Exam III Flashcards
Brain injury stats
- falls are number one cause
- MVA is second leading cause and most likely to be hospitalized
Most common S/S of TBI
- headaches
- neck pain
- difficulty remembering or concentrating
- difficulty with thinking, speaking, reading
- fatigue
- changes in sleep patterns
- dizziness
- nausea
- vomiting
- blurred vision
- increased sensitivity to lights, sounds
- changes in taste/smell
Local (focal) brain damage
-contusions, lacerations, hematomas, herniations
Diffuse brain damage
- axonal shearing, small hemorrhages
- most common in a MVA
Secondary brain damage
- occurs after either a local or diffuse brain injury
- edema, hypoxia, hypotension, infection, salt/water imbalance, concussions or post-traumatic epilepsy (can begin months to year after injury)
Scalp injuries
- abrasion/contusion
- hematoma/herniation
- scalp laceration
Skull fractures
- linear
- comminuted
- compound
Intracranial injuries
- concussion
- epidural hematoma
- subdural hematoma
- ICP monitoring
see a lot of epidural and subdural hematomas in inpatient
Traumatic cerebro-vascular lesions
- aneurysms
- carotid-cavernous fistulas
CN pathology
-most commonly injured are CN II, III, VI, VII, VIII
Prognosis (staging recovery)
- glasgow coma scale
- rancho los amigos cognitive scale
Abscess
enclosed infection with some sort of covering
Meningitis
inflammation of the menginges
CNS infectious disease-therapist guidelines
- self protect form contagious diseases
- understand how etiology and prognosis affects treatment goals
- be able to communicate with other health care providers
- be able to provide patient and family education
Infection
- bacterial
- parasitic
- fungal
- viral
- all of these attack the CNS (most hematogenously, but some through the PNS like rabies, herpes)
Prion
only made up of proteins, no RNA or DNA replication (mad cow disease)
Categorized by location and cause
- brain abscess
- meningitis (leptomeninges=pia and arachnoid mater)
- bacterial, viral or chronic
- Encephalitis
- acute or slow virus
Brain Abscesses
- organisms reach brain tissue (staph, psuedomonas)
- secondary to inflammatory process elsewhere (lungs, heart, sinuses, ear mastoiditis)
- Involves white matter, often reaches frontal and parietal lobes through sup. sagittal sinus
- genearlized infection and increased ICP–specific neuro symptoms
S/S of brain abscesses
- headaches
- convulsions
- hemiparesis
- incoordination
- symptoms depend on where abscess is
Leptomeningitis
- infection spread through CSF with inflammatory process of pia mater, arachnoid mater, and superficial CNS tissue to include subarachnoid space
- organisms cross BBB and blood-CSF-barrier OR with trauma to torn meninges from a contaminated wound
- CSF self contained with no antibodies and few cells–ideal growth medium for micro-organisms
- usually classified as bacterial or viral
Bacterial Meningitis
acute vs. subacute vs. chronic
- inflamed congested pia-arachnoid mater with PMN exudate–obstructs ventricular foramina–INCREASED ICP
- decreased blood sugar levels
- untreated leads to death
Bacterial meningitis agents+ages
Neonate-e.coli
Childhood-H. influenzae
Adolescent-N. meningitides
Adult-S. pneumonia
S/S of bacterial meningitis
- headaches
- vomiting
- fever
- altered consciousness
- convulsions
- nuchal rigidity
- irritability
Biggest difference bw bacterial and viral
Decreased blood sugar in bacterial bc the bacteria use the sugar
Brudzinski Neck Sign
When you passively flex the neck in supine, the patients hip/knees flex bilaterally also
Due to nuchal rigidity
If this happens, stop and contact the doctor IMMEDIATELY!
Viral Meningitis
- S/S similar to bacterial, but not life threatening
- Fulminating–occurs suddenly with great intensity
- affects children and young adults
- viral contamination of CSF with an increase in lymphocytes=”acute viral lymphocytic meningitis”
- blood sugar is normal
Viruses that cause viral meningitis
- coxsackie B
- mumps
- ECHO
- lymphocytic choriomeningitis
Chronic Meningitis
- more slowly evolving
- gelatinous exudate in meninges, increased lymphocytes/plasma cells/macrophages/fibroblasts
- if in the SAS may lead to hydrocephalus
S/S chronic meningitis
- headaches
- vomiting
- mental confusion
- weight loss
- fatigue
- night sweats
- chest pain
- general malaise
S/S of hydrocephalus in adults
- gait disturbances
- incontinence
Medical management for meningitis
- antimicrobial antibiotics for bacterial
- treat viral infections symptomatically–antivirals if caught soon enough, but they usually aren’t very effective
Encephalitis
- viral invasion of brain and SC cells (neurons and glia)
- edema and inflammation of brain/SC destroying white matter
- increased ICP leads to transtentorial herniation
- mononuclear cell infiltrate, increases with immunosuppressed patients (lymphomas, leukemias, organ transplants, AIDS)
- viral latency period of months to years
Transtentorial herniation
-cortex can bulge over onto the tentorium
S/S of encephalitis
- headaches
- fever
- nuchal rigidity
- vomiting
- general malaise–>coma, CN palsies, hemiplegia
Encephalomeningitis
inflammation of brain and spinal cord
Encephalitis
inflammation of brain
Encephalomyeloneuropathy
inflammation of brain, SC, and PNS
Acute encephalitis–Acute Viral
- affects frontal/temporal lobe gray
- most fatal type
- some survive with severe dementia
- herpes simplex I and II CNS primary infection
Acute encephalitis–Parainfectious
- associated with other infections
- rubella measles, paramyxovirus mumps, varicella zoster chicken pox
Acute encphalitis-Acute Toxic
- arbovirus arthropd borne systemic infections
- vertebrate hose, mosquito vectors, tick borne
- lime disease, west nile
“Slow Virus” Encephalitis
- long latent incubation periods
- fatal within months–progressive dementia
- inconventional agents
- produced by prion
- “spongiform” bubbles and holes in brain cortex–resembles a degenerative disease
S/S of slow virus
- first personality abnormalities
- visual and spatial orientation/coordination problems
- leads to severe dementia with myoclonus
Creutzfeld-Jacob Disease Etiology
- familial
- sporadic
- iatrogenic
Creutzfeldt-Jacob Disease
- human form of mad cow
- example of slow virus
- can take decades to show symptoms
- often misdiagnosed
- should be considered when a patient develops rapid dementia and myoclonus
Creutzfeldt-Jacob S/S
- subtle and ambiguous
- depression
- confusion
- personality and behavioral changes
- strange physical sensations
- memory, coordination, visual problems
- language, sight, muscle weakness and incoordination problems worsen
Diagnosis and Prognosis of Creutzfeldt-Jacob
- 14-3-3 protein spinal fluid test is over 95% accurate for diagnosis
- patients die within 6 months-1 year
Brain Tumors
- pathologically benign tumor may be clinically malignant
- many have a propensity for growth beyond the margin of grossly visible tumor–invasive, infiltrating, spread up /down neural axis
- can spread via CSF to produce “carcinomatous meningitis”
- location and size of tumor determines clinical picture
- survival time is shorter for older persons, prognosis is poor
Etiology of brain tumors
-2 groups afflicted:
*0-15 yo
*50-70 yo
Theories of cause:
-heredity
-familial incidence by toxic or infectious exposure
-petrochemicals, organic solvents, rubber
-electromagnetic field exposure
-ionizing radiation, high dose
Common manifestations of brain tumors
- ICP triad (headaches, nausea/vomiting, papilledema–otpic disc edema)
- Cerebellar S/S–equilibrium gait, coordination, ataxia
- Bitemporal hemionopia (temporal 1/2 visual field loss in both eyes, other CN palsies)
- disorders of cognitive ability, speech, personality
- dysfunction of long motor tracts, weakness, head tilt
- sensory disturbances
- symptoms of increased ICP -seiures
- abnormal reflexes (babinski)
Distribution of primary brain and CNS tumors in adults
- glioblastoma (50%)
- meningioma (17%)
- astrocytomas (10%)
- pituitary (4%)
- all others (19%)
Primary CNS neoplasms
- originate within neural tissue
- neuroglia tumors (gliomas)–glioblastoma highly malignant (astrocytoma, oligodendroglioma, ependyoma, medulloblastoma)
- neuron tumors (neuroblastoma, ganglioneuroglastoma)
- pituitary adenomas
- meningioma (arachnoid cells)
Secondary neoplasms
- metastatic tumors, usually carcinomas
2. originate from lungs, breast, skin, kidney, GI tract
Diagnosis of brain tumor
- clinical S/S
- radiology + CT + MRI
- tissue biopsy
- lab findings
Treatment of brain tumor
- chemo
- radiation
- surgery
- sterotactic radiosurgery
- combo of all above
Seizure
- finite event
- result of paroxysmal excessive discharge of cerebral neurons resulting in transient impairment or LOC
- caused by many different underlying physiologic states
- no single brain lesion causes them
Epilepsy
- chronic disorder characterized by recurrent seizures
- usually diagnosis is made when an individual suffers from more than one non-febrile seizure
- 75% have onset before age 20
- potential for activity/participation limitations
- medications for management
Partial seizures
- have clinical or EEG evidence of local onset
- syndrome is characterized by the locus of onset
- temporal, frontal, parietal, occipital
- most frequent and severe for of epilepsy in adults
Simple partial seizures (focal)
- consciousness preserved
- unilateral hemisphere involvement
- may manifest as focal
- motor symptoms: jerking, twitching
- somatosensory symptoms: paresthesias, tingling, light flashes, buzzing, abnormal taste and smell
- autonomic symptoms: nausea, pailor, flushing, pupillary dilation
- cognitive and affective symptoms: illusions, hallucinations, sudden fear
- *patient doesn’t remember**
Complex partial seizure
- associated with alteration or LOC
- bilateral hemispheric involvement
- person appears dazed and confused with random walking, mumbling, head turning or pulling at clothing
- automatic behaviors may be present, but cannot be recalled by the individual
Partial Seizure Secondarily Generalized
- generalized tonic-clonic seizure that develops from either a simple partial or complex partial seizure
- has convulsive manifestations
Generalized seizure
- localized onset is NOT evident
- brain shows diffuse EEG abnormalities
- 6 types
- generalized absence seizures (petit mal)
- atypical absence seizures
- myoclonic seizures
- atonic seizures
- tonic-clonic siezures (grand mal)
- status epilepticus
Generalized absence seizure (petit mal)
- sudden cessation of ongoing conscious activity
- only minor convulsive muscle activity or loss of postural control
- person often stares into space
- onset and end are abrupt and brief
- no preceding aura
- followed by normal activity
- individual is unaware of seizure activity
- frequent in children, often disappear in adolescence
Atypical absence seizure
- similar to generalized absence seizure
- co-exist with other forms of generalized seizure
Myoclonic seuzire
-sudden, brief, single or repetitive muscle contractions involving one body part or entire body
Atonic seizure
-brief LOC and postural tone NOT associated with tonic muscular contractions
Tonic-clonic Seizure (grand mal)
- total loss of control
- sudden LOC with falls common
- tonic phase with generalized rigidty
- lasts ~10 seconds
- respiration may cease briefly
- incontinence of bowel/bladder may occur
- followed by clonic phase with generalized jerking mvt lasting ~1-2 mins
- short seizure recovery may be rapid
- prolonged seizure may induce a deep sleep
Following a grand mal seizure
- patient may experience
- altered speech
- transient paralysis or ataxia
- headache
- disorientation
- muscle soreness
- seizures may be recurring, before or after consciousness is returned
- less common than partial seizures
Status Epilepticus
- MEDICAL EMERGENCY*
- generalized seizures (usually tonic-clonic) are so prolonged or repeated that recovery does not occur between attacks
- adults: tumor, CNS infection, drug abuse
- children under 3: febrile seizures
Causes of symptomatic seizure activity
- changes in hormone levels
- head trauma
- intracranial mass
- CNS infection
- CVA
- toxic substances/poison
- hypoxia
- congenital brain disorders
- degenerative brain disorders (dementia)
- pneumonia (esp for elderly)
- idiopathic
Events that may trigger a seizure
- stress
- poor nutrition
- missed meds
- skipping meals
- flickering lights
- illness
- fever and allergies
- lack of sleep
- emotions; anger, fear, worry
- heat and humidity
Anticonvulsant meds
- valproate (depakene)
- phenytoin (dilantin)
- divalproex dodium (epival)
- phenobarbital (luminal)
- primidone (mysoline)
- benzodiazepines: diazepam (valium), conazepam (klonopin)
- gabapentin (neurontin)
- kepra
Reinforcing Meds
- never abruptly stop your meds
- avoid alcohol–can increase sedation
- until your response to a drug is determined, avoid driving and heavy machinery
- anti-seizure meds can make you drowsy
- may take several dose adjustments to find correct dosage
Side effects
- report side effects to your doctor
- excess fatigue, over sedation, agitation, confusion, tremors, weight gain, diarrhea, irregular menses, dizziness, nausea
- avoid interactions
- some meds are not safe to use while pregnant
Seizure episodes
- are fairly consistent
- behavior may be inappropriate for the time and place, but will most likely not cause harm
What do you do if a patient has a seizure?
- prevent or slow a fall
- protect patient from environment
- rolling patient on side may help keep airway clear
- observation and documentation (timing) are important fo rmed adjustments–esp mouth frothing, eye deviations, incontinence
Other important PT implications
- education and med reinforcement
- building confidence with mobility
- eval of home, work, school
- leisure recommendations
- closely monitor pt during activity
- closely monitor pt following seizure
- patient limitation/precautions may change over time
Subdural ICP sensor with fiber optic transducer tip
-usually placed in nondominant hemisphere to measure ICP
-normal ICP=015 mmHg, can treat to 20 mmHG
PRECAUTION:
-avoid tension, keep transducer at ear level
Femoral arterial line
-for direct and continuous monitoring of bp in femoral artery
-attached to pressure bag that can be carried to mobilize the pt
PRECAUTION:
-if disconnected, pt will bleed from a major artery: apply pressure and call for medical assistance. avoid excessive mvt across the jt
EKG/ECG
Precaution: if lead pops off, monitor will alarm and lose wave form. Reconnect lead
Peripheral IV with infusion pump
Precaution:
- avoid tension
- if across a jt, don’t flex and extend
- apply pressure if pulled out and call for medical assistance (non-emergency)
Foley catheter with balloon tip
Precaution:
- keep bag below the level of the bladder
- reflux increases risk of infection
Chest tube
-allows suctioning of air or fluid from collapsed portion of lung
-placed in intercostals or subcostal space
-sutured to chest wall
PRECAUTION-
-avoid tension or kinking of tube
-keep pleurevac below chest level
Nasogastric tube (NG)
-for tube feedings or suction
PRECAUTION:
-avoid tension
Oral endotracheal tube with balloon tip
-attached by tubing to ventilator
PRECAUTION:
-avoid tension
-if pops off, monitor will alarm, reconnect
Rancho Cognitive Level I
- no response
- total assistance
Rancho Cognitive Level II
- total assistance
- generalized response
- therapy can begin at this level
- responses may be delayed
Rancho Cognitive Level III
- total assistance
- localized response
- the person can attend to you
- can follow one step commands
- can track objects with eyes
Rancho Cognitive Level IV
- max assist
- confused/agitated
- HR and BP increased
- violence is likely
- heightened state of activity
- absent short term memory
- may cry out or scream
- pulls tubes or crawls out of bed
Rancho Cognitive Level V
- max assist
- confused, inappropriate, non-agitated
- difficult for them to learn
- not oriented
- impaired memory
- verbalizations about present events are inappropriate and confabulatory
Rancho Cognitive Level VI
- mod assist
- confused, appropriate
- inconsistently oriented
- remote memory
- vague recognition of staff
- emerging awareness of appropriate responses
- unaware of impairments
- consistently follows simple directions
- verbal expressions are appropriate in highly structured/familiar situations
Rancho Cognitive Level VII
- min assist
- automatic, inappropriate
- consistently oriented
- able to attent to tasks for 30 mins in a non-distracting environment
- unrealistic planning for the future
- unaware of other’s needs and feelings
- unable to recognize inappropriate social interactions
Rancho Cognitive Level VIII
- stand by assistance
- aware of deficits
- purposeful, appropriate
- consistenly oriented
- able to recall and integrate past and recent events
- easily angered
- self centered
- able to acknowledge inappropriate social interaction
Rancho Level IX and X
IX-standby assist on request
X-modified independent
General principles for behavioral management
- moderate stimulation
- provide stability and consistency
- model calm and controlled behavior
- take advantage of distractability
- be prepared for anything, expect the unexpected
- try to understand the underlying meaning of behavior and respond to the cause rather than to the behavior
Impatience-contributing factors
- disinhibition of emotionality
- egocentrism
- misinterpretation of situations
Impatience-examples
- individual expects others to make immediate responses to his/her requests
- individual refuses to sit calmly in waiting room
Impatience-strategies
- do not allow individual to become focused on set time frames
- focus the individual on what steps have to take place
- do not take impatience personally
- distraction
Irritability-factors
- disinhibition
- egocentrism
- misinterpretation of situation
- confusion and overstimulation
Irritability-examples
- complaining
- irritated by normal stimulation like traffic, TV
- feeling anxious with no idea why
Irritability-strategies
- gentle reassurance
- provide reliability
- moderate stimulation
- do not take it personally
- distraction
Outbursts/abusiveness-factors
- may take form of verbal or physical aggression
- acting before thinking
- manifestation of impatience and irritability
Outburst-strategies
- ignore swearing and verbal abuse
- explain that outbursts will not result in his/her desires being met
- indirectly attempt to meet the desire
- accept no physical aggression
- explain to the patient that these actions are socially unacceptable
- never retaliate
Perseveration-factors
- poor memory
- poor problem solving abilities
- need for attention/reassurance
Perseveration-examples
- asking same Q over and over
- telling same story over and over
- compulsive letter writing
Perseveration-strategies
- provide alternative means of holding other attn
- provide reassurance
- set up a small timeframe during which the topic can be discussed
- distraction
Lability-factors
- loss of control over emotions
2. intense mood swings
Lability-strategies
- do not react as if demonstrated emotionality is a “big deal”-NEVER CRITICIZE!
- continue on with conversation or activity as if individual were reacting normally
- keep your own emotions under control
- try to minimize stress
- distraction
Denial-strategies
- allow the individual some denial as a coping mechanism, but do not lie
- allow safe real-life tests to take place so pt can discover what he/she can’t do
- support group
Suspciousness-factors
- may border on paranoia
2. caused by difficulty comprehending social situations and egocentric denial of intellectual difficulties
Suspiciousness-strategies
- do not argue
- ignore accusations
- don’t take it personally
- do not become obviously angry or combative
- distraction
- attempt to eliminate situations which are avoidable
- involve some other trusted person in the discussion of what is real and what isn’t
Overdependency-strategies
- do not cooperate with attempts to abandon activities and responsabilities which are problematic
- offer supportive reassurance
- highlight successful decision making and autonomous endeavors
- do not allow yourself to be overly protective
- encourage individual to become involved in a support group
- do not give guilt trips
- encourage patient to work with other team members
Withdrawal/Depression-Strategies
- develop a schedule with and for the individual and help him/her stick to it
- offer choices instead of yes/no
- discuss good things that have happened
Childish/crude behavior-strategies
- keep calm
- warn others of such tendencies
- each time this happens, a family member or friend should tell him/her in a non-threatening/non-combative manner that the behavior is unacceptable
- before entering a social/public situation remind the individual to avoid these behaviors
- distraction
Wandering/self endangering-strategies
- close supervision
- wanderers should have a contained environment
- danger-proof the house
Common BI complications
- raised ICP
- heterotopic ossification
- decubiti
- DVT
- autonomic dysfunction
- infections/pulm problems
- amnesia
Hetertopic ossification
-formation of bone in abnormal locations
-5-10% of pts with BI or SCI
-etiology unknown
-males more than females
S/S:
-sudden loss of ROM
-swelling
-local heat
-erythema
-non-septic fever
-vigorous stretching should be avoided
Retrograde amnesia
-partial or total loss of the ability to recall events that occurred during the period immediately preceding the BI
Posttraumatic amnesia
-time lapse bw accident and point at which functions concerned with memory are restored
Anterograde amnesia
- decreased attn or inaccurate perception
- inability to develop ongoing short term memory
Levels of alertness
- comatose
- stuporous
- obtunded
- lethargic
- alert
Comatose
-unconscious and unresponsive
Stuporous
-near unconscious with apparent mental inactivity and reduced ability to respond to stimulation
Obtunded
- opens their eyes
- responds slowly to questions
- somewhat confused
- decreased interest in environment
Lethargic
- dull
- sluggish
- appears half asleep
Coma
- rancho level 1
- level of arousal–eyes do not open
- no evidence of awareness to auditory and visual stimuli
- no communication or emotion
- no purposeful motor response
Vegetative state
- rancho level I or II
- eyes open spontaneously, sleep-wake cycles resume, sluggish and poorly sustained arousal
- may move eyes to person or objects
- may orient to sound or startle
- may moan
- cry or smile without apparent cause
- withdrawals from noxious stimuli
- non-purposeful repetitive movement
Minimally conscious state
- rancho level II or III
- eyes open spontaneously
- normal to abnormal sleep-wake cycle
- arousal obtunded to normal
- tracks objects
- localizes sounds
- communication ability
- inconsistent
- localizes noxious stimuli
- reaches for objects
- automatic behaviors
Confusional state
- rancho level IV, V or VI
- fluctuation in level of responsiveness
- response to external stimuli may be accentuated
- able to communicate but disoriented
- impaired attention and memory
- purposeful motor responses
Treatment strategies for Rancho I, II, III
- positioning/splinting
- stimulation
- ROM
Treatment strategies for IV, V
- constant cuing
- ask questions about status
- questionairres
- activity logs
Treatment for level VI
- memory
- problem solving
- simple to complex functional tasks
- simon says, red light/greenlight
Treatment for level VII
- gait
- balance
- ADLs
- memory
- problem solving
- simple to complex functional tasks
Treatment for level VIII
- increase independent attention to greater than 1 hour
- increase independence with non-familiar activities
- decrease self centered attitudes, irritability
Basal Ganglia role in movement and posture
- movement scale (like PD has hypokinesia)
- movement initiation (esp complex tasks)
- movement preparation (esp with internally generated cues)
- identifying one’s own body position relative to the environment
- longer loop postural reflexes
- perceptual and cognitive (not well defined)
Postural changes and parkinson’s
Sign of fatigue
Common BG disorders
- parkinson’s
- huntington’s
- wilson’s
- dystonia
Typical signs and symptoms of basal ganglia disorders
- changes in muscle tone
- decreased movement coordination
- decreased motor control
- decreased postural stability
- presence of extraneous movement
Parkinson’s disease facts
- most common BG disorder
- etiology largely unknown (small percent is hereditary)
- usually affects people over 50 years
- men=women, BUT the older you get the more likely it is to occur in men
- 1 in 3 > 85 years old have PD
Parkinson’s disease S/S
- rigidity (leadpipe, cogwheel)
- bradykinesia
- micrography (small handwriting)
- masked face
- postural abnormalities (flexed posture)
- lack of equilibrium reactions (2/3o f patients with PD fall, 10% fall 1x/week)
- resting tremor
- decreased trunk rotation
Parkinson’s non-motor, cognitive symptoms
- anxiety and depression
- bradyphrenia, mild cognitive impairment
- decreased attention (shifting or selecting), increased distractibility, decreased concentration
- decreased executive functioning
- decreased multi or dual tasking ability
- decreased organization ability
- sleep disturbances (REM behavioral d/o, excessive daytime sleepiness), fatigue
- bladder urgency and frequency
- orthostatic hypotension
- hyposmia (decreased sense of smell causing decreased sense of taste)
- pain/paresthesia
Parkinson’s secondary problems and complications
- muscle atrophy
- respiratory compromise
- decreased vital capacity
- chest expansion
- posture
- rigidity
- UE posturing
- increased energy consumption
- nutritional changes
- osteoporosis
- contracture and deformity
- decubiti
Parkinson’s osteoporosis
-diet, age, decreased activity
Parkinson’s contracture and deformity
- hip and knee flexors
- hip ADD
- plantarflexors
- toe flexors
- neck flexors
- shoulder ADD and IR
Modified Hoehn and Yahr Scale
0-no signs
1-unilateral disease
1.5-unilateral disease with axial involvement
2-bilateral disease without postural instability
2.5-early signs of postural instability (negative pull test)
3-bilateral disease with postural instability, physically independent (positive pull test)
4-severe disability but still able to stand or walk unassisted
5-confinement to W/C or bed
Pull test
- looks at retropulsion
- pt’s feet slightly apart
- pull them back slightly at the hips
- if pt takes 3 or more steps back or falls then test is positive
Parkinson’s treatment
- pharmacological/medical management
- surgery
- nutrition
- exercise
- physical management of symptoms
Pharmacological management
- dopamine agonist or replacement
- symptom management
- see handout of drug summary
Surgical management
- deep brain stimulation (DBS)
- stimulator implanted in the subthalamic nucleus
- allows for faster movement, gait deviations respond well
- disadvantages are low morbidity but significant psychiatric complication concerns (depression/mania)
- onset of symptom relief after implantation is minutes for parkinson’s and days to weeks for dystonia
Parkinson’s nutritional management
- high protein diet can block effectiveness of dopamine replacement
- recommended no more than 15% of calories from protein
- shift protein intake to evening meal to minimize motor fluctuations during the day
- eat a variety of foods
- consider supplements to ensure adequate vitamin/mineral
- OT for adaptive eating
- SLT for dysphagia
- ensure
Exercise and parkinson’s
- longevity and physical activity are related for individuals with PD
- link identified between lack of exercise and development of PD
- aerobic exercise found to reduce PD dysfunction
- additional pulmonary benefits
- improved QOL with decreased depression, improved mood and initiative
Parkinson’s PT referrals
- if you suspect someone has parkinson’s, refer as quickly as possible
- best to refer when initially diagnosed
- become a daily exerciser
- maintain normal movement
- prevent secondary complications
Parkinson’s PT exam
- Unified parkinson’s disease rating scale (UPDRS)
- comprehensive neuro exam
- PT evaluation of medication effectiveness
PT eval of medication effectiveness
- “all day evaluation”
- choose 3-5 impairments or functional limitations that are issues for the patient
- 5-7 minute examinations on the hour and perhaps on the half hour as well
- consult with MD to discuss “best” and “worst” times
- recommendations made for medication titration
Parkinson’s Gait
- decreased velocity
- decreased stride length
- decreased foot clearance
- flat footed progression
- decreased arm swing
- festination (attempt to catch up BOS with COG)
- can definitely use a walker with this patient population
- cue elbow extension to get them upright
Freezing in Gait Triggers
- sudden direction changes, turning, pivoting
- doorways or thresholds
- approaching furniture/obstacles
- turning around to sit
- change in floor pattern
- confined spaces
- crowds
- stress, anxiety, hurrying
Retropulsion triggers
- backing up to sit down
- reaching overhead
- stepping away from sink, counter
- opening door
- carrying items close to body in both hands
- being approached closely/suddenly jostled
Parkinson’s rehab
- aerobic (forced), faster than self-selected pace
- flexibility (to maintain ROM)
- strengthening
- rhythmic exercise (mambo, tai chi)
- functional activity
- pushing complexity
- gait and balance
- decrease fall risk
- changing task and environmental contexts
Parkinson’s respiratory management
- leading cause of death for persons with PD is pneumonia
- preventing pneumonia can be addressed with early aggressive aerobic exercise, maintain regular moderate exercise as disease progresses
Goals for early phase PD (hoehn and yahr 1-2.5)
- prevent inactivity
- prevent fear of falling
- improve physical capacity
Goals for mid phase PD (H and Y 2-4)
- same as early phase
- maintain or improve activities
- transfers, body posture, reaching and grasping, balance, gait)
MRADLs
mobility related activities of daily living
- transfers
- balance
- gait
Goals for late phase PD (H and Y 5)
- same as mid phase plus:
- maintain vital functions
- prevent pressure sores
- prevent contractures
Progressive supranuclear palsy (PSP)
- parkinsons plus syndrome
- similar to PD
- more cognitive impairment
- progression more rapid
- does not respond to L-dopa
- can’t track, vision difficulties
Multiple system atrophy (MSA)
- parkinson plus syndrome
- cortical, BG and cerebellar
- frontal lobe and autonomic dysfunction
- does not respond to L-dopa
- orthostatic hypotension
- big fluctuations in blood pressure
Huntington’s disease
- classic disorder resulting in BG hyperactivity (complete opposite of parkinsons)
- inherited autosomal dominant
- abnormalities in postural reactions
- decreased trunk rotation
- abnormal tone
- extraneous movements
- progressive, not much we can do
Wilson’s disease
- hepatolenticular degeneration
- caused by abnormal copper metabolism
- toxic copper levels
- degeneration of liver and BG
- if recognized and properly treated, the patient functions without restrictions
Tardive dyskinesia
- drug-induced disorder
- dyskinesia=inability to perform voluntary movement
- series of rhythmical extraneous movements
- associated with extension of spine/trunk
Dystonia
-movement disorder characterized by sustained muscle contraction in the extreme end range of a movement, frequently with a rotational component
Generalized dystonia
- usually inherited
- involving entire body
- most prevalent in those with European jewish descent
Focal dystonia
- usually related to repetitive movement produced under high cognitive constraints and attention
- associated with degenration of sensory cortex in the animal model
- most common=spasmodic torticollis
- others include vocal cords, tongue, facial muscles, hand, toes
Dystonia rehab
- botox
- rehab includes
- using only normal, tension-free mvts
- sensory integration
- relearning techniques performed with attn
- huge amounts of practice required
- regular relaxation program
other dystonia facts
- in all cases, excessive co-activation of agonists and antagonists occurs that interferes with timing, execution, and loss of independent jt movements
- some patients have issues with the pons in addition to the BG
- there is generally NO abnormal tone or abnormal reflexes
MS Overview
- immune mediated disease that primarily affects the CNS
- random attacks of inflammation (relapses and exacerbations)
Etiology of MS
- may be the result of an abnormal autoimmune response to an infection or environmental trigger in a genetically susceptible individual
- exact antigen is unknown
Pathophysiology of MS
- inflammatory disease destroying areas of myelin in the CNS (primarily white mattern)
- brain, spinal cord, brain stem, cranial nerves (optic nerve most common)
- axons become irreversibly damaged as a result of inflammation, even in early disease
- multiple areas of scarring or sclerosis
MS Epidemiology
- 90% of patients are diagnosed between the ages of 16-60
- Ms can develop in infancy or after 60
- caucasions>hispanics>african americans
- rare in Asians
- prevalent in temperate zones (esp. if you lived there before 15 years old)
- genetic link
- 1st degree relative with MS increases your risk
Most common MS symptoms
- FATIGUE (88%)
- difficulty walking (87%)
- bowel and bladder problems (65%)
- pain and other sensory changes (60%)
- visual disturbances (58%)
- cognitive problems (44%)
- tremors (41%)
Other common MS symptoms
- nystagmus
- speech difficulty
- incoordination
- weakness
- spasticity
- muscle spasm
- sexual dysfuntion
- emotional instability
Initial presentation of MS
- initial attacks are transient, mild, and self-limited
- many times only in retrospect that individuals recognize these as the first MS presentation
MS Diagnosis
- clinical attacks (timing and symptoms)
- MRI (lesion dissemination over space/time)
- CSF (elevated gamma globulin levels, possibly increased WBC)
- Positive evoke potentials (central nerve conduction testing)
- visual evoked potentials (VEP)
- brainstem auditory evoked potentials (BAEP)
- somatosensory evoked potentials (SSEP)
Factors affecting a more positive prognosis of MS
- females
- onset before age 35
- monoregional vs. polyregional attacks
- complete recovery after an exacerbation, leaving little or no residual impairment
Factors affecting a more negative prognosis
- male
- onset after age 35
- brainstem symptoms such as nystagmus, tremor, ataxia, dysarthria
- poor recovery following exacerbations
- frequent attacks
- african americans (less likely to have Ms, but more likely to have a more progressive form of the disease)
Special issues for pts with MS
- ambiguity of the disease
- unpredictability of the disease
- covert symptoms
- fatigue
- pain
- vision
- bowel and bladder
- paresthesias
Categories of MS
- relapsing/remitting
- primary-progressive
- secondary-progressive
- progressive-relapsing
Relapsing-remitting MS
- most common form of MS at time of initial diagnosis (85%)
- clearly defined disease flare ups (acute attacks)
- with FULL recovery OR
- minimal residual deficit
- periods between disease relapses (remissions) usually free of disease progression
Secondary-progressive MS
- 50% of people with relapsing-remitting develop this form within 10 years
- initial relapsing-remitting course followed by progression with or without occasional relapses, minor remissions with some recovery and plateau
Primary-progressive MS
- relatively rare (10%)
- disease progression from onset
- without plateaus OR
- with occasional plateau and temporary minor improvements possible
- steady increase in disability without “attacks”
Progressive-relapsing MS
- relatively rare (5%)
- progressive from onset
- clear acute relapses with or without full recovery
- periods between relapses characterized by continuing progression
5 categories of MS treatment
- treatment of acute exacerbations
- symptom management
- disease modification
- rehabilitation
- psychosocil support
Factors triggering a relapse
- often unpredictable
- infections (vaccines do not have an affect)
- physical and emotional stress
- heat can increase symptoms (but when you cool down they go away), core temp considerations in exercise
- pool recommendations <85
- last trimester of pregnancy offers a natural protection against relapse (20-40% increased risk for relapse after delivery)
Acute Relapse Management-MS
- natural improvement occurs over 4-12 weeks
- degree of improvement varies
- IV or oral corticosteroids
- methylprednisolone, prednisone
- little evidence that these medications alter the extent of disability or overall course of MS
Symptomatic Treatment-MS
- fatigue
- amantadine (symmetrel), provigil, prozac
- pain
- carbamazepine, baclofen, dilantin
- depression
- valium, diazepam, zoloft, paxil, prozac
- bowel and bladder
- urinary urgency–detrol, ditropan
- constipation–mild laxatives, stool softeners
- spasticity
- baclofen,
- dizziness and vertigo
- intention tremors
Goals of disease modifying agnets-MS
- reduce frequency of relapses
- reduce progression of disability
- reduce number and volume of brain lesions
Avonex
- for treatment of all relapsing forms of MS and for a single clinical episode if MRI is consistent with MS
- weekly IM injection
- Adverse reactions:
- flu symptoms
- depression, anemia, elevated liver enzymes, allergica reactions, heart problems
Rebif
- for all relapsing forms of MS
- 3x/week IM injection
- Adverse reactions:
- flu like symptoms
- injection site reactions, liver abnormalities, depression, allergic reactions, low RBC or WBC
Betaseron and Extavia
- all relapsing forms of MS
- every other day subcutaneous injection
- Adverse Reactions:
- flu symptoms
- inject site reactions
- allergic reactions, depression, elevated liver enzymes, low WBC
- *PRECAUTIONS**
- should not be given to pts with severe and untreated depression–increased suicide risk
Copaxone
- for relapsing/remitting MS
- daily subcutaneous injection
- Adverse reactions:
- injection site reactions
- vasodilation, chest pain, anxiety, palpitations, SOB, flushing (5-10 mins after injection with no long term effects)
Novantrone (Serono)
- for worsening relapsing/remitting MS and for progressive relapsing or secondary progressive MS
- 4x/year IV infusion
Tysabri (natalizumab)
- for relapsing forms of MS for individuals with inadequate response or unable to tolerate other MS treatment)
- every 4 weeks IV infusion
- Adverse reactions:
- increased risk of progressive multifocal leukoencephalopathy (PML), infusion reactions, headache, fatigue, joint and limb pain, abdominal discomfort, diarrhea, rash
PT and MS
- general knowledge pertaining to medication side effects
- coordination of treatment and medication schedule
- make note of changes in patient’s performance
- comprehensive neuro eval
Physical Therapy Treatment of MS
- support coordinated care and patient empowerment
- wellness and health promotion
- fatigue
- weakness
- spasticity
- balance/vestibular
- coordination
- sensory problems
- ambulation and mobility
- ADLs
Fatigue Management-MS
- issues likely contributing that need to be addressed:
- sleep (urinary frequency, ms spasms)
- poor diet
- deconditioning
- movement limitations
- depression
- neuromuscular conditions (more energy consumption by demyelinated axons)
- body core temp (rising slows conduction velocity)
- emotional stress
Effect of heat on MS
- many people are heat sensitive
- while it might aggravate common symptoms, no link to disease exacerbation
- -managing schedule and environment
- pool temp recommended <85 degrees
- cooling garments
Satisfaction with Life Scale-populations
- general
- student
- SCI
- TBI
- MS
Satisfaction with Life Scale-admin and scoring
- self administered or completed by interview
- scores range from 5-35
- higher score indicates better health
- score of 20 represents neutral point at which the respondent is equally satisfied and disatisfied
- review pdf on blackboard
SF-36-populations
Arthritis Back pain Low back pain Multiple sclerosis Musculoskeletal conditions Neuromuscular conditions Osteoarthritis Rheumatoid arthritis Spinal injuries Stroke Trauma Traumatic Brain Injury
SF-36-overview
36 item measure divided into 8 subscales:
(1) Physical Functioning
(2) Role Limitations due to Physical Problems
(3) General Health Perceptions
(4) Vitality
(5) Social Functioning
(6) Role Limitations due to Emotional Problems
(7) General Mental Health
(8) Health Transition
- responses should pertain tot he last 4 weeks
SF-36-scoring
- answers transformed onto a scale from 0 (negative health) to 100 (positive health) to provide a score for each subscale
- mean score=50, SD-10 (for each domain)
- MCID not established
MSQOL-54
- for MS patients
- similar to SF-36
- see pdf
Modified fatigue impact scale
- for MS
- full length is 21 items
- short form is 5
- cut off scores not established
- MCID (smallest -16.2, minimal detectable is 19.3%)
- see pdf
Modified falls efficacy scale-pt population
- adult inpatients
- TBI
- community
- long term care
- MS
- Parkinson’s
- SCI
- stroke
Modified falls efficacy scale-testing and scoring
- 10 item questionnaire
- assess perceptionof balance and stability during ADLs
- assesses fear of falling in the elderly person
- MCID not established
- Cutoff scores:
- > 80=increased risk of falling
- > 70=increased fear of falling
Review MS cheat sheet
in neuro folder
-and review examples of forms
Non-progressive cerebellar dysfunction
- CVA
- tumor
- TBI
Progressive cerebellar dysfunction
- MS
- spinocerebellar degeneration
- Freidrich’s ataxia
- cerebellar cortical atrophy
- olivoponto-cerebellar atrophy
Cerebellar dysfunction prognosis
- follow cerebellectomy=poor
- Bilateral<cortext
- most spontaneous compensation is complete in about 6 months to 1 year
Bilateral lesion of the cerebellum
-severe vertigo and nausea
Cerebellar dysfunction treatment
- postural (core) stability activities for functional tasks (for truncal ataxia)
- proximal stability activities
- developmental sequence
- decrease the degrees of freedom to allow the pt to focus on a particular portion of the task
Other cerebellar dysfunction treatments
- coordination exercises
- consider postural and proximal joint stability with all tasks
- frenkel’s exercises
- visual cues for placements
- temporary reduction of dysmetria and tremor with weights, PNF
Frenkel’s exercises
- very useful when you have a patient with ataxia
- takes 1/2 hour and should be done 2x/day
- coordination, not strengthening
- avoid fatigue
- normal ROM
- progress from lying down exercises (heel slide) progress to sitting, then to standing
- idea behind them is control
Weights and ataxia
- very controversial
- no research shows that it works
- as soon as you take the weight off they have no control again
Cerebellar dysfunction and gait treatment
- visual cues for placement
- weights (weighted vests for truncal ataxia–builds core, but doesn’t help with control)
- beiofeedback
- variety of surface
Treatment for non-progressive vs. progressive
If it’s non-progressive, some control may come back
If it’s progressive, you may need to work on compensatory techniques (with weights)
Cerebellar dysfunction and motor learning
- difficulty with generalization
- increase repititions
- vary task constraints
- vary environmental constratins
- cerebellum is greatly linked to motor learning
