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
34
Q
Rehabilitation FOR ALS
A
- Help the patient maintain their independence and function for as long as possible
- Treat current problems and plan ahead for future problems
- Consider pt to be in early, middle or late stage
- Early stage: minor functional limitations
- Middle stage: increase number of disabilities
- Late stage: more severe
35
Q
MORE Rehabilitation FOR ALS
A
- Have to differentiate between progressive course of disease and lack of impact of interventions
- Physical therapist will need to work with the patient to determine what the patients priorities are
- Pain: use visual analogue scale
- ROM, muscle length, soft tissue flexibility should be analyzed
- Mm tone, cranial nerves, sensation, Postural alignment, balance, gait, skin and functional skills should all be evaluated
36
Q
Disease-Specific and Quality of life measurements FOR ALS
A
37
Q
Intervention FOR ALS
A
- Restorative intervention: remediate or improve impairments and functional limitations:
- Done in early and middle stages
- Compensatory intervention: modify activities, tasks, or environment to minimize functional limitations
- Preventative intervention: minimize potential impairments: ROM, strength, aerobic capacity, prevent pneumonia, functional limitations
38
Q
MORE Intervention FOR ALS
A
- Initially goal will be to postpone onset of functional limitations
- Perform mm strengthening ex
- Encourage the patient to use necessary adaptive equipment and ambulatory devices when necessary
- Cervical mm weakness: head will start flopping forward
- Initially can use soft collar: over time will progress to semi-rigid to rigid collar
- May use cervical thoracic orthosis or sterno occipital mandibular immobilizer: heavy, difficult to don and doff
39
Q
Dysarthria and dysphagia
A
- Address posture and head and neck control
- Position in sitting
- UE mm weakness:
- Use adaptive equipment as needed
- Painful shoulder subluxation: use sling
- Splinting to avoid hand and wrist contractures
40
Q
Shoulder pain FOR ALS
A
- Capsular pattern
- May be due to spasticity or weakness cause imbalance
- Overuse of strong mm, strain, poor positioning, glenohumeral sublux (weakness or fall)
- Treat with inj: analgesics and antiinflam followed by aggressive ROM
41
Q
Respiratory FOR ALS
A
- Educate patients
- Energy conservation techniques
- Proper position to eat with head up to avoid aspiration
- Teach Heimlich maneuver in case of choking
42
Q
LE muscle weakness FOR ALS
A
- Orthoses
- Helps decrease stress on remaining muscles, conserve energy
- Knee impairments:use AFO
- Orthoses needs to be lightweight
- Hinged vs fixed ankle AFO
- Wheeled walker is generally used, occasionally Loftstrand: need to remember that need optimal function with the least energy expenditure
43
Q
Adaptive equipment FOR ALS
A
- Depends on needs
- Decreases mobility
- Poor mobility with LE weakness
- Use 2” cushion to raise person up
- Self powered cushions if have good trunk, control
- Transfer board, transfer belt, swivel cushion
- Lift, electric bed
- Chair glide or stair lift
44
Q
wheelchair FOR ALS
A
- Initially can use a lightweight wheelchair will work, but rent or borrow, do not purchase
- Will need an electric wheelchair
- Lightweight, small turning radius, high reclining back, supports for trunk and extremities
- Power chair: comfort, tilt-in-space, reclining
45
Q
Mm cramps and spasticity FOR ALS
A
- Massage and stretching
- Cold for spasticity
- Prolonged stretch, PROM
- Posture and positioning techniques
- splinting
46
Q
Psychosocial issues FOR ALS
A
- This illness is devestating
- Depending on progression emotional response of patient, loved ones and caregivers may fluctuate
- Watch for patient becoming very depressed, needs to be managed with meds
47
Q
Exercise FOR ALS
A
- Usually ROM and stretching
- Early in process, moderate resistance can be used with 3/5 strength, discuss this with the PT as thinking differs on this
- Overuse fatigue vs disuse atrophy
- With insufficient activity disuse atrophy develops when mm contractions are less than 20%of total tension a muscle is capable of producing
- Overuse fatigue can happen easily: must narrow down the safe range for therapeutic exercisse
48
Q
exercise FOR ALS NEW STUDIES
A
- Newer studies show that in ALS patients who exercise the rate of decline is slower
- Educate family, as they ask questions, answer them or find answers for them
- Give only as much information as they need
49
Q
Vestibular disorder FOR ALS
A
- 15 million people per year have symptoms of dizziness
- Prevelance of complaints increases with age
- Is a significant disability and interferes with quality of life
- Exercises can significantly reduce disability
50
Q
Vestibular system
A
- Is quite complicated
- Peripheral and central components
- Peripheral: 3 functions
- Stabilize visual images on fovea of retina during head movement
- Maintain postural stability
- Provide information for spacial orientation
51
Q
Peripheral vestibular system
A
- Semicircular canals:
- there are 3: horizontal, posterior and anterior
- respond to angular acceleration
- Filled with endolymph which is slightly more dense than water
- Each one has an ampula with a cupula: contains sensory hair cells
52
Q
Otoliths
A
- Otolith made up of saccule and utricle
- Respond to linear acceleration and static head tilt
- Sensory hair cells project into gelatinous mater ial where crystals are located
- Saccule vertical linear accel
- Utricle: excited over horizontal accel or static head tilt
53
Q
Central vestibular system
A
Mostly located in brainstem but there are connections between vestibular nuclei, reticular formation, thalamus, and cerebellum
54
Q
Vestibular system
A
- All parts need to work in unison
- Tonic firing rate: vestibular afferent have a specific rate of firing that increases when head moves, helps detect head movement
- Vestibular-ocular reflex (VOR): allows you to keep a stable gaze when head moves rapidly
- Push-pull mechanism: as you turn one direction the SCC on that side will increase firing and the opposite side will decrease firing
55
Q
can mean vertigo, light headed, disequlibrium, oscillopsia
A
Dizziness
56
Q
an illusion of movement: sense environment moving, usually episodic
A
Vertigo
57
Q
feel like fainting (hypotension, hypoglycemia, anxiety)
A
Light headed
58
Q
off balance: non vestibular, decreased somatosensation or weakness in LE
A
Dysequilibrium
59
Q
subjective experience of motion of an object
A
Oscillopsia
60
Q
duration MATTERS
ASK THEM HOW LONG IT LAST
A
- Minutes: benign paroxismal positional vertigo
- Minutes to hours : menieres disease
- Days: vestibular neuronitis or migraine associated dizziness
61
Q
Testing FOR VESTIBULAR PROBLEMS
A
- Visual analog scale: for intensity
- Dizziness handicap inventory pg 1005: breaks down into physical, emotional and functional
- Functional disabilities scale pg 1005: measures patients response to PT
- Motion sensitivity quotient pg 1006: provides subjective score of dizziness, both intensity and duration
62
Q
Testing POSITIONS FOR VESTIBULAR PROBLEMS
A
- The idea is to move the patients head in different patterns and determine if it causes symptoms
- Eye movement
- Head thrust
- Head shaking
- Positional testing
- Hallpike-Dix test
- Sitting with head rotated to 45 deg, bring into supine with head extended 30 degrees and watch eyes
63
Q
Testing VESTIBULAR PROBS FOR Gait and balance
A
- Gait and balance testing: weight shift, automatic postural responses, ambulation
- Otolith testing: use clicking sounds
- Semicircular canal testing
- Caloric testing
- Rotary chair
64
Q
- Can be caused by misplaced otoconia
- Vertigo nystagmus, N&V and imbalance
- Otoliths break away move the endolymph in the SCC
A
benign paroxysmal positional vertigo
65
Q
- Viral insult, trauma, vascular event
- Spontaneous nystagmus, vertigo, oscillopsia with head movements, postural instability, disequilibrium
- Usually resolves in 7-10 days
A
Decreased receptor input
66
Q
- bilateral vestibular hypofunction
- Meds,meningitis, autoimmune disorders, head trauma, tumors, TIA
- Dysequilibrium
A
Ototoxicity
67
Q
- CVA involving ant-inf or post inf cerebellar artery
- Sudden vertigo, hearing loss, dysdiadochokinesa,
- TBI: vertigo
A
Central NS DYSFUNCTIONS
68
Q
BPPV- INTERVENTION
A
GET ROCKS TO GO BACK WHERE THEY ARE SUPPOSED TO BE
- Goals: otoconia return to vestibule
- Reduced vertigo associated with head movement
- Improved balance
- Enhance decision making skills regarding self treatment strategies
- Demonstrate independence in ADL’s
69
Q
- Move head in different positions in sequence that will move the debris out of the involves SCC and into the vestibule
- After treatment symptoms should resolve
- Pt should be fit with soft collar to avoid vertical head movements that may dislodge otoconia
A
BPPV
Canalith repositioning maneuver (CRM)
70
Q
- Use for posterior or anterior semicircular canal BPPV
- Rot head 45 degrease toward involved side (left)
- Move pt into Hallpike-Dix position with left ear toward ground
- Rotate head 90 degrees to right
- Roll pt onto rt shoulder
- Slowly bring up to sitting with head rot 45 degrees to right
A
BPPV- meneuvers
71
Q
- CRT for right horizontal SCC
- supine: Place head in 20 degrees of cerv flex
- Place head 90 degrees to rt
- Rot head 90 degrees to lft, wait for 15 sec let symptoms stop
- Rot head 90 degrees to rt, wait 15 sec for symptoms to stop
- Roll into prone and wait for symptoms to subside
A
BPPV meneuvers
72
Q
- Brandt-Daroff: for posterior SCC
- Start in sitting, turn head 45 degrees to left side, then quickly lie down on Rt side: remain here for 30 sec
- Slowly return to starting position
- Turn head to right, lie down on left shoulder: remain for 30 sec
- Do 10-20 times 3 times per day until pt is without vertigo for 2 solid days
A
BPPV meneuvers
73
Q
Postural Stability for vestibular probs
A
- Encourage balance strategies withig limitations of patient
- Progress as pt tolerates
- Incorporate head movements when possible (see table 24.9 pg 1018)
74
Q
Motion sensitivity for vestibular probs
A
- Habituation training
- Use when pt has continual complaints of dizziness
- First must know what provokes the dizziness
- Move person in position and leave for 30 sec or until symptoms abate
- Perform ex3-5 times each 2-3 times per day
- Symptoms normally decrease in 2 weeks
75
Q
- Goals: reduce subjective complaints of gaze instability
- Improved static and dynamic balance
- Independent in HEP including walking
- Enhanced decision making skills for ADL’s
- Balance exercises
- Exercises to improve central preprogamming of eye movements (Pg 1010 table 24.1)
- May take 2 years for full recover
- Consider Tai Chi, pool ex
- Avoid activities in dark, quick head movements, may need cane
A
Bilateral vestibular hypofunction
76
Q
- Goals: understand fall prevention strategies and safety precautions to function at home and in community
- Enhance decision making skill regarding use for compensatory strategies to assist in gaze stability
- Independent in HEP including walking
- Recover time approx 6 months, may be incomplete
- Adaptive mechanisms for vestibular issues may be damaged
- Must be careful with pushing too quickly
- If lesion at brainstem level, treat like unilat vestib hypofunction
- Can try habituation therapy
- Gait and balance ex to incorporate somatosensory, visual and vestibular contributions
A
Central Vestibular Hypofunction
77
Q
- Has vertigo AND low frequency hearing loss
- May also have tinnitus or fullness in ear
- Symptoms with periodically get worse, will have fairly severe symptoms of 1-2 hours at a time sometimes days
- Possibly due to increase in endolymph
- Possibly due UVH treatment, gaze and postural stability ex
- This does not stop episodes
A
Menieres Disease
78
Q
- Rupture of oval or round window (between inner and middle ear)
- Will leak endolymph into middle ear
- Vertigo and h earing loss
- Usually due to trauma
- Rest, surgery
- PT is CI unless residual diffulties
should not do therapy just rest
A
Perilymphatic fistula
79
Q
- benign tumor on CN VIII
- Hearing loss, tinnitus, dsyequilibrium
- Surgery
- Therapy afterword to help with dysequilibrium
A
Acoustic neuroma
80
Q
- Normal sensation, can be debilitating
- Sensory input does not match stored neural patterns
- Pallor, nausea, emesis, diaphoresis, motion sensitivity
- PT can help to desensitize
A
Motion sickness
81
Q
- After MVA
- More common to diagnose in Europe
- Upper cervical spine: proprioceptive input into contralateral vestibular nucleus
- Soft tissue inj and jot dysfunction alter afferent input
- May respond to therapy
- Vertebrobasilar insufficiency: pt leans forward, extend neck and rotate to 45 degrees: diplopia, dysarthria, syncope, HA vertigo, nystagmus: must see neurologist immediately
A
Cervical vertigo
82
Q
Contraindications for treating someone in PT
A
- Not appropriate for unstable vestibular disorders
- Menieres
- Perilymphatic fistual
- Sudden hearing loss
- Pressure or fullness in ear
- Severe ringing in ears
83
Q
A
