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Flashcards in Neurological Dysfunction Deck (172)
1

List of infectious neurological diseases

Meningitis
Encephalitis
Brain abscess
Acquired immunodeficiency syndrome (AIDS)

2

Meningitis

inflammation of the membranes of the SC or brain

Etiology: can be bacterial (more rapid) or viral

Treat infective organism with antibiotic therapy; maintain fluid and electrolyte balance

provide supportive symptomatic therapy: bed positioning, PROM, skin care; safety measures if confused

3

Encephalitis

severe infection and inflammation of the brain

Etiology: arboviruses, or a sequela in infleunza, chronic and recurrent sinusitis, otitis, or other infections; bacterial encephalitis, prion-caused disease ("mad cow")

Treat infective organism

Provide supportive symptomatic therapy

4

Brain abscess

infectious process in which there is a collection of pyogenic material in the brain parenchyma

S&S: headaches, fever, brainstem compression, focal signs CN II & VI

can be extension of an infection (meningitis, otitis media, sinusitis, post TBI); typically frontal or temporal lobes or cerebellum

treat infective organism, surgical intervention

provide supportive symptomatic therapy

5

Acquired immunodeficiency syndrome (AIDS)

viral syndrome characterized by acquired and severe depression of cell-mediated immunity

Symptoms: wide ranging, 1/3 of patients exhibit CNS or PNS deficits
-AIDS dementia complex (ADC): symptoms range from confusion and memory loss to disorientation
-motor deficits: ataxia, weakness, tremor, loss of fine motor coordination
-peripheral neuropathy

treat with anti HIV drugs

Provide palliative and supportive care

6

Cerebrovascular Accident

CVA/Stroke

=sudden, focal neurological deficit resulting from ischemic or hemorrhagic lesions in the brain

*most common sites for lesions to occur are at the origin of the common carotid artery, at the main bifurcation of the MCA, and at the junction of the vertebral arteries with the basilar artery

7

Etiological categories for CVA

1- cerebral thrombosis: formation or development of a blood clot or thrombus within the cerebral arteries or their branches

2-cerebral embolism: traveling bits of matter (thrombi, tissue, fat, air, bacteria) that produce occlusion and infarction in the cerebral arteries

3- Cerebral hemorrhage: abnormal bleeding as a result of rupture of a blood vessel (extradural, subdural, subarachnoid, intracerebral)

8

risk factors for CVA

artherosclerosis

hypertension

cardiac disease: rheumatic valvular disease, endocarditis, arrhythmias, cardiac surgery

diabetes, metabolic syndrome

transient ischemic attacks: brief warning episodes of dysfunction (

9

Pathophysiology of CVA

cerebral anoxia: lack of oxygen supply to the brain (irreversible anoxic damage to the brain begins after 4-6 min)

cerebral infarction: irreversible cellular damage

cerebral edema: accumulation of fluids within brain; causes further dysfunction; elevates intracranial pressures, can result in herniation and death

10

CVA: Internal carotid syndrome (ICA)

ICA arises off the common carotid artery, gives off an ophthalmic branch and terminates in the anterior cerebral artery and middle cerebral artery

occlusions commonly produce S&S of MCA involvement with reduced levels of consciousness

lessions involving MCA and ACA distributions may produce massive edema, brain herniation and death

11

CVA: Anterior carotid artery syndrome

rarely involved

ACA supplies anterior 2/3 of the medial cerebral cortex

occlusions proximal to anterior communicating artery produce minimal deficits due to the circle of Willis

**Symptoms:
-affects LE > UE
-contralateral hemiplegia and sensory loss
-can result in mental confusion, aphasia, and contralateral neglect if involvement is extensive on the dominant side

12

CVA: Middle cerebral artery syndrome

most commonly involved

MCA supplies lateral cerebral cortex, BG and large portions of the internal capsule

**Symptoms:
-contralateral hemiplegia UE>LE involvement
-loss of sensation primarily in the arm and face
-homonymous hemianopsia is common
-Left infarction may produce aphasia and apraxia
-occlusion of the main stem of the MCA can cause global aphasia

13

CVA: Posterior cerebral artery syndrome

persistent pain syndrome or contralateral pain and temperature sensory loss can occur

homonymous hemianopsia, aphasia and thalamic pain syndrome also can result from occlusion of this artery

14

CVA: vertebralbasilar artery syndrome

2 vertebral arteries arise off the subclavian arteries and supply the ventral surface of the medulla and the posterior inferior aspect of the cerebellum before joining to form the basilar artery at the junction of the pons and medulla
-the basilar artery supplies the ventral portion of the pons and terminates in the PCA

often results in death from the edema associated with the infarct

if patient survives and the lesion affected the pons: the result could be quadriparxsis and bulbar palsy or a "locked in" state whereby the patient can communicate only by eye blinking

Other vertebral artery symptoms can include vertigo, coma, diplopia, nausea, dysphagia, and ataxia

15

CVA: Anterior inferior cerebellar

results in unilateral deafness, loss of pain and temperature on the contralateral side, paresis of lateral gaze, unilateral Horner's syndrome (ptosis, constructed pupil, and loss of sweating), ataxia, vertigo, nystagmus

16

CVA: superior cerebellar

results in severe ataxia, dysarthria, dysmetria, and contralateral loss of pain and temperature

17

CVA: posterior inferior cerebellar

results in Wallenberg's syndrome
"lateral medullary syndrome"

characterized by vertigo, nausea, hoarseness, dysphagia, ptosis, and decreased impairment of sensation in the ipsilateral face and contralateral torso and limbs
maybe Horner's syndrome too

18

Horner's syndrome

ptosis- drooped upper eyelid
pupillary constriction
absence of sweating

19

Sequential recovery stages of CVA

1: initial flaccidity, no voluntary movement

2: emergence of spasticity, hyperreflexia, synergies (mass patterns of movement)

3: voluntary movement possible, but only in synergies; spasticity strong

4: voluntary control in isolated joint movements emerging, corresponding decline of spasticity and synergies

5: increasing voluntary control out of synergy; coordination deficits present

6: control and coordination almost normal

20

Examining CVA

general signs of increased intracranial pressure

level of consciousness, cognitive function

Speech and communication
-aphasia (typically L CVA)
-perceptual deficits (typically R CVA)

Behaviors

Sensory deficits
-superficial, deep, cortical/combined
-hearing, vision
-CN function

Motor function
-tone and reflexes
-spasticity
-abnormal synergies
-paresis, incoordination, apraxia
-posture and balance
-gait

Outcome measures:
-fugl-meyer
-NIG stroke scale
-postural assessment scale for stroke
-stroke impact scale
-FIM
-functional assessment measure (FAM)

21

R vs. L CVA behaviors

L CVA: slow, cautious, hesitant, insecure

R CVA: impulsive, quick, poor judgement/safety, overestimate abilities

22

Typical gait deficits for CVA

Hip
-poor hip position (retracted, flexed
-Trendelenburg limp (weak abductors)
-scissoring (spastic adductors)
-insufficient pelvic rotation during swing

Weak hip flexors during swing may yield circumducted gait, ER with adduction, backward leaning of trunk or exaggerated flexion synergy

Knee:
-weak knee extensors (knee buckles in stance) - results in compensatory locking of knee in hyperextension
-spastic quads may also yield a hyperextended knee

Ankle:
-foot drop
-equinus gait - PF
-varus foot - weight is borne on lateral side of foot
-equinovarus position

unequal step lengths

decreased cadence, uneven timing

23

Synergies with stroke

primitive and stereotyped movement patterns associated with spasticity
-may be elicited reflexively, as associated reactions or as voluntary movement patterns
-flexion and extension synergies of each extremity

UE flexion synergy:
-scapular elevation and retraction
-shoulder abduction and ER
-elbow flexion (generally strongest component)
-forearm supination and wrist/finger flexion

LE flexion synergy :
-hip flexion (generally strongest component)
-hip abduction, ER
-knee flexion
-ankle DF and inversion
-toe DF

Extensor synergies are exactly the opposite except that wrist/finger flexion and ankle inversion are common to both

24

Hypotonicity:
tx?

floppy, low tone, flaccid
risk of dislocation of AA joint (SCI potential), hip, knee, elbow, shoulder, etc

hypoactive reflexes and shallow breathing patterns

Treatment:
-avoid joint hyperextension
-work for joint compression and facilitation to help normalize tone
-use resistance of functioning muscles and isometric holding to increase activation of inactive muscles
-facilitation techniques:
---quick stretch
---tapping of muscle belly/tendon
---high frequency vibration
---light touch, quick icing
---fast spinning or rolling
---Joint approximation facilitates co-contraction

25

Hypertonicity:
tx?

spastic, high tone with hyperactive reflexes and decreased thoracic mobility
-risk of contractures and deformity
-changes in body position can affect one

Treatment:
-work to inhibit reflex activity via postures, positions or techniques of relaxation training
-inhibition techniques
---prolonged static muscle stretch
---inhibiting postures
---limb movements emphasizing rotation
---slow stroking
---neutral warmth
---prolonged icing
---deep pressure to tendons
---Reciprocal inhibition: using facilitation techniques to the non spastic muscles will cause inhibition of the spastic muscles

26

Perceptual problems associated with stroke (R vs. L)

*depends on the side of the brain that is damaged

R CVA
-problems with spatial relationships and hand eye coordination
-irritability, short attention span
-can't retain info, difficulty learning individual steps
-poor judgement affecting personal safety
-diminished body image with L sided neglect
-quick and impulsive

L CVA:
-apraxia
-difficulty starting and sequencing tasks
-perseveration
-easily frustrated with high levels of anxiety
-inability to communicate verbally
-cautious and slow

27

communication issues with stroke
receptive vs. expressive

1- receptive, Wenicke's or fluent aphasia:
-speech may flow smoothly but auditory comprehension is impaired.
-following commands may be difficult
-use word repetition and manual cues during rehab

2- Expressive, Broca's or nonfluent aphasia:
-syntax is impaired, speech may be slow, vocal is small.
-comprehension is good
-phrase questions in simple "yes" or "no" responses

3- Global aphasia:
-characterized by significant limitations in comprehension
-use of symbolic gestures may help

28

guidelines to promote learning with hemispheric differences (R vs. L CVA)

L CVA:
-develop an appropriate communication base: words, gestures, pantomime; assess level of understanding
-give frequent feedback and support
-don't underestimate learning ability

R CVA:
-use VC; demos or gestures may confuse patients with visuospatial deficits
-give frequent feedback; focus on slowing and controlling movement
-focus on safety
-avoid environmental clutter
-don't overestimate ability to learn

29

TBI

Etiology: MOI is contact forces to to skull and rotational acceleration forces, causing varying degrees of injury to the brain

various S&S associated with localized lesions of the cortex

Primary brain damage
Secondary brain damage
Concussion

30

primary brain injury:

diffuse axonal injury:
-disruption and tearing of axons and small blood vessels from shear-strain of angular acceleration; results in neuronal death and petechial hemorrhages

focal injury:
-contusions, lacerations, mass effect from hemorrhage and edema (hematoma)

coup-contracoup injury:
-injury at point of impact and opposite point of impact

closed or open injury (with fracture of skull)

31

secondary brain damage

hypoxic-ischemic injury:
-results from systemic problems (respiratory or cardiovascular) that compromise cerebral circulation

swelling/edema:
-can result in mass effect, with increased intracranial pressures, brain herniation (uncal, central or tonsillar) and death

electrolyte imbalance and mass release of damaging neurotransmitters

32

Concussion

loss of consciousness, either temporary or permanent, resulting from injury or blow to head, with impaired functioning of the brainstem reticular activating system
-may see changes in HR, RR, BP

33

Levels of brain injury:

Mild TBI:
-Loss of consciousness: 0-30 minutes
-alteration of consciousness: brief; >24 hours
-post-traumatic amnesia: 30 minutes, 24 hours
-post-traumatic amnesia: >1, 24 hours
-alteration of consciousness: >24 hours
-post-traumatic amnesia: >7 days
-Glascow coma scale:

34

Ranchos Los Amigos levels of cognitive functioning

delineates 8 general cognitive and behavioral levels
-descriptive scale of response to stimuli that is useful for communicating or documenting cognitive and/or behavioral status

I- no response to any stimuli

II- generalized response; reacts inconsistently and nonspecifically to stimuli

III- localized response; pt. reacts inconsistently but specifically to stimuli

IV- confused/agitated; heightened state of activity; behavior is bizarre and non purposeful relative to immediate environment; recall and attention span are poor

V- confused/inappropriate: pt. able to respond to simple commands but not to complex tasks; memory is impaired; verbalization is inappropriate

VI- confused-appropriate: pt. is dependent upon external input but can perform consistently; memory improved.

VII- automatic-appropriate: can perform automatically and appropriately in structured environments; judgement remains impaired

VIII- purposeful-appropriate: patient acts appropriately though not perfectly. may have some-problems in stressful or unusual circumstances

35

Glascow coma scale

an objective way to describe a patient's level of consciousness

Each category is quantified:
-eye opening: spontaneous to none
-best motor response: follows commands to abnormal responses to no response
-verbal response: oriented to inappropriate to no response

mild TBI=13-15
moderate TBI=9-12
severe TBI=

36

arousal=

=the overall level of alertness or reaction to stimuli

low arousal associated with coma

high arousal may occur during agitated state following brain injury
-may require quiet environment and consistency in management (daily routine)

37

Recovery stages from diffuse axonal injury:

1: coma:
-state of unconsciousness in which there is neither arousal nor awareness; eyes remain closed, no sleep/wake cycle s

2- unresponsive vigilance/vegetative state:
-marked by the return of sleep/wake cycles and normalization of vegetative functions (respiration, digestion, BP control);
-persistent vegetative state= >1 year

3- mute responsiveness/minimally responsive:
-pt. is not vegetative and does show signs, even if intermittent, of fluctuating awareness

4- confusional state:
-mainly a disturbance of attention mechanisms; all cognitive operations are affected, patient is able to form new memories; may demo either hypoarousal or hyperarousal

5- emerging independence:
-confusion is clearing and some memory is possible
-significant cognitive problems and limited insight remain
-frequently inhibited social behaviors

6- Intellectual/social competence
-increasing independence, although cognitive difficulties (problem solving, reasoning) persist along with behavioral and social problems (mood swings)

*patient can plateau at any stage or regress under conditions of stress or repetitive brain injury

38

examining TBI

general signs of increased intracranial pressure

level of consciousness, cognitive function, learning disorders, memory and complex info processing

CN function

behavior changes

speech and communication

sensory deficits

motor function (cerebellar damage is common)

functional mobility

level of general de-conditioning following prolonged hospitalization

39

management for TBI based on decreased response levels (LOCF I-III)

maintain ROM, prevent contracture, positioning

maintain skin integrity

maintain respiratory status, prevent complications: postural drainage, percussion, vibration, suctioning to keep airway clear

provide sensory stimulation for arousal and to elicit movement: environmental and direct stimulation (auditory, visual, olfactory, gustatory, tactile stimuli)

promote early return of FMS: upright positioning for improved arousal, proper body alignment

40

management for TBI based on mid-level recovery (LOCF IV-VI)

provide structure, prevent overstimulation for confused, agitated patient: closed, reduced stimulus environment, daily schedules and memory logs, relaxation techniques

provide consistency: clear feedback, written contacts

engage patient in task-specific training; limit activities to familiar, well-liked ones; offer options; break down complex tasks into parts

provide verbal or physical assistance

control rate of instruction

emphasize safety, behavioral management techniques

model calm, focused behavior

41

management for TBI based on high level recovery (LOCF VII-VIII)

allow for increasing independence; wean patient from structure, involve patient in decision making

assist paitent in behavioral, cognitive, emotional reintegration: provide honest feedback, prepare for community reentry

promote independence in functional tasks: FMS, ADLs

improve postural control, symmetry and balance

encourage active lifestyle, improved cardiovascular endurance

42

common behavioral difficulties with TBI

depression
dependent
denial
aggressive
sexually inappropriate
agitated
poor judgement

43

Spinal cord injury (SCI)

etiology: partial or complete disruption of SC resulting in paralysis, sensory loss, altered autonomic and reflex activities

Paraplegia= only LEs are involved
Tetraplegia/Quadriplegia= all 4 extremities are involved

Designation of spinal level:
-defined as the most caudal level of the SC that exhibits intact sensory and motor functioning
-muscles must have a grade of at least 3+/5 strength to demo intact innervation
-sensory areas are well demarcated and are innervated by a single SC segment
-complete lesions: total and permanent functional (sensory and motor) disruption of the SC >3 segments below the lesion

MOI:
-flexion- most common lumbar injury
-flexion-rotation- most common cervical injury
-compression
-hyperextension
-nontraumatic causes: disc prolapse, vascular insult, infections

44

Classification of SCI

1- level of injury: UMN injury
-lesion level indicates most distal uninvolved nerve root segment with normal function; muscles must have a grade of at least 3+/5 function
-tetraplegia/quadriplegia: injury occurs b/w C1 and C8, involves all 4 extremities and trunk
-Paraplegia: injury occurs b/w T1 and L1, involves both LEs and trunk (varying levels)

2- degree of injury
-complete: no motor or sensory function below level of lesion
-incomplete: preservation of sensory or motor function below level of injury; spotty sensation, some muscle function
-ASIA score

3- clinical syndromes
-central cord
-brown-sequard
-anterior cord
-posterior cord
-cauda equina
-sacral sparing

45

American spinal injury association (ASIA) impairment scale for SCI

A= complete, no motor or sensory function is preserved in the sacral segments S4-5

B= Incomplete: sensory but not motor function is preserved below the neurological level and includes the sacral segments S4-5

C= Incomplete: motor function is preserved below the neurological level, and most key muscles below the neurological level have a muscle grade of

46

Clinical syndromes of incomplete SCI

Brown sequard syndrome -UMN
anterior cord -UMN
central cord -UMN
posterior cord -UMN
cauda equina -LMN
sacral sparing -

47

SCI: Central cord syndrome:

most commonly occurs with hyperextension injuries with minor trauma to the cervical region

results in damage to the central aspect of the SC affecting the UE sensation and motor functioning with normal LE functioning

-loss of spinothalamic tracts with bilateral loss of P&T
-loss of ventral horn with bilateral loss of motor function: primarily UE
-preservation of proprioception and discriminatory sensation

48

SCI: Anterior cord syndrome

results from trailer to the anterior cord or damage of the anterior spinal artery usually related to flexion injuries of the cervical region

characterized by loss of motor function and loss of pain and temperature below the level of lesion

-loss of lateral corticospinal tracts with bilateral loss of motor function, spastic paralysis below level of lesion
-loss of spinothalamic tracts with bilateral loss of P&T
-preservation of dorsal columns: proprioception, kinesthesia and vibration

49

SCI: Posterior cord syndrome

very rare with deficits of kinesthesia and proprioception

an ataxic gait with a wide base of support may result

-loss of dorsal columns bilaterally- loss of proprioception, vibration, and pressure sensations
-preservation of motor function, pain and light touch

50

SCI: Brown-Sequard syndrome

hemisection of the SC, usually from stab or gunshot

asymmetrical ipsilateral symptoms:
-weakness or motor paralysis, loss of proprioception, vibratory sense, and 2 point discrimination, decreased reflexes, clonus and spasticity

-ipsilateral loss of dorsal columns with loss of tactic discrimination, pressure, vibration and proprioception
-ipsilateral loss of corticospinal tracts with loss of motor function and spastic paralysis below level of lesion
-contralateral loss of spinothalamic tract with loss of P&T below level of lesion; at lesion level bilateral loss of P&T

51

SCI: cauda equina

injury below the L1 segment results in damage to lumbar and sacral roots of peripheral nerves (LMN)

sensory loss, paralysis and loss of bladder/bowel control can occur

because damage is to the peripheral nerve roots, regeneration may be possible

52

SCI: sacral sparing

sparing of tracts to centrally located sacral segments

perianal sensation, rectal spincter contraction, cutaneous innervation in the saddle area and active contraction of the scarily innervated toe flexors are intact

53

changes associated with recovery of SCI

spinal shock
-transient period of reflex depression and flaccidity
-may last several hours or up to 24 weeks

spasticity/spasms

autonomic dysreflexia (hyperreflexia)

heterotypic bone formation

DVT

54

autonomic dysreflexia

(hyperreflexia)

an emergency situation in which a noxious stimulus precipitates a pathological autonomic reflex with symptoms of:
-paroxysmal hypertension
-bradycardia
-headache
-diaphoresis (sweating)
- flushing
-diplopia
-convulsions

occurs in lesions above T6; more prevalent in first 3 years after SCI

examine for irritating stimuli
treat as medical emergency- elevate head, check and empty catheter first

most common cause: bladder distension
other stimuli: rectal dissension, pressure sores, urinary stones, bladder infections, noxious cutaneous stimuli, kidney malfunction and environmental temperature changes

bladder drainage system should be checked immediately and opened if necessary

if lying flat, bring patient to sitting position to lower BP

55

PT goals for SCI

monitor changes associated with recovery
-spinal shock
-spasticity/spasms
-autonomic dysreflexia
-heterotopic bone formation
-DVT

improve respiratory capacity

maintain ROM, prevent contractures, positioning

maintain skin integrity

improve strength

reorient pt. to vertical position (*orthostatic hypotension)

promote early return of FMS and ADLs

improve sitting tolerance, postural control, balance

appropriate wheelchair prescription and independence

gait training

cardiovascular endurance

56

Appropriate wheelchair prescriptions for SCI patients:

High cervical lesions (C1-4)
-require electric w/c with tilt in space seating
-microswitch or puff and sip controls
-portable respirator may be attached

Shoulder function, elbow flexion (C5)
-can use manual chair with propulsive aids (projections) for short distances on smooth surfaces
-may use electric w/c for distances and to conserve energy

Radial wrist extensors (C6)
-manual w/c with friction surface hand rims independently

Triceps (C7):
-same as C6 but with increased propulsion

Hand function (C8-T1 and below)
-manual w/c, standard heigh rims

57

Gait training for SCI patients

Midthoracic lesions (T6-9):
-supervised ambulation for short distances
-requires bilateral KAFO and crutches
-swing-to gait pattern
-requires A
-may prefer standing devices/standing w/c

High lumbar lesions (T12-L3)
-can be independent in ambulation on all surfaces and stairs
-uses a swing through or 4 point gait and bilateral KAFOs and crutches
-may also use reciprocating gait orthoses with walker with or without FES system
-typically I household ambulators, w/c for community

Low lumbar lesions (L4-5)
-independent with bilateral AFOs and crutches or canes

58

Primary physical effects of SCI

Paralysis of voluntary motor control with damage to descending motor tracts, anterior horn cells or spinal nerves

Spasticity
-after spinal shock resolves, reflexes return and progressively become stronger, resulting in spasticity
-more prevalent with higher and incomplete lesions

Loss of sensation
-leads to discoordination of movements, impaired body awareness

Respiration dysfunction

Bowel and bladder incontinence

Genital function

Cardiovascular function

Thermoregulation

59

SCI effects on respiration

depending on the level of lesion, the diaphragm (innervated from C3-5) may not be active, affects patient's ability to breathe (primarily inhalation)
-an artificial ventilator or phrenic nerve stimulator may be required to sustain life

disruption to the intercostals and abdominal muscles can impair respiration- primarily forced expiration and inhalation

following a SCI, tidal volume and vital capacity are reduced and secondary respiration muscles are utilized (scalene)

respiratory dysfunction
-most common cause of death in SCI
-inability to cough effectively allows secretions to build in the lungs and decreases forced expiration
-inadequate inhalation and exhalation can reduce ventilation of the lungs-- lead to atelectasis, pneumonia and respiratory insufficiency

60

SCI effects on bowl and bladder continence

voluntary control of urination and defecation is lost after in injury to the sacral cord S2-4

following spinal shock, 2 types of bladder conditions will develop:
1- Reflex bladders (UMN):
-empty in response to a certain level of filling pressure
2-autonomous or nonreflex bladders (LMN):
-flaccid and can be emptied by increasing intraabdominal pressure or by manually compressing the lower abdomen

61

SCI effects on genital function

injury to the thoracolumbar and sacral regions of the SC alter the functioning of the genitals, disrupting sexual responses

female fertility is unchanged but men are likely infertile

62

SCI effects on cardiovascular function

when an injury to the SC blocks communication between the brainstem and the thoracolumbar cord, sympathetic input to the heart is lost and parasympathetic input remains
-results in bradycardia, peripheral vasodilation and hypotension

orthostatic hypotension occurs due to a drop in BP when the patient moves from horizontal to upright

problems are significant in people with lesions above T6 and often resolve within a few weeks

63

SCI effects on thermoregulation

cord injury that interrupts communication with the hypothalamus can cause hypothermia due to peripheral vasodilation

reflexive tone returns in the peripheral vasculature, resolving this problem

later, hyperthermia occurs due to a loss in sympathetic control of the sweat glands

below the level of the lesion sweating doesn't occur
-to compensate, diaphoresis occurs above the lesion

64

possible complications of SCI

decubitus ulcers

respiratory dysfunction
-most common cause of death in SCI
-inability to cough effectively allows secretions to build in the lungs and decreases forced expiration
-inadequate inhalation and exhalation can reduce ventilation of the lungs-- lead to atelectasis, pneumonia and respiratory insufficiency

contractures

osteoporosis
-loss of calcium from bones below lesion-- ^risk of fractures

DVT

GI dysfunction
-stress ulcers
-bowel obstruction
-fecal impaction
-gastric dilation

autonomic dysreflexia
-occurs in lesions above T6

postural or orthostatic hypotension

heterotopic bone formation

65

orthostatic hypotension

a decrease in BP that occurs when a patient is moved from horizontal to vertical position

the lack of muscle tone and loss of sympathetic vasoconstriction causes venous pooling in the periphery

due to immobilization for 6-8 weeks

symptoms: dizziness and fitness or impending blackout

treatment: slow progression to vertical position while VS are monitored and use of compressive stockings and an abdominal binder to minimize hypotension effects

66

heterotopic bone formation

formation of new bone within muscles or other CT below the lesion

unknown etiology

different from myositis ossificans, which results from trauma to the muscle tissue and presents with bony deposits within muscle tissue

occurs in 16-53% of all patients with SCIs, usually appearing from 1-4 months after injury and can restrict joint ROM

Tx: combo of drug therapy and regular exercise during early stages of ectopic bone formation can be effective

67

Functional ability for SCI C1-C3

"tetraplegia"

capable of talking, mastication, sipping, blowing

key muscles: face and neck

dependent self-care

requires a portable ventilator or phrenic nerve stimulator,

requires a power tilt-in-space w/c with mouth control and a seatbelt for trunk control

SCI at C3 can attain w/c independence with power w/c on smooth level surfaces

68

Functional capabilities for SCI at C4

capable of respiration, scapular elevation

key muscles: diaphragm, trapezius

ventilator usually not needed
-glossopharyngeal breathing is used to cough

chin control to adjust w/c

limited feeding and ADLs amy be possible with use of mobile arm supports, environmental controls, adapted eating equipment head or mouth stick

69

Functional capabilities for SCI at C5

capable of:
-elbow flexion and supination
-shoulder ER &abd to 90, and limited shoulder flexion

key muscles:
-biceps
-brachialis
-brachioradialis
-deltoid
-infraspinatus
-rhomboids
-supinator

mobile arm support assist UE ADL performance

mod to min A required for LE dressing and rolling

dependent for transfers with aid of a sliding board

power chair with hand controls (joystick) for community integration and manual w/c with rim projectors 200-300 ft indoors

driving is possible with van lift

may achieve ischial pressure relief with forward lean but usually dependent

needs assistance for manual cough technique

70

Functional capabilities of SCI at C6

capable of:
-shoulder flexion, extension, IR, adduction
-scapular abduction and upward rotation
-forearm pronation
-wrist extension

key muscles:
-ECR
-infraspinatus
-lats
-pec major
-serratus anterior
-teres minor

can become independent in half care with equipment- transfer with sliding board

independent in rolling and supported sitting can be LTG

use of a manual w/c with projections or friction hand rims for household mobility
-may require a power w/c for community
-locks on casters positioned sideways provide increased stability in transfers

uses manual cough technique independently

can live w/o A if well motivated

can drive automobile with hand controls

71

Functional capabilities of SCI at C7

capable of:
-elbow extension
-wrist flexion
-finger extension

key muscles:
-EPL, EPB
-extrinsic finger extensors
-FCR
-triceps

Independent in LE self ROM exercises

can use manual w/c with friction hand rims for community integration with some difficulty on rough terrain

button hook may be required for independent dressing

able to get w/c in and out of car

72

Functional capabilities for SCI at C8

capable of full use of all UE muscles except hand intrinsics

key muscles:
-extrinsic finger flexors
-FCU
-FPL and FPB

independent in living at home except for heavy work

may be able to independently go up/down curbs with manual w/c

may need tub seat, grab bars, et for full independence at home

able to work in a building free of architectural barriers

73

Functional capabilities for SCI T1-5

capable of:
-full use of UEs
-improved trunk control
-increased respiratory reserve

Key muscles:
-top half of intercostals
-long muscles of the back
-intrinsic finger flexors

independent in all areas including car transfers

standing table for physiologic standing

able to negotiate curbs using "wheelie" technique

participates in w/c sports

74

Functional capabilities for SCI T6-8

capable of:
-improved trunk control
-increased respiratory reserve

Key muscles:
-long muscles of the back including sarcrospinalis and semispinalis

independent in swing-to gait in parallel bars with bilateral KAFO for short distances

supervision with walker and KAFOs in home

will use w/c for community locomotion

75

Functional capabilities for SCI T9-12

capable of:
-increased endurance
-improved trunk control

Key muscles:
-lower abdominals
-all intercostals

independent swing-to or swing-through gait on level surfaces with bilateral KAFOs and a walker or forearm crutches

Independent floor to wheelchair and tub transfers

may be independent household ambulators

will usually use a w/c for outdoor locomotion and energy conservation

76

Functional capabilities for SCI T12-L3

capable of:
-hip flexion and adduction
-knee extension

Key muscles:
-gracilis
-iliopsoas
-quadratus lumborum
-rectus femoris
-sartorius

independent swing-to, swing-through or 4 point gain with bilateral KAFOs and forearm crutches on level surfaces and small elevations.
-Independent home ambulators

may use w/c for energy conservation in community

77

Functional capabilities for SCI L4-5

capable of:
-strong hip flexion and knee extension
-weak knee flexion
-improved trunk control

key muscles:
-low back muscles
-medial hamstring (weak)
-posterior tibialis
-quads
-anterior tibialis

independent home ambulators (can be community)

may use w/c for energy conservation

78

adaptive equipment for SCI

head or mouth stick:
-wooden/metal rod 12-18 inches long
-lesions C3-5
-holds utensils or types/turns pages

Mobile arm support:
-typically attached to w/c
-patients with weak proximal UE to improve function
-pts would have shoulder flexion, ER and elbow flexors between 1-3+
-helps with self-care and hand control in power chair

static wrist-hand orthosis:
-positional hand splint for pts w/o wrist extension (C1-5)
-maintains functional hand position- thumb abduction and palm support
-not functional

Wrist-driven orthosis (tenodesis splint)
-dynamic functional orthosis designed to assist with grasp
-transfers muscle force from wrist extension to provide finger flexion with C6-7 lesion

Wheelchair cushions
-regardless of cushion pressure relief should be performed 3-4x/hour

79

SCI effects on pulmonary function

Vital capacity
-depends on level of lesion and muscles innervated

Coughing
-T10 and below have functional cough
-manual cough- technique of abdominal compression to assist with clearing secretions in patients with weak or nonfunctional cough
---pt. can perform themselves if lesion is C6 or below

glossopharyngeal breathing (frog breathing)
-technique used by high level quadriplegics
--aggressive use of tongue, pharyngeal and laryngeal structures as a respiratory pump to help air and increase VC

80

Respiratory muscle innervations

the diaphragm is the primary muscle of inspiration
-innervated from C3-5

Intercostals (T1-12) assist in inspiration

Abdominals (T5-12) are utilized in forced expiration

Secondary muscles: assist in inspiration
-Trapezius (C1-4)
-SCM (C1-3)
-Scalenes (C3-5)
-Levator scapula (C3-5)

81

Multiple sclerosis (MS)

chronic, progressive, demyelinating disease of the CNS

mostly young adults
more prevalent in colder climates

demyelinating lesions (plaques) impair neural transmission, cause nerves to fatigue rapidly

variable symptoms:
-lesions scattered in time and place
-lesions common in pyramidal tract, dorsal columns and periventricular areas of cerebrum, cerebellar peduncles

Variable course with fluctuating periods
-exacerbations- worsening of symptoms
-remissions --> progressing to permanent dysfunction

precipitating or exacerbating factors: infections, trauma, pregnancy, stress

transient worsening of symptoms: adverse reactions to heat, hyperventilation, dehydration, fatigue

82

S&S of MS

sensory disturbances including tingling, numbness and pain

coordination problems and spasticity

fatigue (especially in the afternoon) ** #1 complaint

diplopia

bowel and bladder problems
-UTI

communication disorders

psychosocial problems including euphoria and/or depression

adverse reactions to heat

respiratory infection- common cause of death

83

Categories of MS

Relapse-remitting MS (RRMS):
-relapses with either full recovery or some remaining neurological S&S and residual deficit
-periods b/w relapse characterized by lack of disease progression

Primary-progressive MS (PPMS):
-disease progression from onset, w/out plateaus or remissions or with occasional plateaus and temporary minor improvements

Secondary-progressive MS (SPMS):
-initial relapsing-remitting course, followed by progression at a variable rate that may also include occasional relapses and minor remissions

Progressive-relapsing MS (PRMS):
-progressive disease from onset but w/out clear, acute relapses that may or may not have some recovery or remission
-commonly seen when onset >40 y/o

84

MS treatment

Medical Management:
-immunosuppressant drugs: treat acute flare ups and shorten duration
-interferon drugs: slow disease progression
-symptomatic management of spasticity
-symptomatic management of urinary problems: anticholinergic drugs

PT Tx:
-restorative following exacerbation
-functional maintenance: ROM, strength
-improve function
-prevent secondary problems
-breathing exercises
-PNF to tolerance
-skin integrity
-improve sensory awareness
-improve motor control/coordination
-postural control, symmetry
-gait or w/c training
-energy conservation

*preferably morning treatments

85

Parkinson's disease

chronic, progressive disease of the CNS (basal ganglia) with degeneration of dopaminergic substantia nigra neurons and nigrostriatal pathways
-decrease in dopamine production and/or receptors in the brain

Etiology: infectious/postencephalic, atherosclerosis, idiopathic, toxic, drug induced
-deficiency of dopamine within the BG corpus striatum with degeneration of substantia nigra
-loss of inhibitory dopamine results in excessive excitatory output from cholinergic system (acetylcholine) of basal ganglia



86

S&S of Parkinson's

resting tremor, rigidity and fatigue
-leadpipe or cogwheel rigidity

difficulty initiating or slowness of movement (bradykinesia)

abnormal gait (festinating or slow shuffling)

flexed posture

mask-like face

decreased postural reflexes

behavioral changes:
-memory loss
-apathy that leads to secondary problems: decubitus ulcers, muscle atrophy, contractures, decreased VC and falls

intellectual impairments/dementia in advanced stages

87

stages of Parkinson's

I: minimal or absent disability
-unilateral symptoms

II: minimal bilateral or midline involvement
-no balance involvement

III: impaired balance, some restrictions in activity

IV: all symptoms present and severe
-stands and walks only with assistance

V: confinement to bed or wheelchair

88

Treatment for Parkinson's

Medical management:
-Sinemet (levodopa/carbidopa): provides dopamine and decreases effects of disease
---adverse effects: nausea, orthostatic hypotension, arrhythmias, dyskinesias, psychoses, abnormal behaviors
-dopamine agonist drugs
-anticholinergic drugs: control tremors
-amantadine: enhances dopamine release
selegiline: increases dopamine; used during early disease to slow progression
-deep brain stimulation in thalamus

PT:
-monitor changes in disease progression and pharm interventions
-prevent secondary impairments
-compensator strategies for movement; repetitive stimulation
-improve strength
-PNF diagonals with rhythmic initiation to overcome bradykinesia
-gait training to increase stride width and length
-endurance

*best to treat in AM following dopamine agonist administration

89

Myasthenia gravis:

a neuromuscular junction disorder characterized by progressive muscular weakness and fatiguability on exertion
-muscular strength worse with continuing contraction, improved with rest

Etiology: autoimmunie antibody- mediated attack on acetylcholine receptors at neuromuscular junction

Generalized myasthenia: usually involves bulbar (extraocular, facial, and muscles of mastication) and proximal limb-girdle muscles

course varies: may progress from mild-severe, typically w/in 18 months

myasthenic crisis: respiratory failure, medical emergency

90

Epilepsy

symptoms?

Common causes?

disorder characterized by recurrent seizures (repetitive abnormal electrical discharges w/in the brain)

Symptoms:
-altered consciousness
-altered motor activity (convulsions): characterized by involuntary muscle contractions; tonic activity (stiffening/rigidity of muscles); clonic activity (rhythmic jerking)
-Sensory phenomena: somatosensory, visual, auditory, olfactory, gustatory and vertiginous sensations
-Autonomic phenomena: associated with sudden attack of anxiety, tachycardia, sweating, piloerection, abnormal sensation risking up in upper abdomen and chest
-Cognitive phenomena: sudden failure of comprehension, inability to communicate, illusions, hallucinations

Common causes of seizures:
-acquired brain disease or trauma: tumor, stroke
-degenerative brain diseases: Alzheimer's dementia, amyloidosis
-developmental brain defects
-drug overdose
-drug withdrawal
-electrolyte disorders: hypo/hypernatremia, hypoglycemia, hypomagnesemia
-hyperthermia
-infections; brain abscess, meningitis, neurocysticercosis
-pregnancy complications: eclampsia

91

Classification of seizures

GENERALIZED SEIZURES:

1-Tonic-clonic (grand mal):
-dramatic loss of consciousness, with a cry, fall and tonic-clonic convulsions of all extremities; often with tongue biting and arrested breathing, urinary and fecal incontinence
-after 2-5 min, contractions subside, and consciousness is gradually regained
-patient is confused, drowsy and amnesiac about the event
-full recovery may take several hours; some attacks are preceded by brief aura

2-Absence seizures (petit mal):
-brief, almost imperceptible lapse of consciousness followed by immediate and full return to consciousness;
-posture is maintained, with no convulsive muscle contractions
-may occur as often as a hundred times a day


PARTIAL SEIZURES

1-Simple partial seizures:
2-Focal motor:
3- Focal motor with march (Jacksonian):
4- Temporal lobe seizure
5- Complex partial seizure

Secondarily generalized seizures: simple or complex partial seizures evolving to a generalized seizure

Status epilepticus: prolonged seizure or a series of seizures (lasting >30 min) with very little recovery between attacks
-may be life threatening
-medical emergency

92

Exam and treatment for epilepsy:

Exam/determine:
-time of onset, duration, type of seizure, sequence of events, frequency, duration
-patient activity at onset, presence of aura
-sensory elements, motor activity: type, degree and location of involvement
-presence of tongue biting, incontinence, respiratory distress
-behavioral elements, changes in mood
-patient responses after seizure

Medical management:
-antiepileptic meds: dilantin
-surgical intervention: lobe resection, hemmispherectomy

PT:
-protect patient form injury during seizure: remain with patient, remove potentially harmful nearby objects, loosen restrictive clothing and don't restrain limbs
-establish airway, prevent aspiration: turn head to side or SL position; wait for tonic-clonic activity to subside before initiating artificial ventilation if needed
-promote regular routines for physical activity and emotional health

93

diseases of the cerebellum

hereditaty ataxia, Friedreich's ataxia

neoplastic or metastatic tumors

infection

vascular: stroke

developmental: ataxic CP, Arnold-Chiari syndrome

Trauma: TBI

drugs, heavy metals

chronic alcoholism

94

lesions/impairments of the cerebellum

tend to produce ipsilateral S&S

Lesions of the archicerebellum
-vestibular symptoms

lesions of the paleo cerebellum
-hypotonia

lesions of the neocerebelum
-ataxic limb movements

asthenia: generalized weakness

hypotonia:
-especially in acute cerebellar lesions, difficulty with postural control of proximal muscles

motor learning impairments:
-decreased anticipatory control, feedback and learning delays

Cognition:
-deficits in information procession, attention deficits

emotional dysregulation: changes in emotional behaviors

95

Lesions of the archicerebellum:

Central vestibular symptoms:
-ocular dysmetria
-poor eye pursuit
-dysfunctional vestibular ocular reflex (VOR)
-impaired hand-eye coordination

Gait and trunk ataxia:
-poor postural control and orientation
-wide based gait

Little change in tone or dyssynergia of extremity movements

96

Lesions of the paleocerebellum

hypotonia

truncal ataxia:
-dysequilibrium, static postural tremor
-increased sway
wide BOS and high guard arm position
posture worse with eyes closed, narrow BOS (romberg)
-ataxic gait
-unsteady, increased falls, uneven/decreased step length, increased step width

97

Lesions of neocerebellum:

produces ataxic limb movements

intention tremor: irregular, oscillatory voluntary movements

dysdiadochokinesia: impaired rapid alternating movments

dysmetria:
-hypermetria: overshooting
-errors or force, direction, amplitude
-rebound phenomenon

Dyssynergia:
-abnormal timing (errors of velocity, onset and stop)
-movement decomposition of agonist/antagonist interactions
-impairments of multijoint coordination, movement sequences and complex motor tasks

errors in timing related to perceptual tasks

98

PT treatment for cerebellar disorders

Goals:
-improve accuracy of limb movements
-improve postural stability and dynamic postural control
-improve functional movement and safety
-stabilize VOR/vision

Eye-head coordination exercise: slow head movements with visual fixation; active eye and head movements

Stability exercises: use of WB postures, carefully graded resistance and approximation to promote steady holding. Use of theraband, weights, weighted waist belts and walkers to decrease ataxic movements

dynamic stability exercises: promote small range control, smooth reversals of movements, movement transitions, using carefully graded resistance

balance training

locomotor training

therapeutic pool: water provides graded resistance, decreases ataxic movement and postural instability

coordination exercises: proprioceptive neuromuscular facilitation (PNF) patterns, ball gymnastics to promote balance

stationary bike: assists timing of reciprocal movements

motor learning strategies: closed environment ideal; focus on practice and repetition; distributed practice

biofeedback

energy conservation

99

characteristics of vestibular disorders:

Dizziness: sensation of lightheadedness, giddiness, faintness

Vertigo: sensation of moving around in space or having objects move around; tends to come in attacks
-if severe: accompanied by nausea

Visual changes
-Nystagmus: involuntary, cyclical movement of the eyeball
-Blurred vision: gaze instability secondary to VOR dysfunction

Disequilibrium or postural instability: vestibular spinal reflex dysfunction; ataxia, gait disturbances; increased risk of falls

Anxiety, fear, depression

Indirect impairments: physical deconditioning, decreased cervical ROM

100

Unilateral vestibular disorders:

Trauma:
-vestibular symptoms seen in 30-65% of patients with TBI

Vestibular neuronitis, labyrinthitis
-acute infection with prolonged attack of symptoms, persisting for several days or weeks
-caused by viral or bacterial infection

Meniere's disease

Benign paroxysmal positional vertigo

tumor
-acoustic neuroma
-gliomas/brainstem or cerebellar medulloblastoma

101

Meniere's disease

recurrent and usually progressive vestibular disease

episodic attacks may last minutes to hours with severe symptoms:
-tinnitus
-deafness
-sensation of pressure/fullness within ear

etiology unknown
-edema of membranous labyrinth is a consistent finding

102

Benign paroxysmal positional vertigo

BPPV

brief attacks of vertigo and nystagmus that occur with certain head positions
-lying down, turning over in bed, tilting head back

may be related to degenerative processes, mechanical impairment of peripheral vestibular system

Tx techniques:
-canalith repositioning treatment: for horizontal SCC BPPV, posterior SCC BPPV
-liberatory maneuver: for posterior
-brandt-daroff exercises: for residual or mild vertigo

103

Hallpike Dix test

patient sits on table; clinician turns patient's head horizontally 45 deg and quickly moves patient down to supine position with neck extended 30 deg below horizontal

check for symptoms - vertigo and nystagmus

return patient to sitting and test other side

+ for BPPV on side that produces symptoms

104

habituation training:

repetition of movements and positions that provoke dizziness and vertigo

105

gaze stability exercises

eye movements:
-side to side eyes on stationary target (X1 paradigm)
-side to side eyes on moving target (X2 paradigm)

head movements up and down, side to side while maintaining eyes focused on a visual target
-progressing slow to fast movements
-standing to walking

106

Peripheral nerve disease/injury

Pathological processes:
1-wallerian degeneration
2-segemental demyelination
3-axonal degeneration

Traumatic nerve injury classes:
Class I-neurapraxia
Class II-axonotmesis
Class III-neurotmesis

107

Wallerian degeneration:

transection (neurotmmesis) results in degeneration of the axon and myelin sheath distal to the site of axonal interruption
-chromatolysis and repair processes occurs in nerve cell body
-endoneuriusm (sheath) does not degenerate but forms a tube directing regeneration

108

Segmental demyelination:

axons are preserved (no wallerian degeneration)
-remyelination restores function

ex: Guillain-barre syndrome

109

Axonal degeneration

degeneration of axon cylinder and myelin, progressing from distal to proximal
"dying back" of nerves

ex: peripheral neuropathy

110

neurapraxia=

Class 1 traumatic nerve injury

injury to nerve that causes a brief loss of function (conduction block ischemia)

nerve dysfunction may be rapidly reversed or persist a few weeks (ex: compression)

111

axonotmesis=

Class 2 traumatic nerve injury

injury to nerve interrupting the axon and causing loss of function and wallerian degeneration distal to the lesion

with no disruption of the endoneurim regeneration is possible

ex: crush injury

112

neurotmesis=

Class 3 traumatic nerve injury

cutting of the nerve with severance of all structures and complete loss of function

re-innervation typically fails without surgical intervention because of aberrant regeneration (failure of regenerating axon to find its terminal end)

113

clinical symptoms of LMN syndrome

weakness/paresis of denervated muscle, hyporeflexia and hypotonia, (rapid atrophy, fatigue

sensory loss: corresponds to motor weakness; proprioceptive losses may yield sensory ataxia

autonomic dysfunction: vasodilation and loss of vasomotor tone (dryness, warm skin, edema, orthostatic hypotension)

hyper excitability of remaining nerve fibers
-sensory dysesthesias: hyperalgesia, pins and needles, numbness, tingling, burning
-motor: fasciculations, spasms

muscle pain (myalgia) with inflammatory myopathies
-ex: post polio syndrome

114

neuropathy

any disease of nerves characterized by deteriorating neural function

polyneuropathy: bilateral symmetrical involvement of peripheral nerves, usually legs>arms, distal segments earlier and more involved than proximal

mononeuropathy: involvement of a single nerve

radiculopathy: involvement of nerve roots

115

trigeminal neuralgia (tic douloureux)

neuralgia of the trigeminal nerve (CN V)

Etiology: results from degeneration or compression
-mean age ~50
-abrupt onset

Characteristics:
-brief paroxysms of neurogenic pain (stabbing and/or shooting pain) recurring frequently
-occurs along unilateral distribution of the trigeminal nerve, mandibular and maxillary divisions (ophthalmic division is rare)
-autonomic instability: exacerbated by stress cold; relieved by relaxation

TENS can be effective for pain relief

116

Bell's palsy

LMN lesion involving facial nerve (CN VII)
resulting in unilateral facial paralysis

Etiology: acute inflammatory process of unknown etiology-- results in compression of the nerve w/in the temporal bone

Characteristics:
-weakened or paralyzed muscles of facial expression (wrinkling the forehead, closing the eye tightly, smiling)
-decrease taste sensation anterior 2/3 of tongue
-loss of control of salivation or lacrimation
-acute onset with max severity in a few hours or days
-commonly preceded by a day or 2 of pain behind the ear
-most fully recover in several weeks or months
-normal sensation

TX:
-protect corneas- artificial tears/patch
-E-stim to maintain tone, support facial muscles
-active facial muscle exercises
-functional retraining- foots, chewing

117

Bulbar palsy (bulbar paralysis)

refers to weakness or paralysis of the muscles innervated by the motor nuclei of the lower brainstem, affecting the muscles of the face, tongue, larynx and pharynx

Etiology: result of tumors, vascular or degenerative diseases of lower CN motor nuclei (ex: ALS)

Examine:
-glossopharyngeal and vagal paralysis: phonation, articulation, palatal action, gag reflex, swallowing
-changes in voice quality: dysphonia (hoarseness or nasal quality)
-bilateral involvement: severe airway restriction with dyspnea, difficulty with coughing
-possible complications: aspiration pneumonia


TX:
-suctioning, oral care
-maintenance of respiratory function, open airway
-elevated HOB
-dietary changes: soft foods, liquids

118

Guillian-Barre syndrome

a polyneuropathy resulting in symmetric motor paralysis and progressive muscular weakness that develops quickly
-probable immune-mediated viral origin
-usually occurs after recovery from an infectious illness (respiratory or GI)

Characteristics:
-involves acute demyelination of both cranial and peripheral nerves (LMN disease)
-sensory loss, paresthesias, pain (sensory loss typically less than motor loss) "stocking/glove" pattern
-motor paresis or paralysis: relative symmetrical distribution of weakness; progresses from LE to UE (ascending pattern) and from distal to proximal; may produce full tetraplegia with respiratory failure
-dysarthria, dysphagia, diplopia, and facial weakness may develop in severe cases
-progression evolves over a few days or weeks
-recovers slow (6 months -2 years) and usually complete (85%); some mild weakness persists; 3% mortality

Complications:
-respiratory impairment and failure
-autonomic instability: tachycardia, arrhythmias, BP fluctuations
-pain: myalgia
-risk of pneumonia
-prolonged hospitalizations and immobility
-relapse: if treatment inadequate

PT:
-ascending (disease progressing) phase: respiratory function, PROM, positioning, skin care
-when stabilized: prevent injury to denervated muscles, avoid overuse and fatigue, begin gentle stretching, and initiate moment in a controlled environment
-descending (recovery) phase: muscle re-ed with a mod exercise program, improve cardiovascular fitness and energy conservation

119

Amyotrophic lateral sclerosis (ALS)

degenerative disease affecting both UMN and LMN (degeneration of anterior horn cells and descending corticobulbar and corticospinal tracts)
-CN can be affected as well

Etiology: unknown; 5-10% genetic (autosomal dominant)

Characteristics:
-muscle weakness is progressive and can affect muscles of respiration
-weakness may appear in hands first progressing to whole body
-dysarthria, dysphagia, dysphonia
-muscle atrophy, cramping and fasciculations (LMN signs)
-spasticity and hyperreflexia (UMN signs)
-often no sensory changes
-typical sparing of bowel and bladder function
-normal cognition
-death typically in 2-5 years

120

stages of ALS

I: early disease
-mild focal weakness
-asymmetric distribution
-symptoms of hand cramping and fasciculations

II:
-moderate weakness in groups of muscles
-some atrophy of muscles
-modI with AD

III:
-severe weakness of specific muscles
-increasing fatigue
-mild-mod functional limitations
-ambulatory

IV:
-severe weakness and wasting of LEs
-mild weakness of UEs
-mod A and AD required
-w/c user

V:
-progressive weakness with deterioration of mobility and endurance
-increased fatigue
-mod-severe weakness of whole limbs and trunk
-spasticity, hyperreflexia
-loss of head control
-maxA

VI: bedridden
-dependent ADLs, FMS
-progressive respiratory distress

121

Post-polio syndrome

new, slowly progressive muscle weakness occurring in people with confirmed history of acute poliomyelitis
-follows a stable period of functioning
-new form of muscular dystrophy
-new denervation occurs with asymmetrical muscle weakness

S&S:
-myalgia
-joint pain
-variable asymmetrical muscle atrophy with decreased strength
-excessive fatigue and decreased endurance contribute to loss of function
-difficulty in concentration, memory, attention
-sleep disturbances

Tx:
-low intensity exercise never to the point of fatigue - stop exercise with pain or weakness
-use orthotic devices as needed to improve function
-endurance and energy conservation

122

nociceptive pain=

response to an immediate noxious stimulus signaling impending tissue damage

inflammatory pain occurs after tissue damage and increases sensitivity to pain

123

neurogenic pain

pain as a result of lesions in some part of the NS (central or peripheral)

usually accompanied by some degree of sensory deficit

1-central neurogenic pain: arises from injury or disease affecting CNS
-pain is often burning, acing or prickling
-hyperanalgeisa and allodynia (pain from normal stimulus)

2- peripheral neurogenic pain: arises from mechanical or chemical damage to peripheral nerves; may include symptoms of paresthesia, dysesthesia and pain

124

Central neurogenic pain

arises from injury or disease affecting CNS
-pain is often burning, acing or prickling
-hyperanalgeisa and allodynia (pain from normal stimulus)

1- central post-stroke (thalamic) pain:
-continuous, intense, central pain occurring on the contralateral hemiplegic side
-result of a store involving the ventral posterolateral thalamus
-autonomic and vasomotor dysfunction is common

2- TBI

3- fibromyalgia

125

Peripheral neurogenic pain:

arises from mechanical or chemical damage to peripheral nerves; may include symptoms of paresthesia, dysesthesia and pain

1- Complex regional pain syndrome I
-AKA reflex sympathetic dystrophy/causalgia
-a complex disorder or group of disorders that develop as a result of trauma affecting body parts and disuse
-CRPS I= tissue injury without nerve damage; CRPS II involves nerve injury
-"regional"= t/o limb, not in a peripheral nerve or distribution
reflex neurogenic inflammation affecting the SNS and pain disproportionate to injury
-pain maintained by the SNS, characterized by burning pain (causalgia)
-usually associated with traumatic injury

2- disorders of peripheral roots and nerves
-neuralgia: pain occurring along the branches of a nerve
-radiculalgia: neuralgia of nerve roots
-paresthesias
-allodynia

3- Herpes zoster (shingles)
-acute, painful mononeuropathy caused by varicella zoster virus
-characterized by vesicular eruption and marked inflammation of the posterior root ganglion of the affected spinal nerve or sensory ganglion of the CN
-ventral root involvement (motor weakness) in 5-10% of cases
-infection can last from 10 days to 5 weeks
-posthepetic neuralgia pain may persist for months or years

4- phantom limb pain
-folowing amputation

126

Complex regional pain syndrome I

-AKA reflex sympathetic dystrophy/causalgia
-a complex disorder or group of disorders that develop as a result of trauma affecting body parts and disuse
-CRPS I= tissue injury without nerve damage; CRPS II involves nerve injury
-"regional"= t/o limb, not in a peripheral nerve or distribution
reflex neurogenic inflammation affecting the SNS and pain disproportionate to injury
-pain maintained by the SNS, characterized by burning pain (causalgia)
-usually associated with traumatic injury

127

Herpes zoster

painful inflammation of the posterior root ganglion, caused by a virus resulting in the formation of vesicles (fluid filled sacs) along the course of a nerve (dermatome)

-acute, painful mononeuropathy caused by varicella zoster virus
-characterized by vesicular eruption and marked inflammation of the posterior root ganglion of the affected spinal nerve or sensory ganglion of the CN
-ventral root involvement (motor weakness) in 5-10% of cases
-infection can last from 10 days to 5 weeks
-posthepetic neuralgia pain may persist for months or years

128

musculoskeletal pain

1- fibromyalgia:

2- myofascial pain syndrome

3- postural stress syndrome
-postural malalignment produces chronic muscle lengthening and/or shortening and stress to soft tissues

4-movement adaptation syndrome
-habituated movement dysfunction leading to muscle strain and pain

129

fibromyalgia:

widespread pain accompanied by tenderness of muscles and adjacent soft tissues

a nonarticular rheumatic disease of unknown origin

130

myofascial pain syndrome

persistent, deep aching pains in muscle

nonarticular in origin

characterized by well defined, highly sensitive tender spots (trigger points)

131

psychosomatic pain

origin of pain experience is due to mental or emotional disorders

132

referred pain

pain arising from deep visceral tissues that is felt in a body region remote from site of pathology, resulting in tenderness and cutaneous hyperalgesia

ex:
-medial L arm and jaw pain with MI
-R subscapular pain from gallbladder attack
-thoracic or flank pain from kidney problems
-L upper quadrant and shoulder pain with spleen damage
-R upper quadrant pain with liver problems

133

SCI MOI

Non-traumatic:
-~10%; most likely in ppl with narrowing spinal canals
-possible causes: disc prolapse, vascular insult, neoplasm, RA, radiation, spinal stenosis, surgery, cardiac arrest, AAA, infection

Traumatic:
-most result from from forces that create violent motions of the head/neck
-Cervical: *C5-7; flexion, vertical loading, and extension accompanied by rotation or lateral flexion are most likely
-Thoracic: less likely d/t rib cage and higher stability; *T12-L1 most common; flexion or vertical compression can cause wedge compression or burst fractures of vertebral bodies damaging the cord
-Lumbar: neuro damage from trauma is usually incomplete due to large vertebral canal and good vascular supply; most common L1-2; cauda equina less likely to sustain a complete injury

actual transection of the cord is rare

Mechanisms of secondary tissue destruction:
-ischemia
-edema
-demyelination and destruction

134

intrinsic vs. augmented feedback

intrinsic= sensory info self acquired during performance of task

augmented: externally presented feedback (VC)

135

knowledge of results vs. knowledge of performance

KR: augmented feedback about the outcome of a movement

KP: augmented feedback about the nature of the movement produced (characteristics)

136

forms of practice

Blocked: repetitive single skill

Variable: varied motor skills, rapid modifications

Random: skills in random order

Serial: group of skills in a predictable order

Massed: relatively continuous practice

Distributed: rest time is larger than practice

Mental: cognitive rehersal

137

strategies for effective learning:

feedback given after every trial improves performance

variable feedback improves learning and retention

early training should emphasize visual feedback (cognitive phase)
later training should focus on proprioceptive feedback (associative phase of learning)

early- closed environment --> open

supportive feedback (reinforcement) to shape behavior, motivate

138

stages of learning

1- cognitive -- "what to do"
-develops understanding of task
-assess abilities
-develop overall understanding of the skill through trial and error

2- associated -- "how to do"
-practices movements
-decreases errors
-refinement of the motor skill through continued practice

3-autonomous -- "how to succeed"
-practices
-minimal level of cognitive monitoring
-largely error free
-after considerable practice the motor performance becomes largely automatic

139

Proprioceptive neuromuscular facilitation (PNF)

uses total patterns of movement and posture to promote motor learning in synergistic muscle patterns and prepare the body for advanced functional skills (gait)

utilizes proprioceptive elements: stretch resistance, overflow, manual contacts, approximation, traction

utilizes motor learning principles: VC, visual guidance of movement, repetition and practice

140

PNF diagonals:

D1 flexion for UE: "disco"
-starts with GH IR, abd and extension
-ends with ER, adduction and flexion
-D1 extension is the opposite

D2 flexion for UE: "seatbelt"
-starts with GH IR, adduction and extension
-ends with ER, abduction and flexion
-D2 extension is the opposite

D1 flexion of the LE
-starts with hip IR, abduction, and extension
-ends with ER, adduction, and flexion
-D1 extension is the opposite

D2 flexion of the LE
-starts with hip ER, adduction and extension
-ends with IR, abduction and flexion
-D2 extension is the opposite

141

PNF diagonal patterns of the head and neck

may be used to enhance breathing and movement patterns

supine or sitting chopping, upper trunk flexion with rotation and UE D1 extension facilitates rolling to prone position

supine lower trunk flexion with rotation to right or left; knees flexing

LE D1 flexion helps rolling in any direction

142

List of PNF techniques

agonist reversals

approximation

contract-relax

hold-relax

repeated contractions

rhythmic initiation

rhythmic stabilization

slow reversal

traction

143

Alzheimer's disease

a chronic, progressive, widespread deterioration of the cerebrum

intellectual decline, loss of memory, confusion, anxiety, depression, loss of reasoning, possible motor impairment, and gait problems or contractures as the disease progresses

144

bipolar disorder

manic-depressive disorder

characterized by mood swings from depression to mania

145

conversion disorder

conversion reaction or hysterical paralysis

a response to severe emotional stress resulting in involuntary disturbance of physical functions

disturbances are often connected with the NS, resulting in problems with vision, sensation, hearing or motor disturbances (hemiplegia, paraplegia, quadriplegia, tics or tremors)

patient is frequently indifferent to the symptoms

146

antidepressants

Valium, Prozac, Elavil

require 3-4 weeks for mood-elevating effect

side effects:
-dry mouth
-blurred vision
-disturbed sleep
-increased anxiety
-disturbed balance
-postural hypotension
-increased HR
-weight gain
-blood glucose fluctuations
-orthostatic hypotension in elderly patients

147

schizophrenia

psychotic disorder

characterizted by loosening of association (fragmented thoughts, errors of logic, bizzarre ideas), autistic withdrawal, ambivalence to themselves and others, and inappropriateness of affect

Meds: Haldol, serouquel, risperdal
-probably block postsynaptic dopamine receptors

Side effects:
-sedation, drowsiness
-insomnia
-seizures
-headaches
-back pain
-tachycardia
-orthostatic hypotension
-dry mouth
-constipation
-weight gain

148

agnosia

inability to recognize familiar objects with one form of sensation (visual agnosia)

149

akinesia

inability to initiate movements

150

aphasia

disturbance to language that results in errors in word choice, comprehension or syntax (word order)

Expressive/Broca's
-severe difficulty in verbal expression with impairment in object naming and writing abilities.
-mostly found in those with L CVA

Global
-most common and severe form of aphasia
-reduced speech AND comprehension
-reading and writing impaired also

Receptive/Wernicke's
-severe disturbance in auditory comprehension
-reading, writing and word recognition also impaired

151

apraxia

inability to perform movements previously learned even though there is no loss of strength, coordination, sensation or comprehension

ideational apraxia: person no longer gets the "idea" of how to do a routine task

ideomotor apraxia: person can't do a task on command but can spontaneously

152

asterognosis

inability to recognize objects by touch alone

153

asynergia

inability to move muscles together in a coordinated movement

154

ataxia

uncoordinated movement, especially gait

155

athetosis

slow involuntary, worm-like, twisting motions

usually seen in forms of CP

156

causalgia

painful burning sensations

often associated with CRPS I

157

Cheyne-stokes respiration

a common and bizarre breathing pattern
-period of apnea lasting 10-60 seconds followed by gradually increasing, then decreasing depth and frequency of respirations

accompanies depression of the frontal lobe and diencephalic dysfunction

postulated to be a result of an abnormality in the neurological respiration center

can occur with severe cases of TBI or CHF

158

chorea

rapid, involuntary, jerky movements

seen especially in Huntington's disease

159

clonus

rhythmic oscillation of a muscle in response to sustained stretch in patients with UMN disease

160

decerebrate rigidity

contraction of the extensor muscles of both the UE and LE because of an injury at the brainstem

161

decorticate rigidity

contraction of the UE flexors and LE extensors

162

delirium

temporary confusion and loss of mental function

often as a result of illness, drug toxicity, or lack of oxygen

often reversible

163

dementia

loss of memory or intellectual functioning

may be reversible if caused by toxins, drugs, metabolic or psychiatric disorders

often slowly progressive and nonreversible if a result of alcoholism, Alzheimer's, infarction, or Parkinson's disease

164

dysmetria

inability to judge distances

seen in cerebellar dysfunctions

165

electromyography (EMG)

study of a graphic record of muscle contraction as a result of electrical stimulation

used to eval the voluntary electrical activity of muscle

166

glove and stocking anesthesia

can occur in generalized peripheral neuropathies in which the distal portions of the nerves degrease resulting in anesthesia of the distal extremities

seen in Guilin-barre

167

Morton's neuroma

an excessive pronation during stance produces compression between the 3rd and 4th metatarsals

nerve can enlarge, forming a neuroma on the interdigital nerve resulting in metatarsalgia

168

nerve conduction velocity (NCV) test

determines speed of propagation of an action potential along a nerve or muscle fiber

if nerve is compressed or damaged, the velocity of AP will be slowed and the latency or time the potential takes to travel between two points will be increased

test utilized to determine the severity of nerve compression prior to surgery

169

nystagmus

rapid, usually back and forth movement of the eyeballs

170

reciprocal inhibition

inhibition of muscles antagonist to those being facilitated

essential for coordinated movement

171

somatagnosia

lack of awareness of the relationship of one's own body parts or the body parts of others

172

visual field deficits

homonymous hemianopsia
-deficit of either the R or L halves of the visual field
-caused by damage to the contralateral optic tract

bitemporal hemianopsia
-deficit of the temporal or peripheral visual fields
-caused by injury at the optic chasm
-AKA tunnel vision

monocular blindness
-blindness in one eye
-result of damage to optic nerve