Neurological Disorders

Question 1

Neurapraxia

Answer 1

Temporary damage to a nerve caused by pressure on the axon that does not cause any structural changes.

Question 2

Axonotmesis

Answer 2

Serious injury to the nerve axon. Often caused by prolonged pressure on the nerve and results in atrophy of the muscles supplied by the nerve and degeneration of the neural axon. Neural sheath of the nerve remains intact.

Question 3

Neurotmesis

Answer 3

Both the axon and the sheath are damaged. Recovery from neurotmesis is problematic because the regrowing axon does not have a path to follow.

Question 4

Deep Tendon Reflexes (DTR)

Answer 4

• or 0 = absent
• or 1 = diminished
  + or 2 = average
  ++ or 3 = exaggerated
  +++ or 4 = clonus

Question 5

Glasgow Coma Scale (GCS) - Check, observe, stimulate, rate

Answer 5

Eye-opening response:
> Spontaneus = 4 p
> To sound = 3 p
> To pressure = 2 p
> None = 1 p

Verbal response:
> Orientated = 5 p
> Confused = 4 p
> Words = 3 p
> Sounds = 2 p
> None = 1 p

Motor response:
> Obey commands = 6 p
> Localising = 5 p
> Normal flexion = 4 p
> Abnormal flexion = 3p
> Extension = 2 p
> None = 1 p

Question 6

Manual Muscle Testing Grades

Answer 6

0 = No observable or palpable muscle contraction.
1 = No observable motion, palpable muscle contraction, no resistance.
2 = Full ROM, gravity minimized, no resistance.
3 = Full ROM, against gravity, no resistance.
4 = Full ROM, against gravity, moderate manual resistance.
5 = Full ROM, against gravity, strong manual resistance.

Question 7

Autism Spectrum Disorder (ASD)

Answer 7

PT intervention: children exhibit a range of developmental delays in gross and fine motor development. Wide variety of treatment options can be used:

• Neurodevelopmental therapy / Bobarth
• PNF
• Balance and coordination training
• Relaxation exercises

Question 8

Cerebral Palsy

Answer 8

The choice of physical therapy interventions is related to the presentation of motor deficits in individuals.

Question 9

Fetal Alcohol Spectrum Disorders

Answer 9

Si and Sy: facial special characteristics, cardiac defects, growth retardation, microcephaly, mental retardation, cognitive deficits, behavioral manifestations, poor coordination, hypotonia, and ADHD.

PT intervention:

• Early PT intervention preferred.
• Type of intervention will depend on manifestations of the disorder.
• Neurodevelopmental PT is commonly used.

Question 10

Alzheimer’s Disease

Answer 10

Progressive degenerative, organic brain syndrome that destroys the neurons of the cerebral cortex causing dementia.

PT intervention: treatment concentrates on encouraging fx independence as long as possible.

Question 11

Amyotrophic Lateral Sclerosis (ALS) aka Lou Gehrig’s disease

Answer 11

Progressive, degenerative disease of the nervous system affecting both upper and lower motor neurons. The sensory system remains intact.

PT intervention: directed at assisting patients to maintain as much independence and fx movement for as long as possible including ADL. Reduction of pain, education of pt and families, assistive equipment, home modifications advice, and exercise programs all play a part in the overall interventions.

Question 12

Cerebrovascular Accident (CVA) and Transient Ischemic Attack (TIA)

Answer 12

TIA if symptoms of CVA only last for a few minutes or hours. However, predictor of a future CVA.

PT intervention: in the ICU
> Bed mobility ex’s
> ROM of the affected limbs
> Active assisted ex’s for the affected limbs
> Active ex’s for the unaffected limbs
> Assisted transfers from bed to chair and ambulation as possible
> Education to family

Question 13

CVA and TIA: Precautions and considerations for PT intervention

Answer 13

1. Read pt chart before treatment (tm).
2. Check with nurse before tm.
3. Check vital signs before tm.
4. Follow all specified recommendations regarding pt position change to prevent pressure ulcers.
5. Observe pt closely during tm for signs of changes in vital signs and discoloration of lips, or ears for signs of cyanosis.
6. Observe pt closely for signs of fatigue.
7. Observe pt closely for any signs of increased weakness or changes in speech such as slurred speech, which might indicate a further CVA.
8. Lock the bed in place or push it up against a wall if moving pt out of bed.
9. Document the volume of any fluids given to pt during tm because fluid intake and output is monitored on the ICU.
10. If pt are on a thickened liquids diet due to swallowing problems be sure NOT to give them water to drink. They might aspirate a thin liquid.
11. Encourage pt to turn their head toward the affected side by standing on the side of the bed of the affected side.
12. Speak to pt and explain exactly who you are and what you are going to do.
13. Be encouraging but make pt do as much as possible for themselves.
14. Keep instructions to simple one word commands or short sentences.
15. Keep treatments fairly short to prevent undue pt fatigue.
16. When getting pt into a sitting position or transferring them out of bed into a chair, ensure that the catheter bag is on the side of the bed the pt is exiting. Keep the catheter bag below the level of the pelvis to prevent flow back of urine into the bladder.
17. Remember that it may not be possible to do more than a few ex’s with pt for the 1st few days. Getting pt into a chair may be the most they can tolerate in one session.
18. Move all IV and feeding hookups to the side of the bed pt will exit.
19. Ask for assistance to perform transfers, particularly for the 1st attempt.
20. Make pt comfortable on completion of the PT session ensuring they are in a good position, have an alarm close to hand, and can reach their essentials such as the telephone.
21. Inform the nurse upon completion of the tm session and verify any change in pt positioning.
22. If family members were requested to leave the room during PT, remember to inform them that they may return to the room. Remind them that the pt may be fatigued after the PT session.

Question 14

Dementia - Non-Alzheimer’s (Lewy Body, Senile Dementia, Vascular Dementia)

Answer 14

PT intervention: directed not toward treatment of dementia but of the neurological and MSK manifestations of the disease process that may be causing the dementia.

Ambulation, strengthening, stretching, and endurance ex’s, balance and coordination activities, and fx training may be needed.

Question 15

Epilepsy, Seizure Disorder, and Epileptic Syndromes

Answer 15

Condition in which numerous neurons in the brain are fired simultaneously leading to a large burst of electrical energy that triggers seizures involving multiple involuntary contractions of muscles.

Types of contractions:

• Absence seizures: brief periods of loss of consciousness, staring, and minimal changes in body mvmt.
• Atonic: temporary loss of muscle tone resulting in collapse and falls.
• Myoclonic/Myotonic: characterized by jerking and twitching mvmt.
• Tonic-clonic: more serious, with loss of consciousness, stiffness and shaking, and loss of bladder control.

PT intervention: indicated for tm of pt’s with a Fx. Some children with associated developmental delay may attend PT for neurodevelopmental treatment (NDT), ambulation, and ex’s for balance, coordination, strengthening, stretching, and endurance.

Question 16

Guillain Barre Syndrome and Acute Inflammatory Demyelinating Neuropathy

Answer 16

Is an autoimmune, neurological disease triggered by a previous infection or traumatic event that causes the immune system to attack the neural tissue.

Si and Sy: almost total paralysis of the muscles (bilaterally), deep tendon reflexes are absent, CerebroSpinal Fluid (CSF) contains high level of protein biomarkers.

PT intervention:

• In early stages instruction to nursing and families regarding passive or active assisted ROM ex’s to all affected limbs to ↓ risk of joint and muscle contractures.
• PT is paced to recovery of peripheral nerves. Interventions may include gait analysis, fx mobility training in a wheelchair and progressive ambulation with appropriate devices, ADL training, progressive resistive ex’s for all limbs and trunk, breathing ex’s and pulmonary hygiene interventions, NDT, and balance and coordination reeducation.

Question 17

Huntington’s Disease

Answer 17

Progressive, hereditary, degenerative neurological disease.

Si and Sy: chorea (involuntary, jerky, uncoordinated mvmts), dystonia (increased muscle tone + involuntary mvmts with rotation that last for prolonged periods), myoclonus (involuntary twitching and spasm of muscles), mvmt tics (brief, repetitive, muscular spasms usually involving the face), and Parkinson-like mvmts.

PT intervention: focus is to keep pt’s independent for as long as possible. Strategies include strength, flexibility, and endurance ex programs; balance ex’s and fall prevention strategies; ambulation and transfers training; advice on energy conservation tq’s; HEP; and instruction to care providers and family members.

Question 18

Multiple Sclerosis (MS)

Answer 18

Autoimmune, chronic, degenerative, demyelinating, neurological disorder of the CNS. Two types: primary progressive MS, and relapsing, remitting MS.

Si and Sy: vary from person to person
> Primary symptoms: tingling, numbness, burning, and pricking and sensitivity to heat; vision disturbances of blurred vision, double vision, and optic neuritis; muscle weakness resulting in speech and swallowing problems, gait deficits, tremors, fatigue, dizziness and loss of balance, and poor coordination of mvmts; cognitive problems including memory and concentration deficits; and bowel and bladder incontinence.
> Secondary symptoms: occur as a result of the primary symptoms, such as pressure sores and frequent urinary tract infections.
> Terciary symptoms: social, psychological, and vocational functioning.

PT intervention: strengthening, stretching, and aerobic ex’s programs, balance and fall prevention ex’s, functional electrical stimulation to improve ambulation abilities, pool ex’s in water below body temp pool (because of skin heat sensitivity).

Question 19

Near-Drowning/Drowning with Partial or Full Recovery

Answer 19

Si and Sy: range from none to severe neurological deficits and pulmonary complications.

PT intervention: largely focused on the neurological rehabilitation of pt’s who survive the 1st few days after the incident.

Question 20

Neuropathy, Peripheral Neuropathy and Polyneuropathy

Answer 20

Disease of the peripheral nerves that affects the motor, sensory, and autonomic systems.

Si and Sy: pain, weakness and atrophy of muscles, fasciculations, muscle cramping, altered or loss sensation, reduction in ability to perform fine motor tasks, balance, coordination, and ambulation.

PT intervention:

• Evaluation is important (MMT, skin sensation testing).
• Treatment: orthotic devices, prevention of contractures, gait training, balance and coordination ex’s, HEP, and general aerobic activities.

Question 21

Parkinson’s Disease

Answer 21

Condition affecting the basal ganglia in the brain, which results in mvmt and behaviour dysfunction.

Si and Sy: nonvoluntary resting tremor, muscle atrophy, cogwheel rigidity of muscles, bradykinesia and akinesia, difficulty initiating mvmts, a masklike facial expression, a shuffling gait pattern, reduced balance, retropulsion, cognitive impairments, breathing difficulties, and speech and swallowing problems.

PT intervention: relaxation tq’s in early stages, breathing ex’s to ↑ excursion of ribs and maintain mobility; gait, balance, coordination, and strength rehab ex’s are extremely important; hot moist packs, electrical stimulation and short-wave diathermy are useful to ↓ pain.

Question 22

Post-Polio Syndrome

Answer 22

Neurological condition exhibited by some people who have had an acute episode of poliomyelitis in early life.

Si and Sy: muscle weakness and atrophy, general fatigue, reduced muscle endurance, loss of energy, and myalgia.

PT intervention: advice re changes in lifestyle to ↓ excessive physical activity, provision of assistive devices for ambulation, and LL orthoses as needed. Low-impact aerobic and strengthening ex’s program designed not to fatigue the muscles of the patient.

Question 23

Spinal Cord Injury (SCI)

Answer 23

Term used for people who have sustained an injury to the spine that reduces or completely disrupts the spinal cord resulting in partial or complete paralysis below the level of injury.

Si and Sy: injury to Cx spine results in tetraplegia or quadriplegia; injury to Tx or Lx spine results in paraplegia involving LL and trunk below level of lesion.

• Immediate phase: 0-2h. Spinal shock, no activity below level of lesion.
• Acute phase: 2-48h. Hemorrhage continues and results in damage to neurons and glial cells.
• Subacute phase: 2/7-2/52. Phagocytes destroy myelin, major scarring occurs.
• Intermediate phase: 2/52-6/12. Scarring matures and neurons start to sprout axon buds.
• Chronic phase: 6/52-lifetime. Stability of symptoms and neurological deficits occur 1-2 years after accident.

PT intervention: functional ES of muscles (when mobility ex’s are contraindicated due to spinal Fx); passive motion of joints and stretching; PNF patterns; mobility training in wheelchair or with ambulatory device; balance ex’s; strengthening of uninvolved limbs

Question 24

Traumatic Brain Injury (TBI) and Head Injury (HI)

Answer 24

External injury to the head that causes damage to the tissue of the brain and results in various manifestations of neurological deficits depending on the area of the brain affected.

PT intervention: indicated for rehab of people with moderate and severe TBI. Focus on motor deficits resulting from TBI. Interventions may include aquatic therapy, NDT, PNF, muscle strengthening, stretching, and endurance ex’s, ambulation, balance and coordination ex’s, and fx reeducation.

Question 25

TBI (pt’s on ICU) precautions and considerations for PT intervention

Answer 25

1. Check vital signs and IC pressure prior to and throughout intervention.
2. Explain what you are doing to pt’s in simple, short statements, even if they appear to be in a coma.
3. Observe pt’s in a coma carefully for responses to mvmt.
4. Alert the nurse of any changes in pt response that seem unusual.
5. Keep tm times fairly short (eg <15’x2/day)
6. Involve family with intervention by explaining reason for intervention and goals. Give explanations away from pt’s.
7. Document PT intervention carefully and objectively in pt’s chart.