Neurodegenerative Diseases

Question 1

__________: impairment of voluntary and spontaneous movement initiation that results in
freezing, especially during gait activities

Answer 1

Akinesia

Question 2

_________: numbness and tingling because of sensory nerve changes

Answer 2

Paresthesia

Question 3

________ gait: small rapid steps that result from a forward-tilted head and trunk posture

Answer 3

Festinating

Question 4

___________: involuntary muscle contraction and relaxation; observed as a muscle twitch

Answer 4

Fasciculation

Question 5

_______: muscle stiffness that impairs movement

Answer 5

Rigidity

Question 6

_________: decreased coordination of movements

Answer 6

Dysmetria

Question 7

____________: slowed motor movements

Answer 7

Bradykinesia

Question 8

Occupational therapy intervention

Answer 8

1. Teach cognitive compensatory strategies.
   a. Minimize distractions and interruptions during task completion.
   b. Use problem-solving techniques.
   c. Use memory aids and written instructions.
   d. Minimize multitasking.
   e. Allow increased time to complete tasks.
2. Provide training in activity strategies and energy conservation.
   a. Alternate periods of rest with periods of activity (e.g., alternate sitting and standing during
   tasks) .
   b. Complete higher priority tasks in the morning.
   c. Use appropriate equipment such as orthotics and powered mobility to minimize energy use.
   d. Use ergonomic adaptations to provide head and arm support.
3. Help the client delegate roles to family members to balance independence with assistance from
   others during occupational performance.
4. Provide environmental modifications and adaptive equipment training for home and work
   safety and independent task performance.
5. Recommend exercise programs that are within the client’s limitations and that promote a
   balance of activity performance and rest periods (e.g., shorter exercise periods every day may
   be better than longer exercise periods 3 times a week).

Question 9

_______ __________ is a chronic, often progressive demyelinating disease of the central
nervous system; a person’s own body attacks the myelin sheath that covers the neurons of the
brain and spinal cord. This demyelination produces scar tissue or plaque (sclerosis) on the
myelin sheath of nerve fibers that interferes with the axons’ ability to conduct impulses. The
result is impaired nerve conduction and inflammation, which causes neurological dysfunction.
The specific location of demyelination differs with each person and dictates symptoms

Answer 9

Multiple Sclerosis (MS)

Question 10

MS

Early
interventions in __________ mobility and ADLs, fatigue management, and role and routine
modifications are critical for preventing and delaying onset of disability

Answer 10

functional

Question 11

MS
Signs and symptoms

1. Clinical presentation

Answer 11

a. Often diverse and difficult to predict, with various combinations and patterns

b. Initial complaints: typically, visual disturbances, dizziness, and weakness. Symptoms at
times worsen (exacerbation) and at other times improve (remission). MS progresses over
time and is eventually irreversible.

Question 12

MS
Signs and symptoms

2. Motor symptoms

Answer 12

a. Impaired balance and coordination (ataxia)

b. Partial or complete paralysis of a part of the body; muscle spasticity, especially in lower
extremities

c. Muscle weakness
d. Fatigue: the most common complaint and debilitating symptom

e. Intention tremors, which occur when a person attempts to engage in meaningful activity,
such as reaching for an object

f. Dysphagia

Question 13

MS Signs and symptoms

3. Sensory symptoms

Answer 13

a. Paresthesia: numbness or tingling
i. Impaired vibratory, proprioceptive, pain, touch, and temperature sensations
ii. Distorted superficial sensation
iii. Impaired sensation, which may affect perceptual skills such as stereognosis,
kinesthesia, or body scheme

b. Vertigo
c. Pain (typically the result of musculoskeletal causes)

Question 14

MS
other signs and symptoms

Visual symptoms
a. Diplopia (double vision) or blurred or dimmed vision, with or without ocular pain
b. Optic neuritis, which causes sudden loss of vision with pain in or behind the eye, with
symptoms possibly subsiding after 3 to 6 weeks without residual impairments
i. Partial loss of vision (scotoma)
ii. Nystagmus
iii. Loss of visual acuity in 80% of people with MS (Atchinson & Dirette, 2012, p. 211)

5. Communication symptoms
   a. Dysarthria
   b. Scanning speech, or slow enunciation with frequent hesitations at the beginnings of words
   or syllables
6. Bladder and bowel symptoms
   a. Incontinence or urinary retention (failure to empty the bladder; Atchison & Dirette, 2012,
   211)
   b. Increased urgency or frequency, as well as constipation (Cooper, 2007, p. 473)
7. Sexual symptoms (Forwell et al., 2014, p. 1081; Stultz, 2014, p. 1156)
   a. Men: erectile dysfunction
   b. Women: decreased libido, lubrication difficulty, and inorgasmia, but ability to conceive and
   carry pregnancy to term remains intact
8. Cognitive symptoms
   a. Short-term memory loss
   b. Attention deficits
   c. Decreased processing speed
   d. Impairment in visuospatial ability
   e. Impaired executive functioning and judgment
   f. “Difficulty with attention, conceptualization, memory, or new learning. . . . difficulty with abstract reasoning and problem solving as well as difficulty with tasks that require either
   rapid or precise motor responses” (Falvo, 2014, p. 111)
9. Emotional symptoms
   a. Depression (although whether it is a manifestation of the neurological condition vs. a
   reaction to the disease is uncertain; Stultz, 2014, p. 1156)
   b. Inappropriate euphoria
   c. Mood swings, irritability, or pseudo-bulbar affect (Stultz, 2014, p. 1156)

Answer 14

Communication
Bladder and Bowel
Sexual
Cognitive
Emotional

Question 15

MS

Goals should address both the exacerbation and remission stages and should be ___________
because of the progressive nature of MS.

Answer 15

compensatory

Question 16

MS
Occupational Therapy Interventions include:

Vision
a. Perform home safety assessment and make recommendations to reduce risk of falls,
including removing clutter, clearing pathways, and using bright or contrasting tape to
mark steps inside and outside the home.
b. Adaptive equipment may include optical devices, large-print reading material, large-button
technology, talking watches, raised-dot markings for technology, and audiobooks
(Kaldenberg, 2014, pp. 702–707).
c. Refer the client to a low vision specialist or to an ophthalmologist or an optometrist as
indicated.
2. Sensory disturbances
a. Provide sensory reeducation.
b. Introduce compensatory strategies such as relying on visual feedback to observe a
desensitized limb and testing the temperature of water for dishwashing or bathing using an
unaffected body part.
3. Urinary incontinence
a. Provide bladder training and instruction in self-catheterization or use of sanitary pads or
absorbent underwear to avoid embarrassment with accidents.
b. Monitor times of day when fluids are consumed to ensure availability of bathrooms to
minimize risk of incontinence.
4. Muscle weakness and other motor difficulties
a. Monitor body mechanics to avoid stressing joints and increasing musculoskeletal pain.
b. Therapeutic exercise can improve overall health and well-being, but the occupational
therapist should emphasize the importance of resting and avoiding fatigue. “A structured
aerobic program has been shown to reduce fatigue and increase endurance” (Forwell et al.,
2014, pp. 1085–1086).
c. Instruct the client in the use of assistive devices. Provide seating and positioning
consultation if the client requires a wheelchair or power mobility.
5. Pain (from spasticity)
a. Advise on a standing home program, such as the use of a standing frame.
b. Use resting orthoses.
c. Maintain hips at 90° or more of flexion to reduce extensor tone in the lower extremities.

Answer 16

Vision
Sensory Disturbances
Urinary Incontinence
Muscle weakness and other motor difficulties
Pain
Fatigue
Ataxia
Dysphagia and dysarthia
Cognitive and emotional Disturbances
ADL adaptations
Vocational Adaptations

Question 17

_________ ________ is a progressive, variable condition that occurs most frequently in
later adulthood, with a mean onset age of 55 to 60 years. Major degenerative changes occur in
the basal ganglia, the gray matter that contributes to complex movements. The substantia
nigra becomes depigmented, affecting the production of dopamine, a neurotransmitter that
influences the speed and accuracy of motor skills, postural stability, cognition, and affect and
expression. The loss or reduction of dopamine leads to the disabling symptoms.

Answer 17

Parkinson’s Disease (PD)

Question 18

Effects of dementia on occupational performance

1. Early stage
   a. During the early stage, ADLs remain intact.
   b. The first signs of memory loss manifest in IADLs.
   c. Dementia affects orientation to place, which impairs community mobility.
   d. The person may become disoriented while traveling away from home.
   e. Financial management is impaired.
   f. Shopping is impaired.
   g. Meal preparation is impaired.
   h. Health management is impaired.
   i. Driving skills need to be reevaluated (Atchison & Dirette, 2012, p. 115).
   j. Learning and reading become difficult.
   k. Work performance is impaired.
   l. Relationships with coworkers and supervisors are affected and may cause unemployment.
   m. Leisure exploration becomes difficult.
   n. The person withdraws from social participation.
   o. Intimacy and sexual expression deteriorate.
   p. Communication is impaired because of language problems.
   q. The person clings to old habits and repetitive routines.
   r. The person neglects old habits and routines.
   s. Roles change.
   t. Cultural and spiritual context remain intact, but participation declines
   . Middle stage
   a. Impairments occur in all areas of occupation.
   b. The person can no longer live alone.
   c. The person may no longer attend to ADLs.
   d. Eating problems and weight loss occur.
   e. IADLs are neglected or performed out of sequence.
   f. Simple home management tasks can be completed with assistance.
   g. The person is dependent in community mobility, financial management, and shopping.
   h. Some cleaning and cooking tasks can be done with supervision.
   i. Safety is a major concern; risks include wandering, letting a stranger into the house, or
   causing a fire (Atchison & Dirette, 2012, p. 116).
   j. The person cannot perform work or education activities.
   k. Leisure participation is limited.
   l. Social participation is typically limited to caregivers.
   m. The person can no longer differentiate days.
   n. Roles continue to be lost.
   o. The cultural context begins to diminish.
   p. Personal and temporal contexts may be confused.
2. Late stage
   a. All areas of occupation are lost.
   b. The person is dependent in all ADLs.
   c. The person can no longer ambulate safely.
   d. Communication is lost.
   e. The person has no understanding of the cultural, social, or spiritual contexts

Answer 18

q

Question 19

Dementia
Occupational therapy interventions

a. Claudia Allen’s Cognitive Disability Theory
b. Cognitive Level 6—planned actions
i. Client is independent.
ii. Disability is absent.
c. Cognitive Level 5—exploratory actions
i. Caregiver standby or supervision is needed for cognitive assist.
ii. Client learns through visible, concrete, and meaningful stimuli.
iii. External cueing can be used.
iv. Client explores the effects of self-initiated motor actions on physical objects.
v. Client uses overt trial-and-error problem solving.
vi. Client can follow a four- to five-step process and learn new concrete ideas.
vii. Client has difficulties with judgment, reasoning, planning, semantic memory, and
episodic memory.
viii. Client abilities include performing dressing, eating, and grooming activities without
assistance (Lewis, 2003, p. 133).
d. Cognitive Level 4—goal-directed activity
i. Client requires minimum cognitive assist.
ii. Attention is directed to visual and tactile cues.
iii. Client is able to understand cause and effect.
iv. Client can no longer problem solve.
v. Client can follow two- or three-step activities.
vi. Activities should be simple, concrete, and supportive of desired social roles.
vii. Labels and pictures can be used as reminders.
viii. Task setup for bathing and grooming is required.
ix. Client can eat independently, but supervision is needed on amount of food eaten.
x. Client needs protection against safety hazards and wandering.
xi. Client needs 24-hour supervision.
e. Cognitive Level 3—manual actions
i. Client requires moderate cognitive assistance.
ii. Attention should be directed to tactile cues (e.g., familiar objects; Lewis, 2003, p. 134).
iii. Goals are not related to outcomes.
iv. Motor actions are limited to one-step, familiar, and action-oriented activities.
v. Client cannot learn new behaviors.
vi. Adapted activities should be used that reinforce the connection between predictable
tactile effects on the environment and client actions (e.g., walking, washing cars,
drying and washing dishes, wiping countertops, vacuuming).
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26
vii. Client needs a routine.
viii. Client should avoid sensory overload.
ix. Client is able to wash hands and face and brush teeth.
x. During grooming and bathing, items should be presented to client one at a time, in
sequential order of use.
xi. Client requires 24-hour supervision.
f. Cognitive Level 2—postural actions
i. Client requires maximum cognitive assistance.
ii. Client’s thinking is highly disorganized.
iii. Attention involves internal cues.
iv. Motor actions are one step, imitated, near reflexive, and familiar, and they involve
gross motor patterns.
v. ADLs can be accomplished by imitating the caregiver (e.g., washing the face).
vi. Spontaneous behaviors are common (Lewis, 2003, p. 135).
vii. Client is able to eat finger foods.
viii. Client paces and wanders.
ix. Client should be taken to the restroom every 2 hours.
x. Client requires around-the-clock supervision.
g. Cognitive Level 1—automatic actions
i. Client requires total cognitive assistance.
ii. Attention is limited to subliminal internal cues.
iii. Motor actions are in response to one-word, near-reflexive directions (e.g., “sip”).
iv. Client needs monitoring to ensure adequate nutrition.
v. Client needs assistance with ambulation and transfers.
vi. Client needs passive, active, or assistive ROM for prevention of bed sores, osteoporosis,
infections, and contractures.
vii. Client is dependent on caregiver for ADLs.
viii. Environment should be consistent, familiar, and modified to elicit orienting
experiences.
ix. Client requires constant 24-hour supervision.
x. This level is the terminal phase of this disease, but death usually occurs before the last
stage of this level (Lewis, 2003, p. 136).

Answer 19

q

Question 20

Guiilain-Barre Syndrome
Occupational therapy
intervention

1. In the plateau phase, modifications are deemed temporary.
   a. Develop and train the client in the use of communication tools, such as signs or picture
   boards.
   b. Provide environmental modifications to ensure access to the call button, remote controls,
   and phone.
   c. Adapt the telephone for hands-free use.
   d. Adjust (and train caregivers on) supine and sitting positions that optimize function and
   comfort and reduce risk of skin breakdown.
   e. Position the client for trunk, head, and upper-extremity stability.
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   rights reserved. For permissions, contact www.copyright.com.
   17
   f. Educate the client and family about the health condition and anxiety reduction techniques
   (Forwell et al., 2014, p. 1095).
2. In the recovery phase, interventions aim to help the client resume occupations and roles,
   rituals, and routines.
   a. Design activities and dynamic splints to help maintain ROM, especially for the wrist,
   fingers, and ankle (hinged drop-foot orthosis).
   b. Instruct the client in safe mobility with appropriate assistive devices (if necessary), and
   help improve independence and safety with functional transfers, such as to the toilet or tub
   or out of bed.
   c. Suggest modified techniques for self-care and other adaptations for the client’s daily
   routine.
   d. Continue to adapt modes of communication on the basis of the client’s priorities (e.g., voice
   operated text messaging).
   e. Educate the client on adaptive equipment and behavior modification techniques for home,
   leisure, community, and work activities.
   f. Provide strategies for energy conservation and fatigue management.
   g. Develop a client-centered fine motor program to maximize strength, coordination, and
   sensation in the hands and fingers.
   h. Complete a home assessment and recommend modifications as appropriate to help ensure
   the client’s safe return home (Forwell et al., 2014, p. 1095).

Answer 20

q

Question 21

GBS
Signs and symptoms

1. Three phases
   a. Onset and acute inflammatory phase: Acute weakness that occurs in at least two
   extremities advances and reaches its maximum in 2 to 4 weeks; 20% to 30% of people with
   GBS need mechanical ventilation.
   b. Plateau phase: Symptoms are at their most disabling, with little or no change over a few
   days or weeks.
   c. Progressive recovery phase: Remyelination and axonal regeneration occur over a period as
   long as 2 years. Recovery tends to start at the head and neck and travel distally. Most
   people experience significant if not complete return of function, with fatigue as the most
   commonly reported residual symptom (Forwell et al., 2014, p. 1094).
2. Rapid progression of symptoms, typically in a symmetrical ascending pattern of flaccid
   paralysis that begins in the feet; paralysis may occur in respiratory muscles (Forwell et al.,
   2014, p. 1094)
3. Pain, mostly in the lower extremities
4. Fatigue
5. Absence of deep tendon reflexes
6. Mild sensory loss in the hands and legs (“glove-and-stocking distribution”)
7. Dysfunction of cranial nerves, including possible facial palsy
8. “Autonomic nervous system (ANS) involvement [that] can result in postural hypotension (when
   one rises from a horizontal position, blood pressure may drop to precariously low levels),
   arrhythmias, facial flushing, diarrhea, impotence, urinary retention, and increased sweating”
   (Forwell et al., 2014, p. 1094)
9. Bladder dysfunction (Forwell et al., 2014, p. 1094)

Answer 21

q

Question 22

ALS has six stages, broken down by their clinical features (see Table 1 in Forwell et al., 2014,
p. 1092).

a. Stage I: The person can walk, is independent with ADLs, and has some weakness.
b. Stage II: The person can walk and has moderate weakness.
c. Stage III: The person can walk but has severe weakness.
d. Stage IV: The person requires a wheelchair for mobility, needs some assistance with ADLs,
and has severe weakness in the legs.
e. Stage V: The person requires a wheelchair for mobility, is dependent for ADLs, and has
severe weakness in the arms and legs.
f. Stage VI: The person is confined to bed and dependent for ADLs and most self-care tasks.

Answer 22

q

Question 23

ALS
Occupational therapy intervention

1. Treatment approaches should be compensatory, “focusing on adapting to disability and
   preventing secondary complications. Goals center on keeping the person as active and
   independent for as long as possible” (Forwell et al., 2014, p. 1093).
2. Home evaluations and home safety assessments should be conducted (Forwell et al., 2014, p.
   1093) .
3. The occupational therapist collaborates with the client and family on many aspects of
   intervention.
   a. Safety, including positioning, transfers, and skin integrity
   b. Augmentative communication equipment
   c. Assessment and management of dysphagia
   d. Social participation
   e. Equipment and environmental modification needs (e.g., first-floor setup; Forwell et al.,
   2014, p. 1093)
4. Exercise can include active, active-assisted, and passive ROM; strengthening; endurance;
   stretching; and home breathing exercise programs, depending on the stage of ALS (Forwell et
   al., 2014, p. 1094). Clients should be instructed on ways to avoid overexertion and muscle
   spasms and to monitor fatigue.
5. The occupational therapist works with the client to select adaptive equipment and technology
   (Forwell et al., 2014, p. 1094).
   a. A neck collar or universal cuff is used for upper-extremity stability during self-care or fine
   motor tasks.
   b. Mobility aids (foot-drop splint, cane, walker) minimize exertion during ambulation,
   compensate for lower-extremity weakness, and reduce risk of falls.
   c. The ideal wheelchair is high backed and reclining, lightweight, turns in a small space, and
   offers support for the head, trunk, and extremities. As ALS advances, the client may
   consider a power wheelchair with adaptable controls that is easily maneuvered with tilt or
   recline and head, trunk, and extremity support.
   d. Voice-operated or hands-free technology can be used for everyday tasks such as using the
   computer, making phone calls, or locking doors.
6. The occupational therapist provides techniques to address dysphagia (Forwell et al., 2014, p.
   1094) .
   a. Minimize distractions during mealtime.
   b. Adapt food consistency (thicken liquids, downgrade diet to soft foods).
   c. Use manual swallowing techniques.
   d. Allow sufficient time for meals.
   e. Ensure that nutritional needs are met, and use alternatives to feeding if issues arise.

7. Physical demands at work should be minimal and sedentary, and the environment should be
wheelchair accessible (Schultz-Krohn et al., 2013, p. 922)

Answer 23

q

Question 24

D1 flexion/extension patter is ___ and away while D2 is down and n.

Answer 24

up

Question 25

Proprioceptive neuromuscular facilitation (PNF) is a technique that involves use of ________ patterns of movement and involves rotational trunk movement.

Answer 25

diagonal