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
What is frontal lobe syndrome?
Impairment of executive function:
Difficulty planning
Personality changes
Perseveration
Response inhibition:
Disinhibition
Sexual disinhibition
Emotional lability
What is involved in behavioural modification?
Monitoring behaviour:
Identify precipitating factors, behaviour and positive reinforcements
Modifying behaviour:
Positive reinforcement, time out, specialist neurobehavioural rehab units
Vocational rehabilitation:
Identify alternative work/educational options, planned withdrawal from work
What are problems that may complicate a return to work in traumatic brain injury?
Cognition: poor concentration, memory, executive function
Behaviour: impaired judgements, disinhibition, aggression
Post concussive symptoms: fatigue, headache
Epilepsy: driving, work on scaffolding etc
Mental health problems: anxiety, depression, loss of confidence
Can patients with head injury drive?
Significant head injury: banned from driving for 6-12 months
Epilepsy: barred from driving for 1 year post last seizure
Must have satisfactory clinical recovery, no visual field or cognitive impairments
What is an initial prostheses?
A generic, adjustable prosthetic limb given after amputation of the lower limb
Assesses patients ability to walk
Improves unsteadiness, promotes exercise
Reduces post op swelling and promotes healing
How is a prostheses made?
Cast made of residual limb
Positive made of cast to replicate size and shape of patients limb
Socket made which fits patients limb to enable weight bearing
Attach joints and shafts to make prosthesis the same length as patients leg
Prosthesis may have cosmetic cover or remain with the components exposed
What are the contraindications to having a prosthetic fitted?
Angina - prosthesis increases energy costs of walking by 20%
Small/painful residual limbs - do not allow prosthetic fitting
Instead, use a wheelchair and sliding board for transfer
What is phantom limb pain?
Pain located in the part of the limb that has been removed
Contributing factors include peripheral and central sensitisation leading to cortical reorganisation of bodies schema
Influences by stress, depression and anxiety
May result from neuroma - benign tumour of transacted nerve
How is phantom limb pain managed?
Pain gradually improves with time - usually gone after a year
Amitriptyline is first line
Massage, hot/cold packs, tens machine
Neuroma - treat worth surgical excision or ablation by phenol injection
What are the appropriate investigations for seizures?
EEG - only to support clinical diagnosis of epilepsy
MRI - to identify structural abnormalities that might cause epilepsy
Bloods - glucose, calcium, UandEs, LFTs
12 lead ECG - to assess for cardiogenic causes
What is double support?
When part of each foot is in contact with the ground at the same time
This period is about 20% of the gait cycle
What are the main components of the stance phase?
Initial contact:
Hip flexed, knee slightly flexed, ankle dorsiflexed
Loading response:
The above movements continue as leg decelerated to foot on ground
Mid stance:
Hip goes from Flexion to dorsiflexion
Knee from Flexion to extension
Ankle dorsiflexes
Preswing:
Hip is neutral
Knee flexes
Ankle plantar flexes and heel lifts off ground
What are the main components of the swing phase?
Initial swing:
Hip and knee flex
Ankle dorsiflexes
To rapidly shorten limb so toes don’t touch ground
Terminal swing:
Leg prepares for initial contact of heel
Rapid hip Flexion
Knee extension
How much of the gait cycle is stance?
60%
How much of the gait cycle is swing?
40%
What factors may cause dysfunction in the stance phase?
Limb instability
Trunk instability
Abnormal base of support
What can cause weakness in knee extension resulting in limb instability?
Central/peripheral neurological conditions:
Polio
L2/L3 duac lesions
Femoral nerve lesions
What compensatory measures may be taken to reduce weakness in knee extension?
Patient may use ipsilateral upper limb to knock knee back in ace during mid stance
Patient may allow knee hyper extension - this is painful!
Forward Flexion of the trunk
Initial contact with forefoot
What is trendelenberg gait?
Pelvis drops in swing phase
Gluteus medius cannot maintain stability
Trunk compensates by flexing to ipsilateral side to shift centre of gravity over stance leg
Other compensatory strategies include extension of trunk at initial contact and arms placed behind centre of gravity
What causes trendelenberg gait?
Reduced activity in gluteus medius causes trunk instability
Due to:
L5 root lesion
Damage to superior gluteal nerve
Direct muscle damage (THR)
What is a stable base of support?
Base of support is created by feet as they contact with ground
Walking is stable when centre of gravity is within base of support
What causes abnormal base of support?
When patients cannot put weight through their feet
Due to:
RA in joints of feet
Spasticity of gastrocnemius and soleus complex, Tibialis anterior and posterior - results in equinovarus foot
What causes impaired limb clearance in swing phase?
Weakness of hip flexors, knee flexors or ankle dorsiflexors
Due to:
Neuro or muscle lesion to iliopsoas, hamstrings, Tibialis anterior
What compensatory strategies may help in impaired Limb clearance?
Movement on to toes of contralateral limb during stance
Hip hitching - excessive hip and knee Flexion
Contralateral Flexion of trunk
Circumduction
What does Varus mean?
Joint points out wards
What does Valgus mean?
Joint points inwards
What is equinovalgus?
Foot deformity in which weight is borne on the medial edge of the foot
May be seen in cerebral palsy
What is equinovarus?
Foot deformity in which weight is borne on the lateral edge of the foot
Due to cerebral palsy, DMD, spasticity of Tibialis posterior anterior, gastrocsoleus etc
What causes impaired limb clearance in swing phase?
Weakness of hip flexors, knee flexors or ankle dorsiflexors
Due to:
Neuro or muscle lesion to iliopsoas, hamstrings, Tibialis anterior
What compensatory strategies may help in impaired Limb clearance?
Movement on to toes of contralateral limb during stance
Hip hitching - excessive hip and knee Flexion
Contralateral Flexion of trunk
Circumduction
What does Varus mean?
Joint points out wards
What does Valgus mean?
Joint points inwards
What is equinovalgus?
Foot deformity in which weight is borne on the medial edge of the foot
May be seen in cerebral palsy
What is equinovarus?
Foot deformity in which weight is borne on the lateral edge of the foot
Due to cerebral palsy, DMD, spasticity of Tibialis posterior anterior, gastrocsoleus etc
How does a patient use a walking aid?
Walking aid eg sticks/crutch used to support the weaker leg
therefore weak leg is moved forward with the stick or both sticks and the strong leg takes the weight of the body
When two sticks and two weak legs, the leg moves forward with the contralateral stick
If two walking aids and one leg, move both forward at the same time, then swing weak leg through
What is kinematic gait analysis?
Study of movement in space and time, regardless of forces generated
Performed with multiple cameras and reflection markers
Each side recorded with eight cameras and 15 markers
Temporal parameters recorded, including stride length, cadence, walking speed
What is kinetic gait analysis?
Study of forces in the body that produce movement
Based on Newton’s third law, and requires 3d force sats from a force plate set on the floor
What is hemiplegic gait?
Affects one side of the body - usually seen in UMN lesion
Associated reaction - shoulder adducted, elbow flexes, wrist pronated
Leg extended and internally rotated
Leg circumspection to compensate for lack of knee Flexion
What is choreiform gait?
Wide based gait with slow leg raising and simultaneous knee Flexion
‘Flinging’ movements of legs
Associated with choreathetoid movements of upper limbs
Causes:
Huntington’s chorea
Dopaminergic medication
What is scissor gait (spastic diplegia)
Spastic cerebral palsy - usually diplegic and paraplegic
Legs flexed slightly at hips and knees, giving crouching appearance
Knees and thighs hit or cross each other
Individual walks on tip toe
Ankles plantar flexes and internally rotated
Shoulders adducted and elbows flexed
Weak back and hip extensors, so shift centre of gravity posteriorly
What is Parkinsonism gait?
Short steps
Reduced arm swing
Stooped posture
Centre of gravity ahead or behind feet
Fearination - hasty but short steps, attempting to compensate for displaced COG
Postural instability - difficulty standing from sitting
What is ataxic gait?
Indicates cerebellar disease
Broad based gait
Lurching quality
Difficulty with turning
Difficulty walking in a straight line
What is antalgic gait?
To avoid acute pain
Limited joint range of motion
Inability to bear weight in affected extremity
Stance phase duration shortened to compensate pain in affected leg
Resultant limp with slow and short steps
What is foot drop?
Inability to dorsiflex ankle
Commonly due to peroneal palsy
Exaggerated hip and knee Flexion to compensate
What is myopathic gait?
Weakness of proximal muscles causes ‘waddling gait’
Non weight bearing hip drops, and trunk shifts to love COG to contralateral side
What is stomping/stamping gait?
When a patient has trouble with proprioception and cannot feel when foot reaches floor
Step transmit vibrations which are detected in the trunk
