1. lhermitte's 2. uhthoff's (heat = worse) 3. charcot's triad 4. visual dysfunction

MS, ALS, GBS, CNS Flashcards by Rebecca Nam

UMN lesions
structure involved:
tone: inc or dec?
reflexes:
sensation: inc or dec?
involuntary mvmts:
voluntary mvmts:

structure: CNS
tone:** increased**
reflexes: increased, clonus, babinski
sensation: decreased
involuntary mvmts: mm spasm
voluntary mvmts: synergistic patterns

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LMN lesions
structure involved: ____
tone: inc or dec?
reflexes: ____
sensation: inc or dec?
involuntary mvmts:
voluntary mvmts:
Dx:

PNS/CNs
tone: decreased
reflexes: decreased
sensation: decreased
involuntary mvmts: fasiculations
voluntary mvmts: weak/absent

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Basal Ganglia lesions
structure involved: ____
tone: inc or dec?
reflexes: ____
sensation: inc or dec?
involuntary mvmts:
voluntary mvmts:
Dx:

BASAL GANGLIA (parkinsons)
tone: increased
reflexes: decreased/normal
sensation: normal
involuntary mvmts: tremor
voluntary mvmts: bradykinesia or akinesia

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Cerebellar lesions
structure involved: ____
tone: inc or dec?
reflexes: ____
sensation: inc or dec?
involuntary mvmts:
voluntary mvmts:
Dx:

cerebellum
tone and reflexes: decreased
sensation: normal
involuntary mvmts: none
voluntary mvmts: ataxia, intention tremor, dysdiadokinesia, dysmetria, nystagmus

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progressive autoimmune disease characterized by chronic, progressive, inflammatory demyelination of CNS neurons

MULTIPLE SCLEROSIS

Myelin produced by oligodendrocytes in the CNS

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MS:
age range
F or M
ethnicity

age: 20-50
Females, although males have more aggressive disease course
African American > White

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First neurological episode or “attack” in MS is called

clinical isolated syndrome (CIS)

could become MS if additional activity occurs

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Relapsing remitting (80-90%) turns into ____ when they suddenly have decline without remission periods

secondary progressive MS
decline is progressive, no remission

RRMS: Clearly defined relapses or exacerbations followed by partial or f

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In order to be diagnosed with CIS, symptoms must last ___
and _______

last at least 24 hours
one lesion in brain and:
1. increased tone
2. lhermitte’s sign
3. uhthoff’s sign

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MS exacerbation

new and recurrent MS symptoms lasting over 24 hrs

pseudoexacerbation: less than 24 hours

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MS is a diagnosis of:

exclusion by neurologist
*2 attacks, 2 brain lesions –> dissemination of space and time

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4 unique ss of MS

lhermitte’s
uhthoff’s (heat = worse)
charcot’s triad
visual dysfunction

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what is charcot’s triad

scanning speech
intention tremor
nystagmus

cerebellum affected in MS

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most common symptoms of MS

fatigue (83%)
heat sensitivity (80%)
walking/balance issues 67% (gait impairments usually early in MS)
stiffness/spasms 63%

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motor symptoms in MS

Paresis or paralysis
Fatigue
Spasticity, spasms
Ataxia: incoordination, intention tremor
Postural tremor
Impaired balance and gait

PT exam: include spasticity, ataxia, B&B, tremors, balance, weakness

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Your patient has visual disturbances (diplopia), and paresthesias progressing to numbness, weakness, fatiguability.

What are you thinking they have?

these are common early symptoms of MS

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sensory symptoms of MS

hypoesthesia, numbness
paresthesia

*heat intolerance

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pain symptoms of MS

Paroxysmal limb pain, dysesthesias
Headache
Optic or trigeminal neuritis
Hyperpathia
Chronic neuropathic pain

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Fatigue symptoms in MS
primary vs seconary

primary: due to plaque location, hypometabolism
secondary: due to decreased efficiency of mvmt, more energy to perform ADLs

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cognitive symptoms of MS

information processing
executive function
memory (short term)
attention, multitasking, concentration

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overactive bladder causes ____
spastic bowel causes -___

overactive bladder: incontinence, frequency/urgency, nocturia
spastic bowel: constipation

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underactive bladder causes;
flaccid bowel causes:

underactive bladder: urinary retention
flaccid bowel: incontinence or constipation

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which diagnosis can impact vestibular system?

MS
75% have balance disorders
49-59% have vertigo/dizziness

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MFIS

modified fatigue impact scale: for MS
21 items: fatigue impact on physical, cog, psychosocial function in past 4 WEEKS

FATIGUE SEVERITY SCALE

not MS specific, many neuro pop ***fatigue within last week** 9 items

score of 1-4.5 on the Expanded Disability Status Scale

fully ambulatory for MS | examined by neurologist

score of 5-9.5 on expanded disability status scale

impaired ambulation with MS

ANPT MS-EDGE recommends students should learn how to use:

Theres a ton but key ones are: 12 item MS walking scale ABC DHI Timed 25 foot walk BERG, DGI, TUG, Trunk impairment scale

12 item MS walking scale (MSWS-12) is a __ reported outcome measure

patient reported *higher score = more walking limitation

MS Functional Composite (MSFC) assesses ____

cognition, gait, UE function 1. timed 25 foot walk test 2. 9 hole peg test 3. 3 sec version of paced auditory serial additional test (PASAT-3) | scores determined with z-scores

What is an MS specific participation measure?

MS IMPACT SCALE (MSIS-29) *impact of MS on day to day during past 2 weeks

4 Movement System Impairment Diagnoses for MS

Movement Pattern Coordination Deficit Force Production Deficit Fractionated Movement Deficit Hypermetria

top 3 patient education for patients with MS

1. energy conservation 2. rest breaks 3. heat sensitivity | also disease process

What is the most common form of motor neuron disease in adults

ALS *alpha motor neuron degeneration in ventral horn of brainstem and motor cortex

ALS presentation: diagnosis of ____

exclusion! Dx requires UMN + LMN ss, and decline function

ALS affects what gender and what age

men > women 40-70 years (55 average)

By the time patients report weakness, most have lost ___% of motor neurons in weak areas

80% (profound, extensive weakness) | *will report functional tasks: walking up stairs, falling, tying shoes

What are UMN signs of ALS

Spasticity Hyperreflexia Pathological reflexes

What are LMN signs of ALS

weakness, decreased endurance *esp weak neck extensors ## Footnote Muscle atrophy Fasciculations Hyporeflexia Hypotonicity Muscle cramps

What are Bulbar signs of ALS

Pseudobulbar Palsy -Emotional lability i.e. inappropriate or uncontrolled laughing or crying -Dysarthria -Dysphagia -Dysphonia -Impairment of voluntary movements of the tongue and facial muscles -Sialorrhea

what respiratory symptoms appear with ALS

Nocturnal respiratory difficulty Exertional dyspnea Accessory muscle use Paradoxical breathing

Why might a patient have muscle/weight loss with ALS?

CACHEXIA complex metabolic syndrome that causes weight and muscle loss.

What is a patient reported outcome measure for ALS to monitor progression of disability

ALS Functional Rating Scale-Revised *higher = better function 0-48

Key impairments besides weakness to watch for with ALS

1. respiration (vent?) 2. dysphagia (precautions w/ swallowing, eating position 3. dysarthria 4. postural control *neck extensors 5. positioning for pressure, pain, breathing *also, keys: nutrition--> need to gain weight, family support, HCP referrals

Whats the main movement system impairment diagnosis in ALS

FORCE PRODUCTION DEFICIT Movement: fractionated if present Muscle tone: mixed (UMN and LMN) Sensation: normal Coordination: may be unable to test due to weakness

If your patient is recently diagnosed with ALS, what kind of exercise is safe?

moderate intensity to help maintain function CV, strengthening without excess fatigue

Post exercise fatigue interfering w/ ADLs Feeling weaker or pain >30 minutes post exercise Excessive soreness 24 – 48h post exercise Severe muscle cramping, heaviness in the extremities, prolonged SOB. These mean that your patient with ALS ______

overworked/overexercised

Which disease is this: Immune-mediated polyneuropathy that affects nerve roots and peripheral nerves, leading to motor neuropathy and flaccid paralysis with possible sensory and ANS effects

GBS AKA AIDP rapid onset | usually after infection

Does GBS affect sensory? Does ALS affect sensory? Does MS affect sensory?

directly, GBS: yes, stocking-glove ALS: no, motor neuron MS: yes

pattern of motor symptoms in GBS

distal--> proximal (hands/feet first, then ascends) relatively symmetrical rapid, progressive

pattern of sensory loss in GBS

glove and stocking (distal--> prox) tingling/numbness

Are respiratory or CNs involved in GBS? What about reflexes?

YES reflexes: decreased

single breath count test below __ indicates what in GBS

below 19 *mechanical vent may be required | 1/3 of patients require ventilation

What is the outcome measure used in GBS

GBS Disability Scale

factors of poor prognosis with GBS

1. Severe weakness (especially tetraplegia) 2. If on vent 3. CN involved: associated with loss of eye movement, swallowing 4. Rapid progression from onset 5. Length of time to nadir 6. Older age 7. History of GI illness 8. Recent cytomegalovirus

primary movement impairment in GBS

force production deficit

What kind of exercises should you use in acute stage of GBS

AAROM, AROM *if 3/5 or less MMT, avoid eccentrics

CDS note: We may be emphasizing compensatory quicker in this population to get them as functional as possible for as best qol as possible.

CNS tumor *after tumor resection, they will temporarily get better *plasticity can occur in short term but tumors can grow back, and they can get better/worse with chemo or radiation

Headache red flags

1. interrupts sleep, worse when waking and better during day 2. posture, coughing, or exercise elicits headache 3. recent onset is worse than usual 4. new onset in older person 5. nausea, vomiting, papilledema, focal neuro signs