
117
What tools can be used to modify maneuvers to achieve 30 degrees of cervical extension?
Pillows, a wedge under the thoracic spine, or a reverse tilt table
## Footnote
These modifications assist in positioning for effective maneuvering.
118
119
What is the King-Devick Test used for?
To assess eye movement in children with reading difficulty and has been proposed for both oculomotor assessment and acute diagnosis in patients with concussion
120
What does the King-Devick Test quantify?
Saccadic movements
121
Why is a baseline measurement required for the King-Devick Test?
Due to variability in performance, for valid post-injury comparison
122
VOMS Scoring
Cut-off scores of ≥2 symptom scores after any VOMS item or a NPC distance of ≥5 cm resulted in high rates
123
What conditions can be included in Acute Vestibular Syndrome?
Vestibular neurititis, labryinthitis, posterior circulation stroke, Demyelinating diseases, posttruamatic vertigo
124
What conditions can be included in Triggered Episodic Vestibular Syndrome?
BPPV, Orthostatic hypotension, perilymph fistula, superior canal dehisence syndrome, VBI, CPPV
125
What conditions can be included in Spontaneous Episodic Vestibular Syndrome?
Vestibular migraine, meniere's disease, posterior circulation TIA, medication side effects, anxiety or panic disorders
126
What conditions can be included in Chronic Vestibular Syndrome?
Anxiety or panic disorder, medication side effects, posttraumatic vertigo, posterior fossa mass lesions, cervicogenic vertigo
127
Diagnostic criteria for 3PD
Must have symptoms for 3 months. Must have symptoms with exposure to complex motion demands or environments. No specific position or direction of head movement causes symptoms. Must have postural relationship, most severe when walking/standing with upright posture and absent or very minor when supine
128
What are the main clinical characteristics of Persistent Postural Perceptual Dizziness (3PD)?
Persisting subjective non-rotational vertigo or dizziness, hypersensitivity to motion stimuli, difficulties with precision visual tasks
## Footnote
These characteristics help in identifying the disorder.
129
What do clinical balance tests typically reveal in patients with 3PD?
Normal values
## Footnote
Despite experiencing symptoms, balance tests do not indicate any abnormalities.
130
What secondary features may develop in some patients with 3PD?
Functional gait disorder with a slow or hesitant gait and/or a 'walking on ice' gait pattern
## Footnote
These features can complicate the clinical picture of 3PD.
131
Do objective tests exist to prove the diagnosis of PPPD?
No objective tests exist
## Footnote
Diagnosis is primarily based on clinical characteristics and patient history.
132
What is the typical symptom progression in patients with PPPD?
A transition from acute to chronic symptoms
## Footnote
For example, acute spinning vertigo of vestibular neuritis to persistent unsteadiness of PPPD.
133
What are common acute vestibular disorders that PPPD often follows?
* Vestibular neuritis
* Benign paroxysmal positional vertigo
* Vestibular migraine
134
What are the normal findings in oculomotor testing for 3PD?
Normal but symptomatic oculomotor testing
## Footnote
Includes smooth, saccade, and VOR cancellation testing
135
What vestibular tests are typically normal in 3PD?
Head impulse and positional vestibular testing normal
## Footnote
No corrective saccades or nystagmus unless comorbid vestibular hypofunction
136
What is the Motion Sensitivity Quotient in 3PD?
Abnormal and usually severe motion sensitivity
## Footnote
Indicates the level of discomfort with motion
137
Red Flags that it is NOT 3PD
Indistinct onset, progressive symptoms (slowly worsening), Falls (gait disturbance is not part of 3PD), constant symptoms regardless of provocative factors
138
What are the classes of medications used in 3PD treatment?
Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs)
## Footnote
These medications are commonly prescribed for managing symptoms of persistent postural-perceptual dizziness (PPPD).
139
What approach is indicated for the chronic hypersensitivity to motion stimuli and visual complexity in PPPD?
Habituation/desensitization approach
## Footnote
This approach aims to reduce sensitivity to motion and visual stimuli, which are core symptoms of PPPD.
140
Habituation for 3PD
Habituation exercises are carried out in a graded fashion to motions that increase symptoms.
The effect of habituation tends to be specific to the motion executed so exercises are specific to motions that aggravate symptoms
141
What is primary lateral sclerosis?
A condition where only the upper motor neurons are damaged.
142
What is spinal muscular atrophy?
A condition where only the lower motor neurons are damaged.
143
What is progressive muscular atrophy?
A condition similar to spinal muscular atrophy, where only lower motor neurons are damaged.
144
What is amyotrophic lateral sclerosis (ALS)?
A condition where both upper and lower motor neurons are damaged; the most common form of motor neuron disease in adults.
145
The diagnoses of ALS requires the presence of...
Signs of lower motor neuron (LMN) degeneration by clinical
Signs of upper motor neuron (UMN) degeneration by clinical examination.
Progressive spread of signs within a region or to other regions
146
Bulbar signs & symptoms
Dysphagia
Dysarthria
Pseudobulbar affect
Pseudobulbar palsy
Sialorrhea
147
UMN signs & symptoms
Spasticity (Clonus)
Hyperreflexia
Pathologic Reflexes (Hoffman, Babinski)
148
LMN signs & symptoms
Muscle Weakness
Muscle Atrophy
Fasciculations
Hyporeflexia
Hypotonicity
Muscle cramps
149
ALS- Axial Findings UMN
unsteadiness and absent abdominal reflexes
150
ALS - Axial Findings LMN
Head drop
Neck extensor weakness
Trouble standing erect
Bent spine
Abdominal protuberance
151
ALS- Respiratory Muscle Findings LMN symptoms
Dyspnea
Orthopnea
Morning Headache
Daytime Sleepiness
Confusion
152
ALS- Respiratory Muscle Findings LMN signs
Tachypnea
Reduced Volume of Speech
Use of accessory muscles of respiration
Abdominal paradox
153
Is moderate-intensity exercise safe for people with ALS?
Yes
154
What should be avoided to prevent overwork-induced muscle damage in ALS patients?
Overexertion with resulting prolonged post-exercise fatigue, muscle pain, or soreness
155
Does exercise significantly strengthen muscles in ALS?
No
156
Pseudoexacerbations
Flare ups in MS lasting less than 2 hours, due to stressors (heat, fatigue, infections)
157
EDSS – 0-3.5
Mild disability, fully ambulatory w/o AD
158
EDSS – 4-6.5
moderate disability – ambulatory to specific distances w/o or w/ AD
159
EDSS – 7-9.5
severe disability – very limited ambulation even w/ aid, W/C or bed bound
160
What is the most common reason for disability and limitations in mobility in Multiple Sclerosis?
Fatigue
## Footnote
Managing fatigue might be most important for improving outcomes.
161
What might be the earliest symptom of Multiple Sclerosis?
Fatigue
162
Define central-type fatigue in Multiple Sclerosis.
Comes abruptly, with or without exertion, triggered by factors such as exertion, heat, humidity, or reduced sleep.
163
What cognitive symptoms can occur alongside fatigue in Multiple Sclerosis?
Mental confusion/dullness, brain fog, brain fatigue, cog fog
164
Fill in the blank: Fatigue is a subjective feeling of tiredness, while _______ is an objective measure of how fast someone gets tired.
fatigability
165
How can fatigability be observed in Multiple Sclerosis?
* Quickly progressive slowing of gait speed/distance
* Progressive weakening of specific contractions
* Worsening of sensation/speech/vision with a repetitive task
166
What is the Modified Fatigue Impact Scale used for?
For impact of fatigue on physical, cognitive and psychosocial function
## Footnote
Recommended best for comprehensive assessment by a recent systematic review (Cohen et al., JNPT, Jan 2024)
167
What does the Fatigue Severity Scale assess?
For impact of fatigue on daily activities
## Footnote
Recommended best for quick screening by a recent systematic review (Cohen et al., JNPT, Jan 2024)
168
Which scale is recommended for comprehensive assessment of fatigue?
Modified Fatigue Impact Scale
## Footnote
As per a recent systematic review (Cohen et al., JNPT, Jan 2024)
169
Which scale is best for quick screening of fatigue?
Fatigue Severity Scale
## Footnote
As per a recent systematic review (Cohen et al., JNPT, Jan 2024)
170
What are two motor problems associated with Multiple Sclerosis?
Spasticity, clonus
## Footnote
These conditions can lead to muscle stiffness and involuntary muscle contractions.
171
What are the coordination problems associated with cerebellar dysfunction in Multiple Sclerosis?
Ataxia, intention tremor, dysdiadokokinesia, dysmetria, dyssynergia
## Footnote
These problems affect balance and coordination.
172
What visual problems can occur in Multiple Sclerosis?
Optic neuritis, Marcus-Gunn pupil, diplopia, nystagmus
## Footnote
These issues arise from optic or oculomotor dysfunction.
173
What sensory problems are commonly reported in Multiple Sclerosis?
Numbness, tingling, parasthesia
## Footnote
These sensations are often indicative of neurological impairment.
174
What is impaired in terms of vibration/position sense in Multiple Sclerosis?
More in LEs
## Footnote
Lower extremities are often more affected than upper extremities.
175
What test is positive for assessing balance in Multiple Sclerosis?
Romberg positive
## Footnote
A positive Romberg test indicates balance issues related to sensory integration.
176
What gait deviations are seen with MS?
hip flexor and DF weakness (steppage gait), hip abd weakness (Trendelenburg gait), hip add tightness (scissoring), cerebellar lesion (ataxic)
177
Is exercising safe for the MS population?
Yes, exercising is safe for the MS population and does not cause relapse
## Footnote
Reference: Pilutti et al, J Neurol. Sci., 2014
178
What can excessive exercise lead to in MS patients?
Pseudo-exacerbations/pseudo-attacks
## Footnote
These are transient worsening of symptoms due to factors like fatigability or rise in body temperature.
179
True or False: Exercise can cause exacerbations, attacks, or relapses in MS patients.
False
## Footnote
Although patients may complain of worsening symptoms after exercise, it does not cause true exacerbations.
180
What is a limitation of quick assessments for MS?
They do not uncover symptoms/deficits and exclude effects of fatigability
## Footnote
Quick assessments may miss underlying issues.
181
When should outcome measures (OMs) be re-tested?
Immediately after a moderately fatiguing activity
## Footnote
This helps uncover symptoms that may appear after fatigue.
182
What types of interventions are recommended for mild MS?
Strengthening, stretching, balance activities, aerobic exercises
## Footnote
These should be performed after a moderate amount of fatigue.
183
What is the goal of exercise for individuals with mild MS?
To get the person to the fatigue level where exercises/activities become moderately challenging, but avoid too much fatigue
## Footnote
This balance is crucial for effective intervention.
184
What practice method is recommended for exercise in the clinic?
Distributed practice
## Footnote
This method should be combined with education on home exercise programs (HEP).
185
What environmental modifications can help manage symptoms during exercise?
Cooling vests, pre-cooling, low room temperature, fans, drinking cool water
## Footnote
These strategies can help mitigate heat-related symptoms.
186
What should be addressed in interventions for moderate MS?
Activity limitations
## Footnote
Interventions should focus on improving the patient's ability to perform daily activities.
187
What should be avoided at the moderate stage of intervention?
Avoid using walking aids as much as possible
## Footnote
This is to prevent hastening disability.
188
What is the primary mobility status of patients with severe MS?
Minimally ambulatory, restricted to wheelchair for all practical purposes.
189
What type of recovery is expected for patients with severe MS?
Less likely to have substantial functional recovery.
190
What assistance do patients with severe MS require?
Assistance for all ADLs/Self-care activities.
191
What techniques should be taught to patients with severe MS?
Compensatory techniques for transfers, bed mobility, wheelchair mobility training.
192
What respiratory techniques may be beneficial for severe MS patients?
Diaphragmatic breathing and pursed lip breathing.
193
What is the Fick equation?
VO2 (oxygen consumption) = Cardiac output (SV*HR) * Arteriovenous oxygen difference (AOC - VOC)
| AOC: Arterial Oxygen content
VOC: Venous oxygen content
194
What happens to COmax as age increases?
It decreases due to decreasing HRmax, even when SV remains stable.
## Footnote
COmax is the product of heart rate (HR) and stroke volume (SV) at maximum workload.
195
How does aerobic training affect COmax?
COmax increases significantly with aerobic training.
## Footnote
This indicates improved cardiovascular efficiency and capacity.
196
Fill in the blank: As age increases, COmax decreases due to decreasing _______.
HRmax
197
What remains the same in arterial O2 content with age?
Ability to load O2 in hemoglobin and O2 saturation
## Footnote
Arterial O2 content is not significantly affected by age.
198
How does venous O2 content change with age?
Venous O2 content becomes higher with age
## Footnote
This change affects the A-V O2 difference.
199
What happens to the A-V O2 difference as a person ages?
The A-V O2 difference gets lower
## Footnote
This reduction can negatively impact maximum workload capacity.
200
What changes occur in the electrical function of the heart for people over 65 years old?
Frequency and regularity can become abnormal
## Footnote
This indicates potential arrhythmias or other electrical conduction issues.
201
What mechanical changes occur in the heart as people age?
The heart becomes fatty, larger, and less efficient, altering force, velocity, and length-tension relationships
## Footnote
These changes can affect overall cardiac output and exercise capacity.
202
What is a consequence of autonomic dysregulation of heart rate in older adults?
Heart rate may be abnormal at rest or with activity
## Footnote
This can lead to difficulty in responding to physiological stressors.
203
What happens to blood vessel elasticity as people age?
Decreased elasticity results in chronic increase in vascular diameter and vessel wall rigidity
## Footnote
This condition is associated with increased risk of hypertension.
204
True or False: Aging leads to increased elasticity in blood vessels.
False
## Footnote
Aging typically decreases elasticity, contributing to vascular stiffness.
205
What are the Effects of age on Pulmonary tissue?
Alveolar size increases, consequently surface area for gaseous exchange decreases
206
What are the effects of age on expiratory and in inpiratory pulmonary function?
Both decline
207
What are the symptoms of COPD?
SOB, increased RR, DOE, barrel chest, hypoxia, inspiratory crackles
208
What are the two main types of COPD?
Emphysema (pink puffers) and chronic bronchitis (blue bloaters)
209
How can COPD sometimes be mistaken?
It can be indistinguishable from the normal aging process
210
Fill in the blank: COPD leads to difficulty breathing out due to obstruction of airway by _______.
inflammation or mucus production
211
Emphysema symptoms
thin appearance, dyspnea, use of accessory muscles for breathing, increased CO2 retention, speaks in short, jerky sentences, will have quiet chest
212
Chronic Bronchitis symptoms
airway flow problem, cyanotic, hypoxia, digital clubbing, bilateral LE edema, increased RR, overweight
213
COPD severity
Stage I: Mild
Stage II: Moderate
Stage III: Severe
Stage IV: Very severe
214
idiopathic pulmonary fibrosis (IPF)
common restrictive disease in older adults, includes shortness of breath and dyspnea on exertion. Harder to breathe in due to lung restrictions
## Footnote
IPF leads to difficulty in breathing due to the restriction of lung expansion.
215
What is the spirometry result indicative of in restrictive lung disease?
FEV1/FVC > 0.8
## Footnote
This ratio indicates that the forced expiratory volume in one second is greater than the forced vital capacity.
216
What happens to lung volumes in restrictive lung disease?
All lung volumes are smaller
## Footnote
This reflects the reduced capacity for lung expansion.
217
Effects of age on muscle performance
Progressive denervation and impaired regeneration muscle, Deficits in absolute force and specific force generation (per cross sectional area), Muscle activation deficits, Deteriorating muscle quality and metabolism.
218
What is sarcopenia primarily defined as?
Age-related loss of muscle mass and strength
## Footnote
Considered a clinical condition with genetic and lifestyle/environmental contributors.
219
What are some contributors to sarcopenia?
Genetic and lifestyle/environmental factors such as nutrition, activity, and inflammation
## Footnote
These factors can influence the development and progression of sarcopenia.
220
What changes occur in whole muscle due to sarcopenia?
* Decreased muscle mass, replaced by increased fat mass
* Decreased muscle strength, particularly in lower extremities
* Slowing of muscle contractile properties and rate of force development
* Reduced rate of cross-bridge cycling
* Alterations in excitation and contraction coupling
* Increased compliance of muscle's tendinous attachment
## Footnote
These changes contribute to functional decline in older adults.
221
What happens to type II muscle fibers in sarcopenia?
Type II (fast twitch) fibers are lost more than type I (slow twitch) fibers
## Footnote
This differential loss affects muscle performance and strength.
222
What is fiber necrosis?
The death of muscle fibers
## Footnote
This condition can be a consequence of sarcopenia.
223
What does fiber type grouping refer to?
Enlargement of motor units
## Footnote
This occurs as a response to the loss of muscle fibers.
224
What is the effect of sarcopenia on satellite cell content in type II muscle fibers?
Reduction in type II muscle fiber satellite cell content
## Footnote
Satellite cells are important for muscle repair and regeneration.
225
True or False: Sarcopenia is only defined by loss of muscle mass.
False
## Footnote
It is also defined by loss of muscle strength and is considered a clinical condition.
226
Fill in the blank: Sarcopenia is characterized by decreased muscle mass and increased _______.
fat mass
## Footnote
This shift can lead to various health issues.
227
What is frailty?
Syndrome in which 3 or more of 5 factors are present
## Footnote
According to Fried et al, 2001
228
What are the 5 factors that indicate frailty?
* Unintentional weight loss (10 lbs in the past year)
* Self-reported exhaustion
* Weakness (grip strength)
* Slow walking speed
* Low physical activity
229
What is the definition of 1 MET?
1 MET = 1 kcal/kg/hour = 3.5 ml O2/kg body weight/min
## Footnote
1 MET represents the amount of oxygen consumed while sitting quietly.
230
How does relative exercise intensity (% VO2 max) change with age for the same activity?
The relative exercise intensity (% VO2 max) required for that activity will increase with age.
231
True or False: Absolute MET for the same kind of activity remains the same regardless of age.
True
232
Fill in the blank: Older people need to work at a higher _______ than younger people to perform an activity of the same absolute MET value.
% VO2
233
BMI Values
Normal – 18.5-24.9 kg/m2
Overweight – 25.0 – 29.9 kg/m2
Obese - >30.0 kg/m2 – increased risk of CV, diabetes, mortality
Obesity paradox – people with CHF have improved survival rate when BMI is >30.0 kg/m2
BMI < 18.5 also increases mortality risk
234
What is the purpose of submaximal exercise testing?
To determine HR response to exercise and to estimate max work rate or VO2max/peak
235
Which parameters should be monitored during submaximal exercise testing?
* HR
* BP
* RPE
* Angina
* Dyspnea
* Claudication
* ECG
* Expired gas (if available)
236
What is the first step in a cycle ergometer test?
Obtain resting HR and BP
237
What is the recommended positioning for a patient on the ergometer?
25 degrees flexion at maximal leg extension
238
How long should the warm-up period last during the cycle ergometer test?
2-3 minutes
239
What is the duration of each stage during the cycle ergometer test?
2-3 minutes
240
When should HR be recorded during the cycle ergometer test?
In the last minute as it reaches steady state
241
At what point should the test be terminated?
When pt reaches 70%HRR (or 70-85% HRmax) or shows adverse symptoms
242
What adverse symptoms may indicate test termination?
* Moderately severe angina
* Dyspnea
* Intense claudication pain
243
What are absolute exercise contraindications?
Unstable angina, uncontrolled cardiac dysrhythmia, uncontrolled CHF, acute infection, recent change in resting ECG
## Footnote
CHF stands for congestive heart failure.
244
What are relative exercise contraindications?
Known significant cardiac diseases, tachy/brady dysrhythmia, chronic infection
## Footnote
Tachy refers to an increased heart rate, while brady refers to a decreased heart rate.
245
What is an absolute indication for stopping exercise?
Drop in SBP > 10 mm Hg with increase in workload with signs of ischemia, signs of poor perfusion, moderately severe angina
## Footnote
SBP stands for systolic blood pressure.
246
What is a relative indication for stopping exercise?
Drop in SBP > 10 mm Hg with increase in workload without signs of ischemia, increasing chest pain, fatigue, SOB, wheezing
## Footnote
SOB stands for shortness of breath.
247
Duke Activity Status Index
self-administered questionnaire, rough estimate of pt’s peak O2 uptake – applicable for older adults with known CVDs where there might be additional risks of stressing pt’s CV system with exercise tests
248
What is the recommended duration of moderate intensity exercise for older adults?
> 150 min per week
## Footnote
This can be achieved through 30 minutes of exercise for 5 days a week.
249
What percentage of HRR/VO2R corresponds to moderate intensity exercise?
40-60% HRR/VO2R
## Footnote
This intensity level is also associated with a Rating of Perceived Exertion (RPE) of 5-6.
250
What is the recommended duration of vigorous intensity exercise for older adults?
> 75 min per week
## Footnote
This can be achieved through 25 minutes of exercise for 3 days a week.
251
What percentage of HRR/VO2R corresponds to vigorous intensity exercise?
60-85% HRR/VO2R
## Footnote
This intensity level is also associated with a Rating of Perceived Exertion (RPE) of 7-8.
252
What is the recommended MET-min/week for older adults?
> 500-1000 MET-min/wk
## Footnote
Higher volumes of exercise can provide additional benefits.
253
What type of exercises are recommended for deconditioned individuals?
Light exercises (<40% HRR/VO2R)
## Footnote
These may be beneficial for those starting out and can include multiple sessions of >10 minutes per day.
254
What should older or deconditioned individuals monitor during exercise progression?
Angina, dyspnea
## Footnote
These symptoms should be closely watched as exercise intensity increases.
255
True or False: More exercise volume is associated with fewer benefits for older adults.
False
## Footnote
More exercise volume is actually associated with additional benefits.
256
What is the recommended number of sets for each muscle group for older adults?
2-4 sets
## Footnote
This applies to resistance training for older adults.
257
What is the recommended rest period between sets for older adults?
2-3 minutes
## Footnote
This is advised for resistance training sessions.
258
What percentage of 1RM is recommended for strength training in older adults?
60-80% 1RM
## Footnote
This range is for 8-12 repetitions per set.
259
How many days per week should older adults engage in resistance training?
2-3 days/week
## Footnote
Sessions should be separated by at least 48 hours.
260
What is the recommendation for training older/sedentary adults in terms of intensity?
40-50% 1RM (10-15 reps-light intensity)
## Footnote
This is specifically for older/sedentary adults.
261
What is the recommended intensity for improving endurance in older adults?
<50% 1RM (15-20 reps per set)
## Footnote
This should be limited to less than 2 sets.
262
What intensity is recommended for the oldest adults (>80 years)?
High intensity (70-80% 1RM) once per week
## Footnote
This may be beneficial for older adults.
263
Fill in the blank: For older adults, resistance training should include _______ for all major muscle groups.
one session or ‘split’ session
## Footnote
This allows for comprehensive training.
264
What is the purpose of pulmonary interventions for geriatric patients?
To improve aerobic endurance and respiratory muscle strength
## Footnote
Particularly for patients with obstructive/restrictive diseases
265
Who is respiratory muscle training used for?
For patients with maximal inspiratory pressure <60cm H2O
## Footnote
Aimed at enhancing respiratory muscle strength and endurance
266
What is the recommended duration and frequency for using the inspiratory/expiratory threshold trainer?
15-30 minutes, 1-2 times/day
267
What breathing strategy can improve exercise capacity in geriatric patients?
Pursed lipped breathing
## Footnote
Proven to improve exercise capacity as measured by 6MWT
268
What are some airway clearance techniques?
Postural drainage, percussion, vibration
269
What effect can the measurement of lower extremity alignment have?
Can have significant effect on posture and weight distribution
## Footnote
Lower extremity alignment is crucial for overall body mechanics.
270
What should be assessed in knee alignment?
Knee alignment should be assessed at different planes
## Footnote
This includes frontal and sagittal planes.
271
What condition can insufficient foot arch aggravate?
Knee valgus
## Footnote
Proper foot arch support is essential for knee alignment.
272
What is the navicular drop measurement considered abnormal?
If drop > 1cm
## Footnote
A significant navicular drop can indicate the need for orthotic support.
273
When is orthotic arch support indicated based on navicular drop measurement?
If drop is 3.5cm
## Footnote
This level of drop suggests substantial arch insufficiency.
274
What does the formula KI = TW/TL x 100 represent?
A formula related to spinal curvature measurement
## Footnote
KI stands for Kyphotic Index, which helps assess the degree of kyphosis based on trunk width and length.
275
What KI value indicates clinical kyphosis?
More than 13
## Footnote
A KI value greater than 13 suggests a clinically significant degree of kyphosis.
276
What is the measurement by angle for forward head posture?
Angle decreases with age: 49 degrees for 65-74 age, 41 degrees for 75-84 degrees, 36 degrees for > 85 years
## Footnote
Angle measurements indicate how forward the head is positioned relative to the spine, which tends to increase with age.
277
What is the normal range for the tragus-to-wall measure?
10-12 cm
## Footnote
This measurement helps assess forward head posture while ensuring the cervical spine is not extended.
278
What should be avoided when taking the tragus-to-wall measure?
Extending the cervical spine
## Footnote
Proper posture is crucial for accurate measurement.
279
What does an occiput-to-wall measure greater than zero indicate?
Classified as flexed posture
## Footnote
A flexed posture increases the likelihood of vertebral fractures and requires further assessment.
280
What is the implication of a flexed posture in the occiput-to-wall measure?
Increases likelihood of vertebral fractures, needs further assessment (referral)
## Footnote
This measurement is critical in evaluating the risk of spinal injuries.
281
How does muscle-tendon unit (MTU) extensibility affect functional ROM?
MTU extensibility affects functional ROM because it determines how well multi-joint muscles can lengthen, influencing overall movement capabilities.
## Footnote
Passive insufficiency occurs when a muscle cannot stretch enough to allow full ROM in a joint.
282
What is passive insufficiency?
Passive insufficiency is the inability of a multi-joint muscle to lengthen sufficiently to allow full range of motion at all joints it crosses.
## Footnote
This can limit functional movements and increase injury risk.
283
Which multi-joint muscles tend to shorten with age?
* Ankle plantar flexors
* Hamstrings
* Hip flexors
## Footnote
Age-related shortening can impact mobility and functional performance.
284
How can joint mobility be assessed?
Joint mobility can be assessed through functional positions such as bending, squatting, and reaching behind.
## Footnote
Functional assessments provide practical insights into a person's mobility.
285
What is the risk zone measurement for men in the Chair Sit-and-reach test?
-4 inches or more
286
What is the risk zone measurement for women in the Chair Sit-and-reach test?
-2 inches or more
287
What is delirium?
Sudden episodic decline in mental function
## Footnote
Delirium is characterized by a rapid onset of confusion and cognitive disturbances.
288
What are the two types of delirium?
Agitated (hyperactive) and quiet (hypoactive) delirium
## Footnote
Sometimes patients can exhibit mixed symptoms.
289
What are possible causes of delirium?
* Medications
* Infections
* Dehydration
* Nutrition/electrolyte imbalance
* Prolonged lying in bed
## Footnote
These factors can contribute to the onset of delirium.
290
What are PT recommendations to prevent delirium?
Early mobilization, walking
## Footnote
Engaging patients in physical activity can help reduce the risk of developing delirium.
291
When should flexibility exercises be started for ALS patients?
Early in the disease course
## Footnote
Incorporate flexibility exercises into a gentle daily routine with caregiver participation as needed.
292
What are the recommendations for strengthening exercises in ALS?
Do not exercise muscles that do not have antigravity strength; Avoid high resistance; Avoid eccentric exercises; Progress as tolerated. Tell the pt to find a weight they can do comfortably 20 times then ask pt to perform 2-3 sets of 10 reps.
## Footnote
The principle of 'start low, go slow' is emphasized.
293
How can ALS patients gauge the intensity of aerobic exercise?
If the patient cannot talk comfortably during exercise, the program is too vigorous. A practical apporach to introducing aerobic exercise is to start with 10 minutes 2-3 times per week and progress as tolerated.
## Footnote
Progress in aerobic exercise should be as tolerated.
294
ALS Stage 1
The patient is in the early stages of the disease and is independent in mobility and ADL.
A specific group of muscles are mildly weak, which may be manifested as limitations in performance or endurance, or both.
The patient is advised to continue normal physical activities.
295
ALS Stage 2
The patient has moderate weakness in groups of muscles. Assessing the need for and providing appropriate equipment and assistive devices to support weak muscles is the primary goal of intervention.
296
What symptoms may indicate overuse in ALS?
An increase in cramping or fasciculations
## Footnote
These symptoms are associated with lower motoneuron (LMN) involvement.
297
How often should ALS patients exercise throughout the day?
Several brief periods throughout the day totaling about 30 to 45 minutes each day
## Footnote
This approach helps manage symptoms and maintain physical function.
298
ALS Stage 3
The patient remains ambulatory but has severe weakness in certain muscle groups that may result in severe foot drop or a markedly weak hand.
The patient may be unable to stand up from a chair without help. Overall, the patient may exhibit mild to moderate limitation of function.
In this stage, as with all other stages, the goal is to keep the patient physically independent.
299
ALS Stage 4
The patient in this stage has severe weakness of the legs and mild involvement of the arms. Thus, the patient uses a wheelchair and may be able to perform ADL.
PROM and AAROM exercises are recommended to prevent contractures. Strengthening exercises and AROM of any noninvolved muscles should be continued.
300
ALS Stage 5
This stage is characterized by progressive weakness and deterioration of mobility and endurance.
The patient uses a wheelchair when out of bed, and arm muscles may exhibit moderate or severe weakness.
Frequent skin checks, patient may be unable to hold their heads up for extended periods, may need soft collar
301
ALS Stage 6
The patient must remain in bed and requires maximal assistance with ADL. A hospital bed should be prescribed.
Frequent repositioning of the body, padding to prevent uneven pressure, and prevention of venous stasis in the legs are crucial.
Progressive respiratory distress develops in this stage, and a suction machine should be available.
Goals in this stage are similar to those of hospice/palliative care
302
What assessment strategy is important when working with MS patients?
Assess before and after fatiguing activity
303
What is Uhthoff’s phenomenon?
Temporary worsening of neurological symptoms potentially after raising body temp
304
Factors indicating poor prognosis for MS
305
Factors indicating better prognosis in MS
306
Fill in the blank: For EDSS 0 – 3.5, the rehab approach is _______.
Restorative/Preventative
307
Fill in the blank: For EDSS 4 – 6.5, the rehab approach is _______.
Restorative/Compensatory
308
Fill in the blank: For EDSS > 7, the rehab approach is _______.
Compensatory/Maintenance
309
What may cause a blunted cardiovascular response during aerobic endurance training for individuals with MS?
If the autonomic system is affected, can use RPE instead
## Footnote
This may necessitate the use of RPE as an intensity measure.
310
What is the guideline regarding exercise during a relapse for MS patients?
No exercise during relapse; readjust and continue after remission
## Footnote
This approach helps avoid further complications.
311
What is the recommended frequency of aerobic training for MS patients with EDSS <2.5?
3-5 days per week
## Footnote
This aligns with general population recommendations.
312
What intensity levels are recommended for aerobic training in MS patients?
60-85% HRpeak or 50-70% VO2peak
## Footnote
These levels ensure effective cardiovascular training.
313
What is the recommended duration of aerobic training sessions for MS patients?
30 minutes recommended; 10-minute sessions with rest breaks for lower capacity/fatigability
## Footnote
Adjusting the duration can help accommodate individual capabilities.
314
What is the frequency of strength training recommended for individuals with MS?
2 days per week
## Footnote
This frequency applies to individuals with an EDSS score of less than 2.5.
315
What intensity is recommended for strength training in individuals with MS?
60-80% of 1RM
## Footnote
1RM stands for one-repetition maximum.
316
How many sets and repetitions are recommended for strength training for MS?
1-2 sets of 8-15 reps
## Footnote
Adjustments may be necessary based on individual capabilities.
317
What should be increased to avoid fatigability during strength training with MS patients?
Rest time between sets (2-5 minutes)
## Footnote
This adjustment helps manage fatigue, which can be a concern for individuals with MS.
318
How should progression in strength training be managed for individuals with MS?
Progression should be slower
## Footnote
This is important to accommodate symptom progression.
319
True or False: The exercise prescription for individuals with an EDSS of less than 2.5 is the same as that for the general adult population.
True
## Footnote
However, adjustments may be needed based on symptom progression.
320
What are some recommended modes of flexibility training for MS patients?
* Static stretches
* PNF stretches
* Tai Chi
* Yoga
## Footnote
These methods can be adapted to individual patient needs.
321
How long should static stretches be held for MS patients?
30-60 seconds
## Footnote
This duration is recommended to optimize effectiveness.
322
What should be used to prevent contractures in MS patients?
Orthoses or night splints as needed
## Footnote
These devices help maintain proper positioning during inactivity.
323
What is necessary in addition to stretching for MS patients?
Combine with strengthening the antagonists and progress to functional use
## Footnote
This approach addresses both flexibility and strength.
324
What is a specific training consideration for ataxic gait?
Proprioceptive loading of upper body, e.g., modified plantigrade posture, weighted vests, weighted walker/cane
## Footnote
Ataxic gait is characterized by a lack of coordination, requiring specific interventions to enhance stability.
325
What exercise is recommended for Trendelenburg gait?
Single-leg stance exercises against a wall, with manual feedback to improve gluteus medius contraction during stance phase
## Footnote
Trendelenburg gait often results from weak hip abductor muscles, particularly the gluteus medius.
326
What is a common intervention for steppage gait?
Strengthening dorsiflexors or using AFOs or Bioness (AFO/FES CPG)
## Footnote
Steppage gait is typically associated with foot drop and requires support for proper foot clearance during walking.
327
Fill in the blank: For ataxic gait, proprioceptive loading can be applied using _______.
weighted vests, weighted walker/cane
## Footnote
These tools help enhance sensory feedback and stability during movement.
328
Interventions for advanced stages of MS
recommended for EDSS > 7-9.5, exercises/activities to teach compensatory techniques for maintaining functional mobility
329
What are the effects of age on expiratory pulmonary function?
Decline in Forced expiratory volume per second (FEV1). Takes longer and more effort to get air out of the lungs.
330
The procedure for submaximal exercise testing works best if we get_________ between _________ and___________.
2 HR data points, 110 beats/min, 70% HRR or 85% age-predicted HRmax
331
What are common vision changes due to the effects of aging?
Impaired visual acuity
Muscle weakness resulting in poor convergence -hyperopia
Cornea thickens resulting in astigmatism
332
Mild Cognitive Impairment characterisitics
consistent memory deficits, normal ADLs, abnormal age- and education-adjusted cognitive measures
333
Dementia characterisitics
Objective evidence of memory and language impairments, impairment of ADLs/IADLs/social participation
334
Counterirritant theory
Built on gate theory. Gating happens via interneurons
Interneurons connect non-nociceptive to nociceptive pathways afferents. Interneurons release NT encephalin/endorphins, which has anti-nociceptive activity, inhibit nociceptive pathways
335
What are 5 descending pathways that provide anti-nociception
PAG
Locus coeruleus – release norepinephrine
Raphe nucleus – release serotonin
Neurohormonal pathways from hypothalamus, adrenal medulla
Descending pathways from cerebral cortex, amygdala
336
Normal state of pain regulation system
signals are transmitted accurately, real nociception felt as pain
337
Suppressed state (antinociceptive) pain regulation system
touch, pressure, vibration transmitted normally, but nociceptive signals inhibited.
338
Sensitized state (temporary pro-nociceptive) pain regulation system
repeated tissue irritation changes NTs and receptor activity, enhancing nociceptive signals – hyperalgesia
339
Reorganized state (persistent pro-nociceptive) pain regulation system
structural reorganization of synapses at dorsal horn, axonal sprouting from mechanical receptors pathways, central pain pathways activated without nociceptive activity, touch becomes painful - allodynia
340
Cluster of 3 symptoms and 1 sign predicted **CSP-dominant** mechanisms with high degree of accuracy are...
1. Disproportionate , non-mechanical, unpredictable pattern of pain
2. Pain disproportionate to the nature and extent of injury or pathology
3. maladaptive psychosocial factors
4. Diffuse/non-anatomic areas of pain/tenderness on palpation
341
Cluster of 2 symptoms and 1 sign predicted **PNP-dominant** mechanisms with high degree of accuracy are...
1. dermatomal or cutaneous distribution
2. History of nerve injury, pathology or mechanical compromise
3. Pain/symptom provocation with mechanical/movement tests
342
Cluster of 3 symptoms and absence of 3 symptoms and 1 sign predicted **NP-dominant** mechanisms with high degree of accuracy
1. localized pain
2. has aggravating/easing factors
3. Intermittent, sharp pain with movement, constant dull ache/throb at rest
Absence of
-Dysesthesias
-Night pain/disturbed sleep
-Burning/shooting/sharp/electric-shock- like pain
-Antalgic postures
343
Stage 1 PD
Unilateral involvement only, usually with minimal or no functional impairment
344
Stage 2 PD
Bilateral or midline involvement, without impairment of balance
345
What is the first sign of impaired righting reflexes in Parkinson's Disease Stage 3?
Unsteadiness as the patient turns or when pushed from standing equilibrium with feet together and eyes closed
## Footnote
This reflects the balance and coordination challenges faced by patients at this stage.
346
How are patients' activities affected in Parkinson's Disease Stage 3?
Somewhat restricted in activities but may have work potential depending on employment type
## Footnote
Patients can still lead independent lives despite mild to moderate disability.
347
Describe the functional capabilities of patients in Parkinson's Disease Stage 3.
Physically capable of leading independent lives, with mild to moderate disability
## Footnote
This stage indicates a balance between independence and limitations.
348
Stage IV PD
Fully developed, severely disabling disease; the patient is still able to walk and stand unassisted but is markedly incapacitated
349
Stage V PD
Confinement to bed or wheelchair, unless aided
350
Cardinal Signs of Parkinson’s Disease
Bradykinesia (abnormal stillness or decrease in facial expressions), Rigidity, Resting tremor (pill rolling), Postural instability (tendency to sway backwards)
351
What characteristic motion is associated with axial rigidity in Parkinson's Disease?
Characteristic 'en bloc' trunk motions.
352
What activities are made difficult due to axial rigidity in Parkinson's Disease?
Activities such as rolling over in bed or turning while walking.
353
List some functional outcomes of rigidity in Parkinson's Disease.
* Flexed posture
* Lack of trunk rotation
* Reduced joint range of movement during postural transitions and gait
354
Exercises should focus on the following principles for rigidity in PD...
-Minimize agonist-antagonist muscle co-contraction (ie, -reciprocal movements)
-Promote axial rotation
-Lengthen the flexor muscles
-Strengthen the extensor muscles to promote an erect posture
355
What are some characteristics of Bradykinesia?
* Poor use of proprioceptive information
* Decreased perception of movement
* Over-estimation of body motion
* Over-dependence on vision
## Footnote
These characteristics can affect balance and movement efficiency.
356
What are the features of Bradykinetic voluntary stepping?
* Delayed time to lift the swing limb
* Weak push-off
* Reduced leg lift
* Small stride length
* Lack of arm swing
## Footnote
These features can lead to difficulties in mobility and increase fall risk.
357
Bradykinesia- Exercise for PD
Focus on:
-Increase speed
-Increase amplitude
-Temporal pacing of their self-initiated and reactive limb and body center-of-mass (CoM) movements
-Promote weight-shift control
-Promote postural adjustments in anticipation of voluntary movements
358
What is one of the most common reasons for falls and dependency?
Freezing of Gait (FoG)
## Footnote
FoG leads to an increased risk of falls, which can result in injuries and loss of independence.
359
List situations when freezing during gait occurs more often.
* Negotiating a crowded environment
* Negotiating a narrow doorway
* Making a turn
* Attention is diverted by a secondary task
* Stepping over obstacles
* Change in surface
## Footnote
These situations can trigger episodes of FoG, making mobility challenging.
360
What is an efficient protocol to elicit freezing of gait (FoG) in patients?
Asking patients to repeatedly make 360-degree turns, Can do 2 minutes with direction reversals every 360 degrees. 180 degree turns may not be sufficent in eliciting FoG.
## Footnote
This method is effective for identifying FoG during assessments.
361
Fallers with PD demonstrate the following...
Reduced reactive postural control
Impaired tandem stand/walk
Impaired single limb balance
Increased number of steps (>7 steps) and time (>3.67 sec) to turn 360°
362
What are some examples of autonomic dysfunction in Parkinson's Disease?
* Constipation
* Orthostatic hypotension
* Sexual dysfunction
* Urinary disturbances
## Footnote
These symptoms can lead to further complications
363
What cognitive impairments are seen in Parkinson's Disease?
* Executive functions
* Memory
* Visuospatial functions
* Potential progression to dementia
## Footnote
Cognitive decline can vary in severity among patients
364
What types of sleep disorders are associated with Parkinson's Disease?
* Restless legs
* REM sleep disorder
* Excessive daytime somnolence
* Vivid dreaming
* Insomnia
## Footnote
Sleep disturbances can exacerbate other symptoms
365
What dysfunction may be indicated by a decreased sense of smell in Parkinson's Disease?
Olfactory dysfunction
## Footnote
This is often an early symptom of the disease
366
What type of discomfort is commonly reported by individuals with Parkinson's Disease?
Pain
## Footnote
Pain can be multifactorial, including musculoskeletal and neuropathic origins
367
What are motor fluctuations?
Motor fluctuations include wearing-off, delayed on, partial-on, no-on, and on-off fluctuations
## Footnote
Motor fluctuations occur after several years of treatment with oral levodopa in PD patients.
368
What types of involuntary movements are classified as dyskinesias?
Dyskinesias include choreic, ballistic, and dystonic involuntary movements
## Footnote
Dyskinesias can occur in Parkinson's disease patients after prolonged levodopa treatment.
369
Fill in the blank: After several years of smooth and stable response to oral levodopa treatment, PD patients invariably develop _______.
[motor complications]
## Footnote
These complications often manifest as motor fluctuations and dyskinesias.
370
Aerobic Exercise parameters for PD patients
3 days/week
At LEAST 30 minutes/session of continuous or intermittent exercise
Moderate to Vigorous Intensity
371
Strength training parameters for PD patients
2-3 days/week, non-consecutive
30 minutes/session
10-15 reps for major muscle groups
Focus on Speed or Power
Target ON time
Focus on extensors
372
Balance Training parameters for PD patients
2-3 days per week, ideally DAILY
Multi-directional stepping
Weight Shifting (e.g. Tai Chi)
Dynamic Balance Activities
Large Movements
Yoga, Dance, Boxing
373
Stretching parameters for PD patients
>2-3 days/week; ideally DAILY
Sustained stretching with deep breathing
Dynamic Stretching before exercise
374
What is the current status of therapies for Parkinson's Disease (PD) regarding Freezing of Gait (FoG)?
Current therapies, including deep brain stimulation and levodopa, are inadequate for treating FoG
## Footnote
This indicates a gap in effective treatment options specifically for FoG in PD patients.
375
What is the most common rehabilitative approach to managing Freezing of Gait (FoG)?
The most common rehabilitative approach is through compensatory strategies, including external cueing strategies
## Footnote
These strategies may include visual, verbal, and rhythmic cues.
376
What factors influence the success of compensatory strategies for Freezing of Gait (FoG)?
Success relies on patients having sufficiently preserved cognitive abilities to retrieve and deploy these strategies in daily life.
377
How long do the benefits of cueing strategies for Freezing of Gait (FoG) typically last?
The benefits of cueing strategies are often transient.
378
What is the 5s method for FoG?
Stop
Stand Tall
Shake it off
Sway (step bwd or shift side to side)
Step big
379
What type of exercises should be performed in environments where freezing typically occurs?
Agility exercises
## Footnote
This emphasizes the importance of practicing in conditions that mimic potential real-life scenarios.
380
What is strategy training?
This strategy bypasses the defective basal ganglia circuit using the frontal cortex to regulate movement size or timing by consciously thinking about the desired movement -> “attention strategies”
381
What is the recommended strategy for newly diagnosed PD individuals and those with mild to moderate disease?
High intensity, variable, distributed practice regimens with regular booster sessions over the longer term
## Footnote
This approach aims to enhance skill acquisition and retention.
382
What strategies are recommended for PD individuals who are more severely affected or have cognitive impairment?
Compensatory strategies
## Footnote
These strategies are tailored to accommodate individuals with advanced age or comorbidities that hinder skill acquisition.
383
What are some specific techniques used in compensatory strategies?
* Repetition and drill practice of a given movement or action sequence
* Avoidance of multitasking
* Use of external cues and reminders
## Footnote
These techniques help individuals perform tasks more effectively despite their limitations.
384
What type of gait disorders are associated with PD?
Cortical-subcortical gait disorders
## Footnote
These disorders affect the automaticity of gait.
385
What should a dual-task gait assessment include?
Targeted cognitive tasks
## Footnote
This includes assessing cognitive flexibility and task prioritization.
386
Fill in the blank: Gait disorders in PD can be unmasked under _______.
dual-task conditions
387
Dual-task gait assessment using targeted cognitive tasks should include assessment of...
cognitive flexibility
task prioritization (trade-off effects)
factors known to modulate susceptibility to dual-task interference (age, gender, processing speed, stress, and cognitive reserve)
388
What are some factors that affect dual task performance?
The environment in which the task takes place
The nature of the secondary task
The age and disease-specific factors of each individual
389
What 4 main subsystems of balance does the HiBalance Program target?
Stability limits
Anticipatory postural adjustments
Sensory integration
Motor agility
390
What principles of motor learning does the HiBalance Program incorporate?
Specificity
Progressive overload
Variation
391
What is Paroxysmal Sympathetic Hyperactivity?
episodic presentation of increased HR/sympathetic symptoms. Pts can have increased HR, BP, RR, temperature, and sweating. Most common in severe TBI
392
How does dysautonomia present following concussion?
393
What is autonomic Dysreflexia in spinal cord injury?
Hyperactive reflex caused by harmful stimuli below the level of the injury
394
What do you do if you notice autonomic dysreflexia?
395
What is Myalgic Encephalomyelitis/Chronic Fatigue Syndrome?
A complex, chronic, debilitating disease associated with multiple pathophysiological changes that affect multiple systems
396
What are the symptoms of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome?
A substantial reduction or impairment in the ability to engage in pre-illness levels of activity, post-exertional malaise, unrefreshing sleep, cognitive impairment, orthostatic intolerance
397
What is crucial for patients with ME/CFS?
It is important to know they can improve, it is crucial to find their theraputic thershold, slow pace of treatment, and extensive education on strategies.
398
What is Mast Cell Activation Syndrome (MCAS)?
Improper functioning of mast cells, constant histamine response -> sympathetic overdrive -> poor response to treatment. These patients respond well to dysautonomia protocol once medically managed.
399
What are the dysautonomia management strategies?
400
What is neurogenic shock?
A condition that may occur after a cervical or high thoracic (T1-T5) injury that interrupts thoracic sympathetic outflow.
401
What are the consequences of neurogenic shock?
Hypotension and bradycardia, which may cause secondary neurological injury and pulmonary, renal, and cerebral insults.
402
Why may fluid infusion alone be insufficient to restore blood pressure in neurogenic shock?
Massive fluid resuscitation may generate pulmonary edema.
403
What is spinal shock?
Refers to the muscle flaccidity and loss of reflexes seen after SCI.
The “shock” to the injured cord may make it initially appear completely functionless.
However, because the cord is usually not completely destroyed in SCI, the duration of this state is variable; recovery usually occurs.
404
What is the first treatment priority for hypotension for patients with SCI?
Fluid resuscitation
## Footnote
Administering fluids helps restore blood volume and pressure.
405
What mean arterial pressure (MAP) has been associated with favorable outcomes in acute spinal cord injury?
85 mmHg for a minimum of 7 days
## Footnote
Uncontrolled studies suggest this target may improve patient outcomes.
406
ASIA A
complete, no sensory or motor function is preserved in S4-5, NOOON sign
407
ASIA B
sensory Incomplete (aka motor incomplete), sensory function is preserved below the neurological level and includes S4 to 5
408
AIS C
motor incomplete,
motor function is preserved below the neurological level
More than half of the key muscles are less than 3/5 strength
409
AIS D
motor incomplete,
motor function is preserved below the neurological level
At least half of the key muscles below the neurological level are greater or equal to 3/5 strength
410
AIS E
incomplete, sensory and motor function is normal
411
What characterizes individuals with a LEMS score of 30 or higher?
Community ambulators
## Footnote
They are able to walk more effectively within the community.
412
What are the walking characteristics of individuals with LEMS ≤20?
Limited ambulators, slow walking velocities, higher heart rates, higher energy expenditure
## Footnote
These factors contribute to their overall mobility challenges.
413
What does a outdoor walking CPR score above 33 indicate?
Increased confidence in patient recovering future outdoor walking ability.
## Footnote
CPR stands for Clinical Prediction Rule, which is used to assess recovery potential.
414
What does a outdoor walking CPR score below 33 suggest?
Worse prognosis for outdoor walking.
## Footnote
A lower score indicates a less favorable outcome in terms of walking ability.
415
What happens to blood volume and velocity of lower extremity arterial circulation after SCI?
Blood volume and velocity are significantly lowered after SCI
## Footnote
SCI refers to spinal cord injury.
416
What is a consequence of the lowering of volume and velocity in lower extremity circulation after SCI?
Heightened thrombosis susceptibility
## Footnote
Thrombosis refers to the formation of a blood clot inside a blood vessel.
417
In which stages of SCI is heightened thrombosis susceptibility most often reported?
Most often reported in those with acute and subacute SCI
## Footnote
Acute refers to the immediate phase following injury, while subacute refers to the phase that follows.
418
What muscles are important to strengthen when wanting to improve wheelchair performance?
Posterior shoulder and upper back muscles
419
What is the important objective of a transfer technique?
To minimize internal joint loads
## Footnote
This objective is crucial for preventing injuries during transfers.
420
What factors should be considered from an individual's perspective when performing a transfer?
* Time it takes to perform the transfer
* How efficiently the transfer can be performed
## Footnote
These factors can significantly impact the choice of transfer technique.
421
Why might wheelchair users adopt a transfer technique that increases shoulder joint loading?
To facilitate a faster or more efficient transfer, particularly if they are free of pain in that joint
## Footnote
Efficiency and speed can sometimes take precedence over joint loading concerns.
422
What is the recommended hand positioning during a transfer?
Hands should be positioned as low as possible in the same plane as the buttocks
## Footnote
This positioning helps maximize recruitment of the larger thoracohumeral musculature.
423
What type of strokes should be used when propelling a wheelchair?
Long, smooth strokes
## Footnote
This technique is preferred over short, frequent strokes.
424
What should you allow your hand to do when finishing the push stroke?
Drift downward
## Footnote
This helps to avoid a rapid change in direction of the arm.
425
What should you push off to obtain better shock absorption?
The tires
## Footnote
Pushing off the pushrim does not provide the same level of shock absorption.
426
What should you do if you lose momentum while propelling up an uphill grade?
Stop and turn chair to the side to rest your arms
## Footnote
This provides a safer way to regain strength before continuing.
427
Why is the arm crank cycle exercise considered a poor choice for training?
It fails to target the muscles most involved in performance of daily activities
428
What is the target heart rate if a stress test was not performed in SCI?
20 – 30 beats above resting.
429
What is the maximum stretch limit for a resistance band?
2.5 times its length
## Footnote
Stretching beyond this limit can cause damage to the band.
430
What is homeostatic plasticity?
The ability of neurons to increase excitability after a period of low synaptic activity and to decrease excitability after a period of high synaptic activity.
## Footnote
It is related to changes in postsynaptic glutamate receptors.
431
How does the time scale of homeostatic metaplasticity compare to gating?
The time scale of homeostatic metaplasticity is protracted, while gating occurs instantaneously.
## Footnote
Homeostatic metaplasticity modulates the resting state of neurons prior to motor training.
432
What triggers gating in neurons?
Disinhibition of intracortical inhibitory circuits due to an increase in calcium in the targeted cortical neurons. This will causes EXCITATION
## Footnote
This process occurs concurrently with motor training.
433
Fill in the blank: Homeostatic plasticity is related to changes in postsynaptic _______.
glutamate receptors
434
True or False: Gating is a slow process that occurs after motor training.
False
435
What happens to neuron excitability after a period of high synaptic activity?
It decreases.
## Footnote
This is part of the homeostatic plasticity mechanism.
436
What is the main effect of gating on neurons?
It allows for immediate changes in neuronal excitability during motor training.
## Footnote
This is crucial for the rapid adaptation of neural circuits.
437
What is Locomotor Training (LT)?
training emphasizing activation of the neuromuscular system below the level of the lesion to induce neuroplasticity and promote recovery of function.
438
What is the scale for Modified Ashworth?
439
What questions should be asked when determining whether to treat spasticity or not?
Does it interfere with function?
Does it negatively impact the caregiver's ability to provide care?
Does it negatively impact hygiene?
Does it cause discomfort?
If yes to these, then explore treatment options.
440
What are the symptoms of withdrawal from intrathecal baclofen?
Rash, hypotension, fever, parathesias, AMS, AD like symptoms, and increased spasticity/rigidity
441
