SCI, ALS and Vestibular Dysfunction Flashcards
1
Q
Physical therapy intervention
A
- Must maximize functional independence
- First focus: bed mobility, transfers and wheelchair mobility
- With progression, focus on: work, home, community reentry
2
Q
- Things that were important at acute phase are still important:
A
- Things that were important at acute phase are still important: ROM, respiratory management, positioning
- Progress resistive exercise program
- Muscle reeducation
- Postural control
- Improve cardiovascular response to ex
3
Q
Skin inspection includes?
A
- Instruct pt in self skin inspection with long handled mirror
- High level: may need help
- Mat program: stability, progress to controlled mobility then skill
- Start with bilateral and symmetrical, then go to weight shift then movement, then improve timing and speed
- Easy to difficult
- Sometimes will progress someone before they have mastery of a skill
4
Q
Mat exercise
A
- As progress: improve strength, functional ROM, awareness of COG, postural stability, balance, determine how to accomplish tasks
- Rolling: important for bed mobility, dressing
- Good starting point on mat
- Learn to use head, neck and UE to move trunk and LE
- Consider how head position will change motion, also try crossing ankles
5
Q
more mat X
A
- Prone on elbows
- Help with bed mobility and working toward quadruped and sitting position
- Proximal stability
- Scap strengthening
- May be difficult initially with lumbar, low thoracic injuries
- Prone on hands
- Hyperext of hips and low back to prepare for amb, standing from WC or rising from floor
6
Q
more mat X
A
- Supine on elbows
- Assist with bed mobility and assume long sit
- Assume position in various ways
- Progress to long sit
- Pull up
- Strengthen biceps and shoulder flexors for WC propulsion(tetra)
7
Q
still more mat X
A
- Sitting
- Need to do both long and short sit
- Good sitting balance and posture
- Tetraplegia: need 100 degrees SLR
- Sitting varies with level of lesion
- Higher lesions: use head forward, trunk flex to maintain position
8
Q
more mat X
A
- Initially maintain position
- Practice balance activities in sitting
- Sitting push ups: very important for transfers, ambulation and wt shifting
- Quadruped position
Practice this leading up to ambulation
Do WB through hips
9
Q
last mat X
A
- Kneeling position
- Establish trunk and motor control
- Lead up activity to ambulation
- Transfers
- Do this once pt has adequate sitting balance
- Start on firm mat and progress to other alternate surfaces
- Usually use lateral scoot type transfer
10
Q
Transfer skills
A
- 3 important components:
- Momentum
- Muscle substitution
- Head-hips relationship
- Pt needs good instruction in components surrounding the skill
11
Q
WC 1 of 3
A
- Will almost always prescribe a wheelchair
- Ambulatory paras will still use wheelchairs for community ambulation due to greater speed, safety and lower energy expenditure
- Power vs manual chair
- Consider energy expenditure (for C5 C6 may still use power chair
- Rigid vs folding frame
- Push rim activated power assist wheelchairs
- C 4 and above: power
12
Q
wc 2 of 3
A
- Wheelchair training program
- Pressure relief: 10-15 seconds of pressure relief for 20 min of sitting
13
Q
wc 3 of 3
A
- Spasticity: may need heel and or toe loops
- May need more than one chair
- Wheelchair skills
- Need to operate wheelchair
- Can use base of hand
- Wheelchair mobility begin on level surfaces, progress to outdoor and uneven
- Wheelies: need to climb curbs
14
Q
ambulation
A
- Need adequate mm strength, postural alignment, ROM, CV endurance
- Orthoses + assistive device = a lot of work
- Slower and more energy
- Give option to pt even if it is only a remote possibility
- Need good ROM and postural alignment
15
Q
SCI and ambulation
A
- Be realistic with patient, provide clear picture and potential benefits
- Give pt the opportunity to try this
- Spinal bracing is too restrictive, so usually depend on LE bracing, assistive devices, adequate ROM, and postural alignment
- Need adequate CV endurance, good respiratory function
- Ambulation may be restricted by spasticity, loss of proprioception, pain, decubitus ulcers, hetertopic ossification,
- Amb with orthosis
- Very few continue to use them
- Some use them for standing and exercise
- If ASIA C or D tetraplegia, within 72 hours of injury, may are ambulatory at discharge
- 1 year post injury
- 5% complete para community ambulators
- 76% incomplete para community ambulators
- Increase strength of available muscles
- Use assistive device
- Use orthoses
- Use compensatory methods to ambulate
- Usually brace ankle or ankle/knee
- Ankle joint: 10-15 degrees dorsiflex
- Knee lock
- COG post to hip, ant to ankle
16
Q
Gait training strategies
A
- Forearm crutches are most appropriate
- Standing from WC
- Crutch balancing
- Ambulation activities: 4pt, 2pt, swing to, swing through
- Move in all directions
- Stair climbing: upstairs backward and downstairs forward
- Curbs: last thing to learn
17
Q
PT for Incomplete SCI
A
- Body weight support treadmill training
- Functional electrical stim
- Low level electrical current to improve function in paralyzed or weak mm
18
Q
Shoulder pain
A
- Usually biomechanical in nature
- Lot of mechanical stress
- Prevent problems with proper postural alignment, strengthening and stretching
- Exercise
- Improve function, strength, endurance, respiratory function, perceive health and quality of life
- UE ergometer, WC propulsion, swimming and circuit training
- 8-12 reps per ex, 2 sessions per week
19
Q
- Also known as Lou Gehrig’s disease
- Degeneration and loss of motor neurons in spinal cord, brain stem and brain: have mix of UMN and LMN S/S
- 30,000 in US have disease at any one time
- 15 diagnosed per day
- Average age mid to late 50’s
- Slightly more men than women
- Autosomal dominant, but large number do not have family history
A
ALS
20
Q
- 70-80 percent: limb onset ALS
- 20-30% bulbar onset ALS: initial involvement in bulbar muscles: middle age women: problems with speaking, chewing, swallowing
- Progressive degeneration and loss of motor neurons in spinal cord, brain stem and motor cortex
- Brain stem nuclei for CN V, VII, IX, X, XII and anterior horn cells in spinal cord
- Anal and external urethral sphincters are usually spared
A
ALS
21
Q
Progression tends to spread locally within a region before moving to other regions
Caudal to rostral spread within spinal cord, and cervical to bulbar region spread occurs faster than rostral to caudal spread
A
ALS
22
Q
- Depends on localization and extent of Motor neuron loss
- Initially focal asymmetrical weakness in LE or UE or weakness in bulbar mm
- Cardinal sign: mm weakness
- Initially weakness tends to be distal: fine motor activity, tripping or slapping foot, change in voice difficulty moving tongue
- Cervical: extensor weakness,
A
Manifestations OF ALS
23
Q
MORE Manifestations
A
- see decreased ROM, jt subluxation, tendon shortening, joint contractures, adhesive capsulitis, ambulation difficulties with distal mm weakness
- Common to fall (46%)
- Fatigue: due to several factors: overburdened neurons, weak mm must work at closer to max strength, sleep disturbance, respiratory impairments, hypoxia, depression, impaired mm contraction activation
- Atrophy, fasciculations, hyporeflexia, decreased or absent reflexes, decreased mm tone, flaccidity, mm cramp
24
Q
MORE Manifestations
A
- May have parasthesia or pain in limbs
- Sensory pathways are generally spared
- UMN loss: spasticity, hyperflexia, clonus, pathalogical reflexes: as get worse will see less UMN signs
- Spasticity: contractures, deformities, dyssynergic movement patterns, abnormal timing, loss of desterity and fatigue
25
Q
- Mixed UMN and LMN so will see mix of flaccid and spastic components
- Dysarthria, impaired speech: start by being unable to project voice, poor enunciation
- Dysphagia: spastic or flaccid palsy
- May see liquid regurge, weak cough reflex
- Sialorrhea: excessive saliva and drooling
- Psuedobulbar effect: poor emotional control
A
Bulbar pathology
26
Q
Other impairments
A
- Respiratory: loss of mm strength and decrease in vital capacity
- Initially fatigeu, DOE, problem sleeping supine, sighing, headaches due to hypoxia
- Tend to adjust activity level as respiratory problems get worse
- VC of <25-30% of predicted: impending respiratory failure or death
27
Q
- Can have mild deficits to severe frontotemporal
- Problems planning, organizing, personality and behavior changes
- Abstract reasoning, verbal fluency, memory, comprehension can also be affected
- Those with bulbar onset more likely to have cognitive impairments
A
Dementia
28
Q
Diagnosis OF ALS
A
- LMN signs by EMG, NCV, mm and nerve biopsies, neuroimaging
- Clinically definite ALS: UMN and LMN findings in 3 of 4 regions (bulbar, cervical, thoracic or lumbar)or UMN and LMN signs in bulbar region plus 2 spinal regions
- ALS is a progressive disease: will see deterioration
- Onset to death usually several months to 20 years
- Death is usually within 3-5 years
29
Q
Prognosis OF ALS
A
- Younger individual is at diagnosis: better long term survival
- Limb onset: better prognosis than bulbar
30
Q
Management OF ALS
A
- Multidisciplinary approach
- DMARDS may extend life for a short time
- Palliative care: disease is not responsive to curative treatment
- Control pain and other symptoms: psychological, social, spiritual problems
- Medical management is symptomatic
31
Q
Task force recommendations FOR ALS
A
- Inform family and patient about diagnoses and prognosis
- Symptom management of silorrhea and pseudobulbar affect
- Nutritional management, PEG
- Management of respiratory insufficiency and ventilation decisions
- Advance directives and palliative care
32
Q
Management of Respiratory Impairments
A
- At risk for respiratory tract infection
- When VC decreases to 50% of predicted: positive-pressure noninvasive ventilation
- When no longer tolerated or not effective: choice of tracheostomy or hospice
33
Q
Muscle cramps, spasticity, fasciculations, pain FOR ALS
A
