Neurology Flashcards
Klumke Palsy
- claw hand
- C8, T1
MM effects: intrinsic hand mm, flex/ext of wrist and fingers
Median nerve Palsy
- Ape hand
C6-8, T1
- thenar mm: no thumb abduction/opposition
Impairments associated with Alzheimers, & what is preserved
- impaired: memory, language, videos palatial skills, cognition, personality.
- preserved: implicit skills ( piano playing?)
- dx: via neurotic plaques at autopsy
What is vascular cognitive dementia?
- how do we measure it?
- multiple small lesions due to poor blood flow (high bp)
- degeneration of medial temporal lobes (staircase pattern of functional loss)
- htn, small hemorrhage, atherosclerotic plaque
- outcome measure: mini mental state exam
PT concerns:
- falls, motor activities, sleep support
Types of seizures
1) primary Generalized seizure:
- bilateral and symmetrical
* * tonic-clinic = dramatic whole body
* * Absence seizure = brief, imperceptible 100x/day
2) Partial Seizures
* * Simple Partial = focal motor, focal motor with March, temporal lobe seizure (change in behavior)
* * complex partial = simple seizure followed by impaired consciousness
Erbs palsy
C5, C6 injury to infants –> birthing injury
- waiters tip position
MM effects: rhomboids, lev scap, SA, delts, supra + infra spinatus, biceps, brachioradialis, brachialis, supinator, long ext of wrist, fingers thumb
Rx:
- immobilize initially
- gentle rom + play exercises
CVA & TIA defined.
Strokes
Cerebral vascular accident
Transient ischemic attack
Stroke s/s?
- Sudden numbness or weakness of face, arm or leg
- confusion, dizziness
- trouble speaking or understanding words
- trouble seeing out of one or both eyes
- trouble walking
- loss of balance and coordination
- headache with no known cause
Stroke: risk factors (non/ modifiable)
Non modifiable:
- age (risk doubles after 55), M>F, FMHx, previous TIA
Modifiable:
- HTN, CAD, DM, cholesterol, smoking, obesity, drugs, birth control??
2 Stoke classifications?
Ischemic stroke:
- 80%, caused by thrombosis, embolic lacunar infarct (deep area of brain, commonly related to DM and HTN)
Hemorrhagic stroke:
- 20%: Aneurysm and AV malformation, often occurs in younger ppl, majority occur in cerebral cortex.
Ischemic stroke: response after injury + Rx
Response:
- death of tissue where there is no blood (core death)
- possible preservation of area surrounding core that is supplied by collaterals (ischemic penumbra)
- release of glutamate, Ca2+, edema, O2 free radicals, degeneration
Rx:
- TISSUE PLASMINOGEN ACTIVATOR (TPA) within 3 hrs (dissolves clot)
- Sx to remove clot
** cerebellum and hippocampus are ++sensitive to ischemia
Hemorrhagic stroke: Rx
Rx:
- Surgery to stop the bleed
- Better long term prognosis for recovery of function than ischemic
What type of stroke has better long term recovery?
- hemorrhagic
Tool used to predict progression and risk of reoccurrence of stroke?
ABCD score:
A = age B = blood pressure C = Clinical features (hemiplegia, speech problems) D = duration
4 common way to prevent reoccurrence of stroke
- anticoagulant (ASA)
- lipid lowering agent
- lifestyle change
- exercise
Stroke: prognostic indicators?
- location, extent, duration
- ability to move fingers (pyramidal motor output intact [white tracts are not plastic])
- cortical (mostly grey matter) vs. Subcortical (white and grey) [grey matter is capable of functional reorganization
Features of a TIA
Transient ischemic blockage of circulation
- mild s/s,
- resolves usually within 24 hrs
- high recurrence (80%) within a year
- can have lasting damage
Brainstem stoke consequences
Very disabling; takes out ascending and descending tracts
What is a TBI? + accompanied by?
Traumatic brain injury:
- change in brain function due to external force
Accompanied by:
- dec or LOC, impaired cognition, physical function, emotional or behaviour changes
TBI classification
1) Closed: no skull# or laceration of the brain, meninges not breached (does not require hitting head)
2) Open: Meninges breached, exposed brain or laceration
TBI mechanisms
- Coup (primary mechanical injury)
- Contracoup (secondary mechanical injury): ischemia + edema
- DIA (diffuse axonal injury): sheering from rotary forces in areas of density change (white and grey matter)
- Contusion
- Anoxic injury forces
Differentiate between primary and secondary brain injury
Primary:
- direct damage from mechanical forces, focal or diffuse
Secondary:
- circulation deficits (bloodflow
4 type of brain hematomas
Epidural:
- Arterial bleed outside the dura
- temporal or tempoparietal most often
- 90% with skull#
Sub-dural:
- Venous bleed b/w arachnoid and dura mater
- Rx: surgery (burr holes/ craniotomy)
Sub-arachnoid:
- fatal b/w arachnoid and pia mater
Intra-cranial:
- most common, blood within the brain under the pia mater
ICP: values + how to monitor
Normal = 0-10mm Hg, >20 for 5 mins is very bad
How to Monitor:
- extra ventricular drain ( need stop cock to avoid back flow)
- sub-arachnoid/dura bolt
- intraparenchymal monitor
- epidural sensor
Cerebral perfusion pressure (CPP): how to calc + normal value + strategy to maintain it.
CPP = MAP - ICP / cerebral vascular resistance
Goal: 70-100 mm Hg
Maintain by keeping HOB at 30 degree to keep MAP above 80
- also helps with ventilator acquire pneumonia
Basal skull # s/s?
- blood or CSF out of nose or ears
- raccoon eyes
- bruising over mastoid (battle sign)
Frontal lobe injury s/s?
- poor planning, judgement, disinhibition
- brocas aphasia (poor language production)
- altered manners, morals, emotions
Parietal lobe injury s/s
- somatosensory function alterations in touch, temp, positional awareness
- language comprehension (wernickes)
- motor planning issues (apraxia)
Temporal lobe injury s/s?
- Comprehensive receptive aphasia (Wernicke’s + Broca’s)
- memory impairment
- auditory processing issues
- integration and regulation of emotion, motivation and behaviours
Occipital lobe injury s/s
- visual problems + visual field deficit
- Contracoup injury more so than coup
Traumatic brain injury: PT related issues
- Respiratory issues
- ICP control
- abnormal posturing
- decreased mobility
- Contracture’s
- confusion/ agitation
- fatigue
- family stress
Respiratory issues post TBI + Rx
- Decreased LOC, comprimised respiratory centre, ++ oral secretion
Rx: - manual tech/ suctioning (O2 always 100%, only suction for 10secs)
ICP control post TBI: Rx
- maintain neural head positioning at all times
- keep Rx short
- Head down posture for drainage is CONTRAINDICATED
Abnormal posturing post TBI: types + Rx
- Decerebrate posturing: UE + LE in extension = Brainstem damage (mid brain) and cerebellum lesions
- Decorticate posturing: Arms flexed, legs extended = cerebral, thalamus, cord, CST damage.
Rx: ICP
Decreased mobility post TBI: Rx,
- Sit and dangle when medically stable
- tube feed off 20 mins prior to mobilizing
- early mobilization to prevent heterotrophic ossification
Caution: DVT, PE, hyper metabolism
Contractures post TBI: Rx
- place muscles in lengthened position 20 mins - 12 hours a day
- resting splints, casting, PROM
Concussion definition + s/s?
- Complex pathological process affecting the brain, induced by traumatic biomechanical forces
- mild form of brain injury (TBI)
S/s:
- loss of consciousness maybe
- behavioural change (emotions)
- cognitive impairment (thinking/ planning ahead)
- sleep disturbance, dizziness, irritability, memory, visual change
What is 2nd impact syndrome?
- Rare/ fatal uncontrolled swelling of brain
- minor 2nd blow before initial symptoms are resolved
Glasgow come scale: categories, score
3 categories: eye opening, verbal response, motor response
Total score out of 15, usually done in acute injury
Rancho Levels of Cognition details
Good predictor of functional outcome after injury (1-10)
Causes of ‘traumatic’ and ‘non-traumatic’ SCI?
Traumatic:
- Falls (40%), transport, sport
- M>F, 15-35
- 18% are T-spine, Lspine complete, 40% C-spine incomplete
Non:
- cancer, infection and inflammation (TB), motor neurone disorders, vascular disease, congenital
- M>F, 50-60yr
- most are paraplegia
SCI early management focus:
- spinal stability
- limiting neurological deficit and promote recovery
- minimize complications
- create environment for spinal column to heal
Definition of myelopathy
Refers to pathology of the SC… When due to trauma its SCI
What is spinal shock? + s/s?
- temporary suppression of all reflex activity below level of injury, can last months
S/s:
- Areflexia
- flaccid paralysis
- ** thought that return of the sacral reflexes mark beginning of spinal resolution
Neurological shock: details + s/s
- body’s reaction to sudden loss of sympathetic control
- injuries above T6
S/s:
- decreased vasomotor tone = hypotension and hypothermia despite normal blood volume
- bradycardia (because of unopposed vagaries stimulation of heart)
- can lead to metabolic issues
What do the doctors mobility orders mean?
“Spine unstable”: column is assumed unstable, +/- neuro deficits
PT must:
- Maintain neutral spine, bed rest, HOB at zero, 2-3 person turns
“Spine Stable”: but needs protection
PT: maintain neutral spine, pt can turn independently, mob + rehab ok
“Spine stable- no restrictions”
- all movements okay within comfort limits
- watch for BP changes
ASIA impairment scale:
A = Complete: No motor or sensory function in the sacral segments S4-5 B = Incomplete: Sensory but not motor function is preserved below the neurological level and includes S4-5 C = Incomplete: motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade LESS than 3 D = Incomplete: motor function is preserved below the neurological level, atleast than half of key muscles below the neurological level have a muscle grade of 3 or MORE E = Normal: motor and sensory functions are normal
5 common clinical SCI syndromes
Central cord Brown squared Anterior cord Conus medulla ribs Cauda equina
ASIA UE myotomes
C5: abd, elbow extensor C6: wrist extension C7: elbow extn C8: thumb ext T1: finger abd
Sacral function:
- voluntary anal contraction: if present indicated MOTOR INCOMPLETE (ASIA C)
Level of lesion defined….
Defined as the most caudal segment with normal sensory and motor function on both sides of body
- sensory level: most caudal segment w/ bilateral score of 2 for both pin prick and light touch
- Motor level: most caudal segment with a grade 3 or more provided all segments above are level 5.
Anterior cord syndrome
Loss of anterior 2/3 of cord:
- Loss of motor, pain and temp below injury level
- preservation of dorsal column ( proprioception, vibration)
Central cord syndrome
Most common SCI syndrome
- UE motor and sensory function more impaired than LE
- often associated with spinal canal stenosis
Brown sequard syndrome:
One side cord more damaged than the other
- ipsilateral loss of motor function and dorsal column (proprioception, vibration) [ they cross in medulla]
- Contralateral loss of P and temp sensation a few levels below lesion
Caudal equina syndrome
Spinal cord terminates at L1-2
LMN lesion s/s
- Areflexia, and flaccid bladder and bowel
SC tracts:
Lateral spinothalamic: Pain + temp
Anterior spinothalamic: Crude touch + pressure
Dorsal columns: Fine touch, stereogenesis, vibration
Lateral corticospinal: 90% cross in the pyramid
Anterior corticospinal: the 10% that crosses at the level of innervations
SCI effects on respiratory function:
- coughing
- Independent breathing
Cough function:
- C1-C3 = absent, C4-T1 = non functional, T2-T4 = poor, T5-T10 = weak, T11 and below = normal
Independent breathing: Need C4 intact
SCI effects on respiratory function:
What innervations are needed for normal vital capacity?
T11 and below
SCI effects on respiratory function:
- mm innervations for breathing
C2-C7: accessory mm of breathing
C3-5: Diaphragm
T1-T11: intercostals
T6- L1: abdominals
C1-C4 SCI:
- pattern of weakness
- possible movements
- mm innervated
- paralysis of trunk and UE, probably diaphragm
- neck movements, slight shoulder retraction + abduction
Full: - C1-C3: SCM, neck extensors + flexors - C2-C4: traps Partial: - C3-C5: Lev scap, diaphragm, supra/infraspinatus - C4-C5: Rhomboids
C1-C4 SCI: PT management
- ROM
- Spasticity management
- neck strengthening
- chest physio
- prevent contractures
C5 SCI:
- pattern of weakness
- possible movements
- major mm innervated
- significant imbalance around the shoulder girdle + no elbow extension, wrist pronation/flex/extn or any hand movement
- possible: shoulder abd/flex/extn, elbow flex/supination, scap add/abd
Full:
- All of the C4 mm + diaphragm, Rhomboids, lev scap
Partial:
- deltoid, biceps, brachioradialis, teres minor,
C5 SCI:
- hand function details
Rx: splints and universal cuffs (no antagonist to flexion)
- possibly tenodesis grip with forearm supination and pronation to achieve wrist flexion and extension
innervations:
- lev scap
- Rhomboids
C3-C4 Dorsal scapular
C4-C5 dorsal scapular
What level of SCI does a patient have a chance to live in the community?
C6 = chance to live w/o care
C6 SCI:
- pattern of weakness
- possible movements
- no wrist flexion, elbow ext, hand mov’t
Possible:
- radial wrist ext, horizontal adduction
- elbow ext via shoulder ER
- TENODESIS grip permitting a weak grasp without hand movements
C6 SCI:
- mobility and transfers ability
- PT role
- slide board transfer possible, manual w/c possible
PT: functional strength, movement tricks, ROM, equipment,
- Lats, serratus and pecs allow weight bearing through extremity and hamstring length will allow them to sit upright and free up their hands
C7- C8 SCI:
- pattern of weakness
- possible movements
- Hand function
- limited grasp/release/ dexterity due to lack of intrinsic mm of hand
- possible: elbow extn (C7), wrist extn, DIP/PIP flex, MP Flex (C8)
Hand:
Descent hand function but no fine motor control
- C7: need to use more tenodesis grip
- C8: more finger flexors, some thumb flexion (no lumbricals)
Having an intact tricep will impact a SCI patient in what way?
Triceps allow independent transfers, manual w/c, independent in most ADL’s
T1-9 SCI (thoracic paraplegia)
- presentation
- Lives in community using a w/c
- has intact UE function
- Respiratory function compromised above T6
- Can stand in a standing frame
- possible trunk spasticity
T10-L1 SCI:
- respiratory function?
- living and mobility status
- normal cough, respiratory fxn intact
- independent community dweller
- limited ambulation may be possible with bracing
L2-L5 SCI:
- intact trunk
- sparing of LE muscles allows for potential of functional walking
- need brace and grade 3 quads to walk w/o KAFO
- cauda equina = hidden disability = Areflexia bladder and bowel and flaccid paralysis
Autonomic effects of SCI on heart and lungs:
- sympathetic NS: location + effects
” fight of flight”
- Chain T1-T11
Effects:
- increase HR, BP, blood flow to skeletal mm
- relaxes bronchial mm (allowing an increase in O2 supply)
Autonomic effects of SCI on heart and lungs:
- Parasympathetic NS: location + effects
“Craniosacral”
- mainly interested in the Vagus nerve
Effects:
- Decrease HR and contractility
- Increases blood flow to smooth mm (rest and digest)
- contracts bronchial mm
General effects of injury of T6 and above:
- Sympathetic effect
- parasympathetic
- effects on heart
Sympathetic:
- very dependent on level of injury (T1-L1 chain)
Parasympathetic:
- remains intact and UNOPPOSED via the vagus nerve in SCI T6 and up. = valgus nerve withdrawal rather than sympathetic drive (normally sympathetic increase HR bit it is no longer intact ,so u must rely on removing parasympathetic)
Heart:
- limited CO + shunting of blood
- Blunting of HR 110-120
Autonomic dysreflexia:
- caused by a massive sympathetic discharge from a noxious stimuli below the level of SCI (with injuries T6 and up)
S/S: - BP increase 20-30 mmHg, bradycardia, severe headache, blurred vision, anxiety, dilated pupils, cool/dry pale skin (vasoconstriction) below injury, sweating Causes: - bladder/ bowel irritation - wound, etc
Rx/ prevention:
- position upright
- remove stimuli, use drugs
- good bowel and bladder routines
- skin and nail care
Orthostatic hypotension: definition + s/s + Rx:
- SUDDEN drop of 20mmHg of SBP, or 10 of DBP
S/S:
- asymptomatic, Dizziness, fainting, lightheaded, headache
Rx:
- mobilize slowly with therapy
- use compression stockings etc
List of common health risks associated with SCI
- DVT and PE
- Heterotrophic ossification
- osteoporosis
- post traumatic syringomyelia
SCI injury and DVT/PE: why + s/s + prevention
- due to venous stasis, transient hypercoagulable state
S/s: sudden LE swelling + increase temp
Prevention:
- anticoagulation meds
- compression stockings
- Sequencial compression devices
- AROM
- early mobilizations
PE tachycardia may be masked by parasympathetic dominance
SCI and heterotrophic ossification:
- 2 Rx contraindications:
- s/s
- Rx
Contraindications:
- Forced PROM or serial casting
S/s: - pain, increased spasticity, warmth/ fever, erythema, swelling, sudden decrease in ROM with abnormal hard end-feel Rx: - PROM within tolerable range + mobility - meds - surgery
SCI and Osteoporosis:
- why
- consequence
Due to Rapid increase in calcium excretion within a few days of SCI
- large incidence of #, especially LE
SCI and post traumatic syringomyelia:
- pathology
- s/s
- Rx:
Formation of an abnormal tubular cavity in the spinal cord
- dura tethers/scars to the arachnoid blocking CSF flow
- CSF is forced into the spinal cord, progressively enlarging the cyst
- leads to compression of cord + vascular supply
S/s: pain, sensory/motor changes, increase spasticity, B & B dysfunction, increased AD, hyperhydrosis
Rx: surgery
What are the two tests for spasticity?
Modified ashworth + Tardieu
spasticity: defined + clinical presentation
- velocity dependent resistance to passive stretch
Characteristics:
- increase mm tone
- increase stretch reflex
- uncontrolled movements
Rx:
- Meds: intra thermal baclofen, Botox
- therapeutic exercises
Spasticity: pros and cons
Pro:
- maintain mm bulk, venous return,
- possible reflex erection
Cons:
- Contracture’s, pain, positioning issues, fatigue
Spastic bladder:
- Location of injury
- presentation
- management
Injury is above the conus
Msg will continue to travel btw bladder and spinal cord since reflex arc is still intact
Bladder can be trained to empty on its own
Rx: intermittent catheter or condom/foley drainage
Flaccid bladder:
- injury location
- pathology
- consequences
- Rx
Injury above T12 in conus and cauda equina injuries
- messages don’t travel btw SC and bladder because the reflex centre is damages
- bladder looses ability to empty reflexively
Rx: must be catheterized b/c bladder will continue to fill
Difference between spastic and flaccid bowel:
-
Spastic = functioning peristalsis and reflex propulsion, reflex contraction of sphincter can lead to stool retention.
- Rx: suppository or digital stim for voiding
Flaccid:
- slow stool retention, incontinence, no reflex
UMN vs LMN lesions and sexual health
UMN lesion = reflex and spontaneous erection but no ejaculation (reduced fertility)
LMN = psychogenic erection possible, but reflex and ejeculation not possible
3 types of pain experienced by SCI patients?
Neuropathic:
- stabbing/burning pain not changed by position or activity- Rx: medication
Nociceptive:
- dull, crampy ache, altered by position and activity - Rx: modalities, exercise, STR, education, posture, positioning
Chronic:
- 2/3 of SCI have chronic pain - Rx: education, exercise, interdisciplinary team
SCI and exercise precautions
Decreased sympathetic impact:
- HR and BP will not have normal response (expect level similar pre and post)
- Use RPE and Borg
- watch for orthostatic hypotension
SCI and respiration:
- what position is ideal diaphragm length/tension curve
- how does sitting affect VC
- effect of the injury on lung volumes
- diaphragm best when lying
- decreased VC in sitting compared to supine
- all lung volumes decrease except residual volume
Tumours: types of Rx
Surgery, radiation, chemotherapy, bio therapy, antiangiogenic, hormone therapy
6 common types of tumours
Epithelial = carcinoma
- Mesenchymal = sarcoma (loose connective tissue from mesoderm)
- Glial = glioma (most common brain tumour)
- lymphoid = lymphoma
- hematopoietic = leukemia
- Melanocytic = melanoma
Common lung carcinomas
- Squamous metaplasia
- squamous diplasia
- carcinoma in situ
- invasive carcinoma
Rate of death with colon cancer
2nd highest cause of death
Breast Ca risk factors + sx side effect
- hormonal and genetic risk factors
- Axillary node dissection common
Prostate Ca Tx?
Sx, radiation, brachytherapy, androgen deprivation therapy
Common Cancers in kids
- Acute lymphocytic leukemia
- non-hodgkins + Hodgkin’s lymphoma
- brain Ca
- sarcoma: osteosarcoma, Ewing’s sarcoma
Skin cancer: types + risks
Basal cell carcinoma (BCC)
- most common skin Ca, low risk of spreading, translucent and red
Squamous cell carcinoma (SCC)
- solid skin tumor (volcano shape), high risk of metastasis
Malignant melanoma:
- most dangerous skin Ca, high risk of metastasis, ABCD rule (>6mm)
Duchenne’s muscular dystrophy:
- pathology
- effects
- Dx
X-link mutation on chr 21, M>F, maternal carrier
- dystrophin protein is not produced (structural component within mm) causing tissue to be prone to damage and necrosis.
Effects:
- mm is replaced by fat and connective tissue
- progressive symmetrical wasting
- w/c by 12… RIP by ~ 20
Dx: genetic testing, physical exam, CK levels
Duchenne’s muscular dystrophy:
- classic signs
- s/s
- Rx
- Gowers sign: pushing through thighs to stand from floor
- Calf pseudohypertrophy: Defined calves by fat and CT
S/s: mm wasting, waddling gait, toe walking, lordosis, difficulty getting getting up and doing stairs, falls, low IQ
Rx:
- maintain strength and balance (no eccentrics)
- respiratory therapy
- prevention of contractures, seating, equipment
types of muscular dystrophy other than duchennes
- Beckers = slower and progressive form of DMD
- Congenital
- myotonic
- spinal mm atrophy: skeletal mm weakness due to anterior horn degeneration. S/s = hypotonia, dec fxn, weakness, fatigue
ALS:
- defined
- etiology + disease course
“Amyotrophic lateral sclerosis”
- motor neurone diseas with gradual deterioration of both UMN and LMN. Presents with both flaccid and spastic paresis
- M > F, etiology is unknown
- 2-5 yrs post Dx (only 10% survive 10 years)
ALS:
- s/s
S/s:
- Paresis in a single muscle group
- mm groups are assymetric ally affected
- fasciculations (twitch)
- metabolic issue of skin (papery, fragile, cold)
- gradual involvement of striated mm
- flaccid + spastic can co-exist
- “selective sparing” no ocular, cardiac, urethral, and anal sphincter
ALS:
- Dx
- Rx
Dx: physical exam, medical Hx, mm biopsy
Rx: meds, rehab for mobility, symptom relief (spasticity, secretions)
Essential tremor:
- defined
- causes
- evoked by voluntary movement
Causes = genetic / increase thalamus activity
What is dystonia? + what is it linked to? + causes?
- Involuntary, sustained muscle contraction, writhing
- linked to a single repetitive action (musicians)
Causes: genetic, different brain origins.
Parkinson’s: defined/ pathology
Chronic neurodegenerative disease in the basal ganglia
- Decreased dopamine produced by Substantia nigra
- dopamine normally inhibits Ach but without dopamine = excessive excitatory output
Parkinson’s: Classic s/s? + others
- Bradykinesia = slowness, can result in freezing
- Resting tremor
- Rigidity (velocity independent resistance to passive stretch)
- Postural instability
+ mask face, loss of automatic movement, micrographia, hypokinesia, depression, dementia, postural hypotension, pain, sleep disturbances, fatigue, fine motor control
Parkinson’s: Rx + outcome measures
- Drugs: L-dopa + anticholinergic (cause mov’t tremor)
- education: exercise as protection
- functional mobility: BIG movements (cueing, posture, cardioresp, falls prevention)
- prevent secondary sequelae
- equipment
- environment safety
Outcome measures: UPDRS + Hoens and Yar
Huntington’s Chorea: defined
Hereditary disorder of atrophy of basal ganglia + personality + dementia
- can’t stop moving + abnormal movements
Rx: symptom management + antipsychotic drugs, safety, nutrition
Multiple Sclerosis: defined + etiology and onset
- inflammatory disease: fatty myelin sheaths around brain + SC axons are damaged. Leads to demyelination + scarring
- etiology is unknown, onset 20-40’s F>M
Multiple sclerosis: types
Relapsing Remitting: - new/old symptoms resurface or worsen - full/partial recovery relapse, each flare up may cause more loss of fxn Primary Progressive: - Gradual worsening of symptoms overtime - no remission but may stabilize Secondary Progressive: - Begins as "relapsing remitting" but steadily worsens - does not remyelinate Progressive Relapsing: - steady progression with attacks
Multiple Sclerosis: symptoms (early)
- mm weakness
- optic neuritis + diplopia
- sensory changes (paraesthesia)
- b/b incontinence
- vertigo
- fatigue
- impaired cognition
- pain
- depression
Multiple Sclerosis: Rx + contraindications
Pharmaceuticals:
- anti-inflammatories + immunosuppressant (heat intolerance side effect)
PT:
- Vestibular dysfunction, proprioception, exercise (pool?)
Avoid: Heat, fatigue, pregnancy
Lyme disease: defined
Bacterial infection “borrelia burgdoferi”, via Ticks
- mimics: MS, GB, fibromyalgia, chronic fatigue syndrome
Stages:
- localized erythema + flu-like s/s
- neuro (headache + neck stiff), msk + cardiac issues
- Bell’s palsy?
- final stage = long term neuro + arthritis + cognitive deficits
Rx: antibiotics
- PT: relieve pain + exercise to increase strength without exacerbating symptoms
Guillain-Barré syndrome:
Antibody mediated demyelination of Schwann cells in PNS from spinal nerves to terminating fibers
Cause: immune disorder, 2/3 ppl had recent illness in last 30 days
S/s:
- onset to peak = 4 weeks
- rapid ascending motor weakness and distal sensory loss (arms, trunk, face)
- absent DTR
- may require ventilation
Rx: meds = immunoglobin, Plasmaphoresis
PT: joint protection, chest tx, mobilize, strength, ROM
Meningitis: defined + potential results + types
Infectious disease causing inflammation of meninges (pia,arachnoid, dura)
- Can lead to thrombosis, infarction, scars, edema
Types:
- Aseptic (fungus, virus, parasite,herpes simplex2, Epstein Barr, lupus)
- Tuberculosis: abscess or edema
- Bacterial: in child its an emergency
Meningitis: s/s + Rx
S/s:
- Brudzinski sign: flexed hip + knees causes neck to involuntarily flex
- fever, headache, seizure, vomiting
- focal CNS signs: nerve palsy, deafness, pain w/ hip or knee flexion
Rx:
Antibiotics/vitals
Encephalitis: Defined + s/s + result
Infection of the brain, SC, brain parenchyma
S/s:
- headache, LOC, Coma
- nausea, vomiting
- agitation
- meninges like irritation
- stiffness
Result: necrosis, hemorrhagic necrosis, scaring
Creutzeldt Jakob disease: presentation + pathology
Movement disorder/dementia: progressive and fatal
Pathology:
- caused by prions (misfolded proteins) = mad cow disease = bovine spongiform encephalopathy
- contracted by ingestion or via the nose
- incubates 5-8 years
Post-Polio Syndrome: defined + initial/later effect
Attacks neurons in the Brainstem + anterior horn cell of SC
Initial effect: death of motor neurons controlling skeletal mm
- some survive, if so there is some recovery via larger motor units
Later effect: high metabolic stress on larger motor units
- gradual deterioration of sprouted fibres = mm weakness and paralysis
Vestibular function + causes of dizziness
- gaze stability
- postural stabilization: balance and equilibrium
- resolve sensory motor mismatch
Causes of dizziness:
- cardiovascular, neurological, visual, psychogenic, cervicogenic, meds, vestibular
Common vestibular s/s + what medication affects vestibular system frequently
Vertigo = subjective experience of nystagmus (room spinning): occurs with BPPV
- Dizziness = discrepancy between R and L side, patient can’t work out where they are in space: may not be vestibular in orgin
- Oscillopsia: blurred vision
Med that effects vestibular = Gentomycin
Differentiate b/w semicircular canal vs Otoliths
Semicircular Canals X 3 = horizontal, anterior, post
- fx: gaze/angular displacement of head
- movement of endolymph will deflect hair cells and excite or inhibit CN VII neurons
Otoliths X 2 = Utricle (horizontal plane), Saccule (sagittal plane motion)
- together detect acceleration and deceleration + pull of gravity, important for posture
BPPV: common presentation, s/s + Ax + Rx?
90% present with crystals in posterior SSC, 80% canalithiasis (free floating in canal)
S/s:
-brief (
Menieres Disease: defined + s/s
Over accumulation of endolymph
S/s: episodic vertigo, tinnitus, fullness of ears, hearing loss
What is VOR?
Vestibulo-occuluar reflex:
- moves your eyes in the opposite direction that your head is turning: allows visual fixation
- deficient in UVL and BVL
UVL: causes + s/s + tests + Rx
Causes: infection, trauma, disease (menieres), sx
S/s acute:
- spontaneous nystagmus away from the affected ear, reduce VOR, vertigo (resolves in a few days), dizziness, Oscillopsia, imbalance
S/s Chronic:
- dizziness, Oscillopsia, imbalance (symptoms worse after rapid head movements)
Tests: head thrust, dynamic visual acuity, balance and gait assessment + Dix hall pike
Rx: conflict resolution exercises (balance, walking etc), education, falls, fitness
BVL: features + s/s + Ax
- no dizziness or vertigo and usually caused by toxic drugs (GENTIMICIN)
S/s: poor balance with eyes closed + increased Oscillopsia
Ax: balance = static, dynamic, composite
Gait Ax: DGI style
Central vestibular loss: causes, Redflags, Rx
Causes: stroke, TBI, MS, tumor, neurodegenerative, etcetera
Redflags: direction changing nystagmus
Dx: collection of oculomotor tests
Rx: based on neuroplasticity (exercise, habits, balance, walking, functional tasks)
Cervicogenic dizziness: Rx
- Manage vestibular dysfunction
- proprioception of neck symptoms
- motor control + endurance (DNF)
Acoustic Neuroma: features
Aka “ vestibular Schewannoma”
- intracranial tumor of Merlin around CN VIII
- causes central vestibular loss
Peripheral neuropathy: defined + causes
Injury to peripheral N due to damage or illness
Causes:
- Lyme disease
- Diabetes
- HIV
- Shingles
- Guillain-Barre
Diabetic neuropathy: presentation + causes
Symmetrical distal polyneuropathy
Causes:
- hyperglycaemia leading to abnormal micro-circulation
- change in insulin levels alter gene regulation
- lose of myelinated + non-myelinated fibres
- vascular changes
- nerve growth reduced
Diabetic Neuropathy: s/s + Rx
S/s:
Burning pain, symmetrical sensory changes, paraesthesia (impaired proprioception/touch/pressure), minimal motor weakness
Rx:
- control hyperglycaemia
- skin care
- exercise: strength (ankles + hips to prevent falling), balance, injury prevention
Complex regional pain syndrome: cause + s/s
Result of dysfunction in central or peripheral nervous system usually post immobilization or trauma
S/s:
- change in color/temp of the skin over the affected limb
- intense burning pain
- skin sensitivity
- sweating
- swelling
- stiffness
CRPS: stages + Rx
- Puffy swelling, red, warm, stiff, allodynia, +ve bone scan
- Inc pain + stiffness, firm edema, cyanosis, atrophy, osteopenia on xray
- Tight, smooth, glossy, cool, pale skin + stiff contractures, nail and hair changes + severe osteoporosis
Rx: early ROM, pain + edema management, education, desensitize
Cerebral palsy: co-morbidities + Risk factors
Co-morbidities:
- hearing and speech
- hydroencephaly
- scoliosis
- hip dislocation
- mental retardation
Risk factors:
- pre-natal infection, malnutrition, maternal seizures
- perinatal prematurity, breech/complicated birth
- low birth weight, low APGAR score,
- post natal infection, toxins, tumor, CVA, anoxia
Cerebral palsy classifications + features
1) Spastic:
-mono,di,hemi,quadri-plegia.
Classified by physiology type: stiffness, dec ROM, movement limited to synergies. Primitive movement patterns- trouble start/stopping
2)Ataxic:
- Rate, range, force duration of movements
- difficulty with rapid movements, coordinated gait, fine motor or balance
3) Dystonic:
- Increased tone, long sustained involuntary movements and postures
- full ROM but tend to lock joints at end range (no mid control)
4) Hypotonia:
- low tone and weakness
5) Athetoid:
- writhe ring movements/ snake like
CP: pathology
“Not consistent”
- intra ventricular hemorrhage = below lining of ventricles
- peri ventricular leukomalacia = common ischemic injury
- small holes surrounding ventricles = death of small brain areas
CP hip dislocation warning signs + features
Query if cannot abduct legs more than 45 degrees
Features:
- Pain ++, hard to stand/walk
- spasticity of adductor long us and iliopsoas
- dislocated posteriorly, pelvic obliquity and scoliolis
Cerebral palsy: Rx
Med Rx:
- bacolfen pump, dorsal rhizotomy (cut dorsal roots of SC),Botox to adductors, serial casting, tendon release, osteotomy
PT Rx:
- manage atypical mm: ROM + orthotics
- “habituation not rehab”
- positioning, sitting modifications: pummel between legs
Spina bifida: defined + types + risk factor
Neural tube defect resulting in vertebral and/or SC malformation
- Spina Bifida Occulta = no SC involvement, may be indicated by hairy tuft
- Spina Bifida Cystica = visible open lesion
- Meningocele = tumor/cyst includes CSF, cord intact
- Myelomenigingcele = cyst includes CSF and herniated cord tissue
Link b/w maternal folic acid + infection + exposure to teratogens
Spina Bifida: s/s + Rx:
S/s:
- flaccid or spastic mm, muscle weakness, contractures, mm wasting, dec/ absent DTR, incontinence, hydrocephalus (chiari malformation), osteoporosis, lordosis, scoliosis, foot deformities (club foot)
Rx:
- ROM, strnegth, functional exercises
- teach transfers
- equipment
- encourage awareness of sensory deficits
- limb protection
Erb’s Palsy:
C5, C6 injury in infants, usually from coming out of birth
Mm affected:
- rhomboidal, lev scap, SA, delts, supra/infra spinatus, biceps, brachioradialis, brachialis, supinator, long extensors or wrist, fingers, thumb
Rx:
- immobilization early
- gentle ROM and play exercises
Klumke palsy: nerves affected + mm
C8, T1
Mm affected:
- intrinsic hand mm, flex/ extensors of wrist and fingers
Ape hand: nerves affected + mm
Ape hand = median nerve palsy = C6, C8-T1
mm affected:
- the air mm of thumb = no thumb abduction and opposition
Alzheimer’s:
- risks + etiology
- impairments
- preserved fxn
- increased age + genetic link with unknown etiology
Impairments: “slow steady decline”
- memory, language, visuospatial skills
- cognition, personality
Preserved: implicit skills ( piano playing,etc)
Dx: autopsy via neurotic plaque formation
Vascular Cognitive Dementia:
- pathology
- risk factors?
- cause of death
- outcome measure
- Rx
- multiple small lesions 2nd to poor blood flow (high BP), leading to degeneration of medial temporal lobes = “staircase pattern of functional losses”
- related to: HTN, small hemorrhages, atherosclerotic plaque.
- death usually from Pneumonia
Outcome measures: Mini mental state exam (MMSE)
PT concerns: Falls, retaining motor skills, reduce restlessness, increase sleep support for care givers.
