Rehab Medicine Flashcards
How is most at risk of MS?
Women (2x as likely)
Between the age of 20-50
Living in countries towards the poles
What is the most common pattern of MS?
Relapsing remitting pattern:
Two episodes of neurological impairment affecting two different parts if the CNS, each lasting longer than 24 hours and occurring at least one month apart
How long do the effects of inpatient rehabilitation last for MS?
Physical and psychological benefits last 6 months
Neuro status and functioning diminishes after discharge
What should the outpatient rehab for MS involve?
For relapsing remitting:
IV corticosteroids combined with rehab provides improvements lasting at least three months
How can fatigue me managed in MS?
Ensure sleep hygiene
Exclude medical problems - hypothyroidism, infection
Review medication that may worsen fatigue - baclofen, carbamazepine
Adaptive equipment
Work simplification
Training energy conservation techniques
How should sphincter disturbance in MS be managed?
Rule out UTI
If prone to retention, teach intermittent self-catheterisation
Overnight symptoms may respond to low dose ADH (desmopressin)
Detrusor hypereeflexia (frequent small volume voiding) - treat with oxybutynin, tolterodine, intavesical botulinum toxin
What functions are impaired in frontal lone stroke?
Personality, expression, movement
Speech and writing - may be damaged
Motor: Hemiparesis - face, trunk, limbs Sitting to standing, standing, walking Abnormal tone Flaccid, spasticity Lack of coordination Loss of dexterity, fine finger movements
What functions may be impaired in parietal line stroke?
Sensation:
may be loss or abnormal sensation
may be perceived as pain
proprioception may be lost compounding limitation of movement
Praxis:
ability to carry out skilled movements
What is praxis?
Ability to carry out skilled movements
Where is praxis located?
Dominant temporo-parietal cortex
What is apraxia?
Loss of skilled movement ability when not explained by weakness, sensory loss or innattention
What is involved in stroke rehabilitation?
Improvement in safe transfers, eg between bed and chair
Independent mobility - training with walking aiding roving abilities in ADL
Return to participation in work or leisure
Prevention of further strokes
What are the main types if perceptual impairment after stroke?
Inattention
Visual agnostic
Visual neglect/hemineglect
Now long should visually impaired stroke patients wait before driving?
In attention and neglect prevent patients from driving
Advise not to drive for minimum of one month, or until impairment resolves if takes longer than one month
Longer for drivers of commercial vehicles
In what types of injuries is spinal cord injury assumed?
Motor vehicle crash
Fall from height
Incidents with impact, crushing, multiple trauma
Loss if consciousness
What symptoms are suspicious of spinal cord injury?
Back or neck pain
Guarding of back or neck
Sensory changes/loss/numbness/tingling
Being unable to pass urine
What is the MRC grading to rate motor movements on each side of the body?
0- total paralysis 1- palpable or visible contraction 2- active movement with gravity 3- active movement against gravity 4- moderate movement against gravity 5- full normal movement
How is sensation graded?
0 - no sensation
1 - abnormal or impaired sensation
2 - intact sensation
What is complete spinal injury?
Patient lacks motor AND sensation at anus
Innervated by S4-5
Usual more severe
What is incomplete spinal injury?
Patient has motor OR sensation at anus
Usually a better prognosis
What is the AISA impairment scale?
1 - complete - no sensorimotor at anus
2- sensory NOT motor function below neurological level, extends through S4-5
3- motor function preserved below neuro level, most muscle 3
5- normal - sensory and motor functions are normal
What are the long term consequences of spinal cord injury?
Spasticity
Osteoporosis
Heterotrophic ossification of soft tissues around joints
Renal failure - renal calculi due to repeat UTIs
Respiratory failure - patients cannot ventilate lungs
At lesions above what neurological level do autonomic complications occur?
Lesions above T7
Due to loss of sympathetic input (esp to heart) from sympathetic chain in cervical and upper half of thoracic spinal cord
Parasympathetic input from vagus is preserved
Results in hypotension and bradycardia
What is vagal stimulation induced cardiac arrest?
Upper airway suctioning, ng tubes and intubation cause reflex increased vagal output
This causes bradycardia and and cardiac arrest
Treat with prophylactic atropine before procedure
Impact of vagal stimulation decreases after a month - can use pacemaker if persists
What is the mechanism behind autonomic dysreflexia?
Due to uncontrolled reflex sympathetic activity to noxious stimuli below level of SCI
Results in reflex hypertension, which would normal be countered by vasodilation in lower limbs
Injury disrupts outgoing autonomic signals from BP centres in brainstem
May result in cerebral haemorrhage, seizure and death
What factors might precipitate autonomic dysreflexia?
Bladder - UTI, over distension, stones Bowel distension- constipation etc Pressure sores Ingrown toenails Complications of pregnancy and labour Sexual activity Other conditions with pain - fracture etc
What are the symptoms of autonomic dysreflexia?
Pounding headache
Feeling of doom/anxiety
Profuse sweating
Chest tightness
Flushing above level of lesions
Pupillary dilatation
Cardiac dysrhythmias
Hypertension and bradycardia
What is the treatment of autonomic dysreflexia?
Get patient to sit - to reduce BP Sublingual nifedipine 10mg Sublingual GTN Monitor BP every five mins Remove precipitating cause
What is post-traumatic amnesia?
Inability to lay down new memories and retain information after traumatic brain injury
Variable duration - may be mins/months
Commonly anterograde amnesia :
Declarative - facts, association
Procedural - motor skis
Biographical - complex every day events
How is post traumatic amnesia managed?
Low stimulus environment
Reassurance, reorientation
Visual clues
Sedate only if essential for safety of patient or others
