Neuro #4 Infectious diseases & CVA pg 147-151 Flashcards
What is Meningitis?
Inflammation of membranes in the spinal cord or brain
What is the etiology of meningitis?
- Bacterial - Escherichia Coli, Haemophilus influenzae, Streptococcus pneumoniae, other streptococci.
or
2. Viral
patients with bacterial meningitis are usually sicker with more rapid time course
Ways to treat meningitis
treat infective organism (bacterial meningitis) with antbacterial therapy (antibiotic, antipyretic); maintain fluid and electrolyte imbalance.
ole of PTs in treatment of patients with meningitis
Provide supporting symptomatic therapy including:
- bed positioning
- PROM
- Skin care to prevent complications of immobility
- Safety measures if confusion is present
What is Encephalitis?
Severe infection and inflammation of the brain
What is the etiology of Encephalitis?
- Arboviruses, or a sequela in influenza (Reye’s syndrome, eastern equine encephalitis, measles)
- Chronic and recurrent sinusitis
- Otitis
- Other infections; bacterial encephalitis, prion-caused disease (kuru, mad cow disease)
Treatment for encephalitis- Medication and PT intervention
Treat infectious organism (bacterial encephalitis)
PTs should provide supportive symptomatic therapy
What is Brain Abscess?
Infectious process in which there is a collection of pyogenic material in brain parenchyma
- It could be an extension of an infection e.g. meningitis, Otitis media, Sinusitis, post TBI; typically frontal or temporal lobes of cerebellum
Signs and symptoms of Brain Abscess
- Headache
- Fever
- Brainstem compression
- Focal signs CN 11 and VI
Treatment of Brain Abscess (2)- Medical and PT intervention
- Treat infective organism
- Surgical intervention
- Provide supportive symptomatic therapy
What is Acquired Immune deficiency Syndrome AIDS?
Viral syndrome characterized by acquired and severe depression of cell-mediated immunity
Symptoms of AIDS
Widespread, 1/3 of the patients exhibit CNS & PNS deficits
- AIDS dementia Complex (ADC)- symptoms range from confusion and memory loss to disorientation
- Motor deficits; ataxia, weakness, tremor, loss of fine motor coordination
- Peripheral neuropathy- hypersensitivity, pain, sensory loss
Treatment of HIV- Medical and PT intervention
- Anti HIV drugs
2. Provide palliative and supportive therapy.
What is a cerebrovascular Accident?
AKA CVA or Stroke
A sudden focal neurological deficit resulting from ischemic or hemorrhagic lesions in the brain
What are the ethological categories of CVA/ Stroke (3)
- Cerebral Thrombus: Formation or development of a blood clot or thrombus within the cerebral arteries or their branches
- Cerebral Embolism: Travelling bits of matter (thrombi, tissue, fat, air, bacteria) that produce occlusion and infarction in the cerebral arteries
- Cerebral Hemorrhage; Abnormal bleeding as a result of rupture of a blood vessel (extradural, subdural, subarachnoid, intracerebral)
What are the risk factors of CVA/Stroke? (5)
- Atherosclerosis
- Hypertension
- Cardiac disease- rheumatic ulvar disease, endocarditis, arrhythmias, cardiac surgery.
- Diabetes, metabolic syndrome
- Transient Ischemic Attack: brief warning episodes of dysfunction (<24 hours); a precursor of major stroke in more than 1/3 of patients
What are the pathophysiology of CVA/Stroke? (3)
- Cerebral anoxia
- cerebral infarction
- Cerebral edema
What is Cerebral Anoxia?
Lack of oxygen supply to the brain (irreversible anoxic damage to the brain begins after 4-6 minutes)
What is Cerebral Infarction?
Irreversible cellular damage
What is Cerebral Edema?
Accumulation of fluids within the brain; causes further dysfunction; elevates intracranial pressures, can result in herniation and death.
What is meant by Neurovascular Clinical Syndromes?
Signs and symptoms associated with occlusion of selected vessels
Two types of Neurovascular Clinical Syndromes
- Internal Carotid Artery Syndrome
2. Vertibrobasilar Artery Syndrome
What is Internal Carotid Artery Syndrome?
ICA arises off of the common carotid artery, gives off an ophthalmic branch and terminates in the ACA and middle cerebral artery MCA;
Signs & symptoms
Occlusion commonly produce s&s of MCA involvement with reduced levels of consciousness; ACA may also be affected.
Lesions involvine ACA and MCA distributions may produce massive edema, brain herniation and death
What is ACA syndrome?
ACA supplies the anterior 2/3 of the medial cerebral cortex. Occlusion of proximal to anterior communicating artery produce minimal defects due to collateral circulation- circle of willis
What is MCA Syndrome?
MCA supplies lateral cerebral cortex, basal ganglia, and large portions of the internal capsule
What is the Vertebrobasilar Artery?
Two vertebral arteries arise off the subclavian arteries and supply the ventral surface of the medulla and the posterior inferior aspects of the cerebellum before joining to form the basilar artery at the junction of the pons and medulla, the basilar artery supplies the ventral portion of the pons and terminates in the posterior cerebral artery PCA.
What are the syndromes associated with the Vertebrobasilar artery?
- Medial Medullary Syndrome
- Lateral Medullary Syndrome - Wallenberg’s
- Basilar Artery Syndrome
- Medial Inferior Pontine Syndrome
- Lateral Inferior Pontine Syndrome
- PCA Syndrome
What is Medial Medullary Syndrome?
Occlusion of the vertebral anterior branch of the lower basilar artery
What is Lateral Medullary Syndrome - Wallenberg’s?
Occlusion of vertebral, posterior inferior cerebellar, or basilar artery
What is Basilar Artery Syndrome?
Produces brainstem signs and symptoms and PCA S&S; Locked-in syndrome (basilar artery occlusion at the level of the pons)
What is Medial Inferior Pontine Syndrome?
Occlusion of the paramedian branch of basilar artery
What is Lateral inferior pontine syndrome?
Occlusion of the anterior inferior cerebellar artery
What is PCA Syndrome?
PCA and posterior communicating arteries supply the midbrain, temporal lobe, diencephalon, and posterior third of cortex; occlusion proximal to posterior communicating artery produce minimal deficits owing to collateral circulation
What are the sequential recovery stages of CVA? 6 stages
Stage 1: Initial flaccidity, no voluntary movement
Stage 2: Emergence of spasticity, hyperreflexia, synergies (mass patterns of movement)
Stage 3: Voluntary movement possible, but only in synergies; spasticity strong
Stage 4: Voluntary control in isolated joint movements emerging, corresponding decline of spasticity and synergies
Stage 5: Increasing voluntary control out of synergy; coordination deficits present
Stage 6: Control and coordination near normal.
What should PTs look for when examining a CVA patient?
- Generalized sign of intracranial pressure
- Level of consciousness, cognitive function
- Speech and communication
- Behavors
- Sensory deficits
- Motor function
What should PTs look for when examining speech and communication in CVA patients?
- Examine for aphasia with lesions of parieto-occipittal cortex of dominant hemisphere (typically L hemisphere)
- Examine for perceptual deficits with lesions of the parietal lobe of nondominant hemisphere (typically R hemisphere)
What behaviors should PTs look for when examining CVA patients?
- Patients with lesions to the L hemisphere (R hemiplegia) are slow, cautious hesitant and insecure
- Patients with lesions of the R hemisphere (L hemiplegia) are impulsive, quick, indifferent; often exhibit poor judgment and safety, overestimating their abilities while underestimating their problems
What sensory deficits should PTs look for in patients with CVA? (3)
- Superficial, proprioceptive and combined sensations of contralateral extremities, trunk and face.
- hearing, vision; examine for homonymous hemianopsia
- Cranial nerve function with brainstem, vertebrobasalar strokes (pseudobulbar palsy)
What motor functional deficits should PTs look for in patients with CVA?
- Presence of abnormal tone and primitive reflexes
- Spasticity
- Loss of selective movements, presence of abnormal limb synergies
- Presence of paresis, incoordination, motor programming deficits (apraxia)
- Postural and balance deficits
- Gait
4 types of synergies experienced by patients with CVA
- UE flexion synergy
- UE extension synergy
- LE flexion synergy
- LE extension synergy
What are the typical gait deficits at the HIP in patients with CVA?
- Poor hip position (retracted, flexed)
- Trendelenburg limp (weak abductors)
- Scissoring (spastic adductors)
- Insufficient pelvic rotation during swing
Weak hip flexors during swing may yield circumducted gait, ER with adduction, backward leaning of trunk or exaggerated flexion synergy
What are the typical gait deficits at the Knee in patients with CVA?
Weak knee extensors- knee flexes during stance; may result in compensatory locking of knee in hyperextension. Spastic quadriceps may yield a hyperextended knee.
What are the typical gait deficits at the Ankle in patients with CVA?
- Foot drop- equinus gait (heel does not touch down)
- Varus foot- weight is borne on lateral side of foot
- Equinovarus position
What are the typical gait deficits associated with unequal step length in patients with CVA?
Leg does not advance through end of stance into toe off
Outcome measures utilized for CVA/ stroke
- Fugl-Meyer Assessment of Physical Performance (FMA)- provides objective criteria for scoring of movements
- NIH stroke scale - provides measurements of acute cerebral infarction
- Postural Assessment Scale for Stroke (PASS)- standardized assessment of postural control and balance in stroke patients
- Stroke Impact Scale- provides a brief assessment of physical and social functioning after stroke
- Functional Independence measure (FIM)- measurement of 1 items of physical , psychological and social functioningfunction
- Functional Assessment Measure (FAM) - in addition to FIM items, the FAM includes additional functional areas including community access, instrumental ADL, safety, employability and adjustment.
List the PT goals, outcomes and interventions for persons being treated for a CVA/stroke
- Monitor changes associated with recovery and inactivity
- Promote awareness, active movement, and use of hemiplegic side
- Improve postural control, symmetry and balance
- task specific training
- Promote independence with ADL/self-care, compensatory training as appropriate
- Improve respiratory and oromotor function; promote functional cardiorespiratory endurance.
- Isokinetic training useful to improve timing deficits, velocity control of movement
- Locomotor training using body weight-support BWS and motorized treadmill training
- EMG biofeedback training using to decrease firing in spastic muscles, increase firing in paretic muscles and improve motor control
- Functional Electrical Stimulation FES- used to stimulate muscle action, reduce spasticity and substitute for an orthosis
- Constraint Induced Movement Therapy (CIMT)
What should a PT do when monitoring changes associated with recovery and inactivity?
- Prevent or minimize indirect impairments/secondary complications
- Maintain ROM and prevent deformitythrough optimal positioning, PROM and mobilizations
- Maintain Skin Integrity
- Avoid traction injuries to arm, development of painful shoulder
- Don’t use overhead pulleys in treatment of hemiplegic UE
2 Teach sensory compensation strategies for sensory and perceptual losses
3. Strengthen all available muscles
How could a PT promote awareness, active movement and use of hemiplegic side in patients with CVA?
- Promote normalization of tone through activities
- Promote selective movement control (out of synergy movements) of involved extrimities; emphasize functional patterns of movement
What are some task specific training performed by PTs when treating patients with CVA?
- Promote active problem solving independence
- Focus on goal-directed tasks, functional mobility skills e.g rolling, supine to sit, sitting, sit to stand, transfers, wheel chair skills and locomotion
- Focus on adapting movements to specific environmental demands
- organize feedback inputs (knowledge of results and performance) and practice schedules to facilitate learning.
What activities do PTs implement to improve respiratory and oromotor function when treating patients with CVA?
- Improve chest epansion, diaphragmatic breathing patterns
- oromotor training
- Aerobic conditioning; cycle ergometry, threadmill or overground walking
- Don’t prescribe exercise or progressive physical activity regiments to patients without monitoring heart rate and BP
What are the guidelines to promote learning with hemispheric differences in patients with L hemisphere lesions -CVA ?
- Develop an appropriate communication base; words, gestures, pantomimes, assess level of understanding
- Give frequent feedback and support
- Do not underestimate ability to learn
What are the guidelines to promote learning with hemispheric differences in patients with R hemisphere lesions -CVA ?
- Use verbal cues; demonstrations or gestures may confuse patients wit visuospatial deficits
- Give frequent feedback: focus on slowing down and controlling movement
- Focus on safety- patient may be impulsive
- Avoid environmental (spatial) clutter
- Do not overestimate ability to learn
