Exam Flashcards
Spinal cord Injury in Canada
-Over 86,000 people living with SCI in Canada
-Over 4500 new SCI cases in Canada each year (estimated).
–>51% cases traumatic, 49% non-traumatic
The top causes for traumatic spinal cord injury include:
–>motor vechile accidents (38%)
–>Falls (37%)
–>Sports (15%)
Spinal Cord Injury in Canada - Cost
Direct costs of healthcare utilization = $123, 674 (2205/06)
- Inpatient rehab care cost = large cost driver to the health care system ($3.6 billion in Canada)
- ->3x more expensive than inpatient acute care
- Manual wheel = ~ $4-5,000
- Power wheelchair = $10-15,00
Tetraplegia
- loss of impairment in motor and/or sensory functions in the cervical segments of the spinal cord
- Results in functional impairments in the arms, trunk, legs and pelvic organs
- Has replaced the term “quadriplegia”
Paraplegia
- Loss of impairment in motor and/or sensory functions in the thoracic, lumbar or sacral segments of the spinal cord
- Results in impairments in the trunk, legs, and pelvic organs
- Arm function remains intact
Complete SCI ~ Incomplete SCI
Definitions based on the ASIA definition
Complete: Absence of sensory and motor functions in the lowest sacral segments
Incomplete: Preservation of sensory or motor functioning below the level of injury, including the lowest sacral segments
SCI Categories Based on Type/Level of impairment
The extent of injury is defined by the American Spinal Injury Association (ASIA) Impairment Scale, using the following categories:
A= Complete: No sensory or motor function is preserved in sacral segments S4-S5
B= Incomplete: Sensory, but not motor function is preserved below the neurologic level and extends through sacral segments S4-S5
C = Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade of less than 3
D= Incomplete: Motor function is preserved below the neurologic level, and most key muscles below the neurologic level have a muscle grade that is greater than or equal to 3
E=Normal: sensory and motor functions are normal
Types of Spinal Cord Injury
Upper motor Neuron Lesion (T12 or higher)
-Spasticity of limbs below lesion
Types of Spinal Cord Injury
Lower motor neuron Lesion (T12 or lower)
- Flaccid paralysis of legs
- Loss of reflexes
- Atonicity of bladder and bowel
- Reduced muscle tone
Myotomes (what neurons innervate what muscle
C3-5 Diaphragm
C5: Biceps (bends elbows), shoulder abduction
C5-C6: Elbow flexion
C6: Deltoids, Extensor Carpi (bends wrist back)
C7: Triceps (straightens elbows) Elbow extension, wrist flexion, finger extension
C8: Palmar Interossei (bends fingers), wrist extension, finger flexion
T1: Dorsal Interossei (spreads fingers) (finger abduction)
T1-T2 Muscles of the chest and abdomen
L2: Iliopsoas (bends hips) (L1,2 Hip Flexion)
L3: Quadriceps Femoris (straightens knees)
L4: Anterior Tibialis (pulls feet up) (knee Extension L3, 4) (Ankle Dorsi Flexion)
L5: Extensor digiti (wiggles toes) (L5, S1 Hip extension and Knee flexion) (1st metatarsal extension)
S1: Posterior Tibialis (pulls feet down) (S1,2 Ankle Plantar flexion)
S3-5: Bladder, Bowel and Sex Organs
Common Types of Incomplete Spinal Cord Injuries
Brown-Sequard Syndrome
Below injury level, motor weakness r paralysis on the side of body (hemiparaplegia). Loss of sensation on the opposite side (hemianesthesia)
Common Types of Incomplete Spinal Cord Injuries: Anterior Cord Syndrome
-Below injury level, motor paralysis and loss of pain and temperature sensation. Proprioception (position sense) , touch and vibraroty sensation is preserved.
Common Types of Incomplete Spinal Cord Injuries
Posterior Cord Syndrome
Below injury level, motor function preserved. Loss of sensory function: pressure, stretch, and proprioception (position sense)
Common Types of Incomplete Spinal Cord
Central Cord Syndrome
Results from cervical spinal injuries. Great motor impairments in upper body compared to lower body. Variable sensory loss below the level of injury.
Impairments Post -SCI
Paralysis -Sensory Problems -Respiratory Problems -Autonomic dysreflexia -Orthostatic hypotension -Pressure ulcer -Bowel and bladder dysfunction -Sexual Dysfunction -Problem in regulating temperature -Pain fatigue -Spasticity and Spasms -Deep Vein thrombosis -Heterotrophic ossification
Referrals for SCI
physicians dentists dentalhygienists pharmacists pharmacy technicians physician assistants nurses advanced practice registered nurses surgeons midwives dietitians psychologists chiropractors social workers phlebotomists occupational therapists optometrists physical therapists radiographers radiotherapists respiratory therapists audiologists speech pathologists paramedics medical laboratory scientists medical prosthetic technicians
OT Assessments
Assessments for ADL/IADL
- Functional Independence Measure (FIM)
- Quadriplegia Index of function
- Modified Barthel Index
- The Catz -Itzkovich Spinal COrd Independence Measure (SCIM)
- Wheel chair Outcome Measure (whOM)
OT Assessments
Leisure
- COPM
- Interest Inventory Checklist
OT assessments
Vocation
- Define client’s abilities and interests
- Observations of clients’ abilities and function
OT assessments
Home and community
-Home visits to assess accessibility and safety is crucial (performed early)
What to consider When Starting your OT Assessment
- Get to know the person
- Read the file -Special attention to other trauma or injuries
- Be flexible with your time
- Functional evaluation
- Talk with significant others
Spinal Cord Independence Measure (SCIM)
SCIM assess the following areas
SCIM III (done by instructor) or SCIM Self Report
Self-care (4 items) Feeding, bathing, dressing and grooming
(transfer is not considered here)
-Respiration and Sphincter Management (4 times)
–>Breathing, secretion clearance, bladder management, bowel management, use of toilet(
-Mobility (room and toilet) and (indoors, outdoors on even surfaces) (9 items)
–> variety of surfaces, move to relieve pressure and wound risk, walk or wheel indoors and outdoors, navigate stairs
-30 to 40 minutes -19 questions
15 minutes for self report
-Typically or most frequently if they can not complete it due to medical issues
scored out of 100, 3 sub scales (the ones above)
OT treatment by Stage
Acute Stage
- 1-2 session(s) per day (each about 15 minutes)
- Positioning
- Splinting
- Tenodesis Grasp
- Family Education
OT treatment by Stage
Rehabilitation Stage
- Support
- Education
- Meaningful Activity
Phases of Spinal Shock
Areflexia (0-1 day)
Initial Relex Return (1-3 days)
-Hyperreflexia (1-4 weeks)
-Hyperreflexia + spasticity (1-12 months)
Areflexia (0-1 day)
- Flaccid paralysis of the muscles
- Absence of reflexes below the level of injury
- Bladder flaccidity
- No control of bowels
- May require ventilator to breathe
What are the OT roles, what do you need to know about the client before approaching the client
Spasticity
- Increased muscle tone below the level of injury after spinal shock
- Triggered by sensory stimuli (touch, infection, or other irritation)
- Might hinder function
Autonomic Dysreflexia
- Uncontrolled sympathetic activity (most common in T6 level or above - rarely in T6 to T10)
- Life Threatening
Clinical Presentation
- Increase in blood pressure
- Pounding heachache
Causes: UTIs, overfull bladder/bowels, bladder or kidney stones, ingrown toenails, decubitus ulcers, pain and invasive procedures such as urinary catheterization
OT intervention for Autonomic Dysreflexia
1) Stop doing activity
2) if BP is high
–>seek medical assistance - do not leave the patient alone
–>Upright posture with head elevated
Loosen all restrictive clothing or devices
-Check for kinks or folds in the urinary catheter
-Continue to monitor BP
Preventative Strategies:
- ->education on the causes and management of symptoms
- ->Creating a regular bowel and bladder schedule
- ->encouraging regular checkups for ulcers and wounds
Orthostatic Hypotension
- A sudden decrease in blood pressure following a transfer into upright position (e.g., supine to sit)
- ->decrease supply returned to the heart plus increase blood pools in LE
Clinical presentation:
- Light headedness/dizziness
- ->sudden weakness
- ->unresponsiveness
- ->loss of consciousness
Common in T6 or above injuries
OT intervention for Orthostatic Hypotension (do not leave the person unattended until a nurse or a physician is present)
- Check blood pressure
- Positioning
- ->If the person is in bed, lower the head of the bed.
- ->if the person is in a wheelchair, lift the person’s legs and observe for signs of relief
- ->If symptoms persist, recline the wheelchair to place the head at or below the level of the heart - If symptoms persist put the person to bed
Monitor BP and seek medical assistance if the above steps did not work
Deep Vein Thrombosis
Blood clot in LE, abdomen or pelvic area, caused by:
- ->reduced blood flow
- ->increased tendency for blood to clot
- ->changes in the blood vessels
Clinical Presentation:
Swelling, localized redness in LE + low-grade fever
OT Interventions to prevent Deep Vein Thrombosis
- Monitor for asymmetries in color, size, and temperature
- Compression stockings
- Physical activity
- education of symptoms and preventative strategies
Pressure Ulcers and stages
-Continuous pressure on bony prominence reduces flow to the area which causes skin breakdown
Stage 1:
- Skin is not broken, but it is red and discoloured
- Superficial dermis and epidermis intact
- “non-blanching” provide pressure on spot, if it remains
- There is a permanent state of inflammation
Stage 2:
- The epidermis or top layer of the skin is broken
- Shallow open sore/blister
Stage 3:
- Break the skin extends through the dermis into the subcutaneous and fat tissue
- Wound drainage and texture around the sides
- Muscle may be visible
Stage 4:
Breakdown extends into the muscle and as far as the bone
-Infection and bone decay can occur
-Dead tissue and drainage are present
-Surgery likely to remove dead tissue (debridement)
Pressure Ulcers are Expensive
- Pressure ulcers cost $9.1-$11.6 billion per year in the US.
- Cost of individual patient care ranges from 20,900, to 151,700 per pressure ulcer
OT interventions for Pressure Sores
Goal: prevention
- cushions
- Tilt and recline wheelchairs
- Repositioning (every two hours while laying in bed; every 15 minutes in the wheelchair)
- Skin inspection on a daily basis
- Skin moisture and shearing
- Offloading pressure
- ->keep pressure off affected area once ulcer has formed
Encourage your client to:
- Have good nutrition - high protein foods
- Drink water
- Do not smoke
- Do physical activity
Physical Activity Guidelines for SCI
-Starting level
The starting level is the minimum level of activity needed to achieve fitness benefits
Aerobic Activity
-20 minutes, 2 times a week of moderate to vigorous intensity AND
Strength-based-training activity
3 sets of 10 reps 2 times a week for each MAJOR muscle group
Start meet exceed
Physical Activity Guidelines for SCI advance level
The advanced level will give you additional fitness and health benefits, such as lowering your risk of developing Type 2 diabetes and heart disease
Aerobic Activity
-30 minutes, 3 times a week of moderate to vigorous intensity AND
Strength-based-training activity
3 sets of 10 reps 2 times a week for each MAJOR muscle group
Start meet exceed
Thermal Irregulation
- Problem with maintaining a proper body temperature (T6 and above)
- Increased risk of developing sunburns, frostbite, hypothermia and heat stroke
OT intervention
- Protect skin from sun and serve temperatures
- Avoid extremes in temperature
- Wear the correct clothing for the weather
Incontinence - Bladder Dysfunction
1) Lower Motor Neuron - Below T12 (flaccid bladder)
- ->non reflexive/flaccid bladder
- Moust catheterize or use external pressure abdomen with fists to remove urine
2) Upper Motor Neuron - Above T12 (spastic Bladder)
- Reflexive/spastic bladder
- Bladder can contract and void reflexively
- Use catheters and specific voiding schedules
OT Role for Bladder management
- Intermittent Catheterization (IC) every 4-6 hours
- Education to use adaptive tool for catheterization
- Managing clothing for individuals with tetraplegia
Bowel Dysfunction
1) Spastic (reflex) Bowel T12 or above
- Stool can be eliminated reflexively if nerves located in the rectum are manually stimulated
2) Flaccid Bowel (Below T12)
- Cannot be stimulated reflexively to empty
- Manual removal is required
OT role in Bowel Management
OT will help with client with:
- Managing oral medication
- Creating daily routines
- Learning how to manage clothing
- Learning how to insert a suppository
- Learning digital stimulation
Sexual Function
Males:
T11 and above injuries
-Complete injuries-reflex erections but no voluntary erections and ejaculations
Reflexogenic Erections from touch are possible in most men at this level of injury; However, psychogenic erections from arousing thoughts, sights, or sound are not usually possible.
The ability to ejaculate si rare
T12 and lower injuries
-Psychogenic erections from arousing thoughts sights,
or sound may possible but reflexogenic erections from touch are usually not
-Not ability to ejaculate especially if the sacral nerves are involved
-Complete injuries at S2-5 = loss of bowel, bladder, genital reflexes and complete loss of erection
Sexual Function
Females
- Dysreflexia (T6 or above) and bladder incontinence during intercourse
- Complications related to pregnancy and delivery
- Less desire, body image problems, menstructual cycle might be delayed, less satisfaction, delayed arousal, delayed oganism
Sexual Function - OT Intervention
Spasticity Management
Grooming
Comfortable environment
Adaptive Equipment
Pain
-65% of people with SCI report having chronic pain
Musculoskeletal Pain
- Dull or aching pain in the bones, joints or muscles
- Secondary overuse; muscles spasm pain; mechanical instability of the spine
Visceral Pain
–>Burning, cramping or constant pain in the abdominal above or below the level of injury
Neuropathic Pain
-Sharp, shooting or burning pain
–>central Pain and segmental Pain
Consequences??????
Fatigue `
very common
Causes:
- Chronic pain, medications and prolonged bed rest may cause fatigue
- Nightly check-ups, overnight medication administration, and frequent repositioning
OT: keep these factors in mind when planning sessions with clients - remain flexible
-Observe and listen to clients for signs and symptoms of fatigue
Psychological Consequences of SCI
- ~30% of people with SCI are at risk of having a depressive disorder although in rehabilitation
- ~approx 27% are at risk of having raised depressive symptoms when living in the community
Higher comparative risks of:
- Anxiety disorder
- Elevated levels of anxiety
- Feelings of helplessness
- Poor quality of life (QOL)
Factors Related to Rehab Prognosis
Attitude
- Type of injury
- Comorbidity
- Age
- Support
Age-Specific Considerations
Children: Natural development
Adolescence and young adults: Student role, sexual role, driver role
Adult: parent role, employment
Older Adults: Complications, falls, physical limitations weakness, = skin integrity
Aging with SCI: chronic Shoulder, elbow and wrist pain, energy conservation, joint protection
How to Talk with Your client?
- Give hope
- Do not give too much information
- Use plain language
- Plan for discharge
- Remain client-centred
Wheelchair Prescription
Proper seating postural alignment
- Pelvic
- ->Neutral alignment
- ->90 degree
- Symmetrical alignment of trunk head
- ->over pelvic
- ->horizontal gaze
- Knee and ankle: 90 degree and thighs in neutral abduction
- Shoulder neutral (avoid elevation, protraction or retraction)
Consider: type of activity bed sores incontinence person's strength -Type of wheelchair
Wheelchair Outcome measure (WhOM)
- Client-centred measure
- Interview based
- Available in English, French and some other languages
- 10-15 minutes to complete
- Participation and satisfaction
- Problems with seating
client centered measure Ask what activities do they want to use the wheelchair for inside and outside the home Part 1 - rate on a likert scale 1-10 Part 2 Satisfaction for: Body positioning Comfort -Skin Break down
re-administer just do the satisfaction again
any satisfaction under 7 there are areas of improvement
whOM per wheelchair
OT Role - To Facilitate Community Integration
Goal: restoring at home and in the community
- Adaption
- Advocacy
- Service Provision
- Assisting with funding to buy assistive devices or amkin modifications in the house/workplace
- ->March of Dimes
- ->tetra Society
Return to Work (RTW) following spinal cord Injury: A systematic Review
- Individuals who sustained SCI during childhood or adolescence had higher adult employment rates
- Most common reported barriers to employment:
- ->problems with transportation
- ->health and physical limitations or lack or work experience
- ->education or training
- ->physical or architectural barriers
- ->Discrimination by employers
- ->loss of benefits
SCI Recovery Within Auto-Insurance Funding System
-Within auto-insurance funding system, SCI considered “catastrophic” injury
-Eligible for $1,00,000 in medical/rehabilitation benefits, which is covered:
–>therapies/medical treatments
-Assistive Devices
-Home accessibility renovations, vehicle mods.
Attendant Care support (i.e Personal Support Worker) - up to $6000 per month (~200 hours per month)
-Eligible for weekly housekeeping services
-Eligible for caregiving benefit if previously provided caregiving support
-Income replacement benefit (up to $400 per week)
Occupational Therapy and Return to Work for Clients After a Brain Injury
- Occupational Therapist’s (in return to work and ABI) use their skills in occupational analysis to bridge the gap between the person’s abilities, limitations, the environment, and the cognitive demands of a job (PEO model)
- Identify, resolve or compensate for issues that contribute to disability
- Facilitate the transition from worker readiness; to re-integration into work tasks; to establishing sustainability at work
- OTs often work in a multi-disciplinary program
Cognition and return to work after mild/moderate traumatic brain injury: A systematic review.
Cognition plays a significant role in predicting and facilitating RTW in patients with TBI
Opportunities and barriers for successful return to work after acquired brain injury: a Patient perspective.
-Three themes that influenced RTW were identified: individually adapted rehabilitation; motivation
Opportunities and barriers for successful return to work after acquired brain injury: a Patient perspective.
- Three themes that influenced RTW were identified: individually adapted rehabilitation; motivation for RTW; and cognitive and social abilities
- An individual adapted rehabilitation was judged important because the patient were involved i their own rehabilitation and required individually adapted support from rehab specialists, employers and colleagues
- A moderate level of motivation for RTW was needed
- Awareness of person’s cognitive and social abilities is essential in finding compensatory strategies and adaptations
Evidence-Based Cognitive Rehabilitation: Updated Review of the Literatur From 2003 Through 2008
- Highlights metacognitive approach to rehab (self-awareness, self-monitoring) anda holistic approach to gain better outcomes
- The study found that participants, despite being more severely disabled and further post-injury, receiving comprehensive-holistic rehabilitation were twice as likely to make clinically significant gains in community functioning
- Examining this evidence base, there is clear indication, that cognitive rehabilitation is the best available form of treatment for people who exhibit neurocognitive impairment and functional limitations after TBI or stroke.
Referral Process
In a private practice setting, referrals typically come through Insurance Companies (LTD, MVA, WSIB) or Employers
- Referral for an assessment, treatment and development of GRTW plan, Discharge
- Expectations for regular reporting and communication
- Consideration of client, third party payer, and employer
Barriers to the Process
- Funding for comprehensive multidisciplinary treatment
- Mismatch between job demands and client ability
- Employer inability to accommodate; lack of education/understanding of brain injuries
- Workplace negativity; previous workplace performance issues
- Client compliance
- Poor communication
- Stigma and “invisible Illness”
- Coping and communicating with “comparisons to BEFORE”
- Client confidence
Assessment Process
The assessment follows a biopsychosocial approach. An interview is conducted including the following sections: client history, exploration of symptoms, subjective report of engagement in meaningful occupations, information about social supports, detailed work information, client goals. Pysocial and COgnitive Assessments. You may assess:
- Ability to follow instructions
- Ability to carry on conversation
- Ability to concentrate, focus on handle distractions
- Ability to make decisions
- Ability to remember
- Ability to finish task
- Insight/self-awareness
Standardized and nonstandardized assessments and activities would be completed
Assessments tool (a few options for brain injury and return to work)
- Repeatable battery for the assessment of Neuropsychological Status (RBANS)
- Comprehensive Trail-Making Test
- Recent Memory Screen
- Attention Vigilance Test
- Plan Your Day
- Divided Attention - UNO
- Edgar’s Garage (memory test)
- Multiple Errands Test.
- Card sort/Card tapping/Foam Sort
- Web-based cognitive assessments
Assessments categorized for Functional Task Performance
Time Management-Multiple Errands Test
-Use of time sheet, complete tasks at certain times throughout the assessment, manage interruptions, monitor time, initiation of tasks
Planning
-Plan your day (time and accuracy)
Organization
-Category organization, mental flexibility (change the categories), category naming (foam sort, coin sort, card sort)
Problem Solving
-Logic puzzles, medication management exercise
Attention
-Vigilance test (finding all the F’s), divided attention card/uno game, with and without distractions, auditory divided attention
Word Finding
-Worksheets - add word with similar meaning, opposite meaning, naming
A job Site Assessment may include
- tour of the workplace
- observation of environment
- Ergonomic assessment of the workstation
- observing employees and/or client completing work tasks
- interview with management or HR to assist in identifying availability of modified duties and/or hours, as the client returns to work.
- Identification of any cognitive factors that may influence safety and productivity at work (e.g. noise level, concentration and attention span, order of work tasks)
Cognitive Abilities Analysis
–>More detailed analysis of the cognitive abilities of the client
Cognitive Demands Analysis
–>more detailed analysis of the cognitive demands of the job
Intervention
Based on Assessment Results
(different options)
-Cognitive Rehabilitation Program
–>Improve cognitive function to better match with physical/cognitive demands of the job
Some examples:
-On-line cognitive games
-Knitting (increase complexity of patterns)
-Paragraph memorization,
-Concentration exercise,
-Mental arithmetic exercise involving grocery tasks,
-Auditory memory exercises
-Reading program
–>throughout the return to work so that reading can be done in a quiet environment with appropriate proactive cognitive rest breaks
–>Prioritize reading requirements and break the requirements into manageable parts
–>Use strategies to improve reading comprehension and retention (highlighting, not taking, etc. )
- Psychsocial Intervention
- Return to Work Planning
- Task or Jo Modification, Compensatory Strategies, Assistive Devices and Job Coaching need would be identified
What is MS
- Degenerative neurological condition
- Disease of white matter
- Attacks Central Nervous System (CNS)
- Affects both men and women - children and adults
- Unpredictable symptoms
Cause of MS
- Exact cause is currently unknown
- Theories: Autoimmune, CCSVI (almost rejected)
- A combination of environmental and genetic risk factors
MS in Canada
10,000 people in Canada (>50 per 100,000 of population
- Commonly diagnosed between 15 to 50
- Estimation of 500 to 1000 children and teens with MS
Types of MS
PRMS- Progressive Relapsing MS
SPMS - Secondary Progressive MS
PPMS - Primary Progressive MS
RRMS - Relapsing Remitting MS
Relapsing-Remitting MS (RRMS)
-Episodes:
Unpredictable onset
- Clearly defined by worsening symptoms or new symptoms appearing
- May also be called attacks, exacerbations, or flare-ups
- Episode length ranges from 48hrs to several months
Hallmark: recovery or “remission” period
Relapsing-Remitting Subgroups
Benign MS
- Following diagnosis, it may be 15-20 years before a flare-up
- physical disability is minimal
- Symptoms mainly affect sight and/or touch
- Clinically Isolated Syndrome (CIS)
- Single episode of neurological symptoms
Progressive-Relapsing MS (PRMS)
- Symptoms steadily worsen from onset of disease
- Clear attacks or flare-ups also occur with or without remission following
- Very rare, in only 5% of those diagnosed
Secondary Progressive MS (SPMS)
- Progresses from RRMS
- Progressed stage where remission is less common
- Continuous worsening of symptoms and accumulating disability
Primary Progressive MS (PPMS)
- Slow progression of disability
- Symptoms may stabilize for periods of time
- Sometimes minor improvement may be seen
- Only seen in 10% of people diagnosed
How does the type of MS impact a person’s life
fill in later
Diagnosing MS
diagnosis generally happens over a period of time
- Physicians look for evidence of lesion on the nerves
- Lesions may or may not cause symptoms
- Diagnostic tests: MRI, Lumbar puncture, Evoked potential (EP)
Common Symptoms of MS
Central
- Fatigue
- Cognitive impairment
- Depression
- Anxiety
- Unstable mood
Visual
- Nystagmus
- Optic neuritis
- Diplopia
Speech
-Dysarthria
Throat
-Dysphagia
Musculoskeletal
- Weakness
- Spasms
- Ataxia
Sensation
- Pain
- Hypoesthesias
- Paraesthesias
Bowel:
- Incontinence
- Diarrhea or Constipation
Urinary
- Incontinence
- Frequency or retention
Less Common Symptoms of MS
- Speech problems
- Swallowing Problems
- Tremor
- Seizures
- Breathing problems
- Itching
- Headaches
- Headaches
- Hearing Loss
MS impact on life
-Employment:
50-70% of people with MS lose their job during the first 5 years after diagnosis
Family
-Having a baby
Marriage
Caregivers
Expanded Disability Status Scale
0-4 Fully ambulatory
5-9 impaired ambulation (Disability precludes full daily activities) 9-confined to bed
10 death
Disease-Modifying Therapies (DMTs)
How they Work:
-Target some aspect of the inflammatory process to reduce relapses and slow disease
What Type of MS:
-Relapsing-Remitting MS and Secondary progressive MS, with relapses
Most common DMTs in MS
copy later
Steroid Medications
Goal: Help to decrease the severity and duration of MS relapses
How they work: Actively suppress the inflammation to improve relapse symptoms and speed healing
General Side Effects:
Short-term
-Difficulty sleeping
Stomach upset
Long-term
Liver and kidney dysfunction
-Decreased bone density
Rehabilitation
main Goal: Maintain general health and prevent loss of function as much as possible
This is achieved through
- Improving impairments
- Educating to compensate for problems
e. g. decline in cognitive function and constipation - Providing adaptive equipment and devices
- Enhancing vocational capabilities
- Counseling to help adapt and cope with the changes
- Educating patients and caregivers on MS and its consequences
- Supporting medical therapies to increase compliance with treatment and manage side effects
Examples of Assessment Tools for MS
- Canadian Occupational Performance Measure (COPM)
- Modified Fatigue Impact Scale or Fatigue Severity Scale to assess fatigue
- 6-Minute Walk Test to assess endurance
- Activities-specific Balance Confidence (ABC) Scale
- Multiple Sclerosis Walking Scale or mobility section of the Functional Independence Measure (FIM) to mobility concerns
- Pittsburgh Sleep Quality Index (PSQI)
- Home Assessment
- Beck Depression Inventory-Fact Screen to assess depression
- ADL, IADL, and dysphagia assessments
- Nine-Hole Peg Test to assess dexterity
- Semmes-Weinstien Monofilaments to test sensation
- Manual Muscle test, ROM evaluation, and grip strength (dynamometry)
Occupational Therapy interventions for M
-Equipment, Behavioural and environmental modifications
-Exercise
-Spasticity management
-Cognitive management
-Pain intervention
-Tremor and ataxia
Employment modification
-Fatigue management
MS Self Management model -Person and Contextual Requirments
I feel like this is important but don’t have a lot of time
Heat Intolerance (uhthoff’s Phenomena)
Marked sensitivity to increased body temperature
Cause: Demyelinated fibers in the NS are very sensitive to even small evaluation of core body temperature resulting in conduction delays or even conduction blocks
Result: In Any MS symptom can present this way; most common presentation is the blurring of vision after physical activity
Common Triggers: Sunbathing, exercise, bot baths, emotion, fatigue, fever
Management: cooling, management of fever if present
Bowel Incontinence
Problems:
- Delayed gastric emptying
- Constipation
- Fecal incontinence
Cause
- Neurologic
- Poor diet
- Medication such as antidepressants, narcotics, muscle relaxants
Physical Activity Guidelines for Adult with MS
To achieve fitness benefits, adults aged 18-64 years with multiple sclerosis who have mild to moderate disability need at LEAST:
30 minutes of moderate intensity aerobic activity, 2 times per week, AND
strength training exercises for major muscle groups, 2 times per week
-Meeting these guidelines may also reduce fatigue, improve mobility and enhance elements of health-related quality of life
Constipation - Intervention ( MS)
-Fluid and fiber intake
-Regular Exercise
-Bowl Program
-20-30 minutes after meal (which is when there is strongest bowel movement)
-Medication
-Sit on toilet for at least 10 minutes
-Rocking back and forth on toilet
-Massaging abdomen
Note: it might take several weeks until treatment si effective
Bladder Dysfunction
Type: usually Spastic
Sometimes flaccid during MS attacks
Urgency
Incontinence
which causes other problems
Interventions: add later
Sexual Dysfunction
Type: Usually spastic
-Sometime flaccid during M attacks
Assessments:
Multiple Sclerosis Intimacy Questionnaire (MSISQ-19)
Likert scale from 1-5 5 ebing always 1 being never (bad symptoms) higher the score the harder the intimacy
Common Problems:
- Erectile Dysfunction
- Impaired genital sensation
- Decrease viginal lubrication
Access to Health Services
- Lack of information provided by the healthcare providers
- Lack of communication and interaction of persons with MS with their HCPS
- Lack of finances
- Inconvenient Location/proximity to services
- People with MS Feel uninformed and involved in decision making surrounding their healthcare
Parkinson’s Disease (PD)
- Progressive neurological condition
- Degeneration of substantia nigra –> Decreased Dopamine –>slowness of movements
- Average age of diagnosis is 60
- 20% are under the age of 50 when diagnosed
- Can start even before age of 40 (early onset).
- Can start even before age of 40 (early onset).
- About 100,000 Canadians are affected
- Estimated about 1 in 100 people over 75 years have PD
Main Symptoms (BRT)
Bradykinesia
Rigidity
Tremor (Resting)
Clinical features of a client with PD
- Head bent forward
- Stooped posture
- Rigidity
- Tremors of the hand/head
- Akinesia (absense or poverty of normal movement)
- Shuffling gait, and/or propulsive gait (festinating gait)
- Mask-like facial expression
- Drooling
- Weight loss
- Loss of Postural reflexes
- Bone demineralization
Other Physical symptoms of PD
- Reduced arm swing
- Postural instability
- Microphonia
- Micrographia
- Sequencing
other Sensory Functions and Pain of PD
- Reduced sense of smell
- Blurred vision, double vision
- Parestesia
- Pain
- Cold Sensation
Other symptoms (more categories)
-Sleep disorders
- Voice and Speech Functions
- ->Dysarthria
- ->Perseveration, language disorders
Functions of Digestive system
- ->swallowing disorders
- ->Constipation, weight loss
Genitourinary and Reproductive Functions
- Urinary disorders
- Disorders in sexual functions
Cardiovascular Functions
-Orthostatic hypotension
Functions of the skin
–>increased sweating
Mental Function (other symptoms for PD)
- Depression
- Anxiety disorder
- Apathy
- Cognitive impairments which can lead to: dementia, visuospatial impairments, obsessive compulsive behaviour
PD over Time
- Usually symptom start unilaterally
- Slow progression
- Decline in motor ability
- Other symptoms develop over time e.g. depression, postural and cognitive problems
- Drug Therapy loses effect over time
- Normal life expectancy
Stages of Parkinson’s disease
- Only unilateral involvement, usually with minimal or no functional disability
- Bilateral or midline involvement without impairment of balance
- Bilateral disease: mild to moderate disability with impaired postural reflexes: physically independent
- Severely disabling disease: still able to work or stand unassisted
- Confinement to bed or wheelchair unless aided
Medication
Levodopa (L-Dopa) –>Dopamine precursor
- Tolerance develops
- Short half life (on/off periods)
- There is medicine with longer half life
Dopamine agonists
- Anticholinergic agents
- Catecholo-omethyl transferase inhibitors
Deep brain Stimulation
- Improves motor symptoms
- Designed to modulate signals
