NEURO PPQ Flashcards
Question 1
Describe three exercises necessary to retrain oro-facial function following progressive bulbar palsy as a result of motor neuron disease. (6)
· Jaw closure
· Lip closure
· Elevate posterior third of tongue
· Facial exercises
o Check for puffing, facilitate with cold fingers inside mouth
o Male patient-shaving grooming facilitate with mirror; don’t ice for too long
Mrs Strange was stabbed in the neck four months ago and was diagnosed with C4 complete quadriplegia. She presents with increased spasticity and has been referred to you as an out-patient for management.
2.1 Discuss any four factors you should include when prescribing caregiver education to her family. (8)
Explain three techniques that you could use to manage her spasticity. (6)
● Movements either passive or assisted - the faster you move the pt the higher the tone becomes, always start with slow movements from proximal to distal. By performing slow movements on the proximal part of the limbs you will find that there is already a change in the distal part of the limb.
● Relaxing techniques - teach the pt to take deep breaths and relax, while performing this the muscles will also relax and let go.
● Correct positioning (in wheelchair and in bed) to prevent shortening of muscles, muscles should always be in a lengthened position.
● Heat therapy - Wrap limbs/entire body in warm towels to allow physiological processes to relax muscles.
● Hydrotherapy can also be used.
● Weight bearing - standing frames or tilt tables depending on the patients’ neurological level and what would be the safest for them. You could also perform weight bearing exercises for upper limbs in puppy prone or in four-point. When targeting the upper limbs you could use slow rhythmical rocking to influence the spasticity.
● Slow stroking/ deep pressure - apply a squeeze/deep pressure over the tightened muscle to allow for voluntary relaxation of that muscle.
● PNF- use rhythmic initiation and very slow reversals to get the antagonistic muscle to work.
● Antagonistic muscle stimulation with functional electrical stimulation to overcome spasticity.
● Advocate for your pt to be placed on medications like Baclofen, Diazepam or botulinum toxin especially if they experience pain with spasticity.
Explain three techniques that you could use to manage her spasticity. (6)
· Range of motion excs
· Prolonged passivee stretching
· Active assisted excs
· Serial splinting
· Hydrotherapy and ultrasound
· Phenol or alcohol or botulinum toxin
· Surgery is indicated after 6/52 of intensive physiotherapy without improvement
· Joint approximation
· Weight bearing with weight shifting
Compare and contrast Parkinson‘s disease and Parkinson‘s Syndrome. (10)
- Parkinson’s Disease (PD)
·Progressive neurodegenerative disorder of the extrapyramidal system.
Lack of dopamine
·Aetiology: Unknown cause that leads to dopamine deficiency
·Signs and Symptoms
-Tremor
-Rigidity
-Bradykinesia
-Impaired balance
-Gait problems
-Affects one side of the body more than the other
·Treatment
Medical mx:
-Replacement therapy →
-Levodopa
-Pallidotomy
-Cell transplantation
-Progressive not curable
Parkinson’s Syndrome
·General term that refers to a group of neurological disorders that cause movement problems similar to those seen in Parkinson’s disease.
Lack of dopamine
·Aetiology: Known cause including drugs, vasculature and some palsy’s that lead to dopamine deficiency
·Signs and Symptoms:
-No tremor
-Rigidity
-Bradykinesia
-Impaired balance.
-Affects both sides of the body equally
·Treatment:
Medical mx:
-Replacement therapy → Levodopa
-Stopping medication causing symptoms
List four forms of multiple sclerosis. (2)
· Progressive-relapsing multiple sclerosis-steady decline since onset with superimposed attacks
· Secondary progressive multilpe sclerosis-initial relapsing-remitting multiple sclerosis that suddenly begins to have decline without periods of remission
· Primary progressive multiple sclerosis-steady increase in disability without attacks
· Relapsing-remitting multiple sclerosis-unpredictable attanks which may or may not leave permanent deficits followed by periods of remission
Discuss four physiotherapy management strategies used during the terminal stage of motor neuron disease. (8)
· Position changing
· Respiratory care
· Pressure care
· Back care for carers
· Advice on feeding positions and diet
· Counseling to patient and carer-refer to social worker
Tabulate any four comparisons and contrasts between spasticity and rigidity. (½x8=4)
Spasticity
·Pattern of muscle Movement: UL Flexors
·Nature of tone: Velocity dependent increase in tone
·Tendon reflexes: Increased
·Clinical signs: UMN (Pyramidal sign)
·Tested through: Quick movements
Rigidity
·Pattern of muscle Movement: Flexors and extensors Equally
·Nature of tone: Constant throughout ROM
·Tendon reflexes: Normal
·Clinical signs: Extrapyramidal sign
·Tested through: Slow movements
Ms Jones is a C4 complete tetraplegic and has developed a Stage III pressure ulcer on her sacrum and is placed on strict bed rest in prone-lying. Discuss the role of the physiotherapist in the management of her pressure ulcer. (8)
Role of physiotherapy
· Education the patient on what pressure ulcers are, how to prevent them and possible complications associated with them.
· Prevention-through effective pressure relief, frequent positioning every 10-15 minutes and optimum seating patterns
· Curative- this can be done using conservative management such as electrolyte substitution and position change.
· Promotive- family education on positioning, transfers, wound care and cleaning (hygiene), as well as providing information about PUs and associated complications
Explain how you would manage a patient with Parkinson’s disease who struggles with initiation of walking. (8)
· Gait initiation by starting with high long steps.
· Trunk mobilisation with emphasis on arm swing.
· Movements should be broken up into small components
· Conscious effort (attention) on the task.
· Where possible, avoid simultaneous task performance
· A mirror can also be used to correct posture.
· Repetition important
· Walking aid use = restriction of normal walking patterns
· Motor-planning problems may complicate aid use.
· One can provide a walking aid so as to reduce falling episodes.
· Proper assessment for selection and use of walking aid necessary
· Freezing =When the patient is approaching the “freezing” time e.g. approaching a door way or about to turn they can:
o count their steps aloud
o stamp their feet
o lift their feet as if stepping over something
o or they can look at anything that has a pattern on it e.g. a rock and again repetition is the best way to learn.
· Lines on the floor and on steps.
· Break tasks down into components, teach each component and then task as a cognitive activity.
· Don’t walk/eat and talk at same time
· Chan et al (1993) reported significant changes in stride length, velocity and cadence in single-subject design following facilitation of pelvic-trunk counter-rotation.
Discuss the expected sensory problems associated with multiple sclerosis. (6)
· Paraesthesia: pins and needles sensation
· Pain: usually muscular in origin
· Loss of proprioception: makes coordinated movements difficult
Muscle strengthening is an important focus of physiotherapy management for patients in the plateau phase of Guillian-Barre syndrome.
Describe the focus of an exercise programme in this phase and give four examples of exercises you would include. (5)
Focus: Muscle strength central stability
Exercises:
● Kneeling
● Rhythmic stabilisation
● Crawling
● Big physioball exercises
A patient with Guillain Barre syndrome may experience periods of postural hypotension which needs to be taken into consideration by the physiotherapist. Discuss this statement. (10)
Postural hypotension refers to a drop in blood pressure upon assuming an upright position. This can have implications for physiotherapists in managing and providing care for these patients due to the following reasons:
· Autonomic Dysfunction: GBS is characterized by immune-mediated damage to peripheral nerves, including the autonomic nervous system. The autonomic nervous system regulates various involuntary functions in the body, including blood pressure control. In GBS, dysfunction of the autonomic nerves can lead to impaired regulation of blood pressure, resulting in postural hypotension.
· Risk of Falls and Safety Concerns: Postural hypotension can increase the risk of falls and related injuries, especially when patients with GBS attempt to stand up or change positions. Physiotherapists need to be aware of this potential issue and take appropriate precautions to ensure patient safety during mobility exercises and transfers. They may need to implement strategies such as gradual positioning changes, providing support during transitions, and closely monitoring blood pressure responses.
· Exercise and Orthostatic Intolerance: Physical activity and exercise are important components of rehabilitation for patients with GBS. However, postural hypotension can lead to orthostatic intolerance, where symptoms worsen upon assuming an upright posture. Physiotherapists should carefully monitor the patient’s response to exercise and modify the intensity, duration, and frequency of therapy sessions to prevent excessive drops in blood pressure and minimize orthostatic symptoms.
· To effectively manage postural hypotension in patients with GBS, physiotherapists may collaborate with other healthcare professionals, such as physicians or occupational therapists, to develop a comprehensive care plan. This plan may include strategies to improve blood pressure regulation, such as appropriate fluid intake, wearing compression stockings, and optimizing medication management under the guidance of a medical professional.
· Regular monitoring of blood pressure before, during, and after therapy sessions can help guide treatment decisions and ensure patient safety.
Explain spasms under the following headings:
a) Type of impairment (2)
b) Outcome measure used to assess spasms (1)
a) Manifests as a muscular problem due to an upper motor neuron lesion and decreased inhibition of the reflexes. These are often a result of exaggerated reflexes in response to sensory stimuli.
b) Penn Spasm Frequency Scale
Describe two supra-spinal level inhibitory influences whose absence could contribute to the occurrence of spasms. (4)
Basal Ganglia - which helps with refinement of and inhibition of certain movements. Absence results in akinesia, rigidity, dyskinesia on the contralateral side
Vestibulocerebellum - which helps with maintenance of balance. It’s absence will lead to bilateral/ipsilateral ataxia with intention tremors
Explain autonomic dysreflexia under the following headings:
a) Causation (3)
b) Prevention (3)
c) Management (3)
a) Causation (3)
· Anything that can cause discomfort to a neurologically intact person can trigger autonomic dysreflexia in a pt with SCI
· Distended bladder or rectum are common stimuli
· Stimulation of the skin from pressure, pain, heat or cold
· Bowel- over distended or irritation
· Skin-related disorders
· Sexual activity
· Other
o Heterotopic ossification
o Acute abdominal conditions
o Skeletal fractures
b) Prevention (3)
· Call doctor to administer an antihypertensive agent with rapid onset and short duration
· Educate pt on
o positioning to enhance comfortability, avoid laying flat supine. Opt for semifowlers
o relaxation positions,
o ACBT with focus on BC
o Monitor vitals
c) Management (3)
General management of Autonomic/Sympathetic dysreflexia (the goal of Rx is to identify and remove the cause of the dysreflexia and thus lower the BP)
· Check the pt’s BP
· If BP is elevated sit them up immediately with feet down to promote orthostatic reduction of BP. If pt unable to sit, elevate head of bed to 90 degrees
· Loosen any clothing or constrictive devices
· Monitor the urinary catheter for any blockage or twisting during movement
· Call doctor to administer an antihypertensive agent with rapid onset and short duration
· Document the episode
· Deterrence/prevention
· Good bladder and bowel care
· Patient education
Explain the physiotherapy management of a patient with Guillain Barre syndrome during the acute phase of the disease. (10)
Physiotherapy Mx: Acute stage (usually up to day 10)
· Respiratory care (ACBT, PD, Manual tech, Sxn..)
· Musculoskeletal: Joint protection (e.g. AFO), Maintenance of joint movement (e.g. AP’s/PA’s – should know when to choose between the two) and soft tissue length
· Skin: positioning & circulatory exercises
· Circulation: Prevent DVT & Postural hypotension
· Psychological support: family and patient
Mr Napo presents with a history of slow onset asymmetrical muscle weakness that has a patchy distribution, increased tone and reflexes, and has poor vision. Write short notes about the pathology of his condition. (12x½ =6)
Mr Napo has multiple sclerosis which is an inflammatory immune mediated demyelinating disease affecting the brain, spinal cord, and optic nerves. The myelin sheath (fragments and disintegrates) is mainly affected, and nerve axons are affected secondarily.
There are patchy areas of demyelination, and this is followed by gliosis.
Loss of myelin sheath and oedema results in decreased nerve impulse conduction. Remyelination occurs, however the re-myelinated axons and myelin sheath are thinner and shorter. Further clinical decline occurs when remyelination fails thereby leaving the axons in a vulnerable state. This failure could be due to a deficiency in the precursor cells, a failure of precursor cell recruitment, or a failure of precursor cell differentiation and maturation. Uhthoff’s phenomenon/syndrome could occur when an increase in body temperature aggravates the decrease in conduction of nerve impulses. Heat increases the hydrolysis of acetylcholine therefore decreased motor unit recruitment leading to muscle weakness and fatigue.
Explain the term “freezing” with regards to Parkinson’s disease. (4)
Freezing is a part of the gait problems faced by patients with Parkinson’s disease and it occurs when the patient has to transition from one movement to another such as turning a corner, standing from seated position. This also occurs because the patient struggles to initiate, transition and stop automatic movements. This often occurs when pt’s with Parkison’s disease are due for their Dopaminergic medication. Freezing episodes can be triggered by transitional movements or an attempt at performing multiple tasks at once.
Mr Ncube has been diagnosed with a Brown Sequard lesion resulting in ipsilateral and
contralateral signs and symptoms following a stab wound to the lower back.
4.1. Name the tract(s) that are involved in the ipsilateral effects and the associated signs
and symptoms. (6)
Brown Sequard Lesion is the hemi-section of the spinal cord, and it has the best prognosis for ambulation. Recovery takes approximately 6 months, and it commences in the ipsilateral proximal extensors then the distal flexors.
4.1. Posterior column – loss of vibration, form perception, two point discrimination, proprioception, and motor function below the level of the injury.
4.2. Name the tract(s) that are involved in the contralateral effects and the associated signs and symptoms. (2)
- Spinothalamic tracts (hemi-anaesthesia/hemi-analgesia)- Loss of pain, temperature sensation and light touch below the level of the injury
Describe the tenodesis grip and its importance when managing a patient with a C6 complete
spinal cord injury. (3)
● Tenodesis grip – passive finger flexion with thumb opposition when performing wrist extension.
● Grip strength can be achieved with a flexor-hinge orthosis/brace. This is important when managing a patient with a complete C6 SCI because it can be utilised to facilitate grasping in tetraplegic patients with intact wrist extension against gravity. This gives the patient more independence with functional tasks such as grooming, dressing, feeding, and personal hygiene activities without the assistance of the caregiver.
Name and discuss two oro-facial problems following motor neuron disease with regards to the possible causes and physiotherapy management. (9)
● Swallowing problems (dysphagia) – this is a result of progressive bulbar palsy which results in LMN signs and symptoms and restricted function of the tongue. The tongue is weak and wasted and sits in the mouth with fasciculations. The patient presents with a hypoactive gag reflex which increases the risk of aspiration, sand decreased lip and jaw closure. The patient will also have a collection of saliva in the mouth leading to drooling. The PT can teach the patient postural techniques where he/she adjusts the head and body position when feeding to optimize swallowing and reduce the risk of aspiration. Referral to a dietician to alter the diet (texture and consistency of foods) as liquids may be easier to swallow compared to solid foods.
● Dysarthria – this is a result of progressive bulbar palsy which results in LMN signs and symptoms and restricted function of the tongue. The patient will present with slurred speech, poor articulation, reduced speech volume and an altered pitch. This is due to muscle weakness of the muscles controlling the tongue, lips, palate, and vocal cords. The PT can assist through strengthening and coordination of the affected muscle groups by using deep breathing exercises as they strengthen the respiratory muscles to help maintain control over speech volume and quality. Referral to a speech therapist will be necessary to ensure the patient gets exercises for articulation.
Explain how technology can affect the building blocks of a health care system. (Explain only
three building blocks). Service delivery, Health workforce, Information, Medical products, vaccines+technology, financing, and leadership and governance (6)
● Acquisition of expensive medical equipment (MRI/CT scans, TENS) can impose a financial burden on the healthcare system; and not all healthcare facilities will be afforded such equipment. Lack of such equipment in certain districts will limit diagnostic capacity of the healthcare workforce there and thus result in poor service delivery. This will have an overall burden on the healthcare workforce in the districts with this technology as they will have to work harder to cover more patients; which also compromises quality service delivery.
● Advances in technology will make it easier to collect and store information which will help the healthcare workforce to make better decisions about patient management thereby improving overall patient outcomes. This will also enable the patients to be active participants in their healing process as they will be able to easily access information regarding their health via the internet or by having easy communication methods with their healthcare provider.
● Improvements in technology within a healthcare system will enable improved and efficient service delivery to the target population of the hospital. For example, transitioning from a paper-based record keeping system to a computer-based system; this will make it easier to keep patient records and integrate patient information across hospitals in different provinces.
Explain the relationship between the rehabilitation process and occupational health. (10)
● The relationship between the rehabilitation process and occupational health is closely intertwined, as both concepts are focused on maintaining and enhancing the well-being of individuals within the context of their work environments.
● Occupational health is a multidisciplinary legislative requirement that aims to protect and promote the physical, mental and social well-being in the workplace. The goals of OH are to prevent risks and hazards in the workplace, thereby promoting physical and psychological health. OH encompasses early risk diagnosis (to limit disability), and adaptation of the work environment according to the capabilities of the workers. Through risk assessment in the workplace, OH workers can be able to mitigate any further consequences of occupational risks with a rehabilitation process.
● The rehabilitation process aims to restore physical, psychological and mental well-being following injury or disability thereby improving quality of life and reintegration into the work environment.
● OH practitioners play a crucial role in identifying workplace hazards and implementing prevention strategies to minimise the occurrence/consequence of occupational hazards. Practitioners are also responsible for creating return-to-work programs for workers that have sustained injury through collaboration with other specialists to ensure gradual and safe reintegration that aligns with the physical and psychological capabilities of the worker. Adaptation of the work environment is often necessary following injury or disability and must be facilitated by the practitioners. An integral part of the rehabilitation process is worker education on appropriate ergonomics in their respective work environment to reduce likelihood of injury or hazard exposure. Evaluation of the steps taken to prevent hazard exposure or to adapt the environment to fit worker capabilities must be done to ensure that changes are beneficial to the worker and that he/she is coping.
