Pathologies related to the head and neck Flashcards
MS, CVA ,PosteriorCirculationCompromise ,Dizziness,CervicalMyelopathy ,Meningitis, BrainTumors, Horner'sSyndrome, ThyroidDisorders
What is multiple sclerosis?
A chronic and progressive neurodegenerative disorder of the CNS
What population is multiple sclerosis greatest in?
White, biological females between 20 and 50 years of age
How does someone get multiple sclerosis?
primarily by a:
- virus leading to an auto-immune response
- presence of another auto-immune condition
- genetic link
What increases the risk of multiple sclerosis?
low vitamin D, smoking, and obesity
What causes multiple sclerosis?
demyelination
sclerotic plaque that blocks neural transmission
What are clinical manifestations of multiple sclerosis? S&S?
Specific to area of CNS involvement
Cycles of exacerbations and remissions
S&S:
Possible immune S&S
fatigue
optic neuritis (FIRST SIGN)
trigeminal neuralgia
widespread neuromusculoskeletal (NMSK) weakness
What is the most common and disabling symptom of MS?
Fatigue
What is optic neutitis?
Unilateral and painful visual disturbances
vertigo may develop due to connection with vestibular system
What is trigeminal neuralgia?
-One of the most widely distributed nerves in the head and face
-sudden and transient shock-like pain
- typically unilateral
(MS S&S)
What can the generalized neuromusculoskeletal weakness with MS cause?
-Abnormal speech or swallowing & weak voice
- Especially balance with ataxia (Incoordination) and abnormal muscle tone = FALL RISK
- Bowel and Bladder dysfunction
- Sexual dysfunction
- cognitive dysfunction
-depression due to emotional and pathogenic changes
What percentage of MS cases present with cognitive dysfuntion?
More than 50%
What should be a part of the systems review with multiple sclerosis?
Hx and Observation
Scan
- resisted testing with multiple joint weakness
- neuro:
*cranial nerves signs (particularly
optic, vestibular, and trigeminal
nerves)
Special Test
- balance tests
- central vertigo
- Lhermitte’s sign
What is Lhermitte’s sign?
Neck flexion or cough producing spine and/or LE shock-like pain
What are PT Implications for Multiple Sclerosis? ( What kind of referral is it?)
Urgent referral
CVAs are the ___ leading cause of death
2nd
CVAs are the ________ cause of long-term disability
leading
Which type of CVA is most common?
Ischemic
What causes an ischemic CVA?
Blocked blood flow, often due to artherosclerosis
What causes an hemorrhagic CVA?
a ruptured blood vessel, often due to HTN, aneurysms, and arteriovenous malformations
What are non-modifiable risk factors for a CVA?
- age
- african americans more than european americans
- biological women due to longer life span than men
What are modifiable risk factors for a CVA?
- CV disease and HTN
- diabetes
- Lifestyle
- SAD and obesity
- lack of exercise
- tobacco use
- cocaine and possible marijuana use
What is the pathogenesis for CVAs?
Disrupted blood flow to the brain
Are stroke symptoms sudden or gradual?
Sudden onset
What determines more specific S&S with a CVA?
Region of brain
What are general CVA S&S?
- multi-segmental HEMI face and/or extremity numbness and weakness/paralysis
- visual disturbance
- speech, swallowing impaired
- severe HA, WORST Ever
- dizziness or fall
What is included in our systems review for CVA?
Hx and Observation
CV Scans
* Neuro tests: CN signs, UMN signs, Teitelbaum’s CPR for hemispheric lesion, vascular tests for carotid
What are PT implications for a CVA? (What kind of referral?)
Emergency Referral
What is the cause of Posterior Circulation Compromise?
CVA, pathological joint instabiliity, arthersclerosis, clot or embolism in carotid or vertebrobasialar veins, sudden arterial dissection, tumors
What are examples of pathological joint instability?
Collagen, genetic, and autoimmune conditions with AA subluxation
Where is the most common place for a clot or embolism with posterior circulation compromise?
Internal carotid
What causes sudden arterial dissection?
Excessive rotation/extension/Tx stress such as with a manipulation or trauma
What happens to arteries with posterior circulation compromise?
Ischemia of the arteries feeding the inner ear, brain stem, and cerebellum
What can be included with the ischemia of the arteries with posterior circulation compromise?
- Vertebrobasilar insufficiency
- Posterior cerebral arteries and their branches
What are affected functions of posterior circulation compromise?
- Inner ear / vestibular function
- brain stem houses cranial nerves and respiratory center
- Cerebellum regulates coordination
- The basilar artery most frequently supplies the trigeminal nerve
What are the 5 D’s and 3 N’s of posterior circulation compromise?
5Ds
- dysarthria
- dysphagia
- diplopia
- dizziness
- drop attacks - without loss of consciousness
& Ataxia, headache
3N’s
- Nausea
- Nystagmus
- Numbness/ paresthesias in face/extremities
What is ataxia?
Incoordination due to cerebellar disorder
** posterior circulation compromise
What is nystagmus?
Involuntary rotary eye movement creating a spinning sensation
What are PT implications for posterior circulation compromise? (What kind of referral?)
Emergency referral
Why can dizziness happen?
Vertigo, Disequilibrium, Pre syncope, Nonspecific
What is presyncope?
Near fainting/ light headedness just before LOC without illusion of spinning
What can cause dizziness?
High stress or medication
What is the pathogenesis of dizziness?
Vasoconstriction reducing posterior circulation to the brain
What are the PT implications for dizziness? ( what kind of referral?)
Emergency referral
What is vertigo?
The illusion of spinning or rotary motion caused by asymmetries in the vestibular system
What is the most common type of vertigo?
BPPV (benign Paroxysmal Positional Vertigo)
What makes up 90% of vertigo episodes?
Peripheral vertigo
What is the primary etiology of BPPV?
Unknown
What can be a secondary etiology of peripheral vertigo?
TBI (traumatic Brain Injury), migraine HAs, ischemia, or anything causing an accumulation of fluid
What is the pathogenesis of vertigo?
Crystals become free floating in semi-circular canals
What would we do to review for vertigo?
Progressive vestibular tests on CV scan
What makes up 10% of vertigo?
central vertigo
What primarily causes central vertigo?
CVA or tumor
What secondarily causes central vertigo?
-Trauma creating a TBI or upper cervical instability
-infection
- Demyelination like with MS
- migraine HAs
What is the pathogenesis of central vertigo?
Due to ischemia to cerebellum or brainstem
Which type of vertigo is treatable by PT?
Peripheral vertigo
Which type of vertigo is an emergency?
Central Vertigo
When does central vertigo happen?
At rest
What is dysequilibrium?
Unsteadiness without illusion of spinning
What is the balance triad with dysequilibrium?
3 primary afferent systems contributing to postural perception and control
- somatosensory system
- vestibular system
- visual pathways
Where does the balance tried mostly happen?
The somatosensory system
What is a part of the somatosensory system with the balance triad?
Pressure, pain, position, motion, vibration, temp throughout the body in muscles, joints, skin, fascia, ligaments, etc
**esp in the LE and trunk
What is the etiology of dysequilibrum?
aging - biomechanical restrains
progressions of neuromusculoskeletal diseases
What causes biomechanics restraints with aging? (dysequilibrium)
Less ROM and strength, insufficient joint receptors
What is the pathogenesis of dysequilibrium?
Dysfunction of the balance triad
What are the implications for PT with dysequilibrium?
Begin a trial of PT, assess and treat MSK condition to improve somatosensory function, assess and treat the balance triad basically with balance training
- potential urgent referral for vestibular or vision component
Where can non-specific dizziness come from?
Phychophysiological or cervical origins
What are some psychophysiological examples with non-specific dizziness?
Psychological disorders such as anxiety phobias and depression
What is the pathogenesis of psychophysiological dizziness?
Vasoconstriction with SNS response
What are clinical manifestations and S&S of phychophysiological dizziness?
Motion sickness
giddiness
feeling removed from their body
sensations of floating
subjective postural imbalances with normal balance testing
What are the PT implications of psychophysiological dizziness? (what kind of referral?)
Urgent physiological consult
What is the pathogenesis of cervicogenic dizziness?
Abnormal afferent input from the neck to the TCN - hypersensitivity
What are the clinical manifestations and S&S of Cervicogenic dizziness?
Dizziness with neck motion
other TCN symptoms
No illusion of spinning or nystagmun
What are the PT implications of cervicogenic dizziness?
Begin a trial of PT to assess and address cervical dysfunction
What is cervical myelopathy?
Slow, gradual and often progressive ischemic compression on cord
T/F cervical spine is the most common area of the spine for myelopathy?
FALSE
- LEAST common
What is the etiology of cervical myelopathy?
Most commonly due to degenerative spinal changes
- lax and buckling ligamentum flavum
- age-related joint changes
- age related disc changes
- vertebral body collapse / fx
- pathological instability (i.e. spondylolisthesis)
What is cervical myelopathy NOT due to?
Trauma
How much of the time is cervical myelopathy malignant?
20% of the time
What can happen with cervical myelopathy but is RARE?
Central disc herniation
What is the history of cervical myelopathy?
Slow, gradual and often progressive onset
What will we find with our observation with cervical myelopathy?
Not acute so not likely to splint
- increased tone or spasticity
- incoordination
What can we expect with A/PROM with cervical myelopathy?
- Primarily limited with UE neuro symptoms into neck ext
- other neck directions may be limited and symptomatic
What will we find with PA stress tests for cervical myelopathy?
Possibly positive for neuro symptoms
What is the CPR for myelopathy?
Cooks CPR (+)
What neuro S&S do we expect with cervical myelopthy?
Primarily in bilateral UEs
- multi segments diminished to light and sharp touch plus to vibration, temp, and/or, 2 pt discrimination
- multi segmental hyperrefexia or clonus with DTRs
- loss of proprioception
- positive UMN tests like hoffman’s babinski, etc and superficial reflexes
- dural mobility negative due to gradual onset
Where can cervical myelopathy extend to if it is more severe?
trunk and bilateral LEs
What are PT implications for cervical myelopathy?
MD referral - EMERGENCY
Stabilize pt
What is meningitis?
An infection leading to inflammation of the brain and spinal cord meningeal membranes
What is the incidence of meningitis?
Rare
What population is viral meningitis most common in?
Adults
What is viral meningitis caused by?
Enteroviruses from GI tract
What population is bacterial meningitis most common in?
young children
What is the most common cause of bacterial meningitis?
Streptococcus pneumonia
What are staph infections associated with?
Surgery, central lines, and trauma
What are the clinical manifestations for recent viral meningitis?
Infection and GI S&S
What are the clinical manifestations for recent bacterial meningitis?
Infection and respiratory S&S
What are additional S&S of meningitis?
Constitutional
neck pain/stiffness
photophobia
HA
What are S&S of increased intracranial pressure with meningitis?
- Altered mental status
- varied UMN deficits (including CN VI Abducens that is susceptible)
- Diplopia
- Painful eye motion
- seizures
What are S&S for review with meningitis to help up RULE it OUT?
Jolt Accentuation of HA test
- HA worsened by neck rotation 2-3x in a second
- most sensitive clinical test to RULE OUT meningitis
What are the best clinical tests to rule IN meningitis?
While supine:
* Kernig test: low back and posterior thigh pain with combined hip flexion and knee extension
* Brudzinskin test - neck flexion produces hip and knee flexion
What are the PT implications with meningitis?
Emergency Referral
What is the mean age for a brain tumor?
60 years old
Brain tumors are the ___ most common primary tumor in children
2nd
What is the most common brain tumor in adults?
Metastatic
What are 50% of metastatic brain tumors from?
The lung
**others from breast and melanoma (skin)
What is the pathogenesis of brain tumors?
Compression of cerebral tissue, at times erosion of bone with tumor growth
What can brain tumors lead to?
Edema and ICP
When are brain tumors most asymptomatic? Why?
In early stages due to brain’s ability to adapt to slow growing tumors
What are S&S of brain tumors?
- Cancer S&S plus specific S&S related to the area of the brain
- HA that is increased with activities further increasing ICP
What kind of neurological symptoms are present with a brain tumor?
- Uni or bilateral with varied UMN S&S based on area of brain affected
- Cranial nerve VI (abducens)
- diplopa
- painful eye motion
- seizures
- speech impairment
What is the incidence of horner’s syndrome
Rare
What is the etiology of Horner’s syndrome?
- pancoast tumor in apical portion of lung that compresses sympathetic ganglion at cervicothoracic junction
- intracranial pathology
- conditions influencing carotid artery and venous sinus
What is the pathogenesis of horner’s syndrome?
Interruption of sympathetic nerve supply to the eye
What are clinical manifestations / S&S of Horner’s Syndrome?
Ipsilateral
* Ptosis (droopy eye lid)
* Miosis (Constricted pupil)
* Lack of facial sweating
* Possibly pain in T2-4 dermatomal region due to shared spinal nerve innervation in the area of the Pancoast tumor
Where is the thyroid?
Anterior, lower neck on both sides of trachea
What are the functions of the thyroid?
- Regulate metabolism
- increase protein synthesis
- calcium and phosphate balance with bone, kidney, and GI tract together
What is the thyroid regulated by?
hypothalamus and pituitary gland
What do hormones act on?
ALL body tissues
What are the different types of thyroid disorders?
Hypo or hyper active
Why is it harder to detect thyroid disorders in older individuals?
It masquerades as other illnesses due to multi-system influence
What are the risk factors for thyroid disorders?
Biological women, particularly in middle ages more than men
- increases with age
What does hyperthyroidism do?
elevates metabolic activity in every system
What is the most common form of hyperthyroidism?
Grave’s disease (autoimmune condition)
What is the pathogenesis of hyperthyroidism?
Increased hormonal secretion
What are clinical manifestations and S&S for review with hyperthyroidism?
- Possible immune S&S
- Symmetric enlargement of thyroid and possible dysphagia
- exophthalmos (eye protrusion)
- proximal muscle weakness
- higher metabolic activity
What are some examples of things that can happen with higher metabolic activity as a result of hyperthyroidism?
- Heat and exercise intolerances, excessive sweating and fatigue
- Weight loss despite increased appetite
- nervousness, hyperactivity, insomnia, and mood alterations
- palpitations and tremors
-low endurance
What does hypothyroidism do?
Slows body’s metabolism
What is the most common thyroid disorder in north america?
Hypothyroidism
What is hypothyroidism from?
- Genetic or autoimmune
- possible damage from surgical ablation, radiation therapy, or medications
What is the pathogenesis of hypothyroidism?
Decreased hormonal secretion
What are some clinical manifestations and S&S for review with hypothyroidism?
Possible autoimmune S&S
Lower metabolic activity
large and spinal joint pain/stiffness
proximal weakness
What are some examples of lower metabolic activity with hypothyroidism?
- slow and steady weight gain
- myxedema
- fatigue and lethargy
- cold intolerances
- dry skin, hair, and nails
What is myxedema with hypothyroidism? What causes it?
Collection of non-pitting boggy edema, particularly around supraclaviciular fossa, eyes and distal extremities
- due to build up of sugars and proteins attracting and retaining water
- may also thicken oral and throat structures thus impairing swallowing, breathing, and speech
