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Rehab Medicine Flashcards

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0
Q

How is most at risk of MS?

A

Women (2x as likely)
Between the age of 20-50
Living in countries towards the poles

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1
Q

What is the most common pattern of MS?

A

Relapsing remitting pattern:

Two episodes of neurological impairment affecting two different parts if the CNS, each lasting longer than 24 hours and occurring at least one month apart

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2
Q

How long do the effects of inpatient rehabilitation last for MS?

A

Physical and psychological benefits last 6 months

Neuro status and functioning diminishes after discharge

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3
Q

What should the outpatient rehab for MS involve?

A

For relapsing remitting:

IV corticosteroids combined with rehab provides improvements lasting at least three months

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4
Q

How can fatigue me managed in MS?

A

Ensure sleep hygiene
Exclude medical problems - hypothyroidism, infection
Review medication that may worsen fatigue - baclofen, carbamazepine
Adaptive equipment
Work simplification
Training energy conservation techniques

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5
Q

How should sphincter disturbance in MS be managed?

A

Rule out UTI

If prone to retention, teach intermittent self-catheterisation

Overnight symptoms may respond to low dose ADH (desmopressin)

Detrusor hypereeflexia (frequent small volume voiding) - treat with oxybutynin, tolterodine, intavesical botulinum toxin

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6
Q

What functions are impaired in frontal lone stroke?

A

Personality, expression, movement
Speech and writing - may be damaged

Motor:
Hemiparesis - face, trunk, limbs 
Sitting to standing, standing, walking
Abnormal tone
Flaccid, spasticity
Lack of coordination
Loss of dexterity, fine finger movements
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7
Q

What functions may be impaired in parietal line stroke?

A

Sensation:
may be loss or abnormal sensation
may be perceived as pain
proprioception may be lost compounding limitation of movement

Praxis:
ability to carry out skilled movements

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8
Q

What is praxis?

A

Ability to carry out skilled movements

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9
Q

Where is praxis located?

A

Dominant temporo-parietal cortex

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10
Q

What is apraxia?

A

Loss of skilled movement ability when not explained by weakness, sensory loss or innattention

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11
Q

What is involved in stroke rehabilitation?

A

Improvement in safe transfers, eg between bed and chair

Independent mobility - training with walking aiding roving abilities in ADL

Return to participation in work or leisure

Prevention of further strokes

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12
Q

What are the main types if perceptual impairment after stroke?

A

Inattention
Visual agnostic
Visual neglect/hemineglect

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13
Q

Now long should visually impaired stroke patients wait before driving?

A

In attention and neglect prevent patients from driving

Advise not to drive for minimum of one month, or until impairment resolves if takes longer than one month

Longer for drivers of commercial vehicles

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14
Q

In what types of injuries is spinal cord injury assumed?

A

Motor vehicle crash
Fall from height
Incidents with impact, crushing, multiple trauma
Loss if consciousness

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15
Q

What symptoms are suspicious of spinal cord injury?

A

Back or neck pain
Guarding of back or neck
Sensory changes/loss/numbness/tingling
Being unable to pass urine

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16
Q

What is the MRC grading to rate motor movements on each side of the body?

A 
0- total paralysis
1- palpable or visible contraction
2- active movement with gravity
3- active movement against gravity
4- moderate movement against gravity
5- full normal movement
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17
Q

How is sensation graded?

A

0 - no sensation
1 - abnormal or impaired sensation
2 - intact sensation

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18
Q

What is complete spinal injury?

A

Patient lacks motor AND sensation at anus

Innervated by S4-5

Usual more severe

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19
Q

What is incomplete spinal injury?

A

Patient has motor OR sensation at anus

Usually a better prognosis

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20
Q

What is the AISA impairment scale?

A

1 - complete - no sensorimotor at anus

2- sensory NOT motor function below neurological level, extends through S4-5

3- motor function preserved below neuro level, most muscle 3

5- normal - sensory and motor functions are normal

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21
Q

What are the long term consequences of spinal cord injury?

A

Spasticity
Osteoporosis
Heterotrophic ossification of soft tissues around joints
Renal failure - renal calculi due to repeat UTIs
Respiratory failure - patients cannot ventilate lungs

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22
Q

At lesions above what neurological level do autonomic complications occur?

A

Lesions above T7

Due to loss of sympathetic input (esp to heart) from sympathetic chain in cervical and upper half of thoracic spinal cord

Parasympathetic input from vagus is preserved

Results in hypotension and bradycardia

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23
Q

What is vagal stimulation induced cardiac arrest?

A

Upper airway suctioning, ng tubes and intubation cause reflex increased vagal output

This causes bradycardia and and cardiac arrest

Treat with prophylactic atropine before procedure

Impact of vagal stimulation decreases after a month - can use pacemaker if persists

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24
What is the mechanism behind autonomic dysreflexia?
Due to uncontrolled reflex sympathetic activity to noxious stimuli below level of SCI Results in reflex hypertension, which would normal be countered by vasodilation in lower limbs Injury disrupts outgoing autonomic signals from BP centres in brainstem May result in cerebral haemorrhage, seizure and death
25
What factors might precipitate autonomic dysreflexia?
``` Bladder - UTI, over distension, stones Bowel distension- constipation etc Pressure sores Ingrown toenails Complications of pregnancy and labour Sexual activity Other conditions with pain - fracture etc ```
26
What are the symptoms of autonomic dysreflexia?
Pounding headache Feeling of doom/anxiety Profuse sweating Chest tightness Flushing above level of lesions Pupillary dilatation Cardiac dysrhythmias Hypertension and bradycardia
27
What is the treatment of autonomic dysreflexia?
``` Get patient to sit - to reduce BP Sublingual nifedipine 10mg Sublingual GTN Monitor BP every five mins Remove precipitating cause ```
28
What is post-traumatic amnesia?
Inability to lay down new memories and retain information after traumatic brain injury Variable duration - may be mins/months Commonly anterograde amnesia : Declarative - facts, association Procedural - motor skis Biographical - complex every day events
29
How is post traumatic amnesia managed?
Low stimulus environment Reassurance, reorientation Visual clues Sedate only if essential for safety of patient or others
30
What is frontal lobe syndrome?
Impairment of executive function: Difficulty planning Personality changes Perseveration Response inhibition: Disinhibition Sexual disinhibition Emotional lability
31
What is involved in behavioural modification?
Monitoring behaviour: Identify precipitating factors, behaviour and positive reinforcements Modifying behaviour: Positive reinforcement, time out, specialist neurobehavioural rehab units Vocational rehabilitation: Identify alternative work/educational options, planned withdrawal from work
32
What are problems that may complicate a return to work in traumatic brain injury?
Cognition: poor concentration, memory, executive function Behaviour: impaired judgements, disinhibition, aggression Post concussive symptoms: fatigue, headache Epilepsy: driving, work on scaffolding etc Mental health problems: anxiety, depression, loss of confidence
33
Can patients with head injury drive?
Significant head injury: banned from driving for 6-12 months Epilepsy: barred from driving for 1 year post last seizure Must have satisfactory clinical recovery, no visual field or cognitive impairments
34
What is an initial prostheses?
A generic, adjustable prosthetic limb given after amputation of the lower limb Assesses patients ability to walk Improves unsteadiness, promotes exercise Reduces post op swelling and promotes healing
35
How is a prostheses made?
Cast made of residual limb Positive made of cast to replicate size and shape of patients limb Socket made which fits patients limb to enable weight bearing Attach joints and shafts to make prosthesis the same length as patients leg Prosthesis may have cosmetic cover or remain with the components exposed
36
What are the contraindications to having a prosthetic fitted?
Angina - prosthesis increases energy costs of walking by 20% Small/painful residual limbs - do not allow prosthetic fitting Instead, use a wheelchair and sliding board for transfer
37
What is phantom limb pain?
Pain located in the part of the limb that has been removed Contributing factors include peripheral and central sensitisation leading to cortical reorganisation of bodies schema Influences by stress, depression and anxiety May result from neuroma - benign tumour of transacted nerve
38
How is phantom limb pain managed?
Pain gradually improves with time - usually gone after a year Amitriptyline is first line Massage, hot/cold packs, tens machine Neuroma - treat worth surgical excision or ablation by phenol injection
39
What are the appropriate investigations for seizures?
EEG - only to support clinical diagnosis of epilepsy MRI - to identify structural abnormalities that might cause epilepsy Bloods - glucose, calcium, UandEs, LFTs 12 lead ECG - to assess for cardiogenic causes
40
What is double support?
When part of each foot is in contact with the ground at the same time This period is about 20% of the gait cycle
41
What are the main components of the stance phase?
Initial contact: Hip flexed, knee slightly flexed, ankle dorsiflexed Loading response: The above movements continue as leg decelerated to foot on ground Mid stance: Hip goes from Flexion to dorsiflexion Knee from Flexion to extension Ankle dorsiflexes Preswing: Hip is neutral Knee flexes Ankle plantar flexes and heel lifts off ground
42
What are the main components of the swing phase?
Initial swing: Hip and knee flex Ankle dorsiflexes To rapidly shorten limb so toes don't touch ground Terminal swing: Leg prepares for initial contact of heel Rapid hip Flexion Knee extension
43
How much of the gait cycle is stance?
60%
44
How much of the gait cycle is swing?
40%
45
What factors may cause dysfunction in the stance phase?
Limb instability Trunk instability Abnormal base of support
46
What can cause weakness in knee extension resulting in limb instability?
Central/peripheral neurological conditions: Polio L2/L3 duac lesions Femoral nerve lesions
47
What compensatory measures may be taken to reduce weakness in knee extension?
Patient may use ipsilateral upper limb to knock knee back in ace during mid stance Patient may allow knee hyper extension - this is painful! Forward Flexion of the trunk Initial contact with forefoot
48
What is trendelenberg gait?
Pelvis drops in swing phase Gluteus medius cannot maintain stability Trunk compensates by flexing to ipsilateral side to shift centre of gravity over stance leg Other compensatory strategies include extension of trunk at initial contact and arms placed behind centre of gravity
49
What causes trendelenberg gait?
Reduced activity in gluteus medius causes trunk instability Due to: L5 root lesion Damage to superior gluteal nerve Direct muscle damage (THR)
50
What is a stable base of support?
Base of support is created by feet as they contact with ground Walking is stable when centre of gravity is within base of support
51
What causes abnormal base of support?
When patients cannot put weight through their feet Due to: RA in joints of feet Spasticity of gastrocnemius and soleus complex, Tibialis anterior and posterior - results in equinovarus foot
52
What causes impaired limb clearance in swing phase?
Weakness of hip flexors, knee flexors or ankle dorsiflexors Due to: Neuro or muscle lesion to iliopsoas, hamstrings, Tibialis anterior
53
What compensatory strategies may help in impaired Limb clearance?
Movement on to toes of contralateral limb during stance Hip hitching - excessive hip and knee Flexion Contralateral Flexion of trunk Circumduction
54
What does Varus mean?
Joint points out wards
55
What does Valgus mean?
Joint points inwards
56
What is equinovalgus?
Foot deformity in which weight is borne on the medial edge of the foot May be seen in cerebral palsy
57
What is equinovarus?
Foot deformity in which weight is borne on the lateral edge of the foot Due to cerebral palsy, DMD, spasticity of Tibialis posterior anterior, gastrocsoleus etc
58
What causes impaired limb clearance in swing phase?
Weakness of hip flexors, knee flexors or ankle dorsiflexors Due to: Neuro or muscle lesion to iliopsoas, hamstrings, Tibialis anterior
59
What compensatory strategies may help in impaired Limb clearance?
Movement on to toes of contralateral limb during stance Hip hitching - excessive hip and knee Flexion Contralateral Flexion of trunk Circumduction
60
What does Varus mean?
Joint points out wards
61
What does Valgus mean?
Joint points inwards
62
What is equinovalgus?
Foot deformity in which weight is borne on the medial edge of the foot May be seen in cerebral palsy
63
What is equinovarus?
Foot deformity in which weight is borne on the lateral edge of the foot Due to cerebral palsy, DMD, spasticity of Tibialis posterior anterior, gastrocsoleus etc
64
How does a patient use a walking aid?
Walking aid eg sticks/crutch used to support the weaker leg therefore weak leg is moved forward with the stick or both sticks and the strong leg takes the weight of the body When two sticks and two weak legs, the leg moves forward with the contralateral stick If two walking aids and one leg, move both forward at the same time, then swing weak leg through
65
What is kinematic gait analysis?
Study of movement in space and time, regardless of forces generated Performed with multiple cameras and reflection markers Each side recorded with eight cameras and 15 markers Temporal parameters recorded, including stride length, cadence, walking speed
66
What is kinetic gait analysis?
Study of forces in the body that produce movement Based on Newton's third law, and requires 3d force sats from a force plate set on the floor
67
What is hemiplegic gait?
Affects one side of the body - usually seen in UMN lesion Associated reaction - shoulder adducted, elbow flexes, wrist pronated Leg extended and internally rotated Leg circumspection to compensate for lack of knee Flexion
68
What is choreiform gait?
Wide based gait with slow leg raising and simultaneous knee Flexion 'Flinging' movements of legs Associated with choreathetoid movements of upper limbs Causes: Huntington's chorea Dopaminergic medication
69
What is scissor gait (spastic diplegia)
Spastic cerebral palsy - usually diplegic and paraplegic Legs flexed slightly at hips and knees, giving crouching appearance Knees and thighs hit or cross each other Individual walks on tip toe Ankles plantar flexes and internally rotated Shoulders adducted and elbows flexed Weak back and hip extensors, so shift centre of gravity posteriorly
70
What is Parkinsonism gait?
Short steps Reduced arm swing Stooped posture Centre of gravity ahead or behind feet Fearination - hasty but short steps, attempting to compensate for displaced COG Postural instability - difficulty standing from sitting
71
What is ataxic gait?
Indicates cerebellar disease Broad based gait Lurching quality Difficulty with turning Difficulty walking in a straight line
72
What is antalgic gait?
To avoid acute pain Limited joint range of motion Inability to bear weight in affected extremity Stance phase duration shortened to compensate pain in affected leg Resultant limp with slow and short steps
73
What is foot drop?
Inability to dorsiflex ankle Commonly due to peroneal palsy Exaggerated hip and knee Flexion to compensate
74
What is myopathic gait?
Weakness of proximal muscles causes 'waddling gait' Non weight bearing hip drops, and trunk shifts to love COG to contralateral side
75
What is stomping/stamping gait?
When a patient has trouble with proprioception and cannot feel when foot reaches floor Step transmit vibrations which are detected in the trunk

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