SCI, ALS and Vestibular Dysfunction Flashcards Preview

SEMESTER 4 - REHAB > SCI, ALS and Vestibular Dysfunction > Flashcards

Flashcards in SCI, ALS and Vestibular Dysfunction Deck (83):
1

Physical therapy intervention

  • Must maximize functional independence
  • First focus: bed mobility, transfers and wheelchair mobility
  • With progression, focus on: work, home, community reentry

2

  • Things that were important at acute phase are still important:

  • Things that were important at acute phase are still important: ROM, respiratory management, positioning
  • Progress resistive exercise program
  • Muscle reeducation
  • Postural control
  • Improve cardiovascular response to ex

3

Skin inspection includes?

  • Instruct pt in self skin inspection with long handled mirror
  • High level: may need help
  • Mat program: stability, progress to  controlled mobility then skill
  • Start with bilateral and symmetrical, then go to weight shift then movement, then improve timing and speed
  • Easy to difficult
  • Sometimes will progress someone before they have mastery of a skill

4

Mat exercise

  • As progress: improve strength, functional ROM, awareness of COG, postural stability, balance, determine how to accomplish tasks
  • Rolling: important for bed mobility, dressing
  • Good starting point on mat
  • Learn to use head, neck and UE to move trunk and LE
  • Consider how head position will change motion, also try crossing ankles

5

more mat X

  • Prone on elbows
  • Help with bed mobility and working toward quadruped and sitting position
  • Proximal stability
  • Scap strengthening
  • May be difficult initially with lumbar, low thoracic injuries
  • Prone on hands
  • Hyperext of hips and low back to prepare for amb, standing from WC or rising from floor

6

more mat X

  • Supine on elbows
  • Assist with bed mobility and assume long sit
  • Assume position in various ways
  • Progress to long sit
  • Pull up
  • Strengthen biceps and shoulder flexors for  WC propulsion(tetra)

7

still more mat X

  • Sitting
  • Need to do both long and short sit
  • Good sitting balance and posture
  • Tetraplegia: need 100 degrees SLR
  • Sitting varies with level of lesion
  • Higher lesions: use head forward, trunk flex to maintain position

8

more mat X

  • Initially maintain position
  • Practice balance activities in sitting
  • Sitting push ups: very important for transfers, ambulation and wt shifting
  • Quadruped position

    Practice this leading up to ambulation

    Do WB through hips

9

last mat X

  • Kneeling position
  • Establish trunk and motor control
  • Lead up activity to ambulation
  • Transfers
  • Do this once pt has adequate sitting balance
  • Start on firm mat and progress to other alternate surfaces
  • Usually use lateral scoot type transfer

10

Transfer skills

  • 3 important components:
  • Momentum
  • Muscle substitution
  • Head-hips relationship
  • Pt needs good instruction in components surrounding the skill

11

WC 1 of 3

  • Will almost always prescribe a wheelchair
  • Ambulatory paras will still use wheelchairs for community ambulation due to greater speed, safety and lower energy expenditure
  • Power vs manual chair
  • Consider energy expenditure (for C5 C6 may still use power chair
  • Rigid vs folding frame
  • Push rim activated power assist wheelchairs
  • C 4 and above: power

12

wc 2 of 3

  • Wheelchair training program
  • Pressure relief: 10-15 seconds of pressure relief for 20 min of sitting

13

wc 3 of 3

  • Spasticity: may need heel and or toe loops
  • May need more than one chair
  • Wheelchair skills
  • Need to operate wheelchair
  • Can use base of hand
  • Wheelchair mobility begin on level surfaces, progress to outdoor and uneven
  • Wheelies: need to climb curbs

14

ambulation

  • Need adequate mm strength, postural alignment, ROM, CV endurance
  • Orthoses + assistive device = a lot of work
  • Slower and more energy
  • Give option to pt even if it is only a remote possibility
  • Need good ROM and postural alignment

15

SCI and ambulation

  • Be realistic with patient, provide clear picture and potential benefits
  • Give pt the opportunity to try this
  • Spinal bracing is too restrictive, so usually depend on LE bracing, assistive devices, adequate ROM, and postural alignment
  • Need adequate CV endurance, good respiratory function
  • Ambulation may be restricted by spasticity, loss of proprioception, pain, decubitus ulcers, hetertopic ossification,  
  • Amb with orthosis
  • Very few continue to use them
  • Some use them for standing and exercise
  • If ASIA C or D tetraplegia, within 72 hours of injury, may are ambulatory at discharge
  • 1 year post injury
  • 5% complete para community ambulators
  • 76% incomplete para community ambulators 
  • Increase strength of available muscles
  • Use assistive device
  • Use orthoses
  • Use compensatory methods to ambulate
  • Usually brace ankle or ankle/knee
  • Ankle joint: 10-15 degrees dorsiflex
  • Knee lock
  • COG post to hip, ant to ankle

16

Gait training strategies

  • Forearm crutches are most appropriate
  • Standing from WC
  • Crutch balancing
  • Ambulation activities: 4pt, 2pt, swing to, swing through
  • Move in all directions
  • Stair climbing: upstairs backward and downstairs forward
  • Curbs: last thing to learn

17

PT for Incomplete SCI 

  • Body weight support treadmill training
  • Functional electrical stim
  • Low level electrical current to improve function in paralyzed or weak mm

18

Shoulder pain

  • Usually biomechanical in nature
  • Lot of mechanical stress
  • Prevent problems with proper postural alignment, strengthening and stretching
  • Exercise
  • Improve function, strength, endurance, respiratory function, perceive health and quality of life
  • UE ergometer, WC propulsion, swimming and circuit training
  • 8-12 reps per ex, 2 sessions per week

19

  • Also known as Lou Gehrig’s disease
  • Degeneration and loss of motor neurons in spinal cord, brain stem and brain: have mix of UMN and LMN S/S
  • 30,000 in US have disease at any one time
  • 15 diagnosed per day
  • Average age mid to late 50’s
  • Slightly more men than women
  • Autosomal dominant, but large number do not have family history

ALS

20

  • 70-80 percent: limb onset ALS
  • 20-30% bulbar onset ALS: initial involvement in bulbar muscles: middle age women: problems with speaking, chewing, swallowing
  • Progressive degeneration and loss of motor neurons in spinal cord, brain stem and motor cortex
  • Brain stem nuclei for CN V, VII, IX, X, XII and anterior horn cells in spinal cord
  • Anal and external urethral sphincters are usually spared

ALS

 

21

Progression tends to spread locally within a region before moving to other regions
Caudal to rostral spread within spinal cord, and cervical to bulbar region spread occurs faster than rostral to caudal spread

ALS

22

  • Depends on localization and extent of Motor neuron loss
  • Initially focal asymmetrical weakness in LE or UE or weakness in bulbar mm
  • Cardinal sign: mm weakness
  • Initially weakness tends to be distal: fine motor activity, tripping or slapping foot, change in voice difficulty moving tongue
  • Cervical: extensor weakness,

Manifestations OF ALS

23

 MORE Manifestations

  • see decreased ROM, jt subluxation, tendon shortening, joint contractures, adhesive capsulitis, ambulation difficulties with distal mm weakness
  • Common to fall (46%)
  • Fatigue: due to several factors: overburdened neurons, weak mm must work at closer to max strength, sleep disturbance, respiratory impairments, hypoxia, depression, impaired mm contraction activation
  • Atrophy, fasciculations,  hyporeflexia, decreased or absent reflexes, decreased mm tone, flaccidity, mm cramp

24

 MORE Manifestations

  • May have parasthesia or pain in limbs
  • Sensory pathways are generally spared
  • UMN loss: spasticity, hyperflexia, clonus, pathalogical reflexes: as get worse will see less UMN signs
  • Spasticity: contractures, deformities, dyssynergic movement patterns, abnormal timing, loss of desterity and fatigue

25

  • Mixed UMN and LMN so will see mix of flaccid and spastic components
  • Dysarthria, impaired speech: start by being unable to project voice, poor enunciation
  • Dysphagia: spastic or flaccid palsy
  • May see liquid regurge, weak cough reflex
  • Sialorrhea: excessive saliva and drooling
  • Psuedobulbar effect: poor emotional control

Bulbar pathology

26

Other impairments

  • Respiratory: loss of mm strength and decrease in vital capacity
  • Initially fatigeu, DOE, problem sleeping supine, sighing, headaches due to hypoxia
  • Tend to adjust activity level as respiratory problems get worse
  • VC of <25-30% of predicted: impending respiratory failure or death

27

  • Can have mild deficits to severe frontotemporal 
  • Problems planning, organizing, personality and behavior changes
  • Abstract reasoning, verbal fluency, memory, comprehension can also be affected
  • Those with bulbar onset more likely to have cognitive impairments 

Dementia

28

Diagnosis OF ALS

  • LMN signs by EMG, NCV, mm and nerve biopsies, neuroimaging
  • Clinically definite ALS: UMN and LMN findings in 3 of 4 regions (bulbar, cervical, thoracic or lumbar)or UMN and LMN signs in bulbar region plus 2 spinal regions
  • ALS is a progressive disease: will see deterioration
  • Onset to death usually several months to 20 years
  • Death is usually within 3-5 years

29

Prognosis OF ALS

  • Younger individual is at diagnosis: better long term survival
  • Limb onset: better prognosis than bulbar

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Management OF ALS

  • Multidisciplinary approach
  • DMARDS may extend life for a short time
  • Palliative care: disease is not responsive to curative treatment
  • Control pain and other symptoms: psychological, social, spiritual problems
  • Medical management is symptomatic

31

Task force recommendations FOR ALS

  • Inform family and patient about diagnoses and prognosis
  • Symptom management of silorrhea and pseudobulbar affect
  • Nutritional management, PEG
  • Management of respiratory insufficiency and ventilation decisions
  • Advance directives and palliative care

32

Management of Respiratory Impairments

  • At risk for respiratory tract infection
  • When VC decreases to 50% of predicted: positive-pressure noninvasive ventilation
  • When no longer tolerated or not effective: choice of tracheostomy or hospice

33

Muscle cramps, spasticity, fasciculations, pain FOR ALS

34

Rehabilitation FOR ALS

  • Help the patient maintain their independence and function for as long as possible
  • Treat current problems and plan ahead for future problems
  • Consider pt to be in early, middle or late stage
  • Early stage: minor functional limitations
  • Middle stage: increase number of disabilities
  • Late stage: more severe

35

MORE Rehabilitation FOR ALS

  • Have to differentiate between progressive course of disease and lack of impact of interventions
  • Physical therapist will need to work with the patient to determine what the patients priorities are
  • Pain: use visual analogue scale
  • ROM, muscle length, soft tissue flexibility should be analyzed
  • Mm tone, cranial nerves, sensation, Postural alignment, balance, gait, skin and functional skills should all be evaluated

36

Disease-Specific and Quality of life measurements FOR ALS

37

Intervention FOR ALS

  • Restorative intervention: remediate or improve impairments and functional limitations:
  • Done in early and middle stages
  • Compensatory intervention: modify activities, tasks, or environment to minimize functional limitations
  • Preventative intervention: minimize potential impairments: ROM, strength, aerobic capacity, prevent pneumonia, functional limitations

38

MORE Intervention  FOR ALS

  • Initially goal will be to postpone onset of functional limitations
  • Perform mm strengthening ex
  • Encourage the patient to use necessary adaptive equipment and ambulatory devices when necessary
  • Cervical mm weakness: head will start flopping forward
  • Initially can use soft collar: over time will progress to semi-rigid to rigid collar
  • May use cervical thoracic orthosis or sterno occipital mandibular immobilizer: heavy, difficult to don and doff

39

Dysarthria and dysphagia

  • Address posture and head and neck control
  • Position in sitting
  • UE mm weakness:
  • Use adaptive equipment as needed
  • Painful shoulder subluxation: use sling
  • Splinting to avoid hand and wrist contractures

40

Shoulder pain FOR ALS

  • Capsular pattern
  • May be due to spasticity or weakness cause imbalance
  • Overuse of strong mm, strain, poor positioning,  glenohumeral sublux  (weakness or fall)
  • Treat with inj: analgesics and antiinflam followed by aggressive ROM

41

Respiratory FOR ALS

  • Educate patients
  • Energy conservation techniques
  • Proper position to eat with head up to avoid aspiration
  • Teach Heimlich maneuver in case of choking

42

LE muscle weakness FOR ALS

  • Orthoses
  • Helps decrease stress on remaining muscles, conserve energy
  • Knee impairments:use AFO
  • Orthoses needs to be lightweight
  • Hinged vs fixed ankle AFO
  • Wheeled walker is generally used, occasionally Loftstrand: need to remember that need optimal function with the least energy expenditure

43

Adaptive equipment FOR ALS

  • Depends on needs
  • Decreases mobility
  • Poor mobility with LE weakness
  • Use 2” cushion to raise person up
  • Self powered cushions if have good trunk, control
  • Transfer board, transfer belt, swivel cushion
  • Lift, electric bed
  • Chair glide or stair lift

44

wheelchair FOR ALS

  • Initially can use a lightweight wheelchair will work, but rent or borrow, do not purchase
  • Will need an electric wheelchair
  • Lightweight, small turning radius, high reclining back, supports for trunk and extremities
  • Power chair: comfort, tilt-in-space, reclining

45

Mm cramps and spasticity FOR ALS

  • Massage and stretching
  • Cold for spasticity
  • Prolonged stretch, PROM
  • Posture and positioning techniques
  • splinting

46

Psychosocial issues FOR ALS

  • This illness is devestating
  • Depending on progression emotional response of patient, loved ones and caregivers may fluctuate
  • Watch for patient becoming very depressed, needs to be managed with meds

47

Exercise FOR ALS

  • Usually ROM and stretching
  • Early in process, moderate resistance can be used with 3/5 strength, discuss this with the PT as thinking differs on this
  • Overuse fatigue vs disuse atrophy
  • With insufficient activity disuse atrophy develops when mm contractions are less than 20%of total tension a muscle is capable of producing
  • Overuse fatigue can happen easily: must narrow down the safe range for therapeutic exercisse

48

exercise FOR ALS NEW STUDIES

  • Newer studies show that in ALS patients who exercise the rate of decline is slower
  • Educate family, as they ask questions, answer them or find answers for them
  • Give only as much information as they need

49

Vestibular disorder FOR ALS

  • 15 million people per year have symptoms of dizziness
  • Prevelance of complaints increases with age
  • Is a significant disability and interferes with quality of life
  • Exercises can significantly reduce disability

50

Vestibular system

  • Is quite complicated
  • Peripheral and central components
  • Peripheral: 3 functions
  • Stabilize visual images on fovea of retina during head movement
  • Maintain postural stability
  • Provide information for spacial orientation

51

Peripheral vestibular system 

  • Semicircular canals:
  •   there are 3: horizontal, posterior and anterior
  •   respond to angular acceleration
  • Filled with endolymph which is slightly more dense than water
  • Each one has an ampula with a cupula: contains sensory hair cells

52

Otoliths 

  • Otolith made up of saccule and utricle
  • Respond to linear acceleration and static head tilt
  • Sensory hair cells project into gelatinous mater ial where crystals are located
  • Saccule vertical linear accel
  • Utricle:  excited over horizontal accel or static head tilt

53

Central vestibular system

Mostly located in brainstem but there are connections between vestibular nuclei, reticular formation, thalamus, and cerebellum

54

Vestibular system 

  • All parts need to work in unison
  • Tonic firing rate: vestibular afferent have a specific rate of firing that increases when head moves, helps detect head movement
  • Vestibular-ocular reflex (VOR): allows you to keep a stable gaze when head moves rapidly
  • Push-pull mechanism: as you turn one direction the SCC on that side will increase firing and the opposite side will decrease firing

55

can mean vertigo, light headed, disequlibrium, oscillopsia

Dizziness

56

an illusion of movement: sense environment moving, usually episodic

Vertigo

57

feel like fainting (hypotension, hypoglycemia, anxiety)

Light headed

58

off balance: non vestibular, decreased somatosensation or weakness in LE

Dysequilibrium

59

subjective experience of motion of an object

Oscillopsia

60

duration MATTERS

ASK THEM HOW LONG IT LAST

 
  • Minutes: benign paroxismal positional vertigo
  • Minutes to hours : menieres disease
  • Days: vestibular neuronitis or migraine associated dizziness

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Testing FOR VESTIBULAR PROBLEMS

  • Visual analog scale: for intensity
  • Dizziness handicap inventory pg 1005: breaks down into physical, emotional and functional
  • Functional disabilities scale pg 1005: measures patients response to PT
  • Motion sensitivity quotient pg 1006: provides subjective score of dizziness, both intensity and duration

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Testing POSITIONS FOR VESTIBULAR PROBLEMS

  • The idea is to move the patients head in different patterns and determine if it causes symptoms
  • Eye movement
  • Head thrust
  • Head shaking
  • Positional testing
  • Hallpike-Dix test
  • Sitting with head rotated to 45 deg, bring into supine with head extended 30 degrees and watch eyes

63

Testing VESTIBULAR PROBS FOR Gait and balance

  • Gait and balance testing: weight shift, automatic postural responses, ambulation
  • Otolith testing: use clicking sounds
  • Semicircular canal testing
  • Caloric testing
  • Rotary chair

64

  • Can be caused by misplaced otoconia
  • Vertigo nystagmus, N&V and imbalance
  • Otoliths break away move the endolymph in the SCC

benign paroxysmal positional vertigo

65

  • Viral insult, trauma, vascular event
  • Spontaneous nystagmus, vertigo, oscillopsia with head movements, postural instability, disequilibrium
  • Usually resolves in 7-10 days

Decreased receptor input

66

  • bilateral vestibular hypofunction
  • Meds,meningitis, autoimmune disorders, head trauma, tumors, TIA
  • Dysequilibrium

Ototoxicity

67

  • CVA involving ant-inf or post inf cerebellar  artery
  • Sudden vertigo, hearing loss, dysdiadochokinesa,
  • TBI: vertigo

Central NS DYSFUNCTIONS

 

68

BPPV- INTERVENTION

GET ROCKS TO GO BACK WHERE THEY ARE SUPPOSED TO BE

  • Goals: otoconia return to vestibule
  • Reduced vertigo associated with head movement
  • Improved balance
  • Enhance decision making skills regarding self treatment strategies
  • Demonstrate independence in ADL’s

69

  • Move head in different positions in sequence that will move the debris out of the involves SCC and into the vestibule
  • After treatment symptoms should resolve
  • Pt should be fit with soft collar to avoid vertical head movements that may dislodge otoconia

BPPV

Canalith repositioning maneuver (CRM)

70

  • Use for posterior or anterior semicircular canal BPPV
  • Rot head 45 degrease toward involved side (left)
  • Move pt into Hallpike-Dix position with left ear toward ground
  • Rotate head 90 degrees to right
  • Roll pt onto rt shoulder
  • Slowly bring up to sitting with head rot 45 degrees to right

BPPV- meneuvers

 

71

  • CRT for right horizontal SCC
  • supine: Place head in 20 degrees of cerv flex
  • Place head 90 degrees to rt
  • Rot head 90 degrees to lft, wait for 15 sec let symptoms stop
  • Rot head 90 degrees to rt, wait 15 sec for symptoms to stop
  • Roll into prone and wait for symptoms to subside

BPPV meneuvers

 

72

  • Brandt-Daroff: for posterior SCC
  • Start in sitting, turn head 45 degrees to left side, then quickly lie down on Rt side: remain here for 30 sec
  • Slowly return to starting position
  • Turn head to right, lie down on left shoulder: remain for 30 sec
  • Do 10-20 times  3 times per day until pt is without vertigo for 2 solid days

BPPV meneuvers

 

73

Postural Stability for vestibular probs

  • Encourage balance strategies withig limitations of patient
  • Progress as pt tolerates
  • Incorporate head movements when possible (see table 24.9 pg 1018)

74

Motion sensitivity for vestibular probs

  • Habituation training
  • Use when pt has continual complaints of dizziness
  • First must know what provokes the dizziness
  • Move person in position and leave for 30 sec or until symptoms abate
  • Perform ex3-5 times each 2-3 times per day
  • Symptoms normally decrease in 2 weeks

75

  • Goals: reduce subjective complaints of gaze instability
  • Improved static and dynamic balance
  • Independent in HEP  including walking
  • Enhanced decision making skills for ADL’s
  • Balance  exercises
  • Exercises to improve central preprogamming of eye movements (Pg 1010 table 24.1)
  • May take 2 years for full recover
  • Consider Tai Chi, pool ex
  • Avoid activities in dark, quick head movements, may need cane

Bilateral vestibular hypofunction

76

  • Goals: understand fall prevention strategies and safety precautions to function at home and in community
  • Enhance decision making skill regarding use for compensatory strategies to assist in gaze stability
  • Independent in HEP including walking
  • Recover time approx 6 months, may be incomplete
  • Adaptive mechanisms for vestibular issues may be damaged
  • Must be careful with pushing too quickly
  • If lesion at brainstem level, treat like unilat vestib hypofunction
  • Can try habituation therapy
  • Gait and balance ex to incorporate somatosensory, visual and vestibular contributions

Central Vestibular Hypofunction

77

  • Has vertigo AND low frequency hearing loss
  • May also have tinnitus or fullness in ear
  • Symptoms with periodically get worse, will have fairly severe symptoms of 1-2 hours at a time sometimes days
  • Possibly due to increase in endolymph
  • Possibly due UVH treatment, gaze and postural stability ex
  • This does not stop episodes

Menieres Disease

78

  • Rupture of oval or round window (between inner and middle ear)
  • Will leak endolymph into middle ear
  • Vertigo and h earing loss
  • Usually due to trauma
  • Rest, surgery
  • PT is CI unless residual diffulties

should not do therapy just rest

Perilymphatic fistula

79

  • benign tumor on CN VIII
  • Hearing loss, tinnitus, dsyequilibrium
  • Surgery
  • Therapy afterword to help with dysequilibrium

Acoustic neuroma

80

  • Normal sensation, can be debilitating
  • Sensory input does not match stored neural patterns
  • Pallor, nausea, emesis, diaphoresis, motion sensitivity
  • PT can help to desensitize

Motion sickness

81

  • After MVA
  • More common to diagnose in Europe
  • Upper cervical spine: proprioceptive input into contralateral vestibular nucleus
  • Soft tissue inj and jot dysfunction alter afferent input
  • May respond to therapy
  • Vertebrobasilar insufficiency: pt leans forward, extend neck and rotate to 45 degrees: diplopia, dysarthria, syncope, HA vertigo, nystagmus: must see neurologist immediately

Cervical vertigo

82

Contraindications for treating someone in PT

  • Not appropriate for unstable vestibular disorders
  • Menieres
  • Perilymphatic fistual
  • Sudden hearing loss
  • Pressure or fullness in ear
  • Severe ringing in ears

83