Management of Select Neurological Diseases

Question 1

Guillan-Barre Syndrome

Answer 1

Acute inflammatory demyelinating polyneuropathy (AIDP)

immune mediated disorder of the PNS myelin

Question 2

Guillain Barre Syndrome

age of onset

Answer 2

15-35 and 50-75 years of age. Older population don’t do as well

Question 3

Hallmark Signs of GBS

Answer 3

Fine parathesias begins with hands/feet

Progressive symmetric ascending paralysis

Tachycradia, hypotension, sweating

Bowel/Bladder dysfunction

Hyporeflexia

Slow progression of Sx over 10-12 days

Question 4

Hx: Patient c/o of paralysis that started in the feet and hands, after a few days, they feel paralyze in the shin and forearm. What Neurological conditions do you suspect?

Answer 4

GBS

Question 5

Clinical Course of GBS

Answer 5

Progressive weakness until a plateau (disease nadir)

Respiratory deficits may be present if respiratory mm is affected (pt will go on vent)

After “nadir” they will slowly recover taking up to 2 years

Question 6

Recovery rate of GBS

Answer 6

50-95%

Question 7

Prognosis of GBS

Answer 7

depends on severity of disease

Poorer prognosis associated with:

• rapid onset of sx
• older age
• prolonged vent (>1 mo)
• slower recovery after nadir

Question 8

DD of GBS

Answer 8

lyme, HIV, sarcoidosis, transverse myelitis (loss of sensation on a distinct line)

Question 9

Testing for GBS

Answer 9

slow NCV

ECG

monitor respiratory status/DVTs

IV immune globulin or plasmophoresis

Question 10

Steroidal use and GBS

Answer 10

not recommended b/c inhibit myelin recovery

Question 11

PT & GBS

Answer 11

Goal: maximize function

Tolerance of upright activity (good seating system)

being gentle stretching, mm reed, postural contro/balance retraining

Functional training

Aqutics

AVOID overworking weak mm (rest before they get tired)

Question 12

Post Polio Syndrome

Answer 12

Complex combination of primary and secondary impairments as a result of polio virus

refers to residual deficits that are further complicated by new onset of sx:

• ms weakness
• joint and ms pain
• fatigue
• cold intolerance
• progressive atrophy

Question 13

complications associated with post polio syndrome

Answer 13

• ms weakness
• joint and ms pain (flaccid paralysis, joint not proper therefore increase compensation
• fatigue
• cold intolerance
• progressive atrophy

Question 14

Onset of PPS

Answer 14

~35 years post polio-myelitis infection

Acute polio myelitis: Acute infectious disease caused by an enteric virus.

Paralytic form causs death of anterior horn cells in SC and motor neuron cells in brain

Question 15

Acute paralytic polio recovery

Answer 15

@ beg: almost all motor units are affected

overtime some recover, some gets destroyed

pt recover with less motor units therefore sprouting has to occur to the affected motor fibers. mm hypertrophy may occur with rehab

utilize compensation techniques

Question 16

Incidence of PPS

Answer 16

due to aging

excessive metabolic stress

autoimmune process

28-64% of patients with polio (1/3 to 2/3)

Question 17

PPS Risk factors

Answer 17

Severeity of acute poliomyletic paralysis

age of onset

amount of recovery

greater physical activity during intervening years

Question 18

Inclusion criteria for Dx of PPS

Answer 18

1. Prior episode of PM with residual with residual motor loss
2. Period of at least 15 years of neuro/functional stability
3. Gradual onset of new weakness or abnormal ms fatigue, atrophy or general fatigue

Question 19

Signs and Symptoms of PPS

Answer 19

progressive mm atrophy & weakness that is usually asymmetrical (unlike GBS) which is proximal, distal or patchy, slowly progressive

Abnormal mm fatigue

mm pain d/t overuse of weak mm

ms tenderness on palpation

joint pain

respiratory insufficiency (2nd to resp mm weakness)

Question 20

Medical mmgt of PPS

Answer 20

Meds to manage pain/fatigue

pt education (compromise joint alignment)

address psychological sequelae (Type A ppl)

Question 21

PT management of PPS (areas to work on)

Answer 21

Fatigue: life style changes (energy conservation, wt loss program, use of AD/orthoses)

weakness (nonfatiguing exercise program, use of submax/max str ex with short reps)

Avoid overuse of weakened mm

Question 22

PT prescription for PPS

Answer 22

exercise in short intervals with rest in b/w

exercise on alternate days

gentle cardiac conditioning

aquatics

pt education/ support

Question 23

Which patient population should you educate to rest before they get tired?

Answer 23

GBS

MS

Question 24

Multiple Sclerosis

Answer 24

Idiopathic autoimmune disease process of UMN (suspect environmental exposure prior to onset and then virus) (onset much earlier compare to GBS which is more recent virus)

Question 25

Onset of MS

Answer 25

2nd or 3rd decade of life female predominance 2-3:1 Progressive, often relapsin and remitting

Question 26

Types of MS

Answer 26

Relapsin remitting (RR) Secondary progressive (SP) Primary Progressive (PP) Progressive Relapsin (PR)

Question 27

Characteristics of relapsin remitting MS

Answer 27

partial or total recovery after relapse/flare or exacerbation

Question 28

Characteristics of secondary progressive MS

Answer 28

Follows RR and characterized by steady progression, minor remissions and plateau without treatment 1/2 RR =\> SP in 10 years pt are never dx as SP, they always convert from RR=\>SP

Question 29

Characteristics of Primary Progressive MS

Answer 29

progressive course from onset with or without plateaus and minor remission

Question 30

Characteristics of progressive relapsing MS

Answer 30

progressive course from onset with acute relapses steeper decline and each relapse is worst

Question 31

Positive prognosis of MS

Answer 31

Female (more common, but better b/c of hormone) onset before 35 years monoregional attack (e.g. only in the back) complete recovery after exacerbation low frequency attacks

Question 32

Negative prognosis factors of MS

Answer 32

Male onset after 35 polyregional attack poor recovery after exacerbation high frequency attacks

Question 33

Signs of MS

Answer 33

Paresthesias change in vision weakness gait and balance dysfunction (Rhomberg M/L & circular sway)

Question 34

Symptoms of MS

Answer 34

Fatigue difficulty walking/balance deficits B&B problems pain visual disturbances cognitive changes tremors

Question 35

How to Dx MS

Answer 35

Dx with Brain/C spine MRI with contrast, CSF analysis Pattern of sx r/o other causes of s/s

Question 36

EDSS

Answer 36

Ordinal scale (0-10.0), Half point increments, lower score = higher function Quantifies disability in 8 functional systems 0 = no clinical signs of MS 10= death \<5.5 Ind ambulating \>5.5 need AD

Question 37

Pharmacological MMt

Answer 37

Disease modifying agents (interfereon Beta 1a/1b which is injection every other day or tiw, copaxone (daily)) Amprya - supplemental drug for functional fatigue corticosteroids for acute Sx Vit D (4000 IU/day b/c MS usually low in Vit D)

Question 38

Goals for PT managament of MS

Answer 38

Manage Fall Risk/balance impairments (50% fall rate, 60% of the fall get injured) Establish regular exercise routine Emphasize health and wellness Equipment Procurement return of functional status prior to last exacerbation Connect client to National MS society

Question 39

PT Management (What to DO)

Answer 39

address balance dysfunction consider fatigue (primary and secondary) consider secondary impairments consider thermosensitivity (inc. temp by 1/2 F slow conductivity, cool by 1F improvement) consider progressive nature

Question 40

PT management (Don't)

Answer 40

Overheat over fatigue assume primary disease has caused all the impairments assume each pt will progress similarly

Question 41

PT management

Answer 41

Maintain flexibilty/str, endurance (ms and cv) balance based torso weighting vest brain derived neurotrophic growth factor (amount affected by exercise) help with neuroplasticity Fall Risk Pt education

Question 42

Why do MS fall?

Answer 42

Decreased proprioception in LEs heat sensitivity divided attention fatigue reduced MS endurance AD use fear of falling decline in function (fatigue and divided attention)