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):

Physical therapy intervention

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


  • 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


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


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


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


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)


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


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


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


Transfer skills

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


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


wc 2 of 3

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


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



  • 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


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


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


PT for Incomplete SCI 

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


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


  • 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



  • 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




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



  • 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


 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


 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


  • 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


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


  • 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 



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


Prognosis OF ALS

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


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


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


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


Muscle cramps, spasticity, fasciculations, pain FOR ALS


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


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


Disease-Specific and Quality of life measurements FOR ALS


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


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


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


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


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


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


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


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


Mm cramps and spasticity FOR ALS

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


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


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



  • 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


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


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


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



  • 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


Central vestibular system

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


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


can mean vertigo, light headed, disequlibrium, oscillopsia



an illusion of movement: sense environment moving, usually episodic



feel like fainting (hypotension, hypoglycemia, anxiety)

Light headed


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



subjective experience of motion of an object



duration MATTERS


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



  • 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



  • 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


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


  • 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


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

Decreased receptor input


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



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






  • 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


  • 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


Canalith repositioning maneuver (CRM)


  • 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



  • 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



  • 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



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)


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


  • 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


  • 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


  • 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


  • 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


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

Acoustic neuroma


  • 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


  • 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


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